Treatment of OsteoporosisDMARDs & BiologicsInflammation ConferenceYellow = high yieldSTEP 1added board fact beyond the lecture
Cross-cutting high-yield rules
Only anabolics build bone (teriparatide, abaloparatide, romosozumab). Every anabolic must be followed by an antiresorptive. Very-high fracture risk → start anabolic.
Drug holiday = bisphosphonates only. Never stop denosumab without a bisphosphonate → rebound multiple vertebral fractures.
Before any biologic: screen latent TB (PPD/IGRA) and hepatitis B. TNF maintains granulomas; rituximab reactivates HBV and causes PML.
RA ladder: NSAIDs/prednisone → low-dose weekly methotrexate (+ folic acid) → add a biologic (anti-TNF) after a negative TB test. Treat to target (DAS28, ACR20/50/70, RAPID3).
Anti-drug antibodies cause secondary failure: chimeric drugs and stop-start dosing raise the risk; regular dosing plus methotrexate lowers it.
Lupus: hydroxychloroquine for nearly everyone; nephritis → steroids + mycophenolate or cyclophosphamide; steroids alone do not protect the kidney.
Colchicine is not in the pharmacology lectures, but the rheumatology cases lecture names it for gout: it binds tubulin → blocks microtubules → stops neutrophil chemotaxis; GI, neuromyopathy and marrow toxicity; avoid with renal/hepatic failure and CYP3A4 inhibitors. Psoriasis/spondyloarthritis biologics (IL-17, IL-12/23) are taught by target only, so they appear here without drug names.