1
Q
How to prevent
A
- Consume adequate Ca++ and Vit D
- Regular weight-bearing exercises
- Reduce the risk factors for osteoporosis (smoking, coffee)
2
Q
New guideline rec bone density testing for:
- Women
- Men
Earlier testing rec for:
A
New guideline rec:
- Women: age 65 or over
- Men: Men 70 or older
Earlier testing rec for POST-menopausal women & men over 50 who:
- Have fx hx of osteoporosis
- Smoke
- Drink 3 or more EtOH/day
- Underweight
- On corticosteroids or drugs that may cause osteoporosis
3
Q
What is:
- Bone mineral density (BMD)?
- Dexa?
A
- BMD: estimate the true mass of bone
- Dexa: is quick, painless and the preferred method to measure BMD
- Dexa Scan is more accurated than doing a X-ray or CAT scan and uses less radiation
4
Q
How do we know that medications such as Bisphosphonate are working
A
- Monitor with a BMD dexa scan. Incr in bone mass can be seen in as little as three months therapy has started
5
Q
What meds can cause osteoporosis
A
- Corticorsteroids
- Antiepileptic
- Aromatase inhibitor: Anastrazole, letrozole, exemestane
- Gonadotropin-Releasing Hormones
6
Q
Evista
- Class
- MOA
- SEs
A
Raloxifene
- Class: Selective Estrogen Receptor Modulators (SERMs)
MOA:
- It antagonizes or blocks estrogen.
- It acts like estrogen to prevent bone loss
- Has the potential to block some estrogen effect in the breast and uterine tissues.
- It decreases bone reabsorption (decrease bone turnover), increase BMD, and decreasing fracture incidence.
SEs
- Hot flashes
- Leg cramps
- VTE events => d/c 72H prior to and during prolonged immobilization
- HyperTG
7
Q
Evista
- DDI
- Pt counseling/CI
A
Raloxifene
DDI
- Cholestyramine: dec abs of Evista
- Warfarin: increase dose to counteract w/ high blood clot in Evista
Pt counseling:
- Take w/ or w/o food
- *Contact MD if DVT or PE sx: change in vision, abnormal vaginal bleeding, breast pain
- *Don’t use if hx of blood clots, pregnant, nursing
- Avoid consume w/ estrogen therapy
- Do not give w/ cholestyramine
- *NOT rec in pre-menopausal women
- *Rec below the kneed compression stockings with 15-30 mmHg to prevent a DVT during a long trip
8
Q
Bisphosphonates
- Drugs in this class
A
- Alendronate - Fosamax (tab, sol’n); Binosto (effervescent tab)
- Resedronate - Actonel; Atelvia (DR)
- Ibandronate - Boniva: tab, IV
- Zoledronic Acid - Reclast: IV
- Zoledronic Acid - Zometa: IV
- Pamidronate - Aredia: IV
9
Q
BisphOsphonates
- MOA
- SEs
A
MOA
- Inhibits bone reabsorption via actions on Osteoclasts or osteoclast precursors
- Stay in bones for years after stopping
- In mild osteoporosis, rec drug holiday (PO) after 5 yrs and 3 yrs for Reclast
SEs:
- GI: N/V/D, abd pain
- Muscle skeletal pain: bone, muscle, joints
- HA, HypoCa++
- Osteonecrosis of the jaw: 0.12% chlorhexidine rinse
- Esophageal sx: GERD/ulcer
- Inc risk of esophageal cancer
- Inc risk of thigh bone fractures
10
Q
BisphOsphonates
- Pt counseling Administration when Stay up right Supplement Exercise Contact MD
A
- Take AM on empty stomach
- Do not eat for at least 30/60 min & stay upright for 30 min
- Swallow tablet with at least 8oz of plain water
- Take supplemental 1200mg/d Ca++ & 800-2000 units/d Vit D
- Weight bearing exercises;
- No smoking & decr EtOH
- Contact MD if diff swallowing, chest pain, or heart burn
- If an extraction or bone surgery is necessary, rec 0.12% chlorhexidine rinse
11
Q
Peridex
- Counsel pt on use of 0.12% chlorhexidine rinse
- SE
A
Chlorhexidine
- Use 1/2 oz (15mL = 1 capful) undiluted BID
- Swish for 30s. Do not eat for 2-3H after
- May cause staining of teeth
- Store at RT
12
Q
Fosamax
- Indication
- Frequency
A
Alendronate PO & sol’n
Dose
- Postmenopausal osteoporosis prevention
- Postmenopausal osteoporosis treatment
- Glucocorticoid induced osteoporosis
- Frequency QD, QW
13
Q
Actonel
- Indication
- Frequency
A
Risedronate PO
Indications
- Paget’s disease of bone
- Postmenopausal osteoporosis tx/ppx
- Osteoporosis tx in men
- Glucocorticoid induced osteoporosis tx/ppx
Frequency
- QD, QW, QM
14
Q
Boniva
- Indication
- Frequency
- PO
- IV
- CI
A
Ibandronate Tab/IV
- I: Treatment and Prevention of postmenopausal osteoporosis
Frequency:
- PO: QD, or QM
- IV: 3mg IV Q3M
CI: HypoCa++
15
Q
Reclast
- Indication
- Dosage
- SEs
- Avoid
- Counseling
A
Zoledronic Acid
- For osteoporosis
- Dosage: 5mg/100mL IV ONCE yearly over 15 min or longer
SEs
- Fever occurs in 20% of patients
- Avoid in renal impairment
=> Drink lot lot of water to protect kidney
16
Q
Zometa
- Indication
- Dose
- Renal dose adj: Y/N
A
Zoledronice Acid
Indications:
- Treatment of hyperCa++ of malignancy
- Multiple myeloma
Dose - HyperCa++: 4mg single dose IV over no less than 15min. - MM or metastatic bone lesions: => CrCl > 60: 4mg IV over 15 min Q3-4W => Renal adj
17
Q
Aredia
- Indication
- Dosage
- Avoid
- SEs
A
PAMidronatE
Indication
- HyperCa++ ass w/ malignancy
- Osteolytic ass w/ breast cancer
- Paget’s
Dosage:
- IV 30-90 mg Q3-4W depending on disease state
- Infuse over 2-24H to decrease renal tox
- AVOID IN RENAL FAILURE
SEs
- Fever
- A.fib, HTN, Tachycardia
- Electrolyte depletion
18
Q
Prolia
Xgeva
- MOA
- SEs
A
DENOsumab
- MOA: Human IgG2 monoclonal antibody which inhibits or rather binds to the RANK ligand (RANK-L) and prevents osteoclast formation
SEs
- back, extremity, musculoskeletal pain
- Hypercholesterolemia
- HypoCa++
- Serious infection
- Dermatoglogical rxn: dermatitis, eczema, rashes
- Osteonecrosis of the jaw
19
Q
Prolia
- Indication
- DF
- Dosage
- Storage
- Advice for pt:
A
DENOsumab
- I: Tx of postmenopausal women with osteoporosis at high risk for fracture
- DF: colorless to pale yellow sol’n. Single use prefilled syringe/vial 60mg/mL
- Dosage: SQ once Q6M
- Storage: Refridgerated
=> advice pt to take 1200 Ca++/d and 800-2000 u/d vit D
20
Q
Xgeva
- Indication
- DF
- Dosage
A
DENOsumab
- I: prevention of skeletal-related events in cancer pts with bone metastases from solid tumor
- DF: SC 120mg/1.7mL
- D: SC 120 mg Q4W
21
Q
Miacalcin
Fortical
- MOA
- Indication
- Dose
- Counseling:
- SEs
- Cautions
- Allergic rxn
A
Calitonin
MOA: Hormonal bone reabsorption inhibition
- Inhibits Ca++ resorption, can treat hyperCa++
- Analgesic effect: increase in circulation beta endophins
Indication
- tx of postmenopausal osteoporosis in females > 5 y.rs PMS in conjunction with Ca+ and Vit D
Dose
- One spray QD nasally (200 IU 0.09mL adm in alternative nostril QD.
- DO NOT SHAKE
SEs
- Rhinitis, Epistaxis (Nosebleed), nasal ulcertations, join pain, HA, allergic rxn (salmon)
Cautions
- Allergic to SALMON, preg C
- Need skin testing
- If nasal mucosa ulceration occurs, dc until heal
- MD should perform periodic nasal exam
22
Q
Miacalcin
Fortical
- Pt counseling
Storage
* Miacalcin
* Fortical
Bottle contain/Prime
Shake
A
Calitonin
- Store un-used in fridgerator
- Allow bottle to reach to RT b/4 use
- May be stored at RT: upright position
=> Fortical 30 days
=> MIacalcin 35 days - Each bottle contains at least 14 doses
- Pump should be primed only when bottle is first opened
- DO NOT shake the nasal spray
23
Q
Miacalcin ( Calcium Salmon)
- DF
- Indication
- Dose:
A
- Injection 200 IU/mL IM/SC
- I: tx of Paget’s disease, hyperCa++, and post menopausal osteoporosis
Dose:
- Osteo: 100u IM/SQ QOD
- Paget’s: 100IU IM/SQ QD x 3 weeks
- HyperCa++: 4IU IM/SQ Q12H up to 8iu/kg Q6H
24
Q
Forteo
A
Teriparatide
25
FOrteo
- DF
- How long to tx it
- Class
- Indication
- Dosage
- Exp Date
- Storage
- Caution
- DDI
- SEs
TeripArAtide
- DF: injection 250 mcg/mL - 3mL pen
- Tx: total of 2 year
- Class: Recomb parathyroid hormone
- I: Postmenopausal women & men w/ osteoporosis who are at high risk for fracture
- D: 20 mcg QD SQ into thigh or abdomen
=> 28 dose pen => d/card after 28d even if not empty
=> Stored under refrigerator at 36-46F at all time
Caution
- transient orthostatic hypoTN, increase uric acid level, transient Ca++ increase
DDI
- Inc Ca++ => may lead to dig toxicity
SEs
- Pain
- HA
- Cough
26
Estrogen Replacement Therapy (ERT)
- Indication
- Hx of historectomy
- No Hx of historectomy
- ERT helps for PREVENTION of osteoporosis in WOMEN not effective for tx
- Postmenopausal estrogen replacement is valuable in osteoporosis prevention
NOT FOR TREATMENT
- No hx of historectomy: no need to d/c => put pt on progesterone to protect her uterine
- Hx of historectomy: d/c progesterone
27
ERT
- Warning
- DDI
Estrogen increase the risk of:
- *Endometrial cancer => add additional amt of progestin
- *Breast cancer
- *Clot: MI/stroke/PE/DVT
- HyperCa++
- *Gallbladder disease
- *elevated BP, TG, fluid retention
- May exacerbate endometriosis, migraine
DDI
- Inducers: will decrease effective
=> St. Johns wort, carbamazepine, rifampin
- Inhibitors: Inc effect erythromycin, ketoconazole
28
Ogen
- Indication
Estropiptate
Indication:
- Atrophic vaginitis or kraurosis vulvae
- Menopause, moderate-to-severe vasomotor symptoms
- Female hypogonadism
- Female castration or primary ovarian failure
- Osteoporosis prophylaxis (females):
- Dose 0.75 mg QD
29
Ortho-Est
Estropiptate
- 0.75 mg QD
30
Premarin
Conjugated Estrogen
- 0.3mg QD
31
Activella
- What is the cycle?
- Estrotiol + Norgestimate
| - 6 days cycle: 3 day estrogen, then 3 days estrogen + progesterone: repeat
32
Premphase
| - Cycle
- Medroxyprogesterone + estrogen
- 0.625 mg tab QD on day 1-14
- 0.625/5mg tab on day 15-28
- Re-evaluate after 3-6mo
33
Estradiol Transdermal Patches
- How to use it
- Preferred for whom?
- Place patch to lower abdomen - avoid breast, waistline and areas where sitting would dislodge it
- Patch may be preferred for women w/ high TG and chronic liver diease
34
Estradiol Patches
Menostar
- 1 patch weekly
Climara
- Patch apply QW
Vivelle-Dot
- Apply BIW
Alora
- Patch apply BIW
35
Climara PRO
- Estradiol + Levonorgestrel
| - Apply QWly
36
What is the rec for Men
- 1st: Rec bisphosphonates
- Rec Forteo (Teriparatide) for men at very high fracture risk or those who can't take bisphosphonate
- Prolia (Denosumab): for men at high risk of fractures due to androgen deprivation therapy for prostate cancer
- Discourage using calcitonin: it's less effective
- Suggested saving testosterone replacement for men with low serum levels
37
Binosto
- Form
Alendronate Effervescent
- 70 mg PO QW, strawberry-flavored effervescent tab.
- Dissolve in water to take a buffered sol'n
38
Atelvia
- Administration
- Frequency
Risedronate Delay release => can take w/ FOOD
- 35mg once a WEEK - after breakfast
- Enteric coating
- Still need to remain upright for at least 30 min after dosing to reduce esophageal irritation
13. Osteoporosis
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