33. Osteoporosis & Hormone Therapy Flashcards
Marvin is a 65 year-old male with NYHA Class I heart failure, prostate enlargement, mild cognitive decline and erectile dysfunction. His medications include valsartan, metoprolol extended-release, hydrochlorothiazide, tamsulosin, finasteride and donepezil. Marvin’s testosterone level is within the normal range. He wishes to use sildenafil, but it is not covered by his Medicare plan and he finds the cost per tablet prohibitive. He asks his physician for another option, and the physician suggests testosterone. Select the correct statement:
A. Testosterone can be used concurrently with finasteride.
B. The testosterone will worsen the cognitive decline.
C. The testosterone cannot be used in heart failure.
D. The testosterone will worsen the prostate symptoms.
E. The popular form of testosterone is called Vivelle.
D. Testosterone therapy can be recommended if the patient has low testosterone with a related condition, such as muscle wasting. These are not present in this case. He is not contraindicated for testosterone, however it would worsen his prostate symptoms and counteract the benefit provided by finasteride.
Avoid use of testosterone with androgen blockers such as finasteride and dutasteride.
Testosterone: Boxed warning: secondary exposure to testosterone in children and women, can lead to virilization in children, women and children should avoid contact with any unwashed or unclothed application sites in men using testosterone gel. CI: breast or prostate cancer. Warning: men with BPH treated with androgens are at increased risk for worsening signs and symptoms, increased risk of thromboembolic events (DVT, PE), never apply to breast or genitals. SE: increased appetite, increase SCr, sensitive nipples, acne, gynecomastia, dyslipidemia, edema, increase PSA, increase hepatoxicity, reduced sperm count, sleep apnea.
A patient will be counseled on the AndroGel pump. He is using it for the first time. Which of the following are correct counseling statements? (Select ALL that apply.)
A. Wipe your hands well on a towel after applying the medication.
B. AndroGel can catch fire when wet on the skin; it is flammable until dry.
C. Do not shower, bathe or go swimming until two hours after application.
D. Do not let young children touch the wet skin or go near the medicine pump.
E. The lower strength (1%) can be applied to the abdomen; the 1.62% strength cannot, and never apply any testosterone to the penis or scrotum.
B, C, D, E. Hands must be washed with soap and water after application. AndroGel is flammable until dry. Do not smoke or walk near open flames.
Testosterone: Boxed warning: secondary exposure to testosterone in children and women, can lead to virilization in children, women and children should avoid contact with any unwashed or unclothed application sites in men using testosterone gel. CI: breast or prostate cancer. Warning: men with BPH treated with androgens are at increased risk for worsening signs and symptoms, increased risk of thromboembolic events (DVT, PE), never apply to breast or genitals. SE: increased appetite, increase SCr, sensitive nipples, acne, gynecomastia, dyslipidemia, edema, increase PSA, increase hepatoxicity, reduced sperm count, sleep apnea.
A patient is going to begin alendronate for osteoporosis. Which of the following are possible side effects, or adverse drug reactions, from bisphosphonate therapy? (Select ALL that apply.)
A. Loose stools, diarrhea, or constipation
B. Alopecia
C. Possible risk of jaw necrosis, with higher risk after dental extractions
D. Gastritis, stomach upset, heartburn
E. Bone pain
C, D, E. The risk of esophageal ulceration is reduced by having the patient remain upright for at least 30 minutes after taking the drug (60 minutes with monthly Boniva). The patient should take a full glass of plain water with the medicine to help wash it down. Patients should be aware of the risk of esophageal ulceration and instructed to be seen right away if they develop dysphagia, odynophagia (pain when they swallow food or liquids), retrosternal pain (behind the breastbone) or new or worsening heartburn.
CI: inability to stand or sit upright for at least 30 minutes (60 minutes for Boniva), difficulty swallowing, esophageal stricture, or at high risk for aspiration, hypocalcemia (correct first before giving bisphosphonate).
Warning: atypical femur fracture, esophageal cancer, osteonecrosis of the jaw (ONJ), bone/joint/muscle pain, esophagitis, hypocalcemia must be corrected prior to use, caution with CrCl <35
SE: hypocalcemia, musculoskeletal pain, abdominal pain, dyspepsia, nausea, vomiting, heartburn, esophagitis, skin rash, eye inflammation
Choose the correct statements concerning raloxifene: (Select ALL that apply.)
A. Common adverse effects include hot flashes and leg cramps.
B. Raloxifene is a selective estrogen receptor modulator.
C. Raloxifene has lower clotting risk than estrogen.
D. The brand name of Raloxifene is Exelon.
E. The dose of raloxifene is 60 mg once daily.
A, B, E. The correct dose of raloxifene is 60 mg once daily. Common adverse reactions include hot flashes and leg cramps. Do not choose raloxifene in a post-menopausal woman who wants to reduce hot flashes (or night sweats); it will worsen the problem.
Raloxifene (Evista): SERM (selective estrogen receptor modulator), think estrogen SE such as clots and other cardiovascular complication. SE: hot flashes, peripheral arthralgia, peripheral edema, pregnancy (X), affects INR. Would not recommend in postmenopausal patient who have hot flash.
Choose the correct statements concerning calcitonin nasal spray: (Select ALL that apply.)
A. Calcitonin nasal spray is a first-line agent, but many women do not like the route of administration.
B. Inhale 1 spray in one nostril daily.
C. Calcitonin nasal spray can cause nasal irritation.
D. Instruct the patient to alternate which nostril they use (left side one day, right side the next).
E. The brand name is Mupirocin.
B, C, D. Calcitonin (Miacalcin or Fortical) does not work well and is used rarely. One spray in one nostril daily provides the 200 IU dose. Alternate nostril: left side one day, right side the next day.
Calcitonin (Miacalcin, Fortical): CI in allergy to salmon calcitonin. Use one spray in one nostril daily and then alternate every day. Calcitonin is used less commonly due to poor bone mineral density improvement and possible cancer risk.
A patient asks the pharmacist if bio-identical hormone replacement therapy is a safer option than using the drugs in products such as Premarin. Choose the safest response:
A. Bio-identical hormone therapy is safer than using “horse” estrogens such as Premarin.
B. Bio-identical hormone therapy is more dangerous than “horse” estrogen.
C. These products may be a safer option, but we really do not know at this time. It’s safest to assume that the health risks are similar to the estrogens that have been studied until more information is available.
D. Bio-identical hormone therapy is only used for males, such as with Testim.
E. Bio-identical hormone therapy is only used for pre-menopausal women who are trying to become pregnant.
C. The term “bioidentical” generally refers to compounds that have the same chemical and molecular structure as hormones that are produced in the human body. Many woman, physicians and compounding pharmacists believe that BHRT is safer, but keep in mind that there are no well designed studies to confirm risk or benefit.
Select the correct statements concerning Brisdelle: (Select ALL that apply.)
A. It contains paroxetine.
B. It is indicated for hot flashes associated with menopause.
C. It can cause hypernatremia; sodium should be monitored during initiation of therapy.
D. It can be used safely with warfarin.
E. It cannot be used with tamoxifen.
A, B, E. This is a formulation of paroxetine; SSRIs can cause hyponatremia (not commonly, but it happens). SSRIs increase bleeding risk when given with anticoagulants. It cannot be used with tamoxifen because paroxetine is a CYP 450 2D6 inhibitor and would block conversion to active tamoxifen. All of the side effect issues from paroxetine in other formulations apply here. Of notable difference, Brisdelle is Pregnancy Category X.
A teenager eats a poor diet (primarily carbohydrates and fruit) and has heavy menstrual cycles. The pharmacist will recommend calcium sources. Which of the following statements is correct?
A. She does not need calcium supplements at this age.
B. When recommending calcium to a teenager the pharmacist should recommend senna 2 tablets QHS taken concurrently.
C. Calcium requires vitamin E for absorption.
D. Calcium citrate is about twice as dense in elemental calcium than calcium carbonate.
E. If she takes two calcium supplements, they should be taken at different meals.
E. She must have calcium supplements if she does not receive adequate calcium in the diet. Children of all age groups should be consuming the calcium they require, preferably as milk or other dairy products and other foods, and then drink primarily water. Fruit juice and soda drinks should be limited to occasional use. Fruit is healthier when eating the fruit. Calcium does not cause constipation in usual doses, however, for patients who take supplements in large doses (for phosphate binders) this is more likely to be a problem (or the patient may be constipated for other reasons).
What is the definition of menopause?
A. No menstrual period for 60 consecutive days.
B. No menstrual period for 120 consecutive days.
C. No menstrual period for 6 consecutive months.
D. No menstrual period for 12 consecutive months.
E. No menstrual period for 24 consecutive months.
D. The period prior to menopause is the perimenopause. During this time, when the estrogen and progestin levels have declined, some women are symptomatic and may desire prescription treatment.
Perimenopause is when periods become irregular and menopause is 12 consecutive months or more without a period.
Marvin is a 65 year-old male who uses valsartan, metoprolol extended-release, hydrochlorothiazide, tamsulosin, finasteride and donepezil. He recently began therapy with AndroGel. Marvin’s four-year old grandson Evan came to visit. It was quite a surprise to Evan’s mother to find that during the visit Evan’s testicles grew at an alarming rate, and pubic hair became visible. What is the likely cause of the premature virilization?
A. Evan played with his grandfather’s testosterone and got it on his hands.
B. Evan ate his grandfather’s testosterone.
C. Evan swallowed the angiotensin receptor blocker.
D. Evan swallowed the finasteride.
E. Evan is maturing at a typical age.
A. Reports of virilization of children due to testosterone exposure are serious and proper counseling is required. Testosterone is not available orally; he may have eaten it but the effect is from touching it. Most cases are due to children just touching Dad’s or Grandpa’s skin when wet, since the shirt is left off until the skin is dry.
Testosterone: Boxed warning: secondary exposure to testosterone in children and women, can lead to virilization in children, women and children should avoid contact with any unwashed or unclothed application sites in men using testosterone gel. CI: breast or prostate cancer. Warning: men with BPH treated with androgens are at increased risk for worsening signs and symptoms, increased risk of thromboembolic events (DVT, PE), never apply to breast or genitals. SE: increased appetite, increase SCr, sensitive nipples, acne, gynecomastia, dyslipidemia, edema, increase PSA, increase hepatoxicity, reduced sperm count, sleep apnea.
Counseling on the use of teriparatide should include the following points: (Select ALL that apply.)
A. There may be a small risk of bone cancer with the use of this medicine.
B. Each injection pen lasts 60 days.
C. Keep the pens frozen until use; refrigerate the pen in use.
D. If you have bone pain you should let your doctor know right away.
E. The brand name of this medicine is Forteo.
A, D, E. Teriparatide comes in a prefilled SC injection pen that lasts 28 days. Each injection provides the 20 mcg dose. The pens are refrigerated. And, most injectable medicines that are fixed doses are designed to last about a month. After 28 days, theForteo pen should be discarded even if some medicine remains.
Teriparatide (Forteo): recombinant human PTH, stimulates new bone formation and depresses osteoclast activity. SQ daily injection for patients at high risk for fracture. Boxed warning: osteosarcoma (do not exceed 2 years of use and inform doctor if you develop bone/joint pain). Warnings: orthostatic hypotension with initial dose, caution in history of urinary stones. SE: hypercalcemia, bone pain, nausea, orthostasis/dizziness, increase HR. Each pen comes with 28 day dose and must be refrigerated (discard after 28 days).
Mike is using the Androderm patch. Counseling points should include: (Select ALL that apply.)
A. Apply each evening.
B. You can apply the patch on your back, abdomen (lower stomach), on the thighs or the upper parts of your arms.
C. Do not apply more than one patch.
D. If your skin is irritated apply over the counter hydrocortisone cream to the skin right before you apply the patch.
E. Remove during an MRI or the skin under the patch will burn.
A, B, C, E. Many patches burn the skin if not remove prior to an MRI. Do not apply to the testicles; apply to the back, abdomen, thighs or upper arms, each evening between 8:00PM and midnight. The patch will not stick to cream or ointment. It can be applied at a different time, but oily skin does not stick to bandages or patches.
Testosterone: Boxed warning: secondary exposure to testosterone in children and women, can lead to virilization in children, women and children should avoid contact with any unwashed or unclothed application sites in men using testosterone gel. CI: breast or prostate cancer. Warning: men with BPH treated with androgens are at increased risk for worsening signs and symptoms, increased risk of thromboembolic events (DVT, PE), never apply to breast or genitals. SE: increased appetite, increase SCr, sensitive nipples, acne, gynecomastia, dyslipidemia, edema, increase PSA, increase hepatoxicity, reduced sperm count, sleep apnea.
Select the statements concerning bone fractures and causes of osteoporosis. (Select ALL that apply.)
A. Osteoclasts build bone and osteoblasts break down bone.
B. Hip fracture is generally an “older” age fracture, as hip bone is dense and loses density slower than the spine.
C. Vertebral (spine) fractures are the most common type of osteoporotic fracture.
D. Men are at risk for osteoporosis if they are using certain medications, such as systemic steroids, drugs for prostate cancer or if they have conditions that increase the risk of poor bone health, such as rheumatoid arthritis and lupus.
E. If men sustain a hip fracture, they have a higher mortality rate at 12 months than women.
B, C, D, E. It’s the opposite: osteoblasts build bone, osteoclasts break down bone.
A patient gave the pharmacist a prescription for Premarin 0.625 mg daily. Which of the following is an appropriate generic substitution for Premarin?
A. Conjugated equine estrogens
B. Ethinyl estradiol, conjugated
C. Medroxyprogesterone acetate
D. Estriol, synthetic
E. Drospirenone
A. The generic name for Premarin is conjugated equine estrogens.
Intravaginal (topical) products are preferred for patients who have vaginal symptoms only such as vaginal dryness and painful intercourse. Treats LOCAL symptoms
Estrogen cream: conjugated estrogens (Premarin), estradiol (Estrace, Estrasorb)
Vaginal estrogen ring (Estring): releases estrogen for 3 months
Vaginal estradiol tablet (Vagifem): inserted into vagina twice per week
Estradiol patch (Vivelle Dot): applied twice a week and rotate sites.
Nancy is a frail 73 year-old female. Nancy has been using alendronate for severe osteoporosis for the past 11 months. However, she has recently had a fall and fractured her hip. The physician has discontinued alendronate and started teriparatide. Counsel the patient on the use of teriparatide: (Select ALL that apply.)
A. The medicine is delivered with a very small needle into your abdomen or thigh.
B. The brand name is Fentora.
C. You should not take this medicine for more than three years.
D. SIt down in a comfortable “easy” chair or on the side of your bed when you inject so you can lie down if you get dizzy without having to stand up.
E. This medication will reduce your chance of having a bone fracture if you take it each day.
A, D, E. Teriparatide [rDNA origin] injection (Forteo) is used for patients who are at very high risk for fracture, or who have already had a fracture due to osteoporosis. It is used for a maximum of two years.
Teriparatide (Forteo): recombinant human PTH, stimulates new bone formation and depresses osteoclast activity. SQ daily injection for patients at high risk for fracture. Boxed warning: osteosarcoma (do not exceed 2 years of use and inform doctor if you develop bone/joint pain). Warnings: orthostatic hypotension with initial dose, caution in history of urinary stones. SE: hypercalcemia, bone pain, nausea, orthostasis/dizziness, increase HR. Each pen comes with 28 day dose and must be refrigerated (discard after 28 days).
A patient has been using calcium citrate 315 mg elemental calcium/tablet for many years. She takes two tablets with breakfast and two tablets at bedtime. She does not consume dairy products or much in the way of vegetables. She had a stroke recently and has been choking on some of her medications. Her daughter has come into the pharmacy to ask if her mother needs to take these “horse pills.” She is wondering if calcium can be taken in a different formulation that is easier to swallow. Which of the following statements are correct: (Select ALL that apply.)
A. She can purchase calcium in chewable formulations.
B. Calcium carbonate has a higher percentage of calcium; she can use smaller tablets.
C. She should not be using calcium supplements.
D. The calcium she is using requires acid in her stomach to be absorbed.
E. She is already using the densest (smallest) formulation of calcium that is available over-the-counter.
A, B. Calcium comes in chewable formulations. Make sure to brush teeth afterwards. Calcium carbonate is taken with meals. Calcium citrate has “acid-independent” absorption and can be taken at any time. She should likely be using calcium with vitamin D.
The Fracture Assessment Tool (FRAX) is used to assess the need for prescription drug therapy in patients with low bone density. Which of the following statements apply to this tool? (Select ALL that apply.)
A. This tool is a computer program where the clinician enters various risk factors for an individual patient.
B. The tool is not well-validated and not recommended by ACOG.
C. Previous fragility fracture is an important determinant of the need for medication.
D. It is not necessary to use this type of tool in most patients since it is well-established that drugs such as alendronate are safe and useful in most patients.
E. Steroid use of 5 mg greater for more than 3 months is an important determinant in poor bone strength as steroid use depletes bone rapidly; however, this does not apply to intraarticular and topical steroids.
A, C, E.
In Margot’s lumbar spine the lowest T-score measurement is -1.8. In the right trochanter the T-score is -0.9 and the left trochanter the T-score is -1.1. She has not had any fractures as an adult. Margot has multiple sclerosis and takes the following medications daily: Copaxone, Zanaflex, Paxil, Detrol and Provigil. Which of the following statements are correct? (Select ALL that apply.)
A. Margot has risk for falling due to her medical condition.
B. She should begin Prolia therapy.
C. She should begin Forteo therapy.
D. Margot has osteoporosis.
E. Margot has risk for falling due to her medicines.
A, E. Margot has osteopenia, based on the T-scores given. She is not a candidate for the high-risk agents, based on her bone density readings and lack of fracture history.
Need a T-score of -2.5 or below to be considered osteoporosis, or history of fracture.
The use of testosterone can cause which of the following effects?
A. Decreased creatinine
B. Decreased cholesterol
C. Increased appetite
D. Improved acne
E. Increased sperm count
C. Testosterone use can increase creatinine, appetite, cholesterol, and cause sensitive nipples and acne. It can cause hepatotoxicity. It is contraindicated in breast or prostate cancer.
Testosterone: Boxed warning: secondary exposure to testosterone in children and women, can lead to virilization in children, women and children should avoid contact with any unwashed or unclothed application sites in men using testosterone gel. CI: breast or prostate cancer. Warning: men with BPH treated with androgens are at increased risk for worsening signs and symptoms, increased risk of thromboembolic events (DVT, PE), never apply to breast or genitals. SE: increased appetite, increase SCr, sensitive nipples, acne, gynecomastia, dyslipidemia, edema, increase PSA, increase hepatoxicity, reduced sperm count, sleep apnea.
What medication might be used in the perimenopause to help a female who experiences uncomfortable vasomotor symptoms? (Select ALL that apply.)
A. Estrogen prescription products
B. Estradiol topical therapy, prepared by a compounding pharmacist
C. Vivelle Dot
D. Premarin
E. Evista
A, B, C, D. Women who are symptomatic may get estrogen, and if they have a uterus, they should receive a progestin in order to prevent endometrial cancer. In the early stage of the perimenopause, when bleeding is heavier and pregnancy risk is present, a woman may receive birth control pills to help reduce the bleeding and to provide pregnancy protection. They also offer some help with symptoms, but later on the symptoms may warrant the use of hormone therapy (HT), which contains higher doses of estrogen.
Raloxifene (Evista): SERM (selective estrogen receptor modulator), think estrogen SE such as clots and other cardiovascular complication. SE: hot flashes, peripheral arthralgia, peripheral edema, pregnancy (X), affects INR. Would not recommend in postmenopausal patient who have hot flash.
Estradiol patch (Vivelle Dot): applied twice a week and rotate sites.
Estrogen cream: conjugated estrogens (Premarin), estradiol (Estrace, Estrasorb)
Cassidy is a 66 year-old female who frequents your pharmacy. The patient has many medical conditions, including hypertension, epilepsy and stress incontinence. She had a myocardial infarction this past spring. During the hospital stay, she was diagnosed with heart failure. Her current prescriptions include Coreg, Lasix, Klor-Con, Catapres TTS and phenytoin. Which of the following medications increase the risk for low bone density? (Select ALL that apply.)
A. Catapres TTS
B. Furosemide
C. Phenytoin
D. Klor-Con
E. Coreg
B, C. Medications with high risk for decreasing bone density include: heparin, loop diuretics, such as furosemide (which waste calcium), phenytoin, anastrozole (Arimidex) and other aromatase inhibitors used for breast cancer and leuprolide (Lupron) and other androgen blockers used for prostate cancer.
Drugs that lower bone density: steroids, depot medroxyprogesterone, anticonvulsants (carbamazepine, fosphenytoin, phenobarbital, phenytoin, primidone), heparin, lithium, excess thyroid hormone, loop diuretic, aromatase inhibitors used for breast cancer, nafarelin (Synarel) for endometriosis, androgen blockers used for prostate cancer, proton pump inhibitors used chronically because they decrease calcium absorption (need acidity for Ca for absorption), thiazolidinediiones (pioglitazone, rosiglitazone), SSRIs
Which of the following are common side effects of the bisphosphonates? (Select ALL that apply.)
A. Joint pain
B. Back pain
C. Stomach upset, nausea, heartburn
D. Dizziness
E. Pancreatitis
A, B, C. All the bisphosphonates can cause esophageal ulceration, and GI upset and burning. The bisphosphonates are very irritating to the GI tract and cannot be crushed or chewed. Patients can experience bone pain with these agents, and joint aches.
Bisphosphonates
CI: inability to stand or sit upright for at least 30 minutes (60 minutes for Boniva), difficulty swallowing, esophageal stricture, or at high risk for aspiration, hypocalcemia (correct first before giving bisphosphonate).
Warning: atypical femur fracture, esophageal cancer, osteonecrosis of the jaw (ONJ), bone/joint/muscle pain, esophagitis, hypocalcemia must be corrected prior to use, caution with CrCl <35
SE: hypocalcemia, musculoskeletal pain, abdominal pain, dyspepsia, nausea, vomiting, heartburn, esophagitis, skin rash, eye inflammation
Which test is considered the gold-standard for identifying low bone density?
A. BMP
B. DEXA
C. MRI
D. Ultrasound
E. CAT scan
B. A bone scan is performed by a dual energy x-ray absorptiometry (DEXA, or DXA) scan. The results are reported for several high-risk locations, including hips and the lower (lumbar) vertebrae.
Gold standard to diagnose osteoporosis is bone scan of hip and spine called DEXA or DXA machine.
A woman suffers from severe hot flashes and night sweats. She has no cardiovascular or breast cancer risk and wishes to use the most effective therapy available to treat these vasomotor symptoms of menopause. Which of the following represents the most effective therapy for this patient?
A. Medroxyprogesterone
B. Black cohosh
C. Estrogen
D. Soy
E. Yam
C. Medroxyprogesterone is a progestin; she may need a progestin if she uses estrogen (if she has a uterus, to protect her from estrogen-induced endometrial cancer). However, the progestin is not providing the benefit; it’s the estrogen. Natural products may be helpful to some women, but are not very effective therapy. However, some women find them useful.
What is the mechanism of action of Brisdelle?
A. Serotonin and norepinephrine reuptake inhibitor
B. Dopamine type 2 receptor blocker
C. Adrenergic neurotransmitter
D. Selective serotonin reuptake inhibitor
E. Monoamine oxidase inhibitor
D. Brisdelle is a new formulation of paroxetine indicated for treatment of hot flashes. It might be useful for women who are not candidates for estrogen, but cannot be used in women who use tamoxifen or are on anticoagulants, such as warfarin.
A patient is asking about raloxifene. Which of the following statements are correct? (Select ALL that apply.)
A. The brand name of raloxifene is Prometrium.
B. Raloxifene is used primarily in women afraid of getting breast cancer.
C. Raloxifene reduces hot flashes.
D. Raloxifene increases bone density to a lesser degree than the bisphosphonates or teriparatide.
E. Raloxifene has a lower clotting risk than estrogen.
C, D. Raloxifene is used in women afraid of getting breast cancer, or in women who had breast cancer and are attempting to prevent recurrence (or cancer occurrence in the contralateral breast).
Raloxifene (Evista): SERM (selective estrogen receptor modulator), think estrogen SE such as clots and other cardiovascular complication. SE: hot flashes, peripheral arthralgia, peripheral edema, pregnancy (X), affects INR. Would not recommend in postmenopausal patient who have hot flash.
A 73 year-old woman has a T-score of -4.3 in her right hip, -4.7 in her left hip and has had several vertebral fractures in her lumbar spine. Her only known medical conditions are osteoporosis and hypertension. She has never had any surgeries. This woman may be a candidate for the following therapy: (Select ALL that apply.)
A. Prolia
B. Estrogen, such as in Premarin, taken with Provera
C. Forteo
D. Teriparatide
E. Denosumab
A, C, D, E. Denosumab (Prolia) and teriparatide (Forteo) may both be useful in this very high-risk patient. Due to her age she is not a reasonable candidate for estrogen.
Teriparatide (Forteo): recombinant human PTH, stimulates new bone formation and depresses osteoclast activity. SQ daily injection for patients at high risk for fracture. Boxed warning: osteosarcoma (do not exceed 2 years of use and inform doctor if you develop bone/joint pain). Warnings: orthostatic hypotension with initial dose, caution in history of urinary stones. SE: hypercalcemia, bone pain, nausea, orthostasis/dizziness, increase HR. Each pen comes with 28 day dose and must be refrigerated (discard after 28 days)
Denosumab (Prolia, Xgeva): monoclonal atnibody that binds to RANKL and prevents interaction between RANKL and RANK (a receptor on osteoclasts), preventing osteoclast formation. SQ injection every 6 months in MD’s office. CI: hypocalcemia. Warning: osteonecrosis of the jaw, atypical femur fractures, serious infections, dermatitis, bone/muscle/joint pain. SE: back pain, limp pain, eczema, rash, hypocalcemia, increased serum cholesterol, pregnancy (X).
