Chapter 49: Osteoporosis, Menopause & Testosterone Use Flashcards by Emily Jansen

Which medications can cause osteoporosis

Anticonvulsants
Aromatase inhibitors
Depo-Provera
GnRH agonists
Lithium
PPIs
Steroids (>/= 5 mg daily of prednisone or prednisone equivalent for >/= 3 months)
Thyroid hormones
Others (heparin, loops, SSRIs, TZDs)

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What is the gold standard to measure BMD and diagnose osteoporosis

DEXA scan

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Who should have BMD measured

All women >/= 65 years & men >/= 70 years

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What is a T-score

compares the patient’s measured BMD to the average peak BMD of a healthy, young, white adult of the same sex

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A T-score at or above __ correlates with stronger (denser) bones

-1

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a T score -1 to -2.4 indicated

osteopenia

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A T-score ≤ ___ correlates with osteoporosis

-2.5

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What is the FRAX tool

estimates the risk of osteoporotic fracture in the next 10 years

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Recommended daily intake of calcium for most adults

1,000-1200 mg elemental Ca

Do not exceed 500-600 mg of elemental Ca per dose

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Calcium carbonate has __% elemental Ca & calcium citrate has __% of elemental Ca

40%
21%

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Which form of calcium is acid-dependent

Carbonate

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Which form of calcium must be taken with food

Carbonate

think of the word CARB = food

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Vitamin D deficiency is defined as < ___ ng/mL

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Vitamin D deficiency should be treated with

cholecalciferol (D3) or ergocalciferol (D2) dosed daily (5,000-7,000 IU) or weekly (50,000 IU)

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SE of calcium supplements

constipation

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Calcium carbonate should NOT be taken with which drug class

PPIs (because it is acid-dependent)

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Which drugs are approved for PREVENTION of osteoporosis

Bisphosphonates (except IV ibandronate); (1st line)
Raloxifene and Duavee

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Which drugs are approved for TREATMENT of osteoporosis

Bisphosphonates (1st line)
Denosumab
Teriparatide
Calcitonin

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Counseling for bisphosphonate administration

must stay upright for 30 min and drink 6-8 oz of plain water

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bisphosphonate SE

esophagitis, hypocalcemia, GI effects (dyspepsia, dysphagia, heartburn, N/V)
RARE: atypical femur fractures, osteonecrosis of the jaw

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Treatment duration with bisphosphonates in patients with low risk of fracture

3-5 years (this is because of the risk of femur fracture and ONJ)

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Denosumab is given via what administration and how often

SC every 6 months

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Denosumab SE/warnings

hypocalcemia, ONJ, atypical femur fractures

HTN, fatigue, edema, dyspnea, HA, NVD, ↓ PO4

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Which drugs are recommended for very high risk patients only (e.g., hx of severe vertebral fractures)

Teriperatide & abaloparatide

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How often are Teriperatide & abaloparatide given and via what route

SC daily

Teriperatide & abaloparatide SE

hypercalcemia, arthralgias, leg cramps, nausea, orthostasis/dizziness

What drugs are alternatives to bisphosphonates if high risk of vertebral fractures

Raloxifene, Bazedoxifene/Estrogens (Duavee)

Raloxifene can be used if

low risk of VTE or high risk of breast cancer

Bazedoxifene/Estrogens can be used in women with ____ for prevention of osteoporosis

an intact uterus

Raloxifene & Bazedoxifene/Estrogens SE

increased risk of breast cancer

Bisphosphonate MOA

inhibit osteoclast activity and bone resorption

All Bisphosphonates reduce vertebral and hip fracture risk, except ____ which only reduces vertebral fractures

ibandronate

Alendronate brand name

Fosamax

ibandronate brand name

Boniva

zolendronic acid bran

Reclast | Zometa for hypercalcemia of malignancy

Ibandronate is given via which route and how often

Oral monthly or IV every 3 months

Zoledronic acid is given via which route and how often

Tx: IV once yearly

Bisphosphonates CI

Hypocalcemia, inability to stand or sit upright for at least 30 min

Bisphosphonates should be separated from ___ for how many hours

calcium, antacids, iron and Mg | 2 hrs

Atelvia DR (risedronate) should not be used with which drug classes

H2RA and PPIs (requires an acidic-gut)

Which drugs are preferred for osteoporosis if pt has esophagitis

IV bisphosphonates

Raloxifene drug class

SERM; ↓ bone resorption

Raloxifene & Duavee CI

Raloxifene: hx of VTE, pregnancy Duavee: breast CA hx, uterine bleeding, hx VTE

Duavee BW

Endometrial CA, ↑ risk of DVT and stroke in post menopausal women

Calcitonin MOA

inhibits bone resorption by osteoclasts

Calcitonin brand name

Miacalcin

Calcitonin formulations

Injection, nasal spray

Calcitonin is used for

treatment of osteoporosis in women > 5 years postmenopause

Calcitonin warnings

Hypocalcemia, ↑ risk of malignancy with long-term use, hypersensitivity reactions to salmon-derived products

Teriparatide and abaloparatide MOA

analogs of human PTH, which stimulates osteoblast activity and increases bone formation

Teriparatide and abaloparatide warnings

Osteosarcoma (bone cancer) hypercalcemia | b/c you're increasing bone formation, i.e. uncontrolled growth of bone cells

Teriparatide and abaloparatide must be kept ____ Teriperatide (Forteo) must be ___

refrigerated protected from light

Denosumab MOA

binds to RANKL and blocks interaction with RANK to prevent osteoclast formation

When is denosumab used

When there is a high risk for fracture

Denosumab brand name | brand name for hypercalcemia of malignancy

Prolia | Xgeva

Denosumab CI

Hypocalcemia, pregnancy

denosumab warnings

ONJ, atypical femur fractures, hypocalcemia

romosozumab indication

postmenopausal women with hx of osteoporotic fractures or multiple risk factors

What is the most effective treatment for vasomotor symptoms

Estrogen | It causes a decrease in LH and more stable temperature control

Women with a uterus should use estrogen in combination with ___ for vasomotor sx | Why?

progesterone | alone increases risk for endometrial cancer

What are the criteria to meet for use or hormone therapy

- Healthy women within 10 years of menopause, ≤ 60 years of age and no CI to use - Patients with RF (age, time since menopause, risk of blood clots, heart disease, stroke and breast cancer) should use non-hormonal treatments (SSRIs, SNRIs, gabapentin, or pregabalin)

17-beta-estradiol brand names

Estrace, Estring, Vagifem

Estradiol TD patch brand names

Alora, Climara, Vivelle-Dot

Conjugated Eqiune Estrogens brand name

Premarin

Medroxyprogesterone brand name (tablet)

Provera

Micronized progesterone brand name

Prometrium

Vivelle-Dot and Alora are applied ___x/week Climara is applied __x/week

2 1

Natural products to use in menopause

Black cohosh, evening primrose oil, red clover, soy

Paroxetine (Brisdelle) should not be used with which drugs

Warfarin or tamoxifen | 2D6 inhibitor - blocks effect of tamoxifen (prodrug) ## Footnote SSRIs increase bleeding risk

Ospemifene (Osphena) indication

oral estrogen agonist/antagonist indicated for dyspareunia (painful intercourse)

Testosterone BW

secondary exposure to testosterone in children can cause early virilization

Testosterone SE

↑ appetite, acne, edema, hepatotoxicity, reduced sperm count Androderm: skin irritation Natesto (gel): nasal irritation

Testosterone gels should be applied when

same time every morning

Androderm should be removed before ___

MRI

testosterone increase ___ (lab value)

hematocrit | can increase clotting risk