Chapter 49: Osteoporosis, Menopause & Testosterone Use Flashcards
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)
What is the gold standard to measure BMD and diagnose osteoporosis
DEXA scan
Who should have BMD measured
All women >/= 65 years
& men >/= 70 years
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
A T-score at or above __ correlates with stronger (denser) bones
-1
A T-score = ___ correlates with osteoporosis
-2.5
What is the FRAX tool
estimates the risk of osteoporotic fracture in the next 10 years
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
Calcium carbonate has __% elemental Ca & calcium citrate has __% of elemental Ca
40%
21%
Which form of calcium is acid-dependent
Carbonate
Which form of calcium must be taken with food
Carbonate
think of the word CARB = food
Calcium deficiency is defined as < ___ ng/mL
30
Vitamin deficiency should be treated with
cholecalciferol (D3) or ergocalciferol (D2)
dosed daily (5,000-7,000 IU) or weekly (50,000 IU)
SE of calcium supplements
constipation
Calcium carbonate should NOT be taken with which drug class
PPIs (because it is acid-dependent)
Which drugs are approved for PREVENTION of osteoporosis
Bisphosphonates (except IV ibandronate); (1st line)
Raloxifene and Duavee
Which drugs are approved for TREATMENT of osteoporosis
Bisphosphonates (1st line)
denosumab
teriparatide
calcitonin
Counseling for bisphosphonate administration
must stay upright for 30 min and drink 6-8 oz of plain water
bisphosphonate SE
esophagitis
hypocalcemia
GI effects (dyspepsia, dysphagia, heartburn, N/V)
RARE: atypical femur fractures, osteonecrosis of the jaw
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)
Denosumab is given via what administration and how often
SC every 6 months
Denosumab SE/warnings
hypocalcemia, ONJ, atypical femur fractures
HTN, fatigue, edema, dyspnea, HA, NVD, ↓ PO4
Which drugs are recommended for very high risk patients only (e.g., hx of severe vertebral fractures)
Teriperatide & abaloparatide
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
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 is given via which route and how often
IV every 3 months
Zoledronic acid is given via which route and how often
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
VTE, pregnancy
-Duavee: breast CA, uterine bleeding
Duavee BW
Endometrial CA, ↑ risk of DVT and stroke
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 BW
Osteosarcoma (bone cancer)
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
Prolia
Denosumab CI
Hypocalcemia, pregnancy
What is the most effective treatment for vasomotor symptoms
Estrogen
Women with a uterus should use estrogen in combination with ___ for vasomotor sx
progesterone
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
- 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)
Estradiol TD patch brand names
Alora, Climara, Vivelle-Dot
CEE brand name
Premarin
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
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
