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13. Osteoporosis > Drugs > Flashcards

Drugs Flashcards

1
Q

How to prevent

A
  • Consume adequate Ca++ and Vit D
  • Regular weight-bearing exercises
  • Reduce the risk factors for osteoporosis (smoking, coffee)
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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
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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
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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
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5
Q

What meds can cause osteoporosis

A
  • Corticorsteroids
  • Antiepileptic
  • Aromatase inhibitor: Anastrazole, letrozole, exemestane
  • Gonadotropin-Releasing Hormones
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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
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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
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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
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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
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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
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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
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12
Q

Fosamax

  • Indication
  • Frequency
A

Alendronate PO & sol’n

Dose

  • Postmenopausal osteoporosis prevention
  • Postmenopausal osteoporosis treatment
  • Glucocorticoid induced osteoporosis
  • Frequency QD, QW
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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

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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++

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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

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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
Q

FOrteo

  • DF
  • How long to tx it
  • Class
  • Indication
  • Dosage
  • Exp Date
  • Storage
  • Caution
  • DDI
  • SEs
A

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
Q

Estrogen Replacement Therapy (ERT)

  • Indication
  • Hx of historectomy
  • No Hx of historectomy
A
  • 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
Q

ERT

  • Warning
  • DDI
A

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
Q

Ogen

  • Indication
A

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
Q

Ortho-Est

A

Estropiptate

  • 0.75 mg QD
30
Q

Premarin

A

Conjugated Estrogen

  • 0.3mg QD
31
Q

Activella

  • What is the cycle?
A
  • Estrotiol + Norgestimate

- 6 days cycle: 3 day estrogen, then 3 days estrogen + progesterone: repeat

32
Q

Premphase

- Cycle

A
  • 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
Q

Estradiol Transdermal Patches

  • How to use it
  • Preferred for whom?
A
  • 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
Q

Estradiol Patches

A

Menostar
- 1 patch weekly

Climara
- Patch apply QW

Vivelle-Dot
- Apply BIW

Alora
- Patch apply BIW

35
Q

Climara PRO

A
  • Estradiol + Levonorgestrel

- Apply QWly

36
Q

What is the rec for Men

A
  • 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
Q

Binosto

  • Form
A

Alendronate Effervescent

  • 70 mg PO QW, strawberry-flavored effervescent tab.
  • Dissolve in water to take a buffered sol’n
38
Q

Atelvia

  • Administration
  • Frequency
A

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 (1 decks)

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