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

New guideline rec bone density testing for: - Women - Men Earlier testing rec for:

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

What is: - Bone mineral density (BMD)? - Dexa?

- 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

Evista - Class - MOA - SEs

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

Evista - DDI - Pt counseling/CI

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

Bisphosphonates - Drugs in this class

- 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

Peridex - Counsel pt on use of 0.12% chlorhexidine rinse - SE

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

Fosamax - Indication - Frequency

Alendronate PO & sol'n Dose - Postmenopausal osteoporosis prevention - Postmenopausal osteoporosis treatment - Glucocorticoid induced osteoporosis - Frequency QD, QW

Actonel - Indication - Frequency

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

Boniva - Indication - Frequency PO IV - CI

Ibandronate Tab/IV - I: Treatment and Prevention of postmenopausal osteoporosis Frequency: - PO: QD, or QM - IV: 3mg IV Q3M CI: HypoCa++

Reclast - Indication - Dosage - SEs - Avoid - Counseling

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

Zometa - Indication - Dose - Renal dose adj: Y/N

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 ```

Drugs Flashcards by Thuy Nguyen

How to prevent

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

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New guideline rec bone density testing for:

Women
Men

Earlier testing rec for:

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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What is:

Bone mineral density (BMD)?
Dexa?

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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How do we know that medications such as Bisphosphonate are working

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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What meds can cause osteoporosis

Corticorsteroids
Antiepileptic
Aromatase inhibitor: Anastrazole, letrozole, exemestane
Gonadotropin-Releasing Hormones

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Evista

Class
MOA
SEs

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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Evista

DDI
Pt counseling/CI

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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Bisphosphonates

Drugs in this class

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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BisphOsphonates

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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BisphOsphonates

- Pt counseling
   Administration when
   Stay up right
   Supplement
   Exercise 
   Contact MD

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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Peridex

Counsel pt on use of 0.12% chlorhexidine rinse
SE

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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Fosamax

Indication
Frequency

Alendronate PO & sol’n

Dose

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

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Actonel

Indication
Frequency

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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Boniva

Indication
Frequency
- PO
- IV
CI

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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Reclast

Indication
Dosage
SEs
Avoid
Counseling

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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Zometa

Indication
Dose
Renal dose adj: Y/N

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

Aredia

Indication
Dosage
Avoid
SEs

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

Prolia
Xgeva

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

Prolia

Indication
DF
Dosage
Storage
Advice for pt:

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

Xgeva

Indication
DF
Dosage

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

Miacalcin
Fortical

MOA
Indication
Dose
- Counseling:
SEs
Cautions
- Allergic rxn

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

Miacalcin
Fortical

- Pt counseling
  Storage
     * Miacalcin
     * Fortical
  Bottle contain/Prime
  Shake

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

Miacalcin ( Calcium Salmon)

DF
Indication
Dose:

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

Forteo

Teriparatide

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

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

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

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

Ortho-Est

Estropiptate - 0.75 mg QD

Premarin

Conjugated Estrogen - 0.3mg QD

Activella - What is the cycle?

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

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

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

Estradiol Patches

Menostar - 1 patch weekly Climara - Patch apply QW Vivelle-Dot - Apply BIW Alora - Patch apply BIW

Climara PRO

- Estradiol + Levonorgestrel | - Apply QWly

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

Binosto - Form

Alendronate Effervescent - 70 mg PO QW, strawberry-flavored effervescent tab. - Dissolve in water to take a buffered sol'n

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