Osteoporosis

Question 1

Treatment Overview

Answer 1

Non-pharm measures at all points. !Ca, Vit D!, exercise, no smoking/alcohol, fall prevention.

Question 2

Pharm Treatment recommended for

Answer 2

Post-menopause with Hx of fragility fractures/osteoporosis or post-fracture.
High risk post menopausal women defined by FRAX. T score 1-2.5

Question 3

Prior to treatment initiation

Answer 3

Ensure normal serum calcium and Vit D > 20ng/mL

Question 4

First Line Agents

Answer 4

Oral Bisphosphonates
IV as second line
Third line High Risk (T score less than 2.5): Denosumab
Third line Very High Risk(T score >2.5):Anabolic agents
Anything greater than a 5% change, go to the next level

Question 5

Bisphosphonates

Answer 5

MOA: Inhibit resorption of the bone; increase bone mineral density
ADR: GI Mucosal irritation: Take first thing in the morning, before food/water/other meds. No mineral water. Remain upright for 30-60 min AND until after first food of the day. Otherwise; ulcers and perforation.
Hypocalcemia: Transient and expected
Osteonecrosis of the jaw: Spontaneous after dentist
D/c if stable for 5+ years

Question 6

Alendronate

Answer 6

IND: Osteoporosis, Paget’s dz
MOA: Inhibit resorption of the bone; increase bone mineral density
BOX: n/a
CON: Hypocalcemia, esophagus badness if taken improperly
ADR: Decreased Serum Ca

Question 7

Risendronate

Answer 7

IND: Osteoporosis, slightly less tolerated than Alendronate
MOA: Inhibit resorption of the bone; increase bone mineral density
BOX: n/a
CON: Hypocalcemia and esophagus badness
ADR: HTN, rash, UTI, aches

Question 8

Ibandronate

Answer 8

IND: Post-menopausal female Osteoporosis
MOA: Inhibit resorption of the bone; increase bone mineral density. Not preferred. Doesn’t work for non-vertebral instances
BOX: n/a
CON: Hypocalcemia and able to take properly
ADR: n/a

Question 9

Zoledronic Acid

Answer 9

IND: 2nd line Osteoporosis + oncology + in Osteoporosis in kidney dz
MOA: Inhibit resorption of the bone; increase bone mineral density. MC IV form. Zometa, 4mg IV: oncology dose every 3 months.
Reclast, 5mg IV every year
BOX: n/a
CON: Hypocalcemia
ADR: Edema/hypotension, GI, FEVER, Low K, Mg, Po4

Question 10

Anabolic Agents

Answer 10

PTH/PTH analog: Stimulate bone formation and remodeling.
Teriparatide and Abaloparatide
Limited to 2 years, use antiresorptive agent (bisphosphonate) after d/c

Question 11

Teriparatide

Answer 11

IND: Osteoporosis
MOA: Recombinant PTH
BOX: n/a
CON: n/a
ADR: Hypercalcemia

Question 12

Abaloparotide

Answer 12

IND: Post-menopause Osteoporosis
MOA: PTH analog; stimulates osteoblasts
BOX: Osteosarcomas
CON: n/a
ADR: Increased uric acid, Ab formation, Injection site rxns

Question 13

Romosozumab

Answer 13

IND: Osteoporosis in P-M females, LIMITED to 12 doses (1 year)
MOA: Sclerostin inhibitor; increases bone formation and decreases resorption
BOX: MI, stroke, Cardiovascular death. D/c if present
CON: Uncorrected Hypocalcemia
ADR: Arthralgias

Question 14

Denosumab

Answer 14

IND: Osteoporosis + cancer. More of a last line
MOA: Binds to RANKL to prevent osteoclast formation.
Prolia: 60mg Osteoporosis
Xgeva: 120mg Oncology
BOX: n/a
CON: Hypocalcemia
ADR: Peripheral edema, skin stuff, hypocalcemia/PO4, diarrhea/nausea, anemia, aches

Question 15

Estrogen Receptor Modulators

Answer 15

Anti-resorptive, less effective bisphosphonates. Reserved for people that can’t have bisphosphonates.
Reduces breast cancer risk
Slight increase in thromboembolic events and hot flashes

Question 16

Raloxifene

Answer 16

IND: Osteoporosis, risk reduction for breast cancer
MOA: Estrogen agonist in the bone/antagonist in the breast
BOX: Increase risk of VTE and CVD
CON: Hx of VTE, pregnancy
ADR: Peripheral edema and hot flashes

Question 17

Vitamin D Analogs

Answer 17

IND: HyperPTH
MOA: Binds to and activates the Vit D receptor in kidney, PTH, intestine, and bones. Stimulates absorption/resorption of calcium
BOX: n/a
CON: Hypercalcemia, Vit D toxicity
ADR: Hypercalcemia, GI.
Doxercalciferol: edema, CNS, anemia