Osteoporosis and Hormone therapy Flashcards
Risk factors for low bone density
Genetics: most common in Caucasians and Asian American women
Advanced age, low bone mineral density, previous fracture, >two alcoholic drinks per day, steroid use greater than three months, bodyweight < 127 pounds or low BMI, decline in estrogen, RA and lupus, low physical activity, inadequate nutrition, Low intake of calcium and vitamin D, smoking
Diagnosis and definitions
Osteoporosis is defined by a T-score s age, sex, BMI, previous fracture, parental hip fracture, current smoking status, steroid use, alcohol intake and a few other measurements
Drugs associated with osteoporosis risk
Steroid use, medroxyprogesterone, anticonvulsants, warfarin and heparin, thyroid hormone, diuretics, aromatase inhibitors used for breast cancer, androgen blockers use for prostate cancer and PPI’s
Nonpharmacologic recommendation
- Avoid drugs associated with risk of falls such as CNS depressants, SSRIs and anti-cholinergics
- Ensure safety around the home suggest proper lighting safe floors, handrails, stairs that are well lit with nonskid treads or carpet
- Weight-bearing exercise
- Adequate intake of vitamin D and calcium
- Smoking cessation
- Reducing alcohol intake
Osteoporosis in Men
Associated with very sick patients and higher mortality rates
Men should be given bisphosphonates for treatment duration of 3 to 5 years as is done with females
Calcium and vitamin D
Calcium requirements:
Pregnancy: 1300 mg per day
Man and women age 19–50:1000 mg per day
Men and women 50+ years: 1200 mg
Calcium absorption is saturable and doses should be divided
Calcium requires vitamin D for absorption
Forms: calcium citrate which requires lower acid and calcium carbonate which is acid dependent absorption and should be taken with meals
Vitamin D intake: age 70 years is 600 international units daily and 71+ years is 800 international units daily (cholecalciferol or vitamin D3 is the preferred source) 50,000 units is a used and renal disease and short-term in adults with deficiency
Drug treatment
First line: bisphosphonates (oral or injectable) for a max duration of five years due to risk of esophageal cancer, osteonecrosis of the jaw and atypical femur fractures
Teriparatide (forteo): used in patients with osteoporosis who are at high risk for having fractures or who have already had osteoporotic fracture and in those who cannot tolerate bisphosphonates
Estrogen is no longer first-line that may be appropriate short-term in younger women without contraindications and can be useful do to time limits currently with bisphosphonates (raloxifene can be used and is used most commonly and women who are at risk and have a fear of breast cancer)
Bisphosphonates:
Work by inhibiting osteoclast activity
Alendronate ( Fosamax, Binosto)
Risedronate (Actonel, Atelvia)
Inandronate (Boniva): PO and IV
Zoledronic acid (Reclast): yearly infusion (can cause flulike symptoms)
70 mg weekly for alendronate
Contraindications:inability to stand or sit upright for at least 30 minutes after taking, hypocalcemia, creatinine clearance <35.
Warning: bisphosphonate should stop after 3 to 5 years, bone, joint or muscle pain may be severe; may cause esophagitis, esophageal ulcers, esophageal erosions
Side effects: hypocalcemia, back pain, arthralgias, dyspepsia, nausea and vomiting, dysphasia, heartburn, Esophagitis (patient should remain upright for at least 30 to 60 minutes)
If severe G.I. symptoms consider injectable bisphosphonate
Notes: do not risk jaw necrosis( get dental work done before therapy is started), and test for calcium and vitamin D levels prior to starting
Raloxifene (Evista)
MOA: estrogen antagonist also called selective estrogen receptor modulator (SERM) also decreases bone resorption
Caveat: used often in women at risk of or who have a fear of breast cancer
Blackbox warning: increased risk of thromboembolic events, risk of death due to stroke in women with coronary heart disease
Side effects: hot flashes, peripheral edema, arthralgia, leg cramps, flulike syndrome, infection, vaginal bleeding, skin changes
Pregnancy category X
Calcitonin (Mialcin, Fortical)
MOA: inhibits osteoclast mediated bone resorption
Not recommended agent but is inhaled, SC or IM
Side effect: rhinitis
Notes: keep refrigerated until used
Teriparatide (Forteo)
MOA: stimulates new bone formation and depresses osteoclast activity
Indication: patients who are at very high risk for fracture, already had a fracture or for those who cannot tolerate bisphosphonates
Dose:Daily SC injection for a max of two years
Blackbox warning: osteosarcoma or bone cancer
Warnings: orthostatic hypotension, kidney stones
Side effects: orthostasis, dizziness, increased heart rate, hypocalcemia
Notes: 28 day pen, keep refrigerated, inject in five or abdomen, sit or lie down due to tachycardia, dizziness post shot
Denosumab (Prolia)
MOA: binds to RANKL and prevents interaction between RANKL AND RANK preventing osteoclast formation thus causing decreased bone resorption and increased bone mass
Indication: high risk patients or those who cannot use other agents
Dose: SC injection every six months
Contraindications: hypocalcemia must check calcium levels prior to using drug
Side effects: fatigue, hypocalcemia, eczema, rash, weakness, Limb pain, nausea, dyspnea, cough
Bisphosphonate counseling
- Take first thing in the morning before you eat or drink anything else except 6 to 8 ounces of plain water
- Take while sitting up or standing and stay upright for at least 30 minutes or 60 minutes with monthly Boniva during which time you’re to have nothing, even medications, other than plain water
- This medication does not work well if you’re not receiving adequate calcium and vitamin D
- If you are taking a PPI discussed with your pharmacist these drugs may increase fracture risk and you may need calcium citrate
- Common side effects include G.I. upset, joint pain, back pain, dyspepsia or heartburn
- Stop taking the medication if you develop difficult or painful swallowing, have chest pain or very bad heartburn that does not get better or severe pain in the bone joint and muscles
- Have any dental work done prior to starting this medication
Teriparatide counseling (Forteo)
- If you feel a fast heartbeat or feel dizzy with the first few doses sit or lie down
- Rare risk of osteosarcoma
- Injection pen last 28 days
- Keep in the refrigerator
- Inject into the thigh or abdomen (rotate)
- Do not exceed two years of use
Calcitonin nasal spray counseling
- Sprayed into one nostril daily (use the other nostril the next day)
- Most common side effect is nasal symptoms
- Keep unused bottle in refrigerator
- Should last for 30 doses
- Consult with your doctor and pharmacist regarding adequate calcium and vitamin D supplements and if you’re taking a PPI
Estrogen use
Improves bone density and has historically been used to prevent postmenopausal osteoporosis
It’s safest during menopause and can be used and younger women without contraindications
The lowest possible dose for the shortest possible time should be given
Estrogen with progestin increases breast cancer risk in the use of this combination should be limited to 3 to 5 years, but women with the uterus need a progestin to reduce the risk of endometrial cancer
Natural products used for vasomotor symptoms
Vasomotor symptoms: hot flashes and night sweats
Black cohosh, red Clover, soy, flaxseed and evening Primrose
Contraindications to estrogen therapy
- Undiagnosed abnormal genital bleeding
- Active or past breast cancer
- Known or suspected estrogen dependent cancer
- Active or past DVT or PE
- Active or recent stroke or MI
- Liver dysfunction or disease
- Known or suspected pregnancy
Nonhormonal treatment for hot flashes
SSRI- Paroxetine (brisdelle)
Blackbox warning: antidepressants increase the risk of suicidal thinking and behavior in children and adolescents and young adults with major depressive disorder and other psychiatric disorders; consider rest before prescribing
Contraindications: MAOIs, search anergic drugs, slow taper with discontinuation, hyponatremia, QT prolongation
Side effects: sexual side effects, sedation, insomnia, restlessness, Trevor, dizziness or weakness, nausea, xerostomia, constipation, diaphoresis
Pregnancy category X
DO NOT USE WITH WARFARIN DUE TO INCREASED BLEEDING RISK FOR TAMOXIFEN DUE TO DECREASED EFFICACY
Common Herman replacement therapy products
Vivelle, Vivelle-Dot patches
Provera (medroxyprogesterone)
Premarin (conjugated estrogen tablets)
Premarin vaginal cream (conjugated estrogen cream)
Prempro (conjugated estrogens/medroxyprogesterone acetate)
Estrogen counseling
- This product does not contain progestin and should not be used in someone with a uterus
- Report any unusual vaginal bleeding right away
- Using estrogens with or without progestins may increase your chances of getting a heart attack, stroke, breast-cancer, and blood clots
- Estrogen uses primarily from menopausal symptoms and should not be continued indefinitely
