Osteoporosis Meds

Question 1

Risks for osteoporosis inlcude?

Answer 1

Low estrogen
Increased age
Ca2+ deficiency 
Vitamin D deficiency 
Increased PTH secretion (adenoma or Vit D deficiency)

Question 2

What are the recommended dietary calcium and vitamin D intake?

Answer 2

Ca2+: 1200mg

Vit D: 800IU

Also weight bearing exercise, avoid excess glucocorticoids, no smoking, limit alcohol

Question 3

What are the clinical uses of estrogen replacement therapy (ERT) in osteoporosis?

Answer 3

Inhibits bone restoration, promotes bone formation, reduce fx…

Long-term use though is actually bad, use the lowest dose possible in postmenopasual women to control vasomotor symptoms

Question 4

These dugs selectively bind to the anti-resorptive surafaces of bone and may be incorporated int o the bone (decrease osteoclast activity, bone resorption, increases density, prevents Fx, inhibits normal and abnormal bone resorption, they are?

Answer 4

Bisphosphonates:

Alendronate, Risedronate, Ibandronate, Zoledronic acid

Question 5

1st line in most pts with osteoporosis in terms of meds?

Also treat Paget’s Disease

Answer 5

Bisphosphonates…

Reduce non-vertebral Fx (except Ibandronate reduces only vertebral Fx)

Long half lives (up to 10 years - treat for 5 and if T-score is less than -3.5, continue to 10)

CI in renal dysfunction

Question 6

AEs of Bisphosphonates?

Answer 6

GI stuff prevalent: pts should NOT lie down for 30-60 min after taking

Osteonecrosis of the jaw

Atypical FXs, esophageal cancer

DI: have to wait at least 30 minutes after taking bisphosphonates before taking any meds, food, drink…but drink water (Ibandronate, must wait 60 min)

Question 7

What are the differences in dosing frequency for the four Bisphosphonates?

Answer 7

Alendronate is PO and taken daily

Risedronate is PO and can be taken daily or weekly or two tabs once per month

Ibandronate is PO or IV, taken monthly or IV every 3 months (for postmenopausal women)

Zoledronic Acid is only IV, used one per year for osteoporosis

Question 8

These two Bisphosphonates are mainly for pts that are unable to take the other two due to GI issues?

Answer 8

Ibandronate and Zoledronic Acid

Question 9

Alendronate and Risedronate are CI in who?

Answer 9

Not recommended in renal issue people

CI in GI stuff, hypocalcemia, and must correct any vitamin D/mineral deficiencies before starting these

Question 10

This drug is a TNF receptor monoclonal Ab that binds to RANKL, inhibiting osteoclast formation and activity?

Answer 10

DenosuMAB

Question 11

DenosuMAB is usually not first line b/c lack of evidence and expense, but mainly used in what pt populations?

Answer 11

Androgen depravation in men, estrogen depravation in women

INITIAL THERAPY IN pts at high risk for Fx and having difficult w/dosing requirement of bisphosphonates or markedly impaired renal function

Not used for prevention of osteoporosis

Question 12

Back, extremity, and MSK pain, hypercholesterolemia, and cystitis are the MC AEs or Denosumab, what are the less common but more serious ones?

Answer 12

Hypocalcemis (if pt at risk)
Oversuppress bone remodeling leading to osteonecrosis of jaw/atypical fractures 
Serious infections (suppresses immune system)
Derm reactions (more common)

Question 13

This hormone antagonizes the effects of PTH?

Answer 13

Calcitonin = lowers serum calcium by inhibiting osteoclastic bone resorption primarily from vertebral and femoral sites (not useful for pelvis/hip)

Comes from salmon when not human and is more potent than humans

Question 14

Only benefit of using calcitonin to treat osteoporosis since it’s not recommended anymore is what?

Answer 14

To reduce pain from osteoporotic Fx (use short-term and withdrawal) b/c it has some analgesic effects

Question 15

The two calcitonin products are what? AEs?

Answer 15

Calcitonin salmon (Miacalcin) nasal spray

Calcitonin salmon (Calcimar) Sub-Q/IM

Serious AE: increased rates of all cancer were seen in multiple studies

Question 16

This drug uses intermittent administration of recombinant human PTH used for pts with high risk fractures (T-score -3.5 of below), unable to tolerate/failed on bisphosphonates, or glucocorticoid-induced osteoporosis?

Answer 16

Teriparatide (PTH 1-34, Forteo) SubQ…shit costs $42,000/year

Increased cancer risk so max us of 2 years

Question 17

Who is Teriparatide CI in?

Answer 17

Those with hypercalcemia and hypercalciuria

May increase risk of osteosarcoma (bone cancer) those with metabolic bone disease/previous skeletal irradiation

Question 18

This Selective Estrogen Receptor Modulator (SERM) is used for prevention and treatment of osteoporosis in postmenopausal women at high risk of breast cancer who can’t take bisphosphonate therapy or don’t want to

Answer 18

Raloxifene (Envista) PO

CI in those with Hx of VTE, those who hip Fx is the primary concern, and it’s teratogenic so not for premenopausal or in pregnancy

Question 19

What are the three DIs for Raloxifene (SERM)?

Answer 19

Bile acid resins, Warfarin, Thyroid hormones (separate admin by 12 hrs)