Osteoporosis & Menopause

Question 1

T-Scores

Answer 1

• DEXA measures BMD for T-score
• Should be tested in women >= 65 yo, men >= 70 yo, and younger patients with high-risk for fracture
• Normal >= -1
• Osteopenia -1 to -2.4
• Osteoporosis =< -2.5

Question 2

Medications with Osteoporosis Risk

Answer 2

• Anticonvulsants (carbamazepine, phenytoin, phenobarbital)
• Aromatase inhibitors
• Depo-medroxyprogesterone
• GnRH
• Lithium
• PPIs
• Steroids (>= 5 mg/d of prednisone or equivalent for >= 3 months)
• Thyroid hormones (excess)
• Other: heparin, loop diuretics, SSRIs, TZDs

Question 3

Calcium

Answer 3

• Recommended Daily: 1000-1200 mg elemental calcium/d
• Don’t exceed 500-600 mg of Ca per dose
• Calcium carbonate - 40% elemental, acid-dependent (DON’T use with PPIs), take with meals
• Calcium citrate - 21% elemental, not acid-dependent, take at any time
• SE: constipation

Question 4

Citamin D

Answer 4

• Required for calcium absorption
• Deficient when Vitamin D < 30 ng/mL
• Treat deficiency with 5000-7000 IU/d OR 50,000 per week
• Take for 8-12 weeks then reduce to maintenance dose (1000-2000 IU/d)
• SE: constipation

Question 5

Fosamax

Answer 5

• Alendronate
• Bisphosphonate: first-line for osteoporosis treatment and prevention
• Treatment: 10 mg PO QD or 70 mg PO Qweek (men and postmenopausal females)
• Prevention in postmenopausal women ONLY (half doses)

Question 6

Actonel

Answer 6

• Risedronate
• Prevention/Tx postmenopausal women: 5 mg PO QD, 35 mg PO Qweek, 75 mg PO x2d/month
• Treatment in males is weekly dose
• Atelvia (DR) - requires acidic gut, DON’T use with PPIs or H2RAs

Question 7

Boniva

Answer 7

• Ibandronate
• Postmenopausal women only, prevention and tx
• Dose: 150 mg PO Qmonthly
• OR 3 mg IV Q3months

Question 8

Bisphosphonate Information

Answer 8

• CI: Hypocalcemia, inability to sit up or stand for 30 minutes (60 for Boniva)
• Warning: ONJ, femur fracture, esophagitis/ulcers/erosions, hypocalcemia, renal impairment (DON’T use if CrCl < 35 for alendronate, 30 for others)
• SE: Dyspepsia, dysphagia, heartburn, N/V, hypocalcemia
• Dental work should be done BEFORE starting treatment due to ONJ risk
• Separate from calcium, iron, antacids, and magnesium by at least 2 hours

Question 9

Reclast

Answer 9

• Zoledronic Acid
• Zometa - for hypercalcemia of malignancy
• Tx (male and postmenopausal women) - 5 mg IV once yearly

Question 10

Injectable Bisphosphonate Information

Answer 10

• CI: Hypocalcemia
• Warning: Same as oral bisphosphonates (don’t use zoledronic acid if CrCl < 35)
• Preferred if esophagitis is present due to increased risk of esophageal cancer

Question 11

Evista

Answer 11

• Raloxifene: SERM (decreases bone resorption)
• Used for prevention and tx (postmenopausal women only)
• Box warning: increased stroke and VTE risk
• CI: VTE and preggo
• SE: Hot flashes, peripheral edema, arthralgia, leg cramps

Question 12

Duavee

Answer 12

• Conjugated estrogens/bazedoxifene
• Used for prevention in postmenopausal women WITH a uterus
• Equine SERM/estrogen combination
• Box Warning: endometrial cancer (unopposed estrogen), increased DVT/stroke risk
• CI: Breast cancer, pregnancy, uterine bleeding, hx/active VTE
• Warning: increased breast and ovarian cancer risk (unopposed estrogen)

Question 13

Miacalcin

Answer 13

• Calcitonin: inhibits bone resorption by osteoclasts
• Nasal spray or injection
• Spray in one nostril daily (alternate)
• Warning: Hypocalcemia, increased malignancy risk, allergic reaction to salmon-derived products

Question 14

Forteo

Answer 14

• Teriparatide
• Analog of PTH which stimulants osteoblasts and bone formation
• Injection (needles not included)
• Box warning: osteosarcoma (bone cancer)
• Warning: HYPERcalcemia
• SE: Arthralgia, leg cramps, nausea, orthostasis/dizziness
• Keep refrigerated and protect from light

Question 15

Prolia

Answer 15

• Denosumab
• Monoclonal antibody that binds to RANKL and percent osteoclast formation
• Used for osteoporosis patients with high-risk of fracture
• Injection: 60 mg SQ Q6months
• CI: hypocalcemia, preggo
• Warning: ONJ, femur fractures, hypocalcemia
• SE: Hypotension, fatigue, edema, dyspnea, HA, N/V/D, decreased phosphate
• Xgeva - used for hypercalcemia of malignancy and bone tumor

Question 16

17-Beta Estradiol

Answer 16

Local Hormone Therapies (preferred especially with only vaginal sxs):

• Estrace - cream
• Estring - ring
• Vagifem - vag tablet
• Systemic options too

Question 17

Premarin

Answer 17

• Cream, oral tablet, and injection
• Conjugated equine estrogens
• Local hormone therapy

Question 18

Systemic Estradiol Therapies

Answer 18

Patches!:

• Alora - twice weekly
• Climara - apply once weekly
• Vivelle-Dot - twice weekly

Question 19

Prempro

Answer 19

• Conjuguated equine estrogens/medroxyprogesterone (MPA)

- Oral Tablets

Question 20

Provera

Answer 20

• Medroxyprogesterone

- Oral Tablet

Question 21

Prometrium

Answer 21

• Micronized Progesterone
• Oral Tablet
• Considered safer than synthetic progestins (medroxyprogesterone)

Question 22

Systemic Hormone Therapy Information

Answer 22

• Box Warnings: Endometrial Cancer, increased VTE/stroke/breast cancer, dementia
• CI: Breast cancer, undiagnosed uterine bleeding, active BTE, and pregnancy (all for estrogen)
• Warning: Increased risk of breast cancer if using estrogen alone

Question 23

Natural Products for Menopause

Answer 23

• Black Cohosh
• Evening Primrose Oil
• Red Clover
• Soy

Question 24

Brisdelle

Answer 24

• Paroxetine
• Non-hormonal tx for moderate to severe vasomotor sxs
• DON’T use with tamoxifen, will block its CYP2D6 metabolism
• Can increase bleeding risk with warfarin (Don’t use together either!)

Question 25

Osphena

Answer 25

• Ospemifene
• Indicated for duspareunia
• NOT indicated for mild sxs
• Only use short-term for mod-severe sxs