Osteoporosis, Menopause, and Testosterone Use Flashcards
In what patient population is osteoporosis most common in?
Postmenopausal women
What medications are used as calcium supplements? What % elemental calcium is in each?
Calcium carbonate (Os-Cal, Tums) - 40% Calcium Citrate (Calcitrate, Citracal) - 21%
How much elemental calcium is in each gram of calcium carbonate and calcium citrate?
Calcium carb: 400mg elemental calcium
Calcium citrate: 210 mg elemental calcium
What medications are approved for prevention and treatment of osteoporosis?
Prevention: Bisphosphonates and Raloxifene
Treatment: bisphosphonates, denosumab, PTH analogs, and calcitonin
Criteria for initiating treatment of osteoporosis and osteopenia
Osteoporosis: postmenopausal women or men >50 with BMD T-score -2.5 or less OR presence of fragility fracture
Osteopenia: T-score -1 to -2.5 AND FRAX score indicates a 10-year probability of major osteoporosis-related fracture 20% or more or 10 year hip fracture probability of 3% or more
What medications are bisphosphonates?
Oral : Alendronate (Fosamax), Risedronate, Ibandronate
Injectable: Ibandronate (Boniva), Zoledronic acid (Reclast)
Oral bisphosphonate CI, warnings, and SE
CI: Hypocalcemia, inability to sit or stand upright for at least 30 minutes
Warnings: osteonecrosis of jaw, atypical femur fractures, esophagitis, esophageal ulcers, erosions, hypocalcemia, renal impairment (do not use if CrCl <30 or 35 (alendronate)
SE: dyspepsia, dysphagia, heartburn, N/V, hypocalcemia
Injectable bisphosphonates CI, warnings, notes
CI: hypocalcemia; zolendronic acid <35 mL/min
Warnings: renal impairment
Notes: preferred if esophagitis is present
Ibandronate q3m
Zoledronic acid q1-2years
What medications are estrogen agonist/antagonist-containing products?
Raloxifene
Conjugated estrogens/bazedoxifene (Duavee)
Raloxifene MOA
decreases bone resorption
Raloxifene and conjugated estrogens/bazedoxifene (Duavee) indication
Raloxifene: prevention and treatment
Duavee: prevention (postmenopausal women with a uterus)
Raloxifene BBW, CI, SE
BBW: increased risk of FTE and risk of death due to stroke
CI: VTE, pregnancy
SE: hot flashes, peripheral edema, arthralgia, leg cramps
Conjugated estrogens/azedoxifene (Duavee) BBW, CI, warnings
BBW: endometrial cancer, increased risk of DVT and stroke
CI: breast cancer, pregnancy, undiagnosed uterine bleeding, hx or active VTE
Warnings: increased risk of breast cancer and ovarian cancer
Calcitonin MOA
inhibits bone resorption by osteoclasts
Calcitonin warnings and notes
Warnings: hypocalcemia, increased risk of malignancy, hypersensitivity reactions to salmon-derived products
Notes: rarely used for osteoporosis treatment
What medications are analogs of human parathyroid hormone? MOA? How long should they be used?
Teriparatide (Forteo)
Abaloparatide (Tymlos)
MOA: stimulates osteoblast activity and increase bone formation
Use for MAX of 2 years
Teriparatide and abaloparatide BBW, warnings, SE, and notes
BBW: osteosarcoma (bone cancer)
Warnings: hypercalcemia
Side effects: Arthralgias, leg cramps, nausea, orthostasis/dizziness
Notes: keep refrigerated; forteo protect from light
What medications are RANKL inhibitors?
Denosumab (Prolia)
RANKL inhibitor MOA
binds to RANKL and blocks its interaction with RANK to prevent osteoclast formation that leads to decreased bone resorption and increased bone mass
Denosumab CI, warnings, SE, dosing
CI: hypocalcemia, pregnancy
Warnings: Osteonecrosis of jaw, atypical femur fractures, hypocalcemia
SE: HTN, fatigue, edema, dyspnea, HA, N/V/D, decreased PO4
Dosing: 60mg SQ every 6 months
Romosuzumab indication and MOA
Indication: postmenopausal females with hx of osteoporotic fracture or multiple risk factors
MOA: inhibits sclerostin, protein that blocks bone formation
When is menopause officially reached?
When the last menstrual period was over 12 months ago
Menopause physiology
Decrease in estrogen and progesterone causes an increased in FSH causing vasomotor symptoms
What hormone therapies are used for menopause?
Estrogen and progestin
What does unopposed estrogen increase the risk of?
Endometrial cancer
What are common local hormone therapies for menopause symptoms?
17-beta-estradiol (vaginal cream, ring, tablet, insert)
Conjugated equine estrogens (vaginal cream - Premarin)
What are common systemic hormone therapies
Estradiol 17-beta-estradiol Conjugated equine estrogens Medroxyprogesterone Micronized progesterone
Systemic hormone therapies BBW, CI, warnings
BBW: endometrial cancer, dementia, increased risk of VTE and stroke, breast cancer
CI: estrogen-containing products: breast cancer, undiagnosed uterine bleeding, active VTE, pregnancy
Warnings: increased risk of breast cancer
What non-hormonal therapies can be used in women for menopause symptoms?
SSRIs and ospemifene
What SSRI is used in menopause?
Paroxetine
Paroxetine notes
Dose lower than depression
7.5mg qhs
Do not use with warfarin (increased INR) or tamoxifen (decreased tamoxifen efficacy)
Ospemifene class and indication
Class: oral estrogen agonist/antagonist
Indication: dyspareunia (painful intercourse)
What medications cause low testosterone in males?
Methadone
Chemotherapy
Cimetidine
Spironolactone
FDA Warning for testosterone use
CV risks
Only use to treat low testosterone levels
Testosterone BBW, SE
BBW: secondary exposure in children - wash hands and cover application site
SE: Increased appetite, acne, edema, hepatotoxicity, reduced sperm count, irritation at application site
