Osteoporosis, Menopause & Testosterone Use Flashcards
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Monitoring:
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Counseling:
Drug-Drug/Food interactions:
class:
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MOA:
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Drug-Drug/Food interactions:
Osteoporosis:
- “porous bones”
- is a condition that causes bones to become weaker and fragile.
- can occur in both men and women of all races
- most common in postmenopausal females.
- about 1 in 2 women AND 1 in 5 men will have an osteo porosis-relate fracture during their lifetime.
-
-
-
- vertebrae (spine)
- proximal femur (hip)
- distal forearm (wrist)
—- Vertebral fractures can occur without a fall and can initially be painless (the only clue may be a gradual loss of height).
—- Hip fractures are the most devastating type of fracture, with higher costs, disability and mortality than all other fractures combined. More common after age 75
—- Wrist fractures, and other types of fractures, appear in younger people and serve as an early indicator of poor bone health.
Osteoporosis can occur as a result of:
- normal age-related bone loss
- women and men lose bone starting around age 30 every year
- menopausal females lose bone at an accelerated rate for 10 years (~1-5% per year)
**Select Patient Characteristics with Osteoporosis Risk:
- Advanced age
- Ethnicity (Caucasian and Asian are at INCREASED Risk)
- Family History
- Sex (FEMALES > Males)
- Low body weight
**Select Medical Conditions/ Diseases with Osteoporosis Risk:
- Diabetes
- Eating Disorders (e.g. anorexia)
- Gastrointestinal diseases (e.g. IBD, celiac disease, gastric bypass, malabsorption syndrome)
- Hyperthyroidism
- Hypothyroidism in men
- Menopause
- Rheumatoid arthritis, autoimmune diseases
- Others [e.g. epilepsy, HIV/AIDs, Parkinson disease]
**Select Lifestyle Factors with Osteoporosis Risk:
- Smoking
- Excessive alcohol intake (> or = 3 drinks per day)
- Low calcium intake
- Low Vitamin D intake
- Physical activity
**Select Medications with Osteoporosis Risk:
- ## Anticonvulsants (e.g. carbamazepine, phenytoin, phenobarbital)
- ## Aromatase inhibitors—- for breast cancer {2 types of treatment: tamoxifen in premenopausal women OR aromatase inhibitors in postmenopausal women}.. tamoxifen is protective for bone. Aromatase inhibitors are not.
- Depo-medroxyprogesterone
- GnRH (gonadotropin-releasing hormone) agonists
- Lithium
- PPis (increased gastric pH deceases Ca absorption)
- Steroids* (> or = 5mg daily of prednisone OR prednisone equivalent for greater than or equal to 3 months)
[*Long-term use of steroids is a major drug contributing factor to poor bone health.] - thyroid hormones (in excess)
- Others: (e.g. Loop diuretics, SSRIs, TZDs)
WITHOUT ___________ you cannot absorb Calcium.
Vitamin D
Background:
- Bone is not “dead tissue” it is living and undergoes constant remodeling.
- Osteoblasts = “cells blast bone on” are cells involved in bone formation.
- ## Osteoclasts = are the cells involved in bone resorption; they break down tissue in the bone.
- Bone health is evaluated by measuring bone mineral density (BMD).
The GOLD Standard to measure BMD and Diagnose osteoporosis is ______1______.
-1 DEXA or DXA scan (Dual-Energy X-ray Absorptiometry scan
[Osteoblasts, building it backup]
- bisphosphonates make Osteoblasts Build quicker BUT STOP the osteoclasts.
{Osteoclasts, Collecting bone for themselves}
Background:
A DEXA or DXA scan measures Bone Mineral Density (BMD) of the spine AND hip. This then calculates a _________ and ________
T-score
AND
Z-score
Who should have there (BMD) Bone Mineral Density measured?
What patients are at High risk for a fracture and can have their BMD checked at an earlier age?
*Women that are Greater than or equal to 65 years old
*Men that are greater than or equal to 70 years old
_____________________________________________________________________________
Patients with:
-A History of a fragility fracture (e.g. a fall from standing height or lower that results in a fracture) that happened after age 50.
-
- Risk for disease or drug-induced bone loss
-
- a parental Hx of Hip fracture or other clinical risk factors (e.g. smoking, alcoholism, low body weight).
Background:
What is a T-score?
How do we interpret?
A T-score compares the patients measured BMD to the average peak BMD of a healthy, young, white adult of the same sex.
T-scores are negative: a score at or above -1 correlates with STRONGER (DENSER) bones, which are less likely to fracture.
[NORMAL]-a T-score of -1 to 2 indicates NORMAL Bone Density [ a T-score greater than or = to -1]
[OSTEOPENIA]-a T-score of -1.1 to -2.4 indicates OSTEOPENIA (low bone mass).
[OSTEOPOROSIS]-a T-score of less than or equal to -2.5 indicates OSTEOPOROSIS. = Diagnosis**
_____________________________________________________________________________
Scores less than -1 reflect the standard deviation from the comparator group. (e.g. A T-score of less than < -2.5 means the patients BMD is at least 2.5 standard deviations below the average BMD for healthy young white adults).
Background:
What is a Z-score?
How do we interpret?
A Z-score compares the patients measured BMD to the mean BMD of an age, sex, and ethnicity-matched population.
(FRAX) Fracture Risk Assessment Tool:
- is a computer based algorithm developed by the (WHO) World Health Organization that estimates _______________
Who is the FRAX Tool intended for?
-
= the risk of osteoporotic fracture in the next 10 years.
- The (FRAX) Fracture Risk Assessment Tool is intended for postmenopausal women AND men > greater than 50 years of age.
Clinical risk factors include:
- patients age
- sex
- weight
- height
- previous fracture
- parental hip fracture
- femoral neck BMD
- smoking status
- steroid use (**greater than or equal to 5mg prednisone [or an equivalent] per day for 3 months.
- alcohol intake (3 or more drinks/day)
- Disorders strongly associated with osteoporosis [e.g. Type 1 diabetes, Chronic liver disease, premature menopause and rheumatoid arthritis.]
Lifestyle Modifications:
-
-
- weight-bearing exercises (e.g. walking, jogging, Tai-Chi)
- muscle-strengthening exercises (e.g. weight training, yoga)
- Stop Smoking**
- Vitamin D and Calcium supplementation**
- Reduce alcohol intake*
- Adopt fall prevention strategies**
Fall Prevention Measures:
If the bone density is low, care MUST be taken to avoid falls.
[Factors that put a patient at increased fall risk include:]
-
-
-
- Hx of falls
- medications that cause sedation or orthostasis (antihypertensives, sedatives, hypnotics, narcotics analgesics*, psychotropics).
-neurologic disorders - conditions causing physical instability or poor coordination (e.g. Parkinson’s Disease, dementia, prior stroke, peripheral neuropathy)
- impaired vision or hearing
- poor health/frailty
- urinary or fecal urgency
Fall Prevention Measures:
If the bone density is low, care MUST be taken to avoid falls.
With a Home safety assessment, what measures should be used to prevent future falls?
- Adequate lighting
- stairs are well-lit with non-skid treads or carpet
- Safe floors (non-skid) and (throw rugs/clutter/cords have been removed)
- Handrails/safety bars in bathrooms and all stairs
- storage is at reasonable heights
- Vision adequate
Prevention:
Calcium AND Vitamin D Supplementation
-
_____________________________________________________________________________
Dietary intake of calcium is preferred, with supplements used if needed.
Excess intake of the recommended allowances may contribute to kidney stones, cardiovascular disease, and stroke.
- children (who can build bone stores)
- pregnancy (when the fetus can deplete the mother’s store’s)
- during the years around menopause when bone loss is rapid.
Prevention:
Calcium AND Vitamin D Supplementation
_________ is required for Calcium absorption.
Vitamin D
_________ deficiency in children causes Rickets and in adults, it causes osteomalacia (softening of the bone).
Vitamin D
Prevention:
Calcium AND Vitamin D Supplementation
Prevention:
Calcium AND Vitamin D Supplementation—
- Calcium absorption is SATURABLE; doses above 500-600mg of Elemental Calcium should be divided.
- There are 2 forms of calcium we use for supplementation:
1)
2)
1) Calcium Carbonate (Tums, Caltrate, Oscal, Oysco)
2) Calcium Citrate (Citracal)
Prevention:
Calcium AND Vitamin D Supplementation—
The RECOMMENDED daily intake for Calcium in most adults is __________.
Patients should NOT exceed ___________ of elemental calcium per dose.
1000-1200mg of elemental calcium daily
500-600mg of elemental calcium per dose
Prevention:
Calcium AND Vitamin D Supplementation—
Calcium Carbonate (Tums, Caltrate, Oscal, Oysco)
____________________________________________________
- products have 40% elemental calcium
- Absorption is ACID-DEPENDENT, so needs an acidic environment to be absorbed. BEST TO TAKE WITH FOOD.
- DO NOT USE WITH PPIs
remember calcium products CAN CAUSE CONSTIPATION
1 gram of Calcium Carbonate = 400mg elemental calcium
Prevention:
Calcium AND Vitamin D Supplementation—
Calcium Citrate (Citracal, Calcitrate)
________________________________________________
- products have 21% elemental calcium
- Absorption is NOT acid-dependent, so can be taken with or without food.
remember calcium products CAN CAUSE CONSTIPATION
1 gram of Calcium Citrate = 210mg elemental calcium
Prevention:
Calcium AND Vitamin D Supplementation—
Vitamin D is required for calcium absorption.
The (NOH) National Osteoporosis Foundation recommends a daily intake of ___________ for Vitamin D.
600 IU = 15mcg daily of Vitamin D
(600 international units)
Treating Vitamin D Deficiency:
Which would be measured and correlate to a Vitamin D serum 25(OH) level of ______________.
The Normal Range for Vitamin D serum 25(OH) level is ________.
-
Treatment is for 8-12 weeks, followed by maintenance therapy.
LESS THAN < 30ng/mL
GREATER THAN > 30ng/mL
- vitamin D3 (cholecalciferol)
- vitamin D2 (ergocalciferol)
Criteria for Initiating Treatment: Osteoporosis
_____________________________________________________________________________
Criteria for Initiating Treatment: Osteopenia, IF HIGH risk:
-
- high risk if they are high risk for falling [e.g. Parkinson’s disease
- Postmenopausal women OR men > 50 years of age with a BMD T-score less than or equal to < -2.5 at the femoral neck, total hip or lumbar spine
OR
- Presence of a fragility fracture, regardless of BMD.
[fragility fracture = a fall from standing height or lower that results in a fracture]
_____________________________________________________________________________ - Low Bone Density (T-score between -1 and -2.5) at the femoral neck, total hip or lumbar spine
AND
- FRAX score indicates a 10-year probability of a major osteoporosis-related fracture greater than or equal to > 20%
OR
a 10-year hip fracture probability greater than or equal to 3%
-
-
-
- Bisphosphonates 1st line in most patients
- (Evista) raloxifene [estrogen agonist/antagonist]
- (Forteo) teriparatide - High risk patients only
- (Tymlos) abaloparatide - High risk patients only
- (Prolia) denosumab - High risk patients only
- (Calcitonin) For Treatment only if other options are not suitable.
-
-
-
- Bisphosphonates 1st line in most patients
- (Evista) raloxifene [estrogen agonist/antagonist]
- (Duavee) conjugated estrogen/bazedoxifene
- Estrogen (with or without progestin) For prevention only in postmenopausal women with vasomotor symptoms; use the lowest possible dose for the shortest duration of time
Bisphosphonates:
_____________________________________________________________________________
- Oral administration: requires staying up right for 30 minutes and, for most products, drinking 6-8oz of plain water.
- Common side effects: esophagitis, musculoskeletal symptoms, hypocalcemia.
- Rare (but serious) side effects: Osteonecrosis of the jaw (ONJ) and atypical fractures
Formulations:
— weekly/monthly options if adherence to administration instructions is difficult.
— quarterly/yearly parenteral options if there are GI side effects or adherence issues with oral options.
Treatment duration: 3-5 years in patients at low risk of fracture (due to the rare risk of femur fracture and ONJ)
remember “bisphosphonates are also used in hypercalcemia of malignancy because they are going to push the calcium into the bone”
Estrogen agonist/antagonists:
- (Evista) raloxifene is a SERM
(estrogen agonists for bone but estrogen antagonists in other tissues)
Fosamax
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alendronate
class: bisphosphonate
Indications: Prevention AND Treatment of Osteoporosis, Paget’s disease
MOA: drug increases bone density by inhibiting Osteoclast activity, which decreases the rate of bone resorption. This leads to an indirect increase in bone mineral density.
Dosage forms:
oral tablet: 5mg, 10mg, 35mg & 70mg
oral solution (70mg/75mL)
Dosing:
*Prevention (Postmenopausal females):
- 5mg PO daily OR 35mg once a week
*Treatment (males and postmenopausal females)
- 10mg PO daily OR 70mg PO once a week
*Glucocorticoid-Induced Osteoporosis:
- 5mg by mouth daily
(postmenopausal women not on estrogen 10mg PO daily)
Max dose:
Renal impairment (Dose adjustment):
Boxed Warnings:
Contraindications:
HYPOCALEMIA
Inability to stand or sit upright for at least 30 minutes
**Abnormalities of the esophagus (e.g. stricture, achalasia “swallowing disorder”)
Warnings:
-*Hypocalcemia MUST be corrected prior to use
Side Effects:
-* dyspepsia “indigestion”, dysphagia “difficulty swallowing”, heartburn, N/V, hypocalcemia.
Monitoring:
Pearls/Notes:
- Check calcium and Vitamin D levels prior to initiating treatment.
*Daily Dosing: skip missed dose, take next dose at regularly scheduled time.
*Weekly dosing: Take missed dose the next morning; DO NOT TAKE 2 DOSES on the same day.
*Monthly dosing: Take missed dose the morning after you remember, UNLESS it is less than one week from the next dose, THEN SKIP IT, DO NOT TAKE 2 DOSES IN THE SAME WEEK.
Counseling:
- Take first thing in the morning before you eat or drink anything with a full glass of water 6-8oz.
- Must stay sitting or standing up (upright) for at least the next 30 minutes and do not eat or drink anything except water during this time.
- Separate from Calcium, antacids, iron, and magnesium by at least 2 hours.
- Can cause dyspepsia “indigestion.”
Drug-Drug/Food interactions:
- Separate from Calcium, antacids, iron, and magnesium by at least 2 hours.
- Use caution with aspirin or NSAIDs (can worsen GI irritation).
Binosto
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Drug-Drug/Food interactions:
alendronate
class: bisphosphonate
Indications: Prevention AND Treatment of Osteoporosis
MOA: drug increases bone density by inhibiting Osteoclast activity, which decreases the rate of bone resorption. This leads to an indirect increase in bone mineral density.
Dosage forms: oral EFFERVESCENT tablet 70mg,
Dosing:
70mg by mouth once weekly
Contraindications:
HYPOCALEMIA
Inability to stand or sit upright for at least 30 minutes FOR BINOSTO
**Abnormalities of the esophagus (e.g. stricture, achalasia “swallowing disorder”)
Warnings:
-*Hypocalcemia MUST be corrected prior to use
Side Effects:
-* dyspepsia “indigestion”, dysphagia “difficulty swallowing”, heartburn, N/V, hypocalcemia.
Monitoring:
Pearls/Notes:
- Check calcium and Vitamin D levels prior to initiating treatment.
*Daily Dosing: skip missed dose, take next dose at regularly scheduled time.
*Weekly dosing: Take missed dose the next morning; DO NOT TAKE 2 DOSES on the same day.
*Monthly dosing: Take missed dose the morning after you remember, UNLESS it is less than one week from the next dose, THEN SKIP IT, DO NOT TAKE 2 DOSES IN THE SAME WEEK.
Counseling:
- Take first thing in the morning before you eat or drink anything with a full glass of water 6-8oz.
- Must stay sitting or standing up (upright) for at least the next 30 minutes and do not eat or drink anything except water during this time.
- Separate from Calcium, antacids, iron, and magnesium by at least 2 hours.
- Can cause dyspepsia “indigestion.”
———————————————————————————————————
Dissolve the effervescent tablet in 4 ounces room temperature plain water only (not mineral water or flavored water).
Wait at least 5 minutes after the effervescence stops and then stir the solution for approximately 10 seconds and ingest.
Avoid lying down for at least 30 minutes after taking BINOSTO and until after their first food of the day.
Do not take BINOSTO at bedtime or before arising for the day.
Failure to follow these instructions may increase the risk of esophageal adverse reactions
——————————————————————————————————
Drug-Drug/Food interactions:
- Separate from Calcium, antacids, iron, and magnesium by at least 2 hours.
- Use caution with aspirin or NSAIDs (can worsen GI irritation).
Fosamax Plus D
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Drug-Drug/Food interactions:
alendronate + cholecalciferol “vitamin D3”
class: bisphosphonate
Indications: Prevention AND Treatment of Osteoporosis
MOA: drug increases bone density by inhibiting Osteoclast activity, which decreases the rate of bone resorption. This leads to an indirect increase in bone mineral density.
Dosage forms: oral tablet
Dosing:
Max dose:
Boxed Warnings:
Contraindications:
HYPOCALEMIA
Inability to stand or sit upright for at least 30 minutes
**Abnormalities of the esophagus (e.g. stricture, achalasia “swallowing disorder”)
Warnings:
-*Hypocalcemia MUST be corrected prior to use
Side Effects:
-* dyspepsia “indigestion”, dysphagia “difficulty swallowing”, heartburn, N/V, hypocalcemia.
Monitoring:
Pearls/Notes:
- Check calcium and Vitamin D levels prior to initiating treatment.
*Daily Dosing: skip missed dose, take next dose at regularly scheduled time.
*Weekly dosing: Take missed dose the next morning; DO NOT TAKE 2 DOSES on the same day.
*Monthly dosing: Take missed dose the morning after you remember, UNLESS it is less than one week from the next dose, THEN SKIP IT, DO NOT TAKE 2 DOSES IN THE SAME WEEK.
Counseling:
- Take first thing in the morning before you eat or drink anything with a full glass of water 6-8oz.
- Must stay sitting or standing up (upright) for at least the next 30 minutes and do not eat or drink anything except water during this time.
- Separate from Calcium, antacids, iron, and magnesium by at least 2 hours.
- Can cause dyspepsia “indigestion.”
Drug-Drug/Food interactions:
- Separate from Calcium, antacids, iron, and magnesium by at least 2 hours.
- Use caution with aspirin or NSAIDs (can worsen GI irritation).
Actonel
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risedronate
class: bisphosphonate
Indications: Prevention AND Treatment of Osteoporosis, Paget’s
MOA: drug increases bone density by inhibiting Osteoclast activity, which decreases the rate of bone resorption. This leads to an indirect increase in bone mineral density.
Dosage forms:
oral tablet: 5mg, 35mg, 150mg. 30mg- [for Paget’s daily regimen]
Dosing:
*Prevention AND Treatment (Postmenopausal females) *
- 5mg PO daily
- 35mg PO weekly
- 150mg PO once a month
Treatment Males
- 35mg PO once weekly
Glucocorticoid-Induced Osteoporosis
- 5mg PO daily
Max dose:
Boxed Warnings:
Contraindications:
HYPOCALEMIA
Inability to stand or sit upright for at least 30 minutes
**Abnormalities of the esophagus (e.g. stricture, achalasia “swallowing disorder”)
Warnings:
-*Hypocalcemia MUST be corrected prior to use
Side Effects:
-* dyspepsia “indigestion”, dysphagia “difficulty swallowing”, heartburn, N/V, hypocalcemia.
Monitoring:
Pearls/Notes:
- Check calcium and Vitamin D levels prior to initiating treatment.
*Daily Dosing: skip missed dose, take next dose at regularly scheduled time.
*Weekly dosing: Take missed dose the next morning; DO NOT TAKE 2 DOSES on the same day.
*Monthly dosing: Take missed dose the morning after you remember, UNLESS it is less than one week from the next dose, THEN SKIP IT, DO NOT TAKE 2 DOSES IN THE SAME WEEK.
Counseling:
- Take first thing in the morning before you eat or drink anything with a full glass of water 6-8oz.
- Must stay sitting or standing up (upright) for at least the next 30 minutes and do not eat or drink anything except water during this time.
- Separate from Calcium, antacids, iron, and magnesium by at least 2 hours.
- Can cause dyspepsia “indigestion.”
Drug-Drug/Food interactions:
- Separate from Calcium, antacids, iron, and magnesium by at least 2 hours.
- Use caution with aspirin or NSAIDs (can worsen GI irritation).
Atelvia
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risedronate (DR) delayed release.
class: bisphosphonate
Indications: Prevention AND Treatment of Osteoporosis
MOA: drug increases bone density by inhibiting Osteoclast activity, which decreases the rate of bone resorption. This leads to an indirect increase in bone mineral density.
Dosage forms: 35mg delayed release (DR) oral tablet
Dosing:
*Prevention AND Treatment (Postmenopausal females) *
35mg PO weekly
Treatment Males
35mg PO weekly
Max dose:
Contraindications:
HYPOCALEMIA
Inability to stand or sit upright for at least 30 minutes
**Abnormalities of the esophagus (e.g. stricture, achalasia “swallowing disorder”)
Warnings:
-*Hypocalcemia MUST be corrected prior to use
Side Effects:
-* dyspepsia “indigestion”, dysphagia “difficulty swallowing”, heartburn, N/V, hypocalcemia.
Monitoring:
Pearls/Notes:
-** REQUIRES AN ACIDIC GUT for absorption; DO NOT USE WITH PPIs and H2RAs**
- Check calcium and Vitamin D levels prior to initiating treatment.
*Daily Dosing: skip missed dose, take next dose at regularly scheduled time.
*Weekly dosing: Take missed dose the next morning; DO NOT TAKE 2 DOSES on the same day.
*Monthly dosing: Take missed dose the morning after you remember, UNLESS it is less than one week from the next dose, THEN SKIP IT, DO NOT TAKE 2 DOSES IN THE SAME WEEK.
Counseling:
- Take first thing in the morning before you eat or drink anything with a full glass of water 6-8oz.
- Must stay sitting or standing up (upright) for at least the next 30 minutes and do not eat or drink anything except water during this time.
- Separate from Calcium, antacids, iron, and magnesium by at least 2 hours.
- Can cause dyspepsia “indigestion.”
Drug-Drug/Food interactions:
- Separate from Calcium, antacids, iron, and magnesium by at least 2 hours.
- Use caution with aspirin or NSAIDs (can worsen GI irritation).
Boniva
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Boxed Warnings:
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Warnings:
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Monitoring:
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Counseling:
Drug-Drug/Food interactions:
ibandronate
class: bisphosphonate
Indications: Prevention AND Treatment of Osteoporosis
MOA: drug increases bone density by inhibiting Osteoclast activity, which decreases the rate of bone resorption. This leads to an indirect increase in bone mineral density.
Dosage forms: oral tablet, (3mg/3mL prefilled syringe for IV infusion)
Dosing:
Prevention and Treatment in Postmenopausal females
PO: 150mg once a month (on the same date every month)
Treatment (Postmenopausal females
3mg IV every 3 months
Administer over 15-30 seconds.
Max dose:
Contraindications:
HYPOCALEMIA
Inability to stand or sit upright for at least 60 minutes
**Abnormalities of the esophagus (e.g. stricture, achalasia “swallowing disorder”)
Warnings:
-*Hypocalcemia MUST be corrected prior to use
Side Effects:
-* dyspepsia “indigestion”, dysphagia “difficulty swallowing”, heartburn, N/V, hypocalcemia.
Monitoring:
Pearls/Notes:
- Check calcium and Vitamin D levels prior to initiating treatment.
*Daily Dosing: skip missed dose, take next dose at regularly scheduled time.
*Weekly dosing: Take missed dose the next morning; DO NOT TAKE 2 DOSES on the same day.
*Monthly dosing: Take missed dose the morning after you remember, UNLESS it is less than one week from the next dose, THEN SKIP IT, DO NOT TAKE 2 DOSES IN THE SAME WEEK.
Counseling:
- Take first thing in the morning before you eat or drink anything with a full glass of water 6-8oz.
- Must stay sitting or standing up (upright) for at least the next 30 minutes and do not eat or drink anything except water during this time.
- Separate from Calcium, antacids, iron, and magnesium by at least 2 hours.
- Can cause dyspepsia “indigestion.”
Drug-Drug/Food interactions:
- Separate from Calcium, antacids, iron, and magnesium by at least 2 hours.
- Use caution with aspirin or NSAIDs (can worsen GI irritation).
Reclast
class:
Indications:
MOA:
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Monitoring:
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Counseling:
Drug-Drug/Food interactions:
zoledronic acid
class: bisphosphonate
Indications: Prevention AND Treatment of Osteoporosis
MOA: drug increases bone density by inhibiting Osteoclast activity, which decreases the rate of bone resorption. This leads to an indirect increase in bone mineral density.
Dosage forms: IV infusion
Dosing:
** Prevention (Postmenopausal females)
- 5mg IV every 2 years
**Treatment (males and postmenopausal females) **
5mg IV once yearly
Glucocorticoid-Induced Osteoporosis
5mg IV once yearly
—Administer OVER greater than or equal to 15 MINUTES————
Boxed Warnings:
Contraindications:
HYPOCALEMIA
Inability to stand or sit upright for at least 30 minutes
**Abnormalities of the esophagus (e.g. stricture, achalasia “swallowing disorder”)
Warnings:
-*Hypocalcemia MUST be corrected prior to use
Side Effects:
-* dyspepsia “indigestion”, dysphagia “difficulty swallowing”, heartburn, N/V, hypocalcemia.
Monitoring:
Pearls/Notes:
- Check calcium and Vitamin D levels prior to initiating treatment.
*Daily Dosing: skip missed dose, take next dose at regularly scheduled time.
*Weekly dosing: Take missed dose the next morning; DO NOT TAKE 2 DOSES on the same day.
*Monthly dosing: Take missed dose the morning after you remember, UNLESS it is less than one week from the next dose, THEN SKIP IT, DO NOT TAKE 2 DOSES IN THE SAME WEEK.
Counseling:
- Take first thing in the morning before you eat or drink anything with a full glass of water 6-8oz.
- Must stay sitting or standing up (upright) for at least the next 30 minutes and do not eat or drink anything except water during this time.
- Separate from Calcium, antacids, iron, and magnesium by at least 2 hours.
- Can cause dyspepsia “indigestion.”
Drug-Drug/Food interactions:
- Separate from Calcium, antacids, iron, and magnesium by at least 2 hours.
- Use caution with aspirin or NSAIDs (can worsen GI irritation).
Zometa*
zoledronic acid
indicated for hypercalcemia of malignancy.
Evista
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Boxed Warnings:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Counseling:
Drug-Drug/Food interactions:
raloxifene
class: estrogen agonist/antagonist [a selective estrogen receptor modulator (SERM)]
Indications: Prevention and Treatment of Postmenopausal females
MOA: decreases bone sorption
Dosage forms: tablet
Dosing: 60mg PO daily
Boxed Warnings:
**Increased risk of VTE (DVT/PE); increased risk of death due to stroke in women with CHD or at risk for coronary events.
Contraindications:
History of or current VTE, pregnancy
Warnings:
Side Effects:
Hot flashes, peripheral edema, arthralgia, leg cramps
Monitoring:
Pearls/Notes:
- Separate raloxifene from LEVOTHYROXINE by several hours*
- Discontinue 72 hours prior to and during prolonged immobilization.
Counseling:
- take with or without food
- this drug has a risk of dangerous blood clots
- this drug can cause hot flashes during the day and can make you feel hot and sweaty during the day.
- discontinue Evista at least 72 hours prior to and during surgery or with prolonged bed rest.
Drug-Drug/Food interactions:
- Separate raloxifene from LEVOTHYROXINE by several hours*
Duanvee
class:
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MOA:
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Dosing:
Max dose:
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conjugated estrogens/bazedoxifene
class:
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Dosing:
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Miacalcin
class:
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calcitonin
class:
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Forteo
class:
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teriparatide
class: Parathyroid hormone 1-34 (analog of human parathyroid hormone)
Indications: used to Treat Osteoporosis when there is VERY HIGH RISK of FRACTURE (previous history of vertebral formation)
MOA: drug stimulates osteoblast activity and increases bone formation.
Dosage forms:
Dosing:
Max dose:
Boxed Warnings:
Contraindications:
Warnings:
**Osteosarcoma (bone cancer): risk dependent on dose and duration of use, do not use in bone malignancy or metabolic bone disease.
**Hypercalcemia: orthostatic hypotension,
Side Effects:
- arthralgias, leg cramps, nausea, orthostasis/dizziness
Monitoring:
Pearls/Notes:
Due to safety issues, the cumulative lifespan treatment duration is RESTRICTED to 2 years or less
Counseling:
** KEEP REFRIGERATED EVEN AFTER FIRST USE **
- Protect from light
- Inject once daily in thigh or abdomen (lower stomach area). Rotate injection sites.
- The device has enough medicine for 28 days. It is set to give a 20mcg dose each day.
- Inject right away after taking out of refrigerator and when done put back into its box then back into the refrigerator.
- If any remains left after 28 days discard.
- Inject sitting down.
Drug-Drug/Food interactions:
Tymlos
class:
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abaloparatide
class: Parathyroid hormone 1-34 (analog of human parathyroid hormone)
Indications: used to Treat Osteoporosis when there is VERY HIGH RISK of FRACTURE (previous history of vertebral formation)
MOA: drug stimulates osteoblast activity and increases bone formation.
Dosage forms:
Dosing:
Max dose:
Boxed Warnings:
Contraindications:
Warnings:
**Osteosarcoma (bone cancer): risk dependent on dose and duration of use, do not use in bone malignancy or metabolic bone disease.
**Hypercalcemia: orthostatic hypotension,
Side Effects:
- arthralgias, leg cramps, nausea, orthostasis/dizziness
Monitoring:
Pearls/Notes:
Due to safety issues, the cumulative lifespan treatment duration is RESTRICTED to 2 years or less
Counseling:
** KEEP REFRIGERATED EVEN AFTER FIRST USE **
Drug-Drug/Food interactions:
class:
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Menopause:
