Osteoporosis, Menopause + Testosterone NAPLEX 2026

most common locations for fractures

vertebrae (spine)

proximal femur (hip)

distal forearm (wrist)

vertebral fracture

can occur without a fall and only clue may be a gradual loss of height

most devastating type of fracture

hip

wrist fractures occur in

younger people and can be an early indicator of poor bone health

medications with osteoporosis risk

Anticonvulsants

Aromatase inhibitors

Depo-Medroxyprogesteron

GnRH Agonists

Lithium

PPIs

Steroids (5+ mg prednisone for 3+ mo)

Thyroid hormones (in excess)

Loops

SSRIs

TZDs

cells involved in bone formation

osteoblasts

patient characteristics osteoporosis risk

-advanced age

-caucasian and asian

-fam hx

-females

-LBW

medical diseases with osteoporosis risk

Anorexia

Diabetes

Gastrointestinal diseases

Hyperthyroid

Hypogonadism

Menopause

RA and other autoimmune diseases

HIV/AIDs

Parkinsons

Epilepsy

osteoclasts

break down bone

gold standard to measure BMD and diagnose osteoporosis

DEXA or DXA scan

DEXA scan

measures BMD of spine and hip and calculates a T-score or a Z-score

Who should have BMD measured

Women >=65 years

Men >=70 years

(5 years apart)

FRAX tool

Estimates risk of osteoporotic fracture in the next 10 years

what is a T-score

compares the patient's measured BMD to the average peak BMD of a healthy, young, white adult of the same sex

what is a Z-score

the difference between an individual variable and the population mean (in units of SD)

T-scores are negative

a score at or above -1 coorelates with stronger (denser) bones

interpreting T-scores

Normal: > -1

Osteopenia: -1 to -2.4

Osteoporosis: < -2.5

lifestyle measures for patients with low bone density

weight bearing exercise and muscle strengthening exercise

-stop smoking and reduce alcohol

vitamin d deficiency in children causes

rickets

vitamin d deficiency in adults causes

Osteomalacia (softening of the bones)

Recommended Vit D intake for adults

1000 - 2000 units daily

calcium absorption is saturable meaning

doses above 500-600 mg should be divided

calcium carbonate

Tum

-40% elemental calcium

-acid dependent absorption

-must take with meals

calcium citrate

Cal-Citrate

-21% elemental calcium

-no acid dependent

-can take with or without food

vitamin d deficiency (<30 ng/ml) treatment

vitamin D2 (ergocalciferol) 50,000 IU (1250 mcg) weekly for 8 weeks OR

vitamin D3 (cholecalciferol) 125-175 mcg (5000-7000 IU) daily

for 8 weeks

recommended daily calcium intake for adults

1,000-1,200 mg per day

1 gram of calcium carbonate =

400 mg elemental calcium

1 gram of calcium citrate =

210 mg elemental calcium

calcium side effects

constipation

medications approved for prevention of osteoporosis

-bisphosponates (besides IV ibandroante)

-estrogen-based therapies, raloxifene

medications approved for treatment of osteoporosis

-bisphosphonates

-denosumab

-parathyroid hormone analogs (teriparatide, abaloparatide)

-calcitonin

Criteria for initiating treatment for osteoporosis

T score

Criteria for initiating treatment for osteopenia if high risk

low bone density (T-score between -1 and -2.5)

AND

FRAX score indicates a 10 year probability of major osteoporosis-related fracture >20% or a 10 year hip fracture probability >3%

bisphosphonates

-first line for txt and prevention of osteoporosis in most pt

bisphosphonates po administration

must stay upright for 30 minutes (60 for ibandronate) and drink 6-8 oz of water

bisphosphonates side effects

esophagitis, hypocalcemia, GI effects

rare but serious side effects bisphosphonates

atypical femur fractures

osteonecrosis of the jaw

bisphosphonates po

Alendronate

Risedronate

Ibandronate

-given daily, weekly or monthly

bisphosphonates iv

ibandronate and zoledronic acid

given quarterly/yearly

bisphosphonates treatment duration

3-5 years

densoumab

Prolia

-alternative to bisphosphonates

-SC administration every 6 months

-HYPOCALCEMIA

teriparatide

Forteo

-for very high risk patients only

SC administration daily

MOA: recombinant PTH analog given subQ, ↑ osteoblastic activity

Clinical use: osteoporosis, causes ↑ bone growth compared to antiresorptive therapies (e.g., bisphosphonates)

Toxicity: transient hypercalcemia

warnings: osteosarcoma (bone cancer)

SE: arthralgias, leg cramps, N, orthostasis/dizziness

Parathyroid hormone 1-34

Teriparatide (Forteo)

Abaloparatide (Tymlos)

Parathyroid hormone 1-34 must be frigerated y/n

yes

Forteo must be

protect from light

Parathyroid hormone 1-34 MOA

stimulates osteoblast activity and increases bone formation

Parathyroid hormone 1-34 txt duration max

2 years or less

abaloparatide

Tymlos

parathyroid hormone analog

BBW: osteosarcoma in rat studies

tx duration restricted to 2 yrs or less

SE: hypercalcemia, arthralgia, leg cramps, increased uric acid

keep refrigerated

tx of postmenopausal women SC daily

raloxifene

Evista

-SERM that decreases bone resorption

-alternative to bisphosphonates if high risk of vertebral fractures

-inc risk for VTE and stroke

-can be used if low VTE risk or high breast cancer risk

SE: vasomotor symptoms, leg cramps

CI: pregnancy and hx or current VTE

conjugated estrogens/bazedoxifene

Duavee

-alternative to bisphosphonates if high risk of vertebral fractures

-inc risk for VTE and stroke

-indication for women with INTACT uterus for prevention of osteoporosis

-also used as treatment for vasomotor symptoms

-SE: inc risk of breast cancer

CI: breast cancer, pregnancy, uterine bleeding, VTE

warnings: endometrial cancer due to unopposed estrogen, risk of DVT and stroke

calcitonin for osteoporosis

-nasal spray - one nostril daily and alternate

-treatment only if other options are not suitable (less effective) and has a high risk of cancer with long term use

-warnings: hypocalcemia, inc risk of malignancy, hypersensitivity to salmon products

estrogen for osteoporosis

for prevention only in post menopasual women with vasomotor symptoms

-use lowest dose possible for shortest time

-last line

bisphosphonates MOA

inhibit osteoclast activity

which bisphosphonate only reduces vertebral fractures and not both hip and vertebral

ibandronate

A _________ should be considered for low risk patients taking bisphosphonates after _________ years of treatment

drug holiday, 3-5

alendronate can be taken

daily or weekly for treatment of osteoporosis and prevention in postmenopausal women

risedronate can be taken

daily, weekly or monthly for prevention and treatment of postmenopausal females

risedronate for male treatment of osteoporosis

weekly

how often is ibandronate taken

monthly

bisphosphonate CI

inability to stand or sit upright for 30 mins

hypocalcemia

bisphosphonate warnings

-osteonecrosis of the jaw

-atypical femur fractures

-esophagitis, ulcers, erosions

-hypocalcemia

-renal impairment

bisphosphonate side effects

dyspepsia, dysphagia, heartburn, N/V, hypocalcemia

due to the risk of jaw decay/necrosis, what should be completed prior to starting treatment with bisphosphonates

dental work

bisphosphonate drug interactions

separate from calcium, antacids, iron, and magnesium by at least 2 hours

Atelvia (delayed release) requires what

type of risedronate, requires an acidic gut so no PPI or H2RA

how often is ibandronate IV

every 3 months

how often is zoledronic acid (Reclast) administered

yearly

IV bisphosphonates CI

hypocalcemia

IV bisphosphonates warnings

renal impairment

denosumab MOA

Binds to RANKL > RANKL can't bind to RANK > no osteoclast stimulation or activation occurs

denosumab dosing

60 mg SC every 6 months

denosumab boxed warning

hypocalcemia in pt with advanced kidney disease

denosumab CI

Hypocalcemia

Pregnancy

denosumab warnings

ONJ, femur fractures, hypocalcemia

denosumab side effects

hypertension

fatigue

edema

dyspnea

headache

N/V/D

↓ Phos

denosumab discontinuation

if discontinued, bone loss can be rapid so should consider alternative agents to maintain BMD

Romosozumab

Evenity (Sclerostin inhibitor)

-indicated for postmenopausal females w history of osteoporotic fracture or multiple risk factors

Binosto

Alendronate effervescent tab

-dissolve in 4 oz plain water, wait 5 min to dissolve

Atelvia

risedronate delayed release

-take with water immediately after breakfast and do NOT take with acid suppressing meds

discontinue raloxifine how many hours before prolonged immobilization

72 hours

menopause

last menstrual period was over 12 months ago

a decrease in what causes an increase in FSH and therefore vasomotor symptoms

estrogen and progesterone

Genitourinary syndrome of menopause

Symptoms affecting urinary and genital systems post-menopause.

-vaginal dryness, burning, painful intercourse

most effective treatment for vasomotor symptoms

systemic hormone therapy with estrogen

estrogen causes a decrease in

LH and more stable temp control

estrogen formulations with a lower risk of VTE and stroke compared to oral

transdermal, topical and low dose oral

what is preferred for patients who are only having vaginal symptoms of menopause

local estrogen

estrogen in women with a uterus

use in combination with a form of progesterone - unopposed estrogen inc risk of endometrial cancer

progestin se

can cause mood disturbances, if taken intermittently spotting can occur

what kind of progestins are considered to be safer than synthetic progestins (medroxyprogesterone)

micronized, Prometrium

criteria for use of hormone therapy for menopause

healthy, symptomatic women who are within 10 years of menopause, <60 years and have no CI

local hormone therapies

17-beta-estradiol

conjugated equine estrogens

17-beta estradiol vaginal cream

Estrace

17-beta estradiol vaginal ring

estring

17-beta estradiol vaginal tablet

vagifem

conjugated equine estrogens vaginal cream

Premarin

estradiol transdermal patch

Vivelle-DOT, Estraderm, Climara

conjugated equine estrogens vaginal tablet and injection

premarin

medroxyprogesterone

Depo-Provera

micronized progesterone

Prometrium