Osteoporosis agents: use considerations

What must be done before initiating osteoporosis meds?

Correct any vitamin D deficiency the patient has

• This will prevent severe hypocalcemia

Where can calcium be found?

Kale, dairy products, juices

What is the preferred source of calcium for patients?

Diet (not supplements)

Calcium carbonate percentage of elemental calcium?

40%

Which drug requires acid to dissolve when administered orally?

Calcium carbonate

Which calcium product causes more GI upset and constipation?

Calcium carbonate

Which drugs should be taken with food?

Calcium carbonate

• Requires acid for absorption; taking with food increases stomach acid content and helps absorption

Which calcium product is preferred with PPIs / H2RAs?

Calcium citrate

• Does not require acidic environment (which PPIs and H2RAs reduce) to be absorbed

Calcium citrate percentage of elemental calcium?

21%

Which drug class interacts with proton pump inhibitors?

Calcium carbonate

• PPIs impair absorption of calcium

Which drug class interacts with stimulant laxatives?

Calcium products

• May quicken GI transit to the point that there is not enough time for calcium absorption

Which drug class interacts with quinolones / tetracyclines?

Calcium products

• Chelation in GI tract causes decreased absorption of quinolones / tetracyclines

Which drug class interacts with iron?

Calcium products

• Impaired calcium absorption

Which drug class interacts with bisphosphonates?

Calcium products

• Impaired calcium absorption

Which drug class interacts with thyroid supplements?

Calcium products

• Impaired calcium absorption

Sources of vitamin D?

Sunlight, fish (trout and salmon)

Which is preferred: D2 or D3?

D3 (cholecalciferol)

When is ergocalciferol preferred over cholecalciferol?

If patient is following a vegan / vegetarian diet

Which osteoporosis drugs have an interaction with CYP inducers?

Vitamin D products

• CYP inducers increase vitamin D metabolism

SERMs

• CYP inducers increase SERMs metabolism

Which osteoporosis drugs have an interaction with aluminum?

Vitamin D products

• Vitamin D products increase aluminum absorption

Which osteoporosis drugs have an interaction with resins?

Vitamin D products

• Resins decrease vitamin D absorption

SERMs

• Resins decrease SERMs absorption

Which bisphosphonate product is IV?

Zoledronic acid

Which drugs are contraindicated at CrCl <30-35?

Bisphosphonates

Which drugs are contraindicated if patient has serious GI issues?

Bisphosphonates

• “Serious GI issues” = esophageal strictures/damage/abnormality; celiac, Crohn’s, gastric bypass, GLP-1 receptor treatment, inability to remain upright

Bisphosphonates place in therapy?

First-line for high-risk patients, except ibandronate

“Take with a significant amount of water” is a counseling point for which drugs?

Bisphosphonates

“Take at least 30 minutes before any food/medications” is a counseling point for which drugs?

Alendronate, risedronate (bisphosphonates)

“Take at least 1 hour before any food/medications” is a counseling point for which drugs?

Ibandronate (bisphosphonate)

“Remain upright, sitting or standing, at least 30-60 minutes after taking” is a counseling point for which drugs?

Bisphosphonates

For which osteoporosis drugs is the risk of hypocalcemia greater if eGFR <30 mL/min or on dialysis?

Denosumab

Denosumab place in therapy?

First-line for high- and very high-risk patients; mostly used for patients with renal insufficiency

For which drugs are contraception needed ≥5 months after last dose?

Denosumab

Which drug is contraindicated in pregnancy?

Denosumab

• That’s why must take contraceptive ≥5 months after last dose

Denosumab route of administration?

SubQ

Drugs that require an HCP to administer

• Denosumab

• Romosozumab

  • 2 separate pens; must be administered simultaneously by HCP

Which drugs require switching to another osteoporosis medication after they have been discontinued? What should they be switched to?

• Denosumab — switch to bisphosphonates

• Romosuzumab — switch to alendronate or denosumab

• Teriparatide, abaloparatide (PTH analogs) – switch to bisphosphonates or denosumab

Which drugs are contraindicated with a history of stroke or MI?

• Romosozumab — if within previous year

• SERMs – if history at all, +with VTE

Which drugs are contraindicated with a history of MI/stroke in the previous year?

Romosozumab

Which drug can only be given for 12 months maximum?

Romosozumab

In which drugs are renal dose adjustments not needed?

• Denosumab

• Romosozumab

• PTH analogs

Which drug is administered as 2 separate pens which must be given simultaneously by an HCP?

Romosozumab

Which osteoporosis drugs are most strongly associated with arthralgia?

Teriparatide

Which osteoporosis drugs are most strongly associated with increased uric acid?

Abaloparatide

Which drugs are contraindicated with persistent hypercalcemia?

PTH analogs

PTH analogs place in therapy?

First-line for very high-risk patients

• Not super common due to not showing evidence of hip fracture prevention

For which drugs should the first dose be given sitting or lying down?

PTH analogs

• To mitigate risk of falls brought on by orthostatic hypotension

Which drug can only be used for up to 2 years?

Abaloparatide (PTH analog)

• Other PTH analog, teriparatide, can be used for more than 2 years

Which drugs are contraindicated with a history of MI/stroke or VTE?

SERMs

SERMs place in osteoporosis therapy?

Not recommended

• Only reduces risk of vertebral fractures

• Used more for menopause

• Raloxifene can be used to reduce breast cancer risk (if patient has OP + high breast cancer risk)

Which osteoporosis drug may be used in combination with other osteoporosis therapies if the patient is at high risk of breast cancer?

Raloxifene (SERMs)

• May reduce risk of breast cancer

• Used in combo with anti-resorptives

Which osteoporosis drugs must be discontinued 72 hours prior to expected periods of immobility?

SERMs

• Immobility increases DVT risk

• Restart after fully ambulatory again

“Avoid prolonged sitting” is a counseling point for which osteoporosis drugs?

SERMs

• Immobility increases DVT risk

Which osteoporosis drugs have no specific duration of therapy?

SERMs

• Continue use until CI or intolerable side effects occur

Which osteoporosis drugs are contraindicated with fish hypersensitivity?

Calcitonin

• Not sufficient to simply take patient’s word for it; must test for fish hypersensitivity prior to initiating calcitonin

Calcitonin place in therapy?

Last-line; for patients who cannot tolerate any other osteoporosis medications

• Not recommended due to low efficacy compared to other agents

Which osteoporosis drugs have intranasal administration?

Calcitonin

“Alternate nostrils” is a counseling point with which osteoporosis drugs?

Calcitonin

• The only intranasal osteoporosis drug

Calcitonin max duration of therapy?

4 weeks(?)

Which drug expires after 35 days when at room temperature?

Calcitonin