Osteoporosis, Menopause, Testosterone Use

Osteoporosis is most common in

postmenopausal women

Type of fracture that may be initially painless and symptom may be a loss of height

vertebral fracture

Type of fracture that occurs in younger people and serves as an indicator to poor bone health

wrist fractures

most devastating fracture

hip

Patient characteristics with osteoporosis risk

Advanced age

Ethnicity (Caucasian + Asian)

Family history

Females

Low body weight

medical diseases and conditions w/ osteoporosis risk

diabetes

eating disorders (anorexia)

GI disease (IBD, celiac, gastric bypass, malabsorption)

hyperthyroidism

hypogonadism

menopause

RA, autoimmune disease

Others: epilepsy, HIV/AIDS, parkinsons

Lifestyle factors with osteoporosis risk

Smoking

Excess alcohol intake: 3+ drinks/day

Low Ca or Vit D intake

Physical inactivity

Medications with osteoporosis risk

Anticonvulsants

Aromatase inhibitors

Depo-Medroxyprogesteron

GnRH Agonists

Lithium

PPIs

Steroids (5+ mg prednisone for 3+ mo)

Thyroid hormones 9excess)

Loops

SSRIs

TZDs

Osteoblast activity

involved in bone formation

Osteoclast activity

break down tissue in bone

Gold standard to measure BMD

DEXA scan

How to read a T-score

-1+: normal

-1 to -2.4: osteopenia

-2.5 and down: osteoporosis

compare and contrast Calcium citrate and calcium carbonate

Calcium carbonate: needs acidic environment and to be taken with food, 40% elemental calcium

Calcium citrate: does not need acidic environment, can absorb in higher pH stomach (fine for elderly and those on PPIs, can be taken with or without food, 21% elemental calcium

Elemental calcium citrate

21%

elemntal calcium in calcium carbonate

40%

scoring tool that estimates risk of osteoporotic fracture in next 10 years

FRAX

Criteria for starting treatment for osteoporosis

Osteoporosis: T-score under -2.5 OR Presence of fragility fracture regardless of BMD

Osteopenia if high risk: T-score between -1 and -2.5 AND FRAX indicating probability of major fracture 20%+ or hip fracture probability 3%+

Prolia generic

denosumab

First line treatment or prevention for most patients of osteoporosis

bisphosphonates

Side effects of bisphosphonates

esophagitis, hypocalcemia, GI effects

Rare side effects of of bisphosphonates

atypical femur fractures

osteonecrosis of the jaw (ONJ) jaw bone becomes exposed and cannot heal due to decreased blood supply

Teriparatide brand

Forteo

When is Forteo indicated

(teriparatide)

very high-risk patients only (history of severe vertebral fractures)

A patient is having GI issues with their PO bisphosphonate. You can counsel them to:

switch to IV: given quarterly or yearly

Treatment duration for Bisphosphonates is _____ due to _____

3-5 years in pt with low risk of fracture (due to risk of femur fractures and ONJ)

Treat vitamin D deficiency with:

ergocalciferol (D2) and cholecalciferol (D3)

Ergocalciferol is vitamin__

D2

cholecalciferol is vitamin D____

D3

Vitamin D deficiency should be treated with ______ for _____ (duration)

vitamin D2 or D3 (ergocalciferol or cholecalciferol)

for 8-12 weeks

Vitamin D intake recommended daily

800-2000 IU daily

Calcium absorption is _______

saturable: doses above 500-600 mg should be divided

Calcium doses above ______ should be divided

500-600

VItamin D deficiency is

D25<30

Raloxifene is an alternative to bisphosphonate in patients with

high risk of vertebral ractures

Raloxifene has increased risk of

VTE/stroke

Bazedoxifene/estrogens can be used in women with

intact uterus for prevention of osteoporosis

Bisphosphonates work by

inhibiting osteoclast activity and bone resorption

Ibandronate only reduces

vertebral fractures

Consider a drug holiday from bisphosphonates after

3-5 years for low risk patients

Contraindications to bisphosphonates

hypocalcemia, inability to stand/sit upright for at least 30 minutes

_____ must be corrected prior to using bisphosphonates

hypocalcemia

Atelvia requires

an acidic gut

(risedronate delayed release)

Bisphosphonates available in injection

ibandronate, zoledronic acid

T/F: Zometa is used for osteoporosis

False: brand of zoledronic acid used for hypercalcemia/malignancy

Brand of zoledronic acid used for bisphosphonate

Reclast

Frequency of Zometa

once yearly for treatment

every 2 years for prevention

Boniva injection frequency

Q3 months

Raloxifene is in the drug class

SERM

Raloxifene works by

decreasing bone resorption

Duavee is ______ to be used only by

conjugated estrogens/bazedoxifene used only for osteoporosis prevention in postmenopausal women with a uterus

Duavee can only be used by a postmenopausal women if she

has an intact uterus

contrindication to Duavee

breast cancer, pregnancy, uterine bleeding, VTE

Calcitonin works by

inhibits bone resorption by osteoclasts

T/F: Calcitonin is rarely used for osteoporosis

true

Teriparatide drug class

analog of human parathyroid hormone

teriparatide works by

increasing bone formation

Warnings for Forteo

Teriparatide-

osteosarcoma, hypercalcemia

Notes about PTH hormone analogs

keep refrigerated

Notes about Forteo

keep refrigerated

protect from light

Denosumab works by

binding to RANKL to prevent osteoclast formation

Denosumab is used when

there is a high risk of fracture

Xgreva is a brand name of ____ used for

Denosumab, hypercalcemia malignancy, bone tumor

Prolia generic

denosumab

Contraindications of denosumab

hypocalcemia - correct prior

pregnancy

warnings with denosumab

ONJ

atypical femur fractures

hypocalcemia

Side effects of denosumab

hypertension, fatigue, edema, dyspnea, headache, NVD, PO4 decrease

Counseling for when to take bisphoshonates

All except Atelvia: take in the morning w/ 6-8 oz water at least 30 min before first food

take atelvia with 40z or more of water immediately after breakfast

Must stay sitting upright at least 30 min. at least 60 min. for Boniva, and until after first food of day

Separate from antacids and polyvalent cations

Atelvia should not be taken with

acid-suppressing medication

Missed dose counseling for bisphosphonate

take next morning if you remember

unless it's less than one week before next dose

do not take two doses in a week

Calcitonin nasal spray counseling

refrigerate unused bottles

let bottle reach room temp before using

store at room temp then discard after 30 doses

prime pump before first use by pressing two white side arms toward bottle, releasing at least 5 sprays until a full spray produces

alterante nostrils daily

Menopause is when

last period was 12 months ago

Estrogen therapy for menopause causes

a decrease in LH and more stable temp. control

For patients with vaginal symptoms only, ____ is preferred

local estrogen products

Dyspareunia treatment includes

astroglide, replens, luvena

Astroglide is safe to use with condoms

Most effective treatment for perimenopausal, menopause vasomotor symptoms

estrogen

Unopposed estrogen for women ___ increases risk of

women with a uterus

increases risk of endometrial cancer

need progesterone