NAPLEX: Male & Female Health - Osteoporosis, Menopause, Testosterone

most common locations for osteoporosis

- vertebrae (spine)

- proximal femur (hip)

- distal forearm (wrist)

risk factors for osteoporosis

patient characteristics

Advanced age

Ethnicity (caucasian, asian)

Family history

Sex (females > males)

Low body weight

risk factors for osteoporosis

conditions

DM

Eating disorders (anorexia)

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

Hyperthyroidism

Hypogonadism in men

Menopause

Rheumatoid arthritis, autoimmune diseases

Epilepsy

HIV/AIDS

Parkinson disease

risk factors for osteoporosis

lifestyle factors

Smoking

Excessive alcohol intake (> drinks/day)

Low Ca intake

Low vitamin D intake

Physical inactivity

risk factors for osteoporosis

medications

Antiseizure medications (carbamazepine, phenytoin)

Aromatase inhibitors

Depo-medroxyprogesterone

GnRH agonists

Lithium

PPI (↑ gastric pH decreases Ca absorption)

Steroids (>5 mg daily prednisone or equivalent for >3 mo)

Thyroid hormones in excess

Loop diuretics

SSRI

TZD

Tenofovir

Heparin

Loop diuretics

osteoblasts

cells involved in bone formation

osteoclasts

cells involved in bone resorption (break down tissue in bone)

interpreting DEXA scans

T-scores are negative - a score at or above -1 correlates with stronger (denser) bones which are less likely to fracture

Normal: > -1

Osteopenia (low bone mass): -1 to -2.4

Osteoporosis: < - 2.5

who should have BMD measured

all women >65 y/o

all men >70 y/o

which populations should have BMD checked earlier

Hx fragility fracture after age 50

Risk for disease or drug induced bone loss

Parental hx of hip fracture

Smoking

Alcoholism

Low body weight

what scan should be performed if DEXA is unavailable

ultrasound

what does a FRAX tool measure

estimate risk of osteoporotic fracture in the next 10 years

osteoporosis prevention

lifestyle measures

Perform regular weight bearing exercise (walking, jogging, Tai-Chi)

Muscle strengthening exercise (weight training, yoga)

Stop smoking + avoid second hand smoke

Reduce alcohol intake

recommended daily Ca intake

1000-1200 mg elemental calcium

what is the maximum amount of elemental calcium per dose

500-600 mg

Calcium absorption is saturable - if dose is above this divide up dose

calcium carbonate (tums)

- % elemental Ca

- absorption

- counseling

40% elemental Calcium

Absorption: acid dependent

Must take with meals

calcium citrate (cal-citrate)

- % elemental Ca

- absorption

- counseling

21% elemental calcium

Absorption; not acid dependent

Can take with or without food

vitamin D supplement agents

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

Ergocalciferol (vitamin D2): 1250 mcg (50000 IU) weekly

osteoporosis prevention

1st line = bisphosphonates

alt: estrogen based therapies: raloxifene, Duavee

- use if high risk of vertebral fractures

last line for postmenopausal women with vasomotor sx: estrogen (with or without progestin)

Use lowest possible dose for shortest duration of time

osteoporosis treatment

1st line = bisphosphonates

Alt = RANKL inhibitor: denosumab (prolia), Romosozumab (Evenity)

High risk patients = parathyroid hormone analogs: teriparatide (forteo), abaloparatide (tymlos)

Last line = calcitonin

osteoporosis treatment

what other supplementation may be necesary

Treatment must include adequate calcium and vitamin D intake

criteria for starting osteoporosis treatment

Postmenopausal women or men >50 y/o

T score < -2.5 in spine, femoral neck, total hip, or 1 / 3 radius OR

- If pt has DM consider treatment for T score < - 2.0 OR

Presence of fragility fracture regardless of BMD

criteria for starting osteoporosis treatment if high risk

Low bone density (T score between -1 and -2.5) AND

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

which bisphosphonate only reduces vertebral fractures

ibandronate

bisphosphonate counseling

take first thing in the morning before eating or drinking anything

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

do not eat for at least 30 min afterwards

separate from Ca, antacids, Fe, Mg by at least 2 hrs

separate at least 30 min from food and beverages (except water)

bisphosphonate treatment duration

3-5 yrs in pt w low risk of fracture

bisphosphonate SE

- esophagitis

- hypocalcemia

- GI effects

- bone pain

rare but serious

- atypical femur fractures

- ONJ

RANKL inhibitors indication

alt for bisphosphonates

use if high risk of fracture

RANKL inhibitor dosing

SC administration q6mo

RANKL inhibitor SE

hypocalcemia

romosozumab indication

alternative for postmenopausal females with hx osteoporotic fracture or multiple risk factors

parathyroid hormone analog indication

high risk pt only (hx of several vertebral fractures)

parathyroid hormone analog treatment duration

2 yrs or less

parathyroid hormone dosing

SC administration daily

parathyroid hormone SE

hypercalcemia

estrogen based therapies (raloxifene, duavee) indications

alt to bisphosphonates for prevention if high risk of vertebral fractures

estrogen based therapies (raloxifene, duavee) warnings

increased risk for VTE, stroke

higher risk in raloxifene than estrogen

raloxifene SE

risk for blood clots

vasomotor sx

hot flashes

duavee SE

risk for blood clots

increased risk of breast cancer

1 g calcium carbonate = _____ mg elemental calcium

400 mg

1 g calcium citrate = _____ mg elemental calcium

210 mg

calcium carbonate (tums) % elemental calcium

40%

calcium citrate (calcitrate) % elemental calcium

21%

calcium carbonate counseling

take with food

do not use with PPI

calcium citrate counseling

take with or without food

bisphosphonate po examples

- alendronate

- risendronate

- ibandronate

what other treatment should be completed prior to using bisphosphonates

dental work

bisphosphonate injectable examples

- ibandronate

- zoledronic acid

when are injectable bisphosphonates preferred

when esophagitis is present

raloxifene counseling

separate from levothyroxine by several hours

discontinue 72 hrs prior to and during prolonged immobilization

what dose of duavee should be used

lowest effective dose for shortest duration possible

duavee CI

women >75 y/o

breast cancer

pregnancy

undiagnosed uterine bleeding

hx of or active VTE MI or stroke

protein C S or antithrombin deficiency

hepatic impairment

calcitonin storage

keep injection and unopened nasal spray bottles refrigerated

parathyroid hormone examples

- teriparatide (forteo)

- abaloparatide (tymlos)

parathyroid hormone storage instructions

keep refrigerated

forteo: protect from light

RANKL inhibitor CI

hypocalcemia (correct prior to using)

pregnancy

romosozumab duration of therapy

limited to 12 mo d/t decreased efficacy after this time

romosozumab storage instructions

keep refrigerated

let sit at room temp for 30 min before administration

menopause

when last menstrual period was over 12 mo ago

menopause treatment options

- estrogen

- progestin

- bijuvia

criteria for use of hormone therapy for menopause

- healthy, symptomatic women within 10 yrs of menopause

- <60 yo

- no CI to use

menopause treatment

pt w risk factors

non hormonal treatments

- ssri

- snri

- fezolinetant

transdermal, local (topical), and low dose PO estrogen products are associated with ______ (lower/higher) risk of VTE and stroke than standard dose of PO estrogen

lower

estrogen safety risks

- VTE

- stroke

- dementia

- breast cancer

divigel application sites

upper thigh

alternate legs daily

elestrin application sites

upper arm and shoulder

estrogel application sites

entire arm from wrist to shoulder

evamist spray application site

inside of forearm (between elbow and wrist) every morning

estrogen patch application site

lower abdomen below waistline

treatment for dyspareunia (painful intercourse)

ospemifene (osphena)

intrarosa (prasterone)

SSRI, SNRI options for menopausal vasomotor sx

paroxetine

citalopram

escitalopram

venlafaxine

desvenlafaxine

which SSRI are not recommended for menopausal vasomotor sx

fluoxetine

sertraline

fezolinetant (veozah)

FDA approved for treatment of moderate - severe vasomotor sx associated with menopause

non hormonal products to treat menopausal vasomotor sx

- ssri, snri

- fezolinetant (veozah)

- gabapentin

- oxybutynin

natural products for menopausal vasomotor sx

Black cohost

Evening primrose oil

Red clover

Soy

Flaxseed

Dong quai

St John's worst

Chasteberry

medications that can lower testosterone

- opioids

- chemo drugs used for prostate cancer

- cimetidine

- spironolactone

testosterone use risks

- increased clotting risk

- non cancerous prostate growth

common SE testosterone

increased male pattern baldness

acne

gynecomastia

MI, HF, stroke

depression

hostility, aggression

liver toxicity

male infertility

risks of testosterone gel formulations

Can cause early virilization if touched by child - leading to enlarged genital organs, aggressive behavior, premature pubic hair

breast / prostate cancer risk

exacerbated BPH sx

testosterone counseling points

- do not let others come in contact w application site + keep application site covered by clothing

- wait at least 2-6 hrs after applying gels before showering / swimming

- gels are flammable when wet

- apply deoderant prior to applying solutions to underarms

androgel pump priming instructions

before first use prime device by pushing down 3 times

do not apply gel released while priming

nasteo pump priming instructions

prime pump 10 times then insert actuator into nostril, depress slowly until pump stops, remove from nose while wiping tip to transfer gel to lateral side of nostril then press on nose + lightly massage

do not blow nose or sniff for 1 hr after administration

systemic hormone therapies for menopause SE

Edema

HTN

Headache

Weight gain

Depression

Nausea

Abdominal pain

Patch: redness/irritation of skin

↑ risk of breast cancer

↑ risk of retinal vascular thrombosis

Lipid effects (↑ HDL, TG, ↓ LDL)

Endometrial cancer

Dementia

↑ risk VTE and stroke

systemic hormone therapies for menopause CI

Breast cancer

Undiagnosed uterine bleeding

Active VTE

Arterial thromboembolic disease

Known protein C, S, or antithrombin deficiency

Hepatic impairment

Pregnancy

which estrogen patches are applied twice weekly

- vivelle dot

- minivelle

which estrogen patches are applied once weekly

- climara

- menostar

why is micronized progestin possibly a preferred treatment for menopause

may have lower risk of breast cancer and CV events in comparison to synthetic progestin medroxyprogesterone

ospemifene (osphena) SE

Hot flashes

Vaginal discharge

Hyperhidrosis

Muscle spasms

VTE risk

ospemifene (osphena) CI

women with severe hepatic impairment

fezolinetant (veozah) SE

Hot flashes

Abdominal pain

Diarrhea

Elevated ALT/AST

Back pain

fezolinetant (veozah) CI

Known cirrhosis

Severe renal impairment (including ESRD)

Concomitant use for CYP1A2 inhibitors

testosterone gel / solution CI

Breast cancer

Prostate Cancer

Pregnancy

Breastfeeding

Aveed: allergy to castor oil or benzyl benzoate

Depo-Testosterone: serious CV, hepatic, or renal disease

xyosted contents

sesame oil

calcitonin indication

hypercalcemia of malignancy

can contribute to cancer

NOT used in osteoporosis

which bisphosphonate can be taken any time of day

risendronate

zolendronic acid (reclast) dosing

once a year

for patients that cannot take oral

15 min infusion

NOT to be confused with Zometa

teriparatide (forteo) pen counseling

- inject once daily in thigh or abdomen, rotate injection sites

- device has enough medication for 28 days, set to give 20 mcg dose daily

- inject right away after taken out of the refrigerator and when done put back into box and then back into the refrigerator

- discard any medication left after 28 days

- inject while sittign down

teriparatide (forteo) SE

warnings:

- hypercalcemia

- orthostatic HoTN

do not use in pt w bone malignancy or metabolic bone disease

use cautiously in pt w urclithiasis (urinary stones)

SE:

- arthralgias, leg cramps, pain

- nausea

- orthostasis / dizziness

- erythema

teriparatide (forteo) storage

keep refrigerated

protect from light

menopause treatment

which hormone is the most effective treatment for vasomotor symptoms

estrogen