33. Osteoporosis & Hormone Therapy Flashcards Preview

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Flashcards in 33. Osteoporosis & Hormone Therapy Deck (69):
1

Marvin is a 65 year-old male with NYHA Class I heart failure, prostate enlargement, mild cognitive decline and erectile dysfunction. His medications include valsartan, metoprolol extended-release, hydrochlorothiazide, tamsulosin, finasteride and donepezil. Marvin's testosterone level is within the normal range. He wishes to use sildenafil, but it is not covered by his Medicare plan and he finds the cost per tablet prohibitive. He asks his physician for another option, and the physician suggests testosterone. Select the correct statement:

A. Testosterone can be used concurrently with finasteride.
B. The testosterone will worsen the cognitive decline.
C. The testosterone cannot be used in heart failure.
D. The testosterone will worsen the prostate symptoms.
E. The popular form of testosterone is called Vivelle.
 

D. Testosterone therapy can be recommended if the patient has low testosterone with a related condition, such as muscle wasting. These are not present in this case. He is not contraindicated for testosterone, however it would worsen his prostate symptoms and counteract the benefit provided by finasteride.

Avoid use of testosterone with androgen blockers such as finasteride and dutasteride.

Testosterone: Boxed warning: secondary exposure to testosterone in children and women, can lead to virilization in children, women and children should avoid contact with any unwashed or unclothed application sites in men using testosterone gel. CI: breast or prostate cancer. Warning: men with BPH treated with androgens are at increased risk for worsening signs and symptoms, increased risk of thromboembolic events (DVT, PE), never apply to breast or genitals. SE: increased appetite, increase SCr, sensitive nipples, acne, gynecomastia, dyslipidemia, edema, increase PSA, increase hepatoxicity, reduced sperm count, sleep apnea.

2

A patient will be counseled on the AndroGel pump. He is using it for the first time. Which of the following are correct counseling statements? (Select ALL that apply.)

A. Wipe your hands well on a towel after applying the medication.
B. AndroGel can catch fire when wet on the skin; it is flammable until dry.
C. Do not shower, bathe or go swimming until two hours after application.
D. Do not let young children touch the wet skin or go near the medicine pump.
E. The lower strength (1%) can be applied to the abdomen; the 1.62% strength cannot, and never apply any testosterone to the penis or scrotum.
 

B, C, D, E. Hands must be washed with soap and water after application. AndroGel is flammable until dry. Do not smoke or walk near open flames.

Testosterone: Boxed warning: secondary exposure to testosterone in children and women, can lead to virilization in children, women and children should avoid contact with any unwashed or unclothed application sites in men using testosterone gel. CI: breast or prostate cancer. Warning: men with BPH treated with androgens are at increased risk for worsening signs and symptoms, increased risk of thromboembolic events (DVT, PE), never apply to breast or genitals. SE: increased appetite, increase SCr, sensitive nipples, acne, gynecomastia, dyslipidemia, edema, increase PSA, increase hepatoxicity, reduced sperm count, sleep apnea.

3

A patient is going to begin alendronate for osteoporosis. Which of the following are possible side effects, or adverse drug reactions, from bisphosphonate therapy? (Select ALL that apply.)

A. Loose stools, diarrhea, or constipation
B. Alopecia
C. Possible risk of jaw necrosis, with higher risk after dental extractions
D. Gastritis, stomach upset, heartburn
E. Bone pain
 

C, D, E. The risk of esophageal ulceration is reduced by having the patient remain upright for at least 30 minutes after taking the drug (60 minutes with monthly Boniva). The patient should take a full glass of plain water with the medicine to help wash it down. Patients should be aware of the risk of esophageal ulceration and instructed to be seen right away if they develop dysphagia, odynophagia (pain when they swallow food or liquids), retrosternal pain (behind the breastbone) or new or worsening heartburn.

CI: inability to stand or sit upright for at least 30 minutes (60 minutes for Boniva), difficulty swallowing, esophageal stricture, or at high risk for aspiration, hypocalcemia (correct first before giving bisphosphonate).

Warning: atypical femur fracture, esophageal cancer, osteonecrosis of the jaw (ONJ), bone/joint/muscle pain, esophagitis, hypocalcemia must be corrected prior to use, caution with CrCl <35

SE: hypocalcemia, musculoskeletal pain, abdominal pain, dyspepsia, nausea, vomiting, heartburn, esophagitis, skin rash, eye inflammation

4

Choose the correct statements concerning raloxifene: (Select ALL that apply.)

A. Common adverse effects include hot flashes and leg cramps.
B. Raloxifene is a selective estrogen receptor modulator.
C. Raloxifene has lower clotting risk than estrogen.
D. The brand name of Raloxifene is Exelon.
E. The dose of raloxifene is 60 mg once daily.
 

A, B, E. The correct dose of raloxifene is 60 mg once daily. Common adverse reactions include hot flashes and leg cramps. Do not choose raloxifene in a post-menopausal woman who wants to reduce hot flashes (or night sweats); it will worsen the problem.

Raloxifene (Evista): SERM (selective estrogen receptor modulator), think estrogen SE such as clots and other cardiovascular complication. SE: hot flashes, peripheral arthralgia, peripheral edema, pregnancy (X), affects INR. Would not recommend in postmenopausal patient who have hot flash.

5

Choose the correct statements concerning calcitonin nasal spray: (Select ALL that apply.)

A. Calcitonin nasal spray is a first-line agent, but many women do not like the route of administration.
B. Inhale 1 spray in one nostril daily.
C. Calcitonin nasal spray can cause nasal irritation.
D. Instruct the patient to alternate which nostril they use (left side one day, right side the next).
E. The brand name is Mupirocin.
 

B, C, D. Calcitonin (Miacalcin or Fortical) does not work well and is used rarely. One spray in one nostril daily provides the 200 IU dose. Alternate nostril: left side one day, right side the next day.

Calcitonin (Miacalcin, Fortical): CI in allergy to salmon calcitonin. Use one spray in one nostril daily and then alternate every day. Calcitonin is used less commonly due to poor bone mineral density improvement and possible cancer risk.

6

A patient asks the pharmacist if bio-identical hormone replacement therapy is a safer option than using the drugs in products such as Premarin. Choose the safest response:

A. Bio-identical hormone therapy is safer than using "horse" estrogens such as Premarin.
B. Bio-identical hormone therapy is more dangerous than "horse" estrogen.
C. These products may be a safer option, but we really do not know at this time. It's safest to assume that the health risks are similar to the estrogens that have been studied until more information is available.
D. Bio-identical hormone therapy is only used for males, such as with Testim.
E. Bio-identical hormone therapy is only used for pre-menopausal women who are trying to become pregnant.
 

C. The term "bioidentical" generally refers to compounds that have the same chemical and molecular structure as hormones that are produced in the human body. Many woman, physicians and compounding pharmacists believe that BHRT is safer, but keep in mind that there are no well designed studies to confirm risk or benefit.

7

Select the correct statements concerning Brisdelle: (Select ALL that apply.)

A. It contains paroxetine.
B. It is indicated for hot flashes associated with menopause.
C. It can cause hypernatremia; sodium should be monitored during initiation of therapy.
D. It can be used safely with warfarin.
E. It cannot be used with tamoxifen.
 

A, B, E. This is a formulation of paroxetine; SSRIs can cause hyponatremia (not commonly, but it happens). SSRIs increase bleeding risk when given with anticoagulants. It cannot be used with tamoxifen because paroxetine is a CYP 450 2D6 inhibitor and would block conversion to active tamoxifen. All of the side effect issues from paroxetine in other formulations apply here. Of notable difference, Brisdelle is Pregnancy Category X.

8

A teenager eats a  poor diet (primarily carbohydrates and fruit) and has heavy menstrual cycles. The pharmacist will recommend calcium sources. Which of the following statements is correct?

A. She does not need calcium supplements at this age.
B. When recommending calcium to a teenager the pharmacist should recommend senna 2 tablets QHS taken concurrently.
C. Calcium requires vitamin E for absorption.
D. Calcium citrate is about twice as dense in elemental calcium than calcium carbonate.
E. If she takes two calcium supplements, they should be taken at different meals.
 

E. She must have calcium supplements if she does not receive adequate calcium in the diet. Children of all age groups should be consuming the calcium they require, preferably as milk or other dairy products and other foods, and then drink primarily water. Fruit juice and soda drinks should be limited to occasional use. Fruit is healthier when eating the fruit. Calcium does not cause constipation in usual doses, however, for patients who take supplements in large doses (for phosphate binders) this is more likely to be a problem (or the patient may be constipated for other reasons).

9

What is the definition of menopause?

A. No menstrual period for 60 consecutive days.
B. No menstrual period for 120 consecutive days.
C. No menstrual period for 6 consecutive months.
D. No menstrual period for 12 consecutive months.
E. No menstrual period for 24 consecutive months.
 

D. The period prior to menopause is the perimenopause. During this time, when the estrogen and progestin levels have declined, some women are symptomatic and may desire prescription treatment.

Perimenopause is when periods become irregular and menopause is 12 consecutive months or more without a period.

10

Marvin is a 65 year-old male who uses valsartan, metoprolol extended-release, hydrochlorothiazide, tamsulosin, finasteride and donepezil. He recently began therapy with AndroGel. Marvin's four-year old grandson Evan came to visit. It was quite a surprise to Evan's mother to find that during the visit Evan's testicles grew at an alarming rate, and pubic hair became visible. What is the likely cause of the premature virilization?

A. Evan played with his grandfather's testosterone and got it on his hands.
B. Evan ate his grandfather's testosterone.
C. Evan swallowed the angiotensin receptor blocker.
D. Evan swallowed the finasteride.
E. Evan is maturing at a typical age.
 

A. Reports of virilization of children due to testosterone exposure are serious and proper counseling is required. Testosterone is not available orally; he may have eaten it but the effect is from touching it. Most cases are due to children just touching Dad's or Grandpa's skin when wet, since the shirt is left off until the skin is dry.

Testosterone: Boxed warning: secondary exposure to testosterone in children and women, can lead to virilization in children, women and children should avoid contact with any unwashed or unclothed application sites in men using testosterone gel. CI: breast or prostate cancer. Warning: men with BPH treated with androgens are at increased risk for worsening signs and symptoms, increased risk of thromboembolic events (DVT, PE), never apply to breast or genitals. SE: increased appetite, increase SCr, sensitive nipples, acne, gynecomastia, dyslipidemia, edema, increase PSA, increase hepatoxicity, reduced sperm count, sleep apnea.

11

Counseling on the use of teriparatide should include the following points: (Select ALL that apply.)

A. There may be a small risk of bone cancer with the use of this medicine.
B. Each injection pen lasts 60 days.
C. Keep the pens frozen until use; refrigerate the pen in use.
D. If you have bone pain you should let your doctor know right away.
E. The brand name of this medicine is Forteo.
 

A, D, E. Teriparatide comes in a prefilled SC injection pen that lasts 28 days. Each injection provides the 20 mcg dose. The pens are refrigerated. And, most injectable medicines that are fixed doses are designed to last about a month. After 28 days, theForteo pen should be discarded even if some medicine remains.

Teriparatide (Forteo): recombinant human PTH, stimulates new bone formation and depresses osteoclast activity. SQ daily injection for patients at high risk for fracture. Boxed warning: osteosarcoma (do not exceed 2 years of use and inform doctor if you develop bone/joint pain). Warnings: orthostatic hypotension with initial dose, caution in history of urinary stones. SE: hypercalcemia, bone pain, nausea, orthostasis/dizziness, increase HR. Each pen comes with 28 day dose and must be refrigerated (discard after 28 days).

12

Mike is using the Androderm patch. Counseling points should include: (Select ALL that apply.)

A. Apply each evening.
B. You can apply the patch on your back, abdomen (lower stomach), on the thighs or the upper parts of your arms.
C. Do not apply more than one patch.
D. If your skin is irritated apply over the counter hydrocortisone cream to the skin right before you apply the patch.
E. Remove during an MRI or the skin under the patch will burn.
 

A, B, C, E. Many patches burn the skin if not remove prior to an MRI. Do not apply to the testicles; apply to the back, abdomen, thighs or upper arms, each evening between 8:00PM and midnight. The patch will not stick to cream or ointment. It can be applied at a different time, but oily skin does not stick to bandages or patches.

Testosterone: Boxed warning: secondary exposure to testosterone in children and women, can lead to virilization in children, women and children should avoid contact with any unwashed or unclothed application sites in men using testosterone gel. CI: breast or prostate cancer. Warning: men with BPH treated with androgens are at increased risk for worsening signs and symptoms, increased risk of thromboembolic events (DVT, PE), never apply to breast or genitals. SE: increased appetite, increase SCr, sensitive nipples, acne, gynecomastia, dyslipidemia, edema, increase PSA, increase hepatoxicity, reduced sperm count, sleep apnea.

13

Select the statements concerning bone fractures and causes of osteoporosis. (Select ALL that apply.)

A. Osteoclasts build bone and osteoblasts break down bone.
B. Hip fracture is generally an "older" age fracture, as hip bone is dense and loses density slower than the spine.
C. Vertebral (spine) fractures are the most common type of osteoporotic fracture.
D. Men are at risk for osteoporosis if they are using certain medications, such as systemic steroids, drugs for prostate cancer or if they have conditions that increase the risk of poor bone health, such as rheumatoid arthritis and lupus.
E. If men sustain a hip fracture, they have a higher mortality rate at 12 months than women.
 

B, C, D, E. It's the opposite: osteoblasts build bone, osteoclasts break down bone.

14

A patient gave the pharmacist a prescription for Premarin 0.625 mg daily. Which of the following is an appropriate generic substitution for Premarin?

A. Conjugated equine estrogens
B. Ethinyl estradiol, conjugated
C. Medroxyprogesterone acetate
D. Estriol, synthetic
E. Drospirenone
 

A. The generic name for Premarin is conjugated equine estrogens.

Intravaginal (topical) products are preferred for patients who have vaginal symptoms only such as vaginal dryness and painful intercourse. Treats LOCAL symptoms

Estrogen cream: conjugated estrogens (Premarin), estradiol (Estrace, Estrasorb)

Vaginal estrogen ring (Estring): releases estrogen for 3 months

Vaginal estradiol tablet (Vagifem): inserted into vagina twice per week

Estradiol patch (Vivelle Dot): applied twice a week and rotate sites.

15

Nancy is a frail 73 year-old female. Nancy has been using alendronate for severe osteoporosis for the past 11 months. However, she has recently had a fall and fractured her hip. The physician has discontinued alendronate and started teriparatide. Counsel the patient on the use of teriparatide: (Select ALL that apply.)

A. The medicine is delivered with a very small needle into your abdomen or thigh.
B. The brand name is Fentora.
C. You should not take this medicine for more than three years.
D. SIt down in a comfortable "easy" chair or on the side of your bed when you inject so you can lie down if you get dizzy without having to stand up.
E. This medication will reduce your chance of having a bone fracture if you take it each day.
 

A, D, E. Teriparatide [rDNA origin] injection (Forteo) is used for patients who are at very high risk for fracture, or who have already had a fracture due to osteoporosis. It is used for a maximum of two years.

Teriparatide (Forteo): recombinant human PTH, stimulates new bone formation and depresses osteoclast activity. SQ daily injection for patients at high risk for fracture. Boxed warning: osteosarcoma (do not exceed 2 years of use and inform doctor if you develop bone/joint pain). Warnings: orthostatic hypotension with initial dose, caution in history of urinary stones. SE: hypercalcemia, bone pain, nausea, orthostasis/dizziness, increase HR. Each pen comes with 28 day dose and must be refrigerated (discard after 28 days).

16

A patient has been using calcium citrate 315 mg elemental calcium/tablet for many years. She takes two tablets with breakfast and two tablets at bedtime. She does not consume dairy products or much in the way of vegetables. She had a stroke recently and has been choking on some of her medications. Her daughter has come into the pharmacy to ask if her mother needs to take these "horse pills." She is wondering if calcium can be taken in a different formulation that is easier to swallow. Which of the following statements are correct: (Select ALL that apply.)

A. She can purchase calcium in chewable formulations.
B. Calcium carbonate has a higher percentage of calcium; she can use smaller tablets.
C. She should not be using calcium supplements.
D. The calcium she is using requires acid in her stomach to be absorbed.
E. She is already using the densest (smallest) formulation of calcium that is available over-the-counter.
 

A, B. Calcium comes in chewable formulations. Make sure to brush teeth afterwards. Calcium carbonate is taken with meals. Calcium citrate has "acid-independent" absorption and can be taken at any time. She should likely be using calcium with vitamin D.

17

The Fracture Assessment Tool (FRAX) is used to assess the need for prescription drug therapy in patients with low bone density. Which of the following statements apply to this tool? (Select ALL that apply.)

A. This tool is a computer program where the clinician enters various risk factors for an individual patient.
B. The tool is not well-validated and not recommended by ACOG.
C. Previous fragility fracture is an important determinant of the need for medication.
D. It is not necessary to use this type of tool in most patients since it is well-established that drugs such as alendronate are safe and useful in most patients.
E. Steroid use of 5 mg greater for more than 3 months is an important determinant in poor bone strength as steroid use depletes bone rapidly; however, this does not apply to intraarticular and topical steroids.
 

A, C, E.

18

In Margot's lumbar spine the lowest T-score measurement is -1.8. In the right trochanter the T-score is -0.9 and the left trochanter the T-score is -1.1. She has not had any fractures as an adult. Margot has multiple sclerosis and takes the following medications daily: Copaxone, Zanaflex, Paxil, Detrol and Provigil. Which of the following statements are correct? (Select ALL that apply.)

A. Margot has risk for falling due to her medical condition.
B. She should begin Prolia therapy.
C. She should begin Forteo therapy.
D. Margot has osteoporosis.
E. Margot has risk for falling due to her medicines.
 

A, E. Margot has osteopenia, based on the T-scores given. She is not a candidate for the high-risk agents, based on her bone density readings and lack of fracture history.

Need a T-score of -2.5 or below to be considered osteoporosis, or history of fracture.

19

The use of testosterone can cause which of the following effects?

A. Decreased creatinine
B. Decreased cholesterol
C. Increased appetite
D. Improved acne
E. Increased sperm count
 

C. Testosterone use can increase creatinine, appetite, cholesterol, and cause sensitive nipples and acne. It can cause hepatotoxicity. It is contraindicated in breast or prostate cancer.

Testosterone: Boxed warning: secondary exposure to testosterone in children and women, can lead to virilization in children, women and children should avoid contact with any unwashed or unclothed application sites in men using testosterone gel. CI: breast or prostate cancer. Warning: men with BPH treated with androgens are at increased risk for worsening signs and symptoms, increased risk of thromboembolic events (DVT, PE), never apply to breast or genitals. SE: increased appetite, increase SCr, sensitive nipples, acne, gynecomastia, dyslipidemia, edema, increase PSA, increase hepatoxicity, reduced sperm count, sleep apnea.

20

What medication might be used in the perimenopause to help a female who experiences uncomfortable vasomotor symptoms? (Select ALL that apply.)

A. Estrogen prescription products
B. Estradiol topical therapy, prepared by a compounding pharmacist
C. Vivelle Dot
D. Premarin
E. Evista
 

A, B, C, D. Women who are symptomatic may get estrogen, and if they have a uterus, they should receive a progestin in order to prevent endometrial cancer. In the early stage of the perimenopause, when bleeding is heavier and pregnancy risk is present, a woman may receive birth control pills to help reduce the bleeding and to provide pregnancy protection. They also offer some help with symptoms, but later on the symptoms may warrant the use of hormone therapy (HT), which contains higher doses of estrogen.

Raloxifene (Evista): SERM (selective estrogen receptor modulator), think estrogen SE such as clots and other cardiovascular complication. SE: hot flashes, peripheral arthralgia, peripheral edema, pregnancy (X), affects INR. Would not recommend in postmenopausal patient who have hot flash.

Estradiol patch (Vivelle Dot): applied twice a week and rotate sites.

Estrogen cream: conjugated estrogens (Premarin), estradiol (Estrace, Estrasorb)

21

Cassidy is a 66 year-old female who frequents your pharmacy. The patient has many medical conditions, including hypertension, epilepsy and stress incontinence. She had a myocardial infarction this past spring. During the hospital stay, she was diagnosed with heart failure. Her current prescriptions include Coreg, Lasix, Klor-Con, Catapres TTS and phenytoin. Which of the following medications increase the risk for low bone density? (Select ALL that apply.)

A. Catapres TTS
B. Furosemide
C. Phenytoin
D. Klor-Con
E. Coreg
 

B, C. Medications with high risk for decreasing bone density include: heparin, loop diuretics, such as furosemide (which waste calcium), phenytoin, anastrozole (Arimidex) and other aromatase inhibitors used for breast cancer and leuprolide (Lupron) and other androgen blockers used for prostate cancer.

Drugs that lower bone density: steroids, depot medroxyprogesterone, anticonvulsants (carbamazepine, fosphenytoin, phenobarbital, phenytoin, primidone), heparin, lithium, excess thyroid hormone, loop diuretic, aromatase inhibitors used for breast cancer, nafarelin (Synarel) for endometriosis, androgen blockers used for prostate cancer, proton pump inhibitors used chronically because they decrease calcium absorption (need acidity for Ca for absorption), thiazolidinediiones (pioglitazone, rosiglitazone), SSRIs

22

Which of the following are common side effects of the bisphosphonates? (Select ALL that apply.)

A. Joint pain
B. Back pain
C. Stomach upset, nausea, heartburn
D. Dizziness
E. Pancreatitis
 

A, B, C. All the bisphosphonates can cause esophageal ulceration, and GI upset and burning. The bisphosphonates are very irritating to the GI tract and cannot be crushed or chewed. Patients can experience bone pain with these agents, and joint aches.

Bisphosphonates

CI: inability to stand or sit upright for at least 30 minutes (60 minutes for Boniva), difficulty swallowing, esophageal stricture, or at high risk for aspiration, hypocalcemia (correct first before giving bisphosphonate).

Warning: atypical femur fracture, esophageal cancer, osteonecrosis of the jaw (ONJ), bone/joint/muscle pain, esophagitis, hypocalcemia must be corrected prior to use, caution with CrCl <35

SE: hypocalcemia, musculoskeletal pain, abdominal pain, dyspepsia, nausea, vomiting, heartburn, esophagitis, skin rash, eye inflammation

23

Which test is considered the gold-standard for identifying low bone density?

A. BMP
B. DEXA
C. MRI
D. Ultrasound
E. CAT scan
 

B. A bone scan is performed by a dual energy x-ray absorptiometry (DEXA, or DXA) scan. The results are reported for several high-risk locations, including hips and the lower (lumbar) vertebrae.

Gold standard to diagnose osteoporosis is bone scan of hip and spine called DEXA or DXA machine.

24

A woman suffers from severe hot flashes and night sweats. She has no cardiovascular or breast cancer risk and wishes to use the most effective therapy available to treat these vasomotor symptoms of menopause. Which of the following represents the most effective therapy for this patient?

A. Medroxyprogesterone
B. Black cohosh
C. Estrogen
D. Soy
E. Yam
 

C. Medroxyprogesterone is a progestin; she may need a progestin if she uses estrogen (if she has a uterus, to protect her from estrogen-induced endometrial cancer). However, the progestin is not providing the benefit; it's the estrogen. Natural products may be helpful to some women, but are not very effective therapy. However, some women find them useful.

25

What is the mechanism of action of Brisdelle?

A. Serotonin and norepinephrine reuptake inhibitor
B. Dopamine type 2 receptor blocker
C. Adrenergic neurotransmitter
D. Selective serotonin reuptake inhibitor
E. Monoamine oxidase inhibitor
 

D. Brisdelle is a new formulation of paroxetine indicated for treatment of hot flashes. It might be useful for women who are not candidates for estrogen, but cannot be used in women who use tamoxifen or are on anticoagulants, such as warfarin.

26

A patient is asking about raloxifene. Which of the following statements are correct? (Select ALL that apply.)

A. The brand name of raloxifene is Prometrium.
B. Raloxifene is used primarily in women afraid of getting breast cancer.
C. Raloxifene reduces hot flashes.
D. Raloxifene increases bone density to a lesser degree than the bisphosphonates or teriparatide.
E. Raloxifene has a lower clotting risk than estrogen.
 

C, D. Raloxifene is used in women afraid of getting breast cancer, or in women who had breast cancer and are attempting to prevent recurrence (or cancer occurrence in the contralateral breast).

Raloxifene (Evista): SERM (selective estrogen receptor modulator), think estrogen SE such as clots and other cardiovascular complication. SE: hot flashes, peripheral arthralgia, peripheral edema, pregnancy (X), affects INR. Would not recommend in postmenopausal patient who have hot flash.

27

A 73 year-old woman has a T-score of -4.3 in her right hip, -4.7 in her left hip and has had several vertebral fractures in her lumbar spine. Her only known medical conditions are osteoporosis and hypertension. She has never had any surgeries. This woman may be a candidate for the following therapy: (Select ALL that apply.)

A. Prolia
B. Estrogen, such as in Premarin, taken with Provera
C. Forteo
D. Teriparatide
E. Denosumab
 

A, C, D, E. Denosumab (Prolia) and teriparatide (Forteo) may both be useful in this very high-risk patient. Due to her age she is not a reasonable candidate for estrogen.

Teriparatide (Forteo): recombinant human PTH, stimulates new bone formation and depresses osteoclast activity. SQ daily injection for patients at high risk for fracture. Boxed warning: osteosarcoma (do not exceed 2 years of use and inform doctor if you develop bone/joint pain). Warnings: orthostatic hypotension with initial dose, caution in history of urinary stones. SE: hypercalcemia, bone pain, nausea, orthostasis/dizziness, increase HR. Each pen comes with 28 day dose and must be refrigerated (discard after 28 days)

Denosumab (Prolia, Xgeva): monoclonal atnibody that binds to RANKL and prevents interaction between RANKL and RANK (a receptor on osteoclasts), preventing osteoclast formation. SQ injection every 6 months in MD's office. CI: hypocalcemia. Warning: osteonecrosis of the jaw, atypical femur fractures, serious infections, dermatitis, bone/muscle/joint pain. SE: back pain, limp pain, eczema, rash, hypocalcemia, increased serum cholesterol, pregnancy (X).

28

Estrogen in any form is contraindicated in the following situations: (Select ALL that apply.)

A. Current or past deep vein thrombosis, pulmonary embolism or stroke or heart attack
B. Liver disease
C. Current or past breast or estrogen-dependent cancer
D. History of severe depression
E. History of suicide attempts
 

A, B, C. In addition, estrogens are contraindicated with abnormal genital bleeding (rule out cancer) and pregnancy.

Estrogen:

Contraindications & Boxed Warning: Clotting, Hormone-dependent cancer anywhere in the "reproductive" tissues and liver cancer, cigarette smoke and serious cardiovascular events

Adverse effects due to estrogen: nausea (may help to take in evening or at bedtime), breast tenderness/fullness, bloating, weight gain or elevated blood pressure. Almost everything in pharmacy is dose-related. If low-dose estrogen pills are used, or if insufficient estrogen, then early or mid-cycle breakthrough bleeding can occur and may require higher estrogen dose (wait at least 3 cycles before switching).

Severe complication from estrogen-containing oral contraceptives (ACHES): ABDOMINAL PAIN (severe). CHEST PAIN (severe), shortness of breath, coughing up blood. HEADACHE (severe), numbness of lips, tongue, arm or leg. EYE PROBLEMS - vision loss, blurring, flashing lights SEVERE LEG PAIN - redness, swelling of calf or thigh. These could be signs of a thrombotic event (MI, DVT, PE).

29

The Institute of medicine and the National Institutes of Health recommend this daily vitamin D dose for adults up to and including 70 years of age:

A. 100 IU daily
B. 200 IU daily
C. 300 IU daily
D. 400 IU daily
E. 600 IU daily
 

E. Some recommend higher doses; at least, the pharmacist should ensure their patients use the minimum recommended intake.

30

Sandra has a creatinine clearance of 20 mL/min. Which bisphosphonate is the best option in this patient?

A. Boniva
B. Reclast
C. Actonel
D. Fosamax
E. None of the above
 

E. Fosamax and Reclast are not recommended in patients with a CrCl < 35 mL/min, and Actonel and Boniva cannot be used with a CrCl < 30 mL/min.

CI: inability to stand or sit upright for at least 30 minutes (60 minutes for Boniva), difficulty swallowing, esophageal stricture, or at high risk for aspiration, hypocalcemia (correct first before giving bisphosphonate).

Warning: atypical femur fracture, esophageal cancer, osteonecrosis of the jaw (ONJ), bone/joint/muscle pain, esophagitis, hypocalcemia must be corrected prior to use, caution with CrCl <35

SE: hypocalcemia, musculoskeletal pain, abdominal pain, dyspepsia, nausea, vomiting, heartburn, esophagitis, skin rash, eye inflammation

Alendronate (Fosamax, Binosto): WEEKLY, PO

Risedronate (Actonel, Atelvia): WEEKLY, PO

Ibandronate (Boniva): MONTHLY, PO & IV

Zoledronic acid (Reclast): YEARLY, IV

IV only: CI in CrCl <30-35, warning (kidney injury and death can occur due to kidney failure), SE (transient post-dose syndrome TPS = flu-like symptoms on day 2-3 such as achiness, runny nose and headache – can take NSAIDs or APAP prior and after)

31

The pharmacist is reviewing a prescription for generic alendronate for an elderly female who lives in a skilled nursing facility. Choose the correct statement:

A. This formulation comes with vitamin D; supplemental vitamin D is not required.
B. She will require adequate vitamin D with this medication.
C. She likely gets adequate vitamin D from sunlight.
D. She does not require calcium with this medication.
E. The brand name for this medication is Actonel.
 

B. A patient using any of the bisphosphonates for low bone density should be obtaining adequate calcium and vitamin D.

32

Ann is an 82 year-old female patient with very low bone density. Which of the following represent options for improving bone density and reducing the risks of falls? (Select ALL that apply.)

A. Loop diuretics such as furosemide
B. Weight bearing exercise, such as walking
C. Ensuring adequate calcium and vitamin D
D. Bisphosphonates, teriparatide hormone
E. Steroids
 

B, C, D. Osteoporosis is usually treated with medications, weight-resistant exercise (such as walking) and adequate calcium and vitamin D.

Drugs that lower bone density: steroids, depot medroxyprogesterone, anticonvulsants (carbamazepine, fosphenytoin, phenobarbital, phenytoin, primidone), heparin, lithium, excess thyroid hormone, loop diuretic, aromatase inhibitors used for breast cancer, nafarelin (Synarel) for endometriosis, androgen blockers used for prostate cancer, proton pump inhibitors used chronically because they decrease calcium absorption (need acidity for Ca for absorption), thiazolidinediiones (pioglitazone, rosiglitazone), SSRIs

33

A patient uses ibandronate. This medication is usually administered in the following formulation:

A. Daily tablet
B. Weekly tablet
C. Monthly tablet
D. Yearly infusion
E. Patch
 

C. Ibandronate (Boniva) also comes in an injection, but most patients use the monthly oral dose of 150 mg.

Alendronate (Fosamax, Binosto): WEEKLY, PO

Risedronate (Actonel, Atelvia): WEEKLY, PO

Ibandronate (Boniva): MONTHLY, PO & IV

Zoledronic acid (Reclast): YEARLY, IV

IV only: CI in CrCl <30-35, warning (kidney injury and death can occur due to kidney failure), SE (transient post-dose syndrome TPS = flu-like symptoms on day 2-3 such as achiness, runny nose and headache – can take NSAIDs or APAP prior and after)

Bisphosphonates

CI: inability to stand or sit upright for at least 30 minutes (60 minutes for Boniva), difficulty swallowing, esophageal stricture, or at high risk for aspiration, hypocalcemia (correct first before giving bisphosphonate).

Warning: atypical femur fracture, esophageal cancer, osteonecrosis of the jaw (ONJ), bone/joint/muscle pain, esophagitis, hypocalcemia must be corrected prior to use, caution with CrCl <35

SE: hypocalcemia, musculoskeletal pain, abdominal pain, dyspepsia, nausea, vomiting, heartburn, esophagitis, skin rash, eye inflammation

34

Which of the following statements concerning denosumab are correct? (Select ALL that apply.)

A. Denosumab is used for hypercalcemia of malignancy in the formulation called Aredia.
B. The brand name for denosumab, when used for high risk patients with osteoporosis, is Prolia.
C. Denosumab can raise serum calcium levels; calcium should be checked prior to initiation of therapy.
D. Denosumab is administered every six months, in a medical office.
E. Denosumab is a monoclonal antibody that prevents osteoclast formation; osteoclasts break down bone.
 

B, D, E. Denosumab is used for hypercalcemia of malignancy in the formulation called Xgeva. Denosumab can lower serum calcium levels; calcium should be checked prior to initiation of therapy.

Denosumab (Prolia, Xgeva): monoclonal atnibody that binds to RANKL and prevents interaction between RANKL and RANK (a receptor on osteoclasts), preventing osteoclast formation. SQ injection every 6 months in MD's office. CI: hypocalcemia. Warning: osteonecrosis of the jaw, atypical femur fractures, serious infections, dermatitis, bone/muscle/joint pain. SE: back pain, limp pain, eczema, rash, hypocalcemia, increased serum cholesterol, pregnancy (X)

35

What is the percentage of elemental calcium in a calcium citrate tablet?

A. 15%
B. 18%
C. 21%
D. 28%
E. 40%
 

C. This means that for each 1000 mg there are 210 mg of elemental calcium in a calcium citrate tablet.

36

Esther had a history of breast cancer at age 42. She is entering the perimenopause and is asking for an agent for relief of hot flashes. Her only known medical condition has been "mild depression that comes and goes" and dry skin. Which of the following agents are contraindicated in this patient? (Select ALL that apply.)

A. Raloxifene
B. Femring
C. Climara
D. Brisdelle
E. Premphase
 

B, C, E. All estrogens are contraindicated with cancers of the breast or reproductive tract (cervical/endometrial, vaginal) and in liver cancer. In actual practice, the vaginal formulations (creams, Estring) may be used but they are technically contraindicated. If used, it is for local (vaginal) symptoms.

Femring (estradiol acetate)

Climara (estradiol transdermal)

Premphase (conjugated estrogens/medroxyprogesterone)

37

A patient asks her pharmacist what to expect when she begins menopause. What is the characteristic symptom of menopause?

A. Hot flashes
B. Night sweats
C. It varies from woman to woman
D. Mood swings
E. Insomnia
 

C. As some women feel little or no symptoms, not every woman will require treatment. In previous days, menopause was looked at as a "disease" that required treatment. Now, it is seen more as a stage of life.

38

Maria is a 60 year-old post-menopausal female who is overweight and sedentary. Last year, while taking a five hour cross-country flight, Maria developed a deep vein thrombosis (DVT). This was her second DVT in two years. She has refused warfarin, but agreed to use an aspirin daily. Aspirin is her only medication. Recently, Maria’s sister was diagnosed with breast cancer. During the work-up, Maria’s sister was found to have low bone density. Maria is inquiring if she can use raloxifene, which she heard might protect her against breast cancer and will help her build strong bones. Choose the correct statement:

A. The brand name of raloxifene is Aromasin.
B. The brand name of raloxifene is Femara.
C. She is contraindicated for raloxifene due to the DVT history.
D. She is contraindicated for raloxifene due to breast cancer risk.
E. She is contraindicated for raloxifene due to her age.
 

C. Raloxifene (Evista) has an increased risk for thromboembolism. Women with active or past history of venous thromboembolism cannot use this medication.

Raloxifene (Evista): SERM (selective estrogen receptor modulator), think estrogen SE such as clots and other cardiovascular complication. SE: hot flashes, peripheral arthralgia, peripheral edema, pregnancy (X), affects INR. Would not recommend in postmenopausal patient who have hot flash.

39

Lilly is a 49 year-old female who went to her physician complaining of hot flashes, depression and irritability. She started feeling this way about six months ago and states she "can't shake her mood." The physician took blood tests and confirmed that Lilly is in the perimenopause. He prescribed Vivelle-DOT. Choose the correct statement concerning Vivelle-DOT.

A. Vivelle-DOT contains conjugated equine estrogens.
B. Vivelle-DOT is an oral formulation.
C. Vivelle-DOT is applied twice weekly.
D. Vivelle-DOT contains a progestin; if she has a uterus she will not need a separate progestin.
E. Vivelle-DOT is known to be more dangerous in cardiovascular risk than Premarin.
 

C. Vivelle-DOT contains estradiol in a transdermal patch. Estradiol, the hormone in Vivelle-DOT, is produced naturally by human females (rather than the estrogens in Premarin, which were produced by pregnant mares). The patch is applied twice weekly, such as Sun/Wed or Mon/Thur.

Formulation Considerations:

Intravaginal (topical) products are preferred for patients who have vaginal symptoms only such as vaginal dryness and painful intercourse. Treats LOCAL symptoms

Estrogen cream: conjugated estrogens (Premarin), estradiol (Estrace, Estrasorb)

Vaginal estrogen ring (Estring): releases estrogen for 3 months

Vaginal estradiol tablet (Vagifem): inserted into vagina twice per week

Estradiol patch (Vivelle Dot): applied twice a week and rotate sites.

40

What percentage of elemental calcium is present in calcium carbonate tablets?

A. 15%
B. 18%
C. 21%
D. 23%
E. 40%
 

E. This means that for each 1000 mg there are 400 mg of elemental calcium in a calcium carbonate tablet.

41

In 2012 the osteoporosis treatment guidelines were updated. Which of the following statements are correct regarding the latest update? (Select ALL that apply.)

A. Estrogen contraindications include any history of clotting, including heart attack and stroke, and any history of estrogen-dependent cancer.
B. Estrogen use typically decreases HDL and increases triglycerides.
C. Due to the risk of atypical femur fracture and osteonecrosis of the jaw, the use of bisphosphonates is limited to 3-5 years.
D. After the bisphonates are discontinued the patient should be switched to a different class of agent.
E. Rather than use a bisphosphonate early, a younger woman with low DVT risk and no related cancer risk could use estrogen until she was older and, consequently, at a higher risk of clotting.
 

A, C, D, E. Due to the risk of atypical femur fracture (a very difficult break) and osteonecrosis of the jaw, the use of bisphosphonates is limited to 3-5 years. Estrogen use typically increases HDL and may increase triglycerides.

42

Mary is a 54 year-old female who suffers from dry, painful intercourse. This started about a year ago after she underwent a total hysterectomy. The following drug may provide benefit and would reduce her exposure to systemic estrogen:

A. Prempro
B. Premphase
C. Vivelle-Dot
D. Climara
E. Estring
 

E. Vaginal products are most useful for patients who have vaginal symptoms (dryness, painful intercourse) only, since these do not expose the women to risks from systemic estrogen. Estring, a vaginal ring that releases estradiol would provide local benefit.

conjugated estrogens/medroxyprogesterone (Prempro/Premphase)

estradiol transdermal (Climara)

Formulation Considerations:

Intravaginal (topical) products are preferred for patients who have vaginal symptoms only such as vaginal dryness and painful intercourse. Treats LOCAL symptoms

Estrogen cream: conjugated estrogens (Premarin), estradiol (Estrace, Estrasorb)

Vaginal estrogen ring (Estring): releases estrogen for 3 months

Vaginal estradiol tablet (Vagifem): inserted into vagina twice per week

Estradiol patch (Vivelle Dot): applied twice a week and rotate sites.

43

Which of the following medications put a patient at increased risk for falls (and consequently) injury and fractures? (SelectALL that apply.)

A. Lortab
B. Soma
C. Loratidine
D. Celexa
E. Armodafinil
 

A, B, D. Many drugs can increase the risk for falls, including pain medications, skeletal muscle relaxants, hypnotics and anxiolytics (including benzodiazepines) and many antidepressants and antipsychotics. Vitamin D may reduce the risk of falls and fractures.

44

The Women’s Health Initiative Trial exposed increased risks of certain health conditions with the use of hormone therapy. The risks included an increase in the following in older women: (Select ALL that apply.)

A. Myocardial infarction
B. Brain tumors
C. Stroke
D. Liver cancer
E. Multiple sclerosis
 

A, C. As the data was reanalyzed, it became apparent that the majority of risk was highest in older women. As a woman ages the estrogen should be replaced with an alternative agent.

45

Sandra has rheumatoid arthritis, hypertension, dyslipidemia and chronic renal disease. She uses the following medications: etanercept weekly, methotrexate weekly, prednisone daily, atorvastatin and enalapril. Which of Sandra's medications puts her at the highest risk for low bone density?

A. Etanercept
B. Methotrexate
C. Prednisone
D. Atorvastatin
E. Enalapril
 

C. Additional risk factors for low bone density include advanced age, more than two alcoholic drinks per day, oral or intramuscular glucocorticoid use (such as prednisone (or equivalent dose of another systemic steroid) taken for 3 months or longer at a dose of 5 mg or more daily.

Drugs that lower bone density: steroids, depot medroxyprogesterone, anticonvulsants (carbamazepine, fosphenytoin, phenobarbital, phenytoin, primidone), heparin, lithium, excess thyroid hormone, loop diuretic, aromatase inhibitors used for breast cancer, nafarelin (Synarel) for endometriosis, androgen blockers used for prostate cancer, proton pump inhibitors used chronically because they decrease calcium absorption (need acidity for Ca for absorption), thiazolidinediiones (pioglitazone, rosiglitazone), SSRIs

46

A prescriber is asking for information about the Reclast injection. (Select ALL that apply.)

A. Reclast contains the same active ingredient as Zometa.
B. Reclast contains the same active ingredient as Aredia.
C. Many patients feel sick for a few days after the injection, with flu-like symptoms.
D. Unlike the other bisphosphonates, it is safer (and acceptable) to use in severe renal insufficiency.
E. The primary use of Reclast is in patients who cannot tolerate an oral bisphosphonate.
 

A, C, E. There are not GI issues as the gut is bypassed. Many patients (up to 40%) will experience the transient post-dose syndrome (TPS) and feel sick for a few days afterwards, with symptoms similar to the flu. Zometa and Aredia are bisphosphonate injections used for hypercalcemia associated with a malignancy. Bisphosphonates are not used in severe renal insufficiency.

Alendronate (Fosamax, Binosto): WEEKLY, PO

Risedronate (Actonel, Atelvia): WEEKLY, PO

Ibandronate (Boniva): MONTHLY, PO & IV

Zoledronic acid (Reclast, Zometa): YEARLY, IV

IV only: CI in CrCl <30-35, warning (kidney injury and death can occur due to kidney failure), SE (transient post-dose syndrome TPS = flu-like symptoms on day 2-3 such as achiness, runny nose and headache – can take NSAIDs or APAP prior and after)

47

Rita will use an estrogen patch for hormone replacement therapy. Counseling points should include: (Select ALL that apply.)

A. If you are using estrogen, such as with this patch medication, you do not need to use calcium or vitamin D.
B. The patch can be used safely for the rest of your life; it helps reduce the effects of aging, as well as helping with hot flashes and bone density.
C. The use of this patch can help keep your bones healthy too.
D. The area where you apply the patch must be clean, dry, free of powder, oil or lotion.
E. Make sure you are taking adequate calcium and vitamin D to help your bones stay strong.
 

C, D, E. Make sure that patients are using adequate calcium and vitamin D. Never apply estrogen to breasts.

48

The Institute of medicine and the National Institutes of Health recommend this daily vitamin D dose for adults 71 years and older:

A. 200 IU daily
B. 600 IU daily
C. 800 IU daily
D. 1000 IU daily
E. 1500 IU daily
 

C.

Vitamin D recommendation: Age 0-70 (600 IU daily), Age 71 and up (800 IU daily)

49

A woman is going through perimenopause and gets what she describes as "waves of heat" that leave her sweaty. At night she sometimes wakes up sweaty. This is surprising as for most of her life she was usually cold at night. Select the correct statements below. (Select ALL that apply.)

A. Estrogen decreases in the perimenopause as estradiol, from the ovaries, is becoming depleted.
B. When the estrogen level is low, a rise in luteinizing hormone occurs.
C. The increase in luteinizing hormone causes disruption in the woman's temperature control system in the brain.
D. Luteinizing hormone causes an increase in progesterone.
E. An increase in progesterone puts women at risk for uterine cancer during the menopause.
 

A, B, C.

50

Ann is an 82 year-old female patient. Her T-scores were -4.2 in the lower spine and -3.4 in the left hip. Which condition is indicated by the patients T-scores?

A. No condition can be determined with this information.
B. She has osteopenia.
C. She has osteoporosis.
D. She has Marfan syndrome.
E. She has Guillain-Barre Syndrome.
 

C. The patient has osteoporosis, which is defined by a T-score

51

Cathy is a 42 year old Hispanic female with a 10-year history of anorexia nervosa. She is 5 feet, 6 inches tall and weighs 111 pounds. Cathy is a nervous person who states that she smokes a cigarette whenever she needs to calm her nerves. She has little calcium in her diet. She says she has had a bad sunburn once and she avoids the sun. She does not take any medications or supplements. Which risk factors for osteoporosis are present in this patient? (Select ALL that apply.)

A. Low calcium and vitamin D intake
B. Low body mass index
C. Ethnicity
D. Smoking
E. History of anorexia nervosa
 

A, B, D, E. Risk factors for osteoporosis present in this patient include thinness (body weight < 127 pounds or low BMI < 21 kg/m2), low calcium and vitamin D intake (long-term) and smoking. Anorexia puts the patient at a similar state to the perimenopausal period, which is high-risk for bone density loss. Ethnicity is a risk factor if Caucasian or Asian.

Risk factors: Caucasian and Asian American women, advanced age, low bone mineral density (T-score), previous fracture as an adult after age 50, more than 2 alcoholic drinks per day, oral or IM glucocorticoid (such as prednisone) for >3 months at dose of 5mg, body weight <127 pound or low BMI <21, decline in adult estrogen levels from menopause, anorexia nervosa, lactation, hypogonadism, rheumatoid arthritis and Lupus, low level of physical activity, smoking, calcium and vitamin D deficiency.

52

Carla is having trouble swallowing her alendronate 70 mg weekly medication due to very dry mouth. What should the pharmacist suggest?

A. Take the medication with food.
B. Crush the tablet and mix with a small amount of applesauce (approximately one teasponful).
C. Take after eating something bready and with a full glass of water.
D. Discuss switching to a bisphosphonate injection, given once yearly.
E. Switch to monthly ibandronate for improved tolerability.
 

D. Plain water only-not mineral water or anything else. Notice the counseling must say at least 30 minutes (longer would let more of the drug get absorbed). The bisphosphonates are very irritating to the GI tract and cannot be crushed or chewed.

Bisphosphonates

CI: inability to stand or sit upright for at least 30 minutes (60 minutes for Boniva), difficulty swallowing, esophageal stricture, or at high risk for aspiration, hypocalcemia (correct first before giving bisphosphonate).

Warning: atypical femur fracture, esophageal cancer, osteonecrosis of the jaw (ONJ), bone/joint/muscle pain, esophagitis, hypocalcemia must be corrected prior to use, caution with CrCl <35

SE: hypocalcemia, musculoskeletal pain, abdominal pain, dyspepsia, nausea, vomiting, heartburn, esophagitis, skin rash, eye inflammation

Alendronate (Fosamax, Binosto): WEEKLY, PO

Risedronate (Actonel, Atelvia): WEEKLY, PO

Ibandronate (Boniva): MONTHLY, PO & IV

Zoledronic acid (Reclast, Zometa): YEARLY, IV

IV only: CI in CrCl <30-35, warning (kidney injury and death can occur due to kidney failure), SE (transient post-dose syndrome TPS = flu-like symptoms on day 2-3 such as achiness, runny nose and headache – can take NSAIDs or APAP prior and after)

53

Doris is a 75 year-old female who has been prescribed weekly alendronate for osteoporosis. Which dosing is required?

A. Alendronate 70 mg once weekly
B. Alendronate 10 mg once weekly
C. Alendronate 35 mg once weekly
D. Alendronate 5 mg once weekly
E. Alendronate 150 mg once weekly
 

A. The dosing for osteoporosis is 10 mg daily or 70 mg weekly.

Px dose: 5mg daily or 35mg weekly

54

A patient gave the pharmacist a prescription for Prempro. Which of the following is an appropriate generic substitution forPrempro?

A. Conjugated estrogens
B. Ethinyl estradiol, conjugated
C. Medroxyprogesterone acetate
D. Estriol, synthetic
E. Conjugated estrogens/medroxyprogesterone
 

E. The generic name for Prempro is conjugated estrogens/medroxyprogesterone.

55

What is the most common application site for the Vivelle-Dot and most estrogen patches?

A. Hip
B. Lower abdomen
C. Buttocks
D. Upper thigh
E. Back
 

B.

56

Identify the application site for the low testosterone (low "T") product Natesto.

A. Underarms
B. Upper arms
C. Nares
D. Shoulders
E. Abdomen
 

C. Application to the nasal passages or the underarms or inside of the thighs reduces the risk of accidental exposure of the testosterone to others. Natesto is applied to the nasal passages, but, unfortunately, requires TID application. It comes with a nasal applicator.

Testosterone application location:

AndroGel 1%, 1.62%: upper arms, shoulders, abdomen (1% only) QD

Vogelxo gel: upper arms, shoulders QD

Axiron solution: underarms QD

Fortesta gel: thighs QD

Natesto gel: nostril TID

57

Select the correct statement regarding low testosterone treatment in older males:

A. Males should be routinely treated with testosterone since lower testosterone is a normal part of the aging process.
B. A benefit to testosterone treatment is improved benign prostatic hyperplasia (BPH) symptoms.
C. Certain men find that using exogenous testosterone can improve their appearance, vigor and/or sexual performance; not all have these benefits.
D. The use of testosterone lowers clotting risk in older men.
E. Low testosterone is called hypergonadism.
 

C. Low testosterone is called hypogonadism. Testosterone treatment is likely to worsen benign prostatic hyperplasia (BPH) symptoms; this is a warning for the use of testosterone. Testosterone should not be used in males with severe BPH symptoms.

Testosterone: Boxed warning: secondary exposure to testosterone in children and women, can lead to virilization in children, women and children should avoid contact with any unwashed or unclothed application sites in men using testosterone gel. CI: breast or prostate cancer. Warning: men with BPH treated with androgens are at increased risk for worsening signs and symptoms, increased risk of thromboembolic events (DVT, PE), never apply to breast or genitals. SE: increased appetite, increase SCr, sensitive nipples, acne, gynecomastia, dyslipidemia, edema, increase PSA, increase hepatoxicity, reduced sperm count, sleep apnea.

58

The Drug Enforcement Administration has placed topical testosterone products into this scheduled category:

A. C-I
B. C-II
C. C-III
D. C-IV
E. C-V
 

C. Testosterone topical formulations are C-III. Estrogen topical formulations are not scheduled.

Testosterone: Boxed warning: secondary exposure to testosterone in children and women, can lead to virilization in children, women and children should avoid contact with any unwashed or unclothed application sites in men using testosterone gel. CI: breast or prostate cancer. Warning: men with BPH treated with androgens are at increased risk for worsening signs and symptoms, increased risk of thromboembolic events (DVT, PE), never apply to breast or genitals. SE: increased appetite, increase SCr, sensitive nipples, acne, gynecomastia, dyslipidemia, edema, increase PSA, increase hepatoxicity, reduced sperm count, sleep apnea.

59

Identify the common ingredient in Natesto, Axiron, Vogelxo and AndroGel:

A. Estrone topical gel
B. Testosterone topical gel
C. Estradiol topical gel
D. Estriol topical gel
E. Estrogen/testosterone topical gel
 

B. AndroGel is a popular product for "low T" in older men. Other pharmaceutical companies hope to pull away market share.

Testosterone: Boxed warning: secondary exposure to testosterone in children and women, can lead to virilization in children, women and children should avoid contact with any unwashed or unclothed application sites in men using testosterone gel. CI: breast or prostate cancer. Warning: men with BPH treated with androgens are at increased risk for worsening signs and symptoms, increased risk of thromboembolic events (DVT, PE), never apply to breast or genitals. SE: increased appetite, increase SCr, sensitive nipples, acne, gynecomastia, dyslipidemia, edema, increase PSA, increase hepatoxicity, reduced sperm count, sleep apnea.

60

What is the rationale behind the flurry of recent low testosterone (low "T") products entering the marketplace over the past couple of years?

A. Females using testosterone
B. High school boys using testosterone
C. Formulations that enable alternate application sites
D. Higher drug concentrations of testosterone
E. Lower drug concentrations of testosterone
 

C. Formulations that enable alternate application sites reduce the risk of accidental exposure to testosterone.

Testosterone: Boxed warning: secondary exposure to testosterone in children and women, can lead to virilization in children, women and children should avoid contact with any unwashed or unclothed application sites in men using testosterone gel. CI: breast or prostate cancer. Warning: men with BPH treated with androgens are at increased risk for worsening signs and symptoms, increased risk of thromboembolic events (DVT, PE), never apply to breast or genitals. SE: increased appetite, increase SCr, sensitive nipples, acne, gynecomastia, dyslipidemia, edema, increase PSA, increase hepatoxicity, reduced sperm count, sleep apnea.

Testosterone application location:

AndroGel 1%, 1.62%: upper arms, shoulders, abdomen (1% only) QD

Vogelxo gel: upper arms, shoulders QD

Axiron solution: underarms QD

Fortesta gel: thighs QD

Natesto gel: nostril TID

61

Osphena is a new drug indicated for dyspareunia. Due to clotting risk present with this drug, it should only be used with the following presentation:

A. Cervical cancer
B. Mild symptoms only from painful intercourse due to menopause
C. Moderate to severe painful intercourse due to menopause
D. Breast cancer
E. Hot flashes/night sweats
 

C. This drug would only be warranted if the symptoms were more severe; topical agents are safer and may suffice.

Ospemifene (Osphena): an oral SERM indicated for dyspareunia (painful intercourse). Topical vaginal products are safer for this purpose. Boxed warning: VTE risk and is not indicated for mild symptoms. Only for short term treatment of moderate-to-severe symptoms.

62

Identify the application site for the low testosterone (low "T") product Axiron:

A. Shoulders
B. Abdomen
C. Underams
D. Nares
E. Upper arms
 

C. Application to the underarms reduces the risk of accidental exposure of the testosterone to others.

Testosterone application location:

AndroGel 1%, 1.62%: upper arms, shoulders, abdomen (1% only) QD

Vogelxo gel: upper arms, shoulders QD

Axiron solution: underarms QD

Fortesta gel: thighs QD

Natesto gel: nostril TID

63

Osphena is an oral Selective Estrogen Receptor Modulator (SERM) indicated for the following condition:

A. Vasomotor symptoms
B. Breast cancer prevention
C. Dyspareunia
D. Low serum testosterone
E. Low serum luteinizing hormone
 

C. Ospemifene (Osphena) is indicated for painful intercourse. All SERMs carry clotting risk and these are used in older patients.

Ospemifene (Osphena): an oral SERM indicated for dyspareunia (painful intercourse). Topical vaginal products are safer for this purpose. Boxed warning: VTE risk and is not indicated for mild symptoms. Only for short term treatment of moderate-to-severe symptoms.

64

Which of the following formulations contains estrogen plus a progestin? (Select ALL that apply.)

A. Premphase
B. Prempro
C. Combipatch
D. EstroGel
E. Climara
 

A, B, C. It should be possible to figure out this question by analyzing the drug names.

Birth Control Nomenclature:

0.5/35 (or similar), usually called monophasic formulation (progestin/estrogen)

Tri or 7/7/7 or Cycl-, triphasic formulation (multiphasic)

Lo, low estrogen <35mcg (when you go below this, there could be spotting because estrogen maintains endometrium lining)

Fe, contains iron

Progestin only, often have "nor" in the name for norethindrone or "pro" found in HRT products for progestin

65

A patient will begin to use Axiron. Counseling should include the following points:

A. Apply deodorant first (prior to Axiron).
B. Apply to the nasal passages with the enclosed applicator.
C. Wait at least 15 minutes before showering after applying the drug.
D. This drug contains topical estradiol therapy.
E. This drug can help treat hot flashes.
 

A. Axiron is applied to the underarms. Deodorant is applied first. Like other topical testosterone gels it is flammable until dry.

Testosterone application location:

AndroGel 1%, 1.62%: upper arms, shoulders, abdomen (1% only) QD

Vogelxo gel: upper arms, shoulders QD

Axiron solution: underarms QD

Fortesta gel: thighs QD

Natesto gel: nostril TID

66

KM is a 58 year-old female with complaints of dry, painful intercourse. She reports this condition began when she was finished with her periods. KM has a history of one pregnancy and one DVT (during the pregnancy). She has no known other medical conditions except for intermittent eczema. Which of the following options would be best to help KM manage this condition?

A. Osphena
B. Premarin topical cream
C. Estring
D. Replens
E. Premarin oral tablets
 

D. Ospemifene (Osphena) and any form of estrogen is contraindicated with clotting history. She may be able to find satisfactory relief with a topical lubricant.

67

Which of the following hormone formulations used for vasomotor symptoms should be recommended as monotherapy in a female who has a uterus?

A. Premarin
B. Estraderm
C. Vivelle-Dot
D. ClimaraPro
E. Climara
 

D. Unopposed estrogen therapy in women with a uterus is dangerous and is a boxed warning. "Pro" indicates a progestin is included; this is not always the case, but is with this drug name.

68

AndroGel comes in 1% and 1.62% strengths. Each can be applied to clean, dry skin on the shoulders or upper arms. In addition, the lower strength only (1%) can be applied to this additional location:

A. The back
B. The buttocks
C. The breasts
D. The abdomen
E. The hips
 

D. The upper strength (1.62%) is not applied to the abdomen, but because it is a higher concentration (delivers more drug) this should not be necessary. Each time the pump is pressed the drug is applied to a different location.

Testosterone application location:

AndroGel 1%, 1.62%: upper arms, shoulders, abdomen (1% only) QD

Vogelxo gel: upper arms, shoulders QD

Axiron solution: underarms QD

Fortesta gel: thighs QD

Natesto gel: nostril TID

69

Which of the following drugs or conditions can lower testosterone? (Select ALL that apply.)

A. Cimetidine
B. Methadone
C. Coreg
D. Normal aging process
E. Effexor
 

A, B, D. Spironolactone can lower testosterone.

Drugs that decrease testosterone levels: methadone, chemotherapy used for prostate cancer, cimetidine, spironolactone.

Decks in Pharmacy Class (61):