Bones

Question 1

Denosumab

1. Drug class
2. Indication
3. Dosage range, Frequency and best admin time
4. Monitoring
5. Counselling

Answer 1

1. Monoclonal antibody
2. OP, increase BMD in prolonged steroid use, hypercalcaemia of malignancy.
3. 60mg/1mL = Prolia - OP and BMD- every 6 months
   120mg/1.7mL - Xgeva - 120mg Q4weeks w/extra doses on Day 8&15 of the initial 4 week cycle.
4. BMD
   - ca2+
   - vit D
   - Monitor plasma Ca2+ - severe hypocalcaemia can result esp at start of tx.
   Supplementation of Ca and VitD
   Renal fn - dose reduce <30mL/min increased risk of hypoCa2+
   Preg - C/I - teratogenic!!
   Cholesterol/lipid levels - commonly causes hypercholestrolaemia.
   After stopping =
   - consider starting alt therapy
   - rebound hyperCa2+ in giant cell tumour
   IF low Ca2+ correct before giving it.
   Osteonecrosis of the jaw
   Consider full dental assessment and complete any dental procedures before starting denosumab to minimise risk; ensure wounds from dental or oral surgery are healed before starting treatment. Risk appears to be dose-related.
5. Supplementation of Ca and VitD
   Ensure adequate contraception for women and for 5 months afterwards.
   There may be rare complications with some dental procedures in people taking denosumab; tell your doctor if you require any dental work and tell your dentist that you are taking this medicine (or have taken it in the past).

Tell your doctor if you have symptoms of low blood calcium (eg muscle spasms, twitches, cramps, numbness or tingling in fingers, toes or around your mouth).

Pts at increased risk for hypocalcaemia:
renal impair, dialysis, hx of hypoparathyroidism, parathyroid or thyroid surgery, GI disease which may impair calcium absorption.

Question 2

Aledronate (Fosamax), Risedronate (Actonel)

1. Drug class
2. Indication
3. Dosage range, Frequency and best admin time
4. Monitoring
5. Counselling

Answer 2

1. Bisphosphonates
2. OP, Pagent’s Disease (risedronate only avail in correct strength), hypercalcaemia of malignancy (Zolendronic Acid ONLY)
3. Aledronate: 70mg ONCE WEEKLY, in combo with 70/140microg of colecalciferol and calcium 500mg on every other day.
   Risedronate: pagents disease: 30mg ONCE DAILY FOR 2 MONTHS.
   OP: 5mg ONCE DAILY or 35mg ONCE WEEKLY or 150mg ONCE A MONTH (Actonel Once A Month).
   Zolendronic Acid = 4mg IV infusion
4. BMD
   - ca2+
   - vit D
   Ca2+ - hypocalcaemia - C/I to start therapy
   osteonecrosis of the jaw
   C/I
   - inability to sit upright or stand for at least 30 minutes
   - oesophageal disorders
   - upper GI conditions (eg: dysphagia), concomitant use of NSAIDs - increases risk of oesophageal S/Es.
   Renal fn - not recommended in reduced renal fn
   Zolendronic Acid - drink at least 2 glasses of water before and after infusion.
5. Swallow whole, do not suck/chew.
   Take on empty stomach 30mins before food/drink (except plain water). (EC tabs can be taken wfood)
   Sit upright/stand for at least 30 minutes after taking this medicine.
   LABEL 4a within 30 minutes for alendronate.
   Stop tablets and see Dr immediately is you have pain on swallowing, new or worsening heartburn, musculoskeletal pain (may rarely be severe and/or disabling). - worst with alendronate
   Headache, gastric discomfort (diarrhoea, N&V), hypocalcaemia. Rare alopecia.

MONTHLY DOSING: same date of each month. If you miss a dose and your next monthly dose is
- >7days away, take it the next morning then return to taking it on normal date
- within 7 days, wait until next dose and keep taking it on normal date
DO NOT TAKE 2 TABLETS IN ONE WEEK!

Question 3

Calcitriol

1. Drug class
2. Indication
3. Dosage range, Frequency and best admin time
4. Monitoring
5. Counselling

Answer 3

1. Vitamin D
2. Tx of hypocalcaemia in hypoparathyroidism, hypophosphataemic rickets, OP- rarely used for this
3. 0.25-1microg OD
4. Monitor:
   - Plasma Ca2+ conc at baseline, twice during week 1, at 2-4 weeks, then every 2-3 months, more often if clinically indicated.
   - Urinary Ca2+ and phosphate conc periodically.
   - more frequently in immobilised ppl and renal impairment.
   Stop tx immediately if hypercalcaemia occurs.
5. Do not take Ca2+ supplements while taking this unless your dr tells you to.
   Dr’s dietary advice, changes in diet (diary) can increase Ca.
   Tell Dr if NandV, constipation, h/ache, frequent urination, thirst or tiredness develop.

Question 4

Colecalciferol

1. Drug class
2. Indication
3. Dosage range, Frequency and best admin time
4. Monitoring
5. Counselling

Answer 4

1. Vitamin D
2. VitD deficiency, OP w/Ca2+/alendronate
3. 75-125microg (3000-5000U) daily for 6-12/52, then 25-50microg (1000-2000U) OD.
4. Wait at least 3 months before retesting serum vitD levels.
   Avoid in severe renal impairment.
   Obesity - may need higher doses.
   Preg&bfeed- safe at physiological doses
5. Oral liquid has several strengths, select carefully.

Question 5

Calcitonin Salmon

1. Drug class
2. Indication
3. Dosage range, Frequency and best admin time
4. Monitoring
5. Counselling

Answer 5

1. Calcitonin agonist
2. Pagent’s, hypercaleamia
3. 50-100 units subcut/IM daily for 3-6 months
4. Ca2+
   Antibodies may develop after prolonged tx.
5. S/Es: flushing, N&V, dizziness, taste disturbance, flu-like smx, paraesthesia - COMMONLY LAST FOR 1-2 HOURS

Question 6

Calcium

1. Drug class
2. Indication
3. Dosage range, Frequency and best admin time
4. Monitoring
5. Counselling

Answer 6

2. Hypocalcaemia, hyperphosphataemia in renal failure, severe hyperkalaemia NOT due to digoxin toxicity.
3. 1300mg daily.
   500mg and 600mg
   chewable, dispersible, swallow whole
4. Ca2+ conc.
   PPI may reduce clinical effect of calcium.
   Milk-alkali syndrome - too much Ca2+, N&V, life-threatening
   Tx w/calcitriol increases risk of hypercalaemia.
   Tx wiht digoxin - no IV Ca2+ bc increased risk of arrhythmia.
5. Constipation, farts, abdo distension, belching.
   Ca2+ Carbonate TAKE WITH FOOD.
   Importance for bone health.

Question 7

Cinacalcet

1. Drug class
2. Indication
3. Dosage range, Frequency and best admin time
4. Monitoring
5. Counselling

Answer 7

1. Increase sensitivity of Ca2+sensing receptors on the parathyroid gland to extracellular Ca2+, thus reducing secretion of parathyroid hormone and reducing serum Ca2+ conc.
2. Hypercalcaemia, primary and secondary hyperparathyroidism
3. 30mg BD, increase every 2-4 weeks if necessary to 60mg BD, then 90mg BD, up to max 90mg 3-4 times d.
   2ndary: 30mg OD, increase every 2-4 weeks, if necessary, to a max of 180mg OD.
4. • Tobacco smoking - increases CL of cinacalcet.
     - Ca2+ serum conc - at baseline, within 1 week of starting or adjusting dose, montly once maintainence dose achieved.
     - Parathyroid 1-4 weeks after start or adjust and thyroid levels. - wait 12 hours after dose before taking blood levels.
     - Smx of hypocalcaemia - paraesthesia, myalgia, cramping, tetany, siezures.
5. Tell dr if you stop or start tobacco smoking as your dose may need to be adjusted.
   Take w/food to increase absorption.
   Smx of hypocalcaemia - paraesthesia, myalgia, cramping, tetany, siezures.

Question 8

Raloxifene

1. Drug class
2. Indication
3. Dosage range, Frequency and best admin time
4. Monitoring
5. Counselling

Answer 8

1. Oestrogen receptor modulator
2. Prev and tx of post-menop OP. Primary prev of breastCa.
3. 60mg OD
4. VTE - C/I in prev hx, prolonged immobilisation, CHD
   Increased risk of hypertiglyceridaemia in prev hx of high levels from oestrogens.
   C/I - in preg and breastfeeding, teratogenic.
5. labels: 21, A
   This medicine can cause hot flushes (especially during the first 6 months of therapy) and leg cramps.
   VTE - pain swelling in legs tell your dr.
   Ensure adequate intake of VitD and Ca2+.
   If vaginal bleeding occurs contact dr. (Not normal)
   May aggravate hot flushes.

Question 9

Darbepoetin alfa

Answer 9

1. Erythropoietin agonist (Aranesp)
2. Anaemia of chronic renal failure
   Chemo-induced anaemia in non-myeloid malignancy
3. 10microg-150microg weekly to monthly.

4. In CKF: dialysis= check Hb every month, non-dialysis= check Hb at start of tx and after dose adjustment, then every 2 months until stable, then every 2 months
Monitor BP regularly
Manage HTN
Iron
VitB12
Folic acid
and correct deficiencies.

5. Before injecting, hold syringe for a few minutes to warm it (reduces pain)
   LABEL: 6
   H/ache, HTN, hypotension, peripheral oedema, flu-like smx, VTE (MI, TIA, stroke are rare).
   Tell your dr immediately if SOB, rash or any skin reaction.

Question 10

Sevelamer (Renagel)

Answer 10

1. phosphate binder
2. Hyperphosphataemia in chronic renal failure
3. Initially 800-1600mg 3 times a day with each main meal, then adjust dose according to serum phosphate concentration.
4. Monitor serum Cl and bicarbonate levels-Cl from sevelamer may exchange for phosphorus in the intestine.
   Monitor serum phosphate, calcium, ALP and parathyroid hormone concentrations.
   Sevelamer may bind fat-soluble vits ADEK; monitor and give supplements if necessary (give 1 hour before or 3 hours after sevelamer).
   Swallowing or GI surgery/motility disorders – use with caution.
   Safe in breast. Preg no data.
5. Swallow tabs whole.
   You may experience GI upset (N&V, diarrhoea, constipation, flatulence, dyspepsia, abdominal pain) cough, dyspnoea.
   Tell dr if you become constipated or have severe abdominal pain or dark stools/blood – may be a sign of GI bleeding/ulcer/ obstruction/perforation/ileus. Important to maintain the diet discussed w/your dr/dietician and not to eat whatever you want (appropriate restriction of dietary phosphate).