Menopause and Osteoporosis Pharmacology

Question 1

Treatment method for mild vulvovaginal symptoms

Answer 1

vaginal moisturizers or lubricants → alleviate dryness, burning, itching, dyspareuria

Question 2

Treatment method for moderate to severe vulvovaginal symptoms

Answer 2

non-systemic vaginal estrogen product → cream, ring, tablet, insert

Question 3

Oral drugs that is FDA approved for dyspareunia

Answer 3

ospemifene

Question 4

Ospermifenese is a SERM (selective estrogen receptor modulator) and what is the MOA in helping vulvovaginal symptoms ?

Answer 4

activates estrogen pathwaays in some tissues and blocks in others
agonist in endometrium

Question 5

Adverse effects of ospermifenese

Answer 5

may cause vasomotor symptoms

Question 6

what are the estrogen warnings for ospemifene?

Answer 6

endometrial cancer, DVT, stroke

Question 7

vaginal insert that is FDA approved for dyspareunia → “treat painful intercourse due to menopause without FDA boxed safety warning”

Answer 7

prasterone

Question 8

nonpharmacologic methods to treat vasomotor symptoms

Answer 8

wear layers, lower room temperatures, decrease intake of spicy food/caffeine/ hot drinks, exercisse, maintain healthy body weight, don’t smoke, relaxation techniques

Question 9

Treatment of vasomotor symptoms as well as preventing endometrial hyperplasia in a patient with intact uterus?
If they had hysterectomy?

Answer 9

progestin + estrogen

just estrogen

Question 10

In treating vasomotor symptoms, which systemic progesterone product has shown better outcomes - medroxyprogesterone acetate (MPA) or micronized progesterone?

Answer 10

micronized progesterone

Question 11

Tissue selective estrogen complex approved for moderate to severe vasomotor symptoms and prevent osteoporosis

Answer 11

conjugated estrogen + bazedoxifene

Question 12

Nonhormonal products that can be used to treat vasomotor symptoms

Answer 12

SSRI (paroxetine), SNRI (venlafaxine), clonidine, gabapentin

Question 13

How effective are phytoestrogens (plant compounds, soy, flaxseed, alfalfa) and black cohosh?

Answer 13

should not be recommended

Question 14

What is the reality of custom prepared or compounded hormone therapies?

Answer 14

lack evidence regarding safety/efficacy/quality
no support saliva testing for adjustments
same risks as traditional therapies
not FDA supported

Question 15

Lifestyle modifications for healthier bones

Answer 15

< 3 drinks/day, exercise, stop smoking, increase dietary calcium intake, lower caffeine intake

Question 16

Receommended calcium intake in women 51 and older and the upper limit of calcium

Answer 16

1200 mg

2000 mg

Question 17

If your patient is on a PPI what calcium supplement is recommended?

Answer 17

calcium citracte

Question 18

why is taking calcium carbonate (tums) contraindicated in patients taking PPI?

Answer 18

PPI will decrease absorption

Question 19

what is the recommended Vitamin D intake in patients > 70 years?

Answer 19

800 units

4,000 units

Question 20

What are the 3 main sources of vitamin D?

Answer 20

sunlight, diet, supplements

Question 21

what organs are involved in creating the metabolically active form of vitamin D (1,25-dihydroxy)?

Answer 21

liver and kidney

Question 22

What meds increase bone resorption?

Answer 22

glucocorticoids
levothyroxine
SGLT2 inhibitors

Question 23

What meds increase osteoclast and/or decrease osteoblast activity?

Answer 23

antiretrovirals
heparin
thiazolidinediones
vitamin A

Question 24

What meds decrease estrogen and sex hormone concentrations?

Answer 24

GnRH

DMPA

Question 25

Med that increase renal calcium elimination

Answer 25

loop diuretics

Question 26

Med that can cause calcium malabsorption

Answer 26

PPI

Question 27

Med that increases Vitamin D metabolism

Answer 27

anticonvulsants

Question 28

This is used to identify patients at risk for osteoporosis or osteoporotic fractices and to determine if need further evaluation (DXA scan) or pharmacologic intervention

Answer 28

Fracture Risk Assessment Tool (FRAX)

Question 29

What are the two values you receive with FRAX?

Answer 29

1. 10 year probability of ANY major osteoporotic fracture | 2. 10 year probability of hip fracture

Question 30

What is the gold standard for BMD measurements?

Answer 30

DXA Scan (central dual energy Xray absorptiometry)

Question 31

Who is recommended to receive DXA scan?

Answer 31

all women +65 years

Question 32

Why is DXA the gold standard fro BMD?

Answer 32

precise and stable calibration, short scan times, low radiation doses

Question 33

T score between -1 and -2.5 indicates

Answer 33

osteopenia

Question 34

T score <2.5 indicates

Answer 34

osteoporosis

Question 35

If your patients has low trauma vertebral or hip fracture and meets the criteria to get central DXA scan (regardless of the score) what should you recommend?

Answer 35

bone healthy lifestyle Calcium (1,000-1,2000/day) Vitamin D (800-1,000/day)

Question 36

``` If your patient has: low trauma hip or vertebral fx osteoporosis FRAX risk >20% FRAX risk for hip >3% + osteopenia what should you give and when should get next DXA? ```

Answer 36

prescription therapy | DXA in 2 years

Question 37

First line prescritpion therapy for osteoporosis

Answer 37

alendronate, risedronate, zoledronic acid, denosumab

Question 38

Second line prescription therapy for osteoporosis

Answer 38

ibandronate, raloxifene, teriparatide, abaloparatide

Question 39

Third line prescription therapy for osteoporosis

Answer 39

calcitonin

Question 40

What are the two types of agents approved for treating osteoporosis?

Answer 40

anti-resorptive and anabolic therapies/formation agents

Question 41

Which three bisphosphonates are first line in preventing the breakdown of bone and decreasing the risk of hip fractures?

Answer 41

risedronate, alendronate, zoledronic acid

Question 42

Which bisphosphonate is not considered first line since the decrease in risk of hip fractures has not been proven?

Answer 42

ibandronate

Question 43

What is important about when to take bisphosphonate?

Answer 43

take prior to food/other meds

Question 44

Which bisphosphonate should be taken immediately after breakfast (unlike the others)?

Answer 44

risedronate (atelvia)

Question 45

two recommendations to decrease the side effects seen when taking bisphosphonates

Answer 45

take with water and remain upright after taking → decreases reflux

Question 46

contraindications for taking bisphosphonates

Answer 46

CrCl < 30-35 pregnancy uncorrected hypocalcemia

Question 47

Rare ADE seen in bisphosphonates

Answer 47

MSK pain, osteonecrosis of jaw, typical (subtrochanteric) femur fractures

Question 48

contraindications and ADE of oral bisphosphonates

Answer 48

serious GI conditions or can't sit/stand after dose | GI complaints

Question 49

When should you consider a "drug holiday" for oral bisphosphonates?

Answer 49

after 5 years (3 years if on IV)

Question 50

Your patient can go on "drug holiday" if they meet what criteria?

Answer 50

no significant fracture history, hip BMD T score < 2.5, fracture risk isn't high

Question 51

This drug is antiresorptive → prevents osteoclast formation by binding to nuclear factor kappa ligant (RANKL)

Answer 51

denosumab → rank ligand inhibitor

Question 52

This is secreted by osteoblasts and normally activates osteoclast precursors → promoting osteolysis and increasing serum calcium levels

Answer 52

RANKL

Question 53

What is the difference between Prolia and Xgeva?

Answer 53

Prolia is first line and Xgeva is not indicated for osteoporosis

Question 54

Contraindications for denosumab (prolia)

Answer 54

uncorrected hypocalcemia or pregnancy

Question 55

This is the prefered antiresorptive treatemtn in patients with renal failure

Answer 55

denosumab (prolia)

Question 56

Antiresorptive that decreases bone resorption by acting as estogen agonist in bone → second line

Answer 56

raloxifene

Question 57

contraindications of ratoxifene

Answer 57

history or current VTE, pregnancy, use of other SERMs

Question 58

Adverse effects of ratoxifene → why its 2nd line

Answer 58

thromboemolic events, hot flashes, increase risk of fatal stroke

Question 59

These anabolic agents mimic the effects of endogenous hormones to stimulate osteoblast function and increases rate of bone formation

Answer 59

PTH analogs → teriparatide or abaloparatide

Question 60

This is recombinant form of endogenous PTH that mimics endocrine effects of endogenous PTH

Answer 60

teriparatide

Question 61

analog of PTH related protein that mimics paracrine effects of endogenous PTH rP

Answer 61

abaloparatide

Question 62

How are PTH analogs efficatious?

Answer 62

low intermittent concentrations of PTH for short period actually INCREASES bone formation

Question 63

contraindications for PTH analogs

Answer 63

increased risk of osteosarcoma

Question 64

ADE of PTH analogs

Answer 64

orthostatic hypotension and hypercalcemia, urolithiasis, increased uric acid, osteosarcoma

Question 65

Last line in treating osteoporosis

Answer 65

calcitonin

Question 66

Antiresorptive that inhibits osteoclastic bone resorption by antagonizing the effects of PTH (similar to human calcitonin)

Answer 66

calcitonin

Question 67

contraindication for calcitonin

Answer 67

hypersensitive to salmon derived products

Question 68

ADE of calcitonin

Answer 68

hypocalcemia, hypersensitivity reactions, nausea, flushing, local inflammation, rhinitis, epistaxis