Module 12: Osteoporosis (b)

Question 1

Osteoporosis

-Info

Answer 1

1. Occurs most commonly in Postmenopausal women
   —Bone loss r/t estrogen deficiency and/or age
2. Refer to Endocrinologist & Rheumatologist

Question 2

Causes of Accelerated Bone Loss?

Answer 2

1. Chronic glucocorticoid use (>/= 5 mg prednisone for >/= 3 months
2. (Depo-provera) — Max 2 yrs and encourage calcium and vitamin D — Eval BMD after 2 yrs of use
3. Some Cancer drugs
4. Excess thyroid hormone
5. Other drugs that are implicated — TZDs, PPIs, anticonvulsants, SSRIs, and some SGLT2i, ART, look diuretics

Question 3

Med Class that minimizes Bone loss?

Answer 3

1. Thiazide diuretics minimize bone los

Question 4

Bisphosphonates

Answer 4

1. First Line treatment for osteoporosis in Postmenopausal women — Preferred initial therapy
2. Inhibit bone resorption, slow down excessive bone loss, stabilize BMD and reduce fracture risk
3. Example Meds: Alendronate (Fosamax) or Risedronate (Actonel) — Initial choice for oral bisphosphonate
   —May be taken daily or weekly — Some are monthly
4. Check renal function**

Question 5

Bisphosphonates

-Patient Education

Answer 5

1. Take on an empty stomach — First thing in the morning w/ 8 oz of plain water
2. Must remain upright for 30 minutes (60 minutes w/ boniva) — During that time DO NOT eat or drink anything
3. D/C if Sx’s of esophagitis develop — look for an option outside of an oral bisphosphonate

Question 6

IV Bisphosphonates

Answer 6

1. Zoledronic Acid (Reclast) — Dosed YEARLY

2. A/E’s include RENAL effects — Monitor renal function

Question 7

Bisphosphonates

-A/E’s

Answer 7

1. Hypocalcemia
2. GI effects (oral) — Esophageal disease — D/C if this occurs
3. Atypical femur fractures? — R/T longer duration of medication >5 years — D/C if this occurs
4. Osteonecrosis of the jaw
   —Higher risk if pt has dental issues or poor oral hygiene — IV admin, CA therapy and glucocorticoids also contribute to A/Es

Question 8

Bisphosphonates

-Holidays?

Answer 8

1. Consider holiday in 5 years if bone density is stable

2. Continue using medication for 10 years (oral) or 6 years (IV) if risk is still high

Question 9

Medications that Inhibit bone resorption

Answer 9

1. Denosumab (Prolia)
2. Raloxifene (Evista)
3. Estrogen-Progestin — NOT recommended

Question 10

Anabolic Agents for Osteoporosis

Answer 10

1. Teriparatide (Forteo)
2. Abaloparatide (Tymlos)
3. Romosozumab (Evenity)

Question 11

Denosumab (Prolia)

Answer 11

1. RANK Ligand inhibitor
2. Inhibits osteoclast formation, decreases bone resorption, increases bone mineral density
3. SubQ injection q6 months
4. Higher cost
5. NOT usually an initial therapy for most Postmenopausal women

A/E’s

• May cause Hypocalcemia — monitor calcium and check prior to initiating therapy
• Osteonecrosis of the Jaw & atypical femur fractures

Treatment Length

• Need INDEFINITE administration
• Increased fracture risk when stopping medication

Question 12

Raloxifene (Evista)

-Estrogen Agonist/Antagonist

Answer 12

1. Inhibits bone resorption
2. Consider in women at high risk for breast cancer
3. LESS effective than bisphosphonates and denosumab
   —Reduces risk of vertebral fractures — No demonstrated benefit for other fracture reduction
4. BBW — Venous thromboembolism risk — FATAL stroke risk
   —Avoid w/ active/previous venous thromboembolism — Caution with CV risk

Question 13

Estrogen-Progestin Therapy

Answer 13

1. NOT a first-line approach for Tx of osteoporosis — Increases risk of breast CA, CVA< venous thromboembolism, & coronary dz.
2. May be considered in women w/ persistent menopausal Sx’s & failed on other Tx’s

Question 14

Anabolic Agents

-Examples

Answer 14

1. Teriparatide or Abaloparatide
2. Romosozumab
3. Anabolic agents stimulate bone formation and activate bone remodeling
4. LIMIT amount of time of therapy to 1-2 years MAX

Question 15

Anabolic Agents

-Teriparatide (Forteo) & Abaloparatide (Tymlos)

Answer 15

1. Parathyroid hormone analog — Stimulates bone formation and activates bone remodeling
2. SQ injection daily
3. Most Expensive

A/Es
-Hypercalcemia/calciúria

4. Only approved for MAX of 2 years
5. BBW — osteosarcoma

Question 16

Anabolic Agents

-Teriparatide (Forteo) — Who can take it?

Answer 16

1. Men or Postmenopausal women w/ severe osteoporosis
2. Pt’s unable to tolerate bisphosphonates
3. Pt’s who fail other osteoporosis therapies (Fx despite medications)

Question 17

Anabolic Agents

- Romosozumab

Answer 17

1. Monoclonal anti-sclerostin antibody — newer anabolic agent for tax of osteoporosis in postmenopausal women at high risk for Fx
2. NOT initial therapy — Severe cases
3. A/Es — Serious CV events in a trial — AVOID in hx of MI or CVA
4. Injected once monthly — Induces GREAT BMD response — LIMITED to 12 monthly doses*

Question 18

Osteoporosis treatment

-Combo treatment?

Answer 18

1. Combination therapy NOT recommended at this time.

Question 19

Osteoporosis

-Calcium and Vitamin D

Answer 19

1. Pt’s treated w/ Pharmacologic therapy for osteoporosis should have:
   - NORMAL serum calcium and vitamin D-25 (OH) levels prior to starting a therapy
2. Calcium — 1200 mg/day
3. Vitamin D — 800 IU daily