Osteoporosis Bone Resorption (RANK L stimulation, Osteoclasts, 3-5 weeks) Bone Formation (OPG, Osteoblasts, 3 mnths) Estrogen: RANKL,

OPG (decreases bone reabsorption maintains bone) PTH: osteoclasts, D3 synthesis (Ca absorbtion) Calcium: low serum Ca PTH Vitamin D: Increased Ca absorption + sig. fracture risk (alone) Risk factors: Genetic Age (65) Drugs Glucocorticoids: 5mgs prednisone daily or equivalent for at least 3 months = Prophylactic bisphosphonate Rheumatoid Arthritis Long term UFH (BMD) Inflammatory Bowel Disease Long term PPI (Ca absorption) Chronic Kidney/Liver Disease Anticonvulsants (Vit. D) Hyperparathyroidism Immunosuppressant Thyrotoxicosis SSRIs Malignancies Lithium Aromatase Inhibitors GnRH agonists Excessive thyroid Thiazolidinedinones Loop Diretics MPA (estrogen, bone resorption) Screen all women 65 or <65 w/ risk factors for BMD Medical Conditions Hx of fracture (adult)

Female Family history Low Body weight

Diagnosis: Either T-score -2.5 OR low trauma fragility fracture Supplements: Calcium: 1200mg (max single dose = 500-600mg). Calcium Carbonate dose with meals Calcium Citrate dose without regard to meals Vitamin D: 800-1000IU Cholecalciferol (D3) OTC Ergocalciferol (D2) RX (high strength) 50,000 IU po weekly x 8 weeks

Class

MoA Osteoclasts & osteoblasts. bone turnover Antiresorptive Hip, vertebral and Nonvertebral fxs

Drug Alendronate (Fosamax) men &women Ibandronate (Boniva) Women only Risendronate (Actonel) IR Men&women

Risendronate (Altevia) DR Women only Zoledronic (Reclast)

Dose & Admin 10mg daily (5mg daily prevention) 70mg weekly (35mg prev.) 2.5mg daily 150mg monthly (same doses for prevention) 5mg daily 35mg weekly 150mg monthly (same doses for prevention) 35 mg daily (not 4 prev.)

Administration Take w/ 6oz. H2O Wait 30min b4 eating/drinking Do not lie down for 30min 60min(Boniva)

AEs Esophageal d/o Upper GI: N, indigestion, dysphagia Rare: Severe bone/joint/muscle pain Osteocronosis of jaw Atypical femur fracture Consider 1-2 yr drug holiday after 4-5 yrs Tx (10 yrs high fracture risk) to prevent atypical femur frature

Warnings CI: CrCl<30-35 (monitor Scr) Hypocalcemia (monitor sCa)

Comments

Bisphosphonate

Take w/ 4 oz. H2O Take immediately after breakfast Do not lie down for 30 min.

Acid 5mg infused over 15 min q 2 yrs

Binds & inhibits RANKL, inhibits osteoclast production MAB Antiresorptive hip, vertebral & non-vertebral fxs)

Denusomab (prolia) Women only

60mg SubQ every 6months

Inject in upper arm, upper thigh or abdomen

Hypocalcemia esp in pts w/ CrCl<30 (not CI in these pts) Dermatologic Rxn Infection (cellulitis, UTI, ear,endocarditis) Osteonecrosis of jaw (rare)

IV acute phase reactions: can still give infusion. Pretreat w/ APAP, ASA REMS: 1)need to monitor AEs 2)submit annual report 3)must dispense w/ med guide

$$$ $1400/yr Only pts that have failed oral Tx $$$ $1650/yr

Class Estrogen Hormone

MoA bone loss, BMD, fx risk

Drug Estrogen Women only

AEs

Warnings HRT risk of breast CA, MI, stroke, VTE

Comments Last line! Lowest dose for shortest time. ONLY prevention in post-menopausal women who need tx for other postmenopausal symptoms

SERM

Estrogen agonist in bone and cholesterol metabolism Estrogen Antagonist in uterus and breast Antiresorptive

Raloxifene (Evista) Women only

Hot flashes (1st 6 months) Leg cramps VTE (esp 1st 4 months) d/c 72 hrs. prior to prolonged hospitalization, avoid restricted movement) Peripheral edema Intranasal: nasal irritation, rhinitis, epistaxis, HA, arthralgia Injection: N, abd. Pain, local site rxn, flushing

Contraindicated if: 1) Hx of DVT/PE 2) Pregnant (cat x) 3) Hx of MI/stroke 4) Uncontrolled HTN, afib, chronic smoker

Vertebral fx risk (no effect on hip & nonvertebral fxs) Calcitonin Ca++, PTH Hormone osteoclasts, bone turnover Antiresorptive Vertebral fx risk (no effect on hip & nonvertebral fxs) If PTH is given intermittently, it actually osteoblast & bone formation Anabolic Agent (only one) Vertebral fx risk (no data on hip & nonvertebral fxs

Calcitonin (Miacalcin) Intranasal SQ Injection Women only (5yrs post menopause) Teripartide (Forteo) 20mcg SQ Inj daily

Allergic-type reactions (bronchospasms, swelling of tongue/throat, anaphylactic shock) Test dose recommended

PTh Hormone

Generally well tolerated N, dizziness, OH, leg cramps, HYPERcalcemia (assess sCa & vit D b4 Tx) Pain @ inj site

Black Box: Do NOT use in pts at risk for osteosarcoma: Pagets disease Pediatric pts Unexplained ALP Prior skeletal radiation

1st dose administered in lying or seated position (risk of OH) $$$ - most expensive $8400/year Therapy not recommended >2 yrs