Presentation on theme: "Management of Osteoporosis"— Presentation transcript:
1Management of Osteoporosis Stephanie Fegley, FNPDepartment of Orthopaedic SurgeryChristiana Care Health ServicesMarch 28, 2014
2Objectives:Identify populations at risk for low bone density or osteoporosis.Recognize when it is appropriate to order a Bone Density Scan (DXA) with or without Vertebral Fracture Assessment (VFA).Select appropriate pharmacologic agent for osteoporosis management based on past medical history and side effect profile.Utilize “fragility fracture panel” to help rule out secondary causes of osteoporosis.
3Nearly an epidemic Reflects the amount of FF per year in the U.S. More than MI, CVA & breast cancer combined.
5StatisticsAt least 44 million Americans are affected by osteoporosis or low bone density.Due to an aging population, the number of Americans with osteoporosis or low bone density is expected to increase significantly.Up to ½ of all women will suffer a FF during their lifetimeUp to ¼ of all men will suffer a FF during their lifetime
7Cost of OsteoporosisDirect care expenditure from osteoporosis-related fractures exceeds $19 billion annually.By 2025, the annual cost of fractures is projected to grow to more than $25 billion, as annual fractures surpass 3 million.
8Painful, yet undertreated Approximately 80% of patients do not receive recommended osteoporosis care following a fragility fracture.Men, who account for 30% of fractures & 25% of cost, are particularly undertreated.
9“No one’s ever died from osteoporosis” Nearly 25% of patients who suffer a hip fracture die within a year.Those who do survive experience significant morbidity, as many experience a loss of independence & may require long-term nursing home care.Others never return to their baseline mobility, and will have to ambulate with a walker or cane & are at increased risk of future falls & fractures.
10Provide a “Teachable Moment” According to AOA, a fragility fracture should be treated as a sentinel event. This will provide opportunities or clinicians to educate patients, fellow physicians & other healthcare providers about the importance of bone health and osteoporosis treatment.The best time to talk to your patient about a fragility fracture and the likelihood of Osteoporosis is while the fracture is fresh.
11Fracture CascadeAbout 50% of people with one fracture due to Osteoporosis will have a repeat fracture.The risk of fracture rises with each new fracture, hence the “cascade effect”Women who have a vertebral fracture are 4x more likely to have another fracture within the next year, compared to women who have never fractured.
12Pathophysiology Age-related changes in bone microarchitecture: Decreased bone volumeDecreased trabecular thicknessDecreased trabecular numberDecreased connectivityDecreased mechanical strengthIncreased cortical porosity
14More at Risk Populations… Post-polio syndromePremature menopauseProstate cancerRheumatoid arthritisSevere liver diseaseSpinal cord injuriesCerebral Vascular AccidentThalassemiaThyrotoxicosisWeight loss
15Medications that will Increase Risk… Oral glucocorticoidsAnticonvulsantsPPIsSSRIsTZDsLithiumAromatase InhibitorsGonadotropin-releasing hormone agonistsChemotherapyHeparinDepo-Provera
16Other Factors that Increase Risk Low dietary Calcium intakeVitamin D Insufficiency or DeficiencyTobacco use in the past 12 monthsConsuming > or = 3 units of alcohol per daySedentary lifestyle2 or more falls in the past yearModerate to high caffeine intake
17Cheap ways to tell if your patient is at an increased risk for fragility fracture: Prior history of fracture after age 50 or >, at fall from standing height or lessOne of the “At risk populations”Is/has been taking one of the medications that increase riskTobacco abuseDrinks > or = 3 units of alcohol per daySedentary lifestyleHistory of > or = 2 falls in the past yearCheck a FRAX
18Fracture Risk Assessment Tool (FRAX) Tool developed by the World Health Organization (WHO) to calculate fracture risk in patients, by combining clinical risk factors with BMD, to generate a 10 year probability of fracture.10 year probability of hip fracture10 year probability of major osteoporotic fracture (spine, forearm, or shoulder fracture)
19When not to use FRAX: When the patient has already had a hip fracture When they have been on treatment for Osteoporosis in the past 2 yearsLess than 40 years oldMost DXA reports will include a FRAX score at the end, if not contraindicated. This is to help the provider determine if treatment is necessary.
21Recommendations for when to order a DXA: Women age 65 years and older and men age 70 and older.Women under 65 and men age about whom there is concern based on clinical risk factor profile or FRAX score.Women and men of any age who have suffered a low-impact fracture.Women and men of any age who are at increased risk as a result of selected medical conditions or treatment with specific medications.
22DXA GuidelinesDXA should be “Central DXA”, with lumbar spine & hips (preferably both hips) scanned.DXA should be interpreted in accordance with International Society for Clinical Densitometry (ISCD)The final diagnosis from DXA is based on the lowest t-score from the spine, proximal femur, or femoral neck, whichever is lowest.Diagnosis from DXA in premenopausal women and men under age 50 is based on z-scores and is reported as normal or low bone density for age.
23DXA Guidelines (cont.)Evaluation of the forearm(s) should be performed if the evaluation of the spine or hip(s) is limited or nondiagnostic.Absolute fracture risk assessment using FRAX should be included in DXA reports for appropriate patients.
24Vertebral Fracture Assessment (VFA) Lateral spine imaging with densitometric VFA is indicated when lowest t-score from DXA is <1.0 and or more of the following is present:Women age >/= 70 years or man age >/= 80 yearsHistorical height loss > 4cm (> 1.5 inches)Self-reported but undocumented prior vertebral fractureGlucocorticoid therapy equivalent to >/= 5mg prednisone or equivalent per day for >/= 3 months.
25How should you write your script? Write to perform a “DXA with VFA” or “DXA with VFA, if indicated”Things to consider:The patient has to lay on their side to have the VFA performed, so if they have a recent fracture, this may be too difficult/painful.Insurance coverage
26Guidelines for follow-up DXA Insert Table 1 from CMG
27Defining Osteoporosis by BMD Insert table 2 from CMG
28Deciding when to treat using FRAX: According to the WHO, you should consider a pharmacologic agent if:10 year probability of a hip fracture is > 3%10 year probability of major osteoporotic fracture (spine, forearm, or shoulder fracture) is > 20%
29Important Physical Exam Findings Eyes- ScleraMouth- Teeth~ In OI can be normal or soft & translucent. Also if you are considering bisphosphonate or Prolia therapy you want to evaluate their dentition to determine increased risk for ONJ.Musculoskeletal- Postural changes such as kyphosis, “lengthening of the arm-trunk axis” (describes shortening of the trunk w/ comparatively long extremities) & tenderness of the spinous processesGait- Try and sneak a peek at them walking in or out of the exam room. Can they get up from a chair without using their hands?Scars- Fracture repairs they have forgotten aboutBMI < 18 increases riskHeight at every office visit!
30Determining the cause… Once you make the diagnosis, don’t forget to rule out secondary causes!Fragility Fracture Panel:Serum CreatinineCalciumAlbuminPhosphorusAlkaline phosphatase (ALP)Thyroid Stimulating Hormone (TSH)Vitamin D 25-OHIntact Parathyroid Hormone (iPTH)
31Vertebral Compression Fractures Approximately two-thirds are never diagnosed, because they are written off as pain associated with aging or arthritis.Think about the cascadeLoss of height (more than 3cm/just over 1 inch)Sudden severe back pain in themid & lower spineIncreased stoop or ‘dowager’shump’
32Conservative Treatment for Compression Fxs Self-Care at home:RestPain relief with NSAIDsMay also need muscle relaxantsIce for 20 minutes every 60 minutes for the first week, then can do heat or ice, which ever feels better.Physical therapy, when permitted~ with emphasis on stretching & strengthening program to decrease risk for further osteoporosis and strengthen muscles supporting the back.
33Conservative Treatment for Compression Fxs Hospital Admission:Inpatient treatment dependant upon pain control, weakness, ambulatory dysfunction, urinary retention, & cauda equina syndrome.TLSO (Thoracolumbosacral Orthosis) brace as needed, when out of bed for comfort.RestPain relief with opiates (usually hydrocodone or oxycodone)May also need muscle relaxantsIce for 20 minutes every 60 minutes for the first week, then can do heat or ice, which ever feels better.Physical therapy, when permitted~ with emphasis on stretching & strengthening program to decrease risk for further osteoporosis and strengthen muscles supporting the back.
36Consequences of Vertebral Compression Fractures KyphosisLoss of heightBulging abdomenAcute & chronic back painBreathing difficultiesDepressionReflux & other GI symptomsLimitation of spine mobility (affecting ADL & ambulation)Need to use walking aid
37Own the BoneLaunched by the American Orthopaedic Association (AOA), to help providers drastically improve efforts of fracture prevention.Christiana Care Health System have been participating in the Own the Bone Registry since January 1, 2012.OTB focuses on 10 measures for the patient with a history of a fragility fracture
3810 Own the Bone Measures Calcium supplementation Vitamin D supplementationWeight-bearing & muscle-strengthening exerciseFall prevention educationSmoking cessationLimiting excessive alcohol intakePharmacotherapyOrdering DXAPhysician referral letter to report the patient’s fragility fracture, risk factors, & recommendations for treatment.Patient education latter to explain bone health risk factors & recommendations for treatment.
39Which is the best Calcium? The majority of these patients should be told to consume 1200mg of calcium per day between diet and supplement combined.Dietary intake of calcium from food sources should be encouraged as much as realistically possible & fill the gap with a Ca supplement when necessary.
40Food Sources of Calcium Lowfat & non-fat dairy products are high in calcium while certain green vegetables and other foods contain calcium in smaller amounts.Calcium fortified foods- Orange juice, cereals, soymilk, English muffins, waffles, breads, snacks, & bottled water.
41Foods that Reduce the Absorption of Calcium Foods with high amounts oxalate & phytate reduce the absorption of Ca contained in those foods.Foods high in oxalate= spinach, rhubarb & beet greensFoods high in phytate= legumes (pinto beans, navy beans, peas), 100% wheat bran* (*space >/= 2 hours after eating foods that contain bran)You can reduce the phytate level to get more Ca from legumes by soaking them in water for several hours, discarding the water, & then cooking them in fresh water.
42Calcium Side Effects Gas or constipation may occur from Ca supplements Some patients complain of nauseaPatient’s should increase fluids & fiber in their diet, but if that does not help, they should try another type or brand of Ca.When starting a new Ca supplement, start with smaller amounts & drink an extra 6-8 ounces of water with it, then gradually add more Ca each week.
43Calcium Supplementation There are many different types of calcium salts (i.e. glubionate, gluconate, lactate, citrate, acetate, phosphate, & carbonate)Calcium Carbonate (40% elemental Ca)Viactiv, Caltrate, Oscal, Tums, numerous store brandsmg of calcium per pillRequires hydrochloric acid for best absorption, therefore remind patients to take with meals.Calcium Citrate (21% elemental Ca) **May need 2 pills per doseCitracal, some store brandsmg of calcium per pillDoes not requires hydrochloric acid for absorption, so it can be taken with or without food.Calcium Phosphate (39% elemental Ca)PostureAbsorption is very similar to Calcium Carbonate
44Is There a “Best” Calcium Salt? The data suggests that both Calcium carbonate & Calcium citrate, taken with meals, have equivalent bioavailability.If you have a patient on a H2 blocker, PPI, or you know has achlorhydria and supplements won’t be taken with meals, Calcium citrate is a better choice.Calcium carbonate is cheaperCalcium phosphate is equivalent to Calcium carbonate in supporting bone building.Study suggests that Calcium citrate has better availability than Calcium carbonate after roux-en-Y gastric bypass.
45Calcium SupplementsMost important factors are those predicting long-term use: palatability, cost, toleranceAdvertised “differences” more apparent than realMagnesium may be helpful with constipationCalcium chews contain Vitamin K- ** Caution in patients taking Coumadin
46Why is Vitamin D so Important? Vitamin D is essential for adequate gastrointestinal absorption of calcium.Insufficient amounts of vitamin D over time reduces serum calcium levels and can trigger a compensatory release of parathyroid hormone.This may produce secondary hyperparathyroidism, resulting in mobilization of calcium from the bone and a reduction in bone mineral density.
47What is the Best Level to Check for Vitamin D Status? 25-OH Vitamin D level is best1,25 OH2 Vitamin D levels are useful in chronic kidney disease, primary hyperparathyroidism, sarcoidosis, oncogenic osteomalacia, vitamin D-resistant rickets, pseudo- vitamin D deficiency rickets, and hypophosphatemic rickets
48What Do the Results Mean? <10ng/mL Severe Vitamin D Deficiency10-19ng/mL Vitamin D Deficiency20-29ng/mL Vitamin D Insufficiency30ng/mL Normal40-60ng/mL Target range for someone with history of Osteoporosis with or without fracture
49Health Risk Associated with Vitamin D Deficiency RickettsOsteomalaciaPrecipitates & exacerbates OsteoporosisIncreased risk of: deadly cancers, cardiovascular disease, Multiple Sclerosis, Rheumatoid Arthritis, & Type I DMCan also cause muscle weakness & increased risk for falls
50Sources of Vitamin D Sunlight Food Supplements & Medications NOF recommendations:Adults < 50 years old: IU/dayAdults >/= 50 years old: 800-1,000IU/day
51SunlightSolar ultraviolet B photons are absorbed by 7-dehydrocholesterol in the skin, leading to its transformation to previtamin D3, which is rapidly converted to vitamin D3.Season, latitude, time of day, pigmentation, aging, sunscreen use (even SPF of 8 reduces preduction by 95%), & glass all influence the cutaneous production of vitamin D3.People with fairer skin make more Vitamin D than people with darker skin.Once formed, vitamin D3 is metabolized in the liver to 25-hydroxyvitamin D3 and then in the kidney to its biologically active form, 1,25-dihydroxyvitamin D3.
52Food Sources of Vitamin D It is extremely difficult to get all the Vitamin D you need from diet alone.Foods high in Vitamin D: fatty fish (i.e. mackerel, salmon, tuna, eel), egg yolks, & liverVitamin D is added to the following foods: milk, some brands of orange juice, soymilk & cerealsThere is no Vitamin D in other dairyproducts like cheese, yogurt, or butter.
53Cholecalciferol (Vitamin D3) Fat soluble; made from irradiation of 7-dehydrocholesterol from lanolin & the chemical conversion of cholesterol.Cholecalciferol 50,000IU is available from at least 1 manufacturer, it is often challenging to find in retail outlets.Mean time to peak= 14 daysAlso, these metabolites have a superior affinity for vitamin D-binding proteins in plasma, relative to ergocalciferol.
54Ergocalciferol (Vitamin D2) Made from ultraviolet irradiation of ergosterol in yeast.Clinical studies indicate that vitamin D2 is much less potent & has a shorter duration of action than cholecalciferol.Ergocalciferol has been used historically to treat Vitamin D deficiency out of convention, or perhaps because high-dose ergocalciferol is more widely available in doses up to 50,000IU per softgel capsule from multiple manufacturers.In patients with severe deficiency, it is often difficult to raise 25-hydroxy vitamin D levels with ergocalciferol.Is 30% less potent than vitamin D3 & has markedly shorter duration of actionMean time to peak= 3 days
55Populations at Risk for Low Vitamin D People who spend little time in the sunSunscreen, clothing, hats, shadePeople with very dark skinElderly peoplePeople living in nursing homes or other institutionsPeople with certain medical conditions such as serious diseases of the nervous system or digestive systemsPeople who are obese
56Osteoporosis Treatment Osteoporosis medications can be classified into two main categories:Antiresorptives~ slow down bone destructionBisphosphonatesCalcitoninsEstrogen agonists/antagonistsEstrogen therapy (ET) & hormone therapy (HT)Receptor activator of nuclear factorKappaB ligand (RANKL) inhibitorAnabolics~ bone-building medicationParathyroid hormone
57A Little Pathophysiology… Bone resorption by OsteoclastsCells release an acid which dissolve collagen & the mineral coating of the boneBone formation by OsteoblastsCells that lay down new collagen to aide in formation of new bone tissue
58AntiresorptivesMost drug therapies work by decreasing the reabsorption of bone. At any given time there is bone that has been reabsorbed but not replaced & this accounts for 5-10% of bone mass.By decreasing reabsorption of bone, a gain in bone density of 5-10% is possible, taking about 2-3 years. However, no drug therapy will restore bone mass to normal.
59BisphosphonatesMost commonly prescribed non-estrogen therapy; acts as an inhibitor of osteoclastic activity.May be beneficial in women who cannot tolerate ET.They are effective in inhibiting bone loss after menopause, since they slow down bone turnover.Unfortunately, this is also what puts these patients at risk for Atypical Femur Fracture (AFF)
60Bisphosphonate Options Alendronate (Fosamax)Ibandronate (Boniva)Risedronate (Actonel)The 3 oral agents above must be taken on an empty stomach, 1st thing in the morning with no other medications. You must take with a full 8oz glass of water and remain upright for at least 30 minutes after swallowing pill.Risedronate (Atelvia)Zolendronic Acid (Reclast)
61Alendronate (Fosamax) Dosing: 70mg weekly (osteoporosis men & women tx), 5mg daily (steroid-induced osteoporosis), 35mg weekly (osteoporosis prevention)Is available in a liquid 70mg/75mls weeklyFDA approved for: 1) the prevention and treatment of Osteoporosis in postmenopausal women and men & 2) treating steroid-induced osteoporosis in men and women.Fracture prevention: Spine, hip & other bonesPossible s/e: Joint, bone or muscle pain. Nausea, reflux, gastritis, or dysphagia. Hypocalcemia, Atrial Fibrillation, AFF, & ONJ.Renal dosing: CrCl <35; avoid use
62Fosamax Plus DDosing: 70mg/2800IU cholecalciferol, 70mg/5600IU cholecalciferol 1 tablet weekly for the treatment of osteoporosis in men or postmenopausal women.Fracture prevention: Spine, hip & other bonesPossible s/e: Joint, bone or muscle pain. Nausea, reflux, gastritis, or dysphagia. Hypocalcemia, Atrial Fibrillation, AFF, & ONJ.Renal dosing: CrCl <35; avoid use
64Ibandronate (Boniva) Dosing: 150mg pill monthly, 3mg IV every 3 months FDA approved for preventing and treating Osteoporosis in postmenopausal women onlyFracture prevention: Spine onlyPossible s/e: Joint, bone or muscle pain. Nausea, reflux, gastritis, or dysphagia. Hypocalcemia, Atrial Fibrillation, AFF, & ONJ.After IV infusion flu-like symptoms, fever & headaches.Renal dosing: CrCl <30; avoid use (po), contraindicated (IV)
65Risedronate (Actonel) Dosing: 35mg weekly (male & postmenopausal osteoporosis), 5mg daily (steroid-induced osteoporosis)FDA approved for: 1) the prevention and treatment of Osteoporosis in postmenopausal women and men & 2) treating steroid-induced osteoporosis in men and women.Fracture prevention: Spine, hip & other bonesPossible s/e: Joint, bone or muscle pain. Nausea, reflux, gastritis, or dysphagia. Hypocalcemia, Atrial Fibrillation, AFF, & ONJ.Renal dosing: CrCl <30; avoid use
66Risedronate (Atelvia) Dosing: 35mg DR weekly **Give with 8oz of water AFTER breakfast, remain upright x 30 min.FDA approved for preventing and treating Osteoporosis in postmenopausal women and men.Fracture prevention: Spine, hip & other bonesPossible s/e: Joint, bone or muscle pain. Hypocalcemia, Atrial Fibrillation, AFF, & ONJ.Renal dosing: CrCl <30; avoid use
67Zolendronic Acid (Reclast) Dosing: 5mg IV every 12 or 24 monthsFDA approved for preventing (24 mo) and treating (12 mo) osteoporosis in postmenopausal women and men. Treating steroid-induced osteoporosis in women and men.Fracture prevention: Spine, hip & other bonesPossible s/e: Joint, bone or muscle pain. Nausea, reflux, gastritis, or dysphagia. Hypocalcemia, Atrial Fibrillation, AFF, & ONJ.Renal Dosing: CrCl <35; or acute renal impairment contraindicatedTip: If your patient has never been on prior bisphosphonate therapy, they will likely experience flu-like chills & body aches up to hours after their first two infusions. This can easily be treated by taking Tylenol 650mg po every 4-6hrs ATC.
68Denosumab (Prolia)Receptor activator of nuclear factor-KappaB ligand inhibitor (RANKL)Dosing: 60mg/ml SC every 6 monthsNurse can inject in abdomen, thighs or upper armsFDA approved: Treating osteoporosis in postmenopausal women and men at high risk of fracture.Fracture prevention: Spine, hip & other bonesPossible s/e: May increase risk of infection, rash, hyperlipidemia , AFF & ONJRenal dosing: None; a great consideration for your patient with CRI or CKD, who is not on HD/PD.
70Other Prolia TipsDepending on the patient’s insurance, you may choose for them to bring their own medication from their pharmacy, go to an infusion center, or do a “buy & bill” from your office.Medication should be kept refrigerated, however once removed from the fridge it must be administered or discarded within 2 weeksMust be out of the fridge a minimum of 30 minutes before administration.Use of a specialty pharmacy will make the prior authorization process much easierStill takes about a month & numerous faxes/phone callsCost= $ per injection
71Osteonecrosis of the Jaw (ONJ) A confirmed case is defined as an area of exposed bone in the maxillofacial region that does not heal within 8 weeks after identification by a health care provider, in a patient who is currently receiving or has been exposed to a bisphosphonate, and has not had radiation therapy to the craniofacial region.
72ONJ in Osteoporosis Patients Prevalence of ONJ in oral bisphosphonate users 0.10%Frequency of ONJ~ % of oral bisphosphonate users, if extraction %60% of ONJ cases have a preceding history of tooth extraction, but only 0.5% of extractions result in ONJONJ has also been reported in patients taking Prolia (Denosumab)Studies have shown that adequate Vitamin D levels may be associated with improved peridontal health & critical for post-surgical oral wound healing.
73Why the Jaw? Thin mucosa overlying osseous tissue Frequent site of microbial colonization and infectionCommon site of surgical intervention or traumaDoes the bone turnover differ than other skeletal sites?
74ONJ Prevention Good oral hygiene- brush teeth BID & floss Inspect teeth & gums daily & look for sore spots/open areasNotify your dentist that you started treatment (bisphosphonates or Prolia)Routine dental cleaningsAvoid dental procedures while on above medicationsWear properly fitting denturesSmoking cessationNotify prescriber of non-healing ulcers
75Atypical Femur Fracture (AFF) 73 y.o. caucasian female w/ history of Osteoporosis on Boniva for nearly 5 years with a previous ankle fx. Presented to ED on 3/16/14 s/p trip & fall over a cord in her bedroom, when she was filling up her water bed. She tripped, fell forward and landed on her knees. The patient immediately felt excruciating pain and her husband called 911.
76Initial X-ray Reveals a L subtrochanteric fracture Patient admits to having “constant cramps” in her L upper thigh 2 weeks prior to her fall, causing her to require a cane for ambulationChance of a AFF 0.05% with bisphosphonate use.
78Drug Holiday Duration of treatment should be based on: Patient’s risk of fracturePharmacokinetics of the agent prescribedPatient preference (shared decision-making)At the 5-year treatment period, reassess the need for continuing treatment based on fracture history, BMD and clinical risk factorsFor those at low or moderate risk, stopping therapy is a possibilityFor those at higher risk, consider continuing therapy, consider drug holiday, or consider alternative medication during drug holidayEnding drug holidayConsider fractures, BMD, biochemical markers, FRAX
79CCHS CPG “Medication Follow-up” For bisphosphonate therapy
80Calcitonin (Miacalcin) Amino acid peptide hormone that inhibits bone resorption by osteoclasts, inhibits uptake of calcium from the intestines, & inhibits resorption of calcium from the kidneysDrug first approved in 1975 for the treatment of Paget’s DiseaseDosing: Nasal spray 200IU/spray in one nostril QD or 100IU IM/SC injection QOD-QDFDA approved for treating osteoporosis in women who are at least 5 years past menopause.Fracture prevention: Spine onlySometimes used to help with the pain associated with hip fractures in the acute post-operative period.Possible s/e: Injectable form~ nausea, skin rash, frequent urination, & warmness. Nasal spray~ Runny or irritated nose, headache & backache. Also, recent studies have shown association w/ malignancy, so CCHS will be removing from formulary.Renal dosing: None
81Calcitonin vs. Placebo~1% improvement in the BMD of the spine & most studies show the the results in the hip and wrist are the same as placebo or slightly better.0.7%Cost= $52.85 per bottle of nasal spray
82Raloxifene (Evista) Classification: Estrogen agonist/Antagonist An oral selective estrogen receptor modulator (SERM) that has estrogenic actions on bone and anti-estrogenic actions on the uterus & breastDosing: 60mg pill dailyFDA approved for preventing and treating osteoporosis in postmenopausal women only.Fracture prevention: Spine onlyPossible s/e: Hot flashes, leg cramps, edema, & DVT/PEs.Renal dosing: None
83Estrogen TherapyEstrogen has a protective effect on the bones prior to menopause, which is why a woman’s risk increases after menopause & women that have premature menopause are at increased risk.Estrogen reduces bone resorption & increases bone formationDosing: varies depending on drug; pill and patch formsClimara, Estrace, Estraderm, Estratab, Ogen, Ortho-Est, Premarin, VivelleFDA approved for preventing osteoporosis in postmenopausal womenFracture prevention: Spine, hip & other bonesPossible s/e: May increase risk of DVT/PE, CVA, MI, breast & ovarian cancer. Vaginal bleeding, breast tenderness, mood changes, & gallbladder diseaseRenal dosing: NoneHepatic Dosing: Contraindicated
84Hormone TherapyWomen past menopause with accelerated bone loss may benefit from hormonal therapy using estrogen with progesterone. The estrogen retards bone resorption and thus diminishes bone loss.This effect is the most prominent in the first years after menopause, while risks from HRT increase.Dosing: varies depending on drug; pill and patch formsActivella, Femhrt, Ortho-Prefast, Premphase, PremproFDA approved for preventing osteoporosis in postmenopausal womenFracture prevention: Spine, hip & other bonesPossible s/e: May increase risk of DVT/PE, CVA, MI, breast & ovarian cancer. Vaginal bleeding, breast tenderness, mood changes, & gallbladder disease.Renal dosing: NoneHepatic Dosing: Impairment/Disease; Contraindicated
85Teriparatide (Forteo) Parathyroid HormoneDosing: 20mcg SC daily for up to 2 yearsCan self-inject in abdomen or thighsFDA approved for treating osteoporosis in postmenopausal men and women at high risk of fractureFracture prevention: Spine and other bonesPossible s/e: Nausea, dizziness & crampsRenal dosing: NoneContraindications: Paget’s Disease (unexplained elev. ALP), young patients with open epiphyses, prior external beam or implant radiation involving the skeleton, & patient’s w/ current or h/o bone malignancies/metastasesMonitoring considerations: After 4 months of therapy, repeat serum Ca, albumin & Vit D 25-OH levels. Do not check a iPTH it will be elevated & do not repeat a DXA in 1 year, wait at least 18 months.
88ForteoInsurance approval will require patient to have a prior fragility fracture or have a t-score of </= -2.5 (Osteoporosis).Use of a specialty pharmacy will make the prior authorization process much easierStill takes about a month & numerous faxes/phone callsYour Forteo sales representative will gladly put you in touch with an educator who works for Lilly, but will (at no cost to you) meet with your patient at a location and time of your choosing, and talk to your patient one on one about Forteo & teach them how to inject. The patient does not need to even be 100% sold on the drug yet.Medication must be kept refrigerated at all times.Lilly also distributes cooler pack/travel kits to patient starting on Forteo for travel.Cost= $1, per pen; 1 pen lasts 28 days (does not include needles)
89Please remember…..Osteoporosis is a chronic, but treatable disease & fragility fractures are preventable.
90Questions Please feel free to contact me: email@example.com (302)