1. Medication Options H ealthPLACE/HOPE Program COPYRIGHT © 2002 Highmark Inc. All Rights Reserved. These materials may not be copied or otherwise reproduced in any manner.

2. Medication Options Are You A Candidate for Medications?  Postmenopausal women with vertebral or hip fractures  Bone mineral density (BMD) T-scores below -2 in the absence of risk factors  BMD T-scores below -1.5 if other risk factors are present  Women over age 70 with multiple risk factors H ealthPLACE/HOPE Program

3. Medication Options Medication Options for the Prevention and Treatment of Osteoporosis  Hormone Replacement Therapy (HRT)/ Estrogen Replacement Therapy (ERT)  Selective Estrogen Receptor Modulators (SERMs)  Bisphosphonates  Calcitonin-Salmon H ealthPLACE/HOPE Program

4. Medication Options Hormone Replacement Therapy (HRT) vs. Estrogen Replacement Therapy (ERT)  HRT is a combination of synthetic progesterone (progestin) and estrogen  ERT is prescribed if you no longer have your uterus  Both can help your body absorb more calcium and prevent bone loss that can occur after menopause H ealthPLACE/HOPE Program

5. Medication Options HRT/ERT  Generic Name: Estrogen  Brand Name(s): Estroderm ®, Premarin ®, Estrace ®, Ogen ®, Premphase ®, Prempro ®, Estratab ®  Function: prevention & management  Availability: oral tablets and skin patches  Dose: varies depending on brand name  Side Effects: menstrual bleeding, breast tenderness, mood disturbances, weight gain H ealthPLACE/HOPE Program

6. Medication Options HRT/ERT  Concerns: breast cancer, endometrial cancer, deep vein thrombosis, heart disease and stroke  Take with adequate calcium and vitamin D  Benefits: improves bone density and reduces fractures (50-80% decrease in vertebral fractures and a 25% decreases in non-vertebral fractures within 5 years of use), reduces risk of colon cancer, increases cholesterol levels, reduces menopausal symptoms and possibly decreases memory loss H ealthPLACE/HOPE Program

7. Medication Options Forms of HRT/ERT  Pill - taken cyclic (sequential) or continuous –combination pill available –metabolized or broken down  Patch - changed 1-2 times a week –combination patch available –absorbed slowly and directly into the bloodstream  Vaginal ring - changed every 3 months  Cream - applied 1-3 times weekly HealthPLACE/HOPE

8. Medication Options Women’s Health Initiative  “ Findings from the WHI study are based on a single HRT product, Prempro® and should not be applied to other HRT products” – National Osteoporosis Foundation News Release, July 2002  Study showed increase risk of: –Breast cancer –Heart attacks –Strokes –Blood clots (lungs and veins)  Study also showed: –37% reduced risk of colon cancer –34% reduction in risk of hip fracture –23% reduction in other osteoporosis fractures H ealthPLACE/HOPE Program

9. Medication Options Selective Estrogen Replacement Modulators (SERMs)  Generic Name: Raloxifene  Brand Name: Evista ®  Function: prevention & treatment  Availability: oral tablets  Dose: 60mg daily, with or without meals  Side Effects: hot flashes, leg cramps, vaginal discharge  Concerns: deep vein thrombosis H ealthPLACE/HOPE Program

10. Medication Options SERMs (Evista®)  Take with adequate calcium and vitamin D  Benefits: improves bone density, reduces risk of vertebral fracture by 40-50% and risk of breast cancer, and can reduce serum cholesterol levels  Produces estrogen-like effects on bone without stimulating breast and uterine tissues (so that the risk of breast or uterine cancer is not increased)  Option for women who are unwilling to use HRT, have contraindications to using HRT (breast cancer), or conditions that prevent use of bisphosphonates H ealthPLACE/HOPE Program

11. Medication Options Bisphosphonates  Generic Name: Alendronate  Brand Name: Fosamax ®  Function: prevention and treatment (approved for men)  Availability: oral tablets  Dose: – 5 mg daily or 35 mg weekly - prevention – 10 mg daily or 70 mg weekly - treatment  Side Effects: irritation of the esophagus, stomach pain, chest pain, heartburn and nausea H ealthPLACE/HOPE Program

12. Medication Options Bisphosphonates (Fosamax ®)  Concerns: esophageal disorders, low levels of calcium, severe kidney disease, allergy to Fosamax®, use of aspirin & NSAIDs  Taken along with adequate calcium and vitamin D  Benefits: improves bone density and reduces fractures by 50% in patients with osteoporosis  Option for women who are unwilling/unable to use HRT or Evista®; option for men and may be first choice for those with previous fracture or high risk of fracture  Instructions: take with plain water and remain upright for at least 30 minutes before first food, beverage and medication of the day H ealthPLACE/HOPE Program

13. Medication Options Bisphosphonates  Generic Name: Risendronate  Brand Name: Actonel ®  Function: prevention and treatment  Availability: oral tablets  Dose: 5 mg daily or 35 mg weekly - prevention and treatment  Side Effects: irritation of the esophagus, stomach pain, chest pain, heartburn and nausea H ealthPLACE/HOPE Program

14. Medication Options Bisphosphonates (Actonel ®)  Concerns: esophageal disorders, low levels of calcium, severe kidney disease, allergy to Actonel ®, use of aspirin & NSAIDs  Taken along with adequate calcium & vitamin D  Benefits: improves bone density and reduces fractures of both hip and spine  Option for women who are unwilling/unable to use HRT or Evista®; option for men and may be first choice for those with previous fracture or high risk of fracture  Instructions: take with plain water and remain upright for at least 30 minutes before first food, beverage and medication of the day H ealthPLACE/HOPE Program

15. Medication Options Calcitonin-Salmon  Generic Name: Calcitonin  Brand Name: Miacalcin ®  Function: treatment  Availability: intranasal (most commonly used) and injectable  Dose: 200 IU per spray each day alternative nostrils; can be administered with meals or medications  Side Effects: runny nose, nasal crusting, nosebleed, nasal ulceration and nausea; transient and usually disappear with continued therapy H ealthPLACE/HOPE Program

16. Medication Options Calcitonin-Salmon (Miacalcin ® )  Take with adequate calcium and vitamin D  Benefits: improves bone density in the hip and especially in the spine (improved by 40%), but not as effectively as HRT, SERMs or bisphosphates. Relieves pain of recent spinal fractures and reduces need for analgesics  Option for women and men who are unwilling to accept or have contraindications to the use of HRT or bisphosphonates  No drug interactions or contraindications (except allergy) H ealthPLACE/HOPE Program

17. Medication Options Combination Therapy  Positive evidence for combination of bisphosphonates and ERT for individuals with severe osteoporosis  Miacalcin ® may be beneficial as an add-on for pain relief of recent spinal fractures  Take with adequate calcium and vitamin D H ealthPLACE/HOPE Program

18. Medication Options Future Therapies  Parathyroid hormone treatment (Forteo®) - stimulates bone formation, increase bone mass dramatically and reduce the risk of vertebral fractures (National Osteoporosis Foundation News Release)  Yearly IV treatment (Zometa®) - produces effects on bone turnover and bone density as great as those achieved with daily oral dosing with bisphosphonates with proven efficacy against fractures (NEJM 2002; 346:653-61) H ealthPLACE/HOPE Program