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When are bisphosphonates CI?
CrCl <30 mL/min
What is Denosumab approved for?
OP in men and PM OP at high risk or failed on other therapy
What is the MOA of Denosumab?
- Inhibits osteoclastogenisis
- Binds and decreases survival of mature osteoclasts
What are the benefits of Denosumab?
- Risk of hip, spine or non-vertebral fracture over 3 years
What is the dose of Denosumab?
60 mg administered by Health care professional
What are the precautions/adverse effects of Denosumab?
- Hypocalcemia must be corrected before starting
- Watch for immunosuppressants = can lead to serious infection
- Dermatitis, rashes and eczema
Denosumab brand name
Raloxifene brand name?
What is the MOA of Raloxifene (Evista)?
Estrogen receptor agonist in the bone and antagonist in the breast and uterus
What is the benefit of Raloxifene (Evista)?
Reduces 3 year risk of vertebral fracture by 30-55%
What are the risks of Raloxifene?
- Increase risk of DVT
- Induce vasomotor symptoms (hot flashes)
How does Raloxifene compare to bisphosphonates?
Does Raloxifene have continued benefits after DC?
What group of drugs does Raloxifene (Evista) belong to?
SERMs = selective estrogen receptor modulators
What group would you want to use Raloxifene (Evista) in?
Women in which you want to prevent invasive breast cancer and treat OP
Teriparatide brand name
What is the only OP drug to build new bone?
What is the MOA of Teriparatide?
- Anti-resorptive and bone building
- Stimulation of osteoblastic activity over osteoclastic
What is the indication for Teriparatide (Forteo)?
- PM OP
- High risk fracture
- Increase in BMD in males with OP at high risk of fracture
- Those who fail other therapies
- GC induced OP
What is the dose and route of administration or Teriparatide?
- 20 ug SQ
- Give for only 2 years followed by a bisphosphanate
What OP drugs need to be stored in the refridgerator?
Teriparatide and Calcitonin
What is the benefit of Teriparatide?
- 65% decrease in vertebral and 53% decrease in non-vertebral fractures over 18 months
- Data for women only
What are the AEs of Teriparatide?
Increased risk of Osteosarcoma with prior radiation therapy
What is the black box warning for Teriparatide?
Calcitonin brand name
What is the MOA of Calcitonin (Miacalcin)?
- Synthetic analog of thyroid hormone produced at elevated calcium levels
- Reduced osteoclasts = decreased reabsorption
What dosage form is Calcitonin (Miacalcin) available in?
- Nasal spray
- Injection (minimal supportive data)
What is the benefit of Calcitonin (Miacalcin)?
Minimal increase in BMD in spine only
What is the dose of Calcitonin (Miacalcin)?
200IU/spray QD, alternate nostrils
When is Estrogen/HRT used for OP?
- To prevent OP in women who also need estrogen for menopausal symptoms
- Rarely used due to risks
What is the MOA of Estrogen/HRT?
- Inhibits osteoclastic activity
- Stimulates Osteoblastic activity
What is the benefit of Estrogen/HRT therapy?
- Increases BMD in spine, hip and forearm
- Reduces risk of vertebral and hip fracture by 34% after 5 years
What are the AE for Estrogen/HRT in OP?
3x increased risk of Thromboemboli, cholelithiasis, fluid retention, mastalgia, HA and abdominal pain
Does the Endocrine society suggest combination therapies for OP?
- NO, despite some research showing increased BMD over single therapies
- Needs more assessment
How often should you have a DXA scan once on a therapy?
How can you assess efficacy of therapies for OP?
- DXA Q2years
- Biochemical markers
- Assess fractures
What are the first line therapies for OP?
- Lifestyle modifications with:
- Zoledronic acid
What are the second line agents for OP?
What are the third line agents for OP?
Calcitonin and Estrogen/HRT