hormone therapy/menopause and osteoporosis
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| benefits of estrogen | decreases vasomotor ADEs (i.e. hot flashes), decreases genitourinary ADEs (i.e. painful intercourse, vaginal atrophy). may also help with mood. decreases bone resorption but does not regenerate bone mass.
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| benefits of progestogen | protects against unopposed estrogen ADEs such as breast cancer, endometrial cancer, irregular bleeding. may also help augment osteoporosis benefits of estrogen.
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| two most problematic issues related to menopause | genitourinary atrophy and vasomotor instability
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| risks of estrogen | breast and endometrial cancers, CHD, bloating, headache, breast tenderness
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| risks of progestogen | irritability, weight gain irritability, depression - all dose related
irregular endometrial bleeding
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| studies have found risks associated with hormone replacement therapy. what are these risks | increased risk of VTE and gallbladder disease, stroke particularly in women getting only estrogen, conflicting evidence regarding coronary heart disease (younger women may have lower risk but older women greater). weak evidence of ovarian and lung CA
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| therapy duration for HRT | try to limit to 3 months at a time. and less than 5 years. if sx recur after 3 months do another 3 months. if sx continue after 3 months continue but recheck after 3 months to 1 year.
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| when should vaginal bleeding be evaluated in women in menopause | if on HRT, any time if on ET only. if cyclic progestogen then any time other than during expected withdrawal bleed.
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| precautions that should be taken with ospemifene and MOA | SERM (selective estrogen receptor modulator) give with progestin in pts with uterus. presents same risks as estrogen
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| drug interactions with ospemifene | rifampin decreases effects, fluconazole increases levels, avoid with other protein bound drugs it is highly protein bound
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| MOA of bazedoxifene | SERM used instead of progestin. can be used in women with uteruses.
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| indications for SSRIs and SNRIs in women with menopause. agents recommended. | alternatives to HT in women with vasomotor symptoms
venlafaxine, fluoxetine, paroxetine, sertraline
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| natural products occasionally used for menopausal symptoms. | black cohosh, evening primrose oil, soy, bioidentical hormones
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| role of clonidine and gabapentin and megestrol in menopause | treatment alternatives for vasomotor symptoms
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| T scores for normal bone mineral density | within 1 SD of young adult mean
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| T scores for low bone mineral density (AKA osteopenia) | between -1 and -2.5 SD below young adult mean
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| T scores for osteoporosis bone mineral density | below -2.5 SD below young adult mean.
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| drugs that increase risk for osteoporotic fractures | corticosteroids, heparin, anticonvulsants, excessive levothyroxine, GnRH agonists, lithium, cancer drugs
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| adequate intake of calcium and vitamin D | at least 1000 mg calcium in women under 51 and men under 70. 1200 in women over 51 and men over 70. and ~800-1000 IU vit D for pts older than 70 yrs and 600 IU for under 70 yrs
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| when to begin screening for osteoporosis | over 65 in women and 70 in men. 50-69 in men with additional risk factors or causes of secondary osteoporosis. postmenopausal women under 65 with previous fractures or risk factors or very thin
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| when to initiate drug therapy in patients with osteoporosis | if hip or spine fracture, if BMD T score <-2.5 at spine, hip or femoral neck. or between -1 and-2.5 if high fracture risk.
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| drug treatment options for osteoporosis other than calcium and vit D | bisphosphonates, SERMS (raloxifine, conjugated estrogens + bazedoxifene) calcitonin salmon, teriparatide, denosumab, HRT
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| ADEs associated with bisphosphonates | GI, headache, musculoskeletal pain, rash, osteonecrosis of the jaw (BRONJ). atypical fractures, esophageal cancer, atrial fibrillation
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| food related concerns with bisphosphonates | must wait for 30 minutes before ingesting anything other than water. exceptions include ibandronate (Boniva) which is 60 minutes and risendronate which must be taken with food.
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| target vitamin D levels | 30 ng/ml in adults, may be ok for 20 ng/ML
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| raloxifene has been shown to prevent specific fracture types. what are these | reduces risk of vertebral fractures by 30-50% but has not shown similar decrease in hip fractures
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| drug interactions exist between raloxifene and warfarin, thyroid hormone and bile acid resins. what is the resulting interaction and any required management | warfarin decreases PT by ~10%. thyroid hormone administration should be separated by 12 hours. bile acid resins decrease raloxifene absortion by 60%
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| MOA of teriparatide (Forteo) | recombinant human PTHwhich regulates bone metabolism, intestinal calcium absorption and renal tubular calcium and phosphate reabsorption
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| drug interactions associated with teriparatide | may increase risk of digoxin toxicity and increases serum calcium levels
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| indications of denosumab | use in postmenopausal women with osteoporosis and in patients with bone loss associated with prostate or breast cancer
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| safety issues associated with denosumab | opportunistic infections, skin infections such as cellulitis, hypocalcemia especially in pts with renal dysfunction and patients should take calcium and D with denosumab.
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