MUSCULOSKELETAL SYSTEM PHARMACOTHERAPY OF OSTEOPOROSIS Mohammed Ejaz Ahmed Dr. Lamyaa Kassem UCP 09-09-2019 Lecture outcomes By the end of this lecture students will be able to: • Establish goals for osteoporosis treatment. • Outline drug and non-drug management strategies of osteoporosis • Outline parameters for monitoring the therapeutic outcomes in osteoporosis treatment. • Educate patients on osteoporosis treatment. 09-09-2019 Introduction • Def: • Osteoporosis-osteon (bone) and poros (pore)-A disease characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk. Introduction (Cont’) • It can be classified as • Primary • Type 1: Postmenopausal osteoporosis, is associated with increased cortical (compact) and cancellous bone loss (spongy bone) resulting from increased bone resorption, typically occurring during the first 3 to 6 years after menopause. • Type 2 :Senile osteoporosis, (loss of bone density) occurs in both women and men 75 years of age and older with a female to male ratio of 2:1. • Secondary: Results from use of various medications or the presence of particular disease states 09-09-2019 Risk factors of Osteoporosis 10-09-2018 Risk factors (Cont’) • Immobility -prolonged bedrest: associated with decreased bone • • • • mass. Weight-bearing exercise helps prevent bone loss. Thirty minutes of weight-bearing exercise three times, three times weekly has shown improvements in bone density and a reduced hip fracture risk in older women. Smoking-Women: have an increased risk for fractures compared with non-smokers. Cigarette smokers may have impaired calcium absorption and lower 17β-estradiol levels Excessive alcohol: predispose both women and men to low BMD. (Consuming more than two alcoholic drinks daily significantly increases the fracture risk). Various medications and medical conditions that have been associated with the development of secondary osteoporosis 10-09-2018 Prevention of osteoporosis • There is a universal recommendations for osteoporosis preventions: 1. Adequate intake of daily calcium and vitamin D 2. Weight-bearing and strengthening exercise (jogging, walking, running, biking, tennis, or weight lifting). Physical activity has numerous benefits in addition to promoting bone health, enhances overall health and well-being, 3. Reduce alcohol consumption, and smoking cessation. Calcium and Vit.D • Calcium and Vit. D are incorporated into the treatment • • • • • plan for all osteoporosis patients Calcium carbonate should take with fluids during or after food. Take with low fiber Diet to increase absorption ADR: Calcium carbonate: urinary stones, constipation, GI irritation, flatulence, hypercalcemia, hypercalciurea Calcium dose by age: The National Academy of Sciences: They recommend 1,000 mg/day of elemental calcium for women younger than 51 years of age. Calcium adverse effects • Most common adverse effects of calcium are constipation, GI irritation, and flatulence. • If doses exceeding 2,500 mg/day of elemental calcium can result in hypercalcemia, hypercalciuria, and possibly, urinary stones. • calcium and vitamin D should be incorporated into all treatment plans. • calcium and vitamin D should be incorporated into all treatment plans. For postmenopausal women with low bone mass and significant risks for the development of a fracture, preventative pharmacological therapies can be incorporated into the treatment plan with estrogen and progesterone therapy, Coffee and sweet potato should be avoided by these patients Vitamin D dose • The recommended daily allowance of vitamin D for women between 51 and 70 years of age is 600 international units/day. • Patients older than 70 years of age an intake of 800 international units/day may be needed. • Experts recommendation: (National Osteoporosis Foundation) • Many experts feel this is not sufficient for females older than 70 • • • • years. the NOF recommend 800 to 1,000 international units/day. This may be achieved from ingesting foods that contain vitamin D (e.g., fortified milk, fatty fish) or Ingesting a daily multiple vitamin containing vitamin D. For individuals with limited exposure to sunlight, vitamin D supplementation may be needed. Pharmacologic Prevention and treatment • Estrogen/Progestin Therapy (EPT) • NO longer used as first line therapy due to significant reporting of serious side effects as coronary heart disease (CHD), stroke, deep vein thrombosis (DVT), pulmonary embolism (PE), and breast cancer were significantly reported. • Healthcare providers are less likely to prescribe ET or EPT for osteoporosis prevention or to continue its use after a women no longer needs EPT or ET for postmenopausal symptoms such as hot flushes. • ET and EPT should be used at the lowest effective doses and the shortest duration indicated. • Longer therapy should only be prescribed in women who have failed other osteoporosis therapies, or when other osteoporosis therapies are contraindicated. CONTRAAINDICATIONS TO ESTROGEN USE • Contraindications to ET include pregnancy; active or history of deep vein thrombosis or pulmonary embolism; active or recent (e.g., within the past year) arterial thromboembolic disease (e.g., stroke, myocardial infarction); undiagnosed abnormal genital bleeding; known, suspected, history of breast cancer; known or suspected estrogen-dependent neoplasia; liver dysfunction or disease; or known hypersensitivity to the product or any of its ingredients. • Others: history of History of Diabetes Mellitus, Asthma, venous thrombosis, arterial thromboembolic disease (e.g., stroke, myocardial infarction); undiagnosed abnormal genital bleeding, liver dysfunction and breast cancer migraine, epilepsy, systemic lupus erythematous • ADR: Nausea, vomiting breast tenderness, weight gain, dizziness and breast enlargement Prevention & treatment • Bisphosphonates• These agents are approved for both the prevention and treatment of osteoporosis in postmenopausal women, with oral bisphosphonates being considered first line therapy by both NAMS and NOF. Alendronate, risedronate, and zoledronic acid are also approved for osteoporosis in men, glucocorticoid-induced osteoporosis prevention, and treatment. • In patients with hypocalcemia, resolve low calcium before starting therapy. • Cautious use in patients with impaired renal function (less than 30 mL/minute) or low serum calcium. • can treat Glucocorticoid induced osteoporosis (GIOP) and it prevents • • • • BMD loss and subsequent fracture in chronic systemic corticosteroids therapy. Alendronate can be used to treat GIOP Used with caution in patients with active upper GI disease, and severe esophageal reflux disease The peak effect occurs in 3 to 6 months and continues for months to years. Alendronate, risedronate, and zoledronic acid are FD Approved for the prevention and treatment of glucocorticoid induced osteoporosis (GIOP). Teriperatide is also approved for GIOP Prevention & treatment • Alendronate • 2.5 and 5 mg/day of alendronate were well tolerated with adverse effects similar to placebo. • Alendronate and EPT both increase BMD, in postmenopausal women without osteoporosis. • Alendronate is an effective alternative to EPT without the well-known side effects. • Risedronate For prevention and treatment of osteoporosis, cause less apparent GI risk than alendronate, but with a higher incidence of constipation in the 5 mg/daily group and diarrhea in the 150 mg/monthly group. • Zoledronic acid • Used infusion for osteoporosis prophylaxis is administered every other year as compared to yearly when treating osteoporosis. • If pt. diagnosis of GERD may preclude her use of oral bisphosphonate therapy for prevention of osteoporosis, but she would be a candidate for zoledronic acid for prevention of osteoporosis • Common adverse effects associated with the use of bisphosphonates (alendronate) include GI symptoms, such as acid regurgitation, dysphagia, abdominal distension, gastritis, nausea, dyspepsia, flatulence, diarrhea, and constipation. • Although rare, esophageal adverse effects, such as esophagitis, esophageal ulcers, and erosions, have occurred and have been followed by esophageal stricture. • In addition, musculoskeletal pain, headaches, and rash have been noted. Duration of therapy • Long-term treatment with bisphosphonates might lead to accumulation within the bone and oversuppression, which may lead to an increase fracture risk. • women with good response to bisphosphonate therapy who are not at high risk for fracture may be able to take a “drug holiday” (e.g., 1 year off therapy) after 3 to 5 years of treatment. Women who are able to reach a T-score of greater than –2.5 may be able to discontinue therapy for several years. Prevention & treatment • SERMS (Selective Estrogen Receptor Modulators) • • • • Raloxifene at a dose of 60 mg/day is the only SERM currently approved by the US FDA for the prevention and treatment of postmenopausal osteoporosis. Raloxifene is contraindicated during pregnancy, lactation and those with active or previous history of venous thromboembolic events. Dose adjustment is needed in hepatic dysfunction. Cholestyramine, when coadministered with raloxifene, may decrease raloxifene absorption by 60%. Women receiving warfarin as well as raloxifene should be monitored closely. This may also be true for some other highly protein-bound medications. Prevention & treatment • PTH (Teriperatide)- The FDA has approved the PTH derivative Teriparatide for use by women and men with osteoporosis who do not adequately respond to other therapies. In addition, those diagnosed as having severe osteoporosis and who are at an increased risk for fracture may be considered • daily injections. Currently limited to those with osteoporosis at very • • • • high fracture risk or those unresponsive to bisphosponate therapy due to high cost ($20/day) and risk of osteosarcoma Calcitonin- Both the injection and the intranasal spray are approved for the treatment, but not the prevention, of postmenopausal osteoporosis for those who have been postmenopausal for at least 5 years. When used intranasally, calcitonin is dosed at 200 international units daily; given subcutaneously or intramuscularly, the dose is 100 international units/day. A patient using calcitonin should have adequate intake of calcium and vitamin D. Intranasal calcitonin ADR: Rhinitis, epitaxis Other adverse effects include arthralgia, headache, and back pain. Prevention & treatment • Combination therapy- there are demonstrable gains in using bisphosponates in combination with SERMs, and estrogen therapy if no contraindications and less than desired benefit on single osteoporosis therapy Osteoporosis in Men • 1.5 million men in U.S. with osteoporosis, 3.5 million at • • • • • • • risk 1 in 6 men at 90 years of age will experience hip fracture. Mortality with hip fracture higher in men than in women. Testosterone therapy is recommended for men at high risk for fracture with low testosterone levels (<200 ng/dL or 6.9 nmol/L) who cannot tolerate the approved pharmacologic agents for osteoporosis Treatment includes testosterone therapy (unless contraindicated) as first line, as well as bisphonate therapy (works equally well in men). Likely role for recombinant PTH and possibly SERMs (raloxifene). Must assure adequate calcium and vitamin D intake, although these are not sufficient for treatment of osteoporosis Diagnosis best made with DEXA, still compared to standard of young woman Establish Goals • No advantage of re-measuring BMD within 1 year • Recommendations for re-measurement in 1 or 2 years once therapy has been started • If evaluated, and no change at one year, not indicative of eventual benefit. • Recommend ensuring adequate calcium Vit D, and additional risk factor reduction (smoking cessation, decreased EtOH, etc.)If significant worsening, likely unresponsive to therapy. If improvement, continue regimen and follow long term. Establish Goals (Cont’) • Fracture risk is still significantly linked to risk of fall • Ability to safely transfer is independent risk factor • Vitamin D has been shown in numerous studies to decrease risk of falls independent of the structural bone benefit • recommend to reduce the hip fracture risk in older patients start 30 minutes weight bearing exercise 3 times weekly Recommended calcium content food • Milk, dry non fat yogurt, cheese, cheddar, ice cream with ice milk. • Fish: sardine, salmon • Fruits and vegetables: Calcium-fortified juices, Spinach, fresh cooked Broccoli, cooked, Collards, turnip greens Soybeans, cooked Tofu, Kale. • Immobility owing to prolonged bed rest has been associated with decreased bone mass. • Conversely, weight-bearing exercise helps prevent bone loss. Exercise throughout life helps maintain skeletal mass and may help reduce bone loss in postmenopausal women. • Exercise appears to stimulate osteoblastic activity to help maintain bone mass. • 30 Thirty minutes of weight-bearing exercise three times weekly has shown improvements in bone density and a reduced hip fracture risk in older women. Patient education • Lifestyle Keep weight bearing exercise Avoid Sedentary (inactive/sitting) life style with less mobility Calcium intake (at least 1,200 mg/day of elemental calcium) Consume diary and calcium rich food Avoid smoking Avoid alcohol intake Get BMD done every 6 months Patient education (Cont’) For adminstration an oral dose of bisphosphonates: IT is best to be taken on empty stomach with 6-8 oz. of water, standing upright for at least 30 (60 minutes with ibandronate) to decrease risk of esophagitis. Patients should ingest adequate calcium and vitamin D, but should not take the calcium or vitamin D at the same time as the oral bisphosphonates • Calcium, 1,200 to 1,500 mg daily • Vitamin D, 800 to 1000 international units daily; also check 25(OH) vitamin D levels • Bisphosphonate therapy (bisphosphonate, depending on the level of risk and dose of glucocorticoid) • Assessment of fragility fractures • Exercise program (appropriate for individual patient, • including fall-risk assessment) • BMD screen if greater than 3 months of glucocorticoid therapy will be needed • Smoking cessation • Limit alcohol to less than or equal Summary • Establish treatment goals • Outline parameters for monitoring the therapeutic outcomes • Educate patient References • Koda-Kimble and Young's (2010 & 2017). Applied Therapeutics 10 th edition. The Clinical Use of Drugs. SECTION 19: GERIATRIC THERAPY • Chapter 105, Osteoporosis • Page No. 2417 to 2433 • DiPiro, J. T. (2008). Pharmacotherapy: A pathophysiologic approach. New York: McGraw- Hill Medical.
