Caution is recommended with warfarin because concurrent use can decrease prothrombin time. Calcitonin: Calcitonin is a synthetic polypeptide hormone created from the calcitonin of salmon, which is more potent than human calcitonin. It should be reserved for patients who cannot take or tolerate estrogens and women who are at least 5 years postmenopause.
Statistical Brief #76
Calcitonin was studied in combination with adequate calcium and vitamin D for up to 2 years' duration. Intramuscular and subcutaneous injection forms IU daily, every other day, or 3 times per week are available as well. Common side effects include rhinitis, epistaxis, sinusitis, and headache.
- Osteoporosis - Symptoms and causes - Mayo Clinic.
- Cyclotomic Fields and Zeta Values?
- The Way It Works.
Parathyroid Hormone: Teriparatide is a recombinant human parathyroid hormone approved for treating osteoporosis. It acts as an anabolic agent, increasing bone mass when given daily. A subcutaneous injection of 20 mcg once daily for no more than 2 years is currently recommended for decreasing the risk of both vertebral and nonvertebral fractures.
Risks should be weighed when teriparatide therapy is being considered, and its use should be avoided in patients already at risk for bone cancers, including individuals with Paget's disease, history of bone metastases, or history of radiation to the bones. Drug interactions are rare; side effects are limited but include leg cramps, dizziness, and injection-site reactions.
Teriparatide is available as a prefilled pen Forteo that should be stored in the refrigerator. Counseling should include instruction on subcutaneous administration into the thigh or abdomen. The best thing a pharmacist can do is to recognize patients at risk and recommend lifestyle modifications to prevent osteoporosis. The importance of lifelong adequate calcium intake, physical activity, and risk-factor reduction for maintaining bone health is something a pharmacist should stress for the whole family. It is important to identify patients on drug therapy whose intake of calcium, vitamin D, and magnesium is inadequate.
It may be necessary to suggest vitamin and mineral supplementation. Combining drug classes for osteoporosis treatment may provide small increases in BMD, but clinical evidence of decreased fracture rates has not been shown. The additional cost, side effects, and risks should be considered before recommending multiple treatments. Adherence to osteoporosis therapies has been notoriously poor. A meta-analysis of the data published between and determined that one-third to one-half of treated patients were not taking their medication as directed.
Osteoporosis prevention can begin at a very early age. Good nutritional habits are always beneficial. As our population grows older and the incidence of postmenopausal osteoporosis increases, the focus can shift to prevention of fractures and research into more efficacious and safer therapies. Proper education of the public, combined with early initiation of treatment, can help reduce the incidence of complications in most women. Department of Health and Human Services.
Rockville, MD: U. National Osteoporosis Foundation.
Stopping osteoporotic fractures
Fast facts on osteoporosis. Accessed February 13, Lindsay R, Cosman F. Harrison's Principles of Internal Medicine. Clinician's Guide to Prevention and Treatment of Osteoporosis. Fracture risk assessment tool. Accessed February 26, Geneva, Switzerland: World Health Organization; Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis.
In a conversation with R. Heaney, MD February Calcium absorption varies within the reference range for serum hydroxyvitamin D. J Am Coll Nutr. Management of osteoporosis in postmenopausal women: position statement of The North American Menopause Society. Clinical Pharmacology [database online; subscription required]. Accessed February 11, Fosamax alendronate sodium package insert. Actonel risedronate sodium package insert. Actonel With Calcium risedronate sodium with calcium carbonate package insert. Boniva ibandronate sodium package insert.
Boniva Injection ibandronate sodium package insert. Reclast zoledronic acid package insert. Evista raloxifene hydrochloride package insert. Miacalcin calcitonin-salmon package insert. Forteo teriparatide [rDNA origin] package insert.
Systematic review and meta-analysis of real-world adherence to drug therapy for osteoporosis. Mayo Clin Proc. Acknowledgment: The authors would like to thank Robert P. Heaney, MD, for his comments and suggestions. Featured Issue Featured Supplements. Subscribe Jobs. US Pharm. Epidemiology Osteoporosis is the most prevalent of the bone diseases. You should also look for a cause of secondary osteoporosis Table 2.
Patients with a Z-score at least 2 SDs lower than average i. Follow-up is an extremely important component of patient care. Encourage patients to keep regularly scheduled appointments so you can follow their progress and adjust treatment plans to meet their ongoing needs. Prostate cancer is the most common type of cancer other than skin cancer in the United States. It is diagnosed in more than , men each year 9 —which means that, potentially, , cases of osteoporosis go undetected every year. Philadelphia, Pa: Saunders; Because of the age range in which prostate cancer develops, many men have a detectable degree of bone loss before they walk through our office door.
For this reason, a work-up for osteoporosis should be part of the routine urological examination. When the patient is also found to have prostate cancer, his risk for osteoporosis rises dramatically if he has substantial androgen activity. As long as his testosterone levels are high, he can produce enough estradiol to prevent osteoporosis, but when he responds to treatment, his testosterone level will fall, causing him to lose some of the protection estradiol provides.
If the cancer starts to spread beyond the prostate, he may be switched to ADT, 9 which, if successful, will lower his testosterone levels dramatically, removing estradiol protection virtually altogether and, thus, sentencing him to a lifetime of significant bone-related morbidity, especially when the cancer metastasizes to bone. The best defense against osteoporosis in prostate cancer is to identify patients with a high risk for fracture during the first clinical visit, select an effective anti-osteoporosis agent, and advise the patient to change his lifestyle and diet to prevent further bone loss.
The only reliable pharmacotherapeutic option currently available is the bisphosphonate alendronate Fosamax ; another bisphosphonate—risedronate Actenol —is also indicated for men, but has not been studied in men receiving ADT. Two intravenous bisphosphonates have been suggested as alternatives for patients who cannot tolerate the oral formulation: pamidronate Aredia and zoledronate Zometa.
Pamidronate appears to slow the rate of bone loss in patients with prostate cancer, but does not seem to increase bone mass. Moreover, its tolerability is poor because of a prolonged perfusion period. Bisphosphonates are adequate during the earliest stages of the disease, when the options are watchful waiting and a radical prostatectomy, radiation therapy, or both. If the cancer does not respond and starts to spread beyond the prostate gland, we usually switch to ADT, often with radiation therapy. Unfortunately, bone-building drug choices are slim to none at this point.
Alendronate is still the best choice in advanced cancer.
If none of these options is suitable, the patient may face a future of severe pain and disability. Several new therapeutic approaches to hormone-refractory prostate cancer are currently under investigation. RANKL promotes the formation, activity, and survival of osteoclasts and, thus, supports the breakdown of bone.
Denosumab blocks its effects by inhibiting osteoclast activity and enhancing osteoblast activity to build bone mass. Interim data from two phase 2 studies suggest that denosumab rapidly suppresses bone turnover after the cancer has metastasized to bone, whether the patient is receiving IV bisphosphonate therapy or not. A phase 3 trial in prostate cancer is currently under way, with preliminary results expected shortly.
S elective estrogen receptor modulators SERMs; e. Additional benefits include the suppression of hot flashes in men 11 and the promotion of a positive lipid profile, coupled with an ability to increase bone density and reduce the risk for fracture at rates similar to those achieved with bisphosphonates. The selective androgen receptor modulators SARMS have demonstrated their ability to reduce peripheral levels of testosterone while maintaining its anabolic effects in bone and muscle. Because exogenous parathyroid hormone PTH can thwart the bone-resorbing activity of the endogenous hormone, PTH analogs have been investigated for their ability to prevent osteoporosis in patients with advanced prostate cancer, but the results have been disappointing.
The PTH analog teriparatide Forteo cannot be recommended for this purpose because it carries a black box warning of an increased risk for osteosarcoma. Some investigators suggest watchful waiting to avoid the adverse effects of ADT. While the tumor is still well localized and slow-growing, and the patient has no symptoms, they recommend monitoring its progress with an annual biopsy, twice-yearly prostate serum antigen PSA and digital rectal exams, and frequent monitoring of the BMD and chemistry panel calcium, PTH, liver function tests, etc.
We have a tendency to overlook osteoporosis in men. With prostate cancer and osteoporosis sharing many risk factors, there is a considerable risk for comorbidity. Certain anti-cancer drugs—particularly androgen deprivation therapy ADT —exacerbate osteoporosis by removing testosterone and its anabolic effects on bone, thereby sharply increasing the risk for fracture. These effects can be reduced by improving BMD before initiating cancer therapy, selecting antineoplastic agents carefully especially true for ADT , and monitoring patients closely for early signs of recurrence.
The future holds promise for drugs that can modulate hormone receptors to reduce testosterone levels while building bone. Editor in Chief Lawrence I.
Related Osteoporosis (Fast Facts), 6 th ed
Copyright 2019 - All Right Reserved