Osteoporosis
Categories:
- Bisphosphonates
- Oral: Must be taken first thing in the morning and on an empty stomach with ≥ 8oz of plain water. Must remain upright for 30mins (alendronate, risedronate) or 60mins (ibandronate)
- 5 year therapy, may extend to 10 if T <-2.5 on next DEXA
- CI: GFR <30-35%, achalasia, Schatzki ring
- SE: GI, hypocalcemia, osteonecrosis of the jaw
- Alendronate (Fosamax)
- 5mg daily or 35mg weekly PO (prevention)
- 10mg daily or 70mg weekly PO (treatment)
- Efficacious in preventing vertebral and non-vertebral fractures as well as hip fractures
- Approved for treatment of osteoporosis in men, glucocorticoid-induced
- Risedronate (Atelvia, Actonel)
- 35mg weekly or 150mg monthly
- Efficacious in preventing vertebral and non-vertebral fractures as well as hip fractures
- Approved for treatment of osteoporosis in men, glucocorticoid-induced
- Zoledronic Acid (Reclast, Zometa)
- 5mg yearly, IV only for treatment, 5mg IV every other year for prevention
- Approved for treatment of osteoporosis in men, glucocorticoid-induced
- Once a year, improved survival if given within 90 days of hip fracture
- May extend to 6 years if very high risk
- Efficacious in preventing vertebral and non-vertebral fractures as well as hip fractures
- SE: 30% have low-grade fever, myalgia, and arthralgia occurring 1-3 days after 1st administration, usually absent with subsequent infusions.
- Ibandronate (Boniva)
- 150mg once a month
- Only efficacious in preventing vertebral fracture
- Approved only for treatment of postmenopausal osteoporosis
- Oral: Must be taken first thing in the morning and on an empty stomach with ≥ 8oz of plain water. Must remain upright for 30mins (alendronate, risedronate) or 60mins (ibandronate)
- PTH Analogs
- Anabolic: stimulates osteoblasts, only ones available
- Reserved for T <-2.5 and a fracture (severe disease)
- Efficacious in preventing vertebral and non-vertebral fractures
- Can only be used for 2 years due to cumulative risk of osteosarcoma, use 1 on one off
- Must transition to either bisphosphonate or denosumab when discontinued (antiresorptive) within 1 month
- No holiday
- CI: CDK
- SE: Theoretical Increased risk of bone osteosarcoma
- Reserved for T <-2.5 and a fracture (severe disease)
- Teriparatide (Forteo)
- MOA: Recombinant human PTH
- 210mg subq monthly
- Abaloparatide (Tymlos)
- MOA: Human PTH Analog
- 80mcg subcutaneous daily
- Anabolic: stimulates osteoblasts, only ones available
- Monoclonal Antibodies
- Denosumab (Prolia, Xgeva)
- MOA: Osteoclast Inhibitor
- Monoclonal antibody inhibits RANK ligand receptors
- Antiresorptives, No need for holiday
- 60mg SQ Q6 months
- Efficacious in preventing vertebral and non-vertebral fractures as well as hip fractures
- Used if unable to take bisphosphonates
- No defined treatment length
- MOA: Osteoclast Inhibitor
- Romosozumab (Evenity)
- Osteoblast activator
- 20mcg subcutaneous daily
- Anabolic
- Associated with transient increased bone resorption (rebound) that teriparatide exacerbates (don’t use)
- Efficacious in preventing vertebral and non-vertebral fractures as well as hip fractures
- 1 year duration of therapy only
- Must transitioned to either bisphosphonate or denosumab when discontinued (antiresorptive) within 1 month
- No holiday
- Denosumab (Prolia, Xgeva)
- Calcium Regulator
- Calcitonin (Miacalcin)
- 200IU intranasal daily for treatment
- Calcitonin Salmon
- 200-unit nasal spray
- To prevent compression fractures
- Antiresorptive, only efficacious in preventing vertebral fracture
- Calcitonin (Miacalcin)
- Other
- Raloxifene (Evista)
- CI: DVT/PE, pregnant, lactating
- Antiresorptive
- Increased risk of VTE, decreased risk of uterine/breast cancer
- Only efficacious in preventing vertebral fracture
- Raloxifene (Evista)