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Calcium
14-18 --- 1,300 mg Male and Female (same for preg/lactation)
19-50 --- 1,000 mg Male and Female (same for preg/lactation)
51-70 --- 1,000 mg Male and 1,200 mg Female
71+ --- 1,200 mg Male and 1,200 mg Female
Doses above 500-600 mg should be divided because calcium is saturable
Calcium citrate (Citracal) has better absorption and be take with or without food
usual 315 elemental calcium (21%)
Calcium carbonate acid-dependent absorption and should be taken with meals;
usual tab is 500-600 mg of elemental calcium (40%)
Both forms come as chewable, liquids, and additives in food products.
Vitamin D selection
IOM and NIH --- 600 IU up to 70 years
800 IU 71+ years
Serum vitamin D level [25 (OH) D] should be measured and supplements given to
reach a level of 30 mg/mL (75 mmol/L)
50,000 units of D2 (ergocalciferol) is given once weekly for 8-12 weeks for
deficiency. Normally D3 (cholecalciferol) is preferred source
Osteoporosis --- 1st line treatment is bisphosphonates --- prevention and/or
treatment of postmenopausal osteoporosis include:
Alendronate (gen. Solu. 70mg/5mL, tab 5,10,35,40,70) (Fosamax 5-10 mg, 70 mg
tab---Binosoto efferves. 70 mgf,,
ibandronate (Boniva) IV 1 mg/Ml, 150 mg tablet --- IV 1yr of IV INJECTION, 3 YR OF
TABLETS, PTS AT LOW RISK SHOULD BE EVALUATED AROUND EVERY 3 TO 5 YEARS
TO DISCONTINUE.
IBANDRONATE (Boniva) postmenopausal osteoporosis 2.5 orallly once daily or 150
orally monthly, 3 mg IV infused over 15 to 30 seconds every 3 months-----
postmenopau. Osteopor proph. 3.6 mg orally daily 150 once monthly
Risedronate (Actonel, Atelvia)- IR 5, 30,35,150, DR-35 MG (Atelvia)-dec bone
den/IBS 5 mg w/ sup CA. IBS remiss. Postmenosteo 35 mesalazine or sulfasalazine,
osteo due to cortico. 5 mg orally with 6 to 8 oz 30 min prior to 1 st food or drink of
day if dietary intake is inadequate pts should also receive sup Ca and Bit D1
Zoledronic acid (Zometa, IV 4mg/100mL, 4mg/5mL),(Reclast IV 5mg/100mL),
PremierPro Rx Zoledronic Acid IV 4MG/100mL0, Zolendronic Acid Novaplus 4 and 5
mg/100 mL, 4mg /5mL)
Multiple Myleoma- 4 mg IV over no less that 15 min every 3 to 4 weeks admin Ca
sup 500 mg and MVI containing 400 IU Vit D
Osteo in man 5 mg IV infused 15 min every 1 year
Daily ca. 19-50 1000 M and F, 51-70 1000 M / 1200 F, 71 + 1200 M and F
Daily Vti D 600 IU up to 70 , 70+ 800 IU
APAP 1000 mg or Ibu 400 mg orally every 6 hours for 3 days beginning 4 hours after
zoledronic acid infusion to reduce influenza symp.
Osteo, 2ndary prop. In pt w/ recent hip fracture, glucocorticoid SAME
5 mg IV over 15 min 1 yearly
Pagets disease
5 mg IV over 15 min 1 yearly; all pat. Receive 1500 mg elemental Ca daily and 800
IU of Vit D particularly during the 2 weeks following admin. APAP 1000 mg or ibu
400mg every 6 hours for 3 days beginning 4 hours post infusion.
Post menopause osteo
5 mg IV over 15 min 1 yearly
Post menopause osteo prophylaxsis
5 mg IV over 15 min every 2 years
Calcitonin (Fortical, Miacalcin)- Fortical 200 IU/1 actuation, Miacalcin --- injection 200
IU/1mL, nasal spray hypercalcemia, pagets disease or postmenopausal osteo.-
Pagets 100 IU IM/SUBQ daily, Post meno. Osteo. 100 IU injection IM/SUBQ daily,
nasal 200 IU (1 spray intranasal/day) alternate nostrils daily
Estrogens (estrogen and/or hormone therapy)
Estrogen agonist/antagonist (raloxifene) EVISTA- BBW deep vein thrombosis-
postmeno osteo,postmeno osteo prophy. 60 mg orally daily sup. Ca and vit D if
needed
tissue-selective estrogen complex (conjugated estrogens/bazedoxifene) 20 mg once
daily postmeno. Osteo.---SERM
PTH (PTH (1-34))
Women who are symptomatic may get estrogen, and if they have a uterus, they should receive a
progestin in order to prevent endometrial cancer. In the early stage of perimenopause, when
bleeding is heavier and pregnancy risk is present, a woman may receive birth control pills to help
reduce the bleeding and to provide pregnancy protection. They also offer some help with
symptoms, but later on the symptoms may warrant the use of hormone therapy (HT), which
contains higher doses of estrogen.
AndroGel comes in 1% and 1.62% strengths. Each can be applied to clean, dry skin
on the shoulders or upper arms. In addition, the lower strength only (1%) can be
applied to this additional location:
Abdomen
The higher strength (1.62%) is not applied to the abdomen.
LT is a 49 year-old female who went to her physician complaining of hot flashes,
depression and irritability. She started feeling this way about six months ago and
states she "can't shake her mood." The physician took blood tests and confirmed
that LT is perimenopausal. He prescribed Vivelle-DOT. Choose the correct statement
concerning Vivelle-DOT.
Vivelle-DOT is applied twice weekly.
Vivelle-DOT contains estradiol in a transdermal patch. Estradiol, the hormone in
Vivelle-DOT, is produced naturally by human females (rather than the estrogens in
Premarin, which are produced by pregnant mares). The patch is applied twice
weekly, such as Sun/Wed or Mon/Thur. It does not contain progestin; women with a
uterus should not use unopposed estrogen.
Vivelle-DOT is not known to be more dangerous in CV risk than Premarin.
The pharmacist is reviewing a prescription for generic alendronate for an elderly female who
lives in a skilled nursing facility. Choose the correct statement:
She will require adequate vitamin D with this medication.
Fosamax
A patient using any of the bisphosphonates for low bone density should be obtaining
adequate calcium and vitamin D.
What is the mechanism of action of Brisdelle?
SSRI. New formulation of Fluoxetine. 7.5 mg po QHS. Used for moderate to severe
symptoms associated with menopause. Lag effect approx. 4 weeks. Do NOT TAKE
WITH WARFARIN (increases risk of bleeding---mechanism is unknown) or TAMOXIFEN
(DECREASES THE EFFICACY of Tamoxifen---metabolites are more potent so slowing
metabolism decreases the efficacy)
Brisdelle is a new formulation of paroxetine indicated for treatment of hot flashes. It
might be useful for women who are not candidates for estrogen, but cannot be used
in women who use tamoxifen or are on anticoagulants, such as warfarin.
A patient will be counseled on the AndroGel Pump. He is using it for the first time.
Which of the following are correct counseling statements? (Select ALL that apply.)
Wash your hands well after application.
Androgel can catch fire when wet on the skin; it is flammable until dry.
Do not let young children touch the site of application or go near the medicine
pump.
Hands must be washed with soap and water after application. AndroGel is
flammable until dry. Do not smoke or walk near open flames. Secondary exposure in
children can cause early virilization.
A patient uses ibandronate. This medication is usually administered in the following
formulation:
IBANDRONATE (Boniva) postmenopausal osteoporosis 2.5 orallly once daily or 150
orally monthly, 3 mg IV infused over 15 to 30 seconds every 3 months-----
postmenopau. Osteopor proph. 3.6 mg orally daily 150 once monthly
Tablet once a month. Ibandronate (Boniva) also comes in an injection, but most
patients use the monthly oral dose of 150 mg.
Fosamax (alendronate)- PREVENTION 35 mg weekly or 5 mg daily post-menopausal
women, TREATMENT (postmeno women and MALES)- 10 mg daily OR 70 MG WEEKLY
ALONE, OR WITH VITAMIN D3 2800 or 5600 IU (CHOLECALCIFEROL), or 70 mg/75mL
solution---drink with at least 2 oz of plain water
men- gluco. 5 mg po daily or 10 mg postmeno. Women not on estrogen
Risedronate (Actonel, Altelvia)- TREATMENT Males 35 mg po weekly, gluco. 5mg
daily, postmeno women 5 mg po day, 35 weekly, 75 two consect. Day/month, 150
mg /monthly (Altelvia)
Zoledronic Acid (Reclast)- Prevention post meno- 5mg IV every 2 years, Treatment-
post meno. Women and osteo. Male- 5 mg IV every 1 year. Gluco- 5 mg IV po 1
yearly
Osphena is an oral estrogen agonist/antagonist indicated for the following condition:
Moderate-severe dyspareunia
Ospemifene (Osphena) is indicated for painful intercourse. It is not indicated for
mild symptoms due to safety risks associated with its use.
Ospemifene is used to decrease painful sexual intercourse (dyspareunia) due to
vulvar/vaginal atrophy. Topical vagina products are actually safer. One of the box
warnings is Risk vs. benefit. This drug has VTE risk and is not indicated for mild
symptoms. Only for short time period for mod-to-severe symptoms.
60 mg po daily take with food. BW Endometrial cancer, CVD, Risk vs benefit.
SE Hot flashes vaginal discharge, hyperhidrosis.
CI undiag. Uncon. Vaginal bleeding, DVT or PE (current or hx), active or hx or arterial
thrombo. Disease (stroke, MI), estrogen-depend. Tumor (known or suspect.), women
who are or may become preg.
A patient has been using calcium citrate 315 mg elemental calcium/tablet for many years. She
takes two tablets with breakfast and two tablets at bedtime. She does not consume dairy products
or much in the way of vegetables. She has started having difficulty swallowing some of her
medications. Her daughter has come into the pharmacy to ask if her mother needs to take these
"horse pills." She is wondering if calcium can be taken in a different formulation that is easier to
swallow. Which of the following statements are correct:
Testosterone topical formulations are C-III. Estrogen topical formulations are not scheduled.
Which of the following hormone formulations used for vasomotor symptoms should
be recommended as monotherapy in a female who has a uterus?
ClimaraPro (estradiol, levonorgestrel) (patch, 0.45 mg estradiol / 0.015 mg
levonorgestrel)
Have to have progestin due to the increase chance for endometrosis
Climara (estradiol)
Premarin (conjugated estrogens)
Select the correct statements concerning bone fractures and causes of osteoporosis.
Hip fracture are more common after age 75 and are the most debilitating type of
fracture.
Osteoblasts build bone, osteoclasts break down bone. Osteoporosis can occur in
men, especially if they are taking certain medications. Vertebral fractures often
occur without a fall.
Counseling on the use of teriparatide should include the following points: (Select
ALL that apply.)
Dizziness for the first few doses of Forteo (teriparatide). Happens within 4 hours
then goes away. For the 1st few doses inject at a place so as to lie down.
Inform PCP if you have joint/bone pain. Comes in pre-filled injection and last 28
days. Each injection is 20mcg and must change needle everyday. Keep in
refridgerator and after 28 days dispose. Inject in thigh or abdomen. Inject around
same time everyday. Only one injection per day, if forget take it as soon as possible.
DO NOT EXCEED FOR MORE THAN 2 years. Need to be taking adequate vit c
(calcium citrate and vit d for drug to work well.
Want to avoid PPI because it increases fractures.
There is a small risk of bone cancer with medication.
If you have bone pain you should let your doctor know right away
The brand name of this medicine is Forteo.
Teriparatide comes in a prefilled SC injection pen that lasts 28 days. Each injection
provides the 20 mcg dose. The pens are refrigerated. And, most injectable
medicines that are fixed doses are designed to last about a month. After 28 days,
the Forteo pen should be discarded even if some medicine remains.
What is the percentage of elemental calcium in a calcium citrate tablet?
21% (calcium carbonate 40%)
This means that for each 1000 mg there are 210 mg of elemental calcium in a
calcium citrate tablet.
The recommended daily intake of vitamin D varies from one organization to another.
In general, what would be a safe recommendation for a 70 year old patient?
800 IU
Some recommend higher doses; at least, the pharmacist should ensure their
patients use the minimum recommended intake.
Which of the following are common side effects of the bisphosphonates? (Select
ALL that apply.)
Bone and joint pain, nausea and heartburn
All the bisphosphonates can cause esophageal ulceration, and GI upset and burning.
Patients can experience bone pain with these agents, and joint aches.
A patient gave the pharmacist a prescription for Premarin 0.625 mg daily. Which of
the following is an appropriate generic substitution for Premarin?
Conjugated equine estrogens
The generic name for Premarin is conjugated equine estrogens.
A teenager eats a poor diet (primarily carbohydrates and fruit) and has heavy menstrual cycles.
The pharmacist will recommend calcium sources. Which of the following statements is correct?
If she takes 4 calcium tablets daily, they should be divided.
Calcium absorption is saturable. Doses above 500-600 mg of elemental calcium
should be divided.
A 73 year-old woman has a T-score of -4.3 in her right hip, -4.7 in her left hip and
has had several vertebral fractures in her lumbar spine. Her only known medical
conditions are osteoporosis and hypertension. She has never had any surgeries.
This woman may be a candidate for the following therapy:
Prolia (Denosumab)- monoclonal antibody that binds to nuclear factor-kappa ligand
(RANKL) and blocks the interaction between RANK (a receptor on osteoclasts),
preventing osteoclast formation; leads to decrease bone resorption and increase
bone mass
Treatment of osteoporosis int post menopausal women at high risk of fracture-
androgen deprivation-induced bone loss in men with prostate Ca, AROMATASE
INHIBITOR-induced bone loss in women with breast CA. 60 mg SC (in medical
setting) every 6 months
CI- hypocalemia
PREG X
Denosumab (Prolia) and teriparatide (Forteo) may both be useful in this very high-
risk patient.
A prescriber is asking for information about the Reclast injection. Choose the correct
statement.
The primary use of Reclast is in patient who cannot tolerate an oral bisphosphonate.
Reclast is zoledronic acid and it is taken once yearly. There are no GI side effects as
the gut is bypassed. Many patients (up to 40%) will experience the transient post-
dose syndrome (TPS) and feel sick for a few days afterwards, with symptoms similar
to the flu. Zometa is a bisphosphonate injection with the same active ingredient
used for hypercalcemia associated with a malignancy.
CI- Renal insuff.. CrCl < 35 alendronate (Fosamex), Zoledronic acid (Reclast), CrCl
<30 ibandronate (Boniva), risedronate (Actonel)
Which risk factors for osteoporosis are present in this patient? (Select ALL that
apply.)
Osteo risk, Genetic factors most important, White and Asian American women
highest, Advanced age, IBS, gastric bypass and celiac disease, alcohol abuse (>3
drinks/day) Epilespsy, Parkinsons disease, stroke, and MS, HIV/AIDS, excessive
thinness, decline in adult estrogen levels, from menopause anorexia nervosa,
lactation, hypogonadism, RA and Lupus, Low level of physical activity and adequate
nutrition- low over life span, calcium and vit D low intake over life span, Smoking
Post menopausal, Low body mass weight ( 106 lbs ?), advanced age, predinose use,
RA
Drugs
Steoid use, longterm, major contributing factor to poor bone health (>5mg/d
prednisone equivalent for >3 months)
Depot medroxyprogesterone acetate (Depo-Provera)
Anticonvulsants( carbamazepine, fospheytoin, phenobarbital, phenytoin, primidone,
( decrease calcium by increase breakdown of vit D)
Heparin, Lithium, Excess thyroid hormone, Loop diuretics (dec. calcium increasing
excretion
Aromatase inhibitors used for breast CA, GnRH (GnRH agonists: nafarelin, goserelin-
used for endometriosis, androgen blockers used for prostat CA and CA Tx, PPI used
chronically (dec calcium absorption due to incr gastric ph
SSRIs, Thiazolidinediones (pioglitzone, rosiglitazone)
The Risk Fracture Assessment Tool (FRAX) is used to assess the need for prescription
drug therapy in patients with low bone density. Which of the following statements
apply to this tool?
Risk of osteoporotic fracture in the next 10 years
Age, sex, BMI, previous fracture, parental hip fracture, femoral neck BMD, current
smoking status, steroid use, alcohol intake, disorders strongly assoc. w/ osteo ( type
I diabetes, chronic liver disease, premature menopause, and RA)
Choose the correct statements concerning raloxifene: (Select ALL that apply.)
Common AE effects include hot flashes, peripheral edema ( has a high clotting risk
Raloxifene is SERM
The dose of raloxifene is 60 mg once daily
Raloxifene is an estrogen agonist/antagonist, previously called a selective estrogen
receptor modulator (SERM). It acts to dec bone-resorption. Conjugated
estrogens/benzedoxifene (Duavee) is an equine (horse) estrogen/SERM combination
indicated for osteoporosis prevention (in postmenopausal women with a uterus) and
for vasomotor symptoms (raloxifene causes vasomotor symptoms). Used often in
women at risk or with fear of breast cancer.
The correct dose of raloxifene is 60 mg once daily. Common adverse reactions
include hot flashes. Do not choose raloxifene in a post-menopausal woman who
wants to reduce hot flashes (or night sweats); it will worsen the problem.
Estrogen in any form is contraindicated in the following situations:
Current or past history of breast cancer
Instruct the patient to alternate which nostril they use (left side one day,
right side the next).
Calcitonin (Miacalcin) does not work well and is used rarely. One spray in one nostril
daily provides the 200 unit dose. Alternate nostrils: left side one day, right side the
next day.
AP is an 82 year-old female patient with very low bone density. Which of the following represent
options for improving bone density and reducing the risks of falls? (Select ALL that apply.)
In MT's lumbar spine the lowest T-score measurement is -1.8. In the right trochanter the T-score
is -0.9 and the left trochanter the T-score is -1.1. She has not had any fractures as an adult. Her
FRAX score is 22%. MT has multiple sclerosis and takes the following medications daily:
Copaxone, Zanaflex, Paxil, Detrol and Provigil. Which of the following statements are correct?