• Patients with hip or vertebral fractures
• T-score < -2.5 at femoral neck or spine
• Post-menopausal women and men > 50 y/o (T-score between -1.0 and -2.5 and 10yr hip fracture probability > 3% or a 10 yr major OP-related fracture probability > 20%)

• FDA approved for OP prevention only
• Only effective while taking medication
• Also, compelling indication for severe hot flashes
• RISKS -- estrogen + progestin (CHD, stroke, breast CA, DVT), estrogen (DVT, stroke)

• > 5 yrs postmenopausal
• Tolerance may develop after 12-18 months

• Rhinitis
• Epistaxis

Do not use Teriparatide in patients with the following risk factors for osteosarcoma:

• Paget's disease
• Unexplained elevations of Alk Phos
• Hypercalcemia
• Patients with history of bone radiation therapy
• Patients with open epiphyses

• Hypocalcemia
• Pain in back, arms, legs, muscle, bone
• Elevated cholesterol
• Increased incidence of infections
• Skin reactions

• All females > 65 yo and males > 70 yo
• Postmenopausal females and males 50-69 yo with risk factors
• Adults with fractures after age 50
• Adults with health conditions or taking medications associated with low bone mass
• Postmenopausal females discontinuing estrogen

• Primary SERM used for OP
• Prevention or treatment of OP in postmenopausal women
• 60 mg PO daily
• Reduces risk of invasive breast CA
• Increases risk of DVT and hot flashes

• Nasal Spray
• IM/SQ injection

Prevention: 5 mg PO daily OR 35 mg PO weekly

Treatment: 10 mg PO daily OR 70 mg PO weekly

Alendronate plus Cholecalciferol

70 mg/2800 IU, 70 mg/5600 IU

• Doses are same for prevention and treatment
• 5 mg PO daily
• 35 mg PO weekly
• 75 mg PO 2 consecutive days/month
• 150 mg PO monthly

• Risedronate delayed release
• 35 mg/week
• For treatment only
• Acid suppressive therapy may interfere w/ absorption

• Prevention or Treatment of OP
• 2.5 mg PO daily
• 150 mg PO monthly
• 3 mg IV bolus q 3 months

ADRs

• Irritation of upper GI mucosa and esophages

Clinical Pearls

• Poor bioavailability
• Take in AM on empty stomach with 8 oz H2O only (Atelvia can be taken immediately after breakfast)
• Do not lie down for > 30 min after taking
• No food, drink, other medications for 30-60 min

• Only available IV
• Treatment: 5 mg IV over 15 min yearly
• Prevention: 5 mg IV q 2 yrs
• Post treat with APAP to prevent acute phase reaction

• Alendronte, Risedronate and Zoledronic Acid -- Reduce hip, vertebral, and non-vertebral fractures
• Ibandronate -- Reduces vertebral fractures

• Invasive dental procedures
• Diagnosis of cancer
• Concomitant therapy with chemo or steroids
• Poor oral hygiene
• Co-morbidities

• PTH
• 20 mcg SQ once daily -- do not use > 2 yrs
• Only drug to increase bone formation
• Give it in pulsatile manner -- given continuously increases osteoclast activity and bone degradation
• ADR -- has been shown to cause osteosarcoma is rats, no evidence in humans yet

MOA

human monoclonal antibody that targets RANKL and inhibits osteoclast development/activity

Uses

For OP and osteopenia secondary to aromatase inhibitor

Last line therapy for OP

Dose

60 mg SQ q 6 months

• Every 2 yrs generally
• Every 6-12 months if on long-term glucocorticoid use -- only necessary for 1st 2 yrs of steroid treatment, then every 2 yrs long term