Osteoporosis, Menopause & Testosterone Use

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))

Forteo (teriparatide)- osteo, primary or hypogonadal in men, due to corticosteroid,

post menopause osteo, high risk of fracture---20 mcg subq once daily, 28.2 or 56.5
mcg sub q once weekly
Receptor activator of nuclear factor kappa-8 ligand (RANKL) inhibitor- denosumab
subQ solution (Prolia 60mg/1Ml) Xgeva 120/1.7 Ml, Osteopor. Male, Postmeno.
Osteo.
Osteo Male- Prolia 60 mg subQ once every 6 months and at least 400 IU vit D orally
daily
Postmeno. Osteo. High risk of fracture--- Prolia 60 mg subQ once every 6 months +
Ca 1000 mg orally once daily and at 400 IU vit D orally once daily
Non-FDA Postmeno osteo. Prop. 60 mg subQ every 6 months
Dosing Alendronate 70 mg po 1 weekly or 10 mg po every day, Binosoto,1 tab po
weekly , 5 mg / day if due to glucocor.

These medicaetions have been studied inap women with postmenapausal

osteoporosis and thereis limited data in men with glucocorticoid-inducded
osteoporosis.
Questions
A patient is asking about raloxifene. Which of the following statements are correct?
Raloxifene is used primarily in women afraid of getting breast cancer.
Raloxifene is used in women afraid of getting breast cancer, or in women who had
breast cancer and are attempting to prevent recurrence (or cancer occurrence in
the contralateral breast).
Orphan drug designation: Reduction of risk of breast cancer in postmeno women
and treatment of hereditary hemorrhagic telangiectasia (broken small capillaries)
Conjugated estrogens/bazedoxifene (Duavee) contains estrogen plus an estrogen a
which is also used gonist/antagonist (bazedoxifene) which is also used for revention
of osteoporosis in post-menopausal women with uterus. Bazedoxifene
preventsendometrial hyperplasis in women with a uterus, just like progestin.
Raloxifene prevents vertebral fractures only and can be used for treating or
preventing osteoporosis and is used MOST COMMONLY in postmenopausal women
who are at risk or have fear of breast cancer.
Calcitonin has fallen out of favor due to reducing only vertebral fractures and has
cancer risk; it is reserved for use when alternatives are NOT SUITABLE.
Ospemifene (Ospehna)- 60 mg po daily w/ food. BW-
RM will use an estrogen patch for hormone replacement therapy. Counseling points
should include: (Select ALL that apply.)
The use of the patch (estrogen) can help keep her bones healthy too.
The area where she applies the patch must be clean, dry, free of powder, oi or
lotion.
Make sure she is taking adequate Ca and vit D to help her bones stay strong.
Make sure that patients are using adequate calcium and vitamin D. Estrogen should
be used at the lowest effective dose and is generally not recommended for women
> 10 years from menopause.
HB is a 76 year old female with osteoporosis. She is 5' 2'' and 110 lbs. Her serum
creatinine is 1.3 mg/dL. Which of the following statements is correct?
It is not safe for HB to use any bisphosph.
CrCl = 29 mL/min
HB has a calculated CrCl of 29 mL/min. Zoledronic acid and alendronate should not
be used when the CrCl is less than 35 mL/min and ibandronate and risedronate
should not be used when the CrCl is < 30 mL/min. Since HB has osteoporosis, she
needs treatment (not prevention).
Which of the following drugs or conditions can lower testosterone? (Select ALL that
apply.)
Methadone (other opioids could be a risk), chemotherapy, cimetidine (inhibit
CYP1A2, 2C9, 2D6) , spiralactone (can inactivate adrenal and testicular cyp 450
enzymes), Docetaxel (Taxotere). Cabazitaxel (Jevtana), Mitoxantrone (Novantrone),
Estramustine (Emcyt)
Docetaxel (Taxotere) + prednisone is normally DOC and the next drug tried is
cabazitaxel (Jevtana).
Which of the following formulations contains estrogen plus a progestin?
Premphase (conj estrogen, medroxyprogesterone)
Premarin ( conjugated estrogens)
Femring (estradiol acetate)
Provera (medroxyprogesterone)
Climara (estradiol)
MK is a 65 year-old male with NYHA Class I heart failure, prostate enlargement, mild
cognitive decline and erectile dysfunction. His medications include valsartan,
metoprolol extended-release, hydrochlorothiazide, tamsulosin, finasteride and
donepezil. MK's testosterone level is within the normal range. He wishes to use
sildenafil, but it is not covered by his Medicare plan and he finds the cost per tablet
prohibitive. He asks his physician for another option, and the physician suggests
testosterone. Select the correct statement:
Testosterone will worsen the prostate symptoms.
Testosterone therapy can be recommended if the patient has low testosterone with
a related condition, such as muscle wasting. These are not present in this case. He
is not contraindicated for testosterone, however it would worsen his prostate
symptoms and counteract the benefit provided by finasteride.
MB is using the Androderm patch. Counseling points should include: (Select ALL
that apply.)
Apply each evening.
Apply the patch to the back, abdomen, thighs, or the upper arms.
Do not apply more than one patch.
Remove during an MRI or the skin under the patch with burn.
2 mg, 4 mg patch. Avoid showering, washing the site, or swimming for > or equal 3
hours after application. After removal, can treat irritation with OTC hydrocortisone.
Remove before MRI. Gels are flammable until dry. Wash hands after application. Do
not dress until skin dry.
Many patches burn the skin if not removed prior to an MRI. Apply to the back,
abdomen, thighs or upper arms, each evening between 8:00PM and midnight. The
same site should not be used for at least 7 days.
A woman suffers from severe hot flashes and night sweats. She has no
cardiovascular or breast cancer risk and wishes to use the most effective therapy
available to treat these vasomotor symptoms of menopause. Which of the following
represents the most effective therapy for this patient?
Estrogen
Medroxyprogesterone is a progestin; she may need a progestin if she uses estrogen
and has a uterus (to protect her from estrogen-induced endometrial cancer).
However, the progestin is not providing the benefit; it's the estrogen. Natural
products may be helpful to some women, but are not very effective
therapy. Replens is an OTC lubricant.
What is the most common application site for the Vivelle-Dot and most estrogen
patches?
Vivelle-Dot, Alora, Minivelle twice weekly, Climara, Menostar weekly, Evamist-
spray on the inside of the foreman each morning.
Gels: Every morning. Flammable. Divigel (upper thigh, alt. sides), Elestrin (upper
arm/shoulder), Estrogel (arm)
Estrogen patches: lower abdomen below the waistline. Avoid waistline, since it can
be rubbed off. Do not apply to breasts.
Mark the schedule you plan to follow on your med package inner flap, or on your
calendar. If you forget to change your patch on the correct date, apply a new one as
soon as you remember.
What is the definition of menopause?
No menstrual period for 12 consecutive months.
The period prior to menopause is perimenopause. During this time, when the
estrogen and progestin levels have declined, some women are symptomatic and
may desire prescription treatment.
What medication might be used in the perimenopause period to help a female who
experiences uncomfortable vasomotor symptoms? (Select ALL that apply.)
Estrogen prescription products
Estradiol topical therapy, prepared by a compounding pharmacist
Vivelle Dot
Premarin

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:

Calcium is available in many forms, including liquids and chewable tablets.

Calcium comes in chewable formulations, liquids, granules/powder.
Select the correct statements concerning Brisdelle:
Contains fluoxetine
Mod-severe symp. With menopause, SE sedation, insomnia, restlessness, tremor,
dizziness/weaknesses, nausea dry mouth, const., diaphoresis
IT CANNOT BE USE WITH TAMOXIFEN OR WARFARIN.
This is a formulation of paroxetine; SSRIs can cause hyponatremia (not commonly,
but it happens). SSRIs increase bleeding risk when given with anticoagulants. It
cannot be used with tamoxifen because paroxetine is a CYP 450 2D6 inhibitor and
would block conversion to active tamoxifen. All of the side effect issues from
paroxetine in other formulations apply here.
MT is a 54 year-old female who suffers from dry, painful intercourse. This started
about a year ago after she underwent a total hysterectomy. The following drug may
provide benefit and would reduce her exposure to systemic estrogen:
Estring (17-b-Estadiol vaginal ring) = these are localized so would reduce exposure
Estrace (vaginal cream)
Vagifem (vaginal tablet)
Vaginal products are most useful for patients who have vaginal symptoms (dryness,
painful intercourse) only, since the risks may be less compared to systemic estrogen
exposure. Estring, a vaginal ring that releases estradiol would provide local benefit.
The Drug Enforcement Administration has placed topical testosterone products into
this scheduled category:
C-III

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)

Unopposed estrogen therapy in women with a uterus is dangerous and is a boxed

warning. "Pro" indicates a progestin is included; this is not always the case, but is
with this drug name.

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)

Select the best treatment option for SC?

Bisphosphonates are used for 1st line.

Atelvia 35 mg once weekly, 10 mg po daily, risedronate 150 monthy, no prevention
dose, prevention dose= alendronate 5 po daily, 35 mg weekly, treatment= 10 mg
daily, 70 mg weekly alone or with vit d3 2800 or 5600 IU cholecalciferol
Ibandronate (Boniva)-2.5mg daily or 150 mg monthly (prevention or treatment)
Bisphosphonates are first line for most patients. Fosamax 5 mg daily is a prevention
dose. Higher doses are needed for treatment.
Based on SC's intake of calcium carbonate, which of the following statements is
correct?
1250 mg BID
2500 mg X 0,4= 1000 mg
Calcium carbonate contains 40% elemental calcium. It should be taken with food
since absorption is acid dependant. There is no advantage to switching to a different
formulation in this patient.
The Womens Health Initiative Trial exposed increased risks of certain health
conditions with the use of hormone therapy. The risks included an increase in the
following in older women:
Stoke

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

Choose the correct statements concerning calcitonin nasal spray:

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.

The use of testosterone can cause which of the following effects?

Increased appetite
Testosterone use can increase creatinine, appetite, cholesterol, and cause sensitive
nipples and acne. It can cause hepatotoxicity. It is contraindicated in breast or
prostate cancer.
Which medication puts SC at increased risk for falls (and consequently) injury and
fractures?
Ramelteon (Rozerem)-melatoning receptor agonist
Many drugs can increase the risk for falls, including pain medications, skeletal
muscle relaxants, hypnotics (e.g., ramelteon) and anxiolytics (including
benzodiazepines) and many antidepressants and antipsychotics.
A patient gave the pharmacist a prescription for Prempro. Which of the following is
an appropriate generic substitution for Prempro?
Conjugated equine estrogens and medroxyprogesterone
The generic name for Prempro is conjugated equine estrogens and
medroxyprogesterone (MPA).

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.)

Weight bearing exercise, such as walking

Ensuring adequate calcium and vitamin D intake
Bisphosphonates
Teriparatide (Forteo)
Osteoporosis is usually treated with medications, weight-resistant exercise (such as
walking) and adequate calcium and vitamin D. Furosemide causes hypocalcemia.
Which of the following statements concerning denosumab are correct?
Denosumab is administered every 6 months, in a medical office.
Denosumab is used for hypercalcemia of malignancy in the formulation called
Xgeva. Denosumab can lower serum calcium levels; calcium should be checked
prior to initiation of therapy.
JV is a 60 year-old post-menopausal female who is overweight and sedentary. Last
year, while taking a five hour cross-country flight, she developed a deep vein
thrombosis (DVT). This was her second DVT in two years. She has refused warfarin,
but agreed to use an aspirin daily. Aspirin is her only medication. Recently,
JV's sister was diagnosed with breast cancer. During the work-up, JV's sister was
found to have low bone density. Due to her sister's new diagnoses, JV is inquiring if
she can use raloxifene, which she heard might protect her against breast cancer
and will help her build strong bones. Choose the correct statement:
She is contraindicated for raloxifene due to her history of DVT.
Raloxifene (Evista) has an increased risk for thromboembolism. Women with active
or past history of venous thromboembolism cannot use this medication.

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?

MT has risk for falling due to her medications.

MT has osteopenia, based on the T-scores given. She is not a candidate for the high-
risk agents, based on her bone density readings and lack of fracture history, but
given her FRAX score she should receive treatment. She is at risk for falling based
on her medical condition and the medications she is taking.
FRAX >20% 10 year probability >3% hip fracture
Which of the following statements are correct regarding the more recent updates to
osteoporosis treatment guidelines?
Due to the risk of atypical femur fracture and osteonecrosis of the jaw, the use of
bisphosphonates is limited to 3-5 years.
Due to the risk of atypical femur fracture (a very difficult break) and osteonecrosis
of the jaw, the use of bisphosphonates is limited to 3-5 years.
A patient asks the pharmacist if bioidentical hormone replacement therapy is a
safer option than using the drugs in products such as Premarin. Choose the safest
response:
It is safest to assume that the health risks of bioidentical hormones are similar to
the estrogens that have been studied until more information is available.
The term "bioidentical" generally refers to compounds that have the same chemical
and molecular structure as hormones that are produced in the human body. Many
woman, physicians and compounding pharmacists believe that bioidentical hormone
therapy is safer, but keep in mind that there are no well designed studies to confirm
risk or benefit.
Inject the medication while sitting down as you may feel dizzy after the first few
doses.
Teriparatide [rDNA origin] injection (Forteo) is used for patients who are at very high
risk for fracture, or who have already had a fracture due to osteoporosis. It is used
daily for a maximum of two years. It should be injected into the thigh or lower
abdomen.