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Achy Breaky Bones

Achy Breaky Bones. Hilary Rowe, BScPharm VIHA Pharmacy Resident 2009-10 Geriatrics Rotation Sept 30, 2009. Outline. Objectives Introduction to the Patient Review of Systems DRP’s Osteoporosis Evidence Recommendation Monitoring. Objectives.

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Achy Breaky Bones

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  1. Achy Breaky Bones Hilary Rowe, BScPharm VIHA Pharmacy Resident 2009-10 Geriatrics Rotation Sept 30, 2009

  2. Outline • Objectives • Introduction to the Patient • Review of Systems • DRP’s • Osteoporosis • Evidence • Recommendation • Monitoring

  3. Objectives • Review pathophysiology & diagnostic criteria for osteoporosis • Review Evidence of teriparatide & zoledronic acid • Discuss therapeutic options for a 94 yo osteoporotic female • Discuss decision & monitoring

  4. Mrs. FT • ID: 94 yo female • Admitted: • urinary retention from a UTI (resolved) • Allergies: • Sulpha (reaction unknown) • SH: • Lives alone, medications in vials, Pharmanet regular, no Hx smoking, alcohol 2 oz drink before dinner

  5. Mrs. FT • Discharge Plan: • Return home to independent living • PMHx: • Oophorectomy, hysterectomy, fractures, HTN, GERD • Meds PTA: • Felodipine, Cilazapril, Rabeprazole, Calcitonin, Tramadol/Acetaminophen, Alendronate, Acetaminophen, Calcium, Vitamin D

  6. Review of Systems

  7. Review of Systems

  8. Review of Systems

  9. Review of Systems

  10. Review of Systems

  11. DRP’s • Mrs. T requires continued assessment of pain on transfer and with physio despite present therapy of tramadol/Acetaminophen, calcitonin, and prn hydromorphone • Mrs. T is at risk of unsteadiness and falls secondary to low Na and would benefit from monitoring and continued re-assessment of her fluid and salt intake

  12. DRP’s • Mrs. T is at risk of falls secondary to experiencing a drug-drug interaction with mirtazapine and alcohol causing drowsiness and a hangover effect and would benefit from counseling in regards to alcohol intake • Mrs. T continues to experience multiple painful fractures despite standard therapy of Alendronate, Ca and Vit D and may benefit from consideration of additional therapies.

  13. Osteoporosis • Osteoclasts - ion channels that pump protons into extracellular space, ↓ in pH dissolves bone • Osteoblasts deposit new bone • Balance between these cells determines if bone is made, maintained, or lost

  14. Osteoporosis • Low bone mass and fragility due to: • peak bone mass is low • bone resorption is excessive • trabecular bone loss and increased porosity in compact bone • bone formation during remodeling is decreased • Diagnosed by fragility fracture or T score <-2.5

  15. Mrs. FT • Patient is on Calcium, Vit D, Calcitonin, Alendronate • Fracture right hip healing (March 09) • Compression Fractures of the spine: recent Sept 18th bone scan T12 & T3 • Lives alone • Cognitively intact and no compliance issues

  16. Goals of Therapy • Reduce hip and vertebral fractures • Prevent hospitalizations • Control Pain • Reduce side effects • Keep patient living independently (quality of life) • Limit financial burden

  17. Therapeutic Options • Alendronate 70mg weekly • Zoledronic acid 5mg infusion yearly • Teriparatide 20 mcg subcutaneous injection daily

  18. Studies to Discuss • Alendronate vs Teriparatide • Alendronate: Decreases the rate of bone resorption by blocking osteoclasts • Zoledronic acid vs Placebo • Zoledronic Acid: Inhibits osteoclast resorption, reducing bone turnover • Teriparatide vs Placebo • Forteo: acts on osteoblasts to stimulate new bone growth and improve bone density

  19. Body et al. J Clin Endocrinol Metab 2002

  20. Black et al. New Engl J Med 2007

  21. Black et al. New Engl J Med 2007

  22. Neer et al. New Engl J Med 2001

  23. Neer et al. New Engl J Med 2001

  24. Patient Considerations • Cost $15,000 per 18 months • Need to apply to Forteo Customer Care • Can patient do injections? • Can patient remember daily regimen? • Benefit to patient? • Drug interactions?

  25. Recommendation • Teriparatide 20mcg subcutaneous daily for 18 mo • Have Forteo nurse teach patient in hospital • Calcium carbonate 500mg elemental BID • Vitamin D 2000 units daily • Continue to mobilize with walker

  26. Monitoring

  27. Monitoring

  28. References • Neer RM, Arnaud CD, Zanchetta JR et al. Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. New Engl J Med 2001;344:1434-41. • Black et al. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. New Engl J Med 2007;356:1809-22. • Body JJ, Gaich GA, Scheele WH et al. A randomized double-blind trial to compare the efficacy of teriparatide [Recombinant Human Parathyroid Hormone (1–34)] with alendronate in postmenopausal women with osteoporosis. The Journal of Clinical Endocrinology and Metabolism 2002; 87(10):4528–4535.

  29. Questions?

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