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Toronto Notes 2019 Common Medications Endocrinology E53
Metabolic Bone Disease Medications (continued)
Drug Class
Mechanism of Action
Generic Drug Name
Canada Name
US Name (if different)
Dosing
Indications
Contraindications
Side Effects
Selective Estrogen Receptor Modulators
Decreases resorption of bone through binding to estrogen receptors
raloxifene
Evista®
60 mg OD
Treatment and prevention of postmenopausal osteoporosis (2nd line)
Lactation
Pregnancy
Active or past history of DVT, PE, or retinal vein thrombosis
Hot flashes
Leg cramps
Increased risk of fatal stroke, venous thromboembolism
Calcitonin
Inhibits osteoclast-mediated bone resorption
calcitonin
Miacalcin®
One spray (200 IU) per d, alternating nostrils
Treatment for postmenopausal osteoporosis (greater than 5 yr postmenopause)
Clinical allergy to salmon-calcitonin
Rhinitis Epistaxis Sinusitis Nasal dryness
Anti-RANKL Monoclonal Ab
Inhibits RANKL (osteoclast differentiating factor) g inhibits osteoclast formation and decreases bone resorption
denosumab
ProliaTM
XgevaTM
60 mg SC q6mo
Treatment for postmenopausal women at high risk of fracture
Prevent skeletal-related events in patients with bone metastasis from solid tumours Also approved for Glucocorticoid-induced osteoporosis, and for men
Hypocalcemia Vitamin D insufficiency
Fatigue/headache/GI injection site reaction Hypocalcemia
Atypical femoral fracture Osteonecrosis of the Jaw
PTH
Stimulates new bone formation by preferential stimulation of osteoblastic activity over osteoclastic activity
teriparatide
Forteo®
20μgSCODx 18-24 mo
Treatment for postmenopausal women with osteoporosis who are at high risk for fracture Treatment for men with primary or hypogonadal osteoporosis who are at high risk for fracture
Paget’s disease
Prior external beam or implant radiation therapy involving the skeleton
Bone metastases
Metabolic bone diseases other than osteoporosis
Orthostatic hypotension Hypercalcemia Dizziness
Leg cramps
Calcium VitaminD
Inhibits PTH secretion Regulationofcalciumandphosphatehomeostasis
1200 mg/d (including diet) Divided in 3 doses
Osteopenia
Osteoporosis
Prevention of metabolic bone disease
Caution with renal stones
Vomiting Constipation Dry mouth
cholecalciferol (vitamin D3)
800-2000IU/d
(higher doses required in Insufficiency or deficiency)
Osteopenia
Osteoporosis
Prevention of metabolic bone disease
Cautioninpatientsondigoxin(riskof hypercalcemiawhich may precipitate arrhythmia)
Hypercalcemia Headache
Nausea and vomiting Constipation
ergocalciferol (vitamin D2)
Drisdol® Erdol®
50,000 IU/wk
Osteoporosis in patients with liver dysfunction, refractory rickets, hypoparathyroidism
Hypercalcemia Malabsorption syndrome Decreased renal function
calcitriol (1,25(OH)2-D)
Rocaltrol®
Start 0.25 μg/d
Titrate up by 0.25 μg/d at 4-8 wk intervals to 0.5-1 μg/d
Hypocalcemia and osteodystrophy in patients with chronic renal failure on dialysis Hypoparathyroidism
Hypercalcemia Vitamin D toxicity
Calcijex®
Start 0.25 μg/d
Titrate up by 0.25 μg/d at 2-4 wk intervals to 0.5-2 μg/d
Also approved for Glucocorticoid-induced osteoporosis