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58 Cards in this Set
- Front
- Back
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Name some contraindications for hormone replacement therapy
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Abnormal, undiagnosed genital bleeding
Breast cancer DVT or PE Estrogen-dependent neoplasia Pregnancy Stroke or MI in past year Thromboembolic disorder/ thrombophlebitis |
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Estrogen & Progestin - Patient education
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AE's may be diminished by starting with low dose and may be alleviated by changing products (transdermal, continuous to cyclic regimen, etc.)
Contact physician if any occur: - Abdominal tenderness, pain, or swelling - Coughing up blood - Disturbances of vision or speech - Dizziness or fainting - Lumps in the breast - Numbness or weakness in an arm or leg - Severe vomiting or headache - Sharp chest pain or SOB - Sharp pain in the claves |
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Estrogen & Progestin - AE's
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Increased risk for venous thromboembolism, stroke, coronary heart disease, & breast cancer
Beneficial effects include reduction in fractures & colorectal cancer |
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Estrogen - Main AE's
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Breast tenderness, heavy bleeding, headache, nausea
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Progestin - Main AE's
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Depression, headache, irritability
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Estrogen & Progestin - Drug-disease interactions
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Esrogen may exacerbate depression, diabetes (glucose intolerance), hypertriglyceridemia, hepatic adenoma, thyroid disorder (increase dose of supplement), impaired hepatic function (poor metabolism of estrogens), cardiovascular disorders (coronary heart disease & venous thromboembolism risk increased)
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Estrogens - Drug-drug interactions
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Decreased estrogen effect:
- CYP450 3A4 inducers (barbituates, carbamazepine, rifampin, St. John's wort), hydantoins, topiramate Decreased effect of: - hydantoins, thyroid hormones, oral anticoagulants Increased effect of: - corticosteroids, TCAs Increased estrogen effect: - CYP450 3A4 inhibitors (itracoazole, ketoconazole, macrolide antibiotics, ritonavir, grapefruit) |
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Progestins - Drug-drug interactions
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Aminoglutethimide may increase metabolism of medroxyprogesterone
Rifampin may increase metabolism of norethindrone |
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Estrogens & Progestins - Monitoring parameters
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Labs not required
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Androgens (testosterone) - MOA
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Precursor hormones to estrogen production by ovaries & peripheral sites
Act at androgen receptor sites or exhibit action following conversion to estrogen Replaces androgen to improve deficiency-related symptoms (decreased sexual desire, decreased energy, diminished well-being) |
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Androgens - Patient education
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Testosterone therapy given only to postmenopausal women who are receiving concurrent estrogen therapy
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Androgens - Contraindications (relative)
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Fluid retention, possible undesirable changes in lipid profile, virilization (lower HDL)
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Androgens - Monitoring parameters
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Labs not required
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Phytoestrogens (isoflavones, lignans, coumestans)
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Food sources: soybeans, flaxseed, alfalfa sprouts
Some studies have shown improvement in vaginal symptoms No evidence supportin gimprovement in other symptoms of menopause (hot flashes, depression, anxiety, headache, myalgia) May have beneficial effects on lipids |
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Name the oral HRT formulations
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Premarin (conjugated estrogen)
Esradiol, Estrace, Gynodiol (micronized estradiol) Estropipate, Ortho-Est, Ogen (estrone sulfate) Estratab, Menest (esterified estrogens) Estradiol Synthetic conjugated estrogen |
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Name the transdermal ERT formulations
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Estraderm (estradiol transdermal system)
Alora, Climara Esclim, Vivelle, Vivelle-DOT |
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Name the injectable ERT formulations
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Estrace vaginal cream
Ogen vaginal cream Premarin vaginal cream Estring vaginal ring Vagifem vaginal tablet |
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Name the combination estrogen-progestin products
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Activella
femHRT Estring Prempro Premphase Climara Pro (transdermal patch) Combipatch (transdermal patch) |
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Name the combination estrogen-androgen products
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Estratest H.S., Syntest H.S.
Estratest, Syntest D.S. |
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What are the benefits to using Progestin-only contraception?
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Appropriate for use in breastfeeding women
Efficacy is less than that of COCs Free of cardiovascular risks associated with estrogen-containing products |
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What is estrogen's MOA in contraception?
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Prevents development of a dominant fllicle by suppression of FSH
Does not block ovulation |
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What is progestin's MOA in contraception?
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Blocks ovulation
Contributes to production of thick and impermeable cervical mucus Contributes to inovlation and atrophy of the endometrium |
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Contraception - Patient Education
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Efficay is high but dependent on proper scheduled use
Does not prevent transmisison of STDs Warning signs of important complications: - severe abdominal pain, severe chest pain, shortness of breath, coughing up blood, severe headache, eye problems (blurred vision, flashing lights, blindness), severe leg pain in calf or thigh Expect changes in characteristics of menstrual cycle Use a back-up if mor than one dose is missed per cycle |
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Contraception - AE's
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Nausea and vomiting - usually resolves within 3 months, breakthrough bleeding, spotting, amenorrhea, altered menstrual flow, melasma, headache, migraine, weight change, edema
Serious and less common: - venous thrombosis, pulmonary embolism, MI, coronary thrombosis, arterial thromboembolism, cerebral thrombosis |
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Contraception - Drug-drug & drug-disease interactions
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Decreased effect of contraceptive:
- ampicillin, griseofulvin, sulfonamides, tetracycline, anticonvulsants (barbiturates, carbamazepine, felbamate, phenytoin, topiramate), NNRTIs, PIs, pioglitazone, phenytoin, rifampin, theophylline Increased plasma level of contraceptives: - atorvastatin, vitamin C, 3A4 inhibitors Decreased effect of: - anticoagulants, benzodiazepine tranquilizers, beta blockers, hypoglycemics (tolbutamide, Diabinese, Orinase, Tolinase), methyldopa, phenytoin Increased effect of: - TCAs, benzodiazepine tranquilizers, beta blockers, theophylline Increased toxicity of cortisone |
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Contraception - Monitoring parameters
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Signs of serious complications
Labs not required |
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Name the progestin-only oral contraceptives
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Ortho Micronir, Errin, Nor-QD, Nora-BE, Camila, Ovrette
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Name the contraindications for combined oral contraceptive use
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Breast cancer, current history of DVT, PE, CVA, or ischemic heart disease
Diabetes with nephropathy, enuropathy, retinopaty, or other vascular disease Headaches Hypertension >160/100 or with vascular disease Lactation <6 weeks postpartum Liver disease Pregnancy Surgery with prolonged immobilization or any surgery on the legs Smoker (>20/day) >35yrs old Structural heart disease complicated by pulmonary hypertension, atrial fibrillation, or history of acute bacterial endocarditis |
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T scores - when to initiate therapy
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T score < -2 and no risk factors
T score < -1.5 with risk factors |
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Osteopenia - T score definition
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T score -1 to -2.5 SD below young adult mean
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Osteoporosis - T score definition
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T score < -2.5 SD below the young adult mean
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Name the risk factors for osteoporosis
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Advanced age, amenorrhea, anorexia, cigarette smoking, current low bone mass, estrogen deficiency as a result of menopause, ethnicity (Caucasian or Asian), excessive alcohol use, family history of osteoporosis or history of fracture in a primary relative, female, history of fracture over age of 50, inactive lifestyle, long-term use of corticosteroids or anticonvulsants, low lifetime calcium intake, low testosterone in men, thin or small frame
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Name the medical conditions associated wiht increased risk of osteoporosis
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aIDS, Cushing's disease, eating disorders, hyperparathyroidism, inflammatory bowel disease, Type I DM, lymphoma and leukemia, malabsorption syndromes, rheumatoid arthritis
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Name the drugs assoicated with an increased risk of osteoporosis
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Anticonvulsants (phenobarbital, phenytoin), cytotoxic drugs, glucocorticoids, immunosuppressants, lithium, long-term heparin use, progesterone (parenteral and long-acting), supraphysiologic thyroxine doses, tamoxifen (premenopausal)
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What are the recommendations for screening for osteoporosis?
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Screen all women >65, postmenopausal women <65 with family history or clinical risk factors, and women with fracture history unrelated to trauma
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Calcium - Patient education
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Only ~500mg absorbed from GI tract at at time, separate doses
Calcium carbonate contains highest level of elemental calcium - take with food to increase absorption Calcium citrate - with or without food |
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Calcium - AE's
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GI upset (nausea, vomiting, cramping, flatulence)
Headache, hypophosphatemia, hypercalcemia |
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Calcium - drug-drug & drug-disease interactions
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May decrease bioavailability of fluoroquinolones or tetracyclines
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Calcium - Monitoring parameters
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Labs not required
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Bisphosphonates - MOA
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Binds to bone (hydroxyapatite) and incorporates into bone to increase and stabilize bone mass
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Bisphosphotanes - Patient education
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Must be taken with a full glass of water (8 ounces) 30 minutes prior to the first meal of the day
Remain in upright position for at least 30min following ingestion Take med on regularly scheduled basis Compliance may be increased by once-weekly dosing |
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Bisphosphonates - AE's
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GI - abdominal pain, dyspepsia, constipation, diarrhea, flatulene, nausea, acid regurgitation, gastritis
CNS - headache |
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Bisphosphonates - Drug-drug & drug-disease interactions
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Decreased effect of bisphosphonates:
- Calcium supplements, antacids - separate by 1 hour Incrased effect of bisphosphonates: - ranitidine (IV may double bioavailability of alendronate) Increased toxicity of: - Aspirin (alendronate >10mg/d may increase risk of upper GI AE's of ASA) |
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Evista - MOA
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Raloxifene
Selective estrogen receptor modulator Estrogen receptor agonist at skeleton - decreases resorption of bone and overall bone turnover |
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Estrogen replacement therapy for osteoporosis treatment - MOA
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Replaces natural estrogen in postmenopausal women to restore protective skeletal benefits
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Estrogen replacement therapy for osteoporosis treatment - Patient education
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Benefits must outweigh the risks
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Estrogen replacement therapy for osteoporosis treatment - Contraindications
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History of thromboembolism, breast, or endometrial cancer
Undiagnosed abnormal genital bleeding Pregnancy |
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Estrogen replacement therapy for osteoporosis treatment - AE's
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Genitourinary - vaginal bleeding or spotting
Other - breast enlargement & tenderness, increased weight Cardiovascular - increased triglycerides |
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Estrogen replacement therapy for osteoporosis treatment - Drug-drug & drug-disease interactions
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Decreased concentration of estrogen:
- rifampin Incrased toxicity of: - hydrocortisone, anticoagulants (increased potential for thromboembolic events) |
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Evista - Patient education
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With or without food
Concomitant use with estrogen not recommended Will not treat symptoms of menopause In the event of prolonged immobilization, discontinue raloxifene 3 days prior to and during the immobile period when possible |
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Evista - AE's
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Cardiovascular - hot flashes, chest pain, syncope
GI - nausea, diarrhea, vomiting Musculoskeletal - arthralgia, myalgia CNS - insomnia, neuralgia Skin - rash, sweating |
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Evista - Drug-drug & drug-disease interactions
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Decreased effect of raloxifene:
- ampicillin, cholestyramine (do not give together) Decreased effect of: - warfarin (PT decreased up to 10%) |
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Miacalcin - MOA
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Calcitonin
Participates in regulation of calcium and bone metabolism Inhibits bone resorption by binding to osteoclast receptors |
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Miacalcin - Patient education
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Injection form given in upper arm, thigh, or buttocks
Nasal spray - use alternating nostrils every day, store in refrigerator until time for use, warm spray to room temp before 1st use, then store at room temp |
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Miacalcin - AE's
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Skin - facial flushing and hand flushing
GI - nausea, diarrhea, vomiting, abdominal pain Taste disorder - salty taste Genitourinary - nocturia, urinary frequency Nasal - rhinitis, nasal dryness, irritation, itching, congestion Ophthalmic - blurred vision, abnormal lacrimation |
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Miacalcin - Drug-drug & drug-disease interactions
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Decreased effect of:
- lithium |
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Forteo - MOA
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Teriparatide (parathyroid hormone)
Increases rate of bone formation by increasing birth rate of osteoblasts and preventing apoptosis, resulting in improved bone mineral density |
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Forteo - AE's
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Musculoskeletal - pain, arthralgia
CNS - paresthesias GI - nausea, diarrhea, abdominal cramps Taste disorder - metallic taste Skin - injection pain, urticaria |
