MP is a 55-year-old postmenopausal woman who presents to your pharmacotherapy clinic to manage her newly diagnosed osteoporosis (T score – 2.7). Her past medical history is significant for hip fractures, hypertension, CKD (Clcr 23ml/min), myocardial infarction with drug-eluting stent placement in right coronary artery 6 months ago, T2DM, depression, and dyslipidemia. Current medications include lisinopril 20mg daily, metformin 500mg BID, atorvastatin 40mg daily, clopidogrel 75mg daily, aspirin 81mg daily and amitriptyline 25mg qHS. Which of the following medications would be appropriate options for MP? (Select all that apply)

A. Forteo

B. Actonel

C. Prolia

D. Reclast

E. Evenity

F. Tymlos

Answers with rationale:

Answers:  A, C, F

Per the American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology (ACE) 2020 Postmenopausal Osteoporosis Guidelines, this patient is characterized as “very high risk/prior fractures” based on the patient’s history of hip fractures. Initial therapy for very high-risk patients includes abaloparatide (Tymlos), denosumab (Prolia), teriparatide (Forteo), zoledronate or zoledronic acid (Reclast), and romosozumab (Evenity).  Alternate therapy for very high-risk patients could include risedronate (Actonel). Risedronate and zoledronate would not be appropriate for MP as bisphosphonates are contraindicated in patients with severe renal impairment defined as CrCl <30ml/min for risedronate and CrCl <35ml/min for zoledronate. Romosozumab has a black box warning on its label for the drug’s potential risk of myocardial infarction, stroke, and cardiovascular death. Romosozumab should not be initiated in patients who have had a myocardial infarction or stroke within the past year. MP’s past medical history lists that she had a MI 6 months ago and therefore romosozumab would be contraindicated in this patient. This leaves options teriparatide, denosumab, and abaloparatide which would be appropriate choices for MP.

Also, it’s important to note that the patient is taking amitriptyline and tricyclic antidepressants are known to increase the risk of falls. Consult with the patient’s PCP to consider switching to a less sedating antidepressant such as Wellbutrin if appropriate.

Good luck to everyone next week on Match Day!

Dr. B

NAPLEX Exam Competencies Covered: Area 3 – Develop or Manage Treatment Plans, Section 3.6 Drug contraindications, allergies, or precautions

Click the links below for more information:

AACE/ACE Postmenopausal Osteoporosis Guidelines 

Romosozumab