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Osteoporosis

Self-Injection Videos

How to inject Forteo and Tymlos

January 30, 2018
How to inject Forteo and Tymlos

Continuing our self-injection series, Dr. Farrell shows us how to inject Forteo (i.e., teriparatide) and Tymlos (i.e., abaloparatide).  Both these medications are used to treat osteoporosis.  Osteoporosis is a disease that causes the bones to lose their strength making them more prone to fractures.  We call these fragility fractures.  They can involve almost any bone but the hips, spine, forearm, and ribs are particularly prone.  Usually fragility fractures happen after a fall but sometimes can even happen after a bad coughing fit.  About 40% women and 13% of men sustain a fragility fracture during their lifetime.  Osteoporosis accounts for about 1.5 million fractures in the United States annually.

Treatment for osteoporosis involves building up bone density.  Weight-bearing exercise, calcium, and vitamin D supplementation are very important, but sometimes it’s not enough.  Today, we’re going to show us how you can give yourself two different osteoporosis medications: Forteo and Tymlos.  Both these medications come as auto-injector pens and both are given on a daily basis.

Preparing for your injection

  • Keep your medication stored in the refrigerator until use
    • Before injecting medication, take the prefilled syringe out of the refrigerator.
    • Allow it to warm up to room temperature.
  • Pick a place in your house that is clean and has room for your materials (such as the kitchen table).
  • Wash your hands thoroughly with either:
    • Soap & water
    • Hand sanitizer
  • Choose an area to inject – Thigh or Stomach.
    • Choose an area that is intact and clear.
    • It should not have any of the following:
      • Cuts
      • Scrapes
      • Bruises
      • Psoriasis patches
      • If you have extensive psoriasis, inject between patches
      • Moles
      • Scars
    • Please rotate area each time you inject (shown in picture below).

Areas to inject subcutaneous medication

  • Cleanse chosen area
    • Cleanse chosen area with either of the following:
      • Alcohol swab
      • Alcohol and a cotton ball
    • Use the chosen alcohol material to “swipe” area
      • Can either use a circular motion or wipe in “strips”
      • Allow the area to dry

How to inject Forteo

  • Inspect the medication to make sure that it is clear (no cloudiness or crystallization)
  • Remove the white cap from the autoinjector pen
  • Peel off the colored paper seal from the pen needle
    • Pen needle is located inside the small plastic casing (pen needle cap)
  • Push the end of the Forteo pen into the opening of the pen needle and screw on until tight, then removed pen needle cap (save for discarding)
  • Take the small cap off the tip of the pen needle and discard
  • Prime the pen
    • Pull the dose knob out until you see a red section below the yellow section and when you see the “0” in the dose window, turn the knob to the right until you see the number “1”
    • Push button down for 5 seconds until you see a couple drops of medication come out
    • A diamond will appear in the dose window when the device has been primed
    • Set the dose by turning the knob past “1” to “2”
  • Pinch cleansed skin and insert the needle at a 90-degree angle
  • Press the button and hold for 10 seconds
  • Pull the needle straight out of the skin
  • You may see a couple drops of the medication on your skin, but do not be concerned, your dose has been delivered

How to inject Tymlos

  • Inspect the medication to make sure that it is clear (no cloudiness or crystallization)
  • Take off the white cap and twist on the pen needle to the injector pen
  • Take off the larger cap and prime the device by turning the knob from “0” to “80”
  • Pinch the skin around the injection site and enter the skin at a 90 or 45-degree angle
    • You may release the pinched skin once the needle is in place if desired
  • Press button while firmly holding the pen against the skin, you may feel a pinch as the needle enters the skin, and slight tingling while the medication is being administered
  • Hold the pen in place for at least 10 seconds to ensure all the medication is administered

After the injection

  • Replace the pen needle cap and turn the opposite way to unscrew the pen needle
  • Properly dispose of the pen needle by discarding the pen needle inside the pen needle cap into your sharps container
    • May be provided by the drug company (depending on the medication)
    • You can purchase a sharps container at your local pharmacy
    • You may use a coffee can if you are unable to attain a sharps container
    • Disposal
      • Hospitals may take sharps
      • Pharmacies and Doctors’ offices are not allowed to take used syringes or needles

For more information regarding Forteo, please follow this link.

For more information regarding Tymlos, please follow this link.

Credits

Jessica Farrell, PharmD.  Clinical Pharmacist, The Center for Rheumatology/Associate Professor, Albany College of Pharmacy and Health Sciences

With the help of Autumn Koniowka. Doctor of Pharmacy Candidate Class of 2018, Albany College of Pharmacy and Health Sciences, and Megan Phillips. Doctor of Pharmacy Candidate Class of 2018, Albany College of Pharmacy and Health Sciences.

A special thanks to Tammy Garren, PhD. Instructional Designer, Center for Innovative Learning, Albany College of Pharmacy and Health Sciences.

Injection site image: By British Columbia Institute of Technology (BCIT). Download this book for free at http://open.bccampus.ca [CC BY 4.0 (http://creativecommons.org/licenses/by/4.0)], via Wikimedia Commons

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

 

Diseases and Conditions

Will I get osteonecrosis of the jaw if I take medications for osteoporosis?

April 12, 2017

Foreword

As a rheumatologist, I regularly depend on the expertise and advice of pharmacists.  Medicine has gotten unbelievably complex.  I truly believe that using a team-based approach is the best way of providing quality-care.  In the clinic, I’m often asked questions about osteoporosis medications.  Bisphosphonates are a class of medications that are commonly used to treat osteoporosis and they’ve come under a lot of scrutiny lately. One of the potential side effects is osteonecrosis of the jaw.  For this week’s edition of RheumDoctor, one of our pharmacy students, Amy DeGennaro, teaches us: what is osteoporosis, what are bisphosphonates, and what is the real risk of osteonecrosis of the jaw.


Believe it or not, our bones are alive. Bones, in our bodies, are constantly renewing just like how our skin is constantly turning over. Our body’s ability to constantly build and breakdown bone is what allows us to grow and heal. This normal bone process over time results in our bones to get slightly thicker, however, we reach peak bone density in early adulthood.  As we age we gradually start to lose bone though.  Reduced bone mass puts us at risk for fractures which can be prevented by treatment.  One of our best treatments (a group of drugs called bisphosphonates) slows the breakdown of bone and reduces the risk of a fracture, which is exactly what we want when treating osteoporosis.

What is Osteoporosis?

Osteoporosis is a disease in which bone density and quality are reduced, which means our bones become more porous and fragile, increasing the risk of fractures greatly. However, this bone loss occurs silently. Often there are no symptoms you would experience until your first fracture. It’s estimated that 200 million people worldwide suffer from osteoporosis. In the United States and in Europe, about 30% of all postmenopausal women have osteoporosis, and even worse at least 40% of these women will sustain one or more fragility fractures in their remaining lifetime.

But it is important not to forget that men suffer as well from osteoporosis.1

What is Osteonecrosis of the Jaw?

Exposed bone, in our mouths, that has persisted for more than 8 weeks. If a section of bone is fractured and does not heal it can cause blood flow to the bone to be interrupted causing bone death.

What Type of Treatment for Osteoporosis is related to Osteonecrosis of the Jaw?

Bisphosphonates: alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), zoledronic acid (Reclast)

Bisphosphonates work very well at inhibiting the breakdown of bone which results in an increase in the density of bone. Bisphosphonates have FDA approved indications for the treatment and prevention of post-menopausal osteoporosis, osteoporosis in men, and glucocorticoid (steroid) induced-osteoporosis. All bisphosphonates on the market have demonstrated reductions in vertebrae fractures and the majority of bisphosphonates show additional reduction in non-vertebral and hip fractures as well.

Such strong inhibition of bone breakdown may theoretically lead to an accumulation of microdamage to the bone which might compromise bone strength or delay fracture healing. However, we have seen, from studying the bones of women on long-term bisphosphonates that there is no increased microdamage, and clinical trials of bisphosphonates did not show evidence of altered healing.2

What are Risk Factors for Osteonecrosis of the Jaw for Patients?

  • Drug-related risk factors
    • Bisphosphonate potency (oral therapies less potent than intravenous)
    • Duration of bisphosphonate treatment
  • Individual risk factors
    • Dental surgery
    • Concomitant oral disease
    • Periodontal disease
    • Ill-fitted dental prosthesis
  • Demographic factors
    • Genetic factors
  • Aggravating factors
    • Heavy smoking
    • Infection

What is the Real Risk of Osteonecrosis?

Osteonecrosis of the jaw (ONJ) is an extremely rare adverse event for patients taking bisphosphonates for osteoporosis.  Reports of bisphosphonate induced ONJ date back to the early 2000’s.  Reviews of current data support that up to 80% of ONJ cases occurred in patients with various cancers. These patients were also treated for a long period of time with high-dose injectable bisphosphonates. It is important to note that these doses were 10x higher than doses used to treat osteoporosis.3

Cases, of ONJ in osteoporotic patients, are extremely rare – not one case was found in more than 3000 patients participating in the clinical trials with zoledronic acid and alendronate. And no causal link between ONJ and bisphosphonate therapy, in these patients, has been convincingly demonstrated.4  

Although there are limitations to all studies, based on this information, the risk of ONJ in patients treated with bisphosphonates for osteoporosis is very low.

What does the American Dental Association Recommend?4

  • Routine Dental Care
  • Not modifying dental care solely because of bisphosphonates
  • Recommend AGAINST discontinuing bisphosphonates just before dental procedures

Conclusion

You should not stop taking your osteoporosis medication without talking to your medical provider. Osteoporosis is a serious but very treatable medical condition. The risk of fractures in people suffering from osteoporosis is very real and serious, while the risk of bisphosphonate-induced osteonecrosis of the jaw is rare. Also, there are  steps you and your doctor can take to help further reduce your risk by ensuring good dental hygiene and  preventive dental checkups  before starting and during treatment with these medications.    

 

Remember it’s always about benefit versus risk!

 

Author: Amy R. DeGennaro, Doctor of Pharmacy Candidate graduating May 2017 from Albany College of Pharmacy and Health Sciences.

Reviewed and approved by:  Jessica Farrell, PharmD.  Clinical Pharmacist, The Center for Rheumatology/Associate Professor, Albany College of Pharmacy and Health Sciences

 

References

  1. International Osteoporosis Foundation. Available at:  iofbonehealth.org
  2. Chapurlat RD, Arlot M, Burt-Pichat B, Chavassieux P, Roux JP, Portero-Muzy N, Delmas PD. Microcrack frequency and bone remodeling in postmenopausal osteoporotic women on long-term bisphosphonates: a bone biopsy study. J Bone Miner Res. 2007; 22:1502-1509.
  3. Hough FS, Brown SL, Cassim B, Davey MR. The safety of osteoporosis medication. South African Medical Journal. 2014;104.4: p279.
  4. Florence R, Allen S, Benedict L, Compo R, Jensen A, Kalogeropoulou D, Kearns A, Larson S, Mallen E, O’Day K, Peltier A, Webb B. Institute for Clinical Systems Improvement. Diagnosis and Treatment of Osteoporosis.  Updated July 2013.
Diseases and Conditions

What do you mean by weight-bearing exercise?

March 22, 2017

Rheumatology primarily, and thankfully, deals with rare conditions with a few notable exceptions.  Osteoporosis being one of those.  According to the CDC

Percent of men 50 years of age and over with osteoporosis of the femur neck or lumbar spine: 4%

Percent of women 50 years of age and over with osteoporosis of the femur neck or lumbar spine: 16%

That’s a lot of people.  It’s also important note, that post-menopausal women are not the only ones that develop osteoporosis.  Men do.  People with inflammatory diseases do.  People that have GI absorption problems also do as well as people that don’t move a whole lot.

What is osteoporosis?

Osteoporosis is a condition that is characterized by weakening of bone.  People that have osteoporosis don’t feel they have osteoporosis.  It’s painless and there are no symptoms, until that is, something very bad happens like a fracture.  Bone strength is determined by bone mass and bone quality.  Think of a tree branch.  Branch A just fell off a healthy tree.  There was a bad storm and it just fell.  Structurally it’s normal.  Now you try to break it in half.  It’s a bit difficult to do.  Now you have Branch B.  This branch fell off a termite infested tree.  It’s partially hollowed out, i.e., the “wood” mass is significantly lower.  You try to break Branch B in half…easy peasy.  Osteoporosis = bone like Branch B.  Minor trauma in osteoporotic bone can result in a fracture.

Risk factors for osteoporosis

The next question is what are some of the risk factors that predispose someone to develop osteoporosis.  The good news is that some of these risk factors can be modified.  The bad news is that some risk factors cannot.

Things you CAN’T change

  • Advanced age
  • Ethnicity (white and Asian)
  • Early menopause
  • Slender build (< 127lbs)
  • Maternal history of hip fragility fracture
  • Certain medical conditions

Things you CAN change

  • Low calcium intake
  • Low vitamin D intake
  • Estrogen deficiency
  • Sedentary lifestyle
  • Cigarette smoking
  • Alcohol excess ( > 2 drinks/day)
  • Caffeine excess (> 2 servings/day)
  • Certain medications

Medical conditions

  • Rheumatoid arthritis
  • Ankylosing spondylitis
  • Lupus
  • Hyperthyroidism
  • Hyperparathyroidism
  • Alcoholism
  • Eating disorders
  • Inflammatory bowel disease
  • History of gastric bypass
  • Celiac disease
  • Renal failure
  • Multiple myeloma

There are a lot more conditions, but this is a quick list of the common ones.

Medications

  • Steroids!!! Like prednisone, methylprednisolone, dexamethasone, etc.
  • Excess thyroid meds
  • SSRIs
  • Proton pump inhibitors, used for heartburn

Before making any changes with your meds, please talk with your doctor. 

How to measure bone density?

Bone density is measured using dual energy x-ray absorptiometry (DEXA).  Just say DEXA, the first word is way too long and complicated.  Sometimes bone density can be measured with a special type of CT or ultrasound but this is not typical and usually is reserved for unusual situations.

The body parts that are typically measured are the lumbar spine, the hip, the femoral neck, and the forearm.  Sometimes the heel is also included.  These areas are best at predicting future fractures, which when you think about it, is what we’re trying to do: Prevent future fractures.

Typically, DEXAs are repeated every two years.  Again, there are some exceptions where DEXAs may be obtained more frequently.  For example, if I have a patient on a “boat-load” of steroids for systemic vasculitis for months and months on end, I may want to repeat the DEXA annually.

Why is it important to treat osteoporosis?

The answer to this question is very simple.  Prevention of fractures.  Other than the fact that fractures are incredibly uncomfortable, multiple studies have shown that fragility fractures particularly hip fractures, increase the risk of dying…  Yes you heard me, dying.  A recent article found that the one year risk of death was 23.6% after sustaining a hip fracture.  This finding is in line with most of the literature.  I don’t know about you but I don’t like these odds.

How to increase bone density?

The answer to this question is not simple.  The simple answer is eat a healthy diet, spend some time in the sun, if you smoke stop, supplement with calcium and vitamin D, regularly perform weight-bearing exercise, and medications.  The problem I have with this advice is that for the most part it is extraordinarily vague, except for the medication bit which will be covered in future posts.

What is weight-bearing exercise?

I’d like to focus on weight-bearing exercise, more specifically, what constitutes weight-bearing exercise.  I get this question a lot.

Before answering, “what is weight-bearing exercise”, we need to know what is NOT weight-bearing exercise.

Swimming is NOT weight-bearing exercise.

Cycling is NOT weight-bearing exercise.

Rowing is NOT weight-bearing exercise.

Don’t get me wrong, these exercises are excellent exercises for cardiovascular health, but they won’t help improve bone mass.  Weight-bearing exercises refers to exercises where you need to move your body against gravity.  These exercises can then be classified into high-impact and low-impact.  High-impact activities are better at building bone density but everyone has their own limits.  If you have severe osteoarthritis you may not be physically capable of performing high-impact activities.  Safety is a concern.  The National Osteoporosis Foundation has a nice list of activities.

High impact weight-bearing exercises are important but they are not the only factor in the equation.  Another major factor are falls, more specifically the prevention of falls.  Hip fractures almost always are directly caused by falls.  Having osteoporosis simply increases the risk of a fall that results in a fracture as opposed to a nasty bruise.  Some of the greatest fall risks include the following:

  • Frailty
  • Visual impairment
  • Cognitive impairment
  • Problems with your legs, this includes osteoarthritis of the knees
  • A cluttered home environment
  • A previous fall within the past 6 months.  This is actually number one on the list.

To help prevent falls, it’s important to try to correct some of the above.  It’s also important to perform activities that will help build muscle strength, balance, and mobility.  Most senior citizen exercise classes like the ones offered by the Silver Sneakers Program, focus on these types of exercises.

How much activity is necessary?

Again, this is difficult to quantify.

A recent Japanese study measured the number of steps per day continuously for 5 years and measured the bone density of participants’ heel on an annual basis.  They also measured the intensity of the activity.  After controlling for baseline density, age, and body mass, they found that bone health was optimal in elderly people who take at least 7000 to 8000 steps per day and/or spend at least 15-20 minutes per day at moderate activity.

It’s important to note that these people did not necessarily go to the gym.  Steps per day can be achieved in numerous natural different ways.  Blue Zone founder Dan Buettner has it as number #1 on the Power 9® list, MOVE NATURALLY.  If you’ve read some of my previous posts or actually heard me in clinic, you’ll know that I’m a huge fan of the Blue Zone Project.  We don’t need fancy supplements or gym memberships to achieve optimal health.  The following are a few examples on how to move naturally.

  • Walk, walk, walk.  Avoid using your car.
  • If you need to use your car, park further away.
  • Using stairs as much a possible, don’t use the escalator.
  • Start gardening.
  • Get rid of mechanical conveniences in the house.  I love my snow blower, but it has to go.

I hope that this has helped you.  If you retain only one thing, MOVE NATURALLY.  This is the secret to optimal bone health.

 

Disclaimer: the abovementioned information does not constitute medical advice.  Every case is unique.  Please contact your local rheumatologist or your physician for more information. 

References

CDC Osteoporosis Statistics

Rheumatology Secrets, 3rd edition

Guerra MT, et al. One-year mortality of elderly patients with hip fracture surgically treated at a hospital in Southern Brazil. Rev Bras Ortop. 2016 Dec 7;52(1):17-23.

National Osteoporosis Foundation

Shephard RJ, et al. Objective longitudinal measures of physical activity and bone health in older Japanese: the Nakanojo Study. J Am Geriatr Soc. 2016 Dec 9. doi: 10.1111/jgs.14553. [Epub ahead of print]

 

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