Advanced Pharmacology:

Case Study
Allison Rogers, BSN, RN-BC
King University
Case Study
An 82 year old Caucasian female
Chief Complaint: Right hip pain
HPI: Onset 2 months ago, worsening in past 2 weeks, continuous achy pain worsens with activity, rates pain
5/10. Denies limited range of motion, muscle or joint stiffness, joint swelling or effusion, or muscle spasms.
Denies redness, swelling, weakness, or difficulty with ambulation or gait. Has not been as active over the
past few weeks due to being afraid she will fall, denies taking any over the counter medications for the
discomfort.
Allergies: NKDA
Medications: levothyroxine 100mcg daily, Occuvite 1 tablet daily; calcium + vitamin D (600mg + 400IU) 1
tablet daily
Past Medical History: Hypothyroidism (onset age 50s), macular degeneration, menopause (age 47),
hysterectomy (age 52), cystocele, rectocele
Family History: Mother (deceased 90) kyphosis, hip fracture, osteoporosis, mouth cancer; Father (deceased
82) hip fracture; brother (deceased 82) lung cancer
Social History: Widowed 9 years ago, lives alone in 2 story house, 4 children (3 living) sees weekly good
relationship, attends Baptist church regularly, walks 0.25 miles daily, attends to flower garden, and enjoys
reading. Denies tobacco, alcohol, or illicit drug use.
Review of Systems
Subjective
General: Reports not very well rested, average 4-6 hours sleep total at night, interrupted at
times. Denies fever, chills, recent weight gain/loss.
Skin: Denies puritis, rashes/hives, edema, ulcerations or breaks in skin, ecchymosis, or
erythema.
Diet: No change in diet or special diet. Reports usually eats three home cooked meals per
day, mixture of baked, broiled, and fried foods. Drinks mainly water and one glass of milk
per day. Rarely eats fast food or convenience foods.
MS: Reports right hip pain (see CC/HPI).
GI: Denies heartburn, reflux, ulcers, nausea, or vomiting.
GU: Denies frequency, hesitancy, urgency, incontinence, dysuria, hematuria, or nocturia.
Review of Systems
Objective
Vital Signs: Temp 98.2F, HR 74, RR 18, BP 124/68, SpO2 99% (room air); 142 pounds,
53, BMI: 25.2, Pain: 5/10
Constitutional: Pleasant, well-groomed Caucasian woman, dressed appropriately for age
and weather. Cooperative and answers questions appropriately. No grimacing, guarding,
or acute distress noted.
Skin: Warm and dry. Intact, no lacerations, abrasions, ulcerations, ecchymosis, erythema,
or rashes.
MS: No edema or erythema noted to joint areas bilaterally. Full range of motion noted to
neck, back, bilateral shoulders, arms, fingers, hips, knees, ankles, and toes. Muscle
strength equal and strong bilaterally legs and feet. DEXA scan reveals T-score of -2.8
Neuro: Able to feel monofilament equally in all aspect of feet bilaterally.
GU: Creatinine clearance 88 mL/min, serum creatinine 1 mg/dL
What is my diagnosis?
Osteoporosis
Pathophysiology Review:
What happens normally?
Normal bone undergoes remodeling, which occurs in 3 phases:
Phase one (activation): osteoclasts form
Phase two (resorption): osteoclasts resorb bone
Phase three (formation): laying down of new bone by osteoblasts
The body is in a constant state of renewal. Old bone is broken down and replaced by
new bone.
Most of the adult skeleton is replaced through this process every 10 years.
In order for this process to work properly, osteoclasts and osteoblasts must
communicate. A protein, called osteoprotegrin (OPG), helps with communication.

(Robinson, 2016, pp.1114-1115)

Pathophysiology Review:
How do hormones play a role?
Hormones are also responsible for the proper growth and storage of minerals in the
bone.
When serum calcium and phosphorus levels are low, the parathyroid hormone
stimulates osteoclasts to resorb bone, causing the release of calcium and phosphorus
back into the bloodstream.
The parathyroid hormone also stimulates intestine to absorb calcium and stimulate the
kidneys to activate vitamin D in order to facilitate the absorption.
Estrogens reduce the bone-reabsorbing action of the parathyroid hormone. Due to this,
conditions of reduced estrogen, such as menopause, increases the risk of osteoporosis.

(Robinson, 2016, p. 1115)

Pathophysiology Review:
What happens in Osteoporosis?
Bone loss occurs when this balance is altered. Bone mass is lost faster than it is
regenerated.
Osteoporosis is characterized by decreased bone mass as a result of this imbalance.
The bone that remains is normal, but there is not enough of it to maintain skeletal
integrity and mechanical support. This results in fractures, commonly of the vertebra,
hip, and wrist.
The World Health Organization (WHO), defines osteoporosis by having bone density of
2.5 standard deviations below the average peak adult bone mass.
Osteoporosis can be generalized, or regional.
(Robinson, 2016, p. 1116)
Who is at risk?

Thin, small-bone frame (body weight < 154 pounds)

Estrogen deficiency (especially in women < 45 years old)
Older persons (women > 62; men > 70)
Diet low in Calcium and Vitamin D
White and Asian
Cigarette use
Alcohol intake (> 2 drinks per day or 14 drinks per week)
Limited physical activity
(Robinson, 2016, p. 1116)
Who is at risk? (Disease processes and Medications)
AIDS/HIV
Amyloidosis
Aluminum and Excess use of Antacids
Ankylosing spondylitis Anticonvulsants (Phenobarbital, phenytoin, carbamazepine)
COPD Cytotoxic drugs (Chemotherapy and Methotrexate)
Cushings Syndrome Glucocorticoids (Prednisone 5mg or more for 3 months)

Eating Disorders Warfarin (use greater than 1 year)

ACTH
Gastrectomy
Gonadotropin-releasing Hormones and Agonists
Irritable Bowel Disease
Immunosuppressants (Cyclosporine and Tracroloimis)
Type 1 DM
Lithium
Malabsorption Syndrome Long-term Heparin use
Hyperparathyroidism SSRIs

Pernicious Anemia Progesterone (long acting)

Rheumatoid Arthritis Thyroxine (for aggressive treatment of Hypothyroidism)

Tamoxifen and Aromatase Inhibitors

Severe Liver Disease
Total Parenteral Nutrition (TPN)
Stroke (CVA)
Proton Pump Inhibitors (used longer than 1 year)
Thyrotoxicosis
Several Blood Disorders

(Robinson, 2016, p. 1115)

Prevention is key
A white woman over 50 has more than a 40% chance of developing an osteoporotic
fracture in her lifetime.
(Robinson, 2016, p. 1112)
5,500 osteoporosis-related fractures in the U.S. every day, 80% are women
(Robinson & Shaw, 2016, p. 542)
Education, education, education
Developing a healthy lifestyle while building bone mass
Low-impact aerobic exercise (such as brisk walking, 20 min, 3-4 times per week)
Decreasing abdominal obesity
Avoid: excessive exercise, excessive dieting, and fad diets (deficient in essential
nutrients)
(Robinson, 2016, p. 1118)
How is it treated?
(Treatment options)
According to all guidelines, Bisphosphonates are the first line treatment therapy for
osteoporosis (Robinson, 2016, p. 1117).
Fosamax, Actonel, Boniva, and Zometa
Other treatment options (Robinson, 2016, pp. 1117-1118):
Selective Estrogen Receptor Modulator (SERM)- Evista
Natural Calcitonin
Synthetic Parathyroid Hormone (PTH)- Forteo
Human Antibody against the Tumor Necrosis Factor RANKL- Prolia
Calcium and Vitamin D
Fosamax (alendronate):
Mechanism of Action
Reduce bone resorption by adhering tightly to bone and inhibiting osteoclastic activity
Potent inhibitor of normal and abnormal bone resorption
(Robinson, 2016, p. 1117; Robinson & Shaw, 2016, p. 543)
Highly selective inhibitor of bone resorption
100-500 times more potent than other drugs in its class
(Robinson & Shaw, 2016, p. 543)
50% reduction of spine and hip fractures (higher than others in its class for reduction
of hip fractures)
(Robinson, 2016, p. 1122)
Fosamax (alendronate):
Mechanism of Action
Metabolism
No evidence of metabolism in animals or humans
Absorption
Mean oral bioavailability is 64% for doses ranging from 5 mg -70 mg
Best absorbed on an empty stomach and taken at least 2 hours before a meal
Distribution
Mainly distributed to the bone.
Terminal half-life is approximately 10 years
Excretion
Urine (the portion of the drug not distributed to the bone)
(Drugs.com, 2016; Robinson & Shaw, 2016)
Fosamax (alendronate):
Drug-Drug & Drug-Food Interactions
Histamine 2 blockers (Pepcid, Zantac), Aspirin, Non-steroidal anti-inflammatory drugs
(NSAIDs)
Bioavailability doubled, increased risk of GI bleeding
Any foods (Take medication on a empty stomach!)
Decreases bioavailability by 40%- take 30 minutes before any food intake
Coffee, orange juice, and mineral water (Take medication with 8 ounces of plain water)
Decreases bioavailability by 60%- take 30 minutes before intake
Supplemental Calcium or Antacids
Interfere with absorption. Bisphosphonates must be taken 1 hour before these medications
(Robinson & Shaw, 2016, pp. 545, 548)
Fosamax (alendronate):
Side-effect Profile
Esophagitis, gastric irritation, GI distress, and dyspepsia (most common)
Taking first thing in the morning and remain upright for at least 30 minutes after taking
(facilitates passage out of stomach, decreasing esophageal irritation)
Musculoskeletal pain
Atrial fibrillation
No recommendations have been made to halt use if know pre-treatment a-fib is present
Osteonecrosis of the jaw (rare)
Has been associated with active dental disease or invasive dental procedures
Recommended to stop 3 months prior and 3 months post elective dental procedures

(Robinson & Shaw, 2016, pp. 543-548)

Fosamax (alendronate):
Side-effect Profile
After 3-5 years of use, it is suggested patients on Bisphosphonates take a drug
holiday of approx. 2-3 years due to potential development of side-effects
The binding effects of the medication with the bone is long-term
(Robinson, 2016. p. 1120; Robinson & Shaw, 2016, p. 546)
Fosamax (alendronate):
Screening and Monitoring
Duel Energy X-ray Absorptiometry (DEXA) scan
Gold standard for measuring bone mineral density
Initially to aid with diagnosis of osteoporosis
Repeated every 1-2 years to determine progress
Serum creatinine
Levels should be below 2.5 mg/dl (recommended to be drawn before initiation of therapy)
Creatinine clearance
Not recommended for CCr 35 or below
Monitor electrolytes
Calcium, Phosphate, Magnesium, and Potassium
Look at the patients history
GI bleeding, PUD, GERD are not good candidates due common GI side effects and esophageal irritation
(Robinson, 2016; Robinson & Shaw, 2016)
Prescription
Family Clinic Kingsport
123 East Stone Drive
Kingsport, TN 37660
Telephone: (234) 567-8900 Fax: (234) 567-9000

Dr. John Doe NPI# 0000000000 DEA# 000000000

Allison Rogers, MSN, FNP-BC NPI# 1234567890 DEA# MN1234567

Name: E.B. Date: 07-26-2016

Address: 1234 Summertime Drive, Kingsport, TN 37660 Date of Birth: 01-02-1934

Rx: alendronate 70mg tablets

Sig: take one tablet P.O. once weekly for osteoporosis
# 4 (four)
Refill: none
Signature of Prescriber: Allison Rogers, FNP-BC
Is there anything else that should be
recommended to this patient?
Calcium plus Vitamin D
Most guidelines suggest supplementation with Calcium and Vitamin D as part of the
treatment protocol for osteoporosis, and should be used in addition to other drug treatments.
It is suggested that Calcium plus Vitamin D be initiated before treatment with
Bisphosphonates.
Vitamin D is necessary for optimal uptake and absorption of calcium.
Recommended Calcium 1,200mg to 2,000mg per day for persons age 50 and older.
Recommended Vitamin D dosage is at least 400 IU per day.

(Robinson, 2016, pp. 1118-1122)

References

Drugs.com [Internet]. (2016). Fosamax. Retrieved from drugs.com website:

https://www.drugs.com/pro/fosamax.html#S12.3

Robinson, M. U. (2016). Hormone replacement therapy and osteoporosis. In T. M.

Woo & M. U. Robinson (Eds.), Pharmacotherapeutics for Advanced Practice Nurse
Prescribers (4th ed.), (pp. 1003-1127). Philadelphia, PA: F. A. Davis Company.

Robinson, M. U. & Shaw, K. (2016). Drugs affecting the endocrine system. In T. M.

Woo & M. U. Robinson (Eds.), Pharmacotherapeutics for Advanced Practice Nurse
Prescribers (4th ed.), (pp. 541-613). Philadelphia, PA: F. A. Davis Company.