Outline of Lecture - Columbia University · 2/17/2009 1 Pharmacology: Therapeutics of Calcium Metabolism John P. Bilezikian, M.D. Professor of Medicine and Pharmacology Chief, Division

2/17/2009

1

Pharmacology: Pharmacology: Therapeutics of Calcium MetabolismTherapeutics of Calcium Metabolism

John P. Bilezikian, M.D.John P. Bilezikian, M.D.Professor of Medicine and PharmacologyProfessor of Medicine and Pharmacology

Chief, Division of EndocrinologyChief, Division of EndocrinologyFebruary 18 2009February 18 2009February 18, 2009February 18, 2009

Outline of Lecture

•• HypercalcemiaHypercalcemia•• HypocalcemiaHypocalcemia•• OsteoporosisOsteoporosis

2/17/2009

2

CAUSES OF HYPERCALCEMIACAUSES OF HYPERCALCEMIA

•• Primary Primary HyperparathyroidismHyperparathyroidism

•• Vitamin DVitamin DToxicityToxicity

•• MalignancyMalignancy•• Other endocrinopathyOther endocrinopathy

HyperthyroidismHyperthyroidismPheochromocytomaPheochromocytomaVIPomaVIPomaAdrenal insufficiencyAdrenal insufficiency

•• MedicationsMedicationslithiumlithium

yyGranulomatous diseaseGranulomatous disease

–– TuberculosisTuberculosis–– SarcoidosisSarcoidosis–– Any otherAny other

•• LymphomaLymphoma•• FHHFHH•• ImmobilizationImmobilization

thiazide diureticsthiazide diureticsthyroid hormone thyroid hormone Vitamin AVitamin AVitamin DVitamin D

•• Acute or chronic renal Acute or chronic renal diseasedisease

Clinical Features of HypercalcemiaClinical Features of Hypercalcemia

•• ConstitutionalConstitutional

•• Central nervous systemCentral nervous system

•• Gastrointestinal tractGastrointestinal tract

•• RenalRenal

•• CardiovascularCardiovascular

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Factors That Influence SymptomatologyFactors That Influence Symptomatologyin Hypercalcemiain Hypercalcemia

S l i t tiS l i t ti•• Serum calcium concentrationSerum calcium concentration•• Rate of riseRate of rise•• DurationDuration•• Individual variabilityIndividual variability

Pathophysiologic Features of Pathophysiologic Features of Acute HypercalcemiaAcute Hypercalcemia

I. New or Existing Stimulus to HypercalcemiaI. New or Existing Stimulus to Hypercalcemia•• Osteoclast activation virtually always presentOsteoclast activation virtually always presentOsteoclast activation virtually always presentOsteoclast activation virtually always present•• Renal tubular conservation of calcium (PTH, PTHRP)Renal tubular conservation of calcium (PTH, PTHRP)•• GI hyperabsorption of calcium (less important)GI hyperabsorption of calcium (less important)•• Reduced mobilityReduced mobilityII. Hypercalcemia Becomes SymptomaticII. Hypercalcemia Becomes Symptomatic

P l iP l i•• PolyuriaPolyuria•• PolydypsiaPolydypsia•• AnorexiaAnorexia

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Pathophysiologic Features of Pathophysiologic Features of Acute HypercalcemiaAcute Hypercalcemia

III. Worsening HypercalcemiaIII. Worsening Hypercalcemia•• Reduced fluid intakeReduced fluid intake•• Continued polyuriaContinued polyuria•• DehydrationDehydrationIV. Reduced Plasma VolumeIV. Reduced Plasma Volume•• Impaired renal functionImpaired renal functionImpaired renal functionImpaired renal function•• Reduced renal calcium clearanceReduced renal calcium clearance•• Rapidly worsening hypercalcemiaRapidly worsening hypercalcemia

At What Level Should HypercalcemiaAt What Level Should HypercalcemiaBe Treated Emergently?*Be Treated Emergently?*

•• < 12 mg/dL ?< 12 mg/dL ?

•• 1212--14 mg/dL ?14 mg/dL ?

•• >14 mg/dL ?>14 mg/dL ?

*Typical nl range 8.4-10.2 mg/dl

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General Management of HypercalcemiaGeneral Management of Hypercalcemia

•• Intravenous rehydrationIntravenous rehydration•• Saline administrationSaline administration•• Diuresis with furosemideDiuresis with furosemide•• Dialysis (if necessary)Dialysis (if necessary)•• MobilizationMobilization•• MobilizationMobilization

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Management of HypercalcemiaManagement of Hypercalcemia

GeneralGeneralR h d tiR h d ti

SpecificSpecificBi h h tBi h h t•• RehydrationRehydration

•• Saline AdministrationSaline Administration•• Diuresis with FurosemideDiuresis with Furosemide•• DialysisDialysis•• MobilizationMobilization

•• BisphosphonatesBisphosphonates•• PlicamycinPlicamycin•• CalcitoninCalcitonin•• Gallium NitrateGallium Nitrate•• PhosphatePhosphate•• MobilizationMobilization •• PhosphatePhosphate•• GlucocorticoidsGlucocorticoids•• Therapy of Underlying Therapy of Underlying

EtiologyEtiology

PPCC

OO

HOHO OHOHCHCH22HOHO CHCH22 NN

CHCH33

PPP

CCCPPP

OOO

OOO

HOHOHO OHOHOH

OHOHOHHOHOHOOHOHOHCHCHCH22NNN

NN NN CHCH32 CC

PPHOHO OHOHOO

OHOH

BisphosphonatesBisphosphonates

OO

PPCCPP

OO

OO

HOHO OHOH

OHOHHOHOCHCH22HOHO CHCH22 CHCH22 NHNH22

CCPPOO

OHOHHOHOCHCH22HOHO CHC 22 NN

(CH(CH22))44 CHCH33

PP

CCPP

OO

OO

HOHO OHOH

OHOHHOHOHHSSClCl

PAMIDRONATEPAMIDRONATE

ALENDRONATEALENDRONATE

IBANDRONATEIBANDRONATE

RISEDRONATERISEDRONATE

TILUDRONATETILUDRONATE

CLODRONATECLODRONATE

OOO

ZOLEDRONATEZOLEDRONATE

PPHOHO OHOH

OO

CHCH33

PP

CCPP

OO

OO

HOHO OHOH

OHOHHOHOClClClCl

PPCC

PP

OO

OO

HOHO OHOH

OHOHHOHOCHCH22HOHO CHCH22 NHNH22

ETIDRONATEETIDRONATE


PP

CCPP

OO

HOHO OHOH

OHOHHOHOOHOH

OO

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Bisphosphonates For Acute Hypercalcemia Bisphosphonates For Acute Hypercalcemia

•• Osteoclast inhibitorsOsteoclast inhibitors

•• Intravenous route necessaryIntravenous route necessary

•• Reduction in serum calcium begins Reduction in serum calcium begins 2424--36 hours after first dose36 hours after first dose

D ration of effect is ariableD ration of effect is ariable•• Duration of effect is variableDuration of effect is variable

PPCC

OO

HOHO OHOHCHCH22HOHO CHCH22 NN

CHCH33

PPP

CCCPPP

OOO

OOO

HOHOHO OHOHOH

OHOHOHHOHOHOOHOHOHCHCHCH22NNN

NN NN CHCH32 CC

PPHOHO OHOHOO

OHOH

Bisphosphonates for Bisphosphonates for hypercalcemia

OO

PPCCPP

OO

OO

HOHO OHOH

OHOHHOHOCHCH22HOHO CHCH22 CHCH22 NHNH22

CCPPOO

OHOHHOHOCHCH22HOHO CHC 22 NN

(CH(CH22))44 CHCH33

PP

CCPP

OO

OO

HOHO OHOH

OHOHHOHOHHSSClCl

PAMIDRONATEPAMIDRONATE

ALENDRONATEALENDRONATE

IBANDRONATEIBANDRONATE

RISEDRONATERISEDRONATE

TILUDRONATETILUDRONATE


OOO

ZOLEDRONATEZOLEDRONATE

PPHOHO OHOH

OO

CHCH33

PP

CCPP

OO

OO

HOHO OHOH

OHOHHOHOClClClCl

PPCC

PP

OO

OO

HOHO OHOH

OHOHHOHOCHCH22HOHO CHCH22 NHNH22

ETIDRONATEETIDRONATE


PP

CCPP

OO

HOHO OHOH

OHOHHOHOOHOH

OO

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Adverse Effects of ParenteralAdverse Effects of ParenteralEtidronate for HypercalcemaEtidronate for Hypercalcema

Hypocalcemia (“overshoot”)Hypocalcemia (“overshoot”)

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Pamidronate in the management of hypercalcemia

Zoledronate vs. Pamidronate For HypercalcemiaZoledronate vs. Pamidronate For Hypercalcemia

Mean Corrected Serum Calcium C at baseline and days 4, 7, and 10 after treatment of hypercalcemia with ( ) zoledronic acid 4mg, ( ) zoledronic acid 8mg, or ( ) pamidronate 90mg.

Major et al, J Clin Oncology, 2001Major et al, J Clin Oncology, 2001

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Management of HypercalcemiaManagement of HypercalcemiaZoledronate vs. PamidronateZoledronate vs. Pamidronate

ZoldronateZoledronate

Zoldronate4mg

Zoldronate8mg

Time to Relapse ofHypercalcemiaMedian Duration ofComplete Response

Zoledronate

Zoledronate

Zoledronate

0 10 20 30 40 50

Pamidronate90mg

DaysDaysMajor et al, J Clin Oncology, 2001Major et al, J Clin Oncology, 2001

Adverse Effects of Adverse Effects of Pamidronate and ZoledronatePamidronate and Zoledronate

•• Mild, transient fever (<2Mild, transient fever (<2°°C)C)

•• Transient leukopeniaTransient leukopenia

•• Small reduction in the serum Small reduction in the serum h h th h tphosphatephosphate

•• Hypocalcemia (“overshoot”)Hypocalcemia (“overshoot”)

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EtiologyEtiology

PlicamycinPlicamycin

•• Potent osteoclast inhibitorPotent osteoclast inhibitor

•• Intravenous, daily for up to 5 daysIntravenous, daily for up to 5 days

•• Reduction in serum calcium Reduction in serum calcium begins 12begins 12--24 hours after first dose24 hours after first dose

•• Duration of effect is variableDuration of effect is variable

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Plicamycin

Adverse Effects of PlicamycinAdverse Effects of Plicamycin

•• Hypocalcemia (“overshoot”)Hypocalcemia (“overshoot”)

•• Hepatic toxicityHepatic toxicity

•• NephrotoxicityNephrotoxicity

•• Bone marrow toxicity (platelets)Bone marrow toxicity (platelets)

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EtiologyEtiology

Calcitonin For HypercalcemiaCalcitonin For Hypercalcemia

•• Osteoclast inhibitorOsteoclast inhibitor•• CalciureticCalciuretic•• IV or SC, Q12 hoursIV or SC, Q12 hours•• Rapid reduction in calcium (within 12 Rapid reduction in calcium (within 12

hours)hours)hours)hours)•• Weak and shortWeak and short--lived effectlived effect

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Calcitonin in the management of hypercalcemia

The Most Rapidly Acting Agents The Most Rapidly Acting Agents For HypercalcemiaFor Hypercalcemia

Calcitonin>Plicamycin>BisphosphonatesCalcitonin>Plicamycin>Bisphosphonates

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Combination Therapy For HypercalcemiaCombination Therapy For Hypercalcemia

•• Use of a rapidly acting agent (calcitonin)Use of a rapidly acting agent (calcitonin)

•• Simultaneous with a more potent, but more Simultaneous with a more potent, but more slowly acting agent (bisphosphonate)slowly acting agent (bisphosphonate)slowly acting agent (bisphosphonate)slowly acting agent (bisphosphonate)

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EtiologyEtiology





•• BisphosphonatesBisphosphonates•• PlicamycinPlicamycin•• CalcitoninCalcitonin•• Gallium NitrateGallium Nitrate•• PhosphatePhosphate•• MobilizationMobilization •• PhosphatePhosphate•• GlucocorticoidsGlucocorticoids•• Therapy of Therapy of

Underlying EtiologyUnderlying Etiology

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Outline of LectureOutline of Lecture

•• HypercalcemiaHypercalcemia• Hypocalcemia•• OsteoporosisOsteoporosis

Clinical Features of HypocalcemiaClinical Features of Hypocalcemia

•• Neuromuscular irritabilityNeuromuscular irritability•• Paresthesias (numbness and tingling)Paresthesias (numbness and tingling)Paresthesias (numbness and tingling)Paresthesias (numbness and tingling)•• Chvostek’s signChvostek’s sign•• Trousseau’s signTrousseau’s sign•• Prolonged QProlonged Q--T intervalT interval•• Carpal, pedal, broncho, or laryngeal spasmCarpal, pedal, broncho, or laryngeal spasm

S iS i•• SeizuresSeizures

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Clinical Features of HypocalcemiaClinical Features of Hypocalcemia

Determinants of signs and symptoms

•• Extent of hypocalcemiaExtent of hypocalcemia•• Rapidity of reductionRapidity of reduction•• Duration of hypocalcemiaDuration of hypocalcemia

SS

Management of HypocalcemiaManagement of Hypocalcemia

Indications for Acute Treatment

•• SymptomsSymptoms•• No symptoms but…No symptoms but…

–– Serum calcium Serum calcium (corrected for serum albumin) <7.5 mg/dL<7.5 mg/dL

–– History of seizuresHistory of seizuresHistory of seizuresHistory of seizures–– Previous compression fracturePrevious compression fracture

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Emergency Management of HypocalcemiaEmergency Management of Hypocalcemia

Intravenous Preparation of Choice

Calcium gluconateCalcium gluconateCalcium chloride (do not use)Calcium chloride (do not use)


FORFOR IMMEDIATEIMMEDIATE RELIEF OF SYMPTOMS:RELIEF OF SYMPTOMS:FOR FOR IMMEDIATE IMMEDIATE RELIEF OF SYMPTOMS:RELIEF OF SYMPTOMS:

11--2 amps of 10% calcium gluconate (93 mg of 2 amps of 10% calcium gluconate (93 mg of elemental calcium/amp) intravenously over elemental calcium/amp) intravenously over 1010 15 i t15 i t1010--15 minutes15 minutes

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To raise the serum calcium by 2To raise the serum calcium by 2--3 mg/dl:3 mg/dl:

1010 15 mg/kg of calcium15 mg/kg of calcium1010--15 mg/kg of calcium15 mg/kg of calciumintravenously (in 1 liter of Dintravenously (in 1 liter of D5W) over 6W) over 6--8 hours8 hours

Example:Example:70 kg individual70 kg individual

15 mg/kg = 1050 mg calcium15 mg/kg = 1050 mg calcium15 mg/kg 1050 mg calcium15 mg/kg 1050 mg calcium

Amps of 10% calcium gluconate = 1050 mg/93 mg/10 ml Amps of 10% calcium gluconate = 1050 mg/93 mg/10 ml ==

Approximately Approximately 11 amps11 amps

•• Underlying etiologyUnderlying etiology

Management of Chronic Hypocalcemia

y g gyy g gy•• Oral calciumOral calcium•• Oral Vitamin DOral Vitamin D

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CALCIUM CONTENT OF MEDICINAL SALTSCALCIUM CONTENT OF MEDICINAL SALTS

SourceSource Calcium ContentCalcium Content(mg/g)(mg/g) % Calcium% Calcium

Carbonate 400 40%Citrate 200 20%Lactate 128 12.8%Gl t 88 8 8%

(mg/g)(mg/g)

Gluconate 88 8.8%Glubionate 65 6.5%

•• Underlying etiologyUnderlying etiology

Management of Chronic HypocalcemiaManagement of Chronic Hypocalcemia

•• Oral calciumOral calcium•• Oral Vitamin DOral Vitamin D

Nutritional (400-800 IU daily)Pharmacological (>1000 IU day)(>1000 IU day)

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Outline of Lecture

•• HypercalcemiaHypercalcemia•• HypocalcemiaHypocalcemia• Osteoporosis

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CALCIUM CONTENT OF MEDICINAL SALTSCALCIUM CONTENT OF MEDICINAL SALTS

Source Calcium Content(mg/g) % Calcium

Carbonate 400 40%Citrate 200 20%

( g g)

How much?H h t ti ?How much at a time?What form?Brand vs generic vs fancy?When?With food or without food?

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Nonpharmacological Approaches to the Management of Osteoporosis*

CalciumCalciumVitamin DVitamin DExerciseExerciseLifestyle Lifestyle (Smoking, Alcohol, etc)(Smoking, Alcohol, etc)

Fall PreventionFall Prevention

**Recommended for virtually everyone!Recommended for virtually everyone!

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Approved Pharmacologic Therapies in the Approved Pharmacologic Therapies in the United States for OsteoporosisUnited States for Osteoporosis

•• Hormone replacement therapy (HT)Hormone replacement therapy (HT)•• RaloxifeneRaloxifene•• BisphosphonatesBisphosphonates

AlendronateAlendronateRisedronateRisedronateIbandronateIbandronateZ l d tZ l d tZoledronateZoledronate

•• CalcitoninCalcitonin•• Teriparatide [humanPTH[1Teriparatide [humanPTH[1--34)]34)]

ESTROGEN REDUCES THE RISK OF ESTROGEN REDUCES THE RISK OF ALL CLINICAL FRACTURESALL CLINICAL FRACTURES

E+P: N=16,608 women ages 45E+P: N=16,608 women ages 45--7979Mean age: 63.2Mean age: 63.2Placebo or estrogen+progestin Placebo or estrogen+progestin RR 0.76 RR 0.76

95% CI (0 6995% CI (0 69--RR 0.70 RR 0.70

95% CI (0 6395% CI (0 63--CEE arm: N=10,739 ages 50CEE arm: N=10,739 ages 50--7979Mean age: 63.6Mean age: 63.6Placebo or CEE 0.625 mg dailyPlacebo or CEE 0.625 mg daily

Fractures: All clinical fractures Fractures: All clinical fractures (less than 10% were vertebral (less than 10% were vertebral fractures)fractures)

1.91%

1.47%

1.95%

1.39%

1%

2%

3%

ed fr

actu

re ra

te (%

)

95% CI (0.6995% CI (0.690.75)0.75)

95% CI (0.6395% CI (0.630.79)0.79)

Treatment intervals: E+P 5.2 years; Treatment intervals: E+P 5.2 years; CEE 6.8 yearsCEE 6.8 years

E+P: Rossouw JE,E+P: Rossouw JE, et al. JAMA. 2002;288:321-333.CEE: Anderson GL, et al. JAMA. 2004;291:1701-1712.

0%

1%

Ann

ualiz

e

E+P CEE

788/8102 503/5310650/8506 724/5429

CEE= conjugated equine estrogen.

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WHI HT Study: Combination ArmWHI HT Study: Combination ArmEffect of HT and Progestin on Hip Fracture Incidence Effect of HT and Progestin on Hip Fracture Incidence

0 70.80.9

ctur

e RH=0.66 (95% CI=0.45-0.98)• Preexisting fractures Elements Not Stated in Paper

00.10.20.30.40.50.60.7

of W

omen

With

Hip

Fra

cO

ver

5.2

Year

s

n=62 n=44

• Baseline BMD status• Calcium or vitamin D intake• Use of bisphosphonates and/or

calcitonin• Age distribution

of fractures

34%

Adapted from: Writing Group for the Women’s Health Initiative. JAMA. 2002;288:321-333.

Placebo(N=8102)

HRT(N=8506)

0% o 6

Risk Benefit

WHI HT StudyWHI HT StudyFindings at Early Interruption of CEE/MPA ArmFindings at Early Interruption of CEE/MPA Arm

Fracture ReductionColon Cancer

29% Increase29% Increase

Stroke

41% Increase41% IncreaseVenous Thrombolic

Events(VTE)


Breast Cancer


Coronary Artery Disease

Threshold LevelEarly STOP=Clear Harm

Threshold LevelEarly STOP=Clear Benefit

Adapted from: Writing Group for the WHI Investigators. JAMA. 2002;288:321-333.

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WHI: Conclusions regarding the skeleton*WHI: Conclusions regarding the skeleton*

•• Estrogen should not be used as a Estrogen should not be used as a primary therapy to prevent bone lossprimary therapy to prevent bone loss

•• Estrogen should not be used as a Estrogen should not be used as a primary approach to the treatment of primary approach to the treatment of osteoporosisosteoporosisosteoporosisosteoporosis

*This is a very controversial issue!

AgonistAgonist

The Concept of an Ideal SERMThe Concept of an Ideal SERM

AntagonistAntagonist

SkeletonSkeleton CardiovascularCardiovascular

Mitlak BH, et al. Drugs 1999;57:653-63.Lufkin EG, et al. Rheum Dis Clin North Am 2001;27:163-85.

BreastBreast UterusUterus

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Raloxifene:A Selective Estrogen Receptor Modulator

Basic Side ChainO

O Basic Side Chain

Estrogen Antagonist(uterus, breast)

OH

O

HO S

Ben othiophene moiet

Estrogen Agonist(bone, lipids)

• BMD (bone mineral density) increase• Decrease in total and LDL cholesterol

Benzothiophene moiety

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RALOXIFENERALOXIFENE

•• WellWell--absorbed from the GI tractabsorbed from the GI tract•• Can be taken any timeCan be taken any time•• Once daily medication (60 mg) Once daily medication (60 mg) •• With or without foodWith or without food•• No contraindications in women with No contraindications in women with

upper gastrointestinal symptomsupper gastrointestinal symptoms

Effects of RaloxifeneEffects of Raloxifene on BMD:on BMD:The MORE TrialThe MORE Trial––36 Months36 Months

44Femoral neckFemoral neckLumbar spineLumbar spine

44* *

33

22

11

00

--11

22

33

22

11

00

--11

22

*

* * *

* **

**

*

--2200 1212 2424 3636

MonthsMonths00 1212 2424 3636

--22

PlaceboPlacebo

Ettinger B, et al. JAMA 1999;282:637-45.

P P < 0.001 for all comparisons< 0.001 for all comparisons

Raloxifene 120 mg/dRaloxifene 120 mg/d Raloxifene 60 mg/dRaloxifene 60 mg/d

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Effects of Raloxifene on New Vertebral Effects of Raloxifene on New Vertebral Fractures: The MORE Trial Fractures: The MORE Trial –– 36 Months36 Months

20

25 Placebo60 mg/d of raloxifene

ract

ure RR, 0.7 (95% CI, 0.6-0.9)

RR, 0.5 (95% CI, 0.4-0.6)

120 mg/d of raloxifene*

5

10

15

20

RR, 0.6 (95% CI, 0.4-0.9)

ents

with

incid

ent v

erte

bral

fr

RR, 0.5 (95% CI, 0.3-0.7)

Ettinger B, et al. JAMA 1999;282:634-45.

*Not FDA-approved dose.

0

5

No pre-existing fractures

% o

f pat

ie

Pre-existing fractures

Raloxifene: Benefits and Risks

Benefits• Improved bone mass

DisadvantagesI d h t• Improved bone mass

• Reduced number ofvertebral fractures

• No breast tenderness• No uterine bleeding or

spotting• Reduced risk of breast

• Increased hot flashes

• Increased leg cramps

• Increased risk of DVT• Reduced risk of breast

cancer* • No increased

cardiovascular risk

DVTand pulmonaryembolism

*New indication, 2007

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Osteoporosis Therapy: Calcitonin•• Calcitonin Calcitonin 200 units daily by nasal spray200 units daily by nasal spray

•• Indication: Indication: treatment of postmenopausal osteoporosistreatment of postmenopausal osteoporosis

Eff tEff t 11•• EffectsEffects11

•• Very small effect (1Very small effect (1--2%) on bone density in spine2%) on bone density in spine

•• No effect on bone loss in women within 5 years of menopause No effect on bone loss in women within 5 years of menopause

•• Reduced incidence of vertebral fractures (36%) in women with preReduced incidence of vertebral fractures (36%) in women with pre--existing existing vertebral fractures vertebral fractures

•• No effect on nonNo effect on non--vertebral or hip fractures has been observedvertebral or hip fractures has been observed

• Side effects: nasal stuffiness

• Contraindications: hypocalcemia, allergy to calcitonin, pregnancy, recent menopause (<5 years)

1Chesnut CH et al. Am J Med. 2000;109:267

THERAPEUTICS

BISPHOSPHONATESBISPHOSPHONATESBISPHOSPHONATES BISPHOSPHONATES

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O

BISPHOSPHONATES APPROVED IN THE US FOR USE IN OSTEOPOROSIS

Alendronate

H2N

O

O

=

=P

P

OHOH

OHOHHO

Ibandronate

HO

CH 3N

O

O

=

=

P

P

OHOH

OHOH

O=

POH

O

=

POHOH

Risedronate

HON O

=

P

P

OH

OHOH

Zoledronate

HONN

O

=

P

P

OH

OHOH

Oral bisphosphonatesOral bisphosphonates•• Poorly absorbed (<1.0%)Poorly absorbed (<1.0%)•• Specific requirements for optimal oral absorptionSpecific requirements for optimal oral absorption

Fasting state with plain water onlyFasting state with plain water onlyFasting state with plain water onlyFasting state with plain water onlyMust be uprightMust be uprightNo food or drink for at least 30 minutes No food or drink for at least 30 minutes (for Ibandronate, 60 minutes)

•• Several halfSeveral half--liveslivesRapid uptake in bone and clearance by the Rapid uptake in bone and clearance by the kidneykidneykidneykidneyProlonged skeletal halfProlonged skeletal half--life (years)life (years)

•• GI intolerance has occurred with orally administered GI intolerance has occurred with orally administered aminoamino--substituted bisphosphonates (alendronate, substituted bisphosphonates (alendronate, risedronate, ibandronate)risedronate, ibandronate)

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The Vertebral FractureThe Vertebral Fracture

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0

10

ALN (2.3%)PBO (0.5%)

ALN (8.0%)PBO (15%) ALN (0.5%)

PBO (4.9%)

Alendronate: Effect on vertebral fractureAlendronate: Effect on vertebral fracture

Frac

ture

Ris

k R

educ

tion 10

20

30

4050

6070

80

55*47*

Liberman et al. New Engl J Med, 1995;333:1437-43Black DM et al. Lancet, 1996;348:1535-41

Clinical vertebral fractureNew morphometric fracturesMultiple morphometric fractures* statistically significant

F

90

10090*

35

ts

Placebo 5 mg Risedronate

Risedronate (VERT:Multinational study)Risedronate (VERT:Multinational study)Reduction in Relative Risk of Reduction in Relative Risk of NewNew

Vertebral FractureVertebral Fracture Over Years 0Over Years 0--3 and Years 43 and Years 4--55

51015202530

ulat

ive

Perc

ent o

f Pat

ient

49%P=0.001

59%p=0.011

05

0-3 Years 4-5 Years

Cum

u

N = 346 N =344 N = 103 N = 109

Reginster et al, OI, 2000.

N = subjects with an evaluable baselineand an evaluable post-baseline spinal x-ray.

Sorensen et al, Bone 32:220-226 (2003)

2/17/2009

36

12

Ibandronate: new vertebral fractures Ibandronate: new vertebral fractures ––2.5 mg daily (ITT)2.5 mg daily (ITT)

2.5mg

4

6

8

10

Inci

denc

e (%

)

Placebo

-62%

p=0.0001

0

2

0 6 12 18 24 30 36Months

Delmas PD et al. Osteoporosis Int 2004;15:792-798

151570%*

Reclast Reduced 3Reclast Reduced 3--Year Risk of Morphometric Vertebral Year Risk of Morphometric Vertebral Fractures (Stratum I)Fractures (Stratum I)

Reclast Placebo

% P

ati

en

ts W

ith

New

V

ert

eb

ral

Fra

ctu

res

60%*

71%*1010

55

1.5%

3.7%(106/2853) 2.2%

(63/2822)

7.7%(220/2853)

3.3%(92/2822)

10.9%(310/2853)

0%

% V

000–1 0–2 0–3

Years

(42/2822)( / )

*P < .0001, relative risk reduction vs placebo (95% confidence interval) Adapted from Black DM, et al. N Engl J Med. 2007;356:1809-1822.

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NONNON--VERTBRAL FRACTURESVERTBRAL FRACTURES

20

NONVERTEBRAL AND HIP FRACTURESNONVERTEBRAL AND HIP FRACTURESALENDRONATE FRACTURE INTERVENTION TRIALALENDRONATE FRACTURE INTERVENTION TRIAL

5

10

15ControlAlendronate

RR=0.5 (0.2,1.0)

NS

0Nonvertebral Fractures Hip Fractures

After data from Black DM et al. Lancet 1996;348:1535-1541

33 total hip fracturesNVFX = all except pathological, traumatic, face/skull

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20

NONVERTEBRAL AND HIP FRACTURESNONVERTEBRAL AND HIP FRACTURESRISEDRONATE VERTRISEDRONATE VERT--NANA

5

10

15Control

Risedronate

RR=0.6 (0.4,0.9)

NS


After data from Harris ST et al. JAMA 1999;282:1344-1352

27 total hip fractures (control + primary treatment group)NVFx = clavicle, humerus, forearm, pelvis, femur, lower leg; no consideration for trauma

20

NONVERTEBRAL AND HIP FRACTURESNONVERTEBRAL AND HIP FRACTURESIBANDRONATE BONE STUDYIBANDRONATE BONE STUDY

5

10

15Control

IBAN 2.5 mg daily

NS

NS


After data from Chesnut CH III et al. J Bone Miner Res 2004;19:1241-1249

10 total hip fractures (control + primary treatment group)NVFx = all except hands, feet, face, and skull

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39

20

NONVERTEBRAL AND HIP FRACTURESNONVERTEBRAL AND HIP FRACTURESZOLEDRONATE HORIZON TRIALZOLEDRONATE HORIZON TRIAL

5

10

15ControlZoledronate

41%*

25%*


140 total hip fracturesNVFX = excluding fingers, toes and facial bones

*P<0.05 Black DM et al, N Engl J Med 2007;356:1809-1822

ISSUES WITH BISPHOSPHONATES

INCONVENIENT DOSING• INCONVENIENT DOSING REQUIREMENTS (IF USED DAILY)

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Bisphosphonates: Weekly DosingBisphosphonates: Weekly Dosing

• Effects of weekly vs daily dosing on BMD and turnover 6

Alendronate1 Risedronate2

nene nene 6dosing on BMD and turnover are the same

• Extrapolation of fracture protection from daily studies is reasonable

• Has improved acceptance, but ff t dh t 0

2

4

% c

hang

e fr

om b

asel

in%

cha

nge

from

bas

elin

% c

hang

e fr

om b

asel

in%

cha

nge

from

bas

elin

0

2

4

Spine BMD Spine BMD

effect on adherence not known

Not a direct comparisonNot a direct comparison

0Daily Weekly

%%Daily Weekly

%% 0

11Schnitzer T, et al. Aging Clin Exp ResSchnitzer T, et al. Aging Clin Exp Res. . 2000;12:12000;12:1--121222Brown JP, et al. Calcif Tissue IntBrown JP, et al. Calcif Tissue Int.. 2002;71:1032002;71:103--111111

BisphosphonatesBisphosphonatesOther administration regimensOther administration regimens

• Monthly dosing– Ibandronate– Risedronate

• Intravenous dosingIbandronate (every 3 months)Ibandronate (every 3 months)–– Ibandronate (every 3 months)Ibandronate (every 3 months)

–– Zoledronate (once yearly)Zoledronate (once yearly)

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Adverse events with bisphosphonates Adverse events with bisphosphonates for osteoporosisfor osteoporosis

•• Upper GI intoleranceUpper GI intolerance•• Acute Phase ReactionAcute Phase Reaction•• “Oversuppression of bone”“Oversuppression of bone”1

•• Osteonecrosis of the jawOsteonecrosis of the jaw2,3

1Odvina et al. J Clin Endocrinol Metab, 20052Bilezikian JP N Eng J Med, 2006 3Khosla et al, J Bone Mineral Res, 2007

♦ Hormone replacement therapy(HT)

All Antiresorptive Antiresorptive Therapies for OsteoporosisTherapies for Osteoporosis

( )♦ Raloxifene♦ Bisphosphonates

• Alendronate• Risedronate• Ibandronate• Ibandronate• Zoledronate

♦ Calcitonin

Inhibit Bone Resorption

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Actions of antiActions of anti--resorptive agentsresorptive agents

Stabilize orStabilize or increase BMD

Maintain trabecular architecture

Increase mineralization density of bone matrix

What the antiresorptivesdon’t do…

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Approved Therapies in theApproved Therapies in theUnited States for OsteoporosisUnited States for Osteoporosis

•• Hormone Hormone • Teriparatide therapy (HT)therapy (HT)

•• RaloxifeneRaloxifene

•• BisphosphonatesBisphosphonates–– AlendronateAlendronate–– RisedronateRisedronate

p[human parathyroid hormone (1-34)]

–– IbandronateIbandronate–– ZoledronateZoledronate

•• CalcitoninCalcitonin

HisGluSer

Human Parathyroid HormoneHuman Parathyroid Hormone

1 10Ser Val Ile Gln Leu Met Asn

LeuH2N

T i tidGly20

30

LysHisLeuAsnSerMetGluArgValGluTrpLeu

Arg Lys Lys Leu Gln Asp Val His Asn Phe

Gly Teriparatide

-COOH

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PTH as a Treatment for Osteoporosis:PTH as a Treatment for Osteoporosis:A Paradox

H PTH b t ti l th fH PTH b t ti l th f•• How can PTH be a potential therapy for How can PTH be a potential therapy for osteoporosis when the clinical disorder of osteoporosis when the clinical disorder of chronic PTH excess, primary chronic PTH excess, primary hyperparathyroidism,hyperparathyroidism,is associated with bone loss?is associated with bone loss?

PTH and Dose Determine Effect on BonePTH and Dose Determine Effect on Bone

Mode EffectMode Effect

Continuous(High Dose) Catabolic

Daily AnabolicDaily(Low Dose) Anabolic

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Teriparatide reduces the incidence of Vertebraland Non-Vertebral Fractures in

Postmenopausal Women with Osteoporosis

Non-vertebral fracturesNew vertebral fracture

6

8

10

12

14

16

18

20

ents

(%) w

ith fr

actu

re

P< 0.01

53%6

8

10

12

14

16

18

20

ient

s (%

) with

fra

ctur

e

P< 0.01

65%

Neer RM, et al. N Engl J Med. 2001;344:1434-41

0

2

4

6

Patie 53%

20 μg PTH0

2

4

6

Pat

20 μg PTH PlaceboPlacebo

What do the bones actually looklike after therapy with PTH?

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Improved Trabecular ConnectivityImproved Trabecular ConnectivityAfter hPTH (1After hPTH (1--34) Therapy34) Therapy

AfterCD: 4.6/mm3Before

CD: 2.9/mm3CD: 2.9/mm

Dempster DW, et al. J Bone Miner Res. 2001;16(10):1846-1853.

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OSTEOPOROSIS

PREVENTABLEPREVENTABLEAND AND

TREATABLETREATABLE

Outline of Lecture - Columbia University · 2/17/2009 1 Pharmacology: Therapeutics of Calcium Metabolism John P. Bilezikian, M.D. Professor of Medicine and Pharmacology Chief, Division

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