1. Bone anabolic Agent
1.1. increase osteoBlastic activity
1.2. Teriparatide
2. Strontium
2.1. Sr+2 is divalent cation resembling Ca+2
2.2. MOA:
2.2.1. Has dual action , both anabolic & Anti-resorptive effects resulting in a rebalance of bone turnover in favour of bone formation, by acting on Ca senseing receptor (CaSR) =>
2.2.1.1. on Osteoblast:
2.2.1.1.1. enhance the differntiation of Pre-osteoBlast to OsteoBlast
2.2.1.1.2. stimulate the expression of Osteoprotegrin (OPG)
2.2.1.2. on OsteoClast:
2.2.1.2.1. Supress the differtiation of pre-osteoClast to osteoClast => increase OsteoClast appoptosis.
2.3. indication:
2.3.1. Osteoporosis
2.3.2. Malignancy-associated hyperclacemia
2.4. Contraidication:
2.4.1. in Severe renal disease
2.4.2. in hyper-sensetivity to it
2.4.3. in increase risk of venous thrombo-embolism
2.4.4. in Phenylketonuria
2.5. interaction:
2.5.1. 2 hours spacing
2.5.1.1. Antacids
2.5.1.2. Food especially containing milk + its products.
2.5.1.3. Oral tetracycline & Quinolones chekate it
2.6. Side effects:
2.6.1. All resolve in 1st 3 months
2.6.1.1. Eczema
2.6.1.2. Nausea & Vomiting
2.6.1.3. Headache
2.6.1.4. GI disturbances
3. Anti-resorptive Agents
3.1. decrease OsteClastic activity
3.2. Bis-phospho-nat
3.2.1. has 2 phosphonate (PO3) groups
3.2.2. Members:
3.2.2.1. Nitrogenous
3.2.2.1.1. Alen-dronate
3.2.2.1.2. Rise-dronate
3.2.2.1.3. Zole-dronare
3.2.2.2. Non-nitrogenous
3.2.3. MOA:
3.2.3.1. structurally similar to Pyro-phosphate / they block steps in cholestrol synthetic pathway within the OsteoClasts => apoptosis of Osteoclasts => inhibiting bone resorption.
3.2.4. indications:
3.2.4.1. Osteoporosis
3.2.4.2. Paget's Diseas
3.2.4.3. Malignancy-associated hyperclacemia
3.2.5. dosing:
3.2.5.1. Once weekly
3.2.5.2. or on 2 consecutive days each month
3.2.5.3. Taken
3.2.5.3.1. am with glass of water
3.2.5.3.2. on empty stomach
3.2.5.3.3. then do not take anything for 1/2 hr
3.2.5.3.4. in upright position
3.2.6. Side effects
3.2.6.1. GI problems
3.2.6.1.1. to avoid give large amount of warer
3.2.6.2. GERD
3.2.6.2.1. to avoid give in empty stomach
3.2.6.3. Flu like manifestation (in IV injusion)
3.2.6.4. Osteo-necrosis of the jaw
3.2.6.4.1. more upon long use
3.2.6.5. Atrial fibrillation
3.2.6.5.1. more in women taking Alen-dronate and Zole-dronate
3.2.7. Contraidication:
3.2.7.1. Decrease renal function
3.2.7.2. peptic ulcer/ GERD
3.3. RANKL inhibitors
3.3.1. Denosu-mab
3.3.2. MOA:
3.3.2.1. it's fully human mono-clonal antibody (MAP) that mimic the activity of Osteoprotegrin (OPG)
3.3.3. Adminstration:
3.3.3.1. S.C every 6 month
3.3.4. Contraindication
3.3.4.1. hypoCalcemia
3.3.4.1.1. correct Ca and vit D levels before starting Denosumab.
3.3.5. side effects:
3.3.5.1. infection
3.3.5.1.1. Urinary & Reapiratory
3.3.5.2. Eczma & skin rash
3.3.5.3. constipation
3.3.5.4. Cataract
3.3.5.5. Joint pains