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To help ensure that hormone replacement therapy is used safely and effectively, pharmacists should consider the following points during patient counseling.
HRT (estrogen alone or with a progestin) is indicated for moderate to severe vasomotor symptoms (eg, hot flashes) associated with menopause, atrophic vaginitis, vulvar or vaginal atrophy, and the prevention of postmenopausal osteoporosis and cardiovascular disease. It is contraindicated in women who are or may become pregnant, those with an active or past history of thrombophlebitis and/or thromboembolic disorders, those with liver disease, and those with undiagnosed abnormal vaginal bleeding. It is also contraindicated in women with known or suspected breast cancer, estrogen-dependent neoplasia, or hypersensitivity to any component of HRT.
The recommended dosage of HRT ranges from 0.3 mg to 0.625 mg estrogen daily (depending on the product), which may be administered any time of day without regard to meals. In women with an intact uterus, adding a progestin is recommended—either 2.5 mg daily or 5 mg on days 15 through 28 of a monthly cycle.
A complete medical and family history should be taken prior to the initiation of estrogen therapy. The pretreatment and periodic physical examinations should include special reference to blood pressure, breasts, abdomen, and pelvic organs and should include a Papanicolaou smear. As a general rule, women using estrogen therapy should have a complete physical examination and a mammogram annually.
HRT can result in changes in vaginal bleeding patterns; breakthrough bleeding or spotting are possible. Patients may also experience some breast tenderness.
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Patients should be instructed that the expected benefits of alendronate may only be obtained when each tablet is swallowed with plain water immediately upon arising for the day and at least 30 minutes before the first food, beverage, or medication of the day.71 Even dosing with orange juice or coffee has been shown to markedly reduce the absorption of alendronate. To facilitate delivery to the stomach, and thus reduce the potential for esophageal irritation, patients should swallow alendronate with a full glass of water (6–8 ounces) 30 minutes before the first food of the day and avoid lying down for at least 30 minutes after taking the tablet.71
Alendronate is indicated for both the prevention and treatment of osteoporosis in postmenopausal women and for the treatment of Paget’s disease of bone.71 When used for the treatment of osteoporosis, alendronate increases bone mass and prevents fractures, including those of the hip, wrist, and spine (vertebral compression fractures).71 When used for the prevention of osteoporosis, alendronate may be considered for postmenopausal women who are at risk of developing osteoporosis and for whom the desired clinical outcome is to maintain bone mass and to reduce the risk of future fracture. Bone loss is particularly rapid in postmenopausal women younger than age 60.71 Since risk factors are often associated with the development of postmenopausal osteoporosis (eg, early menopause, moderately low bone mass, thin body build, family history, Caucasian or Asian race), such risk factors should be considered when choosing this therapy.71
Alendronate is contraindicated in patients with hypocalcemia or abnormalities of the esophagus which delay esophageal emptying, or who are unable to stand or sit upright for 30 minutes. It is also contraindicated in women known to be hypersensitive to alendronate or other constituents of the tablets.
The recommended dosage depends on the indication. For osteoporosis prevention in postmenopausal women, administer 5 mg daily; for osteoporosis treatment, administer 10 mg daily; and for treatment of Paget’s disease, administer 40 mg per day for 6 months.
Patients should be advised that the risk of severe esophageal adverse experiences increases if the complete dosing instructions are not followed. Patients should not chew or suck on the tablet because of a potential for oropharyngeal ulceration.71 In addition, patients should be specifically instructed not to take alendronate at bedtime or before arising for the day. If they develop symptoms of esophageal disease (such as difficulty or pain swallowing, retrosternal pain, or new or worsening heartburn), patients should be instructed to stop taking alendronate and consult their physician.
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To help ensure the safe and effective use of raloxifene, pharmacists should consider the following points during patient counseling.
Raloxifene is indicated for the prevention and treatment of osteoporosis in women following menopause. There is no indication for premenopausal use of raloxifene, and it is contraindicated in women who are or may become pregnant and women with an active or past history of venous thromboembolic events (eg, deep vein thrombosis, pulmonary embolism, retinal vein thrombosis). It is also contraindicated in women known to be hypersensitive to raloxifene or other constituents of the tablets.
The recommended dosage is one 60 mg tablet daily, which may be administered any time of day without regard to meals.
Raloxifene should be discontinued at least 72 hours prior to and during prolonged immobilization (eg, postsurgical recovery, prolonged bed rest), and patients should be advised to avoid prolonged restrictions of movement during travel because of the increased risk of venous thromboembolic events.
Raloxifene is not effective in reducing hot flashes associated with estrogen deficiency.79 In some asymptomatic patients, hot flashes may occur upon beginning raloxifene therapy.
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