General

bazedoxifene/conjugated estrogens

Pronunciation:
ba-ze-dox-i-feen / kon-joo-gay-ted es-troe-jenz

Trade Name(s)

• Duavee
• Duavive 

Ther. Class.

bone resorption inhibitors

hormones

Pharm. Class.

selective estrogen receptor modulators

estrogens

Indications

• Treatment of moderate/severe vasomotor symptoms of menopause in female patients with an intact uterus.
• Prevention of postmenopausal osteoporosis in female patients with an intact uterus (supplemental calcium and vitamin D recommended if dietary intake is not adequate).

Action

Both bazedoxifene and conjugated estrogens bind to α and β estrogen receptors. Conjugated estrogen acts as an agonist at these receptors. Bazedoxifene acts as an agonist in some tissues and an antagonist in other tissues, including the uterus. The combined effect is estrogen replacement while minimizing the risk of endometrial hyperplasia and prevention of postmenopausal osteoporosis.

Therapeutic Effect(s):

Reduced vasomotor symptoms of menopause with reduced risk of endometrial hyperplasia and prevention of postmenopausal osteoporosis.

Pharmacokinetics

Bazedoxifene

Absorption: 6% absorbed following oral administration.

Distribution: Unknown.

Protein Binding: 98–99%.

Metabolism and Excretion: Undergoes extensive metabolism by UGT enzymes in the intestinal tract and liver, undergoes biliary excretion with enterohepatic recycling and elimination in feces (85%).

Half-life: 30 hr.

Conjugated Estrogens

Absorption: Well absorbed following oral administration.

Distribution: Widely distributed; higher concentrations found in sex hormone target organs; enters breast milk.

Metabolism and Excretion: Primarily metabolized by the liver via the CYP3A4 isoenzyme; some metabolites are hormonally active. Metabolites are renally excreted.

Half-life: 17 hr (estrone).

TIME/ACTION PROFILE (effect on vasomotor symptoms†)

Contraindication/Precautions

Contraindicated in:

• Undiagnosed/abnormal vaginal bleeding;
• Hepatic or renal impairment or BMI > 27 kg/m²  (↑ risk of endometrial hyperplasia;
• History of known/suspected breast cancer or other estrogen-dependent cancer;
• Active or past history of thromboembolism including stroke, myocardial infarction, or pulmonary embolism;
• Known protein C, protein S, or antithrombin deficiency or other thrombophilic disorders;
• OB:  Pregnancy;
• Lactation: Lactation;
• Rep:   Women of reproductive potential;
• Geri:  Not recommended for use in patients ≥ 75 yr; has been associated with dementia in patients ≥ 65 yr.

Use Cautiously in:

• Risk factors for thromboembolic phenomenon including diabetes, family history, obesity, or systemic lupus erythematosus.
• History of cholestatic jaundice associated with estrogen use.
• Hypothyroidism (may need ↑ dose of thyroid replacement).
• History of hereditary angioedema (estrogen may provoke).
• History of asthma, diabetes mellitus, epilepsy, migraine, porphyria, systemic lupus erythematosus, or hepatic hemangiomas (estrogen may exacerbate these conditions).

Adverse Reactions/Side Effects

CV: ↑ BP, edema, THROMBOEMBOLISM

Derm: hot flash

EENT: retinal vascular thrombosis

F and E: hypocalemia

GI: cholestatic jaundice, diarrhea, dyspepsia, gall bladder disease, nausea, oropharyngeal pain, upper abdominal pain

MS: muscle spasms, neck pain

* CAPITALS indicate life-threatening.
Underline indicate most frequent.

Interactions

Drug-Drug

•  UGT inducers, including  carbamazepine,  phenobarbital,  phenytoin, and  rifampin, may ↓ bazedoxifene levels and result in ↑ risk of endometrial hyperplasia.
•  CYP3A4 inhibitors, including  clarithromycin,  erythromycin,  itraconazole, ,  ketoconazole, and  ritonavir , may ↑ levels of conjugated estrogens and the risk of endometrial hyperplasia.
•  CYP3A4 inducers, including  carbamazepine,  phenobarbital, and  rifampin, may ↓ levels and effectiveness of conjugated estrogens and alter uterine bleeding patterns.
•  Progestins, other  estrogens, or  estrogen agonist/antagonists  may alter the effectiveness or treatment and/or ↑ risk of adverse reactions; avoid concurrent use.

Drug-Natural Products:

 St. John's wort  may ↓ levels and effectiveness of conjugated estrogens and alter uterine bleeding patterns.

Drug-Food:

Grapefruit juice may ↑ levels of conjugated estrogens and the risk of endometrial hyperplasia.

Route/Dosage

PO (Adults): One tablet (bazedoxifene 20 mg/conjugated estrogen 0.45 mg) once daily.

Availability

Tablets: bazedoxifene 20 mg/conjugated estrogens 0.45 mg

Assessment

• Assess for frequency and intensity of postmenopausal vasomotor symptoms (hot flashes).
• Assess BP before and periodically during therapy.
• Monitor intake and output ratios and weekly weight. Report significant discrepancies or steady weight gain.

Lab Test Considerations:

May cause hypocalcemia.

• May cause ↑ HDL and triglycerides, and ↓ serum LDL concentrations.
• May cause ↑ prothrombin time, partial thromboplastin time, and platelet aggregation time. May ↑ factors II, VII, VIII, IX, X, XII levels. May ↓ antithrombin III and ↑ levels of fibrinogen and fibrinogen activity and plasminogen antigen and activity.
• May cause ↑ thyroid-binding globulin, causing increased circulating total thyroid hormone; may require higher doses of thyroid replacement therapy.
• May cause impaired glucose tolerance.

Implementation

• Supplement calcium and/or vitamin D if diet is inadequate.
• PO Administer once daily without regard to meals.  DNC: Swallow tablets whole; do not crush, break, or chew. 

Patient/Family Teaching

• Instruct patient to take medication as directed. Take missed doses as soon as remembered unless almost time for next dose; do not double doses. Advise patient to keep  Duavee  in original container to protect from moisture; avoid placing in pill boxes or organizers. Open only one blister pouch and one tablet at a time; record date opened and discard after 60 days. Advise patient to read  Medication Guide  before starting therapy and with each Rx refill in case of changes.
• Advise patient to avoid grapefruit juice during therapy.
• Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to avoid concurrent use of Rx, OTC, and herbal products, especially progestins, additional estrogens, or additional estrogen agonist/antagonists, without consulting health care professional; may increase risk of uterine cancer.
• Advise patient to report signs and symptoms of fluid retention (swelling of ankles and feet, weight gain), thromboembolic disorders (pain, swelling, tenderness in extremities; headache; chest pain; blurred vision), new breast lumps, changes in vision or speech, sudden new severe headaches, severe pains in chest or legs with or without shortness or breath, weakness, fatigue, or abnormal vaginal bleeding to health care professional.
• Caution patient that cigarette smoking during estrogen therapy may increase risk of serious side effects, especially for women over age 35.
• Advise patient treated for osteoporosis that exercise has been found to arrest and reverse bone loss. Discuss any exercise limitations with health care professional before beginning program.
• Emphasize the importance of routine follow-up physical exams, including BP; breast, abdomen, and pelvic examinations; Papanicolaou smears every 6–12 mo; and mammogram every 12 mo or as directed. Health care professional will evaluate possibility of discontinuing medication every 3–6 mo.
• Advise patient to notify health care professional promptly if unusual vaginal bleeding occurs during therapy. Vaginal bleeding after menopause may be a sign of uterine cancer.
• Rep:  May cause fetal harm. Advise patient to notify health care professional if pregnancy is planned or suspected and to avoid breastfeeding.

Evaluation/Desired Outcomes

• Reduction in frequency and intensity of moderate to severe hot flashes.

• Decreased risk of development of osteoporosis.

  • Therapy should be used for the shortest time possible and need for therapy evaluated regularly.