Osteoporosis: Pharmacists can enhance prevention, treatment

Pharmacists can educate patients and providers to helpreduce the number and severity of osteoporotic fractures, saysMary Beth O'Connell, PharmD, BCPS, FASHP, FCCP, associateprofessor, Eugene Applebaum College of Pharmacy and HealthSciences, Wayne State University, Detroit.

The bottom line, says Dr. O'Connell, is that patients shouldpractice a fracture prevention/healthy lifestyle; engage infall-prevention strategies; reduce the amount of caffeine theytake in; take calcium 1,200 to 1,500 mg daily in divided doses infood or in supplements (calcium does not decrease fractures butdoes decrease bone loss); and take vitamin D 800 to 1,000 unitsper day. Pharmacists have a key role in educating patients andproviders about vitamin D, she adds, as most don't understand howimportant vitamin D is to bone health. "Vitamin D tells thebowels to absorb calcium," she notes. Also, the above-notedvitamin D dosage is a "key change" in the recommended amounts(National Osteoporosis Foundation guidelines). The desired levelof vitamin D in the blood is >30 ng/mL.

Drugs of choice are bisphosphonates, antiresorptive agents. Thebisphosphonates available have different affinities, binding, andpersistence. There are four agents that are approved and theystack up as follows: alendronate and zoledronic acid >risedronate and ibandronate. All four are approved forpost-menopausal women; alendronate and risedronate are both alsoapproved for men and glucocorticoid-induced osteoporosis.Pharmacists can educate patients about the importance of takingmedications for at least 2 years; "most people only take theirmedications for 6 months. While they come with a cost,medications prevent fractures and save the health system money,"says Dr. O'Connell.

With regard to combination therapy, Dr. O'Connell cautions thatteriparatide should never be used with a bisphosphonate. If thepatient is on a bisphosphonate, "stop it and then go withteriparatide," she says. She states that pharmacists should bearin mind also that this agent "is an injectable and is expensiveand needs preauthorization from Medicare part D."

Improving therapy
When they are indicated, medications are not being used oftenenough, says Dr. O'Connell. She suggests some ways to improvetherapy and treatment for osteoporosis:

• Computer identification of patients in need of treatment
• Fracture liaison team; this can increase the number ofpatients who get treatment
• Patient empowerment for follow-up; this does improveoutcomes, but is still not the "complete answer"
• Case manager (costs about $50 per senior patient -good use ofmoney)
• Standing orders for discharge or from rehab (orders forosteoporosis prevention; anticoagulation; improves dischargeorders)