Osteoporosis therapy enters new era with novel treatments

As Americans enter their senior years, more of them, particularly women, will be at an increased risk of developing osteoporosis. Fortunately, the currently available agents and those in development are able to treat it effectively.

Experts warn, though, that in order for patients to benefit maximally from these agents, they must consume adequate amounts of calcium and also be involved in weight-bearing exercise. Further, in the battle between physicians and insurance companies regarding who gets bone densitometry screening and when, patients may be underdiagnosed and, consequently, undertreated. Therefore, pharmacists are in a key position to counsel patients regarding both the potential need for screening and the optimal use of osteoporosis therapies if they are diagnosed with this disease.

"Bone strength depends on bone density, or how much calcium is deposited in the bones," said McDermott. "Your level of bone density after menopause is a product of your peak bone mass and how fast you lose bone after menopause," he said. "For example, if a woman had relatively low peak bone mass in her youth, she would be more likely to develop osteoporosis shortly after menopause." If she had normal peak bone mass but lost bone more quickly after menopause, she would also be at risk.

"Many factors can affect peak bone mass, the rate of bone loss, and the risk of osteoporosis, but the most important factor may be genetics," McDermott said. "A woman whose mother or sister has had osteoporosis, particularly one who has had vertebral and hip fractures, would be more at risk."

As pharmacists know, long-term use of glucocorticoids for any reason increases the risk of osteoporosis. Bumgardner noted that hyperthyroidism, as in Grave's disease, is a risk factor, and McDermott added that excessive use of synthetic thyroid can increase the risk in patients with hypothyroidism. Chronic use of heparin or a history of eating disorders can also increase the risks, he said.

When to monitor The established method for monitoring bone density is dual-energy X-ray absorptiometry (DXA). However, insurance companies often do not reimburse for DXA screening until a woman is 65 years old, much later than many physicians would hope. "Right at the time of menopause is the most appropriate time to begin screening," McDermott said. "A substantial amount of bone loss can occur between menopause and 65, particularly with women at high risk."

Therefore, some pharmacists are starting to offer DXA screening, for at least some anatomical areas, in the pharmacy setting, Bumgardner said.

Nonpharmacologic strategies For patients who have been diagnosed with or are at risk for osteoporosis, the treatment story doesn't start with medications, both experts stressed. "We first need to make sure that people are implementing the nonpharmacological measures," McDermott said. "If they don't, the drugs won't work as well."

The nonpharmacologic measures include consuming 1,500 mg of calcium daily, either through foods or through supplements, and 400-800 units of vitamin D, as well as getting adequate exercise. In addition to positive changes, patients need to address the negative issues that promote osteoporosis, McDermott said. He stressed the importance of smoking cessation and of reducing the consumption of alcohol and caffeine.