CEimpact Podcast

Updates in Osteoporosis Screening and Treatment

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Osteoporosis remains a significant health concern, with new screening and treatment guidelines aiming to improve prevention and care. This episode explores updated recommendations, the latest therapeutic options, and how medications for other conditions can impact bone health. Stay informed and ready to support your patients—tune in to learn how pharmacists can make a difference.

HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact

GUEST
Erin Raney, PharmD, BCPS, BC-ADM
Professor
Midwestern University College of Pharmacy, Glendale Campus

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CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Explain the updated screening and treatment guidelines for osteoporosis and their implications for patient care.
2. Identify medications that affect bone health strategies for pharmacists to mitigate their impact on osteoporosis risk.

0.05 CEU/0.5 Hr
UAN: 0107-0000-25-088-H01-P
Initial release date: 4/7/2025
Expiration date: 4/7/2026
Additional CPE details can be found here.

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Speaker 1:

Hey, ce Impact subscribers, Welcome to the Game Changers Clinical Conversations podcast. I'm your host, josh Kinsey, and, as always, I'm super excited about our conversation today. Osteoporosis is often called a silent disease, quietly weakening bones until fractures cause serious and life-altering complications. In this episode, we'll unpack the latest screening and treatment guidelines, explore how medications impact bone health and discuss the vital role pharmacists play in protecting patients from this hidden threat. And it's so great to have Erin Rainey as our guest expert for today's episode. Erin, thanks so much for joining us.

Speaker 2:

I'm really excited to be here. Thank you.

Speaker 1:

Yeah, we appreciate you taking time out of your schedule. So for our learners that may not know, you, erin, take just a couple minutes. I always like to give the speaker a few minutes to kind of introduce themselves, talk about your practice site and maybe tell us about you know why you're passionate about today's topic.

Speaker 2:

Well, thank you. I am a professor of pharmacy practice at Midwestern University College of Pharmacy. I'm here at our Glendale Arizona campus and I have been working in the area of family medicine over 20 years and really have developed such a passion for women's health. Over that time I have taught in the classroom about women's health topics, worked within family medicine in that area and have just recently transitioned into working on our campus side, outside of the practice area, and promoting our professional development activities with our students. However, I'm still in the classroom regarding women's health, and that will always be an area of interest. Awesome. Osteoporosis certainly fits in that area. Men get osteoporosis too, so we might end up talking about that.

Speaker 1:

That's true, that's true. Yep, especially, yeah, yeah, for sure, especially if they're on certain medications or that's weakening or whatever. So, yeah, well, that's great. Thanks again for joining us. We appreciate you taking time to talk about. You know, as I mentioned joining us, we appreciate you taking time to talk about.

Speaker 1:

You know, as I mentioned, my segues I feel like sometimes are so dramatic, you know, like this life altering or you know hidden thread or whatever. But it really is like osteoporosis is kind of that silent thing, kind of lurking in the background, that you know people may not fully realize that their bones are just slowly breaking down. So I think it's really something important for pharmacists to be aware of that. This is, you know, I hate to call it a silent disease, but sometimes it is. Sometimes people don't realize it until they fracture something and then realize that they're at risk. So anyway, without further ado, let's jump into, kind of the topic for today, and I always like to set the stage and just make sure we're all on the same page. So let's just briefly touch on the overview of osteoporosis, so remind us exactly what it is kind of, what its implications Talk about, maybe some risk factors and things like that.

Speaker 2:

Sure, Well, osteoporosis in itself is low bone mass, which in itself might not be an issue, except it puts us at risk for fracturing. And when we think about our bone remodeling process throughout our lifetime, it's important that our osteoblasts and osteoclasts have this balanced activity to clear out bone and rebuild bone. That happens at various rates throughout our skeleton throughout our lifetime. What happens as we age for women typically at the age of menopause, and then men, this, not a more steady decline over time, that bone remodeling process gets imbalanced, so the clearing out of the bone is more efficient than the building backup and we end up with a skeleton that is not as strong and resistant to fracture if we were to fall.

Speaker 2:

So one of two out of two women in the US age 50 or over will have a fracture in her lifetime. One of four men will have the same thing. So we know it is a big issue yeah, important for us to pay attention to.

Speaker 1:

I feel like that statistic is a little surprising for me. I don't think I would have realized one in four men, you know, you always just kind of think of osteoporosis being the frail you know disease that hits frail females or whatever. But yeah, that's very interesting. Okay, that's great. Let's talk a little bit about if, as I mentioned, and I've said it a couple of times, it's kind of that silent issue, right, but once we know that it's a problem, or obviously once there's a fracture, what does that do to quality of life for the patient?

Speaker 2:

Right. Fractures are absolutely important to prevent because we do know that sometimes less than half of individuals that have a hip fracture will end up regaining their pre-fracture quality of life in terms of activities of daily living, and sometimes it does change their ability to live on their own. So there's morbidity related to osteoporosis and there's also mortality. So we have increased rates of death after fractures. In some cases it's due to infection rates, pneumonia, having to live in a skilled nursing facility, but I think that's sometimes surprising for the public to recognize that a fracture in the spine or the hip can have such a huge impact on the remainder of their life.

Speaker 1:

Yeah, yeah, I know, actually, for a couple of my grandparents that was the final straw that took them down was was an actual was, a fall in a fracture, and you know they quickly dwindled and and were gone within a few months. So, yeah, it's, it's a very real thing that you know, we think of. You know, as if a kid breaks their arm, like, oh, they're going to get a cast, and then you know it's fine and they're going to be fine in a month or whatever, but you know it's a it's a really big deal when our older patients break something. So, yeah, so what is what's out there to prevent this? Obviously, screenings and medications, but like, let's let's touch on the role of screening and prevention first and then we can touch on the role of actually treatment and maintenance and whatnot. But let's briefly discuss, you know, what are our screening options. What does that look like right now?

Speaker 2:

Right? Well, there's many ways to screen for bone density itself, and the gold standard is a DEXA scan. And the gold standard is a DEXA scan. Usually, the hip and spine is the best place to scan so that we can see right where the most worrisome fractures are occurring and you're testing just those spots.

Speaker 2:

We know that at menopause it is a swift decline in estrogen at that point and that really impacts bone health. So most expert groups agree that at menopause it's important to assess a woman's risk for fracture. If they have an additional risk factor like family history of osteoporosis, they might start their bone density testing at that time. But at least by age 65, every woman should be having bone density testing done. It is important also to remember that the assessment of risk is not just looking at the bones in terms of bone density or a DEXA scan. It's also assessing risk based upon family history and some of our other attributes that might put us at risk for a fracture. That could be the other medications that we're taking, certain disease states that we might have, or other medical conditions, our physical activity level, whether we're a smoker. If we get adequate calcium and vitamin D.

Speaker 1:

So there's a lot that's in play for the picture of assessing risk. Yeah, what about Erin like obesity? Is that an actual risk factor, Like because carrying around the extra weight and again that would lead to inactivity potentially, and things like that? What's your thoughts on that?

Speaker 2:

I think that it's a really interesting question, because we're used to obesity placing a higher cardiometabolic risk for things like diabetes and heart disease. However, a low body weight is actually a greater risk for osteoporosis, and the main reason is that that bearing of weight, that weight bearing activity, even of our own weight, is something that can keep bones stronger throughout life.

Speaker 2:

And so we really want to consider that weight-bearing exercise is something that is important. Now, if someone has obesity, it is important for so many other reasons to achieve good cardiometabolic health, for instance but it isn't a specific risk for osteoporosis fractures.

Speaker 1:

Interesting, yeah, and you talked about menopause. So I just want to go back to that really quickly, so kind of as a summary, because we had a recent podcast on menopause and perimenopause and kind of talking about that. So but just to summarize, we know that women hit menopause at different times in their life, at different phases, and so there's not a by the age of 52, you know you're going to have gone through, you know A, b and C or whatever. So there's you had mentioned 65 for sure is when they should start screening. But at the time of menopause, whenever that is, they should have that discussion to determine whether or not they're at further risk and should they be assessed at that time? Absolutely.

Speaker 2:

Yeah, and premature menopause. The average age of menopause in the US is around 51, 52 years old, so that can be a pretty reasonable broad statement at that age. But if someone has premature menopause younger than 45, especially younger than 40, then bone health is going to be an important issue for managing their lifelong plan there. Because of that lack of estrogen, that's even longer than the typical menopausal.

Speaker 1:

Right, right, yeah, potentially even a decade longer without the estrogen and whatnot. So, yeah, okay, yeah, that makes sense. So we've talked a little bit about screening and how that can play a role in preventing. So what about if we find out that someone does have osteoporosis? Obviously, we know there are treatments out there, but just kind of review with us what are those treatment options like? What are the typical things that patients will undergo?

Speaker 2:

Yes. Well, what's exciting now, as opposed to when I first started teaching about women's health topics several decades ago, is that we have both anti-resorptive agents and anabolic agents, and so we can not only stop or slow the clearing out of the bone, but we can also start building it back, and that's something new just within the last decade, and especially in the last five years, of having medications that can really build bone. So when we look at someone's risk for a fracture, we can take that T-score, which is assessing the risk of a fracture based upon that bone mineral density, and determine how low that bone density is and depending on where they're at. Pretty recent suggestions and guidance are that we might start with an anti-resorptive agent, like a bisphosphonate, or we might actually need to start with an anabolic agent, which is one of our newer drugs, and so that's a big decision point based upon how low is someone's bone density and if they're very high risk for a fracture right now.

Speaker 1:

Yeah, side note here, I uh recently started reading again, uh, the Harry Potter books. And so when we talk about, you know, bone regrowth, you know there was the at times when they actually they had a potion to like regrow bones, and so I'm thinking about, if you know, I wonder if that's what spawned the idea of these 20 years ago. So, probably not. It was probably already under discussion and studies and all that kind of stuff, but I couldn't help my mind going there for a second. So I still find those fascinating, the fact that we do have those agents now that can actually help with strengthening and regrowth, as opposed to just kind of stopping, as you mentioned, the decline. So okay, so that's great.

Speaker 1:

So we've kind of talked, then, about osteoporosis in general. We've reminded our listeners about kind of you know what does that do, the impact on the patient's life, their quality of life, what happens, both you know when, finding out so they might go on treatment, and also just risk and prevention and screening in general. So let's jump into a little bit of you know what are some of the opportunities for us as pharmacists. So that's why we have the Game Changers podcast is we want to be sure that we're giving you know tips and tricks to our listeners so that they can fully practice at the top of their license. So let's talk about what pharmacists can do in this space. So there are some pharmacists who are in a space where screening is happening right. So if they have one of those machines and they're actually doing that, so that's obviously a place. But let's, for those that aren't there and they don't have that opportunity, tell us why it's important to be sure that we're up to date on screening guidelines in general.

Speaker 2:

Yeah, I think that when you are, depending on what setting you're practicing in as a pharmacist, having those touch points with individuals at all ages allows us to help emphasize screening guidelines and also those lifestyle changes that are important and making sure that they're not on medications that might put them at risk for low bone mass. So just having those touch points and being that trusted healthcare provider that's seen them over time and their body's changing as they get older, that that is just an important opportunity to be that resource.

Speaker 1:

Yeah, absolutely Absolutely. And you know, even if it's something as simple as you know, you are learning that your patient is going through menopause. They've asked questions about that. Whatever that could be a moment for you to say, oh, you also need to consider having a discussion with your provider about screening and osteoporosis and things. So, again, just being mindful of how those go hand in hand, that can be a time for us to jump in as a pharmacist as well. So let's, then you set up a great segue. You talked about medications that can cause bone density loss, so let's go ahead and jump in there. What are some of those medications? Where do we see them? What diseases are they treating? What should we be able to look out for?

Speaker 2:

So really I think the prime candidate or the prime problem child with medication-induced osteoporosis is glucocorticoids, and so we're not talking about inhaled products, we're talking about systemic exposure, and it's wonderful that for pulmonary conditions like asthma, we've really moved away from needing long courses of systemic steroids. But for patients who have rheumatologic conditions that might need prednisone or other types of corticosteroid therapy over the long run, that is probably the prime example of a medication-induced risk. And there are actually specific guidelines from the American College of Rheumatology on how to address glucocorticoid-induced osteoporosis, which involves much earlier screening. Even the, the assessment of risk is using a different assessment tool accounting for the glucocorticoids and a lot different recommendations on lifestyle and calcium and vitamin d, and all of that very aggressive care right from yeah, yeah, that's very important.

Speaker 1:

Um, I you know I it's been a while since I've practiced, as I've mentioned before, but, um, what, like? What kind of doses are we talking about for those patients who are using it? On the rheumatoid side of things, what should we be looking out for If we see an occasional steroid here and there, or is it a maintenance dose of 10 milligrams a day or something like that? Where should we be concerned?

Speaker 2:

Yeah, I think when we, when we see the prednisone bursts, let's say, maybe someone's on five or five days of a prednisone product that's not what we're thinking about here it's usually three, three months or longer and five 7.5 milligrams of prednisone equivalent per day over that period of time or more. So it really is usually unique, luckily, because we have so many disease-modifying drugs that are separate from glucocorticoids. Now for rheumatologic disease. But, it does happen and we need to watch for that.

Speaker 1:

Okay, yeah, that's again a great entry point for a pharmacist, because we're seeing all the medications that they're on and so if we're noticing that they're on a maintenance dose of a steroid, that's a great point to jump in and say hey, have you started early screening of osteoporosis, because this is putting you at higher risk. Yeah, let's talk about the-.

Speaker 2:

Other medications I could mention real quick. Yeah, that's what I was going to say. Any others? Yeah, let's talk about that.

Speaker 1:

Other medications I could mention real quick. Yeah, that's what I was going to say, any others yeah?

Speaker 2:

Some things that deplete estrogen. That makes sense because we have that kind of menopausal slide to keep in mind. But there might be aromatase inhibitors used. There's also medications like proton pump inhibitors that affect our stomach acid and the gastric pH and that might cause us to decrease calcium absorption from the gut over time. We're not quite sure how they deplete or cause bone density issues. But some of the diabetes medications thiazolidinediones. So there's epidemiologic evidence of that but not quite sure what to do with that data quite yet. So there's quite a few medications. Even furosemide, a loop diuretic, for instance, is calcium wasting. So there's lots of different mechanisms by which a medication can decrease bone density.

Speaker 1:

Okay, yeah, I was going to mention because I personally am on a PPI and I have been for many years and I've tried to get off and I just can't. But there is that underlying concern that I have as I grow older and am currently just continuously on those. Am I putting myself at higher risk for weakening my bones with a PPI? So I know that there's been some controversial studies back and forth. Some say definitely, some say not a problem, especially at a lower dose, you know whatever. But I'd be one that would love to see more studies on that, just to see if I can continue and be able to, like you know, actually eat things and enjoy them versus. Should I really be looking at the future on that?

Speaker 2:

so well, we know that the calcium citrate is not dependent on the gastric pH for absorption. So if someone is using a calcium supplement, the calcium citrate formulation will be more reliably absorbed if there's that low acid environment from a PPI.

Speaker 1:

That's great. That's great feedback, thank you. Maybe I need to look at taking a supplement of the citrate then, yeah for sure. Okay, so let's talk a little bit about too, while we're on the topic of medications. So I think it's really important that we talked about ones to kind of be on the lookout for, but let's also talk about, you know, the importance of staying on the treatment for osteoporosis, and we know that. You know some of those medications have some bad side effects or whatever, or at least it appears bad, and so, obviously, education is going to be key. But let's talk about how we can make sure that our patients are adherent and we keep those rates high.

Speaker 2:

Yeah, well, there's it's pretty bad statistics based on who actually gets the prescription and fills it Right For osteoporosis meds. Like a quarter of people might not ever fill it for one and then it might be upwards of a half of patients will not complete beyond one year of therapy, depending on the type of medication they're on.

Speaker 1:

So, that's.

Speaker 2:

That's a broad statistic. But first of all we have to get the medication in the patient's body. So we have issues with making sure that they're taking it correctly, whether it is an oral medication, and we have to optimize absorption, or if it's one of the injectable medications, and they need to use those injectable devices correctly. And then we have the fear, like you said, of side effects and concerns. And so really, when we look at bisphosphonates kind of the traditional alendronate or isedronate we know that we can really minimize risk related to gastroesophageal irritation by having the patient take it correctly, sitting upright for 30 minutes after ingesting it, making sure that it's well absorbed on an empty stomach, only with water, 30 minutes before meals. We have all those recommendations down pat. We have all those recommendations down pat, but communicating it to a patient and actually having them understand why, I think that's the key.

Speaker 2:

That's key Because we're asking them to do a lot. You know, being mindful of 30 minutes and sitting up and having to do all of these restrictive things.

Speaker 2:

I've found that many times when I've talked with patients about why they're not wanting to stay on the medication, that annoyance with the scheduling. They never really were understanding why it was needed. And when we talk about the two reasons one is actually to improve absorption of the drug to get into their body, but then to also protect their esophagus I think that goes a long way. That why goes a long way to helping a patient.

Speaker 1:

Right.

Speaker 2:

Be persistent with their therapy.

Speaker 1:

Right, yeah, because, again, you know if, if they were to lie down afterward for a few of the doses, they're probably not going to see an immediate concern, and so then, if they didn't know the why, they would just assume oh well, that was information that didn't really affect me, because apparently nothing is wrong, it's not happening to me. So I think it's really important, like you said, to lay out the why, because not as a scare tactic, but there is a reason why these have these restrictions and it's to protect you and to also, like you said, make sure that the absorption is actually increased and is working. So, yeah, um, what other barriers, um, have you noticed? So, adherence to medications, uh, potentially just the unknown of like, oh, I didn't realize I should start early screening because I went into menopause earlier, or whatever, but any other barriers that you've seen to either treatment or screening?

Speaker 2:

I think the general barrier of cost can be a consideration. There are some agents that are reasonably affordable, but when we look at those patients at highest risk where we need to think about an anabolic agent, there can be a real concern with a financial obstacle in not only paying for the medication, but having access through the prior authorization process.

Speaker 2:

Many times there's stepped approaches that are required to complete before they have access to the medication. Some of those medications do need to be or administered by a health provider. So, in office visits, having transportation, having the opportunity or ability to manage the the timeline. So if you remember your six month injection appointment and don't put that off, these are the types of things that come into play as well, dr.

Speaker 1:

Andy Roark. Yeah, and key too to mention that, although they may be going to a clinic for that injection, if we are aware of that and as the pharmacist, it's something that we can also make sure that we're reminding them of, because we've seen it too often, patients get lost to follow-up with care, and so you know they're probably not going to immediately remember that they're overdue for that injection and then it may be, you know, several months down the road and whatever. So, yeah, I think it's super important just to kind of be aware of what's out there for treatment and, even if it's not something that we're giving or administering, as a pharmacist, understanding kind of the implications that they need to stay on track with the schedule and be adherent.

Speaker 2:

Yeah, and I think that persistence of therapy is so important because most of the medications, except for bisphosphonates, are not durable, so the impact of the benefit from the medication goes away very quickly after it's discontinued. And so if a medication is stopped because a patient hasn't been going to their appointments or they are not aware of the schedule, then they actually could be putting them at risk for losing the benefit of the medication. But even denosumab, if those are every six-month injections, we know that abrupt discontinuation of that can lead to a higher risk for vertebral fractures.

Speaker 2:

There's kind of a rebound osteoclastic activity and so if we get to seven months, eight months, nine months from that injection, then they start having a risk for fracture. That's not far in the future, it's more immediate. So really being aware of that adherence and persistence, Very important Right from the beginning drugs that will fit that person's expectation as well and what they want to engage in.

Speaker 1:

Yeah, for sure, like you said. I mean, if it's a patient that you know and if we're consulted, you know, with other providers on a patient and we know that this patient has transportation insecurities or they have financial insecurities, you know, maybe we're not recommending those particular medications that are where they have to go into the clinic or where they're super expensive or where a PA is required. So I think it's key again to understand what all the options are so that we can make sure that we're giving the best recommendation, you know, when asked, when collaborating with care. So, yeah, Well, we are running out of time, aaron, so I want to be sure that I wrap us up, but is there anything else specific One thing I'd like for you to do, if you don't mind I know we mentioned before we got on the actual recording can you just call out what the screening guidelines are called, just so that patients will, so that our listeners will know what to kind of look for, so they can be sure they're up to date on the guidelines.

Speaker 2:

Yeah, there's actually two resources that I think are amazing the most recent screening guidelines, the US Preventive Services Task Force. Just last month, now that we're in February, they published a final report on the most recent guidelines for screening. That's always evidence-based and supports some of the recommendations I spoke of earlier. The Bone Health and Osteoporosis Foundation is a very important resource for updated guidelines as well, for updated guidelines as well that describe screenings, also for recommendations for men and also some of the other medication recommendations that I've described, and there's been about five different expert groups in the last five years that have updated their osteoporosis guidelines. Whether it's the American Association of Clinical Endocrinologists, the Endocrine Society, the Endocrine Society, the Menopause Society, the International Osteoporosis Foundation All of them have published within the last five years updates, and it's really because of those anabolic agents now that are playing a bigger role in care.

Speaker 1:

In the market, yeah, and so they're really kind of changing things. Okay, yeah, that's great. I just wanted to be sure that listeners knew where to go, because we told them it was important to stay up to date on the guidelines and the resources. So I wanted to be sure we were sharing that. So, okay, before we wrap up, what I always like to do is just kind of kind of briefly touch on the game changer here. Like, let's talk about a summary for today's episode for our listeners. So I'll kick that to you.

Speaker 2:

Well, I think that pharmacists have an amazing opportunity for advocacy for their patients, so advocating not only for awareness and screening and risk assessment, but also for persisting with medication therapy if that is necessary and helping a patient understand their schedule, how to administer the drug, get it into their body and let's keep the regimen going for as long as necessary. So we really have such an important advocacy role.

Speaker 1:

Yeah, that's great. That's great. Well, erin, thanks again. This was great. I really appreciate you taking time of your busy day and sharing your expertise with us. I think again I'll say it once more I feel like it's kind of that silent disease that we don't talk about enough, but it also can be super impactful in a patient's quality of life. So thank you again for sharing that with us.

Speaker 2:

All right, thank you.

Speaker 1:

Yeah, if you're a CE plan subscriber, be sure to claim your CE credit for this episode of Game Changers by logging in at CEimpactcom and, as always, have a great week and keep learning.