Osteoporosis: A practical guide to pharmacist service provision

Case scenario

Carol, a 67-year-old woman, presents to your pharmacy, tells you that she has not been very active since the coronavirus lockdown and that it’s nice to get outside the house. You screen her for osteoporosis using the Know Your Bones tool and find that she has a medium risk of fracture. You suggest she visits her GP for a formal assessment.

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Introduction

In 2012, 4.74 million Australians over the age of 50 years (66%) had poor bone health including more than one million with osteoporosis.¹ The prevalence of osteoporosis is increasing due to Australia’s ageing population.

Over 80% of individuals presenting with fractures arising from minimal trauma (i.e. a fall from a standing height or less) are NOT followed up with appropriate testing, nor prescribed appropriate medications.¹ Even when treatment is initiated the outcomes are less than optimal; observational data of Australian PBS and MBS data provide strong evidence of poor adherence and persistence with therapy after initial prescription of osteoporosis treatment.²

A recent article in Australian Pharmacist provided an update of the epidemiology, diagnosis, and pharmacotherapy of osteoporosis, and identified that pharmacists have a key role in improving health outcomes.³ This article aims to equip pharmacists with the knowledge to practice by focusing on how community pharmacists can deliver public health interventions, including education, screening, and referral, and improve treatment outcomes through patient counselling and providing medication management services. The focus is on increasing bone health and reducing fall risk.

Public health in community pharmacy

Osteoporosis has been described as a paediatric disease with geriatric consequences, as 90% of peak bone density is acquired before 20 years of age.⁴  Educating consumers through public health campaigns promotes healthy bone behaviours and can result in maintenance and/or increasing of bone mineral density (BMD) among individuals of all ages.^5,6

A recent systematic review identified that community pharmacy-delivered public health interventions aimed at identifying people at risk of osteoporosis and/or educating consumers can increase consumer knowledge.⁷ Some evidence also suggests that these interventions can result in clinically significant outcomes such as increased vitamin D/calcium supplement consumption, an increase in weight bearing exercise, and there is some low-quality evidence for improved consumer BMD after 6 months.⁷ Another encouraging outcome is improved physician follow-up after screening, including increased rates of BMD testing with dual-energy x-ray absorptiometry (DEXA) scans and increased intake of antiresorptive medicines.⁷

Screening for osteoporosis in community pharmacy

Know your Bones is an online screening tool for osteoporosis which takes approximately 5 minutes to complete.⁸ Consumers’ responses are used to calculate relative risk and identify modifiable risk factors. When the results indicate medium or high-risk, it prompts consumers to follow-up with their GP.

While consumers can fill out the tool themselves, our team is currently investigating how this works in community pharmacies. In our ongoing study, consumers have expressed that they would find it easier and would prefer if their community pharmacist talked them through the Know Your Bones tool.

The tool is highly recommended in two common clinical situations involving older persons in community pharmacies:

1. on presentation for pain relief following a fall
2. on presentation for ongoing foot pain, which could indicate a stress fracture (especially recently after starting exercise).

When the tool reports that risk is anything but low, it is an ideal opportunity for pharmacists to provide reassurance to patients while encouraging them to engage with the health system. A printout from the tool could be a useful discussion prompt if the pharmacist believes that the presenting patient is ambivalent towards GP referral. Also consider offering a MedsCheck for those eligible.

Some pharmacies have implemented quantitative ultrasound (QUS) BMD testing. The evidence for this service is contentious, and it should be noted that QUS is not recommended as a diagnostic test for osteoporosis.¹ However, studies have shown that the use of QUS is an effective and acceptable screening tool for osteoporosis which can prompt referral for a confirmatory DEXA scan.^1,9

Improving treatment outcomes

PBS medicines such as bisphosphonates and denosumab are effective and safe treatments for osteoporosis, as outlined in the previous Australian Pharmacist article.³ Despite their availability, osteoporosis remains severely undertreated due to both lower rates of prescription than desired and low rates of adherence to therapy. In general, 50% of people using medicines long-term report poor adherence and persistence.¹⁰ For patients taking osteoporosis medicines, 47% discontinue within 6 months, and 50% do not take them as prescribed.¹¹

Bisphosphonates persist in the body for many years and so short gaps in treatment are not likely to significantly affect outcomes. The total length of bisphosphonate treatment is also likely to be relatively short, as a treatment course of 5 – 10 years may be sufficient for many. Denosumab, on the other hand, is a shorter-acting treatment and must be maintained for very long periods.¹² Missing a 6-monthly injection by as little as 2 months has been associated with increased vertebral fractures. Yet disturbingly, Australian data from 2011-2018 shows high rates of discontinuation of denosumab without replacement.²

Forgetting to take an oral bisphosphonate or forgetting a medical appointment to have an injection is described as unintentional non-adherence. This can be overcome to some extent with reminders, dose administration aids and simplification of the medicine regimen.¹⁰

Patients who use injectable osteoporosis therapies can experience a degree of treatment “burden” by being required to return to the medical practice for administration after having their medicine dispensed. Although not explored, this likely contributes to unintentional non-adherence. Pharmacists have a role in smoothing out this process by maintaining good stock availability, prompt dispensing, and advising on appropriate cold-chain handling and storage.

Unintentional non-adherence is no longer recognised as the leading reason for non-adherence to osteoporosis medicines. Intentional non-adherence is considered to be the main problem.¹³

One of the major reasons for intentional non-adherence is because osteoporosis is a silent disease; patients may only attribute fractures to ‘accidents’ or just as part of ‘getting old’ and therefore they underestimate the risk of osteoporotic fracture and its consequences.¹³ As with many other chronic diseases, patients tend to resist using osteoporosis medicines for emotional or psychological reasons.¹⁴ In research settings, patients prescribed osteoporosis medicines ask: ‘Will it cause cancer? Have I been fully informed? Is the doctor over-prescribing? What is the agenda of pharmaceutical companies?’¹⁵ Other concerns relate to uncertainties about adverse effects, generally in the long term, and the fact that it is one more medicine added onto their regimen.¹⁶

Concerns about adverse effects remain a major impediment to osteoporosis treatment, especially the visually confronting, yet very rare osteonecrosis of the jaw (ONJ), which gained prominence through media reporting in 2006. It is important to relate to patients that while ONJ appears nasty, it is extremely rare, and hospital admission due to osteoporosis-related fractures are much more common, with potential for more severe consequences.¹

While patient education can improve adherence rates to osteoporosis medicine,¹⁰ it may be better to use a decision support aid such as the Mayo Clinic Bone Health Choice Decision Aid, or the University of Sheffield’s FRAX tool. Consider informing patients that there is a range of medication options (e.g. oral vs subcutaneous, weekly vs monthly [for oral medicines], and 6-monthly vs yearly [for injectable]; see the 2020 Australian Pharmacist article on Osteoporosis).³ Such options allow for the elicitation of patient preference which can be used to guide shared decision-making, a known means of promoting better adherence.¹⁷

Falls risk

It is important to point out that most people who sustain osteoporotic fractures do so as a result of a fall. Each year, around 1 in 3 community-dwelling adults over 65 years have a fall resulting in a high risk of injury, including osteoporotic fracture.^1,18 Therefore, when community pharmacists identify someone at risk of falls, they can direct these at-risk patients towards preventive management strategies. A good strategy could include referral to the GP for a holistic investigation and development of a management plan.

A positive answer to any of the following 3 questions can help identify individuals at risk of falls:¹

1. Have you had two or more falls in the past 12 months?
2. Are you presenting following a fall?
3. Are you having difficulty with walking or balance?

Preventing fractures – reducing falls risk with deprescribing

In the context of reducing falls risk and fracture rates, pharmacists have an opportunity to identify whether patients living with osteoporosis are also taking fall risk-increasing drugs (FRIDs).^18,20

FRIDs include medicines that cause adverse effects such as postural hypotension, drowsiness, dizziness, blurred vision or confusion. When FRIDs are identified in someone who is known to be osteoporotic, deprescribing them should be considered if appropriate.²⁰ It may be useful to also use the motivational interviewing techniques (as outlined above) to guide the conversation about the possibility of ceasing or decreasing doses of FRIDS.

A MedsCheck focused on osteoporosis

While it is possible to engage patients in conversations about non-adherence and/or deprescribing to reduce falls risk during ad-hoc counselling sessions, these conversations can take time and are best done with privacy. A MedsCheck specifically focused on osteoporosis may be a way to help eligible patients.

Consider using the dispensing history to identify and help patients who:

• Do not collect their osteoporosis medicines regularly
• Have ceased denosumab and have not had a replacement
• Use medicines that increase the risk of developing osteoporosis, especially glucocorticoids
• Use antiresorptive therapy to ensure adequate calcium and vitamin D supplementation
• Have been on antiresorptive therapy for 3–10 years and may benefit from a drug holiday
• Have recently commenced an osteoporosis medicine
• Take osteoporosis medicines as well as one or more FRID.

If appropriate, consider referral to a GP for possible Home Medicines Review (HMR). One study has shown that HMR can lead to the deprescribing of sedative and anticholinergic drugs, therefore pharmacist-led medication reviews and deprescribing are of particular interest to researchers and clinicians worldwide.²¹

Knowledge to practice

This article highlights many opportunities for community pharmacists to improve Australia’s bone health. Screening for undiagnosed health conditions, such as osteoporosis, is a core competency for pharmacists and community pharmacies may be able to reduce the health, social and economic burden of undiagnosed osteoporosis.

A MedsCheck for people using antiresorptive medicines may be a useful way to motivate people to be more adherent to, and persistent with, long-term therapy. It is important to recall that if we prevent falls (through deprescribing inappropriate sedative and anticholinergic medicines) we may be able to prevent the disastrous consequences of poor bone health.

If you wish to be involved in developing the evidence base for the role of pharmacists in osteoporosis, feel free to contact the senior author Dr Stephen Carter at stephen.carter@sydney.edu.au

Key points

1. Osteoporosis is underdiagnosed and undertreated despite the existence of effective treatment.
2. Community pharmacists have a role in identification and referral of patients with undiagnosed osteoporosis.
3. Intentional nonadherence to osteoporosis medicines is the main reason for poor compliance.

Case scenario (continued)

Carol, a 67-year-old woman presents to your pharmacy, tells you that she has not been very active since the coronavirus lockdown and that it’s nice to get outside the house. You screen her for osteoporosis using the Know Your Bones tool and find that she has a medium risk of fracture. You suggest she visits her GP for a formal assessment.

A few months later she returns having been diagnosed with osteoporosis; a DEXA scan revealed a T-score of -2.5. She tells you she had a fall in her living room a few years back and fractured her wrist but was not diagnosed then. Her doctor has now prescribed risedronate 35mg once a week and some calcium and vitamin D supplements.

She was not counselled initially on the risedronate and tended to take all her medicines at night. Gastric upset was identified when she presented to the pharmacy asking for something for heartburn. When conducting a MedsCheck, the pharmacist identified it was the risedronate causing heartburn. They also identified that the risedronate and calcium would interact. The prescriber was contacted, and the patient  was switched to denosumab injections 6 monthly.

When Carol returned to fill her prescription for denosumab, the pharmacist reemphasised the importance of adhering to timely injections and set up dispensing reminders.

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References

1. The Royal Australian College of General Practitioners and Osteoporosis Australia. Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age 2nd edition. 2017. At: www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/osteoporosis

2. Naik-Panvelkar P, Norman S, Elgebaly Z, et al. Osteoporosis management in Australian general practice: an analysis of current osteoporosis treatment patterns and gaps in practice. BMC Family Practice. 2020;21(1):32.

3. Long D, Whatmough S. Australian Pharmacist. Osteoporosis 2020 At: psa-ph.osky.dev/osteoporosis-cpd

4. Hightower L. Osteoporosis: pediatric disease with geriatric consequences. Orthop Nurs. 2000;19(5):59-62.

5. Winzenberg T, Oldenburg B, Frendin S. The effect on behavior and bone mineral density of individualized bone mineral density feedback and educational interventions in premenopausal women: a randomized controlled trial. BMC Public Health. 2006;6:12-.

6. Hind K, Burrows M. Weight-bearing exercise and bone mineral accrual in children and adolescents: A review of controlled trials. Bone. 2007;40:14-27.

7. Manon SM, Phuong JM, Moles RJ, et.al. The role of community pharmacists in delivering interventions for osteoporosis: A systematic review: University of Sydney; 2021. [Pre-publication]

8. Garvan Institute of Medical Research, Healthy Bones Australia. Know Your Bones 2021. At: www.knowyourbones.org.au

9. MacLaughlin EJ, MacLaughlin AA, Snella KA, et.al. Osteoporosis Screening and Education in Community Pharmacies Using a Team Approach. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. 2005;25(3):379-86.

10. Usherwood T. Encouraging adherence to long-term medication. Aust Prescr. 2017;40(4):147-50.

11. Inderjeeth C, Inderjeeth A, Raymond W. Medication selection and patient compliance in the clinical management of osteoporosis. Australian Family Physician. 2016;45:814-7.

12. Anastasilakis AD, Polyzos SA, Makras P, et.al. Clinical Features of 24 Patients With Rebound-Associated Vertebral Fractures After Denosumab Discontinuation: Systematic Review and Additional Cases. J Bone Miner Res. 2017;32(6):1291-6.

13. Silverman SL, Schousboe JT, Gold DT. Oral bisphosphonate compliance and persistence: a matter of choice? Osteoporos Int. 2011;22(1):21-6.

14. Pound P, Britten N, Morgan M, et al. Resisting medicines: a synthesis of qualitative studies of medicine taking. Soc Sci Med. 2005;61(1):133-55.

15. Barker KL, Toye F, Lowe CJM. A qualitative systematic review of patients’ experience of osteoporosis using meta-ethnography. Arch Osteoporos. 2016;11(1):33-.

16. des Bordes J, Prasad S, Pratt G, et.al. Knowledge, beliefs, and concerns about bone health from a systematic review and metasynthesis of qualitative studies. PLOS ONE. 2020;15(1):e0227765.

17. Joosten EAG, DeFuentes-Merillas L, de Weert GH, et.al. Systematic Review of the Effects of Shared Decision-Making on Patient Satisfaction, Treatment Adherence and Health Status. Psychotherapy and Psychosomatics. 2008;77(4):219-26.

18. de Almeida Neto AC, Chen TF. When pharmacotherapeutic recommendations may lead to the reverse effect on physician decision-making. Pharm World Sci. 2008;30(1):3-8.

19. Miller WR, Rollnick S. Motivational interviewing: Preparing people for change, 2nd ed. New York, NY, US: The Guilford Press; 2002. 428-434.

20. World Health Organisation. WHO Global Report on Falls Prevention in Older Age 2007 At: www.who.int/ageing/publications/Falls_prevention7March.pdf.

21. Milos V, Bondesson Å, Magnusson M, et.al. Fall risk-increasing drugs and falls: a cross-sectional study among elderly patients in primary care. BMC Geriatrics. 2014;14(1):40.

22. Kouladjian O’Donnell L, Gnjidic D, Chen TF, et.al. Integration of an electronic Drug Burden Index risk assessment tool into Home Medicines Reviews: deprescribing anticholinergic and sedative medications. Therapeutic Advances in Drug Safety. 2019. Mar 5;10:20.

JONATHAN PHUONG BPharm(Hons) is a pharmacist and PhD candidate at the University of Sydney.

A/PROF REBEKAH MOLES BPharm, DipHospPharm, PhD, GradCertEdStud(Higher Ed), FSHP, FPS, SFHEA, FFIP is a pharmacist and Associate Professor at the University of Sydney School of Pharmacy.

DR KATE LUCKIE BPharm, MHL, PhDis a pharmacist and project manager working on research in musculoskeletal health as part of her role within Maridulu Budyari Gumal– Sydney Partnership for Health Education, Research and Enterprise (SPHERE).

DR STEPHEN CARTER BPharm, MSc, PhD, AACPA, FPS is an academic pharmacist at the University of Sydney with experience in community and medication management.