Podcast
Questions and Answers
What are the two most common types of bone density scores used for osteoporosis?
What are the two most common types of bone density scores used for osteoporosis?
What are the three most common osteoporotic fractures?
What are the three most common osteoporotic fractures?
What is the most serious consequence of falls among older people?
What is the most serious consequence of falls among older people?
What is the name of the online tool used to assess fracture risk?
What is the name of the online tool used to assess fracture risk?
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When is a drug holiday typically advised for bisphosphonate treatment?
When is a drug holiday typically advised for bisphosphonate treatment?
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Denosumab is a suitable treatment for a drug holiday.
Denosumab is a suitable treatment for a drug holiday.
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What is the name of the condition that can occur with bisphosphonate treatment?
What is the name of the condition that can occur with bisphosphonate treatment?
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Vitamin D deficiency can be treated with a loading dose of 300,000 units of vitamin D.
Vitamin D deficiency can be treated with a loading dose of 300,000 units of vitamin D.
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What is the name of the anabolic agent that is recently approved by NICE for osteoporosis?
What is the name of the anabolic agent that is recently approved by NICE for osteoporosis?
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Which of the following is NOT a risk factor for osteoporosis?
Which of the following is NOT a risk factor for osteoporosis?
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Which of the following is NOT a medication used to treat osteoporosis?
Which of the following is NOT a medication used to treat osteoporosis?
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Pharmacists play a crucial role in assessing fracture risk and helping patients with osteoporosis.
Pharmacists play a crucial role in assessing fracture risk and helping patients with osteoporosis.
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What is the name of the guideline that outlines who should be assessed for fracture risk?
What is the name of the guideline that outlines who should be assessed for fracture risk?
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What is the primary role of FRAX?
What is the primary role of FRAX?
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What is the most common side effect associated with bisphosphonates?
What is the most common side effect associated with bisphosphonates?
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Glucocorticoids can both increase bone formation and decrease bone resorption.
Glucocorticoids can both increase bone formation and decrease bone resorption.
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The risk of fractures is lower in patients who have had a history of vertebral fractures.
The risk of fractures is lower in patients who have had a history of vertebral fractures.
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Which of the following interventions is NOT generally recommended for patients with glucocorticoid-induced osteoporosis?
Which of the following interventions is NOT generally recommended for patients with glucocorticoid-induced osteoporosis?
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Younger patients with osteoporosis may require a shorter duration of treatment.
Younger patients with osteoporosis may require a shorter duration of treatment.
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It is acceptable to stop denosumab treatment without a plan in place.
It is acceptable to stop denosumab treatment without a plan in place.
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Besides involvement in treatment decisions, what is a crucial role of pharmacists in managing osteoporosis?
Besides involvement in treatment decisions, what is a crucial role of pharmacists in managing osteoporosis?
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A high T-score indicates an increased risk of osteoporosis.
A high T-score indicates an increased risk of osteoporosis.
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Patients with osteoporosis should avoid taking any medication for at least 30 minutes before taking calcium supplements.
Patients with osteoporosis should avoid taking any medication for at least 30 minutes before taking calcium supplements.
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What is the name given to the event when a patient stops taking bisphosphonates for a period of time?
What is the name given to the event when a patient stops taking bisphosphonates for a period of time?
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What is the primary reason for reviewing bone medication after 10 years?
What is the primary reason for reviewing bone medication after 10 years?
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What is the primary reason for recommending denosumab as a second-line treatment for osteoporosis?
What is the primary reason for recommending denosumab as a second-line treatment for osteoporosis?
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Strontium ranelate has been shown to increase the risk of cardiovascular events.
Strontium ranelate has been shown to increase the risk of cardiovascular events.
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MRONJ (Medication-Related Osteonecrosis of the Jaw) is a common side effect of bisphosphonates.
MRONJ (Medication-Related Osteonecrosis of the Jaw) is a common side effect of bisphosphonates.
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Abaloparatide can be used as a first-line treatment in certain cases of osteoporosis.
Abaloparatide can be used as a first-line treatment in certain cases of osteoporosis.
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A significant risk factor for osteoporosis is a family history of fractures
A significant risk factor for osteoporosis is a family history of fractures
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A low BMI increases the risk of osteoporosis.
A low BMI increases the risk of osteoporosis.
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Glucocorticoids have a greater impact on bone resorption than bone formation.
Glucocorticoids have a greater impact on bone resorption than bone formation.
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It is crucial to ensure that patients with osteoporosis are dentally fit prior to starting bisphosphonates.
It is crucial to ensure that patients with osteoporosis are dentally fit prior to starting bisphosphonates.
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Why is a multidisciplinary approach essential for managing osteoporosis?
Why is a multidisciplinary approach essential for managing osteoporosis?
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Study Notes
MPharm Programme: Osteoporosis in Practice
- The program covers osteoporosis, a condition characterized by porous bones, which increases fracture risk.
- Healthy bone structure is contrasted with osteoporotic bone, highlighting the loss of density and structure.
- Osteoporosis often presents without symptoms, but significantly increases fracture risk.
- The lecture is divided into five sections: role of a pharmacist in osteoporosis, fracture risk assessment, pharmacological treatments, special considerations, and treatment review.
Lecture Overview
- The lecture is broken down into five sections:
- Role of pharmacist and background to practice
- Assessing fracture risk
- Pharmacological therapies
- Special considerations
- Treatment review
- Summary
Section 1: Role of Pharmacist and Background to Practice
- This is a general introduction to the role of a pharmacist and related background information
Osteoporosis: "Porous Bones"
- Osteoporosis is characterized by the loss of bone density and the thinning of bone tissue.
- The loss of density is highlighted by comparing healthy bone with osteoporotic bone.
- This leads to an increased risk of fractures.
What do the Test Results Mean?
- Bone density analysis uses T-scores and Z-scores.
- Lumbar Spine: T-3.0 Z-1.8
- Femoral Neck: T-2.5 Z-1.0
- Total Hip: T-2.6 Z-1.1
- A T-score of -2.5 or lower indicates osteoporosis (standard deviations from young healthy norms).
- A Z-score lower than expected for a patient’s age indicates a low bone density compared with healthy individuals of similar age.
Fracture!
- A fractured bone is indicated by the symbol #
Public Health & Secondary Prevention
- Public health education for younger people is important for effective fracture reduction to reduce morbidity, mortality, and costs.
- Secondary prevention involves fracture liaison services for patient reviews.
- An interdisciplinary approach, including doctors, pharmacists, orthopedics, geriatricians, bone specialists, endocrine specialists, nurses (ward specialists), physiotherapists, occupational therapists, dentists, and more, plays a role in patient care.
Osteoporosis: A Patient's Perspective
- Videos about osteoporosis from the Royal Osteoporosis Society aim to provide context for patients.
- A patient describing their experiences helps to ground decisions, emphasizing the importance of the patient's perspective in treatment decisions.
Fracture Increases Fracture Risk
- Common osteoporotic fractures include hip, wrist, and spine fractures.
- Fractures significantly impact quality of life across an individual’s lifespan.
Hip Fractures in Practice
- Hip fractures are a severe consequence of falls in older adults.
- Reduced function, loss of independence, and high mortality rates are significant concerns.
- Various risk reduction interventions are important, including preventing secondary fractures and assessing adherence to treatment and management.
Vertebral Fracture in Practice
- Spinal fractures lead to acute and chronic back pain and height loss (kyphosis).
- Interventions include fracture prevention, pain control and evaluation, physical therapy, and surgical management as necessary.
Section 2: Assessing Fracture Risk
- Assessing fracture risk involves identifying risk factors associated with osteoporosis.
Risk Factors for Osteoporosis
- Factors associated with fragility fractures and secondary causes include:
- Fragility
- Excess alcohol
- Smoking
- Immobility
- Related medications such as: Corticosteroids, PPIs, anti-epileptics, SSRIs, Aromatase inhibitors, and more
- Underlying conditions such as amenorrhea, eating disorders, inflammatory bowel disease, rheumatoid arthritis, and COPD.
- Parental hip fracture
- Low BMI
- Falls/Fall History
How Do We Identify People Who Might Need Treatment?
- Primary prevention targets people with increased fracture risk but no history of fracture, with NICE G146 providing guidance on assessment.
- Secondary prevention involves people with prior fractures, focusing on reducing further fracture risk.
Assessment of Fracture Risk
- NICE guidelines aim to identify people who need assessment for fracture risk, including older adults who are female (over 65) and male (over 75) along with those with specific risk factors.
- Pharmacists should assess fracture risk as part of patient review.
- FRAX® and QFracture® are examples of risk assessment tools.
- Lifestyle advice, referral for bone density scans (DXA), and initiating treatment may follow assessment.
Fracture Risk Assessment using FRAX
- FRAX is a tool to assess fracture risk (for individuals aged 40-90).
- It provides a 10-year risk of osteoporotic fracture and a 10-year risk of hip fracture.
- Results help clinicians determine risk classification (low, intermediate, high, or very high risk) and inform treatment decisions.
Potential Pharmacist Interventions
- This section details some interventions/actions pharmacists can take.
Action Following Assessment
- Depending on the fracture risk, one or more lifestyle modifications, specialty referrals, or treatment options might be appropriate.
- Lifestyle modifications include advice about smoking, alcohol, calcium intake, a balanced diet, and exercise.
- Referral to other professionals, such as specialized doctors and other health professionals, might be necessary.
- Initiation of treatment (particularly for very high risk) might also include prescription of medications.
Pharmacological Treatment Options
- Antiresorptive medications are often the first line of pharmacological treatment for osteoporosis.
- The drugs in this section are bisphosphonates (oral and parenteral), denosumab, and less commonly used HRT and raloxifene. (Strontium was discontinued due to increased CV risk when it was launched in 2019).
Drugs with an Anabolic Action
- Anabolic drugs (such as romosozumab, teriparatide, and abaloparatide) can be used as first line in certain cases of extreme high risk.
- Anabolic drugs are often more expensive and require specialist prescription.
Patient Information is Essential
- Motivating patients through explanation and shared decision-making is critical for prophylactic treatment.
- Information leaflets and patient education should be provided.
Adherence
- Poor adherence to oral bisphosphonates (BPs) is a prevalent issue.
- Shared decision making and individualized interventions are key to improving adherence.
- Interventions could include intentional or non-intentional strategies, like adjusting the delivery method, etc.
Oral BPs: Often 1st Line
- NICE guidelines recommend oral BPs as first-line treatment for osteoporosis prevention/treatment.
- Key points regarding oral bisphosphonates include drug interaction considerations (e.g., timing of other medications), cautionary measures (e.g., contraindications, warnings like renal failure), and appropriate use conditions (e.g., eGFR criteria).
- Risedronate and alendronic acid are examples of oral bisphosphonates.
Initiation of Treatment
- Clinicians must first identify patients who would benefit from interventions by assessing fracture risk (using tools like FRAX or DXA).
- Patients without contraindications are often given information about the treatment and participate in shared decision making about therapy to prevent future fractures.
- Calcium and vitamin D supplementation should be considered. Referrals to other medical professionals, including specialists, should be considered if necessary.
Oral Bisphosphonates: Rx Advice
- This section provides crucial information to give patients on taking oral bisphosphonate medication (e.g., alendronic acid or risedronate).
- Key information includes administration instructions, potential side effects, and follow-up strategies.
Zoledronic Acid
- Zoledronic acid, a potent intravenous bisphosphonate, is an option for osteoporosis prevention/treatment.
- It is often given to patients who cannot tolerate oral therapies, due to gastrointestinal issues.
- Treatment should be overseen by physicians.
Denosumab
- Denosumab is a second-line treatment option.
- It is administered as an injection, often monthly.
- Monitoring for side effects (e.g., renal, hypocalcaemia issues) is important.
Other Drugs
- Raloxifene is used less frequently for osteoporosis prevention/treatment .
- HRT is another preventative therapy that is often used but should not be considered the first line of treatment for bone protection.
- It may be particularly useful for women in early menopause.
Additional Drugs
- Strontium ranelate may be used for patients with severe osteoporosis in which other therapies are unsuitable or not tolerated..
- Strontium ranelate should be administered by a specialist.
Special Considerations: Younger Patients
- Treatment decisions need to consider all clinical information of the patient including the risk to benefit ratio.
- Treatment decisions need a multidisciplinary approach (include specialist clinics), and carefully consider the patient’s potential for childbearing.
Special Considerations: Renal Impairment
- Medications like Risedronate should be adjusted/ avoided as treatment given patient renal impairment considerations.
- Denosumab should be used with caution in patients with renal impairment.
Special Considerations: Transgender Patients
- Hormones play a crucial role in bone health.
- Treatment adjustments should be made based on a multidisciplinary approach among practitioners.
Section 5: Treatment Review
- This section reviews existing therapies in regards to osteoporosis.
Review of Bone Medication
- MHRA and NOGG recommend periodic review of bisphosphonate use (especially after 5+ years).
- Treatment cessation for prolonged use could be considered. (Drug holidays)
Drug Holiday?
- The section explains the concept of a "drug holiday" for osteoporosis medications.
- Factors such as long-term risks of atypical femoral fractures and ONJ must be considered.
- The section includes data on various medications (e.g., FLEX Trial, VERT-MN/NA, Horizon).
NOGG Suggested BP Review
- The NOGG (National Osteoporosis Guideline Group) recommends a review approach to osteoporosis management.
- Considerations include factors connected to a patient's age, previous fractures, current GC (corticosteroid) use for bone protection , with overall fracture risk being reviewed. This includes the use of FRAX along with BMD to confirm the patient's risk profile.
Rare Side Effects: Atypical Fracture
- Atypical fracture risk is addressed by discussing side effects, such as thigh bone fractures.
Rare Side Effects: BRONJ - MRONJ
- BRONJ and MRONJ are discussed, including their association with other medications (such as denosumab) and the importance of dental considerations.
MRONJ Significant Morbidity
- Severe cases of MRONJ may require a multidisciplinary approach (including dentists) to manage and remove necrotic bone.
Denosumab Review?
- Denosumab's efficacy and possible drug holiday suitability are discussed.
- Studies (e.g., FREEDOM) are referenced to describe effectiveness.
Denosumab Cessation
- Concerns about risks of increased bone resorption and rapid BMD decline following denosumab cessation are highlighted.
- Patients experience rapid decline in BMD after stopping Denosumab therapy, and this is directly addressed.
Could Bone Turnover Markers Help?
- Bone turnover markers (BTMs) are discussed as potentially helping with adherence and treatment decisions.
- Information like how CTX levels can be used to measure bone resorption and formation is included.
Summary
- A summary of the treatments and approaches to osteoporosis is presented, including how treatment tolerance or other relevant factors (e.g., renal function, vitamin D or calcium levels) should be considered in treatment selection.
Osteoporosis Drugs: Generally...
- Treatment options and consideration for drug substitution or addition to other treatments must be included when considering specific patients' needs and information.
- Specific drug guidelines, as well as the use of drug holidays or drug changes that affect the progression of the treatment plan should be addressed.
Pharmacist Interventions to Reduce Fracture Risk
- Pharmacist interventions to reduce osteoporosis in practice involve aspects like identifying risk factors, reviewing bone density scans (DXA or FRAX), determining secondary causes, advising on lifestyle modifications, prescribing/advising on medications, advising patients, identifying and advising on side effects, treatment review, working with multidisciplinary teams, and considering drug holidays.
Further Information
- Various websites, guidelines, and resources (including NICE, NOGG, FRAX, and more.) are included for reference and further study in accordance with the topics mentioned.
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