Boning up on osteoporosis
One to One
Many people concerned about osteoporosis visit their local pharmacy to purchase vitamins and supplements that they believe will prevent bone loss. As the first point of contact about osteoporosis, pharmacists are well positioned to counsel these patients on risk factors, prevention, and OTC products.
For the estimated 57 million Americans who already have osteoporosis or low bone density, pharmacists can serve an even larger role. “Pharmacists are smart partners for patients with osteoporosis. Many people with this disease have questions and concerns, and the pharmacist has the information they need to adhere to their treatment plan,” said Susan Randall, RN, MSN, FNP-BC, Senior Director of Science and Education at the National Osteoporosis Foundation (NOF). “For many people, the pharmacist is more accessible and willing to address their questions than other health care providers.”
Osteoporosis and associated fractures affect men and women of all ages and races. But white and Asian women—especially those who are past menopause—are at highest risk. Other uncontrollable risk factors include family history of osteoporosis or hip fracture and low body weight or small/thin stature.
Controllable risk factors include insufficient calcium and vitamin D, a diet lacking in fruits and vegetables, too much protein or sodium, inactive lifestyle, smoking, and overconsumption of alcohol. Some medications, in particular steroids such as glucocorticoids or corticosteroids, are known to cause bone loss and increase the risk of osteoporosis.
Explain to patients that medications, healthy diet, and weight-bearing exercise can help prevent bone loss and strengthen already weak bones. Patients can also decrease their risk of developing osteoporosis and fractures by not smoking and by limiting alcohol use.
Calcium and vitamin D
Advise patients to get enough calcium and vitamin D. Women aged 50 and younger need 1,000 mg of calcium daily; women aged 51 and older, 1,200 mg daily. Men aged 70 and younger need 1,000 mg of calcium daily; men aged 71 and older, 1,200 mg daily. Food is the best source of calcium, especially foods such as low-fat and nonfat milk, yogurt, and cheese. Patients should get the recommended daily amount of calcium they need from food first and supplement only as needed to make up for any shortfall. Review with patients the wide range of OTC calcium supplements available, and be sure to discuss possible interactions between prescription or OTC meds and calcium supplements.
Vitamin D is a different story: it’s hard to get it from food alone. Natural sources include only a few foods, such as wild-caught mackerel, salmon, and tuna; it is also added to milk and to some other dairy products, orange juice, soymilk, and cereals. According to NOF, adults younger than 50 need 400–800 IU daily; and older than 50 need 800–1,000 IU daily.
Because most people do not get enough of the recommended amount from food or sunlight—the other natural source of vitamin D—advise patients to supplement with either vitamin D2 (ergocalciferol) or vitamin D3 (cholecalciferol). Patients should check to see if any other supplements, multivitamins, or medications they take contain vitamin D. Some patients with very low vitamin D levels may need higher doses, available by prescription. Explain that adequate calcium and vitamin D intake can help prescription medication be more effective.
Antiresorptive medications—bisphosphonates, calcitonin, denosumab, estrogen, and estrogen agonists/antagonists—slow bone loss and lower the risk of breaking bones. The anabolic drug teriparatide is currently the only FDA-approved osteoporosis medicine that rebuilds bone. Counsel patients on the benefits and risks of these medications, including adverse effects and possible interactions with other medications they may be taking. Patients who have pain from broken bones and fractures may need guidance on safe use of OTC pain relievers with their osteoporosis meds.
Among other helpful information available on NOF’s website is “A Guide to Osteoporosis Medicines,” a brochure you can hand out to patients. The National Council on Patient Information and Education offers a “Get the Answers” wallet card with seven key questions to ask about new medications and a section to record all prescription and nonprescription meds, allergies, and emergency contact names.