Medication therapy management (MTM) providers should screen for medications that are associated with an increased risk of osteoporosis and recommend bone mineral density testing to the primary provider, if appropriate.
Adequate calcium and vitamin D intake is essential for prevention and treatment of osteoporosis. An evaluation of dietary calcium intake will assist in determination of required calcium supplementation.
Calcium carbonate is the salt of choice for calcium supplementation because it has the highest percentage of elemental calcium and is the least expensive; however, calcium citrate should be considered for elderly patients with low acid production or those on acid-reducing medications.
MTM providers should assess for appropriate administration of bisphosphonate therapy and counsel patients on the importance of appropriate administration to reduce adverse effects and maximize efficacy of therapy.
Adherence is poor with bisphosphonate therapy and decreases efficacy. MTM providers should screen for nonadherence and recommend changes in pharmacotherapy or other methods to improve adherence.
INTRODUCTION TO OSTEOPOROSIS
Osteoporosis is associated with low bone mass and increased bone porosity, resulting in reduced bone strength and an increased risk of bone fracture.1,2 The hip, spine, wrist, and ribs are the most commonly affected bones.2 Women have a higher risk of developing osteoporosis compared to men. Primary causes of osteoporosis include menopause and osteoporosis of aging.2 Hyperthyroidism and chronic medication use (Table 30-1) are examples of secondary causes. Additional medical conditions associated with osteoporosis are listed in Table 30-2. Table 30-3 lists the risk factors for osteoporosis and osteoporotic fractures. Hip fractures result in the greatest morbidity, mortality and increased healthcare costs in older seniors.3-5
TABLE 30-1Selected Medications Associated with Increased Bone Loss and/or Fracture Risk |Favorite Table|Download (.pdf) TABLE 30-1 Selected Medications Associated with Increased Bone Loss and/or Fracture Risk
|Medications ||Comments |
|Anticonvulsant therapy (phenytoin, carbamazepine, phenobarbital, and valproic acid) ||↓ BMD and ↑ fracture risk; increased vitamin D metabolism leading to low 25(OH) vitamin D concentrations |
Antiretroviral therapy (ARVT)
Nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) (zidovudine, didanosine, lamivudine, and tenofovir)
Protease inhibitors (PI) (nelfinavir, indinavir, saquinavir, ritonavir, and lopinavir)
|↓ BMD (NRTIs > PI), no fracture data; increased osteoclast activity and decreased osteoblast activity |
|Aromatase inhibitors (eg, letrozole and anastrozole) ||↓ BMD and ↑ fracture risk; reduced estrogen concentrations |
|Canagliflozin ||↓ BMD and ↑ fracture risk (FDA reviewing SLGT2 inhibitor class of medications) |
|Furosemide ||↑ fracture risk; increased calcium renal elimination |
|Glucocorticoids (long-term oral therapy) ||↓ BMD and ↑ fracture risk; increased bone resorption and decreased bone formation; dose and duration dependent |
|Gonadotropin-releasing hormone agonists or analogs (eg, leuprolide and goserelin) ||↓ BMD and ↑ fracture risk; decreased sex hormone production |
|Heparin (unfractionated, UFH) or low-molecular-weight heparin (LMWH) ||↓ BMD and ↑ fracture risk (UFH >>> LMWH) with long-term use (eg > 6 months); decreased osteoblast replication and increased osteoclast function |
|Medroxyprogesterone acetate depot administration ||↓ ...|