Pharmacist interventions in osteoporosis management: a systematic review

Pharmacists Improving Osteoporosis Management in Long-Term Care Using Fracture Risk Assessments: A Feasibility Study

OBJECTIVES

The primary outcome of this study is to test the feasibility of pharmacists completing Fracture Risk Scale (FRS) assessments using resident data routinely held by long-term care (LTC) facilities. Secondary outcomes are to ascertain the proportion of residents assessed as high fracture risk who currently receive osteoporosis medicines and explore whether under- or overuse of osteoporosis medicines is occurring based on residents' fracture risk.

DESIGN

Feasibility study.

SETTING AND PARTICIPANTS

Four LTC facilities from southeast Queensland, Australia, with a total of 281 residents participated in the study during April and May 2024.

METHODS

A pharmacist reviewed individual resident files for all residents of participating facilities. Necessary data were extracted from resident files to determine their fracture risk using the FRS manual calculation tool. Residents' use of osteoporosis medicines and nutritional supplements (vitamin D and calcium) was analyzed based on their calculated fracture risk.

RESULTS

FRS assessments were completed for 275 residents (97.9%). There were 149 residents (54.2%) assessed as having a high fracture risk, of which 43 (28.9%) were prescribed an osteoporosis medicine. Conversely, 28 residents (22.2%) with a low fracture risk received an osteoporosis medicine. Underuse of vitamin D and calcium supplements was found for all residents, irrespective of fracture risk.

CONCLUSIONS AND IMPLICATIONS

The feasibility of pharmacists completing FRS assessments was demonstrated. Incorporating the FRS into routine clinical practice provides a promising means to support pharmacists advising on osteoporosis prescribing decisions for LTC residents. Widespread underuse of vitamin D and calcium for all LTC residents and the underuse of osteoporosis medicines by residents with a high fracture risk were found. Future research is necessary to establish if incorporating the FRS into clinical practice can address this undertreatment and reduce fracture rates in LTC.

A study protocol for exploring and implementing a surgical pharmaceutical service model in drug treatment management for patients with osteoporosis fracture in China

Background

Osteoporotic fractures are serious consequences of osteoporosis, which is a condition that can be prevented through effective therapeutic strategies, including the use of anti-osteoporotic medications. However, a significant treatment gap exists in elderly patients with osteoporotic fractures. A multicenter study conducted in China reported that only 20% of elderly patients with hip fractures received appropriate pharmacotherapy post-fracture. This lack of treatment resulted in an increased risk of refracture associated with osteoporosis. Pharmacist-led interventions have proven essential in medication management for osteoporosis and related fractures, potentially bridging the treatment gap. Accordingly, a protocol was developed to assess the impact of pharmacist-led interventions on increasing the continuation rates of anti-osteoporotic drugs and reducing the risk of refracture in patients with osteoporotic fracture, compared to no interventions (grant number: YCTJ-2023-15).

Methods and analysis

This study is a single-center, prospective, and randomized controlled trial. The targeted participants in this protocol were patients aged above 50 years who had been diagnosed with osteoporotic fractures in China. Eligible participants were randomized into intervention and control groups in a 1:1 ratio using a dynamic stratified block randomization method. The control group received standard care, and the intervention group received standard care combined with pharmacist-led care. The intervention group received comprehensive pharmacist-led interventions, including pharmaceutical ward rounds and medication reconciliation, refracture risk evaluation, recommendations to physicians, patient education, and counseling. A 2-year follow-up was conducted to evaluate the outcomes between groups through telephone interviews, pharmaceutical clinics, and e-hospital pharmacy practice. The primary outcome is the ongoing treatment rates of anti-osteoporotic drugs. The treatment rates are defined as the ratio of patients who remain on anti-osteoporotic medications at each follow-up visit to the total number of enrolled participants. Secondary outcomes include treatment initiation rates, medication adherence, re-fractures, and use of drugs that increase fall risk, the frequency of bone mineral density (BMD) assessments, the incidence of inappropriate medication use, adverse drug reactions (ADRs), and patient satisfaction with osteoporotic fracture treatment. Refracture rates were evaluated through a 2-year follow-up, while BMD were measured at baseline, 1 year, and 2 years using dual-energy X-ray absorptiometry (DXA). ADRs and the inappropriate use of medication were monitored through self-reports and medication reconciliation. Patient satisfaction were assessed using the Treatment Satisfaction Questionnaire for Medication version II (TSQM-II). Ethical approval was obtained from the Committee of Ethics of the First Affiliated Hospital of Shantou University Medical College (approval number: B-2023-194). The statistical analysis was performed using Statistics Package for the Social Science (SPSS), version 23.0.

Discussion

We hypothesize that analyzing pharmacists-led interventions provide valuable insights into how pharmacists improve treatment outcomes for patients with osteoporotic fractures. This study aims to address the existing knowledge gap regarding the effectiveness of pharmacist-led interventions in improving the management of osteoporotic fractures in China.

Osteoporosis screening in Australian community pharmacies: A mixed methods study

ISSUES ADDRESSED

Osteoporosis and poor bone health impact a large proportion of the Australian population, but is drastically underdiagnosed and undertreated. Community pharmacies are a strategic location for osteoporosis screening services due to their accessibility and the demographic profile of customers. The aim of this study was to develop, implement and evaluate a community pharmacy health promotion service centred on encouraging consumers to complete an anonymous osteoporosis screening survey called Know Your Bones.

METHODS

The implementation process was documented using the REAIM (reach, effectiveness, adoption, implementation, maintenance) framework. Uptake of the Know Your Bones screening tool was monitored anonymously with website traffic. Surveys and interviews were designed to capture consumer outcomes after screening. Semi-structured interviews were conducted with Australian community pharmacy stakeholders during design and implementation phases to explore their perspectives of the barriers and facilitators.

RESULTS

The service was implemented in 27 community pharmacies. There were 448 visits to the screening website. Interviews were conducted with 41 stakeholders. There were a range of factors that appeared to influence implementation of the service. Perceived acceptability was critical, which depended on staff training, pharmacists' altruism, and remuneration. Staff relied heavily on their existing close relationships with consumers. No consumers completed non-anonymous surveys or agreed to participate in interviews post-screening.

CONCLUSION

Using an implementation science approach, a community pharmacy osteoporosis screening service for the Australian context was designed and found to be acceptable to pharmacy staff and effective in reaching the target population. SO WHAT?: This low-cost and non-invasive health promotion has potential to sustainably increase national screening rates for osteoporosis.

Osteoporosis: a problem still faulty addressed by the Romanian healthcare system. Results of a questionnaire survey of people aged 40 years and over

Purpose

We aimed to investigate the knowledge and awareness level of osteoporosis, its risk factors, the possible causes of underdiagnosis, as well as the preventive measures and lifestyle behavior of the Romanian population.

Patients and methods

A non-interventional, cross-sectional study was performed, consisting of an in-person survey, in 10 pharmacies located in both urban and rural settings in Romania. The survey was distributed to patients ≥40 years old.

Results

Of 189 respondents, 78.8% were women, the majority age group being 60-69 (31.7%) and 50-59 (30.7%) years old and coming from urban areas (69.3%). Although 75.1% of participants declared knowing about osteoporosis, having a moderate level of knowledge, and women being more aware of the pathology, 77.3% have never performed a DXA test. Moreover, participants already diagnosed with osteoporosis did not show a better disease knowledge than those without a diagnosis. Nearly half of the respondents did not know that a family history of the disease increases the risk of developing it and 60% of them thought that symptoms may develop before a fracture occurs. The preventive strategies tend to be disregarded and thus, underused. Moreover, 42.9% of participants reported being diagnosed with osteoporosis, do not undergo treatment, although they are aware of the existence of effective strategies. The dataset was used to build a participant compatibility network. The network's clustering revealed six relevant communities, which are not correlated with questionnaire results but reflect the patterns of feature associations.

Conclusion

Preventive and therapeutic osteoporosis education programs are urgently needed in the Romanian population to decrease disability and high mortality risks and thus, to improve the quality of life.

The evaluation of an osteoporosis medication management service in community pharmacy, a cohort study

Background: Effective treatment of osteoporosis is hindered by poor adherence and lack of persistence with medical therapy. Interventions can be designed to elicit and address patients' concerns about side effects and promote self-management. Objective(s): The aim was to develop and evaluate the impact of a community pharmacy-based medication management intervention on patients' adherence to osteoporosis medicines using both objective and subjective measures of adherence. Secondary aims were to report the proportion of patients that had been referred to their General Practitioner (GP) for assistance with osteoporosis management, and to measure patients' experiences with the service. Methods: This study used a cohort design. Community pharmacy dispensing data were obtained as an objective measure of adherence. Self-reported beliefs about medicines (Beliefs about Medicines Questionnaire) and self-reported adherence (Medication Adherence Reporting Scale 5) were also collected. Data were collected and compared between baseline, 4 weeks after intervention, and endpoint (approximately a year after intervention). Analysis of correlations between measures was also conducted. GP referral percentage and perceived service quality scale (pSQS-SF6) was obtained. Results: Pharmacists and support staff from 26 Australian community pharmacies were recruited and trained to implement the service, and 107 patients were recruited. Of these, 71 were available for follow-up interviews by research team at 4 weeks, and 54 at the endpoint. No changes were found in pre-post analysis for the objective or self-reported measures of adherence. Patients' concerns about osteoporosis medicines were lower at 4 weeks and at the study endpoint compared to baseline. Uptake of pharmacists' referrals to patients' GPs was 48.1% by 4 weeks. Patient experience was rated highly (median pSQS-SF6 = 6.5/7). Conclusions: This study demonstrates the potential of community pharmacy interventions designed to optimize medication adherence by eliciting patients' thoughts and feelings about using osteoporosis medicines and addressing them using motivational interview techniques.

Therapeutic effects of ginsenosides on osteoporosis for novel drug applications

Osteoporosis (OP) is a metabolic bone disease with a high incidence rate worldwide. Its main features are decreased bone mass, increased bone fragility and deterioration of bone microstructure. It is caused by an imbalance between bone formation and bone resorption. Ginsenoside is a safe and effective traditional Chinese medicine (TCM) usually extracted from ginseng plants, having various therapeutic effects, of which the effect against osteoporosis has been extensively studied. We searched a total of 44 relevant articles with using keywords including osteoporosis, ginsenosides, bone mesenchymal cells, osteoblasts, osteoclasts and bone remodeling, all of which investigated the cellular mechanisms of different types of ginsenosides affecting the activity of bone remodeling by mesenchymal stem cells, osteoblasts and osteoclasts to counteract osteoporosis. This review describes the different types of ginsenosides used to treat osteoporosis from different perspectives, providing a solid theoretical basis for future clinical applications.

Development of a program theory for osteoporosis patient education in Denmark: a qualitative study based on realist evaluation

BACKGROUND

Osteoporosis patient education is offered in many countries worldwide. When evaluating complex interventions like these, it is important to understand how and why the intervention leads to effects. This study aimed to develop a program theory of osteoporosis patient education in Danish municipalities with a focus on examining the mechanisms of change i.e. what is about the programs that generate change.

METHODS

The program theory was developed in an iterative process. The initial draft was based on a previous published systematic review, and subsequently the draft was continually refined based on findings from observations (10 h during osteoporosis patient education) and interviews (individual interviews with six employees in municipalities and three health professionals at hospitals, as well as four focus group interviews with participants in patient education (in total 27 informants)). The transcribed interviews were analyzed using thematic analysis and with inspiration from realist evaluation the mechanisms as well as the contextual factors and outcomes were examined.

RESULTS

Based on this qualitative study we developed a program theory of osteoporosis patient education and identified four mechanisms: motivation, recognizability, reassurance, and peer reflection. For each mechanism we examined how contextual factors activated the mechanism as well as which outcomes were achieved. For instance, the participants' motivation is activated when they meet in groups, and thereafter outcomes such as more physical activity may be achieved. Recognizability is activated by the participants' course of disease, which may lead to better ergonomic habits. Reassurance may result in more physical activity, and this mechanism is activated in newly diagnosed participants without previous fractures. Peer reflection is activated when the participants meet in groups, and the outcome healthier diet may be achieved.

CONCLUSIONS

We developed a program theory and examined how and why osteoporosis patient education is likely to be effective. Understanding these prerequisites is important for future implementation and evaluation of osteoporosis patient education.

Safer medicines To reduce falls and refractures for OsteoPorosis (#STOP): a study protocol for a randomised controlled trial of medical specialist-initiated pharmacist-led medication management reviews in primary care

INTRODUCTION

Minimal trauma fractures (MTFs) often occur in older patients with osteoporosis and may be precipitated by falls risk-increasing drugs. One category of falls risk-increasing drugs of concern are those with sedative/anticholinergic properties. Collaborative medication management services such as Australia's Home Medicine Review (HMR) can reduce patients' intake of sedative/anticholinergics and improve continuity of care. This paper describes a protocol for an randomised controlled trial to determine the efficacy of an HMR service for patients who have sustained MTF.

METHOD AND ANALYSIS

Eligible participants are as follows: ≥65 years of age, using ≥5 medicines including at least one falls risk-increasing drug, who have sustained an MTF and under treatment in one of eight Osteoporosis Refracture Prevention clinics in Australia. Consenting participants will be randomised to control (standard care) or intervention groups. For the intervention group, medical specialists will refer to a pharmacist for HMR focused on reducing falls risk predominately through making recommendations to reduce falls risk medicines, and adherence to antiosteoporosis medicines. Twelve months from treatment allocation, comparisons between groups will be made. The main outcome measure is participants' cumulative exposure to sedative and anticholinergics, using the Drug Burden Index. Secondary outcomes include medication adherence, emergency department visits, hospitalisations, falls and mortality. Economic evaluation will compare the intervention strategy with standard care.

ETHICS AND DISSEMINATION

Approval was obtained via the New South Wales Research Ethics and Governance Information System (approval number: 2021/ETH12003) with site-specific approvals granted through Human Research Ethics Committees for each research site. Study outcomes will be published in peer-reviewed journals. It will provide robust insight into effectiveness of a pharmacist-based intervention on medicine-related falls risk for patients with osteoporosis. We anticipate that this study will take 2 years to fully accrue including follow-up.

TRIAL REGISTRATION NUMBER

ACTRN12622000261718.

Perceptions and practices of aged care pharmacists regarding osteoporosis management: a qualitative study

BACKGROUND

Osteoporosis is a common but sub-optimally managed disease among aged care residents. Although pharmacists are one of the key healthcare providers responsible for osteoporosis medication management there is limited research on their involvement.

AIM

This study explored the perceptions and practices of Australian pharmacists regarding osteoporosis management for aged care residents.

METHOD

Semi-structured interviews were conducted with aged care pharmacists. Interviews were recorded, transcribed, and analysed using a constructivist grounded theory approach.

RESULTS

Twenty-one aged care pharmacists were interviewed. Three main themes were identified: osteoporosis is highly prevalent but given low priority, factors affecting pharmacists' management of osteoporosis, and optimism for the future role of pharmacists in osteoporosis management. The complexity of aged care residents' healthcare needs and the silent, insidious nature of osteoporosis contribute to the low priority it is afforded. Barriers identified by pharmacists included their current practice model, limited access to residents' medical histories and difficulties accessing bone mineral density (BMD) testing. Interdisciplinary collaboration and education regarding osteoporosis management were seen as facilitators. Pharmacists were optimistic that an embedded practice model would improve their capacity to influence osteoporosis management.

CONCLUSION

The high prevalence and low priority of osteoporosis in the aged care setting presents pharmacists with an opportunity to improve medication management and reduce fracture risk. Barriers to osteoporosis management identified by pharmacists can be addressed by interdisciplinary collaboration and education. Pharmacists being embedded in aged care could enable more opportunities to contribute to the interdisciplinary team and become champions of osteoporosis management.

Peroxiredoxin 5 regulates osteogenic differentiation through interaction with hnRNPK during bone regeneration

Peroxiredoxin 5 (Prdx5) is involved in pathophysiological regulation via the stress-induced cellular response. However, its function in the bone remains largely unknown. Here, we show that Prdx5 is involved in osteoclast and osteoblast differentiation, resulting in osteoporotic phenotypes in Prdx5 knockout (Prdx5^Ko) male mice. To investigate the function of Prdx5 in the bone, osteoblasts were analyzed through immunoprecipitation (IP) and liquid chromatography combined with tandem mass spectrometry (LC-MS/MS) methods, while osteoclasts were analyzed through RNA-sequencing. Heterogeneous nuclear ribonucleoprotein K (hnRNPK) was identified as a potential binding partner of Prdx5 during osteoblast differentiation in vitro. Prdx5 acts as a negative regulator of hnRNPK-mediated osteocalcin (Bglap) expression. In addition, transcriptomic analysis revealed that in vitro differentiated osteoclasts from the bone marrow-derived macrophages of Prdx5^Ko mice showed enhanced expression of several osteoclast-related genes. These findings indicate that Prdx5 might contribute to the maintenance of bone homeostasis by regulating osteoblast differentiation. This study proposes a new function of Prdx5 in bone remodeling that may be used in developing therapeutic strategies for bone diseases.