NOEI the Patient's Role in the Prevention and Management of Osteoporosis
PODCAST TRANSCRIPT: THE PATIENT’S ROLE IN THE PREVENTION AND MANAGEMENT OSTEOPOROSISSuzanne Jan de Beur, MDI always think that patient education is one of the most powerful things that we can do as physicians. Ithink when you have a patient that is engaged and is a partner with you, that that is when you have themost effect and the most far reaching effect because people are working with you, you are coming upwith decisions together, and then they are motivated in implementing the plan you have come up withtogether. So I am always a big advocate of patient education because if the people can recognize forthemselves risk factors for osteoporosis, they can then be proactive in asking their physicians to screenthem. I am always a big proponent of helping people understand what the risks of osteoporosis are.Now some osteoporosis risks are modifiable and some are not. That gives you some hope; you can workon what is modifiable, but there are some things you’re just stuck with and you have to recognize thatand recognize that that may put you at risk, so you need to be proactive and going out and beingscreened.For osteoporosis, for example, there are a lot of causes that can contribute to bone loss that people maynot necessarily recognize, people or physicians. There are a number of endocrine disorders such ashyperparathyroidism and hyperthyroidism that can predispose to osteoporosis. There aregastrointestinal disorders such as Crohns disease or celiac disease, which can lead to malabsorption ofcalcium and vitamin D and use of steroids that can then lead to osteoporosis. There are hypogonadalstates; hypogonadism in men and women that can contribute to bone loss. There are a number ofgenetic disorders that are associated with low bone density and fractures such as osteogenesisimperfecta. There are a number of rheumatologic and autoimmune diseases such as rheumatoid arthritisthat carry a higher risk of fracture. There are a number of medications that contribute to reduced bonedensity and fracture including glucocorticoids, whether you use them inhaled for say asthma or you usethem for Crohns disease or you are using them for rheumatologic disorders or you are using them forallergy. There are a number of different disorders where glucocorticoids are employed toimmunosuppress people that then result in bone loss. Anticonvulsants such as Dilantin can reducevitamin D synthesis, so there are a number of medications that can also contribute to bone loss. Soraising patients’ awareness about what disorders that they have can contribute to bone loss can behelpful in helping them say, you know I am going to ask my doctor to be screened.There are risk factors for fall. This is a big driver of fractures: poor eyesight or obstacles in the home,problems with psychotropic medications and being unaware, difficulty with proprioception of yourextremities, resulting in falls. So again awareness of fall risk factors is very helpful. Then going back tothe FRAX Risk Assessment Tool, age is a big driver of fracture risk as is gender. Personal history offracture, family history especially a hip fracture in either a mother or father - a big driver of your fracturerisk, glucocorticoids as I talked about, rheumatoid arthritis, current smoking, more than 3 units of alcoholintake, and then a low bone mineral density especially in the femoral neck- these are all going to bethings that will increase your fracture risk and these are things that people should be aware of, Presented by The Johns Hopkins University School of Medicine in collaboration with the National Osteoporosis Foundation. Developed through a strategic educational facilitation by Medikly, LLC. Supported by an educational grant from Lilly USA, LLC, and Amgen Inc.
patients should be aware of when they are thinking about themselves and risk of fracture. You knowevery woman over the age of 65 should be offered bone mineral density testing regardless of their riskfactors, but younger woman, postmenopausal woman with one of these risk factors should be offeredbone mineral density testing. Those on glucocorticoid therapy should be offered bone mineral densitytesting. Those with one of the disorders that I discussed earlier also should be screened with bonemineral density testing, and then over the age of 70, are appropriate for bone mineral density testing.Helping patients understand their risk factors is really critical and educating them about that is important.There are some attitudinal barriers to help patients’ understanding that really a fracture is a big deal. It isnot just something you patch up and everything gets better. Fracture, as I said before, leads to disability,chronic pain and death, and helping people understand that a fracture is really the equivalent of askeletal heart attack and that osteoporosis is silent until that fracture happens. So you need to bescreened for it. You do not want fracture to be your first notion that you have osteoporosis, just like youdo not want a heart attack to be your first notion that you have cardiovascular disease.There are some effective strategies for educating patients and helping them understand their risks. Firstof all there is involving patients in treatment decisions. This is really important. People have access to alot of information and they many times are very engaged in their care. Talking to them about the optionsand having them help you decide what you are going to recommend is really important. Taking intoaccount their preferences and what is going to really be practical for them to accomplish and to sustainover the long-term, and then avoiding putting people on the defensive or trying to press your point ofview without hearing their point of view, because if people are invested then they can carry out the planthat you have made together. Then finally addressing modifiable risk factors is really important becausethey are going to be the ones that are doing it, day in and day out. You are going to help them, guidethem, but they are going to be the ones, every day they are going to have to decide not to smoke thatcigarette, they are going to do one every day that is going to get up and have to do weight-bearingexercise, they are the ones every day they are going to have to monitor their alcohol intake. So reallyhelping them understand what is modifiable and the benefits of modifying those behaviors and thengiving them tools to successfully carry out the behavior is really quite critical.Adrienne Berarducci, PhD, ARNP, BC, CCDI think some of the things we overlook when we are treating patients with osteoporosis is to look at therole actually that other health care providers other than physicians can play in their care. As I mentionedearlier, one of the key things is to capture your patient. You need to get that sound bite when youcapture them and they are interested in talking to you and you can start the dialog about bone healthand bone disease. Getting your MAs involved measuring patients, while they are taking the patient intothe examination room, have them sometimes ask questions. Often as health care providers, we tend tomake patients a little bit afraid, they do not always want to tell us some of their habits and they are littlebit more comfortable telling them to someone else. Also, looking at patient preferences, if you had theopportunity in your practice or you have both male and female healthcare providers, find out what yourpatient’s preference is. Some patients are more comfortable talking to male providers, some are morecomfortable talking to female providers. This is something that even your front office, when the patientmakes an appointment or your MAs can find out for you, just to help get that transition where they starttalking about disease. Some of the more difficult areas to get information from patient, is Presented by The Johns Hopkins University School of Medicine in collaboration with the National Osteoporosis Foundation. Developed through a strategic educational facilitation by Medikly, LLC. Supported by an educational grant from Lilly USA, LLC, and Amgen Inc.
especially on things like smoking, how much do they really smoke a day and alcohol intake. And justmaking it a little bit easier for them to disclose to you exactly how much they are doing and not beingthreatening when you counsel them and also being very realistic.I may have a much firmer hand when I talk to a 40-year-old patient as opposed to when I talk tosomebody who is in their 80s who has smoked for 60 years and more than likely is not going to quit.Even if our goal is to just get them to decrease the habit and let them know that you do not expectthings, you do not expect them to stop immediately, but we are available to offer them help so that theycan quit or can decrease smoking or can decrease alcohol. And there is certainly now enough programsaround on smoking cessation, clinics and other devices that have been very successful. I am finding in myown practice one of the things we do not always think about is the hand-to-mouth habit of smoking notjust the nicotine buzz. We have actually been pretty successful in getting patients to discontinue or atleast decrease smoking when they are using the new electronic cigarettes. Although they still do get thenicotine, they do not get the other untoward effects from cigarette smoking that they did in the past, soit is at least another option for patients who have difficulty.Again, getting them talking about what type of supplements they take and asking patients very frankly.We ask about what medications they are taking and what doses they are taking, but we often do not askpatients what type of other substances that they may be taking. Many patients see infomercials on TVand they think that the things being sold on TV are wonderful to take and they take them. But we need toscreen to see if they are taking any complementary or alternative medicines or homeopathic medicinesor even nutritional supplements, over-the-counter that can interfere with absorption or that can actuallycause more problems. Also, when patients are taking vitamins, we need to ask them what type ofvitamins they are taking. If they tell us a multivitamin, find out what type. Some are taking multivitaminsthat are super mega vitamins that they do not need.Then we have the other extreme with our patients who really do not care to take their medicines. Itbecomes a big issue with compliance and they do not want to admit to the health care provider that theyare not taking their medicines. So we need to look for avenues to find out what compliance really is andwhat we can do to improve it if there is a problem. Some of the issues that we find in practice is thatpatients really are not aware, even though we give them information, on how they should be taking theirmedications and it is something that we can use everybody in the office for. Again, when they first comein we can have MAs ask patients how often they are taking it and looking how we treat this disease.Osteoporosis is not something to be addressed just when there is a fracture; it is something that has tobe addressed lifelong. We have to look at it just like the same way we look at JNC 7 for blood pressure,where somebody has a pre-osteoporotic phase, where they are osteopenic and then they haveosteoporosis or severe osteoporosis. We need to change our way of thinking as health care providersbefore we can change how patients are going to change their way of thinking about this disease. Theystill do not see bone damage until something horrible happens, until they have that sentinal event wherethey have actually fractured. We need to start looking at this and screening for it and start talkingprevention just as we do for blood pressure.We see patients who have high sodium diets and are obese and have risk factors for the disease ofhypertension and we act on it immediately, but we are not doing the same thing with osteoporosis andthat is something we need to do and we need to engage the whole office in that. From the time they Presented by The Johns Hopkins University School of Medicine in collaboration with the National Osteoporosis Foundation. Developed through a strategic educational facilitation by Medikly, LLC. Supported by an educational grant from Lilly USA, LLC, and Amgen Inc.
come into the office until they leave, bone health needs to be included in their visit, in their counselingjust as we do every other disease. Even simple steps of just asking the patient to recall what his typicaldiet is, so we know if they are getting adequate nutrition. Ask them if they fall in the home, these arethings they take a very little time and can be incorporated in the visit. It does not mean that you have tohave a prolonged lengthy visit with the patient, but that can be incorporated in the visit with the patient.Medication compliance, why aren’t they taking their medicine. Some pharmacies now will alert us whenpatients not getting their medications refilled, but we may not know this for several months, so these areareas we are missing. We need to find out what the comfort zone is for patients, and how we askpatients is very important. Do not say, “Are you taking your medications?”, but ask them “Are there areany problems or were you having any problems, any side effects from your medicines or any stomachupset that you have not been able to take the medicine every month?” They seem to be a little bit morewilling to tell you that, “Yes, you know couple months ago I had some heartburn, I was afraid to take themedicine again. ” If you ask them how is it now, have you started that again or you still concerned aboutthis issue, can I help you with this side effect or has the side effect resolved?” At least you get somedialogue going about why they are taking the medicine or not taking the medicine, more importantly.The other thing is to find out what medications they are taking that can interfere with absorption ofosteoporosis medications. Again I cannot emphasize enough the importance of finding out if patients aretaking proton pump inhibitors. And if they are taking them or have been taking them long-term, do theyreally need to remain on the proton pump inhibitor? If there is something that has a less deleteriouseffect on absorption that can be prescribed in getting this patient the same relief. So we need to reallydo medication reviews on all our patients to look for these things. Again, getting them in a situationwhere they feel comfortable enough that they can talk more. Looking for other services available forpatients and changing how we sometimes give medications to patients. All calcium is not created equallyfrom the patients perspective. Calcium tablets are often very big, they are difficult for some patients tochew and they may cause pain. The patients who have poor dentition or again ill-fitting dentures mayhave difficulty taking them. They may cause constipation in some patients. In bariatric patients, we haveeven more difficulty with calcium supplements because they are not absorbing because of the bypasssurgery and we need to look at other mechanisms. This is where it is really important to consider evencompounding pharmacists so that we can get calcium in liquid form or even in effervescent form. Thereis some recent data regarding the effervescent forms of calcium in bariatric populations that actuallyindicates that it is absorbed better. So, we need to look at different methods and different deliverysystems so that the patients will be compliant with their medications and opening the door for them tofeel comfortable to talk to us about why they are not taking the medications and letting them know thatthere are different alternatives that there are other things we can do.Overall being very frank in finding out if the patient absolutely does not wants to take medications. Asmuch as we do not like to do it there are times when we actually have to accept the fact that the patientis not going to be compliant and then look for other strategies to improve bone health either throughdiet, exercise, or modification of other lifestyle behaviors.One of the things we tend to sometimes overlook is how we deal with patients who absolutely areadamantly opposed to taking pharmaceutical therapy for osteoporosis. It is inherent upon us to actuallyevaluate the reasons that they will not take medicines to find the root problem. Is it because there has Presented by The Johns Hopkins University School of Medicine in collaboration with the National Osteoporosis Foundation. Developed through a strategic educational facilitation by Medikly, LLC. Supported by an educational grant from Lilly USA, LLC, and Amgen Inc.
been negative campaigns in newspapers or magazines or other popular media that they are looking at?Has a friend of theirs or a family member orsomeone they have known had an untoward effect from these medicines? Is it a problem with cost andthey cannot afford the medication? Letting them know their risk and being very honest with themupfront, that communicating the 10-year risk for fracture and telling them that based on what we know,pharmacotherapy may be the best thing we can offer to prevent future fracture disfigurement ordisability. However, in some patients that remain adamantly opposed to taking these medications, weneed to be able to offer something different. We need to find out what it is we can do, what we canoffer them in nonpharmacologic therapy and from behavior modification that can help improve theirbone health. This can be things as simple as outlining an exercise program for patients. Looking at whattheir nutritional status is and what their diet habits are or having them make some modifications in theirdiet. In your patients that smoke or drink alcohol that may be will not tell you right out they just do notwant to quit either one, minimizing it, trying to get them to just cut down slowly over time. Again, this iswhere it is key to bring in other multidisciplinary players into this whole bone health picture.Referring patients to exercise programs to help them improve weight bearing and put some mechanicalstress on the joint. Looking at different forms of calcium preparations .Some patients do not like to takechalky tablets. Give them different forms to take. Calcium is available now in liquid form. It is available inflavored chews that patients may be more amenable to take. Finding out if the problem is financial andwhat type of support you can get for the patient. Again, look at what the actual problem is; some are justvery misinformed and a little bit more education may actually improve compliance. Some patients areafraid that they would not be reimbursed by their insurance company and this is another thing we needto look at. They may be opposed to taking the medication because they truly cannot afford it or theirinsurance covers a different medicine. So we need to look at methods we can use that can actually helppatients get their medications also. Dosing also is a problem in some patients; they do not like to takebisphosphonate first thing in the morning and we do have some alternatives now. We havebisphosphonates available that can be taken 2 hours after any meals so patients do not have to take thefirst thing in the morning. Just teaching them how to take them properly, taking them with a full glass ofwater and staying up, wait for at least a half hour after they take the medication. Just taking a little bitmore time to help improve compliance. Again, letting them know the seriousness of this disease.Patients do not understand because they do not see it, they do not see the changes in the bone andthose that have not had a fracture have not suffered the type of pain that many patients do withosteoporosis. In looking at patients individually, not all patients can be given the same type ofinformation or given the same type of message. In some patients we actually need to sometimes inducea little bit of fear, but we have to do that very carefully. Knowing our patient and finding out what theirpreferences are will actually help improve. In looking at them, letting them know that we can work withthem, that we are willing to work with them, and we will revisit what they are doing on their subsequentvisits. Just keeping that plan for them and that goal and let them know that your goal is to preventfracture and injury in the future. Presented by The Johns Hopkins University School of Medicine in collaboration with the National Osteoporosis Foundation. Developed through a strategic educational facilitation by Medikly, LLC. Supported by an educational grant from Lilly USA, LLC, and Amgen Inc.