New Mechanisms to Control Bone Loss: An Update for Managed Care Pharmacists
The contents of this issue of University of Tennessee Advanced Studies in Pharmacy include 4 review articles.
Activity Date: October 2008  — Activity Info: Volume 5, (7)
Goals & Objectives | Faculty | Complete Pre-Test Activity | Introduction | Full Activity Content | CME Test & Evaluation (CME Expired)


Andrea S. Franks, PharmD, BCPS*

Just take a look at the Web sites, books, and TV shows that your patients are interested in these days and you will notice that anti-aging has become a household word. Various mass media campaigns aimed at prolonging life offer a multitude of strategies for combating age-related woes, such as wrinkles, memory loss, weight gain, and, most recently, osteoporosis. Watching the benefits of timely bone mineral density (BMD) testing and calcium/vitamin D supplementation being hailed by highly renowned physicians on popularized talk shows and in major newspapers is certainly a testament to the far-reaching osteoporosis awareness efforts that have taken place over the years. But there is still much work to be done in regard to identifying and treating the growing number of aging Americans who may be at risk for major fractures. As a result of the rapidly aging baby boomers, the prevalence of osteoporosis is expected to increase from the current 10 million affected Americans to 14 million in 2020.1 These demographic changes may cause the number of hip fractures in the United States to double or triple by the year 2040.

As healthcare providers, we are well aware of the devastating consequences of fractures, particularly those involving the hip. Individuals who have suffered a hip fracture have a 2.8- to 4-times greater risk of mortality (within the first 3 months), compared to their healthy counterparts, and they often experience a downhill spiral in physical and mental health that dramatically impairs quality of life.2 Nearly 1 in 5 patients with hip fractures end up in a nursing home, and many of these patients become depressed due to fear of falls and additional fractures.2 Individuals who experience spine fractures also have an increased risk of mortality and suffer from back pain, height loss, and postural changes as a result of kyphosis. Multiple thoracic fractures may result in restrictive lung disease, and lumbar fractures may lead to gastrointestinal complications (eg, constipation, abdominal pain, reduced appetite, and premature satiety).1

From an economic perspective, osteoporosis-related fractures cause over 432 000 hospital admissions, almost 2.5 million medical office visits, and approximately 180 000 nursing home admissions annually in the United States.1 The cost to the healthcare system associated with osteoporosis-related fractures has been estimated at $17 billion in 2005, with hip fractures accounting for 14% of incident fractures and 72% of fracture costs.1

For managed care pharmacists involved in the care of patients with osteoporosis, it is critical to stay informed of all the recent developments that have taken place in the management of this bone disease. In an effort to further this knowledge, this issue of University of Tennessee Advanced Studies in Pharmacy is dedicated to providing the most recent guideline recommendations and treatment options, in addition to emerging therapeutic pathways related to osteoporosis.

Elena M. Umland, PharmD, focuses on the epidemiology and pathophysiology of osteoporosis, and includes a discussion on the role of the endocrine system and the receptor activator of nuclear factor-kB (RANK)/RANK ligand (RANKL)/osteoprotegerin (OPG) pathway in bone remodeling. Dr Umland, an associate dean for academic affairs at the Jefferson School of Pharmacy at Thomas Jefferson University, explores the mechanism by which RANK/RANKL/ OPG directs osteoblast and osteoclast function and the specific endocrine components (eg, estrogen, parathyroid hormone, growth hormone, thyroid hormone, and cortisol) that are considered to have a skeletal influence.

Christina Barrington, PharmD, provides a summary of assessment and diagnoses recommendations from the National Osteoporosis Foundation, pharmacoeconomic considerations of assessing fracture risk, and a review of currently available antiresorptive and anabolic agents. Dr Barrington, a pharmacy director at Health Alliance Medical Plans, discusses specific recommendations for BMD testing, the potential impact of the new World Health Organization fracture risk algorithm (FRAX), and the available fracture reduction evidence pertaining to currently available treatments.

Mary Beth O'Connell, PharmD, BCPS, FASHP, FCCP, explores new and emerging treatment options for osteoporosis, including several important therapeutic pathways that impact osteoblast and osteoclast activity. Dr O'Connell, an associate professor in the department of pharmacy practice at the Eugene Applebaum College of Pharmacy and Health Sciences, reviews the latest safety and efficacy data pertaining to long-acting bisphosphonate formulations, anabolic therapy (including an agent approved in Europe), and off-label use of other agents (ie, growth hormone and testosterone) for osteoporosis. In her discussion on emerging treatments, she focuses on various investigational pathways (eg, RANK/RANKL/OPG, Wnt signaling, and ephrin pathway) as potential therapeutic targets, as well as on antitumor necrosis factor-α and anti–interleukin-1 blockades, αvβ3 integrin inhibitors, cathepsin K inhibitors, and investigational estrogen agonist/antagonists.

Andrea S. Franks, PharmD, BCPS, participates in a clinician interview regarding current osteoporosis-related issues that are of interest to managed care pharmacists. Dr Franks, an associate professor and Director of Education at the College of Pharmacy at the University of Tennessee in Knoxville, addresses critical questions on the role of managed care pharmacists in current prevention and awareness efforts, major breakthroughs and challenges in the diagnosis and management of osteoporosis, therapeutic safety concerns, and emerging therapies.

In the words of the Surgeon General, healthcare professionals can make significant improvements in our nation's bone health by proactively assessing, diagnosing, and treating at-risk patients and then helping them apply this scientific knowledge in their everyday lives.2 Having direct access to patients, pharmacists should become fully involved in this effort.


1. National Osteoporosis Foundation. Clinician's Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2008.
2. US Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Office of the Surgeon General; 2004.

*Associate Professor and Director of Education, College of Pharmacy, Knoxville Campus, University of Tennessee, Knoxville, Tennessee.
Address correspondence to: Andrea S. Franks, PharmD, BCPS, Associate Professor and Director of Education, College of Pharmacy, Knoxville Campus, University of Tennessee, 1924 Alcoa Highway, Box 117, Knoxville, TN 37920. E-mail:

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of her article and all its contents.

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