Pharmacist Consultation for Lupus Low Bone Density Should Include Risk Assessment and Preventive Measures
Much like the complex course and presentation of systemic lupus erythematosus, the story of its bone-related comorbidities is nearly as confusing. While there’s no doubt that people with lupus are at risk for low bone density and osteoporosis, it turns out that many patients fail to get bone density screening or take the recommended medications, calcium, and vitamin D.
Several reasons are often suggested to explain low compliance—costs, worries about side effects, fragmented health care—but so far no one can offer firm answers about why patients with lupus would put their bone health at risk. What is certain is that it’s vital for pharmacists to reach out, encourage compliance and emphasize preventive measures.
Prevalence of Low Bone Density and Fractures in Lupus
Even though low bone density and osteoporosis develop in people with systemic lupus erythematosus (SLE), data from prevalence studies varies due to differences in subjects and scoring systems. Based on the information currently available, the prevalence of osteopenia in SLE patients ranges from 15 percent to 74 percent, while osteoporosis estimates have been as low as 1.4 percent in premenopausal women and as high as 69 percent in postmenopausal women.1
A study published in August 2016 in Lupus reported on data collected from 1807 inception patients of the Toronto Lupus Cohort. Their results say that:2
- Overall prevalence of abnormal bone mineral density (BMD) in lupus patients is 31.5 percent.
- Prevalence of low BMD is 17.3 percent in pre-menopausal women and 43 percent in post-menopausal women.
Regardless of diverse data, the important point is that low BMD leads to osteoporosis, which is a top cause of fractures. Osteoporosis accounts for 80 percent of all fractures in people aged 50 years or older, whether they have lupus or not.3 More specifically to lupus patients, studies over the years have reported a 1.8-fold to 4.7-fold increase of fractures in women with SLE compared to healthy controls. The Lupus study found that 11 percent experienced peripheral and vertebral fragility fractures.
Compliance with Bone Density Screening in Patients with Lupus
When a group of experts released quality indicators to guide SLE care and treatment in March 2009, they recommended that patients taking daily prednisone at a dose of 7.5 mg or more for at least three months should be screened for bone mineral density and take supplemental calcium and vitamin D.4 The American College of Rheumatology recommends a lower threshold of 5 mg of prednisone daily for three months. Meanwhile, the National Osteoporosis Foundation takes it a step farther, suggesting that patients taking 5 mg of prednisone daily for any amount of time or patients with any chronic condition associated with low bone mass should be screened and take supplements.
The recommendations sound good, but there’s a problem—a study in Arthritis Care and Research in July 2010 says that many SLE patients aren’t screened for bone density. The participants for this study came from the University of California San Francisco Lupus Outcomes Study. Their data shows:5
- 69 to 74 percent of SLE patients were screened for BMD sometime within the last 24 months.
- 56 to 58 percent take calcium and vitamin D.
- 54 to 56 percent take antiresorptive or anabolic medications.
- Only 40 percent of those with documented osteoporosis took antiresorptive or anabolic agents.
The results of this study were slightly better than data from earlier research. For example, one group of researchers found that 45 to 50 percent took calcium and vitamin D, while a different study reported that only 40 percent of SLE patients were screened for bone density.
Influencing Factors for Pharmacists to Consider
Since pharmacists are on the front line for SLE patients taking medications, it’s imperative to ask whether they’ve had bone density screening and educate them about the importance of calcium, vitamin D, medication and exercise to prevent osteoporosis. The authors of the study in Arthritis Care and Research reported factors that predict which patients are most likely to receive care on par with the quality indicators:
- One significant factor predictive for bone density screening is age—older women are more likely to get screened, which may be due to age rather than a diagnosis of SLE.
- Caucasian race is the primary factor that predicts compliance with taking calcium and vitamin D.
While the researchers concluded that bone health-related care was sub-optimal—and recommended that the gap may be improved by teaching all SLE patients and their providers about osteoporosis prevention and treatment—they didn’t offer substantial information about why so many lupus patients don’t meet the two quality indicators of screening and calcium/vitamin D prophylaxis. Based on the information in the published study, patients weren’t asked whether screening or supplements were recommended by a health care professional or why they failed to follow through.
The best advice for pharmacists is to ask those questions. Before you spend time counseling, ask if their doctor already talked about bone density screening and supplements. If not, then take the time to educate them. If the answer is yes, ask if they’ve been screened and whether they take supplements. If not, what stops them? Maybe their insurance doesn’t cover supplements, they can’t afford copays for screening or supplements, they need transportation or a referral to a bone density center. Once you uncover the roadblock, you can work with the patient to find solutions.
Pharmacist Intervention Prevents Bone Disease
The patients who were screened and had low bone density were 5.9 years away from their original lupus diagnosis and they had a mean age of 48 years. This suggests two things—if they had been screened earlier, they could have prevented low bone density and they could have more easily prevented adverse effects. It’s imperative for pharmacists to reach out and encourage screening so they can enjoy the remainder of their life without morbidities related to weak bones.
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- “Bone Density Scrutiny Critical for Patients with Lupus,” October 2016, http://www.rheumatologynetwork.com/lupus/bone-density-scrutiny-critical-patients-lupus ↩
- “Prevalence and Associated Factors of Low Bone Mass in Adults with Systemic Lupus Erythematosus,” August 2016, https://www.ncbi.nlm.nih.gov/pubmed/27522094 ↩
- “Osteoporosis,” September 2016, http://emedicine.medscape.com/article/330598-overview ↩
- “A Quality Indicator Set for Systemic Lupus Erythematosus,” March 2009, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2748348/ ↩
- “Osteoporosis Screening, Prevention and Treatment in Systemic Lupus Erythematosus: Application of the Systemic Lupus Erythematosus Quality Indicators,” July 2010, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2953549/ ↩