Rania Habib, MD (Host): Welcome to Hally Healthcast, the wellness podcast from Hally Health, your partner in helping you live your healthiest life. I'm your host, Dr. Rania Habib. Every episode on our podcast addresses a new topic important to your health and well-being, bringing in expert doctors, nurses, pharmacists, and specialists who offer advice and answer your most pressing questions.

Today's episode features two such topics, both quite different yet, as we'll see, totally related. May is National Osteoporosis Awareness and Prevention Month, so it's the perfect time to learn more about the most common type of bone disease. Our second topic impacts virtually every topic we have on this podcast, but few more than this one, so there's no better time than now to address the issue of medication adherence, that is how faithfully we take our medications as prescribed.

Since we have dual topics today, we have with us two experts. Mrs. Bethany Wallen is a registered nurse and a Star Ratings Coordinator at Health Alliance in Champaign, Illinois. Dr. Jena Deschler is a Managed Care Pharmacist for Health Alliance in Champaign. Unfortunately, Dr. Deschler was unable to attend this podcast with us today, but we want to thank her for all her contributions to this episode.

Welcome to you, and thanks for being with us today, Mrs. Wallen.

Bethany Wallen, RN: Good to be here. I'm excited.

Host: Let's begin by talking about osteoporosis. Mrs. Wallen, we know it's a bone disease, and some of us may even have seen its effects on older family members. What exactly is osteoporosis and what causes it?

Bethany Wallen, RN: Yeah. So, osteoporosis is a disease that weakens the bones. Weakened bones are more likely to break or fracture. It has no warning signs or symptoms until you break that bone. Fractures happen most often in the wrist, the pelvis, hip, spine, or upper arm. People with fractures from osteoporosis are twice as likely to have another break if they don't start a treatment plan.

As stated before, osteoporosis occurs when bone mass is lost. So, imagine the bone's inner structure is looking like a honeycomb. With certain risk factors, this inner honeycomb structure in the bone may break down, becoming less and less dense, leading to an increased chance of a fracture. Some risk factors are out of one's control, like age, gender, race, changes in hormones, medications, some medical conditions or family history. Yet on the other hand, some are subjectively within one's control. These factors being diet, level of physical activity, alcohol consumption, and smoking.

Host: Okay. That was an outstanding explanation, Mrs. Wallen. It sounds like you said you highlighted some different risk factors that are associated with osteoporosis, some that are out of our control, and also some that we can change. Could you go into a little bit more detail about these risk factors and what we should do if we're at risk? Is there a screening test for osteoporosis that we could take?

Bethany Wallen, RN: Yeah. Some risk factors that put an individual at an increased risk of osteoporosis that are out of their control include women who are Caucasian or Asian individuals over the age of 65, having a family history of osteoporosis, if they are a woman who went through early menopause before the age of 45.

Some other things are if they have lost about an inch in height; are underweight, so that meaning a body mass index lower than 19; they have digestive disease like Crohn's or Celiac disease; if they have rheumatoid arthritis or are using corticosteroid drugs for three months or more. Some risk factors including diet, level of physical activity, alcohol consumption, and smoking are subjectively within one's control.

And to prevent osteoporosis and future fractures, I have a few tips for these members who maybe are just dealing with some risk factors that maybe they can control. So, that being getting at least 30 minutes of exercise a day, like lifting weights, it doesn't have to be much. You could even use water bottles or soup cans if needed. You could also get enough calcium and vitamin D through your diet. Talking about these two areas of exercise and supplementation with your doctor is definitely recommended. And of course, without being said, smoking cessation or quitting smoking as well as not drinking more than two alcoholic beverages a day would also be beneficial. For someone who is 50 years old or older with osteoporosis risk factors, talking with their doctor about how to prevent osteoporosis and falls would set them up for the best future success. These preventative measures may include education on certain lifestyle changes, discussions on fall safety measures in the home, bone-building medication initiation, or completing a bone density screening.

So you asked, is there a screening for osteoporosis? And there is. This screening test is known as a bone density test, also referred to as a DEXA scan. This test is a non-invasive quick test that uses an x-ray to measure how many grams of calcium or other bone minerals are packed into a segment of bone. Bone density tests are usually done on bones that are most likely to break because of osteoporosis, such as the lumbar spine bones, thigh bone, or the bones in your forearm. For those having a bone density test done at the hospital, they will most likely lie on a padded platform with a mechanical arm that passes over their body. The amount of radiation that they would be exposed to is generally very low, and the test usually only takes 10 to 30 minutes.

Host: That certainly gives us a much clearer picture of this condition and what we can do to prevent it. Now, let's also consider the worst case scenario. For example, I get a DEXA scan, and I'm diagnosed with osteoporosis. Obviously, as you mentioned, bone fractures become my biggest concern, but are there any treatments that have proven effective with this disease? What happens if I do suffer a bone fracture and how do I prevent fractures in the future?

Bethany Wallen, RN: Yeah. Treatment that an individual with osteoporosis can anticipate to work with their provider through includes consuming adequate calcium, vitamin D in appropriate levels for their individual needs; implementing weight-bearing exercise, initiating smoking cessation, like mentioned above; limitation of alcohol, caffeine; adopting fall prevention techniques in their day to day life and at home. Bone-building medications may also be introduced. So, early action is important. Taking bone-building medicine and following through on a treatment plan can help lower fracture risk up to 70%. If you do suffer a fracture due to osteoporosis though, expect to work with your provider to establish a plan of care that best suits your needs through your fracture healing and beyond.

So depending on the type and location of a fracture, different modalities of treatment may be used. So generally, treatment of an osteoporotic fracture may include pain management through pain medications, short-term bed rest, and placement of a brace to hold that fracture in place as it heals. Some preventative measures that may be put in place to reduce the chance of another fracture occurring is the initiation or that continuation of that bone-building medication, scheduling exercise or physical therapy, practicing fall safety in and around the home. All of these will be beneficial to that individual.

And you might be asking, what could you do in the home to prevent a fall in the future? So, these measures are all considered good fall safety measures to use in the home, this isn't all that you could do, but some things may include utilizing night lights, removing clutter, repairing some loose railings next to staircases, utilizing grab bars, and placing a non-slip mat in your bathtub. And you should also remove throw rugs, tape cords and cables next to the wall to limit tripping and keep common pathways clear.

So, medication prescribed for a patient with osteoporosis may be over-the-counter supplement, like before mentioned vitamin D or calcium. Your provider may also or rather prescribe you a prescription medication to help prevent bone loss. It is important to take this medicine as prescribed and talk to your doctor about any questions or concerns that you may have before changing or stopping a medication. For example, talk to your doctor if you have a history of plaque buildup or artery blockages as calcium supplements may not be the best option for you. Staying consistent and taking your medication can allow your bones to become stronger and prevent future fractures.

Host: You've definitely broadened our awareness of this bone-weakening condition and what we can do to keep it at bay. On that note, let's now turn to our second topic, medication adherence. Mrs. Wallen, based on what we've already heard, we know that medication adherence, or how faithfully we take our medications, has a pretty significant bearing on managing chronic illnesses. Could you elaborate on the effects of medication adherence specifically with osteoporosis?

Bethany Wallen, RN: Yeah, taking your medication correctly for any chronic illness or disease leads to better outcomes. For osteoporosis though, not taking your medication properly can lead to reduced bone density and finally lead to an increased risk of fracture. On the other hand, taking your osteoporosis medication as your doctor prescribed can help make your bones stronger and reduce that risk of breaking your bone.

Medication adherence simply means taking the medication you were prescribed, the way it was prescribed, how often or how much it was prescribed. The most common reasons that patients stop taking their medication as prescribed include a lack of knowledge about the disease, in this case osteoporosis; not being able to ask their questions at their doctor visit, side effects, and even forgetting the instructions for taking medications may also be a reason that many stop taking a medication.

So, for example, some initial osteoporosis medications require a person to sit in an upright position for 30 minutes, taking it with a full glass of water. Once you take these particular medications, you cannot eat, drink any other liquids, or take any other medications during that time frame. Doing this will decrease the irritation to your esophagus. But not knowing or understanding things like this could lead a person to stopping their medication.

Host: You've made a terrific and obvious point. We definitely need to take our meds as directed. But that's not always as simple as it sounds, is it? With all the various options available for taking osteoporosis medications, what kind of special challenges do people with osteoporosis face in trying to be diligent about their medication adherence?

Bethany Wallen, RN: The main two prescription treatments include anti-resorptive drugs called bisphosphonates or anabolic medications. Anti-resorptive medications prevents bone loss, may increase bone density, and lowers the risk of broken bones. So examples of these type of medications include alendronate or Fosamax, raloxifene or Evista, zoledronic acid or also known as Reclast, denosumab or Prolia. All of these medications fall into this class. So, these are typically the first choice of treatment for osteoporosis.

Bisphosphonates include some oral options that are inexpensive and cost-effective that can be taken once a day, once a week, or even once a month. Generic Boniva includes an injection given once every three months, while generic Reclast is an IV infusion given once a year. So, patients take the bisphosphonates typically for about five years, and the protective benefits continue even after they stop taking them after that five-year mark. There are also other options such as raloxifene or Evista. This medication works to bind with estrogen receptors in the body and produce estrogen-like effects that decrease bone turnover.

And then, as described above, anabolic medications. These medications build new bones, increase bone density, and lowers the risk of broken bones. Examples of these include medications with the brand names of Forteo, Evenity, and Tymlose. They are typically for those with severe osteoporosis or those who have not responded to other treatments.

So, you need to be open with your provider. I think that's important across the board, because the full picture of your health must be taken into account because bariatric surgeries, kidney health, if you have taken medications for osteoporosis previously, and side effects all go into consideration when your provider chooses the right medication for you.

So, you can speak to your doctor or provider while discussing the addition of one of these valuable medications, but it is important to know your own limitations. For example, if you are started on an oral once-daily medication that requires you to avoid other medications after taking it, but you are on a complicated medication regimen, perhaps the once-a-month option might be better for you. Being aware of how to access your medication formulary can also be helpful, so that you are not caught unprepared with the potential cost of medication and could allow you to gravitate your questions toward a generic medication first.

Host: That's very valuable information. Thank you for sharing, Mrs. Wallen. We've learned a lot today about the medications involved in treating osteoporosis and how they're administered, but also know that there's always a potential downside to medications. Patients have valid concerns over how a medication might interact with another medication or even the possibility of side effects or a bad reaction. From the patient's perspective, where do we turn when we have these questions and what do we do if there's a problem?

Bethany Wallen, RN: Yeah, that is so important and a very good question. You can always discuss any questions that you have with your local pharmacist or a great option is to call Health Alliance and ask to speak to a pharmacist with the health plan. We are there to help navigate the options, side effects, interactions, and any other questions someone may have. This is a great resource for patients as questions tend to come up after leaving the doctor's office, or if the line is too long at the pharmacy. Health Alliance pharmacists can also help you navigate different options for filling the prescriptions in a retail pharmacy, or the easy to use mail order pharmacy, which can sometimes even bring a cost savings benefit.

There are multiple reasons as to why a patient might have a problem with the medication. It could be due to side effects, the cost, how often to take it, but speaking to your provider or your pharmacist would be the best thing to do if you do have a question. Again, we do have pharmacists available at the health plan ready to assist you with these questions. We would much rather you ask the questions to help ease your mind so that you will have a positive response and outcome to taking your medication properly.

Host: Absolutely, I think from the patient perspective, we always forget that we can access the pharmacist and there are a wealth of information to help us with these questions. So, thank you for pointing that out.

Bethany Wallen, RN: Absolutely.

Host: As we wrap up, I have one final question for you, Mrs. Wallen. In light of National Osteoporosis Awareness and Prevention Month, what main message would you want everyone to know about this disease? And bottom line, why is medication adherence so important, especially to people with osteoporosis. What does everyone need to know as a final thought?

Bethany Wallen, RN: Yeah. The most important message that I think that I can express about osteoporosis is that it is preventable. Be your own best advocate, recognize your risk factors and work with your provider to create a plan to increase bone strength balance and your overall health through diet and lifestyle changes. This will help you avoid fractures. Yes, that is the goal here for osteoporosis, but it will also be immensely beneficial in all areas of your health as well.

With those who need treatment, there are so many options available to work with your lifestyle and your needs. It is important to understand that especially for the population of women aged 67 to 85 who've had a fracture need to have that bone mineral density test or that DEXA scan that we talked about or they could be put on a prescription drug for osteoporosis, and that would need to happen six months of that fracture for the best outcomes. It takes time to regrow a bone, so it really is so important to get started right away after a fracture to ensure that no more fractures occur.

Host: Thank you so much for the detailed answer. You have been such a wonderful guest, Mrs. Wallen. And we also want to thank Dr. Deschler, even though she couldn't be here, for her contribution to this episode. Thank you both for everything that you do every day at Health Alliance to help so many individuals and families throughout our communities.

Bethany Wallen, RN: Thank you so much for having me.

Host: I'm your host, Dr. Rania Habib, wishing you well. That concludes today's Hally Healthcast. Tune in next time as we tackle yet another topic important for your health and well-being. And remember, Hally Health is your partner in helping you live your healthiest life. Visit hally.com, that's H-A-L-L-Y.com for resources, information, tips, and much more. Let us help keep you and your family healthy and well. Thanks for listening. We hope you tune in again.