Reinforcing the Foundation: An Osteoporosis Update for Pharmacists | Clinical Corner (July 2025)

With new biosimilars now available and rising fracture risk in aging populations, pharmacists are uniquely positioned to lead in bone health education, prevention and intervention. 

Osteoporosis at a Glance: An Underrated Risk 

Osteoporosis remains one of the most under-diagnosed and under treated chronic conditions in aging adults. According to the National Osteoporosis Foundation, over 10 million Americans currently live with osteoporosis, and another 44 million have low bone density, placing them at increased risk of fracture. Hip fractures carry a nearly 25% one-year mortality rate in adults over 65. 

 Despite available therapies, prevention has been limited due to screening gaps, limited education and affordability barriers. For pharmacists in both retail and health system settings, this creates an opportunity to deliver high-impact, patient-centered care through education, supplementation and support with newer treatment options. 

Newer Therapies Expand Access 

 While bisphosphonates are still the primary treatment, newer therapies for osteoporosis are often injectable products and useful in higher risk patients.  

Forteo (teriparatide) is often considered the first line therapy for patients with very high fracture risk. Patients self-administer teriparatide subcutaneously each day and treatment is limited to 24 months. Patients are often treated with bisphosphonates after discontinuation to preserve bone density that was built. There are currently three generic teriparatide vendors on the market.  

• Jubbonti (denosumab-bddz), which is interchangeable with Prolia 
• Ospmyv (denosumab-dssb)  
• Stobocolo (denosumab-bmwo) 
• Connexus (denosumab-bnht) 

 Prolia and its biosimilars are indicated for the treatment of osteoporosis in postmenopausal women at high risk for fracture. It is injected by a provider every six months and the optimal duration of therapy has not been established. Biosimilars are expected to increase access due to improved affordability and reimbursement flexibility, especially as two additional biosimilar products are expected to launch by the end of 2025.  

Evenity (romosozumab) is injected once monthly by a provider for up to 12 months due to waning anabolic effects after this time. It is often billed as a medical benefit in clinics and more frequently used in post-fracture, high-risk patients 

Mechanism of Action Refresher 

• While many therapies focus on preventing additional bone loss, teriparatide helps new bone formation. Teriparatide is a parathyroid hormone analog. It binds to receptors on osteoblasts to promote bone-building activity.  
• Denosumab and its biosimilars are RANKL inhibitors. RANKL promotes the formation and function of osteoclasts (cells that break down bone). By binding to RANKL, denosumab prevents osteoclast activation, reducing bone resorption. 
• Romosozumab is a sclerostin inhibitor. Sclerostin is a protein that inhibits bone formation. By blocking sclerostin, romosozumab both increases bone formation and decreases bone resorption, offering a dual mechanism that differentiates it from other agents. 

These medications are delivered via subcutaneous injection and require monitoring for hypocalcemia, jaw osteonecrosis, and atypical femur fractures. Patients taking romosozumab should be screened for cardiovascular risks. All patients should be counseled on maintaining adequate calcium and vitamin D intake throughout therapy. 

The Functional Medicine Lens: Why Bones Break Down 

While age, menopause, genetics, and diet are well-established contributors to osteoporosis, a functional medicine perspective broadens the view to uncover additional root causes: 

• Chronic Inflammation: Systemic low-grade inflammation accelerates bone resorption. 
• Oxidative Stress: Free radicals damage bone-forming cells (osteoblasts) and stimulate osteoclasts to increase bone breakdown. 
• Hormonal Imbalance: Estrogen, cortisol and thyroid hormones all influence bone turnover. 
• Nutrient Malabsorption: Poor gut health limits absorption of calcium, magnesium and fat-soluble vitamins. 
• Acid/Base Imbalance: Diets high in processed foods and low in minerals create an acidic environment that leaches minerals, such as calcium, from bone to buffer the pH of the body. 

Understanding these factors allows pharmacists to recommend evidence-based lifestyle interventions alongside medication therapy. 

Hormones and Bone Health: The Role of Thyroid and Estrogen Metabolism 

While estrogen deficiency after menopause is a well-known contributor to osteoporosis, less attention is often given to the biochemical interplay between thyroid hormones, estrogen metabolism and bone turnover. Pharmacists can use this knowledge to identify hormonal contributors to bone loss and recommend appropriate testing or referrals. 

 Thyroid Dysfunction and Bone Loss 

Both overt and subclinical hyperthyroidism accelerate bone turnover by increasing osteoclastic activity and shortening the remodeling cycle. 

•  Thyroid hormone (T3) directly stimulates bone resorption and increases bone remodeling units. 
• Even slightly suppressed TSH levels—as seen in over-treated hypothyroid patients—can lead to significant bone loss, particularly in postmenopausal women. 
• Excessive thyroid hormone replacement is an under-recognized cause of osteoporosis in clinical practice, and pharmacists can play a key role in reviewing thyroid dosing and encouraging follow-up TSH monitoring. 

Key Mechanism:  

T3 enhances RANKL expression and decreases osteoprotegerin (OPG), tipping the balance toward osteoclast activation and bone resorption. 

Estrogen Metabolism Matters, Too 

Estrogen plays a dual role in bone health:   

• It suppresses osteoclast activity, reducing bone resorption.   
• It enhances osteoblast survival, supporting bone formation. 

However, not all estrogen is protective. The way estrogen is metabolized affects its impact on bone tissue: 

• Favorable metabolism involves conversion through the 2-hydroxylation pathway, which produces weak, non-proliferative estrogen metabolites. 
• The 4- and 16-hydroxylation pathways, especially when imbalanced due to inflammation or impaired methylation, can lead to more reactive estrogen metabolites associated with oxidative stress and inflammation.Impaired estrogen detoxification (due to poor methylation, liver congestion, or gut dysbiosis) can further disrupt hormone signaling and contribute to systemic inflammation, both detrimental to bone integrity.

Pharmacist Considerations: 

• In patients with known thyroid disorders, verify TSH is within goal (typically 0.5–2.5 mIU/L for most adults). 
• Encourage routine thyroid monitoring, especially in postmenopausal women on levothyroxine. 
• For patients with suspected estrogen dominance or metabolism issues, recommend referral for hormone and methylation testing when appropriate. Consider offering lab tests, such as ZRT, which looks for both hormone balance and thyroid function for your patients.  
• Support healthy estrogen metabolism with nutrients like B vitamins (especially B6, B12, and folate), magnesium, and calcium-D-glucarate. 

Screening: Catching Bone Loss Before the Fracture 

Early detection of low bone density is critical, particularly because osteoporosis is often silent until a fracture occurs. Pharmacists can play a proactive role in identifying at-risk individuals and guiding them toward appropriate screening and treatment. 

Who Should Be Screened? 

• Women aged 65 and older: Routine bone density screening is recommended. 
• Postmenopausal women under 65: Screening is advised if they have risk factors such as low body weight, smoking, corticosteroid use, or a family history of fractures. 
• Men aged 70 and older: Consider screening, especially if other risk factors are present. 
• Men aged 50–69: Screen based on clinical risk assessment. 

Don’t forget the medications that can cause bone loss, including steroids, anti-epileptic drugs (AEDs), proton pump inhibitors (PPIs), medroxyprogesterone, thiazolidinediones for diabetics, GnRH Antagonists for males with prostate cancer, SSRIs and even loop diuretics. There are mixed reviews about statin medications’ impact on bone loss, but keep in mind that cholesterol is the building block needed for hormone production. The intensity of the statin seemed to be correlated with higher levels of osteoporosis. Pharmacists should use this information to deprescribe (PPIs), optimize therapy and recommend therapy changes to prevent the risk of bone loss. Recommending a baseline screening at the beginning of therapy is advised to be able to see the impact of new medications.  

Recommended Screening Tools 

• DEXA (Dual-Energy X-ray Absorptiometry) Scan   
• FRAX Tool (Fracture Risk Assessment Tool)   
• OST (Osteoporosis Self-Assessment Tool) 

Screening in the Pharmacy: Tools and Opportunities 

• FRAX Calculator App (Free on iOS/Android or via shef.ac.uk/FRAX) 
• Bone Density Screening Devices (e.g., GE Achilles) 
• Point-of-Care Risk Assessment Forms 
• Partner with Local Clinics or DEXA Providers 

Revenue & Community Impact 

• Offer screening events during Medicare Wellness Season 
• Pair screenings with education on fall prevention, supplement bundles and immunizations 
• Collaborate with providers for shared care models and referral pipelines 

Lifestyle Medicine: The True Foundation of Bone Health 
Pharmacists can go beyond calcium and vitamin D by incorporating the following four lifestyle pillars into patient counseling: 

1. Nutrient-Dense Foods

Encourage a bone-supportive diet including: 

• Leafy greens (calcium, vitamin K)
• Berries and citrus (polyphenols, vitamin C)
• Sardines and salmon with bones (bioavailable calcium, vitamin D)
• Cruciferous vegetables (hormone balance)
• Nuts and seeds (magnesium, boron, zinc) 
   

2. Targeted Supplementation

In addition to calcium and vitamin D3: 

• Vitamin K2 (MK-7): Directs calcium to bones, not arteries 
• Magnesium citrate or glycinate: Essential for vitamin D activation 
• Buffered Vitamin C: Supports collagen synthesis in the bone matrix
• Boron and Zinc: Trace minerals critical for bone remodeling
• Omega-3 fatty acids: Reduce inflammation and improve bone mineral density

3. Movement & Muscle Engagement

• Resistance training and weight-bearing exercise 3x/week 
• Postural and balance exercises (e.g., yoga, tai chi) to reduce fall risk
• Avoid sedentary periods longer than 1 hour

4. The Missing Links: Vitamin C and Polyphenols

Emerging research shows that vitamin C not only supports collagen synthesis but also stimulates osteoblast activity. Polyphenols—found in foods like green tea, turmeric, blueberries, and olive oil—help reduce oxidative stress and inflammation, protecting bone integrity at the cellular level. Don’t forget that pirates often developed scurvy due to a lack of vitamin C.  

Pharmacists can fill a critical gap by recommending these often-overlooked nutrients as part of a holistic bone support protocol. 

Pharmacist Applications: In Practice 

• Counsel on biosimilar options   
• Recommend OTC bone-support supplements   
• Offer MTM reviews for drug-induced bone loss risks   
• Screen for fall risk   
• Collaborate with providers   
• Host bone health awareness events