Daniel Holland, PharmD

Health care providers often overlook osteoporosis screening in an important group: men. This tendency may occur because public health officials have placed a heavy emphasis on osteoporosis prevention in women.

Two million men in the United States have osteoporosis and 12 million have osteopenia (lowered bone density). Men constitute 30% of osteoporosis patients and experience worse outcomes post-fracture than women. In fact, the 80,000 American men who experience a hip fracture every year are 50% more likely to die in the 12 months following fracture than women.

The expansion of regular screening in all care settings can improve this population’s quality of life and risk of fracture. Although the US Preventive Services Task Force doesn’t recommend screening men routinely, health care professionals can still deliver crucial osteoporosis screening to this underdiagnosed and undertreated population.

Clinicians can communicate to both men and women that causes of osteoporosis may include:

·      Type 1 or type 2 diabetes mellitus

·      Human immunodeficiency virus infection

·      Antiepileptic drugs, including phenytoin, carbamazepine, primidone, and valproic acid

To mitigate these causes, clinicians should offer the following preventive recommendations to patients, especially older patients, in their clinic:

·      Get at least 30 minutes of exercise each day. Ideally, exercise should incorporate strength training.

·      Get a sufficient amount of calcium each day through diet or supplements.

·      Get a sufficient amount of vitamin D each day. This can be achieved either through 10 minutes of daily sun exposure or through diet.

·      Stop smoking. Studies have suggested that smoking cigarettes can double the odds of bone loss and fracture.

Finally, clinicians can counsel their patients to go get a bone density test to evaluate the strength of their bones and their potential risk for osteoporosis.

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Health care providers often overlook osteoporosis screening in an important group: men. This tendency may occur because public health officials have placed a heavy emphasis on osteoporosis prevention in women. 

Osteoporosis: Not Just For Women

The Affordable Care Act (ACA) successfully decreased the number of uninsured Americans, and many of these patients require a spectrum of care services.

The health care industry consistently predicted that greater insurance coverage would increase demand for medical services, yet physicians’ economic disincentives and long educational processes before practice continue to limit primary care physician (PCP) growth. Non-physician providers are poised to

For example, Michigan’s expanded Medicaid program enrollment has nearly doubled since 2014 (350,000 to 600,000), which this was unexpected. As a coverage perquisite, all new patients needed physical examinations within 90 days of enrollment. The combined pressure of new patient appointments and induced demand among the newly insured concerned and greatly challenged non-physician PCPs in Michigan.

online in the June 2016 issue showing that Medicaid patient appointment availability increased, non-physician providers completed more visits, and wait times remained stable upon Medicaid expansion in Michigan.

The study staff feigned scheduling an appointment at 295 primary care offices accepting Medicaid patients before Medicaid expansion and every 4 months after. The investigators assessed wait times and the proportion of appointments scheduled with non-physician providers.

The percentage of clinics honoring appointments for Medicaid patients increased modestly (49% to 55%) over the 4 months following coverage expansion. Non-physician care providers were responsible for  8% of appointments made prior to expansion, but just 1 year later, this rate increased to 21%.

Wait times remained unchanged over the study period and the median new patient wait time was less than 2 weeks. Practices with more than 3 offices, rural clinics, and safety net clinics (clinics that do not refuse patients based upon ability to pay and provide a variety of services) were more likely to accept new Medicaid patients at baseline.

This variability between clinics disappeared by the end of the study period. Appointment availability persisted after certain ACA-related reimbursement increases expired at the end of 2014. The combination of new non-physician provider hiring and increased utilization allowed appointment availability to persist cost effectively.

Non-physician providers mitigate the critical need to meet the increased demand for appointments.

reported late last year on the proclivity of patients to turn to nurse practitioner-run clinics instead of a PCP because of the rising cost of health care and shortage of PCPs. According to the

, the shortage of physicians is projected to exceed 46,000 within the next decade, and nurse practitioners have been called upon to help fill the void.

Notably, the report cited a warning from those in the medical field that nurse practitioners are not adequate replacements for physicians “who undergo more rigorous training.” However, recent research has shown that

patients receive the same quality of care in retail-based clinics

, which are staffed by nurse practitioners and physician assistants, as primary care offices.

The Affordable Care Act successfully decreased the number of uninsured Americans, and many of these patients require a spectrum of care services.

Affordable Care Act Opening Doors for Retail Health Providers

Topical therapies are generally the least effective treatment option for nail bed fungal infections, also known as onychomycosis.

Onychomycosis is notoriously difficult to treat and cosmetically distressing. One in 4 patients don’t respond to therapy, and up to half of patients will experience relapse.

Beyond efficacy issues, treatment options for onychomycosis come with certain risks. A 3- to 6-month regimen of oral antifungals comes with hepatotoxicity risk and a host of drug interaction possibilities. Most notably, the azole antifungals inhibit the most prevalent and critical hepatic enzyme (CYP3A4) in drug metabolism.

Despite these interaction risks, oral therapy is more effective and takes up to 75% less time to complete than topical therapy. Cure rates for oral therapy fall between 45% to 70%, and total remission occurs for 35% to 80% of patients.

Topical therapy doesn’t come with the numerous drug-drug interactions of oral azole therapy. Adverse effects are limited to localized redness, swelling, and rashes. Most patients don’t experience relief from topical treatments, and the small subset of patients that do usually need courses as long as 12 months to see relief.

Another major disadvantage of topical therapy for onychomycosis is that  only 0.1% of the drug is able to diffuse through the nail to the nail bed. However, penetration and cure can be aided by mechanical and chemical means.

Available topical agents include 8% ciclopirox and 25% undecylenic acid nail lacquers, 13% undecylenic acid cream, and 10% efinaconazole solution (Jublia by prescription only). Ciclopirox completely cures about 7% of patients and mycologically cures 29% to 36% of patients. Meanwhile, efinaconazole accomplishes complete cure for 15% to 18% of patients and mycologic cure for 54% of patients.

Mechanical methods, including nail abrasion and removal, reduce or eliminate the nail absorption barrier and remove fungal debris. Nail avulsion can be accomplished in a clinic setting with local anesthesia and urea or salicylic acid to soften the nail plate. These chemical nail softeners and organic solvents like ethanol, propylene glycol, and polyethylene glycol improve drug penetration through nails, as well.

Clinicians should advise patients to abide by the following recommendations from the Mayo Clinic to prevent infection, relapse, or reinfection of nail beds:

·      Washing infected hands and/or feet regularly with soapy water, then drying thoroughly

·      Keeping nails short, filed straight across, and without nail polish

·      Wearing correctly-sized shoes and sweat-absorbing socks (eg, cotton, not nylon)

·      Avoiding or wearing water-proof footwear in high-risk environments like public showers and around swimming pool

Onychomycosis Treatment: Are Topical Therapies Worthwhile?

If left untreated, Lyme disease can have serious complications.

Lyme disease is the most common tick-borne disease in North America, and your patients may become more susceptible to it as they head outside for summer activities.

It’s common for patients to visit retail clinics when they suspect that they’ve been bitten. The disease initially presents 1 to 2 weeks after the tick bite and develops over the course of a few days. The rash may go unnoticed if it’s in a difficult location to inspect, such as the buttocks, axillae, or behind the knee.

Patients may visit retail clinics to discuss these symptoms without knowing that they’re associated with Lyme disease, so it’s important for retail clinicians to ask questions and proactively perform testing if Lyme disease is suspected.

According to the Mayo Clinic, untreated Lyme disease can also cause the following complications:

Chronic joint inflammation (Lyme arthritis), particularly of the knee

Neurological symptoms, such as facial palsy and neuropathy

Cognitive defects, such as impaired memory

Depression associated with coping from other symptoms

Patients with arthritis who lack neurologic symptoms should receive doxycycline, amoxicillin, or cefuroxime regimens for 28 days. Patients with comorbid Lyme arthritis and neurologic complications or recurrent disease should receive the cefuroxime regimen for 28 days.

Patients may experience a delayed antibiotic response in late-stage Lyme disease by weeks to months. Clinicians may treat a mild arthritis recurrence with a second course of antibiotics. Ongoing fatigue, musculoskeletal pain, or cognitive difficulties after antibiotic therapy will most likely not respond to antibiotics or represent an active infection.

Retail clinicians can help patients reduce the risk of tick bites and tick-borne diseases by pointing out CDC recommendations, which include the following:

Avoid wooded and brushy areas with high grass and leaf litter.

Use products that contain permethrin on clothing.