The Pharmacist's Role
With so many options for HRT, what role should the pharmacist play in the management of HRT in menopausal women? In addition to providing therapy-optimization recommendations and patient counseling to ensure safe and effective HRT use, pharmacists are also being asked by third-party insurance plans to discourage the initiation of, or discontinue the use of, high-risk medications such as estradiol when performing medication therapy management. The pharmacist should review the patient's profile and discuss the risks and benefits of starting or continuing therapy. If the patient wants to discontinue the hormone therapy, possible options for symptom control include local estrogen (e.g., Estring or Premarin Vaginal Cream) for vaginal symptoms; venlafaxine, fluoxetine, sertraline, or paroxetine for vasomotor symptoms; and alendronate, calcium plus vitamin D, or raloxifene for osteoporosis prevention.
Raloxifene (Evista), a selective estrogen receptor modulator, is an option for menopausal and postmenopausal patients who cannot tolerate bisphosphonate therapy for osteoporosis prevention. Raloxifene inhibits bone resorption, reduces the risk of vertebral fracture, and decreases the risk of invasive breast cancer, but it increases the risk of blood clot formation. Some clinicians prefer to limit raloxifene therapy for osteoporosis prevention to a maximum of 8 years, based on insufficient evidence regarding longer use.
In addition to verifying the appropriate hormone product, dosage, frequency, and therapy duration, pharmacists are becoming more involved in therapy selection by collaborating with providers. This is a growing specialty for pharmacists in the arena of compounded products. Pharmacists, as the most trusted healthcare provider, often receive detailed information from female patients about their HRT. Pharmacists are highly accessible to the public, enabling many patients to discuss their symptom improvement—or lack thereof—with a simple phone call as often as necessary. A patient may report improved vasomotor symptoms or a side effect to her pharmacist when she picks up her monthly refill, before she returns to her physician for a follow-up appointment.
Whereas manufactured HRT is available in a specific number of dosages and dosage forms, compounded therapies can be individualized for each patient. Compounded hormone medications can be altered in small increments to alleviate menopausal symptoms while minimizing risks. The bioidentical hormones used in prescription compounding have the exact chemical structure of the body's natural hormones. This allows the product to be recognized by the body and to mimic the function of the hormones the patient produces on her own. Specialty compounding pharmacists gain extensive knowledge, training, and experience in their field, allowing many providers to consider them hormone therapy experts. Many compounding pharmacists work alongside providers to prescribe appropriate HRT for their patients.
In this model, the patient is referred to a pharmacist by a prescriber for an HRT consultation. The patient is asked to give a background history containing pertinent health information and to describe her current menopausal symptoms. This information is combined with the patient's laboratory values, and the pharmacist recommends an appropriate therapy to the prescriber to be approved. Once the therapy is approved, the patient, prescriber, and compounding pharmacist work as a team to adjust the dosage until symptom improvement is seen. Many patients have found relief from menopausal symptoms and improvement in their health and quality of life through this route. As with many compounded medications, there are not many large studies on their efficacy, but compounding pharmacists continue to be a valuable resource for many patients.
US Pharmacist. 2015;40(9):33-37. © 2015 Jobson Publishing