Healthy Bones: Osteoporosis
Management
Laurel Short, MSN, FNP-C
Disclosure
I have no current affiliation or financial interest with any
grantor or commercial interests that may have direct interest
in the subject matter of the CE Program.
Roadmap Osteoporosis overview
Identifying osteoporosis
Treatment Recommendations
Management models for osteoporosis
Special focus on patients with prior fracture
Q&A
Objectives Understand the basic pathophysiology and prevalence of osteoporosis
Identify best practices for assessing fracture risk
Review current treatment recommendations for fractures resulting from
osteoporosis
Describe pharmacologic and non-pharmacologic modalities for
osteoporosis
Recognize clinical models for improved patient identification and treatment
of osteoporosis
Osteoporosis Overview
Osteoporosis Overview Definition: a skeletal disorder characterized by comprised bone
strength, predisposing an individual to an increased risk of
fracture
Patients with osteoporosis are seen across all areas of
healthcare: ER, clinic visits, long term care, hospitalization
Fractures affect health and quality of life for patients and are a
significant economic burden
Osteoporosis
Overview
Osteoporosis is often a “silent
disorder”
Increased risk of fragility fracture
Consequences for patients and
healthcare are costly
2 million osteoporotic fractures occur
annually
Osteoporosis Prevalence
Over 9.9 million Americans
Postmenopausal, osteoporosis fractures more common than CVA, MI, and breast
CA combined!
~1 out of 2 women and 1 out of 5 Caucasian men will suffer an osteoporosis
related fracture
https://dianecasey56.files.wordpress.com/2013/10/bone-picture.jpg
Bone strength:
It’s more than BMD
Bone Mineral Density (BMD): bone mineral content / area
dual energy x-ray absorptiometry (DXA)
number of grams of mineral per area or volume of bone
Bone strength is also determined by bone quality
Difficult to identify those with poor bone quality
Factors: rate of bone remodeling, architecture, degree of
mineralization, damage accumulation, age, previous fragility
fractures
Twincitytourguide.com, Wikimedia.org
Low Impact
Fracture
Definition: Fracture with trauma that would not
usually result in fracture, such as falling from
standing height or lifting objects
May occur with household activities
Can result from the force of sneezing or
coughing (typically advanced osteoporosis)
Common Sites
Humerus
Pelvis
Hip
Spine
Wrist
Ankle
Vertebral Fracture
Cascade 3-fold increase
after one fracture
5-fold increase after a second
7 to 9-fold increase after a third
Patient
Identification
Patient Identification
All postmenopausal women and men age 50 & older should be
screened for osteoporosis risk
History and physical exam to assess need for:
BMD testing
Vertebral imaging
Secondary causes of osteoporosis
Risk Factors
Modifiable
BMD
Medications
Tobacco use
Excess alcohol intake
Weight-bearing exercise
Calcium intake
Vitamin D intake or exposure
Eating disorder
Non-modifiable
Gender
Age
Race
Body type
Hormone levels
Family history
Secondary osteoporosis (eg. Rheumatoid Arthritis)
Physical Exam
Measure height and compare to historical “tallest height”
Clinically significant height loss =
Historical height loss > 4 cm
Documented height loss > 2 cm
Signs/symptoms of vertebral
fracture: back pain, kyphosis,
significant loss in height
Assess gait & balance,
posture, palpate spine for
tenderness
National Osteoporosis Foundation BMD
Screening Guidelines
Women ≥ 65 and Men ≥ 70
Younger postmenopausal women, women in menopausal transition, and men
age 50-69 with clinical risk factors for fracture
Adults with history of fracture after age 50
Adults with a condition (eg Rheumatoid Arthritis) or taking medication (eg
prednisone ≥ 5mg or equivalent for ≥ 3 months) associated with low bone
mass
Osteoporosis Definition based on Bone
Mineral Density (BMD) Testing
Classification BMD T-Score
Normal Within 1 SD of the mean
level for a young adult
reference population
T-score at -1.0 and above
Low Bone Mass 1.0-2.5 SD below the mean
level
T-score between -1.0 and -
2.5
Osteoporosis 2.5 SD or more below the
mean level
T-score at or below -2.5
Severe or Established
Osteoporosis
2.5 SD or more below the
mean level
T-score at or below -2.5
with one or more fractures
Vertebral Imaging
All women ≥ 70 and all men ≥ 80 if BMD T score is ≤ -1.0
In younger women if T score is ≤ -1.5 at the spine, total hip or
femoral neck
In men and women with specific risk factors
If BMD is not available, consider vertebral imaging based on age
Burst FractureCompression Fracture
Orthopedic Treatment Options
Vertebral Compression Fracture
Conservative
Bracing
Relative Rest
Physical Therapy
Pain management
Surgical
Kyphoplasty
Vertebroplasty
Hip and Extremity Fractures
Orthopedic consultation
recommended
Closed vs. Open treatment
determined by stability of fracture
Physical therapy after fracture
healing
Assess risk factors
Consider osteoporosis
medications
Risk Factors: Clinical Application
BMD correlates well with bone strength and predicts fracture
risk
Consider fracture risk based on BMD and presence of
additional risk factors
Include Fall Risk Assessment
FRAX tool can be helpful in the clinical setting to assess risk
and guide treatment
WHO Fracture Risk Assessment: FRAXFRAX tool: Clinical Risk Factors
Current age Rheumatoid arthritis
Gender Secondary causes of osteoporosis
Previous osteoporotic fracture Parental history of hip fracture
Femoral neck BMD Current smoking
Low body mass index (BMI) Alcohol intake ≥ 3 drinks per day
Oral glucocorticoids ≥ 5mg/d of prednisone for 3
months (ever)
http://www.shef.ac.uk/FRAX/tool.aspx?country=9
Patient Identification: Secondary Causes Complete labs if a secondary cause is
being considered
Those with recent fracture, multiple
fractures, or very low BMD should be
evaluated for secondary causes
Complete blood count
Chemistry levels (Calcium, renal
function, phosphorus, magnesium)
Liver function tests
TSH
Serum 25 (OH) Vitamin D
Parathyroid hormone
Osteoporosis
Management
Universal Recommendations for Men
and Women > age 50
Counsel on risk
Advise adequate intake of
calcium and vitamin D
Regular weight bearing and
strengthening exercise
Assess fall risk
Offer interventions to
decrease fall risk
Advise on smoking cessation
Avoid excessive alcohol
intake
Measure height annually
Nutrition Recommendations
Calcium Men 50-70: 1000 mg/day
Women > age 50 and men >70:
1,200 mg/day
Vitamin D Adults age 50 & older:
800-1,000 IU/day
Non-Pharmacologic Interventions
Exercise
Smoking Cessation
Avoid Excessive
Alcohol
Fall Prevention
Orthotics
Pharmacologic Therapy: Who to
treat?Consider for women and men age 50 and older based on:
Hip or vertebral fracture (T-score is not as important as the fracture itself
in predicting future risk)
T-score ≤ -2.5 at the femoral neck, total hip or lumbar spine
Low bone mass and a U.S. adapted FRAX 10-year risk of hip fracture ≥
3% or a 10 year risk of any major osteoporosis-related fracture ≥ 20%
Bisphosphonates
Calcitonin
Estrogens
Estrogen agonist/antagonist
Tissue-selective estrogen complex
Parathyroid hormone
RANKL inhibitor denosumab
Bisphosphonates
Alendronate, alendronate plus D, ibandronate, risedronate,
and zoledronic acid
Inhibit the activity of osteoclasts, to reduce bone resorption
Reduces risk of vertebral fractures 50-70%
Reduces risk of hip and non-vertebral fractures 25-41%
Taken on an empty stomach, remain upright and wait to eat or
drink for 30-60 minutes after
RANKL InhibitorDenosumab: approved for treatment of osteoporosis in postmenopausal women at high risk of fracture
Also used for men at high risk of fracture/to treat bone loss associated with prostate cancer treatment
Reduces incidence of vertebral fracture by ~68%, hip fractures by 40% and non-vertebral fractures by 20%
Given q 6 months as a subcutaneous injection (in clinic)
Starting another agent is recommended at discontinuation, due to rapid bone loss
Estrogen/Hormone Therapy (ET/HT)Approved for prevention of osteoporosis
Women’s Health Initiative (WHI) found that five years of HT (Prempro)
reduced risk of vertebral and hip fractures by 34% and other osteoporotic
fractures by 23%.
Available as oral and transdermal preparations: estrogen, progestin, and
combination estrogen-progestin
If treatment is stopped, bone loss can be rapid- consider other treatment to
maintain BMD
Estrogen Agonist/Antagonist (Formerly
“SERMs”)
Raloxifene: Approved for prevention and treatment of osteoporosis
Action: weak estrogen agonist in some systems; antagonist in others. Goal is
to prevent adverse effects of estrogen.
Reduces risk of vertebral fractures by ~30% in patients with a prior vertebral
fracture
~55% in those without a prior vertebral fracture
Anabolic MedicationsTeriparatide and Abaloparatide: approved for treatment of osteoporosis for
postmenopausal women and men at high risk of fracture; men and women
with sustained glucocorticoid therapy
Anabolic (bone building): stimulates osteoblasts through “partial copy” of
parathyroid hormone
Reduces risk of vertebral fracture by ~65% and non-vertebral fragility
fractures by ~53% in those with osteoporosis
Given by daily subcutaneous injection, for 18-24 months
After discontinuation, maintenance with another agent (eg bisphosphonate)
Meds in the Pipeline… Romosozumab
Increases bone formation by binding to sclerostin, an osteocyte-derived
inhibitor of osteoblast activity.
Sclerostin inhibition is a promising drug mechanism of action because the gene
that encodes sclerostin is expressed only in skeletal tissue
FDA was due to decide on approval July 2017, but further data analysis is
needed due to possible cardiac risk
Follow-upAssess compliance of medication therapies
Review risk factors
Encourage appropriate Calcium and Vitamin D intake
Provide exercise recommendations
Accurate yearly height measurement
Repeat BMD every two years
Care Management Models
Care Management Models
Bone Health Clinic
Fracture Liaison Service
Fragility Fracture Protocol
Let’s Review
Prevention. Detection. Treatment.
Osteoporosis is a common disease in the US, leading to significant morbidity
and mortality
NPs are in a prime position to education patients on their risk of fragility
fracture
Education and treatment should be personalized to engage patients in their
care
Prior fracture at least doubles the future fracture risk
Educate & Empower
Patients
Bone Health is critical to
recognize and manage.
Prevention of fragility fractures is key!
A Few Helpful Resources Excellent quick eval and treatment review in JAMA (online 12/12/16):
Watts N, Manson JE. Osteoporosis and Fracture Risk Evaluation and
Management. Doi 10.1001/jama.2016.19087
Cosman F, de Beur SJ, LeBoff MS, et al. Clinician’s guide to prevention
and treatment of osteoporosis. Osteoporosis Int. 2014;25(7)2359-2381.
AACE/ACE osteoporosis patient decision tool.
http://empoweryourhealth.org/sites/all/files/AACE_Osteoporosis_Decision_
Aid_B.pdf
Wozniak LA, Johnson JA, McAlister FA, et al. Understanding fragility
fracture patients’ decision-making process regarding bisphosphate
treatment. Osteoporosos Int. doi:10.1007/s00198-016-3693-5
Laurel Short, MSN, FNP-CKansas City Bone & Joint Clinic
Physical Medicine & Rehabilitation
@Laurelontherun
Images/graphics: Unless otherwise noted, all images/graphics are
from open sources or property of Laurel Short
Additional ReferencesCooper C, Mitchell P, Kanis JA. Breaking the fragility fracture cycle. Osteoporosis Int. 2011;22:2049-2050.
Davidson KS, Kendler DL, Ammann P, et al. Assessing fracture risk and effects of osteoporosis drugs: bone mineral density and beyond.
Am J Med. 2009;122:992-997.
Eisman JA, Bogoch ER, Dell R, et al; for ASBMR Task force on secondary fracture prevention. Making the first fracture the last fracture:
ASBMR task force report on secondary fracture prevention. J Bone Miner Res. 2012;27:3029-2046.
Ettinger B, Black DM, Dawson-Hughes B, Melton LJ 3rd, McCloskey EV. The effects of a FRAX revision for the USA. Osteoporos Int.
2012;21(1)35-40.
Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls: a
systematic review of recent 10 years and meta-analysis. J Am Med Dir Assoc. 2012;13(2):188.13-21.
Granacher U, Gollhofer A, Hortobagyi T, Kressig RW & Muehlbauer T. The Importance of trunk muscle strength for balance, functional
performance and fall prevention in seniors: a systematic review. Sports Med 2013;43(7):627-641.
Marsh D, Akesson K, Beaton DE, et al. Coordinator-based systems for secondary prevention in fragility fracture patients. Osteoporos Int.
doi:10.1007/s00198-011-1642-x.
Mclellan AR, Wolowacz SE, Zimovetz EA, et al. Fracture liaison services for the evaluation and management of patients with
osteoporotic fracture: a cost-effectiveness evaluation based on data collected over 8 years of service provision. Osteoporos Int.
2011;22(7):2083-2098.
National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis. Washington, DC: National
Osteoporosis Foundation; 2014.
Sale JEM, Beaton D, Posen J, et al. Systemic review on interventions to improve osteoporosis investigation and treatment in fragility
fracture patients. Osteoporosis Int. 2010; doi:10.1007/s00198-011-1544-y
Torgerson D, Iglesias C, Reid D. The economics of fracture prevention. 2011. In: Barlow D, Francis RM, Miles A (eds) the effective
management of osteoporosis. Aesculapius Medical Press, London, pp 111-121.
Van den Bergh JP, van Geel TA, Geusens PP. Osteoporosis, frailty and fracture: implications for case finding and therapy. Nat Rev
Rheumatol. 2012;8(3)163-172.