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

Lshort@kcbj.com

@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.