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
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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
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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 Spine Pelvis Hip 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 Gender Age Race Body type Hormone levels Family history Non-modifiable 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 Low Bone Mass Osteoporosis Severe or Established Osteoporosis Within 1 SD of the mean level for a young adult reference population 1.0-2.5 SD below the mean level 2.5 SD or more below the mean level 2.5 SD or more below the mean level T-score at -1.0 and above T-score between -1.0 and - 2.5 T-score at or below -2.5 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
Compression Fracture Burst 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: FRAX FRAX tool: Clinical Risk Factors Current age Gender Previous osteoporotic fracture Femoral neck BMD Low body mass index (BMI) Oral glucocorticoids 5mg/d of prednisone for 3 months (ever) Rheumatoid arthritis Secondary causes of osteoporosis Parental history of hip fracture Current smoking Alcohol intake 3 drinks per day 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 Avoid Excessive Alcohol Smoking Cessation 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 Inhibitor Denosumab: 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 Medications Teriparatide 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-up Assess 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-C Kansas 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 References Cooper 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 3 rd, 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.