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Med ilearning - The home of CPD for healthcare professionals in Ireland

The home of CPD for Irish healthcare professionals

Osteoporosis is described by the World Health Organisation (WHO) as a “progressive systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture”.1

Osteoporosis constitutes a major public health problem, through its association with age-related fractures, particularly of the hip, spine, distal forearm and humerus.2 It is a silent disease until it is complicated by fractures — fragility fractures occur following minimal trauma or, in some cases, with no trauma. People who have already had an osteoporotic fracture are at higher risk for secondary fractures.

Osteoporosis can be prevented, diagnosed, and treated before fractures occur. Crucially, even after the first fracture has occurred, there are effective treatments to decrease the risk of further fractures. Prevention, detection and treatment of osteoporosis should be mandatory in primary care.


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It has become increasingly clear that many patients are not being given appropriate information about prevention and many patients are not receiving appropriate testing to diagnose osteoporosis or establish osteoporosis risk. Most importantly, many patients who have osteoporosis-related fractures are not being diagnosed with osteoporosis and are not receiving any of the approved, effective therapies.3

Getting the right treatment to the right patient at the right time is of paramount importance if fracture rates are to be significantly reduced as the population ages.5 A wide range of treatments that can reduce the risk of fractures occurring in patients with osteoporosis are now available. These have the potential to improve clinical outcomes for patients with osteoporosis and to reduce costs of medical care associated with fractures

Prevalence

Worldwide, osteoporosis causes more than 8.9 million fractures annually, resulting in an osteoporotic fracture every three seconds.6 The number of new fractures in 2010 in the EU was estimated at 3.5 million, comprising approximately 620,000 hip fractures, 520,000 vertebral fractures, 560,000 forearm fractures and 1,800,000 other fractures.A prior fracture is associated with an 86 per cent increased risk of any fracture.1

About one out of every two Caucasian women will experience an osteoporosis-related fracture at some point in her lifetime, as will approximately one in five men.8

Fragility fractures

Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture, known as low-level (or ‘low energy’) trauma. The WHO has quantified this as forces equivalent to a fall from a standing height or less. Fragility fractures occur most commonly in the spine (vertebrae), hip (proximal femur) and wrist (distal radius). They may also occur in the arm (humerus), pelvis, ribs and other bones.

Although there are some very successful hospital based fracture liaison programmes that capture the fracture and commence treatment, the majority of patients with incidental fragility fractures are followed up in primary care. Failure to initiate further investigation and tests such as DXA and bone profile blood work in patients followed up in primary care is linked directly to failure to treat, and is related to a knowledge deficit regarding exactly who to investigate and treat.9 Awareness of osteoporosis must be increased dramatically. Campaigns are needed to ensure that when an older person sustains a fragility fracture, the first thought of primary care health professionals should be “was that break caused by osteoporosis?”.

There were over 3,500 hip fractures in Ireland in 2016.10 Patients with hip fractures in particular have unacceptably poor outcomes. The average age of a hip fracture patient is over 80 and two-thirds are women. Hip fractures are associated with an 8-36 per cent mortality within one year, with a higher mortality in men than in women.11 There is also a significant reduction in independence, with up to 50 per cent of patients unable to walk independently again, 60 per cent reporting difficulties carrying out one essential activity of daily living and 25 per cent residing in long-term care.11

Although the majority of vertebral fractures are clinically silent, these fractures are often associated with symptoms of pain, disability, deformity and mortality. Multiple spine fractures can result in kyphosis and restrictive lung and abdominal capacity resulting in pain, respiratory issues, reduced appetite and constipation. Vertebral fractures are major predictors of future fracture risk, up to five fold for subsequent fracture risk and two to three fold for fractures at other sites.1

Assessment of fracture risk

All postmenopausal women and men aged 50 and older should be evaluated for osteoporosis risk in order to determine the need for BMD testing and further investigations. In general, the more risk factors that are present, the higher the risk of fracture. Practice nurses are in an ideal position to identify and recognise both primary and secondary risk factors in their patients. Adults who have had a fragility fracture are at higher relative risk of future fracture than those who have not broken a bone. Incident vertebral (or spinal) fractures almost always mean a person requires treatment for osteoporosis.4


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Risk factors for osteoporosis

Nurses in general practice can play an active role by identifying patients who are at risk for osteoporosis, and encouraging patients to make healthier lifestyle choices promoting optimal bone health. Table 2 highlights the risk factors:

Diagnosis

Osteoporosis is defined operationally on the level of bone mass, measured as BMD.13 ‘Severe’ or ‘established osteoporosis’ indicates osteoporosis above, in the presence of, one or more documented fragility fractures.1

Adults identified as being at increased risk of fragility fracture should be offered an assessment. This should include an initial assessment of falls risk in adults aged 65 or over and one or more of the following components:

  • Fracture risk assessment using FRAX
  • Referral for DXA
  • Relevant laboratory and imaging investigations to clarify diagnosis and inform treatment decisions.13

DXA

DXA (alongside fracture risk assessment tools) provides information to support treatment decisions. Information from a DXA scan will indicate whether further assessment by a specialist osteoporosis service is needed as well as providing a baseline measurement for evaluation of response to treatment in the future.

Fracture risk assessment tools

The advent of absolute fracture risk calculators, such as FRAX, provides a means to stratify risk in the older population.5 The UK National Osteoporosis Guideline Group (NOGG) has based its guidance on FRAX, where an intervention threshold is set at a risk equivalent to that expected in a woman with a prior fracture.

Blood tests and other investigations

Blood tests will help to unmask conditions other than primary osteoporosis that present with low BMD or fractures and identify underlying causes of bone loss that might also need to be treated. These are indicated to exclude secondary causes of osteoporosis. Standard blood tests will include those listed in Table 3.

Other tests may be required on an individual basis, taking into account a patient’s co-morbidities.


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Treatment

Lifestyle measures

Many of the lifestyle recommendations for the prevention and treatment of osteoporosis are relevant for the general population such as adopting a less sedentary outlook combined with a healthy balanced diet. Other lifestyle measures that can be recommended to patients involve tackling the risk factors discussed above, and may also enhance health outcomes in the general population. Table 4 summarises advice from the Scottish Intercollegiate Guideline on tackling risk factors.14

Exercise and falls prevention

Regular weight bearing exercise has been shown to have beneficial effects on bone mineral density, and in combination with muscle strengthening exercises can prevent falls by improving agility, posture, strength and balance.3 Regular weight bearing exercise should be tailored to an individual’s abilities and physical condition.13 Fragility fractures are a result of poor bone quality in combination with a low trauma event such as a fall from a standing height. Therefore any assessment or intervention for osteoporosis must also include advice on preventing falls, and protection of fragile bones. Identifying those at risk of fall and fracture (Table 5) and addressing those risks is a key element in prevention. Hip protectors have been shown to prevent hip fractures in residential settings but issues with adherence and compliance act as barriers to their use.15 Consideration should be given to referring suitable patients to a local community based falls prevention exercise programme.

Advice on falls prevention can be found on the following link:

https://www.hse.ie/eng/health/az/f/falls/

Diet

Calcium is important for bone health and muscle performance. Vitamin D helps maintain serum calcium levels by improving its absorption in digestion. Vitamin D has also been linked to preventing falls in at risk older adults in the community.16 The best way to maintain good calcium and vitamin D levels is by insuring sufficient dietary intake of these nutrients. A daily intake of between 700-1200mg of calcium is recommended. A simple calcium questionnaire can help demonstrate if oral supplementation is required, although the patients should first be given the option of increasing their dietary calcium. Calcium intake above 1500mg/day has limited benefit and may be associated with increased risk of cardiovascular disease and nephrolithiasis.3 Some osteoporosis medicines can cause low levels of calcium, and the need for supplementation should be considered.

NOGG (2017) recommends the use of a calcium questionnaire such as the one available on the link below to assess dietary intake of calcium

http://www.cgem.ed.ac.uk/research/rheumatological/calcium-calculator/

Vitamin D in the general population

The main source of vitamin D is from UVB rays when the skin is exposed to sunlight. Due to Ireland’s northerly latitude and limited sun exposure in winter months it is suggested that there are inadequate vitamin D levels for all groups of the Irish population.17 The re-emergence of rickets in Ireland has led to the FSAI recommending supplementation of vitamin D (5µg) for all infants (0-12months) and this may be extended to other at risk groups with priority given to toddlers, pre-school children, pregnant women, older schoolchildren and adolescents.17 Table 6 shows the FSAI (2011) current recommendations for daily intake of calcium and vitamin D,8 although these guidelines are currently being revised. More recent advice from the Scientific Advisory Commission on Nutrition (SACN, 2016) suggests a daily intake of 400IU for adults of all ages, and 800IU in postmenopausal women and men older than 50 years at increased risk of fracture.13


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Pharmacological management

A number of drug treatments have been shown to effectively reduce future fracture risk.

It is estimated that up to 50% of patients who have been recommended bone protection therapy for osteoporosis do not take their medication.19 Reasons for poor compliance may include fear of potential adverse effects, not wanting to take medicine, and poor understanding of osteoporosis and efficacy of treatment. Nurses in general practice can play an important role in explaining the nature of osteoporosis, treatment options, and the risk benefit ratio for bone protection medications, which allows patients to make a more informed choice and may help with adherence to therapy. The relatively ‘silent’ nature of osteoporosis may make it difficult for the patient to buy into the fact that they need medication even though they feel fine. Prior to commencing therapy a frank discussion of the person’s future fracture risk in relation to the risk of adverse effects such as osteonecrosis of the jaw and atypical femoral fracture should take place, and reminders on compliance and correct method of administration at subsequent GP visits are recommended. Please find below a brief description of some of the more commonly used osteoporosis medications.

Bisphosphonates

Bisphosphonates are analogues of inorganic pyrophosphate that decrease bone remodelling, and can be administered either orally or intravenously. Oral bisphosphonates are perhaps the most commonly used bone protection therapy. Bisphosphonates can also be administered intravenously. The fear of rare side effects such as ONJ has led several patients to discontinue or refuse treatment.20 Careful and continuous education of each patient can help allay fears.

Although some suggest there is no evidence to support routine dental examination prior to starting treatment, NOGG guidelines suggest preventative dentistry be considered prior to commencing bisphosphonates or denosumab in the presence of other confounding risk factors for ONJ such as poor dentition, glucocorticoid and tobacco use.17

Bisphosphonates should be taken alone on an empty stomach first thing in the morning with at least 240 mL of water. After administration, the patient should not have food, drink, medications, or supplements for at least one-half hour (alendronate, risedronate)or one hour (ibandronate). Calcium supplements can interfere with the absorption of bisphosphonates, and so should not be taken for at least one hour after.

Denosumab

Denosumab is a fully humanised monoclonal antibody against RANK ligand which interrupts osteoclast development and activity, therefore inhibiting bone resorption. It is given as a subcutaneous injection of 60 mg once every 6 months.

Teriparatide

Teriparatide (recombinant human parathyroid hormone [PTH] 1-34), when administered intermittently, has anabolic skeletal effects that are most marked in cancellous bone. Essentially it encourages the growth of new bone. A hi tech prescription is required as this treatment is not used routinely, and is considered in the presence of severe osteoporosis. While on treatment patients are evaluated and managed in a specialist osteoporosis/rheumatology clinic. Treatment is licensed for 24 months over a lifetime, and involves the daily administration of a subcutaneous injection by the patient or carer. The pharmaceutical company provide education and support for patients.

Hormone replacement therapy

Although not considered a first line of treatment for osteoporosis estrogen replacement can positively influence BMD by supressing osteoclast activity.23 There is good evidence that HRT prevents fractures in postmenopausal women but the risk of adverse effects including cardiovascular disease and cancer is increased in older women and with longer duration of therapy. Therefore, its use is generally restricted to younger postmenopausal women who have menopausal symptoms and are at high risk of fracture.24

Raloxifene

Raloxifene is a selective estrogen receptor modulator that inhibits resorption of bone. It is contraindicated in women with child-bearing potential, a history of venous thromboembolism or unexplained uterine bleeding. Due to its association with increased risk of CVA, it is suggested that it should only be considered for use for prevention of vertebral fractures in postmenopausal women where other treatments are unsuitable or contraindicated.14 Table 7 illustrates some things to consider in the management of patients on osteoporosis medication.


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Promoting bone health

Nurses can play a very important role in promoting optimal bone health for all their patients. Key interventions include:

  • Promotion of good dietary intake of calcium and vitamin D.
  • Promotion of active lifestyle with weight bearing exercise.
  • Recognise at risk patients and initiate interventions.
  • Establish fracture and falls risk in susceptible patients.
  • Recommend further intervention and treatment if fragility fracture diagnosed.
  • Establish if any issues with adherence to recommended treatment, and address concerns.

The Irish Osteoporosis Society (IOS) provides information to the public and health professionals on all aspects of the disease and offers support to people with osteoporosis, their families, and everyone at risk from the disease. The IOS can be accessed on the following link:

http://www.irishosteoporosis.ie/

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