Practice Nurse

Osteoporosis

Osteoporosis is characterized by a reduced bone mass and deterioration of the architecture of bone, giving an increased risk of fracture. A

Apart from age, a low BMD is the greatest risk factor for a fracture. In addition other clinical risk factors i.e. having already suffering a low impact fracture, a parental history of hip fracture, a high alcohol intake and having rheumatoid arthritis are all predictors of fracture at least partially independent of BMD.

One in two women and one in five men over the age of 50 yrs fracture a bone mainly due to poor bone health. Hip fractures alone account for one in five orthopaedic beds and the incidence has been predicted to rise. Fragility fractures cause substantial pain and disability, and are associated with decreased life expectancy. Many of these fractures could be prevented by identifying high risk patients and ensuring management and support as per national guidelines.
Osteoporosis is increasingly being recognised as a long term condition with the majority of care taking place in Primary care.

On completion of the resource you should:

Have an improved knowledge of Osteoporosis; its identification, assessment, treatment and patient support information.

A 67 yr old female patient presents following a trip and fall during which she fractured her wrist. She has normal body mass index (BMI), is generally healthy, is not on any routine medications and smokes ten cigarettes a day. She has never had a DXA scan and is not currently taking bone sparing medications.Which of the following would be the most appropriate intervention?

As it was 'fragility' fracture (a fracture resulting from a fall from a standing height or less, or in the absence of obvious trauma) and this lady is between 50 and 75 yrs a DXA scan is indicated. Half of hip fracture patients suffer a prior fragility fracture before breaking their hip.

TA161 Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women.

Learning points: By routinely managing osteoporosis and falls risk in these patients, in accordance with appropriate national guidance, future hip fracture incidence could be reduced considerably. Arguably (especially in a younger female or in male patient a FRAX assessment may be used to access the need for DXA).

Question 1

An 80 yr old female patient attends your clinic. She has recently been discharged from hospital following a hip fracture which occurred when she fell while walking on ice. She previously fractured her wrist and could generally be described as frail. She has suffered chronic back pain for the past few years and has difficulty mobilising out of doors on her own.

Which would be the most appropriate intervention?

The NICE guidelines recommend that a diagnosis of osteoporosis may be assumed in women aged 75 years and over with a fragility fracture if the responsible clinician considers a DXA scan to be clinically inappropriate. This patient could be considered for treatment with a bone-sparing medication. However in Scotland the Scottish Intercollegiate guidelines (SIGN) recommend that in frail elderly women a DXA scan would be a prerequisite before starting treatment, unless the patient has suffered multiple vertebral fractures.

 Even if the fracture risk is high and the patient requires treatment, it may be helpful to know the BMD as a baseline.

Question 2

An active 52 year woman is worried that she may be at risk of osteoporosis. Her mother sustained a fractured neck of femur at 80 yrs. The patient is a smoker and drinks 3 glasses of wine a day. Her body mass index (BMI) is 20.4kg/m

Which of the following would be the most appropriate?

The FRAX® tool is an algorithm that computes the 10-year probability of a hip fracture or a major osteoporotic fracture. It takes into account and weighs clinical risk factors that predict fracture risk and it can be completed in a couple of minutes online, or on a paper copy of the tool. However it may underestimate risk in a person with multiple fractures or on regular high doses of corticosteroids. Treatment thresholds have been proposed by the NOGG guidelines for use with the FRAX calculated 10-year risk.

Question 3

A 53yr old male newly diagnosed osteoporotic patient requests information on the condition and is anxious to understand if there is a reason for his osteoporosis. He has always been active and healthy, there is no family history of osteoporosis and his Body mass index (BMI) is 20 kgs/m

. He requests blood tests to determine if there is a reason that he has developed osteoporosis at a young age. Which blood tests might be beneficial?

When a patient is diagnosed with osteoporosis, bloods to rule out causes of secondary osteoporosis may be indicated. This is especially so in cases of low BMD for age with no apparent cause and in male patients under 65 yrs of age or premenopausal females. These patients often need referral to a bone health specialist. All of the following conditions can predispose to osteoporosis- Low hormone levels (i.e. untreated menopause < 45 yr, Chemotherapy i.e. Arimadex or Zolidex), Inflammatory bowel disease, Malabsorption (i.e. Coeliac disease), Organ transplant, Diabetes Type I, Hyperthyroidism and COPD. Blood for testosterone levels may also be indicated.

Question 4

A 76 yr old female patient presents having has a DXA scan on which osteoporosis was diagnosed. She has had a range of blood tests and all results were within the normal ranges. She has not previously been treated with bone-sparing medications and there is no history of upper gastrointestinal tract (GIT) problems. Which of the following medications would be most suitable for this patient?

All of the above drugs are effective in reducing fracture risk in patients with osteoporosis. However national guidelines recommend that generic alendronic acid should be first-line therapy unless contra-indicated. Some therapies are licensed for male patients or for glucocorticoid induced osteoporosis and some reserved for severe osteoporosis. Alendronic acid is contraindicated in the presence of certain abnormalities of the oesophagus, inability to stand or sit upright for at least 30 minutes and hypocalcaemia. It is not recommended in patients with renal impairment (creatinine clearance <35 ml/min). An overview of drug treatments can be found on the National Osteoporosis Society website.

Question 5

A 79 year old male patient visits your clinic for a medication review. Having fractured his wrist the previous year he was seen by the Fracture Liaison Nurse. Osteoporosis was diagnosed and his GP commenced treatment with Alendronic Acid. Following a slow 'timed up and go test' he was referred to the Falls intervention team. A home visit lead to provision of new safety equipment and a balance and exercise programme. Postural Hypotension was diagnosed and medication reviews lead to withdrawal of a diuretic. His is now generally now in good health and had not suffered recent falls. He reported that he was taking his Alendronic acid with his other medications after breakfast.

What advice would you give this patient about taking his bone sparing medication?

Alendronate should be taken after an overnight fast and at least 30 minutes before the first medication, supplementation, food or drink (other than water) of the day. It is a poorly absorbed medication and if taken with other products it can bind to them and not be absorbed, hence of no benefit to patient. Tablets should be swallowed whole with a glass of plain water (200 ml) while the patient is sitting or standing in an upright position. Patients should not lie down for 30 minutes after taking the tablet to ensure that it does not travel back up the oesophagus and cause irritation.

Question 6

An 80 year-old woman visits your surgery for annual coronary heart disease review. While undertaking a medicine review you notice that she is not regularly picking up her Alendronic Acid. She has never had a fracture but has been diagnosed with osteoporosis. She reports central chest pain following the medication on several occasions. Which would be the most appropriate course of action?

The patient should be referred to a prescriber to consider the need for alternative medication. Pain behind the sternum (in the absence of other symptoms) could indicate oesophageal irritation caused by the alendronic acid. Alternative medications will be indicated depending on the patient's history of fragility fracture and on the presence of a combination of risk factors, BMD score and the patients' age.

TA160 Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women

Question 7

A patient attends you clinic with concerns regarding her recently diagnosed osteoporosis. She does not have problems with her medication regimen which was explained by her GP but is concerned about what else she can do to help her condition. What advice would you give?

A combination of weight-bearing exercise, a well-balanced diet (including foods from a mixture of nutrients including protein and carbohydrates, fruit, vegetables and dairy products), not smoking, moderate alcohol intake and the use of a calcium supplement can all enhance the effectiveness of osteoporosis medication. Lifestyle advice needs to be reinforced by giving written literature specific to the needs of the patient, incorporating information on the diagnosis, medication and lifestyle measures. A range of information leaflets are available from the National Osteoporosis Society's (NOS) website (www.nos.org.uk) and paper copies can be provided free of charge.

National Osteoporosis Society Information Leaflets

Question 8

A 73yr old female patient you consult arrives with a copy of her DXA report. She was referred for DXA scan by her GP having fallen and fractured her wrist. She is very concerned as to the result and cannot get an appointment to see her GP before she goes on holiday. Her T score is reported to be -2.8 at the hip and -2.1 at the spine. What does this T score indicate?

T score compares a person's bone mineral density to that of someone in her thirties when bones are at their strongest. Scores between +1 and - 1 show normal BMD. Scores between -1 and -2.5 indicate Osteopenia (some thinning of bones). Less than -2.5 indicates osteoporosis e.g. -2.8, demonstrates osteoporosis but not as severe as if it were -3.0. The clinician will look at all risk factors for future fracture and this patient is likely to be prescribed bone sparing medications. Meanwhile an information sheet on the calcium content of foods would enable her to work out her average consumption.

Question 9

You consult a 66 yr old male patient who has had an acute exacerbation of his COPD. He has been on oral Prednisolone for the past three months and has had four courses per year for the past 4 years. He is mobile with a Zimmer and manages all activities of daily living independently. He is concerned that prednisolone 'thins the bones' as he has not had an assessment or bone sparing medication. What intervention would you consider?

Patients who are on, or are expected to be on any dose of steroids for =3 months and are aged > 65 yrs, and female patients who are on oral steroids and have already suffered a fragility fracture should be advised to commence bone-protective therapy http://bookshop.rcplondon.ac.uk/contents/pub89-64206b70-b147-4976-9ee1-bf4948458468.pdf Those patients age < 65 yrs or male patients with no history of fragility fracture should have a DXA scan. Steroid induced osteoporosis develops within 3-6 months but not all patients are susceptible. A patient information leaflet is available.

Glucocorticoids and osteoporosis: Patient Information.

Osteoporosis

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