Osteoporosis Quiz for Nursing Students

Osteoporosis Overview

• A bone disease, occurring when the body loses bone, makes too little bone, or both
• Bones become weak and may fracture easily
• Bone strength depends on density and bone quality

Learning Objectives

• Recognize prevalence and risk factors for osteoporosis
• Describe negative outcomes of osteoporosis
• Interpret T-scores to diagnose osteoporosis/osteopenia
• Calculate FRAX scores to determine if osteopenia needs treatment
• Identify non-pharmacological strategies to decrease fall and fracture risk
• Compare and contrast pharmacological agents for osteoporosis treatment
• Recommend non-pharmacological and pharmacological strategies for osteoporosis treatment

Meet Mrs. Miller

• 72-year-old white female
• PMH: hypertension, type 2 diabetes, GERD, no history of fractures
• Family history: mother had osteoporosis and a hip fracture
• Social history: non-smoker, occasional alcohol (1 glass of wine with dinner 3 times per week)
• Medications: lisinopril, metformin, pioglitazone, famotidine
• Vitals: weight 125 lbs, height 5'4"
• DXA Report (10/31/2022):
  • T-score total hip: -0.9
  • T-score femoral neck: -1.8
  • T-score vertebrae: -2.2

Osteoporosis - "Porous Bone"

• Bone disease characterized by low bone mass and microarchitectural deterioration of bone tissue
• Results in increased bone fragility, leading to a high risk of fractures

Bone Remodeling

• Continuous process where bone is broken down (resorption) and new bone is formed (formation)
• Osteoclasts break down old bone tissue
• Osteoblasts are responsible for bone formation

Natural History of Bone Mineral Density

• Bone loss rate is 0.2-0.5% per year
• Bone mass decreases with age
• Bone loss rate is 1-5% per year during the 10 years after menopause

Common Sites of Fracture

• Vertebral fractures
• Hip fractures
• Wrist fractures

Poll Question

• What percent of women will have an osteoporosis-related fracture during their lifetime? -75%

Osteoporosis Statistics

• 10 million Americans have osteoporosis
• 44 million Americans have low bone density
• A woman's risk of fracture is comparable to the combined risk of breast, uterine, and ovarian cancer
• A man is more likely to break a bone than to get prostate cancer

Negative Outcomes of Osteoporosis

• 24% die within one year
• 40% unable to walk independently
• 80% restricted in activities of daily living
• 33% placed in a nursing home

Risk Factors for Osteoporosis

• Postmenopausal women
• Ethnicity
• Low body weight
• Family history
• Calcium or vitamin D deficiency
• Inactivity
• Smoking
• Excess alcohol
• Rheumatoid arthritis
• Diabetes
• Secondary hyperparathyroidism
• Hyperthyroidism
• Anorexia nervosa
• Celiac disease
• Vitamin D deficiency
• Immobilization
• Depression
• Steroids (prednisone> 5mg daily for >3 months)
• Aromatase inhibitors (anastrozole)
• Proton pump inhibitors (omeprazole, pantoprazole, esomeprazole)
• Glitazones (pioglitazone, rosiglitazone)
• Antiepileptics (carbamazepine, phenobarbital, phenytoin)
• Medroxyprogesterone injections
• Heparin
• SSRIs (citalopram, escitalopram, sertraline)

NOF Screening Recommendations

• Women age 65 and older, regardless of clinical risk factors
• Younger postmenopausal women, women in the menopausal transition, and men aged 50-69 with clinical risk factors for fracture
• Adults with fractures after age 50
• Adults with conditions (e.g., rheumatoid arthritis) or taking medications (e.g., steroids) associated with low bone mass or bone loss

Screening Modalities

• DXA scan

T-Score vs Z-Score

• T-score: compares results to healthy young adults (20-35)
  • Used for diagnosis
• Z-score compares results to people of the same age and gender
  • Used to determine if further work-up is needed

Interpreting T-Scores

• -4 to -2.5: osteoporosis
• -2.5 to -1: low bone density (osteopenia)
• 0 and above: normal

Candidates for Treatment

• Osteoporosis by T-score
• Patients with fragility fracture
• Osteopenia that meets FRAX criteria

FRAX Score

• Decision-making tool for treating osteopenia
• Takes multiple risk factors beyond BMD into account
• Determines 10-year fracture risk (hip and major osteoporotic)

Mrs. Miller's DXA Scan Results (10/31/2022)

• T-score total hip: -0.9
• T-score femoral neck: -1.8
• T-score vertebrae: -2.2

FRAX Score Exercise

• Calculate Mrs. Miller's FRAX score using the provided info

Poll Question

• Should Mrs. Miller receive treatment at this time? -Requires calculation of FRAX score for a definitive answer

Treatment of Osteopenia and Osteoporosis

• Calcium
• Vitamin D
• Risk Reduction
• Falls Reduction
• Exercise
• Pharmacotherapy

Calcium Supplementation

• Calcium from diet preferred over supplements
• Recommended daily calcium intake based on age and sex groups

Sources of Calcium

• Natural sources (beans, lentils, canned sardines, salmon, leafy greens, seeds)
• Fortified foods (milk, yogurt, cheese, orange juice, cereal)
• Supplements (multivitamins, calcium carbonate, calcium citrate)

Calcium in Foods

• Nutritional information about calcium content in foods

Calcium Supplementation Pearls

• Only 500 mg of calcium is absorbed at a time
• Calcium carbonate absorption requires stomach acid; not as well absorbed by those on PPI or H2 blockers
• Calcium citrate doesn't require acid for absorption
• Some patients have difficulty swallowing pills
• Calcium may interact with other medications

Common Supplements

• Table comparing various calcium supplements (brand names, elemental calcium, vitamin D, tablets per day, and cost)

Sources of Vitamin D

• Natural sources (salmon, liver, mushrooms, egg yolks, sun exposure)
• Fortified foods (milk, orange juice, yogurt, butter)
• Supplements (multivitamins, ergocalciferol, cholecalciferol)

25-OH Vitamin D Levels

• Concentration levels:
  • Optimal: Above 30 ng/mL
  • Insufficient: 21-29 ng/mL
  • Deficient: Less than 20 ng/mL

Vitamin D Supplementation

• Cholecalciferol (Vitamin D3): OTC; daily dose of 1,000-2,000 IU
• Ergocalciferol (Vitamin D2): Prescription; 50,000 IU once weekly for 8-12 weeks to treat deficiency (25-OH vitamin D < 20 ng/mL)

Falls Reduction - Statistics

• Falls are the leading cause of death and disability in seniors
• 25% of people over 65 fall each year
• <50% of people who fall tell their doctor
• 20 minutes: time until death in cases of falls
• 95% of hip fractures are caused by falls

Risk Factors for Falls

• Medications
• Lower body weakness
• Vitamin D deficiency
• Gait and balance disturbances
• History of recent falls
• Vision impairment
• Improper footwear
• Home hazards (rugs, steps, handrails, poor lighting)

Lifestyle Measures

• Weight-bearing exercise
• Muscle-strengthening exercise
• Smoking cessation
• Limiting alcohol intake

Pharmacotherapy

• First-line: bisphosphonates and denosumab
• Second-line: calcitonin, raloxifene, estrogen
• Severe osteoporosis: PTH analogs and sclerostin inhibitor

Bisphosphonates

• First-line treatment in most patients
• Approved for women, men, and steroid-induced osteoporosis
• Decreases hip and vertebral fractures
• Zoledronic acid decreases mortality after hip fracture
• Cost-effective
• Mechanism of action (MOA)
• Dosing (oral and intravenous)
• Adverse effects (esophagitis, acute phase reaction, muscle/bone/joint pain, hypocalcemia, rare effects: ONJ, AFF)

Bisphosphonates: Contraindications

• Hypocalcemia
• Inability to remain upright for 30 minutes
• Esophagitis
• Esophageal strictures
• Barrett's esophagus
• Swallowing disorders
• CrCl <35 mL/min (alendronate, zoledronic acid)
• CrCl <30 mL/min (ibandronate, risedronate)

Starting a Bisphosphonate

• Baseline lab tests (calcium, vitamin D, SCr)
• DXA scan to monitor response to therapy
• Counseling points (administration, timing, adverse effects like pain, food intake)

Bisphosphonate Holidays

• Consider holiday for low-risk patients >3 years (zoledronic acid), >5 years (alendronate/ibandronate)
• Patients high risk of fracture or with decline in BMD should restart bisphosphonate
• Treat high-risk patients (history of a fracture, osteoporosis diagnosis, steroid use) for up to 10 years

Denosumab (Prolia)

• Receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitor
• MOA
• Dose: 60 mg subcutaneously every 6 months
• Administration (by healthcare professional, refrigerated)
• Adverse effects (hypocalcemia, infections, rare: ONJ, atypical femur fractures)
• Contraindications
• Cost

Denosumab (Prolia): Discontinuation

• BMD decreases rapidly upon discontinuation
• Bone turnover markers increase above baseline in 12 months
• Rebound fracture risk
• Alternative agents to maintain BMD if discontinuing (bisphosphonate)

Second Line Agents

• Calcitonin (vertebral fracture pain)
• Raloxifene (osteopenia of the spine, high breast cancer risk)
• Estrogen (vasomotor symptoms in women)

Selective Estrogen Receptor Modulator (SERM)

• Raloxifene
  • MOA and indication
  • Dose (60 mg PO daily)
  • Adverse effects (increased risk for DVT/PE and death from stroke, CHD, menopausal symptoms)

Conjugated Estrogens/Bazedoxifene (Duavee)

• Equine estrogen/SERM combination
  • Indication, Contraindications, Dosing, Side effects, Boxed Warnings

PTH Analogs

• Analogs of human parathyroid hormone, stimulating osteoblast activity, increasing bone formation.
  • Decreases risk of vertebral and non-vertebral fractures
  • Used in patients with high risk of fracture.
  • A history of vertebral fractures or multiple fractures.
  • T-score < -3
• Due to safety issues, the cumulative lifetime treatment duration is restricted to 2 years or less
• Followed by a bisphosphonate or denosumab to maintain BMD

Teriparatide (Forteo)

• Treatment for post-menopausal osteoporosis, osteoporosis in men, steroid induced osteoporosis
• Dosing (20 mcg subcutaneously daily)
• Adverse effects (transient orthostasis, arthralgia, leg cramps, hypercalcemia, osteosarcoma)

PTH Analogs – Abaloparatide (Tymlos)

• Indication, Treatment for post-menopausal osteoporosis in women.
• Dose (80 mcg subcutaneously daily), considerations

Romosozumab (Evenity)

• Sclerostin inhibitor
  • MOA, Dosing (210 mg subcutaneously every month), and indication
  • Adverse effects (hypcalcemia, arthralgia, injection site reactions), boxed warning (CV risks)
  • Considerations, cost

Monitoring Therapy

• DXA scans 1-2 years after initiation of therapy (Medicare covers testing every 2 years).
• Assessment of proper administration, tolerability, and side effects.
• Assessment of medication adherence.

Mrs. Miller (additional questions)

• What labs should be obtained before starting treatment?
• What other information is needed before selecting appropriate treatment?
  • The presented lab results for serum calcium and 25-hydroxyvitamin D, and CrCl. Additional considerations include a history of falls and non-pharmacological interventions.

Test your knowledge about osteoporosis, bone loss rates, and key diagnostic criteria such as T-scores and fractures. This quiz covers crucial information that nursing students need to understand about bone health, particularly in postmenopausal women. Challenge yourself with case studies and practical questions related to osteoporosis management.