Practical implications for nurses caring for patients being treated for osteoporosis

Figures & data

Table 1 Modifiable osteoporosis risk factors and recommended actions

Risk factor	Description	Recommendations for patients
Estrogen deficiency	Estrogen deficiency occurs with menopause and results in rapid bone loss in women, contributing to 5%–10% loss of cortical bone and 20%–30% of trabecular bone. This is followed by a slower phase of bone loss of 20%–25% of cortical and trabecular bone in both men and women.^Citation10	Although estrogen replacement has been used in the past to prevent bone loss associated with menopause, increased risk for breast cancer has resulted in this recommendation being rescinded.
Inadequate calcium and vitamin D intake	A lifetime diet low in calcium and vitamin D increases the risk of bone loss. Many people fail to consume even half of the calcium recommended to build and maintain healthy bones.^Citation3,Citation10	Increase dietary intake of calcium; take calcium and vitamin D supplements if dietary calcium intake is inadequate. Modify calcium intake to correspond with recommendations for life stage.^Citation1 Avoid consumption of carbonated soft drinks in place of dairy products or foods fortified with calcium.^Citation1,Citation8
Inactive life style	An inactive or sedentary lifestyle or extended bed rest tends to weaken bones because of lack of adequate weight-bearing exercise. Activity-induced loading promotes bone health.^Citation1,Citation8,Citation10	Integrate weight-bearing exercise into daily activities: walking, hiking, jogging, climbing stairs, weight training, active sports. Strength-training (including weight lifting) or resistance-training activities produce the greatest benefit to bones. Exercises that include jumping are recommended for individuals without significant bone loss as jumping may increase risk of vertebral fractures. Participation in $30 minutes of moderate physical activity on most (or all) days of the week is recommended.^Citation1,Citation8
	Some people are unable to increase their exercise because of pre-existing disabilities that limit their physical activity.	Consult a physical therapist or trainer for a program tailored to the individual.^Citation8
Alcohol abuse	Excessive intake of alcohol may increase bone loss, including in young women and men. Alcohol abuse may increase risk because of poor nutrition and increased risk of falls may increase risk of fracture. Alcohol has been reported to inhibit bone remodeling.^Citation10	Stop or limit alcohol intake to no more than 1–2 ounces a day.^Citation1,Citation10
Smoking	Women who smoke have lower levels of estrogen compared with nonsmokers, and may go through menopause earlier. Smoking may also interfere with absorption of dietary calcium. Toxins produced by smoking may impair the function of bone cells and decrease absorption of calcium from the intestine.^Citation8	Stop smoking; employ smoking cessation strategies.^Citation1,Citation8
Eating disorders	Inadequate nutritional intake may increase risk because of inadequate consumption of foods with calcium and vitamin D and low body weight, which is an independent risk factor.^Citation8,Citation10	Seek treatment for eating disorders. Ensure adequate caloric intake and consumption of foods with calcium and vitamin D. Use calcium and vitamin D supplementation if needed to achieve adequate intake.

Table 2 World Health Organization definitions based on bone density levels

Level	Definition/interpretation
Normal	Bone density is within 1 SD (±1) of the young adult mean.
Low bone mass (osteopenia)	Bone density is between 1 and 2.5 SD below the young adult mean (−1 to −2.5 SD). Often interpreted as osteopenia.
Osteoporosis	Bone density is 2.5 SD or more below the young adult mean (−2.5 SD or lower).
Severe (established) osteoporosis	Bone density is more than 2.5 SD below the young adult mean, and there have been one or more osteoporotic fractures.

Note: Reproduced with the permission of the publisher, from Assessment of osteoporosis at the primary health care level. Geneva, World Health Organisation, 2007 (WHO Scientific Group Technical Report; http://www.iofbonehealth.org/sites/default/files/WHO_Technical_Report-2007.pdf, accessed May 12 2014).⁵

Abbreviation: SD, standard deviation.

Table 3 Selected diagnostic tests used to identify causes of primary and secondary osteoporosis

Tests	Rationale for tests
Chemistry levels
Alkaline phosphatase	Used to identify effects of immobilization, Paget’s disease, acute fractures, other bone diseases
Calcium	Measured prior to initiation of medications; also obtained to rule out hypocalcemia (due to malabsorption syndromes and vitamin D deficiency) and hypercalcemia due to hyperparathyroidism
Liver or kidney function tests	Obtained to identify liver or kidney disease, which may be underlying cause
Complete blood count	Used to rule out bone marrow malignancy, malabsorption syndromes, or infiltrative process (anemia)
Thyroid-stimulating hormone	Used to diagnosis hyperthyroidism; also obtained in patients on thyroid hormone supplementation
Parathyroid hormone	Used to rule out hyperparathyroidism
Total testosterone level (men) Estradiol (women)	Used to exclude hypogonadism as underlying cause
25-hydroxyvitamin D	Used to identify vitamin D deficiency, which should be corrected prior to initiation of treatment of low bone mass or osteoporosis
	Also used to rule out hyperparathyroidism as cause of secondary osteoporosis
24-hour urinary calcium	Used to identify malabsorptive states (such as celiac sprue) or vitamin D deficiency. Identifies hypercalciuria (which is a correctable cause of bone loss)
Biochemical markers of bone turnover	May be obtained in selected patients to assess bone turnover. Markers include serum C-telopeptide, serum bone-specific alkaline phosphatase, osteocalcin, and amino terminal propeptide of type 1 procollagen. Urine tests may include N-telopeptide
Lateral chest X-rays	Anterior-posterior X-rays of the thorax may be used to identify vertebral fractures as a cause of loss of height

Note: Data from Premaor and Compston,⁶ Hofbauer et al⁷ and the National Osteoporosis Foundation.⁸

Table 4 Pharmacologic and nonpharmacologic treatments for osteoporosis

Pharmacologic treatments
Classification, action, medication name, route of administration	Specific precautions and side effects	Outcomes			Teaching points and other nursing actions
Bisphosphonates
Action: inhibit osteoclast-mediated bone resorption
Oral preparations: Alendronate (Fosamax^®), Risedronate (Actonel^®) Ibandronate (Boniva^®)	Oral preparations may be prescribed for daily, weekly, or monthly dosing For all oral preparations, patients are instructed to drink 6–8 oz of plain water, sit upright for 30–60 minutes, and avoid all other oral intake for 60 minutes	Bisphosphonates have been shown to decrease incidence of vertebral and nonvertebral factures^Citation91–Citation94	Emphasize “dental checkup and cleanup” before initiation of therapy; maintain oral hygiene, ensure that patient is aware of the potential side effects and about the importance of regular dental checkups^Citation95
Alendronate sodium (Binosto^®) effervescent tablet for oral administration once weekly	The tablet must be dissolved in 4 oz/120 mL plain water at room temperature After bubbling stops, the liquid is stirred and swallowed after waiting at least 5 minutes until the tablet is completely dissolved Esophageal irritation is likely if administration instructions are not followed Abdominal and musculoskeletal pain, nausea, dyspepsia, constipation, diarrhea, and flatulence^Citation91–Citation94 Although rare, osteonecrosis of the jaw has been reported with bisphosphonates^Citation95,Citation97 Long-term use may be associated with atypical fractures Viral-like illness has been associated with all the bisphosphonates^Citation97,Citation98	Binosto^® is used for the treatment of osteoporosis in postmenopausal women and to increase bone mass in men with osteoporosis^Citation96	Reinforce specific precautions to use when taking oral bisphosphonates to minimize gastrointestinal effects and optimize effectiveness Teach patient about the importance of adequate calcium and vitamin D intake along with bisphosphonates Encourage patient to follow-up with primary care provider for monitoring of laboratory test results and BMD
Intravenous preparations: Zoledronic acid (Reclast^®) (intravenous infusion annually)	Hypersensitivity and viral-like symptoms (fever, muscle pain, headache); other rare risks include osteonecrosis of the jaw Contraindicated in pregnant and nursing women		Adequate hydration and acetaminophen (eg, Tylenol^®) prior to the administration may reduce the incidence of viral-like symptoms (transient fevers and myalgia) hat may occur with Reclast^®91
Receptor activator of nuclear factor kappa-B (RANK) ligand (RANKL)/RANKL inhibitor
Action: inhibits development and activity of osteoclasts, decreases bone resorption, and increases bone density
Denosumab (Prolia^®) Subcutaneous injection every 6 months	Used for patients at high risk for fracture or when other treatments have failed or are not tolerated Back pain, musculoskeletal pain, pain in extremities, cystitis, hyperlipidemia, increased risk of infections Osteonecrosis of the jaw is a rare complication Contraindicated in patients with hypocalcemia Allergic reactions are possible	Can be used in patients with renal failure; used to treat bone loss in women with breast cancer and in men receiving certain treatments for prostate cancer who are at high risk for fracture. Significantly reduces risk of new vertebral and hip fractures in postmenopausal women $75 years of age with established osteoporosis and at high risk for fractures, and achieves significant gains in BMD^Citation99–Citation101 Reduces the incidence of vertebral fractures by about 68%, hip fractures by about 40%, and nonvertebral fractures by about 20% over 3 years^Citation8		Encourage dental care prior to initiation of treatment. Ensure that patient is aware of the potential side effects and about the importance of regular dental care and dental checkups In addition to improved dental hygiene, invasive dental procedures should be avoided during denosumab therapy. Instruct patients to seek care if signs of infection occur
Selective estrogen receptor modulators
Action: nonsteroidal agent binds to the estrogen; acts as an agonist at bone, action on bone similar to action of estrogen
Raloxifene (Evista^®) Daily oral dose	Increased risk of venous thromboembolic events, deep venous thromboembolism, hot flashes, vaginal bleeding, breast pain, leg cramps	Prevents bone loss and reduces the risk of vertebral fractures by 30%–50% in postmenopausal women with low bone mass or osteoporosis with or without prior vertebral fracture^Citation102 Decreases risk of invasive breast cancer (by about 60%)^Citation102,Citation103		Instruct patients taking SERMs to monitor for side effects, especially venous thromboembolic events and deep vein thrombosis, leg cramps, and hot flushes
Recombinant human parathyroid hormone
Action: stimulates osteoblastic activity to increase new bone formation
Teriparatide (Foreto^®) Daily subcutaneous injection	Used in patients at high risk for fracture or if other therapies have been ineffective or not tolerated^Citation91 Has been associated with rare cases of bone tumor and osteosarcoma; hypercalcemia, transient and mild nausea, orthostatic hypotension, and leg cramps; contraindicated in patients with renal impairment^Citation91	Significantly increases bone density at the spine; reduces vertebral and nonvertebral fractures^Citation104 Safety not established beyond 2 years; therefore, not recommended for use beyond 2 years^Citation98		Instruct patients about injection technique and need to keep medication refrigerated at all times Advise patient to report nausea, vomiting, constipation, low energy, or muscle weakness, which may occur with hypercalcemia
Calcitonin
Action: an endogenous polypeptide hormone that inhibits osteoclastic bone resorption
Calcitonin (Miacalcin^®) Available for administration by subcutaneous, intramuscular, and intranasal routes. Nasal spray application daily	Nasal application provides a biological activity of 25%–50% compared with the injectable formulation; hypersensitivity, rhinitis, irritation of nasal mucosa, epistaxis In 2013, the FDA recommended that the use of calcitonin to treat osteoporosis be halted because of low benefit and increased risk of cancer^Citation106	Calcitonin modestly increases bone mineral density at the lumbar spine and forearm^Citation105		If this formulation is prescribed, patients need instructions about appropriate use and precautions
Exercise	Exercise performed in the presence of adequate calcium and vitamin D intake has a modest effect on slowing the decline in BMD^Citation107,Citation108	30 minutes of high or low impact weight bearing exercise or muscle-strengthening exercise on most days of the week is recommended to increase BMD, to improve agility, strength, posture and balance and reduce the risk of falls and fractures^Citation109,Citation110		Multifactorial strategies to encourage exercise and reinforce adherence to an exercise plan are important because exercise adherence is a challenge, especially for elderly^Citation111,Citation112
Nutrition: Calcium and vitamin D	Calcium is considered the primary nutrient for attaining peak bone mass and for preventing and treating osteoporosis When the exogenous supply is inadequate, bone tissue is resorbed from the skeleton to maintain serum calcium at a constant level^Citation8 Vitamin D is required for optimal calcium absorption, muscle performance, balance, which reduce risks for falling^Citation56	A diet rich in fruits and vegetables and that includes adequate amounts of total calcium intake (1,000 mg per day for men aged 50–70 years; 1,200 mg per day for women aged 51 years and older and men 71 years and older); vitamin D intake (800–1,000 IU per day), including supplements if necessary for individuals age 50 and older and of 1 g/kg body weight of protein per day in men and women over the age of 50 years^Citation8,Citation113 Calcium-rich food (dairy products and green leafy vegetables) contribute to bone health and are preferred over supplementation; calcium supplementation should be limited to those with inadequate dietary calcium intake and those at high risk for osteoporosis; inadequate intake is common among all groups, especially the elderly^Citation24 Adequate intake of calcium and vitamin D is needed for medications to be effective^Citation24		Patient teaching is important to ensure that patients in all age groups and those treated for osteoporosis receive an adequate intake of calcium and vitamin D Strategies to reinforce adherence should be implemented An adequate intake of calcium and vitamin D may reduce the risk of fracture and falling^Citation114 Interventions aimed at improving dietary knowledge, health beliefs, self-efficacy, and promoting behavior changes conducted demonstrate the effectiveness of management of osteoporosis^Citation50,Citation51,Citation90,Citation114–Citation121
Protein	Sufficient protein intake is needed to maintain musculoskeletal function^Citation122	An individual’s diet needs to be evaluated to determine appropriate intake of calcium, vitamin D, and protein		Correction of poor protein nutrition in patients with a recent hip fracture has been shown to improve the subsequent clinical course by significantly lowering the rate of complications such as pressure ulcers, severe anemia, and intercurrent lung or renal infection

Note: Manufactuer details are as follows: Fosamax^®, Merck Sharp & Dohme Corp., Whitehouse Station, NJ, USA; Actonel^®, Warner Chilcott, Rockaway, NJ, USA; Boniva^®, F. Hoffmann-La Roche Ltd., Basel, Switzerland; Binosto^®, EffRx Pharmaceuticals SA, Freienbach, Switzerland; Reclast^® and Miacalcin^®, Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA; Prolia^®, Amgen Inc., Thousand Oaks, CA, USA; Evista^® and Foreto^®, Eli Lilly and Company, Indianapolis, IN, USA.

Abbreviations: BMD, bone mineral density; SERMs, selective estrogen receptor modulators; FDA, US Food and Drug Administration.

Table 5 Falls prevention

Outdoors (patient education) Use a cane or walker for added stability Wear rubber-soled shoes for traction Use ice cleats to avoid slipping on ice and falling Walk on grass when sidewalks are slippery In winter, carry salt or kitty litter to sprinkle on slippery sidewalks Be careful on highly polished floors that become slick and dangerous when wet Use plastic or carpet runners when possible Indoors (patient education) Keep rooms free of clutter, especially floors Keep floor surfaces smooth but not slippery Wear supportive, low-heeled shoes even at home Avoid walking in socks, stockings, or slippers Be sure carpets and area rugs have skid-proof backing or are tacked to the floor Be sure stairwells are well lit and that stairs have handrails on both sides Install grab bars on bathroom walls near tub, shower, and toilet Use a rubber bath mat in shower or tub Keep a flashlight with fresh batteries beside the bed to use when getting up in the dark; use a night light If using a step stool for hard-to-reach areas (avoid their use if possible), use a sturdy one with a handrail and wide steps Add ceiling fixtures to rooms lit by lamps to avoid shadows Consider purchasing a cordless phone so that there is no rush to answer the phone when it rings, or so that you can call for help if you do fall Engage in activities to improve strength and balance (eg, muscle strengthening exercises, Tai Chi) Keep closet doors and drawers closed If patient is hospitalized (nursing actions) Encourage patient to use assistive device if used at home Have patient’s shoes readily available and encourage patient to wear them rather than slippers when out of bed Keep bed in a low position to make it easier for the patient to get out of bed safely Avoid full length side rails on bed Maintain adequate light in the patient’s room at all times, including at night Remove objects (eg, chairs, tables) in the patient’s room that serve as barriers to the bathroom Ensure that any spills are cleaned up immediately to prevent patient from slipping and falling Keep call-bell within easy reach of patient at all times Place all objects that may be needed by the patient within easy reach

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