Building Strong Bones: Nurse's Guide to the Latest in Osteoporosis Management in 2023

Michelle Flanagan, MSN, NP

Table of Contents

Types of Osteoporosis
Pathophysiology
Causes and Risk Factors
Signs and Symptoms
Screening and Diagnostic Assessment
Treatment and Management
Patient Education
Recent Treatment Breakthrough
Clinical Experience
Key Takeaways

Osteoporosis is loss of bone mass and density which can lead to bone fragility and increased risk for bone fractures [¹]. Bone fractures can occur anywhere in the body with the most common fractures occurring in the wrist, hip, and vertebra.

In the United States, during 2017-2018, there were 18.8% of women and 4.2% of men 50 years and older with osteoporosis in their lumbar spine or femur neck [²]. Worldwide, there are about 500 million women and men who have osteoporosis, and there are 8.9 million osteoporotic fractures that occur yearly [³].

Types of Osteoporosis:

Primary osteoporosis. Primary osteoporosis is classified as deterioration of bones that leads to increased risk of fracture, which mostly occurs in postmenopausal women and men over 75 years old [⁴].

Secondary Osteoporosis. Secondary osteoporosis is bone loss caused by certain medications or medical conditions [⁵].

Pathophysiology

There are two types of cells that are essential in bone structure; this comprises of osteoclasts (bone resorption cells) and osteoblasts (bone forming cells) ⁴. Every year, about 10% of bone is remodeled with this process ⁴. The remodeling process is regulated by several hormones, such as calcitriol produced by vitamin D3, calcitonin, parathyroid hormone, testosterone, and estrogen ⁴ [⁶]. If the amount of the bone resorbed is greater than the amount formed, then it can lead to osteoporosis ⁴.

Causes and Risk Factors

Osteoporosis has more likelihood of developing in those with certain risk factors including¹:

Age. The older you get, the more likely you are to have bone loss since new growth of bone is slower than the loss.
Gender. Women are at greater risk of developing osteoporosis than men.
Body Frame. Thinner and slender body frames are more likely to develop osteoporosis.
Race. Asian and Caucasian women are the highest risk for developing osteoporosis.
Hormonal Changes. Low estrogen levels, such as in postmenopausal women, increase the chances of bone loss. Low testosterone levels in men can contribute to bone loss.
Family History. There is a greater chance of developing osteoporosis if you have a family member that has it.
Co-morbidities. There are medical conditions and treatments of these conditions that can lead to increased risk for osteoporosis including gastrointestinal diseases, rheumatoid arthritis, malnutrition, type 1 diabetes, and certain types of cancers ¹ [⁷].
Lifestyle. Sedentary lifestyle, chronic alcohol use, and smoking tobacco are additional risk factors.
Medications. Long-term use of proton pump inhibitors, corticosteroids, antiepileptic medications, hormonal cancer treatments, selective serotonin reuptake inhibitors, and thiazolidinediones (for type 2 diabetes treatment) can lead to bone loss.

Signs and Symptoms

Typically, osteoporosis does not have any symptoms and is known as the "silent" disease until a fracture occurs ¹.

Screening and Diagnostic Assessment

Dual-energy X-ray Absorptiometry (DXA) measures bone mineral density (BMD) and should be performed for women 65 years and older and men 70 years and older ⁷. A DXA T-score of -2.5 or higher is a diagnosis of osteoporosis ⁴. A person who presents with a fracture in their adulthood should be evaluated for osteoporosis. Assessing fall risk status is critical to prevent morbidity and mortality.

Treatment and Management

Treatment of osteoporosis should be considered depending on the patient's history and score from the Fracture Risk Assessment Tool (FRAX) ⁷. The FRAX score is used to calculate the probability of a major osteoporotic fracture within 10 years.

Pharmacologic treatment options include:

Bisphosphonates: alendronate (Fosamax), zoledronic acid (Reclast), and risedronate (Actonel)
RANKL inhibitors: denosumab (Prolia)
Estrogen-related therapies.
Calcitonin salmon.
Sclerostin inhibitors.
Parathyroid hormone analogs.

Lifestyle management includes:

Calcium intake. Starting at a young age, it is vital to eat a calcium-rich diet to protect the bone tissue. It is recommended to consume 1000 mg/day for women ages 19-50 and men ages 19-70, and 1200 mg/day for women over age 50 and men over age 70.
Vitamin D intake. For those age 50 and over, they should consume a daily intake of 800-1000 international units of vitamin D through food, sun exposure or by taking a vitamin D supplement.
Weight-bearing exercises. Examples include walking, running, dancing, and jumping.
Preventing Falls. This involves avoiding slippery rugs in the home, using assistive devices, and using non-slip socks/shoes.

Education to Patients

Patients need education on osteoporosis prevention, causes and potential risk factors, as well as treatment options to improve their self-care at home. There should be an emphasis on lifestyle changes including physical exercise, dietary recommendations, fall prevention, smoking cessation, limiting alcohol intake, and taking prescribed medications [⁸].

Poor medication compliance is common, and educating patients on how to take medications will help them adhere to their regime. For example, alendronate (Fosamax) is a commonly prescribed treatment, and this needs to be taken in the morning, prior to any food or drinks, with a full 8 oz glass of water and they need to remain upright for at least 30 minutes after taking the pill [⁹].

Recent Treatment Breakthrough

In 2019, the U.S. Food and Drug Administration approved Evenity (romosozumab-aqqg) to treat high-risk postmenopausal women [¹⁰]. Evenity is an injectable monoclonal antibody that improves new bone growth by blocking the protein sclerostin, which is responsible for stopping bone growth production. It is given as two subcutaneous injections on the same day and then monthly for a maximum of 12 months. The new drug has the warning of increased risk for stroke, heart attacks and cardiovascular death and should be avoided in those at high risk for these conditions.

Recently, a newly developed technology called the deep learning model was created to improve accuracy of osteoporosis risk screening [¹¹]. It uses explainable artificial intelligence (XAI) techniques to evaluate additional variables not identified by conventional methods, and studies suggest it is more accurate than clinical assessment tools and machine-learning models[¹¹]. Since the quality of a DXA scan depends on manual validation, AI-based algorithms have been used and have shown to perform better in trabecular bone score and evaluating bone mineral density[¹²]. Accurate osteoporosis screening is needed to consider initiating treatment.

On February 23rd this year, the World Health Organization (WHO) and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) signed a five-year agreement for an action plan that will help older adults improve their bone health. The objectives will involve applying evidence-based interventions and policies to reduce bone fractures[¹³].

Clinical Experience

In my years of experience as both a registered nurse and a nurse practitioner, I have found that many adults are unaware of the significance of morbidity and mortality surrounding osteoporosis. Many do not realize that their bone health starts in their youth and prevention of bone loss at a young age will determine their BMD in the future.

There have been several incidences where a patient presents to the office with an acute fracture and is unaware of their osteoporosis due to not meeting the age requirements for screening. Therefore, individualizing care based on someone's history and presentation can improve their outcomes.

Key Takeaways

Osteoporosis is loss of bone mass and density.
Most common fractures are wrist fractures, hip fractures, and vertebral fractures.
High-risk patients for osteoporosis include being female, thin body frame, sedentary lifestyle, being Caucasian or Asian, chronic alcohol use, tobacco use, family history of osteoporosis, and older age.
DXA is the primary diagnostic tool for osteoporosis.
The FRAX score is a helpful tool in determining the need for pharmacological therapy.
Prevention with lifestyle changes at an early age can improve BMD as you age.
Regardless of age, any acute pain with movement could indicate a fracture and should be evaluated by a healthcare provider.

References

National Institute of Arthritis and Musculoskeletal and Skin Disease. (2022). Osteoporosis. https://www.niams.nih.gov/health-topics/osteoporosis
Centers for Disease Control and Prevention. (2022). Osteoporosis. https://www.CDC.gov/nchs/fastats/osteoporosis.htm
International Osteoporosis Foundation. (2023a). Epidemiology of osteoporosis and fragility fractures. https://www.osteoporosis.foundation/facts-statistics/epidemiology-of-osteoporosis-and-fragility-fractures
Ji, M.-X., Yu, Q. (2015). Primary osteoporosis in postmenopausal women. Chronic Diseases and Translational Medicine, 1(1), 9-13. https://onlinelibrary.wiley.com/doi/10.1016/j.cdtm.2015.02.006
International Osteoporosis Foundation. (2023b). Osteoporosis. https://www.osteoporosis.foundation/health-professionals/about-osteoporosis
Mohamad, N.-V., & Soelaiman, I.-N. (2016). A concise review of testosterone and bone health. Clinical Interventions in Aging, 11, 1317. https://www.dovepress.com/getfile.php?fileID=32572
LeBoff, M. S., Greenspan, S. L., Insogna, K. L., Lewiecki, E. M., Saag, K. G., Singer, A. J., & Siris, E. S. (2022). The clinician's guide to prevention and treatment of osteoporosis. Osteoporosis International, 33(10), 2049. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9546973/?report=classic
Porter, J. L., Varacallo, M., Castano, M. (2022). Osteoporosis (Nursing). https://www.ncbi.nlm.nih.gov/books/NBK568781/
https://www.accessdata.fda.gov/drugsatfda_docs/label/2004/20560slr030,21575slr002_fosamax_lbl.pdf
FDA. (2019). FDA approves new treatment for osteoporosis in postmenopausal women at high risk of fracture. https://www.fda.gov/news-events/press-announcements/fda-approves-new-treatment-osteoporosis-postmenopausal-women-high-risk-fracture
Suh, B., Yu, H., Kim, H., Lee, S., Kong, S., Kim, J.-W., & Choi, J. (2023). Interpretable Deep-Learning Approaches for Osteoporosis Risk Screening and Individualized Feature Analysis Using Large Population-Based Data: Model Development and Performance Evaluation. Journal of Medical Internet Research, 25, e40179. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9883743/
Inside Precision Medicine. (March 1, 2023). AI-Based algorithm could improve osteoporosis diagnosis and monitoring. https://www.insideprecisionmedicine.com/artificial-intelligence/ai-based-algorithm-could-improve-osteoporosis-diagnosis-and-monitoring/
World Health Organization. (February 23, 2023). New collaboration targets better bone health and ageing. https://www.who.int/news/item/23-02-2023-new-collaboration-targets-better-bone-health-and-ageing