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Osteoporosis: An Overview
Dana Bartlett, RN, BSN, MSN, MA
Dana Bartlett is a professional nurse and author. His
clinical experience includes 16 years of ICU and ER
experience and over 20 years of as a poison control
center information specialist. Dana has published
numerous CE and journal articles, written NCLEX material and textbook chapters, and done
editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written
widely on the subject of toxicology and was recently named a contributing editor, toxicology
section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison
Control Center and is actively involved in lecturing and mentoring nurses, emergency
medical residents and pharmacy students.
ABSTRACT
Osteoporosis is a condition of reduced bone mass that results in fractures
and significant pain that can occur anywhere in the body. It generally results
in elderly individuals but can occur in any age group due to nutritional
deficits and hormonal changes. Nurses play an important role in educating
patients and promoting prevention of bone injury, such as lifestyle changes
and fall prevention. This study focuses on disease etiology, progression and
prevention of injury, including medical regimens to reduce osteopenia and
bone loss.
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Continuing Nursing Education Course Planners
William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,
Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner
Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for all
continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 2 hours. Nurses may only claim credit
commensurate with the credit awarded for completion of this course activity.
Pharmacology content is 1 hour (60 minutes).
Statement of Learning Need
Nurses caring for individuals with osteoporosis as well as their families need
continuing learning to understand the disorder, health risks and prevention
strategies involved.
Course Purpose
To provide an overview of osteoporosis, including its prevalence, signs and
symptoms, diagnosis, prevention, and treatment.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Dana Bartlett, RN, BSN, MA, MSN, William S. Cook, PhD,
Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC - all have no
disclosures.
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
Reviewed by Susan DePasquale, MSN, FPMHNP-BC.
Release Date: 1/1/2016
Termination Date: July 28, 2017
Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
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1. Approximately 80% of the cases of osteoporosis in the United
States occur in
a. women
b. African Americans
c. men
d. young adults
2. Osteoporosis is caused by a disruption in
a. calcium absorption
b. blood supply to the bones
c. bone remodeling
d. the nerve fibers of the bones
3. Post-menopausal osteoporosis is primarily caused by
a. an increase in serum parathyroid hormone levels
b. decreased production of estrogen
c. decreased intake and absorption of vitamin D
d. decreased blood supply to the bones
4. Age-related osteoporosis is primarily caused by
a. decreased exposure to sunlight
b. decreased production of estrogen and testosterone
c. increased renal excretion of calcium and vitamin D
d. a decrease in the number of functioning osteoblasts
5. Which of these is considered first-line treatment for osteoporosis?
a. Calcitonin
b. Parathyroid hormone
c. Vitamin D and calcium supplementation
d. Biphosphonates
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Introduction
Osteoporosis is a chronic bone disease that affects millions of Americans. It
is characterized by an imbalance between bone growth and bone breakdown
that results in decreased bone mass and an increased risk of fractures. The
disease is progressive and clinically silent, and in many cases it is not
detected until someone who has osteoporosis breaks a bone or has a
diagnostic screening test. Treatment can stop the progression of the disease
but cannot reverse osteoarthritis that is established.
Epidemiology
Approximately 54 million Americans have osteoporosis and/or low bone
mass,1 and osteoporosis is the most common metabolic bone disorder in the
United States.2 Approximately 80% of all cases of osteoporosis in the United
States occur in women,2 but it has been estimated that about 1.5 million
American men over age 65 have osteoporosis.3 The incidence of osteoporosis
is lower in African Americans.2 The incidence of osteoporosis increases with
age and the majority of women between the ages of 70-80 meet the clinical
criteria for osteoporosis.4
Definition of osteoporosis and pathophysiology
The World Health Organization (WHO) defines osteoporosis as “ . . . a
systemic skeletal disease characterized by low bone density and
microarchitectural deterioration of bone tissue with a consequent increase in
bone fragility.”5
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The basic cause of osteoporosis is a disruption of bone remodeling. Bone
remodeling is comprised of two processes, bone resorption and bone
formation. Bone resorption is the breakdown of mature bone by cells called
osteoclasts. Bone formation is the construction of new bone by cells called
oseoblasts. When bone construction cannot match bone resorption there is a
net bone loss and osteoporosis results.
Causes Of Osteoporosis
Osteoporosis is classified as primary or secondary. Primary osteoporosis is a
bone disease that is related to aging and hormonal shifts, in the absence of
any disease or condition known to cause osteoporosis. There are two types
of primary osteoporosis that affect adults, post-menopausal osteoporosis
and age-associated osteoporosis. Post-menopausal osteoarthritis is caused
by decrease production of estrogen, which in turn increases the activity of
osteoclasts.2 Age-associated osteoporosis is caused by a progressive
decrease in the number of functioning osteoblasts.
Secondary osteoporosis is caused by a disease process, a medication, or a
life style factor.2 A list of drugs and diseases that may cause secondary
osteoporosis is in Table 1.2,6 In addition, any condition that leads to a lack of
mobility such as a stroke or advanced Parkinson’s disease may result in
reduced bone mass and would be considered a risk factor for developing
osteoporosis.
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TABLE 1: Conditions, Diseases and Medications That Cause or Contribute to
Osteoporosis and Fractures
LIFESTYLE FACTORS:
Alcohol abuse
Excessive thinness
Excess Vitamin A
Frequent falling
High salt intake
Immobilization
Inadequate physical
Low calcium intake
Smoking (active or
activity
passive)
___________________________________________________________
GENETIC DISEASES:
Cystic fibrosis
Ehlers-Danlos
Gaucher’s disease
Glycogen storage
Hemochromatosis
Homocystinuria
Marfan syndrome
Menkes steely hair
diseases
Hypophosphatasia
syndrome
Osteogenesis
Parental history of
imperfecta
hip fracture
Porphyria
Riley-Day syndrome
_______________________________________________________________
HYPOGONADAL STATES:
Androgen insensitivity
Anorexia nervosa
Athletic amenorrhea
Hyperprolactinemia
Panhypopituitarism
Premature
menopause (<40 yrs)
Turner’s & Klinefelter’s syndromes
Endocrine disorders
Central obesity
Cushing’s syndrome
Diabetes mellitus
(Types 1 & 2)
Hyperparathyroidism
Thyrotoxicosis
____________________________________________________________
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GASTROINTESTINAL DISORDERS:
Celiac disease
Gastric bypass
Gastrointestinal
surgery
Inflammatory bowel
Malabsorption
Pancreatic disease
disease
Primary biliary cirrhosis
____________________________________________________________
HEMATOLOGIC DISORDERS:
Hemophilia
Multiple myeloma
Leukemia and
Monoclonal
lymphomas
gammopathies
Sickle cell disease
Systemic
mastocytosis
Thalassemia
__________________________________________________________
RHEUMATOLOGIC AND AUTOIMMUNE DISEASES:
Ankylosing spondylitis
Other rheumatic and autoimmune
diseases
Rheumatoid arthritis
Systemic lupus
___________________________________________________________
NEUROLOGICAL AND MUSCULOSKELETAL RISK FACTORS:
Epilepsy
Multiple sclerosis
Muscular dystrophy
Parkinson’s disease
Spinal cord injury
Stroke
___________________________________________________________
MISCELLANEOUS CONDITIONS AND DISEASES:
AIDS/HIV
Alcoholism
Amyloidosis
Chronic metabolic acidosis
Chronic obstructive
Congestive heart
lung disease
failure
Depression
End stage renal disease
Hypercalciuria
Idiopathic scoliosis
Post-transplant bone
Sarcoidosis
disease
Weight loss
_________________________________________________________
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MEDICATIONS:
Aluminum (in antacids)
Anticoagulants
Anticonvulsants
(heparin)
Aromatase inhibitors
Barbiturates
Cancer
chemotherapeutic
drugs
Depo-
Glucocorticoids (≥ 5
GnRH (Gonadotropin
medroxyprogesterone
mg/d prednisone or
releasing hormone)
(premenopausal
equivalent for ≥ 3
agonists
contraception)
months)
Lithium Cyclosporine A
Methotrexate
Parenteral nutrition
and tacrolimus
Proton pump inhibitors
Selective serotonin reuptake
inhibitors (SSRIs)
Tamoxifen®
Thiazolidinediones
Thyroid hormones (in
(premenopausal use)
(Actos® and Avandia®)
excess)
Risk Factors for Osteoporosis
Factors that increase the likelihood of developing osteoporosis include:

Alcohol use > three drinks a day

Advanced age

Anticonvulsants

Ethnicity: Asian and Causcasian

Family history of osteoporosis

Female gender

Hypogonadism

Low body mass index

Low calcium intake
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
Premature menopause

Previous fractures

Sedentary life style

Thyroid excess

Smoking
Some of the risk factors can be remembered by using the mnemonic
osteroporosis.2
 Low calcium intake
 Seizure medications (anticonvulsants)
 Thin build
 Ethanol intake
 Hypogonadism
 Previous fracture
 Thyroid excess
 Race (Caucasian, Asian)
 Other relatives with osteoporosis
 Steroids
 Inactivity
 Smoking
The World Health Organization (WHO) has
developed an algorithm that uses risk factors
to calculate the 10-year risk of a hip fracture
or any other major fracture caused by
The FRAX tool can be
viewed online at
http://www.shef.ac.uk/
FRAX/.
Click on Calculation Tool
and follow the
instructions.
osteoporosis. This assessment tool is called
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the fracture-risk algorithm, FRAX, and it uses these criteria.

Alcohol intake

Gender

Family history of hip fracture

History of fracture

Low body mass index

Use of oral glucocorticoid therapy

Secondary osteoporosis (i.e., coexistence of rheumatoid arthritis)

Tobacco use Current smoking status
The National Osteoporosis Foundation (NOF) guidelines notes the following
restrictions for the FRAX tool:
1) it is intended to be used for post-menopausal women and men 50 years
of age and older; 2) it was not intended to be used for young adults or
children; 3) the validity of the FRAX tool has been evaluated in patients who
are currently receiving drug therapy for osteoporosis or who previously
received drug therapy for osteoporosis; and, 4) the femoral neck bone
mineral density is preferred when using the FRAX tool.8
Risk Factors for Falls
Most fractures in patients who have osteoporosis are caused by falls. Some
of the risk factors that increase the chances of falling are listed in Table 2.8
The NOF Clinician's Guidelines can be accessed for more information; it
contains the latest information on how to screen individuals with
osteoporosis for their risk of fall injury or bone fractures and on the best
methods to evaluate them, including biochemical markers in men and
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women relative to bone health and the use of supplementation such as
calcium and vitamin D.
Table 2: Risk factors that increase the chances of falling

Poor lighting

Slippery floor surfaces

Advanced age

Dehydration

Medications that cause sedation

Orthostatic hypotension

Poor balance

Poor vision

Previous falls

Urinary incontinence or urgency
Signs and Symptoms
Osteoporosis is typically not associated with any specific signs or symptoms.
Some patients may complain of back pain that is caused by a vertebral
collapse or fracture. Another common presenting symptom is loss of height
with progressive kyphosis. Fractures in other parts of the body may also
occur with minimal or no trauma in someone with osteoporosis.
Complications
The most common complication of osteoporosis is fracture. It has been
estimated that each year in the United States osteoporosis is the cause of
almost 1.5 million fractures,7 and fractures of the vertebrae, proximal femur
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(hip), and distal forearm are the most common.8 The lifetime incidence of
fractures caused by osteoporosis is 40%-50% for women and 13%-22% for
men,9 and approximately 90% of hip and spine fractures in elderly women
are caused by osteoporosis.8
Hip fractures are especially serious. Only 40% of those who suffer a hip
fracture regain their previous level of independence,7 and hip fractures can
cause chronic pain, increased mortality, and loss of function and mobility.8
Vertebral fractures and fractures of the forearm are also a significant cause
of disability, pain, and limitations to activity. Fractures caused by
osteoporosis are not always preceded by noticeable trauma.
Diagnosis Of Osteoporosis
The diagnosis of osteoporosis is often made on screening. The use of dualenergy X-ray absorptiometry (DEXA) measures bone mineral density and is
the preferred method for measuring bone mineral density and diagnosing
osteoporosis.2 The National Osteoporosis Foundation recommends bone
mineral density testing in: 7
 all women age 65 and older
 all men age 70 and older
 postmenopausal women and men above age 50-69, based on risk
factor profile
A DEXA scan compares the bone density of the person being tested to that
of a person 20 - 29 years of age. A score (called a T-score) is reported, with
an average bone density score of zero. Scores above zero indicate more
dense bones than the average person 20 – 29 years of age; and, scores less
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than zero indicate less dense bones than the average person 20 – 29 years
of age. Osteopenia (bones that are thinner than average but not thin enough
to be classified as osteoporosis) is diagnosed when the T-score falls between
-1.0 and –2.4. Individuals that have T-scores less than or equal to –2.5
have osteoporosis.2
When the diagnosis of osteoporosis is made, other laboratory tests may be
done in selected cases to help rule out secondary causes and to help guide
the treatment of osteoporosis. Tests that may be done include:7

Complete blood count

Calcium level

Liver function tests

Magnesium level

Parathyroid horomone (PTH) level

Phosphorus level

Renal function tests

Testosterone and gonadotropin levels in younger men

Vitamin D level
The use of the DEXA scan is the gold standard, but sometimes other tests
are done. Computed tomography scanning can also be used to evaluate the
bone density, but it is more expensive and requires higher doses of radiation
than the DEXA scan, and is therefore infrequently used.5 Plain x-ray can rule
out fractures, but they are not sensitive enough to detect osteoporosis until
a patient’s bone density has decreased by 50%.7
Life Style Factors And Osteoporosis
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Lifestyle factors that may affect bone health include diet, exercise, cigarette
smoking cessation, and the use of alcohol. Lifestyle factors influencing the
development of osteoporosis are discussed in this section.
Diet
Insufficient dietary calcium levels have been identified as a risk factor for the
development of osteoporosis, and calcium supplementation is often
recommended for people at risk for osteoporosis. The National Osteoporosis
Foundation supports the recommendations of the Institute of Medicine for
calcium intake:7
 women age 51 and older and men age 50 - 70 should consume 1000
mg of calcium a day
 women 51 and older and men older than 71 should consume 1200 mg
of calcium a day
The 2014 Clinician’s Guidelines from the NOF notes that clinical trials have
shown that dietary supplementation with calcium and vitamin D can reduce
the risk of fractures, but the preventive role of calcium supplementation is
not clear. Vitamin D deficiency is an important consideration in bone health
that is further discussed below. Meta-analyses of the literature do not show
that calcium supplementation has a significant effect for preventing
fractures, and the use of calcium supplements can have harmful
cardiovascular, renal, and gastrointestinal effects,10 so the decision to use or
not use calcium supplementation must be made on a case by case basis.
Vitamin D deficiency has also been identified as a risk factor for developing
osteoporosis which is widespread,11 and the NOF recommends 800-1000 IU
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of vitamin D every day for people age 50 and older. Vitamin D is needed for
calcium absorption, and it helps increase muscle strength. Some of the
pharmacologic treatments for osteoporosis require adequate levels of
vitamin D.12 However, there is no unequivocal evidence that increasing
vitamin D levels helps to reduce the risk of fractures or prevents bone
loss,13-15 so as with calcium, the decision to use or not use vitamin D
supplementation must be made on a case by case basis.
Physical Exercise
Physical exercise can help increase bone mass and it strengthens muscle,
reducing the risk of fractures and the risk of falls,16 and the NOF
recommends exercise as a preventive measure for people at risk for
osteoporosis.
How much exercise and what type of exercise is needed to increase bone
mass is not clear.16 Additionally, it is uncertain that increasing bone mass is
the endpoint that should be used to measure the preventive effectiveness of
exercise.17 It may be that fall prevention through muscle strengthening is
why physical exercise is important for people who have or are at risk of
developing osteoporosis.17 Non-weight bearing physical exercise, while good
for the cardiovascular system, is not optimal to build and maintain bone
health, but it does encourage physical activity so it can be helpful for fall
prevention. Weight bearing exercises are preferred for patients who have, or
at risk for developing osteoporosis.
Smoking
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Smoking has long been recognized as a risk factor for developing
osteoporosis. Women who smoke have lower bone mineral density than
women who do not, reach menopause several years earlier than nonsmoking women,18 and increase their risk of fractures.19 In women who
smoke, these effects may be caused in part by decreased calcium and
estradiol levels and lower body mass index.19 However, the association
between smoking and fractures in women appears to persist even when
body mass is accounted for and smoking has been reported to be a risk
factor for a low bone mineral density and fractures in men, as well.20 The
mechanisms by which smoking decreases bone mineral density are not
completely understood, but the NOF recommends smoking cessation as an
osteoporosis intervention.
Alcohol Consumption
A drink is typically defined as
Alcohol has also been identified as a risk
14 grams of alcohol, an
factor for the development of osteoporosis.
amount found in 12 ounces of
The effects of alcohol on the development
beer, 5 ounces of wine, or 1.5
of osteoporosis are complex and include a
ounces of 40% hard liquor
direct, negative effect on the osteoblasts,
and endocrine and nutritional deficiencies
that are secondary to alcoholism.21
Alcohol is considered to be an independent
risk factor for the development of osteoporosis,22 and there is an inverse
relationship between the amount of alcohol consumed and the duration of
drinking and osteoporosis.21 The NOF notes in the 2014 guidelines that more
than two drinks a day for women and more than three drinks a day for men
may be detrimental to bone health.8
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Caffeine
High intake of coffee, usually estimated to be ≥ four cups a day, has been
identified as a possible risk factor for the development of osteoporosis.23
Caffeine may be directly harmful to osteoblasts24 or it may increase urinary
excretion of caffeine and decrease the intestinal absorption of caffeine.25 The
mechanism or mechanisms by which caffeine may affect bone mineral
density are not clearly understood, and several recent (2013) studies did not
find an association between high caffeine intake and a significant decrease in
bone mineral density or an increased risk of fractures.25,26
Treatment Of Osteoporosis
The goals of treatment of osteoporosis are: 1) to attenuate or prevent bone
loss; and, 2) prevent falls and fractures. All persons at risk for osteoporosis
should be evaluated for fall risk and be encouraged to make dietary and life
style changes that can help increase bone mineral density and prevent
fractures.
The NOF recommends considering pharmacological treatment in postmenopausal women and men over the age of 50 if the patient has a:

clinically or radiologically confirmed hip or vertebral fracture

T-score ≤ -2.5 at the femoral neck, total hip or lumbar spine

low bone mass (T-score between -1.0 and -2.5 at the femoral neck or
lumbar spine) and a 10-year probability of a hip fracture ≥3 percent
or a 10-year probability of a major osteoporosis-related fracture ≥20
percent based on the US FRAX algorithm
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Pharmacological Therapy for Osteoporosis
The medications that are currently (2014) approved by the Food and Drug
Administration (FDA) for the treatment of osteoporosis are: 1)
bisphosphonate derivatives; 2) calcitonin; 3) estrogen agonist/antagonist; 4)
estrogens or hormone therapy; 5) parathyroid hormone; and, 6) RANKL
inhibitor.
Bisphosphonate derivatives
Bisphosphonate derivatives are considered to be the first-line therapy for the
treatment of osteoporosis.27 These drugs are referred to in the
pharmacological literature as bisphosphonate derivatives, but are commonly
called bisphosphonates. The bisphosphonates that are currently FDA
approved for the prevention or treatment of osteoporosis are: alendronate
(Fosamax®), ibandronate (Boniva®) risedronate (Actonel®), and
zolendronic acid (Reclast®). The basic mechanism of action of these drugs is
inhibition of bone resorption by inhibiting the action of osteoclasts and
osteoclast precursors.
The bisphosphonates have been proven to prevent fractures in patients who
have osteoporosis,27,28 and there is also evidence that these drugs decrease
morbidity and mortality.29 Alendronate has been reported to reduce the
incidence of spine and hip fractures by 50% in patients who have had a
spine fracture or who have osteoporosis of the hip,8 and similar results have
been reported for the other bisphosphonates.8 These drugs are available as
oral or IV medications and, depending on the patient’s need and the
formulation, they are prescribed once a day, once a week, monthly, or every
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three months. In the case of Reclast®, an IV infusion is given every two
years.
The oral bisphosphonates must be taken correctly to ensure that they are
effective and to avoid side effects. Patients that are prescribed an oral
bisphosphonate should be given the following instructions.
 Take the bisphosphonate at least 30-60 minutes before the first food,
drink, or drugs of the day: the amount of time recommended varies
for each drug.
 Do not lie down for at least 30-60 minutes after taking the drug: the
amount of time varies for each specific bisphosphonate.
 Take with a full glass of water - no other liquids, only water.
 If a dose is missed, wait until the following morning to take a dose.
Food and any liquid aside from water can interfere with absorption of the
medication. The bisphosphonate derivatives can cause erosion to the
esophagus, and maintaining an upright posture for 30-60 minutes after
ingestion is recommended to avoid injury to the esophageal mucosa. This
time limit also allows for complete drug absorption and maximal
improvement in bone mineral density.29
The most common side effects of the bisphosphonates are gastrointestinal:
constipation, diarrhea, heartburn, and esophageal irritation. Hypocalcemia is
uncommon, but patients taking these drugs should be monitored to be sure
they are receiving the recommended dietary intake of calcium and vitamin
D. In high doses the bisphosphonates are toxic to the kidney.27 Also,
approximately 50% of bisphosphonates are excreted unchanged and renal
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impairment can cause an accumulation of the drug.29 Because of their
potential for nephrotoxicity and the decreased excretion of these drugs in
patients who have renal impairment, the bisphosphonates typically are
contraindicated if the patient has a glomerular filtration rate < 30-35
mL/minute.8 However, this is considered to be a guideline not an absolute
contraindication.
The level of renal impairment at which drug accumulation becomes clinically
relevant is not known,29 and there is some clinical experience with the use of
bisphosphonates in patients who have an advanced stage of kidney
disease.29
The four most serious complications that have been associated with
bisphosphonate therapy are: 1) osteonecrosis of the jaw; 2) atypical fracture
of the femur; 3) atrial fibrillation; and, 4) esophageal cancer.27,29 These
complications are discussed in more detail below.
Osteonecrosis of the jaw:
Osteonecrosis of the jaw is defined as “ . . . the presence of exposed bone in
the maxillofacial region that does not heal within 8 weeks of identification by
a healthcare provider.”28 This complication is seen most often in patients
who have cancer and are being treated with high doses of IV
bisphosphonates.30 Osteonecrosis of the jaw, as an adverse effect of
bisphosphonate therapy, is quite rare when these drugs are prescribed for
post-menopausal women who do not have pre-disposing risk factors.28 A
2011 study noted an incidence of 0.001% of this complication in patients
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who were taking a bisphosphonate and did not have cancer31 and other
sources have estimated the risk to be quite low, as well.
27
Invasive dental procedures and poor dental hygiene have also been
identified as risk factors for developing osteonecrosis of the jaw while taking
bisphosphonates. The prescribing provider should identify this risk to the
patient and their dentist prior to an invasive dental procedure, and advise
the patient to maintain good dental hygiene while taking a bisphosphonate.29
Atypical fracture of the femur:28
An atypical fracture of the femur is defined by  location in the subtrochanteric region or femur shaft
 minimal or no trauma
 transverse or short oblique fracture line
 absence of comminution
 a medial spike with complete fracture
There are some indications that patients who are taking bisphosphonates for
a long period of time may have an increased risk for this type of
fractures.28,29 However, many of the research findings are limited because
they were derived from case studies or observational series or the study
designs had methodological errors, and there is no evidence that
unequivocally supports a cause and effect relationship between the use of
these drugs and atypical fractures of the femur.28 Yet, even if the
bisphosphonates were a direct cause of this complication, the risk of
developing an atypical fracture of the femur is considered to be very low and
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is far outweighed by the number of hip fractures that are prevented by the
use of bisphosphonates.28,29
Atrial fibrillation:
A 2007 study was the first to propose a link between the use of
bisphosphonates and an increased incidence of atrial fibrilliation.32
Obviously, many patients who are prescribed a bisphosphonate have preexisting risk factors for developing atrial fibrillation, i.e., atherosclerosis and
advanced age, and subsequent research has neither confirmed nor disproved
the association between atrial fibrillation and the use of bisphosphonates.29
However, in a recent (2014) review of the literature the authors noted that
the risk of new-onset atrial fibrillation was slightly increased by the use of
both intravenous and oral bisphosphonates, with the risk in intravenous use
being higher than that of oral use.33 The authors pointed out that the
pathogenic mechanisms by which the bisphosphonates might cause atrial
fibrillation are unknown and that their study did not definitely establish a
cause and effect relationship.
Esophageal cancer:
Between the introduction of alendronate in 1995 and 2008 the FDA received
23 reports of esophageal cancer in which alendronate was suspected to be
the causal factor.34 Subsequent to that, two large observational studies
provided further evidence of a positive association between the use of
bisphosphanates and an increased risk of esophageal cancer.35,36
Esophagitis and esophageal ulceration are adverse effects of the
bisphosphonates and they are risk factors for developing esophageal cancer.
However, at this time a definite link between bisphosphonates and
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esophageal cancer has not been established,27 and the FDA has not
concluded that people taking the oral bisphosphonates have an increased
risk for developing esophageal cancer.37
Calcitonin
Calcitonin is a hormone that is secreted by the thyroid gland. Calcitonin
inhibits the activity of osteoclasts and decreases bone resporption.38
Calcitonin has a labeled use for the treatment of post-menopausal
osteoporosis, and synthetic calcitonin is available as a nasal spray
(Fortical®, Miacalin®) or an injectable (Miacalcin®) that can be given
intramuscularly or subcutaneously.
Calcitonin has been shown to increase bone mineral density. However, there
is limited evidence for its efficacy in decreasing the incidence of
fractures,8,39,40 and the FDA, the manufacturer of Miacalcin® nasal spray,
and other sources concluded that there is an increased risk of malignancies
in patients treated with calcitonin (4.1%) versus patients treated with
placebo (2.9%).38,41,42 The FDA noted the following:
“In a meta-analysis of 21 randomized, controlled clinical trials with
calcitonin-salmon (nasal spray or investigational oral formulations), the
overall incidence of malignancies reported was higher among
calcitonin-salmon-treated patients (4.1%) compared with placebotreated patients (2.9%). This suggests an increased risk of
malignancies in calcitonin-salmon-treated patients compared to
placebo-treated patients. The benefits for the individual patient should
be carefully considered against possible risks.”41
Estrogen agonist/antagonists
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The estrogen agonist/antagonists, which are occasionally called selective
estrogen receptor modulators, are medications, which combine estrogen
receptor agonist activity in bone and estrogen receptor antagonist activity in
breast and uterine tissue. These drugs bind to estrogen receptors in the
bone and increase the activity of estrogen. This in turn directly and indirectly
inhibits the activity of osteoclasts and decreases bone resorption.43-45
There are two estrogen agonist/antagonists that are currently FDA approved
for the treatment and prevention of post-menopausal osteoporosis:
raloxifene (Evista®) and bazedoxifene (Duavee®), which is a combination of
a conjugated estrogen and a selective estrogen receptor modulator. These
drugs have both been shown to significantly reduce the risk of vertebral
fractures and to increase bone mineral density.8,46-49
Raloxifene and bazedoxifene are oral tablets taken once a day. Common side
effects of raloxifene and bazedoxifene are hot flushes, leg cramps, peripheral
edema, and vasodilation.38 The use of these drugs has also been associated
with an increased risk for venous thromboembolic events (VTE) such as deep
vein thrombosis and pulmonary embolism.38 Several clinical trials of
raloxifene noted that the increase in absolute risk for VTE was 1.2 - 1.8.50
Clinical trials of bazedoxifene did not report VTE as an adverse effect of
treatment51-53 or the incidence of VTE was no greater in patients treated with
bazedoxifene than in patients treated with placebo.54
RANKL inhibitor
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Denosumab (Prolia®) is a RANKL inhibitor
that has FDA approval for the treatment of
RANKL
post-menopausal women who are at high
Receptor
risk for fractures, and for the treatment of
Activator
osteoporosis (to increase bone mass) in
men who are at high risk for osteoporosis.
Nuclear factor
Kappa
Ligand
Denosumab is a monoclonal antibody that
has a binding affinity to RANKL. RANKL is
(Note: A ligand is molecule that
binds to another molecule,
often initiating an action)
found on the surface of osteoclasts, and
denosumab prevents RANKL from binding
to and activating its receptor, RANK (Receptor Activator of Nuclear Factor κ
B). This action inhibits osteoclast activity, formation, and survival and by
doing so decreases bone resorption.55 The approved dose of Prolia® is 60
mg, given subcutaneously, every six months.
Denosumab has been proven in large clinical trials to significantly reduce the
risk of hip, vertebral, and non-vertebral fractures and to significantly
increase bone mineral density, as well.56,57 Denosumab has been described
as safe and well tolerated, with no significant difference between denosumab
and placebo or biphosphonates in terms of the risk of adverse effects.57-59
However, serious adverse effects have been associated with the use of
denosumab.38 Some of these, such as hypocalcemia, osteonecrosis of the
jaw, and atypical femoral fractures, are rare or relatively rare and the
association between the drug and these complications is tenuous. But other
adverse effects, such as serious infections of the skin and upper respiratory
tract and urinary tract infections, are significantly more common in patients
taking denosumab than in those who are not.38
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Because of the potential for serious adverse effects, the FDA requires that all
patients who are prescribed Prolia® be given an FDA-approved patient
medication guide. This medication guide warns patients that Prolia® may
cause hip fractures, hypocalcemia, osteonecrosis of the jaw, serious allergic
reactions, serious infections, skin problems, and, severe bone, joint, or
muscle pain. The FDA-approved patient medication guide can be viewed at:
http://www.fda.gov/downloads/Drugs/DrugSafety/UCM214385.pdf.
Parathyroid hormone
Parathyroid hormone is secreted by the parathyroid gland, and its primary
function is to increase serum levels of calcium. Teriparatide (Forteo®) is a
synthetic form of parathyrtoid hormone, and it is approved by the FDA for
the treatment of osteoporosis in postmenopausal women and men who are
at high risk for fracture. Teriparatide stimulates osteoblast function,
increases the gastrointestinal calcium absorption, and increases renal
tubular reabsorption of calcium, all of which act to increase new bone
formation.60,61 Teriparatide increases bone mineral density and bone mass,62
and it has been shown to significantly reduce the risk of vertebral and nonvertebral fractures.8,63,64 Forteo® is given subcutaneously at a dose of 20
mg once a day.
Common side effects of Forteo® are arthralgia, nausea, and pain.60 The FDA
requires that all patients who are prescribed Forteo® be given an FDAapproved patient medication guide. The FDA-approved guide and the
Forteo® package insert both note that during drug testing of Forteo® some
rats developed osteosarcoma, and osteosarcoma has rarely been reported in
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patients who took the drug. The package insert warns that the relevance of
this animal study finding is unclear for humans, but that Forteo® should not
be prescribed for patients who have an increased risk for osteosarcoma. The
patient medication guide can be viewed at:
http://www.fda.gov/downloads/Drugs/DrugSafety/ucm088604.pdf.
Estrogen hormone therapy
The FDA has approved estrogen products for the prevention of osteoporosis.
Estrogen has been shown to significantly reduce the risk of vertebral
fractures and hip fractures.65 However, the FDA also recommends that
because of an increased use of breast cancer, coronary artery disease,
stroke, and VTE that the lowest effective dose of estrogen should be used for
the shortest possible time, and, if possible, other drugs should be used
before estrogen.2,8
Estrogen products are available as tablets and transdermal patches. There
are many estrogen and estrogen derivatives that are in use, i.e., Premarin®,
Estrace®, Femhrt®, Prefest®. A review of the common side effects
associated with all of these drugs is not practical for this study module, and
may be found in any prescription drug guide.
Other drugs, vitamins, and minerals
There are other drugs that are used for the prevention and/or treatment of
osteoporosis, but the ones discussed in this study module are the ones with
FDA approval for these purposes. The role of vitamin D supplementation in
the prevention and treatment of osteoporosis is somewhat controversial.
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Maintaining adequate dietary intake of vitamin D is universally
recommended in treatment recommendations for osteoporosis. However, as
mentioned earlier, there is no unequivocal evidence that increasing vitamin D
levels helps to reduce the risk of fractures or to prevent bone loss.13-15 In
addition, the amount of vitamin D that is needed for the prevention and
treatment of osteoporosis is not known,11,66 and it is not clear that vitamin D
supplementation is effective at preventing falls.67
The role of calcium supplementation in osteoporosis involves similar issues.
Patients who have osteoporosis or at risk for developing osteoporosis are
advised to make sure they have an adequate dietary intake of calcium, but
recent meta-analyses of the literature do not show that calcium
supplementation has a significant effect for preventing fractures.10
Drug duration and drug holidays
The optimal duration of drug therapy for the treatment of osteoporosis is not
known, and after a certain number of years (i.e., five years for denosumab)
there is no information about the effectiveness and the safety of the
medications used to treat osteoporosis.38 Rare complications of osteoporosis
drug therapy such as atypical fractures of the femur and osteonecrosis of the
jaw, appear to become more common when the duration of drug use is
prolonged,38 but there is no data that can be used to decide when the risks
of drug therapy outweigh the benefits.8
Since the therapeutic effectiveness of some of the drugs, specifically the
bisphosphonates, have been shown to extend for several years after they
have been discontinued, the idea of a “drug holiday” has been mentioned in
the medical literature: stopping drug therapy to avoid complications while
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retaining the medication’s therapeutic effects.27,28 However, there is
essentially no data that can be used to decide when and for whom a drug
holiday might be helpful,27 and the NOF 2014 guidelines simply note that
treatment duration decisions should be made individually and that, after
three to five years of drug therapy, a comprehensive risk assessment should
be done.8
The Nurse’s Role: Caring For Patients With Osteoporosis
Nurses have a key role in caring for the patient with osteoporosis during
various stages of disease progression. Patient’s are at risk of fall and injury
and require ongoing monitoring and education of their treatment plan,
medications and health prevention strategies.
Patient Monitoring
Osteoporosis and fractures caused by osteoporosis can be prevented by the
proper attention to diet, exercise, reduction and/or elimination of factors
that increase the risk of a fall, smoking cessation and moderate use of
alcohol, medications, and periodic assessment of the patient’s bone mineral
density and clinical condition. The patient who has osteoporosis should be
given a diet plan and an exercise program, and risk factors for falls should
be identified and eliminated or modified.
The patient’s medication regimen should be periodically reviewed, the height
should be measured every year (a decrease in height could indicate the
presence of a vertebral fracture), and bone mineral density should be
checked by DXA every two years8 or when clinically indicated. The prognosis
for someone with osteoporosis is good, especially if screening catches the
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disease early. Many of the complications of osteoporosis are related to
fracture, and if treatment can prevent fracture then the prognosis is good.
Patient Education
A primary role of the nurse is educating the patient. Nurses should teach
patients who have osteoporosis or are at risk for osteoporosis about lifestyle
changes to maximize bone health. Additionally, nurses should encourage all
patients to perform weight bearing exercise, get adequate calcium and
vitamin D, avoid smoking and excessive alcohol, and get some sun exposure
on the face and hands most days of the week.
Nurses need to understand the screening guidelines and to recommend
screening to appropriate patients. Safety precautions to prevent falls are
critical in patients with osteoporosis. Prevention of falls is important because
patients with low bone mass are at high risk for fracture.
The table below lists fall prevention strategies that nurses may implement.
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FALL PREVENTION STRATEGIES

Assure adequate vision – have patients at risk see an eye doctor

Have occupational therapy perform a home safety evaluation

Assure that the home is free of clutter

Assure that the home has adequate lighting

Assure surfaces in the home are non-skid (floors, mats and shower mats)

Make sure the patient has good shoes

Have the patient perform balance exercises, such as Tia Chi

Encourage regular exercise

Evaluate patient medications as some medications increase the risk for
falls such as anti-anxiety medications, blood pressure medications, pain
medications and sleeping pills. If you suspect a medication is
contributing to falls speak with the doctor.

Encourage the patient to have an evaluation with his/her primary care
provider to assure all medical conditions are well controlled.
Uncontrolled health problems increase the risk of falls.

Recommend assistive devises if appropriate
Helping patients understand osteoporosis and their risk for disease is a
major role of the nurse. Patients who speak intelligently to their doctor will
receive better care. Below is a list of questions that nurses should encourage
each patient to discuss with their doctor to help them fully understand their
disease.

Do I have any risk factors for osteoporosis?

What is my T-score?

What caused this disease in me?
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
What are my risk factors for this disease?

When will I have my next DEXA scan?

Could I benefit from medication to increase my bone density?

What are the side effects of the medications that are being prescribed
for me?

What can I do to reduce my risk of falls?

How much calcium/vitamin D should I take in a day?

What type of exercise should I do? How often should I exercise?

Do any of my health problems put me at risk for falls?

Do any of my medications put me at risk for falls?
The following two case studies help to elucidate many of the key aspects of
diagnosis and treatment that the nurse may encounter when caring for
individuals with osteoporosis.
Case Study 1
A 65-year-old post-menopausal female presents to her doctor for an annual
exam. She is 5’ 4” and weighs 122 pounds. She is afflicted with mild
osteoarthritis of both of her knees, hypertension and mild depression. Her
current medications include a multivitamin daily, hydrochlorothiazide 12.5
mg a day and sertraline 50 mg a day. She averages one alcoholic beverage a
day and does not currently smoke, but quit smoking 10 years ago and has a
20 pack-year history. She does not do any formal exercise, but reports being
quite active cleaning houses, as she owns a house cleaning business.
She
has no family history of osteoporosis, her mother never had a fracture and
she never had a fracture in her life.
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Her doctor recommends that she be screened for osteoporosis by dualenergy x-ray absorptiometry. Her T-score at her hip is – 2.6 and -1.8 at her
spine. When her information was placed into the FRAX calculator she came
up with a risk of a major osteoporotic fracture of 9.8% and the risk of hip
fracture of 2.0%.
She is seen back in her primary care doctor’s office in one week to follow up
on her abnormal DEXA scan. The doctor gives her a diagnosis of
osteoporosis based on her T-score being below -2.5. The doctor discusses
the following points.
1. Start aledronate at 70 mg once a week – she is a candidate for
therapy because she has a T score at her hip of -2.6. Her kidney
function is within normal limits for her age. Renal failure is a reason to
not use bisphosphonates.
2. Routine blood work ruled out any disease of the thyroid or parathyroid.
Alkaline phosphatase, serum phosphate and calcium and vitamin D
levels were normal.
3. She is encouraged to start a calcium supplement. The doctor
recommends 500 mg twice a day in addition to a couple servings of
dairy each day such as milk, cheese or yogurt.
4. Add a vitamin D supplement to get 800 IU of vitamin D each day.
5. The doctor recommended sunlight on the face and hands 2-3 times a
week to maximize vitamin D levels.
6. She was encouraged to engage in weight bearing exercise 5 times a
week.
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7. She was encouraged to perform upper body weight training three
times a week to maximize bone strength in the upper body.
8. She is to have a repeat DEXA scan in 2 years to assess the efficacy of
therapy.
Case Study 2
A 72-year-old female post-menopausal female went to her primary care
physician because she had been having low back pain for approximately five
weeks. The patient has a medical history of depression, GERD, hypertension
and osteoarthritis. She is currently prescribed lisinopril, HCTZ, celecoxib,
omeprazole, and paroxetine.
The patient has been smoking cigarettes for over 40 years, she does not
exercise, and she only leaves the house for brief periods, several days week.
According to the patient, walking is painful because of the osteoarthritis she
has in her hips, and she is worried that she may fall.
The patient admits that her diet is largely prepared foods and she does not
drink milk or eat other calcium-containing foods. She also drinks at least six
cups of coffee a day. She denies recent trauma to her lower back or a fall,
but does report that she first noticed the lower back pain after she bent over
and moved a heavy chair from one part of her living room to another. The
patient is 62 inches tall and weighs 105 pounds. The area of the pain is nontender to palpation and there are no areas of swelling or ecchymosis.
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A plain x-ray of the lumbar spine reveals a fracture, and based on the
patient’s age, gender, post-menopausal status, and the presence of several
risk factors, the physician makes a provisional diagnosis of osteoporosis. The
diagnosis is confirmed by a DEXA scan result of - 3.0. The results of the
laboratory tests the physician ordered are normal except for a vitamin D
level of 20, with the low normal being 30. The physician makes the following
recommendations.
1. Calcium supplementation, 1000 mg a day.
2. Vitamin D supplementation, 800 IU a day.
3. Begin a smoking cessation program.
4. Get at least 30 minutes of direct exposure to the sun, three to five days a
week.
5. Decrease coffee intake to three or less cups a day.
6. Alendronate, 10 mg, daily.
7. Physical therapy consultation for instruction on weight-bearing exercises;
body mechanics for avoiding stress that may cause fractures; assessment
for the need of an assistive device such as a cane or walker; and,
stretching exercises.
8. Psychotherapy consult (the intention being to possibly lessen dependence
on paroxetine as the SSRIs are known to be a risk factor for
osteoporosis).
9. Nutrition consult.
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Case Study 3
A fifty-four year old female presents to her doctor’s office because of
irregular periods and hot flashes. The patient is an advertising executive who
lives a very stressful life and works 60-70 hours a week. She has no
significant medical conditions and takes no regular medications. She does
not engage in regular exercise, eats a lot of fast food and smokes about 2
packs of cigarettes per week. She is 63 inches tall with a body weight of 146
pounds. She reports that her job keeps her locked up inside most of the day.
She drinks about 7-10 alcoholic drinks per week, mostly on the weekend and
consumes about six cups of coffee each day.
Her mother currently lives in a nursing home due to immobility secondary to
a hip that she broke 10 years ago. She is unsure if her mother has been
diagnosed with osteoporosis. She reports no personal history of fracture.
The doctor performs a complete history, physical exam, selected blood work
and a DEXA scan. The history and physical exam were without significant
abnormality except for irregular periods, hot flashes and a slight increase in
body mass index. Blood work showed hormonal levels that suggest
perimenopause. The other abnormality on laboratory evaluation was a low
vitamin D level of 14 ng/dl. The remaining blood work was normal.
Her DEXA scan shows a T-score of -1.4 at the hip and -1.4 at the spine. Her
FRAX score shows a 10-year risk for a major osteoporotic fracture and risk
for a hip fracture at 17 percent and 1.6 percent, respectively. The doctor
diagnoses her with osteopenia and opts to not treat her with
pharmacological agents to treat low bone mass. The physician discusses the
possible short-term benefits of hormone replacement therapy, but after the
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negative effects are discussed with the patient, they decide against hormone
replacement. Her doctor makes the following recommendations.
1. Engage in regular weight bearing exercise at least three times a week.
2. Engage in weight training exercise at least twice a week.
3. Take vitamin D 50,000 IU once a week for 8 weeks and follow up after
treatment for a repeat blood test.
4. Get 10-15 minutes of sunlight exposure at least twice a week on the
face and arms to increase the vitamin D level. Her low vitamin D level
was partly caused by her lack of sunlight exposure.
5. Take 500 mg of calcium supplementation twice a day and consume a
couple servings of dairy each day such as milk, cheese or yogurt.
6. Quit smoking because smoking may contribute to bone loss as well as
lead to many other health problems.
7. Reduce binge drinking. She was counseled about the negative effects
of alcohol on bone as well as overall health.
8. Reduce coffee intake. She was encouraged to switch to green tea. If
coffee is to be continued she is encouraged to cut back and substitute
decaffeinated coffee.
9. She was counseled on stress management and healthy eating. She
was offered an appointment with a stress management specialist and
dietitian.
10. She was encouraged to have a repeat DEXA scan in two years to
assess for progression of her osteopenia.
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Summary
Osteoporosis is a significant public heath problem, and as the population
continues to age it is likely that the number of people who have, or are at
risk for developing osteoporosis, will increase. Although some degree of
bone loss is an inevitable part of aging, identification of those at risk and
preventive measures are critical in the management of the disease.
Risk factors identified in this study module for developing osteoporosis are
either non-modifiable (i.e., age, gender) or modifiable (i.e., use of alcohol,
level of activity, cigarette smoking). Post-menopausal women are at high risk
for developing osteoporosis, but elderly men are at risk, as well. The disease
is clinically silent. Most cases are identified after the patient has suffered a
fracture or by a screening test.
Fractures are the most serious complication of osteoporosis. Screening for
osteoporosis should be done in all women age 65 and older, all men age 70
and older, and, postmenopausal women and men above age 50-69, based on
risk factor profile. The preferred method of measuring bone mineral density
and diagnosing osteoporosis is dual-energy X-ray absorptiometry (DEXA).
The treatment and prevention of osteoporosis is done by attention to diet,
regular weight-bearing exercise, modification of harmful life style habits,
elimination and/or reduction of fall risk factors, and medications that prevent
bone loss or increase bone formation. Bisphosphonates have been proven to
prevent fractures in patients who have osteoporosis and evidence exists that
they also decrease morbidity and mortality.
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The FDA has approved bisphosphonates to treat osteoporosis as well as
other medications used to treat osteoporosis such as calcitonin, estrogen
agonist/antagonist, estrogens or hormone therapy, parathyroid hormone and
RANKL inhibitor. Among these medications, bisphosphonate derivatives are
considered to be the first-line therapy for the treatment of osteoporosis, and
the FDA has approved bisphosphonates for the prevention or treatment of
osteoporosis, such as alendronate (Fosamax®), ibandronate (Boniva®)
risedronate (Actonel®), and zolendronic acid (Reclast®). These medications
act to inhibit bone resorption by inhibiting the action of osteoclasts and
osteoclast precursors.
Common side effects and significant risks exist with the use of
bisphosphonates. High doses are nephrotoxic and approximately 50% of
bisphosphonates are excreted unchanged therefore renal impairment leads
to drug accumulation and toxicity. Prior to taking bisphosphonates, the
patient’s glomerular filtration rate should be evaluated for levels < 30 - 35
mL/minute, which would require the medication be avoided or administered
with extreme caution under consultation with a nephrologist if clinically
indicated.
Serious complications associated with bisphosphonate therapy that have
been identified include osteonecrosis of the jaw, atypical fracture of the
femur, atrial fibrillation, and esophageal cancer. To avoid damage to the
esophagus the patient should follow recommended administration guidelines,
such as remaining in an upright position after taking the bisphosphonate
medication on an empty stomach in the morning.
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There are indications that the prolonged use of medications used to treat
osteoporosis may increase the risk of serious complications, and some
clinicians have suggested using drug holidays to lessen the chances of
serious adverse effects. This issue is unresolved, and the NOF simply
recommends a risk assessment after three to five of drug therapy and
advises that the benefits and risks of long-term drug therapy for
osteoporosis must be evaluated on a case-by-case basis.
Importantly, nurses play a key role in the ongoing care, close follow-up and
education of patients with osteoporosis to best manage symptoms, to avoid
falls and fractures, and to promote preventive strategies.
Please take time to help NurseCe4Less.com course planners evaluate
the nursing knowledge needs met by completing the self-assessment
of Knowledge Questions after reading the article, and providing
feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course
requirement.
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1. Approximately 80% of the cases of osteoporosis in the United
States occur in
a. women
b. African Americans
c. men
d. young adults
2. Osteoporosis is caused by a disruption in
a. calcium absorption
b. blood supply to the bones
c. bone remodeling
d. the nerve fibers of the bones
3. Post-menopausal osteoporosis is primarily caused by
a. an increase in serum parathyroid hormone levels
b. decreased production of estrogen
c. decreased intake and absorption of vitamin D
d. decreased blood supply to the bones
4. Age-related osteoporosis is primarily caused by
a. decreased exposure to sunlight
b. decreased production of estrogen and testosterone
c. increased renal excretion of calcium and vitamin D
d. a decrease in the number of functioning osteoblasts
5. Lifestyle risk factors for the development of osteoporosis include
a. cigarette smoking and excessive use of alcohol
b. male gender and atherosclerosis
c. chronic kidney disease and inadequate intake of calcium
d. African American ethnicity and over-exposure to sunlight
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6. Risk factors for the development of osteoporosis include
a. advanced age and liver disease
b. use of anticonvulsant medications and high-body mass index
c. female gender and sedentary life style
d. abstinence from alcohol and low body-mass index
7. The most important complication of osteoporosis is
a. renal impairment
b. fractures
c. malabsorption syndrome
d. joint contractures
8. Which of these is considered first-line treatment for osteoporosis?
a. Calcitonin
b. Parathyroid hormone
c. Vitamin D and calcium supplementation
d. Biphosphonates
9. Patients who are prescribed a biposphonate should be instructed
to
a. take it in the morning on an empty stomach and remain upright for
30-60 minutes
b. take it in the evening with a fatty food
c. take it with milk and remain upright for 30-60 minutes
d. take it with water only and immediately before going to sleep
10. True or false: Osteoporosis can be prevented but established
osteoporosis cannot be reversed
a. True
b. False
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Correct Answers:
1.
A
2.
C
3.
B
4.
D
5.
A
6.
C
7.
B
8.
D
9.
A
10. A
References Section
The reference section of in-text citations include published works intended as
helpful material for further reading. Unpublished works and personal
communications are not included in this section, although may appear within
the study text.
1. National Osteoporosis Foundation. What is osteoporosis? Retrieved July
17, 2014 from http://nof.org/articles/7.
2. Jacobs-Kosmin D. Osteoporosis treatment & management. eMedicine.
October 4, 2013. Retrieved July 17, 2014 from
http://emedicine.medscape.com/article/330598treatment#aw2aab6b6b1aa.
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3. Finkelstein JS. Epidemiology and etiology of osteoporosis in men.
UpToDate. November 22, 2013. Retrieved July 17, 2014 from
http://www.uptodate.com/contents/epidemiology-and-etiology-ofosteoporosis-inmen?source=search_result&search=osteoporosis&selectedTitle=14%7E150.
4. Lindsay R, Cosman F. Osteoporosis. In: Longo DL, Fauci AS, Kasper DL,
Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal
Medicine, 18th ed. New York, NY: McGraw-Hill; 2012. Online edition,
retrieved July 17, 2014 from www.UCHC.edu.
5. World Health Organization. Prevention and management of osteoporosis.
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