There are two types of osteoporosis – primary and secondary. The majority of cases are primary, occurring spontaneously, mostly in postmenopausal women and in older men. At menopause, there is a lack of estrogen, which is a major cause of osteoporosis. Estrogen deficiency causes an increase in bone breakdown, which results in rapid bone loss. Low levels of sex hormones in men also contribute to osteoporosis. A small percentage of people may have secondary osteoporosis, which is caused by a drug or another disorder, such as Cushing’s disease, chronic kidney disease, hyperthyroidism, hyperparathyroidism, diabetes, multiple myeloma, and rheumatoid arthritis. Drugs that may cause secondary osteoporosis are corticosteroids, thyroid hormones, progesterone, some chemotherapy drugs, and antiseizure drugs. Also, excessive caffeine or alcohol intake, and cigarette smoking can contribute to osteoporosis. Risk factors for primary osteoporosis include a family history of osteoporosis, calcium and vitamin D deficiency, Caucasian or Asian race, female, nulliparity, early menopause, sedentary lifestyle, and small frame/low body weight.
Now let’s look at what symptoms are seen with osteoporosis. Because bone density loss occurs very gradually, no symptoms will be seen at first, and some people may never develop symptoms until a bone breaks. People may have pain depending on the type of fracture – in long bones, the fracture usually occurs at the ends of the bones, and vertebral fractures usually occur in the middle to lower back. Vertebral compression fractures are the most common osteoporosis-related fractures. They often do not cause pain, but the area may be tender, or pain may develop suddenly and worsen with standing and walking. If several vertebrae break, an abnormal curvature of the spine may develop, causing muscle strain, soreness, and deformity. Fragility fractures result from a minor strain or fall, that would not normally cause a fracture in a healthy bone. They commonly occur in the radius, humerus, femur, trochanter, and pelvis. Patients that have had one osteoporosis-related fracture are at increased risk of having more of these fractures.
Early detection and diagnosis of osteoporosis results in decreased probability of fractures and improved quality of life. It is important to identify the patient’s risk factors and history. The diagnosis of osteoporosis is confirmed with bone density testing, which is the only test that can diagnose osteoporosis before a broken bone occurs. The test estimates the density of the bones and the chance of the bone breaking. A bone density test of the hip and spine using a central DXA (dual energy x-ray) machine is recommended. The test is non-invasive and painless, and usually takes less than 15 minutes. Standard x-rays can detect broken bones, but cannot be used in place of bone density tests because they do not show osteoporosis until the disease is well advanced. Screening tests, also called peripheral tests, measure bone density in the lower arm, wrist, finger or heel. Screening tests cannot accurately diagnose osteoporosis, but they can identify people who need to have further bone density testing done. Bone density test results are reported using T-scores, which show how much higher or lower the bone density is compared to that of a healthy 30-year old adult. The lower the T-score, the lower the bone density. A normal T-score is -1.0 and above. Low bone density (osteopenia) will reflect a T-score between -1 and -2.5. A T-score of -2.5 or below is a diagnosis of osteoporosis. A bone density test will also show a Z-score that compares the patient’s bone density to what is normal in someone of their age and size. It is recommended to use Z-scores for children, teens, premenopausal women, and younger men. A DXA scan (bone density test) is recommended for all women 65 yrs old and older; women between menopause and age 65 who have risk factors; patients (men or women) of any age who have had fragility fractures; patients with imaging studies of vertebral compression fractures or decreased bone density; and patients at risk of secondary osteoporosis. Other tests, such as blood tests to measure calcium, vitamin D, and hormone levels; and tests to determine liver and kidney function are also done.
Prevention of osteoporosis is actually more successful than treatment, since it is easier to prevent bone density loss than to restore bone density once it has been lost. The goals are to preserve bone mass and prevent fractures. It is important to quit smoking, avoid excessive alcohol and caffeine; make sure adequate amounts of calcium and vitamin D are consumed; and participate in weight-bearing exercises (such as walking, climbing stairs, or weight training). Drug therapy is indicated for patients who have osteopenia if they are at increased risk of fracture or patients with osteoporosis.
When a patient is treated for osteoporosis, conditions and risk factors that make osteoporosis worse also have to be managed. Osteoporosis treatment involves adequate consumption of calcium and vitamin D – vitamin D helps the body absorb calcium. All men and women should consume at least 1,000 mg of calcium daily, with 800 to 1,000 IUs of vitamin D. Dietary sources of calcium are preferred to supplements – such as dairy products, vegetables such as broccoli, and nuts such as almonds. Food sources for vitamin D include fortified foods, such as cereals and dairy products, and also fish liver oils and fatty fish. If the patient cannot consume the recommended amounts in diet alone, then supplements need to be taken. Calcium supplements are in the form of calcium carbonate or calcium citrate. Vitamin D supplements are given as cholecalciferol (the natural form of vitamin D), or ergocalciferol (the synthetic plant-derived form). Weight-bearing exercise increases bone density and 30 minutes is recommended daily.
Most of the drugs used for prevention of osteoporosis, are also given as treatment. The first drugs usually given are bisphosphonates, which have been shown to prevent the loss of bone density as well as reduce the risk of fractures. Examples include alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), and zoledronic acid (Zometa). Prior to taking bisphosphonates, it is necessary to correct hypocalcemia and/or vitamin D deficiency. Oral bisphosphonates must be taken on an empty stomach with 8 oz of water, at the start of the day. The patient should not lie down for 30-60 minutes, because it can irritate the lining of the esophagus, and they should not have food, drink or drug for 60 minutes because food in the stomach can decrease drug absorption. There are some patients who should not take bisphosphonates, including women who are pregnant or nursing, people with low blood calcium or who have severe kidney disease. Long-term use of bisphosphonates may increase the risk of developing unusual fractures of the femur. To reduce these risks, patients may have to stop taking the drug for 1-2 years, while being routinely monitored for decreasing bone density. The benefits of the drug have to be balanced with the possible side effects. For patients who cannot or prefer not to take bisphosphonates, raloxifene is an estrogen-like drug that is useful in preventing and treating bone loss, but it does have some of estrogen’s negative side effects. Raloxifene can reduce the risk of vertebral fractures and possibly the risk of invasive breast cancer. Another drug sometimes used for osteoporosis treatment is calcitonin, which inhibits the breakdown of bone, and has been shown to relieve pain caused by vertebral fractures. It is usually taken as a nasal spray, and can decrease blood levels of calcium, so levels have to be monitored. There is also concern about long-term use of calcitonin and related increase in cancer rates. Hormonal therapy (such as estrogen), helps maintain bone density in women; however, increased risk of breast cancer, stroke, VTE, and possibly coronary disease exceed the benefits for many women, so it is not usually the treatment option chosen. Denosumab is a drug that prevents bone loss, but is safer than bisphosphonates for patients who have chronic kidney disease. It is given subcutaneously twice a year. Patients should continue taking denosumab, because stopping the drug may cause a loss in bone density and increase the risk of vertebral fractures. Anabolic agents are not considered initial therapy, but may be given to men or postmenopausal women with unusually severe osteoporosis. They can also be given to patients who cannot take bisphosphonates, have bone loss or new fractures while taking bisphosphonates, have unusually severe osteoporosis or many fractures, or have osteoporosis caused by corticosteroids. Anabolic agents stimulate bone formation and activate bone remodeling and can be given up to 2 years during a lifetime, as a daily subcutaneous injection.
Treatment for fractures is done surgically, such as a hip replacement for a hip fracture. A wrist fracture may also require surgery or a cast. Collapsed vertebra can be repaired with vertebroplasty, in which an acrylic bone cement is injected into the collapsed vertebra to help relieve pain and reduce deformity. Remember, the goals of osteoporosis treatment are to preserve bone mass and prevent fractures.
Let’s look at some questions for review:
A patient with osteoporosis is prescribed alendronate (Fosamax); therefore, the nurse should include which of the following when educating the patient? (choose all that apply)
- Take the medication with food and milk to prevent GI upset.
- This medication will prevent the loss of bone density and reduce the risk of fractures.
- Continue taking supplemental calcium and vitamin D – take at least one hour after Fosamax
- Lie down after taking the medication to prevent dizziness.
If you chose B & C, you are correct! Bisphosphonates prevent the loss of bone density & reduce the risk of fractures; but they must be taken on an empty stomach, with no food, drink, or drug at least 1 hour after taking, and the patient must remain sitting up for 1 hour to avoid irritating the lining of the esophagus.
Let’s try another –
What are some specific ways to prevent osteoporosis in postmenopausal women? (choose all that apply)
- Spend 30 minutes in the sun daily
- Eat almonds and yogurt daily
- Take estrogen replacement therapy
- Walk 30 minutes daily
- Eat more chicken
If you chose B & D, you’re correct! The best way to prevent osteoporosis is to increase calcium and vitamin D intake and perform weight bearing exercises daily.
And for the final question –
Which female patients are at an increased risk of developing osteoporosis? (choose all that apply)
- A 63 year old African American on estrogen therapy
- A 55 year old Asian who started menopause prematurely
- A 61 year old Caucasian runner
- A 66 year old Hispanic that smokes and drinks excessively
- A 59 year old with a small frame that never had any children
If you chose B, D, and E, you are correct! Risk factors for osteoporosis include family history, calcium & vitamin D deficiency, cigarette smoking, excessive caffeine or alcohol, Caucasian or Asian race, nulliparity, early menopause, sedentary lifestyle, and small frame or low body weight.
That’s all for now! Thanks for watching and see you next time.