Margaret saunders liberty university february 10 2013
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Margaret Saunders Liberty University February 10, 2013. What is Osteoporosis?. Osteoporosis means “porous bone.” It is a chronic metabolic disease in which bone loss causes decreased density and possible fractures.

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Margaret Saunders Liberty University February 10, 2013

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Margaret saunders liberty university february 10 2013

Margaret Saunders

Liberty University February 10, 2013


What is osteoporosis

What is Osteoporosis?

  • Osteoporosis means “porous bone.” It is a chronic metabolic disease in which bone loss causes decreased density and possible fractures.

  • It is the most common bone disease in humans and is most often diagnosed following a fracture. The hip, spine, and wrist are those most at risk, although any bone can become fractured(Ignatavicius & Workman, 2010).


Bone remodeling

Bone Remodeling

  • Bone is a growing tissue that is constantly forming new bone to replace the old. This process is called bone remodeling. Remodeling cycle consists of two different stages: bone resorption (breakdown or removal) and bone formation. During resorption, osteoclasts on the bone’s surface dissolve bone tissue and create small cavities. During formation, osteoblast fill the cavities with new bone tissue(Ignatavicius & Workman, 2010).


Pathophysiology

Pathophysiology

  • Normally, bone resorption and formation take place in close sequence and remain balanced. However, bone remodeling imbalances can occur for many reasons. This imbalance can result in bone mineral loss, leading to osteoporosis(Ignatavicius & Workman, 2010).

  • As a result, bones become weak and can break from a minor fall or, in serious cases, even from simple actions, like sneezing, coughing, or bumping into furniture.


Pathophysiology1

Pathophysiology

  • Osteoporosis can be classified as regional or generalize.

  • Regional osteoporosis is the result of a immobilization of a limb related to an injury(McCance, Huether, Brashers, & Rote, 2010).

  • Generalized osteoporosis involves a variety of skeletal structures. This class of osteoporosis is further divided into primary and secondary osteoporosis.

    • Primary osteoporosis- The most common type, occurs in postmenopausal women and men older than 70 years.

    • Secondary osteoporosis- This type is a result of many medical conditions, such as hyperparathyroidism or long-term drug therapy, such as corticosteroids(McCance, Huether, Brashers, & Rote, 2010)


Prevalence

Prevalence

  • An estimated 10 million Americans over the age of 50 have Osteoporosis(National Osteoporosis Foundation, 2008).

  • Women remain the largest group affected by osteoporosis, averaging 8 million(Ignatavicius & Workman, 2010).

  • One of every two Caucasian females will have an osteoporosis related fracture, while occurring in one of every five men(Drug information handbook for advanced practice nursing, 2012).

  • About 34 million are at risk for the disease(Lehne, 2013).


Risk factors for primary osteoporosis

Risk Factors for Primary Osteoporosis

Modifiable Risk Factors

Nonmodifiable Risk Factors

  • Chronic low calcium intake

  • Chronic low Vitamin D intake

  • Smoking

  • High alcohol intake

  • Excessive intake of protein, sodium and caffeine

  • Weight

  • Estrogen or androgen deficiency

  • Lack of physical exercise

    (Edmunds, Mayhew, & Bridgers, 2009)

  • Age 65 yrs and older in all women

  • Age 75 yrs and older in men

  • Family history

  • Caucasian or Asian ethnicity

  • Low body weight, thin build

  • Hx of low-trauma fracture after age 50

  • Dementia

  • Cancer

  • Connective tissue disorders

  • Genetic disorders


Causes of secondary osteoporosis

Causes of Secondary Osteoporosis

Disease States

Medications

  • DM

  • Hyperthyroidism

  • Cushing’s syndrome

  • Hyperparathyroidism

  • Metabolic acidosis

  • Paget’s disease

  • Bone Cancer

  • HIV/AIDS

  • COPD

  • Cirrhosis

  • Female hypogonadism

  • Rheumatoid arthritis

    (National Osteoporosis Foundation, 2008)

  • Aluminum-containing antacids

  • Anticonvulsants (only some) such as Dilantin or Phenobarbital

  • Aromatase inhibitors

  • Cancer chemotherapeutic drugs

  • Gonadotropin releasing hormone

  • Heparin

  • Lithium

  • Methotrexate

  • Proton pump inhibitors (PPIs)

  • Selective serotonin reuptake inhibitors (SSRIs

  • Steroids (glucocorticoids)

  • Tamoxifen (premenopausal use)

  • Thiazolidinediones such as Actos and Avandia

  • Thyroid hormones in excess


Sign symptoms

Sign & Symptoms

  • Height loss

  • Increased thoracic kyphosis

  • Fracture history

  • Loss of teeth

  • Protruding abdomen

  • Sudden severe back pain

    (Ignatavicius & Workman, 2010)


Bone mineral density testing

Bone Mineral Density Testing

  • Dual X-ray Absorptiometry Scan (DEXA) is the most familiar and standard way to measure bone mineral density(Lehne, 2013).

  • Quantitative computed tomography (QCT)is usually used to assess the lumbar spine, hip, or total body (Edmunds, Mayhew, & Bridgers, 2009)

  • Quantitative ultrasound densitometry (QUS) used to assess the bone density of the calcaneus or patella.

  • Radiographic absorptiometry (RA) used to assess bone density at a peripheral site, such as the hand.

  • Serial bone density measurements for monitoring should be performed after 2 years of treatment(National Osteoporosis Foundation, 2008).


Dual x ray absorptiometry scan

Dual X-ray Absorptiometry Scan

  • BMD testing is recommended for the following: all women > 65 or men >70 years, high risk postmenopausal women and men 50-69 years, those with a history of fracture, high risk medication, adults with predisposing conditions, and any one with evidence of bone loss(Drug information handbook for advanced practice nursing, 2012).

  • The standard way to measure the BMD is with a DEXA)Diagnosis Dual X-Ray Absorptiometry Scan. Usually performed on the hip or spine, these results are reported in standard deviations (SD) or to simplify communication a T-score(Lehne, 2013).

  • Osteoporosis is noted as a T-score of -2.5. Values of bone mineral density here can help predict fractures at other sites(Lehne, 2013) (Drug information handbook for advanced practice nursing, 2012).

  • Although values of BMD can help diagnose fractures, it is not the only predictor of fractures(Lehne, 2013)


Fracture risk algorithm frax

Fracture Risk Algorithm (FRAX)

  • FRAX is an assessment tool that helps to account for various risk factors such as: family history, low body mass index, and use of glucocorticoids and calculates the individual’s 10-year probability of a hip fracture and the 10 year probability of osteoporotic fracture(Lehne, 2013).

  • This tool is intended for postmenopausal women and men > 50 yrs(Lehne, 2013).

  • Results may not apply to those previously treated(Drug information handbook for advanced practice nursing, 2012).


Non pharmacological therapy nursing care

Non-pharmacological Therapy / Nursing Care

  • Obtain an accurate height and compare to past measurements as this will help to identify any kyphosis.

  • Assessment for back pain that may indicate spinal fracture (most commonly occurring in T8 and L3) (National Osteoporosis Foundation, 2008).

  • Evaluation of impaired vision that may increase the risk of a fall(National Osteoporosis Foundation, 2008).

  • Educate to take medication as directed and document compliance.

  • Education on avoidance of tobacco or alcohol use(National Osteoporosis Foundation, 2008).

  • Recommend physical therapy or rehabilitation to improve physical function and reduce the risk of subsequent falls (National Osteoporosis Foundation, 2008).


Non pharmacological therapy nursing care1

Non-pharmacological Therapy / Nursing Care

  • Provide education on avoiding forward bending and exercising with trunk in flexion, especially in combination with twisting (National Osteoporosis Foundation, 2008).

  • Instruct to avoid long-term immobilization and bed rest to short term if possible (National Osteoporosis Foundation, 2008).

  • Encourage participation in daily weight-bearing and muscle strengthening exercises as tolerated(National Osteoporosis Foundation, 2008).

  • Effective pain management if individual has sustained a fracture.


Non pharmacological therapy nursing care2

Non-pharmacological Therapy / Nursing Care

  • Education on safety is imperative to osteoporosis: remove trip hazards, along with any safety issue in the home environment, the need to wear non-slip shoes, appropriate lighting at stairs, and use of ambulation devices if needed(National Osteoporosis Foundation, 2008).

  • If vertebral fractures are painful and fail conservative management individuals may need kyphoplasty or vertebroplasty (National Osteoporosis Foundation, 2008).

  • Advise to keep all follow up appointments.

  • Reevaluate the need for pharmacological therapy it those at risk and ones already receiving treatment (Edmunds, Mayhew, & Bridgers, 2009).

  • Adequate intake of calcium, at least 1200mg/day and vitamin D, of at least 800-1000IU/day for those over age 50(Drug information handbook for advanced practice nursing, 2012).


Non pharmacological therapy nursing care3

Non-pharmacological Therapy / Nursing Care

Calcium (1200mg/day)

Vitamin D (800-1000 IU/day)

  • Calcium is important for accumulation of bone mass and maintenance of bone health.

  • Sources of Calcium: yogurt, milk, sardines, salmon, cheese, and dark green leafy vegetables(National Osteoporosis Foundation, 2008).

  • Vitamin D plays a major role in the absorption of calcium.

  • Sources of Vitamin D: egg yolks, salt-water fish, liver, fortified milk, cereals, and sunlight(Lehne, 2013).


Pharmacological therapy

Pharmacological Therapy

  • The goal of treatment in osteoporosis is to reduce the occurrence of fractures(Lehne, 2013).

  • There are 2 types of drugs that can be used: antiresorptive (those that can decrease bone resorption) and those that can promote bone formation(Lehne, 2013).

  • Of the drugs used for osteoporosis three are more likely to reduce fractures: teriparatide, denosumab, and zoledronate(Lehne, 2013).


Antiresorptive therapy

Antiresorptive Therapy

  • Antiresorptive therapy works by reducing the osteoclast activity. It retards bone loss, but can not reverse bone loss that has already occurred(Lehne, 2013).

  • This class of medication includes: estrogen, Raloxifene, Bisphosphonates, Calcitonin, and Denosumab(Lehne, 2013).

  • In order for these medications to be effective sufficient intake of calcium and vitamin D are required(Lehne, 2013).


Estrogen

Estrogen

  • Estrogen indirectly suppresses osteoclast production, therefore putting decreasing bone resorption.

  • Most effective if started immediately after menopause, however hormone therapy can increase the risk of breast cancer, myocardial infarction, and stroke In order for these medications to be effective sufficient intake of calcium and vitamin D are required(Lehne, 2013).

  • Although still considered appropriate for menopausal symptoms, hormone therapy is not the drug of choice for osteoporosis (Edmunds, Mayhew, & Bridgers, 2009)


Raloxifene

Raloxifene

Dosing:

  • 60 mg daily oral

  • Selective Estrogen Receptor Modulator (SERM)- reduces the resorption of bone and decreases overall bone turnoff (Edmunds, Mayhew, & Bridgers, 2009).

  • Provides estrogen effects on bone, but does not effect the reproductive tissue, which may decrease the risk of breast cancer.

  • Increased risk of death in women with history of CVA or MI.

  • Women may experience hot flashes, leg cramps, and peripheral edema.

  • Avoid use in bed bound individuals, those with deep vein thrombosis, and those that are pregnant.


  • Bisphosphonates

    Nonhormonal medications that inhibit osteoclast activity to normalize the rate of bone turnover (Edmunds, Mayhew, & Bridgers, 2009).

    These medications are approved for the prevention and treatment of osteoporosis in postmenopausal women.

    Should be taken with 6-8 ounces of water at least 30 minutes prior to food or drink (Drug information handbook for advanced practice nursing, 2012).

    Individuals should remain upright for 30 minutes to reduce the risk of esophagitis and esophageal cancer.

    Dental care is essential as osteonecrosis of the jaw has been reported with bisphosphonates(Drug information handbook for advanced practice nursing, 2012).

    Not recommended for individuals with renal insufficiency. (Edmunds, Mayhew, & Bridgers, 2009).

    At present there are 4 agents in classified as bisphosphonates: alendronate, risedronate, ibandronate, and zoledronate (Lehne, 2013).

    Bisphosphonates


    Alendronate

    Dosing:

    osteoporosis in postmenopausal

    prophylaxis: 5 mg daily or 35 mg weekly oral

    treatment: 10 mg daily or 70 mg weekly oral

    osteoporosis in men

    10 mg daily or 70 mg weekly oral

    Treatment was known to decrease the rate of new fractures(Lehne, 2013).

    Alendronate


    Risedronate

    Risedronate

    Dosing:

    • osteoporosis in postmenopausal

      immediate release: 5mg daily or 35 mg weekly or 150mg monthly oral

      delayed release: 35 mg weekly oral

    • osteoporosis in men

      immediate release: 35 mg weekly oral

  • Decrease effect when taken with antacids, calcium sales, and proton pump inhibitors, avoid taking these medications within 30 minutes of risedronate(Drug information handbook for advanced practice nursing, 2012).

  • Increase effect when taken with NSAIDS and aminoglycosides(Drug information handbook for advanced practice nursing, 2012).


  • I bandronate

    Ibandronate

    Dosing:

    • prevention of osteoporosis in postmenopausal

      2.5 mg daily or 150 mg monthly oral

    • treatment of osteoporosis in postmenopausal

      2.5 mg daily oral or 150 mg monthly oral

      3 mg every 3 months IV over 15-30 minutes

  • Decrease effect when taken with antacids, calcium sales, and proton pump inhibitors, avoid taking these medications within 30 minutes of risedronate(Drug information handbook for advanced practice nursing, 2012).

  • Correct hypocalcaemia prior to beginning therapy.

  • Increase effect when taken with NSAIDS and aminoglycosides(Drug information handbook for advanced practice nursing, 2012).


  • Zoledronate

    Zoledronate

    Dosing:

    • osteoporosis in postmenopausal

      prevention: 5 mg IV every 2 years infused over 15 minutes

      treatment: 5 mg once yearly infused over 15 minutes

    • osteoporosis in men

      10 mg daily or 70 mg weekly oral

  • Highly effective in reducing the incidence of bone fracture across the most common sites: hip, spine, and wrist(Edmunds, Mayhew, & Bridgers, 2009)

  • Renal failure is increased if used with diuretics and nephrotoxic drugs(Lehne, 2013).

  • Ensure hydration prior to dosing(Lehne, 2013).


  • Calcitonin

    Calcitonin

    Dosing:

    • 200 units daily intranasal, alternating nostrils daily

    • 100 units every other day IM or SubQ

  • Useful in the treatment of osteoporosis not the prevention

  • Calcitonin causes inhibition of osteoclast function. Has been shown to increase spinal bone mass in postmenopausal women(Edmunds, Mayhew, & Bridgers, 2009).

  • Ensure that individual has no systemic allergic reaction(Edmunds, Mayhew, & Bridgers, 2009).

  • May require medication holiday to maintain effectiveness(National Osteoporosis Foundation, 2008).


  • Denosumab

    Denosumab

    Dosing:

    • Treatment of osteoporosis in postmenopausal females: 60 mg as single dose once every 6 months SubQ

  • Approved for the treatment of osteoporosis not the prevention(Lehne, 2013).

  • Denosumab reduces the formation and activity of osteoclasts and preserves bone strength(Lehne, 2013).

  • Take in combination with Vitamin D and calcium(Lehne, 2013).

  • Monitor BMD initially and then every 2 years while on treatment(Lehne, 2013).


  • Bone forming therapy

    Bone-forming Therapy

    Teriparatide

    Dosing: 20 mcg daily SubQ rotating sites (initial dose may cause orthostatic hypotension)

    • Teriparatide works by promoting one formation by increasing the activity of osteoblast(Lehne, 2013).

    • Avoid in individuals with increase risk of osteosarcoma(Edmunds, Mayhew, & Bridgers, 2009).

    • There is no evaluation beyond 2 years of treatment, and therefore not recommended(Edmunds, Mayhew, & Bridgers, 2009).

    • Store in the refrigerator. Do not use if frozen(Edmunds, Mayhew, & Bridgers, 2009).

    • Should be reserved for individuals at high risk of fractures due to cost and increase risk of cancer(Edmunds, Mayhew, & Bridgers, 2009).


    Osteoporosis in men

    Osteoporosis in Men

    • About 2 million men have osteoporosis while, another 3 million are at risk.

    • Several factors may contribute to the risk of osteoporosis in men: low testosterone, prolonged use of steroids, Caucasian, deficiency of calcium and vitamin D, smoking, alcohol use and sedentary lifestyle(Lehne, 2013).

    • All men should have adequate intake of calcium and vitamin D.

    • If testosterone deficiency is noted, testosterone replacement therapy should be considered unless contraindicated by testicular cancer or other disorders(Lehne, 2013).

    • There are only 4 medications approved for osteoporosis in men: alendronate, risedronate(only approved dosage of 35mg weekly), zoledronate, and teriparatide(Lehne, 2013).


    References

    References

    • National Osteoporosis Foundation. (2008). Retrieved February 9, 2013, from http://www.nof.org

    • Drug information handbook for advanced practice nursing (13th ed.). (2012). Hudson, OH: Lexicomp.

    • Edmunds, M. W., Mayhew, M. S., & Bridgers, C. (2009). Pharmacology for the primary care provider (3rd ed.). St Louis: Mosby Elsevier.


    References1

    References

    • Ignatavicius, D. D., & Workman, M. L. (2010). Medical-surgical nursing patient-centered collaborative care (6 edition ed.). St. Louis: Saunders Elsevier.

    • Lehne, R. A. (2013). Pharmacology for nursing care (8th ed.). St Louis: Elsevier Saunders.

    • McCance, K., Huether, S., Brashers, V. L., & Rote, N. S. (2010). Pathophysiology: The biological basis for disease in adults in children (6th ed.). St. Louis: Mosby.


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