Dont Be a Bonehead! Recognizing & Treating Low Bone Density - - PowerPoint PPT Presentation

Don’t Be a Bonehead!

Recognizing & Treating Low Bone Density

Kate Sheeran, APRN, AGNP-BC

Disclosures

u No disclosures for the purposes of this

presentation

Objectives

uScope of the problem uCoordination of care models uPost-fracture care and secondary

fracture prevention

uDiagnostic and treatment guidelines

Scope of the Problem

What is a fragility fracture?

u A fall from standing height or less that results in a

fracture

u Most common places to fracture are vertebral body,

femoral neck, wrist and proximal humerus

u The body should be able to sustain a fall like this and not

fracture unless there is an underlying issue making the bones fragile

J Bone Miner Res 2007;22:465–475. Published online on December 4, 2006; doi: 10.1359/JBMR.061113

Incidence of osteoporotic fracture

u54 million adults

• ver age 50 are at

risk for

• steoporotic/

fragility fracture

uThis is half of all

people in this age bracket!

Hospitalization Comparison

0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

Osteoporotic Fracture Stroke MI Breast Cancer

4.9 3 2.9 0.7 Millions

Number of Hospitalizations during 2001 to 2011

Singer, A., et al. Mayo Clin Proc. 2015 Jan;90(1):53-62. doi: 10.1016/j.mayocp.2014.09.011

uFracture related 6-

month mortality risk is 36%

uFracture related

complications include:

uDecreased

functional status & mobility

uChronic pain uPressure injuries uInfections uDepression

By 2025: >3 million fractures $25.3 billion

J Bone Miner Res 2007;22:465–475. Published online on December 4, 2006; doi: 10.1359/JBMR.061113

We just get a failing grade!

Coordination of Care

How we can do better

American Orthopedic Association. What Is Own the Bone? https://www.ownthebone.org/OTB/About/What_Is_Own_the_Bone.aspx Accessed September 5, 2019

Breaking the cycle of fractures

Bone Health Evaluation Education, Treatment Increased BMD, Decreased Fracture Risk!

Bone Health / Fracture Liaison Service Primary Care Provider Busy, Busy

Fracture Liaison Service

u Initial visit: u Bone density testing u Labs u Medications u Medical/dental history u Family history u Lifestyle factors u Fall risk assessment u Education on treatment

• ptions, appropriate

nutrition and supplementation

u Referral as appropriate to

dietician, physical or

• ccupational therapy,

endocrinology or rheumatology

u Initiation of appropriate

treatment

u Ongoing assessment of grief

response and emotional response to changes in health status

Bonanni, S., Sorensen, A. A., Dubin, J., & Drees, B. (2017). The Role of the Fracture Liaison Service in Osteoporosis Care. Missouri medicine, 114(4), 295–298.

Diagnosing & Screening for Osteoporosis

Diagnosis of Osteoporosis

u AACE Clinical Practice Guidelines u T score of -2.5 or below at lumbar spine, femoral neck

• r distal radius

u Low-trauma spine or hip fracture (regardless of BMD) u T score of -1.0 to -2.5 (low bone mass or osteopenia)

with a fragility fracture of proximal humerus, pelvis or possibly distal forearm

u Low bone mass or osteopenia and high FRAX score

American Association of Clinical Endocrinologists. Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis. https://www.aace.com/disease-state-resources/bone-and-parathyroid/clinical-practice-guidelines/clinical-practice Accessed September 5, 2019

USPSTF Screening Guidelines

u Women over 65 u Postmenopausal and

under 65, with risk greater than or equal to that of a 65 year

• ld without risk

factors

u No screening

recommended for men

u Know the risk factors u Parental hip fracture u Smoking u Excess alcohol intake u Sex hormone deficiency u Cerebrovascular accident u Diabetes u History of falls u Long term corticosteroid

https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/osteoporosis-screening1

Osteoporosis Workup

u Renal impairment, cirrhosis,

impaired absorption, multiple myeloma

u Medications contributing to low

bone mass

u Glucocorticoids u PPIs u Aromatase inhibitors u Androgen deprivation therapy u Depo-Provera u SSRIs u Antiepileptic drugs u Heparin and warfarin

Rule out any secondary causes Labs: CBC, CMP , PTH, 25-OH vitamin D, TSH

Panday, K., Gona, A., & Humphrey, M. B. (2014). Medication-induced osteoporosis: screening and treatment strategies. Therapeutic advances in musculoskeletal disease, 6(5), 185–202. doi:10.1177/1759720X14546350

Osteoporosis Treatment & Management

Bone Health Medications

Bisphosphonates : stops bone resorption by inhibiting osteoclast activity; 3-5 years average treatment duration Oral forms

u

Fosamax (alendronate) weekly dosing

u

Actonel (risendronate) weekly dosing

u

Boniva (ibandronate) monthly dosing IV forms

u

Reclast (zoledronic acid) yearly dosing

u

Boniva (ibandronate) every 3 month dosing RANK Ligand Inhibitor: slows bone resorption by inhibiting osteoclast formation and survival; can be given 10+ years

u

Prolia (denosumab) every six months injection Anabolic agents: stimulate bone formation; 12-24 month treatment duration

u

Forteo (teriparatide) daily self- injectable

u

Tymlos (abaloparatide) daily self- injectable

u

Evenity (romosozumab) monthly injectable

Thank You!