Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Osteroporosis
M81.0 – Age-Related Osteoporosis without Current Pathological Fracture
I. DEFINITION
osteoporosis, a largely preventable skeletal disease, is characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk.
II. ETIOLOGY
a. two main factors are responsible for the fragility of bone.
1. reduced bone mass
2. impaired repair of microdamage caused by normal wear and tear of bone, with disruption in continuity of the plates in cancellous (trabecular) bone
III. CLINICAL TYPES
a. Primary or idiopathic osteoporosis
1. type i bone loss occurs primarily in the trabecular compartment and is closely related to postmenopausal loss of ovarian function
2. type ii bone loss involves cortical bone and is thought to be an exaggeration of the physiologic aging process
B. secondary osteoporosis
1. medical conditions
a. Chronic renal failure
b. Gastrectomy and intestinal bypass
c. malabsorption syndrome
d. metastatic cancer
e. Fractures
f. alcoholism
g. Celiac disease
h. Vitamin B12 deficiency
i. Vitamin d deficiency
j. rheumatoid arthritis
2. endocrinopathies
a. Hyperprolactinemia
b. Hyperthyroidism
c. Hyperparathyroidism
d. adrenocortical
e. diabetes
f. turner’s syndrome
g. Premature ovarian failure
h. Hypogonadism
i. Hypercalciuria
3. Connective tissue disorder
a. osteogenesis imperfecta
b. ehlers–danlos syndrome
c. Homocystinuria
d. rheumatoid arthritis
4. medications
a. anticonvulsants
b. antacids (with aluminum)
c. thyroid Ht
d. Glucocorticoids: oral, inhaled
e. Luteinizing hormone-releasing hormone
f. Lithium
g. Long-term depo-Provera use
h. aromatase inhibitors
i. immunosuppressants
j. insulin
k. Phenothiazines
l. Butyrophenones
m. methotrexate
n. Heparin
o. sodium fluoride
IV. HISTORY
a. Woman’s medical history, including but not limited to (refer to Clinical Types, III.B)
B. medication history
1. Current prescription medication
2. Current otC medication
3. Current vitamin and botanical use
C. oB-GYn history
1. age at menarche
2. age at menopause
3. months (years) of oral or other hormonal contraceptive, depo- Provera use
4. Parity
5. estrogen use
6. History of menstrual dysfunction
a. Late menarche
b. oligohypomenorrhea
c. exercise-induced amenorrhea
d. Previous hysterectomy with oophorectomy
7. History of extended breastfeeding
d. nutritional status
1. Height and weight
2. eating habits
3. excessive consumption of caffeine and alcoholic beverages
4. History of an eating disorder
e. Lifestyle
1. excessive use of alcohol
2. smoking
3. High caffeine intake
4. Current and past exercise habits
F. Family history
1. maternal history of osteoporosis or fractures
V. PHYSICAL EXAMINATION
a. Height (compare to previous measurement) (loss of 1.5 in.)
B. Weight; Bmi
C. observe back for dorsal kyphosis and cervical lordosis
d. assess for physical abnormalities that interfere with mobility
e. assess for bone pain
F. assess for change of stature
VI. LABORATORY EXAMINATION
a. Consider one of the following screening tests:
1. X-ray densitometry (deXa) gold standard after age 65 unless oth- erwise indicated by history
2. Bone ultrasound
3. Genotyping
4. Bone turnover markers (urinary n-telopeptide [ntX])
5. single-energy x-ray absorptiometry (measures the bones of the wrist or heel)
6. Quantitative Ct (measures the bone density of the spine) this test is expensive and exposes the woman to a higher dose of radiation than other screening tests.
7. Consider calcium and albumin (hyperparathyroidism)
8. Consider 25-hydroxyvitamin d (vitamin d deficiency)
9. Consider tsH (hyperthyroidism)
10. Consider complete blood cell count (CBC) with sedimentation rate
11. Consider liver function test
12. immunoglobulin a (iga)
13. antitissue transglutaminase (+tGa)
14. iga antiendomysial antibodies (aeas)
15. serum protein electrophoresis
VII. TREATMENT RECOMMENDATIONS
a. initiate treatment in postmenopausal women older than 50 years of age with
1. t score less than 2.5 (excluding two causes)
2. Hip or vertebral fracture
3. Low bone mass and 10-year probability of hip fracture of 3% or more or 10-year probability of any major osteoporosis-related fracture
4. Clinician’s judgment and/or patient preferences may indicate treat- ment for people with 10-year fracture probabilities above or below these levels.
B. medication
1. estrogen (see Hormone Therapy section)
2. Bisphosphonates regime should include Fosamax, actonel, atelvia, and Boniva; an alendronate regimen should include
a. 5 mg/10 mg/d or 35 to 70 mg once a week with 6 to 8 oz of water on arising, at least half an hour before breakfast; or 150 mg monthly with 6 to 8 oz of water on arising, at least 1 hour before breakfast (atelvia may be taken right after breakfast with 4 oz of water.)
b. Calcium supplements and antacids interfere with absorption of alendronate; these should be taken at least half an hour later.
c. to prevent gastrointestinal complications, the woman must remain in an upright position for 30 minutes after taking medication
3. Calcitonin-salmon—Fortical
a. injection treatment: 100 iu sc or im every other day
b. nasal spray treatment: 200 iu intranasally once a day (miacalcin or Fortical)
4. selective estrogen receptor modulators: raloxifene (evista) 60 mg daily
5. Calcium 1,200 mg with vitamin d, 800 to 1,000 iu daily (20 mg), and a multivitamin with magnesium 320 mg daily
6. Forteo (parathyroid hormone) 20 mcg subcutaneously daily (may treat up to 2 years)
7. denosumab (Prolia) 60 mg sc, injected into deltoid, quadriceps, or abdomen every 6 months (persons with latex allergy should not handle gray cap on syringe)
8. Zoledronic acid (reclast) 5 mg iV infusion every year
9. Phytoestrogens
10. medical food, Fosteum (genistein, chelazome, cholecaliferol), 1 capsule twice daily
11. Promising new selective estrogen receptor medication (Lasofoxifene) is being used in europe but is not approved by the Fda in the united states.
C. General measures
1. increase exercise
a. muscle-strengthening exercises concentrating on large muscle groups
b. aerobic exercise: walking, walking on a treadmill, climbing a stairmaster, riding a bicycle, using a cross-country ski-type apparatus
2. increase dietary intake of calcium, vitamin d, magnesium
3. decrease dietary intake of alcohol and red meat
4. decrease or stop smoking (see Smoking Cessation, Chapter 4)
VIII. DIFFERENTIAL DIAGNOSIS
a. osteopenia—reduced bone mass caused by inadequate osteoid synthesis
B. arthritis
C. Paget’s disease
d. Fracture
IX. COMPLICATIONS
a. Fracture with associated complications
B. Physical deformity
C. the benefits of long-term oral bisphosphonate use are unknown because most clinical trials have not exceeded 5 years. indeed, some experts recommend “drug holidays” for patients who have taken oral bisphosphonates for extended periods.
d. in rare cases, osteonecrosis of the jaw
X. REFERRAL/CONSULTATION
a. Lack of response to treatment
B. Fractures
C. nutritional guidance
d. exercise program (organizations providing moderate-to-low cost for physical fitness)
e. smoking cessation
See Appendix I and Bibliographies.
Websites: for menopause: www.mayoclinic.com/health/menopause/DS00119; for hormone therapy: www.nlm.nih.gov/medlineplus/hormonereplacementtherapy
.html; www.osteo.org; www.womenshealth.gov