DefinitionEtiologyEpidemiologyPathophysiologyClinical Manifestation
WorkupRN ManagementMedsDiagnosis and GoalsInterventionAlertsRefs

Progressive skeletal disorder characterized by low bone mass, deterioration of bone tissue and disruption of bone architecture leading to compromised bone strength and increase in the risk of fractures.


Back to Top

Primary osteoporosis:

  • Accounts for 80-95% of cases
  • Not associated with systemic disorders (related to postmenopausal state or age)
  • Age-related - usually starts ≥ 50 years
    • Postmenopausal women
    • Men

Secondary osteoporosis:

  • Accounts for < 5% of cases
  • Secondary to any systemic disease (chronic diseases, drug therapy, or lifestyle)
  • Can start at any age

Idiopathic osteoporosis:

  • Usually young person with fragile bones without any associated disorders
  • Hormone and vitamin levels are normal with no obvious reason to have weak bones
  • Potential causes:
    • Abnormalities of osteoblast function
    • Decreased IGF-1
    • Subclinical estrogen deficiency
    • Increased bone turnover
    • Juvenile osteoporosis


Risk factors


Back to Top
  • Estimated to affect >200 million people worldwide; including ~1.4 million Canadians and >10 million Americans
  • Most are postmenopausal women and the elderly
  • Affects 1 in 4 women and >1 in 8 men over the age of 50
  • At least 80% of fractures in people >60 years of age are related to osteoporosis
  • Major cause of fractures and fall related hospital admissions in Canada

Predominant age:

  • Primary osteoporosis: 50-70 years
  • Age-related osteoporosis: >70 years
  • Secondary osteoporosis: Any age

Predominant sex:

  • Female > Male

Prevalence: Canadian Multicentre Osteoporosis Study (CaMos) estimates

  • Increase as the population ages
  • 21.3% in women >50
  • 5.5% in men >50


Hip and vertebral fractures, in particular, are associated with increased morbidity and mortality.

Hip fracture:

  • Approximately 25% of patients with OP related hip fracture die within a year
  • The risk of recurrent fracture in the year following a hip fracture is 5-10%
  • Nearly 75% of all hip fractures occur in women
  • Approximately 44% of hospital discharges after a hip fracture return home; the others are sent to rehabilitation, long-term care facilities, or other hospitals for continuing care (i.e. loss of independence)

Vertebral fracture:

  • Patients are at highest risk for subsequent fracture in the first few months following a vertebral fracture
  • 20% chance of a repeat vertebral fracture within 1 year of developing a vertebral fracture
  • 50-66% of vertebral fractures are not clinically recognized at the time of the fracture


Back to Top
  • Imbalance between bone resorption and formation results in bone loss
  • Increases in the function and life span of bone resorbing cells (osteoclasts) and/or inadequate bone formation (reduction in osteoblast number/function) can lead to a greater number of remodeling sites or deeper resorption sites that cannot be adequately filled by osteoblasts
  • Bone turnover releases a number of bio­chemical markers categorized as markers of bone formation or bone resorption as a consequence of the physi­ological action of osteoblasts and osteoclasts. These turnover markers can be measured in the serum and urine


Summary of factors that affect bone metabolism:

  • Genetic: Determinants accounts for 40-80% of variability in peak bone mass
  • Age: More common in postmenopausal, risk increases with age, low testosterones in men and decrease calcitonin
  • Nutrition: Low calcium, vitamin D, and protein, with high phosphate and inadequate calories intake, all reduces nutrients needed for bone remodeling
  • Physical exercise: Sedentary life, lack of weight bearing exercise, low weight and body mass index, all decrease muscle and bone strengthening and maintenance
  • Lifestyle choices: Caffeine, alcohol, salt, smoking and lack of exposure to sunlight leads to decreased osteogenesis in bone remodeling
  • Medications: Corticosteroids, antiseizure medications, heparin, thyroid hormone and few others affect calcium absorption and metabolism
  • Comorbidities: Anorexia nervosa, hyperthyroidism, malabsorption syndrome and renal failure are few of the many conditions which may affect the calcium metabolism leading to osteoporosis


Back to Top
Clinical Manifestations:
  • Usually asymptomatic until fracture occurs
  • Fractures of the hip, spine, and wrist are most common
  • Fragility fractures: Fractures with little or no trauma, such as fall from sitting or standing height, off a low couch or sofa, or fall down 1-3 steps
  • Chronic pain is common post-fracture symptom, especially after vertebral fracture
  • Vertebral fracture symptoms
    • Sudden onset of back pain
    • Lying on one's back makes the pain less intense
    • Limited spinal mobility
    • Loss of height over time
    • Reduced rib-pelvis distance
    • A stooped posture or kyphosis, also called a "dowager's hump"
    • Standing or walking will usually make the pain worse
  • Key risk factors for fall


Back to Top
Workup and Diagnosis:
  • Osteoporosis Canada recommends that all postmenopausal women and men older than 50 be assessed for the presence of risks factors for osteoporosis
  • Postmenopausal women over age 50 and men who have risk factors for osteoporosis and fracture based on targeted history and physical examination, or those 65 years and older, should undergo screening with DEXA (dual energy x-ray absorptiometry)
  • There are two stages of assessment in identifying high-risk individuals for osteoporosis:
    • Risk factors identifying those who should be assessed with a Bone Mass Density (BMD) test
    • Risk factors identifying those at risk of osteoporotic (fragility) fracture who should be considered for therapy


Identify risk factors for low BMD, future fractures and falls:

  • Prior fragility fractures after age 40
  • Family history of osteoporotic fracture/ parental hip fracture
  • Medication history
    • Such as: glucocorticoid use greater than 3 months in the prior year at a prednisone-equivalent dose ≥ 7.5 mg daily
    • Chronic heparin therapy
  • Life style factors
    • Current smoking
    • High alcohol intake (≥3 units per day)
    • High caffeine consumption
    • Dietary calcium intake
    • Physical activity
    • Weight loss greater than 10% of weight at age 25
    • Poor nutrition
    • Premature menopause
  • Rheumatoid arthritis
  • Inquire about falls in the previous 12 months and inquire about gait and balance
  • Accurate height and weight measurement
  • Get-Up-and-Go Test
    • Inability to rise from a chair without using the arms and walk a few steps and return
  • Dementia


Back to Top

Physical exam:

  • Measure Weight
    • Weight loss of >10% since age 25 is significant

Screening for vertebral fractures:

  • Measure Height
  • Measurement of height loss is a good clinical indicator of vertebral fracture
    • Historical height loss >6 cm (difference between the tallest recalled height and current measured height) OR
    • Prospective height loss of 2 cm (from two or more office visits within 3 years
  • Measure rib to pelvis distance
    • ≤2 fingers' breadth in vertebral fractures
  • Measure occiput-to-wall distance and kyphosis
    • Measure the distance between the wall and the patient's occiput as the individual stands straight with heels and back against the wall. Vertebral fractures should be suspected if distance between the wall and the occiput >5 cm


For all patients with osteoporosis:

  • Calcium corrected for albumin
  • Complete blood count (CBC)
  • Creatinine
  • Alkaline phosphatase
  • Thyroid-stimulating hormone
  • Serum protein electrophoresis (for patients with vertebral fractures)
  • 25-Hydroxyvitamin D* - m easure in patients with:
    • Recurrent fractures
    • Bone loss despite osteoporosis treatment
    • Co-morbid conditions that affect vitamin D absorption or action
  • *Should be re-measured after three to four months of adequate supplementation and should not be repeated if an optimal level (at least 75 nmol/L) is achieved.


In selected patients based on clinical assessment, additional biochemical testing may be required to rule out secondary causes of osteoporosis, such as:

  • Serum testosterone
  • Urinary free cortisol
  • Vitamin B12 level and intrinsic factor antibody
  • Antigliadin and antiendomysial antibodies
  • Serum phosphate
  • 24 hour urinary calcium



Plain X-rays:

  • Simple x-rays of bones are not very accurate in predicting whether someone is likely to have osteoporosis
  • May show decreased radiodensity and loss of trabecular structure

Spinal osteoporotic fractures

  • Initial assessment is done with antero-posterior (AP) and lateral views of both the thoracic and lumbar spines
  • The standard follow-up only consists of single lateral views of the thoracic and lumbar spine that include T4 to L4 vertebrae


Bone mineral density testing:

  • Expressed in terms of T-scores and Z-scores
  • Based upon lowest value for lumbar spine (minimum two vertebral levels), total hip, and femoral neck. If either the lumbar spine or hip is invalid, then the forearm should be scanned and the distal 1/3 region reported
  • Diagnosis of osteoporosis is derived from the following classification of BMD measures by a WHO Working Group, based on fracture risk:
  • From age 50 or over, the T-score system is appropriate. " T-score" is the number of standard deviations (SD) the patient's BMD is above or below the mean value for that of young-adult reference population
    • Normal BMD: T-score between +2.5 and -1.0, inclusive (2.5 SDs above and 1.0 SD below the young adult mean)
    • Osteopenia (low BMD): T-score between -1.0 and -2.5
    • Osteoporosis: T-score ≤ -2.5
    • Severe osteoporosis: T-score ≤ -2.5 plus fragility fracture
  • Prior to age 50, the age- and sex-matched Z scores are preferred. It is the number of standard deviations below the mean for an age-matched population
    • Below expected range for age: Z-score ≤ -2.0
    • Within expected range for age: Z-score > -2.0
    • Z-score <-2.0 should prompt evaluation for causes of secondary osteoporosis
  • Indications for bone mineral density (BMD) testing:


Back to Top

Dual energy X-ray absorptiometry:

  • Measures bone mineral content and bone area
  • Currently, DEXA remains the most accurate and widely used tool for BMD measurement of the central skeleton in the clinical setting
  • It is used for diagnosis, predicting the relative risk of fracture, and following the effects of treatment for osteoporosis
  • Most often performed on the lower spine and hips
  • Therapeutic progress using central DEXA should be monitored in clinical settings one or two years after initiating therapy
  • Depending on the clinical situation, central DEXA scans (lumbar spine and hip) may be repeated in 1 to 3 years, on the same instrument, using the same procedure

Quantitative computerized tomography (QCT):

  • Quantitative computed tomography (QCT) can be used to assess BMD
  • Measures volumetric bone density of the spine and hip and can analyze cortical and trabecular bone separately
  • In postmenopausal women, QCT measurement of spine trabecular BMD can predict vertebral fractures, whereas pQCT of the forearm at the ultra distal radius predicts hip but not spine fractures
  • There is lack of sufficient evidence for fracture prediction in men

Quantitative ultrasound (QUS):

  • Radiation-free technique used to examine bone in the calcaneus (heel), tibia, patella and other peripheral skeletal sites for two values:
    • The speed of sound in bone (SOS)
    • Broadband ultrasound attenuation (BUA)
  • Both the SOS and BUA are higher in healthy bone than in osteoporotic bone
  • Validated heel QUS devices predict fractures in
    • Postmenopausal women (vertebral, hip and overall fracture risk)
    • Men 65 and older (hip and non-vertebral fractures)


Back to Top

Peripheral measurements:

These technologies can only be used to predict fractures. Often measure BMD at several skeletal sites, such as radius, phalanx, calcaneus, tibia, metatarsal.


  • Uses sound waves to measure density at the heel, shin bone, and kneecap

Peripheral dual-energy x-ray absorptiometry (pDEXA)

  • This test is a modification of the DEXA technique that measures bone density of limbs like the wrist, heel, or finger
  • pDEXA is not appropriate for monitoring BMD after treatment

Single energy X-ray absorptiometry (SXA)

  • Measures the wrist or heel

Dual photon absorptiometry (DPA)

  • This test usually has a slower scan time than the other methods but it can measure bone density in the spine, hip, or total body

Single photon absorptiometry (SPA)

  • Measures bone density in the wrist

X-ray absorptiometry

  • Uses an X-ray of the hand and a small metal wedge to calculate bone density

Peripheral quantitative computed tomography (pQCT)

  • A higher radiation method of measuring bone density from bones in limbs, such as the wrist
  • Predicts hip, but not vertebral fractures


Vertebral Fracture Assessment (VFA):

  • VFA-detected fractures predict future osteoporotic and hip fractures independently of age, weight, and BMD
  • It is used for further risk stratification and to aid in clinical decision-making regarding pharmacologic interventions
  • It will identify moderate (>25% compression) or severe (>40%) vertebral deformities.
  • Unequivocal vertebral fractures (>25% height loss with end-plate disruption) unrelated to trauma are associated with a 5-fold increased risk for recurrent vertebral fractures.
  • The advantages of VFA versus standard spine x-rays are convenience, lower cost and markedly lower radiation exposure


Bone turnover markers (BTMs):

  • Measurements of BTMs may provide information about expected rates of bone loss and fracture risk that cannot be obtained from measurements of BMD
  • Currently, bone turnover markers cannot be recommended for the prediction of bone loss in individual patients and are not reimbursed by provincial health plans
  • Bone formation markers include:
    • Serum osteocalcin
    • Bone specific alkaline phosphatase (BSAP)
    • C- and N-terminal propeptides of type I collagen (PICP, PINP)
  • Bone resorption markers include:
    • Urinary hydroxyproline, urinary pyridinoline (PYR)
    • Urinary deoxypyridinoline (D-PYR)
    • Urinary collagen type I cross-linked N-telopeptide (uNTx)
    • Urinary and serum collagen type I cross-linkedC-telopeptide (uCTx and sCTx)


Back to Top

Assessment of 10-year risk of fracture with the 2010 tool of the Canadian Association of Radiologists and Osteoporosis Canada (CAROC)

Fracture risk assessment under the CAROC (2010 version) is based upon the femoral neck T-score only

The CAROC tool stratifies women and men over age 50 into three zones of risk for major osteoporotic fracture within 10 years:

  • Low (<10%)
    • This group of patients does not need treatment with prescription osteoporosis medications
  • Moderate (10-20%)
    • This group of patients requires further assessment to determine whether prescription treatment will be necessary
  • High (>20%)
    • This group of patients does require prescription osteoporosis medication regardless of their BMD test results

Risk factors used in CAROC are:

  1. Age
  2. Sex
  3. Hip BMD
  4. Steroid use (increases risk level by one category if prednisone daily dose >7.5 mg/day for more than 3 months in the past year)
  5. Prior fragility fracture (increases risk level by one category, but hip or vertebral fracture automatically places the patient in the high-risk category)


Assessment of 10-year probability of fracture with the 2011 WHO Fracture Risk Assessment Tool (FRAX) for Canada

WHO Fracture Risk Assessment tool (FRAX) is based upon a more complete set of clinical risk factors that gives immediate calculation of the 10-year probability of a major fracture (clinical spine, wrist, proximal humerus and hip) or hip fracture alone with or without the addition of bone mineral density (BMD) measured at the femoral neck.

Risk factors used in FRAX are:

  1. Age
  2. Sex
  3. Weight
  4. Height
  5. Previous fracture
  6. Parent fractured hip
  7. Current smoking
  8. Glucocorticoids
  9. Rheumatoid arthritis
  10. Secondary osteoporosis
  11. Alcohol 3 or more units/day
  12. Bone mineral density (BMD) of the femoral neck - (optional)

FRAX Calculation Tool for Canada


Back to Top
RN/Medical Management:

Non-pharmacological measures:

Appropriate dietary intake

  • Maintain adequate protein intake
  • Adequate diet to maintain normal body weight
  • Avoid excess caffeine
  • Low salt intake
  • Limit alcohol consumption



  • The total daily intake of elemental calcium (through diet and supplements) for individuals age 50 and over should be 1200 mg with an upper tolerable level of 2500 mg per day


Vitamin D supplementation

  • Associated with increases in bone mineral density and may reduce fracture risk, particularly when combined with adequate calcium intake


Healthy adults at low risk of vitamin D deficiency:

  • Routine supplementation with 400-1000 IU (10-25 μg) vitamin D3 daily is recommended


Adults over age 50 at moderate risk of vitamin D deficiency:

  • Supplementation with 800-1000 IU (20-25 μg) vitamin D3 daily is recommended.
  • To achieve optimal vitamin D status, daily supplementation with more than 1000 IU (25 μg) may be required
  • Daily doses up to 2000 IU (50μg) are safe and do not necessitate monitoring


Exercise and fall prevention

  • Improves quality of life for those with osteoporosis
  • Exercise should be introduced gradually to avoid injury and excessive muscle soreness. Start with shorter durations and/or lower intensities, and work up to the targets above
  • Thoracic kyphosis may be reduced by a program that includes muscle strengthening, range of motion, and postural alignment exercises


Individuals with osteoporosis or at risk for osteoporosis:

  • Resistance training appropriate for the individual's age and functional capacity and/or weight-bearing aerobic exercises are recommended


Individuals who have had vertebral fractures:

  • Exercises to enhance core stability and thus to compensate for weakness or postural abnormalities are recommended


Individuals at risk of falls:

  • Exercises that focus on balance, such as tai chi, or balance and gait training should be considered


Home safety assessment: effective only for those

  • With severe visual impairment
  • At high risk for falls


Hip protectors

  • May be considered for older adults residing in long-term care facilities who are at high risk for fracture


Back to Top


  • Initiation of pharmacologic treatment for osteoporosis should be considered after assessment of absolute fracture risk by means of a validated fracture prediction tool
  • Pharmacotherapy should be offered to patients at high risk (> 20% probability for major osteoporotic fracture over 10 years)
  • Individuals at high risk for fracture should continue osteoporosis therapy without a drug holiday
  • For those with moderate fracture risk and no other risk factors, treatment should be individualized and may include pharmacologic therapy, or basic bone health measures with monitoring
  • Combinations of antiresorptive agents are not recommended for fracture reduction, as they do not show greater fracture reduction than a single agent


Osteoporosis Society of Canada guidelines recommend using

  • Bisphosphonates, denosumab and raloxifene as first-line therapy for the prevention and treatment of osteoporosis
  • HRT as first-line therapy for the prevention of osteoporosis and as second-line therapy for the treatment of osteoporosis (although risks may outweigh benefits)
  • Nasal calcitonin therapy as second-line therapy for the treatment of osteoporosis
  • In addition, parathyroid hormone may be considered as first-line therapy for the treatment of severe osteoporosis


For postmenopausal women requiring osteoporosis treatment:


Alendronate, Denosumab, Risedronate, and Zoledronic acid

  • Used as first-line therapies for prevention of hip, non-vertebral, and vertebral fractures



  • Can be used as first-line therapy for prevention of vertebral fractures


Hormone therapy

  • Can be used as first-line therapy in post-menopausal women requiring treatment of osteoporosis together with treatment of vasomotor symptoms


Calcitonin, Etidronate

  • May be considered for prevention of vertebral fractures for menopausal women intolerant of first-line therapies (lower efficacy than other options)



  • Reduces vertebral and non-vertebral fractures


For men requiring osteoporosis treatment:


Alendronate, Risedronate, and Zoledronic acid

  • Can be used as first-line therapies for prevention of fractures


Individuals on long-term glucocorticoid therapy:

  • A bisphosphonate (alendronate, risedronate, zoledronic acid) should be initiated at the beginning and should be continued for at least the duration of the glucocorticoid therapy in individuals over age 50 who are on long-term glucocorticoid therapy (three months cumulative therapy during the preceding year at a prednisone-equivalent dose > 7.5 mg daily) [use with caution in premenopausal women]
  • Teriparatide should be considered for those at high risk for fracture who are taking glucocorticoids (three months cumulative therapy during the preceding year at a prednisone-equivalent dose > 7.5 mg daily)
  • For long-term glucocorticoid users who are intolerant of first-line therapies, calcitonin or etidronate may be considered to prevent loss of bone mineral density


Back to Top

Patients with breast cancer:


Women receiving aromatase inhibitor (AI) therapy

  • Zoledronic acid, denosumab and risedronate have been demonstrated to reduce AI associated BMD loss


Women taking adjuvant anastrozole for early breast cancer

  • Risedronate resulted in significant increase in lumbar spine and total hip BMD


Patients with prostate cancer:


Men receiving androgen deprivation therapy (ADT)

  • Denosumab showed a decreased cumulative incidence of new vertebral fractures at 36 months (ARR 2.4%)


Osteoporosis prevention strategies in premenopausal women:

  • Identify risk factors
  • Adequate calcium and vitamin D intake
  • Reduced intake of caffeine and alcohol
  • Weight-bearing and resistance exercises
  • Tobacco avoidance


Osteoporosis treatment strategies in premenopausal women:

  • Osteoporosis is uncommon in premenopausal women, and most cases have a secondary cause
  • Treat the underlying disease process or discontinue the inciting medication, if possible
  • Use of bisphosphonates is approved in premenopausal women, but exercise caution in this population because there are limited data about long-term use


Osteoporotic pain:

Osteoporotic patients experience pain and are managed accordingly. The following options are available:

  • A brace or support (only as a temporary measure)
  • Analgesics
  • Applications of heat and ice
    • Warm showers or hot packs can ease stiff muscles
    • Cold can numb the painful area and can also reduce swelling and inflammation
  • Gentle massage
  • Acupuncture
  • Light stretching/strengthening exercises
  • Avoid heavy lifting
  • Physical activity
    • Bed rest should be minimized
  • Antidepressant medication
    • Sometimes prescribed to help people cope with chronic pain
  • Transcutaneous electrical nerve stimulation (TENS)
  • Consistent, carefully designed weight-bearing exercise should be encouraged
  • In some cases, vertebroplasty, sometimes preceded by kyphoplasty, can relieve severe pain of an acute vertebral fracture
    • In vertebroplasty, methyl methacrylate is injected into the vertebral body
    • In kyphoplasty, the vertebral body is expanded with a balloon, and then injected with cement


Monitoring effectiveness of treatment:

  • Repeat central DEXA scan is an important component of osteoporosis management
  • Identify individuals with continued BMD loss, despite appropriate osteoporosis treatment
  • Repeat BMD assessments after 18 months-two years of therapy. If BMD has stabilized or increased, further BMD testing is not necessary
  • The following techniques may be used to monitor the effectiveness of treatment:
    • Central DEXA: Central DEXA assessment of the hip or spine is currently the "gold standard" for serial assessment of BMD
    • Quantitative computed tomography (QCT) measurement of vertebral trabecular BMD of the lumbar spine can be used to monitor age, disease and treatment-related BMD changes in men and women (not widely available, mainly a research tool)
  • Stable or improved BMD is consistent with successful treatment


- When to refer patients for specialized consultation and care


- Institute of Medicine (IOM) Dietary Reference Intakes (DRIs) for calcium


- Institute of Medicine (IOM) Dietary Reference Intakes (DRIs) for vitamin D


Back to Top


  • ➢ Alendronate (oral)
  • ➢ Etidronate (oral)
  • ➢ Risedronate (oral)
  • ➢ Zoledronic acid (IV)



  • Inhibits bone resorption via actions on osteoclasts or on osteoclast precursors
  • Decrease the rate of bone resorption, leading to an indirect increase in bone mineral density



Prevention of postmenopausal osteoporosis


  • 5 mg PO daily


  • 90-day cycle; etidronate 400 mg PO daily for 14 days, then calcium carbonate 1250 mg PO daily for 76 days (usually other agents preferred)


  • 5 mg PO daily OR 35 mg PO once weekly

Zoledronic acid

  • 5 mg IV once


Treatment of postmenopausal osteoporosis


  • 10 mg PO daily OR 70 mg PO once weekly OR 70 mg/2800 IU Vitamin D or 70 mg/5600 IU vitamin D once weekly


  • 90-day cycle; etidronate 400 mg PO daily for 14 days, then calcium carbonate 1250 mg daily for 76 days (usually other agents preferred)


  • 5 mg PO daily OR 35 mg PO once weekly OR 150 mg PO once monthly on the same calendar day each month or risedronate-EDTA 35 mg once weekly with breakfast

Zoledronic acid

  • 5 mg IV once yearly


Treatment of primary osteoporosis in men


  • 10 mg PO daily OR 70 mg PO once weekly


  • 35 mg PO once weekly

Zoledronic acid

  • 5 mg once yearly IV


Prevention and treatment of corticosteroid-induced osteoporosis in men and women


  • 5 mg PO daily (postmenopausal women not taking estrogen: 10 mg PO daily or 70 mg PO weekly)


  • 90-day cycle; etidronate 400 mg PO daily for 14 days, then calcium carbonate 1250 mg daily for 76 days
  • Note: Use for prevention only


  • 5 mg PO daily or 35 mg PO weekly or 150 mg PO monthly

Zoledronic acid

  • 5 mg IV once yearly


Back to Top

Selective estrogen receptor modulator (SERMs):

  • ➢ Raloxifene



  • Reduces resorption of bone by inhibiting the formation and action of osteoclasts, increasing bone mineral density and decreases overall bone turnover
  • It also has estrogen antagonist effects in uterine and breast tissues



Treatment and prevention of postmenopausal osteoporosis


  • Dosage: 60 mg PO once daily; administered any time of day without regard to meals


Bone metabolism regulator:

  • ➢ Calcitonin



  • Functionally antagonizes the effects of parathyroid hormone
  • Directly inhibits osteoclastic bone resorption
  • Increases the renal excretion of calcium, phosphorus, sodium, magnesium, and potassium by decreasing tubular reabsorption
  • Increases the jejunal secretion of water, sodium, potassium, and chloride



Postmenopausal osteoporosis

Calcitonin (intranasal)

  • One spray (200 IU i.e. 0.2 µg) per day, alternating nostrils daily

Calcitonin (injectable)

  • Subcutaneous/ IM 100 units every other day with supplemental calcium and adequate vitamin D


Note: Recommended in conjunction with an adequate calcium (at least 1000 mg elemental calcium per day) and vitamin D (400 I.U. per day) intake.


RANK ligand inhibitor:

  • ➢ Denosumab



  • Denosumab binds to RANKL, preventing RANKL from activating its only receptor, RANK, on the surface of osteoclasts and their precursors
  • Leads to decreased bone resorption and increased bone mass in osteoporosis
  • In solid tumors with bony metastases, RANKL inhibition decreases osteoclastic activity leading to decreased skeletal related events and tumor-induced bone destruction


Postmenopausal osteoporosis


  • Single injection of 60 mg SC, once every 6 months


Note: Recommended in conjunction with an adequate calcium and vitamin D intake.


Back to Top

Parathyroid hormone analog-Bone formation agent:

  • ➢ Teriparatide



  • Pharmacologic activity of teriparatide, is similar to the physiologic activity of PTH
  • It stimulates osteoblast function, increases gastrointestinal calcium absorption, and increases renal tubular reabsorption of calcium
  • Results in increased bone mineral density, bone mass, and strength
  • Decrease osteoporosis-related fractures in In postmenopausal women



  • 20 µg SC once a day into the thigh or abdominal wall for a maximum of 24 months


Note: Supplemental calcium and vitamin D is recommended if dietary intake is inadequate.


Hormone therapy:

  • ➢ Conjugated estrogens
  • ➢ Conjugated estrogens and medroxyprogesterone



Conjugated estrogens (CE)

  • Estrogens modulate pituitary gonadotropin hormone secretion through a negative feedback mechanism; estrogen replacement reduces elevated levels of these hormones in postmenopausal women
  • Conjugated estrogens reduce bone resorption and retard postmenopausal bone loss

Medroxyprogesterone (MPA)

  • When administered with conjugated estrogens, MPA reduces the incidence of endometrial hyperplasia and risk of adenocarcinoma


Prevention of postmenopausal osteoporosis

Conjugated estrogens

  • 0.625 mg PO once daily
  • Note: Premarin should be prescribed with an appropriate dosage of a progestin for women with intact uteri, in order to prevent endometrial hyperplasia/carcinoma.


Conjugated estrogens (CE) and medroxyprogesterone (MPA)

Continuous therapy with combined estrogen and progestins

  • One conjugated estrogens 0.625 mg/ MPA 2.5 mg tablet OR one conjugated estrogens 0.625 mg/ MPA 5.0 mg tablet taken at the same time daily for 28 days
  • Note: Starting dose of 0.625 mg/2.5 mg is appropriate for most women entering menopause. May consider increasing the dose to the 0.625 mg/5.0 mg therapy if amenorrhea is not achieved within a few months of initiating therapy. Once amenorrhea is achieved, consider dose reduction to 2.5 mg


Cyclic therapy

  • One maroon 0.625 mg conjugated estrogens tablet daily for 28 days at the same time each day and one peach 10 mg MPA tablet daily at the same time from day 15-28 of a 28-day cycle
  • Note: May be used where a higher dose MPA is needed and regular withdrawal bleeding is medically appropriate on an individualized basis.


Back to Top
Diagnosis and Goals:


In patients with osteoporosis who may have spontaneous vertebral fractures after taking a detailed history and physical examination the diagnosis includes:

  • Acute pain related to fracture or muscle spasm
  • Constipation due to immobility, pain medications (like codeine)
  • Risk of injury or additional fractures related to the disease
  • Deficient knowledge about the disease process or its treatment



  • Pain relief by taking appropriate measures and analgesics as prescribed
  • Relieving constipation
  • Taking preventive measures to avoid fall
  • Providing in-depth knowledge of the disease and its treatment


Back to Top
Nursing Intervention:

Relieving Pain:

  • Lying sideways with flexed knees relaxes the back muscles
  • Advise patients to lie down several times a day for short periods; use firm and non-sagging mattress
  • Evidence suggests that salmon calcitonin SCT (with either subcutaneous or intranasal delivery) is an analgesic for the acute pain following osteoporotic fracture, and is often prescribed to for pain relief and for minimizing recurrent vertebral fractures in osteoporosis
  • Applying local heat and intermittent back rub relieves pain
  • Teach clients to pick objects from the floor by holding on to something for support and raising one leg behind them, when bending over to keep the back straight
  • Advise against twisting and bending of the back and use the trunk as a single unit
  • Lumbosacral corset may help temporary support and assistance out of bed, although it is seldom comfortable
  • Vertebroplasty may be considered in some patients
  • Activity is gradually resumed as the pain relieves


Relieving the constipation:

  • Monitor bowel sounds and bowel activity, in case of vertebral collapse involving T10- L2 vertebrae, which may lead to paralytic ileus
  • High fiber diet, increased fluid intake and prescribed stool softener prevent or minimize constipation


Preventing risk of injury:

  • Maintaining good posture, by sitting straight up with a good back support
  • Walking with good balance and back straight to distribute the weight evenly, using all the muscles
  • Discourage bending, twisting, and slouching
  • Encourage walking specially outdoors in sunshine to increase the body ability to produce vitamin D
  • Strengthen the trunk muscles by teaching isometric exercises (The joint and muscle are either worked against an immovable force (overcoming isometric) or are held in a static position while opposed by resistance (yielding isometric)
  • Create safe home environment by providing assistive equipment to prevent risk of fall and injury
  • Provide assistance and supervision if required


Promoting knowledge about the disease and its treatment:


Factors which influence the development of osteoporosis:

  • Inadequate dietary or supplemental calcium and vitamin D as discussed in earlier in management
  • Regular weight bearing exercises with lifestyle modifications


Understanding the medications and its effects:

  • Calcium supplements frequently cause abdominal distension, diarrhea and nausea vomiting; it is always advised to take it with meals
  • Advise to increase fluid intake to prevent formation of renal calculi
  • Advice patients if on hormonal therapy, for periodic screening for breast and endometrium, along with the importance of adherence to the therapy
  • Oral bisphosphonates may cause gastric irritation;(i.e. esophagitis, peptic ulcers), always take on an empty stomach and assume a reclining position for 30 -60mins after administeration
  • Nasal calcitonin is administered daily in alternate nares
  • Continued use of calcium and vitamin D along with other drugs is always advised


Information about the disease process:

  • It is important to know that osteoporosis is the most prevalent disease in Canada
  • Clients should be aware of the daily calcium intake according to the age and recommendations as discussed earlier in management
  • Importance of taking calcium in divided doses to avoid the side effects
  • Patient should exhibit the knowledge that estrogens and bisphosphonates preserves bone mass
  • Patients should be aware that the bone loss starts in the 3rd decade of life


Back to Top
Nursing Alerts:
  • In elderly dietary absorption of calcium is less and elimination is in excess so higher amounts are required which is around 1500 mg daily
  • It is important to monitor bowel elimination, in patients with collapse of T10- L2 vertebrae because they may go into paralytic ileus
  • One of the common reasons in elderly to fall is environmental hazards, which can be prevented by vigilant assessment and prompt removal of the cause


Back to Top

Core Resources:

  • Compendium of Pharmaceuticals and Specialties (CPS). Canadian Pharmacist association. Toronto: Webcom Inc. 2012
  • Day RA, Paul P, Williams B, et al (eds). Brunner & Suddarth's Textbook of Canadian Medical-Surgical Nursing. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 2010
  • Foster C, Mistry NF, Peddi PF, Sharma S, eds. The Washington Manual of Medical Therapeutics. 33rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010
  • Gray J, ed. Therapeutic Choices. Canadian Pharmacists Association. 6th ed. Toronto: Webcom Inc. 2011
  • Katzung BG, Masters SB, Trevor AJ, eds. Basic and Clinical Pharmacology. 11th ed. New York: McGraw-Hill; 2009
  • Longo D, Fauci A, Kasper D, et al (eds). Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2011
  • McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis & Treatment. 49th ed. New York: McGraw-Hill; 2010
  • Pagana KD, Pagana TJ eds. Mosby's Diagnostic and Laboratory Test Reference. 9th ed. St. Louis: Elsevier-Mosby; 2009
  • Skidmore-Roth L. ed. Mosby's drug guide for nurses. 9th ed. St. Louis: Elsevier-Mosby; 2011
  • Skidmore-Roth L, ed. Mosby's nursing drug reference. 24th ed. St. Louis: Elsevier-Mosby; 2011
  • Online resource/weblinks:


Online Pharmacological Resources:

  • e-Therapeutics
  • Lexicomp
  • RxList
  • Epocrates


Journals/Clinical Trials:

  • Bono CM, Einhorn TA. Overview of osteoporosis: pathophysiology and determinants of bone strength. Eur Spine J. Oct 2003;12 Suppl 2:S90-6
  • Bone HG,McClung MR, Roux C et al.Odanacatib, a cathepsin-K inhibitor for osteoporosis: A two-year study in postmenopausal women with low bone density. Journal of Bone and Mineral Research. 2010;25: 937-947
  • Cadarette SM, Jaglal SB, Kreiger N, et al. Development and validation of the Osteoporosis Risk Assessment Instrument to facilitate selection of women for bone densitometry. CMAJ 2000; 162:1289
  • Cadarette SM, Jaglal SB, Murray TM, et al. Evaluation of decision rules for referring women for bone densitometry by dual-energy x-ray absorptiometry. JAMA 2001; 286:57
  • Cooper C, Campion G, Melton LJ 3rd. Hip fractures in the elderly: a world-wide projection. Osteoporosis Int. Nov 1992;2
  • Cummings SR, Nevitt MC, Browner WS, et al. Risk factors for hip fracture in white women. N Engl J Med 1995; 332:767
  • Cummings SR, Melton LJ. Epidemiology and outcomes of osteoporotic fractures. Lancet. May 18 2002;359(9319):1761-7
  • Gullberg B, Johnell O, Kanis JA. World-wide projections for hip fracture. Osteoporos Int 1997; 7:407
  • Jaglal SB, Weller I, Mamdani M, et al. Population trends in BMD testing, treatment, and hip and wrist fracture rates: are the hip fracture projections wrong?. J Bone Miner Res 2005; 20:898
  • Johansson H, Oden A, Johnell O, et al. Optimization of BMD measurements to identify high risk groups for treatment--a test analysis. J Bone Miner Res 2004; 19:906
  • Johnell O, Kanis JA, Black DM, et al. Associations between baseline risk factors and vertebral fracture risk in the Multiple Outcomes of Raloxifene Evaluation (MORE) Study. J Bone Miner Res 2004; 19:764
  • Johnell O, Kanis, JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 2006; 17:1726
  • Kannus P, Niemi S, Parkkari J, et al. Nationwide decline in incidence of hip fracture. J Bone Miner Res 2006; 21:1836
  • Leslie WD, O'Donnell S, Jean S, et al. Trends in hip fracture rates in Canada. JAMA 2009; 302:883
  • Lydick E, Cook K, Turpin J, et al. Development and validation of a simple questionnaire to facilitate identification of women likely to have low bone density. Am J Manag Care 1998; 4:37
  • Mauck KF, Cuddihy MT, Atkinson EJ, Melton LJ, 3rd. Use of clinical prediction rules in detecting osteoporosis in a population-based sample of postmenopausal women. Arch Intern Med 2005
  • Mora S, Gilsanz V. Establishment of peak bone mass. Endocrinol Metab Clin North Am. Mar 2003;32(1):39-63
  • National Osteoporosis Foundation. Clinician's Guide to Prevention and Treatment of Osteoporosis. Available at Accessed May 5, 2008
  • Nymark T, Lauritsen JM, Ovesen O, et al. Decreasing incidence of hip fracture in the Funen County, Denmark. Acta Orthop 2006; 77:109
  • Perez-Castrillon JL, Pinacho F, De Luis D et al. Odanacatib, a New Drug for the Treatment of Osteoporosis: Review of the Results in Postmenopausal Women Journal of Osteoporosis 2010; 2010), Article ID 401581, 5 pages
  • Raisz LG. Pathogenesis of osteoporosis: concepts, conflicts, and prospects. J Clin Invest. Dec 2005;115(12):3318-25
  • Ringe JD, Farahmand P. Advances in the management of corticosteroid-induced osteoporosis with bisphosphonates. Clin Rheumatol. Apr 2007;26(4):474-84
  • Rogmark C, Sernbo I, Johnell O, Nilsson JA. Incidence of hip fractures in Malmo, Sweden, 1992-1995. A trend-break. Acta Orthop Scand 1999; 70:19
  • Seeman E, Delmas PD. Bone quality--the material and structural basis of bone strength and fragility. N Engl J Med. May 25 2006;354(21):2250-61


Back to Top

Philip A. Baer, MDCM, FRCPC, Internal medicine (Rheumatology), Chair, OMA Section on Rheumatology, VP, Ontario Rheumatology Association, ON Canada
.......................................... Nursing Editor:
Sadie Sattan, RN, BScN, MN School of Nursing, Faculty of Health Sciences McMaster University/Mohawk College Hamilton, ON Canada

Copyright © 2011-2019 Innovate R&D

educate Are you a Healthcare professional or patient?

Healthcare Professionals would include: Physicians (MD,OD), Physician assistants, Nurses, Pharmacists,Allied Health Workers (PT, OT, SLP, etc), Chiropractors, Paramedics, Optometrists, Dentists, Podiatrists etc, and students within these disciplines.

educate ** You are required to register **

eDucate is committed to optimizing the delivery of health information across the Healthcare continuum. To this end eDucate uses a wide array of learning tools, including Webinars, Quick Review Charts, Graphs, Brochures, Videos and Slide Presentations.

Professional Membership Benefits include free access to all archived and upcoming Webinars:

educate DISCLAIMER: This website is owned and operated by The Innovate Research and Development LP (Innovate R&D). All references herein to Innovate R&D shall be deemed to include any subsidiary, affiliate, associate or successor corporation of Innovate R&D. By entering and using this site, you agree to the "Terms of Use"for this website. If you do not agree to these terms and conditions then exit from this site immediately. Although Innovate R&D updates this website regularly with material believed to be accurate at the time of posting, Innovate R&D does not guarantee the accuracy, completeness, timeliness or currency of the material and consequently Innovate R&D expressly disclaims any liability for errors or omissions in the material contained in the website. The Innovate R&D website and all contents are provided as-is, and all representations and warranties, express or implied, relating to the website or the content are disclaimed, including any implied warranty of merchantability, fitness for a particular purpose or non-infringement, as well as any warranty of quality, functionality, accuracy, currency, completeness, reliability, operability, use performance or absence of viruses. In no way or event will Innovate R&D or any party that has been involved in the creation, production, promotion and marketing be liable to you or any other party for perceived direct or indirect damages. You assume all responsibility and risk of loss resulting from the use of our website.