The role of the Practice Nurse
Osteoporosis is a condition in which bones lose their strength and are more likely to break, usually following a minor bump or fall. Osteoporosis is also a term used to describe low bone density as measured on a bone density (DXA) scan.
Practice nurses play an essential part in the delivery of quality primary care, and due to the increasing shift of care from acute to primary they have a growing responsibility in management of long term conditions including osteoporosis. Effective fracture prevention is best addressed via a whole system response to the challenge of identifying fragility fractures. Practice nurses and GPs are well placed to identify fragility fractures, assess patients for osteoporosis, treat them and monitor their adherence to treatment, thereby preventing further disabling and costly fractures. For more information about osteoporosis, go to the Introduction section of Osteoporosis Resources for Primary Care.
Identifying patients at risk of osteoporosis
The practice nurse can screen patients for risk factors for osteoporosis, including family history, low BMI, coeliac disease, rheumatoid arthritis, smoking or heavy drinking. Similarly, with the relevant knowledge, practice nurses can identify patients treated with medications that put them at greater risk of osteoporosis such as glucocorticoid (‘steroids’), anti-epileptic drugs, breast cancer treatments such as aromatase inhibitors and prostate cancer drugs. For more information about risk factors for osteoporosis, go to the Introduction section of Osteoporosis Resources for Primary Care.
Patients who are flagged for consideration should also be given lifestyle advice including eating a balanced diet and undertaking appropriate exercise. More information is available on the in our patient publications including the Healthy Living for Strong Bones leaflet.
Identifying patient with fragility fractures
Fractures that occur because of reduced bone strength are described as 'fragility fractures' and many of these will be caused by osteoporosis.
Practice nurses and GPs can play a part in low trauma fracture prevention by identifying all people over 50 years of age with a fracture in their practice, and referring them to a FLS (where there is one) for an assessment for osteoporosis. This should include all fragility fractures excluding face and skull.
If a practice nurse sees a patient who has had a fragility fracture after the age of 50 who has not had a DXA scan or an assessment for osteoporosis, then this should be flagged up for consideration. The practice nurse can refer the patient to the FLS at the local hospital (where available), or arrange for them to be seen by the GP for an assessment and treatment with bone sparing medication and lifestyle advice where necessary. The GP or practice nurse can conduct both an online FRAX assessment and a dietary assessment for calcium intake, refer the patient for a DXA scan if appropriate or start bone-sparing medication such as alendronic acid or risedronate (both administered weekly oral +/- calcium/vitamin D). Where the patient is complex, and where oral treatments have not been tolerated or successful, they can be referred to rheumatology or the local FLS.
Find out more about Fracture Liaison Services at www.nos.org.uk/fls
Identifying vertebral fractures
About Vertebral fractures:
- Vertebral fractures are the most common osteoporotic fracture, but the most challenging to identify systematically (Kanis et al 2000; Samelson et al 2006). Currently, 50-70% of vertebral fractures remain undiagnosed (NICE 2011).
- They are an important cause of morbidity, accounting for 14 additional GP visits per year, compared to 9 after hip fracture and 4 after a wrist fracture (Dolan 1998). It is likely that the significant proportion of the vertebral fractures that currently go undiagnosed, are symptomatic and generate costs to the NHS in repeated GP visits.
- Vertebral fractures are also associated with an 8-fold increase in age-adjusted mortality, similar to that observed following hip fracture. Vertebral fractures are also a strong predictor of costly hip fracture – an increase of risk by 2.8-times (Black et al, 1999; Klotzbluecher et al, 2000).
- A woman with one vertebral fracture has a 5.8 times increased risk of another vertebral fracture and 2.8 times increased risk of hip fracture (Black et al 1999). However, vertebral fractures are highly responsive to treatment, which is known to modify the risk of fracture after 6-12 months (Kirsten et al 2014, Harris et al 1999, Black et al 1996, Chesnut et al, 2004; Meunier et al, 2004).
The role of the Practice Nurse in identifying Vertebral fractures:
- Practice nurses can play a vital role in the identification of osteoporotic vertebral fractures in primary care where most vertebral fractures will present as acute onset back pain with no obvious trauma. Without an assessment for osteoporosis, these fractures are otherwise easily missed. Action to identify and treat vertebral fractures by the practice nurse can quickly modify the patient’s risk of future debilitating fractures.
- If a practice nurse sees a patient with risk factors for osteoporosis, acute onset of back pain and no obvious trauma and/or loss of height, or receives a CT/MRI or X-ray report that highlights a vertebral fracture then it should be highlighted to the GP as a matter of priority for assessment. The patient should be sent for a DXA scan or started on treatment for osteoporosis, whichever is most appropriate.
Follow-up, adherence and support
Follow-up of all patients to check adherence to treatment is central, both to achieving best practice standards and realising the clinical and cost benefits of fracture prevention. Practice nurses are well placed to do this, especially for complex patients and where there is no FLS in place. Patients will benefit form a good working relationship between their practice nurse and the local osteoporosis service or FLS (where there is one).
The NOS publishes a range of leaflets and fact sheets for health professionals to use with their patients to support them to understand and manage their osteoporosis and/or fragility fractures. Visit www.nos.org.uk/publications or telephone our nurse-led helpline on 0808 800 0035.
Denosumab in primary care
Denosumab is a drug that slows bone loss in osteoporosis. It is given as an injection twice a year. It can be taken by postmenopausal women who can’t take alendronate, risedronate, and etidronate (oral bisphosphonates). Some women can’t take oral bisphosphonates because of side effects, such as heartburn, or because they have trouble swallowing. Also, a woman might not be able to take certain bisphosphonates if she can’t follow the special instructions for taking them – for example, having to stay upright for half an hour after taking the drug, and not eating for a while before and after taking it. See "Understanding NICE guidance: Information for people who use NHS services. Denosumab for preventing bone fractures in postmenopausal women with osteoporosis".
In some practices, denosumab injections are given by a GP or Practice Nurse. In these instances, a ‘Shared Care Agreement’ will be in place between specialist services and primary care which will outline how the prescribing and administering responsibilities for denosumab can be shared between the specialist service and primary care.
Practice Nurses and GPs should refer to their local shared care guideline and the NICE Technology Appraisal 204 “Denosumab for the prevention of osteoporotic fractures in post-menopausal women”.
For further information, please refer to the NOS factsheet on Denosumab.
More information for you and your patients
Download our leaflets, posters and factsheets to share with your patients.
Our booklet 'All about osteoporosis' is a fantastic resource to share with patients who are newly diagnosed with osteoporosis.