Osteoporosis is a condition that causes bones to become abnormally thin, weakened, and easily broken. Women are at a higher risk for osteoporosis after menopause due to lower levels of estrogen, a female hormone that helps to maintain bone mass. Fragility fractures of the wrist, spine and hip are the most characteristic ones, but  any fracture may occur. A fragility fracture is defined as a fracture due to fall no greater than person’s height or with normal use.

Risk factors for osteoporosis are:

• age;
• female gender;
• early menopause (<45);
• slender build;
• family history;
• low Ca and vitamin D intake;
• estrogen deficiency;
• sedentary lifestyle;
• smoking;
• alcohol excess (> 2 drinks a day);
• caffeine excess (> 2 servings a day);
• medications (ex., prednisone, excess thyroxine).

Bone mineral density is measured by the dual energy x-ray absorptiometry (DEXA) and is reported as a T-score (a comparison of the patient’s bone mass to that of young normal subjects, age 30). T-score of <- 2.5  makes a diagnosis of osteoporosis even in the absence of a fracture.

Conditions considered as a causes of low bone mass:

• osteomalacia;
• hyperparathyroididsm, hyperthyroidism;
• hypogonadism, Cushing’s syndrome;
• liver disease, renal failure, celiac disease, IBD, COPD;
• rheumatoid arthritis;
• multiple myeloma;
• alcoholism;
• medications (prednisone, cyclosporine, dilantin, heparin, thyroxine, antiseizure medications).

Non-pharmacological measures useful for prevention and management of osteoporosis:

1. Adequate Calcium and vitamin D intake.
2. Adequate exercising (aerobic and resistance).
3. Smoking cessation.
4. Limitation of alcohol consumption to 2 drinks/day or less.
5. Limitation of caffeine consumption to 2 servings a day or less.
6. Fall prevention.

Experts recommend that premenopausal women and men consume at least 1000 mg of calcium per day; this includes calcium in foods  plus calcium supplements. Postmenopausal women should consume 1200 mg of calcium per day (total of diet plus supplements).

The main dietary sources of calcium include milk and other dairy products (cottage cheese, yogurt, or hard cheese) and green vegetables, such as kale and broccoli. A  method of estimating dietary calcium intake is to multiply the number of dairy servings consumed each day by 300 mg. One serving is 8 oz of milk (236 mL) or yogurt (224 g), 1 oz (28 g) of hard cheese, or 16 oz (448 g) of cottage cheese.

Men over 70 years and postmenopausal women suggested to consume 800 international units of vitamin D each day. The optimal dose has not established in premenopausal women or in younger men with osteoporosis, and 600 iu of vitamin D daily is suggested.

Exercise may decrease fracture risk by improving bone mass in premenopausal women and helping to maintain bone density for women after menopause. Exercise may also reduce the tendency to fall due to weakness. Physical activity reduces the risk of hip fracture in older women as a result of increased muscle strength. Experts recommend exercising for at least 30 minutes three times per week. (Read more under “Medical news”).

The benefits of exercise are quickly lost when a person stops exercising. A regular, weight-bearing exercise regimen that a person enjoys improves the chances that the person will continue it over the long term.

Stopping smoking is strongly recommended because smoking cigarettes is known to accelerate bone loss. Women who smoke one pack per day throughout adulthood have a 5-10 percent reduction in bone density by menopause, resulting in an increased risk of fracture.

Measures to decrease a risk of fall may include:

• Removing loose rugs and electrical cords or any other loose items in the home that could lead to tripping, slipping, and falling.
• Providing adequate lighting in all areas inside and around the home, including stairwells and entrance ways.
• Avoiding walking on slippery surfaces, such as ice or wet or polished floors.
• Avoiding walking in unfamiliar areas outside.
• Reviewing drug regimens to replace medications that may increase the risk of falls with those that are less likely to do so.
• Visiting an ophthalmologist or optometrist regularly to get the optimal eye glasses.

OSTEOPOROSIS MEDICATIONS

The non-drug measures discussed above can help to reduce bone loss. The decision about use of a medication should be shared between the patient and physician.

Bisphosphonates: bisphosphonates are medications that slow the breakdown and removal of bone. They are used for both, the prevention and treatment of osteoporosis.

Most people who take bisphosphonates do not have any serious side effects related to the medication. However, it is important to follow the instructions for taking the medication; lying down or eating sooner than the recommended time after a dose increases the risk of stomach upset.

There has been concern about use of bisphosphonates in people who require invasive dental work  due to risk of avascular necrosis or osteonecrosis of the jaw. The risk of this problem is very small in people who take bisphosphonates for osteoporosis prevention and treatment. However, there is a slightly higher risk of this problem when higher doses of bisphosphonates are given during cancer treatment.

Experts do not think that it is necessary for most people to stop bisphosphonates before invasive dental work (eg, tooth extraction or implant). However, people who take a bisphosphonate as part of a treatment for cancer should consult their doctor before having invasive dental work.

Alendronate (Fosamax): is available as a pill that is taken once per day or once per week.

Risedronate (Actonel):  can be taken once per day, once per week, or once per month.

Ibandronate:  is available as a pill that is taken once per day or once per month. It is also available as an injection that is given into a vein once every three months.

Zoledronic acid (Aclasta):  once yearly dose. This medication is given IV over 15 minutes and is usually well tolerated.

Side effects of  zolindronic acid can include flu-like symptoms within 24 to 72 hours of the first dose. This may include a low grade fever, muscle and joint pain. Treatment with tylenol improves the symptoms. Subsequent doses typically cause milder symptoms.

“Estrogen-like” medications: selective estrogen receptor modulators (SERMs), produce some estrogen-like effects in the bone. These medications provide protection against postmenopausal bone loss. In addition, SERMs decrease the risk of breast cancer in women who are at high risk. Currently available SERMs include raloxifene  and tamoxifen.

SERMs are not recommended for premenopausal women.

Estrogen/progestin therapy — In the past, estrogen or estrogen-progestin therapy was considered the best way to prevent postmenopausal osteoporosis and was often used for treatment. A large clinical trial found that combined estrogen-progestin treatment reduced hip and vertebral fracture risk by 34 percent. A similar reduction in fracture risk was seen in women who took estrogen alone.

Estrogen had the additional advantage of controlling menopausal symptoms. However, the study found that estrogen plus progestin does not reduce the risk of coronary artery disease, and slightly increases the risk of breast cancer, stroke, and blood clots.

Thus, estrogen is not recommended for the treatment or prevention of osteoporosis in postmenopausal women. However, some postmenopausal women continue to use estrogen, including women with persistent menopausal symptoms and women who cannot tolerate other types of osteoporosis treatment. Those women are usually protected against osteoporosis and do not need to consider additional medications to prevent it.

Estrogen may be an appropriate treatment for prevention of osteoporosis in young women whose ovaries do not produce estrogen.

Calcitonin — Calcitonin is a hormone produced by the thyroid gland that, together with parathyroid hormone, helps to regulate calcium concentrations in the body. Synthetic calcitonin is sometimes recommended as a treatment for osteoporosis.  Due to its pain-relieving effects, calcitonin may be suggested as a first-line therapy for those who have a sudden, severe onset of pain due to spine fractures. The treatment regimen is typically changed once the acute pain subsides or if the pain fails to subside over a prolonged period (eg, four weeks).

Parathyroid hormone (Forteo): is produced by the parathyroid glands and stimulates both bone resorption and new bone formation. Intermittent administration stimulates formation more than resorption.

Forteo is given by daily injection, is approved for the treatment of severe osteoporosis for 18 months.  Because it requires a daily injection and is expensive, it is usually reserved for patients with severe hip or spine osteoporosis (T score <-2.5 and an osteoporosis-related fracture). It is not recommended for premenopausal women.

Denosumab (Prolia):  is an antibody directed against a factor (RANKL) involved in the formation of cells that break down bone. It is administered as an injection once every 6 months. Although denosumab is generally well tolerated, side effects can include skin infections and eczema. A mild transient lowering of blood calcium levels can occur, but this is not usually a problem in patients with good kidney function, who are taking enough calcium and vitamin D.

Because it is a new drug and there are no long-term safety data, denosumab is usually prescribed for patients who are intolerant of or unresponsive to oral and/or intravenous bisphosphonates. Denosumab should not be given to patients with low blood calcium until it is corrected.

Osteoporosis risk calculator and Osteoporosis Canada website can be found under “Useful links”.