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Osteoporosis and its treatments

Do you or anyone you know have osteoporosis?  Osteoporosis is a skeletal disorder that can lead to bone fractures, and it is common among post-menopausal women.  Often, it can take years to develop.  However, the process can be clinically silent until a fracture occurs.  Osteoporosis can be caused by many different factors, and it can lead to profound medical, psychosocial, and financial consequences.  Luckily, you and your doctor can be proactive in preventing, detecting, and treating it.

What causes osteoporosis?
Osteoporosis results from low bone mass, which compromises bone strength and can cause them to become thin and weak.  The most common manifestation of osteoporosis is a bone fracture, but decreased height and kyphosis (a curvature of the spine that causes a bent-over posture) can also occur.  Bone loss in women begins years before the onset of menopause and accelerates for the following 5-10 years.  There are many risk factors associated with osteoporosis, such as Caucasian or Asian heritage, a slender build, a family history of osteoporosis, and an early onset of menopause.  There are also many modifiable factors that can influence bone loss, such as cigarette smoking, excessive alcohol and/or caffeine consumption (more than 2 drinks a day), a sedentary lifestyle, estrogen deficiency, low calcium and vitamin D intake, and certain medications, such as steroids (prednisone, Medrol, etc.).

How do you diagnosis osteoporosis?
Clinically, osteoporosis is diagnosed when bone mineral density (BMD) is reduced or when a fragility fracture occurs.  Fragility fractures are breaks in bone from little or no trauma, such as from a minor fall or a sneeze.  The most common osteoporosis-related fracture sites include the hip, forearm, and spine.  Dual-energy x-ray absorptiometry (DXA) has become the standard technique to measure BMD and to monitor responses to treatment.  This procedure is similar to other x-rays, where scans are typically taken of the spine, hip and sometimes forearm.  It takes around 10-30 minutes.  A physician will then compare your bone mass to young normal or age-matched subjects to calculate a score.  Osteoporosis is diagnosed if this score is sufficiently low, or if a patient has a characteristic osteoporotic fracture. Other techniques can also be used to detect BMD, such as computer tomography (CT) or ultrasound. 

How is osteoporosis treated?
Like most diseases, osteoporosis can be treated by both medications and non-pharmacologic measures.  In addition to proper calcium and vitamin D supplementation (see below), there are many kinds of medications used to treat osteoporosis.  Of these, the bisphosphonates are the most common and first line agents.  They come in both oral and intravenous formulations and include alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), and zolendronic acid (Reclast).  The oral tablets can be taken weekly or monthly, depending on the specific drug, and need to be taken upon awakening in the morning with a full glass of water.  You have to remain upright and abstain from eating, drinking, or taking your other medications for 30-60 minutes afterwards.  The intravenous preparations are given at either 3 month or yearly intervals and are arranged through your doctor’s office.

Teriparatide (Forteo), also known as parathyroid hormone, is a medication that is given every day as a self-injection (you administer it yourself via an autoinjector, like an epi pen or insulin pen).  This is usually reserved for patients with osteoporosis who have had a fracture or who are at great risk for having fractures.

The newest medication for osteoporosis is denosumab (Prolia).  This medication is also meant for postmenopausal women at high risk for fracture, or patients who have failed or are intolerant to the other medications for osteoporosis.  It is injected subcutaneously every 6 months, but unlike Forteo, it is done in your doctor’s office.

There are other treatments for osteoporosis, such as calcitonin, hormone replacement therapy, and selective estrogen response modulators like raloxifene (Evista).  You should talk with your doctor to find the therapy that would be best for you.

What can I do?
Be sure that you exercise daily.  Weight-bearing exercises, such as walking, and resistance exercises, such as using light weights or resistance bands, are particularly helpful.  Limit your alcohol and caffeine intake, and if you smoke, try to stop.  Be sure that you’re getting enough calcium and vitamin D daily (1 OTC tablet 2-3 times a day).  You might want to make sure that your vitamin D level is adequate, as vitamin D deficiency is becoming more commonly noted.  Your doctor can easily check this with a blood test called a 25-OH vitamin D level.  If you’re on steroids for another medical condition, talk with your doctor about finding ways to minimize the dose if possible.

Despite the prevalence and possible complications of osteoporosis, it is a condition that can be treated aggressively by a variety of measures by you and your doctor.  Talk with your doctor about appropriate medications, supplements, and exercise for you.  Together, we can prevent and treat osteoporosis.