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Osteoporosis: Significance, Risk Factors and Treatment Options

Hormone replacement, Age related illnesses, Women's Health | September 19, 2014 | Author: The Super Pharmacist

age related

Osteoporosis: Significance, Risk Factors and Treatment Options

Osteoporosis literally means "porous bone." It occurs when bones lose an excessive amount of their protein and mineral content, particularly calcium. Over time, the progressive loss of bone mass leads to deterioration of bone strength. As a result, bones become fragile and break easily. Even a sneeze or a sudden movement may be enough to break a bone in someone with severe osteoporosis. The loss of bone occurs silently and progressively. Often there are no symptoms until the first fracture occurs.

Osteoporosis is a serious global health problem. It is by far the most common metabolic bone disease in humans. Often overlooked and undertreated, osteoporosis and associated fractures can result in devastating physical, psychosocial, and economic consequences. Fractures of the hip and spine are of particular concern because they almost always require hospitalisation and major surgery, and may lead to other serious consequences, including permanent disability and even death.

Causes of Osteoporosis

Our bones grow in size, strength and density as our bodies develop during childhood and adolescence. Bone mass reaches its maximum density at around 25 years of age.

Body tissues are continually being "remodeled" throughout our lives in response to microtraumatic events. "Microtrauma" is the general term used to describe small injuries to body tissues. Examples include minor tears or compressive injuries to muscle fibres, tendons, ligaments or bones.

Bone remodeling is the process of bone repair. It requires a fairly equal balance between bone resorption or breakdown and new bone formation. It occurs on a continuous basis where the broken down bone is replaced by new bone growth.

A change in either - increased bone resorption or decreased bone formation, may result in osteoporosis.

As people age, the rate of resorption tends to exceed the rate of replacement which leads to osteoporosis and an increased susceptibility to fractures.

Diagnosing Osteoporosis 

Currently, the most reliable way to diagnose osteoporosis is to measure bone density with a dual-energy absorptiometry scan or DXA. A DXA scan is a short, painless scan that measures the density of your bones, usually at the hip and spine, and in some cases, the forearm.

What Are the Risk Factors for Osteoporosis?

Factors that increase your likelihood of developing osteoporosis include:

  • Gender – you are more likely to develop osteoporosis if you are female, two in every three fractures occur in women
  • Post-menopause – the loss of oestrogen after menopause is a major risk factor
  • Family history of osteoporosis – inherited factors account for a major part of an individual's risk of having the disease
  • Limited physical activity and
  • Inadequate dietary calcium intake
  • Limited exposure to sunlight resulting in low vitamin D intake
  • Cigarette smoking 
  • Excessive alcohol intake
  • Prolonged use of certain medications such as high dose cortisone therapy
  • Some diseases including hyperparathyroidism and intestinal malabsorption

What Measures Help to Prevent Osteoporosis?

Calcium

Adequate calcium intake is essential in the prevention and treatment of osteoporosis. Premenopausal women and men younger than 50 years without risk factors for osteoporosis should receive a total of 1000mg of elemental calcium daily. Postmenopausal women, men older than 50 years, and other persons at risk for osteoporosis should receive a daily elemental calcium intake of 1200mg.

osteoporosisGood sources of calcium include: 

  • dairy products
  • sardines
  • nuts
  • sunflower seeds
  • tofu
  • vegetables especially greens
  • fortified food 

For patients with osteoporosis, daily dosages of 1200-1500mg of calcium are recommended. Commonly used calcium supplements include calcium carbonate and calcium citrate. Calcium carbonate is generally less expensive and is recommended as a first choice option.

Calcium carbonate has better absorption with food, as opposed to calcium citrate, which is better absorbed in the fasting state. Also, fewer tablets are needed with calcium carbonate than with calcium citrate.

Vitamin D

Adults younger than 50 years should receive 400-800 IU of vitamin D3 daily. All adults older than 50 years should receive 800-1000 IU of vitamin D3 daily.

Good sources of vitamin D include:

  • eggs
  • liver
  • butter
  • fatty fish
  • fortified food  

The minimum daily requirement in patients with osteoporosis is 800 IU of vitamin D3 (cholecalciferol). Many patients require higher levels (continuously or for a short period) to be considered vitamin D replete, which is defined as a serum 25-hydroxyvitamin D level of 32 ng/mL.

Vitamin D is available as ergocalciferol (vitamin D2) and cholecalciferol (vitamin D3). Vitamin D is metabolised to active metabolites. When activated in the liver and then the kidney, vitamin D promotes calcium absorption and bone mass. Vitamin D replacement also increases muscle strength and lowers the risk of falling.

Physical therapy

Physical therapy focuses on improving  strength, flexibility, posture and balance to prevent falls and maximise physical function. Postural retraining is key in this population.

Physical therapySpinal bone mineral density (BMD) is directly correlated with the strength of the back extensors; therefore, maintaining and strengthening the back extensors should be emphasised. As soon as the course of therapy allows, weight-bearing exercises should be initiated. Regular weight-bearing exercises are essential for the maintenance of bone mass and is encouraged in people of all ages.

Exercise

Aerobic low-impact exercises, such as walking and bicycling, generally are recommended. During these activities, it is important to maintain an upright spinal alignment. Studies show that exercises that place flexion forces on the vertebrae tend to cause an increase in the number of vertebral fractures in people. Proper therapy for osteoporosis includes 3-5 sessions per week of weight-bearing exercises, such as walking or jogging, with each session lasting 45-60 minutes. A home-exercise program is recommended.

Pharmacologic prevention

Pharmacologic prevention methods include calcium supplementation, raloxifene or bisphosphonates (alendronate or risedronate). Raloxifene and bisphosphonates should be considered as first-line agents for the prevention of osteoporosis for patients with existing risk factors. Oestrogen-progestin therapy is no longer considered a first-line approach for the treatment of osteoporosis in postmenopausal women, because it is associated with an increased risk for breast cancer, stroke, venous thromboembolism, and perhaps coronary disease. Oestrogen is now only recommended if patients are also seeking relief of postmenopausal symptoms.

Recommended medications for Osteoporosis

Currently, no treatment can completely reverse established osteoporosis. Early intervention can prevent osteoporosis in most people. For patients with established osteoporosis, medical intervention can halt its progression. The American College of Physicians has reviewed the evidence and has proposed guidelines for pharmacologic treatments of osteoporosis. The agents currently available for osteoporosis treatment include bisphosphonates, the selective estrogen-receptor modulator (SERM) raloxifene, calcitonin, denosumab, and an anabolic agent, teriparatide (human recombinant parathyroid hormone).

All therapies should be given with calcium and vitamin D supplementation.

There are no studies that have shown that combination therapy with 2 or more agents have a greater effect on fracture reduction than single therapy. The AACE guidelines advise against the use of combination therapy, until the effect of combination therapy on fracture is better understood.

Osteoporosis Medications 

Bisphosphonates

osteoporosisBone cells are created and broken down in a constant cycle. Bisphosphonates encourage bone density by slowing the ‘breakdown’ process. Bisphosphonates are the most commonly used agents for osteoporosis. They have been employed for both treatment and prevention. These medications are commonly used in Australia to treat osteoporosis in men and women.

  • Alendronate (Fosamax) is approved for the treatment of osteoporosis in men, in postmenopausal women, and in patients with glucocorticoid-induced osteoporosis. It has been shown to increase spinal and hip mineral density in postmenopausal women. Well-conducted controlled clinical trials indicate that alendronate reduces the rate of fracture at the spine, hip, and wrist by 50% in patients with osteoporosis. The treatment dose of alendronate is 70 mg/week, to be taken sitting upright with a large glass of water at least 30 minutes before eating in the morning. This helps decrease the risk of heartburn and ulcers in the oesophagus. After taking bisphosphonates, you must wait 30 minutes to ingest food, beverages (except water), and other medications.
     
  • Risedronate (Actonel) reduces vertebral fractures by 41% and nonvertebral fractures by 39% over 3 years. It is approved for the treatment and prevention of postmenopausal osteoporosis, male osteoporosis, and glucocorticoid-induced osteoporosis. Risedronate can be given daily, weekly, or monthly.
     
  • Ibandronate (Bondronat) is the most recently FDA-approved bisphosphonate and is used to prevent or treat osteoporosis in postmenopausal women and can be given orally once a month. Ibandronate increases bone density and reduces the incidence of vertebral fractures. Ibandronate is approved for the treatment and prevention of postmenopausal osteoporosis. It is available as a 150-mg oral tablet and intravenous solution.
     
  • Zoledronate (Aclasta) is the most potent bisphosphonate available. It is given intravenously once a year. Over 3 years, it reduces the incidence of spine fractures by 70%, hip fractures by 41%, and nonvertebral fractures by 25%. A similar effect on vertebral fractures has been shown in men. This medication can be especially beneficial for patients who cannot tolerate oral bisphosphonates or are having difficulty with complying with the required regular dosing of oral medications.

Selective oestrogen receptor modulators (SERMs)

Sites in the female body called ‘oestrogen receptors’ respond to the hormone, oestrogen. SERMs mimic the action of oestrogen and therefore reduce bone loss. Raloxifene (Evista) is indicated for the treatment and prevention of osteoporosis in postmenopausal women. The usual dose is 60 mg given orally daily. It has been shown to prevent bone loss, and data in females with osteoporosis have demonstrated that raloxifene causes a 35% reduction in the risk of vertebral fractures. It has also been shown to reduce the prevalence of invasive breast cancer.

Denosumab

Monoclonal antibodies such as denosumab (Prolia) slow the breakdown of bone. It is indicated to increase bone mass in men and postmenopausal women with osteoporosis who are at high risk of fracture, have multiple risk factors for fracture, are intolerant to other available osteoporosis therapies, or in whom osteoporosis therapies have failed. Denosumab is administered as a twice yearly injection given under the skin.

‚ÄčTestosterone therapyTestosterone therapy

Men with symptoms of testosterone deficiency and low testosterone levels can improve their bone density with testosterone replacement.

Doses of testosterone are given by injections, implants, skin patches, oral capsules, gels or creams to bring the blood levels back up to normal.

Parathyroid hormone

The parathyroid glands make the parathyroid hormone (PTH). This chemical regulates the amounts of calcium, phosphorus and magnesium in the bones and blood.

Parathyroid hormone therapy stimulates new bone formation and can increase bone density and strengths.

  • Teriparatide (Forteo) is a human recombinant parathyroid hormone (1-34) (PTH [1-34]) and is the only available anabolic agent for the treatment of osteoporosis. It reduces the risk of spine fractures by 65% and nonspinal fractures by 54% in patients after an average of 18 months of therapy. It is indicated for the treatment of women with postmenopausal osteoporosis who are at high risk of fracture and is approved for men with hypogonadal osteoporosis who have been intolerant of previous osteoporosis therapy, or in whom osteoporosis treatment has failed, as well as to increase bone mass. This medication is a daily injection used for people with severe osteoporosis when other types of medication are considered either unsuitable or ineffective.

Calcitonin-salmon

Calcitonin-salmon is a hormone that decreases bone resorption, thereby impeding postmenopausal bone loss. It is indicated for the treatment of women who are more than 5 years post menopause and have low bone mass relative to healthy premenopausal women. It is available as an injection and as an intranasal spray. The intranasal spray is delivered as a single daily spray that provides 200 IU of the drug. At this dose, it reduces the incidence of spine fracture by 33%. It is available in parenteral and intranasal forms; however, the intranasal form is more convenient and better tolerated. Calcitonin-salmon should be reserved for patients who refuse or cannot tolerate oestrogens or in whom oestrogens are contraindicated.

Oestrogen and oestrogen derivatives (Hormone replacement therapy - HRT)

Oestrogen derivatives are approved for the prevention of osteoporosis and relief of menopause-associated vasomotor symptoms and vulvovaginal atrophy. In women, the female sex hormone oestrogen plays an important role in maintaining the strength of bone tissue. Menopause causes a marked drop in oestrogen levels, and increases the risk of osteoporosis and osteoporotic fractures. While HRT boosts oestrogen levels and prevents osteoporosis after menopause, it has also been associated with an increased risk of thrombosis (blood clots in the veins) and breast cancer. The lowest effective dose at the shortest duration necessary should be used. The FDA recommends that other approved non-oestrogen treatments be considered first for osteoporosis prevention. Its long-term use is no longer recommended for osteoporosis management.

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