"The body is shaped, disciplined, honored, and in time, trusted." ~ Martha Graham
Osteoporosis prevention and treatment
For those already affected by osteoporosis, prompt diagnosis of bone loss and fracture risk is essential because therapies are available that can slow further loss of bone or increase bone density.
Osteoporosis Prevention: Better than treatment: Some of the most important treatments for preventing osteoporosis include diet, exercise, and stopping smoking.
Diet
The best diet for preventing or treating osteoporosis includes eating an adequate number of calories as well as calcium and vitamin D, which are essential in helping to maintain proper bone formation and density.
Calcium intake
Experts recommend that premenopausal women and men consume at least 1000 mg of calcium per day; this includes calcium in foods and drinks plus any calcium supplements. Postmenopausal women who do not take estrogen should consume 1500 mg of calcium per day. However, you should not take more than 2000 mg calcium per day due to the possibility of side effects.
The main dietary sources of calcium include milk and other dairy products, such as cottage cheese, yogurt, or hard cheese, and green vegetables, such as spinach and broccoli. A rough 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 or yogurt, 1 oz of hard cheese, or 16 oz of cottage cheese.
Calcium supplements (calcium carbonate or calcium citrate) may be suggested if you cannot get enough calcium in your diet. Calcium doses greater than 500 mg/day should be taken in divided doses for good absorption (eg, once in morning and evening).
Vitamin D intake (see entry on "Vitamin D for All?) Much research is going on that seems to link vitamin D deficiency to a host of future illnesses, from certain cancers to neurologic diseases, such as MS and Parkinson's Disease.
The FDA stillrecommend that most people consume 800 – 1,000 International Units (IU) of vitamin D each day. This dose is sufficient to reduce bone loss and fracture rate in older women and men when there is adequate calcium intake.
Milk is the primary dietary source of dietary vitamin D, containing approximately 100 IU per cup. Experts recommend vitamin D supplementation for all patients with osteoporosis whose intake of vitamin D is below 400 IU per day. This can be found in a daily multivitamin or a calcium/vitamin D supplement.
But it may not be sufficient to prevent other long-term illness. One way to determine if you are getting enough vitamin D (and if you are like me, living most of the year in the Northeast, where we absorb NO vitamin D for 6 months of the year), is to look carefully at your diet and family history. Consider getting a blood test to check your vitamin D level. While not yet routinely recommended as a preventive screening test, if you are not getting it in your diet, your environment, and you wear sunblock "vitamin D block" all spring and summer, you may be at risk for a correctable deficiency.
Protein supplements
Protein supplements may be recommended in some people to ensure sufficient protein intake. This may be particularly important if you have already had an osteoporotic fracture.
Alcohol, caffeine, and salt intakeWe generally recommend limiting the amount of alcohol you drink, sorry. Drinking alcohol excessively can increase the risk of fracture due to an increased risk of falling, poor nutrition, etc. It is not clear if restricting caffeine or salt is helpful; these measures have not been proven to prevent bone loss in people who consume an adequate amount of calcium.
Exercise Weight-bearing exercises can improve bone mass in premenopausal women and help to maintain bone density for women after menopause. Physical activity reduces the risk of hip fracture in older women as a result of increased muscle strength. Most experts recommend exercising for at least 30 minutes three times per week. More is better, daily exercise is best.(walking, anything on your feet where your own body weight keeps your bones dense.)
The benefits of exercise are quickly lost if you stop exercising. A regular, weight-bearing exercise regimen that you genuinely enjoy improves the chances of continuing to follow the routine over the long term.
Cigarette smoking contributes to bone loss in several ways. The toxins use up your estrogen, shortening your hormonal benefits by about 5 years in average. In addition, the tissue of smokers does not get an adequate blood supply to promote healing.
Oxygen, which is carried by the blood and is necessary for healing is reduced in smokers. Several studies have shown that smokers who break hips, have surgical procedures or traumatic wounds often take much longer to heal than do non-smokers. Smoking also causes broncospasm which reduces the amount of oxygen available in the bloodstream.
Repeated falling may significantly increase the risk of osteoporotic fractures in older adults. Taking measures to prevent falls can decrease the risk of fractures. Such measures include the following:
- Remove loose rugs and electrical cords or any other loose items in your home that could lead to tripping, slipping, and falling.
- Ensure that there is adequate lighting in all areas inside and around the home, including stairwells and entrance ways.
- Avoid walking on ice, wet or polished floors, or other potentially slippery surfaces.
- Avoid walking in unfamiliar areas outside.
- Review medications. Because certain drugs may increase the risk of falls, drug regimens should be reviewed on a regular basis.
- Correct your vision
Medication monitoring — Prolonged therapy with and/or high doses of certain medications can increase bone loss. The use of these medications should be monitored and decreased or discontinued when possible. Such meds include:
- Glucocorticoid medications (eg, prednisone)
- Heparin, used to prevent and treat abnormal blood clotting (ie, anticoagulant)
- Vitamin A and certain synthetic retinoids (eg, etretinate)
- Certain antiepileptic drugs (eg, phenytoin, carbamazepine, primidone, phenobarbital…)
Osteoporosis Medications —the non-drug measures above can help to reduce bone loss. A medication or hormonal therapy may also be recommended for certain men and premenopausal women who have or who are at risk for osteoporosis.
In the U.S., the National Osteoporosis Foundation (NOF) recommends use of amedication to treat postmenopausal women (and men ≥ 50) with ahistory of hip or vertebral fracture or with osteoporosis based on T-score ≤-2.5 on bone mineral density testing.
In addition, the NOF recommends drug therapy for people who have osteopenia (T-score between -1.0 and -2.5) as well as one of the following risk factors:
- High risk of bone loss long-term use of steroids
- High risk based on history of fracture with minimal force (eg, fall from standing.)
- Estimated 10-year risk of hip or osteoporosis-related fracture ≥3 or ≥20 percent respectively.
The 10-year risk of hip and osteoporotic fractures can be calculated using the WHO FRAX calculator (www.shef.ac.uk/FRAX/.)
Treatment in premenopausal women — The relationship between bone density and fracture risk in premenopausal women is not well defined. A premenopausal woman with low bone density may have no increased risk of fracture. Thus, bone density alone should not be used to diagnose osteoporosis in a premenopausal woman; further evaluation is generally recommended.
Bisphosphonates — Bisphosphonates are meds that slow the breakdown and removal of bone (ie, resorption). They are widely used for the prevention and treatment of osteoporosis in postmenopausal women. These drugs need to be taken first thing in the morning on an empty stomach with a full 8 oz glass of plain (not sparkling) water. The person must then wait:
- At least half an hour (with alendronate, Fosamax) and risedronate, Actonel)
- At least one hour (with ibandronate, Boniva)
before eating or taking any other meds, to reduce side effects and potential complications.
Side effects of bisphosphonates — Most people who take bisphosphonates do not have any serious side effects related to the medication. However, it is important to closely 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.
The risk of this problem is 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 intravenously during cancer treatment.
Dental Work. 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 reduces vertebral and nonvertebral fractures, and decreases the loss of height associated with vertebral fractures. It is available as a pill that you take once per day or once per week.
Risedronate: Actonel is approved for both prevention and treatment of osteoporosis. It can be taken once per day, once per week, or once per month. Risedronate reduces the risk of both vertebral and hip fractures.
Ibandronate : Boniva can be used for prevention and treatment of osteoporosis. It is available as a pill that you take every day or once per month. It is also available as an injection that is given into a vein once every three months.
Although ibandronate reduces the risk of bone loss and spine fractures, there is no proof that it reduces the risk of hip fractures.
Yearly intravenous zoledronic acid can improve bone density, decrease the risk of spine and hip fractures, and decrease the risk of recurrent fractures in high-risk patients with recent hip fx.
Side effects of zoledronic acid can include flu-like symptoms within 24 - 72 hours of the first dose. This may include a low grade fever, muscle, and joint pain. Treatment with a fever-reducing medication (ibuprofen or acetaminophen) generally improves the symptoms. Subsequent doses of ZA typically cause milder symptoms.
Intravenous ZA is an appealing alternative for people who cannot tolerate oral bisphosphonates or who prefer a once yearly to a monthly, weekly, or daily regimen. However, the ideal duration of therapy and long-term safety (>3 years) have not been established.
"Estrogen-like" medications — Certain medications, known as 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 (Evista) and tamoxifen. Raloxifene can be used for the prevention and treatment of osteoporosis in postmenopausal women, although it may be less effective in preventing bone loss than bisphosphonates or estrogen. SERMs are not recommended for premenopausal women.
On the horizon: SERMS that have benefit to bones, breast, uterus and cholesterol!!!This drug, bazedoxifene, is currently in phase III trials, is given with estrogen, to combat hot flashes, night sweats, insomnia, etc, while protecting breast tissue. Look for more information as the data comes in.
SMART trials: The Selective Estrogens, Menopause, and Response to Therapy (SMART-1) trial was a 2-year, double-blind, multicenter, placebo– and active comparator–controlled study involving 7,492 postmenopausal women aged 40-72years.
Reports from SMART-1 showed that the TSEC significantly increased bone mineral density while reducing hot flashes and vulvar/vaginal symptoms compared with placebo (Fertil. Steril. 2009.) Also reassuring is that they found no synergistic effect on clotting events with the combined therapy and TSEC had no effect on blood pressure.
In a substudy of metabolic effects, just presented (not yet published) at the American Society for Reproductive Medicine, patients who took bazedoxifene plus estrogen for 2 years, showed overall favorable changes to their cholesterol patterns, with an 11% decrease in ldl (the "bad cholesterol") and an 11% increase in hdl (the "good cholesterol" that generally is associated with exercise, with mean total cholesterol reduction of about 4%.
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. Data from the Women's Health Initiative (WHI), a large clinical trial, found that combined estrogen-progestin treatment reduced hip and vertebral fracture risk by 34 %. 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 WHI 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 those who cannot tolerate other types of osteoporosis treatment.
Estrogen may be an appropriate treatment for prevention of osteoporosis in young women with amenorrhea (absence of menses). This is often in the form of a birth control pill.
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. Calcitonin may be administered via nasal spray or injection (subcutaneous salmon calcitonin). Nasal administration is typically preferred due to ease of use and because the injections tend to cause more nausea and flushing.
Other drugs are usually recommended before calcitonin because it is not clear if calcitonin increases bone density and decreases the fracture rate outside the spine. However, due to its pain-relieving (analgesic) effects, calcitonin may be suggested as a first-line therapy for those who have a sudden, intense (acute) onset of pain due to vertebral 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).
A PTH prep called Forteo, given by daily injection for two years, is approved for the treatment of severe osteoporosis. It is more effective at building spine bone density than any other treatment, although it is unclear if it also prevents fracture better than other meds (specifically, the bisphosphonates).
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.
Monitoring Response to Treatment— Testing may be recommended to monitor a person's response to osteoporosis therapy. This includes bone mineral density (DXA scan) every 2 years, and possibly laboratory tests that indicate bone turnover (ie, rate of new bone formation and breakdown.)
Bisphosphonate Holiday?
When a patient starts bisphosphonate treatment, the BMD typically rises sharply for a couple of years, and then plateaus and remains stable. It has become reasonable to consider discontinuing bisphosphonate therapy in some patients after 5 years of continuous use, based on long half life of the drug, balanced by the inconvenience and possible side effects.
After patients stop bisphosphonate treatment, their BMD usually declines gradually. Prior analysis of the FLEX data showed that patients who failed to reach a BMD of at least –2.5 usually benefited with fewer fractures when they remained on bisphosphonate treatment.
Studies are ongoing as to who is best candidate for "drug holiday", how to monitor them and when/if to reinstitute therapy.
Summary
- Osteoporosis causes bones to become abnormally thin (osteopenic), weakened, and easily broken. This condition can be treated and prevented with diet, exercise, and stopping smoking.
- Calcium and vitamin D can prevent and treat thinning bones.
- The main dietary sources of calcium include milk and other dairy products, such as cottage cheese, yogurt, or hard cheese, and green vegetables, such as spinach and broccoli. Milk is the primary source of dietary vitamin D, containing approximately 100 IU per cup.
- Calcium and vitamin D can also be taken as a supplement. A total of at least 1000 mg of calcium per day is recommended for premenopausal women and men. Postmenopausal women should get 1200 to1500 mg calcium per day. Experts also recommend 800-1,000 IU of vitamin D daily.
- Exercise can help to prevent and treat thinning bones. Exercise should be done for at least 30 minutes three times per week. Any weight-bearing exercise regimen is appropriate (eg, walking).
- Smoking cigarettes can make bones thinner and weaker. Stopping smoking can reduce this risk!
- Falling can cause fractures in the elderly. Preventing falls can lower the risk of fractures.
- Some medications can cause bone thinning, and risks and benefits of these medications should be re-assessed periodically.
[Edited from uptodate.com, January 2010: Author: Hillel N Rosen, MD, Section Editor: Clifford J Rosen MD, Deputy Editors: Leah K Moynihan RNC, MSN, Jean E Mulder, MD, also OBGYN News December 2011.]
