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Osteoporosis: Don’t Let Your Bone Density Fracture Your Future

Osteoporosis:  Don’t Let Your Bone Density Fracture Your Future
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Osteoporosis is a disease that causes your spine, hip, and wrist to be more susceptible to fractures and breaks. It develops when decreased bone density makes bones weaker and more fragile. So fragile, in fact, that a break can occur from an event as innocuous as a bump. It is estimated that 50% of women and one in five men over 50 years old will have a fracture or broken bone from osteoporosis in their lifetime— and they aren’t to be taken lightly, either. They are extremely painful and can land you in the hospital awaiting major surgery, which may take months to recover from. Worse, complications from osteoporotic breaks can be debilitating and life threatening.  Worryingly, bone deterioration occurs so gradually that most people are unaware of their fragility until a fracture or break occurs. By then, the disease is already in an advanced state.

But how do you know whether you’ll develop osteoporosis? The most common risk factor is age. Both men and women over the age of 60 are at risk for osteoporosis, but women are at higher risk earlier in life than men are. This is mainly because once women go through menopause, their estrogen levels drop–and estrogen is a hormone that protects against bone loss. You are also at higher risk for developing osteoporosis if you have family members who have the disease, are taking corticosteroid medications over a long period of time, or you have rheumatoid arthritis, a vitamin D deficiency, an eating disorder, or a low body mass index. Smoking tobacco and drinking excessively can also put you at risk for osteoporosis.

There is no way to say whether or not you will develop osteoporosis but this doesn’t mean that the only recourse is to hope for the best. It is never too late to take action against bone loss and make your future as fracture-free as possible.

Osteoporosis prevention starts with you

Osteoporosis is usually diagnosed using bone mineral density (BMD) assessments given at around age 65. However, the lifestyle choices you make right now can affect the probability that you will develop the disease. As osteoporosis can develop at a younger age, it important to discuss your risks with your doctor in case you should be taking more aggressive preventative measures now.

Lifestyle choices: Decisions that strengthen your bones Sufficient calcium and vitamin D intake combined with regular exercise keeps your bones strong—and reduces the risk of fractures later in life. In fact, diet and exercise are so effective that lifestyle modifications are the first treatment advice from physicians, and they are always advised concurrently if you do need medication to treat osteoporosis.

Calcium and vitamin D. Many people think that calcium is only important when our bones are still growing, but it’s equally important in adulthood. Calcium is important for both nerve and muscle function, and if we don’t consume enough of it in our diet, our body will break down bone to access it. Also, it is important to remember that as we age, we don’t absorb calcium as efficiently as in our teens. This is where vitamin D comes in. Vitamin D helps absorb dietary calcium more efficiently, so our bodies can use it.  Postmenopausal women and men over the age of 65 need at least 1,300 mg of dietary calcium and all individuals over the age of 51 years should get at least 400-600 IU of vitamin D every day. You should talk to your doctor about supplementing your daily requirements, especially if you are already at risk for developing osteoporosis.

Exercise. Bones, just like muscle, need to be used regularly or they will deteriorate. Weight-bearing exercise, such as dancing, jogging, brisk walking, resistance training, tennis, and volleyball, are all examples of exercise that strengthen your bones. There are also specific exercises you can do to protect your spine and improve your balance for avoiding falls as you age.

The International Osteoporosis Foundation’s website is an excellent resource for information about nutrition, calcium, vitamin D, and exercise for preventing osteoporosis. The website has everything you need to arm yourself for keeping your bones healthy. They also have helpful publications you can download, which you can find here.

Osteoporosis Medications

If you have been diagnosed with osteoporosis, there are effective medications available to protect your bones from fractures and breaks. Treatment for osteoporosis always includes taking vitamin D and calcium supplements, as well as making appropriate changes in diet and exercise. Medications provide additional protection by either slowing down bone deterioration (anti-resorptive) or promoting bone formation (anabolic).

Bisphosphonates Bisphosphonates are the most commonly prescribed medication for treating osteoporosis. They are anti-resorptive and are quite effective— they can reduce fracture incidence by up to 50%. Several bisphosphonates are available including alendronate (Fosomax®), risedronate (Actonel® and Atelvia®), ibandronate (Boniva®), and zoledronic acid (Relcast®). All are protective against both vertebral and hip fractures except Boniva®, which has only shown to be effective for preventing vertebral fractures. The most common form is a pill that is taken daily, but oral bisphosphonates can be problematic because of the strict instructions for taking them and their side effects. As a result, formulations are available that are taken less frequently, or administered intravenously. Because bisphosphonates act by binding to and accumulating in bone, they may continue to be protective even after treatment is stopped, which means a “drug holiday” is sometimes incorporated into long-term therapy.

Side effects/Concerns: Oral bisphosphonates can irritate the stomach and esophagus and if taken incorrectly can lead to ulcers in the esophagus. Nausea, back and joint pain, and flu-like symptoms are common with all bisphosphonates, especially the day after the first dose of Reclast®, however they are less likely following subsequent doses.

There are concerns that long-term use of bisphosphonates may lead to atypical fractures in the femor, called atypical subtrochanteric femur fractures. Studies have shown this to be a very rare event, but patients who develop pain in the hip or thigh should talk to their healthcare providers. Also, some bisphosphonates have been linked with a rare, but serious, condition called osteonecrosis (ONJ), which is breakdown of the jaw. However, the incidence of this is extremely rare in individuals who are taking the medication for osteoporosis.

Selective estrogen receptor modulators (SERMs) SERMS protect against breakdown of bone. They act similarly to estrogen, but they are not hormones. Raloxifene (Evista®) is the only SERM currently available in the US. Like tamoxifen, which is used to treat breast cancer, it acts on the receptor for estrogen. Raloxifene can reduce the risk of spinal fractures by nearly 50%, but it doesn’t appear to be effective in protecting against non-vertebral fractures. Two newer SERMs, lasofoxifene and bazedoxifene, are approved in Europe but are still in clinical trials in the US. Lasofoxifene may have fewer side effects and better bioavailability than raloxifene. SERMs are taken orally every day.

Side effects/Concerns: Hot flashes, leg cramps, and feet swelling can occur when taking Evista® and there is a potential increased risk of blood clots in the veins of the legs or lungs, which can lead to stroke, when taken long-term.

Hormones Although estrogen is a hormone that prevents bone loss, estrogen replacement therapy is rarely prescribed for osteoporosis because it may increase the risk the increase of heart attacks and some types of cancer. The two hormone treatments available for treating osteoporosis are a synthetic analog of parathyroid hormone and calcitonin:

Teriparatide (Forteo®) is a parathyroid hormone fragment and it is the only treatment that significantly stimulates bone formation. It has been shown to reduce the incidence of vertebral fractures by up to 65%. It is prescribed for individuals with severe osteoporosis who are at very high risk for fractures. It is given as a self-administered shot, once a day. A full-length analog of parathyroid hormone, marketed as Ostabolin-C in Europe, is in currently in clinical trials in the US.

Side effects/Concerns: Patients can experience nausea, joint pain, leg cramps, skin irritation, and dizziness after taking Forteo®. The long-term safety of parathyroid therapy is not yet known, but there is a potential risk of increased calcium in the blood. It is usually prescribed for only 24 months.

Calcitonin is a hormone that slows bone loss and has mild affects in increasing bone density. Known as Fortical® or Miacalcin®, is the only treatment available as a nasal spray. However, its effectiveness in reducing the incidence of fractures is not as robust as other drugs so it is not usually a first-line therapy for osteoporosis patients.

Side effects/concerns:  Nasal irritation, headache, dizziness, back and joint pain, and nausea are all side effects of calcitonin spray.

Biological Therapies

Denosumab In 2010, Prolia® was the first biological therapy approved in the US for treating osteoporosis. It is an antibody that blocks the cells responsible for bone resorption, which effectively reduces bone loss. Prolia® is slightly more effective than bisphosphonates. Given as a shot twice a year, dosing is expected to help overcome the difficulties some patients have in adhering to bisphosphonate drugs.

Side effects/concerns:  There is an increased risk for severe infection and dermatological reactions associated with Prolia®. Patients with renal problems are at risk of hypocalcemia (not enough calcium in the blood stream). Also, there is a potential risk of atypical fractures and the development of osteonecrosis of the jaw (ONJ).

Medications on the horizon

Strontium Renelate has been used in Europe since 2004 to treat osteoporosis. It is unique in that it both stimulates bone formation and prevents bone loss in both the spine and hip. It has been shown to reduce vertebral fractures by 24% and hip fractures by 43%. It is taken orally. Strontium malonate, a related drug, is currently in clinical trials in the US.

Side effects/concerns: Although patients can experience nausea, diarrhea, dermatitis, and eczema during the first three months of treatment, the drug is well tolerated overall. There is an increased risk for venous thromboembolisms (VTE) in patients taking strontium renelate.

Odanacatib is an enzyme inhibitor currently in clinical trials in the US. It acts by blocking cathespin K, an enzyme that degrades bone during remodelling. Initial studies have shown that Odanacatib increases bone mineral density in both the spine and hip with minimal side effects.


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