ILibrary: Prevention and treatment of osteoporosis

Prevention and treatment of osteoporosis

02:18 | Posted by Sidharth |

Ideally, osteoporosis is a condition that should be prevented from occurring. But this is unrealistic given our present state of knowledge and ability to influence it.

What steps can I take to prevent osteoporosis?

These general measures can be used by everyone, whether or not you ultimately go on to

develop osteoporosis.

Exercise and lifestyle

Advice for runners

Excessive running may cause increased bone loss.

Because some runners are very thin, they should take advice on the best way to avoid bone problems later in life.

The majority of us who are not in the elite athlete category need not be so concerned.

Healthy bones at least partially reflect healthy living: taking regular exercise is the single most important action anyone can take to improve the strength of their bones.

Exercise also greatly reduces the risk of heart disease, high blood pressure and diabetes, and it has positive effects on mental wellbeing, too.

The sort of exercise that's beneficial in preventing osteoporosis is weight-bearing, such as walking or aerobics.

Stopping smoking should be a priority for anyone interested in enjoying a longer life and keeping away from orthopaedic wards.

Alcohol consumption should also be kept within safe limits.

Diet

Non-dairy food sources of calcium

Nuts and pulses: almonds, Brazil nuts, hazelnuts, sesame seeds.
Green leafy vegetables: broccoli, spinach, watercress, curly kale.
Dried fruits: apricots, dates, figs.
Fish: mackerel, pilchards, salmon, sardines.
Tofu and various calcium-fortified foods.

A good calcium intake is essential throughout life for healthy bones.

There is good evidence that the adequacy of a child’s diet at least partially determines their osteoporosis risk in adulthood.

The recommended daily intake of calcium for an adult is around 800mg.

On average, 250ml (half a pint) cows' milk or 150g (5oz) yoghurt contains 300mg of calcium. Low-fat dairy products contain the same amount of calcium as higher fat varieties.

What about taking supplements?

Calcium supplements can be bought. There are several types available on prescription if someone’s dietary intake is low or marginal.

Frail elderly people with poor mobility may be helped by taking a calcium supplement along with vitamin D.

This type of supplement is safe, but it's best discussed with a doctor first.

Treatment

More detailed intervention depends on individual circumstances, and so only an overview can be presented here.

There are several types of treatment available, and often a combination will be more appropriate than just one.

Hormone replacement therapy (HRT)

Oestrogen seems to protect bone strength. The drop in oestrogen, which occurs following menopause, is mirrored by an increased loss of bone for a few years thereafter. The loss continues, but less steeply, in older women.

Hormone replacement therapy replaces oestrogen and so reduces the rate of bone loss.

The pros and cons of HRT are many, and they are the subject of much debate.

HRT is thought to be of most benefit for preventing osteoporosis if it is started early in menopause and is taken for at least five years. However long-term use increases the risk of side-effects.

Any woman considering HRT should therefore discuss the risks and benefits for her individual circumstances with her doctor before making a decision about treatment.

Briefly, HRT is known to be associated with an increased risk of breast cancer, cancer of the lining of the womb (endometrial cancer), blood clots in the veins (thrombosis), stroke and heart disease.

However, as well as preventing osteoporosis, HRT reduces the symptoms of the menopause, which can be distressing for some women. It's also associated with a reduced risk of bowel cancer.

The length of time that treatment should be continued is also an issue of contention.

Whether or not to use HRT to prevent osteoporosis and how long for will depend on a woman’s individual risk of developing the condition, her personal and family medical history and her individual views on the potential risks and benefits, all of which should be discussed with her doctor.

HRT is not now recommended as a first choice of therapy for long-term prevention of osteoporosis in women who are over 50 years of age because there are other medicines available that do not carry the risks associated with HRT.

There's more information about these medicines below.

HRT remains an option for women over 50 at risk of fractures for whom these other medicines are not suitable.

HRT is also still a suitable option for women who have had an early menopause.

However in this case HRT should only be used for treating menopausal symptoms and preventing osteoporosis until the age of 50, after which time other medicines may be more suitable.

Bisphosphonates

This is a group of medicines that slows the rate at which bone is dissolved, thus favouring a build-up in bone strength over time. Two types are in common use: alendronic acid (Fosamax) and disodium etidronate (Didronel PMO).

Alendronic acid and disodium etidronate can be used in men and women who have, or are at risk of developing, osteoporosis, including where this is secondary to the use of steroid drugs.

Risedronate sodium (Actonel) and ibandronic acid (Bonviva) are other bisphosphonates used only in women after the menopause, but are otherwise similar to the others.

There are slight differences between the bisphosphonates in the available preparations and how frequently they are taken, but they act in the same way.

Alendronic acid and risendronate sodium reduce the occurrence of fractures of the hip and spine, whereas etidronate and ibandronic acid have only been shown to reduce fractures of the spine.

The most common side-effects associated with bisphosphonates are digestive in nature, for example indigestion, diarrhoea, constipation and abdominal pain.

Alendronic acid and ibandronic acid have strict instructions for how they should be taken because they can cause irritation and ulceration of the foodpipe (oesophagus).

Strontium ranelate

Strontium ranelate (Protelos) is used for the treatment of osteoporosis in postmenopausal women. It is usually reserved for women who cannot take bisphosphonates.

It has a dual action of increasing bone formation, as well as decreasing bone breakdown, and it has been shown to reduce the risk of spinal and hip fractures.

Strontium seems to be asociated with an increased risk of blood clots in the veins, but not to the same extent as HRT or raloxifene (see below).

Raloxifene

Raloxifene (Evista) is a type of medicine called a selective oestrogen receptor modulator (SERM). It can be used to both prevent and treat osteoporosis in postmenopausal women.

Raloxifene stimulates bone growth just as oestrogens do, but it has an anti-oestrogen effect on the uterus (womb) and on breast tissue.

The latter effect is seen as desirable because it may reduce the tendency for long-term oestrogen-based HRT to increase the risk of developing breast cancer.

However, raloxifene may increase the risk of developing blood clots in the veins and can't be used by a woman with a past history of deep vein thrombosis (DVT). The risk of thrombosis with raloxifene is similar to the risk with HRT.

It is preferably used only in women who are five years past their menopause. It would be an option for a woman between 55 and 70 years.

It has been shown to reduce the occurrence of spinal fractures, but not hip fractures.

What other treatments are used in osteoporosis?

These treatments are quite specialised and not commonly used.

Calcitonin

Calcitonin (Miacalcic) is a hormone involved in the regulation of bone turnover. It is given by injection or nasal spray and is used for postmenopausal osteoporosis when treatment with bisphosphonates, strontium or raloxifene is unsuitable.

It can relieve pain when used following a collapsed vertebrae. But it has a number of potential side-effects, including allergic reactions.

Calcitriol

Calcitriol (Rocaltrol) is a vitamin D-like compound that can be used in osteoporosis following the menopause or in situations where osteoporosis has been caused by steroid drugs.

Studies of the effect of calcitriol on bone loss and fractures have produced conflicting results, however it has been shown to reduce the risk of spinal fractures but not hip fractures.

Teriparatide

Teriparatide (Forsteo) is used for the treatment of osteoporosis in postmenopausal women and in men with an increased risk of fracture.

It works by increasing the formation of bone and is given by daily injection under the skin, using an injection pen similar to those used by people with diabetes for injecting insulin. It has been shown to reduce the incidence of spinal but not hip fractures.

Hip protectors

Hip protectors are shock-absorbing pads that can be worn to cushion the impact over the hip bone, should a person fall down. They spread the load across a wider area of the upper leg and are useful as an extra measure in an elderly person prone to falls.

Hip protectors come as a sort of girdle with padding at the sides. However, it can be difficult for people to remember to put one on, or even wish to wear one.

Sticking to treatment

Compliance is the business of sticking to the prescribed treatment, whether it be tablets or protective clothing.

Because osteoporosis treatment and prevention needs to be taken for years, poor compliance can be a major issue in treating the condition.

Elderly people are the most at risk of falls. They are also the most likely to become muddled about pills and suffer more severe side effects from them.

Those in sheltered or supervised environments can be given help to remember their medication.

Where this is not possible, and someone is forgetful, using a weekly or monthly dose form of bisphosphonate, supervised by a carer or nurse, might be more reliable than a daily dose.

Osteoporosis and men

Women tend to get more coverage in osteoporosis than men because they:

live longer
have generally weaker bones
experience more osteoporotic fractures.

However, men do develop osteoporosis. Men show an increase in osteoporotic hip fractures after the age of about 70, similar to that shown by women 5 to 10 years younger.

Men may not experience the recognisable hormone shift represented by the menopause in women, but they do experience a steady drop in output of testosterone (the ‘male hormone’) by the testes as they get older.

Like oestrogen in women, testosterone has a protective effect on bone.

Low testosterone and the male menopause

A low level of testosterone can be suspected if there are obvious physical signs, such as an absence of beard growth in a man.

Other, more subtle, symptoms are also thought to be due to a lack of testosterone.

These include:

depression
nervousness
fatigue
poor concentration and memory
flushes and sweats
decreased libido
difficulty obtaining a satisfactory erection.

This is a controversial area and experts remain uncertain about the phenomenon of the 'male menopause'. The situation is not helped by the fact that no easy test for this condition exists.

Low blood levels of testosterone are insufficient to diagnose menopause in men because there is widespread disagreement over:

what is the normal range for testosterone levels
exactly what form of testosterone should be measured in the blood.

The timing of the blood sample also matters because testosterone is released into the bloodstream in pulses, and levels vary throughout the day.

Diagnosing osteoporosis in men

These difficulties need to be tolerated, but a doctor can make allowances for the difficulty in being sure of the diagnosis.

Perhaps more important is being aware of the possibility of osteoporosis in a man:

who has had a fracture at a relatively young age or after relatively little trauma
who shows signs of height loss
whose spine X-rays are suggestive of some bone loss.

Treating osteoporosis in men

Very often the penny simply does not fall, yet men can benefit from all of the treatments that apply to women, other than HRT and raloxifene.

Testosterone treatment is controversial, and uncertain in value in the majority of men who do not have very low testosterone levels.

Osteoporosis management should be along the lines of encouraging exercise, diet supplements and taking the lifestyle measures mentioned above. Bisphosphonate drugs should be used when more active treatment is required.

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