Osteoporosis

Esther Lipstein, M.D.

Osteoporosis is a thinning of the bone that occurs in both men and women as a natural process of aging.  In particular, after menopause, women are more subject to bone loss because of a decreased amount of estrogen.  It is important to evaluate men at risk and post-menopausal women (as well as select individuals treated for certain disease states) for osteoporosis because it can lead to fractures of the hip, spine, shoulder and any other bone in your body.  Hip fractures in the elderly are serious and associated with a 25% risk of death.       

How does one know if they have osteoporosis? A bone density examination is readily available in diagnosing osteoporosis.  It is a radiographic exam with minimal radiation (equivalent to flying on a plane for 5 hours).  The hip, spine and forearm are evaluated for their density and the results are compared to that of healthy 30-year-old women. This is called the t-score.  The t-score result is predictive of the risk for fracture in that individual. Guidelines are as follows:  

1. 1. Above -1.0 is considered normal.
2. 2. Between -1.0 and -2.5 are labeled as osteopenic (low bone mass but not to the extent of osteoporosis).
3. 3. Below -2.5 are consistent with osteoporosis.

 A t-score of -2.0 for instance indicates a 4X risk of fracture in that individual. Decisions regarding treatment are not only made on the basis of the t-scores but also on the patient’s age, medications used, medical conditions, smoking and drinking history, and whether there is a family history of hip fracture, kidney stones or osteoporosis. The decision to treat a patient must be made after considering the risks and benefits of treatment for that particular individual.

There are several different types of treatment for osteopenia and osteoporosis. Most of the medications on the market prevent bones from breaking down. They are known as anti-resorptive medications include the bisphosphonates, Evista, estrogens, and Prolia:

1. 1. The bisphosphonates have been available for almost two decades. The most popular of the bisphosphonates include alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), and zoledronic acid (Reclast).  Reclast is an intravenous option that is given over a 15-minute period once a year for osteoporosis or every two years for osteopenia. The other bisphosphonates are all orally administered either weekly (Actonel and Fosamax) or monthly (Boniva, Actonel) and must be given on an empty stomach first thing in the morning with a plain glass of water.  One cannot lie down and has to wait to eat (one half hour to one hour for Boniva).  A new version of Actonel called Atelvia may be given after breakfast once a week and avoids the wait time for eating.
2. 2. Raloxifene (Evista) and hormone (estrogen) replacement therapy (HRT) are options but patents must be carefully selected as these medications increase the risk of blood clots. Evista, unlike HRT, has an added benefit in that it may actually decrease the risk for estrogen receptor positive breast cancers in women.
3. 3. Prolia is a new option for the treatment of osteoporosis and is given as an injection every 6 months. It is reserved for patients who cannot take bisphosphonates or failed on bisphosphonate therapy. 

Forteo (teriperatide) is the only medication available that actually builds bone.  It is given as a daily injection from a pre-filled pen and is fairly simple to administer. This is reserved for patients with severe osteoporosis or patients who have failed bisphosphonate therapy.  Forteo cannot be given to any patient who has had radiation therapy, as there is an increased risk of bone tumors in rats given Forteo for more than two years.  For this reason, Forteo is given for only for two years and is followed by an anti-resorptive medication (such as Prolia or a bisphosphonate) to preserve the gains in the bone density.

What are the side effects of these medications?

1. 1. Oral bisphosphonates can sometimes cause esophagitis and gastritis (irritation in the esophagus and stomach) and in those patients the intravenous alternative is preferred.
2. 2. Long-term bisphosphonate use can be associated with atypical fractures of the leg.  This is rare, and occurs many years after bisphosphonate use (more than 5 or 7 years).
3. 3. Osteonecrosis (destructive loss of bone) of the jaw is another rare complication. This is more common with intravenous bisphosphonates in patient’s getting chemotherapy and patients with periodontal infection after oral surgery.

  These complications are rare and should not preclude treatment with these medications as the benefits in fracture prevention far outweigh the risks.

One must not forget some basic supplements and the role of exercise in the management of bone loss.

1. 1. Calcium as either calcium carbonate (taken with food) or calcium citrate (less constipating than the carbonate) can be taken as a supplement. A dosage of 1200mg to 1500mg is recommended.
2. 2. Vitamin D3 is crucial to the proper absorption and use of calcium.  Your doctor may do a Vitamin D level to determine what dosage of vitamin D3 you may need. A daily dosage may vary from 1000 to as much as 5000 IU daily depending on the clinical circumstance.
3. 3. Weight bearing exercise is another important aspect in the treatment of patients with low bone mass. A skilled trainer at the gym will help devise a proper workout that will be tailored to your particular needs.