Osteoporosis

Treatment:

OVERVIEW:
Treatments for osteoporosis focus on slowing down or stopping the demineralization process, preventing bone fractures, and controlling pain associated with the disease.

MEDICATIONS:
Estrogen can slow or stop bone loss and, if estrogen treatment begins at menopause, it can reduce the risk of hip fractures up to 50 percent. Many post-menopausal women choose estrogen replacement therapy (ERT) because of its proven usefulness in slowing the progress of or preventing osteoporosis. In some cases, ERT alleviates some of the irritating symptoms of menopause. This method of therapy is fairly inexpensive compared to newer medications for osteoporosis discussed below.

Some women hesitate to use estrogen supplements because of the numerous consequences that have been associated with long-term use. If estrogen replacement therapy is discontinued, bone loss will resume and maximal protection from osteoporosis may indeed require lifelong dosing. Studies show that women who take estrogen for at least seven years between the onset of menopause and the age of 75 have a 50 percent reduction in risk of fractures. However after age 75, the risk is about the same as for those who did not take estrogen at all. In the 75 years and older group, bone mass only differs by about two percent between women who have take estrogen for 10 years and those who have never taken it. Before beginning ERT, the benefits and consequences of the treatment should be weighed and discussed thoroughly with a health care provider. The decision to take estrogen for preservation of bone density is complicated by its effects on other diseases including a relatively small increase in the risk of breast cancer. ERT has classically been thought to reduce the risk of coronary artery disease in post-menopausal women. Recent studies have brought controversy to this issue by providing evidence that women may have a higher incidence of coronary events during the first year on ERT.

Calcitonin, marketed under the name Miacalcin, is currently the only other FDA approved treatment. This drug slows the rate of bone loss and it relieves bone pain. The drug may be administered either by a nasal spray or by injection. The main side effects of calcitonin are nasal iritation from the spray form and nausea from the injectable form. While Calcitonin has been demonstrated to increase bone mineral density and reduce the risk of fractures in controlled studies, it appears to be less effective than ERT or alendronate (discussed below). Along with the newer medications discussed below, it is significantly more expensive than ERT.

A nasal spray form of calcitonin has been developed and is expected to gain FDA approval soon.

Alendronate (fosamax) is a relatively new drug approved by the FDA for both prevention and treatment of osteoporosis. This medication prevents existing bone from being reabsorbed. Studies show that the risk of spinal fractures in post-menopausal women who take alendronate is reduced by nearly 50 percent. The main side effect of alendronate therapy is gastrointestinal upset and irritation/inflammation of the esophagus. As alendronate is difficult to absorb, it is recommended that the medicine be taken on an empty stomach and that the patient remain upright for at least an hour.

Sodium fluoride is a compound that may serve to increase bone formation, unlike other osteoporosis medications that prevent bone loss. Sodium fluoride causes side effects of gastrointestinal upset and joint pains and is not presently FDA approved for osteoporosis. A recent breakthrough in the prevention and treatment of osteoporosis is FDA approval for the medication raloxifene (Evista). Raloxifene is similar to the drug tamoxifen used to treat breast cancer. Both these compounds bind to estrogen receptors that are the molecules that normally bind estrogen. A 1999 study showed that raloxifene reduced risk of vertebral fractures almost 50%. Raloxifene may also have mild protective effects against heart disease and breast cancer though more studies are required. The most serious adverse effect of raloxifene is a very small increase in the incidence of blood clots in the leg veins (deep venous thrombosis) or in the lungs (pulmonary embolus).

LIFESTYLE CHANGES:
Regular exercise can reduce the likelihood of bone fractures associated with osteoporosis. Studies show that exercises requiring muscles to pull on bones, cause the bones to retain and perhaps even gain density. Researchers found that women who walk a mile a day have four to seven more years of bone in reserve than women who don't. Some of the recommended exercises include:

• weight-bearing exercises
• riding stationary bicycles
• using rowing machines
• walking
• jogging

IMPORTANT: Any exercise that presents a risk of falling should be avoided.

Fall prevention is an essential component of any comprehensive osteoporosis treatment program. Measures such as making sure the patient's vision is good and appropriately corrected, avoiding sedating medications, and removing household hazards can significantly reduce the risk of fracture.

A diet that includes an adequate amount of calcium, vitamin D, and protein should be maintained. While this will not completely stop bone loss, it will guarantee that a supply of the materials the body uses for bone formation and maintenance is available. Supplemental calcium should be taken as needed to achieve recommended daily calcium dietary intake (1200 mg a day in all adult white females and 1500 mg a day if at increased risk for osteoporosis). Vitamin D aids in calcium absorption and 400-800 IU per day should be taken by all individuals with increased risk of calcium deficiency and osteoporosis.

MONITORING:
Women who are taking estrogen should have routine mammograms, pelvic exams, and Pap smears.

Patient response to treatment can be monitored with serial bone mineral density measurements every 1-2 years, though such monitoring is controversial, expensive and not universally performed. In the future, use of less elaborate measurements of bone turnover such as the N-telopeptide (Osteomark) urine test discussed above) may become a standard means for following osteoporosis, though experience is presently limited.

Expectations (prognosis):

Progression of the disease can sometimes be slowed or stopped with treatment. Some people become severely disabled as a result of weakened bones. Hip fractures, which are frequently sustained by people with osteoporosis, leave about 50% of victims unable to walk independently. This is one of the major reasons people are admitted to nursing homes. Although osteoporosis is debilitating, it does not affect life expectancy.

Complications:

• compression fractures of the spine
• hip fractures and wrist fractures
• disability caused by severely weakened bones
• loss of ability to walk due to hip fractures

Calling your health care provider:

Call for an appointment with your health care provider if you have symptoms of osteoporosis or if you are interested in testing available for diagnosis or early detection.

References:

1. Managing Osteoporosis, Parts 1-3. Osteoporosis CME Advisory Board. An AMA CME Program for Primary care Physicians. April 1999.

2. Primer on the Rheumatic Diseases. 11th edition. National Arthritis Foundation. 1997.

3. Hulley S. et al., Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in post-menopausal women. JAMA. 1998;280: 605-613.

4. Liberman UA et al., Efect of oral alendronate on bone mineral density and the incidence of fractures in postmenopausal osteoporosis. The Alendronate Phase III Osteoporosis Treatment Study Group. NEJM 1995; 333(22): 1437-1443.

5. Ettinger B et al., Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated wth raloxifene. JAMA 1999; 282: 637-645.

6. Physician's Guide to Prevention and Treatment of Osteoporosis. National Osteoporosis Foundation. Excerpta Medica Inc. 1999.

Updated Date: 05/08/00

Updated by: Ajay Nirula MD, PhD. Rheumatology Fellow University of California at San Francisco Medical Center