Management of Osteoporosis
Even when osteoporosis is diagnosed, lifestyle factors are still important in the management of this condition.
Exercise that is appropriate to the woman's stage of life is recommended regardless of age. It is important for women to discuss exercise options with their treating doctor to ensure that it is safe to take part in an exercise program.
Healthy bones require adequate nutrition. Women need to ensure that they have adequate calcium intake that meets the requirement for their particular age. Ideally calcium should come from your diet. If you do no feel you are getting much calcium in your diet discuss the use of calcium supplements with your doctor.
It is important to have adequate levels of vitamin D. Vitamin D levels can be measured through a simple blood test. Most vitamin D is made in our skin from the action of sunlight converting 7-dehydrocholesterol to produce cholecalciferol. The amount of time you need to be in the sun each day varies according to where you live (more time in the sun the further you live from the equator) and how dark your skin is (people with dark skin need more sun exposure). Some vitamin D can also be obtained from food including foods fortified with vitamin D (milk, soy drinks, margarine and cereals), liver, fish (tuna, salmon, sardines, herring and mackeral) and egg yolk.
For many individuals it is not advisable to increase sun exposure to increase the levels of vitamin D due to the potential harmful affects of sunlight on skin. In this situation, if measured vitamin D levels are not at an optimal level, then it may be necessary to take a vitamin D supplement. Most people will normalise their Vitamin D level over time by taking 1000IU to 2000IU daily. Your treating doctor is in the best position to recommend whether you need to take vitamin D and how much you should take.
To protect bones it is advisable not to smoke. Women who smoke lose bone density faster than women who do not smoke.
Drug Therapies for Osteoporosis
Hormone therapy at the time of menopause protects against bone loss. Oestrogen reduces bone break down so that the amount of bone being formed equals or exceeds that being broken down.
The global Consensus Statement on Menopausal Hormone Therapy (MHT) 2013 advises "MHT is effective and appropriate for the prevention of osteoporosis-related fractures in at-risk women before age 60 years or within 10 years after menopause" (http://www.menopause.org/docs/default-source/2013/ims-ht-ps-2013.pdf).
It is the only treatment shown to prevent fractures in women who do not have osteoporosis or osteopenia.
Tibolone (Livial): This therapy is a different form of hormone therapy for treating menopausal symptoms. Tibolone does not have the same stimulatory effects on the breast as standard forms of hormone therapy. Tibolone, like oestrogen prevents bone loss and has been shown to prevent fracture in women aged 60-79 with osteoporosis. However, tibolone has been associated with a small increase in risk of stroke in older women. This risk is similar to what has been reported for both Evista (see below) and oestrogen in older women.
Bisphosphonates are a class of drug, which function to decrease bone loss. They work by slowing down bone resorption, which allows the bone forming cells time to rebuild normal bone.
The currently available bisphosphonates in Australia, which are recommended for the treatment of osteoporosis, are the tablets Alendronate (Fosamax®) and Risedronate (Actonel®) and an annual intravenous infusion of zolendronate (Aclasta®).
Alendronate and risedronate
Both alendronate and risedronate reduce the incidence of vertebral (spinal bones) and hip fractures. These drugs also reduce the risk of fracture at other sites in the body. The effects of these drugs on risk of fracture usually start within 6 - 12 months of commencing therapy.
These medications are generally well tolerated. They have been associated with side effects of heartburn, abdominal discomfort and ulceration of the oesophagus (food pipe). Hence, these medications must be taken with a full glass of water and the individual needs to remain either sitting upright or standing for the next 30 minutes. After this time, normal activities and eating can be resumed. The incidence of oesophageal ulceration is extremely low when these medications are taken correctly.
These medications can be taken either weekly or once a month. It is advisable that these medications are used cautiously in those with significant reflux esophagitis (heartburn) and those with a hiatus hernia. These drugs are not well absorbed; hence it is important to take them on an empty stomach.
If women are unable to tolerate the oral forms of the bisphosphonates, this is an option to have treatment intravenously, usually once a year. When administered Aclasta is given by an intravenous drip usually over about 15 minutes. Some people experience flu like symptoms for up to 3 days after the infusion and this is usually managed by taking paracetamol.
In order for these medications (bisphosphonates) to be effective in increasing bone mineral density and reducing the likelihood of fracture, women need to ensure that they have adequate vitamin D levels. There still may be a requirement for additional Vitamin D supplementation if the measured Vitamin D levels are low.
Bisphosphonates are primarily prescribed for women (and men) who have osteoporosis as defined on a bone DEXA scan and a history of an osteoporosis related (low trauma) fracture. In this setting the cost of these medications is subsidized by the Australian PBS.
Bisphosphonates are also prescribed for the prevention of fracture for women 70 years and older with osteoporosis ( T score < -2.5 ) and for people on long term therapy (eg prednisolone) also helps to prevent the development of osteoporosis and fracture.
How long a woman should continue a bisphosphonate continues to be debated.
- Long-term therapy is recommended in the recent UK Guidelines for people over 75 years, those who are on long term steroid therapy, people who have had a hip or vertebral fracture and people with osteoporosis of the hip.
- The broad recommendation for the most commonly used medication, bisphosphonates, for other people being treated is for cessation of therapy after 3 for intravenous zolendronate and five years for risidronate and alendronate if the hip T score is above -2.5. As the bisphosphonates are retained in bone for some time, a DEXA should be repeated 1.5 (risidronate and alendronate) to 3 years (zolendronate) after cessation of treatment.
A rare side effect of bisphosphonates is osteonecrosis of the jaw. This is death of jaw bone that has occurred following a major dental procedure in a person who has used bisphosphonate therapy. Nearly all reported cases have been in people treated with a bisphosphonate intravenously as part of cancer therapy. However, women intending to undergo major dental work should do so before considering bisphosphonate treatment.
Strontium ranelate (PROTOS ®)
This medication is approved for the treatment of osteoporosis in Australia. Strontium is a trace element that is naturally found within soft tissues, blood, teeth and bone. Its' mode of action is unclear, but it seems to lead to decreased bone loss and may enhance bone formation. Studies with this medication in postmenopausal women have shown a reduction in vertebral (spinal), hip and other fractures. Protos is taken daily as a powder dissolved in water and then taken on an empty stomach every day.
It is generally well tolerated, but may be occasionally associated with the side effect of diarrhoea. Like other osteoporosis therapies, there may be a requirement for additional vitamin D supplementation if measured vitamin D levels are low.
Strontium has been associated with increased cardiovascular events so there is a recommendation it not be used by women with known cardiovascular disease, including poorly controlled hypertension. It has also been associated with a small increase in risk of thrombosis (venous blood clots)
Raloxifene (Evista® )
This medication is known as a selective estrogen-receptor modulator. In other words it acts at some sites in the body like estrogen but at other sites of the body it functions as an anti-estrogen. In bone it works as an estrogen and leads to an increase in bone mass (density). In the breast and uterus it works as an anti-estrogen and therefore does not stimulate the breast or uterine lining. Due to its anti-estrogen effects in the breast, it reduces the incidence of breast cancer.
Primarily this medication has been shown to reduce the incidence of vertebral fractures (spinal column). The evidence for this medication having a significant effect on fractures at other sites of the body is lacking.
The side effects of this therapy include hot flushes. This therapy is therefore problematic for premenopausal women and women who are currently going through menopause, as it may worsen menopausal symptoms. This therapy is best reserved for postmenopausal women who have gone through the menopause. The other side effect of this therapy is a slightly increased risk of deep vein thrombosis. Hence, women who are on this medication need to consider stopping this therapy if they are going to be immobile for sometime, such as during long airline flights or during hospital admission. The medication can be resumed once mobility is regained. Any woman who has significant risk factors for a clotting disorder should not be prescribed this therapy.
In order for this therapy to be effective it is essential that women have adequate vitamin D levels.
This therapy has been approved for the treatment of osteoporosis in 2010. It has a unique mechanism of action. It is a monoclonal antibody that targets and blocks RANK Ligand, an essential regulator of the cells that break down bone (osteoclasts). In postmenopausal women with osteoporosis, denosumab has been found to increase bone mineral density, reduce bone turnover, and reduce the risk of vertebral, hip and non-vertebral fractures. Denosumab appears to be well tolerated with a safety profile generally similar to placebo. As Densoumab may lower calcium levels when first commenced, women should have their blood calcium level checked and may need to taken calcium supplements when treatment is first commenced.
This therapy has been available in Australia since 2003. It is primarily used in severe osteoporosis. This hormone is administered daily via a subcutaneous (just below the skin) injection. It functions to increase bone formation and also absorption of calcium from the gut and kidney. Calcium and vitamin D supplements may be necessary with this medication and if this is to be done it needs to be monitored under the care of a specialist physician. Most of the studies with this medication have only been for up to 2 years. There appears to be a clear benefit in terms of reducing all types of fractures in postmenopausal women, except for hip fractures. Due to the expense and limited access of this therapy, it is not readily available to all Australians. Its prescription for use is confined to specialists in osteoporosis.
The above advice is a general guide to treatments currently available in Australia and was accurate at the time of production of this document. [August 2013]. This information is provided to complement, not replace, the advice of your health professional.