Building Strong Bones: A Comprehensive Guide to Osteoporosis Treatments

 Osteoporosis is a disease of bone loss, which can lead to an increased risk of fractures.  It is common among older adults and can have a significant impact on one’s quality of life.  We will discuss some of the most effective ways to diagnosis, prevent and the medications that can be used to treat osteoporosis.

Test that you can request for checking your bone health:

• Calcium
• Phosphorus
• Liver function
• Thyroid function test
• Complete blood count (CBC)
• Vitamin D (25-hydroxyvitamin D
• Free testosterone
• Urine Calcium

Test that measures bone density:

• Dual-Energy X-ray Absorptiometry
• Quantitative Computed Tomography
• Quantitative Ultrasound
• Radiographic Absorptiometry
• Magnetic Resonance Imaging (MRI)

What test is best for me to check for osteoporosis?

Women 65 years of age and younger Post menopausal women want to get a DEXA Bone Density Exam

How often should a do a DXA test?

Follow up measurement, every 1-2 years.  It usually takes two years to see a change in your bone density.

What age should I get my first bone density test?

Well, there are two answers.  If you have none of the risk above your first test should be around the age of 65, for a woman.  Second, if you have the risk factors then you should get the first bone density test 50-69 years of age, for women.  Men are a little different as thy can start screening for the first time at 70 years old or younger if you have risk factors.

Exercise

Research has shown that active individuals have higher boned density than people that are not active.  It is important to exercise at least 30 minutes per day, 5 times a week. Regular exercises such as weight- bearing exercises, waking, jogging and weightlifting can help to strengthen bones and improve balance.  This in turn can reduce the risk of falls and fractures.

Calcium and Vitamin D with K2

Balanced diet that is rich in calcium and Vitamin D with K2.  These are essential nutrients for maintaining healthy bones.

Healthy Lifestyle choices

Certain lifestyle choices can increase the risk of osteoporosis.  You can help prevent osteoporosis and improve overall health by maintaining a healthy body weight, stop smoking, moderate alcohol, avoid secondhand smoke and eating a balanced diet.

Fall Prevention

Falls are common causes of fractures in people with osteoporosis.  Taking steps to prevent falls, such a removing tripping hazards from your home, using handrails on stairs, wearing appropriate footwear, can help reduce the risk.  Fall prevention- ask your doctor, if you are Medicare there are home health companies that will come to your house for evaluation.

Medications

Medications should only be used on high risk of osteoporosis, long term steroid use and low T score. There are several types of medication that can be used to treat osteoporosis.  They work by slowing down the process of bone loss or can be used to treat osteoporosis.

Selective Estrogen Receptor Modulators (SERMs)

Raloxifene acts as an estrogen agonist for bone, slow to prevent and treat osteoporosis in postmenopausal women and increases bone density, decrease the risk of fractures.  Raloxifene mimics estrogen’s beneficial effects on bone density in postmenopausal women, without some of the risk associated with estrogen. You should not use if have history of clotting disorders.  Has Side effects of leg cramps, arthralgias, rhinitis, headaches, and hot flashes, blood clots.

Do not use in Premenopausal women because it blocks the estrogen

What is the best medication to use for osteoporosis if I have risk of breast Cancer? SERMs

Bisphosphonates

Alendronate (Fosamax), alendronate plus D, ibandronate (Boniva), risedronate (Actonel), risedronate with calcium supplement and zoledronic acid (Reclast), Pamidronate (Aredia).  Bisphosphonates act to decrease resorption by causing osteoclast apoptosis and decreased function of osteoclasts. 

Bisphosphonates have been shown to be the best treatment option for osteoporosis and is usually seen improvement within a year.  Cannot be used with someone with sever kidney disease. Has side effects of esophagitis, gastritis, dyspepsia, reflux, stomach ulcer, muscular and skeletal pain, osteonecrosis of jaw, femoral fractures (long term use), Hypocalcemia, renal impairment, ocular inflammation, and visual changes.  Not all bisphosphonates are the same.  It has been shown in studies that risedronate alendronate are better tolerated with GI symptoms.

When should I not take it?

Kidney failure with GFR <30

Hypocalcemia

Esophageal abnormality (GERD)

pregnancy

How do I take bisphosphonates? On an empty stomach and full glass of water.  Do not lay down for 30 minutes after taking medications.

IV zoledronic acid (Reclast) is preferred of 1 every year or once every two years for prevention. Studies have shown Reclast reduces the risk of spine fracture by 70 % and hip fracture by 41%.

Ibandronate is administered once every three months.

When do you stop bisphosphonate? Discontinue after 5 years of oral or 3 years IV.  Need to do a drug holiday.

Alendronate (Fosamax), second-generation bisphosphonate, been seen to be most effective with patient with T-scores less than -2.5 or had vertebral fracture.  It has shown that the risk of fractures during a 3 year period decreased by 50%.

Whats the normal dose for Alendronate?

Osteoporosis prevention        5mg/day or 35 mg week

Osteoporosis treatment         10 mg/day or 70 mg once a week

Risedronate (Actonel) reduced the incidence of fractures of spine 41-49% after 3 years.

Postmenopausal osteoporosis            150 mg 1time a month

Ibandronate(Boniva) is used for prevention and treatment of postmenopausal osteoporosis.  In 3 year period the fractures decreased by 50%.

Postmenopausal osteoporosis            150 mg 1time a month or IV 3 mg every 3 months

Uses for Bisphosphonates: osteoporosis, Paget’s disease of bone, pain associated with cancer treatment, multiple myeloma, metastatic carcinoma of skeleton.  Especially beneficial for men, young adults and people with steroid induced osteoporosis.

Denosumab

Used in the treatment of postmenopausal women for osteoporosis.  It is a human monoclonal antibody that binds with RANKL.  RANKL controls the differentiation, proliferation, and survival of osteoclasts.  With the osteoclast activation being decreased there is a decrease bone reabsorption and results in higher bone density.  This allows for the body to slow down the absorption and inhibit the bone resorption.  Treatment with this medication has 68% decrease in new vertebral fractures in 12 months.

Denosumab

Postmenopausal women        60 mg subcutaneous injection twice a year.

Side affects

Cellulitis

Bronchitis

Osteomyelitis

Hypercholesteremia

Lower back pain

Musculoskeletal pain

Can use with kidney failure

Calcitonin

Calcitonin is hormone produced by your thyroid gland, calcitonin reduces bone resorption and may slow bone loss.  Used with acute vertebral fractures and helps with pain.  Its administered intranasal spray.  The dosing for the medications is one spray in one nostril one day and then rotate to another nostril the second day and then rotate.  This is not a first line of treatment for osteoporosis.  It is one of the medications that can get used if you have a patient with gastrointestinal upset or venous thromboembolisms.  There is an injectable form, but this is rarely used in our practice.  Side effects of the intranasal is rhinitis and rarely a nosebleed.

Parathyroid Hormone (PTH)

PTH stimulates osteoblast (bone formation) and osteoclast (bone reabsorption).  If you use it intermitting is cause osteoblast.  Daily treatment with sub injection for 2 years

Side affect

Renal stones

Gout

Hypercalcemia

After the two years have to be transition over to other medications so you don’t loose the new formed bone.

Teriparatide (Ferteo).  Analog of parathyroid hormone and treats osteoporosis in postmenopausal women and men who are at high risk of fractures.  It stimulated new bone growth, as opposed to preventing further bone loss.  It is given once a day by injection under the skin on the thigh or abdomen.

Romosozumab

Humanized monoclonal antibody that inhibits sclerostin.

In conclusion, osteoporosis is a common condition that can have a significant impact on a person's quality of life. While there is no cure for this disease, several treatments are available that can help to slow or even reverse the progression of bone loss. Medications, calcium and vitamin D supplements, exercise, healthy lifestyle choices, and fall prevention strategies can all be effective ways to treat osteoporosis. If you are concerned about your bone health, talk to your doctor about the best treatment options for you.

Author

Dovie McVean, MS, PA-C Certified Physician Assistant, Orthopedic Surgery & Nutritionist