Osteoporosis: A medical disorder that causes the bones to become weak, thin and fragile. Bones that are weaker are more likely to break (fracture). Women are more commonly affected by this disorder because after menopause lower levels of estrogen are produced by the body. Estrogen is a hormone that helps keep the bones strong.
It is very important to detect low bone density (weak bones) because there are treatments available which can protect and actually help build up bone and prevent bone fractures in those people who are at the greatest risk.
Why do we care? Bone fractures, especially in the hip cause a huge change in lifestyle and lead to decreased mobility, decreased ability for patients to care for themselves, and increased risk of death due to physical deconditioning, increased risk of infection (from surgery and also from decreased mobility respiratory illness). In fact, people who sustain a hip fracture are more likely to die than a person of the same age who does not experience this injury. About 20 percent of people who have a hip fracture die within a year of their injury. It is estimated that only one in four persons have a total recovery from a hip fracture. Most people spend from one to two weeks in the hospital after a hip fracture. The recovery period may be lengthy, and may include admission to a rehabilitation facility. People who previously were able to live independently will generally need help from home caregivers, family, or may require the services of a long-term care facility. Hip fractures can result in a loss of independence, reduced quality of life, and depression, especially in older people.
Fractures that occur in the spine due to osteoporosis can lead to pain and cause changes in the curvature of the spine. We’ve all seen older folks who have difficulty walking due to having abnormal curvature of the spine and these patients often have osteoporotic fractures in the vertebra of the back.
Risk factors for osteoporosis:
1) Sex – women are more likely to get osteoporosis than men
2) Age – risk of osteoporosis is higher with increasing age
3) Race – there is a higher risk of osteoporosis in people of white or Asian descent
4) Family history – you are at higher risk of osteoporosis if you have a parent or sibling with osteoporosis, especially if there is a family history of bone fracture
5) Body frame size – men or women who have a smaller body frame size are at higher risk because they have less bone mass to draw from as they age
6) Hormone levels – osteoporosis is more common in patients who have too much or too little of certain hormones (estrogen, testosterone, thyroid, parathyroid or adrenal hormones for example)
7) Low calcium in the diet – a lifelong lack of getting enough calcium increases the risk of developing bones that are thinner and more fragile.
8) Eating disorder – Patients with anorexia are at increased risk of osteoporosis due to decreased nutritional intake of calcium
9) Weight loss surgery – those patients who have surgery to help them lose weight are at higher risk of osteoporosis because of a reduction in the size of the stomach or a bypass of some of the intestines. This may decrease the absorption of calcium or vitamin d.
10) Certain medications – see below
Prevention: Several important steps to maintaining proper bone formation and density can be done without the need of medication. These include proper diet, exercise and not smoking.
A) Diet: Preventing the bones from thinning involves getting enough nutrients, especially calcium and vitamin D.
- Calcium: Most experts agree that men and women who have not reached the age of menopause yet consume at least 1000 mg of calcium each day (combination of diet and supplements). Women who have already gone through menopause should consume at least 1200mg of calcium each day (combination of diet and supplements). Foods that have calcium include dairy milk, cottage cheese, yogurt, hard cheese, green vegetables (especially kale and broccoli). A way to calculate the amount of calcium from food is to multiply the number of servings of calcium rich foods by 300 mg. One serving size of dairy milk or yogurt is 8 oz. 1oz of hard cheese or 16 oz of cottage cheese is one serving size.
- Vitamin D: Most experts also agree that men over age 70 and women who have gone through menopause consume at least 800 international units (IU) for vitamin D each day.
- Alcohol: Drinking more than 3 drinks per day can increase the risk of fracture due to increased risk of falling and poor nutrition.
B) Exercise: We understand that our bones maintain their strength if we continue to use them. Patients who become immobile are at increased risk of bone fractures because their bones tend to become thinner with decreased use and activity. Patients who are more physically active are generally stronger and less prone to falling as well. Exercising 30 minutes or more three times per week or more is recommended to maintain bone strength.
C) Smoking: Smoking cigarettes is known to speed bone loss. One study suggested that women who smoke one pack per day throughout adulthood have a 5-10% reduction in bone density by menopause. If you smoke, I suggest you get help with stopping to help prevent osteoporosis.
We can reduce the risk of bone fractures by reducing falls. Several ways to reduce falls in older adults include:
1) Avoiding (as much as possible) medications that can cause dizziness
2) Provide adequate lighting to areas both inside and outside the home
3) Ensure there are no loose rugs or electrical cords that could lead to tripping or falling
4) Avoid walking in areas outside that are unfamiliar
5) Avoid slippery surfaces such as ice or wet/polished floors
6) Ensure good eye care by visiting an eye doctor regularly
Screening for Osteoporosis: There are several different recommendations for when to start screening for osteoporosis. The U.S. Preventative Service Task Force (USPSTF) recommends screening women who are age 65 or older who has no increased risk of fracture as compared to a 65 yo women of Caucasian decent. If a woman has a previous bone fracture or an early family history of osteoporosis (especially a mother with an early bone fracture) or has thyroid disease or take medications that can increase the risk of thinning the bones, screening earlier is generally recommended.
Assessment tools: There are several tools that have been developed by the WHO (World Health Organization) – (see FRAX) to help assess risk for osteoporotic fractures. These tools ask questions that relate to risk factors for osteoporosis and attempt to calculate a probability of hip fracture even without knowing exact measurements of bone density measured by special x-ray tests.
DXA Bone Mineral Density Test: A bone density test uses special x-rays to determine how many grams of calcium and other bone minerals are packed into a bone segment. Bones that are commonly tested include the spine, hip and forearm. We do this test to identify patients who are at higher risk for bone fracture, as well as to monitor the progress of therapy for patients who are being treated. Bone density tests are not the same as bone scans. Bone scans usually require the patient to get an injection before the procedure and are used to detect bone fractures, bone cancer or bone infections.
Medications that increase the risk of bone thinning: If you take any of these medications, ask your doctor about whether you should have your bone density tested:
1) Glucocorticoids such as prednisone or dexamethasone
2) Anti-Seizure medications such as Dilantin, Tegretol, Phenobarbital or Primadone
3) Heparin – medication to treat abnormal blood clotting
4) Acid reducing medications called proton pump inhibitors (PPIs) such as Prilosec may increase the risk of osteoporosis or fractures but more research is needed.
Treatment for osteoporosis: The treatment really depends on the reason for the decrease in bone density. We might change the patient’s current medications to different medicines that are safer and have less risk for decreasing bone mineral density. Correcting a patient’s thyroid, parathyroid or testosterone imbalance may improve their bone density without the need for other medications. We usually try to ensure that they are getting adequate dietary intake of calcium and vitamin D and may due some lab tests to look for excessive loss of calcium in the urine. We might test the patient’s vitamin D levels along with the hormone levels mentioned above. If there has already been a hip or vertebral compression fracture we will also usually check a bone mineral density (DXA or DEXA) scan to confirm the level of osteoporosis.
The DEXA scan gives us a numerical value that corresponds to the degree of osteopenia (low bone density) or osteoporosis (greater risk of fracture). A normal bone density is when the T-score (measured on the bone density test) is between 0 and 1 standard deviation below the mean. A normal T score may be reported as a T-score of +1 to -1. If the T score is -1 to -2.4 the patient is said to have osteopenia which means that they have a risk of developing osteoporosis if not treated. If the T score is -2.5 or less, the patient is diagnosed with osteoporosis. The lower the T score (higher the negative number), the greater the risk of fracture.
Medical treatment of osteoporosis:
1) Calcium – at least 1200 mg of calcium/day but no more than 2000 mg/day.
2) Vitamin D – at least 800 international units/day – sometimes very high doses such as 50,000 IU/week may be prescribed if your levels are measured to be very low.
3) Bisphosphonates such as Fosamax , Actonel or Boniva are medications that slow the breakdown and removal of bone (bone resorption). These are taken first thing in the morning on an empty stomach with an 8oz glass for still water. There has been some concern about the use of bisphosphonates in people who require invasive dental work – it may lead to avascular necrosis or osteonecrosis. Most experts do not think that it is necessary for most people to stop bisphosphonates before invasive dental work (tooth extraction or implant) because the risk is very small for those people who take bisphosphonates for osteoporosis treatment or prevention. People who take a bisphosphonate as part of a treatment for cancer should consult their doctor before having invasive dental work however.
There is some concern about atypical (stress) hip fractures associated with long-term use of bisphosphonates. Patients who have been taking them for more than 5 years may need re-evaluation to see if further continuation of the medication is recommended.
4) Selective Estrogen Receptor Modulators (SERMs) produce estrogen-like effects on the bone. They include Evista and tamoxifen. In addition to osteoporosis treatment/prevention there is a decrease in the risk of breast cancer in women who are at high risk. These medications are not recommended for women who have not started menopause.
5) Calcitonin is a hormone produced by the thyroid gland that, together with parathyroid hormone, helps regulate calcium concentrations in the body. This may be administered via nasal spray or injection. Nasal administration is usually preferred due to ease of use and less chance of nausea and/or flushing. It’s not clear if calcitonin improves bone in places in the body other than the spine.
6) Parathyroid hormone (PTH) – (prescription preparation name Forteo) produced in the parathyroid glands(non-prescription form) stimulates bone resorption and new bone formation. Clinical trials suggest the PTH therapy is effective in both prevention and treatment of osteoporosis in post-menopausal women and men. It has been proven to reduce spine fracture risk more than any other treatment that we know about. It does, however require a daily injection and is expensive so it’s usually reserved for patients with severe hip or spine osteoporosis with a T score of less than -2.5 (higher number) and osteoporosis-related fracture.
When taking Forteo, we often check a blood uric acid and calcium level at the start of the medication, after 6 weeks, 6 months later and then after 12 months of therapy.
We generally do not use this medication in pediatric and young children whose bones are still growing or in patients with bone cancer, Paget’s disease of the bone and extreme caution is needed in patients who have a history of recent calcium kidney stones.
7) Prolia is a medication that helps improve bone mineral density and reduce fracture in postmenopausal women with osteoporosis. It is an injection under the skin once every 6 months. It’s usually well tolerated but can have side effects such as skin infections or eczema. It should not be given to patients who have a low blood calcium level.
For more information, please check out the following resources:
National Library of Medicine
Osteoporosis and Related Bone Diseases National Resource Center
National Osteoporosis Foundation
National Women’s Health Resource Center (NWHRC)
Osteoporosis Society of Canada
The Hormone Foundation
This document is for informational purposes only, and should not be considered medical advice for any individual patient. If you have questions please contact your medical provider.
I hope that you have found this information useful. Wishing you the best of health,
Scott Rennie, DO