Osteoporosis: A Battle For Your Bones
Medically reviewed by C. Fookes, BPharm. Last updated on May 5, 2019.
Osteoporosis: Common And Serious
Our bones are living, growing structures of tissue made up of collagen, calcium, and other minerals. Although they look solid, they are not, consisting of a harder outer layer surrounding a softer, sponge-like inner core. Throughout our life, our bones are constantly being broken down and built up again.
Osteoporosis occurs when there is a disruption in this process and too much bone is either lost, too little made, or both. As a result, bones become brittle and weak and can easily break from a fall. In more severe osteoporosis, a minor bump or sneeze may be all it takes to break a bone.
More than 10 million Americans have osteoporosis, and another 44 million have low bone density. Women are four times more likely than men to suffer from the condition. Osteoporosis is also more prevalent with age, affecting at least one in ten women aged 60 and two-thirds of women aged over 90.
Symptoms of Osteoporosis Are Often Silent
Most people are not aware they have osteoporosis until something happens, such as a fall, and they fracture (break) a bone. Fractures can be very painful and are more likely to occur in people with osteoporosis in the hip, pelvis, spine, upper arm, or wrist. The older somebody is, the more difficult it is for them to bounce back and regain their independence after a fracture.
As osteoporosis progresses, symptoms become more noticeable and may include:
- Back pain from a collapsed or fractured vertebra
- More frequent fractures, or fractures occurring after the slightest knock
- A gradual loss in height due to weakened or compressed vertebrae in the spine
- A stooped posture or a noticeable Dowager's Hump as vertebral bones collapse on each other.
Osteoporosis: Are You At Risk?
In addition to being female and of an older age, other factors that increase the risk for osteoporosis include:
- A family history of osteoporosis
- Frail build
- Insufficient levels of vitamin D in the body
- Low dietary intake of calcium
- Low levels of estrogen as a result of menopause, surgery, or irregular periods
- Overconsumption of alcohol or caffeine
- Physical inactivity
- Some medical conditions, such as rheumatoid arthritis, Cushing's syndrome, and multiple myeloma
- Long-term use or overuse of medicines such as corticosteroids, levothyroxine, or drugs used to treat epilepsy.
Osteoporosis Prevention: Start Strengthening Your Bones Now
Our bones need calcium, so it is important that you eat enough calcium-rich foods every day. How much is enough? Well, that is debatable, but experts suggest between 500-1000mg per day. That equates to about two to four servings of dairy products; nondairy sources of calcium include almonds, broccoli, figs, tinned whole fish (salmon with bones, sardines), and tofu. Calcium supplements are not recommended, as they may increase the risk of heart disease.
Vitamin D is another substance that is vital for good bone health. Vitamin D is made in our skin when it is exposed to sunlight. This means that people who spend a lot of time indoors or who hardly expose any skin to the sun, such as veiled women or those who are institutionalized or immobile, are at risk of vitamin D deficiency. People with dark skin are also at high risk.
Sun exposure should always be done in accordance with sun safety guidelines; however, if getting outside is not possible, vitamin D supplements are a good alternative.
Physical Activity Helps Keep Your Bones Strong
Both muscle-strengthening and weight-bearing exercises are important for bone health. The force of the muscles pulling against the bones is believed to stimulate the bone-building process increasing bone density and strength.
Muscle-strengthening exercises generally involve lifting weights or use your body's own weight to generate resistance. When done two to three times per week they can make a significant difference to your strength and balance; however, certain exercises may not be safe for some people with osteoporosis so make sure you get advice from your doctor or an instructor knowledgeable about osteoporosis before you begin.
Weight-bearing exercises build bone strength by making you move against gravity while staying upright and can be divided into those that are high-impact - such as dancing, running, tennis, and aerobics - and those that are low impact. Many gym machines such as treadmills, stair-step machines and elliptical trainers are low impact as is fast walking outside. Low-impact weight-bearing exercises are a safe alternative to high-impact exercise in those people with osteoporosis or at risk of breaking a bone.
While yoga and pilates can also improve strength, balance, and flexibility, certain positions - such as those that make you bend forward - may not be safe for people with osteoporosis. Swimming and cycling are also great sports for building muscle strength; however, they do not improve bone density.
Treatments For Osteoporosis
Several different types of medicine are used to treat osteoporosis. Treatment should be considered in postmenopausal women and men aged 50 and older presenting with either a hip or vertebral fracture, a bone density T-score of less than -2.5 (taken at the femoral neck of the hip, or total hip, or lumbar spine), or a low bone mass (T-score of -1.0 to -2.5), and a high risk of hip or other osteoporosis-related fracture.
Bisphosphonates are the preferred treatment; however, hormone therapy, raloxifene, denosumab or teriparatide may be a better option in some people. All require a prescription from a doctor, and apart from teriparatide, all decrease the rate at which bone is broken down. Teriparatide increases the rate at which bone is built up and also increases the absorption of calcium.
Your insurance plan will determine how much your insurance company pays for your osteoporosis medication, and you may have to pay a certain amount or a co-pay. Check your insurance companies website for a list of osteoporosis medications that they are approved to pay for. Some people may also qualify for the Medicare Prescription Drug benefit.
Be very cautious about buying prescription medicine online, either with or without a prescription. Only use online pharmacies that display the VIPPS® Seal on their website. Never buy a prescription medicine without a prescription - you never know what you are getting.
Bisphosphonates: First Choice For Osteoporosis
Bisphosphonates block the action of osteoclasts - responsible for breaking down bone tissue - thereby slowing bone loss. They are the preferred treatment for osteoporosis; however, they may not be suitable for everyone.
Bisphosphonates available in the U.S. include:
- Alendronate (Fosamax, Binosto): may be taken orally daily or a weekly tablet is also available
- Ibandronate (Boniva): can be taken orally monthly or given by intravenous injection every three months
- Risedronate (Actonel, Atelvia): can be taken orally daily, weekly, bimonthly, or monthly
- Zoledronic acid (Reclast, Zometa): given by intravenous infusion over at least 15 minutes once a year when used for treatment or once every two years when used for prevention.
Hormone Replacement Therapy for Osteoporosis
Twenty-to-thirty years ago, hormone replacement therapy (HRT) was considered the gold standard for preventing not only osteoporosis but treating menopausal symptoms as well. That all changed after publication of the results of the Women's Initiative Trial in 2002 which showed the risks associated with HRT use (an increased risk of breast cancer, blood clots, heart attacks, and stroke) outweighed the benefits (decreased rates of hip and vertebral fractures and colon cancer).
HRT may consist of either estrogen therapy alone or an estrogen-progestin combination. While not recommended as first-line osteoporosis therapy, estrogen may still be used to prevent osteoporosis in young women with premature menopause or primary ovarian failure. In women who are postmenopausal, it is usually reserved for those with persistent, intolerable menopausal symptoms or in those who do not tolerate other osteoporosis treatments. Examples of hormonal treatments include Premarin, estradiol, and Femhrt.
Raloxifene: Estrogen-Like Effects Without Cancer Risk
Although raloxifene is not a hormone, it mimics the action of estrogen on bones while at the same time blocking the effect of estrogen on other tissues. Therefore, long-term use of raloxifene does not carry the same risk to breast and womb tissue associated with estrogen-based hormone therapies. However, raloxifene can increase the risk of deep vein thrombosis and stroke and may increase the incidence of hot flushes and leg cramps. Raloxifene may also be used to treat osteoporosis in postmenopausal women with invasive breast cancer. Evidence suggests it may not be as effective as bisphosphonates or estrogen at preventing bone loss.
Duavee: Effective For Menopausal Symptoms And Bone Loss
Duavee is the brand name for a once-daily combined conjugated estrogens/bazedoxifene tablet approved for the treatment of vasomotor symptoms (such as night sweats and hot flushes) associated with menopause and for the prevention of osteoporosis.
The bazedoxifene component of the drug acts as an estrogen antagonist and prevents some of the estrogen side effects (such as excessive growth of the uterine lining) that could occur if estrogen was used by itself. Duavee increases both lumbar spine and hip bone mineral density but carries similar risks to other hormonal products so should only be considered if alternative non-estrogen products are not suitable.
Denosumab: Targeting The Cells That Break Down Bone
Denosumab improves bone mineral density and decreases fracture risk and is approved in postmenopausal women and men with osteoporosis at high risk of fracture. It may also be used to treat bone loss in men with prostate cancer or women with breast cancer undergoing hormone ablation therapy, or for the treatment of glucocorticoid-induced osteoporosis in those at high risk of fracture.
Denosumab is usually reserved for people intolerant of or unresponsive to oral or intravenous bisphosphonates.
Teriparatide: Unique Action Comes At A Cost
Teriparatide (Forteo), is a synthetic form of parathyroid hormone - a hormone produced naturally by the body which helps maintain blood levels of calcium within a very tight range; which in turn controls calcium levels within bone - determining how strong and dense the bones are.
As an osteoporosis medication, teriparatide is unique in that it stimulates bone formation. It may be used by postmenopausal women or men and is given as a daily injection. Evidence suggests it has more of an effect on building bone density and reducing fracture risk in the spine compared to other areas. Forteo is expensive, so is usually reserved for people with severe osteoporosis
Evenity: The Only Bone Builder with a Dual Effect
In April, 2019, the FDA approved Evenity (romosozumab-aqqg) for postmenopausal women at high-risk of fracture. It is currently the only bone builder to increase both bone formation and reduce bone loss.
Evenity is a humanized monoclonal antibody that works by inhibiting the activity of sclerostin, which is a small protein found in osteocytes. It is given by injection by a healthcare provider once a month for a treatment period of 12 months. After the 12-month course, therapy should continue with an anti-resorptive agent.
The main side effects associated with Evenity are joint pain (arthralgia) and headache. Evenity can also increase a woman's risk of having a heart attack and stroke, and for this reason it carries a boxed warning, and should not be given to women with other cardiovascular risk factors.
Tymlos: Another Option For Postmenopausal Women
Tymlos (abaloparatide), approved in April 2017, is a man-made version of a protein related to human parathyroid hormone. It may be considered in postmenopausal women who have tried and not responded to, or been intolerant of, other medications for osteoporosis. Tymlos significantly reduces the risk of vertebral and nonvertebral fractures.
Some animal studies have found that Tymlos is associated with an increase in the risk of osteosarcoma (a type of cancerous bone tumor). It is not known if this increased risk translates to humans; however, authorities have warned that Tymlos should not be given to women already at increased risk of osteosarcoma, including those with Paget's disease of the bone, pre-existing bone malignancies, prior radiation therapy, or hereditary disorders that increase their risk of osteosarcoma.
Tymlos is given by self-injection just under the skin and is available as single-use prefilled pens.
Calcitonin May Not Reduce Fracture Risk
Calcitonin is a hormone that works together with naturally occurring parathyroid hormone to help regulate calcium concentrations on the body. It may be given by nasal spray or injection to women who are five years postmenopausal; however, the nasal spray is preferred because the injection tends to cause nausea and flushing.
Other treatments are usually preferred over calcitonin for the prevention of osteoporosis because it is not clear if calcitonin increases bone density in areas other than the spine or if it prevents fractures. Calcitonin is also used to relieve sudden, intense pain caused by vertebral fractures.
Tips To Fight Off Osteoporosis
There's a lot you can do to decrease your risk of osteoporosis or slow its progress once you have it:
- Make sure you do at least 30 minutes of weight-bearing physical activity, every day
- Ensure your daily diet contains foods that are high in calcium
- Spend some time in the sun each day while still adhering to sun safety guidelines
- Limit how much alcohol you drink - no more than two standard drinks at a time - and have 3 to 4 alcohol-free days per week
- Stop smoking if you smoke.
For those already diagnosed with osteoporosis, take care to reduce your chances of having a fall around your home or when out and about:
- If you have to get up at night ensure a torch is in easy reach or keep lights on in any area you may need to walk
- Remove or firmly anchor any rugs and keep clutter and cords out of the way
- Don't let pets walk around your feet
- wear low-heeled shoes that offer good support
- Get safety rails installed near your shower or bath and by the toilet to prevent slipping
- Be careful when getting out of bed and dressing
- Wear hip protectors (thin, oval, plastic discs that fit over your hip) under your clothes to absorb the shock if you do fall.
Finished: Osteoporosis: A Battle For Your Bones
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