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Osteoporosis

Osteoporosis is a common condition. Bone is living tissue that is in a constant state of regeneration. The body removes old bone (called bone resorption) and replaces it with new bone (bone formation). By their mid-30s, most people begin to slowly lose more bone than can be replaced. As a result, bones become thinner and weaker in structure. This accelerates in women at the time of the menopause. In men bone lost usually becomes more of an issue around age 70.

Osteoporosis is silent because there are no symptoms (what you feel). Sometimes you might notice height lost by noticing your clothes are not fitting right. Other times it may come to your attention only after you break a bone. When you have this condition, a fracture can occur even after a minor injury, such as a fall. The most common fractures occur at the spine, wrist and hip. Spine and hip fractures, in particular, may lead to chronic (long-term) pain and disability, and even death. The main goal of treating osteoporosis is to prevent such fractures in the first place. 

Because Osteoporosis is silent, the bone density test, or DEXA, has become of major importance. The DEXA scan can tell you if your bone is becoming osteoporotic. 

Fortunately, you can take steps to reduce your risk of osteoporosis. By doing so, you can avoid the often-disabling broken bones (fractures) that can result from this condition. If you already have osteoporosis, new medications are available to slow or even stop the bones from getting weaker. These medicines also can decrease the chance of having a fracture.

Cause

Osteoporosis results from a loss of bone mass (measured as bone density) and from a change in bone structure. Many factors will raise your risk of developing osteoporosis and breaking a bone. You can change some of these risk factors, but not others. Recognizing your risk factors is important so you can take steps to prevent this condition or treat it before it becomes worse. 
Major risk factors that you cannot change include:

  • dvancing age, menopause
  • Non-Hispanic white or Asian ethnic background
  • Small bone structure
  • Parents you have broken their hips
  • Prior fracture due to a low-level injury, particularly after age 50

Risk factors that you may be able to change include: 

  • Low levels of sex hormone, mainly estrogen in women (e.g., menopause) 
  • The eating disorders anorexia nervosa and bulimia
  • Cigarette smoking
  • Alcohol abuse
  • Low calcium and vitamin D, from low intake in your diet starting during your teens and 20’s or inadequate absorption in your gut
  • Sedentary (inactive) lifestyle or immobility
  • Certain medications, including the following: glucocorticoid medications , excess thyroid hormone replacement in those taking medications for low thyroid or hypothyroidism
  1. heparin, a commonly-used blood thinner
  2. some treatments that deplete sex hormones, such as anastrozole and letrozole to treat breast cancer or leuprorelin to treat prostate cancer and other health problems
  • Diseases that can affect bones
  1. endocrine (hormone) diseases (hyperthyroidism, hyperparathyroidism, Cushing's disease, etc.) 
  2. inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis, etc.)

Symptoms

Osteoporosis is more common in older women, mainly non-Hispanic white and Asian women. Yet it can occur at any age, in men as well as women, and in all ethnic groups. People over age 50 are at greatest risk of developing osteoporosis and having related fractures.

Diagnosis

You can learn if you have osteoporosis by having a simple test that measures bone mineral density—sometimes called BMD. BMD —the amount of bone you have in a given area—is measured at different parts of your body. Often the measurements are at your spine and your hip, including a part of the hip called the femoral neck, at the top of the thighbone (femur). Dual energy X-ray absorptiometry (DEXA) is the best current test to measure BMD. 
The test is quick and painless. It is similar to an X-ray, but uses much less radiation. Even so, pregnant women should not have this test, to avoid any risk of harming the fetus.

Treatment plan

If you have osteoporosis, your health care provider will advise the following: 

  • Calcium. Make sure you are getting enough calcium in your diet or you might need to consider taking supplements. The National Osteoporosis Foundation recommends 1,000 milligrams (shortened as mg) per day for most adults and 1,200 mg per day for women over age 50 or men over age 70. 
  • Vitamin D. Get adequate amounts of vitamin D, which is important to help your body absorb calcium from foods you eat. The recommended daily dose is 400–800 International Units (called IU) for adults younger than age 50, and 800–1,000 IU for those age 50 and older. (These are the current guidelines from the National Osteoporosis Foundation.) You may need a different dose depending on your blood level of vitamin D, sometimes as high as 50,000 unit a week for 12 weeks. 
  • Physical activity. Get exercise most days, especially weight-bearing exercise, such as walking. Most people with Osteoporosis or High FRAX scores will also need a medication. A number of medications are available for the prevention and/or treatment (“management”) of osteoporosis.

Bisphosphonates. The US Food and Drug Administration (better known as the FDA) has approved certain drugs called bisphosphonates to prevent and treat osteoporosis. This class of drugs (often called “anti-resorptive” drugs) helps slow bone loss, and studies show they can
decrease the risk of fractures.

With all of these medications, you should make sure you are taking enough calcium and vitamin D, and that the vitamin D levels in your body are not low. (Your doctor can measure your vitamin D level with a blood test.) Alendronate, risedronate and ibandronate are pills that you must take on an empty stomach with water only, or else you will not properly absorb the medicine. These drugs sometimes can irritate the esophagus (the tube that goes from the throat to the stomach). Therefore, you should remain upright for at least an hour after taking these medications. There have been reports of rare side effects that may be linked to use of bisphosphonates. These include osteonecrosis of the jaw (also called jaw osteonecrosis or ONJ) and atypical femoral fractures: 

Calcitonin (Calcimar, Miacalcin). This medication, a hormone made from the thyroid gland, is given most often as a nasal spray or as an injection (shot) under the skin. It is FDA- approved for the management of postmenopausal osteoporosis and helps prevent vertebral (spine) fractures. It also is helpful in controlling pain after an osteoporotic vertebral fracture. 

Estrogen or hormone replacement therapy. Estrogen treatment alone or combined with another hormone, progestin, has been shown to decrease the risk of osteoporosis and osteoporotic fractures in women. However, combination estrogen and progestin can increase the risk of breast cancer, strokes, heart attacks and blood clots. Estrogens alone may raise the risk of strokes. Consult with your doctor about whether hormone replacement therapy is right for you. 

Selective estrogen receptor modulators. These medications, often referred to as SERMs, mimic estrogen’s good effects on bones without some of the serious side effects such as breast cancer. However, there is still a risk of blood clots and stroke with use of SERMs. The SERM raloxifene (Evista) decreases the risk of spine fractures in women. It is approved for use only in postmenopausal women. 

Teriparatide. Teriparatide is a form of parathyroid hormone that helps stimulate bone formation. It is approved for use in postmenopausal women and men at high risk of osteoporotic fracture. It also is approved for treatment of glucocorticoid-induced osteoporosis. It is given as a daily injection under the skin and can be used for up to two years. If you have ever had radiation treatment or your parathyroid hormone levels are already too high, you may not be able to take this drug.

Strontium ranelate. This medicine is approved for managing postmenopausal osteoporosis in several countries around the world, but not the U.S. (Brand names include Protelos, Protos, Osseor, Bivalos, Protaxos and Ossum.) Studies show it lowers the fracture risk in postmenopausal women. The drug comes as a powder, which women dissolve in water and take daily. Because of an increased risk of blood clots, it should be used with caution in women who have a history of or risk of blood clots such as deep venous thrombosis or pulmonary embolism. 

Denosumab (Prolia). This new class of “antiresorptive” drug is a fully human monoclonal antibody, a type of immune therapy. It works against a protein that interferes with the survival of bone-resorbing cells. This treatment is approved for use in postmenopausal women who have osteoporosis and are at high risk of fracture. Another approved use is for women and men at high risk of bone loss and fractures from hormone-depleting medications used to treat breast and prostate cancer. Patients receive this medicine as an injection under the skin every six months. This medication can make your calcium levels go very low, so your calcium and vitamin D levels should not be low when you start to take this medicine. There may be an increased risk of infections when using this drug. There have also been rare reports of ONJ linked to use of denosumab.

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