Osteoporosis is becoming a hot topic in today's health as there is increased attention by more women and men who are now aware of complications associated with osteoporosis and the questions surrounding available treatment options. Since this is a disease that is very common among women, especially after menopause, I feel it is important to start my first hot topic series by addressing this issue. Young females (including teenagers) who may be at risk for this disease and women of child bearing age can start to think ahead and make lifestyle changes that can help prevent the onset of this disease. Since osteoporosis does have a strong genetic component, women who are prone to get this disease should engage in strategies to halt the progression or treat the disease. I will be discussing male osteoporosis so my male readers should pay attention as well.

Knowledge is power!  

Let’s go back to the basics of this bone disorder.

What is Osteoporosis?

What are the symptoms of Osteoporosis?

Who is at risk for Osteoporosis?

How is fracture risk calculated?

What about male Osteoporosis?

What can a woman do to prevent or treat Osteoporosis?

When is medication necessary for prevention or treatment?

What medications are available for the treatment of Osteoporosis?

Are there any debates surrounding some of the available established treatments?

What other therapies are available if someone fails a bisphosphonate or has a new fracture while taking a bisphosphonate?

What is the take home message?

What is Osteoporosis?

Osteoporosis, is defined as a disorder of low bone mass causing bones to become thin, weak, and brittle.  This deterioration in the skeleton can result in an increased incidence of fractures in the spine, hip and other sites, such as the wrist. Some of these fractures result from low trauma such as coughing, sneezing, or tripping after losing balance.

Osteopenia refers to the disorder where bone density is lower than normal but not severe enough to meet the criteria for osteoporosis.

According to the National Osteoporosis Foundation, 10 million Americans are diagnosed with osteoporosis and 34 million people have osteopenia.

Osteoporosis is a major public health problem that can cause substantial disability, rising health care costs, and morbidity among postmenopausal women or pre menopausal women with certain risk factors for this bone disease. It is crucial to identify patients who are at risk for falls and fractures secondary to minor trauma.

What are the symptoms of Osteoporosis?

1. Moderate to severe back pain

2. Loss of height

3. Change of posture

4. Change in upper spine curvature or development of a “hump” in the upper back

5. No symptoms at all

Who is at risk for Osteoporosis?

Some of these risk factors include age, family history, history of previous fracture, race, vitamin D deficiency, low body mass index, excessive alcohol intake and smoking history. Certain medications like steroids, and specific diseases, such as thyroid disease and rheumatoid arthritis can increase a person’s risk for weak bone health. Patients who present with no prior treatment history and who carry a diagnosis of osteoporosis or osteopenia with risk factors for a fracture should have a thorough evaluation for future fracture risk.

See complete list of risk factors below:

1.    Age (older age, especially after age 50)

2.    Gender (females are at higher risk than males)

3.    Ethnicity (Caucasian and Asian females have higher risk)

4.    Early age of menopause

5.    Low bone mineral density detected by DEXA (T score of -2.5 or lower)

6.    Prior fractures and falls

7.    Family history

8.    Body mass index (very thin people have higher risk)

9.    Smoking and moderate to excessive alcohol use

10.  Steroid use and certain medications

11.  Chronic diseases

          a.    rheumatoid arthritis

          b.    thyroid disease

          c.    chronic lung disease

          d.    multiple sclerosis

          e.    inflammatory bowel disease

          f.     anorexia

Other factors to be considered include vitamin D deficiency, inactive lifestyle, and low estrogen and testosterone levels.

How is fracture risk calculated?

Every patient who thinks that she or he may be at risk for osteoporosis should consult a doctor. The physician should obtain a thorough history and a painless bone densitometry exam (DEXA) during the initial assessment. It measures the bone mass in the hip, spine, wrist, heel, or hand.

DEXA scan will give provide the patient with a T score:

Recently the World Health Organization (WHO) has created an online tool called FRAX, which can be utilized to quantify a patient's 10-year probability of a hip or major osteoporotic fracture by using bone mineral density and risk factors. For certain patients who have not been treated for osteoporosis, the physician can calculate a FRAX score. This tool is available on the internet and can be calculated for females of different ethnicities and countries.

FRAX tool

What about males and Osteoporosis?

For my male readers... I have not forgotten about you!

This disease DOES NOT only affect females.  Males are at risk as well, however not as often as females.  According to the National Osteoporosis Foundation, one in every four men over the age of 50 is at risk for a fracture due to osteoporosis and over 2 million men have osteoporosis.  Most of the risk factors which have been addressed with women also apply to men, however, low testosterone levels, hypogonadism (the testes do not properly function), steroid use, and prostate cancer,specifically places males at higher risk for bone loss.
It is important to speak with your healthcare provider about your risk factors and  assess your fracture risk to avoid morbidity and mortality from hip and spine fractures. Please follow the lifestyle modifications below to prevent and treat osteoporosis.

What can a woman do to prevent or treat Osteoporosis?

Making important lifestyle changes should be a priority in the prevention of this bone disorder!

Smoking cessation and limiting excessive alcohol intake is essential. Excessive alcohol intake (more than 2-3 ounces a day) or chronic alcohol use can interfere with the replacement of bone tissue resulting in decreased bone density. Alcohol interacts with many hormones and cells, particularly the osteoblast or cell that is responsible for forming new bone. Alcohol can exert its effects on the pancreas and liver, which are two organs that play a key role in calcium and vitamin D absorption. It is no surprise that smoking does not promote good health. Nicotine consumption can result in the generation of free radicals or molecules that alters the body’s natural defenses. These radicals destroy the bone remodeling cells. Smoking can also increase a hormone called cortisol which accelerates bone deterioration.

You’ve heard this statement time and time again. Exercise in moderation is never a bad thing.

Exercise has been shown to stimulate estrogen production and bone formation cells.

Women should engage in balance training programs with strengthening exercises. Recommended exercises for women who have osteoporosis or at risk for low bone mass may include regimens with the use of free weights that is appropriate for the individual person, flexibility exercise programs, and low impact aerobics. Women are also encouraged to participate in swimming, walking dancing, yoga and Tai Chi. In addition to low impact activity, a fall prevention strategy may help with fracture prevention. Simple measures like ensuring adequate lighting in the house or work place, proper shoes, or removing hazards in the home that can lead to tripping may greatly reduce the incidence of falls and fractures.

Having a diet rich in calcium and vitamin D and low alcohol intake will help with promoting good bone health. Women need adequate calcium and vitamin D. Most adults will require 1,200 to 1,500 mg of calcium per day. Good sources of calcium can be found in milk, yogurt, cheese, nuts (almonds), sardines, dark green vegetables, orange juice, and soy milk. It is known that most people only get half the required amount of calcium through diet so oral supplements are often needed. Vitamin D helps the body absorb calcium better.

Refer to Dr. Maggie Section on more information on vitamin D.

When is medication necessary for prevention or treatment?

Sometimes women and men may develop worsening bone density despite their participation in good lifestyle modifications. It is always important to remember that age, family history/genetics, and other risk factors still may place a woman or man at risk for worsening bone mass and subsequent fractures despite lifestyle changes.

Many females may require medications to increase their bone density and strength. There are many available treatment options for osteoporosis based on each individual’s clinical history and calculated fracture risk based on her personal risk factors.

Every patient is different and must discuss with her physician the options that she has to best prevent or treat this disease.

Some of these medications aim to help build bone mass and increase bone strength and other medications aim to prevent further bone loss. Other drugs affect the interaction of the different cells involved in the bone remodeling process. Estrogen has also been used for osteoporosis treatment and prevention. Estrogen helps protect the skeleton by promoting calcium absorption and preventing the death of osteoblasts or bone forming cells.

Note: Males must also discuss treatment options with their physician since all the medications listed below have not yet been approved for the treatment of male osteoporosis.

What medications are available for the treatment of Osteoporosis?

Here is the most updated list of the medications that are available:

1. Bisphosphonates

   - Aledronate (Fosamax)

   - Risedronate (Actonel)

   - Ibandronate (Boniva)

   - Zoledronic Acid (Reclast)

2. Parathyroid Hormone (Forteo).

3. Denosumab (Prolia)

4. Selective Estrogen Receptor modulators (Raloxifene/Evista)

5. Calcitonin

Are there any debates surrounding some of the available established treatments?

For many years, physicians have prescribed this class of medication to prevent and treat osteoporosis. Many women are familiar with this drug class, which includes risedronate (Actonel), alendronate (Fosamax), ibandronate (Boniva), and zoledronic acid (Reclast). These drugs target certain cells called osteoclasts, which digest bone and lead to bone loss. Fosamax and Actonel are given orally. Ibandronate is given orally and by IV administration monthly. Reclast is administered once a year by an infusion. These drugs have been prescribed to women for many years to halt the progression of worsening bone density. These drugs have been very effective for preventing and treating fractures in some females, however, the length of treatment with these drugs should be limited and reevaluated from time to time. There are side effects with these medications that should be discussed with your physician based on your medical history. Here are a few adverse effects which should be carefully noted.

Hypocalcemia or low calcium levels may worsen with this medication. Patients who have low calcium levels are not candidates for this therapy and should have their physicians monitor the calcium levels closely. All patients must continue to take calcium and vitamin D supplements while on this drug.

Osteonecrosis of the jaw, which leads to damage and death of the jaw bone, specifically the mandible and maxillae, has also been reported with this condition. This condition has been seen with delayed healing after a tooth extraction or infection. An oral exam should be performed and good oral hygiene should be maintained prior to taking this medication. Women who have kidney impairment or kidney disease should not be taking this drug.

In the last year, there have been several reports of increased atypical non traumatic fractures (subtrochanteric fractures) that occur in some patients who are on long term bisphosphonate use, usually more than four years. There is some suggestion that long term bisphosphonate use may alter the quality and structure of the bones, making them brittle.

Other risk factors that have been noted include steroid use, history of prior low trauma, age and active co morbid conditions, such as rheumatoid arthritis, vitamin D deficiency, and Diabetes. These fractures, which occur at a specific site of the femur can be diagnosed by X ray. Women who sustained this type of fracture will usually complain of aching thigh pain. 

I personally have seen more consults for osteoporosis management in patients who have sustained a new fracture while taking a bisphosphonate. This is not to say that bisphosphonates are not good drugs. Personally, I try not to treat patients with a bisphosphonate for more than 3-5 years if bone density is improving and no fractures have occurred. The patient may require a “drug holiday”.  

It is important to remember that the risk of a hip fracture is higher than the risk of a woman developing an atypical fracture so women should still seek treatment for osteoporosis prevention and management. Ask your physician to review with you the duration of bisphosphonate use yearly while assessing bone density status and fracture risk.

What other therapies are available if someone fails a bisphosphonate or has a new fracture while taking a bisphosphonate?

Women should seek alternative therapies if:

a. They are unable to take a bisphosphonate because of a personal medical history with a contraindication for use

b. They can’t tolerate the drug because of side effects

c. They fracture despite being on a bisphosphonate

d. They have worsening bone density despite being on a bisphosphonate

e. They don’t feel this drug is the best for their treatment regimen

Other therapies that are available for osteoporosis treatment and or prevention include:

1. Denosumab (Prolia)

2. Parathyroid Hormone (Forteo)

3. Selective Estrogen Receptor modulators (Raloxifene/Evista)

There is no 'right' answer to which Osteoporosis drug you should take. They all have risks and they all have rewards. Every patient is different and must discuss with her physician the options that she has to best prevent or treat this disease. Keep in mind that not treating osteoporosis is risky and may lead to lifetime disability. No therapy is permanent. Some of these medications aim to help build bone mass and increase bone strength and other medications aim to prevent further bone loss.

Denosumab or Prolia, a newly FDA approved medication, is an injection every six months administered by a physician. This medication works by preventing the interactions of two crucial molecules which play major roles in the bone remodeling and repair process. 

Another alternative is a daily injection for two years called Teriparatide Injection or Forteo. It is a synthetic form of the human body’s parathyroid hormone. This injection, which is given to the thigh or stomach area increases bone strength, bone density, and forms new bone. This is a great drug for patients who have progressive worsening bone density despite prior medication use or who have multiple fractures and need to form new and stronger bone. It is a daily injection so the patient must feel comfortable administering the medication daily.

Another drug therapy to treat and prevent osteoporosis is raloxifene or Evista which belongs to a class of drugs called selective receptor modulators (SERMs). This drug mimics the effects of estrogen by increasing bone strength and thickness through hormonal effects. I would recommend this drug if there is a family or personal history of breast cancer since this daily oral medication decreases a woman’s risk of developing invasive breast cancer only. I tend to be very selective with the females that can take this drug because of its side effects. Evista does increase a woman’s risk of acquiring a blood clot in the legs and lungs. Also, if a woman has a history of coronary artery disease and smoking, then she has a higher risk of developing a fatal stoke with this medication. You must speak with your doctor and evaluate your risk profile.

Sometimes surgery may be recommended if patients are undergoing pain from vertebral fractures. Two surgical options include vertebroplasty and kyphoplasty.

Last thoughts….

It is fair to say that all the drugs indicated for osteoporosis have adverse effects and each woman and man has to look at her/his personal history and evaluate her comfort level with the drug side effect profile when discussing options with a physician before making a final decision. Keep in mind that not treating osteoporosis is risky and may lead to lifetime disability. No therapy is permanent.

Each patient is able to discontinue a medication for a short period of time and initiate a trial with another medication until the goal of improving bone strength and quality is achieved. A woman/man should search for the medication that will offer improve bone health while offering a low risk profile. In this age, the field of osteoporosis prevention and treatment is constantly evolving. New medications that target the different mechanisms in the bone remodeling process are being researched and invented all the time to prevent subsequent fractures.

I hope that with more education about this public health concern, people will empower themselves to play active roles in improving their bone health. For more information on osteoporosis, please visit the National Osteoporosis Foundation and American College of Rheumatology websites: