Diseases

Osteoporosis Information

Calcium supplements for osteoporosis

Building strong and healthy bones requires an adequate dietary intake of calcium beginning in childhood and adolescence for both sexes. Most importantly, however, a high dietary calcium intake or taking calcium supplements alone is not sufficient in treating osteoporosis and should not be viewed as an alternative to or substituted for more potent prescription medications for osteoporosis. In the first several years after menopause, rapid bone loss may occur even if calcium supplements are taken.The following calcium intake has been recommended by the National Institutes of Health Consensus Conference on Osteoporosis for all people, with or without osteoporosis:

• 800 mg/day for children 1-10 years of age
• 1,000 mg/day for men, premenopausal women, and postmenopausal women also taking estrogen
• 1,200 mg/day for teenagers and young adults 11-24 years of age
• 1,500 mg/day for postmenopausal women not taking estrogen
• 1,200 mg-1,500 mg/day for pregnant and nursing mothers
• The total daily intake of calcium should not exceed 2,000 mg.

1. Excluding dairy products, the average American diet contains approximately 250 mg of calcium.
2. There is approximately 300 mg of calcium in an 8-ounce glass of milk.
3. There is approximately 450 mg of calcium in 8 ounces of plain yogurt.
4. There is approximately 130 mg of calcium in 1 cup of cottage cheese.
5. There is approximately 200 mg of calcium in 1 ounce of cheddar cheese.
6. There is approximately 90 mg of calcium in ½ cup of vanilla ice cream.
7. There is approximately 300 mg of calcium in 8 ounces of calcium-fortified orange juice.

Choosing an osteoporosis medication

In choosing a medication for osteoporosis, a physician will consider all aspects of a patient's medical history as well as the severity of the osteoporosis.If a postmenopausal woman has other menopausal symptoms such as hot flashes and vaginal dryness, HRT will be the proper choice for these menopausal symptoms as well as for the prevention of osteoporosis. After the menopausal symptoms have passed, some other nonestrogen prescription medication will be considered for the longer term.If the prevention and treatment of osteoporosis is the only issue under consideration, then bisphosphonates such as alendronate, ibandronate, or risedronate are more effective than menopausal hormone therapy in preventing osteoporotic fractures and less likely to be associated with substantial adverse effects. So far, bisphosphonates are the most well-studied and effective category of prescription medication for treating postmenopausal osteoporosis.A few serious esophageal conditions preclude the use of oral bisphosphonates, specifically esophageal stricture or achalasia. In these two conditions, it is likely that the bisphosphonate tablets will be retained in the esophagus and lead to esophageal inflammation, ulceration, and scarring. Caution often is advised for people with dysphagia (trouble swallowing) because the dysphagia may be a manifestation of a problem in the esophagus that will cause the bisphosphonate tablets to get stuck. Caution also is advised when there is gastritis, duodenitis, or ulcers because of the possibility that the bisphosphonate will aggravate the inflammation associated with these conditions. Any worsening of gastrointestinal symptoms should be reported immediately, but the vast majority of people tolerate bisphosphonates without symptoms when the prescribing directions are followed carefully. Fortunately, GERD or heartburn, which are common, are not reasons for withholding bisphosphonates but they are considered when selecting optimal treatment for an individual. Prescribing directions should be followed carefully. Moreover, intravenous bisphosphonates, such as zoledronate (Reclast) or injectable denosumab (Prolia), may be given to those with esophageal strictures, achalasia, dysphagia, or gastrointestinal side effects from oral bisphosphonates.In patients with GERD or who have symptoms of heartburn, risedronate may prove to cause less irritation to the esophagus than alendronate, but now intravenous bisphosphonates, such as zoledronate may be preferred.Calcitonin is a weaker antiresorptive medication than bisphosphonates. It is reserved for patients who cannot take or will not consider taking other medications. Raloxifene also is a weaker medication for improving bone density or preventing fractures as compared to estrogen or bisphosphonates. In patients with moderate to severe osteoporosis, it is advisable to use the more potent antiresorptive medications (bisphosphonates). In addition, the safety and effectiveness of more than three years of raloxifene, or more than 24 months of teriparatide, have not been well studied.Estrogen replacement and raloxifene differ in their side effects and also in their effects on cholesterol levels. For example, raloxifene does not raise the "good" HDL cholesterol but estrogen replacement does. Both estrogen and raloxifene lower the "bad" LDL cholesterol.

Exercise, quitting cigarettes, and curtailing alcohol

Exercise has a wide variety of beneficial health effects. However, exercise does not bring about substantial increases in bone density. The benefit of exercise for osteoporosis has mostly to do with decreasing the risk of falls, probably because balance is improved and/or muscle strength is increased. Research has not yet determined what type of exercise is best for osteoporosis or for how long it should be continued. Until research has answered these questions, most doctors recommend weight-bearing exercise, such as walking, preferably daily for optimal health.A word of caution about exercise: It is important to avoid exercises that can injure already weakened bones. In patients over 40 and those with heart disease, obesity, diabetes mellitus, and high blood pressure, exercise should be prescribed and monitored by physicians. Extreme levels of exercise (such as marathon running) may not be healthy for the bones. Marathon running in young women that leads to weight loss and loss of menstrual periods can actually promote osteoporosis.Smoking one pack of cigarettes per day throughout adult life can itself lead to loss of 5%-10% of bone mass. Smoking cigarettes decreases estrogen levels and can lead to bone loss in women before menopause. Smoking cigarettes also can lead to earlier menopause. In postmenopausal women, smoking is linked with increased risk of osteoporosis. Data on the effect of regular consumption of alcohol and caffeine on osteoporosis is not as clear as with exercise and cigarettes. In fact, research regarding alcohol and caffeine as risk factors for osteoporosis shows widely varying results and is controversial. Certainly, their effects are not as great as other factors. Nevertheless, moderation of both alcohol and caffeine is prudent.

Hormone therapy (menopausal hormone therapy)

Estrogen hormone therapy after menopause (previously referred to as hormone replacement therapy or HRT) has been shown to prevent bone loss, increase bone density, and prevent bone fractures. It is useful in preventing osteoporosis in postmenopausal women. Estrogen is available orally (Premarin, Estrace, Estratest, and others) or as a skin patch (Estraderm, Vivelle, and others).Estrogen also is available in combination with progesterone as pills and patches. Progesterone is routinely given along with estrogen to prevent uterine cancer that might result from estrogen use alone. Women who have had a hysterectomy (surgical removal of the uterus) may take estrogen alone since they no longer have a uterus to become cancerous. Nasally delivered estrogen and lower-dose combination pills of estrogen and progesterone are also being studied. However, due to adverse effects of HRT, such as increased risks of heart attack, stroke, blood clots in the veins, and breast cancer; HRT is no longer recommended for long-term use in the therapy of osteoporosis. Rather, HRT is used short term to relieve menopausal hot flashes.Every woman needs to have an individualized discussion regarding HRT with her doctor because each woman will place different weight on the risks and benefits of the treatment.

Medications that prevent bone loss and breakdown

Currently, the most effective medications for osteoporosis that are approved by the FDA are antiresorptive agents, which decrease the removal of calcium from bones. The bone is a living dynamic structure; it is constantly being built and removed (resorbed). This process is an essential part of maintaining the normal calcium level in the blood and serves to repair tiny cracks in the bones that occur with normal daily activity and to remodel bone based on the physical stresses placed on the bone. Osteoporosis results when the rate of bone resorption exceeds the rate of bone rebuilding. Antiresorptive medications inhibit removal of bone (resorption), thus tipping the balance in favor of bone rebuilding and increasing bone density. HRT is one example of an antiresorptive agent. Others include alendronate (Fosamax), risedronate (Actonel), raloxifene (Evista), ibandronate (Boniva), calcitonin (Calcimar), zoledronate (Reclast), and denosumab (Prolia).BisphosphonatesBisphosphonates decrease the risk of hip fracture, wrist fracture, and spine fracture in people with osteoporosis and can improve the T-score. Alendronate (Fosamax), risedronate (Actonel, Atelvia), ibandronate (Boniva), and zoledronate (Reclast) are bisphosphonates.To reduce side effects and to enhance absorption of the medicine, all bisphosphonates taken by mouth (orally) should be taken in the morning, on an empty stomach, 30 minutes before breakfast, and with at least 8 ounces (240 ml) of water (not juice). This improves the absorption of the bisphosphonate. Taking the pill sitting or standing (as well as drinking adequate amounts of liquids) minimizes the chances of the pill being lodged in the esophagus, where it can cause ulceration and scarring. Patients should also remain upright for at least 30 minutes after taking the pill to avoid reflux of the pill into the esophagus. Newer intravenous bisphosphonates, such as ibandronate (Boniva) and zoledronate (Reclast), bypass the potential esophagus and stomach problems.Food, calcium, iron supplements, vitamins with minerals, or antacids containing calcium, magnesium, or aluminum can reduce the absorption of oral bisphosphonates, thereby resulting in loss of effectiveness. Therefore, oral bisphosphonates should be taken with plain water only in the morning before breakfast. Also, no food or drink should be taken for at least 30 minutes afterward.Alendronate (Fosamax)Alendronate (Fosamax) is a bisphosphonate antiresorptive medication. Alendronate is approved for the prevention and treatment of postmenopausal osteoporosis as well as for osteoporosis that is caused by cortisone-related medications (glucocorticoid-induced osteoporosis). Alendronate has been shown to increase bone density and reduce fractures in the spine, hips, and arms. Fosamax is taken by mouth once a week to prevent and treat postmenopausal osteoporosis. Alendronate is the first osteoporosis medication also approved for increasing bone density in men with osteoporosis, either in a daily or a weekly dosing schedule.Fosamax generally is well tolerated with few side effects. One side effect of alendronate is irritation of the esophagus (the food pipe connecting the mouth to the stomach). Inflammation of the esophagus (esophagitis) and ulcers of the esophagus have been reported infrequently with alendronate use.Risedronate (Actonel)Risedronate (Actonel, Atelvia) is another bisphosphonate antiresorptive medication. Like alendronate, this drug is approved for the prevention and treatment of postmenopausal osteoporosis as well as for osteoporosis that is caused by cortisone-related medications (glucocorticoid-induced osteoporosis). Risedronate is chemically different from alendronate and has less likelihood of causing esophageal irritation. Risedronate also is more potent in preventing the resorption of bone than alendronate.Ibandronate (Boniva)Ibandronate (Boniva) is a bisphosphonate for prevention and treatment of postmenopausal osteoporosis. It is available in formulations for both daily and monthly oral use as well as for intravenous use every three months.Zoledronate (Reclast)Zoledronate (Reclast) is a unique intravenous bisphosphonate antiresorptive medication that is given once every year. This formulation seems to have very good ability to strengthen bones and prevent fractures of both spinal and nonspinal bones. The convenience of once-a-year dosing is obvious. As with all bisphosphonates, patients taking Reclast must be taking adequate calcium and vitamin D prior to and after infusion of the medication for optimal results. Generally, patients are given acetaminophen (Tylenol) the day of the infusion and for several days afterward to prevent occasional minor muscle and joint aches. The infusion lasts approximately 20-30 minutes. Reclast is used to treat and prevent osteoporosis in postmenopausal women and increases bone mass in men with osteoporosis. Reclast is also used to treat and prevent steroid-induced osteoporosis (glucocorticoid-induced osteoporosis). Reclast reduces risk of fractures after a low-trauma hip fracture. Reclast should not be used in patients who have had avascular necrosis or during/prior to pregnancy.Selective estrogen receptor modulators (SERMs)Raloxifene (Evista)Raloxifene (Evista) belongs to a class of drugs called selective estrogen receptor modulators (SERMs). SERMs work like estrogen in some tissues but as an antiestrogen in other tissues. The SERMs were developed to reap the benefits of estrogen while avoiding the potential side effects of estrogen. Thus, raloxifene can act like estrogen on bone but as an antiestrogen on the lining of the uterus where the effects of estrogen can promote cancer.The first SERM to reach the market was tamoxifen (Nolvadex), which blocks the stimulative effect of estrogen on breast tissue. Tamoxifen has proven valuable in women who have had cancer in one breast for preventing cancer in the second breast. Raloxifene is the second SERM to be approved by the FDA. Evista has been approved for the prevention and treatment of osteoporosis in postmenopausal women. In a three-year study involving some 600 postmenopausal women, raloxifene was found to increase bone density (and lower LDL cholesterol) while having no detrimental effect on the uterine lining (which means that it is unlikely to cause uterine cancer).Because of its antiestrogen effects, the most common side effects with Evista are hot flashes. Conversely, because of its estrogenic effects, Evista increases the risk of blood clots, including deep vein thrombosis (DVT) and pulmonary embolism (blood clots in the lung). The greatest increase in risk occurs during the first four months of use. Patients taking raloxifene should avoid prolonged periods of immobility during travel, when blood clots are more prone to occur. The risk of deep vein thrombosis with raloxifene is probably comparable to that of estrogen, about two to three times higher than the usual low rate of occurrence. Evista decreases the risk of spinal fractures in postmenopausal women with osteoporosis, but it is not known if there is a similar benefit in decreasing the risk of hip fracture. (The only agents that are definitely proven to decrease the risk of hip fracture are bisphosphonates and denosumab.)Calcitonin (Calcimar, Miacalcin)Calcitonin (Calcimar, Miacalcin) is a hormone that has been approved by the FDA in the U.S. for treating osteoporosis. Calcitonins come from several animal species, but salmon calcitonin is the one most widely used. Calcitonin can be administered as a shot under the skin (subcutaneously), into the muscle (intramuscularly), or inhaled nasally (intranasally). Intranasal calcitonin is the most convenient of the three methods of administration.Calcitonin has been shown to prevent bone loss in postmenopausal women. In women with established osteoporosis, calcitonin has been shown to increase bone density and strength in the spine only.Calcitonin is a weaker antiresorptive medication than bisphosphonates. Calcitonin is not as effective in increasing bone density and strengthening bone as estrogen and the other antiresorptive agents, particularly bisphosphonates. In addition, it is not as effective as bisphosphonates in reducing the risk of spinal fractures and has not been proven effective in reducing hip fracture risk. Therefore, calcitonin is not the first choice of treatment in women with established osteoporosis. Nevertheless, calcitonin is a helpful alternative treatment for patients who cannot tolerate other medications.Common side effects of either injected or nasal spray calcitonin are nausea and flushing. Patients using Miacalcin Nasal Spray can develop nasal irritation, a runny nose, or nosebleeds. Injectable calcitonin can cause local skin redness at the site of injection, skin rash, and flushing.Teriparatide (Forteo)Teriparatide (Forteo) is a synthetic version of the human hormone, parathyroid hormone, which helps to regulate calcium metabolism. Unlike other medications for osteoporosis that reduce the resorption of bone, teriparatide very effectively promotes the growth of new bone. Forteo is self-injected into the skin. Because long-term safety is not yet established, it is only FDA-approved for 24 months of use. It reduces spinal fractures in women with known osteoporosis, but it is not known if there is a similar reduction in the risk for hip fracture. Generally, after a two-year course of teriparatide the patient is switched to bisphosphonate therapy to maintain bone density.Denosumab (Prolia)The latest treatment approved for osteoporosis is denosumab (Prolia), an injectable antibody that blocks a chemical messenger that plays a role in promoting bone thinning by the bone cells that are responsible for bone resorption. Prolia strengthens bone by increasing its density and reduces fractures. Prolia is administered by twice yearly injections under the skin. Denosumab is used for the treatment of postmenopausal women with osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture, or patients who have failed or are intolerant to other available osteoporosis therapy. Denosumab can cause increased risk of infections and low blood calcium levels (hypocalcemia).

Monitoring osteoporosis therapy

The controversy of bone density testing in patients already taking osteoporosis medicationThe American Medical Association and other reputable medical organizations recommend that repeat bone density testing (DXA scans) not be done for monitoring osteoporosis treatment or prevention on a routine basis. It is sometimes difficult to know just how to use repeated bone density measurements during therapy. Here are a few of the most important reasons:

1. Bone density changes so slowly with treatment that the changes are smaller than the measurement error of the machine. In other words, repeat DXA scans cannot distinguish between a real increase in bone density due to treatment and a mere variation in measurement from the machine itself.
2. The real purpose of osteoporosis treatment is to decrease future bone fractures. There is no good correlation between increases in bone density with decreases in fracture risks with treatment. For example, alendronate has been shown to decrease fracture risk by 50% but only to increase bone density by a few percent. In fact, most of the fracture reduction with raloxifene is not explained by raloxifene's effects on bone mineral density.
3. One density measurement taken during treatment will not help the doctor plan or modify treatment. For example, even if the DXA scan shows continued deterioration in bone density during treatment, there is not yet research data demonstrating that changing a medication, combining medications, or doubling medication doses will be safe and helpful in decreasing the future risk of fractures.
4. Even if bone density deteriorates during treatment, it is quite likely that the patient would have lost even more bone density without treatment.
5. Recent research has shown that women who lose bone density after the first year of HRT will gain bone density in the next two years of therapy, whereas women who gain in the first year will tend to lose density in the next two years of therapy. Therefore, bone density during treatment fluctuates naturally, and these fluctuations may not correlate with the prevention of fractures due to the medication.

Osteoporosis facts

• Osteoporosis is a condition of fragile bone with an increased susceptibility to fracture.
• Osteoporosis weakens bone and increases risk of bones breaking.
• Bone mass (bone density) decreases after 35 years of age, and bone loss occurs more rapidly in women after menopause.
• Key risk factors for osteoporosis include genetics, lack of exercise, lack of calcium and vitamin D, personal history of fracture as an adult, cigarette smoking, excessive alcohol consumption, history of rheumatoid arthritis, low body weight, and family history of osteoporosis.
• Patients with osteoporosis have no symptoms until bone fractures occur.
• The diagnosis of osteoporosis can be suggested by X-rays and confirmed by tests to measure bone density.
• Treatments for osteoporosis, in addition to prescription osteoporosis medications, include stopping use of alcohol and cigarettes, and assuring adequate exercise, calcium, and vitamin D.

Prevention of hip fractures in elderly people with osteoporosis

Elderly people with osteoporosis can decrease their risk for hip fracture by maintaining muscle strength, coordination, and balance with exercise programs. Throw rugs and animals in pathways of the home should be minimized or eliminated. Good lighting is essential for safe walking to the restroom both day and night.Additionally, for those elderly people who use canes for walking, etc., it is essential that the rubber tips of the canes are regularly checked for any signs of wear. When this rubber wears through it presents a serious risk of causing the cane (and, therefore, the person) to slip, which can result in serious bodily harm -- including hip fracture.ControversyCurrently, it is not clear as to how long patients with osteoporosis being treated with bisphosphonates should continue the bisphosphonate treatment. Many doctors are interrupting treatment for a "drug holiday" off of the drug as it may not be necessary after five to seven years. Guidelines for duration of treatment of osteoporosis with bisphosphonates are being developed.

Prevention of osteoporosis due to long-term corticosteroids

The long-term use of corticosteroids (such as prednisone, cortisone, and prednisolone) can lead to osteoporosis. Corticosteroids cause decreased calcium absorption from the intestines, increased loss of calcium through the kidneys in urine, and increased calcium loss from the bones. To prevent bone loss while on long-term corticosteroids, patients should

1. have an adequate calcium (1,000 mg daily if premenopausal, 1,500 mg daily if postmenopausal) and vitamin D intake (the actual level of Vitamin D can be measured with a simple blood test); however, calcium alone or combined with vitamin D cannot be relied upon to prevent bone loss from corticosteroids unless other prescription medications are added;
2. discuss with their doctor the use of either alendronate, risedronate, and zoledronate, which have been approved for the prevention and treatment of corticosteroid-induced osteoporosis;
3. discuss with their doctor about having a DXA bone density scan as well as blood testing for calcium, kidney function, and vitamin D prior to beginning therapy and monitoring for osteoporosis during therapy.

Vitamin D for osteoporosis

An adequate intake of calcium and vitamin D are important foundations for maintaining bone density and strength. However, calcium and vitamin D alone are not sufficient to treat osteoporosis and should be given in conjunction with other treatments. Vitamin D is important in several respects:

• Vitamin D helps the absorption of dietary calcium from the intestines.
• The lack of vitamin D alone can cause calcium-depleted bone (osteomalacia), which further weakens the bones and increases the risk of fractures.
• Vitamin D, along with adequate calcium (1,200 mg of elemental calcium), has been shown in some studies to increase bone density and decrease fractures in postmenopausal women but not in premenopausal or perimenopausal women.

• 800 IU/day for men and women over the age of 71
• 600 IU/day for women in other age groups, men, and children
• 400 IU/day for infants under 12 months