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Osteoporosis

What is Osteoporosis?

Osteoporosis, or porous bone, is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased risk of fractures of the hip, spine, and wrist. Men as well as women are affected by osteoporosis, a disease that can be prevented and treated.

What is Bone?

Bone is living, growing tissue. It is made mostly of collagen, a protein that provides a soft framework, and calcium phosphate, a mineral that adds strength and hardens the framework.

This combination of collagen and calcium makes bone both flexible and strong, which in turn helps it to withstand stress. More than 99 percent of the body's calcium is contained in the bones and teeth. The remaining 1 percent is found in the blood.

Old bone is removed (resorption) and new bone is added to the skeleton (formation) continuously. During childhood and teenage years, new bone is added faster than old bone is removed. As a result, bones become larger, heavier, and denser. Bone formation outpaces resorption until peak bone mass (maximum bone density and strength) is reached around age 30. After that time, bone resorption slowly begins to exceed bone formation.

For women, bone loss is fastest in the first few years after menopause, and it continues into the postmenopausal years. Osteoporosis will develop when bone resorption occurs too quickly or when replacement occurs too slowly.

What are the Risk Factors for Osteoporosis?

Certain risk factors are linked to the development of osteoporosis and contribute to an individual's likelihood of developing the disease. Many people with osteoporosis have several risk factors, but others who develop the disease have no known risk factors. There are some you cannot change and others you can.

Risk factors you cannot change:
Gender - Women have less bone tissue and lose bone faster than men because of the changes that happen with menopause; women are therefore at increased risk for osteoporosis.
Age - Bones become thinner and weaker with increasing age.
Body size - Small, thin-boned women are at greater risk.
Ethnicity - Caucasian and Asian women are at highest risk than African American and Hispanic women.
Family history - Fracture risk may be due, in part, to heredity. People whose parents have a history of fractures also seem to have reduced bone mass and may be at risk for fractures.

Risk factors you can change:
Sex hormones - Abnormal absence of menstrual periods (amenorrhea), low estrogen level (menopause), and low testosterone level in men can bring on osteoporosis.
Calcium and vitamin D intake - A lifetime diet low in calcium and vitamin D makes you more prone to bone loss.
Medication use - Long-term use of glucocorticoids and some anticonvulsants can lead to loss of bone density and fractures.
Lifestyle - An inactive lifestyle or extended bed rest tends to weaken bones.
Cigarette smoking - Cigarettes are bad for bones as well as the heart and lungs.
Alcohol intake - Excessive consumption increases the risk of bone loss and fractures.

How can You Prevent Osteoporosis?

Several steps can lower an individual's risk of osteoporosis.

Calcium: An inadequate supply of calcium over a lifetime contributes to the development of osteoporosis. Many published studies show that low calcium intake appears to be associated with low bone mass, rapid bone loss, and high fracture rates. Good sources of calcium include low-fat dairy products, such as milk, yogurt, cheese, and ice cream; dark green, leafy vegetables, such as broccoli, collard greens, bok choy, and spinach; sardines and salmon with bones; tofu; almonds; and foods fortified with calcium, such as orange juice, cereals, and breads.

Calcium needs change during one's lifetime. The body's demand for calcium is greater during childhood and adolescence, when the skeleton is growing rapidly, and during pregnancy and breastfeeding. Postmenopausal women and older men also need to consume more calcium. Also, as you age, your body becomes less efficient at absorbing calcium and other nutrients. Older adults also are more likely to have chronic medical problems and to use medications that may impair calcium absorption. The recommended daily intake of calcium varies between 210 mg/day for infants to 1300 mg/day for pregnant or lactating women.

Vitamin D: Vitamin D plays an important role in calcium absorption and in bone health. It is made in the skin through exposure to sunlight. While many people are able to obtain enough vitamin D naturally, studies show that vitamin D production decreases in the elderly, in people who are housebound, and for people in general during the winter.

Exercise: Like muscle, bone is living tissue that responds to exercise by becoming stronger. Weight-bearing exercise is the best for your bones because it forces you to work against gravity. Examples include walking, hiking, jogging, stair climbing, weight training, tennis, and dancing.

Smoking: Smoking is bad for your bones as well as for your heart and lungs. Women who smoke have lower levels of estrogen compared to nonsmokers, and they often go through menopause earlier. Smokers also may absorb less calcium from their diets. Alcohol: Regular consumption of 2 to 3 ounces a day of alcohol may be damaging to the skeleton, even in young women and men. Those who drink heavily are more prone to bone loss and fractures, because of both poor nutrition and increased risk of falling.

Medications that cause bone loss: The long-term use of glucocorticoids (medications prescribed for a wide range of diseases, including arthritis, asthma, Crohn's disease, lupus, and other diseases of the lungs, kidneys, and liver) can lead to a loss of bone density and fractures. Bone loss can also result from long-term treatment with certain antiseizure drugs - such as phenytoin (Dilantin) and barbiturates; gonadotropin-releasing hormone (GnRH) drugs used to treat endometriosis; excessive use of aluminum-containing antacids; certain cancer treatments; and excessive thyroid hormone.

What are the Symptoms Osteoporosis?

Osteoporosis has no symptoms and is often undetected until it results in fractured bones. Broken bones are almost always immediately apparent; collapsed vertebrae may initially be felt or seen in the form of severe back pain, loss of height, or spinal deformities such as kyphosis (severely stooped posture).

How is Osteoporosis Diagnosed?

A bone mineral density (BMD) test is the best way to determine your bone health. BMD tests can identify osteoporosis, estimate the risk for fractures, and measure the response to osteoporosis treatment. The most widely recognized bone mineral density test is called a dual-energy x-ray absorptiometry or DXA test.

How is Osteoporosis Treated?

A comprehensive osteoporosis treatment program should focus on proper nutrition, exercise, and safety issues to prevent falls that may result in fractures. In addition, several prescription medications are available to treat osteoporosis.

Currently, alendronate, raloxifene, risedronate, and ibandronate are approved by the U. S. Food and Drug Administration (FDA) for preventing and treating postmenopausal osteoporosis. Teriparatide is approved for treating the disease in postmenopausal women and men at high risk for fracture. Estrogen/hormone therapy (ET/HT) is approved for preventing postmenopausal osteoporosis, and calcitonin is approved for treatment.

Bisphosphonates - Alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva), are medications from the class of drugs called bisphosphonates. Like estrogen and raloxifene, these bisphosphonates are approved for both prevention and treatment of postmenopausal osteoporosis. Another bisphosphonate, zoledronic acid (Reclast), is approved for the treatment of postmenopausal osteoporosis. Alendronate is also approved to treat bone loss that results from glucocorticoid medications like prednisone or cortisone and is approved for treating osteoporosis in men. Risedronate is approved to prevent and treat glucocorticoid-induced osteoporosis and to treat osteoporosis in men.

Alendronate, risedronate, and zoledronic acid have been shown to increase bone mass and reduce the incidence of spine, hip, and other fractures. Ibandronate has been shown to reduce the incidence of spine fractures. Alendronate is available in daily and weekly doses. Risedronate is available in daily, weekly, and twice monthly doses. Ibandronate is available in a monthly dose and as an intravenous injection administered once every three months. Zoledronic acid is available as an intravenous injection administered once yearly. Oral bisphosphonates should be taken on an empty stomach and with a full glass of water first thing in the morning. It is important to remain in an upright position and refrain from eating or drinking for at least 30 minutes after taking a bisphosphonate. Some bisphosphonates are marketed with calcium and vitamin D supplements. These nutrients are important for everyone, and people should include adequate amounts of them in their diets.

Raloxifene - Raloxifene (Evista) is approved for the prevention and treatment of postmenopausal osteoporosis. It is from a class of drugs called estrogen agonists/antagonists, commonly referred to as selective estrogen receptor modulators (SERMs). Raloxifene appears to prevent bone loss in the spine, hip, and total body. It has beneficial effects on bone mass and bone turnover and can reduce the risk of vertebral fractures. While side effects are not common with raloxifene, those reported include hot flashes and blood clots in the veins, the latter of which is also associated with estrogen therapy.

Calcitonin - Calcitonin (Miacalcin, Fortical) is a naturally occurring hormone involved in calcium regulation and bone metabolism. In women who are at least 5 years past menopause, calcitonin slows bone loss, increases spinal bone density, and may relieve the pain associated with bone fractures. Calcitonin reduces the risk of spinal fractures and may reduce hip fracture risk as well. Studies on fracture reduction are ongoing. Calcitonin is currently available as an injection or nasal spray. While it does not affect other organs or systems in the body, injectable calcitonin may cause an allergic reaction and unpleasant side effects including flushing of the face and hands, frequent urination, nausea, and skin rash. The only side effect reported with nasal calcitonin is nasal irritation.

Teriparatide - Teriparatide (Forteo) is an injectable form of human parathyroid hormone. It is approved for postmenopausal women and men with osteoporosis who are at high risk for having a fracture. Unlike the other drugs used in osteoporosis, teriparatide acts by stimulating new bone formation in both the spine and the hip. It also reduces the risk of vertebral and nonvertebral fractures in postmenopausal women. In men, teriparatide reduces the risk of vertebral fractures. However, it is not known whether teriparatide reduces the risk of nonvertebral fractures. Side effects include nausea, dizziness and leg cramps. Teriparatide is approved for use for up to 24 months.

Estrogen/Hormone Therapy - Estrogen/hormone therapy (ET/HT) has been shown to reduce bone loss, increase bone density in both the spine and hip, and reduce the risk of spine and hip fractures in postmenopausal women. ET/HT is approved for preventing postmenopausal osteoporosis and is most commonly administered in the form of a pill or skin patch. When estrogen - also known as estrogen therapy or ET - is taken alone, it can increase a woman's risk of developing cancer of the uterine lining (endometrial cancer). To eliminate this risk, physicians prescribe the hormone progestin - also known as hormone therapy or HT - in combination with estrogen for those women who have not had a hysterectomy. Side effects of ET/HT include vaginal bleeding, breast tenderness, mood disturbances, blood clots in the veins, and gallbladder disease. Estrogen therapy is approved for treatment of menopausal symptoms but should be prescribed for the shortest period of time possible. When used solely for the prevention of postmenopausal osteoporosis, any ET/HT regimen should only be considered for women at significant risk of osteoporosis, and nonestrogen medications should be carefully considered first.

*The health information contained herein is provided for educational purposes only and is not intended to replace discussions with a healthcare provider. All decisions regarding patient care must be made with a healthcare provider, considering the unique characteristics of the patient.