Management of Osteoporosis

Osteo

Lifestyle factors

Even when osteoporosis is diagnosed, lifestyle factors remain important in the management of this condition.

Exercise
Exercise that is appropriate to the woman's stage of life is recommended regardless of age. It is important for women to discuss exercise options with their treating doctor to ensure that it is safe to take part in an exercise program. Although the standard recommendation is weight bearing exercise, such as walking. This is not sufficient.  Exercise needs to be:

Weight bearing with some impact to strengthen bones

Challenge balance and mobility for fall prevention

Include resistance training to strengthen muscles.

CalciumHealthy bones require adequate nutrition. Women need to ensure that they have adequate calcium intake that meets the requirement for their particular age. Ideally calcium should come from your diet. If you do no feel you are getting much calcium in your diet discuss the use of calcium supplements with your doctor.

Vitamin D
It is important to have adequate levels of vitamin D. Most vitamin D is made in our skin from the action of sunlight converting 7-dehydrocholesterol to produce cholecalciferol. The amount of time you need to be in the sun each day varies according to where you live (more time in the sun the further you live from the equator) and how dark your skin is (people with dark skin need more sun exposure). Some vitamin D can also be obtained from food including foods fortified with vitamin D (milk, soy drinks, margarine and cereals), liver, fish (tuna, salmon, sardines, herring and mackeral) and egg yolk.

Vitamin D deficiency is defined as a level below 30nmol/L (12ng/ml). Although it is often recommended that people have levels above 75nmol/L (30ng/ml) evidence to support this is lacking. For many individuals it is not advisable to increase sun exposure to increase the levels of vitamin D due to the potential harmful effects of sunlight on skin. In this situation, if measured vitamin D levels are not at an optimal level, then it may be necessary to take a vitamin D supplement. Most people will normalise their Vitamin D level over time by taking no more than1000IU daily. Your treating doctor is in the best position to recommend whether you need to take vitamin D and how much you should take.

Avoid smoking
To protect bones it is advisable not to smoke. Women who smoke lose bone density faster than women who do not smoke.

Drug Therapies for Osteoporosis

Hormone Therapy

Hormone therapy at the time of menopause protects against bone loss. Oestrogen reduces bone break down so that the amount of bone being formed equals or exceeds that being broken down.

The Global Consensus Statement on Menopausal Hormone Therapy (MHT) 2016 advises

MHT is the only therapy available with RCT-proven efficacy of fracture reduction in a group of postmenopausal women not selected for being at risk of fracture and with mean T-scores in the normal to osteopenic range. MHT, including tibolone, can be initiated in postmenopausal women at risk of fracture or osteoporosis before the age of 60 years or within 10 years after menopause.

Initiation of MHT after the age of 60 years for the indication of fracture prevention is considered second-line therapy and requires individually calculated benefit/risk, compared to other approved drugs.

If MHT is elected, the lowest effective dose should be used.
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Tibolone (Livial®): This therapy is a different form of hormone therapy for treating menopausal symptoms. Tibolone does not have the same stimulatory effects on the breast as standard forms of hormone therapy. Tibolone, like oestrogen prevents bone loss and has been shown to prevent fracture in women aged 60-79 with osteoporosis. However, tibolone has been associated with a small increase in risk of stroke in older women. This risk is similar to what has been reported for both raloxifene (see below) and oral oestrogen in older women.

Bisphosphonates

Bisphosphonates are a class of drug, which decrease bone loss. They work by slowing down bone resorption, which allows the bone forming cells time to rebuild normal bone.

The currently available bisphosphonates in Australia, which are recommended for the treatment of osteoporosis, are the tablets alendronate and risedronate and an annual intravenous infusion of zolendronate. Before being treated with a bisphosphonate you should have your kidney function checked.

Rare adverse effects of bisphosphonates include osteonecrosis on the jaw bone (ONJ) and atypical femoral fracture (AFF). ONJ occurs because of inadequate blood flow in the jaw bone. It is mostly associated with major dental procedures and occurs more often in people who have cancer. The main was y preventing ONJ is by having good dental hygiene.

AFFs are fractured that occur in the thigh bone without trauma and are believed to reflect bone ‘microdamage’ or micro-cracks that fail to heal. Warning signs are thigh or groin pain. AFFs are rare in people who have taken a bisphosphonate for less than 2 years (1.8 per 100,000 person-years) but increase with frequency after treatment duration of over 10 years (up to 107.5 per 100,000 person-years) [Dell RM et al J Bone Miner Res, 27 (2012), pp. 2544-2550]

Alendronate and risedronate
Both alendronate and risedronate reduce the incidence of vertebral (spinal bones) and hip fractures. These drugs also reduce the risk of fracture at other sites in the body. The effects of these drugs on risk of fracture usually start within 6 - 12 months of commencing therapy.

These medications are generally well tolerated. They have been associated with side effects of heartburn, abdominal discomfort and ulceration of the oesophagus (food pipe). Hence, these medications must be taken with a full glass of water and the individual needs to remain either sitting upright or standing for the next 30 minutes. After this time, normal activities and eating can be resumed. The incidence of oesophageal ulceration is extremely low when these medications are taken correctly.

These medications can be taken either weekly or once a month. It is advisable that these medications are used cautiously in those with significant reflux esophagitis (heartburn) and those with a hiatus hernia. These drugs are not well absorbed; hence it is important to take them on an empty stomach.

Zolendronate 

For people unable to tolerate the oral forms of the bisphosphonates, this is an option to have treatment intravenously, usually once a year. When administered zolendronate is given by an intravenous drip usually over about 15-20 minutes. Some people experience flu like symptoms for up to 3 days after the infusion so it is recommended that paracetamol is taken before the infusion to prevent this. Usually no more than 3 annual infusion are given

In order for these medications (bisphosphonates) to be effective in increasing bone mineral density and reducing the likelihood of fracture, women need to ensure that they have adequate vitamin D levels. There still may be a requirement for additional Vitamin D supplementation if the measured Vitamin D levels are low.

Other Considerations

Bisphosphonates are primarily prescribed for women (and men) who have osteoporosis as defined on a bone DEXA scan and a history of an osteoporosis related (low trauma) fracture. Bisphosphonates are also prescribed for the prevention of fracture for women 70 years and older with osteoporosis ( T score < -2.5 ) and for people on long term therapy (eg prednisolone) also helps to prevent the development of osteoporosis and fracture.

How long a woman should continue a bisphosphonate continues to be debated.

  • Long-term therapy is recommended in the recent UK Guidelines for people over 75 years, those who are on long term steroid therapy, people who have had a hip or vertebral fracture and people with osteoporosis of the hip.
  • The broad recommendation for the most commonly used medication, bisphosphonates, for other people being treated is for cessation of therapy after 3 for intravenous zolendronate and five years for risidronate and alendronate if the hip T score is above -2.5. As the bisphosphonates are retained in bone for some time, a DEXA should be repeated 1.5 (risidronate and alendronate) to 3 years (zolendronate) after cessation of treatment.

Raloxifene 

This medication is a selective estrogen-receptor modulator. In other words it acts at some sites in the body like oestrogen but at other sites of the body it functions as an anti-oestrogen. In bone it works as an oestrogen and leads to an increase in bone mass (density). In the breast and uterus it works as an anti-oestrogen and therefore does not stimulate the breast or uterine lining. Due to its anti-oestrogen effects in the breast, it reduces the incidence of breast cancer.
Primarily this medication has been shown to reduce the incidence of vertebral fractures (spinal column). The evidence for this medication having a significant effect on fractures at other sites of the body is lacking.

The side effects of this therapy include hot flushes. This therapy is therefore problematic for premenopausal women and women who are currently going through menopause, as it may worsen menopausal symptoms. This therapy is best reserved for postmenopausal women. The other side effect of this therapy is a slightly increased risk of deep vein thrombosis. Hence, women who are on this medication need to consider stopping this therapy if they are going to be immobile for some time, such as during long airline flights or during hospital admission. The medication can be resumed once mobility is regained. Any woman who has significant risk factors for a clotting disorder should not be prescribed this therapy.

In order for this therapy to be effective it is essential that women have adequate vitamin D levels.

Denosumab

This therapy was been approved for the treatment of osteoporosis in 2010. It has a unique mechanism of action. It is a monoclonal antibody that targets and blocks RANK Ligand, an essential regulator of the cells that break down bone (osteoclasts). It is given as a subcutaneous injection every 6 months.

In postmenopausal women with osteoporosis, denosumab has been found to increase bone mineral density, reduce bone turnover, and reduce the risk of vertebral, hip and non-vertebral fractures. Denosumab may lower calcium levels when an injection is given commenced. If you are going to have a densoumab injection you should have your kidney function and blood calcium level checked and you may need to take calcium supplements when treatment is given. Side effects of denosumab include rash or skin itch and less commonly fever/chills. Muscle spasm, cramping or tingling in fingers and toes may indicate low serum calcium and if these symptoms occur you should contact a doctor immediately.

Denosumab may also be associated with osteonecrosis of the jaw and atypical femoral fracture ( see bisphosphonate section above).

Teriparatide

This therapy has been available in Australia since 2003. It is primarily used in severe osteoporosis. This hormone is administered daily via a subcutaneous (just below the skin) injection. It functions to increase bone formation and also absorption of calcium from the gut and kidney. Calcium and vitamin D supplements may be necessary with this medication and if this is to be done it needs to be monitored under the care of a specialist physician. Most of the studies with this medication have only been for up to 2 years. There appears to be a clear benefit in terms of reducing all types of fractures in postmenopausal women, except for hip fractures. Due to the expense and limited access of this therapy, it is not readily available to all Australians. Its prescription for use is confined to specialists in osteoporosis.

Disclaimer
The above advice is a general guide to treatments currently available in Australia and was accurate at the time of production of this document. This information is provided to complement, not replace, the advice of your health professional.