How do osteoporosis medications work. What are the different types of osteoporosis drugs available. Which osteoporosis treatment is most effective for bone density loss. How long should patients take osteoporosis medications. What are the potential side effects of osteoporosis drugs.

Understanding Osteoporosis and Bone Density Loss

Osteoporosis is a condition characterized by weakened, brittle bones resulting from an imbalance in the bone remodeling process. To comprehend the impact of osteoporosis and the necessity for treatment, it’s crucial to understand the underlying mechanisms of bone health.

The Bone Remodeling Process

Throughout our lives, our skeletal system undergoes constant renovation through a process called bone turnover. This process involves two main types of cells:

• Osteoclasts: Responsible for breaking down and removing old bone
• Osteoblasts: Tasked with laying down new bone

In healthy individuals, these two processes are balanced, maintaining optimal bone density. However, after menopause, the rate of bone removal accelerates, often outpacing bone formation. This imbalance can lead to significant bone loss and, ultimately, osteoporosis.

Diagnosing Osteoporosis

How is osteoporosis diagnosed? The primary method for diagnosing osteoporosis is through bone density measurement, typically performed on the hip and spine using dual-energy x-ray absorptiometry (DEXA). The results are expressed as a T-score, which compares an individual’s bone density to that of a healthy 30-year-old woman.

Doctors generally recommend medication if a patient meets one of the following criteria:

• A T-score of -2.5 or lower, indicating osteoporosis
• A history of hip or vertebral fracture caused by a fall from standing height
• A T-score between -1.0 and -2.5 (osteopenia) with a high risk of fracture in the next 10 years, as determined by a fracture risk calculator

Bisphosphonates: The First Line of Defense Against Osteoporosis

When it comes to treating osteoporosis, many doctors initially turn to a class of drugs known as bisphosphonates. These medications are particularly effective in slowing bone breakdown and are often the starting point for patients with very low T-scores.

Types of Bisphosphonates

What are the different forms of bisphosphonate medications? Bisphosphonates are available in several formulations:

1. Oral pills:
   • Alendronate (Fosamax)
   • Ibandronate (Boniva)
   • Risedronate (Actonel, Atelvia)

   These can be taken daily, weekly, or monthly, depending on the specific medication and dosage.

2. Injections:
   • Ibandronate (Boniva), administered once every three months
3. Intravenous infusions:
   • Zoledronic acid (Reclast), given once a year

Efficacy and Considerations

The choice of bisphosphonate often depends on the location of bone loss and the patient’s specific needs. Alendronate, risedronate, and ibandronate have all demonstrated effectiveness in reducing spine fractures. For individuals with a history of hip or non-spinal fractures, alendronate and risedronate may be preferred over ibandronate.

Patients with gastrointestinal issues or those unable to remain upright for the required 30 to 60 minutes after taking an oral bisphosphonate may be better suited for injectable or infusion forms of these drugs, which offer comparable efficacy.

Potential Risks and Long-Term Use

While bisphosphonates are generally safe and effective, there are some concerns associated with their long-term use. These include:

• Rare occurrences of atypical fractures of the thighbone (femur)
• Osteonecrosis (bone death) in the jaw, though this is more common in cancer patients receiving high-dose intravenous bisphosphonates

Due to these potential risks, most doctors recommend limiting bisphosphonate treatment to about five years. Importantly, the bone-protective benefits of these drugs continue even after discontinuation.

Alternative Osteoporosis Medications: Beyond Bisphosphonates

For postmenopausal women who are not starting with a bisphosphonate or have completed a five-year course, several alternative medications are available for osteoporosis treatment.

Selective Estrogen Receptor Modulators (SERMs)

Raloxifene (Evista) is a SERM that plays a dual role in osteoporosis treatment and breast cancer prevention. How does raloxifene work? It binds to estrogen receptors throughout the body, producing estrogen-like effects, including decreased bone turnover. Raloxifene is particularly effective in reducing the risk of vertebral fractures in patients with spinal osteoporosis.

Potential side effects of raloxifene include:

• Hot flashes
• Muscle pain
• Increased risk of deep-vein thrombosis (blood clots in the leg)

Parathyroid Hormone Analogs

Teriparatide (Forteo) and abaloparatide (Tymlos) are synthetic versions of parathyroid hormone that increase bone density and strength. These medications can significantly reduce the risk of fractures in the spine and other bones, making them suitable options for patients with very low bone density and vertebral fractures.

Key considerations for parathyroid hormone analogs:

• Treatment is typically limited to two years
• After treatment, patients are usually switched to a bisphosphonate to maintain bone density
• Daily self-administered injections are required

Advanced Osteoporosis Treatments: Monoclonal Antibodies and Beyond

As our understanding of bone biology advances, new treatments for osteoporosis continue to emerge. Two notable options in this category are denosumab and romosozumab.

Denosumab (Prolia)

Denosumab is a monoclonal antibody administered as a twice-yearly injection. How does denosumab work to prevent bone loss? It inhibits the formation of bone-dissolving osteoclast cells, effectively slowing down bone resorption.

Key points about denosumab:

• It may be an option for patients who cannot tolerate bisphosphonates
• Once started, treatment is usually continued indefinitely
• Discontinuation can lead to accelerated bone resorption

Romosozumab (Evenity)

Romosozumab is a newer addition to the osteoporosis treatment arsenal. This medication works by inhibiting sclerostin, a protein that naturally inhibits bone formation. By blocking sclerostin, romosozumab promotes bone formation while simultaneously decreasing bone resorption.

Important considerations for romosozumab:

• It is typically administered as monthly injections for one year
• After the initial treatment period, patients are usually transitioned to other osteoporosis medications to maintain bone density
• It may be particularly beneficial for patients at high risk of fracture

Tailoring Osteoporosis Treatment to Individual Needs

When it comes to osteoporosis treatment, there is no one-size-fits-all solution. The choice of medication depends on various factors, including the severity of bone loss, fracture history, overall health, and personal preferences.

Factors Influencing Treatment Choice

What factors do doctors consider when selecting an osteoporosis medication? Several key considerations come into play:

• T-score and fracture risk
• Location of bone loss (e.g., spine, hip, or other areas)
• Presence of other health conditions
• Ability to adhere to medication regimens
• Potential side effects and their impact on quality of life
• Cost and insurance coverage

Combination Therapies and Sequential Treatments

In some cases, doctors may recommend combination therapies or sequential treatments to maximize the benefits of osteoporosis medications. For example:

• Starting with a bone-building agent like teriparatide or romosozumab, followed by a bisphosphonate to maintain gains in bone density
• Combining a SERM like raloxifene with a bisphosphonate for enhanced fracture protection
• Transitioning between different classes of medications based on long-term efficacy and safety considerations

Managing Side Effects and Long-Term Considerations

While osteoporosis medications can be highly effective in preventing fractures and maintaining bone density, it’s essential to be aware of potential side effects and long-term considerations.

Common Side Effects and Management Strategies

How can patients manage common side effects of osteoporosis medications? Here are some strategies for addressing common issues:

• Gastrointestinal discomfort from oral bisphosphonates:
  • Take the medication with a full glass of water on an empty stomach
  • Remain upright for the recommended time after taking the pill
  • Consider switching to an injectable or infusion form if problems persist
• Hot flashes from SERMs:
  • Dress in layers
  • Keep a cool environment
  • Practice relaxation techniques
• Injection site reactions:
  • Rotate injection sites
  • Apply ice to reduce swelling
  • Consult with a healthcare provider if reactions are severe or persistent

Long-Term Safety Considerations

What are the long-term safety considerations for osteoporosis medications? While these drugs are generally safe and effective, prolonged use may be associated with rare but serious side effects:

• Atypical femur fractures: More common with long-term bisphosphonate use
• Osteonecrosis of the jaw: Primarily associated with high-dose intravenous bisphosphonates
• Increased risk of certain cancers: Some studies have suggested a potential link between long-term bisphosphonate use and esophageal cancer, though evidence is inconclusive

To mitigate these risks, doctors often recommend periodic reevaluation of treatment plans, including “drug holidays” for some patients on long-term bisphosphonate therapy.

Complementary Approaches to Osteoporosis Management

While medications play a crucial role in osteoporosis treatment, they are most effective when combined with lifestyle modifications and other supportive measures.

Nutrition and Supplementation

How can diet and supplements support bone health in osteoporosis patients? A balanced diet rich in calcium and vitamin D is essential for maintaining bone density. Key nutritional considerations include:

• Calcium: Aim for 1000-1200 mg daily from food sources or supplements
• Vitamin D: 800-1000 IU daily, with higher doses for some patients based on blood levels
• Protein: Adequate protein intake supports bone health and muscle strength
• Fruits and vegetables: Provide essential nutrients and may help maintain bone density

Exercise and Fall Prevention

Regular physical activity is crucial for maintaining bone density and reducing fracture risk. Effective exercise strategies for osteoporosis patients include:

• Weight-bearing exercises: Walking, jogging, dancing
• Resistance training: Using weights or resistance bands to strengthen muscles and bones
• Balance exercises: Tai chi, yoga, or specific balance training to reduce fall risk
• Posture and flexibility exercises: To maintain proper alignment and reduce strain on the spine

In addition to exercise, fall prevention strategies are essential for reducing fracture risk. These may include:

• Home safety modifications: Removing tripping hazards, improving lighting
• Regular vision and hearing checks
• Reviewing medications that may affect balance or cause dizziness
• Using assistive devices when necessary, such as canes or walkers

By combining appropriate medications with lifestyle modifications and preventive measures, patients with osteoporosis can significantly reduce their risk of fractures and maintain their quality of life. Regular follow-up with healthcare providers is essential to monitor progress, adjust treatments as needed, and ensure the best possible outcomes in managing bone density loss and osteoporosis.

Osteoporosis drugs: Which one is right for you?

There’s no one-size-fits-all answer when it comes to osteoporosis. Understanding your options begins with knowing what’s available.

Throughout our lives, our bones undergo constant renovation. In a process called bone turnover, cells called osteoclasts break down and remove old bone, and then cells called osteoblasts lay down new bone. After menopause, the rate of bone removal speeds up, and bone formation doesn’t always keep pace. The net result can be bone loss and ultimately the weakened, brittle bones of osteoporosis.

Even if you’ve been diagnosed with osteoporosis, a fracture isn’t inevitable. Many drugs available today can slow the rate of bone loss—and can rebuild bone strength.

Your doctor will determine whether you have osteoporosis by measuring your bone density—usually at the hip and spine—using dual energy x-ray absorptiometry (DEXA). The result, expressed as a number called a T-score, compares your bone density with that of a healthy 30-year-old woman.

The doctor will likely recommend medicine if you have

• a T-score of –2.5 or lower—the definition of osteoporosis
• a history of hip or vertebral (spinal) fracture caused by a fall while standing (in contrast to a fall from a height)
• a T-score between –1.0 and –2.5 (called osteopenia) and a high risk of hip or osteoporosis-related fracture in the next 10 years according to a fracture risk calculator.

Osteoporosis treatment: Where to start

To slow bone breakdown, many doctors first turn to one particular class of drugs. If someone has a very low T-score, doctors typically start with the bisphosphonates.

There are several bisphosphonates to choose from:

• pills, such as alendronate (Fosamax), ibandronate (Boniva), or risedronate (Actonel, Atelvia), taken daily, weekly, or monthly
• injections of ibandronate (Boniva), given once every three months
• intravenous infusion of zoledronic acid (Reclast), given once a year.

Your doctor will also consider where your bone loss is centered. Alendronate, risedronate, and ibandronate have all been shown effective for reducing spine fractures. For women with a history of hip or non-spinal fractures, alendronate and risedronate may be better options than ibandronate.

If you have gastrointestinal problems like reflux, or if you can’t sit or stand upright for the full 30 to 60 minutes required after taking an oral bisphosphonate, then your doctor may put you on an injection or infusion of these drugs, which works about as well as the oral versions.

You might have read about risks associated with bisphosphonate drugs—particularly fractures of the thighbone (femur) and osteonecrosis (bone death) in the jaw. Though these concerns are real, they are more common in people taking intravenous bisphosphonates to treat cancer that has spread to the bones, or in women who are on long-term, high-dose bisphosphonates.

Doctors acknowledge that the risk of these side effects also increases with long-term use of bisphosphonates, so most women take these drugs for about five years. The good news is that the bone-protective benefits continue even after you stop taking bisphosphonates.

Other drug options

For postmenopausal women who aren’t starting with a bisphosphonate, or those who’ve already been on one for five years, here are a few other options.

Raloxifene (Evista), a selective estrogen receptor modulator (SERM), is perhaps best known for its role in breast cancer prevention and treatment, but it serves double duty in treating osteoporosis, too. It works by binding with estrogen receptors around the body to produce estrogen-like effects, one of which is to decrease bone turnover. For people with osteoporosis of the spine, raloxifene reduces the risk of vertebral fractures. The main side effects are hot flashes, muscle pain, and an increased risk of blood clots in the leg (deep-vein thrombosis).

Teriparatide (Forteo)and abaloparatide (Tymlos) are synthetic versions of parathyroid hormone that increases bone density and strength. They can reduce the risk of fractures significantly in the spine and other bones. They are a reasonable option for someone with very low bone density and vertebral fractures. Doctors usually limit  this particular treatment to two years and then switch patients to a bisphosphonate to maintain bone density. Women on teriparatide or abaloparatide need to give themselves a daily injection.

Denosumab (Prolia) is a monoclonal antibody given as a twice-yearly injection. It prevents bone-dissolving osteoclast cells from forming. Denosumab may be an option if a woman cannot tolerate bisphosphonates. Once started, women usually stay on this therapy indefinitely because if stopped than bone resorption will accelerate.

Romosozumab (Evenity) is another monoclonal available for women with very severe osteoporosis, usually considered after a woman has had a fragility fracture. It acts by blocking sclerostin, a protein that inhibits bone formation. The medication is injected once a month using two separate prefilled syringes for a full dose. Romosozumab should only be taken for one year, because its bone-making activity wanes after 12 months.

Calcitonin (Miacalcin, Fortical) has been around since the 1980s, making it the oldest osteoporosis drug. It’s a hormone that binds to osteoclasts to prevent bone loss. When taken as a daily nasal spray or by injection, calcitonin can reduce spinal fractures, but it hasn’t been shown effective for preventing other types of fractures and is not a first-line treatment for most women.

Image: towfiqu ahamed/Getty Images

FDA-Approved Medications for Osteoporosis Treatment

• FDA-Approved Medications For Osteoporosis Treatment (PDF)

What is osteoporosis?

Osteoporosis is a bone-thinning disease. It causes your bones to become thin and weak. They are at greater risk for breaking. A broken bone may happen even from falling from a standing position.

Are there medications available to help stop or prevent osteoporosis?

If you have been told you have osteoporosis, lifestyle changes may not be enough. Medication may be needed to stop bone loss and to prevent broken bones. Talk to your health care provider and review your medical history and risk factors about whether you need medication. You can discuss the benefits and potential risks of a medication. While on medication, it’s still important to:

• Eat a well-balanced diet.
• Get the right amounts of calcium and vitamin D.
• Exercise every day.
• Do not smoke.
• Limit alcohol.
• Try to prevent falls. At home, you can remove small floor rugs and install grip bars in the shower.

How do osteoporosis medications get FDA approval?

The efectiveness and safety of the medication is rigorously tested before it is approved by the Food and Drug Administration (FDA). FDA approval means the medication has been proven to:

• Slow bone loss.
• Increase bone density.
• Reduce fracture risk at the spine or hip.

What are the FDA-approved medications for osteoporosis?

• Antiresorptive medication prevents bone loss, may increase bone density, and lowers the risk of broken bones.
• Anabolic medication builds new bone, increases bone density, and lowers the risk of broken bones.

Antiresorptive medications include a class of drugs called bisphosphonates. These medications include:

• Alendronate (Fosamax™, Fosamax™ Plus D)
• Risedronate (Actonel™, Actonel™ with Calcium, and Atelvia™)
• Ibandronate (Boniva™)
• Zoledronic acid (Reclast™)
• Denosumab (Prolia™)
• Estrogen therapy or hormone therapy
• Raloxifene (Evista™)
• Bazedoxifene and estrogen (Duavee™)

The anabolic medications are:

• Teriparatide (Forteo™)
• Abaloparatide (Tymlos™)
• Romosozumab (Evenity™)

How do you take your osteoporosis medication?

The medication will say how it should be taken and how often. Medications come in pill form, an injection, or are given intravenously (in the vein).

How do I learn more about the medication I choose to take?

Education is the key to achieve healthy bones and reduce your fracture risk. It is important to understand the potential benefits and risks of any medications. Speak to your health care provider to get the information you need.

NYSOPEP Resource Center

Helen Hayes Hospital
West Haverstraw, NY
(845) 786-4772
www.NYSOPEP.org

Osteoporosis. Treatment of osteoporosis, symptoms, causes, diagnosis

Video

• Subject: Q&A
• Subject: Diagnosis and treatment

Title

• Causes of disease
• Diagnostics
• Methods of treatment

Osteoporosis is a disease characterized by weight loss and loss of bone mass and bone density, resulting in weak and brittle bones. In the presence of osteoporosis, the risk of bone fractures, especially the femur, vertebrae, and wrist, increases.

Osteoporosis is considered a disease of older women. However, osteoporosis can start much earlier. Since peak bone density is reached by the age of 25, it is important to have strong bones by this age in order to maintain bone strength later in life. Adequate calcium intake is an important part of strong bones.

Nearly 10 million people in the United States have osteoporosis. Another 18 million people have low bone mass, which dramatically increases their risk of developing osteoporosis. As life expectancy increases, the number of patients with osteoporosis will increase. About 80% of patients with osteoporosis are women. In people over age 50, one in two women and one in eight men have a high chance of developing fractures.

According to the WHO, the prevalence of osteoporosis among postmenopausal women is 14% (50-59 years), 22% at 60-69 years of age, 39% at 70-79 years of age, and 70% at 80 years of age or older. The frequency of osteoporosis does not strongly depend on the ethnic factor, but, nevertheless, a greater risk in people of white and Asian race.

Causes

Osteoporosis occurs when there is an imbalance between new bone formation and old bone resorption. The body is not able or sufficient to create new bone tissue, or more than necessary destroys the old one (both processes can take place). The two most important minerals needed for normal bone formation are calcium and phosphorus. In a young body, these minerals are used to build bones. But calcium is also essential for the normal functioning of the heart, brain, and other organs. In order to maintain the functions of the most important organs and ensure the necessary level of calcium in the blood, the body absorbs the necessary calcium from the bone tissue, which is a store of calcium. When there is a decrease in the amount of calcium in the blood or insufficient intake of it with food, then conditions arise for a violation of bone tissue regeneration.

Typically, bone loss occurs over a fairly long period of time. Quite often, osteoporosis is detected only after the appearance of a bone fracture. As a rule, with such a late diagnosis, the disease is already advanced and the damage to health can be serious.

The main cause of osteoporosis is usually the lack of sufficient amounts of certain hormones, in particular estrogens in women and androgens in men. In women, especially over 60 years of age, who often have osteoporosis. Menopause is accompanied by a decrease in estrogen levels and this increases the risk of developing osteoporosis in women . Other factors that can lead to bone loss in this age group are inadequate intake of calcium and vitamin D, lack of exercise, and other age-related changes in the endocrine system (other than lack of estrogen).

Other causes that can lead to osteoporosis include: long-term use of corticosteroids (Cushing’s syndrome), thyroid disease, poor muscle development, bone tumors, certain genetic disorders, complications with certain drugs, and low calcium levels in diet.

Other risk factors for osteoporosis:

• Women are at greater risk than men, especially women who are thin and short, as well as older women.
• White or Asian women, especially those with a family history of osteoporosis.
• Women, in the postmenopausal period, including those who have had an operative removal of the reproductive organs or with menstrual irregularities.
• Smoking, eating disorders such as anorexia nervosa or bulimia nervosa, low dietary calcium, alcohol abuse, sedentary lifestyle, taking anticonvulsants.
• Rheumatoid arthritis is also a risk factor for osteoporosis.
• Having a parent with osteoporosis is also a risk factor.

Therefore, if a woman is post-menopausal and has back pain, it is necessary to see a doctor in order to conduct an examination and start treatment. In addition, it is necessary to be examined for the presence of osteoporosis in the presence of other risk factors. For example, in the presence of fractures or pain in the muscles of the bones. In these cases, it is necessary to check the bone density.

Diagnosis

First of all, the doctor is interested in the presence of somatic diseases, lifestyle, the presence of bone fractures. Laboratory tests are used to determine the level of calcium, phosphorus, vitamin D, the level of hormones (estrogen testosterone), the level of thyroid (parathyroid) hormones, tests that determine the excretory function of the kidneys.

Based on the medical examination, the doctor may recommend a bone mineral density test – densitometry. This method of examination allows diagnosing osteoporosis before the bone begins to break down and allows you to predict the possibility of bone fractures in the future. In addition, the determination of bone density allows you to monitor the effectiveness of the treatment, as well as the degree of development of osteoporosis over time, and therefore densitometry should be performed regularly (annually). There are several types of devices that allow you to determine the density of bone tissue. All densitometry techniques are painless, non-invasive and safe. Comprehensive examination devices measure bone density in the hip, spine and entire body. Peripherals can measure density at the finger, wrist, knee, calf, and heel.

Densitometers using DXA (dual energy X-ray absorptiometry) measure bone density in the spine, hip, or entire body. The density measurement is based on the different absorption of the X-ray beam depending on the density of the bone tissue. The X-ray radiation used in such densitometers is very low, and therefore the study is practically harmless to the patient and medical personnel.

Densitometers SXA (Single Energy X-Ray Absorptiometry) is a small x-ray machine that measures bone density at the heel of the leg and kneecap.

In addition, ultrasound densitometry can be used for screening. As a rule, the ankle is examined using this method. If screening reveals certain disorders, a DXA densitometer test is required to confirm the diagnosis. Bone mineral density is determined by comparison with that of a healthy person of appropriate age and sex. A significant decrease in density indicates the presence of osteoporosis and a high risk of bone fracture. Depending on the results of densitometry, the doctor prescribes the necessary treatment.

For patients who have marginal results, a new method for determining the 10-year probability of bone fracture using a program called FRAX is especially useful. This calculation method takes into account all the risk factors for a given individual and determines personally their risk of fractures and, therefore, the need for treatment.

Treatment

Treatment for osteoporosis is aimed at slowing or stopping mineral loss, increasing bone density, preventing bone fractures, and reducing the pain associated with the disease.

Almost 40% of women with osteoporosis will break a bone during their lifetime. In those patients who have suffered a compression fracture, in almost one case in five, another vertebral fracture occurs after some time. In such cases, they speak of cascading fractures, when each new fracture provokes more fractures. Therefore, the main goal of treating osteoporosis is to prevent fractures.

Diet : At a young age, when bone mass is being formed, it is necessary to have a complete diet with sufficient calcium and vitamin D. (dairy products, fish, etc.). In addition, at this age, sufficient physical activity is necessary for good growth of both muscle and bone tissue. A diet rich in calcium and vitamin D is also beneficial in the presence of already established osteoporosis.

Observation after fractures. If the patient has a history of bone fractures, careful monitoring by a group of specialists (orthopedist, rheumatologist, endocrinologist) and a physiotherapist is necessary for a very accurate rehabilitation, since the regeneration of bone tissue susceptible to osteoporosis is extremely slow

Physical exercises : Lifestyle changes is also part of the treatment. Regular exercise can reduce the chance of bone fractures associated with osteoporosis.

Research shows that exercise leads to muscle action on bone tissue, which stimulates bone growth and thus not only maintains but also increases bone density.

Studies have found that women who walk 1-2 km daily gain a 4-7 year reserve of bone density. Exercise can also be weighted, depending on the degree of osteoporosis, but the load should be very gentle. In addition, classes on a bicycle ergometer, jogging, etc. give a good effect. But any physical activity must be agreed with the attending physician.

Medical treatment

Estrogens. For women just after menopause, estrogen is one way to prevent bone loss. Estrogen can slow or stop bone loss. And if estrogen treatment is started during menopause, it can reduce the risk of hip fracture by up to 50%. This can be taken as a tablet or as a patch (eg, Vivelle, Climara, Estraderm, Esclim, Alora). But recent studies have questioned the safety of long-term estrogen use. Women who take estrogen have an increased risk of certain types of cancer. Although at one time it was thought that estrogens had a protective effect on the heart and blood vessels, recent studies have shown that estrogens, on the contrary, cause an increase in the incidence of coronary heart disease, stroke and venous thromboembolism. Many women who take estrogens report side effects such as breast tenderness, weight gain, and vaginal bleeding. The side effects of estrogens can be reduced by proper dosage and combination with other drugs. But if a hysterectomy is performed, then estrogens are directly indicated.

SMRE. For women who cannot or do not want to take estrogens, selective estrogen receptor modulators (SERMs) such as raloxifene (Evista) may be considered. These drugs are especially indicated in the presence of relatives with breast cancer, and estrogens in this case are contraindicated. The effect of raloxifene on bone tissue and cholesterol levels is comparable to that of estrogen. In addition, raloxifene does not stimulate the uterus or mammary glands, which reduces the risk of a hormone therapy profile. Raloxifene may cause hot flashes. The risks of blood clots are comparable to the risks of taking estrogens. Tamoxifen (Nolvadex), which is commonly used to treat certain types of breast cancer, also inhibits bone breakdown and preserves bone mass.

Calcium : Calcium and vitamin D are essential for bone growth as an adjunct to estrogen replacement therapy.

Recommended daily intake of 1200-1500 mg (with food and calcium supplements). You can take no more than 600 mg once, since a large amount of calcium will not be absorbed immediately. It is better to divide the intake of calcium into two doses (for breakfast and dinner).

A daily vitamin intake is also recommended. D 800-100 IU, which is also necessary for the absorption of calcium and thus increases bone mass.

Bisphosphonates : Biophosphonates are medicines taken either orally (alendronate, risedronate, etidronate) or; intravenously (zoledronate – Reclast, Aklasta). These drugs slow down bone loss and, in some cases, increase bone mineral density. The intake of these drugs and their effectiveness is monitored using DXA control densitometry.

When taking these medicines orally (by mouth), it is important to stand or sit upright for at least 30 minutes after swallowing the medicines. This helps to reduce the effect of drugs on the mucous membrane and prevent heartburn or even the formation of ulcers in the esophagus. After taking bisphosphonates, you must wait 30-40 minutes and do not take any food or other medicines (only water is possible). Before taking bisphosphonates, it is necessary to determine the level of calcium in the blood and the excretory function of the kidneys.

Alendronate (Fosamax). In clinical trials, alendronate has shown that its use reduces the risk of vertebral and femoral neck fractures by 50%. The most common side effects of this drug are nausea, heartburn, and constipation. This medicine is taken daily or once a week.

Risedronate (Actonel): This drug is used to treat and prevent osteoporosis. Gastrointestinal disturbances are the most common side effects of this drug. Women with severely impaired renal function should refrain from taking this drug. The results of a recent study showed that daily use of risedronate can lead to a significant reduction in new vertebral fractures (62%) in postmenopausal women with osteoporosis compared to a similar group not taking the drug.

Etindronate (Didronel): This drug has been approved in the US for the treatment of Paget’s disease, but this drug has been shown to be highly effective in treating osteoporosis and clinical trials have proven this.

Ibandronate (Boniva): This drug has been introduced relatively recently and is used to prevent and treat osteoporosis in postmenopausal women.

Zolendronate (Reclast): This is a powerful intravenous bisphosphonate given once a year. This drug is especially useful for patients who cannot tolerate oral bisphosphonates or who have difficulty adhering to the required regular dosages of oral medications.

Other hormones : These hormones are involved in the regulation of calcium and/or phosphate metabolism in the body and thus prevent bone loss.

Calcitonin (Myacalcin): Calcitonin is a hormone (derived from salmon) that slows bone loss and may increase bone density. The drug can be administered by injection (two to three times a week) or as a nasal spirea.

Teriparatide (Forteo). Teraparatide contains a portion of the human parathyroid hormone. First of all, it regulates the metabolism of calcium and phosphate in the bones, which promotes the formation of new bone tissue and leads to an increase in bone density. This drug is given as a daily injection. When taking drugs for the treatment of osteoporosis, dynamic monitoring is necessary (mammography and ultrasound of the pelvic organs when taking estrogens and blood and urine tests when taking other drugs).

Prevention and prognosis

Bone strengthening in childhood and adolescence may be the best defense against osteoporosis later in life. Up to 98% of the mass of the skeleton, a woman receives up to 30 years. Recommendations for the prevention of osteoporosis are as follows:

• Eat a balanced diet rich in calcium and vitamin D.
• Exercise
• Lead a healthy lifestyle, do not smoke or abuse alcohol.
• Take medication to improve bone density as needed.

With adequate treatment, the progression of osteoporosis can be slowed or stopped. However, some people become disabled as a result of impaired bone density. Almost 26% of patients with osteoporosis develop fractures of the hip, pelvic bones, vertebrae, wrist, shoulder. Hip fractures are quite common and, as a rule, after them 50% of patients cannot walk independently. In addition, with a fracture of the femoral neck, the risk of mortality is very high due to complications caused by prolonged immobilization (up to 20%). At age 80, 15% of women and 5% of men have hip fractures. Thus, osteoporosis is a serious disease that requires earlier diagnosis, prevention and treatment.

Osteoporosis – symptoms and treatment – symptoms, diagnosis, treatment at NCC №2 (Central Clinical Hospital of the Russian Academy of Sciences)

What is osteoporosis and what are its causes

Osteoporosis is a systemic metabolic disease characterized by a decrease in bone mass, as well as a decrease in bone density and strength. The reasons may be:

• hormonal changes in menopausal women
• hereditary factors
• malabsorption of vitamins and microelements in the intestine
• calcium and vitamin D deficiency
• dietary or malnutrition
• long-term use of hormonal drugs
• decrease in testosterone in men
• diseases of the thyroid gland
• smoking, excessive consumption of alcohol or coffee
• lack of physical activity.

What makes bones brittle

Bones are characterized by constant processes of destruction and restoration. Special cells control the amount of bone tissue, participate in its regeneration and remineralization. With hormonal and metabolic disorders in the body, the balance of the processes of formation and destruction of bones is disturbed. This causes a decrease in their mass and the content of minerals responsible for strength and hardness – calcium, phosphorus and magnesium. Violation of the microstructure and the occurrence of bone fragility leads to their pathological fractures.

In most cases, the diagnosis of osteoporosis is made when the disease reaches an irreversible stage and manifests itself in the form of bone fractures. Only timely diagnostic measures help to identify pathology at an early stage and correctly approach preventive and therapeutic measures.

Symptoms of osteoporosis

This disease differs in that the clinical symptoms do not bother the patient until the moment of bone fracture. It occurs in response to minor stress or injury. Most often, fractures of the vertebrae, femoral neck, as well as the bones of the shoulder and forearm occur, which becomes the reason for the diagnosis and accidental detection of the disease. But there are some signs by which one can suspect a developing pathology.

The first warning signs may be:

• brittleness and slow growth of nail plates
• dry skin and hair
• nocturnal cramps in the calf muscles.

As the disease progresses, more noticeable manifestations occur:

• change in posture in the form of stoop and the appearance of a “hump”
• pain in the back, hips, ribs and chest
• intolerance to a long stay of the body in one position
• painful sensations in the bones and joints when the weather changes.

Decreasing height is an important clinical sign. Measurement of body length after 45 years is an important diagnostic technique that does not require special skills and equipment. A decrease in height by about 3-4 cm by the age of 60-70 is a direct sign of progressive osteoporosis.

Risk factors

Women at menopause are the main risk group for osteoporosis. The natural decrease in the level of estrogens at this time leads to a redistribution of the balance of bone metabolism towards the processes of destruction. Men who experience symptoms of low testosterone (a sharp increase in body weight, a decrease in libido) are also more likely to develop pathological bone fragility.

Other common risk factors for developing osteoporosis are:

• previously diagnosed disease in parents
• long-term use of steroid drugs
• underweight, thin build
• diagnosed rheumatoid arthritis
• diabetes mellitus type I and II
• bad habits
• sedentary lifestyle
• vitamin and mineral deficiency
• over 65 years of age.

In order to timely detect the disease, the listed categories of people need to undergo diagnostics to determine bone mineral density.

Classification and stages of development of osteoporosis

Osteoporosis is a progressive metabolic disease that, if left untreated, develops in several stages:

1. Osteopenia. A state of diffuse decrease in bone density. It develops mainly in people of mature and old age. Reversible with timely treatment, symptoms are rare
2. Osteoporosis. This is a significant loss of bone tissue, difficult to treat and characterized by vivid symptoms. It can develop as an independent disease or against the background of other concomitant pathology (deficiency state, endocrine or genetic disorders). Depending on the reasons, they are distinguished:

• primary (independent) osteoporosis. Up to 80% of patients suffer from this form of the disease. It is classified according to the reasons for which it occurred: for example, postmenopausal or senile
• secondary. May occur as a result of taking certain medications or as a complication of the underlying disease.

Degrees of osteoporosis

Osteoporosis is classified according to severity:

• 1st degree. It has no pronounced symptoms and is detected only with special diagnostics in the form of a slight loss of bone density
• 2 degrees. Mild weight loss and moderate decrease in bone density
• 3 degrees. It is characterized by a pronounced severity with noticeable symptoms and clear changes found on examination.

Sometimes experts distinguish the most severe and dangerous 4th degree of bone demineralization. In this case, a person’s height can decrease to 10 cm, external pathological changes in the skeleton are clearly visible. On the x-ray, the bones practically “glow” due to the strong loss of mass.

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Why osteoporosis is dangerous

Osteoporosis is a disease that can be asymptomatic for many years. In this regard, the patient is diagnosed late and therapeutic measures are not prescribed in time.

With the progression of the disease, not only the skeleton suffers, but also other organs: the functions of the lungs, heart, and stomach are impaired.

The main danger of osteoporosis are fractures, which are called pathological, because they occur as a result of minor injuries or light household stress.

Fractures due to osteoporosis

The risk of fractures increases every year in patients with osteoporosis. After the first episode, the likelihood of a re-fracture during the first year increases by about 3 times. In the case of several fractures in the spine, the entire musculoskeletal system is destabilized, the patient develops chronic back pain. In this regard, there is a violation of neuromuscular conduction and an increased tendency to falls.

The most dangerous in osteoporosis is a fracture of the femoral neck. According to statistics, about 30-40% of victims die from this injury during the first year. Of those who manage to save their lives, 70% remain disabled and need constant assistance throughout their lives.

Osteoporosis diagnostics

Densitometry is considered the “gold standard” in the diagnosis of osteoporosis. This is a safe and painless method that allows you to determine the mineralization of bones. Its essence lies in the fact that with the help of ultrasound, bone density is examined. The advantage of this examination is its high information content and the ability to detect pathology at the earliest stages.

Since osteoporosis is caused by metabolic or metabolic disorders in the body, one study is not enough to make a correct diagnosis. To confirm the disease and develop an effective treatment plan, consultation with an endocrinologist is required.

Forecast. Can osteoporosis be cured

Osteoporosis can be treated only at an early stage, when bone fragility is still not very pronounced, and deformities and other pronounced symptoms are not observed in the body.