Treatments for osteoporosis focus on slowing down or stopping bone loss, preventing bone fractures by minimizing the risk of falls, and controlling pain associated with the disease.
MEDICATIONS:
There are several different kinds of drugs used to treat osteoporosis. They vary in their side effects, benefits, and costs.
BIPHOSPHONATES
Biphosphonates are a type of drug used for both the prevention and treatment of osteoporosis in postmenopausal women. The two biphosphonates currently approved for osteoporosis -- alendronate (Fosamax) and risedronate (Actonel) -- prevent existing bone loss and reduce the risk of spinal and hip fractures.
While side effects are generally mild, potential side effects include stomach upset and irritation of the esophagus. Because biphosphonates are difficult to absorb, these medicines should be taken on an empty stomach. The patient should not lie down or consume food or beverages (other than water) for at least 30 minutes after taking the medicine. The physician may also recommend taking calcium and Vitamin D supplements.
Actonel is approved for use in men with osteoporosis. Both Actonel and Fosamax prevent and treat osteoporosis in men and women taking daily steroids for chronic conditions like asthma and arthritis.
RALOXIFENE
Raloxifene (Evista) is another drug used for the prevention and treatment of osteoporosis. Raloxifene is similar to the breast cancer drug tamoxifen. Raloxifene can reduce the risk of spinal fractures by almost 50%. (It does not appear to prevent other fractures, including those in the hip.) It may have protective effects against heart disease and breast cancer, though more studies are required.
The most serious side effect of raloxifene is a very small risk of blood clots in the leg veins (deep venous thrombosis) or in the lungs (pulmonary embolus).
ESTROGEN REPLACEMENT THERAPY
Estrogen can slow or stop bone loss and, if estrogen treatment begins at menopause, it can reduce the risk of hip fractures up to 50%. Therapy is most effective if started at menopause, as most bone loss occurs 3-6 years after the onset of menopause.
Many post-menopausal women choose estrogen replacement therapy (ERT) because of its proven usefulness in slowing the progress of or preventing osteoporosis. In some cases, ERT alleviates some of the irritating symptoms of menopause. This method of therapy is fairly inexpensive compared to the newer medications for osteoporosis discussed below.
If estrogen replacement therapy is discontinued, bone loss will resume. Maximal protection from osteoporosis may indeed require lifelong dosing. Studies show that women who take estrogen for at least seven years between the onset of menopause and the age of 75 have a 50% reduction in risk of fractures.
However after age 75, the risk is about the same as for those who did not take estrogen at all. In the 75 years and older group, bone mass only differs by about 2% between women who have taken estrogen for 10 years, and those who have never taken it.
Some women hesitate to use estrogen supplements because of the numerous potential risks that have been associated with long-term use. Before beginning ERT, the benefits and consequences of the treatment should be weighed and discussed thoroughly with a health care provider.
Women who have had a hysterectomy may take estrogen alone. Women with an intact uterus must take a combination of estrogen and progesterone. The decision to take estrogen for preservation of bone density is complicated by its effects on other diseases, including a relatively small increase in the risk of breast cancer.
ERT has classically been thought to reduce the risk of coronary artery disease in post-menopausal women. Recent studies have brought controversy to this issue by providing evidence that women may have a higher incidence of coronary events during the first year on ERT.
CALCITONIN
Calcitonin, marketed under the names Miacalcin (nasal spray) and Calcimar (injectable), is a medication that slows the rate of bone loss and relieves bone pain. The main side effects of calcitonin are nasal irritation from the spray form, and nausea from the injectable form.
While calcitonin slows bone loss and reduces the risk of fractures, it appears to be less effective than ERT or biphosphonates. As with some of the other newer medications, it is significantly more expensive than ERT.
LIFESTYLE CHANGES:
Regular exercise can reduce the likelihood of bone fractures associated with osteoporosis. Studies show that exercises requiring muscles to pull on bones cause the bones to retain and, perhaps, even gain density. Researchers found that women who walk a mile a day have four to seven more years of bone in reserve than women who don’t. Some of the recommended exercises include:
- Weight-bearing exercises
- Riding stationary bicycles
- Using rowing machines
- Walking
- Jogging
IMPORTANT: Any exercise that presents a risk of falling should be avoided.
Fall prevention is an essential component of any comprehensive osteoporosis treatment program. Measures such as making sure the patient’s vision is good and appropriately corrected, avoiding sedating medications, and removing household hazards can significantly reduce the risk of fracture. Other ways to prevent falling include wearing good-fitting shoes, avoiding walking alone on icy days, and using bars in the bathtub, when needed.
A diet that includes an adequate amount of calcium, Vitamin D, and protein should be maintained. While this will not completely stop bone loss, it will guarantee that a supply of the materials the body uses for bone formation and maintenance is available.
Supplemental calcium should be taken as needed to achieve recommended daily calcium dietary intake. Current recommendations are for nonpregnant, menstruating women to consume 1000mg/day, pregnant women need 1200mg/day, and postmenopausal or nursing mothers should consume 1500 mg/day.
High-calcium foods include low-fat milk, yogurt, ice cream and cheese, tofu, salmon and sardines (with the bones), and leafy green vegetables, such as spinach and collard greens. Vitamin D aids in calcium absorption and 400-800 IU per day should be taken by all individuals with increased risk of calcium deficiency and osteoporosis.
MONITORING:
Women taking estrogen should have routine mammograms, pelvic exams, and Pap smears.
Patient response to treatment can be monitored with serial bone mineral density measurements every 1-2 years, though such monitoring is controversial, expensive, and not universally performed. In the future, use of less elaborate measurements of bone turnover, such as the N-telopeptide (Osteomark) urine test (discussed above) may become a standard means for following osteoporosis, though experience is presently limited.
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