Treatment of Osteoporosis
The goals of treatment are to reduce the risk of future fractures and the severity of the fractures should they occur, and to mitigate any effects of osteoporosis and fractures on the rest of the body. There are many medications in use and in development for prevention and treatment of osteoporosis. Most of the approved medications are antiresorptive; they retard the destructive phase of bone turnover and slow resorption of the minerals to the bloodstream.
Medications classified as antiresorptives include bisphosphonates, estrogen, selective estrogen receptor modulators (SERMs) and calcitonin. Antiresorptives produce a modest increase in bone density. This modest increase and the slowing or stopping of further bone material has been enough to benefit millions of people who have taken these drugs.
The first medicines that were developed for treating post-menopausal women with osteoporosis were the bisphosphonates alendronate (Fosamax) and risedronate (Actonel). Bisphosphonates are still considered first-line therapy by most doctors. They reduce vertebral and non-vertebral fractures and have few side effects. Alendronate and risedronate have been on the market a long time and been used by millions. These drugs reduce the risk of the most fracture-prone areas - the vertebrae, hip, and wrist - by 40-50%. They're well-tolerated when taken as advised by a physician. They are usually taken by pill first thing in the morning with water 30 minutes (give or take) prior to eating breakfast.
Another type of medications are anabolic agents, which promote new bone growth. Teriparatide, a form of human parathyroid hormone (PTH), commercially known as Forteo is used to treat osteoporosis; it may double the rate of bone formation, and studies have shown it can reduce vertebral fractures as much as 70% and nonvertebral fractures by nearly 50%. Forteo must be taken as an injection on a regular basis because the effects gradually wane; the patients keep the medicine in their refrigerator and injects themselves. It is still a relatively new drug and long-term safety data is being compiled. Bisphosphonates work by stopping bone reabsorption to the blood stream while parathyroid hormone works by stimulating new bone growth. The two seem to impair each other. Recent research suggests that bone resorption is necessary for the hormone’s new growth stimulation to work. Giving patients both reduces the effectiveness of the hormone.
Strontium ranelate incorporates the element strontium, which is found in trace amounts throughout the human skeleton, and is believed to slow bone breakdown and increase bone formation. It is taken orally at 2 grams/day, which is pretty large compared to other drugs. The half-life inside the body is 60 hours. It is effective in increasing bone density and reducing the apparent risk of fracture. However, because of the many alternatives, it is rarely used by doctors unless there are unusual circumstances.
Raloxifene, or Evista is the only SERM approved in the US for osteoporosis prevention and treatment. Studies have shown it reduces spinal fractures by 40-50% (comparable to bisphosphonates) and has minor side effects (hot flashes, leg cramps, and blood clots in a small number of patients). It increases bone density, but not at the same rate as bisphosphonates, and may help reduce the risk of breast cancer. Additionally, it lowers low-density lipoprotein (or bad) cholesterol levels.
Calcitonin is a naturally occurring hormone that helps promote bone density in several ways. It reduces the amount of calcium that is lost in the urine, keeps calcium in bones, and inhibits the action of the cells that break down bones (osteoclasts).
Calcitonin supplements are employed for treatment of osteoporosis, though they aren't widely used, and have been shown to produce a modest reduction in vertebral fractures. The hormone is administered through a nasal spray, and has mild side effects such as stomach upset and flushing. Miacalcin nasal spray can cause runny nose and respiratory symptoms.
Hormone therapy agents include Premarin, Prempro, Estrace, Estraderm, and Climara. Hormone therapy is for osteoporosis prevention only, not treatment, which many people did not understand when it first went into widespread use. It reduces vertebral and hip fracture rates by approximately 34% according to the Harvard Women's Health Watch, but the negative side effects have severely dampened enthusiasm for hormone replacement therapy. Premarin, a form of estrogen, increases the risk of stroke and uterine cancer. Further, if patients take if with progestin (a synthetic hormone used in birth control pills and often given to post-menopausal women), they face an increase in the risk of heart attack, blood clots, breast cancer, and stroke.
Estrogen, both natural and supplemental, has a long and contentious story with osteoporosis. Estrogen inhibits bone resorption and its decline in the bodies of post menopausal women was long thought to be one of the causes of osteoporosis. The rate of bone loss declines over time. Men with a deficiency of estrogen are also more apt to get osteoporosis than other men.
In the past hormone replacement therapy was the first line prevention/treatment for bone density loss, results from large studies have shown that conjugated estrogens can dangerously increase the risk of heart attack, stroke, and breast cancer in older women. Therefore hormone replacement therapy is not usually used as an osteoporosis treatment.
Which treatment is best?This may be surprising, but a large study published in the Annals of Internal Medicine found that the popular drugs are all about the same. The authors reviewed hundreds of studies of bisphosphonates, denosumab and teriparatide. The conclusion they arrived at was that all the drugs work at reducing fracture risk. Typical risk reduction was 40 to 60 percent for factres of the spine and 20 to 40 percent for fractures of other bones.
The American College of Physician's guide to pharmacalogic treatment recommends doctors prescribe bisphosphonates or other drugs to anyone with osteoporosis or who has had a fragility fracture.
Osteoporosis is so common that general practitioner doctors with even a little experience have seen and treated patients. Osteoporosis is usually addressed at first by the patient's family doctor/internist or gynecologist (although this is not the gynecologist's specialty.) More specialized doctors that may treat osteoporosis include geriatricians, endocrinologists, rheumatologists, orthopedic surgeons, and physiatrists (rehabilitation physicians). Your regular doctor might refer to you one of those specialists if you have advanced osteoporosis or difficult symptoms. We have a page with suggestions for questions for your doctor.
As a silent disease, osteoporosis does not cause appreciable pain until there is a bone fracture or failure. Unfortunately, the pain can be severe after a break or a vertebrae collapse. Calcitonin, although not often used for osteoporosis treatment any more, has been shown to help with pain, as has teriparatide. We do not know of any evidence that bisphosphonates alleviate pain from osteoporosis, although the use of those drugs in preventing bone loss probably helps stop the pain from getting worse. Bisphosphonates are given to patients with advanced cancer that has, or could, metastasize to the bone – partly as a palliative measure to reduce pain. Surgery relieves pain for patients who need it.
For some patients with advanced osteoporosis, surgical techniques such as vertebroplasty and kyphoplasty are sometimes employed. New materials have been developed as bone implants.
As bone density is used for diagnosis, so it is used to tell how the patient is responding. Because treatment and response times are so long, it can be difficult to assess the efficacy in a given patient. Some have suggested a switch to a goal-directed treatment plan. In such a strategy, a target risk or bone density level would be established and treatments would be assessed and adjusted over time to get to the target. Hypertension is treated the same way - with a set blood pressure goal and therapies adjusted to achieve the goal.
Management of long-term conditions such as osteoporosis, where effective therapies are available, succeed or fail to a large part depending on whether the patient keeps up the treatment. Bisphosphonate drugs work for most patients, although with some side effects, but they can’t work unless the patient takes them. This is one reason infusion treatment is used – the patient is relieved of the burden of taking a daily or weekly pill. The lack of visible symptoms and the hassle of swallowing the pill and remaining standing for 20 minutes lower the tendency of people to keep their regimen up. A meta-study found better compliance among patients told to swallow the pill once a week than those prescribed a daily dose. However, the compliance even for those taking the drug once a week was poor, and on average people stop taking the drug within a year. A small study found that when nurses checked up on the patients, the compliance numbers improved. Another study found that the introduction of Medicare Part D had little effect on compliance.
You can try to slow or stop the progression of osteoporosis with methods and interventions that do not include drugs. These include exercise, diet, and nutritional supplements. The efficacy of nutritional supplements is dubious, but many people use them. There are also methods and programs to reduce the risk of falls. Merchants even sell hip protectors to cushion the hips in the case of falls. News: Finding could lead to new treatments for osteoporosis
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