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 different 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 bloostream. Drugs in this category do not build bone beyond what is produced to help fill the remodeling spaces. Medications classified as antiresorptives are bisphosphonates, estrogen, selective estrogen receptor modulators (SERMs) and calcitonin. Antiresorptives are proven to produce a modest increase in bone density. This has been enough to benefit millions of people who have taken these drugs. The effects of long-term use (over 10 years) are not clear.
The first medicines that were developed for treating post-menopausal women were bisphosphonates alendronate (Fosamax) and risedronate (Actonel). Bisphosphonates are still considered first-line therapy by most doctors. They both reduce vertebral and non-vertebral fractures and have very few side effects. Both have been on the market a long time and been used by millions of people. 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. Side effects include nausea, heartburn, esophageal irritation, and stomach irritation. They are usually taken first thing in the morning with a water 30 minutes (give or take) prior to eating breakfast.
Another set 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; 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 a self-administered injection because the effects gradually wane, and the dearth of long-term safety data is still 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 patient’s 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 decrease bone breakdown. It is rarely used.
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% (as well as 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 LDL (or bad) cholsterol.
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 is for treatment of osteoporosis only, though it isn't widely used, and has shown to produce a modest reduction in vertebral fractures. It is administered as/through a nasal spray, and has mild side effects such as stomach upset and flushing. Macalcin 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 dampaned enthusiam for hormone replacement therapy. Premarin, a form of estrogen, increases the risk of stroke and uterine cancer according to the publication. Further, if patients take if with progestin (a synthetie 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 politically contentious story with osteoporosis. Estrogen inhibits bone resorption and its decline in the bodies of post menopausal women is part of the reason for 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.
While 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.
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. Doctors are also advised to consider treatment for people past age 62 or with low T-score.
Future treatment of osteoporosis and osteopenia may involve combination therapy - two drugs which work in different ways. A combination might be made up of one drug that builds up the bone tisse and makes it stronger and less prone to fracture, while a second drug prevents breakdown.
A website at Washington University provides some interesting flowcharts outlining suggested ways to decide what form of treatment to provide. We can't vouch for them; always ask your doctor. Washington University page (click on links under Algorithms for charts.)
Doctors
Osteoporosis is so common that general practioner 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. Ideas for questions for your doctor.
Surgery
For some patients with advanced osteoporosis, surgical techniques such as vertebroplasty and kyphoplasty are sometimes employed. New materials have been developed as bone implants.
New approaches
The protease family cathespin has been found to play a part in bone turnover, and drug investigators are trying to find ways to inhibit these materials in the body. Integrins on the surfaces of bone cells mediate attachment between the osteoclasts and other tissues. If drugs can be found that latch onto these inhibitors, they could be effective in slowing bone turnover. The biochemical pathway of osteoclastic hydrogen ion transport is also a potential target for pharmaceutical investigators.
Non-Pharmaceutical Management
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 nutrional 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.
The Scottish Intercollegiate Guidelines Network has more.
Research Reports
Denosumab for osteoporosis - Report on two drug company sponsored studies on the monoclonal antibody denosumab. This drug inhibits a cytokine that helps osteoclasts function. It seems to help patients maintain bone density. Denosumab is a monoclonal antibody and likely to be quite expensive. One benefit is that it does not cause phossy jaw.
Sources for Material on this Page: National Library of Medicine, Mayo Clinic, University of Michigan
Last updated: Nov 10, 2011
