Osteoporosis treatment guidelines
WHAT IS OSTEOPOROSIS?
Osteoporosis is a disorder in which the bones lose mass and density and become prone to fractures. It frequently affects women during and after menopause, and it is also common in elderly men.
Osteoporosis is a disorder that causes bones to become porous, weak and brittle. It usually affects older adults and occurs when low levels of calcium, phosphorus and other minerals cause bones to lose mass. The early stage of decreased bone density is called osteopenia.
Osteoporosis occurs when bones lose mass and density, which is partly a result of a decrease in calcium, phosphorus and other minerals. When this occurs, bone strength decreases and the bone’s internal supporting structure declines. Instead of being dense with interconnecting pieces, bone becomes porous and weak.
Osteoporosis by itself does not cause any pain but because of the changes caused in the bones, the resultant fractures are painful. The fractures occur most often in the spine, hip or wrist and cause sudden, searing pain. Osteoporosis affected bones may suffer a fracture even from minor events such as coughing, bending over or sneezing can break.
WHAT CAUSES OSTEOPOROSIS?
Old age brings about certain natural degenerative changes in the bones. Osteoporosis, however, hastens this deterioration in the bones. Osteoporosis also happens because of:
Certain life style factors such as physical inactivity, low-calcium diet, smoking and alcohol abuse.
Reduced levels of sex hormones.
Corticosteroid or other immuno-suppressive therapy
- Other diseases
Diseases like arthritis, diabetes, asthma or cancer can also increase the risk of osteoporosis.
WHAT ARE THE TYPES OF OSTEOPOROSIS?
Osteoporosis is generally of two types:
- Primary Osteoporosis
Primary of the more common type of osteoporosis is:
Senile Osteoporosis- caused by aging.
Idiopathic Osteoporosis- caused by unknown factors.
- Secondary Osteoporosis- It could result from another disease, a medical treatment or lifestyle factors.
WHY IS OSTEOPOROSIS MORE PREVALENT IN WOMEN?
Osteoporosis is most common in women during and after menopause because lower levels of the hormone estrogen weaken bones. However, the disease also affects men and – in rare cases – children. In addition to aging, other contributors to osteoporosis include endocrine and many other disorders, a diet low in calcium and vitamin D, lack of weight-bearing exercise and use of certain drugs, such as corticosteroids taken by mouth for extended periods.
When women reach menopause (change that occurs when a woman’s body no longer releases eggs), bone loss is accelerated even further. Bone loss related to menopause usually lasts for about 10 years. This continues until about age 60, when bone loss slows but does not stop. In contrast, men initially do not lose as much bone mass as they age. However, by age 65, men lose bone at the same rate as women. The risk of developing osteoporosis depends on the amount of bone mass developed between 25 and 35 and how rapidly it is lost during aging.
One in two women and one in four men over the age of 50 is likely to suffer an osteoporotic fracture during their lifetime.
WHAT GENERALLY ARE THE CAUSES OF OSTEOPOROSIS?
Body has its inherent capacity of bone remodeling. This process of creating new bone (formation) and breaking down old bone (resorption) continues throughout life. Scientists are unsure why this process occurs. The resorption and formation of bone are essential in repairing small fractures and replacing bone.
The process of bone remodeling generally takes two to three months to complete the cycle. Younger people generate new bone faster than old bone is broken down, causing bone mass to increase. By age 20, people have generally accumulated most of their bone mass. Bone mass peaks during the mid-30s. After that, more bone is lost during remodeling than is gained. No exercise and not getting enough calcium (through diet) and vitamin D (through diet and sunshine) can accelerate the process.
Risk Factors for osteoporosis are:
- Gender and age
Fractures attributed to osteoporosis are more common in women than in men. This increased risk in women is due to the fact that they:
- Tend to start out with lower bone mass
- Tend to live longer than men
- Experience a sudden drop in estrogen during menopause (either natural or surgical) which accelerates bone loss
However, by age 65, men lose bone at the same rate as women. By age 75, osteoporosis is equally likely in both sexes. Osteoporosis will cause a hip fracture in 6 percent of men after age 50 and a vertebral fracture in 5 percent of that population.
- Ethnic background
Asians and Caucasians are most likely to experience osteoporosis. African-Americans and Hispanics have lower incidences, but risk remains fairly high.
- Inherited factors
Osteoporosis runs in families, and a person’s risk increases if parents or siblings have the disease.
- Body structure
People who are thin or have small body frames have less bone mass, which puts them at higher risk.
- Specific lifestyle factors
Smoking and use of other tobacco products weakens bones, although the exact relationship between tobacco use and osteoporosis is yet to be established.
- Sedentary lifestyle
Bone development begins in childhood and is strongly influenced by exercise. Exercise throughout life can increase bone density. Weight-bearing exercise, such as walking, aerobics or lifting dumbbells, is particularly beneficial in building bone mass.
Excess consumption of alcohol reduces bone formation and interferes with the body’s ability to absorb calcium. Among men, alcoholism is one of the greatest risk factors for osteoporosis.
Lifetime exposure to estrogen is a factor for women. Those who began menstruating at an earlier-than-normal age or who experience menopause later in life are at reduced risk for osteoporosis. However, women are at higher risk if they:
- Have experienced absence of menstrual periods (amenorrhea)
- Suffer from menopause before attaining the age of 40 years.
- Undergo surgery for removal of their ovaries without taking hormone replacement therapy (HRT)
For men, a low level of testosterone (male hypogonadism) is a risk factor for osteoporosis as well as insulin resistance, sexual dysfunction and other health problems. Testosterone levels decline as men age, a rising incidence of male hypogonadism has been recorded in recent decades. Below-normal levels of estrogen and estradiol in men may also promote osteoporosis.
- Eating disotders
A history of anorexia nervosa or bulimia in women and men elevates the risk of lower bone density in the lumbar spine and hips.
Either type of arthritis- Rheumatoid or Juvenile Rheumatoid Arthritis can both cause diseases of the joints and pain causing limited mobility and bone loss.
- Cardiovascular diseases
People suffering from any cardiovascular disorder like coronary artery disease, heart attack, heart failure and stroke are more prone to osteoporosis also..
- Diabetes Mellitus
Type 1 diabetes and possibly type 2 diabetes, which is far more common, increase the risk of osteoporosis in men and women.
- Polycystic Ovarian Syndrome
It causes an endocrine disorder that result in irregular menstrual cycles. The irregular estrogen levels associated with this condition may increase the risk of lower bone density.
- Other Diseases
Most diseases have the potential to raise the risk of osteoporosis. Diseases like asthma, chronic obstructive pulmonary disease (COPD), gastrointestinal diseases including liver disease and inflammatory bowel disorders, kidney disease, hypercalciuria (excess calcium in the urine, a sign of kidney stones), neoplastic disease (e.g., cancer or benign tumors), ankolysing spondilytis, cystic fibrosis, homocysteinuria (high levels of an amino acid called homocysteine), a genetic bone disease called osteogenesisimperfecta and a rare cellular disorder called systemic mastocytosis carry an increased risk of osteoporosis.
- Long Term Medication
Continued use of some corticosteroids or other immunosuppressants damages bones. These medications are used to treat RA and other forms of arthritis, asthma, psoriasis, lupus and other chronic conditions.
- Intra Muscular Birth Control Medicines
These medicines, especially if used by teenagers cause decrease in bone density.
Excess discharge of thyroid hormone in people suffering from an overactive thyroid (hyperthyroidism) can cause excessive bone loss. Medicines taken to treat the reverse condition of too little thyroid hormone (hypothyroidism) are also prone to bone loss. Regular blood testing to monitor thyroid levels is essential in such cases.
- High Blood Pressure Medicines
Patients taking some diuretics suffer from excessive levels of calcium in their blood. These medicines are prescribed to treat high blood pressure to prevent build up of fluids in the body. This calcium loss can cause osteoporosis.
- Hormonal Treatment
Treatment for prostate cancer and use of some types of anticoagulants, anticonvulsants and antacids containing aluminum are known to contribute to bone loss.
- Low Calcium levels
In addition to lack of dietary calcium, medical procedures (such as stomach surgery) and medical conditions (such as Cushing’s disease, parathyroid disease and digestive disorders) that inhibit the absorption of calcium can also contribute to bone loss.
- Cancer Treatment
Radiation treatment for cancers in the pelvic area may raise the risk of osteoporotic fractures.
- Stem Cell transplant
A type of stem cell treatment called hematopoietic cell transplantation reduces bone mineral density in children and sometimes causes osteopenia (a type of bone weakness) or osteoporosis.
- Lead consumption
Exposure to lead during childhood might limit bone development and predispose a person to osteoporosis later in life.
- Cola Consumption
Drinking cola may be an independent risk factor for low hipbone mineral density in women.
WHAT ARE THE SIGNS AND SYMPTOMS OF OSTEOPOROSIS THAT ONE CAN LOOK FOR?
In initial stages there are no symptoms of osteoporosis. At a later stage it causes back pain, loss of height, stooped posture. Osteoporosis gets noticed generally, by a fracture in the spine, hip or wrist. Falls, sudden jerks or even coughing, sneezing or bending over can lead to fractures in osteoporotic bones resulting in severe and sudden pain. Sometimes loss of height is the first presenting symptom in the physician’s office.
In advanced stages, osteoporosis causes fractures especially in bones that support a person’s weight, such as the spine or hips, or are injured in a fall, such as the wrist.
WHAT ARE SPECIFIC PECULIARITIES OF FRACTURES CAUSED BY OSTEOPOROSIS?
Fractures due to osteoporosis are noticed only because of sudden pain. Vertebral fractures are the most common fractures associated with osteoporosis. In many cases, these fractures will occur without symptoms and will not be detected unless an x-ray is performed. Fractures also manifest as sudden back pain, particularly when bending and lifting. Such pain often recedes for several weeks before returning as a chronic, dull ache. This pain usually subsides gradually but may persist for months.
Fractures occur in vertebrae that deteriorate to the point where they begin to compress. These compression fractures can cause severe pain and require an extended period of recovery. An accumulation of such fractures may cause a person to lose several inches of height as posture becomes stooped. This abnormal curvature of the spine (thoracic kyphosis creates a rounding of the back known as dowager’s hump. The abdomen may become compressed, causing it to protrude.
Multiple vertebral fractures
These may lead to hip discomfort due to a decrease in the space between the bottom of the rib cage and the top of the pelvis. Other symptoms include difficult or labored breathing and digestive abnormalities, such as constipation and early feelings of fullness while eating.
Such fractures often occur after a person falls. They almost always require hospitalization and surgery like joint replacement. They can result in disability or even death from postoperative complications. 24 percent of hip fracture patients aged 50 or older die in the first year after the fracture.
Although women are two to three times more likely to suffer hip fractures than men, they are less likely to die from the fracture than males.
Hip fractures are usually marked by severe pain in the hip or groin, an inability to put weight on the injured leg, and stiffness, bruising and swelling around the hip area.
Fractures of the wrist usually occur in the lower end of the radius, the bone on the thumb side of the forearm. This causes backward displacement of the wrist and hand and is often known as a Colles’ fracture. These fractures may occur when a person uses an outstretched hand to try to break a fall. Symptoms include pain, swelling just above the wrist, deformity of the arm just above the wrist and inability to hold or lift an object of significant weight.
WHAT DIAGNOSTIC OR MONITORING TESTS ARE REQUIRED FOR OSTEOPOROSIS?
Timely and early detection of osteoporosis can help in proper and timely treatment to slow further progress of the disease and aid reversal. The physician will compile the patient’s medical history and physical examination to check for:
- Reproductive history and time of menopause, or, for men, symptoms of low testosterone levels
- Past or present medical conditions
- Medications taken
- Lifelong intake of calcium
- Lifelong exercise patterns
- Habits including use of tobacco and alcohol
Blood tests are conducted to rule out any other disease / body condition that may cause osteopenia or bone thinning. These body conditions could be:
It causes demineralization, softening and weakening of the bones.
- Multiple Myeloma
A cancerous growth (tumor) in the bone marrow.
- Hyper or Hypo Thyroidism
Excessive or reduced and deficient activity of the thyroid gland, respectively.
- Renal dysfunction
Difficulty for kidneys to function adequately for removal of all body waste to maintain a healthy state.
Bone Density Measurement
Some tests are conducted to accurately measure the bone density of the patient. These tests could be any one or more of:
Dual Energy X-ray Absorptiometry (DEXA) Scan
This test is used to measure the bone density of bones most likely to suffer a fracture due to osteoporosis and these are bones in the spine, hips and wrists. This popular test involves scanning of the bones with an x-ray detector. It shows the extent of various x-rays passing through the bones and displays the result in a colour coded computerized image showing patients bone density. DEXA scan can be repeated over time to compare the results to assess any changes in the bone density before and after treatment.
Single photon Absorptiometry
The bone density of the forearms and heels is measured through this test.
The bone density of the spine and hips is measured through this test.
Computed Axial Tomography (CAT) Scan
A rotating x-ray machine is used to record detailed cross sectional images of the body. These sliced images are then used to ascertaining the bone density in the spine. This non-invasive or minimally invasive test may be used in place of a DEXA scan.
Ultra Sound Imaging
This technique uses high frequency sound waves to create visual images of the internal body structures. The density of the heel can be measured with the help of this test.
WHICH CATEGORY OF PEOPLE IS AT A GREATER RISK FOR OSTEOPOROSIS?
Though women are at a higher risk than men to suffer from osteoporosis, men are also likely to suffer from this.
Any woman who is not taking hormone replacement therapy (HRT) and falls in any of these categories:
- Takes medicines like corticosteroids that are likely to cause osteoporosis.
- Suffers from Type-1 diabetes, liver disease, kidney disease or has a family history of osteoporosis.
- Experienced early menopause.
- Over age 50 years, post menopausal and has at least one of the risk factors for osteoporosis.
- Over age 65 years, post menopausal and never had a bone density test.
Any man with risk factors for osteoporosis is advised to consult a physician about screening for this disease. Osteoporosis is perceived to be a disease of the women only. Men are also likely to suffer from osteoporosis and should undergo bone density measurement tests. Men above 70 years should get tested for any bone loss and even younger men with any risk factor should be examined for this.
Bone density measurements are expressed as T–scores, which reflect the patient’s bone density compared to that of a healthy adult of the same sex. A patient’s bone density will also be compared to a Z-score, which is the number of standard deviations above or below what is expected for someone of the same age, sex, weight and ethnic or racial origin.
Dental x-rays over time may also help diagnose osteoporosis by revealing bone loss in the jaw, according to recent research.
WHAT ARE THE TREATMENT OPTIONS AVAILABLE FOR OSTEOPOROSIS?
Osteoporosis could be caused by another disease or treatment for something. In such a situation it is best to resolve the underlying cause or minimize the risk. The doctor could reduce the dosage of the concerned medicines like corticosteroids or immunosuppressive medicines etc. The physician can try an alternative medicine or discontinue the drug. The patients should never stop taking the medicine on their own.
Calcium and vitamin D supplements are generally recommended for people suffering from osteoporosis.
Weight bearing exercises like walking are advised for osteoporosis patients. High impact activities like jumping etc. are not recommended, especially for patients with advanced osteoporosis, to avoid stress fractures due to the exercise.
Medicines for osteoporosis could include:
These help in preventing/inhibiting bone breakdown (resorption), preserve bone mass and increase bone density in the spine and hips and in turn help in preventing fractures. As preventive therapy these are prescribed for people requiring long-term use of corticosteroids, and also to people with cancer or other conditions that can weaken bones.
Bisphosphonates are administered in tablet form as a daily or once a month dose. These are even given as an injection once every three months. The use of bisphosphonates should be started and discontinued under the directions of a qualified physician only.
Potential side effects associated with bisphosphonates include nausea, abdominal pain and irritation of the esophagus. There have been rare cases of jawbone deterioration (osteonecrosis). Esophagitis can be prevented by taking the pill with a full glass of water (8 ounces) and by not lying down for about half an hour after taking the pill on an empty stomach. Bisphosphonates are not advised for patients who already have esophageal strictures (narrowing) and in patients who are unable to stand or sit in an upright position for 30 minutes.
- Hormone Suplements
Certain medicines are given to patients to supplement their hormonal deficiencies. These include:
SERM’s OR Selective Estrogen Receptor Modulators
These medications block estrogen receptors in breast cells. They are used to fight breast cancer but are also helpful in strengthening bones in women after menopause. The probable side effects of these are hot flushes, stomach upset or blood clots.
Produced by the thyroid gland, this hormone reduces bone resorption and may slow bone loss in postmenopausal women. Calcitonin may also prevent spinal fractures but does not appear to lessen the risk of hip fracture. Administered via nasal spray, it irritates nasal passages and causes nausea in some patients. Due to its high cost it is not usually recommended as the first line of treatment.
This injectable synthetic version of parathyroid hormone helps to regulate calcium and phosphate metabolism in bones. It may be prescribed to women or men at high risk for fractures. Side effects may include nausea, dizziness and leg cramps.
Men who have or are at high risk for osteoporosis, because of low levels of testosterone, are prescribed these to make up the deficiency.
- HRT or Hormone Replacement Therapy
This had long been the primary treatment for osteoporosis in women. By taking estrogen or combined estrogen and progesterone replacements, women have been able to slow down or halt the loss of bone mass associated with menopause. Long term HRT exposes a woman to serious risks including breast cancer and formation of blood clots. HRT is no longer recommended as a primary means of controlling osteoporosis.
Physiotherapy is used to improve balance, strength and mobility in patients.
A great deal of research on osteoporosis is being conducted and additional medicines are being developed.
CAN OSTEOPOROSIS BE PREVENTED? WHAT STEPS ARE REQUIRED TO PREVENT BONE ERSION?
Building Bone Mass
Dietary and lifestyle habits of early ears determine the risk to a large extent. The most effective preventive measure for osteoporosis is to build bone mass at a young age through exercise and a good diet so that a store of strong bone material is built up for later years. People of all ages can strengthen their bones through improved diet, regular exercise and not smoking.
The risk of osteoporosis for both sexes depends on the amount of bone mass attained between ages 25 and 35, and how rapidly the bone is lost later. Higher levels of bone mass earlier in life help accumulate a store of bone that takes longer to deteriorate during aging. Some experts have suggested that young people can increase their bone mass by as much as 20 percent, which builds a store of skeletal mass crucial to preventing osteoporosis.
Presence of low bone mass is known as osteopenia. The possible courses available to an individual to improve bone mass are:
- Regular Exercise
About 30 to 45 minutes of regular physical activity everyday can help build strong bones and slow bone loss, and the benefits can start at any age. Strength training exercises and weight-bearing activities can help build bone mass. Balance-improving exercises like yoga and tai chi, can help reduce the risk of falls. Older adults without a history of regular exercise can still increase bone density through exercise. Examples of weight–bearing activities include:
- Walking, hiking, running or jogging
- Aerobics, calisthenics or skipping
- Stair climbing
- Weight lifting
- Skiing or skating
- Tennis, racquetball, squash or handball
- Field hockey, soccer or other field sports
Daily Calcium Intake
Calcium is particularly important while the skeleton is growing, in childhood and adolescence years and during pregnancy and breastfeeding. As people age, the body becomes less efficient at absorbing calcium. Chronic health problems and other medications can also interfere with absorption. Good sources of calcium include foods such as:
- Milk, low-fat yogurt and cheese
- Green vegetables such as spinach and broccoli
- Canned salmon
- Calcium-fortified orange juice
- Tofu fortified with calcium
- Soy beverages
- Nuts such as almonds
Generally, it is recommended that people consume 1,000 milligrams (mg) of calcium a day until age 50. After menopause, women should consume 1,000 mg daily if they are taking hormone replacement therapy (HRT) and 1,500 mg daily if they are not taking HRT. Men over age 50 should consume 1,200 mg of calcium daily.
For people who cannot eat dairy products, calcium supplements can help meet daily requirements. If side effects such as constipation occur, calcium citrate or phosphate formulas may be better tolerated than calcium carbonate.
Vitamin D Intake
Vitamin D is essential for absorbing calcium. Milk is the primary source of vitamin D in the diet, and one cup contains 100 International Units (IU) of vitamin D. People ages 51 to 70 are urged to get 400 IU of vitamin D each day, while those over 70 should get 600 IU each day. Vitamin D is also found in eggs, fatty fish and cereal. The skin also produces vitamin D from sunlight, and small amounts of daily sun exposure can help meet vitamin D requirements. An additional benefit of fatty fish is omega-3 fatty acids, which may also promote bone mineral density.
Smoking increases bone loss, because it reduces the body’s ability to absorb calcium. It also decreases a woman’s production of estrogen.
No or Limited Alcohol consumption
Having more than two drinks a day may decrease bone formation and reduce the body’s ability to absorb calcium.
Hormone Replacement Therapy
Testosterone replacement therapy may reduce men’s risk of osteoporosis, decrease fatigue and improve mood. Yet it may increase the risk of prostate cancer. Short-term HRT can have several benefits for women undergoing menopause, but the serious health risks of longtime HRT simply as a method of preventing osteoporosis is no longer encouraged.
Coffee and Cola Consumption
Consuming excess caffeine like having more than three cups of coffee a day may raise the risk of osteoporosis.
Corticosteroids Based treatment
Patients advised to take corticosteroids for longer periods to treat arthritis etc. are advised to take bisphosphonates also to reduce bone loss.
Bulimia / Anorexia Nervosa treatment
Eating disorders like anorexia nervosa or bulimia raise the risk of osteoporosis and must be treated at the earliest.
- Preventing Fractures
An individual suffering from osteoporosis can take following steps to avoid fractures:
Adopting Good posture and Ergonomics
Keeping the head held high, chin in, shoulders back, upper back flat and lower spine properly arched prevents avoidable stress on the spine. Good posture can be maintained by:
Placing a rolled towel in the small of the back while sitting or driving.
Not leaning over when reading or doing homework.
Using proper lifting techniques by bending at the knees rather than the waist and lifting with the legs while keeping the upper back straight.
- Preventing Injuries due to falls
Unexpected falls are the source of many fractures, especially those of the hip and wrist. Several steps, as mentioned below, to reduce the risk of falling can be taken:
Wear low-heeled shoes with non-slip soles.
Eliminate potential sources of slipping in the home or workplace, such as poorly placed electrical cords and area rugs.
Install adequate lighting in all areas inside and around the home.
Avoid walking on ice, wet or polished floors, or other slippery surfaces.
Do not walk in poorly lit or unfamiliar areas.
Make allowance for effects of medicines
Certain drugs may cause drowsiness or otherwise impair a person’s coordination or mental alertness and it is necessary to be aware of the same and plan accordingly in advance.
Treatment for any ailment likely to cause falling
Any health condition that may increase the risk of falling must be treated on priority. Ailments like poor vision, reduced strength in any limb- hands or legs, posture and waking disturbances deserve immediate attention.
Severe and chronic pain due to any reason should not be ignored. Pain can limit mobility and its intensity can increase over time.
Use of Hip Pads
Fat deposit and muscles around the hips cushion the fall and reduce chances of hip fractures. In old age wearing of external hip pads may provide a cushion that lessens the risk of fracture when a person falls.
Statins, drugs used to control cholesterol, may be at a reduced risk from osteoporotic fractures. The results of these drugs on women are yet to be assessed fully.