Osteoporosis - Bone Disease

Every three seconds, a fracture occurs due to osteoporosis. That means by the time you finish these two sentences, about three osteoporotic fractures will have occurred in the world. Osteoporosis is a disease caused by deterioration of bone tissue and low bone mass and it drastically increases your risk for a fracture. In the United States alone, 53 million people are affected by Osteoporosis/Osteopenia and most affected people are women. In fact, one in three women over 50 will have a fracture due to Osteoporosis.

Osteoporosis is the most common metabolic bone disease in the United States and can result in devastating physical, psychosocial and economic consequence. It is overlooked and undertreated largely because it shows no symptoms before causing fracture. Fractures are much more dangerous than just a broken bone and are very dangerous to overall health. Sixty percent of older women who have a fracture due to Osteoporosis will die within 1 year of having the fracture. Many of the risk factors for Osteoporosis are genetic, however through good nutrition and exercise early in life, Osteoporosis is possible to prevent.

Risk Factors

Both women and men are at risk of Osteoporosis, however women are much more likely to be diagnosed with the disease due to their smaller body frame and loss of hormones at menopause. Caucasian women are especially at risk, especially those with a slim, petite body frame. In fact, a Caucasian woman and an Asian woman can have the same bone density score, but the Caucasian woman will be more likely to have a fracture than the Asian woman.

Other Risks Include:

• Age
• Small body size
• Family history of Osteopenia or Osteoporosis
• Absence of menstrual periods
• Menopause
• Anorexia Nervosa (eating disorder)
• Medications (glucocorticoids, anticonvulsants, GnRH drugs, cancer treatments)
• Hyperthyroidism or excessive thyroid medication
• Celiac Disease​
• Parathyroid Disease
• Myeloma (Bone marrow cancer)
• Smoking cigarettes
• Alcohol consumption
• Inactive lifestyle
• High caffeine consumption
• Excess soda intake (especially diet)
• Inadequate Calcium and Vitamin D intake (especially during adolescence)
• Gastric Bypass

All About the Bones

“Osteo” means “bone” and “poros” means “passage” or “pore” in Greek. When you combine the two words, you get Osteoporosis which may be translated into “porous bone”. This description comes from the very large pores and holes in the bone tissue that occurs with bone degradation. ​

Contrary to what they seem, bones are not solid, like a rock. They are porous, constantly changing tissues! Every day, bone tissue is broken down and built back up by your bone cells. When you are growing through childhood and adolescence, your bone cells build more bone than they break down. Because a large component of bone is Calcium, it is essential that your body has enough Calcium during this time so you can have strong, healthy bones throughout your life. Ninety percent of bone tissue acquisition occurs when you are a child and teenager. ​​

By the time a woman has reached her early 20s, her peak bone mass has been reached. This means that her bones are the healthiest they will ever be at this age. After this, bone mass and health only remains steady and then begins to decline with age. When a woman reaches menopause and her Estrogen levels drop, bone mass also takes a drastic fall. In the first year of menopause alone, women will lose 6% of their bone mass. Women who have reached a healthy bone mass before this 6% drop will be safe from Osteoporosis, but those who haven’t are at serious risk of the bone disease. Estrogen is now known to play a very important role in bone health. This is why women who begin Hormone Replacement Therapy (HRT) at the beginning of menopause typically have stronger, healthier bones. ​

Nutrition and Exercise

Vitamin D

Adults should get at least 600 IU of Vitamin D each day. Food is generally a poor source of the vitamin. Sunlight is the best way to get enough Vitamin D but is still dependent on many factors including sunscreen use, skin color, latitude, season, and more. If you choose to use a Vitamin D supplement, 1000-2000 IUs are generally a safe dose, but it is important to consult your doctor to discuss any potential drug interactions. Vitamin D is also stored in your body’s fat and can be toxic if too much is taken.

Calcium

From ages 9-18, children and adolescents should get 1,300 mg Calcium per day. At age 19, this number declines to 1,000 mg until age 51 then increases back to 1,200 mg per day for females. The reason for this increase with age is because your ability to absorb Calcium declines with age. Some medications and conditions also interfere with Calcium absorption. Dairy products and fortified dairy substitutes are the best sources of Calcium in the diet. Dark leafy greens and fish are also good sources of Calcium. People who do not consume enough Calcium are at a much greater risk of Osteoporosis. Low Calcium intake is associated with low bone mass, fast bone loss, and more fractures. ​

Exercise

Exercise is another important component in the prevention of Osteoporosis. Many studies have shown that exercise, especially during childhood and adolescents, help build strong bones. Weight bearing, resistance, and aerobic exercises are especially good for bone health. After childhood and adolescence, these types of exercises are still important in the prevention of Osteoporosis. Examples of good exercises to prevent Osteoporosis include walking, hiking, jogging, tennis, weight lifting, isometrics, and dancing.

Screening and Diagnosis

At my office, routine screening begins at age 60, but women should be screened earlier if they have risk factors or have had a fracture. A DEXA (Dual Energy X-ray Absorptiometry) scans your body and measures the density of your bones. A DEXA is done every five years to check the health of your bones and is done every two years if your bone density is low (Osteopenia or Osteoporosis).

Osteoporosis is diagnosed with by the T-Score given by your DEXA scan. It is considered a silent disease since it usually shows no symptoms until a fracture occurs and at that time, it is usually too late to prevent the disease.

To the right, you can see an example of an image you'd see on your DEXA. The three lines represent the 90th, 50th, and 10th percentile for bone density. On the right is the T-Score and on the bottom is age in years. The green zone represents healthy bones (T-Score -1.0 to 2). The yellow zone represents Osteopenia (T-Score -2.5 to -1) and the red zone represents ​Osteoporosis.

T-Scores by DEXA:

2 to -1.0 is normal
-1.1 to -2.5 is Osteopenia 
-2.6 and less is Osteoporosis

Osteoporosis (T-Score -2.6 and less). You can see in this image that bone density for all people, regardless of your peak bone mass, begins to decline around age 45. Those in the 90th percentile will not reach Osteopenia until around 95 and will never have Osteoporosis. Those in the 50th percentile, or average, will reach Osteopenia by about 60 and never reach Osteoporosis. While those in the 10th percentile will have Osteopenia by age 50 and Osteoporosis by age 65. A woman can fall anywhere on this graph. On this graph, this woman is about 38 with a T-Score of +1.0 which is normal. ​

Treatment

Before Osteoporosis occurs, it is important to focus efforts on prevention through excellent nutrition and exercise. Currently, not treatment can completely reverse Osteoporosis, but early interventions can prevent it for most people. Once Osteoporosis is diagnosed, medication is used to halt progression of the disease. Exercise is especially important to continue because it increases coordination, balance, and muscle strength, therefore decreasing the likelihood of a fall which would cause a fracture. ​

Medications are also used to treat Osteoporosis, and some are more effective than others. The downside, however, is that it is typically a game with the insurance and most insurances will need a poor reaction to two types of Osteoporosis treatment before they approve the last, but most effective treatment for the disease.

Medications for Osteoporosis

First-Line Agents

• Bisphosphonates (Fosomax, Actonel, and Reclast)
  • ​These agents all work by slowing down the cells that cause bone to break down while still allowing the cells that build bone to function. Fosomax and Actonel are once a week pills while Reclast is a once a year intravenous infusion.
  • Treatment review with a Bisphosphonate is recommended after 5 years due to concerns over spontaneous femur fracture and to evaluate renal function.
  • Concern with longterm treatment with a Bisphonsphonte include osteronercrosis of the jaw and atypical femur fractures.
    
  • Concerns with Reclast include risk of kidney failure, requiring dialysis, acute phase reaction (within the first 3 days of infusion) of fever, fatigue, bone pain, muscle pain, chills and influenza-like symptoms
    
• Prolia​
  • Prolia is an injection given twice a year and is a medication called a RANK ligand inhibitor. It works by decreasing the breakdown of bones and increasing bone density and strength.
  • Prolia is very effective, but not often approved by insurance companies straight away. Before approving Prolia, insurance usually likes to see a patient have a poor response to other first-line agents first. It is a shame since I have witnessed firsthand the positive effects on the bone of this medication which also has fewer side effects.

Second-Line Agent

• ​Boniva
  • Boniva is another Bisphosphonate and also works by slowing down the cells that break down bone. Boniva is either taken as a pill once a month or through the vein every three months.
  • If not taken properly by the directions, Boniva has the possibility of damaging the esophagus. It is important to always take this medication as directed if it is in pill form.

Second or Third-Line Agent

• Evista
  • Evista is a Selective Estrogen Receptor Modulator (SERM) that works by stimulating bone health in the same what that your natural Estrogen stimulated bone health before menopause. Evista may also help reduce the risk of breast cancer in women with Osteoporosis. Evista is an oral pill.
  • Evista (a SERM) si most useful in younger postmenopausal women without severe osteoporosis. It does carry an increase risk for deep vein thrombosis (DVT), stroke and hot flashes. It has the additional benefit of reducing the risk of Estrogen positive breast cancers because it blocks the estrogen receptors in the breast.
    

Last-Line Agent

• Calcitonin
  • Calcitonin is a hormone responsible for decreasing the amount of calcium that circulates in the blood. By stopping the cells that break down bones, less calcium is released into the blood and broken down.

For failed alternative agent or very high fracture risk:

• Forteo
  
  • Forteo is a form of hormone produced by your parathyroid glands that works by stimulating the cells that build bone to lay down new bone. It is a daily injection given for 18 months.

Other Medical Therapies

• Hormone Replacement Therapy

  • Estrogen is effective in maintaining bone health and can improve osteoporosis; however, Osteoporosis itself is not a main reason to begin Hormone Replacement Therapy.

• Combination Therapy 

  • Combination Therapy refers to using more than one agent at a time. This shows no improvement in reducing fracture risk over using just one agent at a time.​

• Calcium Supplementation

  • Though calcium is an important component of bone health, it is associated with some problematic effects on your heart health. The safest way to get more Calcium for your bone health is to increase the amount of Calcium you get naturally from foods and supplement with Vitamin D rather than supplementing with Calcium and Vitamin D together.

• Duavee

  • Duavee, although not specifically a medication for Osteoporosis, has the dual benefit of having Estrogen and a SERM. Both of these stimulate bone health, however the SERM has the added benefit of protecting the lining of the uterus, therefore eliminating the need for synthetic Progestin (the hormone most associated with the increase risk for breast cancer).

​

Fall Prevention

Preventing dangerous falls is essential in Osteoporosis. Avoiding slippery and wet surfaces may help prevent falls. Some women may need the use of a cane or a walker in order to insure that a fall will not be likely to occur. By keeping your home clean and tidy, you are also less likely to trip over something on the floor. Rubber carpet guards can help hold carpets and rugs in place so they are less likely to slip around. Though socks and stockings are great for keeping your feet warm, they can add to slipperiness, especially on smooth surfaces like tile or wood. Avoid wearing them at home, or buy socks with rubber dots on the bottom to increase “stickiness”. Rubber mats and shower handles can also be used in the shower or tub to decrease the likelihood of a fall in such a slick area.

Conclusion

Osteoporosis is a silent disease that affects many women around the world. Many different people are at an increased risk of developing the bone disease, namely small, Caucasian women ages 50 and older. Your bones reach their maximum health in your early 20s, so it is important to get plenty of Calcium and Vitamin D and to perform weight bearing exercises before this time. Because of Estrogen loss in Menopause, there is a drastic decrease in bone mass. This causes a great increase in the risk of Osteoporosis development. A DEXA scan measures your bone density and risk of Osteoporosis. At -2.6 and less, you are considered to have Osteoporosis and at this time, medications are added to your routine of nutrition and exercise. Fall prevention is also critical in the prevention of fractures and many steps may be taken to help a woman reduce her risk of breaking a bone. ​