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Osteoporosis

Recent Advances in Diagnosis & Treatment

Dr. J. Bernard Walsh, Consultant Physician and Senior Lecturer, Department of Medicine for the Elderly, St. James's Hospital and Trinity College Dublin.

Osteoporosis is increasing in Western society. This increase could in part be related to the reduction in exercise, changes in diet and increasing longevity of the population. Over 40% of all women over the age of 50 will experience an osteoporotic fracture in their life time. The most common fractures are those of the vertebral column, the forearm (Colles fracture) and the hip.

Diagnosis

The diagnosis of osteoporosis is most commonly made after a person has had a fracture from minimal trauma but it can be confirmed on DEXA scan which measures 'Bone Mineral Density' and this is a reflection on the amount of bone that a person has at a specific site.

One normally measures the bone mineral density of the lumbar spine and the hip.

The DEXA scan result will either tell whether the bone density is slightly reduced which is termed osteopaenia or whether or not a patient's bone density is more markedly reduced and then it is classified as osteoporosis. The risk of a fracture is a very graduated one as some patients that are classified as osteopaenia are also at significant risk of fracture especially if they have other risk factors such as impaired balance or a previous history of a fracture.

Bone markers can also help in deciding if a person is at a higher risk of having a bone fracture.

Prevention of Osteoporosis

One normally builds bone up until the age of 30. The bone stabilises until around the age of 50. The thinning of bone from 50 onwards is much greater in women than in men and women as a result are four times at higher risk of developing an osteoporotic fracture. It therefore is important to build a strong skeleton and this is where a balanced diet is important. A good intake of Calcium and Vitamin D is essential. This is present in dairy produce or in other food stuffs such as sardines, tuna, nuts, dried fruit and green vegetables such as broccoli.

Exercise is critically important as half an hour or more of brisk weight bearing exercise a day is very protective in preserving bone and also in building muscle strength and maintaining good balance.

Adjustment of Lifestyle

Lifestyle is very important. In addition to exercise a person should avoid smoking completely and alcohol intake should be moderate as both smoking and exercise contribute to osteoporosis.

Other Underlying Causes of Osteoporosis

It is very important to exclude medical conditions which can contribute to osteoporosis and these include an overactive Thyroid, Malabsorption such as Coeliac Disease, Inflammatory Bowel Disease, Chronic Liver Disease, Renal Failure and a bone marrow condition known as Myeloma.

Women with an early menopause are also at high risk of osteoporosis and these patients should discuss with their doctor whether HRT is indicated. HRT is no longer recommended as first line treatment for osteoporosis in women. But in women with a very early menopause at around 40 some doctors will still consider it for other reasons. The advice of one's GP is essential here.

Drug Treatment for Osteoporosis

1. Calcium and Vitamin D

It is very important that all patients take a Gram of Calcium and 800 units of Vitamin D a day.

Calcium and Vitamin D preparations are particularly of value in the Nursing Home population who would have very little exposure to sun light. The preparations most commonly used are Calcichew D3 Forte one twice daily, Idéos one tablet twice daily or Osteofos D3 one sachet daily.

2. Selective Estrogen Receptor Modulator (SERMs) e.g. Raloxifene (Evista)

For women who are after the menopause such as in their mid 50's who are noted to be osteopaenic or osteoporotic a drug such as Raloxifene (Evista) which is an oestrogen analogue but is protective against breast cancer and heart disease as well as strengthening bones is a good option. It is well tolerated but because of a very slight increase in the incidence of leg thrombosis in some patients it is best used in patients who are active and mobile and who are non smokers. It is a very effective drug for preserving bone and helps to prevent and delay the onset of bone thinning. It can also be used in women of an older age.

3. Bisphosphonates - Alendronate (Fosamax) and Risedronate (Actonel)

These drugs are Alendronate (Fosamax) and Risedronate (Actonel) and they are very effective at reducing the incidence of fractures by 50% over a three year period. They act by slowing down bone turnover so that bone has a greater chance of mineralising and the process of osteoporosis is slowed down.

4. PTH - Parathyroid Hormone (Forsteo)

This drug has only recently been introduced. It is given on a daily basis for eighteen months. It is given by subcutaneous injection by a very small needle and it comes in a pen with a months supply of the drug. It is very well tolerated and once the patients get used to handling the pen there is little problems in the administration. It is a highly effective therapy and it reduces the incidence of vertebral fracture over an eighteen month period by over two thirds and of severe vertebral fractures by 90%. It is the first bone building drug that has become available. Other drugs work mainly by slowing bone breakdown while PTH works by stimulating new bone formation. It is of particular benefit in patients with severe osteoporosis with vertebral (backbone) fractures.

5. Strontium (Protelos)

Strontium Ranelate will be making its appearance in Ireland later on this year. Its acts by slowing bone breakdown but also by stimulating new bone formation so its mode of action is also different from other drugs that are currently on the market.

Its overall efficacy appears to parallel the Bisphosphonates. It has a promising future as an extra tool in our battle against this illness.

6. Hip Protectors

Hip protectors are highly effective for frail elderly patients who have a tendency to fall. In patients who wear them they can reduce the incidence of fractures by up to 80%. Compliance may be an issue and it is very important that they are worn at all times by patients who are frail with impaired gait and who have a tendency to fall. They are particularly of value in the Nursing Home population.

Summary

The diagnosis and the treatment of osteoporosis has made huge strides over the last decade. The increasing availability of new therapies discussed above and our increasing experience in their use has meant that we now are able to optimise the treatment for each individual patient. The importance of diet, exercise and the use of hip protectors for frail elderly is central to any treatment but a combined integrated approach can mean that many at risk people can live a full fruitful life from a bone health point of view without the perceived inevitable development of fragile bones and bone fractures as they get older.