Make no bones about it, there are new treatments for osteoporosis

You’ve seen the old ads before with famous stars sporting milk moustaches. You’ve heard the admonition: drink milk for your calcium needs to avoid osteoporosis, a major source of morbidity and mortality in the world today. After all, an estimated one in three women will sustain an osteoporosis-related fracture in their lifetime. These fractures result in increased disability and excess mortality. On average, 24 percent of people with hip fractures, secondary to osteoporosis, die within one year of their fracture.

Osteoporosis is a major health threat; an estimated 75 million people have osteoporosis in Europe, the USA, and Japan. Asians, including Filipinos, are predisposed to developing this condition. In 2002, the direct impact of this disease translated to an estimated treatment cost in the USA of $17.5 billion (US $48 million per day!). In the European Union, the estimated total direct cost of osteporosis-related fractures in 2003 was an astounding 25 billion euros!

How does osteoporosis happen? Actually, your bones are being rebuilt each and every day. Specialized cells (called osteoclasts) break down bone material while other specialized cells (called osteoblasts) build new bones in a process that helps the body repair damage. However, as you age, you add new bone material more slowly, and the breakdown can outpace its replacement. In women, bone density can decrease rapidly when estrogen levels plummet after menopause. As bones lose density, they break more easily. When bones lose enough of their structural integrity, the condition is called osteoporosis. Although the majority of osteoporosis patients are women, about 20 percent of osteoporosis-related fractures occur in men – meaning they, too, can benefit from taking care of their bones.

Diagnosis

Osteoporosis is not painful. That is why it is often called the "silent disease." The fractures are the painful part. The most visible symptoms of osteoporosis are broken hips and spinal compression and deformity (the result of numerous small spinal fractures healing), but the disease is present before an actual injury makes it obvious. Unfortunately, many people don’t realize they have the disease until they suffer a fracture.

This is particularly unfortunate because osteoporosis is easy to diagnose with a bone density scan. Several different techniques are used to measure bone density. The most widely used is dual-energy x-ray absorptiometry (DEXA or DXA), which uses two low-dose x-ray beams. A bone density scan can range from P2,750 to P4,200.

Most health organizations recommend measuring a woman’s bone density starting at age 65, or sooner if necessary, as in women with significant risk factors who are going through their menopause. While there aren’t comparable guidelines for men, the International Society for Clinical Densitometry recommends screening all men 70 and older.

Building Stronger Bones

If you have osteoporosis or are considered at risk because of a low bone density, you can still strengthen your bones and prevent fractures. The first advice doctors have for older adults is to get their calcium and exercise. You’ll need at least 1,200 mg of calcium per day, plus 400 IU of vitamin D (600-1,000 IU if you’re over 70), which promotes calcium absorption. The best sources of calcium are foods such as milk, cheese, yogurt, and green leafy vegetables. The best sources of calcium are foods such as milk, fish, cheese, and margarine. You can also get vitamin D by going out in the sun, since vitamin D, which is synthesized in the skin, is also activated by sunlight. About 10 minutes of daily sun exposure will provide you with enough vitamin D. Because of concerns about the rising rates of skin cancer, it is recommended that people get vitamin D from food and wear sunscreen outside. Though some experts believe sunscreen interferes with the body’s ability to produce vitamin D, dermatologists maintain that most people who wear sunscreen receive enough incidental sunlight to boost their levels of vitamin D.

Weight-bearing exercises, such as walking, are ideal for building bone strength (but talk with your doctor before starting any new exercise program). When you walk, your bones have to support the weight of your body. That support and the slight pounding the bones get with each step actually stimulate bone production. Ideally, work out for 30 minutes or more every day; if that’s not possible, do at least three workouts per week. Focus on activities in which your heels strike the ground. Aside from walking, that includes dancing, golf, tennis, badminton, and others. Strength train your upper and lower body two to three times per week (with a day of rest between sessions), aiming for three sets of 10 repetitions. Include exercises that target the hips and back, which are most vulnerable to fracture. Quit smoking and limit alcohol. Both nicotine and alcohol can harm bone. Cut also caffeine and soda. Diet soda may not pack on the pounds but it will help you lose calcium.

Drug Treatments

If you already have osteoporosis or are at high risk for it, you will probably need drug treatment to further develop your bone strength. Most osteoporosis drugs slow the body’s natural breakdown of bone tissue.

Currently, the most popular drugs are bisphosphonates, such as alendronate (Fosamax) and risedronate (Actonel), which can both treat and prevent osteoporosis by slowing bone loss. These older bisphosphonates are taken daily or weekly, but a new drug ibandronate (Bonviva by Roche) has recently been approved on a once-monthly dose.

The main drawbacks to bisphosphonates are that they have to be taken on an empty stomach and you can’t bend down or lie down for at least 30 minutes after taking the pill. Also, side effects such as abdominal pain, upset stomach, and nausea may occur with these drugs. And these drugs are not recommended for people who have kidney problems.

Estrogen has also been effective in treating osteoporosis, but it has dangerous side effects at higher doses – particularly an increased risk of heart attack, stroke, and breast cancer. Researchers are working on hormone-based treatments with the protective benefits of estrogen but with fewer risks. One of these, raloxifene (Evista), works like estrogen to stop bone loss, without many of its side effects. It can increase the risk of blood clots, however.

Another relatively new medication is teraparatide (Forteo), which attacks osteoporosis by promoting the growth of cells that create new bone. Teraparatide, which is given by daily injection, decreases the risk of vertebral fracture by as much as 65 percent, but because its risks aren’t fully understood yet, the drug should be used cautiously, and only in patients who have not had bone cancer or skeletal radiation therapy. A big drawback for teraparatide at this time is its prohibitive price, which is currently out of reach for majority of Filipinos.

Challenges

In osteoporosis management, one of the major challenges today is the poor patient adherence to osteoporosis medications. Indeed, recent studies showed that compliance and persistence in taking osteoporosis medications are suboptimal, and that poor compliance compromises therapeutic outcomes. No doubt, part of the reason may be economic, as noted with teraparatide therapy, since long-term treatment is required for optimal and sustained therapeutic benefits. But there are other factors as well.

For instance, adherence has been improved by reducing dosing frequency from daily to weekly; 55 percent of patients receiving a weekly bisphosphonate persisted with therapy compared with only 20 percent in daily bisphosphonate users after two years. However, these levels can still be improved. It is anticipated that extending the dose-free interval with a once-monthly medication may improve patient compliance further. This is supported by a recently published study which demonstrated that as much as 75 percent of patients prefer the once-monthly ibandronate and find it more convenient than the weekly bisphosphonates.

If you think you have osteoporosis or have a high risk for the disease, talk with your doctor. It is comforting to know that treatments available for this disease today are effective and can help you avoid the disabling complications that commonly develop if you leave this condition untreated. Don’t waste time. Act now!