Osteoporosis prevention and treatment
Patient information: Osteoporosis prevention and treatment
Author
Hillel N Rosen, MD Section Editor
Clifford J Rosen, MD Deputy Editor
Leah K Moynihan, RNC, MSN
Jean E Mulder, MD
OSTEOPOROSIS OVERVIEW — Osteoporosis is a common problem that causes bones to become abnormally thin (osteopenic), weakened, and easily broken (fractured). Women are at a higher risk for osteoporosis after menopause due to lower levels of estrogen, a female hormone that helps to maintain bone mass.
Fortunately, preventive treatments are available that can help to maintain or increase bone density. For those already affected by osteoporosis, prompt diagnosis of bone loss and fracture risk are essential because therapies are available that can slow further loss of bone or increase bone density.
This topic review discusses the therapies available for the prevention and treatment of osteoporosis. A separate topic discusses bone density testing. (See “Patient information: Bone density testing”).
OSTEOPOROSIS PREVENTION — Some of the most important treatments for preventing osteoporosis include diet, exercise, and stopping smoking. These recommendations apply to men and women. (See “Overview of the management of osteoporosis in postmenopausal women”).
Diet — An optimal diet for preventing or treating osteoporosis includes eating an adequate number of calories as well as calcium and vitamin D, which are essential in helping to maintain proper bone formation and density.
Calcium intake — Experts recommend that premenopausal women and men consume at least 1000 mg of calcium per day; this includes calcium in foods and drinks plus any calcium supplements. Postmenopausal women who do not take estrogen should consume 1500 mg of calcium per day. However, you should not take more than 2000 mg calcium per day due to the possibility of side effects. (See “Patient information: Calcium and Vitamin D for bone health”).
The main dietary sources of calcium include milk and other dairy products, such as cottage cheese, yogurt, or hard cheese, and green vegetables, such as spinach and broccoli (show table 1). A rough method of estimating dietary calcium intake is to multiply the number of dairy servings consumed each day by 300 mg. One serving is 8 oz of milk or yogurt, 1 oz of hard cheese, or 16 oz of cottage cheese.
Calcium supplements (calcium carbonate or calcium citrate) may be suggested if you cannot get enough calcium in your diet (show table 2). Calcium doses greater than 500 mg/day should be taken in divided doses (eg, once in morning and evening).
Vitamin D intake — Experts recommend that most people consume 800 International Units (IU) of vitamin D each day. This dose appears to reduce bone loss and fracture rate in older women and men when there is adequate calcium intake (described above). (See “Calcium and vitamin D supplementation in osteoporosis”).
Milk is the primary dietary source of dietary vitamin D, containing approximately 100 IU per cup. Experts recommend vitamin D supplementation for all patients with osteoporosis whose intake of vitamin D is below 400 IU per day. This can be found in a daily multivitamin or a calcium/vitamin D supplement.
Protein supplements — Protein supplements may be recommended in some people to ensure sufficient protein intake. This may be particularly important if you have already had an osteoporotic fracture.
Alcohol, caffeine, and salt intake — A healthcare provider may recommend limiting the amount of alcohol you drink. Drinking alcohol excessively can increase the risk of fracture due to an increased risk of falling, poor nutrition, etc.
It is not clear if restricting caffeine or salt is helpful; these measures have not been proven to prevent bone loss in people who consume an adequate amount of calcium.
Exercise — Weight-bearing exercises can improve bone mass in premenopausal women and help to maintain bone density for women after menopause. Physical activity reduces the risk of hip fracture in older women as a result of increased muscle strength. Most experts recommend exercising for at least 30 minutes three times per week.
The benefits of exercise are quickly lost if you stop exercising. A regular, weight-bearing exercise regimen that you genuinely enjoy improves the chances of continuing to follow the routine over the long term. (See “Patient information: Exercise”).
Stop smoking — Stoppping smoking is strongly recommended if you are at risk for osteoporosis because smoking cigarettes is known to spped bone loss. One study suggested that women who smoke one pack per day throughout adulthood have a 5 to 10 percent reduction in bone density by menopause, resulting in an increased risk of fracture. (See “Patient information: Smoking cessation”).
Preventing falls — Repeated falling may significantly increase the risk of osteoporotic fractures in older adults. Taking measures to prevent falls can decrease the risk of fractures. Such measures may include the following:
Remove loose rugs and electrical cords or any other loose items in your home that could lead to tripping, slipping, and falling.
Ensure that there is adequate lighting in all areas inside and around the home, including stairwells and entrance ways.
Avoid walking on ice, wet or polished floors, or other potentially slippery surfaces.
Avoid walking in unfamiliar areas outside.
Because certain drugs may increase the risk of falls, drug regimens should be reviewed on a regular basis. In some cases, the healthcare provider may decide to substitute a medication if it has a risk of causing falls. In addition, people with poor vision should see an eye specialist (eg, optometrist or ophthalmologist) for corrective lenses (glasses).
Medication monitoring — Prolonged therapy with and/or high doses of certain medications can increase bone loss. The use of these medications should be monitored by a healthcare provider and decreased or discontinued when possible. Such medications include the following:
Glucocorticoid medications (eg, prednisone)
Heparin, a medication used to prevent and treat abnormal blood clotting (ie, anticoagulant)
Vitamin A and certain synthetic retinoids (eg, etretinate)
Certain antiepileptic drugs (eg, phenytoin, carbamazepine, primidone, phenobarbital, and valproate)
OSTEOPOROSIS MEDICATIONS — The non-drug measures discussed above can help to reduce bone loss. A medication or hormonal therapy may also be recommended for certain men and premenopausal women who have or who are at risk for osteoporosis.
Who needs treatment with a medication? — People with the highest risk of fracture are the ones most likely to benefit from drug therapy. In the United States, the National Osteoporosis Foundation (NOF) recommends use of a medication to treat postmenopausal women (and men ≥ 50 years) with a history of hip or vertebral fracture or with osteoporosis (T-score ≤ -2.5). An explanation of T-scores is provided in table 3 (show table 3).
In addition, the NOF recommends drug therapy for people who have osteopenia (T-score between -1.0 and -2.5) as well as one of the following risk factors (show table 4):
High risk of bone loss from long-term use of prednisone or another glucocorticoid
High risk of future fracture based upon previous history of fracture with minimal force (eg, fall from standing height)
Estimated 10-year risk of hip or osteoporosis-related fracture ≥ 3 or ≥ 20 percent respectively.
The 10-year risk of hip and osteoporotic fractures can be calculated using the World Health Organization FRAX calculator (http://www.shef.ac.uk/FRAX/), click on Calculation Tool, and select country.
However, some people who do not meet these criteria will benefit from a medication to treat osteoporosis or osteopenia. The final decision about use of a medication should be shared between the patient and healthcare provider.
Treatment in premenopausal women — The relationship between bone density and fracture risk in PREmenopausal women is not well defined. A premenopausal woman with low bone density may have no increased risk of fracture. Thus, bone density alone should not be used to diagnose osteoporosis in a premenopausal woman; further evaluation is generally recommended. (See “Evaluation and treatment of premenopausal osteoporosis”).
Bisphosphonates — Bisphosphonates are medications that slow the breakdown and removal of bone (ie, resorption). They are widely used for the prevention and treatment of osteoporosis in postmenopausal women. (See “Bisphosphonates in the management of osteoporosis in postmenopausal women”).
These drugs need to be taken first thing in the morning on an empty stomach with a full 8 oz glass of plain (not sparkling) water. The person must then wait:
At least half an hour (with alendronate (Fosamax®) and risedronate (Actonel®))
At least one hour (with ibandronate (Boniva®))
before eating or taking any other medications. These dosing instructions help to reduce the risk of side effects and potential complications.
Side effects of bisphosphonates — Most people who take bisphosphonates do not have any serious side effects related to the medication. However, it is important to closely follow the instructions for taking the medication; lying down or eating sooner than the recommended time after a dose increases the risk of stomach upset.
There has been concern about use of bisphosphonates in people who require invasive dental work. A problem known as avascular necrosis or osteonecrosis of the jaw has rarely developed in a small number of people who used bisphosphonates. The risk of this problem is small in people who take bisphosphonates for osteoporosis prevention and treatment. However, there is a slightly higher risk of this problem when higher doses of bisphosphonates are given into vein during cancer treatment.
Most experts do not think that it is necessary to stop bisphosphonates before invasive dental work (eg, tooth extraction or implant) unless the bisphosphonate is given monthly or every three months (usually for people with cancer). In this case, the patient should consult their healthcare provider for a specific recommendation.
Bisphosphonates are not recommended for premenopausal women who could become pregnant because of the unknown effects on a developing fetus.
Alendronate — Alendronate (Fosamax®) reduces vertebral and nonvertebral fractures, and decreases the loss of height associated with vertebral fractures. The dose for treatment is 10 mg per day, and the dose for prevention is 5 mg per day. Alendronate is usually taken as a weekly 70 or 35 mg pill.
Risedronate — Risedronate (Actonel®) is approved for both prevention and treatment of osteoporosis. It can be taken once per day (5 mg), once per week (35 mg), or once per month (75 mg taken two days in a row). Risedronate reduces the risk of both vertebral and hip fractures.
Ibandronate — Ibandronate (Boniva®) can be used for prevention and treatment of osteoporosis at a dose of 150 mg once monthly. It is also available as an injection that is given into a vein once every three months. Although ibandronate reduces the risk of bone loss and spine fractures, there is no proof that it reduces the risk of hip fractures.
Zoledronic acid — A once yearly intravenous dose of zoledronic acid (Reclast®) is now available for the treatment of osteoporosis. This medication is given into a vein over 15 minutes and is usually well tolerated. Yearly intravenous zoledronic acid can improve bone density, decrease the risk of spine and hip fractures, and decrease the risk of recurrent fractures in high-risk patients with recent hip fracture [1] .
Side effects of zoledronic acid can include flu-like symptoms within 24 to 72 hours of the first dose. This may include a low grade fever, muscle, and joint pain. Treatment with a fever-reducing medication (ibuprofen or acetaminophen) generally improves the symptoms. Subsequent doses of ZA typically cause milder symptoms.
Intravenous ZA is an appealing alternative for people who cannot tolerate oral bisphosphonates or who prefer a once yearly to a monthly, weekly, or daily regimen. However, the ideal duration of therapy and long-term safety (>3 years) have not been established.
“Estrogen-like” medications — Certain medications, known as selective estrogen receptor modulators (SERMs) produce some estrogen-like effects in the bone. These medications provide protection against postmenopausal bone loss. In addition, SERMS decrease the risk of breast cancer in women who are at high risk. Currently available SERMs include raloxifene (Evista®) and tamoxifen. Raloxifene can be used for the prevention and treatment of osteoporosis in postmenopausal women, although it may be less effective in preventing bone loss than bisphosphonates or estrogen. (See “Patient information: Tamoxifen and raloxifene for the prevention of breast cancer”).
SERMs are not recommended for premenopausal women.
Estrogen/progestin therapy — In the past, estrogen or estrogen-progestin therapy was considered the best way to prevent postmenopausal osteoporosis and was often used for treatment. Data from the Women’s Health Initiative (WHI), a large clinical trial, found that combined estrogen-progestin treatment reduced hip and vertebral fracture risk by 34 percent. A similar reduction in fracture risk was seen in women who took estrogen alone.
Estrogen had the additional advantage of controlling menopausal symptoms. However, the WHI found that estrogen plus progestin does not reduce the risk of coronary artery disease, and slightly increases the risk of breast cancer, stroke, and blood clots. The details of the WHI are discussed elsewhere. (See “Patient information: Postmenopausal hormone therapy”).
Thus, estrogen is not recommended for the treatment or prevention of osteoporosis in postmenopausal women. However, some postmenopausal women continue to use estrogen, including women with persistent menopausal symptoms and those who cannot tolerate other types of osteoporosis treatment.
Estrogen may be an appropriate treatment for prevention of osteoporosis in young women with amenorrhea (absence of menses). This is often in the form of a birth control pill. (See “Patient information: Menstrual cycle disorders (Absent and irregular periods)”).
Calcitonin — Calcitonin is a hormone produced by the thyroid gland that, together with parathyroid hormone, helps to regulate calcium concentrations in the body. Synthetic calcitonin is sometimes recommended as a treatment for osteoporosis. Calcitonin may be administered via nasal spray or injection (subcutaneous salmon calcitonin). Nasal administration is typically preferred due to ease of use and because the injections tend to cause more nausea and flushing. (See “Calcitonin in the prevention and treatment of osteoporosis”).
Other drugs are usually recommended before calcitonin because it is not clear if calcitonin increases bone density and decreases the fracture rate outside the spine. However, due to its pain-relieving (analgesic) effects, calcitonin may be suggested as a first-line therapy for those who have a sudden, intense (acute) onset of pain due to vertebral fractures. The treatment regimen is typically changed once the acute pain subsides or if the pain fails to subside over a prolonged period (eg, four weeks).
Parathyroid hormone (PTH) — PTH is produced by the parathyroid glands and stimulates both bone resorption and new bone formation. Intermittent administration stimulates formation more than resorption. Clinical trials suggest that PTH therapy is effective in both the prevention and treatment of osteoporosis in postmenopausal women and in men.
A PTH preparation called Forteo®, given by daily injection for two years, is approved for the treatment of severe osteoporosis. It is more effective at building spine bone density than any other treatment, although it is unclear if it also prevents fracture better than other treatments (specifically, the bisphosphonates). Because it requires a daily injection and is expensive, it is usually reserved for patients with severe hip or spine osteoporosis (T score <-2.5 AND an osteoporosis-related fracture). It is not recommended for premenopausal women. MONITORING RESPONSE TO TREATMENT — Testing may be recommended to monitor a person's response to osteoporosis therapy. This may include measurement of bone mineral density (DXA scan) or laboratory tests that indicate bone turnover (ie, rate of new bone formation and breakdown). (See "Patient information: Bone density testing"). SUMMARY Osteoporosis causes bones to become abnormally thin (osteopenic), weakened, and easily broken. This condition can be treated and prevented with diet, exercise, and stopping smoking. Calcium and vitamin D can prevent and treat thinning bones. The main dietary sources of calcium include milk and other dairy products, such as cottage cheese, yogurt, or hard cheese, and green vegetables, such as spinach and broccoli (show table 1). Milk is the primary source of dietary vitamin D, containing approximately 100 IU per cup. Calcium and vitamin D can also be taken as a supplement (eg, in a pill, show table 2). A total of at least 1000 mg of calcium per day is recommended for premenopausal women and men. Women after menopause should consume 1200 to1500 mg calcium per day. Experts also recommend 800 International Units (IU) of vitamin D each day. Exercise can help to prevent and treat thinning bones. Exercise should be done for at least 30 minutes three times per week. Any weight-bearing exercise regimen is appropriate (eg, walking). Smoking cigarettes can cause bones to become thinner and weaker. Stopping smoking can reduce this risk. Falling can cause fractures in the elderly. Preventing falls can lower the risk of fractures. Some medications can cause bone thinning. Such medications include glucocorticoid medications (eg, prednisone), heparin, vitamin A and certain synthetic retinoids (eg, etretinate), and certain antiepileptic drugs (eg, phenytoin, carbamazepine, primidone, phenobarbital, and valproate). You should talk to your provider about the risk of bone thinning if you take one of these medications (see "Medication monitoring" above). There are several medications that help prevent osteoporosis in women after menopause. We think alendronate (Fosamax®), risedronate (Actonel®), or raloxifene (Evista®) are the best medications for prevention (see "Bisphosphonates" above). Alendronate (Fosamax®) or risedronate (Actonel®) are recommended to treat women after menopause who have osteoporosis (see "Bisphosphonates" above). Zoledronic acid (Reclast®) or raloxifene (Evista®) may be suggested for patients who cannot tolerate oral bisphosphonates, or who have difficulty taking the medication, including an inability to sit upright for 30 to 60 minutes Parathyroid hormone (Forteo®) is another medication that can be used to treat osteoporosis. We recommend this medication for men or postmenopausal women with severe hip or spine osteoporosis (see "Parathyroid hormone (PTH)" above). Hormone replacement (eg, estrogen, progesterone) is not usually recommended to prevent osteoporosis in women after menopause. Hormone therapy is recommended for some young women who do not have a monthly menstrual period (see "Estrogen/progestin therapy" above). Testing may be recommend to monitor how the bones respond to osteoporosis treatment. This may include a bone density scan (DXA) or laboratory tests. (See "Patient information: Bone density testing"). WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation. This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information. A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine (www.nlm.nih.gov/medlineplus/healthtopics.html) Osteoporosis and Related Bone Diseases National Resource Center Toll-free: (800) 624-BONE (2663) TTY: (202) 466-4315 (www.osteo.org) National Osteoporosis Foundation Phone: (202) 223-2226 (www.nof.org) National Women's Health Resource Center (NWHRC) Toll-free: (877) 986-9472 (www.healthywomen.org) Osteoporosis Society of Canada Phone: (416) 696-2663 x 294 (www.osteoporosis.ca/) The Hormone Foundation (www.hormone.org/public/osteoporosis.cfm, available in English, Spanish, French, Italian, German, and Portuguese) [1-6] Use of UpToDate is subject to the Subscription and License Agreement . REFERENCES 1 Lyles, KW, Colon-Emeric, CS, Magaziner, JS, et al. Zoledronic Acid and Clinical Fractures and Mortality after Hip Fracture. N Engl J Med 2007; :. 2 Delmas, PD, Bjarnason, NH, Mitlak, BH, et al. Effects of raloxifene on bone mineral density, serum cholesterol concentrations, and uterine endometrium in postmenopausal women. N Engl J Med 1997; 337:1641. 3 Rossouw, JE, Anderson, GL, Prentice, RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA 2002; 288:321. 4 Fulton, JP. New guidelines for the prevention and treatment of osteoporosis. National Osteoporosis Foundation. Med Health R I 1999; 82:110. 5 Gregg, EW, Cauley, JA, Seeley, DG, et al. Physical activity and osteoporotic fracture risk in older women. Ann Intern Med 1998; 129:81. 6 NIH Consensus Development Panel on Optimal Calcium Intake. Optimal calcium intake. JAMA 1994; 272:1942. ©2009 UpToDate® • customerservice@uptodate.com www.uptodate.com