• What is osteoporosis?
• What are the symptoms of osteoporosis?
• What are the consequences of osteoporosis?
• Why is osteoporosis an important public health issue?
• What factors determine bone strength?
• What are the risk factors for developing osteoporosis?
• How is osteoporosis diagnosed?
• Who should have bone density testing?
• How is osteoporosis treated and prevented?
  • Exercise, quitting cigarettes, and curtailing alcohol
  • Calcium supplements
  • Vitamin D
  • Estrogen Replacement Therapy
  • Medications that prevent bone loss and breakdown
  • Choosing an osteoporosis medication
  • Prevention of osteoporosis caused by long term corticosteroids
  • Monitoring osteoporosis therapy - (the controversy of bone density testing in patients already taking osteoporosis medication)
• Prevention of hip fractures in elderly persons with osteoporosis
• The Future
• Osteoporosis At A Glance

What is osteoporosis?

Osteoporosis is condition that features loss of the normal density of bone. Osteoporosis leads to literally abnormally porous bone that is more compressible like a sponge than dense like a brick. This disorder of the skeleton weakens the bone leading to an increase in the risk of breaking bones (bone fracture).

Normal bone is composed of protein collagen and calcium. Osteoporosis depletes both the calcium and the protein from the bone, resulting in either abnormal bone quality or decreased bone density . Bones that are affected by osteoporosis can fracture with only a minor fall or injury that normally would not cause a bone fracture. The fracture can be either in the form of cracking (as in a hip fracture ) or collapsing (as in a compression fracture of the vertebrae of the spine). The spine, hips, and wrists are common areas of osteoporosis-related bone fractures, although fractures can also occur in other skeletal areas such as the ribs.

What are the symptoms of osteoporosis?

The osteoporosis process can operate silently for decades. Some osteoporosis fractures may escape detection until years later. Patients may not thus be aware of their osteoporosis until suffering a painful fracture. Then the symptoms are related to the location of the fractures.

Fractures of the spine (vertebra) can cause severe "band-like" pain that radiates around from the back to both sides of the body. Over the years, repeated spine fractures can cause chronic back pain as well as loss of height or curving of the spine, which gives the individual a hunched-back appearance.

A fracture that occurs during the course of normal activity is called a stress fracture. For example, some patients with osteoporosis develop stress fractures of the feet while walking or stepping off a curb.

Hip fractures usually occur as a result of a fall. With osteoporosis, hip fractures can occur as a result of trivial accidents. Hip fractures may also be difficult to heal after surgical repair because of poor bone quality.

What are the consequences of osteoporosis?

Osteoporosis bone fractures are responsible for considerable pain, decreased quality of life, lost workdays, and disability. Up to 30% of patients suffering a hip fracture will require long term nursing home care. Elderly patients can further develop pneumonia and blood clots in the leg veins that can travel to the lungs ( pulmonary embolism ) due to prolonged bed rest after a hip fracture. Some 20% of women with a hip fracture will die in the subsequent year as an indirect result of the fracture. In addition, once a person has experienced a spine fracture due to osteoporosis, he or she is at very high risk of suffering another such fracture in the near future (next few years).

Why is osteoporosis an important public health issue?

In the United States, more than 10 million people have osteoporosis of the hip and almost 19 million more have low hip bone density. Between 4 to 6 million postmenopausal white women have osteoporosis, and an additional 13 to 17 million have low hip bone density. One in two white women will experience a bone fracture due to osteoporosis in her lifetime. In 1993, the United States incurred an estimated loss of 10 billion dollars due to loss of productivity and health care costs related to osteoporosis. With the aging of America, the number of people with osteoporosis related fractures will increase exponentially. The pain, suffering, and economic costs will be enormous.

What factors determine bone strength?

Bone mass (bone density) is the amount of bone present in the skeletal structure. The higher the density is, the stronger are the bones. Bone density is primarily determined by genetic factors, which can modified by environmental factors and medications. For example, men have a higher bone density than women. Black Americans have a higher bone density than white or Asian Americans.

Normally, bone density accumulates during childhood and reaches a peak by around age 25. Bone density is then maintained for about ten years. After age 35, both men and women will normally lose 0.3 to 0.5% of their bone density per year as part of the aging process.

Estrogen is important in maintaining bone density in women. When estrogen levels drop after menopause , bone loss accelerates. During the first five to ten years after menopause, women can suffer up to two to four percent loss of bone density per year! This can result in the loss of up to 25 to 30% of their bone density during that time period. Accelerated bone loss after menopause is a major cause of osteoporosis in women.

What are the risk factors for developing osteoporosis?

Factors that will increase the risk of developing osteoporosis are:

1. Female gender, Caucasian or Asian race, thin and small body frames, and a family history of osteoporosis. (Having a mother with an osteoporotic hip fracture doubles your risk of hip fracture.)
2. Cigarette smoking , excessive alcohol and caffeine consumption, lack of exercise, and a diet low in calcium.
3. Poor nutrition and poor general health.
4. Malabsorption (nutrients are not properly absorbed from the gastrointestinal system) from conditions such as Celiac  Sprue .
5. Low estrogen levels such as occur in menopause or with early surgical removal of both ovaries. Another cause of low estrogen level is chemotherapy , such as for breast cancer . Chemotherapy can cause early menopause due to its toxic effects on the ovaries.
6. Amenorrhea   (loss of the menstrual period) in young women also causes low estrogen and osteoporosis. Amenorrhea can occur in women who undergo extremely vigorous training and in women with very low body fat (example: anorexia nervosa ).
7. Chronic diseases such as rheumatoid arthritis and chronic hepatitis C , an infection of the liver.
8. Immobility, such as after a stroke , or from any condition that interferes with walking.
9. Hyperthyroidism , a condition wherein too much thyroid hormone is produced by the thyroid gland (as in Grave's disease) or is caused by taking too much thyroid hormone medication.
10. Hyperparathyroidism, a disease wherein there is excessive parathyroid hormone production by the parathyroid gland (a small gland located near the thyroid gland). Normally, the parathyroid hormone maintains blood calcium levels by, in part, removing calcium from the bone. In untreated hyperparathyroidism, excessive parathyroid hormone causes too much calcium to be removed from the bone, which can lead to osteoporosis.
11. Vitamin D deficiency. Vitamin D helps the body absorb calcium. When vitamin D is lacking, the body cannot absorb adequate amounts of calcium to prevent osteoporosis. Vitamin D deficiency can result from lack of intestinal absorption of the vitamin such as occurs in celiac sprue and primary biliary cirrhosis.
12. Certain medications can cause osteoporosis. These include heparin (a blood thinner), anti-seizure medications phenytoin (Dilantin) and phenobarbital, and long term use of corticosteroids (such as Prednisone ).

How is osteoporosis diagnosed?

A routine x-ray can reveal osteoporosis of the bone, which appears much thinner and lighter than normal bones. Unfortunately, by the time x-rays can detect osteoporosis, at least 30% of the bone has already been lost. In addition, x-rays are not accurate indicators of bone density. The appearance of the bone on x-ray is often affected by variations in the degree of exposure of the x-ray film.

The National Osteoporosis Foundation, the American Medical Association, and other major medical organizations are recommending a dual energy x-ray absorptometry (DEXA) scan for diagnosing osteoporosis. DEXA measures bone density in the hip and the spine. The test takes only 5 to 15 minutes to perform, uses very little radiation (less than one tenth to one hundredth the amount used on a standard chest x-ray ), and is quite precise.

The bone density of the patient is then compared to the average peak bone density of young adults of same sex and race. Osteoporosis is defined as bone density of more than 25% below the average peak bone density of young adults of the same sex and race. Osteopenia (a milder form of bone loss than osteoporosis) is defined as bone density of between 10% to 25% below the average peak bone density of young adults of the same sex and race.

Who should have bone density testing?

The National Osteoporosis Foundation guidelines state that there are several groups of people who should consider DEXA testing:

1. All postmenopausal women below age 65 who have risk factors for osteoporosis.
2. All women aged 65 and older.
3. Postmenopausal women with fractures, although this is not mandatory because treatment may well be started regardless of bone density.
4. Women whose decision to use medication might be aided by bone density testing.

The National Osteoporosis Foundation guidelines state that bone density testing does not need to be performed if a person has a known spine fracture because the condition will be treated with or without bone density results. In addition, bone density testing is not appropriate if the person undergoing the test is not willing to take any treatment based on the results. Therefore, if bone density testing is done, it should be performed on people willing to be treated if need be, based on the results.

How is osteoporosis treated and prevented?

The goal of osteoporosis treatment is the prevention of bone fractures by stopping bone loss and by increasing bone density and strength. Although early detection and timely treatment of osteoporosis can substantially decrease the risk of future fracture, none of the available treatments for osteoporosis are complete cures. In other words, it is difficult to completely rebuild bone that has been weakened by osteoporosis. Therefore, prevention of osteoporosis is as important as treatment. Osteoporosis treatment and prevention measures are:

1. Life style changes including quitting cigarette smoking, curtailing alcohol intake, exercising regularly, and consuming a balanced diet with adequate calcium and vitamin D.
2. Estrogen replacement therapy for postmenopausal women and women with other low estrogen conditions.
3. Medications that stop bone loss and increase bone strength, such as alendronate (Fosamax), risedronate (Actonel), raloxifene (Evista), calcitonin (Calcimar), and teriparatide (Forteo).

Exercise, quitting cigarettes, and curtailing alcohol

Exercise has a wide variety of beneficial health effects. However, exercise does not bring about substantial increases in bone density. The benefit of exercise for osteoporosis has mostly to do with decreasing the risk of falls, probably because balance is improved or muscle strength is increased. Research has not yet determined what type of exercise is best for osteoporosis or for how long. Until research has answered these questions, most doctors recommend weight-bearing exercise, such as walking, preferably daily.

A word of caution about exercise: it is important to avoid exercises that can injure already weakened bones. In patients over 40 and those with heart disease , obesity , diabetes mellitus , and high blood pressure , exercise should be prescribed and monitored by their doctors. Finally, extreme levels of exercise (such as marathon running) may not be healthy for the bones. Marathon running in young women that leads to weight loss and loss of menstrual periods can actually cause osteoporosis.

Smoking one pack of cigarettes per day throughout adult life can itself lead to loss of 5% to 10% of bone mass. Smoking cigarettes decreases estrogen levels and can lead to bone loss in women before menopause. Smoking cigarettes can also lead to earlier menopause and increase the risk of osteoporosis. Smoking cigarettes can also negate the protective effect of estrogen replacement therapy on bone in postmenopausal women. Therefore, nobody should smoke, regardless of the current condition of his or her bones.

Data on the effect of regular consumption of alcohol and caffeine on osteoporosis is not as clear as with exercise and cigarettes. More than two drinks of alcohol a day may increase bone loss. More than 2 cups of coffee daily can also cause bone loss. These effects do not seem to be as powerful as other factors. Nevertheless, moderation of both alcohol and caffeine is prudent.

Calcium Supplements

Building strong and healthy bones requires an adequate dietary intake of calcium and exercise beginning in childhood and adolescence for both sexes. Most importantly, however, a high dietary calcium intake or taking calcium supplements alone is not sufficient in treating osteoporosis, and should not be viewed as an alternative to or substituted for more potent medications such as estrogens or medications that prevent bone breakdown. In the first several years after menopause, rapid bone loss can occur even if calcium supplements are taken.

The following calcium intake has been recommended by The National Institutes of Health Consensus Conference on Osteoporosis for all people, with or without osteoporosis:

1. 800 mg/day for children ages 1 to 10
2. 1000 mg/day for men, premenopausal women, and postmenopausal women also taking estrogen
3. 1200 mg/day for teenagers and young adults ages 11 to 24
4. 1500 mg/day for post menopausal women not taking estrogen
5. 1200mg to 1500 mg/day for pregnant and nursing mothers
6. The total daily intake of calcium should not exceed 2000 mg.

Daily calcium intake can be calculated by the following method:

1. Excluding dairy products, the average American diet contains approximately 250 mg of calcium.
2. There is approximately 300 mg of calcium in an 8-ounce glass of milk or yogurt, or 16 ounces of cottage cheese.
3. A person on an average American diet who also drinks one glass (8 ounces) of milk will receive an estimated 550 mg of calcium.
4. A person on an average American diet who drinks two glasses of milk (or one glass of milk and 16 ounces of cottage cheese) will receive 850 mg of calcium.

Unfortunately, surveys have shown that average women in the United States are consuming less than 500 milligrams of calcium per day in their diet, less than the recommended amounts. Additional calcium can be obtained by drinking more milk and eating more yogurt or cottage cheese, or by taking calcium supplement tablets as well from calcium-fortified foods, such as orange juice.

The various calcium supplements contain different amounts of elemental calcium (the actual amount of calcium in the supplement). For example, Caltrate, Os-Cal and Tums are calcium carbonate salts. Each 1250 mg of calcium carbonate salt tablet (such as Caltrate 600 mg, Os-Cal 500 mg, or Tums 500 mg extra strength) contains 500 mg of elemental calcium. A person who needs 1000 mg/day of calcium supplement can take one tablet of Tums 500 mg extra strength (containing 500 mg of elemental calcium) twice daily with meals.

The calcium supplements are best taken in small divided doses with meals. The intestines may not be able to reliably absorb more than 500 mg of calcium all at once. Therefore, the best way to take 1000 mg of a calcium supplement is to divide it in two doses. Likewise, a dosage of 1500 mg should be divided into three doses.

Calcium supplements are safe and generally well tolerated. Side effects are indigestion and constipation. If constipation and indigestion occur with calcium carbonate supplements, calcium citrate (Citracal) can be used. Certain medications, such as proton-pump inhibitors (Prilosec, Prevacid, Protonix, and Aciphex), which are used in treating GERD (acid reflux) or peptic ulcers, can interfere with the absorption of calcium carbonate. In these cases, calcium citrate is preferred.

Many "natural" calcium carbonate preparations, such as oyster shells or bone meal, may contain high levels of lead and probably should not be used.

Vitamin D

An adequate calcium intake and adequate body stores of vitamin D are important foundations for maintaining bone density and strength. However, vitamin D and calcium alone are not sufficient treatment for osteoporosis. They are given in conjunction with other treatments. Vitamin D is important in several respects:

1. Vitamin D helps the absorption of calcium from the intestines.
2. A lack of vitamin D causes calcium-depleted bone ( osteomalacia ), which further weakens the bones and increases the risk of fractures.
3. Vitamin D, along with adequate calcium (1200 mg of elemental calcium), has been shown in some studies to increase bone density and decrease fractures in postmenopausal, but not in premenopausal women.
4. Furthermore, osteoarthritis (degenerative arthritis) of the knees appears to be worse in patients who are deficient in vitamin D. Patients with osteoarthritis whose body stores of vitamin D are relatively low may benefit from an increased vitamin D intake or sunlight exposure.

Vitamin D comes from the diet and the skin. Vitamin D production by the skin is dependent on exposure to sunlight. Active people living in sunny regions (Southern California, Hawaii, countries around the equator, etc.) can produce most of the vitamin D they need from their skin. Conversely, lack of exposure to sunlight, due to residence in northern latitudes or physical incapacitation, causes vitamin D deficiency. In less temperate regions such as Minnesota, Michigan, and New York, skin production of vitamin D is markedly diminished in the winter months, especially among the elderly. In that population, dietary vitamin D becomes important.

Unfortunately, vitamin D deficiency is quite common in the United States. In a study of hospitalized patients in a general medical ward, vitamin D deficiency was detected in 57% of the patients. An estimated 50% of elderly women consume far less vitamin D in their diet than is recommended.

The Food and Nutrition Board of the Institute of Medicine has recommended the following as an as adequate vitamin intake: 200 IU daily for men and women 19 to 50 years old, 400 IU daily for men and women 51 to 70 years old, and 600 IU daily for men and women 71 years and older.

An average multivitamin tablet contains 400 IU of vitamin D. Therefore, one to two multivitamins a day should provide the recommended amount of vitamin D. Alternatively, vitamin D can be obtained in combination with calcium in tablet forms, such as Caltrate 600 + D (600 mg of calcium and 200 IU of vitamin D) and others.

Chronic excessive use of vitamin D, especially above 2000 units/day, can lead to toxic levels of vitamin D, elevated calcium levels in blood and urine, and may also cause kidney stones. Since various dietary supplements may also contain vitamin D, it is important to review vitamin D content in dietary supplements before taking additional vitamin D.

Estrogen Replacement Therapy

Estrogen hormone replacement therapy  (HRT) has been shown to prevent bone loss, increase bone density, and prevent bone fractures. It is useful in both preventing and treating osteoporosis in postmenopausal women. Estrogen is available orally (Premarin , Estrace, Estratest , and others) or as a skin patch (Estraderm, Vivelle, and others). Estrogen is also available in combination with progesterone as pills and patches. Progesterone is routinely given along with estrogen to prevent uterine cancer that might result from estrogen use alone. Women who have had a hysterectomy (surgical removal of the uterus) may take estrogen alone. Also being studied are nasally delivered estrogen and lower-dose combination pills of estrogen and progesterone.

Estrogen replacement therapy is usually safe and well tolerated. The risks of estrogen that are being studied and are still controversial at this time include breast cancer, stroke, and blood (venous) clots in the legs. Therefore, every woman needs to have an individualized discussion regarding estrogen replacement with her doctor because each woman will have a different balance of risk and benefit expected from estrogen replacement therapy.

Medications That Prevent Bone Loss and Breakdown

Currently, the most significant medications for osteoporosis and the only ones approved by the FDA for use in the United States are the anti-resorptive agents, which prevent bone breakdown. The bone is a living dynamic structure; it is constantly being removed (resorbed) and rebuilt. This process is an essential part of maintaining the normal calcium level in the blood. When the rate of resorption exceeds that of rebuilding over time, osteoporosis results. Anti-resorptive medications inhibit bone removal (resorption), thus tipping the balance in favor of bone rebuilding and increasing bone density. Estrogen replacement therapy is one example of an anti-resorptive agent. Others include alendronate (Fosamax), risedronate (Actonel), raloxifene (Evista), calcitonin (Calcimar), and parathyroid hormone/teriparatide (Forteo).

Alendronate (Fosamax) is a biphosphonate anti-resorptive medication. Alendronate is approved for the prevention and treatment of postmenopausal osteoporosis as well as for osteoporosis that is caused by cortisone-related medications (glucocorticoid-induced osteoporosis). Alendronate has been shown to increase bone density and reduce fractures in the spine, hips, and arms. In addition, a new once-a-week dose schedule has been approved for alendronate to prevent and treat postmenopausal osteoporosis. Alendronate is the first osteoporosis medication also approved for increasing bone density in men with osteoporosis, either in a daily or a weekly dose schedule.

Alendronate is generally well tolerated with few side effects. One side effect of alendronate is irritation of the esophagus (the food pipe connecting the mouth to the stomach). Inflammation of the esophagus (esophagitis) and ulcers of the esophagus have been reported infrequently with alendronate use.

To reduce side effects and to enhance abortion of the medicine, alendronate should be taken in the morning, on an empty stomach, thirty minutes before breakfast, and with at least 8 ounces (240 ml) of water. Taking the pill sitting or standing minimizes the chances of the pill being lodged in the esophagus. Patients should also remain upright for at least 30 minutes after taking the pill to avoid reflux of the pill into the esophagus.

Risedronate (Actonel) is another bisphosphonate anti-resorptive medication. Like alendronate, this drug it is approved for the prevention and treatment of postmenopausal osteoporosis as well as for osteoporosis that is caused by cortisone-related medications (glucocorticoid-induced osteoporosis). Risedronate is chemically different from alendronate and has less likelihood of causing esophagus irritation. Risedronate is also more potent in preventing the resorption of bone than alendronate.

Food, calcium, iron supplements, vitamins with minerals, or antacids containing calcium, magnesium , or aluminum can reduce the absorption of risedronate, thereby resulting in loss of effectiveness. Therefore, risedronate should be taken with plain water only in the morning before breakfast. Also, no food or drink should be taken for at least 30 minutes afterwards.

Raloxifene (Evista) belongs to a class of new drugs called selective estrogen receptor modulators (SERMs). SERMs work like estrogen in some tissues but not like estrogen in other tissues. The SERMs are developed to reap the benefits of estrogen while avoiding the potential side effects of estrogen. Thus, raloxifene can act like estrogen on bone, but not like estrogen on the lining of the uterus.

The first SERM to reach the market was tamoxifen , which blocks the stimulative effect of estrogen on breast tissue. Tamoxifen has proven valuable in women who have had cancer in one breast in preventing cancer in the second breast. Raloxifene is the second SERM to be approved by the FDA. Raloxifene has been approved for the prevention and treatment of osteoporosis in postmenopausal women. In a tow year study involving some 600 postmenopausal women, raloxifene was found to increase bone density and lower LDL cholesterol, while having no stimulative effect on the uterine lining (which means that it is unlikely to cause uterine cancer).

The most common side effects with raloxifene are hot flashes . Raloxifene also increases the risk of blood clots, including deep vein thrombosis (DVT) and pulmonary embolism (blood clots in the lung). The greatest increase in risk occurs during the first 4 months of use. Patients taking raloxifene should avoid prolonged periods of immobility during travel, when blood clots are more prone to occur. The risk of DVT with raloxifene is probably comparable to that of estrogen, about 2 to 3 times higher than the usual low occurrence rate.

Calcitonin (Calcimar, Miacalcin) is a hormone that has been approved by the FDA in the United States for treating osteoporosis. Calcitonins come from several animal species, but salmon calcitonin is the one most widely used. Calcitonin can be administered as a shot under the skin (subcutaneously) or into the muscle (intramuscularly), or inhaled nasally (intranasally). Intranasal calcitonin is the most convenient of the three methods.

Calcitonin has been shown to prevent bone loss in postmenopausal women. In women with established osteoporosis, calcitonin has been shown to increase bone density and strength in the spine only.

One unique benefit of calcitonin is its short term relief of pain immediately after an osteoporosis-related bone fracture. Several studies have shown that calcitonin can decrease pain and the need for pain medications in patients with recent painful fractures.

Calcitonin is not as effective in increasing bone density and strengthening bone as estrogen and the other anti-resorptive agents. Therefore, aside from the situation of a recent painful fracture, calcitonin is not the first choice of treatment in women with established osteoporosis. Nevertheless, calcitonin is a helpful alternative osteoporosis treatment for patients who cannot tolerate other medications.

Common side effects of either injected or nasal spray calcitonin are nausea and flushing. Patients using Miacalcin Nasal Spray can develop nasal irritations, a runny nose, or nosebleeds. Injectable calcitonin can cause local skin redness at the site of injection, skin rash, and flushing.

Teriparatide (Forteo) is a synthetic version of the human hormone, parathyroid hormone, which helps to regulate calcium metabolism. It promotes the growth of new bone, while the other osteoporosis medications improve bone density by inhibiting bone resorption. Teriparatide (Forteo) is self-injected into the skin.

Fluoride is unique in that it also stimulates bone formation. However, the bone formed by fluoride stimulation appears to be weaker than normal bone and may be more prone to fracture. Fluoride is being perfected to ensure that it decreases the incidence of fracture. Fluoride also causes frequent side effects such as stomach upset and pain in the joints and lower extremities. Fluoride is not a FDA approved treatment for osteoporosis in the United States.

Even though a recent study suggests that using a slow release fluoride preparation in lower doses may be better tolerated and more effective in building stronger bone and reducing bone fractures in the spine, there is still insufficient data to recommend fluoride as a treatment for osteoporosis.

Choosing an osteoporosis medication

In choosing a medication for osteoporosis, a doctor will take into account all aspects of a patient's medical history and the severity of the osteoporosis.

If a postmenopausal woman has other menopausal symptoms such as hot flashes and vaginal dryness, estrogen will be the proper choice for these menopausal symptoms as well as for the prevention of osteoporosis. After the menopause symptoms have passed, estrogen or some other osteoporosis medication will be considered for the longterm.

If the prevention and treatment of osteoporosis is the only issue under consideration, then bisphosphonates such as alendronate and risedronate are equally as effective as estrogen replacement.

In patients with GERD or who have symptoms of heartburn, risedronate may prove to cause less irritation to the esophagus than alendronate.

Calcitonin is a weaker anti-resorptive medication than estrogen, alendronate (Fosamax), and risedronate (Actonel). It is reserved for those who cannot take or will not consider taking the other medications. Raloxifene is also a weaker medication in improving bone density than estrogen, alendronate (Fosamax), and risedronate (Actonel). Thus, in patients with moderate to severe osteoporosis, it is important to use the more potent anti-resorptive medications. The safety and effectiveness of more than 3 years of raloxifene use have not been well-researched.

Estrogen replacement and raloxifene differ in their side effects and also in their effects on cholesterol panels. For example, raloxifene does not raise the "good HDL cholesterol ," but estrogen replacement does. They both lower the "bad LDL cholesterol."

Prevention of osteoporosis due to long term corticosteroids

The long term use of corticosteroids (such as Prednisone, Cortisone , and Prednisolone ) can lead to osteoporosis. Corticosteroids cause decreased calcium absorption from the intestines, increased loss of calcium from the kidneys, and increased calcium loss from the bones. To prevent bone loss while on long term corticosteroids, patients should:

1. Have an adequate calcium (1000 mg daily if premenopausal, 1500 mg daily if postmenopausal) and vitamin D intake. (Calcium alone without vitamin D does not prevent bone loss from corticosteroids.)
2. Discuss with the doctor about using either alendronate or risedronate, both of which have been approved for the prevention and treatment of corticosteroid-induced osteoporosis.
3. Patients embarking on long term corticosteroids should discuss with their doctor regarding DEXA bone density scan prior to beginning therapy and careful monitoring for osteoporosis during therapy.

Monitoring osteoporosis therapy - (the controversy of bone density testing in patients already taking osteoporosis medication)

The American Medical Association and other reputable medical organizations have determined that repeat bone density testing (DEXA scans) is NOT helpful in monitoring osteoporosis treatment or prevention. It is scientifically premature to measure bone density as a way of monitoring osteoporosis medications. Doctors simply do not know how to use these repeat bone density measurements during therapy. The reasons are:

1. First, bone density changes so slowly with treatment that the changes are smaller than the measurement error of the machine. In other words, repeat DEXA scans cannot distinguish between a real increase in bone density due to treatment or a mere variation in measurement from the machine itself.

2. Second, the real purpose of osteoporosis treatment is to decrease future bone fractures. There is no good correlation between increases in bone density with decreases in fracture risks with treatment. For example, alendronate has been shown to decrease fracture risk by 50%, but only to increase bone density by a few percent.

3. Third, bone density measurement taken during treatment will not help the doctor plan or modify treatment. For example, even if the DEXA scan shows continued deterioration in bone density during treatment, there is not yet research data demonstrating that changing a medication, combining medications, or doubling medication doses will be safe and helpful in decreasing the future risk of fractures.

4. Fourth, and very important, even if bone density deteriorates during treatment, it is quite likely that the patient would have lost even more bone density without treatment.

5. Fifth, recent research has shown that women who lose bone density after the first year of hormone replacement therapy will gain bone density in the next two years, whereas women who gain in the first year will tend to lose density in the next two years of therapy. Therefore, bone density during treatment naturally fluctuates and this may not be relevant to the fracture protection of the medication.

For all of these reasons, bone density testing during treatment is not considered helpful. In the future, however, if ongoing research shows us how to adjust these medication doses or use them in combinations to maximize fracture prevention, testing decisions will clearly change.

Prevention of hip fractures in elderly persons with osteoporosis

The FDA has approved hip protector garments for the prevention of hip fractures in the elderly persons with known osteoporosis. Brand names available include Hipsaver and Safehip. These can be especially helpful for selected patients who are in the nursing home environment.

The Future

Osteoporosis research is expanding rapidly. The future will bring many new effective treatments for the costly disease. For example, injections of the hormone, parathyroid hormone, have been shown to significantly increase the low bone density from osteoporosis. This new treatment is not yet commercially available. Parathyroid hormone treatment will require daily injections into the skin and has already demonstrated promising results in both men and women with osteoporosis.

Osteoporosis At A Glance

• Osteoporosis refers to thinning of bone (decreasing bone mass and density) resulting from depletion of bone calcium and protein.
• Osteoporosis weakens bone, and increases risk of bone fracture.
• Bone mass (bone density) decreases after age 35 years, and decreases more rapidly in women after menopause.
• Risk factors for osteoporosis include genetics, lack of exercise, lack of calcium and vitamin D, lack of estrogen, cigarettes and alcohol, and certain medications.
• Patients with osteoporosis have no symptoms until bone fractures occur.
• Diagnosis can be suggested by x-rays and confirmed by using tests to measure bone density.
• Treatments for osteoporosis include stopping alcohol and cigarettes, exercise, calcium, vitamin D, estrogen, and medications to increase bone density.

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