Monday, May 20, 2013
Osteoporosis, the most common metabolic bone disease, can be defined as a disorder of low bone mass causing bones to become thin, weak, and brittle. Osteopenia refers to the disease where bone density is lower than normal but not severe enough to meet criteria for osteoporosis.
Peak bone mass is usually reached between the ages of eighteen and thirty because of calcium and estrogen’s effects on the skeleton. Approximately around the age of forty, bone will start to break down faster than it is replaced, therefore causing decrease in bone mass. This is especially in the first five years after menopause when estrogen levels quickly decline.
This deterioration in the skeleton can result in an increased incidence of fractures. Osteoporosis is a major public health problem that can result in low-trauma or fragility fractures, which cause substantial disability, rising health care costs, and morbidity among postmenopausal women and older men.
Dr. Cadet points out that “This condition is not acutely life threatening but can lead to debilitating fractures of the hip and spine along with various complications. These fractures may result in long hospitalization and rehabilitation periods leading to decreased future ambulation.” She emphasizes that complications from an osteoporotic fracture may significantly impact a patient’s daily activities and quality of life.
It is crucial to identify patients who are at risk for falls and fractures secondary to minor trauma. Some osteoporotic fractures may escape detection for years since most patients may not be aware of their osteoporosis and remain asymptomatic until they suffer a painful fracture. Osteoporosis is often referred to as a “silent disease”. Early diagnosis and treatment can lower a patient’s risk for fractures in the spine, hips, wrists and other sites.
Symptoms of Osteoporosis:
1) Moderate to severe back pain
2) Loss of height
3) Change of posture
4) Change in upper spine curvature or development of a “hump” in the upper back
5) No symptoms at all
1) Age (increased risk with older age, especially after fifth decade)
2) Gender (females are more at risk)
3) Ethnicity (Caucasian and Asian females have higher risk)
4) Early age of menopause
5) Low bone mineral density detected by DEXA
6) Prior fractures and falls (in patient’s personal history)
7) Family hip fracture history
8) Body mass index (very thin people have more risk)
9) Smoking and alcohol use (more than 2 drinks of alcohol several times a week)
10) Steroid use for asthma, pulmonary disease, or autoimmune disease
11) Chronic Diseases:
a) rheumatoid arthritis
b) thyroid disease
c) chronic lung disease
e) inflammatory bowel disease
f) Cushing’s disease
g) multiple sclerosis
Other factors to be considered include vitamin D deficiency, inactive lifestyle, certain medications, low estrogen and testosterone levels, and loss of height.
Vitamin D and Bone Health
Vitamin D is a crucial element involved in bone metabolism and calcium, phosphorous, and magnesium absorption.
Vitamin D deficiency can result in osteoporosis, postural instability leading to frequent falls, bone pain, abnormalities in immune function, and possibly may play a role in cardiovascular health and cancer prevention.
Usually, vitamin D can be obtained from sunlight and certain foods, however, many females have be found to be deficient in this vitamin. The active form of vitamin D is converted in the liver and kidney. Since excessive sun exposure is not recommended secondary to fear of skin malignancy, women and men are encouraged to obtain extra fat soluble vitamin D from other sources such as cod liver oil, fish oil, fortified dairy products (milk, orange juice, yogurt) and over the counter or prescribed supplements. The usual recommended dose for vitamin D3 is 400 to 800 international units (IU).
Some older patients or individuals with certain medical conditions who suffer from moderate to severe deficiency may require higher doses (1000IU, to 50,000IU).
These medical conditions may include:
b)intestinal condition ( such as malabsorption, Inflammatory Bowel Disease, Celiac Disease)
d)conditions requiring steroid use and seizure medications
Ask your physician to check your vitamin D level through a blood test and treat according to level. Repeat levels should be checked to avoid vitamin D toxicity, which can lead to high calcium levels in the blood and urine, kidney stones, muscle weakness, bone pain, confusion, and vomiting.
Every patient who thinks that she or he may be at risk for osteoporosis should have the physician obtain a painless bone density test (DEXA). It measures the bone mass in the hip, spine, wrist, heel, or hand.
DEXA scan will give provide the patient with a T score:
T score Diagnosis
+1 to -1 Normal bones
-1 to -2.5 osteopenia
-2.5 or lower osteoporosis
Recently the World Health Organization (WHO) has created a tool called FRAX, which can be utilized to make a treatment decision by using bone mineral density as well as factors such as weight, height, calcium and vitamin D status, smoking and alcohol intake, family history and and country-specific fracture and mortality data to quantify a patient's 10-year probability of a hip or major osteoporotic fracture. Once the patient’s risk is determined, she will be asked to participate in a prevention and/or treatment program.
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Prevention and treatment of osteoporosis
This involves a complex regimen which includes pharmacologic and non pharmacologic interventions. Patients are able to reduce the risk for further bone loss. Diet and weight-bearing exercises can help make bones stronger. Lifestyle modification can be instituted through smoking cessation, drinking in moderation, and staying active with an exercise regimen.
Options for exercises:
Walking or climbing stairs
Low impact aerobics
Muscle strength training (weight lifting)
Balance and posture exercises
Patients should try and do at least 30 minutes of physical activity every day and strength train 2-3 times a week. Speak with your doctor and physical therapist before beginning an exercise program.
As mentioned previously, patients need adequate calcium and vitamin D. Most adults will require 1,200 to 1,500 mg of calcium per day. Good sources of calcium can be found in milk, yogurt, cheese, nuts (almonds), sardines, dark green vegetables, orange juice, and soy milk. It is known that most people only get half the required amount of calcium through diet so oral supplements are often needed. Vitamin D helps the body absorb calcium better.
Good sources of vitamin D:
Milk, fish, cereal with milk, yogurt, sunlight and supplements
Reducing the incidence of falls is important for patients to reduce the risk of broken bones, especially in older age.
Some strategies include:
1) Making sure that there is adequate lighting in the home
2) Make stairs safe by adding handrails
3) Keeping household items within easy reach
4) Keeping floors clear by removing small rugs
5) Using stable mats in the bathroom (shower area)
There is no cure for osteoporosis, however, physicians may prescribe medications that are approved by the FDA to help stop or slow further bone loss, maintain bone strength, help form new bone, and reduce the risk of fractures.
There are many available therapeutic options for the treatment and prevention of osteoporosis. These pharmacologic therapies act on the bone remodeling process in different ways.
Some medications are used to prevent bone from further being digested by bad cells called osteoclasts, while other drugs stimulate certain cells called osteoblasts to stimulate bone formation. Other therapies intervene at the hormonal level by mimicking the effects if estrogen to increase bone strength. The newest therapy (Denosumab or Prolia) works by preventing the interactions of molecules that break down and repair bone.
Here is a list of medications for osteoporosis treatment:
-Zoledronic Acid (Reclast)
2)Parathyroid Hormone (Forteo)
3)Selective Estrogen Receptor Modulators/SERMs (Raloxifene/Evista)
4) Denosumab (Prolia)
5) Calcitonin has been used by patients in the past.
It is fair to say that all the drugs indicated for osteoporosis carry a risk of side effects and each woman has to look at her personal history and comfort level when she discusses options with her physician. Keep in mind that not treating osteoporosis is risky and may lead to lifetime disability. No therapy is permanent.
Each patient is able to discontinue a medication for a short period of time and initiate a trial with another medication until the goal of improving bone strength and quality is achieved. A woman should search for the medication that will offer improve bone health while offering a low risk profile. In this age, the field of osteoporosis prevention and treatment is constantly evolving. New medications that target the different mechanisms in the bone remodeling process are being researched and invented all the time to prevent subsequent fractures.
Sometimes surgery may be recommended if patients are undergoing pain from vertebral fractures. Two surgical options include vertebroplasty and kyphoplasty.
Dr. Cadet states that ”It is surprising that the risk of osteoporosis for women is equal to the risk of breast, ovarian, and uterine cancers combined according to the National Osteoporosis Foundation. Given the significant reduced quality of life for the patients and the substantial pain, disability and mortality that exists following a sustained fracture, it is crucial to educate individuals about this condition and strive to institute a protocol for primary and secondary osteoporosis prevention and treatment especially in women.