By Dr. Madhavi Garimella

Sunday marked World Osteoporosis Day and presents an opportunity to discuss this bone disease.

What is osteoporosis?

Osteoporosis, which means “porous bone” is a condition of weakening of the structure of the bone leading to an increased risk of fracture. Many people have osteoporosis and do not know about it as they have no symptoms at all. Osteoporosis does​ not​ cause any pain unless you have a fracture.

Why should we worry about osteoporosis?

Osteoporosis is a major cause of morbidity in older Americans. A hip fracture can cause quite a setback in terms of costs both in terms of time, money and morale due to surgery and rehabilitation. Therefore if we can do anything to reduce that risk, we should.

Some facts about osteoporosis:

The National osteoporosis Foundation (NOF)  says, “Worldwide, one in three women and one in five men over the age of 50 will experience an osteoporotic fracture. In fact, every three seconds a bone will break, somewhere in the world, because of this disease. Many people won’t know they have osteoporosis until their first fracture, which is why it’s called the ‘silent disease’. Even after a break, it often goes untreated.”

Why do we have osteoporosis?

Bone in our body is being constantly remodeled. Old bone is removed and new bone is laid in its place. We build the maximum bone in our teens and 20s and reach “peak bone mass” in our “bone bank” around 30. Building bone mass depends on a lot of factors including gender, race, exercise, diet to name a few. (It is thus important that we emphasize healthy eating habits and exercise to children and adolescents). As we grow older, we lose more bone than we gain. The bone is more “holey” or porous as it is less dense.

Who is at risk?

Several factors increase the risk, among them are:

• Being above the age of 60
• Being underweight
• Family history of a parent having broken a hip
• Certain medical disorders such as Rheumatoid Arthritis
• Certain medical treatments such as long term use of oral steroids
• Smoking
• Excessive alcohol defined as more than 3 units of alcohol per day ( A unit of alcohol varies slightly in different countries from 8-10g of alcohol. This is equivalent to a standard glass of beer (285ml), a single measure of spirits (30ml), a medium-sized glass of wine (120ml), or 1 measure of an aperitif (60ml) )
• A previous osteoporotic fracture
• A prior osteoporotic fracture greatly increases your risk for another fracture. In fact, after a fracture, ​you are five times more likely to suffer a second one within just 1 year

Can men have osteoporosis, too?

Women are more prone to osteoporosis as there is a rapid decline in the female hormone estrogen, at menopause. Estrogen is one of the major bone building hormones. While men do not have such a rapid decline in hormones, they too can have osteoporosis​. ​Your doctor may screen you based on if they think you have the risk factors.

What can I do to prevent it?

You can minimize your risk by making sure you follow a healthy lifestyle with adequate calcium, vitamin D and exercising every day with attention to weight bearing or resistance exercises like walking, jogging, skiing and even going up and down stairs.

How much calcium and vitamin D do I actually need?

It is recommended that women up to the age of 50 get about 1200 mg a day and above age 50 about 1200-1500 mg a day. The recommendation is to get that amount from ALL sources,  preferably food for optimal absorption. 

We get about 300 mg of calcium daily from all food sources. A cup of milk or yoghurt supplies 300 mg, however vegans and lactose intolerant people need not despair. Green vegetables are great sources of calcium, too. For example one 1 cup cooked collard greens contains 358 milligrams of calcium, one cup of cooked spinach has 240 mg and 1 cup of mustard greens has about 150 mg of calcium. So you could vary your diet and make up the requirement just by eating healthy without needing to take a supplement.

Vitamin D is important to help absorb calcium from the gut. The recommendations are for adults under the age of 50 should get 800 IU (international units) of vitamin D each day. Adults over the age of 50 need 800 to 1,000 IU daily.

Can I take too much calcium or Vitamin D?

Yes, taking more than 1200 mg of calcium per day will not necessarily build more bone. Your body gets rid of extra calcium which then predisposes to kidney stones.

Similarly, you could develop toxicity by taking too much vitamin D as it is stored in the body in fat cells and can accumulate. Doctors generally recommend a blood level of greater than 30 ng/ml .

When and how do we treat osteoporosis?

Your doctor reviews your bone density scan to determine need for treatment. She/he may decide that you would benefit from treatment in addition to adequate vitamin D, calcium and exercise if you have osteoporosis based on your scan. Whether you have osteoporosis or osteopenia is based on a score called T score. A score of less than -2.5 signifies osteoporosis. A score of between  -1.0 to -2.5 is defined as low bone mass or osteopenia. 

Your doctor could additionally recommend treatment based on your risk for fracture, even if you do not have osteoporosis and just have osteopenia by the T score. This risk can be calculated using a model called FRAX.

Since osteoporosis is caused by bone loss being greater than bone gain, the first line medications target bone loss and help to suppress it. They are called antiresorptives. The most popular medicines belong to a family called ​bisphosphonates​.  They are alendronate (Fosamax®), risedronate (Actonel®), ibandronate (Boniva®) and zoledronic acid (Reclast®), which can be taken orally or given intravenously. 

Another drug with a similar mechanism of action is denosumab (Prolia®). This is given under the skin every six months and works by blocking the cells that breakdown bone. Estrogen and estrogen like agents – raloxifene (Evista®) also work similarly Bone building agents called  ​anabolics​ used in severe osteoporosis, include parathyroid hormone (teriparatide) /Forteo® and abaloparatide/Tymlos®. These are a daily shots taken up to two years. Typically these are reserved for cases of severe osteoporosis or failure to respond to any of the first line agents.

A new medicine approved by the FDA in April 2019 only for women with osteoporosis is romosozumab-aqqg /Evenity®. This is a monthly shot administered at the medical facility which can be given up to 12 months. This works mainly by building bone and to a lesser extent preventing bone loss as well.

Your doctor chooses a medication based on your risk for fracture, co-existing medical conditions and prior treatment or may refer you to a specialist to consider options.

I have heard that these medicines have many side effects and are causing fractures. Are they safe for me?

As with every other medication, these medicines have rare immediate reactions like rashes, joint pains and other side effects associated with long term use. There have been long term concerns about jaw necrosis as well as concerns of fractures with minimal trauma.

The theory behind these fractures is that these drugs which prevent bone breakdown are interfering with the body’s natural ability to heal microfractures and repair itself. Thus, the bone may be thick because we prevented bone loss,  but not necessarily  healthy and is brittle. Management of osteoporosis is limited, because there is no direct way to examine the bone and insurances often do not cover bone densities other than once every two years. 

However,these side effects have been seen mostly among people who have taken the medications for a long time. The fact remains that typical hip fractures far outweigh the number of atypical femur (thigh bone) fractures. 

Doctors nowadays give patients “drug holidays” based on their risk and how long they have taken these medications.

Interestingly, there are “side benefits” to taking these drugs, which have been noted in a few observational studies like reduction in breast, colon and gastric cancer, stroke and overall mortality.

The bottomline as with any medication, is evaluating the risk:benefit ratio and making an informed decision with your physician in terms of what is best for YOU .

What else can I do?

In addition to medications, strength training, adequate calcium and vitamin D, simple measures to reduce falls​ should be undertaken. Go over your medication list with your physician to try to reduce any medications which can affect mental clarity like pain medications, muscle relaxants and sleeping pills. The NIH website has great recommendations for fall precautions 

Outdoors:

• Use a cane or walker for added stability.
• Wear rubber-soled shoes for traction.
• Walk on grass when sidewalks are slippery.
• In winter, carry salt or kitty litter to sprinkle on slippery sidewalks.

Indoors:

• Keep rooms free of clutter, especially on floors.
• Watch for sleeping pets on the floor
• Keep floor surfaces smooth but not slippery.Be careful on highly polished floors that become slick and dangerous when wet.
• Wear supportive, low-heeled shoes even at home.
• Avoid walking in socks, stockings, or slippers, unless they are skid proof.
• Be sure carpets and area rugs have skid-proof backing or are tacked to the floor.
• Be sure stairwells are well lit and that stairs have handrails on both sides.
• Install grab bars on bathroom walls near the tub, shower, and toilet.
• Use a rubber bath mat in the shower or tub.
• Keep a flashlight with fresh batteries beside your bed.
• If using a step stool for hard-to-reach areas, use a sturdy one with a handrail and wide steps.
• Add ceiling fixtures to rooms lit by lamps.
• Consider purchasing a cordless phone so that you don’t have to rush to answer the phone when it rings, or so that you can call for help if you do fall.
• Use plastic or carpet runners when possible.

Resources:

• Hormone Health Network osteoporosis Information: www.hormone.org/osteoporosis/index.cfm
• The National Institutes of Health Osteoporosis and Related Bone Diseases National Resource Center: www.niams.nih.gov/Health_Info/Bone/Osteoporosis/overview.asp
• MedlinePlus (National Institutes of Health): www.nlm.nih.gov/medlineplus/osteoporosis.html
• National Osteoporosis Foundation: www.nof.org
• Mayo Clinic: ​www.mayoclinic.com/health/osteoporosis/

Dr. Madhavi Garimella specializes in Internal Medicine as well as Endocrinology, Diabetes and Metabolism. She practices at Medical Associates of Northern New Mexico  http://www.mannm.com/