Osteoporosis treatment options
If you have osteoporosis, your doctor will suggest treatment based on your age, sex, previous medical history and how advanced your osteoporosis is. There are various medicines available to treat the condition.
The bisphosphonates are often the initial type of medicine that doctors prescribe for confirmed osteoporosis in women following menopause. They can also be used to treat osteoporosis in men. Bisphosphonates can slow bone loss, improve bone density and reduce the risk of fractures. They include alendronate (e.g. Fosamax, Adronat, Alendro), risedronate (Actonel) and zoledronic acid (Aclasta).
There are also formulations combined with calcium, e.g. etidronate and calcium (Didrocal), risedronate and calcium (Actonel Combi), or combined with vitamin D, e.g. alendronate and cholecalciferol (Fosamax Plus Once Weekly). Risedronate is also available in combination with both calcium and cholecalciferol (Actonel Combi D).
Bisphosphonates can give some people stomach upsets and should be taken on an empty stomach to minimise side effects. Also, people are advised to stay upright for 30 minutes after taking risedronate and alendronate, as they can sometimes irritate the oesophagus (gullet). Once-weekly bisphosphonate formulations are available which reduce the risk of gastrointestinal side effects. Risedronate (Actonel) is also available as a once-a-month treatment, which may be more convenient. Zoledronic acid (Aclasta) is a once-a-year intravenous infusion treatment (medicine that is given via a drip into a vein), which can be useful for people who do not tolerate oral bisphosphonates.
Other side effects of bisphosphonates may include musculoskeletal pain and fatigue.
A rare side effect of bisphosphonates is osteonecrosis of the jaw, which can cause severe jaw pain, swelling and infection in the jaw region, and loosening of teeth and exposed bone. These symptoms can occur spontaneously, but are more common following a tooth extraction. Make sure you maintain good oral hygiene and tell your dentist if you are taking bisphosphonates.
Calcium supplements and bisphosphonates should be taken several hours apart.
Raloxifene (Evista) belongs to the class of drugs called selective oestrogen receptor modulators. This medicine is used as an alternative to bisphosphonates in women who have been through menopause. It is not hormone replacement therapy (HRT) and does not relieve menopausal symptoms, but it works in a similar way to HRT on bone tissue. It has been shown to reduce bone loss and increase bone density, and can reduce the risk of backbone fractures.
Raloxifene may make hot flushes worse and may cause leg cramps and increase the risk of blood clots and fatal stroke. There is evidence that it reduces the risk of breast cancer.
Hormone replacement therapy (HRT)
HRT has been used as treatment for established disease as well as for prevention of osteoporosis. HRT can prevent bone loss and reduce fracture rates in women who have been through menopause, although nowadays it is not recommended purely for fracture prevention unless a woman also has menopausal symptoms that need treating.
HRT probably has its best effect when started at the time of menopause, as bone loss after the menopause occurs quite rapidly for the next 5 to 10 years. However, if you are considering using it long term, you and your doctor will need to weigh up the possibility of an increased risk of breast cancer, heart attack, stroke and thromboembolism (blood clots) against the benefits for your bones. The risks and benefits of taking HRT need to be assessed on an individual basis for each woman and vary depending on age, the type of HRT, and other factors.
Results from large international studies such as the Women's Health Initiative (WHI), the Million Women Study, and Women's International Study of long Duration Oestrogen after Menopause (WISDOM) have provided doctors with a clearer picture than previously of the ratio between the risks and benefits for women taking HRT.
The side effects of HRT depend on the type of hormones, the way they are taken, and doses involved. Not all women can safely take HRT, such as women with severe liver disease or a history of stroke.
Teriparatide (Forteo) is a synthetic version of human parathyroid hormone. It increases bone formation, thus increasing bone density, and reduces the risk of fractures. Forteo can be used to treat osteoporosis in post-menopausal women and osteoporosis in men when other medicines are considered unsuitable and when there is a high risk of fractures. It cannot be used by people who have Paget’s disease. It can cause dizziness and leg cramps.
Strontium (Protos, discontinued in 2017) increases bone density and reduces the risk of fractures, and can be used to treat osteoporosis in women who have been through menopause. It can cause headache, dermatitis and gastric upset. Caution is advised in people at risk of, or with a history of, clotting disorders.
Nandrolone (Deca-Durabolin) is an anabolic steroid that works by increasing bone mass. It is approved for treating osteoporosis only in certain situations. It is given by injection into a muscle, for example in the buttock or upper leg. Side effects of nandrolone include water retention, which causes swelling of the ankles or feet. In addition, women may experience hoarseness of the voice, acne and increased body hair.
Taking calcium supplements can slow bone loss, although they do not completely stop it occuring. It can be difficult for some people to achieve the recommended optimal calcium intakes through their diet alone, so supplements can be a useful way of making up the deficit.
If you take bisphosphonates, calcium supplements should be taken several hours apart from the bisphosphonates. Supplements that are based on calcium carbonate (e.g. Caltrate) are best taken with food, because stomach acids help the calcium absorption. Calcium citrate tablets, which are better absorbed in older people, can be used as an alternative to calcium carbonate.
Vitamin D preparations help the body to absorb calcium. It is essential for bone health.
Most people obtain enough Vitamin D from sunlight, but elderly people who stay mostly inside, people who are very careful about covering up and wearing a hat and sunscreen when outside, or people who are shrouded for cultural reasons may become vitamin D deficient. People who have been diagnosed as vitamin D deficient should take supplements.
Calcium plus vitamin D
Some calcium tablets have vitamin D included to assist with the absorption of the calcium. Calcium in combination with vitamin D may reduce fracture rates in postmenopausal women and in frail older people confined to institutions.
Calcitriol (e.g. Rocaltrol, Kosteo) is a prescription-only biologically active form of Vitamin D that can be used to treat osteoporosis. Studies of whether calcitriol reduces fractures are conflicting.
Exercise in early life is very important to maximise bone density, but even after the menopause, weight bearing and resistance exercises can help maintain bone strength by slowing the rate of bone loss. Exercise also helps reduce the risk of falls and fractures by improving muscle strength and balance. Smoking and alcohol, however, can reduce bone density.
Exercises such as Tai Chi, that improve balance, can reduce the likelihood of falls and subsequent fractures, however, people who have osteoporosis should consult a healthcare professional before beginning an exercise programme as they must take special precautions when exercising.
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