COLUMN:

Bone Up on Osteoporosis

Mother, aged 50, and Daughter, aged 25, are discussing 75-year-old Grandmother’s recent hip fracture. Grandmother is making slow progress in physical therapy and will likely need help at home when she is discharged from the hospital.

“Thank goodness we don’t have to worry about osteoporosis!” Mother and Daughter say. But they are wrong.

Osteoporosis is a condition where the bones are fragile and susceptible to fracture. One in three women and one in nine men older than 80 years old will have a hip fracture. In the U.S., 26 percent of women over 65 and 50 percent of women over 85 have osteoporosis. The World Health Organization considers osteoporosis second only to heart disease as a leading health care problem, yet as many as half of the people who have osteoporosis are unaware of their condition and are untreated.

Daughter is at increased risk for osteoporosis because of her family history of hip fracture. Peak bone density is reached by the age of 30. After that, there is a slow decline in bone density with a more rapid decrease after menopause. In order to maximize her bone density, Daughter should get regular weight bearing exercise, include 1,000 milligrams of calcium in her daily diet, avoid smoking and excessive alcohol consumption, and see her gynecologist if her menses is irregular or absent.
Osteoporosis is a silent disease that reveals no symptoms until a person has a fracture. The most rapid bone density loss occurs during the years around menopause. Mother needs to be getting exercise and 1,500 milligrams of calcium daily to prevent osteoporosis. She should consider taking 400 IU of vitamin D daily (the amount in most multi-vitamins) because although people are exposed to lots of sunlight in Hawaii, vitamin D deficiency is still not uncommon.

Mother also needs to have a DXA (dual energy x-ray absorptiometry) bone density test. The test is simple, uses minimal radiation and is covered by most medical insurance. A score that is greater than -2.5 (-2.6, etc.) is defined as osteoporosis, but since Mother has a family history of osteoporosis, she may be considered for additional treatment if her score is greater than -1.5 (-1.6, etc.) with such risk factors.

If she has low bone density, Mother should take measures to prevent falls, including eliminating household clutter, loose rugs and poor lighting in her home. Exercises such as tai chi may improve her balance. Sedatives, heavy lifting and high-risk activities should be avoided. While calcium and vitamin D can help reduce the decline in bone density, Mother should seriously consider a medication such as a bisphosphonate.

Prescription bisphosphonates include Alendronate (Fosamax) and Risendronate (Actonel) given orally daily or weekly, and Ibandronate (Boniva) given orally daily or monthly or given intravenously every three months. Taken with calcium, bisphosphonates have been shown to increase bone density and decrease fracture rates. They need to be taken on an empty stomach, however, since food interferes with absorption and the patient should avoid lying down for 30 minutes to prevent irritation of the esophagus.

Recently, there has been concern about a very rare complication of bisphosphonates—osteonecrosis of the jaw, a non-healing bone lesion. Although it has occurred in patients on oral medication, it usually appears in patients receiving high-dose intravenous bisphosphonates who have had tooth extractions. Patients on bisphosphonates planning dental extractions or implants should discuss the possibility of osteonecrosis with their dentist. They should receive regular dental care, including cleaning and gum care, as poor oral hygiene is a risk for this complication.

Alternatives to bisphosphonates include Raloxifene (Evista), estrogen and calcitonin. Isoflavones, a class of phytoestrogens commonly derived from soy protein, have been touted as a natural remedy for osteoporosis, but the studies have been short term, somewhat conflicted and without long-term safety information. More studies are needed before isoflavones can be recommended.

Grandmother faces a 10 to 20 per-cent mortality rate in the year after a hip fracture, and a less than 50 percent chance of regaining her prefracture mobility and independence. This is why prevention is so important. She should be on all of the preventive measures and medications as her risk of further fractures is high even if her bone density is not in the osteoporotic range.

If she has already been on all of the above and still suffers a fracture, she could be a candidate for Teriparatide (Forteo), which increases bone mass more than other medications, but must be given by a daily injection. Strontium, available in Europe, is undergoing clinical trials in the U.S. and may be another option in the future.

While less common and less well studied, men also have osteoporosis. Disorders that can increase the risk of osteoporosis include a history of stomach surgery, chronic liver disease, anorexia nervosa, alcoholism and the use of antiseizure medications.

The World Health Organization is working on guidelines to better identify individuals at risk for fracture. While this may include bone density, other factors such as family history, previous fractures, medications such as steroids and illnesses such as rheumatoid arthritis are likely to be included in the overall fracture risk assessment. The guidelines are expected within the next couple of years and will likely change the current one-size-fits-all approach.

Twenty years ago, doctors believed osteoporosis to be an inevitable part of aging and few treatments were available. Today, there are known interventions for prevention and a number of medications for treatment that not only improve bone density, but, more importantly, help prevent debilitating fractures.

May is National Osteoporosis Month. You can learn more about the condition by checking the local newspapers for related events and the Web sites for the National Osteoporosis Foundation, www.nof.org, and the National Women’s Health Information Center, www.4woman.gov/faq/osteopor.htm.

Rae Nagao Teramoto, M.D. is an endocrinologist at Kuakini Medical Plaza, 321 North Kuakini Street, Suite #201 in Honolulu. Her phone number 523-8611. This column provides general information only; it is not intended to replace recommendations you would receive from your physician after undergoing a thorough physical examination and should not be considered as medical advice.

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