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Osteoporosis and Osteopenia (bone loss)

Questions addressed in this section include the following:

How can I tell if I have osteoporosis and what can be done to prevent it?

What medications are used to treat osteoporosis?

I was told I have osteopenia. Should I worry?

How can I tell if I have osteoporosis and what else can be done to prevent it?

The diagnosis of osteoporosis can be made through a variety of tests that measure bone density. Women who are at risk for osteoporosis, should consider having a bone density test. Risk factors for osteoporosis include:
• Small bones -- usually found in thinner women.
• Cigarettes, alcohol, and caffeine -- another reason to quit those bad habits. Smoking is particularly hard on your bones.
• Family history of osteoporosis -- Did mom start to lose height and develop a curvature in her upper back? Did she fracture her hip? If so, she had osteoporosis and you will too.
• White or oriental race -- osteoporosis is found less frequently among African-American women.
• Inadequate calcium intake -- women rarely consume adequate quantities of calcium. Your peak bone mass is reached by age 35. If your diet was deficient in dairy products before age 35, your risk of osteoporosis is increased substantially.
• Insufficient exercise -- Your bone density is maintained through regular exercise, particularly weight bearing exercise such as walking, cycling, and dancing.
• Late menarche (onset of menses) or early menopause.
• Anorexia -- women with a history of anorexia are more likely to have low bone density from inadequate diet and decreased estrogen production.
• Pregnancy and breastfeeding -- These pose extra demands on your calcium. Extra calcium intake is required to meet these demands if bone loss is to be prevented.
• Certain medications including corticosteroids (anti-inflammatory steroids used often in asthma and arthritis), anticonvulsants (anti-seizure), furosemide diuretics (“water pill” -- used for fluid retention and high blood pressure), thyroid replacement (used for an underactive thyroid gland) and aromatase inhibitors (used in the prevention and treatment of breast cancer). If you require these medications, you should consider special measures to decrease bone loss.

Of the currently available methods for assessing bone density, DEXA scanning is best. If you have your bone density measured, try to find a facility that employs this technique.

A proper diet is important in the prevention of osteoporosis. Teenagers should increase their calcium intake through diet and supplements to at least 1000 mg. The teens are critical bone building years. Unfortunately, most teenage girls do not drink large quantities of milk. The easiest way to combat this is to keep a role of Tums or Rolaids on the dinner table and give them one at each meal (see below). Women ages 25 to 50 should have an intake of 750mg. In menopause the requirements again increase to 1000-1200mg. Consuming foods rich in calcium is vital (see table below). However, it is almost impossible to consume enough calcium through your diet alone (without gaining a zillion pounds). Most women in menopause need to take a calcium supplement to reach their goal. Calcium supplements are available over-the-counter. Most of them contain calcium carbonate, as do the antacids Tums and Rolaids. Refer to the back label for the amount of elemental calcium (may be abbreviated Ca++) provided per tablet. Calculate how much calcium you are getting in your diet (from the chart) and add supplemental calcium to reach the 1000 mg. goal. You can only absorb 750 mg. of calcium at one time so it is best to divide your supplements and take them throughout the day. Calcium carbonate is best absorbed with a little food or orange juice. I recommend CitraCal for my patients because it is calcium citrate, which can be taken with or without food. Vitamin D is also critical for calcium absorption and bone mineralization. Many people get sufficient vitamin D from exposure to the sun or diet (fatty fish, butter, egg yolks, liver, and fortified milk), but vitamin D deficiency is fairly common. I recommend that all of my menopausal patients obtain a 25 OH Vitamin D blood level to ensure that they are not deficient. Most of the calcium supplements are available with Vitamin D. I recommend 800 IU-1000 IU for menopausal patients. Vitamin D supplements are available separately if you are not getting enough with your calcium supplement. Many calcium supplements also contain magnesium which is another mineral involved in bone metabolism. The addition of magnesium also helps prevent constipation.

Foods Containing Calcium
                                 Amount               Calcium (mg.)         Fat (grams)
Cheese                      1 oz.                   150-220                  6-9
Cottage Cheese         1 cup                  210                         9.5
Hard Ice Cream          1 cup                  175                         14
Milk                            1 cup                   300                        whole 8 / lowfat 5 / skim 1
Low-fat yogurt           1 cup                   350-400                  2.5-3.5
Almonds                     1 oz                     66                           16
Scallops, steamed       3 1/2 oz              115                         1.4
Shrimp, raw                3 1/2 oz              63                            .8
Broccoli, cooked         2/3 cup                88                           .3
Spinach, cooked         1/2 cup                83                           .3
Kale, cooked               3/4 cup               187                          .7
Turnip greens, cooked 2/3 cup              184                          .2
Beans, canned             1/2 cup               68                           3.2
Green beans, cooked    1 cup                  62                          .2
Chickpeas, garbanzos    3 1/2 oz             75                           2.4
Sweet potato, baked    1 small                 40                           .5
Figs, dried                     5 med.               126                          1.3
Raisins, dried                5/8 cup                62                          .2
Orange, raw                 1 med.                 56                          .1

Exercise is effective at slowing the loss of bone in menopause. Some studies indicate that it may even be able to increase bone density. The best exercises are those that are weight-bearing in nature such as walking, bicycling, dancing, and step climbing. Also, exercises against resistance using machines found at fitness facilities and weightlifting are good. Exercise also helps develop your muscles and maintains a healthy heart.

What medications are used to treat osteoporosis?

Estrogen is very effective at slowing down bone loss, but in view of its additional risks, it is not recommended as first line therapy solely for that indication. There are other agents used for treating osteoporosis. Bisphosphonates are a group of drugs that inhibit bone breakdown. Fosamax (now available in the generic alendronate) was one of the first, and is still probably the most widely used, non-hormonal medication for the prevention and treatment of osteoporosis. Actonel and Boniva are two other commonly used oral bisphosphonates with the advantage that they can be taken monthly instead of weekly. A more recent entry is Reclast, administered as a once a year intravenous infusion. The oral bisphosphonates are taken with a full glass of water upon arising in the morning before you consume anything else. After taking them, you must remain upright (No, you can’t go back to bed) and cannot eat or drink anything for at least 30-60 minutes (longer is better) for optimal absorption. A newer oral bisphosphonate, Atelvia, can be taken after breakfast. Some people develop upper gastrointestinal distress from oral bisphosphonates. If you have a history of reflux (“heartburn”) or gastritis, Reclast may be a better option.

Prolia is an example of a different class of medication that also helps you retain bone mass. It is administered as a subcutaneous injection every six months. Prolia can lower your calcium level so you should have a normal level before starting Prolia. The most common side effects are bone, joint, or muscle pain. Prolia may increase the risk of serious infections so you should probably avoid it if you have a tendency toward getting infections. You should also avoid it if you have poor kidney function, a history of pancreatitis, or a history of severe allergic reactions (anaphylaxis).

Raloxifene (Evista) was the first SERM to gain approval from the FDA for menopausal women. SERMs bind to estrogen receptors in the body and in some areas act like estrogen, while in other areas act like an anti-estrogen. They prevent osteoporosis and bone fractures, have no adverse impact on your uterus, and reduces your risk of breast cancer. Overall it does not appear to cause excess risk for your heart, although there may be a small excess risk for stroke. Like oral estrogen, it causes an excess risk for DVT. More importantly, it does not treat vasomotor menopausal symptoms. In fact, it increases the frequency, although not the severity, of hot flashes. It is therefore not indicated for the treatment of menopausal symptoms. It is a reasonable drug to be considered in women for the prevention of osteoporosis, particularly those who are at excess risk (see osteoporosis section). More SERMs are in development and there is certainly a possibility for one to contain most of the benefits of estrogen without most of the risks.

Forteo and Tymlos are different than Prolia and the bisphosphonates. Prolia and the bisphosphonates work primarily by helping to reduce bone turnover, thereby maintaining the bone mass you already have made, Forteo and Tymlos actually build new bone. They are administered as a daily subcutaneous injection. While this sounds intolerable, it is really not that bad. The injection uses a needle that is so tiny that at most you feel a little pinch. Forteo and Tymlos are usually reserved for people with particularly severe osteoporosis. They can only be administered for up to two years.

Calcitonin ( Miacalcin, Fortical) is a drug that is generally administered by nasal spray that decreases the breakdown of bone. It also appears to have an analgesic (pain relieving) effect in women with spinal compression fractures. Calcitnonin is not as effective as the other medications listed above and has fallen out of favor. The FDA no longer recommends its use. 

All of these medications have risks associated with their use. Your doctor can help you decide if any of these are appropriate for you after reviewing your bone density and medical history. Two potential complications of osteoporosis medications have been widely publicized and deserve a separate comment. Prolonged use of bisphosphonates (generally regarded as greater than five years) have been associated with a condition called osteonecrosis of the jaw, a rather devastating condition that can lead to chronically exposed, deteriorated areas of bone. It is uncommon and generally seen in women with cancer who are getting chemotherapy and bisphosphonate infusions. Because of its rarity (compared to the likelihood of getting fractures when you have osteoporosis), it is not felt to be a reason for stopping bisphosphonates. As a precaution, some physicians recommend that patients who are undergoing dental procedures that will involve the bone (tooth extraction, implant) hold their bisphosphonate for a variable period of time before and after the procedure. I also ask them to consult their dentist who has a better idea of the condition of their jaw. The second widely publicized complication of prolonged bisphosphonate use is the development of an atypical fracture that occurs in the mid part of the femur (your thigh bone). Again, this is a fairly rare occurrence. If one has significant osteoporosis with a high risk of hip fracture or spinal compression fractures, there may still be a benefit to continuing bisphosphonates beyond five years. Practitioners, even experts in the field, are not in agreement regarding the continuation of bisphosphonates beyond five years. Some doctors will stop them automatically after five years. Others will give their patients a 1 to 2 year drug holiday before resuming bisphosphonate use. Still others will continue the bisphosphonates without stopping at all. It is my opinion that one must evaluate each patient individually prior to arriving at a decision. At this time, there are no randomized clinical trials to give us the best answer.

Another advance in the management of bone loss is the use of the FRAX calculator. This was developed in order to help physicians decide when medication is necessary in people who have significant bone loss, but not osteoporosis. Not many doctors are currently using this tool, but they should. The patient's age, weight, height, gender, bone density score, and certain specific additional risk factors are entered into the calculator, which then gives the practitioner your 10 year risk of developing any fracture and your 10 year risk for hip fracture. A more reasonable decision can then be made as to whether you should start medication.

For additional information:
National Osteoporosis Foundation
Suite 602, Dept. J
2100 M Street, NW
Washington, DC 20037-1207

I was told I have osteopenia. Should I worry?

Osteopenia refers to the fact that you have some bone loss, but it is not severe enough to label osteoporosis. Its definition comes from the use of DEXA bone density scanners. The measurements made with these scanners are compared to the average bone density of 35-year-old women. Because your bone mass peaks at age 35, you will almost always have less bone, or osteopenia. By itself, this label means very little. Your doctor will look at something called your T score. The more negative your T score, the worse your bone density. When the T score reaches -2.5, you have osteoporosis. Usually at that point, treatment with medication is recommended. Any score less than -2.5 should be evaluated with the FRAX calculator.The FRAX calculator uses information about you and your bone density in order to predict your risk of any fracture, and more specifically a hip fracture over the next ten years. If you exceed thresholds set by the National Osteoporosis Foundation, then medication is indicated.