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Osteoporosis Treatment

A comprehensive osteoporosis treatment program focuses on nutrition, exercise, safety-precautions to prevent falls that may result in fractures and, if necessary, medication to slow or stop bone loss, increase bone density and reduce fracture risk. If you are at risk for or have osteoporosis, there are several treatment and preventive measures that your health care professional may recommend:

  • a diet rich in calcium and vitamin D
  • regular weight-bearing exercise
  • avoid smoking and excessive drinking of alcohol ("moderate drinking" for women and older people is defined by the National Institute on Alcohol Abuse and Alcoholism as one drink per day — one drink equals: 12-ounce bottle of beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of 80-proof distilled spirits)
  • medications to stop bone loss, improve bone density and prevent fractures
  • surgery or external fixation for fractured bones
  • a new technology, where cement is injected into the affected vertebra called vertebraplasty or kyphoplasty, can be considered for particularly painful vertebral fractures
  • Hip protectors or pads for women at high risk of hip fracture, especially if they're thin.

There are several medications approved by the U.S. Food and Drug Administration (FDA) for the prevention and/or treatment of osteoporosis. These medications may postpone bone loss indefinitely, but only when they are taken regularly. As with any medication therapy, there are certain risks and side effects. Ask your health care professional about the risks and benefits of the recommended treatment for your specific health needs.

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Postmenopausal Estrogen Therapy

Postmenopausal estrogen therapy has been shown to be highly effective in reducing bone loss and increasing bone density in the spine and hip, even when started after age 70. Postmenopausal estrogen therapy and combination estrogen-progestin therapy (commonly called HRT) are available in a variety of applications: pills, creams, skin patches, vaginal ring and injections.

Once thought safe for the long-term prevention of osteoporosis and heart disease as well as for the short-term relief of menopausal symptoms such as hot flashes, the safety of postmenopausal hormone therapy for either use is now under intense scrutiny by the Federal government — scrutiny triggered by major studies of postmenopausal hormone therapy published in 2002.

In January 2003, the U.S. Food and Drug Administration (FDA) announced that it would require a new, highlighted and boxed warning on all estrogen products for use by postmenopausal women. Five products currently on the market in the U.S. contain estrogen and progestin, while 15 contain estrogen alone. The so-called "black box" is the strongest step the FDA can take to warn consumers of potential risks from a medication. The warning highlights the increased risk for heart disease, heart attacks, stroke and breast cancer from supplemental estrogen — risks identified by one part of the Women's Health Initiative, one of the largest studies of women's health ever undertaken. While other sections of the WHI are still underway, the study that identified the health risks associated with postmenopausal estrogen-progestin therapy was abruptly halted.

Also emphasized by the "black-box" warning is that estrogen products are not approved for heart disease prevention. It advises health care professionals to prescribe estrogen products at the lowest dose and for the shortest possible length of time. Women taking estrogen products are cautioned to have yearly breast exams, perform monthly breast self-exams and receive periodic mammograms.

Because every woman's risk profile is different, women who are considering postmenopausal hormone therapy as a treatment option or who now take it to prevent osteoporosis should discuss their personal risks for heart disease and breast cancer with their physician. They may wish to review their options and treatment plans with their health care professional in light of the FDA's recent warning. Alternative treatments and preventive medications are available.

New, lower-dose versions of the hormone therapies used to treat symptoms of menopause are currently being developed. The FDA recently approved a low-dose version of the combination estrogen-progestin treatment sold as Prempro, which is expected to be available in the summer of 2003

If you are currently using postmenopausal hormone therapy, talk with your health care professional first before stopping your medication; if you are using it to relieve menopausal symptoms, stopping the medication abruptly could make your symptoms worse. How you taper off your medication will depend on what type of therapy you are using. Conditions such as low bone density may return to pre-therapy levels and require another type intervention, if estrogen or estrogen-progestin therapy is stopped.

There are other drugs and lifestyle strategies to keep bones strong that don't involve the same risks. Other drugs prescribed to prevent and/or treat osteoporosis include the following (see Prevention section for lifestyle strategies):

  • Alendronate (Fosamax, from the bisphosphonate class of drugs) is a bone-specific medication approved by the FDA to treat and prevent osteoporosis. Alendronate has been shown to increase bone mass and reduce the risk of spine, hip, wrist and other fractures by approximately 50 percent in women with osteoporosis. Alendronate has also been approved for the treatment of glucocorticoid-induced osteoporosis. Alendronate tablets should be taken on an empty stomach and with a full 6 to 8 ounce glass of water. The manufacturer recommends taking this medication first thing in the morning, at least 30 to 60 minutes before the first food, beverage, or medication of the day. To minimize side effects — which can include irritation of the gastrointestinal tract, other digestive problems, and ulcers — remain in an upright position for at least 30 minutes after taking this medication. Alendronate can be taken daily or as a weekly medicine regimen.
  • Calcitonin (Miacalcin) is approved for the treatment of women who are five years postmenopausal and cannot tolerate estrogen therapy. Studies demonstrate that this medication helps maintain bone mass and modestly reduces vertebral fracture risk. It has not been shown to protect against other fractures. Because calcitonin is a protein, it cannot be taken orally as it would be digested before it could work. Instead, it is taken as a nasal spray or (less common) in injection form. Possible side effects include nasal irritation and inflammation.
  • Raloxifene (Evista), taken as tablets, is a medication approved for the prevention and treatment of osteoporosis. Raloxifene has positive estrogen-like effects on bone but not on the breast or lining of the uterus. It is from a new class of drugs called selective estrogen receptor modulators (SERMS) that appear to prevent bone loss at the spine, hip and total body. Raloxifene has been shown to reduce the chance of spinal fracture by half in women with osteoporosis, but there is no data confirming that it reduces the risk of any fractures other than those of the spine. Possible side effects include hot flashes, blood clots in the veins (similar to estrogen) and leg cramps.
  • Risedronate (Actonel, another type of bisphosphonate drug), taken as tablets, is a bone-specific medication approved to treat and prevent osteoporosis. It has been shown to increase bone mass and reduce the risk of spinal, hip and other nonspinal fractures in women with osteoporosis. It has also been approved for the prevention and treatment of glucocorticoid-induced osteoporosis. To minimize side effects — which can include irritation of the gastrointestinal tract, other digestive problems and ulcers — remain in an upright position for at least 30 minutes after taking this medication. Take any vitamins, calcium and antacids at least 30 minutes after you take risedronate. As always, discuss any symptoms with your health care professional.
  • Teriparatide (Forteo), a new drug approved by the FDA in Nov. 2002, is the first medication that actually stimulates bone formation instead of slowing the breakdown of bone. The drug is administered by injection once a day and carries a special warning because in laboratory tests Teriparatide caused cancerous bone tumors in rats. However, such tumors -were not observed in 2,000 people who tested the drug in clinical trials. Side effects may include nausea, dizziness and leg cramps.

Discuss with your health care professional which therapies and lifestyle strategies, such as increasing calcium intake and exercise, are the safest, most effective options to meet your health needs and to prevent osteoporosis.

Preventing Falls Is Key

Preventing falls also is an important aspect of osteoporosis treatment to reduce the likelihood of fracturing a bone in the hip, wrist, spine or other part of the skeleton. Falls can be caused by environmental factors, such as slippery floors and poorly lit rooms, as well as by impaired vision and/or balance, chronic diseases that impair mental or physical functioning, and certain medications, such as sedatives and antidepressants. It is important to be aware of any physical changes that may affect your balance or gait. Discuss any changes or concerns with your health care professional.

Consider making some of these changes to help eliminate environmental factors that could lead to falls:

  • Indoors: Keep floor surfaces smooth but not slippery and clear of clutter; wear supportive, low-healed shoes even at home; avoid walking in socks, stockings or slippers; be sure stairwells are well lit and that stairs have handrails on both sides; install grab bars on bathroom walls near tub, shower and toilet; and use a rubber bath mat in the shower or tub.
  • Outdoors: Use a cane or walker for added stability; wear rubber-soled shoes for traction; walk on grass when sidewalks are slippery; use caution on highly polished floors that are slick when wet. Use plastic or carpet runners when possible. Some older women at high risk of falls and hip fracture might want to consider hip protectors. These devices are thin shields that can be incorporated into underwear.

The American Geriatrics Society (AGS) recently released clinical practice guidelines to assist health care providers in assessing the risk of falls in older individuals and provide management strategies for reducing fall risk. The recommendations appeared in the May 2001 issue of the Journal of the American Geriatrics Society. The Society has also developed a companion consumer guide that shares tips on reducing the risk of falls. For more information on the Guidelines for the Prevention of Falls in Older Persons and the consumer guide, visit the American Geriatrics Society.

Research and New Treatments on the Horizon

In a recent study conducted by scientists at Ohio State University, 35 pre-menopausal women with breast cancer were treated with chemotherapy, and experienced accelerated bone density loss (eight percent). This surprising result was observed after only 12 months of chemotherapy treatment. The results of this study support a role for bone density scans in those women who develop chemotherapy-induced ovarian failure, according to the lead researcher on the study.

Young women who exercise regularly and use birth control pills may not get the boost in bone strength seen in women who exercise and do not use oral contraceptives, according to a study reported in the June 2001 issue of Medicine & Science in Sports & Exercise. According to the lead researcher for this study, oral contraceptives may control blood estrogen levels and prevent the exercise-induced increase (in bone). Other investigators have not yet confirmed this finding.

Research sponsored by the National Institutes of Health have made a number of significant discoveries that are expected to open a number of exciting new osteoporosis-related research areas:

  • identification of a gene essential for the formation of bone
  • finding that estrogen causes "programmed cell death" in cells that are responsible for degradation of bone (osteoclasts)
  • a "time-release" preparation of sodium fluoride is being evaluated as a possible treatment for osteoporosis and fracture reducer — without the significant side effects associated with earlier versions of this controversial agent
  • Lasofoxifene is a newer, potent selective estrogen receptor modulator (SERM) currently undergoing clinical trials in postmenopausal women. Similar to raloxifene (the only SERM with FDA approval for postmenopausal osteoporosis), lasofoxifene does not appear to stimulate uterine tissue, a negative effect associated with other SERMs, such as tamoxifen. The drug is presently in large, multi-center trials and may be approved sometime in the next several years.
  • A once yearly, 15-minute infusion of a drug called zoledranate is currently being tested in large, multi-center studies for its efficacy in treating osteoporosis. This drug could be approved within the next several years.

Copyright 2003 National Women's Health Resource Center Inc. (NWHRC).

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