Osteoporosis.

Lack of calcium in bones leading to a higher risk of fractures, is called osteoporosis.

Osteoporosis and fragility fractures are associated with premature death, by 3 times in men and twice in women.

People aged over 75 who have had a fragility fracture have a reduction in their life expectancy of about 10 years, 5 years in those aged between 60 and 75. So osteoporosis carries risks.

Fractures are associated with the development of other diseases, reduced quality of life and loss of independence (for example 25% of the elderly require nursing home placement after a hip fracture)
So – not at all good, and this needs attention as many at-risk people are undertreated.

Osteoporosis Prevention:

Vitamin D:
Is required for normal calcium absorption and bone health
Residents of nursing homes have benefitted from Vit D supplements, but in health community-dwelling individuals results for supplementation have been equivocal. Excessive Vit D levels may actually be harmful.
The normal range for Vit D is under review. Many people seem to have low levels, perhaps due to long work hours and sun-safe practices.
Due to an explosion over recent years in testing Vit D, it has now been restricted as a Medicare-funded blood test to certain at-risk groups, rather than as a blanket screening measure.
We should all try and spend a few minutes each day getting sun exposure to prevent minor deficiencies from occurring and prevent the need for costly supplements.
The current recommendation for doctors is to provide Vit D supplements to patients who have osteoporosis and have a level of less then 25nmol/l.

Calcium:
The current recommendation is that we receive a daily intake of calcium of 800-1200mg.
This comes mainly from dietary sources.
Supplements might be useful if that intake cannot be achieved; this is most important in patients with other conditions, such as kidney or bowel disease.
Studies show that the value of calcium supplements in reducing fracture risk is equivocal.

Exercise:
Sensible, moderate levels of exercise are of course recommended throughout life as part of a healthy lifestyle, but there is no evidence specifically proving that evidence reduces fracture risk.
Falls prevention:
Reducing the risk of falls has obvious benefit in reducing injury, but it is difficult to prove an absolute reduction in risk of fracture.
GP’s are able to refer at-risk patients to Falls Clinics, such as at Sir Charles Gardiner Hospital.

Lifestyle measures:
Cease smoking
Avoid excess alcohol
Avoid being excessively underweight, or obese
Medical conditions contributing to osteoporosis:
Many, but some of the most common would be early menopause, overactive thyroid gland, use of steroid medications, malabsorption conditions such as Coeliac Disease.

Management options for osteoporosis:

Specific medication is available, and funded on the PBS, for patients who have had a fracture and have a sufficiently low Bone Mineral Density to put them in the osteoporotic range.
For those under 70 with osteoporosis shown on a Bone Mineral Density (DEXA) scan, PBS funded medication even without a prior fracture.

Hormonal treatments:
Hormone replacement therapy (HRT):
Reduces the risk of fracture.
Some increased risk of breast cancer and possibly cardiovascular disease, however some sources indicate that these risks have been overestimated.
Can cause an increased risk of deep-vein thrombosis especially in combination with immobility (e.g. long haul travel)

Testosterone replacement:
In males with deficiency, may be of benefit, but needs to be weighed against any possible risks of for example prostate cancer.
HRT and testosterone generally not used just as an osteoporosis treatment measure.
Raloxifene (“Evista”)
Has been shown to reduce fracture risk, especially for spine fractures
Also reduces breast cancer risk and recurrence
Tibolone (“Livial”)
Reduces risk of fractures including the hip
Can help with menopausal symptoms such as hot flushes, vaginal dryness
No increase in breast cancer risk, but may cause some increased risk of cardiovascular disease (not shown in all studies)

Bisphosphonates:
All reduce fracture risk
Oral formulations can occasionally cause gastric side effects
Convenience is improved by formulations designed for once weekly, or even once monthly, oral dosing; in addition there is an intravenous formulation that can be given just once per year.

Avascular necrosis (areas of bone degeneration) of the jaw:
Widely reported in the press
Originally reported when using bisphosphonates at very much higher doses for bone cancers
The risk in people being treated for osteoporosis is very low, approximately 1 in 10,000 patient years of treatment.
The current recommendation is to complete dental work before commencing bisphosphonates, and adhere to good dental hygiene practices, but avoidance of further dental work is not required.
Atypical fractures of the hip:
Extremely rare, perhaps 1 in 100 of all fragility fractures combined.
The benefits of bisphosphonates outweigh the risk of these fractures.

Denosumab:
Works on particular antibody receptor sites to reduce osteoclast activity (osteoclasts resorb calcium from bones).
Given as an injection twice per year, so very convenient
Equivalent efficacy to bisphosphonates, but has the potential to cause avascular necrosis of the jaw and atypical fractures.

Conclusion:

Osteoporosis is common, especially in women, and as we age.
Many people with OP are not receiving optimum treatment that could reduce their fracture risk.
It is especially important that those over the age of 70, or who have had a fracture, are screened (with a Bone Mineral Density scan), and treated effectively as required.
The media has perhaps overblown the potential risks of medications such as bisphosphonates, and the vast majority of patients taking these will not have side effects. Many different formulations and medications are available.
As ever, come in and have a discussion with your GP about your potential risks of OP.

Adapted from Medicine Today, Nov 2014.

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