What is osteoporosis?
Osteoporosis is a condition which reduces the amount of bone mass in the skeletal structure. This means the strength of the bone is decreased and are therefore easier to break. A bone density scan is conducted to diagnose the condition, which would compare a person’s bone density to their peers. A certain level of bone density would indicate whether the patient has osteoporosis.
What are the main causes of osteoporosis?
As we age beyond 30, there is a diminution in our bone density. But there is a wide range of conditions which can cause osteoporosis and is not determined purely by old age. Conditions such as inflammatory joint disease, unusual conditions like multiple sclerosis, effecting a person’s mobility, and inflammatory bowel disorders, can all lead to developing osteoporosis. Over active thyroid and some endocrine diseases or disorders of the glands can also cause osteoporosis.
A common cause is what is called post-menopausal osteoporosis. After the age of 50, women lose the protective effect of oestrogen on their bones. This means their bone density starts to decline more rapidly than men. Roughly ten years after the menopause, if the female is osteoporotic, she will start to develop risk factors. And ten years after this, unfortunately if they haven't been diagnosed, they may start to experience hip fractures.
How can osteoporosis be prevented?
If a person is over 30 their chances of being diagnosed with osteoporosis is pretty low unless they have one of the associated conditions which causes it. Sometimes there are unexpected conditions like eating disorders which can be associated with diminution in bone density.
In order to improve bone density, people should do regular weight bearing exercises, and have a healthy diet with adequate amounts of Calcium and Vitamin D. This is particularly important for women in those years running up to the menopause. Following the menopause, it is important for women to be aware of what their bone density is and if they have any risk factors to decide on the best course of action.
Who are the types of people who get osteoporosis?
Although it is more common in women than men, about 15% of the male population will get osteoporosis. Family history can also be important. The single greatest family history risk factor is if a parent has had a hip fracture. Smoking history and alcohol excess are also significant risk factors.
What measures can the patient implement in their daily lives, in addition to receiving treatment?
Doing regular weight bearing exercises like walking, running, skipping, and jumping. This helps to ensure the compression and decompression of the bone to make the bone stronger and develop new bone. These exercises help improve the core strength to prevent you from falling over. This will be important as we grow older. If someone who is over 50 has osteoporosis, their ten-year probability of having a fracture is likely to be less than five percent. But someone over 80 with osteoporosis has a ten-year probability of having a hip fracture of about 46 percent.
What are the different types of treatment available?
For most people, it is all about maintaining a healthy lifestyle and diet, and being educated about osteoporosis. Adequate Calcium and Vitamin D in the diet is very important. Certain drugs can be associated with osteoporosis like chronic steroid use, for example, so these should be avoided.
The majority of patients who have had a fracture are prescribed with a group of drugs called bisphosphonates. These are either administered as a tablet once a week, once a month, or as an infusion therapy once a year. The type of treatment depends on personal preference and current mobility. For example, someone with stomach ulcers cannot take the tablet as treatment. Some people cannot take the once a week tablets because they upset the stomach.
Intravenous therapy once a year is quite convenient for most people. The treatment only takes about half an hour and is conducted every year for three years. This gives the patient six years of protection against further fractures.
Alternatively, patients can have an injection which is a biologic treatment administered every six months, called denosumab. This would be given for five years, after which a reassessment would take place to see how the patient’s bone density has improved.
Intravenous therapy and injections are very attractive for the majority of people who cannot tolerate the oral bisphosphonates group of drugs. And there a lot of new treatments coming on to the market for osteoporosis and also the sequential use of these type of treatments. Patients can therefore have one type of treatment for a while and then one of the other treatments if they prefer.
What are the benefits of treatment?
The benefits are that if you take bisphosphonates, for example, or the intravenous once a year treatment, this will reduce your risk of fracture by 76%, hip fracture by 46%, and your overall risk of having another fracture. If you have a vertebral fracture, which is a fracture of the spine, you have got a 500% increased risk of having another one within a year. This risk is reduced almost instantly with intravenous treatment, rather than the oral treatment, as it works very quickly. There is also an analgesic effect thus reducing swelling in the bone.
What are the possible side effects?
It is not uncommon for people to report stomach upset or heart burn when taking the oral bisphosphonates. There are rarer side effects like the condition called avascular necrosis of the jaw, which occurs in about one in 100,000 patients.
There is also a condition called atypical hip fracture which occurs in patients who have been on bisphosphonates for more than seven and a half years. It is advisable, therefore, that patients who are at low risk take oral bisphosphonates for no more than five years and then consider a bisphosphonate holiday for two years. However, patients who are high risk and may have had multiple vertebral fractures or have already had a hip fracture, are encouraged to continue the drugs for up to ten years.
Who administers the treatment?
Oral drugs are administered by the patients after advice from the doctor, tailored to the individual. The intravenous drugs can be given in the hospital once a year for three years and then the patient does not have to come back for six years. The denosumab is often first given in the hospital and then subsequent injections can take place in a general practice.
How much Calcium and Vitamin D should osteoporosis patients take daily?
The current advice and guidance is that the patient should take between 800 milligrams and a thousand milligrams of Calcium and 800 units of Vitamin D a day.
How do patients get enough of these nutrients?
Vitamin D is made by the sun shining on the skin and converting cholesterol into Vitamin D. However, here in the UK there is an inadequate amount of sunlight. Many people spend more time indoors today and indoor lighting tends to keep UV radiation that we need away from us. This means we are going to become more Vitamin D deficient as a population. Calcium is obtained entirely though the diet providing the body absorbs it. Vitamin D is more difficult as it is obtained mainly through oily fish in the diet or vitamin supplements.
What are the best exercises?
Any form of weight bearing exercise like walking, jogging or running. Some people may like to do weight lifting but this is only advisable depending on their fracture risk. Exercises to avoid with osteoporosis are contact sports, such as rugby and football. Skiing can pose a risk, but this is not a significant worry if a patient is receiving treatment.