The major treatment strategies for osteoporosis include a variety of medications, as well as calcium and Vitamin D supplementation. In addition, there are surgical techniques available to treat vertebral fractures that don't respond to medical therapy.
In this section, you will find information on:
- Medications
- Calcium and Vitamin D supplementation
- Treating kyphosis
- Treating wrist fractures
- Treating hip fractures
- Treating spinal fractures
- Surgical techniques for treating vertebral fractures
Medications
Several medications are approved to treat osteoporosis, many of which are also used to prevent the disease. New drugs are also on the horizon.
In this section, you will find information on:
- Hormone therapy (HT)
- Bisphosphonates
- Selective estrogen receptor modulators (SERMs)
- Calcitonin
- Parathyroid hormone (Teriparatide PTH 1-34)
- Investigational treatments
Hormone therapy (HT)
Estrogen is important for maintaining bone in premenopausal women, and physicians often prescribe it, commonly in combination with progestin, for women at menopause. The primary reason for starting HT in postmenopausal women is to treat hot flashes, mood disorders, and other symptoms of menopause caused by estrogen deficiency. However, even though HT is no longer FDA approved for prevention or treatment of osteoporosis, estrogen does protect bone during the years of rapid bone loss immediately following menopause and may also be effective in preventing hip fractures.
The use of estrogen alone and combined with progestin (both fall under the umbrella of hormone therapy, or HT) is not without risks, including blood clots, heart attack, and increased incidence of breast cancer. Because individual circumstances differ, you should discuss the benefits and risks of HT with your doctor.
Bisphosphonates
Bisphosphonates are compounds that inhibit bone breakdown and slow bone loss. They have been shown to increase bone density at the hip and spine and decrease the risk of fractures at both places. All bisphosphonates must be taken on an empty stomach in the morning with a glass of water, and the person should wait 30 minutes or more before taking anything else by mouth. An upright posture must be maintained for at least 30 minutes—and preferably one hour—to minimize the risk of stomach discomfort.
Alendronate (brand name Fosamax) is a bisphosphonate that is approved by the FDA for preventing and treating osteoporosis in postmenopausal women and men. It has been shown to increase bone density at the hip and spine and decrease fractures and is available as a daily 10-mg or a once weekly 70-mg pill.
Risedronate ( Actonel) is also a bisphosphonate approved by the FDA for preventing and treating osteoporosis in postmenopausal women and men. It is available as a daily 5-mg or once weekly 35-mg pill. While bisphosphonates may cause stomach or esophageal discomfort, some studies show that this problem occurs less often with risedronate than with daily alendronate.
Ibandronate (Boniva) was approved by the FDA in 2003 and went on sale in the United States in 2005. It is similar to other bisphosphonate drugs but is a stronger formulation, so it's taken only once per month. Side effects and dosing instructions are similar to the other bisphosphonates. It has been shown to decrease fractures at the spine.
SERMs
Selective estrogen receptor modulators (SERMs) are compounds that have estrogenlike effects on some parts of the body (such as bone) and anti-estrogen effects in other areas (such as the breast). Raloxifene (Evista) is the only SERM that is FDA approved for the prevention and treatment of postmenopausal osteoporosis. Raloxifene is taken as a daily tablet (60 mg), with or without food. Raloxifene increases bone density at the spine, but its effect does not appear to be as powerful as the bisphosphonates. It has been shown to reduce spine fractures but not hip fractures.
Although it is not a hormone, raloxifene acts like the hormone estrogen to protect the bones and the heart. It does not stimulate uterine or breast tissue; therefore, it does not cause menstrual periods or breast tenderness. However, it also does not stop hot flashes and, not infrequently, makes them worse. There is preliminary evidence that raloxifene may reduce the risk of breast cancer and heart disease, but studies are ongoing. This drug sometimes causes leg pain; and it also may cause blood clots, although this is very rare.
Calcitonin
For both men and women already suffering from osteoporosis, doctors will occasionally prescribe calcitonin(Miacalcin). In women who are at least five years beyond menopause, calcitonin slows bone loss and increases spine bone density, though it is not nearly as powerful as the bisphosphonates. Calcitonin may also reduce the risk of spine fractures.
Because calcitonin is a protein, it cannot be taken orally; it would be digested before it could work. Calcitonin is available as a nasal spray. Though it may cause occasional nasal irritation, overall it is well tolerated.
Parathyroid hormone (Teriparatide PTH 1-34)
Teriparatide is a commercially made copy of parathyroid hormone (PTH), which the body makes to maintain a normal blood calcium level. Two years ago, the medication was approved by the Food and Drug Administration for the treatment of osteoporosis in postmenopausal women and in men. Teriparatide (brand name Forteo) is the first anabolic (bone-building) medication available. It increases bone density significantly at the spine and to a ldesser degree at the hip over two years, and is shown to decrease the risk of spine fractures.
Because Teriparatide is a protein, it must be injected under the skin (simlar to insulin) once a day. There are very few side effects—occasional dizziness or muscle cramps. Overall, the drug is very well tolerated and easy to use.
There was concern in the early stages of research that some rats developed bone cancer from Teriparatide, but the rats were on very high doses throughout their entire lives. There has been no cancer in humans, and the risk is considered to be extremely low. Teriparatide is used for two years, after which patients switch to another medication to maintain bone density.
There was concern in the early stages of research that some rats developed bone cancer from Teriparatide, but the rats were on very high doses throughout their entire lives. There has been no cancer in humans, and the risk is considered to be extremely low. Teriparatide is used for two years, after which patients switch to another medication to maintain bone density.
Investigational treatments
Several medications are currently under investigation and may someday expand the treatment options available to patients. These include new forms of bisphosphonates, additional SERMs, Strontium Ranelate, Osteoprotogerin, and many other small proteins that appear to stimulate bone.
A new bisphosphonate under investigation is zoledronic acid (Zometa). Instead of taking a daily or weekly pill, people may one day receive a single intravenous (in a vein) dose of medicine once a year to treat osteoporosis. Currently available for the treatment of a calcium disorder associated with cancer, Zometa must be shown to reduce the incidence of bone fractures before the Food and Drug Administration will approve it for general use in treating osteoporosis. Studies are currently underway. Early data show that after one infusion, bone density increased at 12 months, and bone turnover decreased for 12 months in postmenopausal women.
Calcium
As well as preventing osteoporosis, calcium is part of an overall treatment program, since it plays an important role in maintaining normal, healthy bone. Yet, national surveys have shown that many Americans are not consuming enough calcium. The National Academy of Science recommends that adequate calcium and vitamin D be taken daily by everyone. For adults, a calcium intake of 1,000 mg daily is recommended; for those with osteoporosis, 1,200 mg; and for those taking glucocorticoids (steroids), 1,500 mg. Calcium can be found in many foods, including dairy products, dark green leafy vegetables, and fortified juices. If you are unable to get enough calcium through your diet, your doctor can recommend an appropriate calcium supplement.
The calcium in supplements needs to be easily absorbed by the body. You can be sure of this if the tablet dissolves almost entirely in a small glass of warm water or vinegar within 30 minutes. Also read the label to determine the actual amount of calcium in the supplement, which is usually referred to as elemental calcium. Since there are several different types of calcium and a variety of supplements available, you should discuss the choices with your doctor.
Some people are lactose intolerant and have difficulty digesting dairy products because they lack the enzyme lactase, which is needed to break down the milk sugar lactose. Milk fermented with certain bacteria (called acidophilus) is well tolerated, as are yogurt and hard cheeses. If you are lactose intolerant, you can treat lactose-containing foods with commercial preparations of lactase or buy milk products that are lactose free.
Vitamin D is essential because, without it, the body is unable to absorb calcium. The daily recommended dose of 400 IU is contained in most multivitamins. There are very few dietary sources of vitamin D, so people not taking a multivitamin can choose a vitamin D supplement instead. Some calcium supplements contain vitamin D, but make sure to check the dose.
Kyphosis
Kyphosis describes the progressive spine hump which is a result of physical changes in the spine and adjacent muscles, tendons, and ligaments occurring after vertebral fractures. The degree of kyphosis varies with the number of fractures and muscle strength. To minimize the curvature, you will need to learn flexibility and strengthening exercises for your back and torso. Specialists in physical medicine and rehabilitation at a rehabilitation clinic can work with you on these exercises.
A back brace or support may be beneficial during the healing period for several reasons: 1) It helps the patient avoid strenuous bending; 2) it provides some pain relief by supporting the spine and distributing body weight; and 3) it helps reduce the degree of kyphosis. If a brace is used too much or for too long a time, the back muscles will weaken, which is actually worse for spinal osteoporosis because strong muscles help support the spine. Physical therapy, in the form of exercises to strengthen the back and torso, can be performed even while the individual is wearing the brace.
Another type of support you might find useful is a cane or walker. While you are recovering from the fracture, you may be a little unsteady on your feet, and a cane or walker will give you better balance. A very firm mattress is the best type for people with spinal osteoporosis. For comfort, you can cover it with synthetic sheepskin or an egg crate mattress pad. If you have a very soft mattress, you may have to buy a new one. But before you do that, try putting a piece of plywood on top of the box spring, beneath the mattress. This may provide the support your spine needs.
You will be able to resume nearly all of your normal activities, with minimal changes to your routine. You can still travel and still garden. In fact, being active is beneficial to your health.
The changes you do have to make involve the way you move and the safety of your environment. For example, no more bending from the waist to pick something up; instead, you'll have to learn to bend your knees. Activities that require a twisting motion of the torso, such as golf, put a heavy strain on the spine and should be avoided. And no lifting of anything heavier than a light bag of groceries, depending on the severity of the osteoporosis.
Wrist fractures
Wrist fracture is the most common type of fracture before the age of 75. In women, the number of wrist fractures increases at menopause and plateaus after age 65. This increased incidence is most likely related to the rapid loss of bone in the years following menopause.
The wrist is made up of two bones in the lower arm, the radius and ulna, plus the small bones of the hand. The most common wrist fracture occurs when a person extends an arm to break a fall. The hand and forearm take all the weight and force from the fall, and one or both of the wrist bones breaks. When the radius breaks within 1 or 2 inches of the wrist (the distal radius), the fracture is called a Colles fracture, named after the doctor who first described it. Colles fractures occur most frequently in post-menopausal women. Usually, an X-ray can confirm the diagnosis. Once the fracture is diagnosed, appropriate treatment begins.
The appropriate treatment depends on the location and severity of the fracture. A simple fracture means that the bone has broken, but the broken edges remain close enough together that simple manipulation realigns the involved bone (known as reduction of the fracture). A more complex fracture means that multiple pieces of bone are broken or that the joint is involved. In this case, a cast alone may be inadequate and surgery may be required.
The first cast or splint may extend above the elbow to restrict movement of both the elbow and wrist. Your healthcare provider will teach you exercises for your fingers and shoulder on the affected side. It is important that you perform these exercises for short periods of time several times a day, even while in the cast. This will prevent finger stiffness later on, one of the side effects of the Colles fracture.
Over the first two to three weeks, your wrist may be X-rayed weekly. If the bones have slipped out of position, an operation may be needed to reposition the bones and fix them in place. In most cases, the cast or splint is removed after six or eight weeks. Both active and passive exercises for the hand, wrist, forearm, elbow, and shoulder will help you regain your strength and maintain mobility. After the cast or splint is removed, you may use a wrist splint or elastic wrap to support and protect the joint. Sometimes, the wrist may not look exactly the same as it did before the fracture, but with proper physical/occupational therapy, little function will be lost.
Hip fractures
More than 300,000 people, most of them over 65, are hospitalized for hip fractures each year. It is considered a serious injury not so much for the break itself but for potentially life-threatening complications—like infection and blood clots—that can occur after surgery. It is also hard to fully regain mobility and activity afterwards. People with osteoporosis are at particular risk of breaking a hip during a fall, because their bones are thinner. In fact, risk factors for hip fractures closely parallel those for developing osteoporosis: female, small and thin stature, and lack of activity all increase the odds of breaking a hip.
Once the hip is broken—in the elderly, usually through a fall—there are several options for treatment, depending on the condition of the individual patient and the type of fracture. Surgery is almost always needed; if it's not appropriate because of another illness or condition, treatment involves traction and a long period of bed rest. Two types of fracture are most common.
- Femoral neck fractures: These breaks, which occur close to the "ball" part of the hip joint, account for about 40 percent of hip fractures. There is a risk of osteonecrosis, where the blood supply to the bone is lost. To avoid this, the most common treatment for elderly people is to replace all or part of the hip. Hip replacements can last for as long as two decades. Since surgery to revise a worn joint replacement can be complicated, younger patients who would be expected to wear out their replacement hip parts may instead be treated by placing screws into the bone to support the fracture site and encourage healing.
- Intertrochanteric fractures: About half of hip fractures fall into this category. The break is farther from the neck of the femur, or thigh bone, than a femoral neck fracture. The most common treatment is surgery to place a screw through the bone and into the head of the femur and a plate along the side, which encourages the bone to knit together.
Recovery from surgery requires several months and includes intensive therapy and rehabilitation.
Spinal fractures
A fractured vertebra can take anywhere from six to eight weeks for the bone to set and up to 12 weeks to heal completely. But recovery from a vertebral fracture goes beyond healing the bone. Recovery becomes an ongoing process to enable you to regain strength and mobility and to resume your daily activities.
Everyone experiences a slightly different recuperation. You may find your posture changing and have some nagging pain. This is because a vertebral fracture results in a deformity of the vertebra itself, which affects the muscles, tendons, ligaments, and nerves near the fractured bone. Fortunately, there are steps you can take to minimize these consequences of vertebral fracture.
Bed rest for the first two to three days following a fracture is important. The body has suffered a trauma—a broken bone—and needs time and rest in order to heal. How long you stay in bed depends on how much pain you feel and how long you can be up before your back starts hurting again. In general, people are encouraged to be active as soon as pain permits. For pain control, you'll be given over-the-counter analgesics and perhaps treatment with heating pads, ice packs, and gentle massage. If the pain does not subside, you may be given prescription painkillers.
While it's important to rest after you've had a vertebral fracture, it is also important to get up and around as soon as you can. Bones and muscles respond well to movement and activity, and in the long run, you'll improve more quickly if you are able to slowly ease back into your usual routine. If you have access to a pool, walking in the water is a great way to maintain and use your muscles without putting stress on the bone, which is healing.
For patients whose fracture does not heal or who have progressive deformity or multiple fractures, minimally invasive treatments such as vertebroplasty and kyphoplasty can relieve the pain and prevent progression. Percutaneous vertebroplasty (PVP) is a minimally invasive method that involves the injection of bone cement into the collapsed vertebral body to stabilize the vertebra. While the technique has been shown to provide pain relief, it does not expand the collapsed vertebra, potentially locking the spine in a humped posture. In addition, the bone cement has a slight tendency to leak upon injection.
The kyphoplasty technique is a more complex procedure with some potential advantages over traditional medical and surgical treatments for fractures. It involves the introduction of a tube into the vertebral body, followed by insertion of an inflatable bone tamp (IBT) designed to restore the vertebral body toward its original height, while creating a cavity to be filled with bone cement. This allows the alignment of the spine to be restored, providing patients with cosmetic and functional improvement. Data from many published reports indicate that kyphoplasty has a significant positive effect on patient quality of life.
Surgical procedures for vertebral fractures
Two surgical procedures may be used to treat vertebral compression fractures that don't respond to bedrest, pain medication, and bracing:
Vertebroplasty is a procedure to reinforce a collapsing vertebral body using a special cementlike material. With the patient lying on his or her stomach, the doctor inserts a hollow needle, called a trocar, through the skin and into the vertebra. A type of X-ray, called fluoroscopy, is used to guide the needle into position. A contrast agent (dye) is injected to help the doctor see and avoid blood vessels.
Once the needle is in place, a syringe is inserted to inject the cement mixture into the bone. As the cement hardens, it permanently reinforces the weakened vertebra. The procedure is usually done on both the right and left sides of the fractured vertebral body. Vertebroplasty can relieve the pain and prevent further collapse of the vertebral body. It cannot correct the spinal curve but may help prevent progression of the curvature.
Kyphoplasty is similar to vertebroplasty in that it uses a type of bone cement to reinforce the vertebral body. During kyphoplasty, however, an inflatable balloonlike device is inserted into the vertebra through the bone needle. As the balloon is inflated, it opens up a space that is then filled with the bone cement. In addition to stabilizing the vertebra and relieving pain, kyphoplasty restores the height of the vertebra, thereby correcting some of the spinal curve.
Last reviewed on 12/12/2006
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