Osteoporosis 101: Diagnosis, Treatment and Prevention

By Dr. Emory Hsu

Should I worry about osteoporosis?

As you get older, your doctor may talk to you about osteoporosis, a disease that occurs when the creation of new bone doesn’t keep up with the body’s removal of old bone, resulting in bones becoming fragile and brittle. When most of us think of osteoporosis, we often think about a broken bone – maybe having an arm or leg in a cast for a few weeks, and then returning to life as normal. Yet while osteoporosis may not seem as serious as other medical problems, the reality is that the disease can have severe consequences.

Broken bones prevent you from engaging in normal daily activities and can be serious enough to require nursing home care or can lead to other major medical issues. One in five seniors who get a hip fracture (perhaps the most feared complication of osteoporosis) will die from complications within the 12 months following the injury.

And it’s a common disease. Over 50 million Americans are thought to have osteoporosis. Estimates suggest it leads to over 2 million broken bones each year, generating nearly $19 billion in medical costs in the United States alone. But while all these statistics are scary, the good news is that there are very effective treatments for the disease, as well as opportunities to decrease the risk of developing osteoporosis.

What are the symptoms and how is it detected?

Most people with osteoporosis don’t experience any symptoms. Bones can deteriorate without any pain or weakness. Some people may only find out they have osteoporosis after they break a bone.

Thus, screening is recommended for many adults, especially if you are over age 65, have other medical problems such as rheumatoid arthritis, or take certain medications such as steroids. The most common way a physician will screen for osteoporosis is by having a picture of your bone density taken, usually at the spine or hip. This is called a DXA (dual-energy X-ray absorptiometry) scan, which is a quick and painless X-ray-based scan that takes only a few minutes and can be done on an outpatient basis without any fasting or preparation beforehand. The results are reported as a “score”: T and/or Z score. The lower the score, the worse the bone strength is. A T score of -2.5 or lower is usually osteoporosis, while a T score of lower than -1 is considered osteopenia, meaning low bone density with a risk of osteoporosis. If your DXA scan is normal, usually it does not need to be repeated for another 10 years unless medical conditions change, whereas if it shows low bone density, your endocrinologist may want to repeat it in as few as two years. What can I do to prevent osteoporosis?

As with so many other medical conditions, good nutrition and exercise are important to help prevent the disease. Getting enough calcium and vitamin D helps maintain strong bones. If you don’t like milk, no worries! Beyond dairy products, there are many other good dietary sources of calcium such as leafy vegetables, and vitamin D sources, such as mushrooms, as discussed in a previous EmPower Magazine article http://www.empoweryourhealth.org/magazine/vol7_issue3/calcium-and-supplements-what-you-need-to-know.

If you don’t get enough of these minerals in your food, in general, adults can take 1,000 milligrams of calcium each day, and menopausal women can take 1,200 milligrams daily. There is controversy as to exactly how much supplemental calcium should be taken, so it’s best if the calcium comes from food and not supplements.

For people who do not get much exposure to sunlight or enough vitamin D (which slows bone loss) in their diet, taking a supplement with at least 800 IU (international units, a measure used for drugs and vitamins) may be beneficial. Some experts even suggest taking more -- in the range of 1,000 to even 2,000 IU daily. This is something you should discuss with your endocrinologist, as there is the possibility of taking too much and becoming vitamin D toxic. Vitamin D is often called ergocalciferol or cholecalciferol (different types of vitamin D). Whichever you take, ingesting the supplement with the daily meal that has the highest fat content will help your body absorb the vitamin D.

And if you smoke, quitting is the goal since recent studies have shown a direct relationship between tobacco use and decreased bone density.

What if I have osteoporosis?

There’s no need to worry. There are many good treatments now available to prevent the risk of fractures and even to help reverse osteoporosis. First, your endocrinologist will make sure that there isn’t some other disease causing the osteoporosis. Whether or not to test for these diseases will depend on your medical history and physical exam. If you have conditions such as hyperthyroidism (an overactive thyroid), hypogonadism (low sex hormone levels), hyperparathyroidism (an overactive parathyroid gland or glands), kidney stones, or cancers, be sure to tell your doctor.

Also, your doctor will go over any medications you are taking as some – such as steroids, stomach acid controllers, or hormone therapies – can affect your bone strength. Your doctor will discuss an appropriate dose of calcium and vitamin D to be taking, which may be different from the daily over-the-counter dosage that people take to prevent osteoporosis. Staying active, especially with weight-bearing exercises, is beneficial. Weight-bearing exercise means an exercise that puts stress on your skeleton, such as walking, but not swimming. Be sure to get rid of any tripping hazards (clutter on stairs, loose rugs) at home, but be sure to stay as active as you can be.

Your endocrinologist will use a special calculator to estimate your personalized risk of a major fracture, called FRAX. If the risk is high, additional treatment will be recommended. Sometimes even if you don’t have osteoporosis, if you are at high risk of developing the disease, such as when taking long-term high-dose steroids, your doctor will start treatment as well.

What are the medication treatment options?

In addition to calcium and vitamin D, there are prescription medicines that can treat osteoporosis effectively. The most common class of medicines used to treat osteoporosis is called bisphosphonates. Bisphosphonates have been shown to reduce various types of fractures and improve bone density. These are drugs such as alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), and zoledronate (Reclast/Zometa). While the bisphosphonates all work in the same manner by reducing the ability of cells to break down bone, there are differences between these medicines: some brands are taken daily, whereas others are taken weekly or monthly, and some require intravenous infusion. Accordingly, they have slightly different levels of effectiveness and side effects. Your endocrinologist will recommend the one that is best for you.

After starting this medication, you will need to have your blood tested to make sure your calcium and vitamin D levels are adequate and that your kidney is handling the medications well. There are rare but serious side effects. If your bisphosphonate is a pill, you should be sure to swallow it with just a little water and not lie down for an hour afterwards in order to maximize absorption as well as to prevent the medication from irritating your esophagus. If you have serious kidney problems, the risk of bisphosphonates may outweigh the benefits. If you had recent dental work, tell your doctor before starting bisphosphonates, as jaw bone changes have been reported in those with dental work that start on bisphosphonates. Potential side effects will be thoroughly reviewed with you by your endocrinologist.

When medical conditions prohibit the safe use of bisphosphonates, or when they just do not seem to be working, other treatment options are available. Denosumab (Prolia or Xgeva) also affect cells that break down bone, but do so by stopping their activation. Teriparatide (Forteo) works to increase cells that make bone. For postmenopausal women, hormonal therapies (such as estrogen or drugs that act like estrogen) can be considered. And there are promising new drugs in the development pipeline.

So, what’s the bottom line?

While osteoporosis can be a silent disease, physicians now have effective and safe ways to prevent it and to treat it. In addition to exercise, calcium and vitamin D, your doctor will review your risks for fracture and discuss with you what medications could prevent fractures from happening.

Dr. Emory Hsu is conducting research on osteoporosis and microbiota at Emory University in Atlanta, Georgia. He graduated with an undergraduate degree from Harvard University and from medical school at Vanderbilt University, during which he was a Howard Hughes Medical Institute “Cloisters” Research Scholar for a year at the National Institutes of Health near Washington, D.C. He completed his Internal Medicine residency at Emory University, where he is now an Endocrine Fellow.