Osteoporosis: Boning up on treatment AN APPLE A DAY By Tyrone M. Reyes, M.D.

(The Philippine Star) Updated March 13, 2012 12:00 AM Comments (0)
The main goal of treatment is to prevent fractures by slowing bone loss or strengthening bone. Healthy bones are in a state of continuous breakdown and rebuilding(aprocesscalled remodeling). | Zoom Hard as bone thats an expression weve all heard. But what does it really mean? Healthy bones are indeed hard. Your skeletal system does a yeomans work in supporting your body and facilitating your movements. When you have osteoporosis (literary porous bones), though, you can no longer count on the fact that your bones are sturdy enough to withstand even routine stress. A twist, a bend, an unexpected jolt can snap a dangerously weak bone. Sadly, many people have no inkling that they have been losing bone mass for years until a painful fracture of the wrist, spine, or hip brings the problem into sharp focus. For the individual, the consequences of an osteoporosis-related fracture can be devastating. Many older adults never regain the good health and quality of life they enjoyed before suffering a broken bone. Physical complications ranging from ongoing pain and stooped posture to breathing and digestive problems are common. Hip fractures can significantly impair a persons mobility, making it impossible to drive, cook, or even walk across a room without assistance. While its easy to paint a gloomy picture about the dangers of osteoporosis, the alternative scenario is bright. You dont have to wait until the damage is done to fight the disease. Today, doctors have sophisticated tools to identify bone thinning in the earliest stages and home in on who should begin treatment and when. For those in greatest danger of an osteoporosis-related fracture, a number of highly effective medications to curb the bone loss are already available, and more options are on the way. Todays article can serve as a guide to the pharmaceutical options available to reap long-term bone benefits. Youll find the latest information on the various medications for osteoporosis, how they work, and what their possible side effects are. The bottom line is clear: Its never too late or too early to begin thinking about your bones. So, lets get started. Medication options The main goal of treatment is to prevent fractures by slowing bone loss or strengthening bone. Healthy bones are in a state of continuous breakdown and rebuilding (a process called remodeling). This bone turnover comes in two distinct phases resorption (breakdown) and formation. Cells called osteoblasts are constantly at work forming new tissue depositing calcium to keep bones strong. At the same time, osteoclasts are resorbing old bone and removing calcium. At any one time, about seven percent of your bodys bone calcium is on the move. When you are young, this process happens quickly, and you make more bone than you lose, but as you grow older, you start to lose more bone than you make. Different osteoporosis medications target different phases of the remodeling process. Most approved drugs, such as bisphosphonates, are antiresorptive that is, they protect existing bone from being broken down or resorbed . Only one, teriparetide (Forteo) works at exclusively stimulating new bone formation. Prescription choices Many drugs have been approved to treat osteoporosis. They have been found effective in preventing or treating osteoporosis. Bisphosphonates, for example, are all very effective in reducing bone fracture risk by about 40 percent. Some have hormonal effects. Like all drugs, they also have side effects. The more common ones are usually mild and may go away. The more serious ones are rare. There are even some unexpected benefits for a few drugs, such as possibly reducing breast cancer risk. Bisphosphonates are the most widely-prescribed drugs for osteoporosis, and have been available since 1995. These include alendronate (Fosamax, Fosavance), ibandronate (Bonviva), risedronate (Actonel), and zolendronic acid (Zometa, Aclasta). Some may be taken daily, weekly, or monthly. Zolendronic acid can be administered intravenously up to once a year only. Side effects include diarrhea, leg and arm pain, irritation of the esophagus, flu-like symptoms, and fever. Calcitonin (Miacalcic) is a hormone involved in calcium regulation and bone metabolism. Side effects include nasal irritation (for the nasal spray), headache, flushing of the face, and urinary frequency. It helps in relieving pain caused by osteoporotic spine fractures. Raloxifen (Evista), a selective estrogen receptor modulator (SERM), mimics estrogen to keep bones strong. The same type of drug used in some breast cancer treatments, it can provide the benefits of estrogen without many of its drawbacks. Side effects include hot flushes, leg cramps, and blood clots. Women at high risk for stroke (such as those with uncontrolled hypertension) should not take it. One good potential side effect: It may decrease the risk of certain types of breast cancer. Teriparatide (Forteo) is a hormone that rebuilds bone in people who already have osteoporosis. It comes as a selfadministered daily injection and is approved for two-year use. Side effects include leg cramps and dizziness.

Note: Hormone therapy (estrogen with progestin or alone), once widely prescribed to prevent bone loss is now known to increase the risk of heart disease and breast cancer, and is thus no longer recommended for osteoporosis. Newer drugs Two new agents include strontium ranelate (Protos) and denosumab (Prolia). Protos is available in European Union countries and in the Philippines, but not in the US. In the largest ever bone biopsy study in osteoporosis, which was reported only last year, Protos was found to have significantly greater bone-forming activity than the commonly prescribed bisphosphonate, alendronate. Its superior bone-forming efficacy is linked to its innovative dual mechanism of action which rebalances bone turnover in favor of the formation of newer and stronger bone. The investigators point out that the favorable results can be attributed to the drugs unique mechanism of action which, unlike bisphosphonates that block bone resorption and formation, combines the dual effects of increasing or maintaining bone formation and decreasing bone resorption. Theres also evidence it may be safer than bisphosphonates. Some researchers have concluded that Protos should be first-line treatment for postmenopausal osteoporosis, and also point out that compliance is better that is, patients find it easier to take than bisphosphonates (which have to be taken on an empty stomach, and the patient must remain upright for 30 minutes afterwards). However, as a relatively new medication (it was approved for use in Europe only in 2004), not enough is known about its long-term effects. Over-the-counter supplements containing the mineral strontium are also available in health food stores. These products are not the same as strontium ranelate. There is no evidence that they have similar beneficial effects or that they have any role in treating or preventing osteoporosis. In June 2010, the US FDA approved Amgens denosumab (Prolia) in preventing fractures in postmenopausal women. Doctors welcomed the news as it offers a good alternative for patients who cant take bisphosphonates and the other drugs. Prolia is available in the US but not yet in the Philippines. The drug is a little bit different from other medications for osteoporosis in that its complicated biological molecule an antibody was especially designed to bind to, and inactivate, a protein in the body involved in bone metabolism. It is given as an injection twice a year. Prolias effectiveness appears comparable to bisphosphonates drugs. Osteoporosis drugs under scrutiny Lately, two serious complications have been reported in the medical literature on the prolonged use of bisphosphonate drugs. The most serious but rare side effects are bone loss in the jaw (osteonecrosis) and a possible increase in the risk of unusual fractures of the thigh bones (femur). Most of those who developed osteonecrosis of the jaw are cancer patients taking intravenous forms of bisphosphonates. On the other hand, the risk of atypical fracture is greatest in patients who have used biphosphonates continuously for more than five years. Most experts say that osteonecrosis of the jaw is extremely rare (estimated risk is 0.7 cases/100,000 patients) for those taking the oral form of the drug and advise that the benefits of bisphosphonates for preventing fractures outweigh the risks. It may be prudent, however, that if you are contemplating major dental work, you probably should have it done before starting on bisphosphonates. As regards the side effect of unusual fracture of the thigh bone, experts also point out that the absolute risk was small and that the known benefits of alendronate for preventing major fractures also outweigh this uncertain risk. At any rate, the US FDA notes that it remains unclear, at this time, if bisphosphonates actually caused these fractures. If youve been taking bisphosphonates for a while and are concerned about the long-term risks, talk with your doctor about taking a drug holiday. Theres little scientific evidence on how long you should take a bisphosphonate for osteoporosis or how long a drug holiday should last. But in the April 2010 issue of the Journal of Clinical Endocrinology and Metabolism, clinicians suggest that doctors should base their decision on individual fracture risk. They recommend 10 years of bisphosphonate therapy for people at high risk of fracture, followed by one- to two-year drug holiday before resuming therapy. A patient at lower risk might be treated for five years before taking a break or even stopping altogether. If you take a drug holiday, have your bone mineral density (BMD) tested after a year or two. If it has declined significantly, you may need to resume the medication. Of course, drugs are not the only way to boost your bone health. You need to stop smoking, limit your alcohol consumption, do regular weight-bearing exercises, such as walking, jogging or racquet sports, and others.