The importance of an early osteoporosis diagnosis and treatment cannot be overstressed. All osteoporotic fractures are associated with significant morbidity and can cause pain, disability, sometimes hospital admission, and mortality.
About 10 million people (both men and women) in the United States suffer from osteoporosis. About one in two white women and one in five white men suffer from osteoporosis-related fractures in their lifetime.
Osteoporosis is a progressive metabolic bone disease caused by low bone density and deterioration of bone structure that increase the risk of fractures.
Early diagnosis and prompt treatment significantly reduce the severity of symptoms and the risk of morbidity.
How is osteoporosis diagnosed?
Your healthcare provider may order a test to obtain information about your bone health condition. The bone density test for osteoporosis is painless and quick. It determines how dense or thick your bones are by using X-rays.
Bone mineral density (BMD) tests, also known as dual-energy X-ray absorptiometry (DEXA or DXA) scans, use very small amounts of radiation (X-rays) to determine the proportion of minerals in your bones.
BMD tests help to diagnose osteoporosis and assess your risk of fracture. In most cases, only certain bones are checked — usually, the bones of the hip, spine, and wrist, where osteoporosis fractures mostly occur.
The BMD tests become necessary because the regular X-rays will show the presence of osteoporosis only when the disease is advanced.
The DXA machine measures the number of x-rays absorbed by tissues and bone and correlates it with bone mineral density. It converts bone density test results to your T score and Z score.
The T score tells you the amount of bone you have and compares it with that of the normal population of younger people. It determines your risk of developing a fracture and whether you need medication.
What your T-scores mean:
- -1 and above: Your bone density is normal
- Between -1 and -2.5: You have osteopenia
- -2.5 and lower: Most likely osteoporosis
Your Z score tells you the amount of bone you have in comparison to those in your age group. This score may indicate the need for further medical tests.
The BMD test is indicated in all women over the age of 65 years. It may be indicated earlier for those women who have risk factors for osteoporosis. In men, it is indicated over age 70, or earlier in men with risk factors.
How often should you test your bone density?
If you are on medication for your diagnosed osteoporosis, you should have a bone density test every 1 to 2 years.
If you don’t have osteoporosis, your doctor may advise a bone density test every 2 years, especially for menopausal and post-menopausal women.
The American Academy of Family Physicians recommends not to use dual-energy x-ray absorptiometry (DEXA) to screen for osteoporosis in women younger than 65 years or in men younger than 70 years with no risk factors.
Presently, no treatment can completely cure or reverse established osteoporosis, though it can halt its progression. However, early medical therapy can help to prevent osteoporosis in most people.
Treating osteoporosis involves treating existing fractures, preventing them, and using medications to strengthen bones.
Treatment options are several and a number of factors will help your doctor select the best option for you.
- Your age
- Your risk of developing a fracture
- Any history of previous bone injury
The treatment aims to prevent loss of bone mass and strengthen weakened bones. Management for osteoporosis will include natural treatments such as exercise, dietary changes, stopping smoking, and lowering alcohol and caffeine intake.
Vitamin D and calcium supplements, and adequate exposure to sunlight can also improve bone health. All the above-mentioned factors may reduce the risk of osteoporosis by promoting bone health.
Management of young patients with osteoporosis consists of treatment of secondary etiological factors, improving lifestyle, a bone-friendly diet that includes calcium and vitamin D, and physical exercise
- A prescribed diet plan: Your osteoporosis diet should be well-balanced and should contain plenty of dairy, fish, fruits, and vegetables. Your diet should include foods that are good sources of bone-friendly nutrients, such as protein, calcium, magnesium, zinc, and vitamins D, C, and K. However, otherwise, you may need to take supplements to fulfill your need.
- Certain exercises specially designed for osteoporosis: Some exercises recommended for osteoporosis are walking, dancing (for the young), and low-impact aerobics such as stationary bicycling and swimming. These types of exercise directly benefit the bones in your legs, hips, and lower spine and slow mineral loss.
- Vitamin and mineral supplements of calcium and vitamin D and some minerals
The treatment options chosen are based on your risk of fracture estimated by using the bone density test. If your risk is low, the treatment may focus on eliminating the risk factor(s) that make you prone to bone loss and falls that can lead to fractures.
Medications for osteoporosis include:
Bisphosphonates are the drugs of choice for men and women who are at high risk of fractures.
- Alendronate (Binosto, Fosamax)
- Ibandronate (Boniva)
- Risedronate (Actonel, Atelvia)
- Zoledronic acid (Reclast, Zometa)
Bisphosphonates slow down osteoclastic bone resorption and thereby prevent your bones from losing calcium and other minerals. This helps your bones to remain strong.
Side effects of oral Bisphosphonates include nausea, abdominal pain, and heartburn. Intravenous bisphosphonates can cause fever, headache, and muscle aches.
Very rarely, complications of bisphosphonates can include a crack in the middle of the thighbone (femur) and delayed healing of the jawbone after an invasive dental procedure due to osteonecrosis.
Denosumab (Prolia, Xgeva) produces similar if not better results as Bisphosphonates do, with respect to bone density and reduces the risk of fractures. Again as with bisphosphonates, denosumab can cause the same rare complication of causing breaks or cracks in the femur bone of the thigh and osteonecrosis of the jaw.
It is administered as a subcutaneous shot every six months and you may have to take it indefinitely. Stopping Denosumab can increase your risk of spinal fractures.
Estrogen, especially when started soon after menopause, can help maintain bone density. However, estrogen therapy can increase the risk of breast cancer and blood clots in postmenopausal women. Blood clots can cause a stroke.
Therefore, estrogen is typically used in younger women to increase bone health or in women whose menopausal symptoms require treatment.
Raloxifene, sold under the brand name Evista among others, is used to prevent and treat osteoporosis in postmenopausal women. It reduces the risk of spine fractures by 30 percent.
It is not a hormone and belongs to a class of drugs called estrogen agonists/antagonists that provide the beneficial effects of estrogens without its potential side effects. Raloxifene is a selective estrogen receptor modulator (SERM).
Raloxifene (Evista) has beneficial effects in increasing bone density in postmenopausal women, without risks of breast cancer associated with estrogen. However, Raloxifene may increase your risk of blood clots. How flashes are another possible side effect.
Testosterone replacement therapy can help improve symptoms of osteoporosis in men with a gradual age-related decline in testosterone levels.
Bone-building medications are indicated in cases of severe osteoporosis and when the more common treatments have failed to give the expected results. They include:
- Teriparatide (Bonsity, Forteo). This effective and powerful drug for treating osteoporosis stimulates new bone growth. It is a parathyroid hormone analogue and is administered daily by subcutaneous injection for up to two years.
- Abaloparatide (Tymlos) is indicated in postmenopausal women with osteoporosis and facing a high risk for fracture. It is also a parathyroid hormone analogue. It is given as a subcutaneous injection daily for only two years.
- Romosozumab (Evenity) is the latest new anabolic agent (bone-building) to treat osteoporosis. It is indicated in postmenopausal women with a high risk for fracture. It is administered as an injection every month for up to one year only.
After you stop taking any of these bone-building medications, you generally will need to take another osteoporosis drug to maintain the new bone growth.
Compression fractures of the vertebra caused by osteoporosis are treated by vertebroplasty and kyphoplasty. This is also an option to treat painful spine fractures.
With vertebroplasty, surgical polymethylmethacrylate (PMMA) cement is injected into the fractured bone through a hollow needle into the fractured bone. This is done under image guidance. The cement hardens, which then stabilizes the fractures, adds support to your spine and gives relief from pain.
In kyphoplasty, the interventional radiologist inserts a balloon through the needle into the fractured bone and creates a cavity. The balloon is then removed and a cement mixture is injected into the cavity.
In some cases of compression fracture, where there is severe narrowing of the spinal canal, surgical treatment may be required.
The early osteoporosis diagnosis and treatment significantly improve the prognosis for osteoporosis. The sooner bone loss is diagnosed and treated the better it is. Patients with osteoporosis need to increase their bone mineral density (BMD) and reduce the risk of fractures.
They can do this with a regular exercise plan, a diet rich in calcium, vitamin D, some minerals, and osteoporosis medication.
In addition, patients can decrease their risk of falls and fractures through rehabilitation and modification of their homes and surroundings by removing obstacles.
Further medical management to prevent worsening of the condition can be prevented by providing medication for pain management and, if necessary, orthotic devices.