I Have Osteoporosis, Now What? By Dr. Chris Prakash, MD
Q: I am a 65 year old woman. My bone density test showed that I have osteoporosis. My doctor prescribed Fosamax but I could not tolerate it. What should I do?
A: Osteoporosis (or bone loss) is a very common disease. According to The World Health Organization, almost 1 in 4 women ages 60 to 70 have osteoporosis. The incidence goes up to 70% in women more than 80 years old. Weakening of bones is a normal aging phenomenon. However, if untreated, it can have drastic physical and emotional consequences. So, treating osteoporosis can have enormous benefits.
Who is at risk?
You may be at risk if:
- You are a woman (especially thin, or of advanced age).
- You are white or Asian, especially with a family member with osteoporosis.
- Postmenopausal (including if you had early or surgically induced menopause).
- If you have any of the following: Cigarette smoking, low amounts of calcium in the diet, heavy alcohol consumption, inactive lifestyle, and use of certain medications, such as corticosteroids and anticonvulsants.
How is the diagnosis made?
A bone mineral density test or a DXA scan is done (dual energy X-ray absorptiometry). This measures the bone density of the spine and hip. The result is compared to others your age (to calculate the Z-score) and to young adults (to calculate the T- score). Normal T score is -1 or higher. Osteopenia is defined as a score between -1 and -2.5. You have osteoporosis if the T score is -2.5 or lower.
How is Osteoporosis treated?
Even though medications form the backbone of management of osteoporosis, ancillary measures are important to enhance the efficacy of treatment. This will include a combination of dietary, exercise, and lifestyle modification approaches.
- Exercise – Weight-bearing physical activity strengthens bones.
- Calcium and Vitamin D – According to National Institutes of Health (NIH), adults should get 1200 mg of calcium daily (8oz of milk has 300 mg). Calcium supplementation may be necessary to make up the difference. Vitamin D is essential for calcium absorption and bone health. 800 – 1000 units a day are recommended but the recommendations vary widely.
- Quit smoking as smoking cigarettes speeds up bone loss.
- Limit alcohol – If you drink alcohol, consider limiting it to one drink a day or less.
Which medications are used?
Bisphosphonates are a class of medications that are the first choice to treat osteoporosis. These include:
- Alendronate (Fosamax) – orally weekly
- Risedronate (Actonel) – orally monthly
- Ibandronate (Boniva) – intravenous infusion every 3 months
- Zoledronic acid (Reclast) – intravenous infusion once a year
Hormones, such as estrogen, and some hormone-like medications, such as raloxifene (Evista), can also be used, but are prescribed less often now, due to their side-effects, and because bisphosphonates are so effective.
A new medication called Prolia has been approved for use in osteoporosis. This is a RANK ligand inhibitor with a unique mechanism of action. It is given as a subcutaneous injection every 6 months at the doctor’s office. It is more expensive than other treatments, and is indicated for use only after failure of other treatments.
What side effects can I expect?
- The most common side effect with bisphosphonates is stomach upset and heartburn (can be avoided by taking the medication on an empty stomach)
- Some people experience pain or aching in their bones.
- Bisphosphonates also have the potential to cause Osteonecrosis of the jaw. This is a rare condition in which a section of jawbone dies and deteriorates. This may occur after a dental extraction, after trauma to the jaw or sometimes even just spontaneously. It happens primarily in patients with cancer in the bones, who receive high doses of bisphosphonates.
- Note of Caution: Before starting a bisphosphonate, make sure your teeth are healthy, and practice good oral hygiene.
How do I decide which drug to take?
The decision to take one drug over another is often personal, and is based on your preference, convenience, and dosing schedule. Your doctor might recommend a monthly dose of medication if it’s going to be better tolerated or better accepted. But if you’re the type of person who might forget to take your medicine every month, you might do better taking it once a week. Some women prefer an injection given yearly, which ensures that they are fully protected until their next treatment.
This information is strictly an opinion of Dr Prakash, and is not intended to replace the advice of your doctor. Dr Chris Prakash is a contributing columnist, and author of eParisExtra’s “The Doctor is In” column. He is a medical oncologist at Texas Oncology Paris. He is board certified in Internal Medicine, Oncology and Hematology. He lives in Paris, TX with his wife and two children, and can be reached at 9037850031, or Sucharu.firstname.lastname@example.org