A Family Doctor's Tale - OSTEOPOROSIS

DOC I HAVE OSTEOPOROSIS

I have seen many elderly women and men walking with their back at an angle.

It is so sad to realize that many of these people are not taking care of their bone health.

They should be at least taking more calcium (present in milk and fish) and vitamin D (present in sunlight and fish oil).

They also should have a bone density test to determine the strength of their bones.

There are so many new drugs which are able to stop bone loss and improve bone strength such as Fosamax, Evista, Actonel.

Osteoporosis, which literally means porous bones, is a condition in which the bones become weak and brittle, resulting in a greater likelihood of breaking after minor trauma.


Bone is constantly being removed and replaced in our body.


Osteoporosis occurs when bone is lost faster than it can be replaced.

Osteoporosis is a silent disease.

People with osteoporosis often do not know that they have the condition.


Fractures from osteoporosis commonly occur in the wrist, spine and hip.


Persons with hip fractures suffers considerable loss of function and becomes dependent on others.

Factors that will increase the risk of developing osteoporosis are:

1.Female gender;


2.Caucasian or Asian race;


3.Thin and small body frames;


4.Family history of osteoporosis (for example, having a mother with an osteoporotic hip fracture doubles your risk of hip fracture);


5.Personal history of fracture as an adult;


6.Cigarette smoking ;


7.Excessive alcohol consumption;


8.Lack of exercise;


9.Diet low in calcium;


10.Poor nutrition and poor general health;


11.Malabsorption (nutrients are not properly absorbed from the gastrointestinal system) from conditions such as celiac sprue;


12.Low estrogen levels (such as occur in menopause or with early surgical removal of both ovaries);


13.Chemotherapy can cause early menopause due to its toxic effects on the ovaries;


14.Amenorrhea (loss of the menstrual period) in young women also causes low estrogen and osteoporosis; Amenorrhea can occur in women who undergo extremely vigorous training and in women with very low body fat (example: anorexia nervosa);


15.Chronic inflammation, due to diseases (such as rheumatoid arthritis and chronic liver diseases);


16.Immobility, such as after a stroke, or from any condition that interferes with walking;


17.Hyperthyroidism, a condition wherein too much thyroid hormone is produced by the thyroid gland (as in Grave's disease) or is caused by taking too much thyroid hormone medication;


18.Hyperparathyroidism, a disease wherein there is excessive parathyroid hormone production by the parathyroid gland (a small gland located near the thyroid gland). Normally, the parathyroid hormone maintains blood calcium levels by, in part, removing calcium from the bone.

In untreated hyperparathyroidism, excessive parathyroid hormone causes too much calcium to be removed from the bone, which can lead to osteoporosis;


19.Vitamin D deficiency. Vitamin D helps the body absorb calcium. When vitamin D is lacking, the body cannot absorb adequate amounts of calcium to prevent osteoporosis. Vitamin D deficiency can result from lack of intestinal absorption of the vitamin such as occurs in celiac sprue and primary biliary cirrhosis;


20.Certain medications can cause osteoporosis. These include long-term use of heparin (a blood thinner), anti-seizure medications phenytoin (Dilantin) and phenobarbital, and long term use of oral corticosteroids (such as Prednisolone).

The risk of Osteoporosis can be determined by:

substract the weight in kg from the age in years


If the number is less than 0 the risk is low


If the number is between 0-20 the risk is moderate


If the number is above 20 the risk is high and you should see the doctor.

Investigations to confirm Osteoporosis:

1.Routine X-rays cannot detect osteoporosis until it is quite advanced and there is a lot of bone loss.

2.Bone Mineral Density:

The best way to detect osteoporosis is to carry out a Bone Mineral Density (BMD) test to measure density (solidness) at various sites (e.g. hip, spine). It will help to assess your risk of having a fracture.

BMD is frequently measured by dual energy X-ray absorptiometry (DXA). It is a painless procedure.

DXA measures bone density in the hip and the spine. The test takes only 5 to 15 minutes to perform, uses very little radiation (less than one tenth to one hundredth the amount used on a standard chest x-ray), and is quite precise.

The bone density of the patient is then compared to the average peak bone density of young adults of same sex and race. This score is called the "T score," and it expresses the bone density in terms of the number of standard deviations (SD) below peak young adult bone mass.

Osteoporosis is defined as bone density T score of –2.5 SD or below.
Osteopenia (between normal and osteoporosis) is defined as bone density T score between –1 and –2.5 SD.

Complications of Osteoporosis:

1.Osteoporosis bone fractures are responsible for considerable pain, decreased quality of life, lost workdays, and disability.
Up to 30% of patients suffering a hip fracture will require long term nursing home care.


2.Elderly patients can further develop pneumonia and blood clots in the leg veins that can travel to the lungs (pulmonary embolism) due to prolonged bed rest after a hip fracture.


3.Some 20% of women with a hip fracture will die in the subsequent year as an indirect result of the fracture.

The pain, suffering, and economic costs will be enormous.

Treatment of Osteoporosis:


The goal of osteoporosis treatment is the prevention of bone fractures by stopping bone loss and by increasing bone density and strength.

Although early detection and timely treatment of osteoporosis can substantially decrease the risk of future fracture, none of the available treatments for osteoporosis are complete cures.

In other words, it is difficult to completely rebuild bone that has been weakened by osteoporosis.

Therefore, prevention of osteoporosis is as important as treatment.

Osteoporosis treatment and prevention measures are:

Osteoporosis treatment and prevention measures are:

Lifestyle Changes:

1.Exercise has a wide variety of beneficial health effects especially weight-bearing exercise, such as walking.

However, exercise does not bring about substantial increases in bone density.

The benefit of exercise for osteoporosis has mostly to do with decreasing the risk of falls, probably because balance is improved and/or muscle strength is increased.

It is important to avoid exercises that can injure already weakened bones.

In patients over 40 and those with heart disease, obesity, diabetes mellitus, and high blood pressure , exercise should be monitored.

Cessation of Smoking :Smoking cigarettes decreases estrogen levels and can lead to bone loss in women before menopause.

Decrease regular consumption of alcohol and caffeine on osteoporosis is not as clear as with exercise and cigarette.

Medications:

1.Medications that stop bone loss and increase bone strength:

alendronate (Fosamax),
risedronate (Actonel),
raloxifene (Evista),
ibandronate (Boniva),
calcitonin (Calcimar);

2.Medications that increase bone formation such as teriparatide (Forteo).

3..Calcium Supplements

Building strong and healthy bones requires an adequate dietary intake of calcium and exercise beginning in childhood and adolescence for both sexes.

800 mg/day for children ages 1 to 10

1000 mg/day for men, premenopausal women, and postmenopausal women also taking estrogen

1200 mg/day for teenagers and young adults ages 11 to 24

1500 mg/day for post menopausal women not taking estrogen 1200mg to 1500 mg/day for pregnant and nursing mothers

The total daily intake of calcium should not exceed 2000 mg

Daily calcium intake can be calculated by the following method:

Excluding dairy products, the average diet contains approximately 250 mg of calcium;

There is approximately 300 mg of calcium in an 8-ounce glass of milk;

There is approximately 450 mg of calcium in 8 ounces of plain yogurt;

There is approximately 1300 mg of calcium in 1 cup of cottage cheese;

There is approximately 200 mg of calcium in 1 ounce of cheddar cheese;

There is approximately 90 mg of calcium in ½ cup of vanilla ice cream;

There is approximately 300 mg of calcium in 8 ounces of calcium-fortified orange juice.

Additional calcium can be obtained by drinking more milk and eating more yogurt or cottage cheese, or by taking calcium supplement tablets as well from calcium-fortified foods.

Calcium supplements are safe and generally well tolerated.

Side effects are indigestion and constipation.

4.Vitamin D:
Vitamin D is important in several respects:

Vitamin D helps the absorption of calcium from the intestines.

A lack of vitamin D causes calcium-depleted bone (osteomalacia), which further weakens the bones and increases the risk of fractures.

Vitamin D, along with adequate calcium (1200 mg of elemental calcium), has been shown in some studies to increase bone density and decrease fractures in older postmenopausal, but not in premenopausal or perimenopausal women.

Vitamin D comes from the diet and the skin. Vitamin D production by the skin is dependent on exposure to sunlight. Daily Vitamin D intake are:

200 IU daily for men and women 19 to 50 years old,

400 IU daily for men and women 51 to 70 years old, and

600 IU daily for men and women 71 years and older.

But if a person already has osteoporosis, it is advisable to ensure 400 IU twice per day as usual daily intake, most commonly as a supplement alongside prescription osteoporosis medication.

5.Hormone therapy (menopausal hormone therapy)

Menopausal hormone therapy (previously referred to as hormone replacement therapy or HRT) has been shown to prevent bone loss, increase bone density, and prevent bone fractures. It is useful in preventing osteoporosis in postmenopausal women.

Medications that prevent bone loss and breakdown

Osteoporosis can be monitored with:


1.Repeat bone density testing (DXA scans) is NOT indicated in monitoring osteoporosis treatment or prevention on a routine basis.

2.Bone density changes so slowly with treatment that the changes are smaller than the measurement error of the machine.

The real purpose of osteoporosis treatment is to decrease future bone fractures.

There is no good correlation between increases in bone density with decreases in fracture risks with treatment.

In the future, however, if ongoing research brings new technology or new therapies, testing decisions will clearly change.