Osteoporosis Treatment Guide - Cleveland Clinic

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OSTEOPOROSIS TREATMENT GUIDE

Osteoporosis Treatment Guide

An estimated 10 million Americans have osteoporosis.

Another 34 million have low bone mass. If left

untreated, osteoporosis can be both debilitating and

painful. Fortunately, there are steps you can take to

prevent osteoporosis from ever occurring. Or, if you

already have the disease, early detection and proper

medical care can help you slow or even reverse its

progress and prevent fractures.

Read on to educate yourself about osteoporosis. You

can use this guide as a resource as you begin to learn

about the disease. Your better understanding can help

you communicate with your doctor so that, together,

you can arrive at the right preventative and/or

treatment options.

Osteoporosis is responsible for more than 1.5 million fractures each year.

Almost half of all women older than age 50 will break a bone because of osteoporosis. An estimated one in four men will, too.




A look inside your bones:

Your bones are made of living, growing tissue. An out-er shell of cortical or dense bone encases trabecular or spongy bone. The inside of healthy bone resembles a sponge. In addition to supporting the body and protecting vital organs, bones store calcium and other minerals. The major storehouse for calcium is the bone, which contains more than 90 percent of your body’s total calcium. The bone is constantly remodel-ing, being broken down and built up in order to supply the body with needed calcium and repairing areas of damaged bone to keep the bones strong. Up until about age 25 to 30, a person normally builds more bone than he or she loses. In women at menopause, bone breakdown outpaces bone buildup, resulting in a loss of bone mass. In a person with osteoporosis,

bone mass is lost at an accelerated rate.

WHAT IS OSTEOPOROSIS?

Osteoporosis is a disease that weakens bones, making them

more susceptible to sudden and unexpected fractures. Literally

meaning “porous bone,” it results in an increased loss of bone

mass and strength.

Although we do not know the exact cause of osteoporosis, we

do understand how the disease develops. When osteoporosis

occurs, the bone’s architecture is altered resulting in a weakened

internal structure of the bone.

Who is at risk?

Bone loss in women accelerates after menopause. Women over age 50 have the greatest risk for developing osteoporosis, but the disease can strike at any age.

Some people are more prone to developing osteoporosis. There are many risk factors which, when present, increase your chance of having osteoporosis:

• Female gender

• Thin and/or small frame

• Age (all women over age 65 should have a bone density test regardless of the presence of any risk factors)

• Family history of osteoporosis

• Premature menopause (younger than age 45)

• Absence of menstrual periods (amenorrhea)

• Anorexia nervosa or bulimia

• Diet low in calcium

• Use of certain medications, such as corticosteroids and anticonvulsants, aromatase inhibitors (used for breast cancer), and androgen deprivation therapy in men (used for prostate cancer)

• Low testosterone levels in men

• Inactive lifestyle

• Cigarette smoking

• Excessive alcohol use (more than three glasses of wine, beer or liquor per day)

• Being Caucasian or Asian, although African Americans and Hispanic Americans are at risk as well

• Diseases such as intestinal problems, kidney problems, hormonal problems, kidney stones, liver disease

• Organ transplant recipients

This microscopic image shows thinning bone, with large honeycomb holes, that put you at increased risk for fractures.




What are the symptoms?

Osteoporosis is often called a silent disease because bone loss occurs without symptoms. The first symptom is often a fracture (break) includ-ing a collapsed vertebrae (bones in the spine).

Collapsed vertebrae might initially be felt or seen in the form of severe back pain, loss of height or stooped posture (a kyphosis, often called a

dowager’s hump).

Why are fractures such a big concern?

Breaking a bone is serious, especially if you are older. Osteoporosis can cause a break in any bone, but those in the hip, spine and wrist are the most common.

Hip fractures are a particularly dangerous health consequence of osteoporosis. Roughly 20 percent of patients die within the first year after being diagnosed with a hip fracture. Hip fractures often result in a loss of independence and the need for nursing home care.

It is best to get evaluated at an early stage, so you can begin a preven-tion or treatment strategy before suffering a fracture or any other

symptom of osteoporosis,

How can I know if I have osteoporosis?

Painless and accurate medical tests can provide you with information about your bone health before problems begin. Bone mineral density tests (BMD tests), also known as dual energy X-ray absorptiometry (DXA) scans, are X-rays that use very small amounts of radiation to de-termine the bone density most often of the spine, hip, wrist.

These tests help detect the presence of osteoporosis, determine how quickly you are losing bone mass and predict your risk of fracture. They also are used to follow the course of the disease and monitor the effects of various treatments.

All women over age 65 and men at age 70 should have a bone density test. Patients with risk factors for low bone mass and bone loss should

be tested at a younger age. Your physician can order these tests for you.

Men Get Osteoporosis, Too

Osteoporosis is more common in women,

but it is not just a “women’s disease.” In fact,

20 percent of cases of osteoporosis are in

men – that’s 2 million American men. One

in eight men over the age of 50 is at risk for

developing osteoporosis.

Osteoporosis is not as common in men

because men’s skeletons are larger. Any bone

loss men have starts later and isn’t as rapid.

They also lack any drastic hormonal changes

coinciding with the bone loss (as in women

and menopause). However, it is just as impor-

tant for men to seek prevention and treatment

because the disease, left untreated, can lead

to real consequences. For instance, an esti-

mated 80,000 men will fracture a hip each

year – and they are more likely than women

to die within a year from a problems related to

that injury. In some studies, about 20 percent

of women and double that number of men

will die in the first year after hip fracture.




How you can prevent osteoporosis

Building strong bones before age 25 to 30 is the best defense against developing osteoporosis later in life. But, good nutrition and a healthy lifestyle at any age can help prevent osteoporosis or minimize its effect on your life.

Follow these guidelines to build and maintain strong bones:

Eat a balanced diet rich in calcium and vitamin D. Pre-menopausal women need 1,000–1,200 milligrams of calcium each day, while post-menopausal women need 1,200–1,500 milligrams daily.

Calcium supplements are an effective alternative for those with low dietary calcium intake. Vitamin D helps the body absorb calcium. The body manufactures vitamin D when it is exposed to sunlight. The vitamin is also available in fortified milk, the National Osteoporosis Foundation recommends 800 to 1,000 IU per day.

Exercise regularly. Do 30 minutes of weight-bearing exercise — such as walking or jogging — three to four times a week.

Maintain a healthy lifestyle. Both smoking and excessive alcohol intake reduce bone mass. It’s best to avoid smoking altogether and consume no more than three alcoholic drinks per day.

Prevent falls so you can stay active. Accidental falls — and the broken bones that often result — can limit your activity and threaten your independence. If you have osteoporosis, it is important to protect yourself against falls. This is especially important if you feel unsteady on your feet or have a history of falls.

Take the following precautions to make your home safe:

• Remove loose household items, keeping your home free of clutter. • Remove wires across open floor. • Install grab bars on tub and shower walls and beside toilets. • Install proper lighting. • Apply treads to floors and remove throw rugs. • Buy hip pad protectors if you are a frequent faller.

Physical therapy and balance training also may help to prevent falls.

DXA (Dual Energy X-ray Absorptiometry)

The most accurate test available for the

detection of osteoporosis is the dual energy

X-ray absorptiometry (DXA). The test mea-

sures the bone density (the amount of cal-

cium) in your hips and spine and takes about

10 to 15 minutes. Radiation exposure is a

fraction (one-tenth) of the amount in a

standard chest X-ray.

The procedure is similar to getting an X-ray

taken: You will wear a hospital gown and be

asked to lie on your back while they perform

the test. No needles or injections are involved.

Results are performed by specially trained

certified technologists and reviewed by board-

certified physicians. Test results are provided

to your physician, who will then discuss the

results with you.

You may find an ultrasound machine in retail

stores that measure bone mass in your heel.

However, while ultrasound is a reasonable

predictor of your risk for fracture, it is not as

good as the DXA and can’t measure bone in

your hips and spine, where the most com-

mon debilitating fractures occur. In addition,

ultrasound is not approved for repeat testing

to follow changes in bone density over time.




How is osteoporosis treated?

Treatment plans typically include a diet rich in calcium or calcium supplements and vitamin D, a weight-bearing exercise program and possibly drug therapy.

The drugs approved to treat osteoporosis fall into two types: antiresorptives (which slow the breakdown of bone) and anabolics (which speed up your rate of bone formation).

Alendronate (Fosamax®), ibandronate (Boniva®), zoledronic acid (Reclast®), (risedronate (Actonel®), raloxifene (Evista ®), denosumab (Prolia®) are antiresorptive agents and teriparatide (Forteo®) is an anabolic agent, and are already approved for preventing or treating osteoporosis. Many other options are currently under investigation.

Your doctor will help determine what medication is right for you based on factors including the severity of your osteoporosis, your gender, known side effects and any other medical conditions you may have.

Eat and drink this:

The best dietary sources of calcium are:

• Dairy products, including milk, cheese,

yogurt, cream soups and pudding

• Green vegetables, such as broccoli,

spinach and greens

• Seafood

• Dried peas

• Beans

Vitamin D helps your body use calcium.

Adequate amounts of this vitamin can be

obtained through exposure to the sun and

the following foods:

• Eggs

• Fish

• Fortified milk

At a glance: Approved osteoporosis drugs

Drug name Type How it’s taken

Alendronate (Fosamax®) Antiresorptive Daily or weekly pill or weekly liquid

Ibandronate (Boniva®) Antiresorptive Monthly pill or 4x/yr IV infusion

Zoledronic acid (Reclast®) Antiresorptive Once yearly IV infusion

Risedronate (Actonel®) Antiresorptive Daily, weekly, monthly, or twice-monthly pill

Raloxifene (Evista ®) Antiresorptive Daily pill

Denosumba (Prolia®) Antiresorptive Injection every 6 months

Teriparatide (Forteo®) Anabolic Daily injection

Physical therapy can teach you to improve your function. A physical therapist can show you the best way to move from one position to another and how to best prevent falls. They also can teach you how to use walking aids such as crutches, a walker or a cane, when needed.

For patients with recent spine fractures, our doctors can refer you to a spine surgeon who will perform an evaluation to determine if you are a candidate for a surgical procedure. Kyphoplasty is one procedure used that may relive pain and may restore collapsed vertebrae to nearly normal height if performed soon after fracture.




Improving your infusion experience

Cleveland Clinic’s Department of Rheumatic and Im-

munologic Disease offers convenient infusion locations

throughout the region, including the recently opened

eight-bed Infusion Center located on the fifth floor of

the Cleveland Clinic Main Campus Crile building.

The state-of-the-art center at the main campus was

specially designed to improve both comfort and patient

experience of rheumatology patients who require

infusion therapy, such as osteoporosis medications.

For more information, call 866.275.7496. We

offer flexible scheduling from 8 a.m. to 5 p.m.

Monday through Friday.

About Cleveland Clinic’s Center for

Osteoporosis and Metabolic Bone Disease

If you are concerned about your risk for osteoporosis or have been diagnosed with the disease, the Cleveland Clinic Center for Osteoporosis and Metabolic Bone Dis-ease can help.

Our center is devoted to the evaluation and treatment of patients with osteoporosis and other forms of diseases that affect bone. Its nationally recognized osteoporosis team includes specialists in rheumatology, endocrinology and radiologists who collaborate with experts in other Cleveland Clinic specialties, including orthopaedic sur-gery, internal medicine, physical rehabilitation, physical therapy, pain management and geriatrics, as needed.

We utilize a state-of-the-art bone densitometer, which assessed bone density in the hip and spine, as well as radius and total body, if needed. This technique allows the physicians to evaluate the degree of bone loss, to diagnose osteoporosis and the risk for future fracture.

Our researchers pioneered research in preventing bone loss and remain at the forefront of testing new osteopo-rosis treatments. If you have osteoporosis, you may be able to participate in one of our clinical trials to deter-mine the effectiveness of new medications.

The Cleveland Clinic Department of Rheumatology is ranked #2 in the nation by U.S.News & World Report.

To learn more about the Osteoporosis and

Metabolic Bone Disease Center and to meet

our staff, visit clevelandclinic.org/rheum.

For appointments, call 866.275.7496.

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Osteoporosis Treatment Guide - Cleveland Clinic