Osteoporosis or thinning bones is a disease of bones. The bone weakens due to decrease in bone density. Osteoporosis literally means “porous bones”. In osteoporosis body stops producing as much bone as it did before. There is deterioration of bone formation leading to brittle or fragile bones. This increases the risk of painful fractures especially in spine, hip and wrist. Osteoporosis related fractures may occur during fall or even mild stresses such as bending or coughing.
Osteoporosis can occur both in males and females. However, it is more common in females after menopause (cessation of menses) around 50 years and above. During menopause there is a drop in female hormone (oestrogen) that protects against osteoporosis. Osteoporosis is a silent disease as there is no symptom in the early phase of the disease. The weakening of the bones may lead to multiple fractures and bone pain. The weakening of spine may lead to stoop and backache.
Bone is constantly being renewed as old bones are replaced by newer bone tissue. The new bone formation (osteoblastic activity) and old bone destruction or resorption (osteoclastic activity) maintains the optimum bone density and integrity of its structure. This process is termed as remodelling that continues throughout the life.
Bone density is at peak in the late 20s. After the age of 35 years bone destruction is faster than it s formation. This imbalance between formation and destruction leads to weakening of the bones and if in excess, osteoporosis results.
- Post-menopausal women
- Family history of osteoporosis
- Age above 50 years
- Being Asian
- Low sex hormones (oestrogen in females or testosterone in males)
- Excessive alcohol
- Deficiency of calcium and Vitamin D
- Lack of exercise
- Overactive thyroid gland
- Long term use of certain drugs eg. antacids, steroids, anti-seizure drugs, antidepressants, anticancer, thyroid hormone etc.
- Eating disorders
- Gastro-intestinal disease
- Weight loss surgery
- Kidney disease
- Liver disease
- Lung diseases
- Rheumatoid arthritis
- Sedentary life style
- Female athlete (loss of menses, eating disorder and excessive exercise)
Usually there is no symptoms in the early phase of the disease. However, the patients may have the following symptoms as the disease progresses:
- Back pain, may be due to fractured or collapsed spine
- Loss of height over time
- A stooped posture
- A bone fracture that occurs much more easily then expected.
Fractures are a common symptoms of osteoporosis and may result in disability. The most common fractures are of wrist, spine, shoulder and hip. Hip fracture require prompt surgery as associated with serious complications.
Bone density is measured by a special X ray based scan known as DEXA (dual energy X ray absorptiometry) or bone densitometry. A medical history along with few specific laboratory investigation can also help diagnose osteoporosis. There are certain biomarkers in the blood and urine that are altered in osteoporosis. The assessment of these biomarkers suggest the diagnosis of osteoporosis.
Life style modification has shown to reduce the risk of osteoporosis. People should take care of the followings for prevention of osteoporosis.
- Calcium & Vitamin D supplementation: Calcium is essential for bones and prevention of osteoporosis. Adults above 18 years require 1000 mg of calcium daily. Women above 50 years and all adults after 70 years should take 1200 mg of calcium. Dietary sources of calcium are milk, cheese, yogurt, green vegetables, and fish.
Vitamin D help the body to absorb calcium. The main source of vitamin D is exposure to sunlight, salt water fish and liver. The usual daily requirement for Vitamin D in an adult is 600-800 IU per day. In case of inadequate intake of vitamin D or poor exposure to sunlight, vitamin D supplementation can be recommended
- Protein: Protein is the building blocks of the bone. Vegetarians and vegans can get good protein from soya, nuts, and pulses. Dairy products are also rich source of protein for vegetarians.
- Body weight: Maintain optimum body weight. Low body weight increases the risk of bone loss and fractures. Excess body weight increases the risk of fractures in arms and wrist.
- Stop smoking and consumption of tobacco
- Reduce intake of alcohol
- Weight bearing exercises or resistance exercise. Walking, jogging, running, skipping rope, and skiing are some of the exercises that help strengthen the bones.
- Taking care to prevent fall.
The treatment of osteoporosis is mainly aimed at life style modifications to maintain or prevent further damage to the bones. There are several medications that are used for the treatment of osteoporosis and thus prevention of fractures.
The recommendations of treatment are often based on an estimated risk of fractures in next 10 years. Treatment may not include any drug if the fracture risk is low. Only life style changes may help prevent any complication of osteoporosis. The following drugs are used in the treatment of osteoporosis for high risk patients:
a. Bisphosphonates: This includes, alendronate, risedronate, zoledronic acid and ibandronate. These drugs are mainly used as first line therapy. These drugs reduce the bone resorption thus increases the bone density. The main side effects include heart burn, nausea and abdominal pain. The use of these drugs are usually not recommended for more than 5 years due to the risk of damage to the thigh bone and jawbone.
b. Hormones: Female hormone oestrogen may be recommended in post-menopausal females. Raloxifene has oestrogen like effects and safer to use in osteoporosis. In men, testosterone may be beneficial though never recommended alone for the treatment of osteoporosis.
There are few special biological therapies that are being used for the treatment of osteoporosis. These are quite expensive and require to be administered as subcutaneous injection.
a. Denosumab: This drug has better efficacy that bisphosphonates for increasing bone density. It is administered under the skin every 6 months.
b. Teriparatide: This drug stimulates the bone growth and increases the bone density. It is given by daily injection below the skin. The maximum duration of treatment with teriparatide is 2 years. After teriparatide treatment another drug for osteoporosis is recommended to maintain the bone density.
c. Intranasal calcitonin: Calcitonin nasal spray is used with calcium and vitamin D in women with post-menopausal osteoporosis. There are conflicting opinion about the use of intranasal calcitonin for osteoporosis as the studies have shown the higher incidences of cancer in patients taking this drug.
Approximately one in two women and one in four men above 50 years of age will get fracture due to osteoporosis. Some of the fractures are fatal in elderly populations. Several patients with osteoporosis require long term nursing home care. The problem of osteoporosis is often overlooked by the patient due to its silent nature and also underdiagnosed by the treating doctors. It is highly recommended to consult the physician above 50 years of age for the screening of osteoporosis.