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What’s new in osteoporosis?

Prevention and treatment options

By Yasmin Orandi, MD

From Minnesota Healthcare News

Osteoporosis is increasing in our population—and so is the discussion about guidelines for prevention and treatment options. According to the National Hospital Discharge Summary, 310,800 total hip replacements were performed among inpatients aged 45 and older in 2010, up from 138,700 in 2000. That’s an increase from 142.2 to 257.0 for every 100,000 persons. One in two women now get osteoporosis, along with one in four men.

Risk factors
We are learning more about the risk factors associated with osteoporosis, including the following:

  • Diets low in calcium and vitamin D
  • Physical inactivity
  • Tobacco and alcohol use
  • Being a woman
  • Thin body frame or body mass index of 19 or less
  • Advanced age
  • Caucasian or Asian descent
  • Family history
  • Too much thyroid hormone in women
  • Too little estrogen in women
  • Low testosterone in men
  • Eating disorders, such as anorexia or bulimia
  • Secondary causes, including gastrectomy, weight-loss surgery, and conditions such as Crohn’s disease, celiac disease, and Cushing’s disease
  • Certain medications, including long-term use
    of corticosteroids, aromatase inhibitors, selective serotonin reuptake inhibitors, methotrexate, some anti-seizure medications, and proton pump inhibitors
  • Excessive caffeine use
  • Osteopenia

Screening guidelines
The U.S. Preventive Services Task Force recommends dual-energy X-ray absorptiometry (DEXA) scans for women 65 years and older and for younger women with increased fracture risks, as determined by the World Health Organization’s Fracture Risk Assessment Tool (FRAX). FRAX is an algorithm based on probabilities that can help physicians determine the likelihood of someone breaking a bone within the next 10 years. These probabilities are based on a person’s age, weight, height, alcohol consumption, and history of osteoporosis, among other factors.

There are no guidelines for rescreening women who have a normal DEXA screen. Some suggest intervals of every four years, but insurance generally covers screening every two years, which is what I recommend to my patients. Routine screening for men is not suggested unless they have risk factors.

Current recommendations for patients with osteoporosis
Encouraging adequate amounts of calcium and vitamin D is still the recommended advice for those with osteoporosis. Most studies suggest 1200 mg of calcium and 800 international units of vitamin D daily for postmenopausal women with osteoporosis. Premenopausal women are encouraged to consume 1000 mg of calcium and 600 international units of vitamin D daily.

For men between the ages of 51 and 70, the recommended dietary allowance is 1000 mg of calcium daily, but after age 70, they should take in 1200 mg each day.

In the past, physicians have recommended that at least half of this intake for both men and women come from dietary sources, such as dairy products, broccoli, kale, canned salmon, sardines, and soy, with the rest from calcium supplements such as calcium carbonate and calcium citrate. Calcium citrate is the recommended choice for patients taking proton pump inhibitors or H2 blockers or who have achlorhydria.

Studies now indicate, however, that prescribing calcium supplements should be done with care, as new cardiovascular risks are becoming more prevalent. These risks occur when the total calcium intake exceeds recommended amounts or supplements are given in large doses, bringing the total intake above 2000 mg per day. Some physicians believe it is wise to avoid doses greater than 500 mg of calcium at one time. Personally, I encourage calcium to come from diet unless patients cannot tolerate milk or have a diet very low in calcium.

Our bodies need vitamin D to absorb calcium, but the amount of recommended vitamin D is controversial and under discussion by experts. For adults 19 to 70, the RDA is 600 international units each day, increasing to 800 units after age 71. The Institute of Medicine has defined the safe upper limit for vitamin D as 4000 units per day, although sometimes higher doses are required during initial treatment of vitamin D deficiency or when coexisting conditions require higher doses.

I always ask my patients whether they are taking additional dietary supplements, such as multivitamins, that might contain vitamin D before I prescribe extra vitamin D. Too much of this vitamin, especially if taken with calcium supplements, can lead to hypercalcemia, hypercalciuria, or kidney stones.

The goal is to get a patient’s vitamin D level above 30. In addition to sunlight, good sources of vitamin D include oily fish, such as tuna and sardines, egg yolks, and fortified milk. The two most common forms of vitamin D supplements are ergocalciferol and cholecalciferol. Cholecalciferol works more efficiently.

While calcium and vitamin D are critical to preventing and treating osteoporosis, I always encourage my patients to make lifestyle changes that can decrease their chances of breaking a bone. This includes:

  • Increasing the amount of exercise. A good balance of strength and cardiovascular exercise, coupled with weight-bearing exercise, is best. Good weight-bearing exercises are walking, jogging, tennis, and climbing stairs.
  • Decreasing caffeine intake. I tell my patients to restrict their caffeine intake to no more than 2.5 cups of coffee or 5 cups of tea per day. A recent South Korean study reported that drinking coffee within these guidelines can actually reduce a person’s risk of osteoporosis.
  • Drinking in moderation or not at all. That means fewer than four alcoholic drinks per day for men and fewer than two for women. Alcohol can interfere with the body’s ability to absorb calcium.
  • Stopping the use of tobacco. While smoking has been connected to bone loss, it is difficult to separate smoking from other risk factors common to smokers, such as alcohol intake, small body mass, physical inactivity, and poor diets. Women who smoke also have an earlier menopause than nonsmokers.
  • Making the home safe. Most falls take place in the kitchen, bath, or on steps. I encourage patients to assess the risk of falling and remove any risk factors, such as throw rugs, dark hallways, or slippery floors.
  • Increasing exposure to sunlight or ultraviolet light to 30 minutes per day, five days a week. Sunlight contributes to our body’s production of vitamin D.

New medications
Most physicians today recommend bisphosphonates, including alendronate (Fosamax) or ibandronate (Boniva) as a first-line medication for osteoporosis. These medications are usually well tolerated and cost less than some of the newer pharmaceutical agents on the market today. I usually stop them after five years, as fewer patients are willing to take medications due to the risk of femur fractures and jaw necrosis, both of which have had a lot of media coverage in recent years.

Other common osteoporosis medications include selective estrogen receptor modulators (SERMs) like raloxifene (Evista) or newer SERMs such as lasofoxifene.

Teriparatide, marketed as Forteo, is an anabolic agent that treats osteoporosis and also stimulates bone formation. Other similar drugs are in clinical studies, as are drugs that communicate with the chemical that signals bone-eating cells (osteoclasts) to block that signal. Scientists believe there may be other ways to speak to osteoclasts through signaling mechanisms.

Osteoporosis in men
More attention is being given to osteoporosis in men, although guidelines for testing are less clear than they are for women. Bone density measurements are obtained infrequently in men. Therefore, the diagnosis of osteoporosis is often made as a result of incidental osteopenia seen on radiographs or by fracture or height loss. Routine screening is not yet widely recommended, but the Male Osteoporosis Risk Estimation Score (MORES) is a scoring algorithm to identify men at risk for osteoporosis and therefore candidates for DEXA screening.

Taking the time
I recommend that physicians take the extra time to address bone health during annual exams. We have a lot of health screenings to go over in a short time, and bone health can be overlooked, along with counseling for risk factors, calcium, and vitamin D, but prevention is much easier than managing osteoporosis or treating painful fractures.

Yasmin Orandi, MD, is a family medicine physician at the Apple Valley Medical Clinic.

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