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About Osteoporosis

What is Osteoporosis?

Osteoporosis literally means “porous bones”. It is a condition of thinning of the bone.

normal bone Bone in Osteoporosis
Normal Bone Bone in Osteoporosis
©2006 Les Laboratoires Servier. Available for educational use from www.servier.com/pro/SMART/home_smart.asp

Osteoporosis causes bone to become fragile, and increases the risk of fractures (broken bones).

Each year in Britain, there are around 120,000 spine fractures, 85,000 hip fractures and 50,000 wrist fractures which are due to Osteoporosis.

How is Bone Formed?

Throughout a person’s life time, from childhood, through adolescence and adulthood, into old age, bone is constantly being formed, resorbed (taken away), and formed again in the body.

The process of forming, maintaining and re-modelling bone is the result of the work of two types of cell in the body.

Osteoclasts (excavating cells) dig tiny pits in bone, and osteoblasts (bone-forming cells) then come along to fill these holes in.

Excavating Cells at work(Resorption) Bone-forming Cells at work (Remodelling)
Excavating Cells at work(Resorption) Bone-forming Cells at work (Remodelling)
©2006 Les Laboratoires Servier. Available for educational use from www.servier.com/pro/SMART/home_smart.asp

These processes of resorption and remodelling enable bones to grow properly in our younger years, and when we reach adulthood, our bones are able to adapt to the mechanical stresses and strains of our day-to-day activities.

What happens in Osteoporosis?

During adulthood, bone formation keeps pace with the activity of the excavating cells in the body, and bone structure and strength is maintained. As we become older, the balance between the bone-forming cells and the excavating cells changes, so that there is overall loss of bone, and the bones become thinner with age.

In osteoporosis, the process of bone thinning may start earlier or progress more rapidly than expected. This results in what doctors call “a loss of bone mass”, or a “loss of bone density” (bone thinning), and if it is not treated, can lead to fractures. The fractures that occur due to osteoporosis are known as “low trauma” fractures, because the force needed to break the bone (e.g. the wrist, spine or hip) is low.

Normal hip bone Hip bone in Osteoporosis
Normal hip bone Hip bone in Osteoporosis
©2006 Les Laboratoires Servier. Available for educational use from www.servier.com/pro/SMART/home_smart.asp

Early Warning Signs

The process of bone-thinning itself is painless, but it can lead to fractures which may cause pain.

A person with osteoporosis may be unaware that they have the condition until they:

Events such as these may lead the patient or health care professional to consider a possible diagnosis of osteoporosis.

Who can get Osteoporosis?

Women

Osteoporosis is twice as common in women than it is in men, and is most common in women after the menopause. By the age of 80, about 70% of women will have osteoporosis of the hip, spine, or forearm.

Among women aged 50, the chance of having an osteoporotic fracture at some point in the future is around 53%.

Men

Among men aged 50, the chance of having a fracture due to osteoporosis at some point in the future is about 20%.

Osteoporosis in pregnancy

Osteoporosis in pregnancy is very rare. For more information on this, see the National Osteoporosis Society website:
http://www.nos.org.uk/about/osteoporosis-associated.htm

Osteoporosis in Children

It is very rare for children to have osteoporosis. More information on this can be found on the National Osteoporosis Society website, at:
http://www.nos.org.uk/about/osteoporosis-in-younger-people.htm

Causes and Risk Factors for Osteoporosis

There are a number of risk factors which are associated with osteoporosis. It is important to remember that having one or more of these risk factors does not mean that a person will definitely develop osteoporosis.

However, having one or more risk factors will make an individual more likely to develop osteoporosis than someone who does not have any risk factors.

Occasionally, some people will develop the condition despite having no risk factors at all.

Risk Factors for Osteoporosis

Being Female

Osteoporosis is much more common in women than men. The reasons for this a re two-fold. Firstly, women tend to have a lower bone density than men. Secondly, when a woman reaches the menopause, her ovaries stop producing oestrogen. This fall in oestrogen levels causes the rate of bone thinning in women to speed up temporarily in the first ten years after the menopause.

Men tend to have larger bones than women, and because they do not go through the menopause, their bones thin at a slower rate as they age. Very occasionally, osteoporosis can also affect children and young people and pregnant women. However, this is very rare.

Genetic Factors and Family History

It has been found that osteoporosis runs in families. If you have a first degree relative (such as mother, father, or sister) who has had a low trauma fracture (e.g. hip, wrist or spine) then you are more likely to develop osteoporosis.

Osteoporosis and hip fractures have been found to be more common in Caucasian (white) and Asian women, and less common in black African women.

Age

Bone density increases to its maximum by the age of 30. From the age of 40 onwards, the bones very gradually start to become thinner. As we get older, we become more prone to osteoporosis.

Low Body Weight

Small people with a slim build have a greater risk of osteoporosis than taller people with a heavy build.

Conditions which may cause you to lose weight (such as coeliac disease or Crohn’s disease), can also increase the risk of osteoporosis.

This is also the case for eating disorders such as anorexia nervosa.

Poor Diet

A low dietary calcium intake or vitamin D deficiency increases the risk of osteoporosis.

Hormonal Factors

Hormonal factors which increase the risk of osteoporosis:

Smoking

Smoking is associated with increased risk of osteoporotic fractures

Excessive alcohol consumption

Drinking too much alcohol leads to an increased risk of osteoporosis.

Immobility or a lack of physical exercise

In order to be healthy, bones need to be exercised! Weight bearing exercise, such as walking or running, is important to reduce your risk of osteoporosis.

Use of corticosteroids

Corticosteroid treatment (such as prednisolone) for conditions such as asthma or arthritis increases the risk of osteoporosis.

Diagnosis and Monitoring of Osteoporosis

How is Osteoporosis diagnosed?

In order to make a definite diagnosis of osteoporosis, a DXA scan is usually required.

The doctor may also ask for X-rays and blood or urine tests.

What is a DXA Scan?

DXA stands for Dual energy X-ray Absorptiometry. The DXA scan uses a very small X-ray dose (less than a day of normal background radiation) to measure the density of bone in key places in the body. Usually the hip and spine are measured because these areas are among the most liable to break if the bone becomes too thin. Sometimes measurements are made of the wrist.

You do not usually have to get undressed to have a DXA scan. You will be asked to lie on a firm couch for a few minutes while the arm of the DXA machine passes over you. It is painless, and there are no injections involved.

DXA scanning:
DXA scanning
Compston JE, Rosen CJ, Fast Facts – Osteoporosis 4th edition. Oxford, Health Press Ltd, 2004 (www.fastfacts.com)

DXA scans are particularly useful for measuring changes in your bone density over time (for example over a couple of years).

If you have previously had a DXA scan at a different hospital, it may be difficult to compare the results of your new scan at Addenbrookes hospital with the results of your previous scan. It is much better to use information obtained by comparing readings from exactly the same DXA scanner at exactly the same hospital.

The results of the DXA scan enable the doctor to compare your bone density to average values, using T-scores.

DXA Scan of Spine DXA Scan of Hip
DXA Scan of Spine DXA Scan of Hip
World Health Organisation. Prevention and Management of Osteoporosis. Geneva: WHO 2003

What is a T-score?

A T-score for your bone density shows how porous your bones are compared to average bone density. This is expressed in standard deviations (SD) from the normal average value for a healthy young adult woman. A negative T-score (this means one with a minus sign in front of it) tells you how far away you are from the bone density of a normal young adult when their bones are at their best.

T-score between 0 and –1 SD is considered normal
T-score between –1 and –2.5 SD is classed as osteopenia
T-score below –2.5 SD is classed as osteoporosis

Osteopenia means that the bones are thinner than average, but not thin enough to be classed as osteoporosis.

T-scores are useful to help determine whether action needs to be taken to build up the bones to reduce the risk of fractures.

Heel Ultrasound

Bone density can also be measured using a method called Quantitative Ultrasound, or Heel Ultrasound. This involves passing sound waves through the heel of the foot. It is painless, and takes just a few minutes.

Research has found that heel ultrasound can be used to predict the likelihood of some types of fracture in some groups of patients. However, heel ultrasound is not as reliable as a DXA scan.

Monitoring Osteoporosis

If you have been diagnosed with Osteoporosis, the doctor is likely to want to monitor your condition, to see whether any lifestyle changes or treatments have a beneficial effect.

This may involve follow-up appointments every one or two years with your GP, for blood or urine tests. Sometimes an X-ray may be required. You may also need visit to a metabolic bone clinic at the hospital approximately every three years, to have a DXA scan and to see a specialist.

Osteoporosis Treatment

Why is it important to treat Osteoporosis?

When bones become thin, they are more likely to break. Certain areas of the body are most at risk of a fracture in osteoporosis.

(a) Normal spine (b) Osteoporotic fractures of the spine
Spine
Compston JE, Rosen CJ, Fast Facts – Osteoporosis 4th edition. Oxford, Health Press Ltd, 2004 (www.fastfacts.com)

Prevention of Osteoporosis

There is much that can be done at each stage of life to help prevent osteoporosis, and to help tackle it if you know that you have osteoporosis:

Healthy Diet

A healthy diet is very important to help guard again osteoporosis. Both children and adults need a diet which contains enough calcium and vitamin D.

Calcium
Calcium is the main mineral found in bone, and is essential for healthy bones. Dairy products such as milk, cheese, and yoghurt are good sources of calcium, as are fish which are eaten with the bones, such as sardines and whitebait.

Vitamin D
Vitamin D is vital for the absorption of calcium by the body. As well as being found in dairy products and fish oils, it is produced by the body when the skin is exposed to sunlight.

Exercise

Weight bearing exercise strengthens the bones and helps to prevent osteoporosis. The best activities for increasing bone strength are those which involve walking or running. Low-impact activities such as swimming or cycling, whilst they are good for general fitness, are not as effective in the prevention of osteoporosis.

Whatever your age, increasing your physical activities is likely to be beneficial. If you are elderly, exercise can help to improve your muscle tone, balance and confidence, thereby reducing your chances of having a fall.

Healthy Lifestyle

Avoid smoking – smoking affects the hormones in the body, and can increase the risk of osteoporosis in both men and women.

Don’t drink too much alcohol – drinking excessive amounts of alcohol increases the risk of osteoporosis and fractures. The recommended maximum alcohol intake is 14 units per week for women, and 21 units per week for men. A unit is a single measure of spirits, a small glass of wine, or half a pint of beer, cider or lager.

Drug Treatment for Osteoporosis

(see drug information section on this website)

Your doctor may recommend medication to help protect your bones if you are diagnosed as having osteoporosis. There are several different types of drugs which your doctor may consider.

First-Line Treatments

These are drugs which are commonly used for the treatment of osteoporosis.

Other Drugs

These are other drugs used to treat osteoporosis, they are usually used if treatment with first-line drugs has either not been successful or has caused side-effects.

Bisphosphonates

Bisphosphonates work by slowing down the activity of the cells which break down bone (osteoclasts), and enabling the bone-forming cells (osteoblasts) to build up the bones. This helps to increase the density of the bones, and reduces the risk of fractures.

Remember – if you are taking Calcium or Vitamin D supplements as well as a Bisphosphonate, do not take your Calcium or Vitamin D supplement on the same day as your Bisphosphonate!

Some commonly used bisphosphonate drugs:

Alendronate (Fosamax)
Alendronate is generally used for the treatment of:

Alendronate may not be appropriate for people who have a history of digestive problems or kidney problems.

Taking Alendronate

Alendronate must be taken when the stomach is empty, otherwise it will not work. If you are prescribed Alendronate, you must take it with a glass of water in the morning at least 30 minutes before you have any food or drink. Once you have taken your Alendronate tablet, you must keep upright (sitting, standing or walking) for at least 30 minutes.

Remember – if you are taking Calcium or Vitamin D supplements as well as Alendronate, do not take your Calcium or Vitamin D supplement on the same day as your Alendronate!

Side Effects: Some people who take Alendronate find that they suffer from symptoms of heartburn and pain in the stomach or oesophagus (food-pipe). If this happens to you, stop taking Alendronate and contact your doctor.

Risedronate (Actonel)

Risedronate is generally used for:

Risedronate may not be appropriate for people who have a history of digestive problems or kidney problems. If you have low levels of calcium in the blood, this should be treated before starting Risedronate treatment.

Taking Risedronate:

Risedronate is available as either a weekly or a daily tablet. The tablet must be taken with a large glass of water, and swallowed whole.

The weekly tablet must be taken when the stomach is empty, otherwise it will not work. If you are prescribed weekly Risedronate, you must take it with a glass of water in the morning at least 30 minutes before you have any food or drink. Once you have taken your weekly Risedronate tablet, you must keep upright (sitting, standing or walking) for at least 30 minutes.

If you are taking the daily Risedronate tablet, you must either take it in the same way as for the weekly tablet, described above, or later in the day with water, on an empty stomach, at least two hours after and two hours before taking food (i.e. in the middle of a four hour fast). Once you have taken your daily Risedronate tablet, you must keep upright (sitting, standing or walking) for at least 30 minutes

Remember – if you are taking Calcium or Vitamin D supplements as well as Risedronate, do not take your Calcium or Vitamin D supplement on the same day as your Risedronate!

Side Effects: Some people who take Risedronate may find that they suffer from symptoms of heartburn and pain in the stomach or oesophagus (food-pipe). If this happens to you, stop taking Risedronate and contact your doctor. It is possible that you may find that you feel sick, of have constipation or diarrhoea. Occasionally some people may have general aches and pains associated with Risedronate.

Cyclical Etidronate (Didronel)

Etidronate is generally used for:

Etidronate may not be appropriate for people who have a history of kidney problems, or who have high levels of calcium in their blood or urine. Etidronate is not normally prescribed for men with osteoporosis.

Taking Cyclical Etidronate (Didronel):

Each Didronel packet contains 14 days of Cyclical Etidronate tablets and 76 days of effervescent Cacit tablets, making up a 90-day pack of tablets.

Cyclical Etidronate is taken once a day for 14 days. It must be taken with water, on an empty stomach, two hours after and two hours before taking food (i.e. in the middle of a four hour fast). During the four-hour period, it is very important not to take any other food, tablets, or drink (other than water) during the four-hour period.

After 14 days of taking Cyclical Etidronate, one effervescent Cacit tablet is taken for 76 days. The Cacit tablet should be dissolved in water and taken with food.

Remember – if you are taking Calcium or Vitamin D supplements as well as Didronel, do not take your Calcium or Vitamin D supplement on the same day as your Didronel!

Side Effects: some people taking Cyclical Etidronate find that it makes them feel sick, and they may have diarrhoea.

Calcium and Vitamin D Supplements

These should be prescribed with bisphosphonate tablets, it is important that any calcium or vitamin D supplement is taken at another time of day, ideally with food. Many people take the calcium and vitamin D supplement on 6 days of the week and the bisphosphonate on the seventh day.

Ibandronate (Bonviva)

Ibandronate is generally used for:

Ibandronate may not be appropriate for people who have a history of digestive problems or kidney problems. If you have low levels of calcium in the blood, this should be treated before starting Risedronate treatment.

Taking Ibandronate:

Ibandronate is a monthly tablet. The tablet must be taken with a large glass of water, and swallowed whole.

The Ibandronate tablet must be taken when the stomach is empty, otherwise it will not work. You must take your Ibandronate tablet first thing in the morning, at least on hour before you have any food or drink. Once you have taken your Ibandronate tablet, you must keep upright (sitting, standing or walking) for at least one hour.

Remember – if you are taking Calcium or Vitamin D supplements as well as Ibandronate, do not take your Calcium or Vitamin D supplement on the same day as your Ibandronate!

Side Effects: Some people who take Ibandronate may find that they suffer from symptoms of heartburn and pain in the stomach or oesophagus (food-pipe). If this happens to you, stop taking Ibandronate and contact your doctor. Some people find that when they first take Ibandronate, they have mild flu-like symptoms. These symptoms usually decline with time.

Hormone Replacement Therapy (HRT)

In women, hormone replacement therapy is used to replace oestrogen. In men, different hormone replacement drugs are used to replace testosterone.

Hormone replacement therapy is no longer used as a first line treatment for osteoporosis.

Selective Estrogen Receptor Modulators (SERMs )

Raloxifene (Evista) is currently the only SERM drug. It is taken as a single tablet, once a day.

Raloxifene is generally used for the treatment of:

SERMs work by mimicking some of the effects of oestrogen in the body. It has been found to help prevent fractures in the spine, but not the hip.

Side Effects – Raloxifene can increase the risk of blood clots and heart disease. It may also be associated with flu-like symptoms, swollen feet or hands, and leg cramps. Raloxifene may cause typical menopausal symptoms, such as hot flushes.

Raloxifene is usually only used in people who have not responded to, or not been able to tolerate bisphosphonate treatment for osteoporosis.

Active Vitamin D (Calcitriol)

Calcitriol is generally used for the treatment of:

Calcitriol works by increasing the absorption of calcium in the diet, and by reducing the amount of calcium excreted from the body.

Taking Calcitriol

It is taken as a capsule, twice a day, and requires regular blood tests to monitor the level of calcium in the blood.

Side Effects: Some people taking Calcitriol may develop blood calcium levels which are too high. The symptoms associated with this can include vomiting or feeling sick, headaches, drowsiness or weakness. If you suffer these side effects, you should contact your doctor straight away.

Calcitonin

Calcitonin is a hormone normally produced by the thyroid gland. It works by inhibiting osteoclasts (bone excavating cells). This helps to enable osteoblasts (bone-forming cells) to build up the bones.

Calcitonin can be injected twice a day, or taken as a nasal spray. It helps to prevent fractures in the spine.

It is usually used in people who have not responded to, or not been able to tolerate other drugs for osteoporosis.

Teriparatide (Forsteo)

Teriparatide is generally used for:

It cannot be used in women who are pregnant or breast feeding, and it cannot be used in children. Furthermore, it must not be used in people who have:

Teriparatide works by stimulating osteoblasts (bone-forming cells) to rebuild bone. This helps to build up and strengthen the bones.

Teriparatide is taken as a series of daily injections under the skin, which you can do for yourself. It has to be kept in a refrigerator, and it can only be prescribed by specialists.

Treatment with Teriparatide must last for no more than 18 months.

Side Effects: some people taking Teriparatide may feel sick, dizzy, have painful limbs, or headaches.

Strontium Ranelate (Protelos)

Strontium Ranelate is a new type of drug. It reduces the risk of fractures in the spine, and may also reduce the risk of hip fractures, even in those over 80 years of age.

Strontium Ranelate is currently only licensed for use in:

Further research is underway to see whether, in the future, it could also be used in men.

Strontium Ranelate is taken as a sachet of powder, dissolved in water. It is taken once a day, ideally at bed time. It should be taken at least two hours after your last meal, and at least two hours before you have any food or drink other than water.

Side Effects: There is some evidence of a small increase in the risk of blood clots in the calf, and some people may experience diarrhoea or nausea.

Osteoporosis Resources

Links to other resources

National Osteoporosis Society website: http://www.nos.org.uk

This website provides information about:

BoneZone website: http://www.bonezone.org.uk

This is a website for kids and teenagers. It is run by the National Osteoporosis Society, and has lots of helpful advice and information.

Arthritis Research Campaign Booklet on Osteoporosis: http://www.arc.org.uk/about_arth/booklets/6028/6028.htm

Further Advice

The National Osteoporosis Society runs a helpline service. You can find out more about this on the National Osteoporosis Society website, or you can contact the National Osteoporosis Society Helpline directly:

Further Reading

Fordham, J N. Osteoporosis: Your Questions Answered. London, Churchill Livingstone, 2004

Prepared by Suzie McRitchie Pratt in conjunction with the Department of Rheumatology, Addenbrookes Hospital

 
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