Monday, November 5, 2007

How osteoporosis is treated

To maintain bone health:

Make sure there is enough calcium in your diet (1000 mg per day of calcium for women before menopause and 1500 mg per day for women who are postmenopausal).

Get adequate vitamin D intake, which is important for calcium absorption and to maintain muscle strength (400IU per day until age 60, 600-800 IU per day after age 60). Doses can be adjusted according to blood levels of vitamin D.

Get regular exercise, especially weight bearing exercise.

A number of medications are also used for the prevention and treatment of osteoporosis:

Bisphosphonates: Alendronate (Fosamax), risedronate (Actonel) and ibandronate (Boniva) have been FDA-approved for the prevention and treatment of osteoporosis in postmenopausal women. (Alendronate is the only one currently approved for management of osteoporosis in men.) Both alendronate and risedronate are approved for the prevention and treatment of glucocorticoid-induced osteoporosis in men and women. These medications help slow down bone loss and have been shown to decrease the risk of fractures. All are pills that must be taken on an empty stomach with water. Because they have the potential for irritating the esophagus, remaining upright for at least an hour after taking these medications is recommended. Alendronate and risedronate can be taken once a week, while ibandronate can be taken once a month. An IV form of ibandronate, given through the vein every 3 months, also has been FDA-approved for osteoporosis management. Two other IV forms of bisphosphonates available, pamidronate (Aredia) and zoledronic acid or zoledronate (Zometa), are not currently FDA-approved for osteoporosis management.

There have been reports of jaw osteonecrosis (permanent bone damage of the bones of the jaw) resulting from high dose IV bisphosphonates used primarily in the management of people with underlying cancers. The risk for this problem in those taking these medications at doses recommended for osteoporosis management is not clearly established, but appears to be low.

Use of bisphosphonates in women who are pregnant or breastfeeding is not well studied. Animal studies show that bisphosphonates cross the placenta and enter fetal bone. The risk of fetal harm in humans is theoretical. Thus, the anticipated benefits of bisphosphonates in women who are pregnant or want to become pregnant should be weighed against the potential risks. Calcitonin is safe in pregnancy. Blood calcium levels in women who take bisphosphonates during pregnancy should be monitored.

Calcitonin (Calcimar, Miacalcin): This medication, a hormone made from the thyroid gland, is given usually as a nasal spray or as an injection under the skin. It has been FDA-approved for the management of postmenopausal osteoporosis and helps prevent vertebral (spine) fractures. It also is helpful in controlling pain after an osteoporotic vertebral fracture.

Estrogen or Hormone Replacement Therapy: Estrogen therapy alone or in combination with another hormone, progestin, has been shown to decrease the risk of osteoporosis and osteoporotic fractures in women. However, the combination of estrogen with a progestin has been shown to increase the risk for breast cancer, strokes, heart attacks and blood clots. Estrogens alone may increase the risk of strokes. Given the complexity of this decision, consult with your doctor about whether hormone replacement therapy is appropriate for you.

Selective Estrogen Receptor Modulators (SERMs): These medications mimic estrogen’s good effects on bones without some of the serious side effects such as breast cancer. Raloxifene (Evista) decreases spine fractures in women, and is approved for use only in women at this time.

Teriparatide (Forteo): Teriparatide is a form of parathyroid hormone that helps stimulate bone formation. It is approved for use in postmenopausal women and men at high risk for osteoporotic fracture. It is given as a daily injection under the skin and can be used for up to 2 years. If you have ever had radiation treatment or your parathyroid hormone levels are already too high, you may not be able to take this medication.

Strontium ranelate (Protelos): A powder dissolved in water and taken daily, this medication has been shown to reduce the risk for fractures in postmenopausal women. It is currently available in Europe, but not the USA. Because of an increased risk of blood clots, it should be used with caution in women who have a history or risk for deep venous thrombosis or pulmonary embolism.

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