Osteoporosis Patient Education

 This education packet contains 4 parts:

Part 1- What is osteoporosis and what causes it?

Part 2- What are the symptoms of osteoporosis, and how is it diagnosed?

Part 3- What does an osteoporosis treatment plan consist of?

Part 4- What medications treat Osteoporosis? Are these medications safe?

Part 1– What is osteoporosis, and what causes it?

Osteoporosis is a disease that causes bones to become weak and more likely to fracture (break). Bone is living tissue that is constantly being broken down and replaced. When the creation of new bone doesn’t keep up with the removal of old bone, bone becomes weaker and more likely to fracture.

While we are young, the body makes new bone faster than it breaks bone down, with the result being that bone mass increases. This process continues into our 20s, and most people reach their peak bone mass by their early 20s. After this point, bone mass is lost more quickly than it’s created.

How likely a person is to develop osteoporosis depends partly on how much bone mass they attained in their youth (this is why we focus so much on building strong bones in children!)

There are some risk factors for osteoporosis that we can control, and others that we have no control over.

Part 2- What are the symptoms of osteoporosis, and how is it diagnosed?

Symptoms of osteoporosis

Osteoporosis does not usually cause any symptoms. Contrary to what many patients believe, osteoporosis does not cause joint pain. Many people of been told in the past that they have osteoarthritis, which is a word very similar to osteoporosis, but means a very different thing.  “Osteoarthritis” refers to chronic joint pain, which is usually related to wear and tear on the joints. On the other hand, “osteoporosis” refers to weakness of the bones. These two conditions have nothing to do with one another.

Since osteoporosis often has no symptoms, it goes untreated for years. Without treatment, the bones become more brittle with time, until a bone breaks after a sudden strain, bump, or fall. The most common bones to break due to osteoporosis are the hip, spine, or wrist. A collapsed vertebra (bone in your spine) may cause severe back pain, spinal changes, or loss of height with a bent over posture (as shown in the figure[i] below).

Diagnosis of osteoporosis

Osteoporosis is diagnosed in one of two ways:

1. If you have ever had a fragility fracture, you have osteoporosis. A fragility fracture is not just any fracture. We define fragility fracture as a broken bone in the spine or hip, that happens with minimal or no trauma.
2. Bone densitometry. The other way of diagnosing osteoporosis is with a type of x-ray called “bone densitometry”, which is also called a DXA scan. With a DXA scan, doctors can compare your bone density to what is expected for someone of your same age, gender, and race.

Once osteoporosis is diagnosed, doctors should try to determine if there are any conditions that are contributing to it. This includes several tests:

• Vitamin D levels, to check for vitamin D deficiency.
• An electrolyte panel, which will tell us the level of calcium in the blood and how well the kidneys are working.
• Hormone testing, including thyroid hormone and parathyroid hormone. For men, we will also check testosterone levels.
• Depending on circumstances, your doctor might need to do more intensive blood testing.

Part 3- What does an osteoporosis treatment plan consist of?

1. Diagnose and treat any metabolic condition is contributing to osteoporosis

Most people with osteoporosis do not have any other underlying metabolic problems that are making their bones weaker, but this should at least be confirmed. Your doctor should check the blood tests described in the last section.

2. Exercise

Research is ongoing about the benefits of exercise for osteoporosis, but most doctors believe that weight-bearing exercise programs and exercises targeting flexibility and balance are very important for osteoporosis by decreasing the risk of falling and decreasing the fear of falling.

There are many options for exercise. Examples of weight-bearing exercises include working in the yard, walking, and stair climbing. Examples of exercise that improves flexibility, range of motion, and balance include Yoga and Tai Chi. Try to get at least 30 minutes of exercise 5 days per week.

3. Make sure your diet has enough calcium

This is an often overlooked aspect of managing osteoporosis. You may have read things in the newspaper or watched things on TV that gave conflicting information about how much calcium someone needs. This is what you need to know:

Men and women between the ages of 18 and 50 need 1,000 mg of calcium a day. This daily amount increases to 1,200 mg when women turn 50 and men turn 70. Many people are not getting enough calcium in their diet, so you should assess how much calcium you get, and make dietary changes if needed. Be aware that even if you’re lactose intolerant, you can still get plenty of calcium in your diet! For example, almond milk is lactose-free, and has 450mg of calcium in it.

Please review the table below, which lists out most of the highest calcium foods and drinks.

What if I can’t get enough calcium through the diet? 

Some people are not able to get enough calcium from their diet, either due to dietary restrictions or due to their habits leading them to not consume calcium-rich foods. If you are not able to get enough calcium from your diet, then you should take a supplement. There are 2 common forms of calcium in supplements, calcium carbonate and calcium citrate.

Calcium carbonate is the most common form of calcium supplement that people take. It is the least expensive, and for most people it will work just fine. However, there are some people for which calcium carbonate is not ideal. In particular, people who have conditions causing difficulty with absorbing nutrients (history of bariatric surgery or inflammatory bowel diseases) may not absorb this medicine well. Also, patients taking acid reflux medications (Zantac, Nexium, etc.) may not absorb this medication very well. And finally, patients who cannot remember to take this medicine with food will not absorb this medicine very well either. Besides more difficulty with absorption, another potential problem with supplements containing calcium carbonate is that they may cause gastrointestinal side effects, including constipation, flatulence, and bloating.

Calcium citrate is more expensive, but there are some patients who do better on this form of calcium.  Since it is more readily absorbed than calcium carbonate, it is the preferred form of calcium supplement to take in patients with a history of bariatric surgery, inflammatory bowel diseases, or acid reflux medication use. Because it is very well absorbed, it can be taken with or without food. It is also much less likely to cause gastrointestinal side effects than calcium carbonate is.

4. Maintain a healthy vitamin D level

Vitamin D is absolutely necessary to your body’s ability to absorb calcium from the diet. Vitamin D is formed in the skin from being exposed to the sun. 10 to 15 minutes of direct sunlight 2 to 3 times a week will help keep your vitamin D level in a healthy range.

For people with osteoporosis, many experts recommend a vitamin D level of 30 – 60.

If your vitamin D level is below 30, you would likely benefit from a vitamin supplement.

5. Set up your home to make falls less likely

There is a lot that you can do to reduce the odds for falls. Wearing properly fitting shoes, removing home hazards, and using assistive devices in some cases.

6. 6. Osteoporosis medications

Most people with osteoporosis would benefit from being on a medication to reduce the risk of fractures. Please read the next section for more.

Part 4- What medications treat osteoporosis? Are these medications safe?

Medicines for osteoporosis help prevent bone loss and increase bone density, which decrease the osteoporotic fractures[ii]. The table below outlines the common osteoporosis drugs, and how much they reduce the risk of fractures.

Common side effects of osteoporosis drugs

• Acid reflux: this is only seen in oral osteoporosis drugs.
• Flu-like symptoms: This is uncommon in oral osteoporosis drugs, but about 1 in 20 patients receiving the injectable osteoporosis drugs (reclast and prolia) can have flu-like symptoms for 1-3 days after the injection.
• Low calcium (“hypocalcemia”): This is uncommon in oral osteoporosis drugs, but about 1-2 out of 100 patients[xii] receiving injectable osteoporosis drugs (reclast and prolia) can cause low calcium levels in the blood.

Rare side effects of osteoporosis drugs

Osteonecrosis of the jaw (ONJ):

• 01% over 10 years[xiii]. In other words, one out of every 10,000 people to take this medication for 10 years could get ONJ.
• ONJ is a rare condition where the bone of the lower or upper jaw becomes exposed (usually because of tooth extractions) and does not heal properly. This is a very rare side effect, and the risk is thought to be primarily for people on high doses of medication in the setting of cancer.

Atypical femoral fractures (AFF):

• 5% over 10 years [xiv]. In other words 5 out of every 1000 people to take this medication for 10 years could have an atypical femoral fracture.
• An atypical femur fracture is called “atypical” because of the location and condition of the fracture. AFFs start as a weakening of the outer rim of the femur below the hip area. The tiny crack that occurs is a kind of stress fracture, but unlike stress fractures in people who overdo exercise training, this fracture occurs with regular life activities. An AFF is also different from more common osteoporosis fractures that happen after a single injury – like a fall; AFFs develop slowly from repeated, normal activities. In about 2 of the 3 people who get an AFF, there are warning signals that occur over many weeks to months before the bone breaks. If nothing is done about the early warning signs, the crack continues to grow and eventually the thigh bone breaks in two. The warning sign of AFF is an aching pain in the groin or thigh.

The risk of side effects from osteoporosis drugs is MUCH smaller than the potential benefit

As an example, let us take a patient who has a 20% risk of osteoporotic fracture over 10 years (a 10 year risk of osteoporotic fracture is given in the FRAX score that comes with bone density scan reports). Osteoporosis drugs have differences between them and some are stronger than others, but in general most osteoporosis drugs will reduce the risk of an osteoporotic fracture by about 50%. By osteoporotic fracture, we mean a fracture in the humerus (arm bone), the wrist, the hip, or the spine (vertebra). With this example in mind, let’s look at the comparison of risks and benefits of treatment:

• If untreated, 2,000 out of every 10,000 people with a 20% risk would have an osteoporotic fracture.
• If these same 10,000 people were treated with an osteoporosis medication:
  • Only 10% of treated people (1,000 out of every 10,000) would have an osteoporotic fracture. In other words, 1000 fewer people would have an osteoporotic fracture.
  • 50% of the treated people (50 out of every 10,000) would have an atypical femoral fracture.
  • 01% of the treated people (1 out of every 10,000) could have osteonecrosis of the jaw.

While this is just an example, it clearly shows how unlikely it is someone will have a rare side effect, and how likely it is that someone would benefit from an osteoporosis medication.

Where can I learn more?

American Association of Clinical Endocrinologists https://www.aace.com

National Osteoporosis Foundation– https://www.nof.org

Hormone Health Network– https://www.hormone.org

References cited in this education packet:

[i] https://www.endocrineweb.com/guides/osteoporosis-prevention/lowering-your-risk-osteoporosis

[ii] Hopkin, RB, et al. The relative The relative efficacy of nine osteoporosis medications for reducing the rate of fractures in post-menopausal women. BMC musculoskeletal disorders, 2011

[iii] Pyon, EY. Once-monthly Ibandronate for postmenopausal Osteoporosis: Review of a new dosing regimen. Clin Ther. 2006

[iv] Salvatore G, et al. Update on Raloxifene: Mechanism of Action, Clinical Efficacy, Adverse Effects, and Contraindications. Obstetrical & Gynecological survey. 2013.

[v] Wells GA, et al. Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008

[vi] Cranney A, et al. Meta-analyses of therapies for postmenopausal osteoporosis. III. Meta-analysis of risedronate for the treatment of postmenopausal osteoporosis. Endocr Rev. 2002

[vii] McClung MR, et al. Effect of risedronate on the risk of hip fracture in elderly women. Hip Intervention Program Study Group. NEJM. 2001

[viii] Black DM, et al. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. NEJM. 2007

[ix] Cummings SR, et al. Denosumab for prevention of fractures in postmenopausal women with osteoporosis. NEJM 2009.

[x] Neer RM, et al. Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. NEJM. 2001.

[xi] Cosman F, et al. Effects of Abaloparatide-SC on Fractures and Bone Mineral Density in Subgroups of Postmenopausal Women With Osteoporosis and Varying Baseline Risk Factors. J bone miner res. 2017.

[xii] Black DM, et al. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. NEJM. 2007

[xiii] Alder RA, et al. Managing Osteoporosis in Patients on Long-Term Bisphosphonate Treatment: Report of a Task Force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2016

[xiv] Burr SE, et al.Atypical subtrochanteric and diaphyseal femoral fractures: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2010