New Guideline For Drug Treatment Of Men And Women With Osteoporosis Or Low Bone Density

ACP recommends that physicians offer drug treatment to men and women who have been diagnosed with osteoporosis or a previous fracture not caused by substantial trauma. The guideline also recommends that doctors and their patients consider drug treatment to prevent fracture for men and women who are at risk of developing osteoporosis.

The authors did not find evidence to prove that one drug is definitively better than another medication. They recommend that physicians make individual treatment decisions based on the risks, benefits, and side effects profile of available drug options. However, there is good information that bisphosphonates are reasonable options for beginning drug treatment as they decrease the risk of vertebral, non-vertebral, and hip fractures.

"Because treatment options may affect various parts of skeletal system differently, we analyzed the available evidence on numerous drugs to prevent fractures in men and women," said Vincenza Snow, MD, FACP, a co-author of the guideline and director of clinical programs and quality of care at ACP. "Bisphosphonates can be considered a first-line therapy, particularly for patients at risk for hip fracture. However, there is no clear evidence showing the appropriate duration of treatment with these drugs."

A common side effect of bisphosphonates is upset stomach, but a rare and more serious risk involves breakdown of the jaw bone.

Among other available treatment options, the authors found that estrogen reduces the risk of vertebral, non-vertebral, and hip fractures, but can increase the risk of certain cancers, stroke, and blood clots. Studies show that drugs that work on estrogen receptors have no serious side effects and decrease spine fractures but not hip fractures.

In May 2008, ACP released a clinical practice guideline on screening for osteoporosis in men. The guideline calls for physicians to periodically assess the risk factors for osteoporosis in older men. Clinicians should obtain a DXA (dual-energy x-ray absorptiometry) scan for men who are at increased risk for osteoporosis and are candidates for drug therapy. ACP also recommends further research to evaluate osteoporosis screening tests in men.

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Osteoporosis.

What is osteoporosis?

Osteoporosis, or porous bone, is a disease in which there is a loss of bone mass and destruction of bone tissue. This process causes weakening of the bones and makes them more likely to break. The bones most often affected are the hips, spine, and wrists.

Who is affected by osteoporosis?

Osteoporosis affects over 10 million Americans, with women four times more likely to develop osteoporosis than men. Another 34 million have low bone mass and therefore have an increased risk for osteoporosis. Estrogen deficiency is one of the main causes of bone loss in women during and after menopause. Women may lose up to 20 percent of their bone mass in the five to seven years following menopause.

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Possibles Causes

Osteoporosis is a disease caused principally by the significant loss of bone mineral density (BMD). Early in life, more bone is laid down than is removed, and an individual’s peak bone mass is typically achieved by around age 30. After peak bone mass is reached, the remodeling process (the process of laying down new bone and removing old bone) takes away more bone than is replaced. Hence making the bones more prone to osteoporosis (and consequently to fracture).

Thus, the process of bone loss typically begins between one’s early to late thirties. Starting from about that age to the onset of menopause, women lose a certain amount of bone steadily every year, as follows:

• Trabecular bone (the spongy bone inside the hard, cortical bone) is lost at a rate of about 1% per year

• Cortical bone (the hard bone) is lost at a rate of about 0.5% per year

Estrogen plays an important part in maintaining bone strength because it helps keep bone remodeling (which is now taking away more bone than is added) rates low. There are two lines of cells for bone remodeling, the bone-eating cells (osteoclasts) and the bone-forming cells (osteoblasts). Without estrogen, the osteoclasts are favored and more bone is resorped (removed) than laid down, resulting in thinning of the bone.

Therefore, when women reach menopause and their estrogen levels decrease, the rate of bone loss increases to about 2% to 3% per year. After 8 to 10 years, the rate of bone loss returns to the previous rate of 1% and 0.5% per year, respectively. This loss of bone density, particularly after women reach menopause, is one of the primary causes of osteoporosis in women.

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Treatment Alternatives.

• Weight-bearing exercise
  Exercise is an important treatment for osteoporosis to maintain healthy bones. Activities that stress bones have been shown to have a positive effect in maintaining and increasing bone mass and preventing osteoporosis. Individuals who live a sedentary lifestyle have weaker bones and are subjected to a higher risk of sustaining pathologic fractures. While resistance forms of exercise (e.g. light weights) are excellent to stimulate bone production, even light aerobic exercise (e.g. aerobics, jogging, walking) can help strengthen bones and prevent osteoporosis.

• Nutrition supplementation
  Calcium supplementation is an important treatment to ensure oral intake is at least 1200 to 1500 mg every day. Comsuming this quantity of calcium is a difficult task considering that to do this you would have to eat or drink the equivalent of five glasses of milk each day. Because of this, many patients at-risk for osteoporosis should take an oral calcium supplement each day. This can be taken with Vitamin D (400-800 Units is recommended) to help increase the absorption. Also, caffeinated substances (e.g. coffee, soda, etc.) decrease calcium absorption, and should be avoided!

• Medications
  There are several available medications used for osteoporosis treatment. These include:

  • Bisphosphanates (Fosamax)
    Bisphosphanates (e.g. Fosamax, Actonel) are a type of medication that helps to regulate calcium and prevent bone breakdown. Bone turnover, or replacement of old bone with new bone, is a normal process within our body. In patients with osteoporosis, the replacement with new bone does not maintain pace with the breakdown of old bone. Bisphosphanates slow the rate of bone breakdown to help maintain bone mass by inhibiting the osteoclast, the cell responsible for bone breakdown.
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