Osteoporosis requires a multifaceted approach to treatment incorporating nutrition, prevention, education--and medications if necessary. Patients need advice on proper exercise and nutrition, as well as the risk of breaking a bone in an accidental fall. When the time comes to choose appropriate medication, there are several to choose from, each with its own risks and benefits. Consult your doctor about which medication will work best for you and discuss the risk/benefit ratio of any treatment.
Dietary Supplementation
The first line of therapy against osteoporosis is supplementation with calcium and vitamin D. They can decrease bone resorption and make osteoporosis medications more effective, too. Calcium citrate and calcium carbonate are widely available; the carbonates have more calcium but may cause flatulence and constipation. The citrates need normal stomach acidity, so they are not effective with patients who use antacid medications.
Bisphosphonates
Currently regarded as the "gold standard" against which other osteoporosis treatments are measured, bisphosphonates decrease bone loss (resorption). A randomized trial has shown that alendronate increases bone mass density (BMD) and reduces the risk of both vertebral and nonvertebral fracture. They are available in oral and intravenous forms, and side effects consist of mostly indigestion and nausea.
Selective Estrogen Receptor Modulators (SERMs)
These agents have estrogen antagonizing effects in some tissues and agonizing effects in others. Currently raloxifene has been shown to increase BMD and decreases the risk of fracture in women that have undergone menopause, but has shown no effects on nonvertebral fracture risk. It may reduce the risk of breast cancer and cardiovascular disease, but studies are still ongoing. Side effects include cramping and hot flashes, along with a possible increased risk of blood clots.
Calcitonin
This is a naturally occurring hormone secreted by the thyroid, and it helps regulate blood calcium levels. It has antiresorptive properties but much less so than other agents. Since it is a peptide and the gastrointestinal system would destroy it, it must be administered by nasal spray and can cause side effects in the nose, such as minor bleeding or congestion.
Estrogen
While this had been previously the mainstay for postmenopausal osteoporosis, the Women's Health Initiative (WHI) has data that shows that despite the decrease in bone mass loss and reduction in fracture risk, the potential drawbacks were too severe to recommend estrogen treatment. They included increased risk of cancer, heart problems and blood clots.
Teriparatide (or parathyroid hormone/PTH)
This is the first available agent that actually stimulates bone formation; all previous agents only prevented or slowed the resorption. It is delivered via daily injection and reduces both vertebral and nonvertebral fracture incidence. Its effects include anything associated with high levels of PTH, which can include hypercalcemia, increased uric acid levels and cramping.
References
- Practice of Geriatrics, 4th ed. Duthie 2007.
- Osteoporosis International. "Multinational, placebo-controlled, randomized trial of the effects of alendronate on bone density and fracture risk in postmenopausal women with low bone mass: Results of the FOSIT study." Pols HA, Felsenberg D, Hanley DA. 1999; 9:461-468.
- Endocrinology Metabolism Clinic of North America. "Selective estrogen receptor modulators in the prevention and treatment of postmenopausal osteoporosis." Fontana A, Delmas PD. 2003; 32:219-232.
