What is osteoporosis?
The medical term “osteoporosis” means pores in the bone, or simply a porous bone. This disease progressively makes bones weak and a person becomes highly susceptible to sudden and unexpected bone fractures. A person suffering from osteoporosis gradually loses bone mass and strength. This disease often develops asymptotically with no pain and is usually not detected until the weakened bones lead to painful fractures. Most of the fractures occur in hip, wrist, and spine.
Statistical figures of osteoporosis
Approximately, 200 million people are estimated to have osteoporosis globally. In United States (US), 54 million people are affected by this disease. It can occur in both genders equally. However, females are four times highly vulnerable to catch osteoporosis compared to men. Presently, approximately, two million men in US are suffering from osteoporosis and 12 million are at risk of developing this disease. After age 50, one in two female and one in four male may develop osteoporosis-related fracture in their lifetimes coupled with low bone density (osteopenia) that puts them at risk of developing osteoporosis. As per the statistical data, osteoporosis-related fractures are progressively increasing around the globe with two million fractures being reported every year.
What causes osteoporosis?
The interior architecture of healthy human bone looks like a sponge called as trabecular bone. The cortical dense bone (outer hard shell) wraps around the spongy bone. Under osteoporotic condition, the “holes” in the “sponge” grow larger and increases in number that progressively weakens the trabecular bone. When the body needs calcium, bones breaks down and rebuild again. This process is called normal bone remodelling that supplies calcium to the body when needed. Up to the age of thirty, frequency of bone formation is more compared to its breakdown. After the age of thirty five, bone breakdown occurs at a much faster rate than bone formation, leading to a gradual loss of bone mass. In osteoporotic condition, bone mass deceases at a dramatic rate more particularly in females after post-menopause life. Postmenopausal women are at higher risk of developing osteoporosis with the rapid bone loss in the first ten years. Post-menopause changes the normal hormonal physiology of females along with the decrease in production of estrogen hormone whose one of the key function is to protect against the excessive bone loss. Men over the age of fifty are more likely to have an osteoporosis-driven bone loss compared to develop prostate cancer.
Risk factors of osteoporosis
Osteoporosis has been often linked to ethnicity. Caucasian and Asian women are more likely to develop osteoporosis. Petite and thin people are at higher risk to develop osteoporosis because they have less bone to lose compared to people with more body weight and larger frames. Family history (genetics) also contributes in developing the early onset of osteoporosis. Hormonal imbalance in hyperthyroidism, parathyroidism, adrenal dysfunction, and hormone driven treatment for breast or prostate cancer or a history of missed periods may lead to osteoporosis. Other risk factors include history of bariatric surgery or organ transplant, inflammatory bowel disease (ulcerative colitis, Crohn’s disease, and celiac disease), and multiple myeloma. Other risk factors are usage of steroid drugs, and medications for treating seizures.
Controlling risk factors
You can control over some of the risk factors for osteoporosis. These are as follows:-
Eating habits: You are more likely to develop osteoporosis if your body doesn’t have enough calcium and vitamin D3. Although eating disorders like bulimia or anorexia are risk factors, however, they can be treated.
Lifestyle:People who live sedentary (inactive) lifestyles have a higher risk of osteoporosis.
Tobacco use: Smoking increases the risk of fractures.
Alcohol use: Increases the risk of osteoporosis.
Steroid drugs: Unnecessary usage of steroid drugs and steroid injection for treating post-menopausal complication increases the risk of breast cancer.
Diagnosis of osteoporosis
Bone mineral density (BMD) tests, also known as dual-energy X-ray absorptiometry (DEXA or DXA) scans is the best way to determine the bone density. All women over the age of sixty five should go through DEXA scan. Men over age seventy, or younger men with risk factors, should also consider to go through a bone density test.
Treatment of osteoporosis
Treatments for established osteoporosis may include exercise, vitamin and mineral supplements, and medications. Exercise and supplementation are often suggested to help for preventing osteoporosis. Weight-bearing, resistance and balance exercises are all important.
Medications currently in vogue to treat osteoporosis
There are several classes of medications used to treat osteoporosis. These are as follows:
Hormone and hormone-related therapy
This class includes estrogen, testosterone and the selective estrogen receptor modulator like raloxifene (Evista®). Testosterone might be prescribed by physician to increase the bone density in males with low levels of it. Raloxifene acts like estrogen. In addition to treat osteoporosis, raloxifene might be used to reduce the risk of breast cancer in some women. For osteoporosis, raloxifene is generally used for five years. Calcitonin-salmon (Fortical® and Miacalcin®) is a synthetic hormone that reduces the chance of spine fractures.
Bisphosphonate-driven osteoporosis treatments are considered as anti-resorbtive drugs. They stop the body from re-absorbing bone tissue. There are several formulations with various dosing schemes (monthly, daily, weekly and even yearly) and comes in market with different brands like Aledronate (Fosamax®, Fosamax Plus D®, Binosto®), Ibandronate (Boniva®. Risedronate: Actonel®, Atelvia®), and zoledronic acid (Reclast®). Of these products, Boniva and Atelvia are recommended only for women, while the others can be used by both women and men.
Denosumab (Prolia®) is a product that is available in injectable form given every six months to both women and men. It is often used when other treatments have failed. It can be used even in some cases of reduced kidney function. Its long-term effects are not yet known, but there are potentially serious side effects. These include possible problems with thigh or jaw bones and serious infection.
These agents build bone in people who have osteoporosis. Currently, three drugs that come under the definition of anabolic drugs have been approved. These are Romososumab-aqqg (Evenity®) approved for postmenopausal women who are at a high risk of fracture. This anabolic agent assists in new bone formation and decreases the bone breakdown. Teriparatide (Forteo®) and Abaloparatide (Tymlos®) comes in injectable form and is given daily for two years.
When should osteoporosis be treated with medication?
Women whose DEXA scan test shows T-scores of -2.5 or lower, such as -3.3 or -3.8, should begin therapy to reduce their risk of fracture.
Calcium and vitamin D3 (cholecalciferol) are very important agents to prevent osteoporosis. The recommended amount of daily calcium intake is 1,000−1,200 mg daily via diet and/or supplements. Taking more than this amount of calcium has not been shown to provide additional bone strength but may be associated with an increased risk of kidney stones, calcium buildup in the blood vessels and constipation. There are different ideas about the necessary levels of vitamin D3, but it’s true that many people do not have adequate levels and might need to take supplements.
Reference Range of vitamin D3
The major circulating form of vitamin D3 is 25-hydroxyvitamin D3 (25(OH)D3); thus, the total serum 25(OH)D3 level is currently considered the best indicator of vitamin D3 supply to the body from cutaneous synthesis and nutritional intake. The reference range of the total 25(OH) D3 level is in between 25−80 ng/mL.
How can you prevent osteoporosis?
Your diet and lifestyle are two important risk factors you can control to prevent osteoporosis. Diet
To maintain strong and healthy bones, diet should be rich in calcium throughout the life. One cup of skim or 1% fat milk contains 300mg of calcium. Besides dairy products, other good sources of calcium are salmon with bones, sardines, kale, broccoli, dried figs etc.
Personal suggestions: People that live in Kashmir valley are not frequently exposed to sunlight that makes less availability of Vitamin D3 in the body. Some of our females and males are confined to houses and receive low sunlight especially in winters. We personally suggest them to get their Vitamin D3 level checked if at all they have bone related issues. Get best Vitamin D3 supplement like Lumina 60K, and/or Neuro D3 60,000 IU from SunPharma-India.
Note: It is best to try to get the calcium from food and natural products.
Dr Arif Bashir is a PhD in Clinical Biochemistry (molecular respiratory medicine), Post-Doctorate in Cancer Stem Cell Biology, and Assistant Professor, Clinical Biochemistry, Department of Higher Education, Government of J&K.
Dr Naveed Nazir Shah, Professor & Head, Department of Respiratory Medicine, Govt. Medical College, Srinagar, and Head, Chest Disease Hospital-Srinagar.