Osteoporosis is a painful degenerative disease with a high prevalence in the United States. It is estimated that about 10 million men and women in the US suffer from this debilitating condition. Osteoporosis is a bone disease that is preceded by low bone mineral density (BMD) and deterioration of the bone structure. In simple terms, it is a bone disorder that weakens the bones and makes them more susceptible to fractures, and increases their probability of breaking.
The condition typically doesn’t manifest any symptoms until the occurrence of a fracture usually in the wrist, hip, and spine which more often than not necessitates hospitalization. Gender-wise, it is more prevalent in women than in men, but it is also diagnosed in men. Aside from the negative impact on the health of the older population, it also places a great economic burden on the health care system.
The management and treatment of this bone disease are imperative to improve quality of life and lessen cost and economic burden on the health care system. There have been several therapeutic advancements in the diagnosis and treatment of osteoporosis in recent years, as scientists have become more familiar with bone morphology and the etiology of the disease.
THE ETIOLOGY OF OSTEOPOROSIS
The causes associated with osteoporosis are grouped into primary and secondary osteoporosis.
- Primary osteoporosis is associated with aging and deficiency in sex hormones. Aging causes deterioration of the bone trabeculae. The bone undergoes degenerative processes as we age, but wear and tear can cause the bones to become brittle and weak, hence making them vulnerable to fractures. Also, the decline in estrogen levels in post-menopausal women causes a considerable decline in bone loss, while sex hormone-binding globulin decreases estrogen and testosterone in men as they age, which can lead to loss of bone density over time.
- Secondary osteoporosis is related to comorbid conditions and medications. This means that it is caused by certain diseases and medications that interfere with bone health, such as those that impair the balance of calcium, vitamin D, and sex hormones in the body. An example of such a disease is crushing’s a disease that increases bone loss through the production of excess glucocorticoid. In addition, a health condition like rheumatoid arthritis and other inflammatory diseases may necessitate long-term glucocorticoid therapy which can cause secondary osteoporosis.
OSTEOPOROSIS TREATMENT OPTIONS
The treatment plan for osteoporosis involves treating and preventing fractures and strengthening the bones. Treatment takes into consideration certain factors like age, sex, susceptibility to fracture, and history of bone injury. You will need to discuss with your doctor to get the best osteoporosis treatment that is well suited for your condition.
If you are not highly susceptible to getting fractures or you have been diagnosed with osteopenia (low bone mineral density that is not low enough to be diagnosed as osteoporosis), your doctor might only recommend lifestyle changes without the use of medication to treat the condition. These include performing specific exercises, quitting smoking, cutting back on alcohol consumption, eating healthy, and taking extra caution not to experience falls.
If you are found to be at an increased risk of bone fracture, medications may be prescribed to activate the bone regeneration process in your body. Some of the drugs prescribed for these reasons include
1.Antiresorptive medication: Includes biphosphonates, hormone replacement therapy (HRT), and other drugs that decrease bone deterioration.
- Examples of bisphosphonate drugs are Fosamax, Boniva, Reclast, and Actonel. Biphosphonates work to slow down bone deterioration in the body. These classes of drugs are approved for post-menopausal women, but Boniva is also prescribed for men.
- Hormone replacement therapy used to be the only approved treatment for osteoporosis in women. However, its use became controversial due to safety concerns. The therapy was reported to increase the risk of breast cancer and cardiovascular diseases in women. Follow-up studies later debunked these claims. Nevertheless, you should discuss with your doctor the possible risks before opting for hormone therapy.
2 . Anabolic drugs: Include drugs that accelerate bone formation. Only two of these drugs are currently approved for use. These are; Teriparatide parathyroid hormone (Forteo) and abaloparatide (Tymlos)
- Selective estrogen receptor modulators (SERMs): These are drugs that have the same effect on the bone as the hormone estrogen. They work to promote an increase in bone mineral density and reduce the risk of fracture (particularly in the spine). These drugs include raloxifene and bazodocifene.
- Shots for osteoporosis treatment: These are osteoporosis treatment injections that are injected subcutaneously (under the skin). An example is a denosumab (prolia) injection which is used to treat several osteoporosis conditions, such as osteoporosis that is caused by corticosteroid medications. It is also used to reduce the risk of fracture. It can also be prescribed as an alternative medicine for patients who cannot take oral medication for osteoporosis.
- Osteoporosis treatment infusion: These are infused forms of bisphosphonates that are injected into the vein. The approved bisphosphonate infusions are Boniva and zoledronic acid (Reclast). Boniva is infused into the body once every three months, while Reclast is infused once a year.
- Potential stem cell treatment: A 2016 study conducted at the University College, London discovered that stem cells that are shed by babies and transferred into the mother’s amniotic fluid may be a potential treatment for uncommon bone disorders and osteoporosis. Researchers collected stem cells from human amniotic fluid and injected them into mice to help strengthen weak bones. Results obtained found that the stem cells did strengthen the bones and even contributed to bone regeneration in the mice. Another study also reported similar findings after transferring stem cells from the amniotic fluid of mice into mice that had osteoporosis.
This means that stem cell therapy is a promising treatment for osteoporosis and researchers hope to make a breakthrough soon.
OSTEOPOROSIS TREATMENT SIDE EFFECTS
As with all treatments, osteoporosis therapy is associated with certain side effects.
- Bisphosphonates have been linked to gastrointestinal issues such as stomach upset, heartburn swallowing difficulties, and irritation of the esophagus. Infusion biphosphonates or those given as injections can cause flu-like symptoms. Prolonged use of bisphosphonates(more than 5 years) is associated with the cracking and breaking of the thighbone. In rare and complicated cases, they may cause Jaw bone deterioration (osteonecrosis).
- Raloxifene (SERM) can cause hot flushes, leg cramps, and blood clotting.
- Side effects of anabolic drugs such as teriparatide include nausea and vomiting.
- Hormone replacement therapy is associated with an increased risk of developing breast cancer, stroke, and ovarian cancer.
OSTEOPOROSIS TREATMENT GUIDELINES
Published osteoporosis treatment guidelines for osteoporosis vary across several organizations. These guidelines serve as a guiding template in the treatment of osteoporosis across the different categories of people affected. It helps clinicians make an accurate diagnosis and prescribe the best treatment that is well suited to each case. let’s take a look at a summarized updated osteoporosis treatment guidelines (2020) as stipulated by the joint collaboration of two esteemed Institutes.
The American Association of Clinical Endocrinologists ( AACE) and American College of Endocrinology (ACE) 2020 Guidelines
The American Association of Clinical Endocrinologists (AACE) in collaboration with the American College of Endocrinology(ACE), released an updated osteoporosis treatment guideline earlier this year. The recommendations are purely based on a review of multiple studies and the supporting clinical evidence attached to the literature. 69.5% of the 368 citations that the recommendations are based on, were considered high-level quality evidence. The recommendations are summarized as follows :
PATIENTS CONSIDERED TO BE AT HIGH RISK
- Those with recent fractures within the previous year.
- Those who get fractures while undergoing approved osteoporosis treatment,
- Those who have multiple fractures and patients who become exposed to fractures while on drugs that cause skeletal injury such as prolonged use of corticosteroids
- Patients with a T-score <-3.0
- Patients who are susceptible to falls or those with recent injuries associated with falling
- Those with FRAX (Fracture risk assessment tool) assessed high fracture probability.
The guideline recommends that potent treatments are needed for susceptible and high-risk fraction osteoporosis patients. The guideline also noted that FRAX may give an underestimated analysis of fracture risk in diabetic patients. To counter this, rheumatoid arthritis may be substituted for type 2 diabetes in the FRAX algorithm, or trabecular bone score can serve as an adjustment for FRAX scores for more accurate predictions.
Suggested initial treatment for patients highly susceptible to fracture includes abaloparatide, romosozumab, zoledronate, denosumab, and teriparatide. This therapy is also recommended for patients unable to use the oral form of treatment. Also, all patients diagnosed with osteoporosis but not highly susceptible to fracture should also be considered as high-risk to fracture patients.
THE USE OF ROMOSOZUMAB FOR POSTMENOPAUSAL OSTEOPOROSIS
The new drug romosozumab promotes an increase in bone density and helps in bone repair. The guideline task force suggested that the drug be considered a “rescue drug” for patients highly susceptible to bone fracture, especially those that have been treated with abaloparatide or teriparatide in the past. It is also recommended for patients with a history of radiation exposure. It is advised that patients who may be predisposed to cardiovascular issues or who have suffered a stroke or myocardial infarction in the recent past should not be treated with romosozumab. It is also not recommended as preventive therapy for post-menopausal osteoporosis.
Patients should only be treated with romosozumab for a year only and then followed up with other long-term drugs like bisphosphonates.
SWITCHING BETWEEN THERAPEUTIC AGENTS
The guideline states that patients switching from romosozumab or denosumab can receive oral biphosphonates following treatment completion. This may help to prevent bone loss after stopping the use of the above-mentioned drugs.
Romosozumab therapy can be done for a year before sequential therapy; (Teriparatide or abaloparatide therapy for 2 years, and then zoledronate therapy for six years, under the condition that the patient is stable and actively responding to treatment).
In the event that the patient becomes unstable, that is bone deterioration worsens or fracture occurs, zoledronate therapy should be replaced with another anabolic agent before antiresorptive therapy is administered.
Denosumab therapy can be continued until the patient no longer shows signs of being highly susceptible to fracture. In the event that denosumab therapy is stopped, patients should be switched to an alternative antiresorptive treatment. It is not recommended to transition from denosumab to an anabolic agent because of the probability of BMI decline.
A full and detailed report of the 2020 guidelines can be found in the AACE journal