Common osteoporosis treatment, quick guidance on 3 meds.

Introduction

We will delve into osteoporosis treatment. But why a Rheumatologist is talking about this topic? As Rheumatologists, due to the fact that we deal with steroids use and chronic disease, we seem to became the experts of osteoporosis treatment as both these issues increase the risk of osteoporosis. Before delving further, I suggest reading this article “Osteoarthritis, Rheumatoid arthritis, and osteoporosis.

Why are you confusing me?” as I have seen confusion among patients and some health care providers alike. Osteoporosis is a disease without symptoms but makes you at risk of fractures. When we treat osteoporosis, we are mainly preventing complications of it. If you have pain from whatever reason, generally speaking, treatment of osteoporosis will not improve pains. Keep in mind, the stage before osteoporosis, we call osteopenia. Osteopenia does not necessitate drugs but does necessitate weight bearing exercise and good supplementation.

Fracture

Fractures, especially of hips, in elderly increase risk of death. That is one reason the medical community is vigilant about providing osteoporosis treatment. Of course, just idea of fracture is not fun and we want to prevent that regardless. Add on top of that, the down side of spending more money on treating a fracture compared to a preventive treatment. Of course, the financial effect is measured on a global scale rather than on individual scale.

Who to screen for osteoporosis?

Before jumping to osteoporosis treatment, whom do I screen for osteoporosis? Easy answer: any postmenopausal woman. Hard answer which I prefer: any human at higher risk such as personal history of diabetes, cancers, endocrinological disease, and autoimmune joint disease. Obviously smoking and alcohol abuse are high risk issues. Finally medication such as reflux medication (proton pump inhibitors such as omeprazole), seizure medication, diuretic for heart disease (such as furosemide and hydrochlorothiazide), and thyroid hormones in excess.

Honestly, the list is hard to follow. However, to make it easy, if you have a chronic disease requiring seeing a specialist or you have frequent visits to you primary to tweak 3 or more medications, you likely need DEXA (bone density) scan -especially if you are a woman.

Exercise and osteoporosis treatment

A quick word on exercise. Obviously, it is important for prevention of osteoporosis. But there are some research papers which showed that weight bearing exercise (weight lifting compared to running and other exercises) could improve bone density if done carefully. Regarding supplements, namely calcium and vitamin D, long story short do not over do it.

For calcium: concentrate on taking calcium for dietary sources (such as milk and eggs, vegan options exist) as it has less risks compared to supplements.

For vitamin D, I recommend going by your level. For general population, levels above 40nmol/l are acceptable. You can always add foods that has higher vitamin D, but I would not push supplement. For osteoporosis/osteopenia, it is a bit different story in which 50 nmol/L is recommended and preferably greater than 75 nmol/L. If you have kidney disease, nephrologist has to manage vitamin D as it is more complex business.

Osteoporosis drugs

Coming to drugs for osteoporosis treatment. There is a list of hormonal therapies both estrogen (female hormone) based and parathyroid hormone based. I will make it simple and practical and avoid academic discussion. From practical perspective, typically we start with oral bisphosphonate which are drugs that slows down bone loss. They come in infusion form (given directly to your vein), which are likely more effective.

The down side to these, you can only use them for 3-5 years at most, as after that they have higher chance of cause different type of fractures, meaning their benefit/harm balance get skewed after 5 years. Common names are alendronate, ibandronate, and zoledronic acid acid(infusion). “What if they do not work? Or I have kidney issue and can’t take them? Or I could not tolerate the medication? Or my esophagus has issues?”.

Next step would be denosumab (Prolia), another injectable under the skin (subcutaneous injection). It is generally more effective and more expensive osteoporosis treatment. “What if that does not work?” that is a trickier question than you think. As “did not work” is so subjective in osteoporosis treatment. In the past with less effective drugs, our goal was only to keep numbers on DEXA scan stable. Now with newer drugs, we think we want improvement of numbers. Also, if someone already has fracture, we typically try jump to more aggressive therapies.

Romosozumab (Evenity) is a drug, initially designed for rare diseases, found its way to osteoporosis. At the time of this article, it can be used only for 12 courses of injections (each course is 1 injection in each arm) spaced out monthly. We do not give these medications for patients with history of heart attacks, strokes, and/or their equivalents. For both Prolia and Evenity, we have to be careful in patients with prior history of cancer as they are biologics.

Osteonecrosis of the jaw

Let me talk side effects before talking about Teriparatide (parathyroid hormone emulator). For bisphosphonate, Prolia, and Evenity as osteoporosis treatments: they all have this one rare side effect called “osteonecrosis of the Jaw”. I will simplify to a fault. This means part of the jaw bone could die out and this is a painful disease and could affect teeth. “OH doc!! are you crazy!!”. Ok going back to the beginning of the paragraph, it is a rare issue. Going to the beginning of the article, osteoporosis can lead to fractures and fractures could be deadly. “But doc!! what should I do? I am scared”.

I recommend being regular with your dentist and keep them informed of your osteoporosis treatments, as they might prefer doing major procedures before starting osteoporosis treatments. “But doc!! I am still scared.” Ok some research showed that a protocol of following a special kind of dentist, called “Oromaxillofacial surgeon”, every 4 months could catch early signs of the issues. “But doc!! is this an overkill!!” possibly and probably for pill bisphosphonate, hard to say though. I think it should depend on discussion with your dentist. If your oral health is normal, then probably monitoring might be too much. If you have 7 cavities, 6 crowns, and periodontal disease; then probably monitoring is a good idea.

Last resort therapy

Ok let us say you are high risk for osteonecrosis of the Jaw or above meds all failed or not recommended. At this point, I suggest working with an endocrinologist with an older therapy called Teriparatide. There are several ways to administer this medication but it somewhat tricky and complex to discuss in an article. Teriparatide is not an easy medication to manage, even by physicians. Endocrinologist, also might consider hormonal therapy but this is also more complex discussion. I will consider future articles in consultation with an endocrinologist on their view of osteoporosis treatment.

Summary

In summary, eat healthy, lift weights, and keep vit D > 40 at least (preferably through diet). If you have osteoporosis, then talk to your provider about pills bisphosphonate or infusion. If not possible such as issues with your kidney, then Prolia would be an option. Finally, in worst cases, Evenity is a good option for 1 year but NOT in patients with prior stroke, heart attack, or similar issues.