Definition and Diagnosis

Our bodies are constantly resorbing old bone and building new bone to keep our bones healthy. When this process results in more bone resorption than formation bones can become weak and are more likely to fracture. We call this condition osteoporosis.

Osteoporosis is diagnosed with the use of a Bone Density Test. The test gives us something called a T-Score. The more negative the T-score the weaker the bones. A normal T-Score is 0 to -0.9. If the number is from  -1 to -2.4 we call this osteopenia which means the bones have become weaker but the risk of a fracture has not reached critical levels yet. Osteoporosis is defined as a T-score greater than or equal to -2.5.  At this level there is a significant increased risk of fracture.

Risk Factors

Some people live to a ripe old age and never get osteoporosis while others show evidence of the disease in their 40's. There are many factors that determine who gets osteoporosis and when. Some of these factors are under our control and others are not.
  • Age – risk goes up with age
  • Sex – women are at greater risk than men
  • Caucasian or Asian race are at increased risk
  • Family history – people who have a parent or sibing with a history of hip fracture are at increased risk
  • Frame size – people who are small framed are at higher risk
  • Steroid use – frequent use of steroids increases risk
  • Sedentary lifestyle
  • Smoking
  • Alcohol use – more than two drinks per day increases risk.

Who needs to be screened?

Although men can develop osteoporosis this is relatively uncommon unless they have unusual risk factors. All women over 65 should be screened for osteoporosis and women with multiple risk factors as outlined above should begin screening no later than age 60.

How often should bone density tests be repeated?

While there is no consensus agreement on how often to repeat bone density tests one recommendation suggests repeat bone density testing every couple of years in patients receiving treatment for osteoporosis. In addition it has been suggested that patients with osteopenia might repeat their bone density test depending on their results according to the following schedule.

Bone Density Result Bone Density Frequency
-1.0   to -1.49 Every 10-15 years
-1.5   to  -1.99 Every 3-5 years
-2.0   to  -2.49 Every 2 years

Treatment Options

Patients who have osteopenia or who have not yet developed a problem can make some changes that may reduce the rate of bone loss in the future.

Non-Prescription Options

  • Calcium
  • Vitamin D
  • Weight bearing exercises
  • Quitting Smoking

Medications

While the  non-medication interventions listed above may slow the progression of osteoporosis, they will not reverse the bone loss that has already occurred. By the time a patient has bone loss severe enough to meet the definition of osteoporosis, medications are the only way to significantly reduce the risk of a fracture. The availble options are listed below.

Fosamax (alendronate), Boniva (ibandronate), Actonel (risedronate)

These drugs which are known as Bisphosphonates are oral medications. They are some of the first drugs developed for the treatment of osteoporosis. In healthy bones there is a balance between bone formation and bone break down ( resorption). Bisphosphanates inhibit bone resorption thereby increasing the amount of bone. This class of drugs is considered the best first choice of therapy for most patients who need treatment.
Pros:
  • Bisphosphonates significantly reduce the risk of both fracture of the spine and the hips.
  • Inexpensive and available in generic form
  • Self administered

Cons:

  • Irritation of the esophagus in some patients.  This is more likely to happen if the patient does not follow the instructions when taking the medication. Patients who have a history of severe esophageal reflux are also at higher risk of this side effect.
  • Small increased risk of fracture in the long bone of the upper leg.
  • Very rare risk of a bone problem called osteonecrosis in the jaw bone.
While side effects always sound scary its important to put them in perspective. In regards to the upper leg fractures and osteonecrosis of the jaw, the average physician who treats hundreds of patients with these medications over his or her career will most likely never see a single patient who has one of these side effects but they will see dozens of patients with hip and spine fractures due to untreated or undiagnosed osteoporosis. The risk of side effects is much less than the risk of not treating this condition.

Bisphosphonates are usually discontinued after 5 years to reduce the risk of unwanted side effects.
       
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Reclast

This drug is a bisphosphonate but unlike Fosamax, Boniva, and Actonel it is given as an intravenous infusion rather than orally. It is indicated for patients who can not take oral Bisphosphanates for some reason.
Pros:
  • Reduces risk of fracture in the spine, hips and other areas
  • Once yearly dosing

Cons:

  • Requires a 15 minute infusion in the doctors office
  • Expensive and not covered by some insurance companies unless there is a reason patient can not take less expensive medication.
  • Requires blood work prior to each treatment.       
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Evista

This drug is often referred to as a “designer estrogen” because it mimics the effects of estrogen in some tissues like the bones, but blocks the effects of estrogen in other areas like the breasts. Evista significantly reduces the risk of spinal fractures but has not been as effective at preventing fractures in other areas of the body like the hips. It may be a good choice in women who can not take bisphosphanates.
Pros:
  • Reduction of spinal fractures.
  • Because Evista blocks the effects of estrogen in the breast there was a reduction of breast cancer risk seen in women who took Evista

Cons:

  • Some woman may experience hot flashes and other menopausal symptoms such as leg cramps.
  • Small increase risk of blood clots in the legs in women who take Evista ( 1.2 cases per 1000 patients on Evista)
  • Some insurance companies require preauthorization for this drug and some dont cover it at all.       
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Prolia

Prolia is a man made antibody that binds to the cells responsible for bone resorption and stops their activation so they don't resorb bone. This drug may also be considered in women who can not take bisphosphonates or in cases where osteoporosis has worsened despite treatment with bisphosphonates.
Pros:
  • Reduces risk of fracture in the spine, hips and other areasDosing every six months

Cons:

  • Small increase in the rate of back and muscle pains
  • Slight reduction in calcium levels
  • Must be given in the doctors office
  • Expensive and not covered by some insurance companies unless there is a reason patient can not take less expensive medication.       
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Forteo

Forteo is similar to a naturally occurring hormone known as PTH ( parathyroid hormone). Unlike some of the drugs above which work by preventing resorption of old bone, this drug works by stimulating new bone formation. This drug may also be considered in women who can not take bisphosphonates or in cases where osteoporosis has worsened despite treatment with bisphosphonates.
Pros:
  • Risk of fracture reduced in all areasCan be self administered

Cons:

  • Must be administered as a daily injection
  • Some reports of leg cramps and dizziness
  • Elevated calcium levels can sometimes occur

Note: Treatment is limited to two years, after which it is recommended treatment be continued with a bisphosphanate. There was an increase in bone tumors seen in mice treated with very high doses of this drug but no such association has been found in humans treated with the standard dose of Forteo.       

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Summary of Screening Recommendations

First Bone Density
Average Risk -  Age 65
High RIsk - Age 60

Repeat Bone Density
Frequency of repeat bone density tests depends on the results of first test. 
  • If first bone density result is -1.0   to -1.49, Repeat every 10-15 years
  • -1.5   to  -1.99, Repeat every 3-5 years
  • -2.0   to  -2.49, Repeat every 2 years

Summary of Treatment Recommendations

Osteopenia  (T-score -1.0 to -2.4) This milder case of bone loss can be treated with Calcium, Vit D, Exercise, Smoking Cessation and reduction in alcohol intake. If the calulcated Hip fracture risk is more than 3%  ( see Fracture Risk Calculator here) or if the major fracture risk is equal to or greater than 20% medication should also be considered

Osteoporosis - Requires making the same  lifestyle changes recommended for osteopenia but often with the additon of medication to repair this more severe level of  bone loss.

First Line Medicaions:
Bisphosphonates like Fosamax, Actonel, or Boniva. Usually taken for five years.
Click Here for more info.

Second Line Medications: 
Evista, Reclast, Prolia, or Forteo for patient who can not take first line medications for some reason.
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Note: Calcium, Vitamin D, Exercise, and Smoking Cessation will only slow further bone  loss, not reverse the damage already done.

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