Osteoporosis.

Osteoporosis is a disease that threatens more than 28 million Americans (National

Osteoporosis Foundation, 2000). Characteristics of osteoporosis include a reduction
of bone density and a change in bone structure, both of which increase susceptibility
to fracture. The normal homeostatic bone turnover is altered: the rate of bone
resorption is greater than the rate of bone formation, resulting in a reduced total bone
mass. Suboptimal bone mass development in children and teens contributes to the
development of osteoporosis. With osteoporosis, the bones become progressively
porous, brittle, and fragile; they fracture easily under stresses that would not break
normal bone. Osteoporosis frequently results in compression fractures (Fig. 68-7) of
the thoracic and lumbar spine, fractures of the neck and intertrochanteric region of the
femur, and Colles’ fractures of the wrist. The probability that a 50-year-old Caucasian
woman will experience a hip fracture during her lifetime is 14%; for a Caucasian
man, it is 5% to 6%. The risk for African Americans is lower—6% for women and
3% for men (NIH Consensus Statement, 2000). Multiple compression fractures of the
vertebrae result in skeletal deformity. Osteoporosis is a costly disorder not only in
terms of health care dollars but also in terms of human suffering, pain, disability, and
death. The gradual collapse of a vertebra may be asymptomatic; it is observed as
progressive kyphosis. With the development of kyphosis (“dowager’s hump”), there is
an associated loss of height (Fig. 68-8). Frequently, postmenopausal women lose
height from vertebral collapse. The postural changes result in relaxation of the
abdominal muscles and a protruding abdomen. The deformity may also produce
pulmonary insufficiency. Many patients complain of fatigue

Prevention

Primary osteoporosis occurs in women after menopause and later in life in men, but it
is not merely a consequence of aging. Failure to develop optimal peak bone mass
during childhood, adolescence, and young adulthood contributes to the development
of osteoporosis without resultant bone loss. Early identification of at-risk teenagers
and young adults, increased calcium intake, participation in regular weight-bearing
exercise, and modification of lifestyle (eg, reduced use of caffeine, cigarettes, and
alcohol) are interventions that decrease the risk for development of osteoporosis,
fractures, and associated disability later in life. Secondary osteoporosis is the result of
medications or other conditions and diseases that affect bone metabolism. Specific
disease states (eg, celiac disease, hypogonadism) and medications (eg,
corticosteroids, antiseizure medications) that place patients at risk need to be
identified and therapies instituted to reverse the development of osteoporosis.

Pathophysiology

Normal bone remodeling in the adult results in gradually increased bone mass until
the early 30s. Gender, race, genetics, aging, low body weight and body mass index,
nutrition, lifestyle choices (eg, smoking, caffeine and alcohol consumption), and
physical activity influence peak bone mass and the development of osteoporosis (Fig.
68-9). Although the consequences of osteoporosis (eg, fractures) occur with aging,
osteoporosis is not a disease of the elderly. Rather, its onset occurs earlier in life,
when bone mass peaks and then begins to decline. Loss of bone mass is a universal
phenomenon associated with aging. Age-related loss begins soon after the peak bone
mass is achieved (ie, in the fourth decade). Calcitonin, which inhibits bone resorption
and promotes bone formation, is decreased. Estrogen, which inhibits bone
breakdown, decreases with aging. On the other hand, parathyroid hormone (PTH)
increases with aging, increasing bone turnover and resorption. The consequence of
these changes is net loss of bone mass over time. The withdrawal of estrogens at
menopause or with oophorectomy causes an accelerated bone resorption that
continues during the postmenopausal years. Women develop osteoporosis more
frequently and more extensively than men because of lower peak bone mass and the
effect of estrogen loss during menopause. More than half of all women older than 45
years of age show evidence of osteopenia. World Health Organization (WHO)
diagnostic categories for osteoporosis are based on BMD scan findings (Walker-Bone
et al., 2001).
Treatment and Prevention

Treatment of osteoporosis is aimed at preventing or reducing bone fractures and

maintaining or increasing bone density. There are several treatments for osteoporosis,
but prevention is still very important. Many of the treatment and prevention strategies
for osteoporosis are similar.

Maintenance of good bone strength requires that you have a regular intake of calcium
and vitamin D. Osteoporosis Canada recommends 1,000 mg of elemental calcium
daily (diet plus supplements) for men and women between the ages of 19 and 50
years, and 1,200 mg for men and women over the age of 50 years. They recommend
400 IU to 1,000 IU of vitamin D daily for adults between the ages of 19 and 50 years
who are not at high risk of osteoporosis, and 800 IU to 2,000 IU for both adults over
the age of 50 and people at high risk of osteoporosis. Vitamin D supplements are
widely available.

Osteoporosis Canada also recommends regular weight-bearing exercises and a

healthy lifestyle with no smoking or excessive intake of alcohol.

Weight-bearing exercises (such as walking, weight training, or climbing stairs) play a

role in strengthening bones and preventing fractures. Posture and balance can be
improved through exercise and can significantly reduce the risk of bone fractures.

For teenagers and young adults under 30 years of age, weight-bearing exercises have
the added benefit of increasing the peak bone mass (i.e. BMD). Beyond the age of 30,
treatment can only prevent or delay the loss of BMD.
There are several medications that can be used to treat osteoporosis. Many of these
treatments may also be used to prevent osteoporosis for people who are at high risk of
developing it. The following are some of the osteoporosis medications available in
Canada:

bisphosphonates (e.g., alendronate, etidronate, risedronate, zoledronic acid): These

are one of the main groups of medications that may be used to prevent and treat
osteoporosis. These medications slow down bone loss and help repair bone, reducing
the chance of fracture.

selective estrogen receptor modulators (SERMs; e.g., raloxifene): These may also be
used to prevent and treat osteoporosis in women.

denosumab: Given as an injection, denosumab is part of a class of medications called

RANK ligand inhibitors. It stops the breakdown of bone, helping to strengthen your
bones and lowering the chances of fracture.

testosterone: This is not recommended for the treatment of osteoporosis in most men.
However, in some cases where osteoporosis in men is the result of hypogonadism,
which is a condition of low levels of the male hormone testosterone, testosterone
replacement therapy (androgen) may be used alone or with a bisphosphonate.

hormone-replacement therapies (HRTs): A variety of HRTs are available for women

who have reached menopause. Estrogen replacement helps to preserve bone and
manage menopausal symptoms, but the therapy has a number of health risks. If you
are taking or are considering taking HRT, talk to your doctor about the risks and
benefits.

parathyroid hormone analogues (e.g., teriparatide): This class of medication builds

new bone faster than it breaks it down, and can be used to treat severe osteoporosis.

Two or more medications may also be used in combination to treat some cases of
osteoporosis. In addition, doctors usually recommend that you continue to get enough
calcium and vitamin D.
Causes

Bone is made up mostly of minerals such as calcium. The bones in our bodies are
constantly being broken down and replaced with new bones. This bone-building cycle
takes about 100 days and is influenced by the hormones produced in our bodies (such
as estrogen in women) as well as by the levels of calcium and vitamin D.
Osteoporosis occurs when bone tissue and minerals are lost faster than the bone is
replaced.

In Canada, osteoporosis affects about 1 in 4 women and 1 in 8 men over the age of
50.

Factors that may increase the risk of osteoporosis include:

drop in estrogen after menopause: The rate of bone loss increases significantly after
menopause because the ovaries stop producing estrogen, a hormone that plays a
major role in the bone repair process. Female athletes and women who suffer from
anorexia nervosa may also be at increased risk for osteoporosis. In both cases, the
menstrual cycle is disrupted or lost and levels of estrogen in the body drop
dramatically. Women who experience early menopause (before 45 years of age) are
more likely to have osteoporosis.

family history and body type: Osteoporosis tends to run in families, and the risk of
this condition is greater for individuals with elderly relatives who have had a bone
fracture, especially if it is a parent who has had a hip fracture. People of European
and Asian descent are most at risk. People who are thin or "small-boned" also have a
higher risk of osteoporosis. People who have had a fracture in the vertebrae are also at
increased risk.

lifestyle factors and health conditions: Lifestyle factors such as smoking and
excessive alcohol and caffeine intake, taking specific medications (such as
corticosteroids), and having certain medical conditions (such as those that affect
nutrition absorption [e.g., Crohn's disease, celiac disease], primary
hyperparathyroidism, rheumatoid arthritis, and hypogonadism) may also contribute to
bone loss. People with type 2 diabetes are more likely to suffer a hip or shoulder
fracture than those without diabetes.

lack of exercise: The bone is a living tissue that, like the muscles, gradually become
stronger with exercise. People who are physically active are less at risk of developing
osteoporosis, as their bones are stronger and less likely to lose strength with age. By
contrast, a person who is bedridden or inactive for a lengthy period of time loses bone
mass very quickly and is at high risk of osteoporosis.

lack of calcium or vitamin D: Calcium and vitamin D are very important in the
maintenance of healthy and strong bones throughout life and in the prevention of
osteoporosis. Vitamin D helps the body increase absorption of calcium. In Canada,
we don’t get enough sun to produce sufficient vitamin D, particularly during winter
months, and it is very difficult to get enough vitamin D through diet alone.

Symptoms and Complications

Osteoporosis itself does not usually cause noticeable symptoms. However, weakened
bones can break much more easily, such as with a minor fall. Fractures most
commonly occur in the hipbones, wrists, or spine. Hip fractures are more frequent in
people over the age of 75 years.

Some fractures caused by osteoporosis, such as hairline breaks in the spine, may
cause little or no pain and may go unnoticed, even when they show up on an X-ray.
By contrast, spinal crush fractures, where the vertebral column crumbles or collapses,
are much more painful and can lead to deformed posture and height loss.

Another symptom caused by osteoporosis is chronic back pain. This pain can worsen
even when you are making small movements such as regular activities around the
house, or while coughing, laughing, or sneezing. You may even feel pain when you
are standing still.