9 Mar 2017
Mary’s story is not atypical. She is 68 years old and has osteoporosis: a condition in which people lose bone mass, resulting in thin, porous bones. The condition affects 54 million Americans, mostly women, and according to the National Osteoporosis Foundation (NOF), nearly half of the female population and up to one-quarter of men will experience osteoporotic fractures due to this disease.
While Mary has not fractured bones, she suffers from back pain as a result of the condition. Three years ago she started treatment with Zometa, an intravenous medication she receives every six months which has stabilized her bone condition. When dietary changes and exercise are not effective in treating osteoporosis, intervention with medication is often the next step.
Dr. James Hellerman, an endocrinologist with Phelps Medical Associates in Tarrytown, treats patients with hormonal disorders such as hyperthyroidism and diabetes. These conditions put patients at higher risk for osteoporosis. Genetics, bone structure and body weight, and ethnicity are also risk factors, as are long-term steroid use, low testosterone in men, smoking, and excessive alcohol consumption.
“A lot of patients are already seeing the doctor who is going to make the decision to treat [osteoporosis],” says Dr. Hellerman. For instance, rheumatologists already have a group of patients who are at high risk for osteoporosis because of their arthritis and accompanying long-term steroid use.Gynecologists and primary care doctors often diagnose and treat osteoporosis since they are the doctors women visit most frequently. They are also accustomed to seeing the condition in their patients as everyone begins to lose bone density at about the age of 30 (men included), with loss accelerating for women across the menopause transition.
The three main reasons Dr. Hellerman will propose medication as a treatment for osteoporosis are if the patient:
1) has suffered a fracture caused by very little trauma, also known as a low-impact fracture;
2) has a T-score on a bone density scan (DXA) more negative than -2.5. (A T-score compares bone density of the patient to what would be expected in a healthy young adult at peak bone mass.); or
3) if she/he has a calculation of the Fracture Risk Assessment Tool (FRAX) that suggests a high probability of developing a fracture over the next ten years.
Patients have osteopenia if they have a T-score between -1 and -2.5 on a DXA. This is lower than normal bone mass but is not yet osteoporosis. Adding sufficient calcium and vitamin D, exercising, not drinking, and not smoking may reduce a patient’s risk of further bone loss.
According to the NOF, there are many medications used to treat osteoporosis. Antiresorptive drugs such as estrogen, calcitonin, denosumab, and bisphosphonates are intended to slow bone loss. Also, there is one therapy that rebuilds bone: the anabolic drug teriparatide (brand name Forteo).
If a younger patient has severe osteoporosis, Dr. Hellerman will search for a reversible cause such as a silent form of celiac disease or hyperthyroidism. Just as with a younger patient, in an older woman, Dr. Hellerman will treat the patient based on her symptoms: how severe her bone loss is, which part of her anatomy is involved, and whether certain side effects are acceptable to her. “We usually try to start with the simplest and least expensive treatment first and see whether we get the effect we want. If there are fractures, we’re going to go a little bit faster,” he explains.
While bisphosphonates are the most common osteoporosis medications, their effect on bone density plateaus after three to five years. With these drugs, patients often have concerns about rare, serious side effects such as an atypical fracture of the femur or osteonecrosis of the jaw after invasive dental work.
Hellerman says he has never seen an atypical fracture of the femur in any of the patients he’s treated for osteoporosis with bisphosphonates. He goes on to comment that most osteoporosis experts think these rare side effects occur when someone has been on an oral bisphosphonate for a long time: perhaps five to ten years. A patient might take a “drug holiday” if the bisphosphonate is losing its effectiveness and this may reduce a patient’s risk of the rare side effects. However, patients at high risk for fractures will generally start another medication right away. Dr. Hellerman works with a patient’s dentist if dental work is needed when the patient is on bisphosphonates.
For patients who have rheumatic disease or severe osteoporosis of the spine, Forteo is used. This is given by daily injection, can be used for two years, and should not be given to someone who has active cancers that can spread to bone.
While Dr. Hellerman believes the medications are very safe, if patients are fearful of taking them, he may have them talk with a patient who has tolerated the drug well. This often is effective in calming patients’ fears.
“We don’t tell people you must take this medication,” explains Hellerman. “We try and present the best available evidence about where they are, what their risks are, and what the benefits of medication are, in addition to everything else they are doing. He emphasizes, “We point out to them that these are just guidelines and that everybody is different. Everybody has the right to make the choice that’s right for them.”
From the Publisher: For some tasty recipes to support healthy eating for your bones, check out these suggestions: