26.04.2024
Diseases of the joints

Medical management of bone health

Osteoporosis is loss of bone strength because of reduced bone mineral density, which means bones are thinner and have a greater risk of fracture.

Lifestyle management for bone health

Lifestyle influences bone health and can be an important area to focus on both for prevention of bone loss and management of bone health. For more information go to healthy living & bone health, calcium and vitamin D.

This usually occurs with age, so the focus from early on is to:

  • prevent bone loss
  • maintain existing bone strength
  • treat existing osteopenia (mild thinning of the bones with no increased risk of fracture; this occurs before the bones develop osteoporosis) and osteoporosis

Prevention, maintenance and treatment all benefit from:

  • a diet that includes:
    • calcium
    • limited caffeine
    • limited alcohol
  • adequate vitamin D
  • calcium and vitamin D supplements if you have a deficiency
  • physical activity – especially weight-bearing exercise
  • not smoking
  • adequate oestrogen (if appropriate)
  • attention to the increased risks to bone health created by:
    • illness such as thyroid disease
    • medications such as corticosteroids
  • medical treatment to decrease bone loss and reduce the risk of fracture
  • fall prevention strategies to prevent fractures occurring in the first place

Illness, disease & medications

If you have an illness or take medication, which increases your risk of osteoporosis, it is important to:

  • be aware of this impact
  • discuss the effects with your doctor
  • have regular testing of your bone density

Medical management of bone health

Oral contraceptive pill (OCP)
Who might be helped by taking the OCP The OCP may help extreme athletes, women with current eating disorders, or those with low oestrogen levels for other reasons who have either stopped having their periods, or have periods very infrequently. A lack of periods is associated with low oestrogen levels, which reduces bone density.
How it works Using the OCP can restore oestrogen levels to normal, and research has shown that this may allow bone density to be better preserved.
Possible side effects/risks
  • There is a small increased risk of deep vein thrombosis (DVT) (blood clots in the veins) with the OCP
  • Women who smoke should not take the OCP as the risk of DVT is increased
  • It is not clear whether the OCP improves bone mass in those with already lowered bone density
Hormone replacement therapy (HRT)
Who might be helped by taking HRT HRT can help women around the time of menopause because with menopause there is a dramatic fall in oestrogen levels and the loss of bone is accelerated.
How it works HRT can lead to higher levels of oestrogen which can increase bone density and this reduces the risk of fractures.
Possible side effects/risks
  • The use of HRT is for menopause symptoms and is not currently recommended as a first line therapy for osteoporosis in postmenopausal women
  • HRT has been linked to a slight increase in risk of breast cancer after 4-5 years of use in those who take combined oestrogen and progesterone
  • The effects of HRT last only whilst you are taking it and as soon as you stop, the rate of bone loss returns to the rate it was progressing before you started HRT
Bisphosphonates

Taking bisphosphonates can assist women at high risk of fracture, with a history of low trauma fracture and who have other risk factors for osteoporosis.

There are several kinds of bisphosphonates:

  1. Tablets (weekly or monthly)
    • Alendronate (brand name Fosamax)
    • Risedronate  (brand name Actonel)
  2. Intravenous infusion (once yearly)
    • Zoledronic acid (brand name Aclasta)
How they work
  • These medications are taken up by the skeleton and reduce the rate of bone loss
  • Bisphosphonates reduce the risk of spinal and hip or other fractures
  • These drugs usually become effective within 6-12 months
Possible side effects/risks
  • They are generally well tolerated
  • Some women, particularly women who suffer from heart burn and/or have a hiatus hernia, may experience:
    • heartburn
    • abdominal discomfort
    • ulceration of the oesophagus – but when taken correctly the chance of oesophageal ulceration is low

For bisphosphonates to be effective in increasing bone mineral density, it is important to have an adequate intake of calcium and vitamin D. It is also important to have a dental check-up and tell your dentist you are taking bisphosphonates as they can affect the bone in your jaw if you need to have a tooth removed.

Cost of bisphosphonates

You can have the cost of bisphosphonates subsidised if you:

  • have already had a low trauma fracture (a fracture from a standing height) and/or
  • are over 70 and have osteoporosis diagnosed by a DXA scan
  • have been taking prednisolone in doses greater than 7.5mg for more than three months and have osteopenia or osteoporosis
Raloxifene (brand name Evista)

Taken as a daily tablet

How it works
  • This is a selective oestrogen-receptor modulator drug or SERM that  improves bone density and reduces the risk of spinal fractures
  • It acts like oestrogen at some sites in the body and as an anti-oestrogen in other sites (such as the breast and uterus and so reduces the risk of breast cancer)
Possible side effects/risks
  • Hot flushes, which can make it difficult for women who are going through menopause
  • There is a slightly increased risk of deep vein thrombosis (DVT or blood clot in a vein deep in the body), so if you are going to be immobile for some time such as a long air trip you should get your doctor’s advice about whether to stop this treatment
Other medications

Other medications used to treat osteoporosis include:

Medication Who they work for How to take Possible side effects/risks
Strontium Ranelate (brand name Protos) Patients with severe osteoporosis. Taken daily as granules mixed with water. Should not be used in those at significant risk of cardiovascular events, unless otherwise advised by their doctor.
Parathyroid hormone (PTH) – Teriparatide (brand name Forteo) Patients with severe osteoporosis who have been on other osteoporosis medications but:

  • continue to have fractures and
  • have very low bone mineral density
 A daily injection for 18 months. There may be an increased risk of bone cancer with long-term use.
Denosumab (brand name Prolia) Available for use in postmenopausal women with osteoporosis. An injection given twice a year. There may be a slightly increased risk of skin infections.

For more information on any medications to treat osteoporosis please see your doctor.

Eating disorders

If you have an eating disorder, it is vital to get help to treat the eating disorder to ensure:

  • your nutrition meets your body’s needs
  • your oestrogen levels are high enough

If you have a past history of an eating disorder, it is vital to assess your bone strength as therapies are available to assist you.

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