Treating osteoporosis: risks and management

Abstract

Osteoporosis, osteopenia and minimal trauma fractures are becoming increasingly common in the ageing population. Fractures cause increases in morbidity and mortality and have a significant financial impact on the healthcare system and society.Addressing risk factors for osteoporosis early may prevent or delay the onset of fractures and use of drugs. Calcium and vitamin D supplementation may benefit people with a high risk of deficiency (e.g. institutionalised older people) but may not be required in people without risk factors. Impact and resistance exercises and physical activity can increase bone density and prevent falls.Antiresorptive drugs such as bisphosphonates and denosumab remain first-line treatment options for osteoporosis. The ongoing need for bisphosphonates should be assessed after five years and treatment may then be interrupted in some patients. Progressive bone loss will recur slowly. Denosumab therapy should not be interrupted without switching to another therapy, as posttreatment bone loss can progress rapidly. All patients will need ongoing monitoring and most will require some long-term therapy once started.Raloxifene may be considered in women who do not tolerate first-line antiresorptive drugs. Romosozumab is a new anabolic treatment for osteoporosis and, together with teriparatide, is subsidised as second-line therapy for individuals with severe disease and multiple fractures. Specialist referral should be considered for patients who sustain fractures while undergoing osteoporosis therapy.predicted using the Garvan Fracture Risk or FRAX calculators. 6,7 Age, a family history of hip fractures and previous fractures are key risk factors. All men and women over the age of 50 years who have sustained a fracture have a higher risk of subsequent fractures and should be assessed and considered for treatment. Bone mineral density testing is also recommended and subsidised for all men and women over 70 years of age. Along with falls-risk screening, it is recommended as part of general health checks for all individuals, yet medical record audits indicate that this prevention strategy is currently underused. 8 Osteoporosis can be defined using bone mineral density testing, which generates a T-score and Z-score. The T-score reflects the number of deviations from the peak bone mass of age-, sex-and ethnicity-matched norms. A T-score less than -2.5 indicates a significant reduction in bone mass. The Z-score reflects the number of standard deviations from the average bone mass of age-, sex-and ethnicity-matched norms. A Z-score less than -2.0 should prompt a more complete search for secondary causes of osteoporosis. Management strategiesAddressing lifestyle risk factors, appropriately treating predisposing conditions and minimising the unnecessary prescription of drugs associated with osteoporosis may slow the decline in bone

Sex differences in musculoskeletal injury and disease risks across the lifespan: Are there unique subsets of females at higher risk than males for these conditions at distinct stages of the life cycle?

“…However, this treatment option is now being revisited. In light of such reluctance regarding use of HRT, a number of other options have been developed including bisphosphonates, monoclonal antibodies against proteins involved in bone cell function, vitamin D, and anabolic peptides such as parathyroid hormone fragment and calcitonin ( Zhou et al, 2014 ; Mulder et al, 2016 ; Chandran, 2022 ; Lim, 2022 ; Zhu and March 2022 ). Such interventions vary in effectiveness and side-effects, and thus, many patients are now using those with lower risks.…”

Prolactin-Raising and Prolactin-Sparing Antipsychotic Drugs and the Risk of Fracture and Fragility Fracture in Patients With Schizophrenia, Dementia, and Other Disorders

“…J Clin Psychiatry 84:1, January/February 2023 e2 Chittaranjan Andrade intake, low physical activity, and low calcium and vitamin D content in diet; medical conditions such as vitamin D deficiency and endocrine disease; and use of drugs such as glucocorticoids and treatments for cancer. 8,9 Osteoporosis may also result from long-term hyperprolactinemia, probably through reduction in sex hormone levels. 10,11 Relevant to the present article, antipsychotic drugs that raise prolactin levels have been associated with reduced bone mineral density (BMD) and osteoporosis.…”

Osteoporosis

“…4 Selective estrogen receptor modulators (SERMs) Raloxifene and bazedoxifene are classified as estrogen receptor agonists and reduce postmenopausal bone loss. 25 While also used for breast cancer prevention, these medications decrease bone resorption by affecting estrogen receptors. 17 The SERMs mainly reduce the risk of vertebral fractures.…”

“…9,17,25 There is an increase in BMD in both the hip and lumbar spine. 25 Baseline calcium and vitamin D levels must be obtained before initiating therapy as denosumab reduces serum calcium levels. 25 Denosumab is administered subcutaneously every 6 months.…”

“…17,25 It is recommended for postmenopausal females at high risk for fractures and severe osteoporosis. 17,25 It is effective in improving bone density in the spine and hip. 25 25 Serum calcium and parathyroid hormone levels must be closely monitored while a patient receives teriparatide.…”