Prevention and treatment of osteoporosis
Nonpharmacologic therapy
Nonpharmacologic therapy can be divided into the categories of nutrition, lifestyle, and fall prevention. These represent the foundation for the management of osteoporosis, without which patients are unlikely to achieve the full benefit of pharmacologic therapy. Calcium and vitamin D supplementation have been shown to increase BMD and reduce the risk of fractures in prospective trials. The average American diet is deficient in calcium, and many Americans have an insufficient daily intake of vitamin D. The National Osteoporosis Foundation recommends that all adults have a daily intake of at least 1200 mg elemental calcium with diet plus supplements, and 400–800 IU vitamin D per day for patients at risk of deficiency [39].
Lifestyle intervention for osteoporosis includes regular weight-bearing exercise and avoidance of unhealthy behavior, such as cigarette smoking and excess alcohol intake. Patients with low BMD and high risk for falling may benefit from additional measures, such as muscle strengthening, fall prevention, balance training, Tai Chi, extra care with the dosing of certain drugs (e.g., sedatives, hypnotics, antihypertensives, anticonvulsants), nightlights, handrails, grab-bars, removal of slippery carpets and dangerous obstacles at home, correction of impaired eyesight and hearing, and the wearing of hip protectors.
The decision to treat
Since the goal of treatment is to prevent fractures, selection of patients for drug treatment should be based on level of fracture risk. Current guidelines for initiation of pharmacologic therapy are based on T-score or T-score plus clinical risk factors. While these guidelines are a helpful for appropriate patient populations, over-reliance on T-scores alone may underestimate or overestimate absolute fracture risk and lead to inappropriate therapy. For example, a healthy 30 year-old premenopausal woman with a T-score (or Z-score) of -2.1 probably has a low 5–10 year absolute fracture risk and would probably not benefit from pharmacologic therapy, while an elderly man or woman with a T-score of -1.4 and a history of fragility fracture is at high risk for future fracture and could expect a significant reduction in fracture risk with therapy. Efforts are currently underway to develop a standardized methodology for calculating and expressing absolute fracture risk, which is arguably the best way of establishing therapeutic thresholds. Personal issues and non-skeletal effects of medications are also important to consider in the decision to treat and drug selectionPharmacologic therapy
The medications that are FDA-approved for the management of osteoporosis may be divided into antiresorptive agents (estrogen, alendronate, risedronate, and calcitonin) and anabolic agents, of which there is now only one-teriparatide. These agents can be expected to stabilize or increase BMD [Table 7] and reduce fracture risk by approximately 50% in most patients. All of the FDA-approved medications have been shown to reduce the risk of vertebral fractures, while only estrogen, alendronate, and risedronate have reduced the risk of hip fractures in prospective clinical trials. ]The Women's Health Initiative was the first large prospective randomized placebo-controlled trial to show reduction of hip fracture, vertebral fracture, and other nonvertebral fractures with conjugated equine estrogen (CEE) plus medroxyprogesterone acetate (MPA) [40] and CEE alone . However, the study was stopped before its planned completion date due to increased risk of adverse events. Considering the small but significant increase in the risk of breast cancer, stroke, coronary heart disease, and venous thromboembolic disease with CEE plus MPA, and the increase risk of stroke with CEE alone, it is likely that estrogen will not be used as a drug of first choice for the treatment of osteoporosis, and that its main use will be for the control of menopausal symptoms. The bisphosphonates, alendronate and risedronate, are both proven to reduce the risk of hip fractures, and may be good choices in elderly patients and any patients with high risk of hip fracture. Raloxifene and calcitonin are useful agents where reduction of hip fracture risk is not a primary concern, with the added benefit that raloxifene may reduce the risk of breast cancer and calcitonin may have an analgesic effect in patients with acute painful vertebral fractures. Teriparatide, human recombinant 1–34 parathyroid hormone, is approved for use in women and men at high risk for fracture. Despite its greater expense and the inconvenience of daily subcutaneous injections for a 2-year course of therapy, this agent is a welcome addition to the pharmacologic armamentarium for selected patients. Current evidence suggests that there is no added benefit to combining teriparatide with alendronate, but read more
