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Patients at risk for osteoporosis (e.g. steroid use) are generally treated with vitamin D and calcium supplements. In renal disease, more active forms of Vitamin D such as paracalcitol or (1,25-dihydroxycholecalciferol or calcitriol which is the main biologically active form of vitamin D) is used, as the kidney cannot adequately generate calcitriol from calcidiol (25-hydroxycholecalciferol) which is the storage form of vitamin D.
In osteoporosis (or a very high risk), bisphosphonate drugs are prescribed. The most often prescribed bisphosphonates are presently sodium alendronate (Fosamax®) 10 mg a day or 70 mg once a week, risedronate (Actonel®) 5mg a day or 35mg once a week or and ibandronate (Boniva® once a month).
Other medicines prescribed for prevention of osteoporosis include raloxifene (Evista®), a selective estrogen receptor modulator (SERM). Estrogen replacement remains a good treatment for prevention of osteoporosis but, at this time, is not recommended unless there are other indications for its use as well. There is uncertainty and controversy about whether estrogen should be recommended in women in the first decade after the menopause; hopefully new research will provide guidance.
Recently, teriparatide (Forteo®, recombinant parathyroid hormone 1-34) has been shown to be effective in osteoporosis. It is used mostly for patients who have already fractured, have particularly low BMD or several risk factors for fracture or cannot tolerate the oral bisphosphonates. It is given as a daily injection with the use of a pen-type injection device. Teriparatide is only licensed for treatment if bisphosphonates have failed or are contraindicated (however, this differs by country and is not required by the FDA in the USA. However, patients with previous radiation therapy, or Paget's disease, or young patients should avoid this medication).
Oral Strontium ranelate (Protelos® - Servier) is the first in a new class of drugs called a Dual Action Bone Agents (DABA's), and has proven efficacy in the prevention of vertebral and non-vertebral fractures (including hip fracture). Strontium Ranelate works by stimulating the proliferation of osteoblast (bone building) cells (there is some debate about this), and inhibiting the proliferation of osteoclast (bone absorbing) cells. This means that strontium Ranelate increases BMD by forming new bone, rather than just preserving existing bone. In comparison to bisphosphonates which only act on one aspect of bone remodeling, strontium ranelate also preserves bone turnover, allowing the microarchitecture of the bone to be continuously repaired as it would in healthy bone. Strontium ranelate is taken as a 2g oral suspension daily, and is licenced for the treatment of osteoporosis to prevent vertebral and hip fracture (this may differ by country and is not approved in the USA). Strontium ranelate has show significant efficacy at reducing both vertebral, and non-vertebral fractures in patients over the age of 80, who are the most at risk where osteoporosis is concerned. Strontium ranelate has side effect benefits over the bisphosphonates, as it does not cause any form of upper GI side effect, which is the most common cause for medication withdrawal in osteoporosis.
Changes to lifestyle factors and diet are also recommended; the "at-risk" patient should include 1200 to 1500mg of calcium daily either via dietary means (for instance, an 8 oz glass of milk contains approximately 300 mg of calcium) or via supplementation. The body will absorb only about 500 mg of calcium at one time and so intake should be spread throughout the day. However, the benefit of supplementation of calcium alone remains, to a degree, controversial since several nations with high calcium intakes through milk-products (e.g. the USA, Sweden) have some of the highest rates of osteoporosis worldwide. A few studies even suggested an adverse effect of calcium excess on bone density and blamed the milk industry for misleading customers. Some nutrionists assert that excess consumption of dairy products causes acification, which leeches calcium from the system, and argue that vegetables and nuts are a better source of calcium and that in fact milk products should be avoided. This theory has no proof from scientific clinical studies. Similarly, nutritionists believe that excess caffeine consumption can also contribute to leaching calcium from the bones. In any case, thirty minutes of weight-bearing exercise such as walking or jogging, three times a week, has been shown to increase bone mineral density, and reduce the risk of falls by strengthening the major muscle groups in the legs and back.
In a recent study that examined the relationship between calcium supplementation and clinical fracture risk in an elderly population, there was a significant decrease in fracture risk in patients that received calcium supplements versus those that received placebo. However, this benefit only applied to patients who were compliant to their treatment regimen. The very large Women's Health Initiative study did not find a fracture benefit from calcium and vitamin D supplementation, but these women were already taking (on average) 1200mg/day of calcium (12).
Increasing vitamin D intake has been shown to reduce fractures up to twenty-five percent in older people, according to recent studies.
There is some evidence to suggest bone density benefits from taking the following supplements (in addition to calcium and vitamin D): boron, magnesium, zinc, copper, manganese, silicon, strontium, folic acid, and vitamins B6, C, and K. This is weak evidence and quite controversial.
Exercise is of great importance for people suffering from the osteoporosis syndrome. Regular load bearing exercises can help both to delay the onset of the condition, and to relieve pain; this is because regular movement can help to keep joints supple. It is important to be shown how to do exercises for osteoporosis by a professional physiotherapist; this will ensure that the sufferer gains full benefits and does not cause further damage. Sufferers of osteoporosis must learn to judge their own pain thresholds and exercise accordingly.
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Important notice:
The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other
qualified health provider with any questions you may have regarding a medical condition.
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