Osteoporosis Prevention, Detection and Treatment

As seen in the Consultant Connection December 2012 Issue
By: Cody Siebenaller, ONU, PharmD Candidate, ICP Clinical Pharmacy Student

Osteoporosis Prevention
Recommendations for all ages and populations
  • Maintain an adequate intake of vitamin D and calcium to help support bone formation during childhood and to prevent bone loss after the age of 20
  • Perform weight bearing exercises on a regular basis to promote the body to continue maintaining bone structure and function
  • Avoid tobacco use and limit alcohol consumption to a few drinks a week. Studies have shown that moderate alcohol intake can actually promote greater bone density. However 3 or more drinks a day has been proven detrimental to bone health.

Adequate Vitamin D and Calcium Supplementation Chart
 

Age/Gender Daily Vitamin D Requirement Daily Calcium Requirement
Children 1 - 3 400 IU 500 mg
Children 4 - 8 400 IU 800 mg
Children 9 - 18 400 IU 1300 mg
Men 19 and older 400 to 800 IU 1000 mg
Women Age 19 to 49 400 to 800 IU 1000 mg
Women Age 50 and older 800 to 1000 IU 1200 mg


Osteoporosis Detection
Bone Mineral Density
  • Bone mineral density is measured on the T-Score using the DEXA scan
  • The T-Score is a measurement of how dense a patients bones are compared to a healthy person of the gender at age 30
  • The T-Score is reported in standard deviations from the baseline healthy patient
  • Recommend yearly screenings for female patients 65 and older and male patients 70 and older and patients with risk factors

Signs and Symptoms of Osteoporosis

  • Back pain
  • Height Reduction over time
  • Bone fractures that occur easily
  • Bent over stature

 

Classification T-Score Ranges
Normal 0 to -1
Osteopenia
-1 to -2.5
Osteoporosis -2.5 and lower

Risk Factors for osteoporosis include:
  • Postmenopausal women and men older than 50
  • Endocrine disorders,
  • Excessive alcohol intake and tobacco use
  • Gastrointestinal diseases
  • Low Vitamin D and calcium intake


Osteoporosis Treatment Options
Bisphosphonates

  Bisphosphonates are first line treatment for osteoporosis and for the prevention of the progression from osteopenia to osteoporosis. Oral bisphosphonates must be taken 30 minutes or more before first food or drink in the morning with 8 ounces of water and the patient must remain upright for 30 minutes after administration. Side effects of bisphosphonates include hypocalcaemia, headache, constipation and esophageal erosion if patient does not remain upright after taking the medication. Patient calcium levels should be monitored.
Bisphosphonate Dosing Chart for Osteoporosis Prevention and Treatment


Bisphosphonate Prevention Dose Treatment Dose
Alendronate 5 mg daily or 35 mg weekly 10 mg daily or 70 mg weekly
Ibandronate 2.5 mg daily or 150 mg monthly Oral: 2.5 mg daily or 150 mg monthly

IV: 3 mg every 3 months
   
Risedronate 5 mg daily or 35 mg monthly or one 75 mg tablet on two consecutive days monthly or 150 mg monthly Females: Prevention Dose
Males 35 mg weekly
Zoledronic Acid IV: 5 mg infused over at least 15 minutes every 2 years IV: 5 mg infused over at least 15 minutes every year

Selective Estrogen Receptor Modulators (SERMs)
SERMs are second line therapy for patients with osteoporosis and osteopenia that are refractory to bisphosphonate treatment. Currently raloxifene is used for the prevention and treatment of osteoporosis in postmenopausal females.  It is given orally without regards to meals in a 60 mg dose. Side effects include cardiovascular events such as chest pain, venous thromboembolism, edema and neuromuscular events. Patients should be monitored for signs of clotting and cardiovascular problems.

Estrogen/hormone therapy
Estrogen or hormone therapy with hormones such as ethinyl estradiol,  norethindrone, and norgestimate have been used for treatment of postmenopausal women with osteoporosis but it should only be considered after patients have failed other therapies or the patients need hormone therapy for other disease states. This is due to the increase risks associated with hormone therapy including breast cancer, heart disease, stroke, DVT’s and venous thromboembolisms.  Estrogen should not be unopposed in women with an intact uterus because it can lead to endometrial cancer.

Calcitonin
Calcitonin can be give I.M. or SubQ 100 units every other day or intranasally 200 units alternating nostrils daily. It is a 4th line treatment and patients require calcium and vitamin D supplementation and monitoring due to hypocalcaemia risks. 

Parathyroid Hormone
Administered subQ 20 mcg once daily for women with a high fracture risk due to osteoporosis. Side effects include orthostatic hypotension so should be administered lying down at first and it shouldn’t be used for more than 2 years.

Prolia
Generic name denosumab, monoclonal developed to treat osteoporosis
Indications: Treatment of osteoporosis in postmenopausal women at high risk for fracture; treatment of bone loss in men receiving androgen deprivation therapy (ADT) for nonmetastatic prostate cancer; treatment of bone loss in women receiving aromatase inhibitor (AI) therapy for breast cancer; prevention of skeletal-related events (eg, fracture, spinal cord compression, bone pain requiring surgery/radiation therapy) in patients with bone metastases from solid tumors (Lexi-Comp)
Currently not on guidelines for treating osteoporosis, but will most likely be soon. Different from other treatments in the fact that it is a monoclonal that attaches to the RANKL thus preventing osteoclast formation.


References:
Meunier, Pierre J. “Cyrus Cooper, Stephen Gehlbach and Robert Lindsay (eds): Prevention and Treatment of Osteoporosis: A Clinician’s Guide.” Osteoporosis International 16.10 (2005): 1306. Print.
“How Much Calcium to Take with Vitamin D?” LIVESTRONG.COM. Web. 28 Mar. 2012. <http://www.livestrong.com/article/407483-how-much-calcium-to-take-with-vitamin-d/>.
Staff, Mayo Clinic. “Definition.” Mayo Clinic. Mayo Foundation for Medical Education and Research, 13 Dec. 2011. Web. 28 Mar. 2012. <http://www.mayoclinic.com/health/osteoporosis/DS00128/DSECTION=symptoms>.
Lexi-Comp OnlineTM , Osteoporosis Management Lexi-Drugs OnlineTM , Hudson, Ohio: Lexi-Comp, Inc.; March 28th 2012
International Osteoporosis Foundation Online.  http://www.iofbonehealth.org/ ; March 28th 2012
Facts and Comparisons. Online Database. factsandcomparisons.com. Accessed March 28th 2012


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