Osteoporosis, what you need to know

AUTHORS:

Fellow Emeritus, Professor Moira O’Brien, FRCPI, FFSEM, FFSEM(UK), FECSS, FTCD. Consultant in osteoporosis and Sports Medicine since the 70s and osteoporosis since 1990 when she set up the first osteoporosis clinic in the anatomy department of TCD. Founder and President of the Irish Osteoporosis Society. She is currently the only Osteoporosis consultant in Ireland and works in Affidea Dundrum.

Michele O’Brien, CEO of the Irish Osteoporosis Society. Michele set up the first Falls Prevention service for senior citizens in Ireland in 2000 and has worked for the IOS Charity for 23 years.

Introduction

Osteoporosis is the most common bone disease worldwide, it is a silent disease, as there are no signs and symptoms. There is a significant amount of misinformation and myths about osteoporosis, both in the public and Healthcare domain.

For example, the Irish Osteoporosis Society (IOS) have been saying for decades that it affects all age groups and both sexes, yet most believe it only affects old women.

Findings from a recent survey by Athena Pharmaceuticals found that one in five adults have fractured a bone since they turned 40, over a third of these people reported to have had a fragility fracture and the rate of these low impact fractures was high amongst 40 to 54 year olds. Prevention ideally should start in childhood, which is why physical activity should be mandatory in all schools and integrated into the school curriculum, as not only does it help to prevent Osteoporosis but obesity and a list of other diseases.

More men die from the complications of osteoporotic fractures than cancer of the prostate and men have a higher risk of morbidity and mortality than women.

More women are affected, and more women die from the complications of osteoporotic fractures, than the combined deaths from cancers of the breast, ovaries, and cervix.

Now that you have picked your jaw up from the floor, these are some of the many reasons why all health care professionals need to review their knowledge on Osteoporosis, so the prevention, diagnosis and treatment rates can be improved, and why fragility fractures in those under 65 should have bone loss ruled out, as the cost of treating fractures will double by 2030. Osteoporosis is characterised by low bone density, abnormal changes in the microarchitecture of bone tissue, particularly cancellous bone, making it more fragile, with an increased risk of low trauma fractures. It is essential to find the cause/s of bone loss and modify as many risk factors as possible going forward.

The commonest bones to fracture are the cancellous part of the distal radius, the body of the vertebrae or the hip (neck of femur) and vertebrae but any bone can be affected. A low trauma fracture (trip and fall from a standing height or less) is usually the first sign of this silent disease, along with loss of height, postural changes such as their head protruding forward, rounded shoulders and/or a Dowagers hump developing.

It is estimated that up to 500,000 people in Ireland may have osteoporosis and that over 50,000 osteoporotic fractures occur each year in Ireland. 1 in 2 women and 1 in 4 men over 65, will develop an osteoporotic fracture in their lifetime, if it is not prevented. Younger people will develop osteopenia and/or osteoporosis if they have risk factors for bone loss, which is why in an ideal world any patient being put on a new medication or diagnosed with a new condition should be red flagged if either place them at risk for bone loss, so a plan can be implemented to decrease their risk of fracturing. Some of the many examples; Oral steroids, early menopause, eating disorders, RA. 20% of Irish people aged 60+who fracture their hip will die within 6 to 12 months from a blood clot, infection or pneumonia which are the secondary effects of a fracture. Osteoporosis is rarely on a discharge letter or on death certificate, even though reading the notes, the patients were admitted and treated because they had low trauma fractures. In 2022, the cost of acute hip fracture care was estimated at ¤48,569,325 nationally.

Many patients in Ireland and worldwide have untreated low trauma osteoporotic fractures, despite the fact that there are effective and safe medications available.

Osteoporotic fractures impose a huge social and financial burden in Europe and Ireland, blocking acute beds, 50% of older people who suffer an osteoporotic hip fracture, lose their independence, have poor quality-of-life, which significantly increases costs to the Health Service. Increasing age is a factor and Ireland has one of the highest rates of fragility fractures in Europe, along with one of the greatest increases in the number of its population over the age of 80. Women and men over the age of 65 are the highest risk group but prevention in earlier life will save millions of euros long term.

NOTE: Calcium and vitamin D supplements are not treatments. Intake of Calcium and Vitamin D is essential not only for bone health; however they should preferably be taken through food. How much the patient takes from food should be assessed prior to prescribing a calcium and vitamin D supplement, as many appear to just need vitamin D supplements.

70% of the population will develop back pain in their lifetime, this may be due to a variety of causes, either local or referred. Back pain associated with loss of height and changes in posture are red flags for osteoporotic vertebral fractures. 50% of women with vertebral fractures go undiagnosed. 75% of people with vertebral fractures may only have intermittent back pain, but 25% will have extreme pain which in many cases the pain can only be relieved by daily injections of teriparatide, which it is believed to occur secondary to the increase in rebuilding of bone.

It is very important to differentiate undiagnosed osteoporosis with osteoarthritis and degenerative disc disease, which may affect the L4, L5 nerve roots, causing pain in the distribution of the gluteal and sciatic nerves. This pain is usually aggravated by sitting too long or standing too long. Many patients may have a combination of both osteoporosis and osteoarthritis in the vertebrae.

The increased osteophytes give a false higher reading on a DXA scan of the lumbar spine, which is why the coloured images on a DXA scan should be viewed and reported as well as individual vertebrae, not just the average of the four vertebrae. Fractures or multiple myeloma or secondaries from cancer in the body of the vertebrae may also cause increased false higher readings, making the bone appear healthier than it is. Cause of back pain must be investigated and addressed, and vertebral fractures ruled out.

NOTE: Low bone density increases the incidence of musculoskeletal problems.

There are over 200 causes of bone loss, either the disease itself or the treatment for the disease or lifestyle choices/addictions.

Osteoporosis and its associated risk of increased fractures is rarely considered as a complication of these diseases or their treatment. You must find the causes using a multidisciplinary approach to prevent fractures, as many patients have more than one risk factor. Example A 20 year female on Depo Provera who is on an antidepressant that causes bone loss, with low calcium and vitamin D intake and is obese.

The most common cause of low bone density in females is oestrogen deficiency and testosterone deficiency in males. Family history of osteoporosis will increase the risk of osteopenia and/or osteoporosis by 70%. Genetic disorders such as cystic fibrosis, osteogenesis imperfecta, diabetes, haemochromatosis, homocystinuria and other metabolic disorders are risk factors. Chromosomal abnormalities such as Turner’s syndrome (XO) and Klinefelter’s (XXY ) in males will result in low sex hormone levels, which is why any men lucky enough to be diagnosed must have their testosterone levels checked.

Menstrual problems: Late menarche, first period after the age of 15, irregular periods, PMT, loss of periods for more than 4 months not due to pregnancy, eating disorders or Reduced Energy Deficiency Syndrome RED-S in athletes, early menopause before the age of 45, endometriosis, PCOS and Depo-Provera particularly in the teenage years during the growth spurt.

Men who have had a testis removed, cancer of the testes or trauma causing torsion of the testes, viral or bacterial infections, need to be put on a bone loss prevention plan for osteoporosis and may require testosterone replacement therapy.

Stress either mental or physical, particularly if they have sleep issues, will increase cortisol levels which will reduce sex hormone levels. Other hormones such as high levels of cortisol, prolactin, thyroxine and parathyroid, growth hormone will affect bone metabolism.

Low levels of vitamin D (normal level for bone health should be 70 nmol per litre to 125) affects the absorption of calcium and may cause an increase in the secretion of parathyroid hormone, which takes calcium from bone, to maintain the narrow range of calcium in the blood. Hyperparathyroidism may also be due to an adenoma of the parathyroids.

Low levels of vitamin D may be due to lack of exposure to sun, inadequate intake of vitamin D in the diet or as a result of malabsorption including untreated coeliac disease or gluten and wheat intolerance, Ulcerative colitis or Crohn’s disease to name a few.

Many drugs can cause bone loss, corticosteroids, chemotherapy, radiation, aromatase inhibitors for breast cancer, androgen suppression for prostate cancer. proton pump inhibitors, warfarin, anticonvulsants and prolactin raising medication.

Poor lifestyle advice may also be a cause of developing low bone density. Running or walking they should alter the speed and the course, as bones respond to differences in strain. Cycling and swimming are non-weight bearing exercises. Patients with and without osteoporosis should not do yoga as it contains forward flexion bending exercises, as this will compress the anterior aspect of the lumbar vertebrae, increasing the risk of fractures, excess stress on the discs and sciatic nerve. Adequate sleep and reducing stress is very important.

Nutrition plays an important role, bones require adequate calories, first-class proteins, supplemented milk’s with calcium, vitamin D, vitamin C, iron and folate help absorption. Fluid intake is also essential they should drink at least 1/2 to 2 L a day.

Diagnosis of osteoporosis

1. A detailed questionnaire (available by email from IOS) which helps find risk factors for bone loss. 95% of those who contact the IOS their causes of bone loss appear to have been assumed. If any cause of bone loss is not found and could be addressed, such as gluten sensitivity, a patient will continue to lose bone and not get the full benefit from their treatment.

2. A DXA scan - DXA is the gold standard for diagnosing osteopenia and osteoporosis, currently it is the best predictor of fractures. DXA helps to monitor response to treatment

and improve compliance. The DXA definition of osteoporosis is a T score of -2.5. The T score above 1 is normal. Osteopenia is a T score between -1 and -2.49, most fractures occur in the osteopenia range of -1.5 to -2.49. A T score of -2.5 and low trauma fracture or T score of -3 or higher is considered severe osteoporosis. For every one standard deviation of bone mineral density, the relative risk fracture is significantly increased. A DXA scan should measure the posterior anterior view of the lumbar spine, L1 to L4. Ideally the value of each vertebra should be reported not just the total values, as the density may vary, due to osteoarthritic changes, particularly in individuals with scoliosis or a dowagers hump. Increased calcium in the hyaline cartilage of the vertebrae will give a higher T score and a false high result. Increased density may also be due to vertebral fractures, multiple myeloma or secondaries.

NOTE: If a person’s DXA scan results decline, the cause/s of the decline should be investigated and addressed, changing their treatment is not the solution, as they could continue to lose bone.

3. Blood Investigations for causes of bone loss - List available by email from IOS. This process should also include bone turnover markers in the blood, CTX1 measures bone loss, while PINP measures bone formation. If a patient has stopped taking Denosumab (an antiresorptive) without taking another antiresorptive, or the injection has been delayed for more than approximately 4 weeks, an increase in the blood level of CTX1 may occur, indicating a high risk of spontaneous vertebral fractures.

4. Treatment plan to prevent fractures or further fractures put in place.

Monitoring bone health:

Effective and safe medications are available to treat osteopenia and osteoporosis. Most medications have possible side effects, but the benefits to bone health by preventing future fractures usually far outweighs the risk.

Treatments include

Hormone replacement therapy

- HRT should not be used in post-menopausal women just to prevent bone loss, unless they have menopausal symptoms.

Antiresorptive medication

- Bisphosphonates are nonhormonal and have to be incorporated into bone and are appropriate for some patients but not all and they can only be prescribed for 5 years in total. They may cause irritation of the oesophagus and proton pump inhibitors should not be prescribed for patients to tolerate them, as this will cause further bone loss.

Monoclonal antibody denosumab (Prolia)

The anabolic agent teriparatide for severe Osteoporosis

Evenity (Romosozumab) has been approved by the EMA several years ago but is still not available for patients in the ROI.

Patients must understand the importance of taking the medication correctly and the consequences of stopping it without consulting their doctor, especially Prolia for dental work or as many tell the IOS, they read up on the internet they can treat their bone loss without a prescribed medication, all they need to do is buy certain supplements!

Compliance is a major problem which can be improved by DXA and 6 monthly bone turnover markers particularly CTX1 if available, as many tell the IOS they fill their bisphosphate prescription but do not take it. If you have noncompliant patients you could refer them to the IOS.

The effect of medication on the prevention of bone loss must be monitored ideally by annual or Biannual DXA’s to improve compliance and to ensure the patient is responding to the treatment, as repeat DXA scanning is much cheaper than bone markers. Since bone loss is silent, the IOS does not recommend repeat DXA scanning every 5 years, as significant bone loss can have occurred. A DXA scan contains 10% radiation of a regular chest X-ray, and a person has been exposed to more radiation traveling from Dublin to New York, than having a DXA scan.

NOTE: Are those who have heart attacks only monitored once every 5 years? At least these patients, if this was the case would usually have signs or symptoms, with bone loss there are none, except fractures that could have been prevented by monitoring the patient.

You must find and treat the causes of osteopenia or osteoporosis. Treatment also depend on whether they are pre or postmenopausal, their age, the results of the questionnaire and blood tests, the DXA result and if they have fractured. Some patients may have difficulty in swallowing or absorbing medication, while others are needle phobic which cognitive therapy can help.

It is rarely ever too late to investigate and treat a patient to improve their quality of life and prevent further fractures, the IOS know of 90-year-olds who have significantly improved their bone health and regained their independence.

Exercise

80% of the skeleton is composed of cortical bone and 20% is cancellous. Cortical responds more to weight bearing and differences in strain. Cancellous bone is more sensitive to hormonal changes and is more fragile and is lost first. Osteoclasts are multinucleated giant cells that remove old bone, and this process takes 3 weeks, while the osteoblasts build up new bone and this process takes several months. Weight-bearing activity stimulates the osteoblasts, and they maintain the balance of bone formation and removal. When this balance is disrupted, more bone is removed than replaced causing osteopenia and/or osteoporosis.

Weight-bearing exercise plays an essential role in treatment. Patients should be advised by a physiotherapist who specialises in bone health and can understand a DXA scan report. There is no exercise programme that suits all those with bone loss and patients should be individually assessed. It is much safer to initiate exercises with elderly patients without weights, as many have never lifted weights in their life, for elderly patients there are very basic exercises on the IOS website. By slowly increasing the weights this will reduce the risk of the patient being very sore and non-compliant and also reduces the risk of fracturing. It makes no sense to rush into maximum weights, as many calls to the IOS helpline are from those who are in agony or fractured while exercising, especially those who have been instructed to do forward flexion. A patient should be thoroughly investigated and on an Osteoporosis treatment prior to an exercise program being initiated Lifestyle advice on nutrition particularly the importance of adequate calories, fluids as well as vitamin D as it plays an important role in calcium absorption and bone metabolism. Adequate sleep and reducing stress are important factors as they increase bone loss by increasing cortisol levels. Reduce high caffeine intake, excessive alcohol and excessive fibre in their diet no more than 30g a day and cease smoking. References upon request