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Prevention
and treatment of osteoporosis
Adequate calcium,
vitamin D, appropriate exercise and, in some cases, medication are
important for maintaining bone health. Currently, bisphosphonates
(alendronate and risedronate), calcitonin, estrogens, parathyroid
hormone and raloxifene are approved by the US Food and Drug
Administration (FDA) for the prevention and/or treatment of
osteoporosis.
The bisphosphonates (alendronate
and risedronate), calcitonin, estrogens and raloxifene affect the
bone remodeling cycle and are classified as anti-resorptive
medications. Bone remodeling consists of two distinct stages: bone
resorption and bone formation. During resorption, special cells on
the bone's surface dissolve bone tissue and create small cavities.
During formation, other cells fill the cavities with new bone
tissue. Usually, bone resorption and bone formation are linked so
that they occur in close sequence and remain balanced. An
imbalance in the bone remodeling cycle causes bone loss that
eventually leads to osteoporosis and fracture risk. Anti-resorptive
medications slow or stop the bone-resorbing portion of the
bone-remodeling cycle but do not slow the bone-forming portion of
the cycle. As a result, new formation continues at a greater rate
than bone resorption, and bone density may increase over time.
Teriparatide, a form
of parathyroid hormone, is a newly approved osteoporosis
medication. It is the first osteoporosis medication to increase
the rate of bone formation in the bone remodeling cycle.
Antiresorptive
Medications
For more detailed
information on the actions, administration and possible side
effects for each of the following medications, please consult the
Package Insert, available on-line and at pharmacies.
The information
provided here regarding particular medications is intended solely
for general information and should NOT be relied upon for any
particular diagnosis, treatment, or care. Inclusion in this list
does not imply an endorsement by NOF of any particular medication
or manufacturer.
For more detailed
information on the actions, administration and possible side
effects for each of the following medications, please consult the
Package Insert, available on-line and at pharmacies.
Bisphosphonates
Alendronate Sodium (brand name Fosamax®)
Alendronate is
approved for both the prevention (5 mg per day or 35 mg once a
week) and treatment (10 mg per day or 70 mg once a week) of
postmenopausal osteoporosis. Alendronate reduces bone loss,
increases bone density and reduces the risk of spine, wrist and
hip fractures.
Alendronate also is
approved for treatment of glucocorticoid-induced osteoporosis in
men and women as a result of long-term use of these medications
(i.e., prednisone and cortisone) and for the treatment of
osteoporosis in men.
Risedronate Sodium
(brand name Actonel®)
Risedronate is
approved for the prevention and treatment of postmenopausal
osteoporosis. Taken daily (5 mg dose) or weekly (35 mg dose),
risedronate slows bone loss, increases bone density and reduces
the risk of spine and non-spine fractures.
Risedronate also is
approved for use by men and women to prevent and/or treat
glucocorticoid-induced osteoporosis that results from long-term
use of these medications (i.e., prednisone or cortisone).
Administration and
Side Effects of Bisphosphonates
Side effects for
alendronate and risedronate are uncommon but may include abdominal
or musculoskeletal pain, nausea, heartburn, or irritation of the
esophagus.
Alendronate and
risedronate must be taken on an empty stomach, first thing in the
morning, with eight ounces of water (no other liquid), at least 30
minutes before eating or drinking. Patients must remain upright
during this 30-minute period.
Calcitonin
(Brand name Miacalcin®)
Calcitonin is a
naturally occurring hormone involved in calcium regulation and
bone metabolism. In women who are more than 5 years beyond
menopause, calcitonin slows bone loss, increases spinal bone
density, and, according to anecdotal reports, may relieve the pain
associated with bone fractures. Calcitonin reduces the risk of
spinal fractures but has not been shown to decrease the risk of
non-spine fractures. Studies on fracture reduction are on going.
Because calcitonin is a protein, it cannot be taken orally as it
would be digested before it could work. Calcitonin is available as
an injection (50-100 IU daily) or nasal spray (200 IU daily).
While it does not
affect other organs or systems in the body, injectable calcitonin
may cause an allergic reaction and unpleasant side effects
including flushing of the face and hands, urinary frequency,
nausea and a skin rash. Side effects for nasal calcitonin are not
common but may include nasal irritation, backache, bloody nose,
and headaches.
Estrogen Therapy
(ET) and Hormone Therapy (HT)
(Multiple brand names are available.)
Following analysis of
the Women's Health Initiative study, the FDA made the following
recommendations for all ET and HT preparations:
-
Prescribe lowest
possible doses of ET/HT for the shortest period of time to
manage symptoms of menopause;
-
Discuss alternative
osteoporosis medications for women at risk for or diagnosed with
osteoporosis.
Estrogen therapy
(ET)/Hormone therapy (HT) is approved for the prevention of
osteoporosis. ET has been shown to reduce bone loss, increase bone
density in both the spine and hip, and reduce the risk of hip and
spinal fractures in postmenopausal women. ET is administered most
commonly in the form of a pill or skin patch that delivers a low
dose of approximately 0.3 mg daily or a standard dose of
approximately 0.625 mg daily and is effective even when started
after age 70.
When estrogen is taken
alone, it can increase a woman's risk of developing cancer of the
uterine lining (endometrial cancer). To eliminate this risk,
physicians prescribe the hormone progestin in combination with
estrogen (hormone therapy or HT) for those women who have an
intact uterus. ET/HT relieves menopause symptoms and has been
shown to have a beneficial effect on bone health. Side effects may
include vaginal bleeding, breast tenderness, mood disturbances and
gallbladder disease.
The Woman's Health
Initiative (WHI) study recently confirmed that one type of HT,
Prempro®, reduced the risk of hip and other fractures as well as
colon cancer. The WHI also confirmed that this HT is associated
with a modest increase in the risk of breast cancer, strokes,
heart attacks and venous blood clots.
A study from the
National Cancer Institute (NCI) recently reported that long-term
use of ET may be associated with a small increase the risk of
ovarian cancer. However, a meta-analysis by the Centers for
Disease Control (CDC) did not find an association of either ET or
HT with ovarian cancer.
Raloxifene
(Brand name Evista®)
Raloxifene, 60 mg a
day, is approved for the prevention and treatment of
postmenopausal osteoporosis. It is from a class of drugs called
Selective Estrogen Receptor Modulators (SERMs) that have been
developed to provide the beneficial effects of estrogens without
their potential disadvantages. Raloxifene increases bone mass and
reduces the risk of spine fractures. Data are not yet available to
demonstrate that raloxifene can reduce the risk of hip and other
non-spine fractures.
Raloxifene appears to
decrease the risk of estrogen-dependent breast cancer by 65% over
4 years.
While side effects
were not common, those reported included hot flashes and deep vein
thrombosis, the latter of which is also associated with estrogen
therapy. Raloxifene is taken in pill form, once a day with or
without meals.
Bone Forming
Medications
Parathyroid
Hormone
(Brand name Fortéo®)
Teriparatide, a form
of parathyroid hormone, is approved for the treatment of
osteoporosis in postmenopausal women and men who are at high risk
for a fracture. This medication stimulates new bone formation and
significantly increases bone mineral density. In postmenopausal
women, fracture reduction was noted in the spine, hip, foot, ribs
and wrist. In men, fracture reduction was noted in the spine, but
there were insufficient data to evaluate fracture reduction at
other sites. Teriparatide is self-administered as a daily
injection for up to 24 months.
Side effects include
nausea, leg cramps and dizziness.
To receive the latest
scientific information on osteoporosis and ideas on how to better
cope with this disease, please consider joining NOF as a member.
Individual members of the National Osteoporosis Foundation ($15)
receive our quarterly patient newsletter, Osteoporosis Report, and
a copy of our 70-page comprehensive patient handbook, Boning Up on
Osteoporosis. Several levels of health professional memberships
are available.
Join on-line
today.
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