Osteoporosis Q&A

• Dr Peter Prouse is a consultant heumatologist based at The Hampshire Clinic
• Dr Mike Irani  is a consultant rheumatologist based at The Runnymede Hospital, The Princess Margaret Hospital and The Syon Clinic

What is osteoporosis?

Dr Peter Prouse: Bone is a living tissue that is constantly renewing itself. This is best when we are younger but as we get older bone is not able to renew itself as well. Osteoporosis means that our bones have become abnormally weak and may break in an accident such as minor fall.

Dr Mike Irani: Osteoporosis is a medical condition in which the bones become brittle and fragile.

What causes osteoporosis?

Dr Peter Prouse: Because bone is an active tissue that is constantly renewing itself, it means that old bone is broken down and removed and new bone is made to replace it. This process is normally well-balanced but as we get older, old bone is broken down more quickly than new bone is made therefore our bones can become weaker. This is a normal part of ageing but for some people this process can become abnormal for different reasons and so bones become abnormally weak. This is called osteoporosis.

Dr Mike Irani: Typically, osteoporosis occurs as a result of hormonal changes, or deficiency of calcium or vitamin D. Other factors that increase the risk of developing osteoporosis include inflammatory conditions such as rheumatoid arthritis, Crohn's disease and chronic obstructive pulmonary disorder (COPD).

Conditions that affect the hormone producing glands such as an overactive thyroid or parathyroid gland may also cause osteoporosis. A family history of osteoporosis, particularly history of a hip fracture in a parent, increases the probability of developing osteoporosis as does long term use of certain medications such as oral steroids.

Disorders of malabsorption in the intestines may also cause this as does heavy drinking and smoking. Anorexia and renal disease may also cause osteoporosis.

Other drugs such as anti-seizure medications, chemotherapy, proton pump inhibitors for treatment of hyperacidity states or medication for treatment of depression such as selective serotonin re-uptake inhibitors (SSRI's). Not enough exercise is also deleterious to bone health.

Who is affected by osteoporosis?

Dr Peter Prouse: There are many causes for osteoporosis and while any one can develop osteoporosis, women are approximately four times more likely to do so than men.

• Family history: Osteoporosis does run in families and this is likely to be due to inherited, genetic factors that cause osteoporosis
• Hormones: Women who have an early menopause before the age 45 or have had a hysterectomy where one or both ovaries are removed are at great risk through oestrogen deficiency
• Poor diet: People whose diet is very poor and who are significantly under-weight are also at risk of developing osteoporosis. This is especially so for people who may have suffered from medical conditions such as anorexia nervosa
• Heavy smoking: Smoking lowers oestrogen levels in women and testosterone levels in men and is known to weaken bones
• Heavy drinking: A high alcohol intake also reduced the body's ability to make bone normally and can result in increased weakness of bone
• Other medical conditions: Conditions such as having an over-active thyroid for a long period of time; conditions that can cause severe inflammations such as rheumatoid arthritis and inflammatory bowel disease; conditions which lead to poor absorption of food from the bowel, such as coeliac disease, Type I diabetes, chronic liver disease, hyperthyroidism and conditions causing prolonged immobility can also lead to the development of osteoporosis

Certain medications such as prolonged use of steroids can also weaken bone. Drugs used to suppress oestrogen and testosterone can also lead to weakening of the bones. There are a number of other drugs, on which your GP will have more information, that can also lead to weakening of bones and development of osteoporosis.

Dr Mike Irani: Patients with any of the above risk factors but it becomes more common with age affecting about 15% of white people in their 50s and 70% of those over 80 years of age. It is more common in woman than men and 2-8% of males are affected whereas 9-38% of females are affected.

About 22 million woman and 5.5 million men in the European Union had osteoporosis in 2010. In the United States in 2010, approximately 8 million women and 1.2 million men had osteoporosis. White and Asian people are at greater risk.

What are the symptoms of osteoporosis?

Dr Peter Prouse: Usually there are no symptoms of osteoporosis and it is only discovered when a person breaks a bone in a relatively minor fall or accident. Most commonly this is a broken or fractured wrist or fracture in the spine, but the most severe fracture due to osteoporosis is that of a hip fracture.

Dr Mike Irani: The process itself has no symptoms until a fracture occurs. These occur in situations where healthy people would not normally break a bone and are therefore called fragility fractures. Typical fragility fractures occur in the vertebral column, rib and wrist (Colles' fracture).

How is osteoporosis diagnosed?

Dr Peter Prouse: There are no signs therefore it may only be diagnosed by either having a bone density scan called a DEXA scan, which can detect abnormally fragile bones or it may be diagnosed if there is a fall resulting in severe fracture such as a hip or spinal fracture.

If your GP suspects that you may be at risk of osteoporosis he/she may suggest that you have a DEXA scan to measure your bone density and then to assess your risk of fractures occurring. Depending on the result, it may be recommended that you have treatment.

Dr Mike Irani: Osteoporosis is diagnosed by taking a thorough history of the risk factors and conditions which may lead to falls.

There are non-modifiable but potentially modifiable risk factors which have to be identified and addressed. Tests such as vitamin D levels, and if a fracture is suspected, a blood test called bone alkaline phosphatase would help. Raised parathyroid hormone level may occur with vitamin D deficiency and this increases bone resorption leading to bone loss.

A definitive test is Dual Energy X-ray Absorptiometry scan (DEXA) which helps to classify bone mineral density to normal, osteopaenia or osteoporosis depending on the density of the bone.

What treatments are available for osteoporosis?

Dr Peter Prouse: If your osteoporosis is diagnosed because you have had a fracture, the initial treatment will involve pain relief and you may need to see an orthopaedic surgeon for the fracture to be treated.

If you have suffered a fracture due to osteoporosis or if you have been diagnosed as having osteoporosis from a bone density scan you will also need treatment to reduce the risk of another fracture occurring.

There are five main types of drugs commonly used to treat osteoporosis and these include bisphosphonates, Strontium ranelate, Teriparatide, Raloxifene and Denosumab. These treatments may take the form of tablets, injections or infusions into a vein. These treatments are generally also given with Calcium and Vitamin D supplements.

In general we would recommend that most people are treated initially with a bisphosphonate but this may vary depending on the severity of the osteoporosis.

Dr Mike Irani: Treatment of patients varies according to their category of bone mineral density (BMD). We will tailor your treatment plan based on your individual results.

What can you do to manage the condition?

Dr Peter Prouse: Diet is very important in preventing osteoporosis through having an adequate and appropriate diet, particularly with an adequate intake of Calcium and maintaining normal Vitamin D levels. In addition regular exercise is important particularly weight bearing exercise, which is, any activity that involves putting your body weight through your bones, such as walking and running.

As smoking affects hormone levels which could cause osteoporosis, we would strongly recommend that you stop smoking. Also drinking a lot of alcohol, that is more than 3 units a day can also lead to weakening of bone we would therefore recommend keeping with the maximum amount of alcohol recommended by the Government, that is 2 – 3 units a day for women and 3 – 4 units a day for men.

Dr Mike Irani: Under the age of 75 years, follow-up scans should be performed two years after the commencement of active treatment or those with significant osteopenia but in people over 75 years of age the scans are unreliable due to presence of degenerative changes in bones, particularly the spine. Treatments are available for osteoporosis but this depends on the bone mineral density (BMD) found on the DEXA scan. I might advise:

Patients with normal bone mineral density

Lifestyle advice of exercise, discontinuing smoking and moderate alcohol consumption is needed to ensure that an adequate calcium and vitamin D intake. A repeat DEXA scan in two years is recommended.

Patients with osteopaenia in which the BMD is moderately lost according to DEXA scan

Calcium and vitamin D, lifestyle advice and a repeat scan in three years is recommended. However, secondary causes have to be excluded with liver function test, ESR (inflammatory marker) and thyroid function tests.

Patients with significant osteoporosis

A repeat scan in two years and treatment with anti-bone resorptive agents such as bisphosphonates is recommended if the BMD continues to decrease.

Patients with frank osteoporosis

The calcium and vitamin D, lifestyle advice and repeat scan in two to three years is recommended as well as exclusion of secondary causes of osteoporosis. Anti-resorptive drugs should be recommended for that stage of BMD loss as well.

Other treatments such as denosumab, which is given by injection every six months, can help to further help to ameliorate bone loss but in order to increase BMD, parathyroid hormone analogue, Teriparatide, given daily may help.

Of course, appropriate management of a fracture if it is present is essential as is correction of posture with appropriate physiotherapy.