Osteoporosis

Osteoporosis is a condition when the bones become brittle and weak. The bones are so fragile that even bending forward or coughing might cause a spine fracture. Hip, spine and wrist are the common locations of osteoporotic fractures. This disorder is very common among elderly population and post-menopausal women are at highest risk. It is estimated that one out of four females in India above the age of 50 years has osteoporosis.

Bones consist of living cells which constantly degrade a part of the existing bone and replaced it with new bone. This bone-turn over mechanism is very active in young age and gradually decreases with age. Hence peak bone mass is achieved at an age of 25-30 years and after that there is gradual fall in the bone mass. When it is reduced to such an extent that it makes bone fragile and weak, the condition is labelled as osteoporosis. The bone turn over mechanism is regulated by many factors such as hormones, physical activity, dietary habits, genetics and many other factors.

The causes of osteoporosis are:

• Post-menopausal hormonal changes in female (most common cause).

• Senile osteoporosis (Old Age)

• Dietary factors: Low intake of food rich in calcium; dietary disorders; gastrointestinal surgery (Bariatric surgery)

• Lack of adequate exposure to sunlight

• Sedentary lifestyle and lack of exercises

• Medications: Steroids, antiepileptic medications, anti-cancer drugs , immunosuppressant drugs

• Medical conditions: Celiac disease, Inflammatory bowel disease, kidney or liver diseases, Cancer, Lupus, Multiple myeloma, Rheumatoid arthritis

• Hormonal imbalance: Low sex hormones (oestrogen/testosterone), high levels of thyroid, parathyroid or adrenal hormones etc.

• Excessive smoking and alcohol intake

• Genetics: Asian race, short and thin body frame, family history of hip fractures

• There are no symptoms in the early stages of osteoporosis but in advanced stages:

• Loss of height over time, stopped posture

• Back pain – caused by collapsed/fractured vertebrae

• Hip/wrist pain – caused by hip/wrist fractures

Healthy diet, Regular exercises and adequate sunlight exposure are the essential to prevent osteoporosis.

Healthy diet, Regular exercises and adequate sunlight exposure are the essential to prevent osteoporosis. Part of the old bone is degraded and replaced with new bone constantly. This bone turn-over system is very active when you are young i.e. at the age of 20-30 years. Hence the peak bone mass is achieved in this young age. Gradually with age the new bone formation cannot keep pace with the bone destruction. In females after menopause, there is a significant reduction in hormones that regulate bone formation. Hence in patients, who didn’t have a high peak bone mass at young age, there is a high likelihood that they will develop brittle bones later on and are at risk of developing osteoporosis. Simply, if you have a higher bone mass, you will have some reserve to cope with loss at a later age. So the prevention strategies should start at a very young age.

Healthy diet:

Diet should contain following ingredients for good bone health:

Proteins: Pulses, Legumes, Milk; Egg, Meat & Fish (for non-vegeterians)

Calcium: Milk, Banana, , Bajra, Dark Green leafy vegetables, Soya beans and Fish (Sardines, Salmon & Pilchards)

Regular exercise:

Physical activities increases new bone formation and help to build strong bones. Better to start exercises early in life. Activities as exercises, jogging, running, skipping rope and stair climbing are good for the young. However, it is never too late to start. Elderly people can do regular walking to gain most benefit of it. Exercises also help to reduce obesity.

Sunlight:

Exposure of 30 mins of sunlight in the morning 8 am to 11 am helps body to get Vitamin D. It is important for calcium absorption and calcium metabolism. If you are mostly housebound or officebound, if you are living in high altitude then daily vitamin D supplementation of 600-800 IU is recommended.

Plain x-rays can show that weaker bones are lighter and thinner in appearance. But the diagnosis of osteoporosis can be made by estimation of bone mineral density (BMD). It can be measured by Ultrasound (Ankle BMD) or DEXA SCAN (Whole Body BMD or Hip & Spine BMD). DEXA scan is more accurate for measurement of BMD. In some cases additional tests such as Complete Blood Count, Renal function test, Liver function test, Thyroid function test, Sr. Calcium, Sr. Phosphates, Sr. Vitamin D, Sr. Parathyroid hormone, 8am testosterone. Additional testing in form of radiographs, CT-Scan or MRI for diagnosing spine or hip fractures are necessary. Sometimes a diagnosis of hip or spine fracture is an enough evidence to suggest severe osteoporosis that needs to be treated.

Smoking cessation, reducing alcohol intake, increase exercises and a well balanced diet rich in calcium.

The treatment is divided into two components: 1) Medical management of osteoporosis 2) Treating the complications if any

Medical management consists of

Calcium and Vitamin D supplementation

Bone forming agents such as Parathyroid hormone (Given as subcutaneous injection of 20 microgram or 8 units daily for 12-18 months). Recently a monoclonal antibody in form of Romozumab (Eventity) (Monthly injections for a year). Rarely in women with early menopause Raloxifene or other estrogen supplements are suggested.

Anti-bone resportion agents such as Denosumab (Given as single 60 microgram subcutaneous injection every 6 months for 8-10 years). It is to be taken daily for indefinitely and basic requirement is normal dental hygiene and normal calcium and vitamin D levels.

Bisphosphonates such as alendronate, zolendronate etc. These medications are cheap and easily available. They have to be taken on empty stomach and patient has to remain in erect position for 2 hours after taking these drugs to avoid heartburn, gastritis and nausea. To be avoided in patients with GERD.