A bone disease characterised by loss of bone density and deterioration, osteoporosis is a common condition that affects many patients and their families. Fortunately, diet, calcium, vitamin D, and weight-bearing exercise can help prevent bone disease, and for patients already suffering from osteoporosis, specific pharmacological treatments can reduce the risk of fractures and may prolong survival.  

“When bone resilience is compromised, the patient is exposed to an increased risk of fragility fracture, occurring from low-impact mechanical forces which would normally be tolerated,” Dr Federico Pennestri et al. reported in Fragility Fracture Prevention – Implementing a Fracture Liaison Service in a High Volume Orthopaedic Hospital (published in International Journal of Environmental Research and Public Health). “Fragility fractures cause substantial pain and severe disability, leading to a reduction in life expectancy and quality of life. Hip fractures, in particular, are associated with a significant social and healthcare burden,” the authors explained. “About 24% of patients over 50 years old die within one year following a hip fracture, while nearly 50% suffer long-term disability or require long-term nursing home care (25%).”  

“Osteoporosis, as evidenced by fragility fractures, is common with increasing age in both women and men,” warned Dr Yvonne Selecki and Prof John Eisman in Osteoporosis and fragility fractures: A practical approach (published in Medicine Today). “The presence of a fragility fracture signals an increased risk of further fractures and is associated with both high morbidity and increased mortality. Fragility fractures can affect almost any bone in the skeleton. Although spine, hip and wrist fractures are perhaps the most common, fractures of the proximal humerus, pelvis, distal femur, proximal tibia, and multiple ribs are also associated with an increased risk of further fractures.”  

CAUSES 

Osteoporosis is the result of bone loss, which can happen for several reasons. The two most common reasons for bone loss are when patients don’t get enough calcium from their food or have low levels of oestrogen. According to the US Office of Women’s Health, the most common cause of low oestrogen levels is menopause. After menopause, the ovaries make insufficient amounts of oestrogen with some patients losing up to 25% of bone mass in the first ten years after menopause.  

SYMPTOMS 

This condition is often referred to as a ‘silent’ disease because bone loss typically occurs without symptoms. The NIH Osteoporosis and Related Bone Diseases National Resource Centre explained that patients may not be aware that they have osteoporosis until their bones become so weak that a sudden strain, bump, or fall causes a bone to fracture or a vertebra to collapse. Collapsed vertebrae may initially be felt or seen in the form of severe back pain, loss of height, or spinal malformations such as kyphosis. Cleveland Clinic advised patients to look out for the following: 

• Loss of height (getting shorter by a couple of centimetres or more) 
• Change in posture (stooping or bending forward) 
• Shortness of breath (smaller lung capacity due to compressed disks) 
• Bone fractures 
• Pain in the lower back 

PREVENTION & TREATMENT 

The aim of prevention and treatment is to prevent the occurrence of future fractures, explained Professor Cyrus Cooper et al. in What is osteoporosis? (published in Postgrad Medical Journal). “Lifestyle changes that might help to diminish the frequency of osteoporosis and fractures should be encouraged. These include improving nutrition (adequate calcium and vitamin D intake), maximising physical activity, reducing smoking, and avoiding heavy alcohol consumption. Moreover, attempts should be made to reduce the risk of falling for elderly people.”  

PREVENTING FALLS 

A wide range of factors may influence a patient’s risk of falling. Environmental hazards, for example, uneven or slippery surfaces, loose rugs and poor lighting may be thought of as the most obvious causes of falls, but individual factors play a significant role, the Australian Institute of Health and Welfare (AIHW) explained. “Older patients are more prone to falls because of the general deterioration in bodily function associated with ageing. This may include muscular weakness, poor circulation (which may cause temporary dizziness when getting up out of a chair or bed), and changes in cognitive function. Patients with certain chronic illnesses, congenital conditions, or disabilities that affect muscular strength, balance, consciousness, or mobility are also at higher risk of falling. Other factors that increase risk include problems with eyesight, use of sleeping pills, and side effects of some medications.  

According to the AIHW: “The focus of most fall prevention activities is to target modifiable risk factors. These include changing or adapting behaviours to limit the risk posed by individual factors and removing or limiting exposure to environmental hazards e.g. installing grab rails and non-slip floor strips. Regular physical activity is important as this can help to strengthen the muscles and improve balance and mobility.”  

PHARMACOLOGIC TREATMENT 

“Bisphosphonates are universally regarded as first-line treatment for osteoporosis in postmenopausal and elderly women, in men, and in a number of secondary osteoporosis, including glucocorticoid-induced osteoporosis,” Professor Stephen Hough et al. stated in The safety of osteoporosis medication (published in South African Medical Journal).  

Pharmacists Lindsay Baun and Tricia Russell listed alendronate, ibandronate, risedronate, and zoledronic acid as bisphosphonates used for the prevention and treatment of osteoporosis in Overview of the Management of Osteoporosis in Women (published in US Pharmacist). “Normal bone turnover involves a balance of bone formation (osteoblasts creating bone) and bone resorption (osteoclasts destroying bone) however, an imbalance can lead to bone loss and potential fractures. Bisphosphonates are antiresorptive agents and they inhibit bone resorption by inhibiting osteoclast activity,” the pharmacists explained.  

Other possible medications include selective oestrogen receptor modulators (SERMs), testosterone therapy, parathyroid hormone, and menopausal hormone therapy. A potent inhibitor of bone resorption, denosumab is not yet registered in SA for the treatment of osteoporosis but is available on Section 21 application to the Medicines Control Council.  

The National Osteoporosis Foundation South Africa stressed that no ideal drug can be recommended for the prevention and treatment of osteoporosis. “The choice of a pharmacological agent will, therefore, largely depend on the disease profile, patient profile, available resources, and personal preferences.”  

“The impact of a pharmacist’s knowledge of osteoporosis management can help ensure the proper use of medications, appropriate vitamin supplementation, and patient counselling on recommended lifestyle changes,” Baun and Russell concluded.