What should be done for osteopenia? Part 2, Treatment

Last week’s Health Tip discussed osteopenia, the stage of bone density between normal and the disease state of abnormally low bone mass known as osteoporosis. While treatment with medications is usually warranted in someone with osteoporosis, this is not always the case with osteopenia. This has to do with the unpredictable nature of the progression of osteopenia and the potential for serious side effects from the medications. Fortunately, almost everyone with lower than normal bone mass can benefit from lifestyle measures to retard the progression of bone loss. In today’s Health Tip we’ll look at those lifestyle measures and discuss medications used in treating osteopenia when progression to osteoporosis is likely to develop.

Lifestyle measures for preventing bone loss:

1. Receiving an adequate amount of calcium. The National Academy of Sciences recommends that women older than age 50 consume at least 1,200 mg per/day of calcium. In many cases, adequate amounts of calcium can be obtained from the diet. The major food contributors of this nutrient to people in the United States are milk, yogurt, and cheese. Calcium supplements may be required when an adequate dietary intake cannot be achieved.
2. Getting enough Vitamin D. The National Osteoporosis Foundation recommends a daily intake of 800 to 1,000 international units (IU) of vitamin D for adults age 50 and older. Important dietary sources of vitamin D include vitamin D-fortified milk, breakfast cereals, egg yolks, and fish. The body is also capable of producing Vitamin D through exposure to sunshine.
3. Performing weight bearing exercise. In weight-bearing exercise, bones are strengthened as the feet and legs bear the body’s weight. Examples include walking, jogging, tennis, dancing, and stair climbing. Studies have also shown improvement in bone density from weight training. Resistance exercises that focus on the back and hip (hip extension, hip abduction/ adduction, squats, etc.) appear to be particularly beneficial.
4. Avoiding cigarette smoking. Studies have shown a direct relationship between cigarette smoking and decreased bone density. This may be due to the effect of toxins in cigarette smoke on certain hormones in the body responsible for bone health. For example, women who smoke often produce less estrogen and tend to reach menopause earlier. .Another explanation is that many smokers have other osteoporosis-related risk factors, such as physical inactivity or excessive alcohol intake. Quitting smoking has been shown to reduce this progression of bone loss.
5. Moderating alcohol intake. Alcohol consumption can inhibit the body’s absorption of calcium. Excessive intake has been linked to an increase in fractures of the hip, spine and wrist. Mental impairment due to alcohol intake can also lead to accidents with subsequent broken bones. It is recommended that women have no more than the equivalent of one drink (e.g. 12 oz. beer or 6 oz. wine) per day.

When medications may be needed. No drugs have been developed specifically for treating osteopenia. The drugs that are sometimes used are the ones used in the treatment of osteoporosis. Treating osteopenia with medications (along with lifestyle management) is sometimes referred to as “osteoporosis prevention”. The FRAX algorithm, discussed in last week’s Health Tip, is an important tool in determining if treatment of osteopenia should be considered.

The most important criteria in this consideration are: 1) a high risk of progressing from osteopenia to osteoporosis based on the FRAX algorithm and 2) an elevated risk of osteoporosis-related fracture. The most common class of medications used in the prevention and treatment of osteoporosis are the bisphosphonates. Alendronate (Fosamax), risedronate (Actonel), and zoledronic acid (Reclast) are bisphosphonates that have received Federal Drug Administration (FDA) approval for this indication. They work by slowing down the natural process that breaks down and repairs bone. Most bisphosphonates are taken by mouth, once a week or once a month, but Reclast is given by injection, usually once a year. Drugs that are sometimes used in treating osteopenia but do not have FDA approval for that indication include calcitonin and teriparatide. Calcitonin (Fortical and Miacalcin) is a hormone produced normally by the thyroid gland that helps to slow the rate at which the bone breakdown occurs. Teriparatide (Forteo) is a preparation of a hormone produced by the parathyroid gland that is it is usually reserved for patients with severe hip or spine osteoporosis. Hormone replacement therapy (HRT), using estrogen with or without progesterone, is sometimes used, but is not generally recommended to prevent osteoporosis in women after menopause. This is because of concern regarding development of breast or uterine cancer, stroke, and blood clots. HRT, however, may be reasonable in younger women whose ovaries do not make estrogen normally. Raloxifene (Evista) is a medication used for osteoporosis prevention that is primarily intended for postmenopausal women. It works in a similar manner as the hormone estrogen to help maintain bone density.