• Osteoporosis

    The word osteoporosis means spongy (porous) bone. Bone is made up of minerals, mainly calcium salts, bound together by strong collagen fibres.Our bones have a thick, hard outer shell (called cortical or compact bone) which is easily seen on x-rays. Inside this, there’s a softer mesh of bone (trabecular bone) which has a honeycomb-like structure.

    Bone is a living, active tissue that’s constantly renewing itself. Old bone tissue is broken down by cells called osteoclasts and is replaced by new bone material produced by cells called osteoblasts.

    • In childhood and adolescence, new bone is formed very quickly. This allows our bones to grow bigger and stronger (denser). Bone density reaches its peak by our mid to late-20s
    • After this, new bone is produced at about the same rate as older bone is broken down. This means that the adult skeleton is completely renewed over a period of 7–10 years
    • Eventually, from the age of about 40, bone starts to be broken down more quickly than it’s replaced, so our bones slowly begin to lose their density

    Everybody will have some degree of bone loss as they get older, but the term osteoporosis is used only when the bones become quite fragile. When bone is affected by osteoporosis, the holes in the honeycomb structure become larger and the overall density is lower – which is why the bone is more likely to break (fracture).

  • Symptoms of osteoporosis

    Quite often the first sign of osteoporosis is breaking a bone in a minor fall or accident. Fractures are most likely to happen at the hip, spine or wrist. Spinal problems occur if the bones in your spine (vertebrae) become weak and lose height (described as a vertebral crushfracture). This usually happens around the middle/lower back. If several vertebrae are affected, your spine will start to curve and you may become shorter. This can sometimes cause back pain and some people may have difficulty breathing simply because there’s less space under their ribs.

    People who have spinal fractures will also have a greater risk of hip and wrist fractures. Spinal fractures can even occur without any injury.

  • Who gets osteoporosis?

    Anyone can get osteoporosis but women are about four times more likely than men to develop it. There are two main reasons for this:

    • The process of bone loss speeds up for several years after the menopause, when the ovaries stop producing the female sex hormone oestrogen
    • Men generally reach a higher level of bone density before the process of bone loss begins Bone loss still occurs in men but it has to be more severe before osteoporosis occurs

    A number of other risk factors can increase your chances of developing osteoporosis.

    Risk Factors

    Steroids (especially if taken by mouth)

    Steroids (corticosteroids) are drugs which are used for a range of inflammatory conditions, for example rheumatoid arthritis. They can affect bone production by reducing the amount of calcium absorbed from the gut and increasing calcium loss through the kidneys. If you’re likely to need steroids, such as prednisolone, for more than three months, your doctor will probably recommend calcium and vitamin D tablets and possibly other treatments to help protect against osteoporosis.

    A lack of oestrogen in the body (oestrogen deficiency)

    If you have an early menopause (before the age of 45) or a hysterectomy where one or both ovaries are removed, this increases your risk of developing osteoporosis. This is because they cause your body’s oestrogen production to reduce dramatically, so the process of bone loss will speed up. Removal of the ovaries only (ovariectomy or oophorectomy) is quite rare but is also linked with an increased risk of osteoporosis.

    Lack of Weight-Bearing Exercise

    Exercise encourages bone development, and lack of exercise means you’ll be more at risk of losing calcium from your bones and so more likely to be diagnosed with osteoporosis. The only exception to this is that women who exercise so much that their periods stop will have a higher risk of developing osteoporosis because of a lack of oestrogen. Muscle and bone health have been shown to be linked so keeping up your muscle strength with exercise is important. This will also reduce the risk of falling

    Poor Diet

    – If your diet doesn’t include enough calcium or vitamin D, you’re at greater risk of osteoporosis (see section ‘Diet and nutrition’)

    Heavy Smoking

    Tobacco is directly toxic to bones, and smoking reduces the cells’ ability to make bone. It also lowers the oestrogen level in women and may cause early menopause. In men, smoking lowers testosterone activity, which can also weaken the bones

    Heavy Alcohol Consumption

    Drinking a lot of alcohol reduces your body’s ability to make bone. It also increases your risk of breaking a bone as a result of a fall

    Family History

    Osteoporosis does run in families, probably because there are inherited factors that affect bone development. If a close relative has suffered a fracture linked to osteoporosis then your own risk of a fracture is likely to be greater than normal. It’s not yet known if there’s a particular genetic defect that causes osteoporosis, although we do know that people with a very rare genetic disorder calledosteogenesis imperfecta are more likely to suffer fractures

    Other factors that affect your risk include:

    • Ethnicity
    • Low Body Weight
    • Previous Fractures
    • Medical Conditions such as Coeliac Disease (or sometimes treatments) which affect Absorption of Food
  • Diagnosis

    There are no clear physical signs of osteoporosis, and it may not cause any problems straight away. If your doctor thinks you may have osteoporosis, they may suggest you have a DEXA (dual-energy x- ray absorptiometry) scan to measure the density of your bones. The scan is readily available and involves lying on a couch, fully clothed, for about 15 minutes while your bones are x-rayed. The dose of x-rays is very small – about the same as spending a day out in the sun. The possible results are:

    Normal

    Your risk of a low-impact fracture is likely to be low.

    Osteopenia

    Your bone is weaker but your risk of a low-impact fracture is relatively small. You may or may not need treatment depending on what other risk factors you have. You should discuss with your doctor how you can reduce your risk (see ‘Self-help and daily living’).

    Losteoporosis

    You have a greater risk of low-impact fractures and you may need treatment – discuss this with your doctor.

  • Who should have a scan?

    There’s no good evidence that screening everybody for osteoporosis would be helpful. However, you should speak with your doctor about having a scan if:

    • You’ve already had a low-impact fracture
    • You need steroid treatments for three months or more
    • You had an early menopause (before the age of 45)
    • Either of your parents has had a hip fracture
    • You have another disease which can affect the bones – for example, coeliac disease, inflammatory bowel disease (crohn’s disease or ulcerative colitis), rheumatoid arthritis, diabetes and hyperthyroidism (overactive thyroid)
    • Your body mass index (bmi) is less than 19
  • Treatments

    If you’re diagnosed with osteoporosis following a low-impact fracture, the fracture will need to be treated first. The next step is to begin treatment to reduce the risk of further fractures.

    Treatment of fractures

    Most fractures are first treated in A&E, and you’ll usually have a follow-up appointment at a fracture clinic to see how things are going.

    Unless you have a vertebral compression fracture, the fractured area will usually be put in a cast for several weeks so you can’t move it to allow the fracture to heal. In some cases the fracture may need manipulation by a specialist before this is done. This may be carried out in A&E, but you may need to be admitted to hospital. You’re also likely to be admitted if the fracture needs surgical fixing.

    It’s likely that you’ll also need pain relief medications, for example:

    • Painkillers (analgesics) such as paracetamol, codeine and occasionally morphine
    • Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen

    Prevention of fractures

    Self-help measures such as diet and weight-bearing exercise can help to reduce the risk of fractures, but a number of specific treatments are also available.

    You’re likely to have a bone density scan before you start treatment, although this may not be needed, for example, if you’re 75 or over. Once you’ve started treatment your bone density may be monitored in one of the following ways:

    • Bone density scans, usually of the spine and/or hips, every 2–5 years depending on your individual circumstances
    • Blood and urine tests to show how well your bone is renewing itself – these aren’t so widely available as bone density scans

    If you’re taking hormone replacement therapy (HRT), you’ll also have regular blood pressure checks and breast scans (mammograms). Your bone density should start to improve after 6–12 months, although you may need longer-term treatment to further reduce your fracture risk.

    Because longer-term treatment can sometimes have side- effects your doctor may suggest a break from your treatment after 3–5 years. The benefits of osteoporosis treatment last a long time so these won’t be lost if your doctor does suggest a ‘treatment holiday’.

  • Calcium and vitamin D

    It’s recommended that you try to get enough calcium from your diet without using supplements. However, combined calcium and vitamin D supplements are often given alongside other osteoporosis treatments, especially if you struggle to get enough from other sources. Vitamin D is needed for the body to absorb and process calcium.

    If you’re a woman over 70 and take a calcium-only supplement, don’t have more than the recommended daily intake, as there have been concerns that this may affect heart health. This seems to apply only to supplements and not calcium from food.

  • Bisphosphonates

    Bisphosphonates are a group of drugs that work by slowing bone loss; in many people, an increase in bone density can be measured over five years of treatment. They reduce the risk of hip and spine fractures. Bisphosphonates can be taken by mouth (orally) or through a drip (intravenous infusion) or injection.

    Oral treatment

    Oral bisphosphonates tend to be poorly absorbed by the body and can cause irritation of the gullet (heartburn), so it’s very important that you carefully follow the instructions for taking your medication:

    • Take it on an empty stomach with a glass or two of plain tap water. Other drinks may prevent the drug being properly absorbed by the body
    • You shouldn’t eat anything or drink anything other than tap water, or take any other medication or supplements for at least 30 minutes afterwards (45 minutes for Bonviva). This is to help ensure the medication is effectively absorbed
    • You’ll need to stay upright (sitting, standing or walking) for up to an hour afterwards to prevent the medication flowing back from your stomach and causing heartburn. You shouldn’t lie down before you’ve eaten

    Intravenous treatment

    If you can’t tolerate bisphosphonates by mouth, it’s possible to have them through a drip into a vein (intravenous infusion) or as an injection:

    • Pamidronate is given as an infusion – this takes about an hour and can be repeated every three months
    • Zoledronate is also given as an infusion – this takes 20 minutes or more but is only given once a year
    • Ibandronate can be given by mouth (monthly) or by intravenous injection (every three months). The injection takes seconds