Revised insights into Osteoporosis

Osteoporosis

Brief Treatment Summary

Osteoporosis is a condition where bones lose density making fractures more likely. Approximately 50% of women and 20% of men over fifty experience a fracture due to osteoporosis. It is most common in postmenopausal women. Previously in this column. I discussed osteoporosis in more detail so in this article I discuss medication only (quick summary), but lifestyle and diet including calcium and vitamin D have an enormous influence on osteoporosis.

Bisphosphonates

Examples include alendronic acid, risedronate sodium, and ibandronic acid. They work by slowing down bone loss.

Oral bisphosphonates are taken once weekly, apart from ibandronic acid which is once a month. They can reduce the frequency of fractures by 50%. Bisphosphonates are safe in patients aged under 65 and over 65. Oral bisphosphonates must be taken on an empty stomach (preferably half hour before breakfast) with a good glass of water, and you should sit or stand upright for half an hour after taking (not lie down) as risk of oesophageal irritation if the tablet gets stuck in the oesophagus. Alendronic acid is also available in liquid form for these with poor swallow.

Common side effects (over 1 in 100):

• Gastrointestinal (e.g.) Indigestion
• Muscle, joint or back pain and stiffness
• Headache
• Tiredness

Denosumab

Denosumab (e.g., Prolia^®) is an alternative option if intolerant to oral bisphosphonates given by six monthly subcutaneous injections. Denosumab is a monoclonal antibody that slows the rate bones break down.

Patients should take adequate calcium and vitamin D while on denosumab as it can lower calcium levels. Side effects are rare with the most common being skin infections.

Parathyroid hormone peptides

Teriparatide is the only osteoporosis drug in this class and brands include Forsteo^®, Terrosa^® and Livogiva^®. Teriparatide works through the fact it is similar to parathyroid hormone which regulates calcium levels and the activity of cells involved in bone formation. It is a subcutaneous injection (usually into side of stomach usually); directions are one 20mcg injection daily. It should be used for a maximum of two years. The most common adverse effects are nausea, limb pain, headache, and dizziness. Teriparatide is held in reserve for women post-menopause with severe osteoporosis with very high fracture risk.

Selective oestrogen receptor modulator

(e.g.) Raloxifene. This is a synthetic hormone that mimics the effect of oestrogen on the bones. The dose is raloxifene 60mg daily. It reduces the risk of fractures by approx. 47%. Raloxifene is associated with increased risk of venous thrombosis and exacerbation of hot flushes. It should be used with caution in women with history of or risk factors for stroke.

Romosozumab

Romosozumab (Evenity^® 105mg Subcutaneous Injection) is a monoclonal antibody treatment for severe osteoporosis and is the first new osteoporosis drug in over 10 years. I will discuss it in more detail next week.

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