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Brittle bones leading to fractures, especially in the spine and hips. When bones lose density, low-velocity trauma such as a ground-level fall or even rolling over in bed can cause bones to break.
Bones are constantly being regenerated. In fact, every 10 years your entire skeleton turns over and is regenerated with brand new bone. Bodies use osteoclasts to break down bone, and osteoblasts to build up bone. After 40 years of age, both men and women begin to lose bone density; this is a physiologic or normal process. Additionally, loss of sex steroid (either estrogen or testosterone) can cause further bone loss. When women go through menopause, a relative decrease in estrogen levels may cause hot flashes, vaginal dryness, and promote greater bone loss.
Besides hormone loss and aging, other factors that reduce bone density include alcohol use, chronic corticosteroids, high thyroid hormone levels, gastrointestinal malabsorption, cigarette use, sedentary lifestyle, Vitamin D deficiency, and certain cancers.
To diagnose Osteoporosis, the current preferred test is a DEXA scan (dual-energy x-ray absorptiometry). This x-ray test measures density and compares it to a healthy young adult. The test scoring is given in two forms: a T score and FRAX score. The T score measures density loss in units of standard deviation. A T score of -1.0 to -2.4 is borderline abnormal and labeled Osteopenia. A T score of -2.5 or worse is diagnostic of Osteoporosis. The other way to earn the diagnosis is via an abnormal FRAX result. FRAX reflects the risk of fracture over the next 10 years. If the risk for any fracture is >20% or the risk for hip fracture specifically is >3%, then Osteoporosis is diagnosed.
DEXA scans are considered very safe and low risk for radiation. In fact, one way we measure radiation risk is with “natural background radiation” levels, or what you receive from Radon-222 and other elements in the soil, water, and air all around us. The DEXA scan has less risk than 2 days of background risk. This amount is less than a chest X-ray (3 days), flying on an airplane (7 days), or a CT scan of the head (60 days).
Lifestyle therapy measures include weight-bearing regular exercise, reduction of alcohol intake, adequate Vitamin D3 and calcium intake, and tobacco cessation.
Prescription medications start with the bisphosphonates. Oral Alendronate (Fosamax) pills once weekly (generic & cheap) or IV Zoledronic acid (Reclast) infusions yearly will reduce bone reabsorption by osteoclasts (anti-resorptive effect). The improved bone density reduces the risk for spine and hip fractures, whether a person has never had a fracture (primary prevention) or is trying to prevent a repeat fracture event (secondary prevention). Combining bisphosphonates with other drug classes concurrently is not recommended, as no significant additive gains are seen, and the combination can potentially cause paradoxical skeletal fragility.
Bisphosphonate courses are recommended for 3-5 years, then assessment is made to determine if a “drug holiday” is advisable. If a person is very high risk, such as ongoing corticosteroid use, multiple fractures, or T scores worse than -2.5, then drug holiday may not be offered. In contrast, if the T score has improved and markers of bone turnover are suppressed (serum C telopeptide), then the bisphosphonate can be held for 2-3 years followed by reevaluation. When the T score begins to worsen again and/or the bone turnover markers pick up steam, then the medicine can be restarted.
Why take a drug holiday? A low risk of atypical femur (thigh bone) fracture can occur past 8 years of continuous use, so taking 2-3 years off can reverse the risk profile back to baseline.
Alternatives to bisphosphonates include injectable options. Teriparatide (Forteo) and Abaloparatide (Tymlos) are derived from human parathyroid hormone (PTH) and are effective bone-building options, however they require daily home injection, are very expensive, and can be taken for only 2 years. Denosumab (Prolia) is a monoclonal antibody that can be injected every 6 months in clinic. While more convenient than daily injection, it is also quite spendy.
