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Prevention and treatment of osteoporosis
Written by Dr Dan Rutherford, GP
Raloxifene
Raloxifene is a type of medicine called a selective oestrogen receptor modulator (SERM). It can be used to both prevent and treat osteoporosis in postmenopausal women.
Raloxifene stimulates bone growth just as oestrogens do, but has an anti-oestrogen effect on the uterus (womb) and on breast tissue.
The latter effect is seen as desirable because it may reduce the tendency for long-term oestrogen-based HRT to increase the risk of developing breast cancer.
However, raloxifene may increase the risk of developing blood clots in the veins and can't be used by a woman with a past history of deep vein thrombosis (DVT). The risk of thrombosis with raloxifene is similar to the risk with HRT.
It is preferably used only in women who are five years past their menopause. It would be an option for a woman between 55 and 70 years.
It has been shown to reduce the occurrence of spinal fractures, but not hip fractures.
What other treatments are used in osteoporosis?
These treatments are quite specialised and not commonly used.
Calcitriol
Teriparatide
Hip protectors
Hip protectors come as a sort of girdle with padding at the sides. However, it can be difficult for people to remember to put one on, or even wish to wear one.
Sticking to treatment
Because osteoporosis treatment and prevention needs to be taken for years, poor compliance can be a major issue in treating the condition.
Elderly people are the most at risk of falls. They are also the most likely to become muddled about pills and suffer more severe side effects from them.
Those in sheltered or supervised environments can be given help to remember their medication.
Where this is not possible, and someone is forgetful, using a weekly or monthly dose form of bisphosphonate, supervised by a carer or nurse, might be more reliable than a daily dose.
Osteoporosis and men
However, men do develop osteoporosis. Men show an increase in osteoporotic hip fractures after the age of about 70, similar to that shown by women 5 to 10 years younger.
Men may not experience the recognisable hormone shift represented by the menopause in women, but they do experience a steady drop in output of testosterone (the 'male hormone') by the testes as they get older.
Like oestrogen in women, testosterone has a protective effect on bone.
Other, more subtle, symptoms are also thought to be due to a lack of testosterone. These include:
This is a controversial area and experts remain uncertain about the phenomenon of the 'male menopause'. The situation is not helped by the fact that no easy test for this condition exists.
Low blood levels of testosterone are insufficient to diagnose menopause in men because there is widespread disagreement over:
The timing of the blood sample also matters because testosterone is released into the bloodstream in pulses, and levels vary throughout the day.
Diagnosing osteoporosis in men
Perhaps more important is being aware of the possibility of osteoporosis in a man:
Treating osteoporosis in men
Testosterone treatment is controversial, and uncertain in value in the majority of men who do not have very low testosterone levels.
Osteoporosis management should be along the lines of encouraging exercise, diet supplements and taking the lifestyle measures mentioned above. Bisphosphonate drugs should be used when more active treatment is required.
Calcitriol is a vitamin D-like compound that can be used in osteoporosis following the menopause or in situations where osteoporosis has been caused by steroid drugs. Studies of the effect of calcitriol on bone loss and fractures have produced conflicting results, however it has been shown to reduce the risk of spinal fractures but not hip fractures.
Teriparatide is used for the treatment of osteoporosis in postmenopausal women and in men with an increased risk of fracture. It works by increasing the formation of bone and is given by daily injection under the skin, using an injection pen similar to those used by people with diabetes for injecting insulin. It has been shown to reduce the incidence of spinal but not hip fractures.
Hip protectors are shock-absorbing pads that can be worn to cushion the impact over the hip bone, should a person fall down. They spread the load across a wider area of the upper leg and are useful as an extra measure in an elderly person prone to falls.
Compliance is the business of sticking to the prescribed treatment, whether it be tablets or protective clothing.
Women tend to get more coverage in osteoporosis than men because they:
These difficulties need to be tolerated, but a doctor can make allowances for the difficulty in being sure of the diagnosis.
Very often the penny simply does not fall, yet men can benefit from all of the treatments that apply to women, other than HRT and raloxifene.
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