eMedicine Specialties > Orthopedic Surgery > Systemic Diseases

Osteoporosis: Treatment & Medication

Author: Julie Lin, MD, Assistant Professor, Department of Rehabilitation Medicine, Weill Medical College of Cornell University; Assistant Attending Physiatrist, Physiatry Department, Hospital for Special Surgery
Coauthor(s): Joseph M Lane, MD, Professor of Orthopedic Surgery, Weill Medical College of Cornell University; Chief, Metabolic Bone Disease Service, Hospital for Special Surgery
Contributor Information and Disclosures

Updated: Apr 30, 2009

Treatment

Medical Care

Medical care includes the administration of adequate calcium, vitamin D, and antiosteoporotic medication such as bisphosphonates¹³ and PTH. In addition, potentially treatable underlying causes of osteoporosis such as hyperparathyroidism and hyperthyroidism should be ruled out or treated if detected.

A meta-analysis was performed to evaluate the efficacy of oral supplemental vitamin D in preventing nonvertebral and hip fractures among older individuals (65 y or older). The meta-analysis included 12 double-blind, randomized, controlled trials (RCTs) for nonvertebral fractures (n = 42,279) and 8 RCTs for hip fractures (n = 40,886) and compared oral vitamin D (with or without calcium) with either calcium alone or placebo. The results showed that nonvertebral fracture prevention with vitamin D is dose dependent, and a higher dose reduced fractures by at least 20% for individuals aged 65 years or older.¹⁴

Surgical Care

Therapeutic procedures include vertebroplasty and kyphoplasty. Vertebroplasty and kyphoplasty are 2 new minimally invasive spine procedures used for the management of painful osteoporotic vertebral compression fractures.

• Vertebroplasty was pioneered in France in the 1980s and was initially used for pathologic fractures. It has been gradually redirected toward osteoporotic vertebral compression fractures. Vertebroplasty was first used for this indication in the United States in the early 1990s.
  • Vertebroplasty involves percutaneous injection of methylmethacrylate into a fractured vertebral body, either through a transpedicular or an extrapedicular route. This procedure can be performed under local or general anesthesia with fluoroscopic assistance.
  • Because this is a continuous insertion into an unprepared bed, a venographic injection is often used to ensure that the needle is not directly aligned with an exiting vein. After verification of appropriate placement, 1-4 mL of a specially prepared methylmethacrylate-containing enhanced radiographic visualization material is then inserted directly with a syringe. One or more levels of the spine can be treated in a single setting.
  • Although the bone cement is injected under pressure, this procedure does not have the potential to correct compression deformities.
  • Extravasation of the cement into the epidural space is a potential complication of this method.
• Kyphoplasty has been used since the mid 1990s and is similar to vertebroplasty, which was pioneered in the 1980s, but a few key differences exist.¹⁵
  • Kyphoplasty involves the use of a balloon inserted into the vertebral body with fluoroscopic guidance. An extrapedicular approach is used in the midthoracic region, while a pedicular route may be used in the thoracolumbar or lumbar spine. The balloon is instilled with radiographic contrast at pressures up to 360 pounds per square inch, which compacts the cancellous bone and re-expands the vertebral body, thus reducing the fracture.
  • The balloon tamp creates a cavity into which polymethylmethacrylate is infiltrated. This acrylic bone cement stabilizes the vertebral body and restores vertebral body height.
  • This procedure has been successful both in reducing the amount of kyphosis and in restoring vertebral body height. It also has successfully reduced pain. Recent studies have shown kyphoplasty to be a safe and minimally invasive spine procedure that results in improved function in elderly patients, allowing them to participate in increased activities, with resulting improvements in independence and quality of life.

Consultations

Consultations can include discussions of nonmedical/nonpharmacologic management of osteoporosis.^16,17

Diet

A diet that includes adequate vitamin D and calcium is essential. Recommendations for patients with osteoporosis include daily dosages of 400-800 IU of vitamin D and 1200-1500 mg of calcium. Good sources of calcium include dairy products, sardines, nuts, sunflower seeds, tofu, vegetables such as turnip greens, and fortified food such as orange juice. Good sources of vitamin D include eggs, liver, butter, fatty fish, and fortified food such as milk and orange juice. Patients who ingest inadequate amounts of vitamin D and calcium should receive oral supplementation. The following conditions can interfere with nutrition:

• Alcohol intake: Excessive alcohol intake can interfere with calcium balance by increasing PTH production and by inhibiting the enzymes that convert inactive vitamin D to its active form. In addition, alcohol can result in hormonal deficiencies and can increase the tendency for falls.
• Anorexia nervosa: Poor nutritional states, such as in anorexia nervosa, an eating disorder, have been strongly associated with bone loss. Nutritional and endocrine factors contribute to bone loss. In particular, low estrogen states, which result from low body weight, result in significant bone loss.

Activity

• Tai Chi Chuan: Tai Chi Chuan and specific physical therapy programs have been shown to be particularly effective in improving balance and reducing falls.
  • Wolf et al monitored 200 elderly community dwellers who received Tai Chi and computerized balance training. After a 15-week intervention, the authors documented decreased fear of falling responses. In addition, Tai Chi was shown to reduce the risk of multiple falls by 47.5%.²²
  • Campbell et al monitored 233 elderly community dwellers randomized to an individually tailored physical therapy program in the home compared with usual care and an equal number of social visits. The authors found that after one year, the mean rate of falls was lower in the exercise group than the control group (0.87 versus 1.34, respectively). In addition, after 6 months, subjects in the exercise group had improved balance.
• Balance and strengthening programs: Other types of exercise training programs may also positively impact balance and strength.
  • Carter et al demonstrated that osteoporotic women aged 65-75 years who underwent a 10-week community-based physical activity intervention program improved their static balance, dynamic balance, and knee extension strength, although they did not benefit from a significant reduction in fall risk factors.²³
  • Sinaki and others demonstrated strengthening of the back extensor muscles to reduce kyphosis and decrease the risk of sustaining vertebral compression fractures.^24,25
• Impact exercises: In postmenopausal women, impact exercises can increase bone mineral density in the hip and spine.
  • Chien et al examined the efficacy of a 24-week aerobic exercise program consisting of treadmill walking followed by stepping exercises in osteopenic postmenopausal women aged 48-65 years. Women who exercised had increased bone mineral density in L2-L4 and the femoral neck, as well as improved quadriceps strength, muscular endurance, and peak exercise oxygen consumption (VO₂ max), while values in the control group declined.²⁶
  • Also, Snow et al found increased bone mineral density of the femoral neck, trochanter, and total hip in 18 postmenopausal women (average age 64 y), who wore weighted vests and participated in jumping exercises 3 times per week for 32 weeks of the year over 5 years.²⁷

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications. The Agency for Healthcare Research and Quality (AHRQ) has reviewed the effectiveness, possible harms, adherence, and selection of various medications for preventing fractures among postmenopausal women with osteoporosis.²⁸

Bisphosphonates

These agents inhibit bone resorption via actions on osteoclasts or osteoclast precursors.

Alendronate (Fosamax)

Inhibits bone resorption via actions on osteoclasts or osteoclast precursors.

Risedronate (Actonel)

Inhibits bone resorption via actions on osteoclasts or osteoclast precursors.

Anabolic bone agents

Help to build bone by stimulating osteoblasts.

Teriparatide (Forteo)

Recombinant human PTH (rh PTH [1-34]), which has an identical sequence to the 34 N-terminal amino acids of human PTH.

Calcium and vitamin D supplements

Calcium and vitamin D are essential in order to increase bone density.

Calcium citrate and vitamin D (Citracal-D)

Calcium citrate is better absorbed than calcium carbonate, especially in patients taking antacids or proton pump inhibitors. Vitamin D must be administered with calcium.

Calcitonin analogs

These agents inhibit osteoclastic bone resorption.

Calcitonin (Miacalcin nasal spray)

Inhibits osteoclastic bone resorption and decreases tubular resorption of calcium, phosphate, sodium, magnesium, and potassium.

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