eMedicine Specialties > Physical Medicine and Rehabilitation > Medical Diseases
Osteoporosis (Primary): Treatment & Medication
Updated: Sep 25, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Rehabilitation Program
Physical Therapy
The goals of physical therapy focus on improving a patient's strength, flexibility, posture, and balance in order to prevent falls and maximize his/her physical function.13,14 Postural retraining is key in this population, and strengthening of the back extensors should be emphasized.15 The bone density of the spine is directly correlated with the strength of the back extensors; therefore, maintaining the muscular strength of the back extensors is essential.
Regular weight-bearing exercises are essential for the maintenance of bone mass.5 Various activities, such as walking, hiking, stair climbing, jogging, and resistive/weight training, are helpful in maintaining or increasing bone mass. (Swimming does not involve weight bearing; therefore, it is not helpful in promoting bone formation.) The physical therapist must address balance training, because fall prevention is important in eliminating the complication of fracture. Improving one's balance can significantly lower the risk of falling. Balance training incorporates the strengthening of various parts of the body (eg, trunk, legs), proprioception, and vestibular input.
Proper therapy for osteoporosis includes 3-5 sessions per week of weight-bearing exercises, such as walking or jogging, with each session lasting 45-60 minutes. The patient should be instructed in a home exercise program that incorporates the necessary elements for improving his/her posture and overall physical fitness.
Occupational Therapy
Training in the performance of activities of daily living (ADLs) and in the proper use of adaptive equipment are essential to the prevention of future falls.14
Medical Issues/Complications
Patients with osteoporosis are at a high risk for recurrent fractures of the hips, vertebrae, ribs, and wrists.2 Patients with multiple fractures have significant pain, which leads to functional decline and a poor quality of life (QOL).16 They are also at risk for all the complications of immobility, including deep vein thrombosis (DVT) and pressure ulcers. Patients with osteoporosis develop spinal deformities and a dowager's hump, and they may lose 1-2 inches of height by their seventh decade of life. These patients can lose their self-esteem and are at an increased risk for depression.
Consultations
For a patient with osteoporosis in the diagnostic and therapeutic phases, the most important consultation is with an endocrinologist. Endocrinologists are helpful in the diagnosis of osteoporosis; they can aid in the obtainment of the proper laboratory tests and imaging studies needed to rule out causes of secondary osteoporosis. In patients with uncontrolled pain that does not respond to conventional therapies, an invasive pain specialist may be consulted for proper interventional procedures.
Other Treatment
- Vertebroplasty is performed by interventional radiologists, invasive physiatrists, and spine specialists who inject methyl methacrylate into the fractured vertebrae. This procedure is performed on an outpatient basis, and initial studies report good results.17
Related Medscape topic:
CME/CE Comparative Effectiveness of Treatments To Prevent Fractures in Men and Women With Low Bone Density or Osteoporosis: AHRQ Executive Summary
Medication
Medications used in the treatment of osteoporosis are classified into 2 primary categories. The first includes medications that help to stimulate bone formation, such as vitamin D and bisphosphonates. The second includes medications that reduce bone resorption, such as estrogen, bisphosphonates, calcitonin, calcium, and vitamin D.18
Related Medscape topics:
CME/CE Guidelines Address Pharmacologic Treatments to Prevent Osteoporotic Fractures
CME Women Compliant With Bisphosphonate Therapy May Be Able to Take Drug Holiday
Hormone replacement
Hormones are used to increase serum estrogen levels, which in turn decrease the rate of bone resorption.19
Conjugated estrogens (Premarin)
In the past, estrogen replacement was considered a primary therapy for prevention of postmenopausal osteoporosis. Estrogen had the additional advantages of controlling menopausal symptoms and, presumptively, of preventing or delaying cardiovascular disease. However, data from the Women's Health Initiative (WHI) revealed that estrogen-progestin therapy does not reduce the risk of coronary heart disease; it was instead found to increase the risk of breast cancer, stroke, and venous thromboembolic events.
As a result of these findings, other antiresorptive agents are now the drugs of choice and are prescribed more frequently for the prevention and treatment of osteoporosis in postmenopausal women.
Adult
0.3 mg/d PO on day 21 of 28-d cycle; add progestin on days 10-14
Pediatric
Not established
May reduce hypoprothrombinemic effect of anticoagulants; co-administration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes may reduce estrogen levels; pharmacologic and toxicologic effects of corticosteroids may occur as a result of estrogen-induced inactivation of hepatic P450 enzyme; loss of seizure control noted when administered concurrently with hydantoins
Documented hypersensitivity; pregnancy; thromboembolic disorders; breast and endometrial cancer; undiagnosed vaginal bleeding
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in breastfeeding and impaired liver function; caution warranted in CAD (possible increase in coronary events in patients on hormonal therapy for osteoporosis)
Estradiol (Estrace, Vivelle, Climara, Estraderm, Esclim, Alora)
Restores estrogen levels to concentrations that induce negative feedback at gonadotropic regulatory centers; this, in turn, reduces the release of gonadotropins from the pituitary. Estradiol increases the synthesis of DNA, RNA, and many proteins in target tissues; it also inhibits osteoclastic activity and delays bone loss. In addition, evidence suggests a reduced incidence of fractures.
Adult
Tab: 1-2 mg/d PO in cyclic regimen of q3wk on and 1 wk off
Transdermal: Initiate with patch that releases at least 0.05 mg/d of estradiol; adjust dosage if necessary to control concurrent menopausal symptoms
Pediatric
Not recommended
May reduce hypoprothrombinemic effects of anticoagulants; estrogen levels may be reduced with co-administration of barbiturates, rifampin, and other agents that induce hepatic, microsomal enzymes; corticosteroid levels may increase with concurrent ethinyl estradiol; use with hydantoins may cause spotting or breakthrough bleeding; increased fluid retention caused by estrogen intake may reduce seizure control
Documented hypersensitivity; thrombophlebitis, undiagnosed vaginal bleeding
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in hepatic impairment, migraine, seizure disorders, cerebrovascular disorders, breast cancer, or thromboembolic disease, and CAD
Ethinyl estradiol and norethindrone (Femhrt)
Used to treat moderate-to-severe vasomotor symptoms and to prevent osteoporosis associated with menopause.
Adult
1 tab PO qd
Pediatric
Not established
Phenobarbital, phenytoin, paramethadione, carbamazepine, troglitazone, rifampicin, and griseofulvin induce enzymes that decrease levels of contraceptive steroids; oral anticoagulants may increase thromboembolic potential
Documented hypersensitivity, endometrial and hepatic cancer; thromboembolic disorders; undiagnosed vaginal bleeding; smokers >35 y; cardiovascular disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hepatic impairment, migraine, seizure disorders, cerebrovascular disorders, breast cancer, or thromboembolic disease, CAD
Calcitonin analogs
These inhibit osteoclastic bone resorption. Although no research data support the idea that the use of intranasal calcitonin reduces the incidence of fractures, studies do show an increase in bone density with the use of calcitonin.
Calcitonin (Miacalcin, Osteocalcin injection)
Lowers elevated serum calcium levels in patients with multiple myeloma, carcinoma, or primary hyperparathyroidism. A higher response can be expected when serum calcium levels are high. Calcitonin is now FDA approved for the treatment of osteoporosis. It is administered intranasally. The onset of action occurs approximately 2 h after injection, with the drug's activity lasting 6-8 h. Calcitonin may lower calcium levels by about 9% for 5-8 d if it is given q12h. The IM route is preferred at multiple injection sites with dose >2 mL.
Adult
1 spray/d into alternate nostrils
Pediatric
Not applicable
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hypocalcemia; examine urine sediment during prolonged therapy
Bisphosphonates
These agents progressively reduce bone loss and increase bone mass.
Alendronate sodium (Fosamax)
Widely used first-line therapy for the treatment of osteoporosis.
Adult
Postmenopausal females:
Prophylaxis: 5 mg PO once qd or 35 mg PO once qwk
Treatment: 10 mg PO once qd or 70 mg PO once qwk
Males:
10 mg PO once qd or 70 mg once qwk
Pediatric
Not approved
None reported
Documented hypersensitivity; hypocalcemia, abnormalities of the esophagus, inability to stand upright for 30 min
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in upper GI disease; must be taken at least 30 min before first food, beverage, or medication of the day and should be taken with large amounts of water; caution in renal impairment
Monitor therapy if taking aminoglycosides, aspirin, or phosphate supplements
Consider therapy modification if taking antacids, calcium salts, iron salts, magnesium salts, or NSAIDs
Risedronate (Actonel)
Potent aminobisphosphonate. Inhibits bone resorption via actions on osteoclasts or osteoclast precursors. In a comparative study, normalization of alkaline phosphatase levels was achieved in 77% of the patients treated with risedronate, compared with 10% of the patients treated with 400-mg etidronate. After 12 and 18 mo, 60% and 53% of patients treated with risedronate still had alkaline phosphatase levels in the reference range. Used in patients with GI side effects, with alendronate as first-line therapy.
Adult
5 mg PO qd
Pediatric
Not established
None reported
Documented hypersensitivity, hypocalcemia, or renal impairment
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor hypercalcemia-related parameters (eg, serum levels of calcium, phosphate, magnesium, potassium); maintain adequate intake of calcium and vitamin D to prevent severe hypocalcemia; caution in active upper GI problems; do not administer with alendronate for osteoporosis in postmenopausal women; adverse effects include diarrhea, headache, and arthralgia
Monitor or modify therapy if taking antacids, calcium salts, or multivitamins with minerals
Caution advised if taking aspirin/caffeine/CNS depressant combinations or aspirin/opiate combinations
Ibandronate (BONIVA)
Inhibits osteoclast-mediated bone resorption. In postmenopausal women, ibandronate reduces bone turnover rate, leading to a net gain in bone mass.
Adult
2.5 mg PO qd; administer with water at least 1 h prior to first food or beverages (other than water) of the day
Pediatric
Not established
Multivalent cations (eg, calcium, aluminum, magnesium, iron) decrease absorption, administer ibandronate at least 1 h prior to vitamin and mineral supplements; NSAIDs may aggravate GI irritation
Documented hypersensitivity; uncorrected hypocalcemia; inability to stand or sit upright for at least 60 min following drug administration
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause upper GI disorders (eg, dysphagia, esophagitis, ulceration), minimize GI risk by standing or sitting upright 1 h following dose; calcium and vitamin D supplementation required; not recommended with severe renal impairment (ie, CrCl <30 mL/min)
Selective estrogen receptor modulators
Like estrogen, these are antiresorptive agents. However, because of their selective receptor-modulating property, they provide the beneficial effects of estrogens without the adverse effects.
Raloxifene (Evista)
Selective estrogen-receptor modulator that decreases bone loss. The FDA approved raloxifene for the treatment of osteoporosis. It is used to prevent bone loss and reduce the incidence of fractures.
Adult
60 mg PO qd; supplement with 400 U/d vitamin D
Pediatric
Not established
None reported
Documented hypersensitivity; active thromboembolic disorder; pregnancy or planned pregnancy, and DVT or history of DVT, breastfeeding
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in history of venous thromboembolism, pulmonary embolism, cardiovascular disease, renal or hepatic insufficiency, concurrent use with estrogens, and history of cervical/uterine carcinoma
Nutritional supplements
These supplements are used to increase calcium levels.18
Calcium carbonate (Oystercal, Caltrate)
Calcium supplementation in patients at young ages has been proven to lower the incidence of fractures.
Adult
1000-1500 mg PO qd in divided doses
Pediatric
Not applicable
May decrease effects of tetracyclines, atenolol, salicylates, iron salts, and fluoroquinolones; IV administration antagonizes effects of verapamil; large intakes of dietary fiber may decrease calcium absorption and levels
Renal calculi, hypercalcemia, hypophosphatemia, renal or cardiac disease, digitalis toxicity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hypercalcemia or hypercalcuria may occur with therapeutic amounts
Parathyroid hormone
Parathyroid hormone promotes new bone formation, leading to increased bone mineral density. Teriparatide is a biologic product containing a portion of human parathyroid hormone, which primarily regulates calcium and phosphate metabolism in bones. Teriparatide is approved for men and women at high risk of fracture because of primary or hypogonadal osteoporosis or postmenopausal osteoporosis, respectively.
Teriparatide (Forteo)
Recombinant human parathyroid hormone rhPTH (1-34), which has a sequence that is identical to 34 N-terminal amino acids (biologically active region) of 84 – amino acid human parathyroid hormone (PTH). Teriparatide acts as endogenous PTH, regulating calcium and phosphate metabolism in the bones and kidneys. The drug works primarily to stimulate new bone by increasing the number and activity of osteoblasts (bone-forming cells). Additional physiologic actions include the regulation of bone metabolism, renal tubular re-absorption of calcium and phosphate, and intestinal calcium absorption. When administered with calcium and vitamin D, teriparatide increases bone mineral density and decreases the risk of fractures in patients with osteoporosis.
Adult
20 μ g SC qd
Pediatric
Not established
None reported
Documented hypersensitivity; increased risk of osteosarcoma (Paget disease of bone or unexplained elevations of alkaline phosphatase levels, open epiphyses, or prior skeletal irradiation therapy); children or growing adults; patients with bone metastases or history of skeletal malignancies, and persons with metabolic bone diseases other than osteoporosis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor for hypercalcemia; may cause orthostatic hypotension (particularly after first several doses), dizziness, or leg cramps
More on Osteoporosis (Primary) |
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| Differential Diagnoses & Workup: Osteoporosis (Primary) |
 Treatment & Medication: Osteoporosis (Primary) |
| Follow-up: Osteoporosis (Primary) |
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Further Reading
Keywords
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