eMedicine Specialties > Pediatrics: General Medicine > Nutrition
Osteoporosis: Treatment & Medication
Updated: Aug 21, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Management is primarily medical, depending on the underlying condition. If the underlying condition is optimally managed and osteopenia persists, then management depends on bone dynamics.
- When bone resorption exceeds bone formation, try an antiresorptive agent (eg, bisphosphonate). The most current generation of oral bisphosphonates includes alendronate and risedronate. The primary parenterally administered bisphosphonate is pamidronate. Safe and effective pediatric doses have not been established; however, current clinical trials are investigating the use of alendronate in children with osteogenesis imperfecta, and preliminary results indicate that the drug is safe.
- Pamidronate is currently under study in children with burn injuries. The dose of pamidronate is 1.5 mg/kg weekly for 2 weeks with a maximum dose at any one time of 90 mg, which is the adult upper limit of normal. In a 2-year follow-up study by Przkora et al evaluating changes in bone density and histology following the initial treatment with pamidronate, data supported a long-term effect on trabecular bone density and bone mineral content of the lumbar spine.10 Total body bone mineral content eventually showed recovery in patients with burn injuries on placebo therapy; therefore, the effect on cortical bone did not appear long lasting. Data obtained from clinical studies in adults are very promising. However, caution in the overuse of these drugs is warranted because the drugs remain in bone for a long time and an osteopetrosislike condition has been reported.
- Osteopenia secondary to low bone formation is more difficult to manage because of the absence of a safe and effective anabolic agent. PTH, which is potentially very promising when given intermittently to osteoporotic adults, is not approved for use in children because of the detection of osteogenic sarcoma in rats that were given very high test doses.11
- Recombinant human growth hormone is a useful anabolic agent for children with growth hormone deficiency; its benefits for others with osteopenia have not been extensively studied. It does improve bone mineral content in burned children if given for a year, but the need for repeated injections and the cost are limiting.12
- Anabolic steroids (eg, testosterone, oxandrolone) may be helpful in forming new bone; however, consider the risks of premature closure of the epiphyses, short stature, and hirsutism. Also consider the potentially increased risk for tumor development. However, in a 2004 study, oxandrolone was given for 1 year to a group of children following burn injury.13,14,15,16 No epiphyseal closure was demonstrated, and only 2 cases of clitoral hypertrophy were observed (both were reversed after cessation of the drug).
Surgical Care
- Unless a resectable tumor can be identified as the cause of osteopenia or osteoporosis, surgery is unlikely to play a role in treatment. In most cases, the cause is systemic and results in widespread disease.
Consultations
- Consult an endocrinologist to assist in the management of any patient with bone loss.
Diet
- Calcium and vitamin D are the most important dietary nutrients to help prevent adult osteoporosis.
- The NIH Consensus Conference on Osteoporosis recommended a calcium intake of 800 mg/d until age 10 years, 1200 mg/d during adolescence, and 1000 mg/d after adolescence.1
- Calcium intake should be increased for women who are pregnant, for women who are lactating (1200 mg/d), and for individuals older than 65 years (1500 mg/d).
- An intake of 400-800 international U/d is also recommended.
- A diet rich in dairy products is recommended to help provide the calcium and vitamin D required.
Activity
- Activity plays a role in the prevention of osteoporotic fractures.
- Several recent studies in the United States and in Europe have established that regular weight-bearing exercise, such as jumping, in school-aged children improves bone mass.17 However, once the exercises are stopped, the gains are lost.
Medication
Therapy includes antiresorptive agents such as bisphosphonates (eg, alendronate, risedronate, pamidronate). Hormone replacement therapy (eg, estrogen, estrogen analogs) does not have a role in pediatric therapy.
Bisphosphonate bone-resorption inhibitors
These agents prevent bone loss from diminishing bone mass on an ongoing basis. They are available in parenteral and oral dosage forms for acute and chronic treatment, respectively.
Pamidronate (Aredia)
Inhibits normal and abnormal bone resorption. Appears to inhibit bone resorption without inhibiting bone formation and mineralization. Administered IV, usually 2 doses with a 1-wk interval. Approved for use in hypercalcemia of malignancy and Paget disease. Has also been used in children with osteopenic bone disease.
Adult
60-90 mg/dose IV administered over 8-24 h; dilute in dextrose and water solutions
Dose based on serum calcium measurements
Pediatric
Not established; experimental studies use 1.5 mg/kg/dose IV; not to exceed 90 mg/dose (published results are promising)
Calcium or vitamin D may antagonize the antihypercalcemic effects of the drug
Documented hypersensitivity; hypocalcemia, cardiac failure, and 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
Carcinogenicity and mutagenicity are not observed; decreased fertility and increased mortality observed in rats when administered PO; no known effects on breastfeeding; monitor hypercalcemia-related parameters, such as serum levels of calcium, phosphate, magnesium, and potassium once treatment begins; adequate intake of calcium and vitamin D is necessary to prevent severe hypocalcemia; caution when administering bisphosphonates in patients with active upper GI problems
Alendronate (Fosamax)
PO bisphosphonate approved as an antiresorptive agent to treat Paget disease and postmenopausal osteoporosis.
Adult
Paget disease: 40 mg PO qam 30 min before first food or beverage; continue treatment for 6 mo
Postmenopausal osteoporosis treatment: 10 mg PO qam 30 min before first food or beverage; alternatively, 70 mg PO qwk
Administer dose with 6-8 oz of plain water
Pediatric
Not established
Dietary supplements, food, and medicines may interfere with absorption; medications (eg, antacids) interfere with absorption; histamine receptor antagonists (eg, ranitidine, cimetidine) can interfere with absorption; nonsteroidal anti-inflammatory agents can exacerbate inflammatory effects
Documented hypersensitivity; limited data in small open-labeled studies have been published
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
GI conditions (eg, duodenitis, gastritis, gastroesophageal reflux disease, ulcers) may worsen; renal functional impairment may reduce excretion of the drug; tumors increased in rats with larger than recommended doses for 2 y; mutagenicity has not been observed; no effect on fertility; effects on pregnancy and reproduction not known; hypocalcemia can occur in pregnancy following exposure; unknown whether alendronate enters human breast milk
More on Osteoporosis |
| Overview: Osteoporosis |
| Differential Diagnoses & Workup: Osteoporosis |
 Treatment & Medication: Osteoporosis |
| Follow-up: Osteoporosis |
| References |
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References
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Further Reading
Keywords
osteoporosis, low bone mass, pediatric osteoporosis, juvenile osteoporosis, fracture, compromised bone strength, osteopenia, chronic liver disease, burn injuries, Paget disease, hyperparathyroidism, hypophosphatemic metabolic bone disease, idiopathic juvenile osteoporosis, bony deformities, cardiopulmonary compromise, reduced bone density, kyphosis, kyphoscoliosis, short stature, long bone deformities, lordosis, scoliosis, pigeon breast deformity, hip fractures, inflammatory bowel disease, rheumatoid arthritis, trauma
