HRT reduces the breakdown of bone while being taken and has been shown to conserve bone mass and reduce the risk of fracture. It is particularly appropriate for bone protection in women who have an early or premature menopause, when it is generally recommended to continue HRT until the average age of the menopause. For older women who may have, or are thought to be at risk of osteoporosis, HRT would be helpful if they also suffered from menopausal symptoms since none of the other treatments for osteoporosis control menopausal symptoms. If HRT is stopped, bone loss then resumes so if HRT has been taken for bone protection, either bone density measurement or other treatment should then be considered.
See also: Osteoporosis information on the Benefits of HRT page.
Bisphosphonates reduce bone resorption and reduce fracture risk. They are not easily absorbed from the bowel and can cause gut irritation and indigestion but are generally well tolerated. To aid absorption and reduce the side effects, they should be taken first thing in the morning, when the stomach is empty, and with plain tap water. Bisphosphonates currently available are alendronate, etidronate, risedronate and ibandronate. Both alendronate and risedronate can be taken as a once weekly preparation which is more convenient than daily administration and ibandronate is available as a once monthly preparation.
Selective Estrogen Receptor Modulators (SERMs) act by selectively binding to estrogen receptors in some cells. In so doing, they produce some estrogenic effects, such as the beneficial bone effect but also produce opposite effects such as antioestrogen effect on breast tissue. The only SERM currently available for osteoporosis is raloxifene which is a tablet taken once daily. It can be used by postmenopausal women and has been shown to reduce risk of spinal fracture in women with osteoporosis. It does not stimulate either the lining of the uterus or the breast and in fact reduces the risk of breast cancer. Like H.R.T. it confers a small increased risk of venous blood clot but unlike H.R.T. it does not control menopausal symptoms such as flushes and may occasionally cause them. Raloxifene has been shown to reduce cholesterol level but the significance of this on risk of heart disease is unclear.
Parathyroid hormone, or teriparatide, is the first of a new class of drugs which acts by stimulating the formation of new bone, rather than reducing breakdown of bone which is the way HRT and bisphosphonates work. Bone formation is stimulated by teriparatide stimulating the bone-forming cells, osteoblasts. In so doing, fracture risk, particularly spinal fracture, is significantly reduced. Teriparatide can be used by postmenopausal women with severe osteoporosis and is administered by a daily self-injection for up to 18 months. Currently, it is only prescribed by specialists.
Calcium and Vitamin D should be considered along with any treatment for osteoporosis. Supplements are recommended in frail, elderly who have other risk factors for osteoporosis as a preventive treatment (since high doses of calcium and vitamin D have been shown to reduce bone loss in elderly postmenopausal women), in addition to treatment for osteoporosis if aged over 70 years and in addition to treatment for osteoporosis if aged under 70 years and diet is insufficient. When calcium and vitamin D supplements are taken in addition to a weekly bisphosphonate therapy, the supplements should not be taken on the day of the bisphosphonate.
Calcium calculator. You can find a daily dietary calcium calculator here
Strontium Ranelate is the first osteoporosis treatment which has a dual action in not only preventing bone loss but also increasing bone formation. It has been shown to significantly reduce the risk of vertebral and hip fracture and is well tolerated. It is taken as a sachet of powder which is dissolved in a glass of water, once daily at bedtime preferably at least 2 hours after eating. Any calcium supplements also prescribed, should be taken at least 2 hours before.
Denosumab (Prolia) November 2011
Denosumab ( Prolia) is one of the newest drugs used in the management of osteoporosis. It is a human monoclomal antibody which works by blocking the action of a substance called Rank Ligand which is involved in bone formation. Rank Ligand stimulates the production and activity of the cells which break down bone (osteoclasts) and Denosumab works against this substance therefore improving the density and strength of bones and reducing the risk of fractures.
It has been shown to be effective in reducing the risk of vertebral (spine) and non-vertbral fractures and is licensed for use in post-menopausal women with osteoporosis. It is given as a 6 monthly sub-cutaneous injection (a small injection just under the skin) and can be given either in hospital clinics or in GP surgeries.
References [Refs. 13-17]