Health Tips

While osteoporosis does affect both men and women, it has disproportionately affected post-menopausal women. Osteoporosis remains underdiagnosed and undertreated in Malaysia, with very little data documented on its prevalence. 77% of Malaysian women living with post-menopausal osteoporosis (PMO) do not know they’re suffering from it. This is because first and foremost, osteoporosis is a silent disease with no symptoms and often goes unnoticed until patients experience a fracture. There is also a lack of awareness about the condition, and people generally do not recognise osteoporosis as a health priority.

What is osteoporosis?

The word ‘osteoporosis’ literally means ‘porous bone’. It is a condition where a person gradually loses bone material, leading to decrease in bone density. As a result, his or her bones become gradually more fragile and are more likely to break. 

Image credit: BruceBlaus, CC BY-SA 4.0 , via Wikimedia Commons

While osteoporosis remains as a silent disease, some people with osteoporosis may experience the following telltale signs and symptoms:

• Pain due to fractures following a minor fall. Typical osteoporotic fractures occur at the wrist, spine and hips causing pain, deformity and in the case of a hip fracture, an inability to walk.

• A gradual loss of height due to spinal fractures. If you have lost 6 cm (2.5 inches) in height since you were a young adult, you may have had a spine fracture.

• A stooped posture (hunched back) due to multiple spine fractures. This may cause a person to find that his/her clothes do not fit properly.

• Persistent lower or upper back pain in the bones and/or muscles

• Brittle fingernails

Consult a doctor if you suspect that you may experience osteoporosis.

Elderly woman with osteoporosis showing a curved back from compression fractures of her spines. Image credit: James Heilman, MD, CC BY-SA 3.0 , via Wikimedia Commons

Women are at a higher risk for osteoporosis after menopause due to lower levels of estrogen, a female hormone that helps to maintain bone mass. The good news is, preventive treatments are available that can help to maintain or increase your bone density. If you have already been diagnosed with osteoporosis, medical treatments are also available that can slow further loss of bone or increase bone density.

Who needs medical treatment for osteoporosis?

Photo by Nino Liverani on Unsplash

To understand if you really require treatments for osteoporosis, your doctor may conduct a bone mineral density (BMD) measurement on your lumbar spine, total hip or femoral neck. Such measurement yields T-score, which allows the doctor to evaluate how serious your bone loss is. 

According to the World Health Organization (WHO), the bone loss can be classified as the following:

• Normal = -1 or higher

• Osteopenia = Between -1 and -2.5. A person with osteopenia does not yet have osteoporosis but is at risk of developing it if not treated.

• Osteoporosis = -2.5 or lower

Based on your T-score, health condition and fracture risk, your doctor can talk to you about the risks and benefits and help you make a decision about treatment.

Medications for osteoporosis

Bisphosphonates

Most people with osteoporosis are being treated with a class of medications known as the bisphosphonates. Bisphosphonates work by slowing down the breakdown and removal of your bone (a process known as resorption). Common options include:

1. Alendronate/ alendronic acid (Brand name: Fosamax®/ Fosamax Plus® - with added vitamin D) 

   • Alendronate is only available as oral medication, meaning it can only be ingested.

   • Dosage for osteoporosis treatment: 10 mg daily or 70 mg once a week

   • Dosage for osteoporosis prevention: 5 mg once daily or 35 mg once a week

2. Ibandronate/ ibandronic acid (Brand name: Bonviva®)

   • Ibandronate is available both as oral medication and injection.

   • Dosage for osteoporosis treatment: 150mg (1 tablet) once a month.

   • Note: Unlike other bisphosphonates, ibandronate is primarily used to reduce spine fracture rate but not hip fracture rate.

3. Risedronate/ risedronic acid (Brand name: Actonel®)

   • Risedronate is only available as oral medication

   • Dosage for osteoporosis treatment: 5 mg daily. Alternatively, for postmenopausal osteoporosis, 35 mg once weekly, or 75 mg on 2 consecutive days of each month, or 150 mg once monthly.

4. Zoledronate/zoledronic acid

   • Zoledronate is only available as an injection only.

   • It is given once every year. Zoledronate is given into a vein by IV over 15 minutes and is usually well tolerated.

Take your oral bisphosphonate correctly

If you’re taking any oral bisphosphonate, you should know that this is not your ordinary medication. Oral bisphosphonate has a really poor oral absorption, and can cause nasty side effects to your upper gastrointestinal tract and jaws if the medication is not taken properly. To ensure a proper absorption as well as minimising the side effects, keep in mind of the following:

• Each oral tablet should be taken first thing in the morning with at least 6 oz (180 ml) of plain water (not coffee, juice, mineral water, or milk) at least 30 minutes (60 minutes for oral ibandronate) before consuming any food, supplements, or medications. 

• An exception is delayed-release risedronate, which is administered immediately after breakfast with at least 4 oz (120 ml) of plain water.

• Remain upright (sitting or standing) for at least 30 minutes after alendronate and risedronate and 1 hour after ibandronate administration to prevent irritation and ulceration to your stomach and food tract.

• Take care of your oral hygiene to prevent a very rare side effect of oral bisphosphonate known as osteonecrosis, i.e. tissue deaths of the jaw. Brush teeth at least 2 times daily, even better if you can brush/gargle after you eat. Floss at least 3 times weekly. Osteonecrosis occurs more commonly in patients with cancer, receiving higher-dose intravenous bisphosphonate therapy and other risk factors including glucocorticoid therapy and diabetes.

• Tell your doctor if you require any dental work and tell your dentist that you are taking this medicine (or have taken it in the past).

If you forgot to take your oral bisphosphate for the week (e.g. alendronate or risedronate), it can be taken the next day. If more than 1 day has elapsed, continue your usual schedule of 1 dose once a week on your chosen day, and next dose should be 1 week later of that chosen day. Do not double the dose to make up for the missed dose.

If you forgot to take your oral bisphosphonate for the month (e.g. ibandronate), it can be taken up to 7 days before the next scheduled dose.

Hormone replacement therapy

In general, hormone replacement therapy is prescribed to post-menopausal women to reduce menopause symptoms such as hot flashes, not so much in preventing osteoporosis. This therapy does come with a tiny benefit of protection against osteoporosis, although it does not work as well as bisphosphonates.

If you’re interested to learn more about menopause, read our article here; for more information on hormone replacement therapy, read here.

“Estrogen-like” medications

Certain medications, known as selective estrogen receptor modulators (SERMs), produce some estrogen-like effects in the bone, thereby reducing bone loss. An added benefit of SERMs is they decrease the risk of breast cancer in women who are at high risk. Examples are raloxifene and tamoxifen. Nonetheless, they’re less effective than bisphosphonates and hormone replacement therapy at preventing bone loss. 

Equally important preventative strategies

Osteoporosis prevention remains an integral part to prevent further bone loss in both men and women:

1. Ensure at least 1000 mg of calcium intake per day, whether that's from diet or supplements. But the intake should not be more than 2000mg to minimize side effects such as higher risk of cardiovascular disease and stomach discomfort.

2. Ensure at least 600 IU (15 micrograms) of vitamin D intake per day. 

3. Exercising for at least 30 minutes three times per week

4. Stop smoking - Scientists found that smoking one pack per day throughout your adult life can contribute to 5 to 10 percent reduction in bone density. 

5. Avoiding falls, which include the following strategies:

   1. Removing loose rugs and electrical cords or any other loose items in the home that could lead to tripping

   2. Providing adequate lighting in all areas inside and around the home, including staircase and entrance ways.

   3. Reviewing your medication regimens to replace medications that may increase the risk of falls with those that are less likely to do so.

   4. Visiting an ophthalmologist or optometrist regularly to check your vision

6. Speak to your healthcare professional about other medications that you’re taking, as some of them may increase risk of bone loss. Examples are prednisolone and certain medications for epilepsy. If necessary, your healthcare professional may review your treatment and recommend a reduced dose or switch to other options. 

A word from Doc2Us

If you have any questions related to osteoporosis, you can consult our professional doctors and healthcare professionals on Doc2Us. Doc2Us is a mobile application that allows you to talk to a doctor or any healthcare professionals via text chat at any time and from anywhere. For better communication, you can even send our online doctor images or voice messages related to your medical inquiry.

Download Doc2Us app on Apple App Store, Google Play Store and Huawei App Gallery; or use our web chat at https://web.doc2us.com/

Note: Doc2Us is not for medical emergencies. In the event of urgent medical conditions, please call 999.

Disclaimer: As a service to our users and general public, Doc2Us provides health education contents. Please note the date of last review or update on all articles. No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.

References

1. UpToDate - Patient education: Osteoporosis prevention and treatment (Beyond the Basics)

2. CPG - Management of Osteoporosis (revised 2015)

Cover image credit: Photo by Nino Liverani on Unsplash

Written by

Ms Joyce Toh