Treatment and Monitoring

Treating the patient diagnosed with osteoporosis takes a multipronged approach that includes an assessment of additional risk factors that the patient can control or modify. Unless the patient has a history of renal stones or hypercalcemia, one of the first steps is to encourage increased calcium and vitamin D intake through diet or supplementation. Habits that are known to correlate with increased bone loss, such as smoking or excessive alcohol consumption, are discouraged. Exercise, particularly weight-bearing exercise, improves bone density and is encouraged.

One of the most important aspects of treatment is fracture prevention. By some estimates, osteoporosis leads to more than 1.5 million fractures annually, including 300,000 fractures of the hip, 250,000 of the wrist, and about 700,000 fractures of the vertebra. For many patients, a fracture is more than an inconvenience; it is a serious, potentially life-threatening event. The risk of mortality following a fracture increases with age, particularly for men. Surviving the event does not mean a return to normalcy. About a quarter of patients who were independent and ambulatory before sustaining a hip fracture require long-term care afterward. Patients who have severe osteoporosis experience fractures with minimal trauma; but for most, the fracture occurs as the result of an accidental fall. Therefore, preventing falls is a primary goal for many patients. A home visit by an occupational therapist may identify the need to improve lighting, secure rugs, or for the use of supports or handrails.

Currently available drug therapy focuses on suppression of bone resorption. Because of the relationship between estrogen and bone resorption, hormone replacement therapy was for many years the first therapeutic option. But this changed in 2002 when data from the Women's Health Initiative suggested increased risks of breast cancer, coronary artery disease, stroke, and pulmonary embolism with a combined estrogen-progesterone formula. Although these risks were not found with other estrogen therapies, there was concern that for many women the risks outweighed the bone benefits. For these women, and when hormone therapy is contraindicated, there are other options. The bisphospho-nates are probably the most frequently prescribed drugs for the treatment of osteoporosis and osteopenia. Alendronate, the most widely used of the class, acts by inhibiting farnesyl diphosphate synthase within the osteoclast, causing the cell to undergo premature apopto-sis. Second- and third-generation bisphosphonates are thought to also induce osteoclast death but by inhibiting mitochondrial respiration. Selective estrogen receptor modulators (SERMs) have been developed specifically to target the estrogen receptors of bone yet have minimal activity to the estrogen receptors in reproductive tissue. Calcitonin may be administered parenterally via intramuscular or subcutaneous injection, or intranasally, and acts by inhibiting osteoclasts.

One of the most promising therapeutic interventions is the use of parathyroid hormone fragments and analogs. Teriparatide is a biosynthetic PTH fragment containing the biologically active region of the molecule. A small dose is given once daily as a subcutaneous injection to mimic the conditions under which PTH stimulates bone formation. At this writing, teriparatide is the only drug available to increase bone formation.

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