Osteoporosis - risk factors, pharmaceutical and non-pharmaceutical treatment

Tański W, Kosiorowska J, Szymańska–Chabowska A. Osteoporosis - risk factors, pharmaceutical and non-pharmaceutical treatment. DOAJ (DOAJ: Directory of Open Access Journals). 2021;25(9):3557-3566. doi:10.26355/eurrev_202105_25838

Link to Original Article: https://www.researchgate.net/publication/351703729_Osteoporosis_-_risk_factors_pharmaceutical_and_non-pharmaceutical_treatment

Key Points

1. Osteoporosis is a widespread metabolic disease affecting over 200 million patients worldwide, particularly elderly women, and significantly reduces patient's quality of life.

2. The World Health Organization (WHO) criteria define osteoporosis as low bone mineral density, with a T-score ≤ −2.5, and it affects bone strength, leading to an increased risk of fractures.

3. Potentially modifiable risk factors for osteoporosis include vitamin D deficiency, smoking, alcohol consumption, low calcium intake, sedentary lifestyle, and insufficient sun exposure.

4. Pharmaceutical treatments for osteoporosis include bisphosphonates, calcium and vitamin D3 supplements, denosumab, teriparatide, raloxifene, and strontium ranelate, but patient compliance with medication is low.

5. Exercise, kinesitherapy, treatment at health resorts, physical therapy, and a balanced diet play a significant role in the prevention and management of osteoporosis.

6. Nutritional deficiencies, including calcium, vitamin D, and protein, significantly impact bone health, and a balanced diet along with supplementation when necessary is essential in preventing bone loss.

Introduction

The research paper discusses osteoporosis as a metabolic disease of the skeletal system, posing a significant public health concern, especially among the elderly, leading to disability and often being diagnosed after an initial fracture. The most common location of fractures are vertebra, hips, and wrists. Osteoporosis typically appears silently and asymptomatically, and often diagnosed when the first fracture occurs. It primarily affects women over 60 (60%) and men over 70 (20%), with approximately 30% of women and 20% of men aged 50 and above experiencing osteoporosis-related fractures. The prevalence of the disease is expected to rise substantially by 2040. Osteoporosis is defined by the World Health Organization (WHO) criteria as low bone mineral density, but it can also occur in patients with normal bone density who experience fractures. Bone strength is determined by both mineral density and tissue quality. The disease significantly impacts the quality of life and is associated with high rates of morbidity and mortality. The progression of osteoporosis can be limited by following a proper diet, leading a healthy lifestyle, taking dietary supplements, and receiving appropriate treatment, emphasizing the importance of education on disease prevention. The consequences of osteoporosis are presented in a table within the paper.

Risk Factors

The natural progression of osteoporosis involves bone tissue loss associated with slowing metabolic processes in the body. Non-modifiable risk factors include advanced age, female sex, genetics, Caucasian race, history of fractures, and diagnosis of dementia. Potential modifiable risk factors include vitamin D deficiency, smoking, alcohol consumption, low calcium intake, low or excessive phosphorus intake, protein deficiency or high-protein diet, excessive consumption of coffee, sedentary lifestyle or lack of mobility, and insufficient sun exposure.

Treatment of Osteoporosis

The impact of osteoporosis on quality of life (QoL) is significant, encompassing physical, emotional, and psychological disability, compounded by the pain following fractures in the hip, spine, or wrist. Evaluating the QoL in both men and women with osteoporosis before fractures occur is crucial for developing effective treatment plans to alleviate symptoms throughout the disease's progression. In the comprehensive treatment of osteoporosis, specialists have identified two intervention stages.

Stage I involves primary care, encompassing lifestyle modifications and fall prevention, along with supplements and medications to address bone health. It also emphasizes the importance of maintaining an adequate calcium and vitamin D intake. Additionally, exercise, particularly weight-bearing and muscle-strengthening exercises, is recommended.

Stage II involves specialist care for detailed evaluation of all fracture risk factors, patient education, and pharmaceutical and non-pharmaceutical treatments with emphasis on physical therapy, fall prevention, vitamin D supplementation, diet modification, and monitoring of treatments.

Some of the strategies for osteoporosis preventions include optimizing peak bone mass in young adults, implementing a four-stage diagnostics plans for osteoporosis fractures, measuring bone strength accurately, decreasing gaps in treatment, utilizing safe and most effective medications, providing optimal non-pharmaceutical strategies, and providing new treatment strategies.

Pharmaceutical Treatment

The pharmaceutical treatment for osteoporosis commonly involves bisphosphonates, along with calcium and vitamin D3 supplements, and regular blood tests. Denosumab is also used to inhibit osteoclast activity, providing a rapid but reversible antiresorptive effect. In severe osteoporosis with fractures, teriparatide may be used as a strong promoter of bone formation, although its availability is limited due to cost and non-refundable status in some healthcare systems. Raloxifene, another treatment option, has potential complications such as thrombosis and hot flushes. Strontium ranelate can effectively reduce the risk of fracture by inhibiting bone resorption and promoting bone formation, but it has adverse cardiovascular effects and limited availability in some regions.

Despite the high mortality rate associated with femoral fractures, poor patient compliance with osteoporosis medications is common. Epidemiological data indicates that approximately 30-50% of patients do not adhere to the prescribed treatment regimen. Some of the reasons for poor adherence include increased restrictions in the daily activities, lack of knowledge regarding the consequence of poor adherence, and lack of motivation to continue pharmaceutical treatment, and lack of training for physicians to motivate patients to adhere to medications.

Other Treatment Methods

Exercise with osteoporosis

Physical activities for people living with osteoporosis include decreased pain, decreased risk for falls and fractures, improved activation of the sensorimotor system, improved gait, and increased subjective quality of life.

Exercise therapy in the early stage of osteoporosis

Primary strategies in the early stage of osteoporosis are patient education with emphasis on proper posture, anti-kyphosis exercises using individual or group program, and resistance exercises. Exercises that unload the body include hydrotherapy in a water temperature of 25 to 30 degrees Celsius can complement exercise therapy. In addition, exercises should focus on coordination, balance, and gait with the main goal of exercise being increased independence, delayed aging, and promotion of movement.

Exercise therapy in advanced osteoporosis

In advanced osteoporosis, the structure of the bone has changed. As a result, exercises should focus on bone tissue regeneration, delaying demineralization, and improving muscle strength and physical function. Patients may also use crutches and canes for gait. Patients may don neck braces to decrease cervical spine overload caused by spinal muscle strain.

Exercise therapy in late osteoporosis

The use of corrective exercises should be tailored to each patient's conditions with focus on reducing pain by regulating muscle tension and unloading bone structures. It emphasizes the importance of exercises to improve lung ventilation, isometric exercises to relax muscles, and the use of walking supports and orthotics to facilitate safe, independent walking in patients with fractures. Additionally, it highlights the effectiveness of physical exercises in maintaining appropriate bone mineral density and preventing fractures.

Most commonly used exercises

1. Breathing exercises: pain as a result of osteoporosis and fracture interfere with breathing patterns and movement. A shallow breathing pattern is seen due to decreased activation of muscles of inspiration and expiration as well as decreased chest recoil and movement. It also leads to accumulation of mucus in the airway. Breathing exercises improves respiratory performances, vital lung capacity, and breathing/coughing without pain.

2. Posture and joint mobility: osteoporosis weakens the bone structure that results in changes of the normal spinal curvature and pain with movement. Decreased movement due to changes to the spinal curvature and pain also results in contractures. Passive and assisted exercises are recommended during the initial stage followed by elimination of poor postural habits and behaviors.

3. Resistance exercise: exercises should focus on proper posture to ensure bone structures are not stressed. All resistance exercises should be performed slowly with a gradual increase in load and range.

4. Balance exercise: people with osteoporosis may have impairments in the vestibular system that slows reactionary movements to prevent falls. Balance exercises should focus on sensorimotor skills to promote neural flexibility and improve coordination.

5. Training for everyday activities: exercises should focus on independent functioning and improving quality of life.

6. Water exercises: the recommended water temperature is 25 to 30 degrees Celsius to promote increased range of motion and promote temporary pain reduction.

Health Resort Medicine and Physical Therapy

The research paper highlights the prevalence of osteoporosis and the importance of early identification of at-risk patients to prevent fractures. It emphasizes the need for a comprehensive approach to treatment, including pharmaceutical interventions, lifestyle changes, physical therapy, social support, and psychotherapy. The paper discusses the system of health resort medicine in Poland, which combines pharmaceutical treatment, physiotherapy, psychotherapy, and dietary interventions, and emphasizes the use of natural therapeutic procedures such as balneotherapy, hydrotherapy, and physiotherapy. It also discusses the potential benefits of low-frequency alternating magnetic fields, light therapy, and UV phototherapy in improving bone mineral density and alleviating chronic pain in osteoporosis patients.

Diet

The Diet section of the research paper emphasizes the impact of nutritional deficiencies on muscle function and bone tissue quality, particularly during childhood and adolescence, when skeletal development and peak bone mass accumulation occur. The intake of calcium, vitamin D3, and protein plays a pivotal role in maintaining the normal functioning of the skeletal system. Adequate intake of these substances ensures the mechanical strength of bone tissue and reduces the risk of falls and fractures in the elderly. The recommended daily intake of calcium and vitamin D is 1200 mg and 800 IU, respectively, which has been shown to decrease the risk of fracture in individuals over 65 years and postmenopausal women.

Calcium

The research paper emphasizes the importance of a balanced diet for adequate calcium intake, with the required daily intake ranging between 1000 and 1300 mg depending on various factors such as age, lifestyle, sex, and physiological state. Good dietary sources of calcium include dairy products, sesame seeds, nuts, almonds, and pulses. To increase calcium intake, supplements containing calcium ions in organic or inorganic compounds can be used, with organic forms such as gluconate, citrate, or lactate being more bioavailable and better absorbed and retained by the body. The paper highlights that the efficacy and absorbability of dietary supplements vary based on their calcium ion content, chemical form, and excipients used.

Vitamin D

The research paper discusses the prevalence of vitamin D3 deficiencies in Poland, particularly during autumn and winter when skin synthesis is insufficient. Deficiencies are common in people with joint diseases and the elderly. The recommended supplementation dosage is 800-1000 IU/day in adults, with higher doses of 7000 IU per day for 8-12 weeks for osteoporosis patients with low serum levels, followed by a maintenance dose of 2000 IU per day. Vitamin D has various health benefits, including reducing bone resorption, improving bone quality, and reducing fall risk by enhancing balance, muscle strength, joint mobility, coordination, and quality of life. Deficiencies lead to a loss of muscle strength, grip strength, and mobility, with levels below 50 nmol/L associated with a higher risk of balance disorders and levels below 30 nmol/L associated with lower muscle strength.

Protein

The research paper emphasizes the significant role of protein in the development of osteoporosis. Both excessive and insufficient dietary intake of protein can contribute to bone loss. Protein deficiency impairs collagen synthesis, which is vital for bone mass, and also affects the synthesis of IGF-1, a growth factor essential for normal bone tissue. The balance between animal and plant protein in the daily diet is crucial in preventing osteoporosis, as excessive consumption of animal protein can result in the release of phosphates and carbonates from bone, leading to decreased bone mineral density. Therefore, incorporating pulses as an alternative source of protein is recommended. Diets with a high ratio of animal to plant protein are associated with a higher incidence of osteoporotic fractures.

Additionally, phytoestrogens have been shown to have a positive impact on bone tissue. Consumption of soy isoflavones by postmenopausal women was found to be positively correlated with bone mineral density. Phytoestrogens, in combination with vitamin D, are thought to activate osteoblasts and play a significant role in preventing postmenopausal osteoporosis. Therefore, including phytoestrogens and vitamin D in the diet is important for bone health.

Conclusion

The research paper highlights the prevalence of osteoporosis will continue to grow with the aging population. A comprehensive approach is needed to provide complete treatments of a person with osteoporosis.