Current Treatment Paradigms
Measurement of bone mineral density is the best method for confirming the diagnosis of osteoporosis and is commonly used for monitoring the response to therapy. Bone density is usually measured at two sites, most commonly the spine and hip, using the technique of dual energy X-ray absorptiometry (DEXA) of bone density and structure. Spinal X-rays may be appropriate to examine for vertebral wedge or compression fractures. These fractures may be associated with pain but often occur silently and result in height loss and increased curvature of the spine (kyphosis).
Treatment of osteoporosis is aimed at preventing further fractures. It is important to select treatment individually for each patient. Treatment with calcium, vitamin D metabolites, oestrogen, selective oestrogen receptor modulators, bisphosphonates or calcitonin may be considered.
Intranasal or injectable calcitonin is an alternative to HRT or bisphosphonates. The results of a study show that salmon calcitonin nasal spray reduces the incidence of vertebral fractures by 25-35% at a daily dose of 200 IU. Some patients may also benefit from the analgesic effect intranasal calcitonin has on bone pain. Salmon calcitonin nasal spray is only available in some countries for the treatment of patients with vertebral fractures.
Parathyroid Hormone (prescription)
The bone-forming effects of parathyroid hormone (PTH) have been known to exist for more than 70 years. However, it is only in the last 5-10 years that data have emerged to provide consistent and encouraging results in animals and humans. A recent multinational study on postmenopausal women with prior vertebral fractures demonstrates that a synthetic fragment of PTH may be useful in the management of osteoporosis. In late 2002 an injectable form of PTH became available for the treatment of osteoporosis.
Bisphosphonates are potent inhibitors of bone resorption, acting through the inhibition of osteoclast function. In 2003 these products sold US$3.8 billion. Randomised controlled trials have shown that treatment with these agents can significantly increase bone density and reduce further fracture risk. This class of compound does however suffer from a range of side effects, including oesophageal ulceration.
Hormone Replacement Therapy (prescription)
Oestrogen replacement therapy (HRT) has been the treatment of first choice in most peri-menopausal women. HRT reduces the formation of osteoclasts and is recommended to be given for at least 5 years. Unfortunately recent published studies have highlighted the potential increased risk of other disease states, such as breast cancer, with prolonged HRT use.
Calcium (non prescription)
Calcium is weakly anti-resorptive (i.e. a weak inhibitor of bone resorption) and supplementation may reduce negative calcium balance and so reduce bone resorption, particularly in older age. Controlled trials have demonstrated calcium supplementation can prevent bone loss in postmenopausal women and this has been associated with a modest reduction in fracture risk in longer-term studies. Unfortunately many elderly patients find it difficult to ingest calcium supplements.
Vitamin D (non prescription)
Vitamin D supplementation is recommended in institutionalised or house-bound elderly subjects who are often vitamin D deficient. Active vitamin D metabolites may be appropriate in patients with known or presumed calcium malabsorption.
Medications for rheumatoid arthritis are aimed at relieving symptoms and slowing or halting its progression, while treatments for osteoarthritis are used to treat the pain and mild inflammation of the condition.
Injectable Anti-TNF products
Injectable Anti-TNF products are so called disease-modifying antirheumatic drugs or DMARDS. TNF is a cytokine, or cell protein, that acts as an inflammatory agent in rheumatoid arthritis. TNF blockers, or anti-TNF medications, target or block this cytokine and can help reduce pain, morning stiffness, and tender or swollen joints. There are currently 3 TNF blockers, available only as infusion or injection, approved for treatment of rheumatoid arthritis with 2003 sales of US$3.3 billion.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
This group of medications, which includes aspirin, helps relieve both pain and inflammation if taken regularly. Prescription NSAIDs can provide higher dosages and more potency than over-the-counter NSAIDs. Older NSAIDs can lead to side effects such as indigestion and stomach bleeding. Other potential side effects may include damage to the liver and kidneys, ringing in your ears (tinnitus), fluid retention, and high blood pressure. Newer agents called COX-II inhibitors cause less adverse stomach effects as they suppress only the enzyme involved in inflammation.
These medications reduce inflammation and slow joint damage. In the short term, corticosteroids can make patients feel dramatically better. But when used for many months or years, they may become less effective and cause serious side effects. Prolonged corticosteroid use is also a major cause of osteoporosis.