Treatment

Osteoporosis is currently both underdiagnosed and undertreated in Germany. An optimal therapy is considered to reduce mortality. The therapy is divided into osteoporosis and fracture prophylaxis and drug therapy.

The basic therapy recommends physical activity to strengthen muscle strength and an optimal diet to reduce the risk of osteoporosis and associated fractures. Alcohol and nicotine abuse should be avoided. Furthermore, a sufficient intake of vitamin D3 and calcium is mandatory.

If necessary, both substances must be supplemented with medication, as they play an important role in bone metabolism and thus have an influence on the development of osteoporosis. Part of the prophylaxis is also to reduce the risk of falling. This can be achieved by discontinuing sedative medication or by using walking aids.

Heat and heliotherapy have also shown positive results in the treatment of osteoporosis. Psychosocial support is also recommended. The second important component of osteoporosis treatment is drug therapy.

The bisphosphonates are considered the drugs of first choice. Other drugs include raloxifene, strontium ranelate, denosumab and the parathormone. Overall, the therapy lasts at least 3 to 5 years, with the exception of the drug parathormone, which may be administered for a maximum of 24 months.

During the treatment, regular re-evaluation and follow-up is essential to determine further therapy. This evaluation should be based on the current guidelines. Drug therapy is considered a special therapy and is based on 2 principles: Firstly, antiresorptive and secondly anabolic therapy.

Antiresorptive means that drugs are used which inhibit the breakdown of bone by certain cells (so-called osteoclasts).These include drugs such as bisphosphonates, estrogens, SERMs such as Raloxifene (= selective estrogen receptor modulator) and Denosumab. The anabolic therapy is intended to promote bone formation. Such stimulation is achieved by the parathyroid hormone.

All the above-mentioned drugs count as “Class A drugs”, as they significantly reduce the risk of fractures in existing osteoporosis. The indication for drug therapy should be made as soon as certain criteria are met. These include low bone density, the presence of risk factors, and old age.

In addition to the standard drugs mentioned above, there are others such as fluoride and calcitonin. Fluoride promotes bone formation, calcitonin inhibits bone resorption. The bisphosphonates are considered to be the first choice medication for osteoporosis.

They show an antiresorptive effect by inhibiting the bone-destroying cells (=osteoclasts). This can lead to an increase in bone density. Regular intake of bisphosphonates can reduce the recurrence of fractures by up to 75%.

Alendronate, risedronate, ibandronate and zoledronate are available as preparations. The latter preparation only needs to be taken once a year. For the other preparations you can choose between a daily or weekly dose.

Bisphosphonates are contraindicated if there are diseases of the esophagus such as strictures or varicose veins or if patients suffer from ulcers of the stomach. Existing renal failure (GFR < 35ml/min), pregnancy and low calcium levels also prohibit the use of bisphosphonates. As an undesirable side effect, this can lead to complaints in the stomach and intestinal tract.

In addition, the development of aseptic bone necrosis of the jaw is possible. However, this side effect is more likely to occur when bisphosphonates are administered intravenously as part of a tumor therapy. To prevent undesirable side effects such as inflammation of the esophagus, care should be taken to take the bisphosphonates in the morning and at least 30 minutes before meals.

The purpose behind this is to avoid complex formation with calcium. In addition, they should be taken with sufficient liquid and in a sitting position. The diagnosis of osteoporosis is made as a combination of medical history, clinical examination, and the use of medical devices.

In the anamnesis, the degree of physical activity must be determined and the exact medication plan must be documented. Certain medications, like low levels of physical activity, increase the risk of osteoporosis. Women should also be asked about the time of menopause, as the associated drop in oestrogen levels can also provoke osteoporosis.

In the context of osteoporosis there is a reduction in body size, so regular measurements can provide an initial indication of manifest osteoporosis. Physical examination also reveals the so-called “fir tree phenomenon” in many patients: These are skin folds on the patients’ backs that run like a fir tree from the middle of the spine to the bottom diagonally outwards, i.e. they resemble a fir tree and form due to the reduction in body height. After a blood sample is taken, various parameters can be measured.

Special attention should be paid to values such as alkaline phosphatase, calcium, phosphate, creatinine, vitamin D, etc. Some of the values also serve to exclude various differential diagnoses. In addition, hormones such as TSH as thyroid hormone and certain values in urine can be determined to detect the first signs of osteoporosis.

The diagnostic tools available are x-rays and so-called osteodensometry. The X-ray image contains various criteria that indicate the presence of osteoporosis. These include, for example, increased radiation transparency of the bones, which means that the bone is less dense.

In addition, X-rays are also very good for visualizing possible vertebral body fractures. The diagnosis of osteoporosis can be verified by means of a test. This test includes a bone density measurement and is also known as osteodensometry.

The best known method is the measurement of bone surface density (unit in g/cm2) and is called “Dual X-ray Absorptiometry (=DXA).Other possible methods include quantitative computed tomography (=QCT), which, in contrast to DXA, measures the true physical density (unit in g/cm3) and quantitative ultrasound (=QUS). The latter method does not show any radiation exposure compared to the other tests. In a broader sense, the so-called “time up on go” test, the “chair-rising” tet and the tandem stand can also be used to assess the risk of falling in risk patients.

Based on these test results, it is possible to assess how mobile the patients are and how high the risk is of falling during everyday movement tasks, which in the case of existing osteoporosis is inevitably associated with an increased risk of fracture due to the lower bone density. DXA stands for “Dual X-ray Absorptiometry”. X-rays can be used to calculate the areal density of bone mineral content (g/cm2).

The measurement is carried out on the lumbar spine (lumbar spine 1-4), on the femur near the trunk and on the femoral neck bone. The minimum values of all 3 measurements are decisive. Two scores are then used to define the presence of osteoporosis.

The so-called T-Score describes the standard deviation (SD) from the mean value of the maximum bone density in comparison to a 30-year-old, healthy person of the same sex. A T-score of more than 2.5 SD below the norm is called osteoporosis. The preliminary stage of osteoporosis, osteopenia, is defined as osteopenia at a T-score of 1 to 2.5 SD below the norm. As soon as a fracture is added to the more than 2.5 SD below the norm, this is referred to as manifest osteoporosis. In addition, risk factors such as smoking or immobilization have an influence on the T-score: If an additional risk factor is present, the T-score is increased by 0.5, and if there are 2 or more risk factors, the T-score is increased by 1.0.