Osteoporosis manifests as a loss of bone mass, thinning of bone tissue, and changes in the microarchitecture of the bone. These changes increase the likelihood of a bone fracture. Low bone mass and degeneration of the microstructural structure of skeletal tissue are the hallmarks of osteoporosis, according to the WHO, and osteonecrosis and increased fracture risk follow suit. Osteoporosis affects an estimated 200 million men and women worldwide, most of whom are over 60. An osteoporotic fracture is a medical condition that can harm a patient’s quality of life. According to the International Osteoporosis Foundation, one in three women and one in five men over 50 may have an osteoporotic fracture in their lifetime. People of all sexes and ethnicities are affected by osteoporosis in large numbers, and as the population ages, this incidence will rise. It is a calm condition until fractures, which can cause severe subsequent health problems or even death. Estimates suggest that more than 200 million persons worldwide have osteoporotic hip fractures. According to statistics, osteoporosis affects 30% of women in Europe and the United States. Throughout their careers, 40% of postmenopausal women and 30% of men are anticipated to survive an osteoporotic fracture.
Considering that the survival rate is rising worldwide, osteoporosis will impact people’s welfare and place a financial strain on most nations. As a result, osteoporosis has to be effectively controlled, and this may be done by comprehending the pathophysiologic mechanisms that underlie this condition. In all nations, the likelihood of a hip fracture rises dramatically with age. When the rate of resorption outpaces the rate of bone formation, bone loss occurs. Bone tissue is continually destroyed and rebuilt due to resorption and formation. PBM (peak bone mass) is reached around the time of puberty, but after that point, bone mass begins to deteriorate. Bone mass is shaped during a person’s life (increases exponentially and takes on its overall form). Genetics, health, nutrition, endocrine state, gender, and physical activity all have a role in PBM (Sözen, 2017). Bone remodelling is used to fix microfractures and stop them from forming, which helps maintain a healthy skeleton by removing old bone and replacing it with new bone. Resorption rates grow out of proportion with production rates as people age (resorption exceeds absorption), which raises the risk of fracture. Bone loss reveals the microarchitecture when certain conditions cause more significant resorption than creation. Other ageing-related functional deficits exacerbate fracture risk due to the loss of individual bone plates. Increased bone fragility and fracture risk can be seen by biochemical markers that indicate bone production or deposition. Fractures have been linked to mortality, persistent pain, and disability. A 2.5-fold increased risk of recurrent fractures, a death rate of 15-20% within a year, and a higher mortality rate in men than in women are all associated with hip fractures. Long-term nursing home patients with hip fractures often have a worse quality of life, are more socially isolated, are sad, and have reduced self-esteem. Osteoporotic individuals are more likely to experience fragility fractures, also known as spontaneous fractures or fractures brought on by minor trauma (such as a fall from a standing height or less).
The patient may initially report losing height due to the compression of the vertebrae caused by the fractures; an increment can impartially recognize this deformity in the range between the occiput and the wall caused by dorsal kyphosis (dowager’s hump), which is more pronounced in the existence of numerous fractures. Finding out if a person has lost at least 1.5 inches (4 cm) of height in the past or has lost at least 0.8 inches (0.8 cm) in the future is critical. (2 cm). Numerous vertebral thoracic fractures can lead to restrictive lung disease and cardiac problems (Sözen,2017). Acute and persistent back pain, long-term disability, a negative self-image, social isolation, depression, and postural limitation can all be brought on by compression fractures of the spine. Lumbar fractures can affect abdominal morphology and reduce the volume between ribs and pelvis, resulting in gastrointestinal problems such as early satiety, reduced appetite, stomach discomfort, constipation, and distention.
Prevention of falls
Most osteoporotic fractures result from falls; consequently, a program must be designed for osteoporosis therapy that is efficient in preventing falls. Falls are more likely to happen to elderly and weak people, those who have had a stroke or are taking drugs that lower mental alertness, and people who are older and frailer. Even though there are various therapies that lower the chance of falling, none appear to lower the incidence of fractures (Sözen,2017). Hip guards reduce fracture risk; however, they have little effect on the likelihood of tripping and falling. Weight-bearing exercises, back strengthening, and balance training treatment may help older adults with severe kyphosis, back stiffness, and gait instability.
Strategy for an osteoporosis patient
To determine a patient’s fracture risk, a thorough medical history and physical examination, BMD testing, vertebral imaging to search for vertebral fractures, and the WHO-defined 10-year estimated fracture probability test are all carried out on them. All postmenopausal women and men over 50 should be examined for osteoporosis risk to establish the need for bone density tests and vertebral imaging (Lewiecki,2019). If more risk factors are present, the probability of fracture increases. Because there are no symptoms before a fracture, osteoporosis often goes undiagnosed for an extended period, preventing patients from receiving the proper therapy. It is possible to both prevent and cure osteoporosis, though.
Pharmacologic agents for the treatment of osteoporosis
Before starting treatment, all osteoporotic patients should have a secondary causes examination and BMD measurements using central DXA, including spinal imaging studies. If treatment monitoring is intended, BTM levels should also be acquired. The primary objectives of treatment for patients with osteoporosis are to decrease the chance of falling and injury while strengthening the bones and preventing fractures, help alleviate bone deformities and fracture symptoms and keep one’s bodily functioning. The bulk of modern osteoporosis and fracture prevention therapies, often known as antiresorptive medicines, work to slow down bone resorption. Serum, bisphosphonates like alendronate, risedronate, ibandronate, and zoledronic acid, selective estrogen receptor modulators (SERMs), raloxifene, a human monoclonal antibody against receptor activator of NF-B ligand (RANKL), denosumab, and strontium ranelate are among them (SR) (Lewiecki,2019). Osteoporosis treatments and anti-fracture medications are depicted in the following diagrams. Only alendronate, risedronate, zoledronic acid, and SR have been demonstrated to reduce vertebral and hip fractures, even though other antiresorptive drugs increase bone mass. The subsequent treatments, however, are exclusively effective for spinal fractures.
Nevertheless, compared to vertebral fractures, hip fractures result in higher rates of morbidity, death, and medical expenses. Except for the anabolic drugs now on the market (namely PTH), none of these antiresorptive treatments encourages bone growth. They are especially beneficial for people with severe or long-term osteoporosis. Unfortunately, all osteoporosis medications suffer from low patient adherence and tenacity, which reduces the effectiveness of treatment.
Universal recommendations for all patients
Any program for preventing or treating osteoporosis should include a variety of interventions, such as maintaining an adequate calcium and vitamin D intake, engaging in lifelong, regular weight-bearing and muscle-strengthening exercises, quitting smoking and drinking excessive amounts of alcohol and taking care prevention strategies. If there is not a sufficient external source of calcium, low serum calcium levels will promote bone resorption, raising calcium levels to expect. Since their requirements for calcium increase, the aged are more likely to experience calcium insufficiency. Males between the ages of 50 and 70 are advised by the Institute of Medicine (IOM) to eat 1000 mg of calcium daily, while women over 50 and males over 70 are advised to consume 1200 mg. All calcium supplements absorb better when taken with meals, predominantly when stomach acid is not secreted. Calcium dosages shouldn’t exceed 500–600 mg per dose for best absorption. The least costly and requiring the fewest number of pills is calcium carbonate, although it has the potential to result in gastrointestinal (GI) issues. Although calcium citrate is more costly and requires more tablets to get the correct amount, neither its absorption nor the development of GI issues relies on stomach acid. Too much oxalate, which binds to calcium and prevents calcium absorption, is present in several food products. More than 1200–1500 mg per day may increase the risk of kidney stones, stroke, and cardiovascular disease. According to the IOM, calcium absorption, bone health, muscular function, and balance depend on vitamin D. Adults should take 800 IU of vitamin D per day beyond 70. Saltwater fish, liver, milk, juices, fortified cereals, and juices are the primary dietary sources of vitamin D (Noh,2020).
Supplements containing V-D2 (ergocalciferol) or V-D3 (cholecalciferol) are acceptable. V-D deficiencies are widespread in older adults. Celiac disease, inflammatory bowel disease, gastric acidity, pernicious anaemia, proton pump inhibitors, chronic renal and liver dysfunction, patients using medications that speed up the breakdown of V-D (like certain anticonvulsants), or patients taking glucocorticoids are included in this group. Risk factors for V-D deficit should be considered when testing serum 25(OH)D levels. According to recommendations, take V-D supplements in amounts that raise serum 25(OH)D levels to about 30 ng/mL (75 nmol/L). Osteoporosis patients may require a higher dosage than the 800-1000 IU/day advised for those with the condition. From 2000 IU to 4000 IU, the safe daily intake of V-D for most adults was raised in 2010.
Alcohol should not be used in excess since it is unhealthy for bones. The causes are many and include a propensity for falls, a lack of calcium, and chronic liver illness, all of which contribute to a propensity for V-D deficit. One drink is equivalent to 120 mL of wine, 30 mL of liquor, or 260 mL of beer, and people prone to osteoporosis should not consume more than seven drinks each week. Caffeine Patients should be counselled to limit their daily caffeine consumption to one or two servings (8 to 12 ounces each). According to many studies, coffee consumption and the risk of fractures are linked.
Maintaining a regular weight-bearing exercise program (such as walking for 30–40 minutes each session) and practising back and posture exercises for a brief time on most days is advised throughout life. Active children and adolescents attain a more significant peak bone mass than idle ones. These activities reduce the risk of falls in older adults by enhancing balance, strengthening muscles and slowing bone loss brought on by inactivity (Noh,2020). Pushing, tugging, side-bending, lifting, and bending actions compress the spine and can result in fractures. Thus, patients should refrain from doing these activities to avoid falls. The majority of osteoporotic fractures are precipitated by falls. Thus, precautions should be taken in the home, especially for weak patients and drugs that may impair mental awareness and increase the risk of a stroke.
Antiresorptive agents
The most often prescribed medications for treating osteoporosis are bisphosphonates. Male osteoporosis, osteoporosis caused by glucocorticoids, and postmenopausal osteoporosis are all treated and prevented using alendronate. Risedronate is used to treat and prevent osteoporosis in both men and women, as well as glucocorticoid-induced osteoporosis in the former. For postmenopausal osteoporosis, Ibandronate is a different BP that may be utilized (Noh,2020). In postmenopausal women with osteoporosis, it has been shown to help reduce the incidence of spinal fractures, but not for hip or non-vertebral fractures, particularly for those at greater risk. Besides glucocorticoid-induced osteoporosis, zoledronic acid prevents and treats postmenopausal, male, and other kinds of osteoporosis. Once a year, it is administered intravenously as a 5-mg infusion lasting at least 15 minutes.
Conclusion
As a result, most patients are confined to a lengthy course of therapy. Besides lowering blood pressure, pharmacological treatment’s significance decreases after treatment stops. Hence they can persist for lengthy periods after lowering blood pressure medication is stopped. Alendronate, risedronate, ibandronate, and zoledronic acid require a treatment review after five years of use. Osteoporosis therapy should continue for patients at risk of fractures until new evidence suggests otherwise. Recurring fractures can aggravate osteoporosis, a common and sometimes unnoticed illness. Fluorosis fractures are expected to affect 50% of women and 20% of men over 50 at some point in their life. Indeed, these fractures cause long-term disability, diminished well-being, higher mortality, and astronomical medical and labour expenses for both patients and the country. Osteoporosis may be detected early on and treated to keep fractures at a minimum. Primary care physicians should thus be responsible for osteoporosis prevention, diagnosis, and therapy.
References
Lewiecki, E. M., Ortendahl, J. D., Vanderpuye‐Orgle, J., Grauer, A., Arellano, J., Lemay, J., … & Singer, A. J. (2019). Healthcare policy changes in osteoporosis can improve outcomes and reduce costs in the United States. JBMR Plus, 3(9), e10192. https://asbmr.onlinelibrary.wiley.com/doi/full/10.1002/jbm4.10192
Noh, J. Y., Yang, Y., & Jung, H. (2020). Molecular mechanisms and emerging therapeutics for osteoporosis. International journal of molecular sciences, 21(20), 7623. https://www.mdpi.com/1422-0067/21/20/7623/htm
Sözen, T., Özışık, L., & Başaran, N. Ç. (2017). An overview and management of osteoporosis. European journal of rheumatology, 4(1), 46–56. https://doi.org/10.5152/eurjrheum.2016.048 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5335887/
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