Know the facts	Know your risk factors	Prevention
Know Your Bone Status	Talk to Your Doctor	Additional Resources

Osteoporosis: Talk to Your Doctor

• Questions to Ask Your Doctor
• Bone Mineral Density Tests
• Medications to Prevent and Treat Osteoporosis

Speaking with your doctor about osteoporosis will help you better understand your own risk for the disease as well as available prevention or treatment options.

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Questions to Ask Your Doctor

Listed below are several questions that are intended to help you discuss osteoporosis with your doctor:

• Based on my medical history, lifestyle and family background, am I at risk for osteoporosis?
• How do I know if someone in my family suffered from osteoporosis? (What physical signs or symptoms should I be looking for?)
• Am I currently taking any medication that puts me at higher risk for developing osteoporosis?
• How do I best prevent (or treat) osteoporosis?
• How do I know if my bone density is low?
• How much calcium is right for me? How do I best obtain this calcium?
• Should I engage in exercise? What kind of exercise is best? How often should I exercise?
• How do I know if I have fractured a bone in my spine?

If you have osteoporosis or if your doctor believes you are at high risk for the disease, you may want to ask the following questions:

• What medications are available to help me?
• What are the benefits/side effects of these medications?
• Will these medications interact with other medications I am already taking for other conditions?
• How do I know that my prevention or treatment program is effective?
• Do any of the medications I am taking for other conditions cause dizziness, light-headedness, disorientation or a loss of balance that could lead to a fall?

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Bone Mineral Density Tests

Your doctor can help you determine whether you should have a Bone Mineral Density (BMD) test. BMD tests cannot stand alone. They should always be a part of a complete medical workup supervised by your doctor.

Indications for a BMD test

Your doctor may consider ordering a BMD test for you if you fall into one of the following categories:

• A postmenopausal woman under age 65 who have one or more additional risk factors for osteoporosis in addition to being postmenopausal and female.
• A woman age 65 and older regardless of additional risk factors.
• A postmenopausal woman who presents with fractures. (This is to confirm diagnosis and determine disease severity).
• A woman who is considering therapy for osteoporosis if BMD testing would facilitate the decision.
• A woman who has been on hormone replacement therapy (HRT/ERT) for a prolonged period of time.

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Medications to Prevent and Treat Osteoporosis

Consult your physician about the medication that is appropriate for you.

Although there is no cure for osteoporosis, there are steps you can take to prevent it or to slow or stop its progress. The FDA has approved the following medications for postmenopausal women to prevent and/or treat osteoporosis:

• Bisphosphonates
• Alendronate
• Risedronate
• Calcitonin
• Estrogen/Hormone Therapy
• Selective Estrogen Receptor Modulators (SERMs)
• Raloxifene
• Parathyroid Hormone - Teriparatide

Adequate calcium, vitamin D, appropriate exercise and, in some cases, medication are important for maintaining bone health. For more detailed information on the actions, administration and possible side effects for each of the following medications, please consult the package Insert, available on-line and at pharmacies.

Antiresorptive Medications

The bisphosphonates (alendronate and risedronate), calcitonin, estrogens and raloxifene affect the bone remodeling cycle and are classified as anti-resorptive medications. Bone remodeling consists of two distinct stages: bone resorption and bone formation. During resorption, special cells on the bone's surface dissolve bone tissue and create small cavities. During formation, other cells fill the cavities with new bone tissue.

Usually, bone resorption and bone formation are linked so that they occur in close sequence and remain balanced. An imbalance in the bone remodeling cycle causes bone loss that eventually leads to osteoporosis and fracture risk. Anti-resorptive medications slow or stop the bone-resorbing portion of the bone-remodeling cycle but do not slow the bone-forming portion of the cycle. As a result, new formation continues at a greater rate than bone resorption, and bone density may increase over time.

Bisphosphonates

Alendronate Sodium

Alendronate is approved as a treatment for osteoporosis in men and is approved for treatment of glucocorticoid (steroid)-induced osteoporosis in men and women.

Alendronate is approved for both the prevention (5 mg per day or 35 mg once a week) and treatment (10 mg per day or 70 mg once a week) of postmenopausal osteoporosis. Alendronate reduces bone loss, increases bone density and reduces the risk of spine, wrist and hip fractures.

Alendronate also is approved for treatment of glucocorticoid-induced osteoporosis in men and women as a result of long-term use of these medications (i.e., prednisone and cortisone) and for the treatment of osteoporosis in men.

Risedronate Sodium

Risedronate is approved for prevention and treatment of glucocorticoid-induced osteoporosis in men and women.

Risedronate is approved for the prevention and treatment of postmenopausal osteoporosis. Taken daily (5 mg dose) or weekly (35 mg dose), risedronate slows bone loss, increases bone density and reduces the risk of spine and non-spine fractures.

Risedronate also is approved for use by men and women to prevent and/or treat glucocorticoid-induced osteoporosis that results from long-term use of these medications (i.e., prednisone or cortisone).

Administration and Side Effects of Bisphosphonates

Alendronate and risedronate must be taken on an empty stomach, first thing in the morning, with eight ounces of water (no other liquid), at least 30 minutes before eating or drinking. Patients must remain upright during this 30-minute period.

Side effects for alendronate and risedronate are uncommon but may include abdominal or musculoskeletal pain, nausea, heartburn, or irritation of the esophagus.

Calcitonin

Calcitonin is a naturally occurring hormone involved in calcium regulation and bone metabolism. In women who are more than 5 years beyond menopause, calcitonin slows bone loss, increases spinal bone density, and, according to anecdotal reports, may relieve the pain associated with bone fractures. Calcitonin reduces the risk of spinal fractures but has not been shown to decrease the risk of non-spine fractures. Studies on fracture reduction are ongoing. Because calcitonin is a protein, it cannot be taken orally as it would be digested before it could work. Calcitonin is available as an injection (50-100 IU daily) or nasal spray (200 IU daily).

While it does not affect other organs or systems in the body, injectable calcitonin may cause an allergic reaction and unpleasant side effects including flushing of the face and hands, urinary frequency, nausea and a skin rash. Side effects for nasal calcitonin are not common but may include nasal irritation, backache, bloody nose, and headaches.

Estrogen Replacement Therapy (ERT) and Hormone Replacement Therapy (HRT)

On January 8th, 2003, the Food and Drug Administration (FDA) issued a statement advising women and health care professionals about important new safety changes to labeling of all estrogen and estrogen with progestin products for use by postmenopausal women. National Osteoporosis Foundation (NOF) is currently in the process of reviewing our materials with regard to this statement. Visit the FDA Web site at for more information about the labeling change.

Estrogen replacement therapy (ERT)/Hormone replacement therapy (HRT) is approved for the prevention of osteoporosis. ERT has been shown to reduce bone loss, increase bone density in both the spine and hip, and reduce the risk of hip and spinal fractures in postmenopausal women. ERT is administered most commonly in the form of a pill or skin patch that delivers a low dose of approximately 0.3 mg daily or a standard dose of approximately 0.625 mg daily and is effective even when started after age 70.

When estrogen is taken alone, it can increase a woman's risk of developing cancer of the uterine lining (endometrial cancer). To eliminate this risk, physicians prescribe the hormone progestin in combination with estrogen (hormone replacement therapy or HRT) for those women who have an intact uterus. ERT/HRT relieves menopause symptoms and has been shown to have a beneficial effect on bone health. Side effects may include vaginal bleeding, breast tenderness, mood disturbances and gallbladder disease.

Selective Estrogen Receptor Modulators (SERMs)

Raloxifene

Raloxifene, 60 mg a day, is approved for the prevention and treatment of postmenopausal osteoporosis. It is from a class of drugs called Selective Estrogen Receptor Modulators (SERMs) that have been developed to provide the beneficial effects of estrogens without their potential disadvantages. Raloxifene increases bone mass and reduces the risk of spine fractures. Data are not yet available to demonstrate that raloxifene can reduce the risk of hip and other non-spine fractures.

Raloxifene appears to decrease the risk of estrogen-dependent breast cancer by 65% over 4 years.

While side effects were not common, those reported included hot flashes and deep vein thrombosis, the latter of which is also associated with estrogen therapy. Raloxifene is taken in pill form, once a day with or without meals.

Bone Forming Medications

Parathyroid Hormone

Teriparatide, a form of parathyroid hormone, is approved for the treatment of osteoporosis in postmenopausal women and men who are at high risk for a fracture. This medication stimulates new bone formation and significantly increases bone mineral density. In postmenopausal women, fracture reduction was noted in the spine, hip, foot, ribs and wrist. In men, fracture reduction was noted in the spine, but there were insufficient data to evaluate fracture reduction at other sites. Teriparatide is self-administered as a daily injection for up to 24 months.

Side effects include nausea, leg cramps and dizziness.