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How to Treat Osteoporosis?


Things to note:
Prevention
  • Adequate energy and protein intake.
  • Adequate dietary calcium intake (greater than 1 g/day) particularly in the young, in breastfeeding mothers and in the elderly.
  • Weight bearing exercises, e.g. brisk 30 minutes walk 3 times a week.
  • Smoking cessation.
  • Ensure alcohol intake is less than 10 units /week.
  • Avoid falls.

Medical Treatment:
Routine supplementation with calcium and vitamin D marginally increases the risk of myocardial infarction and stroke. Therefore, it is only recommended for use in the institutionalised frail elderly patients, where it may reduce the incidence of hip fractures.
In institutionalised frail elderly patients:
* Calcium, elemental, oral, 1 000 mg daily.
PLUS
* Vitamin D, oral, 800 units daily.
Secondary prevention of osteoporotic fracture, including patients on long- term corticosteroids
In severe osteoporosis, i.e. patients who have a T-score of -2.5 (severe osteoporosis) plus an osteoporotic fracture:
* Alendronate, oral, 10 mg daily for a maximum duration of 5 years.
This should be given with:
* Calcium, elemental, oral, 1 000 mg daily.
PLUS
* Vitamin D, oral, 800 units daily.
Hormone replacement therapy
This is not indicated in all postmenopausal women. Symptomatic menopausal women and those with osteoporosis risk factors will benefit most. The benefits need to be weighed against evidence of potential harm, including the emergence of risks as therapy continues.
Note:
Contraindications to HRT:
  • Breast cancer,
  • Endometrial cancer,
  • Women equal to or greater than 60 years,
  • Thrombo-embolism,
  • Coronary heart disease,
  • Active liver disease,
  • Porphyria cutanea tarda, and
  • Women without severe menopausal symptoms.
Intact uterus (no hysterectomy)
HRT can be offered as sequentially opposed or continuous combined preparations. Continuous combined preparations have the advantage of less breakthrough bleeding, but should only be commenced once the woman has been stable on sequentially opposed therapy for a year. Treatment should be planned for 5 years but reviewed annually.
Sequentially opposed therapy:
* Conjugated equine estrogens, oral, 0.3-0.625 mg daily for 21 days.
  • Add medroxyprogesterone acetate, oral, 5-10 mg daily from day 11-21.
  • Followed by no therapy from day 22-28.
OR
* Estradiol valerate, oral, 1-2 mg daily for 11 days.
  • Add medroxyprogesterone acetate, oral, 10 mg daily from day 11-21.
  • Followed by no therapy from day 22-28.
Equivalent doses to medroxyprogesterone acetate:
* Norethisterone acetate, oral, 1 mg daily from day 11-21.
* Cyproterone acetate, oral, 1 mg daily from day 11-21.
Continuous combined therapy, e.g:
* Conjugated equine estrogens, oral, 0.3-0.625 mg plus medroxyprogesterone acetate, oral, 2.5- 5mg daily.
OR
* Estradiol valerate, oral, 0.5-1 mg plus norethisterone acetate, oral, 0.5-1 mg daily.
Note:
Start at the lowest possible dose to alleviate symptoms. The need to continue HRT should be reviewed annually. A mammogram should be done once a year, and abnormal vaginal bleeding requires specialist consultation/Referral Any unexpected vaginal bleeding is an indication for excluding endometrial carcinoma as with other cases of postmenopausal bleeding. The use of transvaginal ultrasound to measure endometrial thickneBeta plus the taking of an endometrial biopsy are recommended.
Uterus absent (post hysterectomy)
HRT is given as estrogen only. Estrogen supplementation to prevent postmenopausal osteoporosis requires long-term treatment.
* Estradiol valerate, oral, 1-2 mg daily.
OR
* Conjugated equine estrogens, oral, 0.3 mg daily or 0.625 mg on alternative days up to a maximum of 1.25 mg daily.
Only indicated early in menopause, if vasomotor symptoms are significant. Review contra-indications before initiating therapy.

When to refer:
  • To establish diagnosis (bone densitometry).
  • For initial assessment.
  • Initiation and monitoring response to therapy and 18-24 monthly bone mineral density (BMD).
  • Fractures suspected to be due to osteoporosis for consideration for alendronate.