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Bone Health Q & A

Whether you want to protect yourself against loss of bone density, or you’re looking for the best ways to treat osteoporosis, Professor David M Reid, Consultant Osteoporosis Specialistof Twenty-five Harley Street Day Clinic answers your questions

Can I protect myself from developing osteoporosis?

Yes, to an extent – once you know you are at risk. One in two women over the age of 50 will have an osteoporosis related fracture in their lifetime but the good news is that fracture risk can both be predicted and in many cases safely prevented by treatment.

Can osteoporosis-related fractures be predicted?

Clinical risk factors which include, amongst many others, an early menopause (less than the age of 45), a family history of hip fracture and smoking, can be detected by online risk calculators such as the FRAX calculator but often that is not enough to ensure safe use of drugs to prevent fractures. A measurement of bone density (DEXA or DXA scan) of the spine and hips at any time after the age of 40 can significantly improve individual risk assessment and allow targeting of treatment advice.

Does the DEXA scan predict all low-trauma fractures?

Not all low-trauma fractures (those that occur after a fall from standing height or less) can be predicted by DEXA alone but when combined with the FRAX risk factors most are predictable. However it can be a challenge predicting or detecting those at risk of vertebral or spine fractures which are often “silent” in that they occur without pain and do not present until the patient presents with a stoop or loss of height often noted when the individual cannot reach high cupboards in their kitchen! However the best DEXA services now offer a scan from the side which allows the detection of vertebral fractures. A further issue with spine DEXA scans has been that as we get older we often develop wear and tear changes in our back which interfere with the measurement of bone density. A recent add-on tool called Trabecular Bone Score which is available at a few NHS DEXA scanning units and at 25 Harley Street can improve the prediction of vertebral fractures and is not influenced to the same extent by those wear and tear changes which we sadly all get in time.

Are the treatments for those at significant risk for osteoporosis-related fractures safe?

The answer is undoubtedly YES with the benefits of therapy far out-weighing the risks of the drugs used for most patients. Drug treatment for prevention and treatment has suffered recently from scare stories which, while they should not be ignored, can be easily minimised with sensible prescribing.  It would be good if non-drug therapy such as diet and exercise was enough but sadly that is not the case in those at high risk. However for good bone health both men and women should ensure they get enough vitamin D from the sun and supplements combined (at least 400 IU daily as a standard for all adults and 800 IU for those with osteoporosis risk) along with moderate dietary calcium and as much weight bearing exercise as possible.

Can HRT help protect against osteoporosis?

HRT, which used to be first line therapy in women, has suffered from the “bad press” issue. However many experts would now agree that it can be used safely up  until the age of about 60 without significant excess risk of heart attacks, strokes or invasive breast cancer  – some specialists would say that some preparations of HRT can be used for a much longer period.

What other drugs are used to treat osteoporosis?

Bisphosphonates are the main group of drugs used in those who do not wish HRT or are over 60. They are also used in men! While generally well-tolerated the usually used versions alendronic acid and risedronate are given by mouth once weekly and have rather complex dosing instructions. They also can cause indigestion and often patients would prefer if they could be given by injection. The good news is that one, zoledronic acid, can be given by drip once per year and another drug which works in the same way on bone, denosumab, is given under the skin every 6-months. For those who have already had spine fractures or who have very severe osteoporosis, another drug called teriparatide, has strong bone building effects but needs to be injected under the skin by the patient and is rather expensive. All these treatments are available via the osteoporosis service at 25 Harley Street. All these drugs are generally safe and well-tolerated  but they do have some very rare side-effects which can be easily avoided with good advice from a specialist.