Herni Suprapti

Osteoporosis is a condition characterized by a

decrease in the density of bone, decreasing its
strength and resulting in fragile bones.

Osteoporosis literally leads to abnormally porous

bone that is compressible, like a sponge.

This disorder of the skeleton weakens the bone and

results in frequent fractures (breaks) in the bones.

is a condition of bone that is slightly less dense than

normal bone but not to the degree of bone in
osteoporosis.

Normal bone is composed of protein, collagen, and

calcium, all of which give bone its strength.

Bones that are affected by osteoporosis can break

(fracture) with relatively minor injury that normally
would not cause a bone to fracture.

The fracture can be either in the form of cracking

(as in a hip fracture) or collapsing (as in a compression
fracture of the vertebrae of the spine).

The spine, hips, ribs, and wrists are common areas

of bone fractures from osteoporosis although
osteoporosis-related fractures can occur in almost any
skeletal bone.

Building strong and healthy bones requires an adequate

dietary intake of calcium beginning in childhood and
adolescence for both sexes.

Most importantly, however, a high dietary calcium

intake or taking calcium supplements alone is not
sufficient in treating osteoporosis and should not be
viewed as an alternative to or substituted for more potent
prescription medications for osteoporosis.

In the first several years after menopause, rapid bone

loss may occur even if calcium supplements are taken.

800 mg/day for children 1-10 years of age

1,000 mg/day for men, premenopausal women, and

postmenopausal women also taking estrogen

1,200 mg/day for teenagers and young adults 11-24 years of

age

1,500 mg/day for postmenopausal women not taking

estrogen

1,200 mg-1,500 mg/day for pregnant and nursing mothers

The total daily intake of calcium should not exceed 2,000 mg.

Excluding dairy products, the average American diet contains

approximately 250 mg of calcium.

There is approximately 300 mg of calcium in an 8-ounce glass of milk.

There is approximately 450 mg of calcium in 8 ounces of plain yogurt.

There is approximately 130 mg of calcium in 1 cup of cottage cheese.

There is approximately 200 mg of calcium in 1 ounce of cheddar cheese.

There is approximately 90 mg of calcium in cup of vanilla ice cream.

There is approximately 300 mg of calcium in 8 ounces of calcium-fortified

orange juice.

Unfortunately, surveys have shown that the average

woman in the U.S. is consuming less than 500 mg of
calcium per day in their diet, less than the
recommended amounts.

Additional calcium can be obtained by drinking more

milk and eating more yogurt or cottage cheese or by
taking calcium supplement tablets as well from
calcium-fortified foods, such as orange juice.

The various calcium supplements contain different

amounts of elemental calcium (the actual amount of
calcium in the supplement).

For example, Caltrate, Os-Cal, and Tums are calcium

carbonate salts.

Each 1,250 mg of calcium carbonate salt tablet (such as Caltrate

600 mg, Os-Cal 500 mg, or Tums 500 mg extra strength)
contains 500 mg of elemental calcium.

A person who needs 1,000 mg/day of calcium

supplement can take one tablet of Tums 500 mg extra
strength (containing 500 mg of elemental calcium)
twice daily with meals.

The calcium carbonate supplements are best taken

in small divided doses with meals since the intestines
may not be able to reliably absorb more than 500 mg
of calcium all at once.

Therefore, the best way to take 1,000 mg of a

calcium supplement is to divide it into two doses.
Likewise, a dosage of 1,500 mg should be split into
three doses.

are safe and generally well tolerated.

Side effects are indigestion and constipation.

Some patients have difficulty swallowing calcium tablets.

If constipation and indigestion occur with calcium carbonate supplements,

calcium citrate (Citracal) can be used.

In this situation, chewable candy-like calcium in the form of Viactiv is

available.

Certain medications can interfere with the absorption of

calcium carbonate.

Examples of such medications include proton pump inhibitor such as

omeprazole , lanzoprazole, and rabeprazole, which are used in treating
GERD (acid reflux) or peptic ulcers. When these medications are being
taken, calcium citrate is preferred.

Many "natural" calcium carbonate preparations,

such as oyster shells or bone meal, may contain high
levels of lead or other harmful elements and should
be avoided.

An adequate intake of calcium and vitamin D are

important foundations for maintaining bone density
and strength.

However, calcium and vitamin D alone are not

sufficient to treat osteoporosis and should be given in
conjunction with other treatments.

Vitamin D helps the absorption of dietary calcium

from the intestines.

The lack of vitamin D alone can cause calciumdepleted bone (osteomalacia), which further weakens
the bones and increases the risk of fractures.

Vitamin D, along with adequate calcium (1,200 mg of

elemental calcium), increase bone density and
decrease fractures in postmenopausal women but not
in premenopausal or perimenopausal women.

comes from the diet and the skin.

Vitamin D production by the skin is dependent on

exposure to sunlight.

Active people living in sunny regions (Southern California, Hawaii,

countries around the equator, etc.) can produce most of the vitamin D
they need in their skin.
Conversely, lack of exposure to sunlight, due to residence in northern
latitudes or physical incapacitation, causes vitamin D deficiency. In less
temperate regions such as Minnesota, Michigan, and New York,
production of vitamin D by the skin is markedly diminished in the
winter months, especially among the elderly. In that population,
dietary vitamin D becomes more important.

800 IU/d for men and women over the age of 71

600 IU/d for women in other age groups, men, and

children

400 IU/d for infants under 12 months

But if a person already has osteoporosis, it is

advisable to ensure 400 IU twice per day as the usual
daily intake, most commonly as a supplement
alongside prescribed medications for osteoporosis.

An average multivitamin tablet contains 400 IU of

vitamin D.

Therefore, one to two multivitamins a day should provide the

recommended amount of vitamin D.
Alternatively, vitamin D can be obtained in combination with
calcium in tablet forms, such as Caltrate 600 + D (600 mg of
calcium and 200 IU of vitamin D) and others.

Adequate levels of calcium and vitamin D are essential

for optimal bone health, especially when used with
prescribed medication for osteoporosis.

Chronic excessive use of vitamin D can lead to toxic

levels of vitamin D, elevated calcium levels in blood and
urine, and may also cause kidney stones.

Since various dietary supplements may also contain

vitamin D, it is important to review vitamin D content in
dietary supplements before taking additional vitamin D.

Estrogen hormone therapy after menopause

(previously referred to as hormone replacement
therapy or HRT) has been shown to prevent bone
loss, increase bone density, and prevent bone
fractures.

It is useful in preventing osteoporosis in

postmenopausal women.

orally (Premarin, Estrace, Estratest, and others) or

skin patch (Estraderm, Vivelle, and others).

is available in combination with progesterone as

pills and patches.

Progesterone is routinely given along with estrogen to prevent

uterine cancer that might result from estrogen use alone.

Women who have had a hysterectomy (surgical

removal of the uterus) may take estrogen alone since
they no longer have a uterus to become cancerous.

Nasally delivered estrogen

lower-dose combination pills of estrogen and
progesterone

However, due to adverse effects of HRT, such as

increased risks of heart attact, stroke, blood clots in
the veins, and breast cancer;

HRT is no longer recommended for long-term use in the therapy

of osteoporosis.
Rather, HRT is used short term to relieve menopausal hot
flashes.

antiresorptive agents
which decrease the removal of calcium from bones.

The bone is a living dynamic structure; it is

constantly being built and removed (resorbed).

This process is an essential part of maintaining the

normal calcium level in the blood and serves to repair
tiny cracks in the bones that occur with normal daily
activity and to remodel bone based on the physical
stresses placed on the bone.

Osteoporosis results when the rate of bone

resorption exceeds the rate of bone rebuilding.

Antiresorptive medications inhibit removal of bone

(resorption), thus tipping the balance in favor of bone
rebuilding and increasing bone density.

HRT is one example of an antiresorptive agent.

Others include

Alendronate
Risedronate
Raloxifene
Ibandronate
Calcitonin
Zoledronate
Denosumab

decrease the risk of hip fracture, wrist fracture, and

spine fracture in people with osteoporosis.

Alendronate
Risedronate
Ibandronate
Zoledronate

To reduce side effects and to enhance absorption of

the medicine, all bisphosphonates taken by mouth
(orally) should be taken in the morning, on an empty
stomach, 30 minutes before breakfast, and with at
least 8 ounces (240 ml) of water (not juice).

This improves the absorption of the biphosphonate.

Taking the pill sitting or standing (as well as drinking

adequate amounts of liquids) minimizes the chances of
the pill being lodged in the esophagus, where it can cause
ulceration and scarring.

Patients should also remain upright for at least 30

minutes after taking the pill to avoid reflux of the pill into
the esophagus.

Newer intravenous bisphosphonates, such as

ibandronate and zoledronate, bypass the potential
esophagus and stomach problems.

Food, calcium, iron supplements, vitamins with

minerals, or antacids containing calcium, magnesium,
or aluminium can reduce the absorption of oral
bisphosphonates, thereby resulting in loss of
effectiveness.

Therefore, oral bisphosphonates should be taken

with plain water only in the morning before breakfast.
Also, no food or drink should be taken for at least 30
minutes afterward.

Raloxifene (Evista)

SERMs work like estrogen in some tissues but as an

antiestrogen in other tissues.

The SERMs were developed to reap the benefits of

estrogen while avoiding the potential side effects of
estrogen.

Thus, raloxifene can act like estrogen on bone but as an

antiestrogen on the lining of the uterus where the effects
of estrogen can promote cancer.

The first SERM to reach the market was tamoxifen,

which blocks the stimulative effect of estrogen on
breast tissue.

Tamoxifen has proven valuable in women who have

had cancer in one breast for preventing cancer in the
second breast.

is the second SERM to be approved by the FDA.

Evista has been approved for the prevention and

treatment of osteoporosis in postmenopausal
women.

was found to increase bone density (and lower LDL

cholesterol) while having no detrimental effect on the
uterine lining (which means that it is unlikely to cause
uterine cancer).

Because of its antiestrogen effects, the most common side effects

with Evista are hot flashes

Conversely, because of its estrogenic effects, Evista increases the

risk of blood clots, including deep vein thrombosis (DVT) and
pulmonary embolism (blood clots in the lung).

The greatest increase in risk occurs during the first four months of
use.

Patients taking raloxifene should avoid prolonged periods of

immobility during travel, when blood clots are more prone to occur.
The risk of deep vein thrombosis with raloxifene is probably
comparable to that of estrogen, about two to three times higher
than the usual low rate of occurrence.

decreases the risk of spinal fractures in

postmenopausal women with osteoporosis, but it is
not known if there is a similar benefit in decreasing
the risk of hip fracture.

(The only agents that are definitely proven to

decrease the risk of hip fracture are bisphosphonates
and denosumab.)

is a hormone for treating osteoporosis.

come from several animal species, but salmon calcitonin

is the one most widely used.

can be administered as a shot under the skin

(subcutaneously), into the muscle (intramuscularly), or
inhaled nasally (intranasally).

Intranasal calcitonin is the most convenient of the three

methods of administration.

has been shown to prevent bone loss in

postmenopausal women.

In women with established osteoporosis, calcitonin

has been shown to increase bone density and
strength in the spine only.

is a weaker antiresorptive medication than bisphosphonates.

is not as effective in increasing bone density and

strengthening bone as estrogen and the other antiresorptive
agents, particularly bisphosphonates.

In addition, it is not as effective as bisphosphonates in

reducing the risk of spinal fractures and has not been proven
effective in reducing hip fracture risk.

Therefore, calcitonin is not the first choice of treatment in

women with established osteoporosis.

Nevertheless, calcitonin is a helpful alternative treatment for

patients who cannot tolerate other medications.

Common side effects of either injected or nasal

spray calcitonin are nausea and flushing.

Patients using Miacalcin Nasal Spray can develop

nasal irritation, a runny nose, or nosebleeds.

Injectable calcitonin can cause local skin redness at

the site of injection, skin rash, and flushing.