INTRODUCTION:

Very simply put, osteoporosis is a condition of the bones and joints which become fragile due to calcium deficiency. Our bones are essentially made of 3 major minerals, namely, calcium, phosphorus, and magnesium. Out of these, calcium is the most important of all since it is the chief constituent of the bone mass. Another important factor is of vitamin D, which is also known as the sunshine vitamin because the skin can synthesize the vitamin in presence of sunlight. Vitamin D is essential as it helps the body absorb the calcium from the foods in the intestine. Without vitamin D, calcium absorption remains poor, even with sufficient intakes, thus resulting in the deficiency.Calcium itself is a mineral which is an important constituent of bones, teeth and plays a very crucial role in heart rhythm regulation and other important metabolic functions.

The body always gives preference to maintaining the levels of calcium in the blood constant, which means that bones are second on the list! Whenever the levels of calcium go low in the blood, calcium from the bones are mobilized to meet the shortfall. Over a period of time, the bones become weak and fragile due to the loss of calcium.

In women, hormones play a major role too in bone strength. The female hormone estrogen ensures calcium is absorbed with the help of vitamin D. In menopause and in the postmenopausal state, this hormone levels drop, which means less and less of calcium, is absorbed. Certain medications and long-term steroid use can also result in osteoporosis.

Symptoms of Osteoporosis:

Weak, fragile bones and joints are usually the main characteristics. Fractures are sometimes the first sign of osteoporosis and are usually the time at which point the condition is diagnosed. Hip and wrist are most commonly affected, but other joints can be affected as well.

Management of Osteoporosis:

Nutrition:

Nutrition is the cornerstone of management and prevention of osteoporosis. The major bone minerals are calcium and vitamin D, which are essential for preventing osteoporosis. Calcium is what imparts the hardness or strength to the bone, although phosphorus and magnesium also play a role. A diet deficient in calcium could be the major risk factor. Although calcium is present in many foods, its bioavailability remains a challenge since it is not 100% absorbed in the intestine. Dairy products such as milk, curd, yogurt, cheese, paneer63 are the best sources of calcium from which about 35% of calcium is absorbed.

Studies conducted by the National Institute of Nutrition in India also report that Indian diets are poor in calcium and there is a very low intake of this mineral. Besides, there are some substances present in vegetarian sources, called pytates, which impair the absorption of calcium. Indian habitual diets as per a study was done by Harinarayan et al have a higher amount of phytates as compared to western diets.

Improving calcium intake is essential. Dairy products such as milk, yogurt, curd, paneer being the best sources should be included in the daily diet. About 800ml of a combination of the above-mentioned dairy products would provide the day’s recommended amounts of calcium. Other sources include fish, chicken, seafood and vegetarian sources include green leafy vegetables, millets like ragi and bajra, whole pulses like horse gram, kidney beans, moong, seeds, and nuts.

Vitamin D:

This sunshine vitamin is manufactured in the human skin when exposed to sunlight. Certain hormones in the human skin can convert an inactive substance to the active form of vitamin D with the help of ultraviolet rays of the sun. Even though there is plenty of sunshine in most places around India, there is still a widespread deficiency of vitamin D. This could be because of the increased amounts of time spent indoors in air-conditioned offices, less time out in the playgrounds as far as children are concerned, increased use of sunscreens, scarves or full-length dresses worn by women. Additionally, vegetarian diets are devoid of vitamin D since the only known sources of this vitamin are fish such as cod, fish eggs, and whole eggs. A study done recently in 2016, found that the bone mineral density at the hip was significantly reduced due to vitamin D deficiency in urban Indians.

Malnutrition:

Having a low body mass index of below 18 is known to increase the risk of osteoporosis. Malnutrition or undernutrition also is many times synonymous with low body fat percentage. Many studies have linked body fat with bone health, with fat being essential to develop the skeleton that has the correct density.

Physical Activity:

A sedentary lifestyle that has become the hallmark of urbanization has resulted not only less time spent outdoors but also poor physical activity. Weight-bearing and strengthening exercises such as weight training enhance the bone strength and calcium uptake of bones. Even with abundant calcium in the diet, if bones and muscles are not exercised, they do not actively take up the calcium. Regular physical activity and strengthening exercises will help keep osteoporosis at bay.

Hormones and steroids:

Decreasing hormone levels put women of menopausal age at increased risk for osteoporosis. Many women are placed on hormone therapy to treat menstrual irregularities or menopausal symptoms. Steroid use to is a major risk factor for osteoporosis. Optimizing calcium and vitamin D intake when steroids are inevitable, exercising regularly and taking up weight training, ensuring sunlight exposure are some of the ways to minimise the damage caused by steroids or decreasing levels of hormones.

Types of osteoporosis:

Postmanupasual Osteoproisis:

The word osteoporosis virtually means "porous bones." It happens once bones lose associate degree excessive quantity of their protein and mineral content, mainly calcium. So, bone mass and bone strength gets decreased. As a result, bones become fragile and break simply. Even a sneeze or a small movement is also enough to interrupt a bone in somebody with severe pathology.

Estrogen Osteoporosis:

Women have the higher incidence of osteoporosis than men do. The disease typically progresses with no symptoms or pain. Generally, pathology is not seen, till the weakened bones cause painful fractures, typically within the back or hips. Estrogen does not improve the activity of cells that build bone it will cut back the activity of the cells that take away bone, known as the osteoclasts.

Alcohol Osteoprosis:

Alcohol directly impacts bone health for several reasons. Because, excessive alcohol interferes calcium balance, which is an essential nutrient for healthy bones. It also increases the parathyroid hormone levels, in turn reduce the body’s calcium. Calcium balance is further varied by alcohol ability to interfere with the production of vitamin, essential for calcium absorption.

Osteoporosis in Women:

There are different reasons why women are more prone to get osteoporosis than men, including: Women have a tendency to have slender bones than men. Estrogen, a hormone in ladies that secures bones, diminishes pointedly when ladies achieve menopause, which can bring about bone degradation. Osteoporosis becomes common with age. Fractures are the most dangerous part of osteoporosis.

Steroid-induced Osteoporosis:

The word osteoporosis means porous bones. Steroid-induced osteoporosis is osteoporosis, arising due to use of glucocorticoids, involving mainly the axial skeleton. The synthetic glucocorticoid drug, prednisone is the main cause after prolonged intake. The use of thiazide diuretics and gonadal hormone replacement has also been recommended, with the use of calcitonin, bisphosphonates and sodium fluoride.

Primary Osteoporosis:

There are two types of osteoporosis: primary and secondary. In case of primary osteoporosis, the condition is caused by age-related bone loss (sometimes called senile osteoporosis) or the cause is unknown (idiopathic osteoporosis). The term, idiopathic osteoporosis is used only for men less than 70 years old. The majority of men with osteoporosis have one secondary cause.

Alternative Treatment of Osteoporosis:

The goal of any alternative treatment is, to find ways in managing diseases or healing without the use of drugs. Herbs and Supplements Used for Osteoporosis are Red Clover, soybeans and Black Cohosh. Acupuncture is the therapy, used in traditional Chinese medicine. This practice involves placing very thin needles in strategic points on the body. This is believed to stimulate various organs and body functions that may help in healing.

Osteomalacia:

Osteomalacia is the softening of the bones caused by decreased bone mineralization. Osteomalacia, in children is known as rickets. Signs and symptoms can include diffuse body pains, muscle weakness and fragility of the bones. The most common cause of osteomalacia is deficiency of vitamin D. Measures to prevent and treat osteomalacia usually involve intake of vitamin D and calcium supplements.

Osteomyelitis:

Osteomyelitis is infection and inflammation of the bone or bone marrow. It can be subclassified on the basis of the causative organism and the route, duration and anatomic location of infection. Chronic Osteomyelitis is often defined as Osteomyelitis, which has been present for more than one month. In children, long bones are usually affected. In adults, vertebrae and pelvis are most commonly affected.

Idiopathic Osteoporosis:

Osteoporosis is rare in children. When it occurs, it is usually caused by an underlying medical disorder or by medications used to treat the disorder. This is known as secondary osteoporosis. Sometimes there will be no cause of osteoporosis in a child. This type of osteoporosis is known as idiopathic osteoporosis.

Treatment for osteoporosis:

Advanced Osteoporosis Treatment:

Sodium fluoride is employed to treat Osteoporosis in women. It stimulates bone formation and will increase bone density in ladies with Osteoporosis by eight per cent annually within the spine and by four percent within the proximal femur. However it decreases cortical bone density within the radius by two per cent annually. Bone with excess fluoride content has associate abnormal structure, and its fragility could also be increased. So sodium fluoride therapy will increase bone mineral density.

Osteoporosis Treatment Program:

If you have osteoporosis, your treatment program will focus on:

· Proper nutrition – especially a diet rich in calcium and vitamin D, which may include a recommendation to take calcium and vitamin D supplements

· Exercise, which not only improves your bone health but increases muscle strength, coordination and balance.

· Safety issues to prevent falls that may result in fractures, such as removing loose rugs around your house.

In addition, your physician may prescribe a medication to slow or stop bone loss, increase bone density, and reduce your risk of fracture.

Bisphosphonates:

Bisphosphonates, the most commonly used medications used to treat osteoporosis, decrease the activity of bone-dissolving cells. Throughout your lifetime, old bone is removed and new bone is added to your skeleton. As you get older the breakdown of your bone gets faster – the bisphosphonates slow down that process.

Bisphosphonates have been approved by the U.S Food and Drug Administration (FDA) for both the prevention and treatment of osteoporosis for women after menopause and for men.

The following bisphosphonates have been approved by the FDA for sale in the U.S.:

Actonel (risedronate):

· Can increase your bone mass and reduce your chances of spine, hip, and other fractures.

· Is available in daily, weekly, twice monthly, and once-a-month doses.

Boniva (ibandronate):

· Can reduce your chances of spine fractures. Boniva does not reduce your chances of hip and other fractures.

· Is available in a monthly dose and as an intravenous injection given once every three months.

Fosamax (alendronate):

· Can increase your bone mass and reduce your chances of spine, hip, and other fractures.

· Is available in daily and weekly doses.

Reclast (zoledronic acid):

· Can increase your bone mass and reduce your chances of spine, hip, and other fractures.

· Is available as an intravenous injection given once yearly.

Side effects for oral bisphosphonates include gastrointestinal problems such as difficulty swallowing, inflammation of the esophagus and stomach ulcers.

Side effects for intravenous bisphosphonates include flu-like symptoms, fever, pain in muscles or joints, and headache. These side effects can occur shortly after receiving an infusion and generally stop within two to three days. There also have been rare reports of osteonecrosis of the jaw and of visual problems in people taking oral and intravenous bisphosphonates.

Raloxifene:

Evista (raloxifene), approved by the FDA for the prevention and treatment of osteoporosis for women after menopause, belongs to a class of drugs called selective estrogen receptor modulators (SERMs). Evista has estrogen-like effects on the skeleton but blocks estrogen effects in the breast and uterus. Evista slows bone loss and reduces your risk of fractures in the spine, but no effect on hip fractures has been seen. Evista can also be used to help prevent breast cancer in women who are at high risk for breast cancer. Evista is taken in pill form once each day. While side effects are not common with Evista, you may experience hot flashes and blood clots in deep veins.

Calcitonin:

Calcitonin, available as brand name Miacalcin and Fortical, is a naturally occurring hormone that helps to regulate calcium levels in your body.

In women who are at least five years past menopause, calcitonin slows bone loss; increases spinal bone density, reduces the risk of spinal fractures, and may relieve the pain associated with bone fractures.

Calcitonin is available as an injection (given under the skin or into a muscle every day or every other day) or as a daily nasal spray.

Injectable calcitonin may cause an allergic reaction and unpleasant side effects including flushing of the face and hands, frequent urination, nausea, and skin rash. The only side effect reported with nasal calcitonin is nasal irritation.

Teriparatide:

Forteo (teriparatide), an injectable form of human parathyroid hormone, is approved for postmenopausal women and men with osteoporosis who are at high risk for having a fracture.

Unlike the other drugs used in osteoporosis, Forteo acts by stimulating new bone formation in both the spine and the hip. Given as a daily injection for up to 24 months, it increases bone tissue and bone strength and has been shown to reduce the risk of spine and other fractures.

Side effects include nausea, dizziness, and leg cramps.

Forteo also has a black box warning from the FDA because of the small possibility that Forteo may increase your risk of developing osteosarcoma, a rare but serious cancer. Because of this risk, you should not use Forteo unless you have osteoporosis and at least one of the following conditions is met: You have already had at least one bone fracture; your doctor has determined that you are at high risk of fractures, or you cannot take or do not respond to other medications for osteoporosis.

Estrogen/Hormone Therapy (ET/HT):

ET/HT has been shown to reduce bone loss, increase bone density in both the spine and hip, and reduce the risk of spine and hip fractures in postmenopausal women. ET/HT is most commonly given in the form of a pill or skin patch.

When estrogen – also known as estrogen therapy or ET – 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 – also known as hormone therapy or HT – in combination with estrogen for those women who have not had a hysterectomy.

Side effects of ET/HT include vaginal bleeding, breast tenderness, mood disturbances, blood clots in the veins, and gallbladder disease.

Because of recent evidence that breast cancer, strokes, blood clots, and heart attacks may be increased in some women who take estrogen, the FDA recommends that you take the lowest effective dose for the shortest period possible. Estrogen should only be considered if you are at significant risk for osteoporosis, and you should consider first taking osteoporosis medications that do not have any estrogen.

New Injectable Osteoporosis Drug Approved:

The FDA has approved abaloparatide (marketed as Tymlos) for the treatment of postmenopausal women with osteoporosis who are at high risk for fracture — that is, those who have had a prior osteoporotic fracture, have multiple fracture risk factors, or have failed or cannot tolerate other osteoporosis therapies.

The osteoanabolic agent is a synthetic analog of human parathyroid hormone (PTH)-related protein. Approval was based on findings from a placebo-controlled, phase III trial in which abaloparatide reduced the incidence of new vertebral fracture by 86% over an 18-month period. The drug also cut the risk for nonvertebral fracture by 43%. Teriparatide, a previously approved recombinant PTH, showed similar benefits in the same trial.

Abaloparatide is given as a daily, subcutaneous injection. Like teriparatide, its label carries a warning about a potentially increased risk for osteosarcoma.

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Received on 30.06.2017 Accepted on 14.07.2017

Asian J. Pharm. Res. 2018; 8(1):39-43.

DOI: 10.5958/2231-5691.2018.00008.4