Diagnosing and treating Osteoporosis
Osteoporosis is a disease which makes bones brittle, leading to a higher risk of breaks than in normal bone. It occurs when bones lose minerals, such as calcium, more quickly than the body can replace them, causing a loss of bone thickness (bone density). Osteoporosis is a common disease in Australia with 1.2 million people estimated to be affected. In New Zealand, it is estimated that at least 1 in 3 women and at least 1 in 5 men will suffer from an osteoporotic fracture during their lifetime.
We spoke to endocrinologist and chemical pathologist, Dr Ailie Connell, to discuss the role of pathology in the diagnosis and management of the disease.
“Those most at risk of developing osteoporosis are post-menopausal women. During the menopause, oestrogen levels rapidly decrease, causing bones to lose calcium and other minerals at a quicker rate. In addition, as a person ages they lose bone density, so the older you are, the more fragile your bones become. There are also specific risk factors for osteoporosis including some diseases such as rheumatoid arthritis, chronic liver and kidney disease.
“Unfortunately most osteoporosis is asymptomatic; there are no early signs. The first sign that someone is developing osteoporosis would be if they broke a bone in a situation where you wouldn’t expect to break a bone. This would be called a minimal trauma fracture. Osteoporosis can also be picked up in people who are at risk by doing bone mineral density testing, which is a type of X-ray” said Dr. Connell.
A bone mineral density test is performed to determine how rich a person’s bones are in minerals such as calcium and phosphorus. The higher the mineral content, the stronger, denser and less likely to break is the bone. The bone density scan will determine if bones are in the range of normal, low bone density (osteopenia) or osteoporosis, and whether any action is needed to improve bone health.
“The pathologist’s role is to look for reversible causes of osteoporosis, including imbalances in calcium levels. In terms of managing the disease, one of the major therapies for osteoporosis involves stopping the normal bone mechanism for removing and replacing bone so the bone is only replaced. This means that your bones can become stronger and it also means that the turnover is significantly decreased, so there is less renewing of the bones. We can monitor that through the use of assays called bone turnover markers”, said Dr Connell.
Most osteoporosis medicines work by making the cells that break down bone (osteoclasts) less active but allowing the cells that form new bone (osteoblasts) to remain active, therefore reducing bone loss and increasing bone strength over time.
“Bisphosphates, widely prescribed for the treatment of osteoporosis, include alendronate, risedronate, ibandronate and zoledronic acid. There is another drug on the market called denosumab which is very similar, and these are all known to reduce the risk of fractures significantly and to offer a good prognosis. However, I do find it difficult to say ‘prognosis’ because, while these drug therapies reduce the risk of fracture by 30%, the patient still has a significant risk of fracture, which can still get worse over time. This risk of fractures is still there, it is just less than it would have been.
“There are new drug therapies but they are not in practice yet and they are still a few years away yet” said Dr. Connell.
It is important not to rely solely on medications for the treatment of osteoporosis. Regular exercise, good nutrition including calcium-rich foods, avoiding smoking, and limiting alcohol consumption can all have positive effects on bone health.
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This article appeared in the October 2018 Edition of ePathWay which is an online magazine produced by the Royal College of Pathologists of Australasia (http://www.rcpa.edu.au/Library/Publications/ePathway).
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