Fragile: handle with care

Old age and osteoporosis is like a package deal. One inevitably follows the other. Yet, the awareness level one of the most common diseases is abysmally low. Garima Arora gives a low down on the 'disease of the bones'

There are a number of factors that contribute to the strength of the skeleton and its ability to withstand trauma and avoid fractures. However, one of the most important contributory factors to this is the bone mineral density. It is known that a child from birth up to the age of 20-25 years gains bone mass. It is at this age that the individual reaches what is called the peak mass index (PMI) of the bone. And beyond this age both men and women gradually lose bone as part of the aging process. This is when the horrors of osteoporosis set in.

Osteoporosis essentially means weakening of the bone. 'Osteo' means bone and 'porosis' means porous. So it is basically a skeletal disorder characterised by compromised bone strength that increases the risk of fracture.

The causes

The onset of osteoporosis depends on the peak adult bone mass of the individual and the speed of bone loss in latter years of life. "In developing countries like India, there is a lot of malnutrition and under nutrition. Intake of Calcium and Vitamin D is low. Because of this the Peak mass of the bone to begin with is only low. Since this peak bone mass becomes like your bank balance for life any further deterioration is like a withdrawal from an already low or exhausted fund. And hence we see diseases like osteoporosis to be so rampant," says Dr Manoj Chaddha, Managing Director-Endocrinology, a consultant at Mumbai's Hinduja Hospital.

"The peak bone mass of an individual is also determined by genetics, but may also be modified by environmental factors. It is believed that genetic factors contribute up to 60-80 percent to the bone mass, while environmental factors account for the remaining 20-40 percent," says Dr Manoj R Kandoi, Consulting Orthopaedic and Trauma Surgeon, Founder President, Institute of Arthritis Care and Prevention. Genetically there are two main factors that effect the bone mass and skeletal formation of an individual, namely race and gender. For e.g. Caucasian females tend to have a lower peak bone mass than African- American women. Also peak bone mass is lower in women than in men. Before puberty bone mass is acquired at equal rates but after puberty males tend to acquire greater bone mass than females. Also factors like menstrual cycle and multiple pregnancies effect degeneration of bones further. This is probably one of the reasons that osteoporosis is more common in women than in men.

For women who are more affected by the disease than men it is menopause, which is the threshold. Since it is the oestrogen hormone that has a protective effect on the bones, post menopause Osteoporosis sets in rapidly. However this degeneration is always a combination of osteoporosis and some amount of osteomalacia, which is degeneration of bones in elderly people. Post menopause, a woman loses bone mass at around three percent per year. In fact it is only beyond the age of 60-65 that men tend to lose the same amount of bone. This aging process coupled with lifestyle inadequacies like smoking, consuming excessive alcohol, physical inactivity and lower intake of calcium and Vitamin D especially after a pregnancy leaves a woman more vulnerable to the disease.

"People relate osteoporosis with old age and women only. This can be very wrong. An individual can develop osteoporosis due to medically related reasons also," says Dr Kaushik Bhujani, Rheumatologist, Wockhardt Hospitals. For e.g. if an individual has a thyroid deficiency and is on thyroid supplementation, over time the bones of the person do tend to become weak. Also, rheumatical arthritis is known to cause osteoporosis as so is spondilysis. Surgery of the stomach or any disease affecting the bone marrow can also lead to osteoporosis. Long term treatment of steroids, use of anticonvisants, antipsychotics, tricyclic, antidepressants and long acting benzodiazepines also make an individual vulnerable to the disease.

The numbers

What reflects best the lack of awareness of the disease in India and other developing countries is that that there is no dependable data available on the incidence of the disease. There are no objective statistics or numbers available that supplement quantitative quotes. "We are overwhelmed by the number of patients that we see. There isn't any kind of a methodological database from where you can quote and say that these are the number of patients that you see. The numbers would be large. But we do not have any data," says Bhujani. Relying on international figures for osteopeorosis incidence would not give a true picture for India given that the disease depends on the gene pool of the population.

Rx

"The market for osteoporosis is very big!" exclaims Bhujani. However, until a few years ago the only molecule one ever heard of was Osteofos. And the only company producing it was Cipla. It had become a household name to an extent that if a prescription were given to a chemist asking for Restofos he would still refill the prescription for Osteofos. However, today a combination of drugs, lifestyle changes and precautionary measure seems to be what every doctor is prescribing.

In a proven case of osteoporosis the minimum amount of calcium that ought to be prescribed is 1000 mg of elemental calcium. The emphasis here is on the term 'elemental calcium'. However, consumption of elemental calcium is different from the regular calcium available in the market. Tablets that claim containing 500 mg of calcium in fine print will equal to elemental calcium of 200 mg because for a tablet with 1000 mg the elemental calcium is only 40 percent. In effect if it is calcium citrate that one is prescribed elemental calcium is only 24 percent. "So if you were to walk into a chemist shop and were to say give me the best calcium tablet that is available say a 1000 mg tablet when you read the fine print you will see the elemental calcium is 240 mg only," explains Bhujani. So what you require is at least 1000 mg of elemental calcium and sometimes 1500 mg depending on the severity of the case. This along with vitamin D, which is prescribed at least 800 international units per day, is what forms the basic medication to deal with osteoporosis. "Each tablet of calcium even today only contains 250 international units. So we are deficient to start with, even with the tablets," adds Bhujani.

Coupling this basic medication routine with some sort of physical activity is very essential. Most doctors today prescribe weight-bearing exercises since gravitational exercises tend to improve bone mass. Beyond this there are two kinds of drugs available. One that prevent bone loss and the other that promote bone growth. Both are different in functionality and utility and are prescribed according to severity of the disease. Attempts at reducing bone loss involve use of standard medication of calcium and Vitamin D to begin with. Alendronate is the drug the brand Ostephous contains. Risedronate is a newer generation molecule of alendronate. What these drugs do is that they reduce further bone loss. They are available in very convenient preparations to be taken only once a week, which really does not take a lot of effort from the patient's side. Today, one of the latest preparations is emandronate, which has to be taken only once a month. These are the anti resoptive agents, which prevent further bone resoption. These drugs cannot be prescribed until the patient is adequately supplemented with calcium and Vitamin D, which bring us back to the basic medication.

Technology and advanced R&D brings more sophisticated means of administering medication, like a spray called Calcitonen, which is to be taken intra-nasally. All the patient needs to do is take two puffs into their nostrils. The same medication is also available as an injectable, where the patient administers the drug the same way a diabetic would use insulin injections. Though it is known to reduce in efficacy over a period of time, it does reduce bone pain especially in the case of osteoporosis-related fractures, which can be very painful. However, one of the biggest drawbacks of this drug is that it is expensive. While Novartis markets the product in the international market, Sun Pharmaceuticals' Osteospray is available in the domestic market.

Over the years, hormonal medication for osteoporosis has received flack from many doctors. It has been proved that hormone supplements cannot be prescribed to a patient at just any point in time as they have a lot of side effects including the risk of breast cancer. However, there are other molecules available, called hormone agonists, which mimic the behaviour of hormones, and improve the bone strength. One such hormone agonist is relaxofine, which is similar to oestrogen. The hormone agonist contributes marginally to the improvement of bone mass. Another alternative is strontium ranelate which is available in the powder form. This increases bone strength without adding to the bone in any way. It's like a metallic powder that deposits there.

Human parathyroid hormone, which is also called human parathormone, is a popular drug in the bone forming segment. This is available by the brand name Forteo. Eli Lilly is the only company in the world manufacturing it. More importantly, this is the only molecule in the world that increases bone mass by actually contributing to bone mass.

"In the end it all comes down how aware people are. Though we are still low on that quotient there are people making efforts," says Chadha. The National Osteoporosis Foundation (NOF), provides recommendation for healthy bones for all patients. The manifest recommends adequate intake of at least 1200 mg/d of dietary calcium and 400-800 international units of Vitamin D, regular weight bearing and muscle strengthening exercises and avoidance of tobacco use and alcohol abuse.

The other side

Side effects are as inherent to a drug as the qualities that it possesses to fight the ailment.

Alentorate and risedronate belong to the bisphosphonate family. An important thing to keep in mind with these drugs is that they need to be taken on an empty stomach in the morning with water and the patient needs to be in an upright position for an hour after taking the medicine. If the tablet happens to come in contact with the food pipe it will cause an ulcer there called oesophagitis. Constant consumption of drugs tends to have a reciprocally adverse effect on the bones of the patient. These medicines become deposited in the bones of the patient. Beyond a point of time the bone might become saturated with these medicines, which might be a problem. Thirdly, these drugs cannot be administered during pregnancy if the case of osteoporosis is not related to menopause.

One of the foremost reasons osteoporosis is so rampant and appears in such severity is because there is no awareness. "Even in a metro like ours I come across people quite often who have not even heard the term 'rheumatology /rheumatologist'. I sincerely believe that a lot needs to be done in my specialty to be able to take it to the masses. There is hardly any Indian data on the behaviour of rheumatic diseases and the response to treatment in our people. Patient education, clinical research, and epidemiological studies in Indians with rheumatic diseases need to be carried out," says Bhujani. This is probably another evil that if not at least destroyed, but can be bought under check with adequate knowledge. "Knowing your enemy well enough is half the battle won," says Chadha.

garima.arora@expressindia.com