What is osteoporosis?

Osteoporosis is a bone condition where you have weakness or decreased strength in your bones. Osteoporosis is caused by the loss or breakdown of bone and can also be referred to as low bone mass (quantity). Loss and breakdown of bone can lead to bone fractures especially in areas of the spine, wrist, hip, and shoulder.

Osteoporosis can occur in both women and men and typically occurs later in life. Bone loss has no symptoms until you break a bone. Breaking bones can decrease your ability to carry out everyday activities, cause disfigurement, and affect your mobility and even self-esteem.

What causes osteoporosis?

There is no single cause for osteoporosis because bone loss can occur as a result of many risk factors. Some of these risk factors can be things you can change (potentially modifiable) and some of these risk factors are things you cannot change (non-modifiable).

Risk factors that contribute to development of osteoporosis include:

• Age
• Gender (women more likely than men)
• Genetic susceptibility (often detected by having a parent with a history of hip fracture)
• Menopause, especially if prior to age 45
• Use of certain medications
• Having a medical condition that may contribute to bone loss such as thyroid conditions, hormone disorders, Rheumatoid Arthritis, Celiac disease, conditions that affect the absorption of foods, chronic liver or lung disease
• Low body weight
• Consuming 3 or more alcoholic drinks per day
• Smoking
• Having a sedentary (inactive) lifestyle

Having one or more of these risk factors that causes osteoporosis can increase your chances of breaking a bone. A fragility fracture is commonly used to describe the type of fracture (breaking of bone) that occurs with osteoporosis. When you break a bone with a fall that was from standing height or less, this is referred to as a fragility fracture. The most common site for a fragility fracture is the spine, wrist, hip, and shoulder.

What is the role of Bone Density Tests?

This is an enhanced type of x-ray exam used to measure the density of your bones – it is known as a dual energy x-ray absorptiometry (DXA or DEXA). As you lay on a special exam table, an x-ray is used to scan your spine, one (or both) hips to determine the amount of x-ray that can pass through your bones. A radiologist will interpret your exam by analyzing the images taken, and send a report to your referring doctor. Your result will often be reported in the form of a score:

T-Score: This is a mathematical number (the number of standard deviations above or below the average) showing the amount of bone you have compared to that of an AVERAGE younger/healthy adult with peak bone mass of the same gender. A negative T-score means you are below the average. The lower the T-score, the farther below average your bone density is.

A DXA or DEXA BMD is one diagnostic tool often used to help diagnose osteoporosis and assist in determining an individual’s risk for developing a fracture(s) over time; it is not a routine test to be done automatically each year, but rather should be carefully selected based upon the presence or absence of other fracture risk factors. It is important to remember the risk of developing osteoporosis is not determined by one diagnostic tool or test alone. Having a low BMD is only ONE risk factor for Osteoporosis. You also need to consider the other risk factors that cause osteoporosis.

What are my chances of having a fracture?

Having one or more of the risk factors that causes osteoporosis can increase your chances of breaking a bone. There are two tools that can be used to calculate the risk of you having a fragility fracture over the next 10 years: the CAROC (Canadian Association of Radiologists/Osteoporosis Canada) risk calculator and the FRAX® (World Health Organization) risk calculator. Your risk of breaking a bone over the next 10 years is calculated in the form of a percentage.

CAROC (Canadian Association of Radiologists/Osteoporosis Canada)

This is a tool used by medical professionals to calculate your absolute 10-year risk of having a fracture. It will look at your BMD, age, gender, fracture history and steroid use to determine your 10-year risk of having a fracture. This is the link to the CAROC tool: http://www.osteoporosis.ca/multimedia/pdf/CAROC.pdf

FRAX® (World Health Organization)

This is a tool developed by the World Health Organization (WHO) to calculate the risk of you having a hip fracture or major orthopaedic fracture (spine, forearm, hip and shoulder) over the next 10 years. Your risk is calculated according to the region (CANADA) you live, and provides an estimate of the percentage chance of you breaking a bone (hip and major orthopaedic) over the next 10 years. This is the link to the FRAX® tool: http://www.shef.ac.uk/FRAX/

What is the role of nutrition for Bone Health?

Most of what you see and read about nutrition and bone health is about calcium and vitamin D.   Although calcium and vitamin D have their roles, it is also important to eat a well-balanced diet which includes vegetables, fruits, whole grains and protein-rich foods.  These foods provide many nutrients that are important for our bones such as vitamin D, vitamin K, magnesium, phosphorus, potassium, protein and anti-oxidants.  Eating a well-balanced diet will also give you the energy and protein your body needs to not only maintain a healthy weight, but function well.  For online tools and resources to support Canadians with health eating, please visit Canada's Food Guide

Also, check out Eating Well with Osteoporosis from Alberta Health Services

Calcium/Vitamin D: An area of ongoing controversy - the views expressed below reflect the updated (October 2018) opinions of the Osteoporosis Clinic physicians.

Calcium and vitamin D supplementation have long been considered an important part of maintaining bone health.  This is because the skeleton cannot harden properly without enough calcium and vitamin D.  However, as more research is done, we are learning that although calcium and vitamin D are important for bone health, this does not necessarily mean that everyone needs to take calcium and vitamin D supplements.

For the majority of adults, recent research has shown that calcium and vitamin D supplements most likely have no effect (or a very tiny effect) on bone density and risk of fracture.  In addition, a large trial just completed at the University of Calgary showed that taking high doses of vitamin D (4000 IU per day or more) had detrimental effects on bone density and bone structure.  This study also found an increased risk of having high levels of calcium in the urine (possible kidney stone risk) with high dose vitamin D supplementation.

Healthy adults over age 50 who have not had any osteoporotic fractures and are not on treatment with osteoporosis medications may not get any significant benefits from calcium and vitamin D supplements.  Taking into account the research that is available at this time, it is reasonable for these individuals to aim to achieve a total daily calcium intake of 1200 mg through their diet.  it is not clear whether people with dietary calcium intake of less than 1200 mg/day get any benefit from supplementation with additional calcium.  Vitamin D supplementation with 400 to 1000 IU/day might be considered, as this dosage range is expected to prevent vitamin D deficiency in most people and is unlikely to cause harm.

It is still possible that calcium and vitamin D supplementation may have bone health benefits in adults who are taking osteoporosis medications, and in the elderly, especially those who live in an assisted living facility or nursing home.  For these individuals, getting 1200 mg of calcium each day (ideally through diet) and taking vitamin D 800-1000 IU/day may be beneficial and is unlikely to be harmful.  Daily vitamin D doses of up to 2000 IU/day have not been shown to cause any harm although is it also not clear whether increasing the dose above 1000 IU/d provides any benefit either.

Adults with risk factors for severe vitamin D deficiency (chronic liver disease, inflammatory bowel disease etc) may benefit from a vitamin D blood test to help decide about supplementation.

In general cases, the risks of taking vitamin D at a dose at or above 4000 IU/day likely exceed any benefits.

Calcium

What is Calcium and what does it do for my bones?

Calcium is a mineral that is used for different biochemical processes in your body. Its main role is to build and maintain strong bones and teeth. 

How much Calcium do I need?

The table below shows how much calcium you need daily.

Osteoporosis Canada, 2010

• There is no benefit to getting more calcium than your recommended intake.
• It is best to get calcium from food sources, as foods have other important nutrients in them.
• Before taking a calcium supplement, calculate your daily calcium intake from food sources.

How do I calculate my calcium intake?

1. Record your food intake for 3 days, include meals snacks and all beverages as well.
2. If you are eating a well-balanced diet, according to Canada’s Food Guide, give yourself a baseline of 300mg calcium. Most diets provide at least 300 mg calcium from all foods throughout the day.
3. Add up your calcium-rich food sources using the Food Sources of Calcium table below or the online calcium calculator.

Nutrient amounts from Canadian Nutrient File, 2015

Helpful Tip: Find out the amount of calcium in a food by reading food labels. If the amount of calcium is not included in milligrams (mg) on the food label, you will need to look at the % daily value amount listed on the Nutrition Facts table.  To calculate how much calcium is in the food, take away the % and add a zero.  The % Daily Value for Calcium on an original Nutrition Facts table is based on 1100 mg.  By the end of 2022, all pre-packaged foods will need to include the amount of calcium in mg on the Nutrition Facts Table

For example: with the original Nutrition Facts Table, 40% Daily Value calcium = ~450 mg calcium per serving

Do I need a calcium supplement?

• For healthy adults who have not had fractures due to osteoporosis and are not taking medication for osteoporosis, taking calcium supplements is not expected to have a significant effect on bone health and may not be necessary.  Obtaining 1000 - 1200 mg of calcium per day through the diet may be a reasonable goal.
• For adults who have had osteoporotic fractures, those who are taking pharmacologic osteoporosis treatment and the elderly: Obtaining 1200 mg/day of calcium (ideally through the diet but possibly with the addition of a supplement), may be beneficial and is unlikely to be harmful.
• However, it may be harmful to take too much calcium from supplements and so the recommended daily maximum should not be exceeded.

I’ve calculated my calcium intake from foods and my intake is still low, what type of calcium supplement should I take and how much?

Types of Calcium Supplements:

• Calcium Carbonate: Must be taken with food.
• Calcium Citrate: Can be taken with or without food. Use this form if you are taking a medication to reduce stomach acid or to prevent gastric reflux or if you have any nutrient malabsorption issues or Irritable Bowel Disease.

Amount of Calcium Supplement:

• Take only as much as needed to achieve your recommended intake.
• The amount of elemental calcium is used to calculate your daily intake from supplements.
• Do not take more than 500-600 mg of elemental calcium at one time in order for maximum absorption.

Vitamin D

Vitamin D increases the absorption of calcium and is necessary for normal bone mineralization.

How much Vitamin D do I need?

* For healthy adults who have not had fractures due to osteoporosis and are not taking medication for osteoporosis: taking vitamin D supplements is not expected to have a significant effect on bone health and may not be necessary.
* For adults who have had osteoporotic fractures, those who are taking drug therapy for osteoporosis and the elderly, taking a vitamin D supplement of 800 - 1000 IU per day may be beneficial and is unlikely to cause harm
* For adults with risk factors for severe vitamin D deficiency, a blood test to check vitamin D levels may be helpful before making a decision about treatment
* For all adults: taking vitamin D supplements at doses of 4000 IU per day or more has no proven benefits and may be harmful (may actually be associated with bone loss).

Where can I get vitamin D?

• Your skin makes some Vitamin D from sunlight. In Canada, sunlight is limited from October to March. SPF (sun protective factor), clothing, pigmented skin and glass all reduce the amount of vitamin D that is made from sun exposure.
• Food sources include: fish, milk, fortified soy, almond or rice beverage, margarine, eggs. However, food sources alone will not be enough to meet your daily vitamin D needs.
• Supplements: available in pills, chewable, sprays and liquid drops. Be mindful of other supplements that include additional Vitamin D.  Check the product label for an 8-digit NPN number (Natural Product Number) to ensure that Health Canada has reviewed the product.
• Osteoporosis Canada recommends supplementing with Vitamin D year round.

What other dietary factors affect bone health?

Caffeine

• Limit to no more than 400 mg caffeine per day.
• Sources include energy drinks, teas, coffee-based drinks, colas and chocolate.

Get the Facts on Caffeine

Sodium

• Limit to less than 2300 mg sodium per day.
• Most of the sodium and salt we eat comes from processed and packaged foods, and restaurant foods.
• Sodium also comes from the salt we add at the table or in cooking.

Tips: Use less processed and packaged foods, read labels, and choose foods lower in sodium. Limit salt added to cooking or at the table.  Get the facts on sodium here

Alcohol

Limit to no more than 1 drink for women and 2 drinks for men per day.

1 drink is equal to:

• 12 oz (355 ml) of 5% alcohol beer, cider or cooler
• 5 oz (142ml) glass 12% alcohol wine, or
• 1½ oz (43 ml) of 40% distilled alcohol.

Smoking

• This is a major risk factor for bone loss and fracture.
• If you needed another reason to quit smoking, this is it!

Eating a Well-Balanced Diet

• Eat a balanced diet from all four food groups of Canada’s Food Guide to Healthy Eating to help keep bones strong and help to prevent fractures.
• Fruit and Vegetables provide nutrients that are important for bone health.

Healthy Weight

• Maintaining muscle mass and staying at a healthy weight are both important for bone health.
• If you are losing weight without trying or have poor appetite, talk to your healthcare provider.

Physical Activity

Being active every day is important for healthy bones. Make sure to include the following exercises:

• weight bearing
• strength training
• balance training
• posture training

If you have osteoporosis, talk to your doctor before starting a physical activity program.

For more information on physical activity and osteoporosis, go to Osteoporosis Canada’s website.

What kind of medication options exist for reducing fracture risk?

Bisphosphonates

The bisphosphonate medications target the bone cells that are responsible for degradation and thinning of bone - the “osteoclasts”. Treatment with these medications prevents bone loss and strengthens the bones. The bisphosphonates are available as daily, weekly, monthly or once-a-year intravenous injection. These medications are deposited in the skeleton, where they stay for months to years. These medications continue to prevent fractures even after people stop taking them.

Once-a-week tablets

What are they called?
Generic names: alendronate (weekly), risedronate (weekly, monthly), etidronate (daily).These medications are also known by their trade (pharmaceutical) names of Fosamax and Actonel. These two medications are very similar.

What do they do?
These medications strengthen bones, prevent bone loss and reduce risk of fractures.

How do I take them?
They come as an oral tablet that can be taken once a week or once a month. Take in the morning with a full glass of water. Avoid eating, drinking, and other medications for at least 30 to 60 minutes. Do not lie down or bend down for 30 minutes. Minerals such as calcium, iron, magnesium should be taken a different time of the day.

How long do I take them for?
Most major studies of the oral bisphosphonates have lasted for 3 to 5 years. However, these medications are shown to be safe and effective when taken for up to 10 years. How long you should take oral bisphosphonates will depend on your risk of breaking a bone, and this decision should be made jointly between you and your doctor. In most cases, treatment will be recommended for 5 to 10 years, followed by a 2 to 5 year break.

Who should not take these medications?
Some people with kidney problems should not take oral bisphosphonates, and it is important that your doctor is aware of your kidney function before prescribing these medications. Those who cannot sit or stand for 30 minutes after taking oral bisphosphonates should not take them.

What side effects might I expect?
These tablets can cause stomach upset and can worsen heartburn. It is important to take them as directed by your doctor or pharmacist.

In rare cases, people who are treated with these medications have developed jaw problems (also called ‘osteonecrosis of the jaw’) and fractures of the femur bone (also called ‘atypical femoral fractures’). These problems are very rare, and the risk of having one of these problems is estimated to be less than 1 in 10,000 over 3-5 years of treatment. The risk seems to increase the longer you have been on treatment, and seems to decrease after treatment is stopped. More information about atypical femoral fractures and osteonecrosis of the jaw is available here.

What are the costs involved?
The generic forms of alendronate, risedronate and etidronate cost between $20 and $30 per month. These medications are covered by most drug plans and by Senior’s Blue Cross.

Once-a-year infusion ZA Website printable for patient

What is it called?

Generic name: zoledronic acid, or zoledronate.This medication is also known by its trade (pharmaceutical) name, Aclasta.

What does it do?
This medication strengthens the bones, prevents bone loss and reduces risk of fractures.

How do I take it?
This medication is given as an intravenous infusion, usually once a year. The infusion generally takes 15-30 minutes. Your physician will enrol you into one of the infusion programs.

How long do I take it for?
Major studies of this medications have lasted for 3 years (3 injections). However, zoledronic acid is shown to be safe and effective when taken for up to 6 years (6 injections). How long you should take this medication will depend on your risk of breaking a bone, and this decision should be made jointly between you and your doctor. In most cases, treatment will be recommended for 3 to 6 years, followed by 3 to 5 years off medications (sometimes called a “drug holiday”).

Who should not take this medication?
Some people with kidney problems should not take these medications, and it is important that your doctor is aware of your kidney function before prescribing these medications.

What side effects might I expect?
About 10 to 20% of people will have a flu-like reaction to the first injection of this medication. The reaction usually occurs within 1 or 2 days of the injection. The type of reaction varies from person to person, but the most common symptoms are aching joints and muscles, and a low grade fever. This reaction almost always resolves on its own within a few days.

In rare cases, people who are treated with zoledronic acid have developed jaw problems (also called ‘osteonecrosis of the jaw’) and fractures of the femur bone (also called ‘atypical femoral fractures’). These problems are very rare, and the risk of having one of these problems is estimated to be less than 1 in 10,000 for 5 years of treatment. The risk seems to increase the longer you are treated, and seems to decrease after treatment is stopped. More information about atypical femoral fractures and osteonecrosis of the jaw is available here.

What are the costs involved?
The generic form of zoledronic acid costs approximately $400 per injection. This medication is covered by some drug plans. It is only covered by Senior’s Blue Cross in special circumstances.

Denosumab

Denosumab belongs to a class of medications called ‘monoclonal antibodies’. Monoclonal antibody medications have been developed for a number of medical conditions. Currently, denosumab is the only monoclonal antibody that is available in Canada for the treatment of osteoporosis. Like the bisphosphonate medications, denosumab targets the bone cells that are responsible for degradation and thinning of bone - the “osteoclasts”. Treatment with denosumab prevents bone loss and strengthens the bones. This medication is active in the skeleton for as long as it is taken, but the beneficial effects of the medication stop within a few months of the last dose.

What is it called?

Generic name: denosumab

This medication is also known by its trade (pharmaceutical) name, Prolia.

What does it do?

This medication strengthens the bones, prevents bone loss and reduces risk of fractures.

How do I take it?

This medication is given as a subcutaneous (under the skin) injection, every 6 months. These injections can usually be given by your family doctor or pharmacist.

How long do I take it for?

Denosumab appears to be safe and effective when taken for 10 years or longer. However, the optimal length of treatment is not currently known. The effects of the medication seem to reverse quite quickly after it is stopped. Therefore, some experts recommend continuing this medication indefinitely. If treatment with denosumab is stopped, your doctor may recommend treatment with a longer-lasting medication (such as a bisphosphonate) so that the benefits of the denosumab can be maintained.

Who should not take this medication?
People with low blood calcium levels should not take Denosumab. Talk to your doctor or pharmacist if you are allergic to rubber or latex.

What side effects might I expect?
Up to 10% of people may develop eczema, a skin condition with dryness, redness or itching. Because this medication has an effect on the cells of the immune system, it is possible that taking denosumab may increase a person’s risk of infection. In clinical trials, people who took this medication had a slightly increased chance of developing a skin infection. However, there was no increased risk of overall infections.

In rare cases, people who are treated with denosumab have developed jaw problems (also called ‘osteonecrosis of the jaw’) and fractures of the femur bone (also called ‘atypical femoral fractures’). These problems are very rare, and the risk of having one of these problems is estimated to be less than 1 in 10,000 for 5 years of treatment. The risk may decrease after treatment is stopped. More information about atypical femoral fractures and osteonecrosis of the jaw is available here.

What are the costs involved?
Denosumab costs approximately $400 per injection ($800 per year). This medication is covered by some drug plans. It is only covered by Senior’s Blue Cross in special circumstances.

Hormone Replacement Therapy

After menopause, the ovaries no longer produce estrogen. Estrogen helps to maintain bone thickness, which is why women lose considerable amounts of bone following menopause. Treatment with estrogen following menopause has been shown to decrease bone loss and also to decrease the risk of fractures. In women who have not had their uterus removed, estrogen must be given along with progesterone, to prevent build-up of the lining of the uterus. Although, treatment with estrogen can reduce the risk of fracture, its use has been associated with a slightly increased chance of having a blood clot or developing breast cancer, particularly in women aged 60 or older. Because other, potentially safer, medications are available to protect the bones, hormone replacement therapy is usually only used in women who also need it for other reasons, such as hot flashes. Most physicians recommend only using hormone replacement therapy for 3-5 years, and stopping before age 60.

An exception to this recommendation is women who go through menopause much earlier than age 50. In women who have premature menopause (either because their ovaries are removed, or stop working early), it is generally felt that the benefits of treatment with estrogen outweigh the risks, at least up until age 50.

What is it called?
Generic name: estrogen, usually also given with progesterone.

Trade (pharmaceutical) names for estrogen include: Premarin, Estrace, EstraDerm, Estra-Dot.

Trade (pharmaceutical) names for progesterone include: Provera and Prometrium.

What does it do?
Estrogen strengthens the bones, prevents bone loss and reduces risk of fractures.

How do I take it?
This medication can be taken as a once-a-day tablet. It can also be given as a skin patch or gel.

How long do I take it for?
If you are over age 50, most physicians recommend treatment for no more than 3-5 years, stopping prior to age 60. Your physician may recommend a longer treatment period if you are younger than 50.

Who should not take this medication?
Estrogen should not be taken by women who have a history of breast cancer, blood clots, coronary artery disease, liver disease or tobacco use. Your physician may also recommend against this medication if you have a family history of breast cancer or disorders of blood clotting.

What side effects might I expect?
The side effects of treatment with estrogen appear to depend on age, typically becoming more frequent in women older than 60.

Hormone replacement therapy has been shown to increase the risk of breast cancer (about 2.5 cases for every 1000 women treated), blood clot (about 5 extra cases for every 1000 women treated), and heart disease (about 2.5 extra cases for every 1000 women treated).

What are the costs involved?
Hormone replacement therapy costs approximately $20 per month. This medication is covered by Blue Cross.

Raloxifene

Raloxifene is a type of medication called a ‘selective estrogen receptor modulator’. This medication acts in the same was as estrogen on the bones, but has the opposite effect to estrogen in some other parts of the body. Raloxifene helps to prevent bone loss and reduce the risk of fracture. However, in contrast to estrogen, it actually decreases the risk of developing breast cancer.

What is it called?
Generic name: raloxifene

This medication is also known by its trade (pharmaceutical) name, Evista.

How does it work?
This medication strengthens the bones and prevents bone loss.

How do I take it?
This medication is taken as a tablet, once a day.

How long do I take it for?
This medication appears to be safe and effective when taken for long periods of time. Therefore, most specialists recommend long-term treatment.

Who should not take this medication?
People who have a history of blood clots should not take this medication.

What side effects might I expect?
This medication may worsen post-menopausal symptoms, such as hot flashes. It has also been shown to increase the risk of blood clot (about 1 extra case for every 1000 women treated).

What are the costs involved?
Raloxifene costs approximately $20 per month. This medication is covered by Blue Cross.

Calcitonin

Calcitonin is another type of medication that has been used in the past to prevent bone loss. However, some recent research has suggested that treatment with calcitonin might be associated with a slightly increased chance of developing cancer later in life. Therefore, this medication is no longer available in Canada.

Teriparatide

Teriparatide targets the body’s bone building cells - the “osteoblasts” - stimulating these cells to start building new bone. It is the only bone-building medication that is currently available in Alberta.

What is it called?
Generic name: teriparatide

This medication is also known by its trade (pharmaceutical) name, Forteo.

How does it work?
This medication builds new bone.

How do I take it?
This medication is given as a subcutaneous (under the skin) injection every day. People who are taking teriparatide need to give themselves an injection of this medication each day.

How long do I take it for?
This medication has been approved to use for 2 years. After the 2-year treatment period, many physicians recommend treatment with another medication (such as a bisphosphonate) to maintain the benefits of the teriparatide.

Who should not take this medication?
People who have had cancer of the bones, or a bone disease called ‘Paget’s disease’ should not take this medication.

What side effects might I expect?
In some people, this medication has been shown to cause leg cramps, aches and pains, dizziness, and nausea.

Early studies of this medication in rats found that some of the rats developed a type of bone cancer (osteosarcoma) after taking this medication. This has never been reported in human clinical trials. However, treatment exceeding 2 years is not recommended due to lack of long term studies.

What are the costs involved?
Teriparatide costs approximately $1000 per month or $12,000 per year. This medication is not usually covered by drug plans. Coverage is sometimes available, in extenuating circumstances.

Romosozumab

Romosozumab is the newest anti-fracture medication to become available (Canadian market release June 2019). This is a new type of medication that falls into what are called "anabolic" therapies becasue of their ability to build new bone [teriparatide is the other anabolic osteoporosis medication on the market].  Romosozumab works by inhibiting a hormone called sclerostin which normally limits the amount of new bone formed.  In other words, this therapy helps by "taking your foot off the brake of new bone formation."

What is it called?
Generic name: romosozumab.  
This medication is also known by its trade (pharmaceutical) name, Evenity.

What does it do?
This medication builds new bone and also reduces bone loss thereby decreasing the risk of fractures.

How do I take it?
This medication is given as two subcutaneous (under the skin) injections, every month.  These injections may be given by your pharmacist, family doctor or yourself.  If you choose to do self-injection, training can be provided by the patient support program.

How long do I take it for?
Romosozumab is taken once a month, consecutively, for 12 months.  After the 1 year treatment period, many physicians recommend follow up treatment with another medication (such as a bisphosphonate) to maintain the benefits of romosozumab.

Who should not take this medication?
People with heart problems, such as heart attack or stroke and those with low blood calcium levels should not take romosozumab (see below for more details)

What side effects might be possible?
Romosozumab is generally very well tolerated; in clinical studies, it did not seem to cause any symptomatic side effects any differently than a placebo injection with the exception of a 5% chance of local skin irritation from the injection.  Headache and joint pains have been seen on occasion.  It only builds bone in your existing normal skeleton (i.e. it does not cause bone formation or calcification in other parts of your body).

There is however ongoing controversy about whether Romosozumab might be linked to a tiny increase in the risk of heart attack or stroke.  This is an issue which has been very carefully studied over the past few years and even still there is no clear agreement among bone scientists.  The issue arose during the course of 2 very large clinical trials done in older women with osteoporosis.  In one clinical trial, half the women received romosozumab and half received placebo injections for 1 year; in this trial, there was no sign of heart disease or stroke.  In the other clinical trial, half the women received romosozumab and half received alendronate for 1 year and in this trial, there was a small increase in the risk of heart attack or stroke in the romosozumab group.  The amount of risk increase was less than 1% but it was still not zero.  Despite many subsequent experiments, scientists have not been able to come up with any kind of explanation as to why this might have happened with this drug and so there is an ongoing debate about whether the increased heart attack/stroke risk is real or just a chance occurrence that happened to show up in that second trial.  For now, in order to be on the safe side, this medication is "not recommended" for women with a history of prior heart attack or stroke.  For those who have not had heart attack or stroke but who are at high risk of heart disease/stroke, a careful discussion about risk/benefit should be had with your physician.

What are the costs involved?
Romosozumab costs approximately $840 per month ($10 000 per year) at time of this web entry.  This medication is covered by some drug plans.  Alberta Senior's Blue Cross does not cover romosozumab at this time.

Rare side effects of osteoporosis medications

Osteonecrosis of the Jaw (ONJ)

What is it?

• An area of exposed bone in the jaw that does not heal for 8 weeks or more
• May or may not be painful
• Most cases have occurred in people who are receiving bisphosphonate medications for cancer in much higher doses than we use for osteoporosis
• It has been associated with bisphosphonate medications and denosumab (Prolia)

How frequently does it occur?

• The risk of developing this condition is estimated to be less than 1 in 10,000 for a five-year treatment course
• The risk may increase with longer treatment duration and is likely to decrease when the medication is stopped

What are the risk factors?

• Smoking, heavy alcohol intake
• Invasive dental procedures (this does not include regular cleanings, fillings or root canals)

What can I do to prevent it?

• Maintain good oral hygiene, go for regular dental check-ups
• Let your doctor know if you are having major dental surgery. They may decide to stop the medication temporarily after the surgery, until the wound has healed
• Stop smoking

Atypical femoral fractures (AFF)

What are they?

• Fractures of the thigh bone (femur)
• Can occur without falling or trauma
• May occur in both legs
• They have been associated with bisphosphonate medications and denosumab (Prolia)

What symptoms do they cause?
Some people develop a dull aching pain in one or both thighs before the femur bone fractures. You should inform your doctor if this happens.

How frequently do they happen?

• The risk of having one of these fractures is estimated to be between 1 in 1000 and 1 in 10,000 for a five-year treatment course
• For every one of these fractures that occurs because of osteoporosis medications, approximately 100 hip fractures are prevented
• The risk may increase with longer treatment duration and is likely to decrease when the medication is stopped

What are the risk factors?
The risk seems to be higher in people of Asian ethnicity, people who are taking steroid medications (such as prednisone), and people with rheumatoid arthritis.

SPINE BRACING information

Cascade Orthotics specializes in spine bracing… their team works specifically out of FMC with the spine/trauma group.  Cascade does carry the Spinomed Brace (http://mediusa.com/portfolio-item/spinomed-iv-ap/).   Cascade Orthotics specialists can provide phone consultation for other spine brace options with an orthotics specialist if the pt may benefit from additional recommendations after their brace assessment…

Cascade Orthotics   403-283-7872

2636 Parkdale Blvd NW

Calgary, AB T2N 3S6

http://www.cascadeorthotics.com/

Cascade Orthotics asks the brace prescription include the pt diagnosis, type of brace recommended, and referring physician’s contact information.  The prescription is good for 3 months, otherwise Cascade will call to have it re-submitted.   Cascade’s orthotics specialist will take care of the client declaration and funding submission with Alberta Aids to Daily Living (AADL).  If the client was a senior, the brace would be covered by AADL… pt should review this with Cascade Orthotics to confirm coverage at their time of assessment.