Osteoporosis & bone health

Bone is living tissue, taken down and rebuilt all through life. In osteoporosis the rebuilding falls behind: more bone is removed than is laid down, and its inner framework grows thinner and more open. Bones reach their greatest strength in early adulthood, and a slow loss begins in everyone from about the mid-thirties.

After the menopause, as oestrogen falls, bone is lost faster, so osteoporosis is commoner in women, though men develop it as well. Several things can hurry the loss, among them long courses of steroid tablets, an overactive thyroid or parathyroid gland, an early menopause, and conditions that stop food being absorbed properly. Osteoporosis can be linked with other kinds of metabolic bone disease.

When a bone of the spine gives way it usually squashes down on itself rather than snapping apart. Such a break is stable, so it does not harm the spinal cord, but it can leave pain, a loss of height and a rounded back.

Some things make osteoporosis more likely. Your risk may be higher if you:

• Have been through the menopause, more so if it came early, before 45
• Have a family history of osteoporosis, or a parent who broke a hip
• Have taken steroid tablets for three months or more, especially at high doses
• Are underweight
• Smoke, or drink heavily
• Have already had a bone break from a minor fall
• Have another condition that weakens bone, such as rheumatoid arthritis, coeliac disease or an overactive thyroid

An assessment of bone health looks at your own risk and, where it helps, measures how dense your bones are. The measurement comes from a DEXA scan, a short and painless scan that uses a low dose of X-rays. A tool such as FRAX or QFracture estimates how likely a break is within ten years, often first, to decide whether a scan would help, and FRAX can take in a scan result too. The estimate sits beside a full look at your health, so a scan result is not read in isolation.

Dr Borukhson offers a dedicated assessment of osteoporosis and bone health. She arranges a DEXA scan when the assessment shows it would help and talks you through what it shows. Where they add something, specialised blood and urine tests of bone turnover can be done as well. These measure how active the bone is, and are used chiefly to judge, over time, how well your bones answer treatment.

The goal is stronger bones and a lower chance of a break. Depending on your assessment, it can combine exercise, diet and making sure your calcium and vitamin D are adequate, a medicine that protects or builds bone where one is needed, and scans to follow how things are going.

If a medicine is called for, most people start with a bisphosphonate, which slows the loss of bone: alendronic acid as a tablet taken once a week, or zoledronic acid given as a drip into a vein once a year. Denosumab, an injection just under the skin every six months, is an alternative, and a small number of people at very high risk may be offered a medicine that builds new bone. Calcium and vitamin D are kept adequate alongside any of them. HRT, hormone replacement therapy, can be a first choice too for some women past the menopause, younger women whose risk of a break is high in particular, provided their own chance of its side effects is low.

Each medicine has its practical points. Alendronic acid has to be taken in a set way to be absorbed: when you first get up, on an empty stomach, with a glass of plain tap water, staying upright for 30 minutes before any food, drink or other medicine. Before a zoledronic acid drip, make sure your doctor knows if you have, or are at raised risk of, a fast and irregular heartbeat (atrial fibrillation). After a first drip, flu-like aches, a fever or a headache are common for a day or two, a simple painkiller can ease them, and they are much less likely after later drips; a fever that lasts beyond a few days, or climbs, is for your GP or NHS 111 the same day, as When to seek help says. If you have had problems with your teeth or gums, a dental check before treatment starts is worthwhile, and regular check-ups during it are for everyone, since a rare side effect of these medicines affects the jawbone. Denosumab injections must keep to time, within four weeks either way, and the medicine must not stop without a follow-on unless, after less than two years of it, a specialist has said it can. For anyone on steroid tablets for a long time, the steroids in rheumatology guide explains why bone protection usually goes with them. You and Dr Borukhson settle the plan together.

Protecting your bones mostly means caring for your health in general.

• Keep active with a mix of weight-bearing exercise and work that strengthens the muscles, which also steadies your balance and makes a fall less likely; our guide to exercise and staying active sets out the general approach
• Eat for your bones: food rich in calcium, and enough vitamin D, which sunlight cannot supply in a UK winter, so everyone is advised to consider a daily supplement of 10 micrograms in autumn and winter
• Stop smoking and keep alcohol within the advised limits, since both raise the risk of osteoporosis
• Clear your home of things that could trip you, and have your sight and hearing checked regularly

Osteoporosis is usually a lasting condition rather than one that goes away, yet with treatment and these steps bone strength can be kept or improved, and having osteoporosis does not mean that a bone will certainly break.

Osteoporosis itself is silent. What needs help is a bone that may have broken, a warning sign in the back, or a side effect of a medicine, and these are set out below, the gravest first, with the route each one needs.

Treat any of these as a 999 or A&E emergency: call 999 and do not drive yourself to A&E.

• Severe illness with suspected sepsis: a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, since these can be signs of meningitis or sepsis, as can a very bad headache, confusion or a first seizure with a fever or feeling unwell; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• A joint you cannot put weight on or move, or that has moved out of place, or, after a fall or injury, very bad pain or any tingling or numbness
• After an injury, a crack heard as it happened, or skin around it that has turned blue, grey or cold, since these can be signs of a broken bone
• Numbness or tingling around the back passage, genitals or inner thighs, new difficulty passing urine or controlling your bladder or bowels, a change in feeling during sex, or pain, tingling, weakness or numbness in both legs, since these can mean pressure on the nerves at the base of the spine, which needs emergency treatment
• Back pain that began after a serious accident, such as a car crash or a fall from a height, or that comes with chest pain
• Chest pain that is crushing, tight or like a pressure, that spreads to an arm, the jaw, the neck, the stomach or the back, that comes with breathlessness, sweating, feeling sick or feeling light-headed, or that came on suddenly and does not go away
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine
• An eye that suddenly and completely loses its sight

Any of these needs an assessment that is urgent, on the same day, from your GP or NHS 111:

• Sudden, severe pain in the back or the neck, or pain there that is fast getting worse, or pain starting in the spine after a small strain, a lift, a cough or a light knock, since a spine thinned by osteoporosis can break under very little force and the break should be confirmed that day; pain that follows a serious accident is in the first list
• A fever, feeling hot, cold or shivery, or generally unwell, with the back pain, since an infection in the spine has to be found the same day
• A bone outside the spine that you think may be broken, even after a small fall or bump, which needs an X-ray the same day at an urgent treatment centre or A&E, with NHS 111 to tell you which; very bad pain, tingling or numbness after the fall or bump, or a joint that takes no weight, will not move or is out of place, is in the first list, and a limb left at an odd angle or changed in shape is a 999 or A&E emergency too
• While you take alendronic acid: heartburn, or heartburn that is getting worse, pain or difficulty when you swallow, flu-like aching and feeling generally unwell (sometimes with a high temperature), severe pain in the joints, muscles or bones, or black or red poo, which need a doctor or NHS 111 straight away, and heartburn or trouble swallowing means stopping the tablet too, since they can be signs of an ulcer in the food pipe; vomiting blood, or the signs of a serious allergic reaction (lips, mouth, throat or tongue suddenly swollen, a tight throat, difficulty breathing, skin, tongue or lips turning blue, grey or pale, or sudden confusion or fainting), is a 999 or A&E emergency: call 999 and do not drive yourself to A&E
• On a bone-protection medicine such as alendronic acid, zoledronic acid or denosumab: a loose tooth, sores in the mouth, or pain or swelling in the mouth or jaw, or new pain, aching or discomfort in the thigh, hip or groin, or weakness that comes with it, since these can be the first signs of the rare damage to the jawbone, or the rare break of the thigh bone, that these medicines can cause; tell your dentist too about anything in the mouth
• Tingling in the fingers, the toes or around the mouth, or muscle cramps, spasms, twitches or stiffness, on a bone-protection medicine, since these can mean your blood calcium has dropped too low; any difficulty breathing, a heartbeat that has become irregular, confusion, or muscles that lock in place with them is a 999 or A&E emergency, as the calcium may then have fallen very low
• Skin that has turned red, swollen or sore to the touch, while you have denosumab, since the medicine can, uncommonly, let a serious skin infection take hold; with a very high temperature or feeling hot, cold or shivery, a fast heartbeat or fast breathing, purple patches on the skin, which may be less obvious on black or brown skin, feeling dizzy or faint, confusion, or skin that is cold, clammy or pale, or with the sepsis signs in the first list, it is a 999 or A&E emergency: call 999 and do not drive yourself to A&E
• A new red, painful eye, or sight that has blurred, dimmed or changed, which needs an eye casualty or urgent eye clinic the same day, as does an eye that light hurts, since bisphosphonates can inflame the eye, uncommonly after a zoledronic acid drip and rarely with alendronic acid

A fever that has not settled within a few days of a zoledronic acid drip, or that is climbing, needs your GP or NHS 111 the same day, since it has gone beyond the drip's usual reaction and its cause has to be found. Short of the signs in the lists above, if a denosumab injection is running more than four weeks late, or the medicine is due to stop with no other treatment lined up to follow it, contact your GP or the team that gives it within days, since the bone it protected can be lost quickly and some people have had several breaks in the spine in the months after stopping. Height that is slowly lost, a back that is becoming rounded, or an earlier break after a minor fall that no one has assessed are reasons to book a routine appointment with your GP, and a long course of steroid tablets about to begin is one to raise with the doctor who starts it, since bone protection is often begun at the same time. If you cannot tell how urgent something is, asking is never a mistake.

Osteoporosis seldom shows itself before a bone breaks, and once one has broken, the chance of another is highest straight after it and stays raised over the next two years. Even so, the moment is often lost. A fracture liaison service, set up to find and treat osteoporosis after a first break, cuts the chance of a further break by 30% to 40%, yet only half of NHS trusts in England have one, and 38% of people in the UK cannot reach one. The aim is to find the risk and treat it before any bone breaks. If the risk factors above describe you, an assessment of your bone health is well worth having.

Is a DEXA scan something I need?

Not always: what decides it is your own risk. Being past the menopause, osteoporosis or a broken hip in the family, long courses of steroid tablets, a low body weight, or an earlier break from a minor fall each make the question worth asking, and a DEXA scan is arranged when the assessment shows that it would help the decision. The scan is short and painless, and its X-ray dose is very small.

What is involved in an assessment of bone health?

It goes through your risk factors, your health and any bones you have broken, and decides whether a DEXA scan would add to the picture of your bone density. Blood and urine tests of bone turnover can be added where they would help: they show how busy the bone is, and later how it is answering treatment. Each result is read against your health as a whole, and you are told plainly what it means for you.

I have already broken a bone. Is an assessment still worth having?

Yes, and all the more so. Breaking a bone in a minor fall is one of the strongest hints that the bones have weakened, and it raises the chance of another break, most of all in the first year or two after it; half of people who break a hip have had an earlier break that could have flagged the risk. Assessing and treating the bones after a first break sets out to strengthen them and to make the next break less likely.

How long does treatment for osteoporosis go on?

Usually for years, with reviews along the way so that it can be adjusted as your bones respond. Denosumab needs particular care: an injection should not run more than four weeks late, and the medicine should not be stopped unless another treatment is ready to follow it (after less than two years on it, a specialist may advise otherwise), because the bone it has been protecting can be lost again within a short time. What follow-up you will have, repeat scans included, is settled with you at the outset.

Can I see whether the treatment is doing its job?

Osteoporosis seldom makes itself felt, so progress is followed with tests rather than by how you feel, and no single test can prove beyond doubt that a medicine is working, though the medicines are known to lower the risk of a break. A repeat DEXA scan shows how bone density changes over the years, and blood and urine tests of bone turnover show how the bone is answering the medicine; together they let the plan be kept or changed at each review.