Bone Mineral Density & Osteoperosis

OHIP Funded Testing

How often does OHIP cover BMD tests for high-risk individuals?

For individuals identified as high risk for osteoporosis, OHIP covers annual BMD tests. This means these individuals can have this test once every 12 months.

How often does OHIP cover BMD tests for low-risk individuals?

For individuals considered to be at low risk, OHIP covers a baseline BMD test and a second BMD test 36 months (3 years) after the baseline. Subsequent BMD tests for low-risk individuals are covered once every 60 months (5 years).

What do I do if I believe I'm at risk for osteoporosis?

If you believe you are at risk for osteoporosis, you should consult with your healthcare provider. They can assess your risk factors and refer you for a BMD test if necessary. Remember that early detection and management of osteoporosis can significantly decrease the risk of future fractures.

Age Appropriate Testing

I'm over 65. Should I get BMD testing?

Yes, everyone above 65 should have a bone density test. You do not need another medical condition to qualify for a Bone Density Test.

I'm between 50 and 65. Should I get BMD testing?

You should discuss testing if any of the following apply to you:

• You have had a 'Fragility Fracture'

  • ie. A fracture after a fall from standing height or less

  • i.e. A fracture without any identifiable trauma

• You are on medication from This List

• Diagnosis of hypogonadism

• Menopause younger than age 45

• Diagnosis of Celiac Disease, Crohn's Disease, Gastric Bypass, Small Bowel Resection

• Diagnosis of Hyperparathyroidism

• Diagnosis of Rheumatoid Arthritis, Psoriatic Arthritis, Lupus, Ulcerative Colitis

• Diagnosis of Cushing's Disease, Hyperthyroidism (not well controlled), Osteogenesis Imperfecta

• Weight < 60kg (132 lbs)

• Parent had a hip fracture

• Current Smoker

• 'Osteopenia' discovered on an x-ray

• Alcohol - 3 or more standard drinks per day

I'm younger than 50. Should I get BMD testing?

You should discuss testing if any of the following apply to you:

• You have had a 'Fragility Fracture'

  • ie. A fracture after a fall from standing height or less

  • i.e. A fracture without any identifiable trauma

• You are on medication from This List

• Diagnosis of Hypogonadism

• Gone through menopause younger than age 45

• Diagnosis of Celiac Disease, Crohn's Disease, Gastric Bypass, Small Bowel Resection

• Diagnosis of Hyperparathyroidism

• Diagnosis of Rheumatoid Arthritis, Psoriatic Arthritis, Lupus, Ulcerative Colitis

• Diagnosis of Cushing's Disease, Hyperthyroidism (not well controlled), Osteogenesis Imperfecta

Osteoporosis

What is osteoporosis?

Osteoporosis is a disease that weakens your bones, making them more likely to break. It happens when your bone density is low and your bone structure deteriorates. This condition often remains unnoticed until a fracture happens, usually from minor trauma.

How is osteoporosis diagnosed?

Doctors usually diagnose osteoporosis by measuring something called bone mineral density. They use a painless and non-invasive method known as dual-energy x-ray absorptiometry. It's a fancy term for a type of x-ray that helps doctors see how dense or thick your bones are.

What is the main purpose of our bones and how do they develop?

Bones are an essential part of our body. They provide structure to our bodies, safeguard our vital organs, and serve as storage for minerals, such as calcium and phosphorus. These minerals are critical for bone growth and stability. We continue to build bone mass until approximately 30 years of age. After this point, we begin to experience a gradual loss in bone mass. While the peak bone mass we can achieve is heavily reliant on genetics, numerous other factors that we can change, like nutrition, physical activity, and specific diseases or medications, can also impact bone mass.

How are bones maintained over time?

Our bones are continuously undergoing a process known as remodeling. This is where osteoclasts (cells that break down bone) resorb old bone, and osteoblasts (cells that build new bone) replace it. This balancing act is crucial for maintaining the mechanical strength of our bones and repairing any damage. However, if there's an imbalance where more bone is broken down than is built, osteoporosis can occur.

How do hormones and other substances affect the health of our bones?

Different hormones and substances have important roles in keeping our bones healthy. For example, hormones you may have heard of, like estrogen and testosterone, help by mainly stopping bones from breaking down. There are also certain substances that can change how our bones are shaped or rebuilt. One of these is called RANKL. RANKL is made by special cells that help create new bone and can bind to different cells that are involved in the breakdown of bone. When RANKL does this, it causes more bone breakdown.

What does "Primary Osteoporosis" mean?

Primary osteoporosis typically comes with getting older and is linked to changes in hormones our bodies produce. As we age, the small framework within our bones can start to deteriorate, leading to this condition. For example, women produce less of a hormone called estrogen after they go through menopause, and this can cause a lot of bone loss. In men, as they age, certain proteins can reduce the activity of two hormones—testosterone and estrogen—contributing to a decrease in bone density over time.

What does "Secondary Osteoporosis" mean?

Secondary osteoporosis is caused by certain diseases or medications rather than aging or hormonal changes. These diseases often involve imbalances in calcium, vitamin D, or hormones, all of which are essential for healthy bones. Some examples include Cushing's syndrome, which can speed up bone loss, and inflammatory diseases like rheumatoid arthritis. In fact, some treatments for inflammatory diseases can lead to secondary osteoporosis. For instance, medicines called glucocorticoids, which are commonly used to treat such conditions, are the most frequent culprits of drug-induced osteoporosis.

Are the causes of secondary osteoporosis different for men and women?

Yes, the causes can vary between men and women. For men, things like excessive alcohol use, using glucocorticoids, or having a condition called hypogonadism (where the body doesn't produce enough testosterone) can lead to osteoporosis. Prostate cancer treatment can also increase men's risk of osteoporosis. For women, osteoporosis can occur due to several causes such as conditions that lead to too much calcium in the urine, inability to absorb calcium, overactive parathyroid glands, lack of vitamin D, overactive thyroid glands, Cushing’s disease, and a rare condition called hypocalciuric hypercalcemia, where the calcium levels in blood are high but low in urine.

What medications cause Osteoperosis?

• Anti-Seizure medications: Phenytoin, Phenobarbital, Carbamazepine, Primidone

• Blood Thinners: Heparin

• Oral Corticosteroids: prednisone, methylprednisolone, dexamethasone

• Immune Suppressants: cyclosporine, tacrolimus

Do PPIs cause osteoperosis?

Currently, a direct causal relationship between chronic PPI use and the development of osteoporosis and fractures remains unproven. There is ongoing research and debate about this topic.

Fractures

What is a fragility fracture?

A fragility fracture is a type of bone fracture that occurs more easily than expected, typically resulting from a fall from standing height or less, or even without any identifiable trauma. This kind of fracture is a sign that your bones might be weaker than normal, a condition often associated with osteoporosis. Common sites for fragility fractures include the hip, spine, and wrist, but they can occur in other bones as well.

What's the difference between a fragility fracture and a normal fracture?

A normal fracture and a fragility fracture are both types of bone breaks, but they occur under different circumstances and generally indicate different underlying bone health conditions.

A normal fracture typically results from a high-energy impact or trauma, like a car accident or a fall from a significant height. These fractures can happen to anyone, regardless of the condition of their bones, because the force applied to the bone is greater than it can withstand.

On the other hand, a fragility fracture occurs from a relatively minor incident, such as a fall from standing height or less, or sometimes without any clear trauma at all. This type of fracture suggests that the bones are weaker than normal, which is often a sign of osteoporosis or another bone-weakening condition. If you've had a fragility fracture, it means that your bones might be more susceptible to fractures in the future, even from minor incidents.

What does it mean to be "at risk of falls"?

Being "at risk of falls" refers to having a higher likelihood of falling due to various factors. These factors can be related to your health, physical condition, medication use, or the environment around you.

Health and physical conditions that can increase the risk of falls include aging, muscle weakness, poor balance or coordination, chronic health conditions like heart disease or diabetes, and cognitive conditions such as dementia. Additionally, the use of certain medications that affect your alertness, balance, or blood pressure can also contribute to a higher risk of falls.

Environmental factors include poor lighting, uneven or slippery surfaces, clutter or obstacles in your walking path, and lack of supportive equipment like handrails in critical areas of your home.

If you are identified as being at risk of falls, it means that one or more of these factors apply to you. Your healthcare provider will then work with you to implement strategies to minimize this risk and help prevent falls and related injuries, like fractures.

If I am identified as being at risk for falls, what measures will be taken?

If you are found to be at risk of falls, your healthcare provider will develop a tailored fall prevention plan for you. This plan is designed to minimize the chances of experiencing a fall and thus reduce the risk of fractures.

Here are some key components of a fall prevention plan:

Environmental Modification: Making your surroundings safer can significantly reduce the risk of falls. This includes removing tripping hazards such as loose rugs or clutter, ensuring adequate lighting, installing handrails in critical areas like bathrooms and stairways, and using non-slip mats in wet areas.

Exercise and Physical Therapy: Regular physical activity can improve your strength, balance, and coordination, making falls less likely. You might engage in tailored exercises or even a physical therapy program to help improve your stability.

Medication Review: Your healthcare provider will review your medications to check if any could increase your risk of falling, for instance, by causing dizziness or drowsiness. If such medications are found, your provider might adjust the dosages or switch to alternative medications.

Footwear Assessment: Wearing proper footwear can prevent falls. Your healthcare provider might suggest footwear that fits well, offers good support, and has non-slip soles.

Vision Checks: Regular eye check-ups are crucial as poor vision can increase the risk of falls. If you have vision problems, they should be addressed with the appropriate corrective lenses or other treatments.

Assistive Devices: If necessary, your healthcare provider might recommend using devices like canes or walkers to improve your stability while moving around.

Remember, the goal of this plan is to help you maintain independence and safety. Please discuss any concerns you might have about falling with your healthcare provider so that the plan can be customized to your needs.

How will my risk of fracture affect my treatment?

The probability of you experiencing a fracture, often termed as your 'fracture risk,' plays a crucial role in formulating your treatment plan. This risk can be categorized as low, moderate, or high, based on various factors such as your age, bone mineral density, and previous history of fractures.

• If you're at low risk, you may not need medication for osteoporosis. Instead, preventive measures like regular exercise, fall prevention, maintaining a balanced diet with sufficient calcium and vitamin D intake, and quitting smoking may be recommended to maintain bone health.

• For those at moderate risk, apart from lifestyle adjustments, medication may be considered based on additional risk factors. These could include a family history of osteoporosis or certain underlying health conditions. It's important to discuss these factors with your healthcare provider to determine the most appropriate treatment strategy.

• If you're at high risk, which might be due to a past fragility fracture or a high probability of fracture in the next decade, medication for osteoporosis is generally recommended. Again, this will be tailored to your individual circumstances, taking into account your medical history, co-existing health conditions, and personal preferences.

In all scenarios, the goal is to reduce your fracture risk and protect your bone health in the best possible way. Regular monitoring of your bone mineral density may also be carried out to assess the effectiveness of the treatment and make necessary adjustments. Remember that your active involvement and understanding of your treatment plan are key to its success.

Medication - Bisphosphonates

What are bisphosphonates?

Bisphosphonates are a type of medication designed to prevent or slow down bone loss, making them particularly useful in the treatment and prevention of osteoporosis.

How do bisphosphonates work to treat osteoporosis?

Bisphosphonates work by binding to the bone and preventing its breakdown, which leads to an overall increase in bone mass. This action helps slow down the progression of osteoporosis.

What are some examples of bisphosphonates?

Examples of bisphosphonates include Alendronate, Risedronate, and Zoledronic acid. These drugs have been shown to increase bone density and reduce the risk of fractures in people with osteoporosis.

How should bisphosphonates be taken?

Bisphosphonates are usually taken orally with a full glass of water, preferably on an empty stomach, at least 30 minutes before breakfast or any other medications. You should remain upright for at least 30 minutes after taking the medication to help prevent stomach irritation.

Are there any side effects associated with taking bisphosphonates?

Yes, there can be side effects. The most common ones associated with oral bisphosphonates include heartburn, indigestion, and irritation of the esophagus. If taken intravenously, you might experience fever and muscle aches.

Can bisphosphonates cause complications? If so, what are they?

Although rare, bisphosphonates can cause complications. One possible complication is osteonecrosis of the jaw, a condition where the bone in the jaw becomes exposed and doesn't heal properly. Another potential complication is atypical femur fractures, which are unusual breaks in the thigh bone that occur with minimal or no trauma.

What is a "drug holiday"?

A "drug holiday" is a break from a medication. In the context of bisphosphonates, this could be a period of time when a patient stops taking the medication.

When might a "drug holiday" be considered for someone taking bisphosphonates?

A "drug holiday" might be considered after several years of use, especially if the risks of continued use outweigh the benefits. This decision should be made in consultation with a healthcare provider, taking into consideration individual risk factors and the specific medication being used.

Can I stop bisphosphonate treatment after a few years?

Possibly. Some research suggests that many individuals maintain their bone mass and reduced bone remodeling even after stopping the treatment with a bisphosphonate called alendronate. However, the decision to stop should be made with a healthcare provider.

Who should consider continuing bisphosphonate treatment beyond five years?

People with very low bone density or a high risk of certain types of fractures may benefit from continuing bisphosphonate treatment beyond five years. This should be decided in consultation with a healthcare provider, taking into account the person's specific condition and treatment results.

Medication - Denosumab

What is denosumab and what does it do?

Denosumab is a type of medicine used to treat a condition called osteoporosis, which makes bones weak and more likely to break. It works by blocking a specific protein that causes bone breakdown, thereby helping to keep bones stronger.

Who should use denosumab?

Denosumab is suggested by medical experts as a first choice for people who have a high chance of breaking their bones and for those who can't take medications by mouth. It can also be used by women who have gone through menopause and have a high chance of fractures, women who have breast cancer and are undergoing a certain type of treatment, as well as men with weak bones or prostate cancer receiving a specific treatment.

How well does denosumab work in preventing bone fractures?

A research study showed that using denosumab every five months for three years helped reduce the risk of fractures (broken bones) in women who had gone through menopause and had osteoporosis. For instance, it lowered the chance of new spinal fractures by 68%, and reduced the risk of other types of fractures by 20-40%.

How do people receive denosumab?

Denosumab is given as an injection, like a vaccine shot, every six months by a healthcare professional. It's available in a ready-to-use syringe or a one-time-use vial.

Are there side effects to using denosumab?

Denosumab is generally safe to use, but some people may experience side effects like allergies, serious infections, skin issues, muscle pain, and high cholesterol. It can also lead to low calcium levels, so it's important to have your calcium checked before starting the treatment. In very rare cases, it can cause serious conditions that affect the jaw bone and leg bone.

Can people with kidney problems use denosumab?

Denosumab is safe for people with mild to moderate kidney problems, but is not recommended for those who need dialysis or have severe kidney disease. If someone has severe kidney issues, there's a higher chance of having low calcium levels when using denosumab.

Is it okay to stop using denosumab after starting the treatment?

Medical guidelines suggest not to stop using denosumab once you start the treatment. This is because stopping the medication can lead to a decrease in bone strength after two years and an increase in the activity of bone breakdown after one year.

Medication - SERMS

What are Estrogen Agonist/Antagonists?

Estrogen Agonist/Antagonists, also known as selective estrogen receptor modulators (SERMs), are a class of drugs used in the treatment of osteoporosis. They can both act like estrogen (agonist) and oppose estrogen (antagonist) in different parts of the body.

What is Raloxifene and how does it work?

Raloxifene is a type of Estrogen Agonist/Antagonist (EAA) drug. It works by acting like estrogen on the bone, which helps to reduce bone loss and increase bone density. At the same time, it works against estrogen in breast and uterine tissue.

Who should use Raloxifene?

Raloxifene is recommended as a first-line therapy for patients who only need to reduce the risk of spine fractures. It can also be considered in women with a higher risk of vertebral fractures who may also be at risk for breast cancer. In some cases, it can be used as a less strong treatment to prevent bone loss in high-risk patients during a break from another osteoporosis medication called bisphosphonates.

How effective is Raloxifene in reducing fracture risk?

Research has shown that women who took Raloxifene daily had a lower relative risk of new spinal fractures. However, its effectiveness in preventing non-spinal fractures was not significant. This drug also helped increase bone density in certain parts of the body.

How is Raloxifene administered and what are its side effects?

Raloxifene is taken once a day in a 60 mg dose, and it doesn't matter if it's taken with or without food. Some side effects include hot flashes, vaginal bleeding, and worsening of pre-existing high triglycerides, a type of fat in the blood. It can also cause blood clots and should be avoided by women with certain conditions including those who may become pregnant, are pregnant, or are breastfeeding.

Medication - Calcitonin

What is Calcitonin?

Calcitonin is a synthetic version of a hormone found in animals, including humans. The specific effects of calcitonin on human bone health are not fully understood, but it is known that calcitonin receptors are present on cells involved in bone formation and breakdown. It's approved by Health Canada for the treatment of osteoporosis in women who have been postmenopausal for more than five years and when other treatments aren't suitable.

How effective is Calcitonin in treating osteoporosis?

A study found that a daily dose of 200 IU of calcitonin reduced the risk of new spinal fractures by 33% in postmenopausal women with osteoporosis. However, there isn't enough data to show that calcitonin reduces fractures in non-spinal bones. As a result, it's not usually the first treatment choice for osteoporosis.

How is Calcitonin administered?

Calcitonin comes in a nasal spray form that's given as one spray in one nostril per day, switching nostrils each day. Calcitonin injections are also available, but they're not commonly used.

What are the side effects of Calcitonin?

The most common side effects of calcitonin include nasal irritation, runny nose, back pain, joint pain, nosebleeds, and headaches. People older than 65 may be more likely to have nasal side effects. Skin testing might be considered before treatment if there's a suspicion of an allergy to calcitonin because serious allergic reactions have been reported.

What are the long-term risks of using Calcitonin?

A long-term review by the FDA in 2013 suggested a very small increase in cancer rates among patients treated with calcitonin. Health care professionals are advised to weigh the benefits of calcitonin for osteoporosis therapy against these potential risks and consider other available treatments.

Teriparatide

What is Teriparatide (Forteo) and how does it work?

Teriparatide is a type of osteoporosis treatment that helps stimulate new bone growth. It works similarly to a natural hormone in our bodies that helps control bone formation. It is suggested for use in patients with a history of fragile fractures, those at high risk of fractures, or those unable to take oral therapy.

How effective is Teriparatide in treating osteoporosis?

Studies have shown that teriparatide can help reduce the chance of new spinal and non-spinal fractures and increase bone density in postmenopausal women with osteoporosis. It was also found to be more effective than alendronate, another osteoporosis medication, in preventing new spinal fractures in high-risk patients.

How is Teriparatide administered?

Teriparatide is given as an injection under the skin once a day in the thigh or abdomen. The treatment period is typically limited to two years due to safety concerns identified in animal studies.

What are the potential side effects of Teriparatide?

Teriparatide should be avoided in patients with certain conditions like Paget’s disease of the bone, unexplained elevated levels of a certain enzyme in the body, prior bone radiation treatment, bone cancer, or conditions that lead to high calcium levels. After stopping teriparatide therapy, another type of osteoporosis treatment is recommended to avoid bone density decline.

Alcohol

What is Osteoporosis Canada’s guidance on alcohol consumption?

Osteoporosis Canada, in line with CCSA’s 2011 guidelines, advises that regular consumption of three or more alcoholic drinks per day may increase the risk of osteoporosis.

How does alcohol consumption increase the risk of osteoporosis?

Alcohol affects the body's ability to absorb calcium and vitamin D, which are crucial for bone health. Heavy drinking can also lead to hormone disruptions, affecting bone health. Additionally, it can lead to lifestyle issues like poor nutrition which is a contributing factor to bone loss.

What is the link between alcohol and falls risk?

High alcohol intake is associated with an increased risk for falls. Falls are especially dangerous for people with osteoporosis, as their bones are more likely to break.

Does this mean I can't drink alcohol if I have osteoporosis?

Not necessarily. While heavy drinking is discouraged, moderate or occasional alcohol consumption isn't necessarily harmful. It's best to discuss your personal situation and alcohol use with your healthcare provider.

Does Osteoporosis Canada's guidance apply to all types of alcohol?

The guidance does not specify a type of alcohol. It's the number of drinks consumed daily that is associated with an increased risk of osteoporosis.

References

2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary Alexandra Papaioannou, Suzanne Morin, Angela M. Cheung, Stephanie Atkinson, Jacques P. Brown, Sidney Feldman, David A. Hanley, Anthony Hodsman, Sophie A. Jamal, Stephanie M. Kaiser, Brent Kvern, Kerry Siminoski, William D. Leslie CMAJ Nov 2010, 182 (17) 1864-1873; DOI: 10.1503/cmaj.100771

Tu KN, Lie JD, Wan CKV, Cameron M, Austel AG, Nguyen JK, Van K, Hyun D. Osteoporosis: A Review of Treatment Options. P T. 2018 Feb;43(2):92-104. PMID: 29386866; PMCID: PMC5768298.

Kanis JA, Johansson H, Oden A, et al. A meta-analysis of prior corticosteroid use and fracture risk. J Bone Miner Res 2004;19:893-9.

Reid IR, Bolland MJ, Grey A. Effect of calcium supplementation on hip fractures. Osteoporos Int 2008;19:1119-23.

Hanley DA, Cranney A, Jones G, et al.; Guidelines Committee of the Scientific. Advisory Council of Osteoporosis Canada. Vitamin D in adult health and disease: a review and guideline statement from Osteoporosis Canada (summary). CMAJ 2010;182:1315-9.

Cummings SR, San Martin J, McClung MR, et al. Denosumab for prevention of fractures in postmenopausal women with osteoporosis. N Engl J Med 2009;361: 756-65.