 Our bones maintain their density through bone remodeling, which repeats bone formation by osteoblasts and bone resorption by osteoclasts. In this process, if bone formation is reduced or bone resorption is excessive, bone density decreases, resulting in osteopenia and osteoporosis. In particular, during menopause, the risk of osteoporosis increases as female hormones, which play an important role in the balance of bone remodeling, drop sharply. Professor Shin Jeong-ho (Department of Obstetrics and Gynecology, Korea University Guro Hospital) emphasizes, “Osteoporosis increases the risk of fracture, and long-term treatment strategies are important because once an osteoporotic fracture occurs, re-fracture can be repeated over and over again.” |
– What is the initial treatment strategy for patients with osteopenia and osteoporosis in menopause?
It is determined whether drug treatment is necessary according to the osteopenic state, and a treatment suitable for the patient’s condition is selected.
For example, if a relatively young woman around 50 years old has menopause symptoms and a decrease in bone density, female hormone therapy is selected. During menopause, as female hormones, which play an important role in the bone remodeling process, become insufficient, bone density sharply decreases.
In the late 50’s to early 60’s, vertebral fractures occur most often due to a sharp decrease in bone density of the spine. Therefore, a SERM agent such as Evista, which is specialized for targeting vertebral fractures, is used.
The risk of hip and hip fractures increases after the age of 70, and in that case, the strategy of using denosumab and then switching to bisphosphonate drugs is used when treatment is finished.
– Decrease in female hormones after menopause causes various diseases as well as decreased bone density. What should be considered when selecting a treatment for osteopenia and osteoporosis?
Raloxifene (trade name; Evista Plus), one of the SERMs, has been proven to improve bone density and reduce the risk of breast cancer through large-scale clinical studies. In the case of breast cancer, although the number varies from study to study, it is known that it reduces the risk by as little as half to as much as about three-quarters. Therefore, it can be said that it is a treatment with great advantages for women in their late 50s to 60s, the most common age of breast cancer.
In addition, raloxifene can be safely used in patients with hypertension, diabetes, and kidney disease, and it does not significantly affect the action of these drugs. In general, people over the age of 60 often take various medications for various diseases. In this case, taking raloxifene as a treatment for osteoporosis can be a safe choice.
– Why do you need long-term treatment for osteopenia/osteoporosis?
Osteoporosis treatment is to prevent further bone loss and lower the risk of fracture, not to ‘cure’ osteoporosis itself. Therefore, once diagnosed with osteoporosis, you should think of managing it for the rest of your life.
The same is true for patients with osteopenia who have not yet reached osteoporosis. The actual number of fractures is higher in osteopenia than in osteoporosis, and the risk of fracture is about 2.5 times higher than that of normal people. Therefore, if necessary, it is recommended to start management at an early stage from the osteopenia stage.
– What is the reason for the lack of awareness of osteoporosis treatment, especially long-term treatment?
This is because weak bones are an indicator through examination, not a symptom that can be directly felt. At least after experiencing a fracture, most patients recognize their bone condition, and even after experiencing an osteoporotic fracture, many people do not take osteoporosis medication once the fracture is recovered.
However, it should be recognized that osteoporosis is a disease that, once diagnosed, continues to increase the risk of fracture. Fractures when young are painful and uncomfortable, but osteoporotic fractures in old age can lead to death. In particular, in the case of hip fractures, the mortality rate reaches about 20% within one year, and vertebral fractures, which are common in postmenopausal women, also have a high re-fracture rate and mortality.
In addition, we believe that the current insurance benefit system has an impact on the long-term non-sustainability of osteoporosis treatment. Currently, if you have a history of fractures, insurance benefits are available for the first 1 to 3 years, but after 3 years, the insurance will be applied after checking whether you meet the eligibility criteria through a bone density test once a year. From the patient’s point of view, it can be very inconvenient to make a reservation and visit the hospital once a year and continue the test.
Korea is the only country that conducts an annual bone density test for insurance benefits for osteoporosis treatment. In the United States and Western Europe, once osteoporosis is diagnosed, insurance benefits continue to be recognized. This is because osteoporosis is viewed as a chronic disease that must be managed for life, just like high blood pressure. The domestic insurance benefit system should also be improved to reflect this point.
– However, there is a burden of taking the treatment for a long time. Is it safe to take long-term osteoporosis drugs?
Although bisphosphonates and denosumab are effective drugs, there is a risk of jaw bone necrosis or atypical fractures of the femur when taken for a long time, and bone turnover is delayed due to too strong inhibition of bone resorption. There is this. Therefore, after 3 to 5 years of use, or when entering dental treatment, there is a rest period.
Raloxifene (Evista Plus) suppresses bone resorption to a natural degree and maintains it in a pre-menopausal state, so there is no need to take a break for long-term use as well as dental treatment. It is considered a very safe drug because there is no concern about side effects such as jaw bone necrosis.
There are great advantages to using raloxifene in the strategy of sequential treatment. If you change from using a bisphosphonate agent to another bone formation accelerator, the effect of the drug may not appear well. However, if you change from using raloxifene to a bisphosphonate or parathyroid hormone, the effect of the drug is well exhibited. The fact that raloxifene does not interfere with the action of subsequent drugs is a great advantage in long-term treatment strategies.
– Like Evista Plus, osteoporosis treatment + vitamin D combination drugs are coming out a lot. what is the reason
Several clinical studies have demonstrated that calcium and vitamin D play a very important role in the treatment of osteoporosis. Therefore, for osteoporosis treatment, calcium and vitamin D must be taken together.
However, in the case of calcium, there are reports that gastrointestinal disorders or excessive calcium intake may increase the risk of cardiovascular disease in some cases. Therefore, in my case, I tend to take a strategy of taking osteoporosis drugs and vitamin D as medicine and taking calcium through food.
The biggest advantage of the osteoporosis treatment + vitamin D combination is that it improves medication compliance. No matter how much emphasis is placed on the importance of vitamin D, there are many cases where patients take only the treatment and do not take vitamin D after taking the treatment for a long time. At this time, if an osteoporosis treatment + vitamin D complex is given, the treatment effect can be enhanced while taking the treatment and vitamin D together.
– Advice on bone management for postmenopausal women
Menopause is a very big change in life. As they undergo hormonal changes as rapid as puberty, they not only weaken bones, but also increase the risk of adult diseases such as high blood pressure and diabetes. Therefore, if you enter menopause, you should pay attention to the decrease in female hormones and the diseases caused by it.
Above all, remember that how you manage your bone health during menopause determines the rest of your life for the next 40 to 50 years, and I advise you to start more active management.