Contributor: Dr. Staci-Marie Norman, PharmD, DCES

Hello Fall! Can you believe that we are moving into the season of changing colors and cooler evenings? I hope that September finds you settling into our new routine of masks and social distancing. If you have kids e-learning from home, I commend you. That is one stress I'm glad I don't have to deal with during this incredibly stressful time.

This month we're talking about women's health. One area that many of us don't think about until it becomes an issue is our bones. Osteoporosis and osteopenia are two areas that really haven't been talked about in the past because there wasn't much that could be done for thinning bones other than taking calcium. But we now know so much more about the process of bone build-up and thinning, and we have effective treatment options to slow or even reverse bone loss.

Our bones are building and rebuilding throughout our lives. We actually “turnover” about 10% of our bone each year through the process of “remodeling”. Think about that - we essentially turn over all the bone mass in our body approximately every ten years! Two bone cells are the primary drivers of the remodeling process: the osteoclasts and the osteoblasts. The osteoblast is responsible for laying down new bone, and the osteoclast is responsible for absorbing old, worn out, or damaged bone. Many factors control these, but our hormones are a key part.

First and foremost, as women, we should build as much bone as possible in our young life. We build bone by consuming calcium and by stressing our bones through weight-bearing exercises. We should also avoid things that can damage bone development, such as smoking and excessive alcohol consumption. There is also concern about consuming too much soda pop because of the phosphoric acid it contains, so milk is a better beverage choice! A diet high in calcium, along with weight-bearing exercise, can help build the maximum bone density into our early thirties.

Both women and men should be concerned with bone loss, but the loss begins twenty years earlier for women. This is due to menopause. As women lose estrogen, the balance of the remodeling process is disrupted. The osteoclasts are stimulated to increase the amount and rate of bone reabsorption, while the osteoblast slows down the amount of new bone they are building. This imbalance leads to osteopenia, which is the first sign of bone loss, and eventually, to osteoporosis.

So, what can you do to protect your bones? This might sound like a broken record, but a healthy diet and exercise will help keep your bones strong - and may also help your blood glucose management. Your bones need calcium, and vitamin D. Calcium-rich foods include dairy, so your mom was right about drinking your milk, and eating dark green leafy vegetables and salmon. Vitamin D is a little harder to get through your diet, but you can get it from salmon and sardines, and many dairy products are supplemented with vitamin D. Vitamin D is also produced by the body when you are in the sun, however, due to skin cancer risks, most of us slather ourselves with sunscreen. Unfortunately, this decreases the amount of vitamin D we can produce, meaning we might need to add vitamin D through food or supplements. Vitamin D is vital to our bones because it helps the calcium in our diet absorb and be used in bone formation. Exercise, especially weight-bearing, is also important. Remember those osteoblasts that build bone? When you exercise, the bones are put under stress, and this stimulates the osteoblasts to lay down more bone to help heal the stressed bone, thus increasing bone density. So, keep going on those walks, you are helping your blood glucose and building your bones up!

Even with the best efforts, sometimes we cannot escape the aging process, genetics, or other circumstances, such as medications that are hard on the bones. If osteopenia or osteoporosis does develop, we now have an arsenal of medications to treat the bones.

The typical recommendation for osteopenia is increased calcium and vitamin D. Estrogen receptor modulator (Evista), or estrogen therapy if menopausal, or calcitonin (Miacalcin) might be added. In later stages of osteopenia and osteoporosis, a bisphosphonate, such as Fosamax, Boniva or Actonel might be added. These work by slowing down the osteoclasts reabsorption of bone, inactivating them so that the osteoblasts have time to catch up with bone production. These are all oral medications that can be taken daily, weekly, or monthly. As with any medication, there are potential side effects. The most common is a burning feeling in the esophagus after taking the medication. It is recommended that these medications are taken 30 minutes before any food with a glass of water, and then you must sit upright for 30 minutes to decrease this effect. There are also some reports of unusual bone fractures and jawbone deterioration.This could be due to the fact that the remodeling process is disrupted by inactivating the osteoclasts. Because of this, it is recommended that a patient take a break from the bisphosphonate after five years. Reclast is a once-yearly infused bisphosphonate, which eliminates the esophageal burning but can still have the other side effects. Another therapy option is Prolia, a RANK ligand inhibitor. It stops the osteoclast from being stimulated to reabsorb bone. Prolia is given every six months as an infusion, and because it only stops the osteoclasts while it is present and does not inactivate them permanently, it does need to be continued for continued effect. As for potential side effects, they are the same as the bisphosphonates except for the esophageal burring.

Another way of slowing osteoporosis and even rebuilding bone is by stimulating the osteoblasts to lay down new bone. Forteo was the first medication to work in this fashion. It is a daily injection for two years. Tymols is the second medication in this family of drugs. It is also a daily injection for 18 months. After rebuilding bone, it is then recommended that patients be put on an antiresorptive as discusses earlier. The newest medication is Evenity, which works by stimulating the osteoblasts to lay down bone. It also has some antiresorptive effects by slowing down the osteoclasts. It is a monthly injection for one year, and like Forteo and Tymols, needs to be followed by an antiresorptive. As with all these medications, bone fractures and jaw deterioration are rare but potential side effects. With Evenity, there is a risk of increased cardiovascular disease.

The good news is that we have some excellent options to keep our bones healthy, but you play a large part in this bone health by eating right and exercising. So why not kill two birds with one stone and fill your plate with dark green leafy veggies and get out for that after-dinner walk!

Dr. Staci-Marie Norman, PharmD, DCES received her bachelors from Purdue University (’94) and her Doctor of Pharmacy from the University of Oklahoma (’96). In 2000 Dr. Norman added to her credentials by becoming a Certified Diabetes Care and Education Specialist. She is currently the Clinical Coordinator and staff pharmacist for Martin’s Pharmacy. Dr. Norman is a national faculty member for the American Pharmacist Association, teaching certificate programs in both diabetes and cardiovascular disease. She serves on the advisory board that oversees development and revision of these programs. Along with teaching and development responsibilities for APhA, Dr. Norman serves as a peer reviewer for research grants and publication submission. Dr. Norman has also spoken for Abbott, Bayer, Lilly, Mannkind, and Lifescan as a diabetes specialist.