Current smoking, compared with never smoking, doubles the risk of hip fracture.34 Consumption of more than 1 alcoholic drink/day or more than 7/week is associated with osteoporosis and fracture, while moderate consumption of 1 drink/day or less is associated with decreased risk.35 Excessive caffeine intake is also associated with increased osteoporosis risk and should be avoided. This effect appears to result from substitution of calcium-containing beverages such as milk or fortified orange juice with caffeinated, non–calcium-containing beverages such as colas.
Treatment for fracture prevention and pain relief
The goals of therapy for osteoporosis are fracture prevention and pain relief to maximize physical function.15 Prior fracture is associated with a fivefold risk of future fractures.5 About 20% of women who experience a vertebral fracture have another fracture within 1 year.36 Currently available therapies (Table 2) are antiresorptive: they slow bone turnover and allow bone formation to exceed resorption. Trials of antiresorptive agents in elderly women with osteoporosis and baseline vertebral fracture demonstrate that 1 new vertebral fracture is prevented for each 12 to 35 women treated for 2 to 3 years.14,37Table 3 summarizes the results of key treatment studies and provides information on the number of women that need to be treated (NNT) for the study period to prevent 1 fracture.
TABLE 2 Drug therapy for prevention and treatment of postmenopausal osteoporosis
Drug (trade name)
Indication and dosage
Possible side effects (% of patients)
Cost per month*
Calcium and vitamin D (generic, Tums, Citracal, and others)
Prevention and treatment: 1200–1500 mg/day calcium and 800 IU/day vitamin D
Nausea, dyspepsia (uncommon), constipation (10%)
$5 (both)
Estrogen† (Premarin, Ogen, Estrace, Estraderm, and others)
Prevention: 0.625 mg/day conjugated equine estrogen or the equivalent; 0.3 mg/day may be effective
Nausea, breast tenderness, vaginal bleeding, mood alterations, headache, bloating
$14–$28
Alendronate (Fosamax)
Prevention and treatment: 5 mg/day or 35 mg/week
Nausea, dyspepsia esophageal irritation
$67
Risedronate (Actonel)
Prevention and treatment: 5 mg/day or 35 mg/week
Abdominal pain, nausea, diarrhea
$67
Raloxifene (Evista)
Treatment: 60 mg/day
Hot flashes (6%), leg cramps (3%)
$70
Calcitonin nasal spray (Miacalcin)
Treatment: 200 IU/day (1 spray in 1 nostril per day)
Rhinitis (5%), epistaxis, sinusitis
$66
*Average wholesale cost to the pharmacy for 30 days of therapy; (Drug Topics Red Book. Montvale, NJ; Medical Economics Co., Inc, 2002.)
†Women with a uterus need to take a progestin such as medroxyprogesterone acetate (Provera $30/month, generic $9/month) or a combination estrogen/progestin product (Prempro $33/month, FemHRT $26/month).
TABLE 3 Clinical trials of drug therapy for the prevention of fracture in postmenopausal women with osteoporosis
Calcium with or without vitamin D has been reported to positively affect fracture incidence.14 Vitamin D alone does not decrease the incidence of hip fractures.38 Calcium, 1200 to 1500 mg/day, and vitamin D, 800 IU/day, should be used concurrently with other forms of pharmacologic treatment. Calcium supplements are best absorbed with meals; for maximum absorption, calcium should be taken in doses of 500 mg or less.29,39
Minor gastrointestinal adverse effects may occur (most often constipation, 10%),14 which is often resolved by switching to a different preparation.40 Calcium in doses up to 1500 mg/day does not increase the risk for renal calculi and may, in fact, decrease risk.40,41 Calcium interferes with the absorption of certain medications, including tetracycline and quinolone antibiotics, which should be taken several hours apart from calcium. Calcium carbonate requires an acidic environment to dissolve. Patients taking stomach acid–suppressant therapy should use calcium citrate because it does not require an acidic environment for dissolution or should take their calcium supplement with meals. Traces of lead may be present in natural sources of calcium (bone meal, oyster shell, limestone, and dolomite), but can be avoided by use of over-the-counter calcium carbonate tablets (Tums).
Estrogen
Data from the Women’s Health Initiative (WHI) demonstrated that hormone replacement therapy (HRT) combining an estrogen and a progestin reduced hip and vertebral fractures by 1 in 2000 women per year and reduced all fractures by 1 in 333 women per year.42 Estrogen has a positive effect on BMD whether given in early or late postmenopause.43 Rapid bone loss as assessed by BMD does not occur after stopping HRT.44 However, in elderly women who have never used HRT, BMD is similar to those who have used it for 10 years and then stopped for at least 10 years.43 The effect of short-term (< 5 years) HRT during perimenopause on lifetime risk of osteoporotic fracture is unknown.
