FAQs with Dr. Pandit: Osteoporosis

Osteoporosis is a common and potentially debilitating disease that affects an estimated 54 million Americans. Often referred to as a silent disease, osteoporosis can progress with no symptoms or warning signs until a fracture occurs. At Texas Diabetes and Endocrinology, we believe that preventing bone fractures is a priority.

In honor of Osteoporosis Awareness and Prevention Month, endocrinologist Dr. Keta Pandit is sharing everything you need to know about the condition.

What are the most common signs of osteoporosis?

Osteoporosis is characterized by low bone mass that results in microarchitectural disruption which causes decreased bone strength and increased risk of fracture. Some people may develop small microfractures in the vertebral spine, which may result in loss of height or hunched posture, known as kyphosis. Unfortunately, osteoporosis has no clinical manifestations until there is a fracture.

What risk factors raise a person’s chances of getting osteoporosis?

Women are much more likely to develop osteoporosis compared to men. Upon menopause women are not exposed to Estrogen, which is responsible for promoting bone growth. Therefore, postmenopausal women are at an increased risk of getting osteoporosis. Those with a family history of hip fractures or osteoporosis are also at an increased risk and should inform their doctor so that screening can be done appropriately. 

Other factors that can increase osteoporosis risk can include: 

  • smoking
  • daily use of alcohol
  • history of steroid use
  • early menopause in women
  • low testosterone in men
  • excessive use of thyroid hormones or history of hyperthyroidism
  • hypercalciuria
  • chronic medical conditions like diabetes and HIV

At what age should patients start thinking about osteoporosis prevention?

​The National Bone Health & Osteoporosis Foundation (NBOF) and the U.S. Preventive Services Task Force(USPSTF) both recommend screening for osteoporosis in women of age 65 and above. NBOF also recommends screening early for all postmenopausal women with known risk factors. Regardless, all women of postmenopausal age are recommended to have adequate calcium and vitamin D to prevent bone loss.

For men, the recommendations have varied. NBOF recommends screening for all men over age 70 and as early as 50 years or older for men with risk factors. On the other hand, USPSTF has not provided a set guidance for what age men should be screened for osteoporosis.

What is one of the most common misconceptions patients have about osteoporosis?

One of the most common misconceptions about osteoporosis is that it presents pain in your bones or joints. Osteoporosis is a silent disease, and it does not present with any pain, unless there is a fracture or a bone deformity that comes from a previous history of fracture. 

Many people believe that adequate intake of dairy in their diet is sufficient to prevent bone loss. However, you may not necessarily have adequate calcium despite daily use of dairy products. 

Does osteoporosis affect men and women differently?

Women tend to have younger onset of bone loss and lose bone at a faster rate compared to men. Estrogen deficiency plays an important role in osteoporosis development, which is one of the factors that makes women more susceptible to osteoporosis compared to men. 

How can someone best protect themselves from osteoporosis?

Prevention of osteoporosis begins with ensuring you have enough calcium and Vitamin D in your diet. Other steps you can take to maintain bone density include:

  • eating a well-balanced diet
  • regular exercise with weights
  • avoiding alcohol and smoking

How is osteoporosis treated?

The landscape of medications for osteoporosis has changed in the last two decades. All medications work in a different pathophysiology, but the goal is to build bone and reduce fracture rates. 

Oral bisphosphonates, IV bisphosphonates and denosumab work by reducing the rate at which bones break down. Oral bisphosphonates including weekly Alendronate (Fosamax) or monthly Residronate (Actonel) and Ibandronate (Boniva) are the standard of treatment for osteoporosis in the beginning stages. However, these medications are known to cause reflux. 

Those that cannot take the oral bisphosphonates can resort to annual IV zoledronic acid (brand name Reclast), which is also a bisophosnate. Alternatively, denosaumab (Prolia) can also be utilized which is an injection given every 6 months.

For patients that have severe osteoporosis, which is defined as a history of a fracture in the hip or spine or wrist, or very low scores on their bone density scans, stronger medications can be used. These medications belong to a class of medications called anabolic treatment, known as Teriparatide (Forteo), Abaloparatide (tymlos) or Romosozumab (Evenity). These medications build stronger bone by speeding up the bone building process. Teriparatide and Abalopartide are daily injections approved for two years and Romosozumab is a monthly injection approved for one year. After their recommended time frames, patients will generally switch to either IV Reclast or Prolia depending on how they respond to the treatment. 

Long term use of osteoporosis medications is discouraged as there is a risk for developing atypical femoral fracture or osteonecrosis of the jaw. Therefore, we recommend stopping medications temporarily, known as a drug holiday. After 3-5 years of treatment (or up to 8-10 years of treatment in some cases), a drug holiday is recommended. During the ‘drug holiday’, bone density is measured annually or every two years, and treatment can begin after 2-3 years of drug holiday if bone loss progresses.

Dr. Keta Pandit is a board certified endocrinologist and obesity medicine specialist with a special interest in the treatment of adrenal and pituitary disorders. She sees patients at our Central Austin office. 

If you’d like to learn more about our osteoporosis and fracture treatment services, please call Texas Diabetes and Endocrinology at (512) 458-8400 or request an appointment online

Don’t forget to follow us on Facebook and Instagram and check back with us each month as we provide you helpful wellness and health information.


By Dr. Tira Chaicha-Brom

Osteoporosis is a condition of weak bones and carries a high fracture risk and in turn increased mortality. Unfortunately, this condition typically goes undiagnosed because it is typically asymptomatic, unless someone was to have a fracture. 10.2 million Americans have osteoporosis and 43.4 million have the precursor osteopenia. Often, people will assume that having a “hunchback” is a sign of osteoporosis, but that is not always the case. If someone were to have lost some height, this could indicate a vertebral fracture which would be diagnostic for osteoporosis.  Sometimes people will assume that because they are old and have hip or back pain, that they have osteoporosis. However, osteoporosis does not hurt and the pain that patients complain about is more likely related to arthritis which is due to joint pain. Osteoporosis typically affects women more than men due to menopause but it is often underdiagnosed in men since they are not usually screened for the disease.

How is osteoporosis diagnosed if it is asymptomatic?  We typically order a bone density. A bone mineral density (BMD) is a painless procedure where one is laying on his/her back and x-rays are taken of the spine and hip and sometimes, the wrist.  A BMD can help predict the risk of fractures but it is not used to diagnose fractures, which would require a different imaging study such as a plain film X-rays.  For post- menopausal women and men above the age of 70 a T-score of -2.5 or lower on a BMD is diagnostic for osteoporosis.  Interestingly, though, most fractures occur in the osteopenia range since more patients will be in this category.  Another way a patient could be diagnosed with osteoporosis is to have an osteoporotic, or fragility, fracture. This type of fracture occurs from a fall from a standing position and results in a fracture of a large bone such as the hip, spine, or arm and often excludes fractures of the feet or fingers.

Our bones are the strongest when we are in our 30s and after that we start to lose bone density.  Some people will lose bone density at a faster rate than others due to changes in sex hormones (estrogen and testosterone) among other factors such as weight, medications (especially long term steroid use), or smoking. Other risk factors for bone loss include being thin, diabetes, inflammatory bowel disease, and a family history of osteoporosis.  If you are diagnosed with osteoporosis, typically your doctor or endocrinologist will evaluate your blood or urine to look for causes to explain the bone loss, but oftentimes there are no underlying reasons.

The United States Task Force recommends starting to screen women at the age of 65 years old for osteoporosis with a bone density. Even though they do not recommend screening for men, the National Osteoporosis Foundation recommends for men to be screened starting at years old.  Patients with certain risk factors may be screened before these ages.

There are several treatments available for osteoporosis which are offered based on a patients risk for fracture.  Typically, if a patient is of high risk for fracture then oral medications can be used but for those who are very high risk, it oftentimes requires medications that are injected. Most of the options will help prevent further loss of bone (bisphosphonates and denosumab). One class of medications will help develop new bone (PTH analogs) and another class can do both – increase bone and also stop it from declining (romosumab).  Each of these medications has its own side effect profile and your doctor can help you determine which treatment is appropriate for you. 

            Oftentimes, patients will be scared to start a medication due to the potential side effects. One of the more commonly prescribed medications for osteoporosis is the bisphosphonates (e.g. Fosamax/alendronate, Boniva/ibandronate, Actonel/risedronate). This class of medication has been around since 1990 and is very effective.  The two main side effects are osteonecrosis of the jaw (ONJ) and atypical femur fractures (AFF).  ONJ refers to exposed jaw bone that does not heal within 8 weeks.  AFF is a mid-thigh fracture after low or no trauma.  Both of these side effects are very rare and can be seen in <0.01% of patients.  Typically the bisphosphonates are used for 3-5 years before considering stopping the medication. The time limit on these medications is in order to prevent these side effects from happening. If the BMD shows it is improving after a certain amount time on the medication, then the medication may be held for 1-2 years (drug holiday) and if the BMD declines again, then the medication can be resumed.

            Some patients wonder if osteoporosis can be prevented. Weight bearing exercise and an adequate intake of calcium and vit D can help, but these may not be enough.  The recommended amount of calcium is 1200mg daily, in combination of diet and supplements, for all adults over the age of 50, as per American Association of Clinical Endocrinology (AACE 2020) guidelines.  The recommended vit D for adults over 50yo is 1000-4000 I.U. daily.  There are currently no guidelines for recommending vit K although many supplements on the market already sell vit D with vit K.  Limiting caffeine and alcohol consumption and smoking cessation can also prevent further bone loss.  There are no over the counter treatments that have been shown to be adequate to treat osteoporosis.

            Another very important factor that is often overlooked is to consider fall risks.  As we age, our eye sight, hearing, and proprioception may not be as good as they were when we were younger so we are more likely to fall. We need to look around the house and consider rugs, poor lighting, pets, and certain shoes as trip/fall hazards.

Osteoporosis is a very serious condition that is associated with a high fracture and mortality risk. It affects men, women, and every ethnicity/race and advancing age is a risk factor. A BMD is a simple tool that can be used to screen for this disease and very effective treatment options are available to prevent fractures.  

What you need to know about Osteoporosis

Osteoporosis is a growing public health concern. It is characterized by low bone mass and decreased bone strength which results in an increased risk for fracture. This disease can affect both men and women. Current estimates are that 5.1% of men and 24.5% of women age 65 years and older have osteoporosis of the hip or spine.

Osteoporosis can be diagnosed with a BMD (bone mineral density) assessment.

Most experts recommend a BMD assessment in all postmenopausal women 65 years and older.

Many experts also recommend a BMD assessment in women younger than 65 who are at increased risk for osteoporosis.

Some experts recommend a BMD assessment for men over the age of 70.

Osteoporosis is a silent disease. As such, there are no clinical manifestations until the affected individual suffers a fracture. This is why early diagnosis is important -we have therapies that can slow or even reverse the progression of osteoporosis so that fracture risk is reduced. One of our goals at Texas Diabetes and Endocrinology is to deliver interventional therapies that will maintain quality of life for an aging population. If you have osteoporosis, we can perform a thorough evaluation and offer an individualized treatment plan.

Here are things you can do on your own to preserve bone mass:

  • Limit alcohol consumption to <2 drinks daily
  • Avoid smoking
  • Take a daily walk for at least 30-45 minutes
  • Consume foods containing vitamin D (dairy and fish from the ocean) and/or take a supplement
  • Consume foods containing calcium (dairy, green leafy vegetables) and/or take a supplement.

Links for more information:

New Medication Option for Osteoporosis Treatment

The Food and Drug Administration (FDA) has approved Tymlos (abaloparatide) injection for the treatment of postmenopausal women with osteoporosis at high risk for fracture. High risk for fracture is defined as history of osteoporotic fracture, multiple risk factors for fracture, or patients who have failed or are intolerant to other available osteoporosis therapy. In postmenopausal women with osteoporosis, Tymlos reduces the risk of vertebral and nonvertebral fractures.

Clinical Data

The FDA’s approval of Tymlos was based on results from the ACTIVE trial and an extension of this trial. These studies demonstrated significant reductions in the risk of vertebral and nonvertebral fractures regardless of age, years since menopause, presence or absence of prior fracture and bone mineral density (BMD) at baseline. In clinical studies, Tymlos reduced the incidence of new vertebral and nonvertebral fractures, and increased bone mineral density (BMD).

The results from the ACTIVE trial were published in the Journal of the American Medical Association in August of 2016, and the results of the first six months of ACTIVExtend were published in the Mayo Clinic Proceedings in February 2017.

Specifically, in the ACTIVE trial, TYMLOS demonstrated significant reductions in the relative risk of new vertebral and nonvertebral fractures compared to placebo in the ACTIVE trial of:

  • 86% in new vertebral fractures
  • 43% in nonvertebral fractures

The absolute risk reductions were 3.6% and 2.0%, respectively.

Safety information

Abaloparatide caused a dose-dependent increase in the incidence of osteosarcoma (a malignant bone tumor) in male and female rats. The effect was observed at systemic exposures to abaloparatide ranging from 4 to 28 times the exposure in humans receiving the 80 mcg dose. It is unknown if Tymlos will cause osteosarcoma in humans.

For this reason, the use of Tymlos is not recommended in patients at increased risk of osteosarcoma including those with Paget’s disease of bone or unexplained elevations of alkaline phosphatase, open epiphyses, bone metastases or skeletal malignancies, hereditary disorders predisposing to osteosarcoma, or prior external beam or implant radiation therapy involving the skeleton.

Adverse Reactions: The most common adverse reactions (incidence ≥2%) are hypercalcemia, hypercalciuria, dizziness, nausea, headache, palpitations, fatigue, upper abdominal pain and vertigo.

Reminders About Osteoporosis

Osteoporosis is a silent disease, often displaying no signs or symptoms until a fracture occurs, leaving the majority of people with osteoporosis undiagnosed and untreated. Osteoporotic fractures create a significant healthcare burden. An estimated two million osteoporotic fractures occur annually in the United States, and this number is projected to grow to three million by 2025.

The National Osteoporosis Foundation (NOF) has estimated that eight million women already have osteoporosis, and another approximately 44 million may have low bone mass placing them at increased risk for osteoporosis

Screening is key to diagnose osteoporosis. Once osteoporosis is diagnosed, it is very important to undergo a thorough evaluation to look at secondary factors that can contribute to osteoporosis. Once the evaluation is complete, you and your physician can review the best treatment plan for you.

Next Page »