Treatment of osteoporosis

Increasing calcium intake may have a modest effect on bone loss. One study in post-menopausal women showed that women with a higher calcium intake lost 1 to 2% less bone mass compared to a control group over two years of follow-up.

An adequate intake of calcium is at least 1500mg per day, which can be obtained from eating two or three servings of dairy products.

Exercise is thought to improve bone density and bone strength and is generally recommended in the elderly at increased risk of fractures due to osteoporosis.

Vitamin D supplementation has been shown to reduce the rate of hip fractures in the elderly, but is only likely to be necessary or appropriate in people who live in parts of the world where exposure to the sun is limited for more than half the year, such as northern Europe, the northern United States and Canada. Vitamin D is synthesised by the body as a result of exposure to ultraviolet light, but supplementation at high levels could lead to toxicity.

Two randomised studies, one in 31 patients1 and the other in 82 patients showed that adding the biphosphonate drug alendronate (Fosamax, 70mg once weekly) to vitamin D and calcium supplements resulted in a significantly greater increase in bone mineral density when compared with vitamin D and calcium supplementation.2

Another biphosphonate drug, zoledronate, showed efficacy in reducing bone mineral loss over one year in a randomised trial in 30 HIV-positive people with evidence of moderate bone mineral loss. Individuals who received a single infusion of 5mg of zoledronate experienced a 4.7% increase in bone mineral density over 12 months, compared to a 0.7% increase in the placebo group.3

Anabolic steroids have been shown to increase spinal bone density by 2 to 3% after treatment but no effect on the rate of fractures has been seen. However, a study of the steroid oxandrolone had no effect on bone mineral density among a small group of HIV-infected individuals.4 Growth hormone also had no effect on bone mineral content in HIV-infected men with lipodystrophy.5

In severe osteoporosis, several drugs have been tested to reduce the risk of fractures. A vitamin D analogue called calcitriol (Rocaltrol / Calcijex) has been shown to reduce fracture rates in post-menopausal women. Disodium etidronate (Didronel), calcitonin (Forcaltonin / Miacalcic) and alendronic acid (Fosamax) have all been approved for the treatment of osteoporosis in post-menopausal women.

However, few studies have investigated whether these treatments are effective in HIV-positive people diagnosed with osteoporosis. One study comparing vitamin D and calcium supplementation with or without alendronic acid in 31 HIV-infected people with osteopenia found that spinal bone mineral density improved by 5% in the alendronic acid group and 1% in the supplement-only group at 48 weeks.6 Another study using a similar protocol in 40 HIV-infected people with osteopenia, found that alendronic acid was significantly more effective in reducing bone turnover, although two people in each group experienced fractures due to minimal trauma.7 A small, non-randomised study of vitamin D and calcium supplements in HIV-infected children with osteoporosis also found little benefit from this type of supplementation.8

Switching from a PI-based to a PI-sparing regimen has not been shown to improve bone mineral density after 48 weeks,9 10 suggesting either that improvement of the problem could take longer, or that PIs are not the cause of the problem. The condition did not worsen during the follow-up period, regardless of whether people stayed on PI therapy or switched to an non nucleoside reverse transcriptase inhibitor (NNRTI)-containing regimen.

References

  1. Mondy K et al. Alendronate, vitamin D and calcium for the treatment of osteopenia/osteoporosis associated with HIV infection. J Acquir Immune Defic Syndr 38: 426-431, 2005
  2. McComsey G et al. Alendronate with calcium and vitamin D supplementation is superior to calcium and vitamin D alone in the management of decreased bone mineral density in HIV-infected patients: results from ACTG 5163. Fourteenth Conference on Retroviruses and Opportunistic Infections, Los Angeles, abstract 42, 2007
  3. Huang J et al. A double-blinded, randomized controlled trial of zoledronate therapy for HIV-associated osteopenia and osteoporosis. AIDS 23: 52–57, 2009
  4. Lawal A et al. Equivalent osteopenia in HIV-infected individuals studied before and during the era of highly active antiretroviral therapy. AIDS 15(2): 278-280, 2001
  5. Lawal A et al. Effect of growth hormone on osteopenia HIV+ patients. Eighth Conference on Retroviruses and Opportunistic Infections, Chicago, abstract 635, 2001
  6. Mondy K et al. Alendronate, vitamin D, and calcium for the treatment of osteopenia/osteoporosis associated with HIV infection. Tenth Conference on Retroviruses and Opportunistic Infections, abstract 134, 2003
  7. Guaraldi G et al. Alendronate Reduces Bone Turnover in HIV-associated Osteopenia and Osteoporosis. Eleventh Conference on Retroviruses and Opportunistic Infections, San Francisco, abstract 742, 2004
  8. McComsey GA et al. The effect of calcium and vitamin D on bone mineral density in HIV-infected children with osteoporosis. Tenth Conference on Retroviruses and Opportunistic Infections, abstract 779, 2003
  9. Hoy J et al. Osteopenia in a randomised multicenter study of protease inhibitor substitution in patients with the lipodystrophy syndrome and well-controlled HIV viremia. Seventh Retroviruses Conference, San Francisco, abstract 208, 2000
  10. Claxton S et al. Circulating leptin and lactate levels are not associated with osteopenia in HIV-infected men. Eighth Conference on Retroviruses and Opportunistic Infections, Chicago, abstract 634, 2001
This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.