Breakfast and bone density

By Keryn Curtis

The most effective treatments for osteoporosis – the category of drugs known as bisphosphonates – have always come with an annoying downside.  They need to be taken on an empty stomach, ideally at least half an hour before breakfast, and then the patient needs to remain upright for half an hour or painful indigestion can result.

It is a downside that has made treatment for osteoporosis difficult for many elderly people, especially those with cognitive impairment.

However a new version of the bisphosphonate, Actonel EC, newly listed on the Pharmaceutical Benefits Scheme (PBS), means at least one of those challenges can be overcome.  The difference with this bisphosphonate treatment is that it can be taken along with breakfast 

According to Professor Peter Ebeling, Head of Endocrinology at Western Health, Melbourne, the government’s decision to subsidise Actonel EC represents an important advance in treating osteoporosis.

He said many patients find it challenging to follow complex instructions on how to take their medication, so anything that makes it easier for the patient is very helpful.

“Without the special enteric coating and calcium binding agent of Actonel EC, eating breakfast or even drinking a simple cup of coffee or glass of orange juice at the same time would significantly reduce the absorption of the medication, compromising its effectiveness.

“But with Actonel EC, people with osteoporosis requiring a bisphosphonate tablet can still have breakfast and have optimal fracture protection,” Prof Ebeling said.

The GP in aged care

Above: GP, Dr Ian Brown

Canberra general practitioner, Dr Ian Brown has a keen interest in family medicine, particularly aged care.  He says the older style bisphosphonates have not always been well tolerated and have therefore often not been used in aged care; but he hopes the new options will make it easier.

“One of the other barriers is the ageist barrier. Doctors and staff might think, oh the person is frail and in their final years so we needn’t bother.  My response is that we are in the business of preventing pain so please, bother!” Dr Brown said.

 “There’s no age at which you shouldn’t think about treating people for osteoporosis. If you can help someone avoid being in chronic pain in their last years, there’s a benefit. 

There’s nothing served in condemning people to chronic pain.” 

Dr Brown said the community, including aged care, seriously underestimates the impact of osteoporosis.

“The whole area of risk of osteoporosis is underestimated right throughout the community and probably by medical practitioners too. It can be overlooked.”

Dr Brown said there were some well tested approaches to improving a person’s vulnerability to osteoporotic fractures but that they were often easy to overlook.  

“In aged care, and especially in community aged care, carers need to be mindful that whatever a person has in terms of bones should be preserved – so nutrition, exercise and vitamin D are all important as well as medication.”

“If an elderly person at home fractures a hip, then the stats for their subsequent problems and outcomes are alarming,” said Dr Brown. 

 “People taking anti-osteoporosis medications still experience fractures but much less than rest of the community. Falls prevention needs to be paramount. So you need to keep places uncluttered and watch for obvious risk factors like use of bifocals or other sight problems that might impact on safety. 

“Other modifiable things include continued attention to diet and supplements and other environmental elements.  People in the age group should be reminded to discuss good calcium, vitamin D levels and their sun exposure needs with their doctor.  They should also be aware that certain symptoms– such as back pain – might require more attention.” 

The person with osteoporosis

Above: Rosemary McQualter

At 58, Rosemary McQualter is not a typical case study in osteoporosis.  Rosemary has a rare progressive inflammatory neuropathy (PIN) which has required regular doses of prednisolone – an anti-inflamatory class of drugs used to treat allergic disorders, skin conditions, ulcerative colitis, arthritis, lupus, psoriasis, or breathing disorders including asthma.

“The PIN affects my peripheral nervous system and I have had to be treated for months with a prednisolone infusion.  But prednisolone attacks your bone density. People don’t realise the potential effect of prednisolone on bone density,”she says.

“I think people are really blasé. Often it’s not until they have a fracture that they take any notice. Carers also need education, that’s why I agreed to do this to put myself out there for this campaign,” Ms McQualter said.

As well as having osteoporosis, Rosemary McQualter is herself a personal care worker.  She has recently spent five years caring for a very elderly woman with vertebral osteoporosis. 

“My client was prescribed a bisphosphonate and it was always difficult getting her to take it at the right time. It is best on empty stomach, first thing in morning, half an hour before breakfast, so it can’t be taken at the same time as the other medications and then she would have to sit up with it for half an hour afterwards.

“You can’t lie down with the tablet because it can cause painful indigestion.  The old one had to be taken half an hour before the first meal of day.  So this new tablet is a big improvement because it can be taken with all the other medications at breakfast.” 

Ms McQualter said she didn’t think diet and other strategies for preventing osteoporosis or retaining bone density were a high priority for aged care.  

“Community carers will tend to focus first and foremost on safety in the home for the client and providing the right aids.  But diet and exercise are part of the duty of care in preventing fractures.

“Often its not until they have a fracture that they take any notice.  There needs to be more education, that’s why I agreed to put myself out there. To create more awareness and to emphasis the importance of establishing good bone density in your early years.”

“We should all be having herbal tea or low caffeine tea or decaffeinated coffee and eating hard cheeses and oily fish. In aged care, we need to get people into weights and walking on the treadmill,” she said.