OSTEOPOROSIS AND ITS HOMOEOPATHIC MANAGEMENT

Dr. Archana Narang (MD), Dr. Saurav Arora, Dr. Latika Nagpal
Thyroid Clinic, Dr. B. R. Sur Homoeopathic Medical College & Hospital, shmc.thyroidclinic@gmail.com
INTRODUCTION
Osteoporosis is defined as “a systemic skeletal disease characterized by low bone mass & micro architectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture”. Both low bone mass and bone quality play an important role in osteoporosis. The former can be easily measured and hence has become the diagnostic tool for osteoporosis. The World Health Organization (WHO) operationally defines osteoporosis as a bone density that falls 2.5 standard deviations (SD) below the mean for young healthy adults of the same gender, also referred to as a T-score of –2.5. Postmenopausal women who fall at the lower end of the young normal range (a T-score of >1 SD below the mean) are defined as having low bone density and are also at increased risk of osteoporosis.
EPIDEMIOLOGY
Osteoporosis is a global problem occurring in every geographical area & affecting 150 million men & women worldwide. Globally, osteoporosis is highest in Whites & Asians, & lowest among Blacks. Each year, osteoporosis causes more than 1.5 million fractures, resulting in permanent disability, loss of independence and death. It is predicted that one out of every two women & one in eight men over 50 will have an osteoporosis related fracture in her or his lifetime.
 
CAUSES AND RISK FACTORS
As age advances, the incidence of osteopenia and osteoporosis increases & with the progressive aging of the world population, there will be a resultant increase in the osteoporotic fractures in coming decades. Although the effects of osteoporosis are seen in elderly population, particularly women, the roots of osteoporosis are laid down with roots in pediatrics, which is a matter of great concern. Physiological evidences shows that the bone mass is formed maximum at the early ages of life. Bone architecture is formed as a result of calcium deposition along with other macro and micro nutrients. The key factor here is Vitamin D, whose deficiency is an iceberg phenomenon especially in children. Its deficiency can only become apparent after bones become soft and weak. Majority of population especially in metro cities are now becoming couch potatoes covered all the time with stress and closed environment & work areas, not exposing themselves to adequate sunlight. This is resulting in Vitamin D deficient states, which will be apparent in later stages of life when bones compromises for maintaining the serum calcium level to normal and on the other hand intestinal absorption and/or calcium channelization is disturbed. This forces bone to sacrifice and hence bone architecture is weakened and a person is more at risk of developing fractures. In majority of subjects, the total calcium and ionic calcium levels in serum/plasma are found to be in normal range despite of vitamin D deficiency.
Of all the varieties, postmenopausal osteoporosis is the commonest & most preventable. Postmenopausal osteoporosis today is recognized to be a major public health problem & is a common cause of morbidity and mortality in women. According to World Bank report, the world wide population of postmenopausal women which was 470 million in 1990s is expected to increase to 1.2 billion by the year 2030 & 76% of these women would be living in developing countries. It is projected that by the year 2030, the population of postmenopausal women in India will be the 2^nd highest in the world, second to that in China. As regards the current burden of osteoporosis & in actual numbers, it accounts for 30 million women
Osteoporosis can be classified as follows:

1. Primary osteoporosis: is more common form and is due to age related loss of bone.
2. Secondary osteoporosis: has an equal sex distribution & can occur at any age.

Causes include

1. Endocrine diseases (Cushing’s syndrome, hyperthyroidism, hypogonadism in males).
2. Gastrointestinal disorders like inflammatory bowel diseases causing malabsorption.
3. Drugs like corticosteroids, cancer chemotherapy, anticonvulsants, heparin, barbiturates, gonadotropins releasing hormone, aluminium containing antacids.
4. Multiple myeloma.
5. Chronic renal failure.
6. Prolonged immobilization.
7. Osteogenesis imperfecta.
8. Inflammatory arthritis. (ankylosis spondylitis, rheumatoid arthritis)
9. Malnutrition.

Most cases of male osteoporosis are due to disease or drug therapy. However, in 30% to 45% of affected individuals no cause can be identified.
RISK FACTORS FOR OSTEOPOROSIS


Personal characteristics:
Age>65 years
BMI<19
Early menopause (before 45 years)/surgical Menopause
Family history of osteoporotic fractures
Past history of fragile fracture
Amenorrhoea>1 year duration (other than pregnancy)
Life style factors:
Alcoholism
Smoking
Physical inactivity
Low calcium intake
 
 
Drugs
Long term steroids, Dialantinsodium, replacement therepy) thyroxine, hydrocortisone), heparin, warfarin
Medical disorders:
Rheumatoid arthritis
Hypogonadism
Primary hyperparathyroidism
Thyrotoxicosis
Addison’s disease
Cushing’s syndrome
Malabsorption syndromes
Chronic liver disease
Organ transplantation
Chronic renal failure
Prolonged immobilization
DIAGNOSIS
Subjects with decreased bone density usually have no complaints or specific abnormal physical findings. Those with vertebral compression fractures will have kyphosis, protruding abdomen & height loss. In severe cases, this can lead to hunched over appearance known as “Dowager’s hump”. Back tenderness is usually only present after an acute fracture.
The diagnostic process should focus on determining the type and degree of bone loss. A detailed history, physical examination & diagnostic tests are essential to make a correct diagnosis, keeping in mind the causes & risk factors.
Measurement of bone mass
Guidelines for bone mass measurement by National Osteoporosis Foundation can be summarized as:

• In postmenopausal women, assuming they have one or more risk factors for osteoporosis in addition to age, gender, and estrogen deficiency.
• Further recommend that bone mass measurement be considered in all women by age 65, a position ratified by the U.S. Preventive Health Services Task Force.

FDA-Approved Indications for BMD Tests:
Estrogen-deficient women at clinical risk of osteoporosis
Vertebral abnormalities on x-ray suggestive of osteoporosis (Osteopenia, vertebral fracture)
Glucocorticoid treatment equivalent to 7.5 mg of prednisone, or duration of therapy >3 months
Primary hyperparathyroidism
Monitoring response to an FDA-approved medication for osteoporosis
Repeat BMD evaluations at >23-month intervals, or more frequently, if medically justified
Non invasive techniques which are now available for estimating skeletal mass or density are:

• Dual-energy x-ray absorptiometry (DXA)
• Single-energy x-ray absorptiometry (SXA)
• Quantitative CT
• Ultrasound

Laboratory evaluation:

• General evaluation includes complete blood count, serum and 24-h urine calcium, and renal and hepatic function tests and is useful for identifying selected secondary causes of low bone mass, particularly for women with fractures or very low Z-scores.
• An elevated serum calcium level suggests hyperparathyroidism or malignancy, whereas a reduced serum calcium level may reflect malnutrition and osteomalacia. In the presence of hypercalcemia, a serum PTH level differentiates between hyperparathyroidism (PTH) and malignancy (PTH), and a high PTHrP level can help document the presence of humoral hypercalcemia of malignancy. A low urine calcium (<50 mg/24 h) suggests osteomalacia, malnutrition, or malabsorption; a high urine calcium (>300 mg/24 h) is indicative of hypercalciuria.
• Measurement of 25 (OH) D level should be estimated in individuals who have osteoporosis-related fractures or bone density in the osteoporotic range.
• Hyperthyroidism should be evaluated by measuring thyroid-stimulating hormone (TSH).
• In clinical suspicion of Cushing’s syndrome, urinary free cortisol levels or a fasting serum cortisol should be measured after overnight dexamethasone.
• Serum albumin, cholesterol, and a complete blood count is to be checked when bowel disease, malabsorption, or malnutrition is suspected.
• Myeloma can masquerade as generalized osteoporosis, although it more commonly presents with bone pain and characteristic “punched-out” lesions on radiography. Serum and urine electrophoresis and evaluation for light chains in urine are required to exclude this diagnosis. A bone marrow biopsy may be required to rule out myeloma.

Biochemical Markers
Biochemical markers are now days being used for the measurement for index of the overall rate of bone remodeling. These markers are usually characterized as those related primarily to bone formation or bone resorption, which measure the overall state of bone remodeling at a single point in time. Markers of the bone resorption may help in the prediction of fracture risk independently of bone density. The primary use of biochemical markers is for monitoring the response to treatment.
Commonly used biochemical Markers of Bone Metabolism in Clinical Use:-

 
 
HOMOEPATHIC TREATMENT AND MANAGEMENT OF OSTEOPOROSIS
 
GENERAL MANAGEMENT:
Management of osteoporotic fractures:
Treatment of the patient with osteoporosis involves management of acute fractures as well as treatment of the underlying disease. Hip fractures almost always require surgical repair if the patient is to become ambulatory. Depending on the location and severity of the fracture, condition of the neighboring joint and general status of the patient, procedures may include open reduction and internal fixation with pins and plates, hemiarthroplasties, and total arthroplasties.
Management of underlying disease:

• The first part of management of osteoporosis is education of the patient thoroughly, to reduce the impact of modifiable risk factors associated with bone loss and falling.
• Glucocorticoid and other medications, if present, should be evaluated to determine to be truly indicated and being given in adequate doses as low as possible.
• In Hypothyroid subjects, TSH testing should be performed to determine that an excessive dose is not being used, as thyrotoxicosis can be associated with increased bone loss.
• Patient should be encouraged to stop smoking and alcohol consumption as these risks are commonly associated with multiple system involvement.
• Treatment for impaired vision is recommended, particularly a problem with depth perception, which is specifically associated with increased falling risk

Nutritional Recommendations:
Calcium

• Larger studies are now available to support that optimal calcium intake reduces bone loss and suppresses bone turnover.
• The preferred source of calcium is from dairy products and other foods (milk, yogurt, and cheese) and fortified foods such as certain cereals, waffles, snacks, juices, but many subjects require calcium supplementation.

• Calcium supplements containing carbonate are best taken with food since they require acid for solubility. Calcium citrate supplements can be taken at any time.
• Although side effects from supplemental calcium are minimal (eructation and constipation mostly with carbonate salts), individuals with a history of kidney stones should have a 24-h urine calcium determination before starting increased calcium to avoid significant hypercalciuria.

Vitamin D
Vitamin D is synthesized in skin under the influence of heat and ultraviolet light. However, large segments of the population do not obtain sufficient vitamin D in absence or partial exposure to sunlight. Thus Vitamin D deficiency is becoming an alarming situation leading to more incidences of Osteopenia and osteoporosis.
Other Nutrients
Other nutrients such as salt, high animal protein intakes, and caffeine may have modest effects on calcium excretion or absorption. Adequate vitamin K status is required for optimal carboxylation of osteocalcin. States, in which vitamin K nutrition or metabolism is impaired, such as with long-term warfarin therapy, have been associated with reduced bone mass. Research concerning cola intake is controversial but suggests a possible link to reduced bone mass through factors that are independent of caffeine.
Exercise
Exercise habits should be consistent, optimally at least three times a week
 
HOMOEOPATHIC MANAGEMENT OF OSTEOPOROSIS
According to 6^th and 7^th aphorism of Organon of medicine, the physician should clearly perceive the preventable, curable and manageable part of a disease condition. He should also clearly look into the pathophysiology of the disease as to say the factors which modify and cause internal derangement. Thus it becomes necessary to look into causa occasionalis and dynamic causes of disease. The underlying condition guides us to treat an individual rationally and ethically.
The aim and objective of Homoeopathic management of osteoporosis can be achieved by:

• Dietary intake of intake of calcium required by body.
• Correction of intake of calcium apart forms food to regulate the daily requirement of calcium.
• Correction of intestinal absorption of calcium.
• Correction of assimilation of calcium channels in body by constitutional approach.
• Exercise, in the form of light exercises and/or meditation.
• Therapeutic correction in case the above criteria fail or partially improve the patient.

If we go back and analyze the definition of osteoporosis, we may observe the increased fragility of bones due to disturbed mitochondrial architecture of bones. Keeping this concept in minds the following rubrics from Synthesis (Treasure edition), can be taken into consideration:

• EXTREMITIES – OSTEOPOROSIS: Bor-pur. cortiso. dys. Mucor
• GENERALS – OSTEOPOROSIS: arg-met. bacls-7. calc-f. cortico. cortiso. dys. fl-ac. morg-p. palo.
• GENERALITIES – BRITTLE bones – general: asaf. banis-c. bar-c. bufo calc-f. calc-p. Calc. carc. cor-r. cupr. fl-ac. Lac-ac. lyc. Merc. par. ph-ac. pip-n. ruta SIL. sulph. Symph. thuj.
• GENERALS – SOFTENING bones: am-c. ASAF. aur. bar-c. Bell. bufo calc-f. Calc-i. calc-p. CALC. caust. cic. con. Ferr-i. ferr-m. Ferr-p. ferr. guaj. hecla Hep. iod. ip. Kali-i. Lac-c. Lyc. mag-f. mag-p. MERC. mez. Nit-ac. nux-m. Ol-j. parathyr. petr. ph-ac. Phos. plb. Psor. Puls. rhod. ruta Sep. SIL. staph. Sulph. syph. ther. thuj.
• GENERALS – BONES; complaints of: Arg-met. ASAF. aur. bell-p-sp. Calc-f. Calc-p. Calc. castor-eq. chin. chlam-tr. cocc. cupr. daph. eup-per. fl-ac. hep. kali-bi. kali-i. lyc. merc-pr-r. merc. mez. Nit-ac. PH-AC. Phos. Phyt. PULS. pyrog. rhod. rhus-t. Ruta sel. sil. staph. Sulph. syph.

There can be other general rubrics in cases of osteoporosis also (being a part of symptom totality), which may guide us to find the similimum for a case. But for reference purpose and to show the remedies that have direct affect on the bones especially in osteoporosis the above mentioned rubrics were taken into consideration. This method is disease specific not individual specific, thus it becomes important here to note that it is not a shortcut to find the similimum but an aid to confirm the similimum by incorporating the remedies that have direct affects on bones.
Now let us review the reportorial and remedial totality of osteoporosis by repertorising the above mentioned symptoms:-
On the theoretical view all the rubrics found in synthesis with respect to osteoporosis were repertorise with the above reportorial results.

• The line of treatment of osteoporosis depends upon the cause of osteoporosis. Most common form is primary osteoporosis which is due to age and therefore can be corrected by dietary intake of calcium or by calcium supplementation. Certain drugs like Calc carb., Calc phos., Calc iod., and Silicea have shown good results.
• In GIT disorders causing malabsorption, homoeopathic medication can be done on totality of symptoms with which patient presents to the doctor. The homoeopathic medication will increase the intestinal absorption and assimilation of calcium.
• Osteoporosis resulting from inflammatory conditions of GIT or joints can be managed by medicines like Argentum met., Asafoetida., Calc., Merc., Nit. ac., Fl. ac., Phytolacca., etc

If one analyze above mentioned aims and objectives of management, one can find the scope of Homoeopathy in management and treatment of osteoporosis. Correction in absorption, assimilation, and channelization of calcium in and across the bones and serum are nothing but part and parcel of Constitutional treatment.
It is seen that 60 – 80 % of the calcium is absorbed from the total intake of calcium taken through oral route, but this can be reduced in cases of impaired intestinal absorption of calcium. In these cases, patient is poorly responsive to proper dietary and/or oral intake of calcium supplements. Thus it becomes very much essential to understand this disease at the ground level. Hitting arbitrarily in wrong direction will result in failure both on part of physician and an individual. Our philosophy teaches us to clearly perceive the true essence and staging of ‘dis-ease’ so that the suffering of an individual can be reduced according to nature’s law of cure.
Homoeopathy being an evidence based science of therapeutics has a lot to offer to individuals suffering from osteoporosis provided it is used judicially and rationally, so that ‘to restore sick to health, to cure as it is termed’ is achieved.