Authored by Christina L Silva
In the world of nursing and medicine, many diseases and
physical or mental impairments are treated with pharmaceuticals
or medication. For some diseases such as type 1 diabetes, a
pharmaceutical or medication, insulin, is the proper treatment
and one that is absolutely necessary. Not all conditions fall into
the category of required medications; a couple of these conditions
would be osteoporosis and osteopenia. The treatment guidelines
call for medications based on t-scores and fracture risk Tuck S,
et al. [1], even if the medication has bad or life-threatening side
effects and even if there are other potential treatments that can be
effective
In a search of the literature, osteoporosis treatment is built
around the use of pharmaceutical treatment regimens [1,2,3]. The
treatment regimens are based on dual energy x-ray absorptiometry
(DXA) t-scores and history of patient fractures. Examples of the
treatment guidelines include bio phosphonates for T scores < -2.5,
denosumab if patient intolerant of bio phosphonates and T-score
< -2.5 or history of fracture, consider teriparatide as second line
treatment if patient has issues with oral bisphosphonates and T
score < -2.5 or history of fragility fracture [1]. In all of the studies
reviewed, weight bearing exercise was not mentioned. Hind K &
Roberts C [4] concluded that we have an osteoporosis epidemic
today due to increased amounts of sedentary activities. In children,
more are playing video games instead of outside running and
jumping. In older adults, retirement has become filled with sitting
and sedentary activities. Pharmaceuticals can only do so much.
When using medications such as denosumab, the patient is at a
higher risk of fracture after the discontinuation of the medication
especially if the patient had been on bio phosphonates previously
[5]. With medications abounding, it can be easy to prescribe a magic
pill, but a better solution might be more physical activity. Even
though each medication has a potential side effect, medication is
the first treatment modality offered to patients. Another treatment
modality that could be offered is weight bearing exercise. Lack of
weight bearing exercise is listed as a risk factor for osteoporosis,
Faust V [6] but little is found about its potential as a treatment
modality. As an osteoporotic patient, the author, has experienced this
scenario for years. At initial diagnosis of osteopenia, weight bearing
exercise was mentioned in passing yet medications were ordered
and discussed as the way to approach this potentially debilitating
condition. The idea of non-compliance with the medication was not
discussed nor were alternatives to medication. Once the diagnosis
progressed to osteoporosis and post bone fracture, more advanced
medications were ordered. These medications are more invasive
and require injection of denosumab either every 6 months or the
use of teriparatide daily [1]. Even with the need for more invasive
types of medication, the use of weight bearing activity remained an
unspoken alternative. The following is a case study of the author’s
medical history and a call for more holistic and alternative methods
to be used in treatment of osteoporosis [7].
The patient is a slender, Caucasian female who had a hysterectomy
and bilateral oophorectomy at the age of 27 and comorbidities of
gastroesophageal reflux disease and endometriosis. By the age
of 35, she had the diagnosis of osteopenia and was ordered the
first line treatment of bisphosphonates. Unfortunately, she had a
comorbidity of gastroesophageal reflux and was unable to take the
first line treatment. The patient was prescribed denosumab after
this but with preauthorization requirements, it took a year and a
half to get the medication approved. During this period, exercise
was mentioned but it was not prescribed as a treatment. In 2010,
the patient had suffered a radial fracture from a fall and in 2015
she had a fifth metatarsal fracture from landing on her foot wrong.
The radial fracture required a cast, but the fifth metatarsal fracture
required an open reduction internal fixation with 2 plates and 6
pins. It was after the 2015 injury that denosumab was discontinued
and teriparatide was discussed and initiated. Teriparatide was used
by patient for about 19 months.
After it was discontinued, the patient did not have any
medication prescribed. In August 2018, the patient began a
weightlifting regimen per her own want for a healthier body. As per
guidelines, a DXA was performed every two years starting in 2015.
For associated t-scores, treatment modality, and major side effects,
refer to Table 1.
As is shown in Table 1, the patient had positive outcomes
with both the teriparatide and weightlifting. The teriparatide was
a 19month regimen and the weightlifting was 9 months. The side
effects of the teriparatide include bone cancer and joint pain. The
side effects of the weightlifting include building of muscle mass,
increased energy, and muscle strength. Both have a positive effect
on bone density.
Discussion
For a young patient who had previously only been prescribed
medication as a treatment with minimal increase in t-score, the
double T-score increase after only nine months of weight bearing
exercise was astonishing. This leads to questioning why weight
bearing exercise had not been a prescribed treatment? Why is the
first line a pharmaceutical agent even when the patient is young?
Why are insurance companies not paying for a gym membership
or weight machines or other devices to allow for weight bearing
exercise to be part of a treatment? Not all patients can afford to
go to the gym and not all patients diagnosed with osteopenia or
osteoporosis are of Medicare age that would allow for a covered
gym program, the silver sneakers program (https://www.medicareproviders.
net/plans/fitness?Creative). Medicare supplemental
plans are realizing the benefits of seniors having to access to a gym.
Will other health insurance companies see a need for non medicated
consumers to have access to a gym at a reasonable cost? Instead of
making medication a first line treatment for all patients, the protocol
should include ordering weight bearing exercise for those who are
capable of performing it. The side effects are all positive- weight
loss, building of muscle mass, healthy self-image, and of course an
increase in bone density. The results could be beneficial to so many
other disease processes too. For medical professionals that believe
in alternative solutions, could this be considered? Could insurance
companies be lobbied to add this type of treatment? The positives
of this type of treatment far outweigh the difficulty in finding a way
to get it covered.
None.
No conflict of interest.
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