Osteoporosis and MS

Osteoporosis is a progressive condition that weakens the bones causing them to become thin and brittle. Because the bones are more fragile, you're more prone to them breaking. This could be as a result of a fall, but even something as simple as coughing or sneezing could lead to a broken rib. More than 3 million people in the UK are affected by osteoporosis.

If you have MS, you may be more at risk of osteoporosis than other people. 

Losing bone density is a normal part of ageing, but it happens more quickly in some people than others. The following are some of the factors which can increase your risk of osteoporosis.

• Age – your bones are strongest when you're a young adult and in your 20s. Bone loss gradually happens naturally from your mid-30s.
• Gender – both men and women can be affected by osteoporosis, but it's more common in women. Women typically have a smaller bone structure than men and changes in the levels of hormones that occur during menopause also play a role. Levels of oestrogen, which is essential for healthy bones, fall after the menopause and can lead to a rapid decrease in bone density. Women are at even greater risk if they have an early menopause (before 45), if their periods stop for 6 months or more (amenorrhea) due to factors such as excessive dieting or overexercising, or if they undergo a hysterectomy before the age of 45. The risk of osteoporosis is increased in men with low testosterone levels.
• Weight – if you're underweight (BMI of 19 or less).
• Family history – if someone else in your family has osteoporosis, especially if a parent has had a hip fracture.
• Diet and dietary conditions – if your diet is low in vitamin D and calcium. If you live with a condition such as coeliac disease or Crohn's disease, which affect your ability to absorb nutrients from food. Also eating disorders such as bulimia and anorexia can increase your risk.
• Smoking and drinking – if you smoke or regularly drink too much alcohol.
• Medication – long-term use of medications that affect bone strength or hormone levels.

You may have been told you have osteopenia. This is where you have a lower bone density than is average for your age, but the reduction is less severe than is seen in osteoporosis. Osteopenia puts you at a higher risk of going on to develop osteoporosis.

Your bones are constantly repairing and renewing themselves in response to a complex set of biochemical and physical triggers. The inflammation seen in MS may affect this process. This means you may have a lower bone density than someone without MS, which puts you at a higher risk of developing osteoporosis and fractures. A review of the literature on osteoporosis in MS in 2022, estimated that nearly 1 in 5 people with MS have osteoporosis and more than 2 in 5 have osteopenia. This is higher than in people of a similar age and gender who don’t have MS.

If you’re unable to exercise regularly, have decreased mobility or problems with weight-bearing, your bones might not get the signals to keep them strong and they can weaken over time.

The drugs that you take to manage your MS symptoms, or treat relapses, may also affect your bone health. Long term exposure to steroids (relapses), or antidepressants (nerve pain and depression) can increase your risk of osteoporosis. However, research suggests that the disease modifying drug fingolimod (Gilenya) may protect against osteoporosis among women.

Osteoporosis is often only diagnosed if you have a fall or sudden impact which leads to a fracture. However, if you have MS, you might want to consider talking to your MS team about your risk of osteoporosis and whether it’s advisable to determine the health of your bones.

You may be referred for a bone density scan, known as a DEXA (dual energy X-ray absorptiometry) scan. The scan takes between 10 to 20 minutes and is painless. Low dose X-rays are used to see how strong your bones are, and your result is compared to that of a healthy young adult. The difference between them is calculated to generate a score, known as the T score, on which your diagnosis will be based.

A T score:

• equal to or greater than -1 is normal
• between -1 and -2.5 is osteopenia
• equal to or below -2.5 is osteoporosis.

If you have osteoporosis, your doctor can evaluate your future risk of breaking a bone using an online tool such as the FRAX® tool.

Treatment includes managing any current fractures and preventing future breaks. You may be prescribed dietary supplements or medication to help strengthen your bones.

If you’ve been diagnosed with osteopenia or osteoporosis, your doctor will decide what treatment might benefit you based on a number of factors including your age, gender, your fracture risk and whether you’ve had any previous breaks.

You might not need, or want, to take medication. However, it’s important to make sure you’re getting enough calcium and vitamin D through your diet or a supplement. 

Calcium is the main mineral found in bone and healthy adults require 700 milligrams (mg) of calcium a day to maintain healthy bones. This can usually be achieved through a varied diet. If you have osteoporosis, you may need higher amounts, usually through supplements. Your GP or MS team can advise you.

Vitamin D helps the body absorb calcium. It is recommended all adults have 10 micrograms (ug) of vitamin D a day. In the spring and summer months, you should be able to get all the vitamin D you need from sunlight on your skin. However, during the autumn and winter months, or if you prefer to cover your skin or are limited in how much you can get outside, you may want to consider taking a daily supplement.

The following are some of the treatment options for osteoporosis. They are also sometimes used to treat osteopenia.

• Biophosphonates – this class of drugs slow the rate that bone is broken down. Alendronic acid, ibandronic acid and risedronic acid are the most commonly used medications to increase bone density. They’re given as a tablet or by injection. They usually take about six to 12 months to be effective.
• Selective oestrogen receptor modulators (SERMs) – SERMs have a similar effect on bones as oestrogen. They help maintain bone density and reduce the risk of fracture, especially of the spine. Raloxefine, the only SERM used for osteoporosis, is given daily as a tablet.
• Parathyroid hormone – this is produced naturally by the body and regulates the amount of calcium in the bones. Treatments can be given by injection to stimulate the cells which create new bone and increase bone density. It’s only used in a small number of people whose bone density is very low or where other treatments haven’t worked.
• Hormone replacement therapy (HRT) – HRT is used by some women who are going through the menopause to help control their symptoms. It can also help to keep bones strong and reduce the risk of a break. It’s not specifically recommended for osteoporosis and is rarely used.
• Testosterone treatment – this can be used in men with osteoporosis which is caused by low levels of testosterone.

If you’ve broken a bone after a fall, you may be referred to a fracture liaison service. This is a multidisciplinary team who can provide you with care to reduce your risk of further fractures. This will include assessments such as a bone check, a falls assessment and falls prevention training. You may also be offered treatment.

Some of the risk factors for osteoporosis are down to your genes, age and gender, and there’s nothing you can do to change the risks associated with these factors. However, you can influence the risks associated with lifestyle factors such as diet, exercise, smoking and how much alcohol you drink.

• Diet – try to include calcium rich foods, such as leafy green vegetables, dried fruit and yoghurt, in your diet. If you’re deficient in vitamin D, you could adjust your diet to include more oily fish, eggs and red meat, try to spend more (safe) time in the sun, or talk to your doctor about supplements. If you’re not deficient in vitamin D, then taking extra has not been shown to affect bone density. 
• Exercise – if you can exercise regularly or stay active, you will help to reduce your risk. Weight-bearing exercises (where your feet and legs support your weight) and resistance exercises are particularly crucial to help improve bone density. Weight-bearing exercises could include walking, running, dancing or exercise classes, but not swimming or cycling. Examples of resistance exercises, which use muscle strength, so the tendons pull on the bones, include squats, lunges, push-ups or using weights or weight equipment.
• Smoking and alcohol intake – if you smoke, stopping will reduce your risk of osteoporosis. Try to limit the amount of alcohol you drink each week – the NHS recommends an upper limit of 14 units of alcohol a week – and avoid binge drinking.
• Preventing falls – there are some simple strategies you can introduce to try and reduce your risk of falling and breaking a bone. Check your home and remove trip hazards such as trailing cables, clutter or low pieces of furniture and keep it well lit.

Your GP or MS team may be able to answer any questions you have about living with osteoporosis.

The Royal Osteoporosis Society has lots of information about osteoporosis, including specific exercises to keep your bones healthy, and they also run a free telephone helpline service which is run by specialist nurses. They can also point you to local support groups if you think it would be helpful to talk to other people living with osteoporosis.

• Healthy Bones
• Exercise and MS
• Vitamin D
• Osteoporosis - NHS website
• Bone density scan (DEXA scan) - NHS website
• FRAX® tool
• Bone health - NHS website
• Strong bones after 50: fracture liaison services explained - Royal College of Physicians
• The Royal Osteoporosis Society
• Exercise videos for healthy bones - Royal Osteoporosis Society