Royal Alexandra Hospital Foundation

Dr. Nese Yuksel is a Professor with the University of Alberta’s Faculty of Pharmacy & Pharmaceutical Sciences. In addition to her academic position, she continues to practice in two multidisciplinary clinics, one being the Menopause Clinic at the Lois Hole Hospital for Women, and the other the Multidisciplinary Bone Health Clinic at the Kaye Edmonton Clinic.

She has been actively involved with osteoporosis for a couple of decades, including clinical, teaching and research in the area. She is also an active member of the Women and Children’s Health Research Institute (WCHRI).

TELL US ABOUT YOUR EXPERIENCE WORKING WITH OSTEOPOROSIS.

I first started in the area of osteoporosis back in the late 1990’s when I began with the menopause clinic and the osteoporosis clinics at the Grey Nuns Hospital. I have been teaching osteoporosis for our pharmacy students for many years and have done presentations for health care professionals on the topic. Additionally, I am also actively involved with Osteoporosis Canada, and I am on the Osteoporosis Canada Scientific Advisory Council (SAC).

I’ve also conducted and published osteoporosis-focused research specifically around assisting pharmacists in their practice.

What made you want to focus much of your research on women’s health?

Women’s health and osteoporosis care are passions of mine. I’ve tried to integrate my clinical experience and interest in the areas of osteoporosis and women’s health (including menopause and contraception) and tie it to my teaching and research. A lot of this comes just from seeing patients in clinical practice where many research questions are generated. That is, we may have evidence for some things, but other times there may not be enough studies to know what may work best, this is how research questions come about.

Firstly... what is osteoporosis?

Most simply, osteoporosis is when one’s bones become weak, frail and can break more easily. What happens with osteoporosis is that there is a loss of bone strength over time—this can be loss of both bone quantity and bone quality—which can lead to fractures.

Osteoporosis is called “silent” as it’s generally not symptomatic until a fracture occurs. That is, you may not know it until you break something. Even spine fractures can happen and people won’t know. In fact, only a third of spine fractures are symptomatic.

To help diagnose osteoporosis, a bone mineral density test can be done to capture the bone quantity. As well, it is important to look at all of your risk factors for osteoporosis to capture your risk for further bone loss and fractures. Measuring height changes is important when looking for spine fractures and also sometimes your doctor will order a spine x-ray to see if you have had a spine fracture.

Osteoporosis is often called the ‘silent thief’ because bone loss occurs without symptoms unless one has fractured. - Osteoporosis Canada

What makes osteoporosis such a dangerous condition?

Fractures, and the ripple effects of fractures, carry some of the biggest impact for people with osteoporosis.

It is because of fractures—and the fear of fracturing—that can lead people with osteoporosis having a reduced quality of life. They can face lowered self-esteem, loss of mobility and independence, disfigurement, and even death. Click here for more facts about the disease.

What are some of the risks of osteoporosis?

The focus is on risk factor assessment for osteoporosis, meaning we look at who would have a higher risk for fractures. For osteoporosis, your risk profile and bone density would be assessed, to look at what your chance of getting a fracture in the next 10 years.

What gets missed often is a “fragility fracture.”. A fragility fracture is a fracture which occurs from standing height or less (this is in comparison to a trauma fracture). What happens sometimes is that these types of fractures may be overlooked as a sign of osteoporosis. In assessing for osteoporosis, the types of fractures you have had are important and how these fractures occurred. If a fracture occurred from standing height or less it could be a fragility fracture.

Fragility fractures represent 80% of all fractures in menopausal women over the age of 50. - Osteoporosis Canada.

Osteoporosis has a number of factors to consider when assessing one’s risk profile:

• Aging is a major factor. 
• Fragility fracture after the age of 40.
• A family history of osteoporosis is a risk, especially parental hip fractures.
• Certain medications such as glucocorticoids, like prednisone, as well certain medications such as those used for breast cancer or prostate cancer which affect hormone levels, can result in lower bone density or fractures.
• Medical conditions like rheumatoid arthritis, diabetes, malabsorption, and celiac disease… all of these are risk factors.
• Women who go into menopause early (before the age of 45) would also be at extra risk.
• Also lifestyle factors such as smoking, excessive alcohol use or not getting enough calcium and vitamin D are risks.

Click here to take Osteoporosis Canada’s Know Your Risk quiz.

Who should get a bone mineral density?

Anyone over 65 years should get a baseline bone mineral density. As well, postmenopausal women and men over the age of 50 who have risk factors for fractures should get bone mineral density.  Younger people (less than 50) may need to get tested if they have conditions which lead to bone loss or fractures.

What can people do to protect themselves from osteoporosis?

Many risk factors are actually rooted in lifestyle choices, so changing them can be crucial to preventing further bone loss.

• Quitting smoking
• Avoiding excessive alcohol consumption - more than 2 drinks per day is considered a risk.
• Limiting caffeine intake - to less than 4 cups of coffee or caffeinated drinks per day.
• Taking enough calcium and vitamin D - Osteoporosis Canada recommends 1200 mg of elemental calcium daily (this is with both your diet and supplements). Try to get as much in the diet as possible and then add in a calcium supplement to get to 1200 mg. For vitamin D, Osteoporosis Canada recommends 800 - 2000 IU per day.
  • Osteoporosis Canada has a very helpful tool called the Calcium Calculator.
• Exercise - There are some great recommendations on the Osteoporosis Canada website (click here for the “Too Fit To Fracture” Cheatsheet). Generally the recommendation is to get about 30 minutes of exercise ‘most days of the week’ (4-5 days a week). Even walking is great, as long as it is weight bearing on the bones. Also important are exercises which help with core strength and balance to prevent falls such as balance exercises, strength training and posture awareness.
  
  

ARE THERE MEDICATIONS TO TREAT OSTEOPOROSIS?

Luckily, there are a number of osteoporosis medications that work well in preventing fractures. There are medications that can prevent further bone loss (called antiresorptives) and there are medications that can build up bone (bone formation agents). Some of these medications are taken orally, while others are injections. A couple of these medications are taken once a week while others are given daily, every month, every six months or even yearly.

What’s the main approach for combating osteoporosis?

The main goal is to prevent fractures, as once you have had a fracture, you have a higher chance of having another fracture. Capturing your risk profile before the first fracture is important so that future fractures can be prevented.

Avoiding falls is very important. It is important to look at medications that can lead to falls, areas in your home that can lead to falls or other risks for falls. A multidisciplinary team can help identify fall risks and ways to reduce falls.

Additionally, it is important to consider ways to avoid putting additional strain on your spine. These are called “Spine Sparing Strategies.”

What is the most surprising fact about osteoporosis?

The biggest misconception is that it is a normal part of aging.

“Just because you’re getting older, getting fractures is a normal thing.” This is not true. Aging is a risk factor for bone loss, but just because you are older it does not mean you have osteoporosis or should get fractures.

Osteoporosis is also extremely common—fractures from osteoporosis in women are more common than heart attack, stroke and breast cancer combined! 

Fractures from osteoporosis are more common than heart attack, stroke and breast cancer combined. - Osteoporosis Canada

Another misconception is that it is ONLY in women—not true, men get osteoporosis as well. It is estimated that 1 in 3 woman and 1 in 5 men will break a bone because of osteoporosis in their lifetime. Women and men both begin to lose bone sometime in their 40’s but women lose faster, especially once a woman reaches menopause and for the next 10 years after menopause. In fact, the first 10 years after menopause are when women lose the greatest amount of bone density, because of the loss of estrogen.

Osteoporosis is UNDERDIAGNOSED and UNDERTREATED. A number of studies have shown that osteoporosis, even when someone has had a fragility fracture, is not always assessed, and treated. We call this a care gap.

How is COVID affecting osteoporosis patients?

A main issue is people may not get their medication refills on time, which may affect continuing or adhering to their medication (for example the oral medications which are commonly taken once a week).

Some of these medications are given by injection for example every six months or yearly. It is really important that these administration times not be missed, but there may be possibility of missed doses because of the pandemic (for example if someone is worried about going out to get their yearly injection at a facility or going to a pharmacy to get their six month subcutaneous injection).

And of course, for some patients who have risk factors for osteoporosis but who have not been diagnosed yet, there may be delays in getting properly assessed for osteoporosis and fractures.

What does Osteoporosis Month mean to you?

It’s important to bring awareness to overall bone health. You should consider your own risk factors for bone loss and osteoporosis, and how you can improve your bone health. If you are over the age of 50 and have some of the risk factors, as identified above, you should think about getting assessed for osteoporosis. Also think about lifestyle factors for osteoporosis.

Is there anything you’d like to share about your own personal experience working with osteoporosis?

I have a family history of osteoporosis, my grandmother had osteoporosis. I know it affected her mobility, and saw firsthand the outcomes of osteoporosis, so I’ve been passionate about it from a personal level for many years. I’m thankful for the opportunity to work with lots of amazing patients at the clinic, as well as the multidisciplinary teams—this has helped me learn so much about osteoporosis care.

Where can people go for more information?

Osteoporosis Canada is a great resource for information on osteoporosis, including risk factors, testing and management. You can visit their website at osteoporosis.ca

Why are donations important for advancing treatment for and understanding of osteoporosis?

Funding is hugely important. We have great medications and treatments but still have a lot of unanswered questions around osteoporosis and need more info on how to go about approaching different patient populations.

As a pharmacist, we want to understand the patient experience and understand how we can help people adhere to their medications. It would be amazing to be able to individualize it to each person, but need to have that evidence first. Funding gives us the ability to answer those questions that are coming from our patients and out of clinical experiences.

 

Thank you to Dr. Nese Yuksel for sharing her knowledge and helping us all better understand the importance of good bone health!

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