Treatment of osteoporosis in children

Indications for consultation of other specialists

Indications for the consultation of other specialists arise for the unclear reason of osteoporosis, especially its severe form. In these cases, consultations of the endocrinologist, genetics, orthopedist, oncologist are possible.

Indications for hospitalization

Children with osteoporosis require hospitalization in the presence of fractures, secondary osteoporosis for the treatment of the underlying disease, as well as with significantly reduced BMD without fractures, if the cause of osteoporosis is not defined. In this case, hospitalization with a diagnostic purpose is necessary.

The goals of osteoporosis in children

• elimination of complaints (pain syndrome);
• prevention of bone fractures;
• slowing or stopping bone loss;
• normalization of bone metabolism;
• ensuring the normal growth of the child.

Correction of osteoporosis in childhood is complicated by the fact that unlike an adult patient with a formed bone tissue, the child still has to accumulate calcium in the bones to create in the future peak bone mass.

Non-drug treatment of osteoporosis in children

Symptomatic treatment involves a diet that is balanced by calcium, phosphorus, protein, fats, trace elements.

As symptomatic analgesics for acute pain use:

• Immobilization (short-term, more often for several days, no more than 2 weeks);
• extremely cautious stretching of the spine under the guidance of an experienced methodologist in physiotherapy;
• the use of a semi-rigid contiguous corset with the grip of the thoracic and lumbar spine;
• muscular relaxation with the use of drugs that reduce muscle tone, but not more than 3 days;
• NSAIDs.

With chronic pain, which, as a rule, has less intensity, special importance is gained by a gentle motor regime with the exception of sudden movements, tremors, lifting of weights. It requires a dosed physical exercise in the form of special exercises to strengthen the muscles of the back, which not only increases the stability of the spine, but also improves its blood supply, preventing further reduction of bone mass. Showing a light massage, including underwater.

Medical treatment of osteoporosis in children

Symptomatic means of treatment of osteoporosis, in addition to analgesics, are preparations of calcium salts.

Calcium preparations are considered to be a group of medicines for an additional but not the main treatment of osteoporosis.

Pathogenetic treatment includes the prescription of drugs aimed at various components of the bone remodeling process:

• suppression of increased bone resorption;
• stimulation of bone formation;
• normalization of both these processes;
• normalization of mineral homeostasis (elimination of a probable vitamin D deficiency).

Along with the classification of drugs presented, the primary mechanism of action is the division of drugs according to the proven ability for them to reliably prevent new bone fractures.

Preparations of the first line are:

• bisphosphonates of the last generation (salts of alendron, risedron, pamidronic acids);
• calcitonin;
• estrogens, selective modulators of estrogen receptors;
• active metabolites of vitamin D. 

Pathogenetic drugs for the treatment of osteoporosis

Classes of drugs	Preparations
Slowing bone resorption	Estrogens, selective modulators of estrogen receptors Calcitonins Bisphosphonates Calcium
Stimulating bone formation	Fluorides Parathyroid hormone A growth hormone Anabolic steroid Androgens
Acting on both links of bone tissue remodeling	Active metabolites of vitamin D Oseine hydroxyapatite complex Ipriflavone Substances containing phosphates, strontium, silicon, aluminum Thiazides

For the rest of the anti-osteoporetics, a significant reduction in the incidence of new bone fractures has not been proven.

In glucocorticoid osteoporosis, various stages of bone tissue exchange have been disrupted, but in children the processes of resorption are more intensified. In this case, the drugs of the first and third groups are successfully used.

Preparations of the last generation of bisphosphonates (salts of alendron, risedronic acid) - the most powerful in action on bone tissue, they not only increase BMD, but also reduce the risk of fractures, including vertebrae. Bisphosphonates are the drugs of choice, including in children abroad. They are successfully used to treat not only postmenopausal, but also glucocorticoid osteoporosis. However, in Russia there is no authorization for the use of these bisphosphonates in childhood.

The preparation of the group of bisphosphonates of the previous generation - etidronic acid differs in availability and cheapness. Data on its positive impact on the bone are ambiguous. Some authors believe that the effectiveness of etidronic acid in glucocorticoid osteoporosis is very small (a thousand times less than alendronic acid). Other researchers have shown that etidronate significantly, according to their data, reduces bone resorption only in the fourth year of treatment of osteoporosis.

It is also known that ethidronic acid with continuous use adversely affects osteoblasts, making the bone not only dense, but also fragile (the effect of the "frozen bone"). To avoid this negative influence, it is recommended to assign it on a discontinuous scheme (there is no single protocol), for example, 2 weeks to take, 11 weeks not to take, repeating the cycles. This drug is traditionally used, for example, in Canada, a number of other countries, but not used in the US. Russian authors in a few studies have shown the effectiveness of the intermittent etidronate scheme in the treatment of osteoporosis in patients with rheumatic diseases.

The means with the fastest antiresorptive and analgesic effect include calcitonin (most often salmon calcitonin is used). It has a strong effect on bone tissue. The drug has 2 dosage forms - injection (in the bottle) and nasal spray. The effect of calcitonin, including analgesic, in parenteral use is more pronounced than when placed in the nasal passage. Injectable calcitonin is more effective in osteoporosis of the spine than in osteoporosis of other bones, and intranasal calcitonin, according to some data, has less efficacy relative to the impact on the BMD of the spine. However, it is more convenient to apply the spray, especially in children.

Despite the long use in the practice of calcitonin in the form of a nasal spray, there is no single recommendation on the regimen of its use. Some authors give data on its positive effect with a daily appointment for one year or even 5 years. Others insist on various intermittent schemes, for example, 1 month - "on" (assign), 1 month - "off" (not assigned) or 2 months - "on", 2 months - "off". Repeat the cycle, they recommend at least 3 times.

In the literature, information has appeared on the prospective possibility of using oral calcitonin in adult patients, but this dosage form is undergoing clinical trials.

Over the years, traditional vitamin D preparations have been used to treat osteoporosis.

They are divided into 3 groups:

• Native vitamins - cholecalciferol (vigantol, vitamin D ₄ ), ergocalciferol (vitamin D ₂ ).
• Structural analogues of vitamin D ₂ (liver metabolites) - dihydrotachysterol (tachystin); 25-OH-D ₄ (calcidiol) - used primarily in the treatment of hypocalcemia.
• Active metabolites of vitamin D - Lalf-OH-D ^ (alfacalcidol), 1-alpha-25-OH ₂ -0 ₃ - calcitriol (rocalaltrol).

The liver metabolite calcidiol does not have any advantages over native forms of vitamin D. It is believed that compensating for vitamin D deficiency in native forms is not a cure, but a dietary recommendation.

Foreign authors have shown that native vitamin D and liver metabolites, even at high doses, are not able to increase bone mineral density and prevent bone loss, including with glucocorticoid osteoporosis.

Calcitriol has a good speed of action and a narrow therapeutic range, so when it is used there is a high risk of hypercalcaemia and hypercalciuria. The most safe in this regard are the preparations of alfacalcidol.

Alfacalcidol has a multifaceted effect on bone tissue, acts quickly, is easily dosed, quickly removed from the body, does not require hydroxylation in the kidneys to effect its metabolic effect. The peculiarity of this form is that for conversion to the final product (alpha-25-OH-D., (Calcitriol) only hydroxylation in the liver at position 25 is necessary. The speed of such transformation is regulated by the physiological needs of the organism, which to a certain extent prevents the risk of development hypercalcaemia.Alfacalcidol can also be effective in kidney disease, since the impaired stage of renal hydroxylation is not involved.

Thus, only active metabolites of vitamin D really increase BMD and reduce the risk of bone fractures.

Alfacalcidol is the only anti-osteoporotic remedy that can be used without calcium preparations. However, the addition of calcium salts to the treatment of osteoporosis increases the effectiveness of the basic drug (the loss of bone mass slows down, the frequency of bone fractures decreases more). Alfacalcidol in combination with calcium carbonate is successfully used for the treatment of glucocorticoid osteoporosis. It serves as a "freight elevator", delivering calcium at the "place of demand".

A kind of "breakthrough" in the treatment of osteoporosis in the 21st century. Became the appearance of a dosage form of parathyroid hormone. It has a double effect on the bone - reduces resorption and has an anabolic effect (stimulates osteogenesis). By efficiency, it is superior to all known anti-osteoporotic drugs.

But the injection mode of administration for 1-1,5 years limits daily its use. In addition, there was evidence that with prolonged use of parathyroid hormone in rats, osteosarcoma may develop. The drug is very promising, but it needs further study, especially in children.

Most studies on the treatment of osteoporosis are based on the long-term use of 1 or 2 osteotropic drugs that affect one of the many mechanisms of the development of the disease. Taking into account the heterogeneity and multifactority in the pathogenesis of osteoporosis, the physiology of bone tissue, in which the processes of bone resorption and bone formation are inextricably linked throughout life, it seems appropriate to use drugs that affect the different sides of the bone remodeling process. Apply the scheme as a simultaneous long-term use of 2 or 3 drugs that affect bone resorption or bone formation, and their sequential appointment. You can use constant or intermittent treatment regimens. The active metabolites of vitamin D are often combined with calcitonin and bisphosphonates, including in children. For example, in the treatment with calcitonin, the development of hypocalcemia and a secondary increase in parathyroid hormone levels are possible. Adherence to the treatment of alfacalcidol helps prevent these undesirable effects, potentiate the positive effect of calcitonin.

Treatment of osteoporosis in children is a difficult, completely unsolved problem.

For the treatment of osteoporosis, including glucocorticoid, in children, bisphosphonates, calcitonin, active metabolites of vitamin D in combination with calcium preparations are used.

The use of hormonal drugs (estrogens, selective modulators of estrogen receptors) in childhood is unacceptable because of undesirable interference in the hormonal background of a child or adolescent.

Domestic researchers note a good curative effect of calcitonin in osteoporosis and alfacalcidol in osteopenia in children.

Preparations of alfacalcidol are safe, have good tolerability in children, possibly their long-term use.

Combined therapy of osteoporosis in children (as in adults) is used very successfully, more often combine calcitonin spray with alfacalcidol.

Thus, despite the large number of drugs for the treatment of osteoporosis in the pharmaceutical market, at the disposal of a practical pediatrician there are not so many first-line drugs. Among them - bisphosphonates (in the territory of Russia only salts of etidronic acid), calcitonin, active metabolites of vitamin D in combination with calcium preparations. In the available literature, there are no clear unified recommendations for prescribing these drugs in children, which requires further research in this area.

Surgical treatment of osteoporosis in children

Surgical treatment of osteoporosis in children is not used.

Prognosis for osteoporosis

The prognosis for life with different types of osteoporosis in childhood is usually favorable.

The prognosis for potential fractures depends on the degree of BMD reduction, the adequacy of anti-osteoporotic therapy, the fulfillment of dietary recommendations by the child, and compliance with the motor regime.

With secondary osteoporosis, with the elimination or minimization of its underlying cause, complete BMD normalization is possible.

Osteoporosis in children is more often a complication of severe somatic diseases, a consequence of drug therapy. Timely preventive maintenance, symptomatic treatment in combination with pathogenetic therapy favorably influence the processes of bone remodeling, calcium homeostasis, significantly improve the prognosis.