La osteoporosis, literalmente – huesos porosos – es una enfermedad crónica ampliamente difundida que ha incrementado su cantidad de pacientes en todo el mundo. Una tercera parte de las mujeres posmenopáusicas y uno de cada cinco hombres, con edades por encima de los 50 años, padecen osteoporosis.
Los huesos pierden densidad, se vuelven frágiles y pueden fracturarse fácilmente, lo que lleva subsecuentemente a la perdida de la movilidad, calidad de vida y mortalidad (sabemos que de tres mujeres postoperadas de fractura de cadera, una morirá en menos de un año). A pesar de todo esto, la osteoporosis está siendo diagnosticada muchas veces a tiempo, adecuadamente tratada y, en combinación con modificaciones en el estado de vida, de alimentación y un tratamiento médico objetivo, pueden evitarse un gran número de fracturas. (1,2)
Hoy en día se encuentran disponibles diversas clases de medicamentos efectivos para tratar la osteoporosis, entre ellos, para mí, destaca uno muy especial, el Raloxifeno, cuyo principal efecto es prevenir las fracturas osteoporóticas vertebrales, las cuales son las principales fracturas que ocurren en la mujer posmenopáusica por arriba de los 50 años. Estas están asociadas con dolor vertebral importante, discapacidad, actividad física limitada, aumento en el número de días que pasan en cama las pacientes, cifosis (joroba) y la pérdida de tamaño. Muchas pacientes acuden conmigo para decirme que aunque el dolor de columna no es mucho, pero que se lo
achacan al trabajo que realizan, barrer, lavar, cocinar; lo que notan es que están perdiendo altura y les está apareciendo una jorobita. Sabemos que las mujeres con fracturas vertebrales tienen cuatro veces más el riesgo de sufrir una segunda fractura en lapso de un año. Varias fracturas vertebrales aumentan el riesgo de mortalidad, por lo que es definitivamente importante prevenir la primera fractura vertebral cuanto sea posible. (3)
El descenso en los niveles de estrógenos que se produce en la menopausia conlleva un aumento acusado de la resorción ósea, pérdida de hueso y riesgo de fractura. La pérdida de hueso es particularmente rápida durante los primeros diez años tras la menopausia, cuando el incremento compensatorio en la formación ósea no es suficiente para restablecer las pérdidas por resorción. Otros factores de riesgo que pueden producir osteoporosis son la menopausia precoz, osteopenia, complexión delgada, origen étnico caucásico o asiático e historia familiar de osteoporosis. Los tratamientos sustitutivos generalmente revierten la excesiva resorción ósea. Aunque otros factores como el fumar, la bebida (2-3 copas de vino al día), mala alimentación, demasiada fibra, anorexia, etc., pueden favorecerla.
Desde que la disminución de la densidad mineral ósea (DMO) está asociada con un incremento del riesgo de fractura vertebral, la valoración de la DMO es actualmente una herramienta valiosa para determinar en qué pacientes debemos actuar en forma terapéutica. ¿Pero qué es la DMO? Hagan de cuenta que tienen en el lado derecho un kilo de algodón y su altura de varios centímetros. Bien, ahora en el lado izquierdo tienen un kilo de plomo, el tamaño compacto se debe a su “densidad mineral” que es muy alta, como verán ambos son dispares en relación a tamaño, altura y densidad; aunque el peso siga siendo un kilo. Ahora toquen el algodón, sus dedos se meten entre las fibras del mismo, esto quiere decir que la densidad es muy poca. En cambio en el plomo es imposible que sus dedos lo atraviesen esto nos dice que la densidad está “súper”. Así ocurre con nuestros huesos, la densidad empieza a perderse lentamente, hasta que se fracturan.
Otro efecto positivo en el tratamiento con Raloxifeno es que actúa sobre el metabolismo de los lípidos séricos y el riesgo cardiovascular: Los ensayos clínicos han demostrado que una dosis diaria de 60mg de Raloxifeno disminuye significativamente el colesterol total de un 3 a 6%, y el LDL colesterol (malo) entre un 4 a 10 %. En las mujeres con valores iniciales de colesterol elevados se observaron los mayores descensos.
Pero quizá uno de los mayores logros que tiene el raloxifeno es sobre el tejido mamario: Raloxifeno está indicado para la prevención de cáncer de mama en mujeres posmenopáusicas con osteoporosis. El estudio sobre el tratamiento de la osteoporosis incorporó 7705 mujeres posmenopáusicas con osteoporosis. Luego de 4 años en este estudio, el tratamiento con Raloxifeno, comparado con el placebo, redujo el riesgo total de cáncer de mama en un 62%, el riesgo de cáncer de mama invasivo en un 73% y el riesgo de cáncer de mama invasivo con receptores estrogénicos (RE) positivos en un 83%.
Efectos sobre el endometrio:En los ensayos clínicos, Raloxifeno no estimula el endometrio posmenopáusico. Después de tres años de tratamiento con raloxifeno no se incrementaron los riesgos de cáncer de endometrio ni de ovario. (4)
Desafortunadamente, aunque sabemos que los medicamentos que prescribimos para la osteoporosis son efectivos, necesitan ser tomados por largo plazo y esto quiere decir por lo menos un año. Y esto es el problema; a pesar de que es necesario por lo menos un año el tratamiento, la mayoría de nuestros pacientes a los que se les prescriben, los dejan de tomar en escasos meses. En muchas ocasiones, esto no se lo comentan a su médico, y cuando se llega a presentar una fractura, nosotros como médicos consideramos que dicho tratamiento en menos efectivo de lo que en realidad es.
Suspender el tratamiento puede dejar vulnerables a los pacientes frente a las fracturas. Y la labor de nosotros los médicos es reforzar la información hacia los pacientes sobre los beneficios de cumplir con el tratamiento. Afortunadamente existen ahora muchas opciones terapéuticas que se pueden administrar por vía oral, a diario, cada semana, cada mes, cada tres meses, cada año. Cada uno de ellos tiene sus características y es labor del médico, primero convencer al paciente de que no abandone su tratamiento y segundo darle la mejor alternativa del mismo.
Platicaremos en artículos futuros sobre las características de cada uno de los medicamentos para tratar la osteoporosis.
Muchos años se estableció que la osteoporosis es una “epidemia silenciosa” y así se ha considerado todavía, sin embargo, el dolor ha empezado a aparecer y es cuando debemos pensar que esto del silencio no es del todo cierto.
REFERENCIAS:
1.- International Osteoporosis Foundation (on behalf of The European Parliament Interest Group and EU osteoporosis Consultation Panel). Osteoporosis in Europe: Indicators in progress. February 2005.
2.- Keene GS et al. Mortality y morbidity after hip fractures. British Medical journal 1993;307:1248-503.- J.A. Kanis et al. Effect of raloxifene on the risk of new vertebral fractures in postmenopausal women with osteopenia or osteoporosis: reanalysis of the Multiple Outcomes of Raloxifene Evaluation trial. Bone 33 (2003)293-300.
3.- http://www.lilly-argentina.com/medicamentos/prospectos/EVISTA.pdf
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