Osteoporosis Ask The Expert

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Published on Physicians Practice (http://www.physicianspractice.com)
November 14, 2007
By Maria Luisa Bianchi, MD [1]
Questions this month have been answered by: Maria Luisa Bianchi, MD, Italy, OBGYN.net
Osteoporosis Editorial Advisor
Q: I am a 49 year old white female who was diagnosed with a L2-L4 standard deviation of -4.1 in
May of this year. My doctor prescribed Fosamax and hrt, but I am anxiously awaiting for Forteo to be
available. Do you have any idea when this will be available?
A: Forteo is under the approval of FDA. It will be available early in 2002. However, as a general rule,
a "new" drug is not necessarily the best drug for everybody.
If Fosamax + HRT will prove effective in your case, I think that your doctor will not change your
therapy, even
after Forteo is available.
Q: I am 61 years old; had a Mastectomy in 1983, an ovahysterectomy in 1984, colon cancer surgery
in 1987. I cannot take Hormones because of early breast cancer. Was originally given Evista for
Osteoporosis, but had extreme side effects. I have been on Fosomax for 30 days (70mg-once a
week). While I realize I really need to take this medication, I believe I am having new problems and
want to know if it could be a side effect from this drug. If so is there anything I can do or take to
relieve them. A few hours after going to bed, I am awakened several times with cramps in my legs
and feet so bad that I am in extreme pain. The only way I have been able to relieve them is to get in
the tub and run hot, hot water on them. It feels like they are going to break in two they cramp so
bad. I have had minor leg cramps before but nothing like this. Could Fosomax cause very severe leg
and foot cramps?
A: In a study comparing placebo (a pill without any drug) with fosamax (10 mg per day), leg cramps
were not found in the fosamax group (0%) while they were 1.0% in the placebo group. In my long
clinical experience with fosamax (in the dosage of 10 mg per day) in osteoporotic patients, I never
saw this adverse reaction. However, it is not possible to exclude a relationship between your
symptom (severe cramps) and Fosamax. Some hints:
1. Report the symptom to your doctor, and check with him if there are other explanations for your
cramps. Please tell your doctor about your milder cramps in the past.
2. How often and when you are having these cramps may be important to evaluate the possible
relation with the drug. Since you are taking Fosamax in a high dosage once a week, if these cramps
are worse the night after taking it, and tend to fade away by the end of the week, this may suggest a
likely relation with the drug or the weekly dose taken all at once.
3. You may suspend Fosamax for one or two weeks: if the cramps do disappear, they're highly likely
to be caused by the drug.
Q: I read somewhere that the loss of an ovary increases the risk of osteoporosis. Is this correct? I
lost one ovary in my early childhood and I am now a PCO sufferer. Does this put me in a higher risk
category? I am 37 years old. Should I be seeing my doctor for further evaluation?
A: One healthy ovary is generally sufficient to produce enough estrogen to maintain a normal
menstrual cycle. If this is the case, the risk of osteoporosis is not increased until menopause.
However, if your polycystic ovary results in hypogonadism (amenorrhea) there may be an increased
risk. An evaluation of your gonadic (hormonal) function will clarify the matter. Prolonged periods of
amenorrhea (6 months or more) are a risk factor for osteoporosis and generally require hormonal
therapy.
Q: I am a 46 year old female. I have a fairly active life style, and walk at least 3 times a week.
About a year ago I had a bone density test and I have osteopenia. Recently I had a repeat test, and it
has stayed pretty close to the same. I still have periods, although I have noticed some changes. My
doctor just put me on Fosamax, and I took one for the week. She also wanted to start me on HRT,
and I said I wanted to wait, and start one at a time. She said we could start the hrt in a few months.
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Why would she want to start me on both? Why would I need both? I am very nervous about taking
Fosomax because it is so new. Which one would be the better of the two choices? I am white, weigh
130 lbs, and am 5'4" tall. I have never smoked, and I only occasionally have a glass of wine. I'm
afraid if I don't do something else besides the calcium, and Vit. D that I will look and feel horrible by
the time I'm 50. I would appreciate your feedback.
A:
My opinion in these cases is to start hrt as one enters menopause. If there is only osteopenia,
and the bone mass is not decreasing, I think that physical activity, adequate dietary calcium (or
supplements), and hrt is sufficient. By the way, Fosamax is not a new drug (even if the once-a-week
dosage is new) and it's commonly used for osteoporosis. Generally hrt + fosamax may be given
together when there is a rapidly worsening bone loss which does not respond to hrt alone. A glass of
wine is perfectly safe. When you are 50, you'll smile of your thoughts of today!
Q:
I have a 16 year old daughter who was put on Allese birth control tablets. She stopped menstruating
because of a tendency to over exercise . She is taking 2 - 600 mg. tablets of Caltrate Plus per day. Is
there anything else she should be doing to protect her bones? Is there any other advice or resources
you could tell me about that would be helpful for me and her physician?
A: Amenorrhea is a common complication of over-exercise (e.g. in female athletes). This should
be avoided in adolescents because their skeleton is still growing and they need normal hormone
levels. The pill, Alesse, was given as a hormone replacement therapy. The first thing to do is to
reduce the physical exercise to acceptable levels for this age, and generally menstruations will
reappear spontaneously. Calcium supplements such as Caltrate are needed only if the diet is not
adequate. Your daughter needs about 1.5 g of calcium every day. The calcium richest foods are: milk
(also skimmed), yogurt, cheese. Many other foods are calcium-enriched.
Q: I have a strong family history of blood clots but have never had one myself. My father had
numerous strokes due to clots (as did his entire family) and my mother had clots while being treated
for ovarian cancer. The cancer caused her demise. I am now 53 and have osteoporosis. What do you
consider to be the safest treatment for osteoporosis for someone with my family history?
A: I think that bisphosphonates (such as alendronate or risedronate) are the best choice for
osteoporosis in your case, as they don't have any effect on blood clotting. Of course, regular physical
activity (e.g. brisk walking for 30 minutes daily) and a correct dietary intake of calcium (about 1200
mg/day - from food or supplements or a combination of them) are recommended in addition to the
drug.
Q: I am 51 yrs old. When I was 39 I underwent a total hysterectomy (not cancer related). I was
placed on Premarin and six months later developed breast cancer which was estrogen related, so I
was taken off Premarin. I was placed on Tamoxifen for about six years and then taken off. I had a
dexa done recently which showed osteopenia. One doc recommended Fosomax and another doctor
recommended the natural DIM supplement as well as Miacalcin. I read that Miacalcin is a hormone
however--how safe is it in light of the estrogen-related breast cancer? What is the best way to
strengthen/protect bones in this instance.
A: Miacalcin is calcitonin, a calcium-regulating hormone unrelated to estrogens (no effect on
breast). The scientific data show that alendronate (Fosamax) has a greater effect than calcitonin to
increase bone density and to reduce the risk of fractures. In my opinion, Fosamax would be the best
choice in your case. Of course, regular physical activity (e.g. brisk walking for 30 minutes daily) and
a correct dietary intake of calcium (about 1200 mg/day - from food or supplements or a combination
of them) are recommended in addition to the drug.
Q: How are bone densities used to evaluate the severity of osteoporosis?
A: Bone densitometry is used to diagnose the presence of osteoporosis even before the occurrence
of fragility fractures. According to the WHO, a T-score higher than -1.0 means "normal", between -1.0
and -2.5 means "osteopenia" (some decrease of bone mineral density), and below -2.5 means
"osteoporosis" (severe decrease of BMD, with risk of fractures). T-score is a comparison between the
subject and a population of young healthy subjects of the same sex. The WHO thresholds given
above have been validated for DXA bone density tests in Caucasian (white) post-menopausal
women. Further studies are being made for other populations, and for other equipments (e.g.
ultrasound).
Q: I was taking HRT for 6 years and recently I was taking FemHRT every other day for about one
year. I was doing fine, but with all the controversy about cancer and being on HRT long term, my
doctor and I decided that I go off of FemHRT and try Fosamax once a week for my bones. I do have
some bone loss, that's why I went on HRT 6 years ago. I am feeling the effects of being off of
FemHRT, jittery, headaches and just not feeling myself anymore. I guess I may be having withdrawal
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symptoms, I have started to take fosamax but am very concerned about this drug. I also have begun
taking Remefemin. How safe is Fosamax? Can it give you headaches? Can it raise your blood
pressure? Can it just make you feel out of sorts? Is progesterone cream a better way to protect the
bones?
A: After withdrawal of estrogen replacement therapy, it is normal to have some of the symptoms of
menopause, which should fade away with time. If there is osteoporosis, it is recommended that a
woman, after discontinuing HRT, be put on another drug. Progesterone has no proven effect on
bones. Alendronate (Fosamax) is one of the drugs of choice for osteoporosis. If taken following the
rules (e.g. on a empty stomach, not lying down after taking it, waiting 30-45 minutes before eating)
it generally is a very safe drug with no untoward effects. It has no effect on bone pressure. There are
thousands of people who have been taking it for many years. This drug is active only on bone.
Q: What would be the negative aspect of taking 70mg Fosomax weekly for 2 years, 2cc of
Premarin Vaginal Cream weekly for 1 year, and .625mg of Premarin daily for 10 years for
Osteoporosis? The most recent bone
density test showed some improvement.
A: It is not possible to answer your question, as nobody can foresee what could happen with any
drug over a period of years. Any drug - and even more so a combination of drugs - can have
untoward effects for a specific person.
Both estrogens (Premarin) and alendronate (Fosamax) are useful for osteoporosis. They are not
given together as a rule, except in special cases. Estrogen replacement therapy is probably the first
choice for a woman in menopause. Fosamax can be added, usually in severe cases, if estrogens after one or two years - do not halt the progression of the disease. Generally hormone replacement
therapy is given for 5-10 years, then if there
is osteoporosis it is replaced by another drug. Fosamax, once started, is usually given for an
unlimited period of time.
Statistically, long-term HRT increases the risk of breast cancer, and that's why it's important to
undergo periodic visits and mammographs. Alendronate acts essentially at bone level and its main
adverse effect is esophagitis (especially if it is not taken following the rules).
Q: I am a 23 year old who has lupus, and the common treatment for lupus is prednisone which I
have been on for seven years the majority of this time taking more than 10 mg per day. I can not
take any hormonal type medication because it upsets my lupus yet I am already having bone
fractures due to the osteoporosis (my leg is in a cast now). I have been doing research myself to find
an alternative to knee replacement sugery (that my doctor is suggesting I do) and I discovered
Actonel and Fosomax. I am upset because I have not been informed of this medication by my doctor
already. I am currently on prednisone 7.5mg every other day, coumadin for blood clots at varying
doses, usually between 10mg and 15mg and Imuran 50mg 3X's per day. Do these drugs interfere
with my current medications and do either of these drugs contain hormones?
A: Osteoporosis drugs cannot generally avoid knee replacement surgery, if it's really needed.
Alendronate (Fosamax) and risedronate (Actonel) are not hormones.
They can be taken with the other drugs. You are probably being given Coumadin only in this period
of immobilization
to avoid blood clotting.
There is good evidence that alendronate is effective in
corticosteroid-induced osteoporosis even in young patients. Probably risedronate is also active. If
you take Fosamax or Actonel, you should avoid a pregnancy because the effects of these drugs on
the embryo and fetus are not known.
Moreover, in steroid-induced osteoporosis, you should be aware that a correct calcium intake - in line
with
the recommended daily allowance, about 1 gram a day at your age - is needed, and a supplement of
calcifediol (25-hydroxy-vitamin D) is recommended.
When you can, please resume a moderate but regular physical activity (e.g. walking) which is also
important in the prevention and treatment of osteoporosis.
Q: I am a premenopausal, 51-year young woman who is generally in good health. I watch what I
eat and exercise on a regular basis. I had a bone density scan and found I had osteopenia. I started
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taking Evista but was told that since I already take Premphase not to take Evista. I now take Actonel
but find I have shortness of breath and just don't feel "normal" for me. Is it the Actonel? If so, what
else can I take?
A: In my opinion, if you have osteopenia and you are already taking hormone replacement therapy
(Premphase), your bones should be sufficiently protected, and before adding a second drug you
should wait and see if there is any further bone loss (with another bone density scan after 18-24
months).
Raloxifene (Evista) is not for use in premenopausal women and - being a kind of modified estrogen - I
think it's not recommended as a second drug in addition to other estrogens (Premphase).
Actonel is acting on bones much in the same manner as estrogens do. Generally it is used alone, but
sometimes it is given in addition to HRT when the bone density continues to decrease.
I never heard of "shortness of breath" in relation to bisphosphonates. Anyway, Actonel is a relatively
new drug, so it's better to refer any unexpected symptom to your doctor.
Q: I really need some help. I am 53 yrs old and recently had a bone density test. T scores were
-3.0 in hip and -2.3 in spine. I was put on fosamax70mg. once a week. Problem with heartburn (since
I have inflamed stomach) had to discontinue taken this med. I am now on Miacalcin (nasal spray). I
am concerned for two reasons: I noticed that the Miacalcin is recommended 5 yrs after menopause. I
am only 3 yrs. Also I wonder if this medication alone is sufficient for someone with my T score. I am
also taking 1500 mgs. of calcium daily.
A: If you cannot take bisphosphonates (such as Fosamax) the drugs for osteoporosis are:
- hormone replacement therapy (estrogens)
- raloxifene
- calcitonin (Miacalcin)
The choice must be made with your doctor. Studies have demonstrated that Miacalcin reduces the
risk of fracture in post-menopausal osteoporosis in women. Calcitonin is a hormone produced in the
thyroid gland and acts only on bone blocking calcium loss. It has no relation with sexual hormones
and has been used also in women just after menopause without any problem. To evaluate its
efficacy in your case, the only way is to re-evaluate your bone density with a new bone scan after at
least 12 months of therapy.
Q: I am pleased to see such outstanding resources at this site.
I am the clinical coordinator of a multispeciality clinic. We have seen depo provera induce
Osteoporosis in women. Three have been employees and they were all about 24-28 years of age,
with light hair and eyes and skin. All had low but normal scores of -.88 to-.93 on their BMD's before
the use of depo. Within 2 years all were -3.2 or greater in the spine. The other 5 women were older
(mid thirties) and did not have a prior scan. We scanned them after use of depo for 2 or more years
and found them to also be Osteoporotic (-3.8 or higher) We no longer use Depo in our facility b/c we
are concerned with the lialibility it may have. Our physicians have been following closely these
women after removal of depo and the spine shows no further loss but only one has had a slight
increase in 2 years.
How often are you seeing this occur and can the trabecular bone strength be returned? Suggestions?
We changed treatment to Birth Control and did an overall assessment of risk factors for bone health
but have not seen a positive affect.
A: Regarding Depo-Provera (medroxyprogesterone acetate or DMPA) and bone there are some
controversial data. In fact, some studies showed a decrease of bone mass with DMPA use, while
others did not. However, data on the effects on bone mass during long term use in a very large
group of women are not available yet.
It seems that younger women are more at risk to lose bone than older women (18-25 years vs >30
years); bone loss is prevalently at spine; the presence of a correct calcium intake and a regular
physical activity, as well as being a non-smoker, seem to be able to reverse the negative effect of
DMPA on bone.
In the absence of conclusive data, I suggest that DMPA is better avoided in young women. Data on
the full or incomplete recovery after DMPA withdrawal are not available.
Q: I'm 58 and have osteo. My Dr. said walk. I bought a treadmill and have been using it a lot. Is
there a limit as to how much I should do? I'm walking at about 3mph for 30-40 minutes 5 days a
week.
A: Walking is very good for bones and the cardiovascular system also. The minimum suggested
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is 30 minutes 4-5 days a week. You obviously can walk as much as you like if you aren't tired, and if
your breathing and your pulse are normal.
Q: I have just heard about this new treatment, Forteo, for Osteoporosis! Please tell me what you
know about this! It is suspposed to cure Ospeoporosis? That is hard to believe. Please tell me
everything you know and can find out about this. I do have Osteoporosis of the spine and Osteopenia
of the hip. I am 65, thanks.
A: As a general rule, a therapy must be given only by a physician after seeing the patient, and the
use of parathyroid hormone (Forteo) is particularly difficult and should be carefully monitored to
avoid risks.
Parathyroid hormone (PTH) is a hormone produced by the parathyroid glands (4 little glands near the
thyroid gland), which is involved in the calcium regulation in our body. Among its various actions,
PTH has also an action on bone, increasing both bone formation and bone resorption (destruction).
For patients with severely reduced bone density, PTH could be a valid therapy in alternative to other
agents. PTH at the appropriate dosages stimulates bone formation, while bisphosphonates,
estrogens and SERMs only reduce bone resorption. PTH can only be given by injection.
I think that you must consult your doctor to verify if Forteo can be the correct treatment for your
osteoporosis.
You can read the FDA Endocrinologic and Metabolic Drugs Advisory Committee Briefing on
Forteo, a new drug in the treatment of osteoporosis; includes Medical Review Efficacy, Medical
Review Safety, Statistics, Pharmacology & Toxicology Summary, Errata for Pharmacology &
Toxicology Summary.
Q: I am a 38 year old female who has bone density scores of -2.0 in the hip and -2.3 in the
spine. My physician prescribed fosomax 70mg weekly and Maxide 25mg daily. Blood work showed a
vitamin b12 deficiency which I was on injections monthly. The b12 deficiency may have been related
to long-term prevacid use for reflux, however I have recently had surgery to correct the reflux and
no longer am taking prevacid. A 24-hour
calcium test revealed high levels of calcium in my urine which is the reason I was given maxide. I
now have a mild potassium deficiency (3.2) and am taking micro-k potassium. My physician
determined that I am premenopausal from a blood test and also that my PTA intact results were
normal (47). I am told that my osteopenia is most likely caused from genetic reasons now that tests
are completed.
My question is whether there is any other tests or other drugs to help my condition and whether
maxide is used to treat my condition. The manufacturer said that no studies have been done for
osteopenia and that they hadn't heard of its use for this. Any suggestions or thoughts?
A: I suppose that your doctor give you Fosamax (alendronate) for osteopenia and Maxide (a
diuretic) for idiopathic hypercalciuria (loss of calcium in the urine). The therapy with fosamax +
maxide is a standard therapy in this case.
These two conditions may be related. The hypercalciuria is often determined by a defect of the
tubular resorption of calcium by the kidneys, and it often determines a low bone mass. I think that by
PTA you actually mean PTH (parathyroid hormone). If this is
normal, this excludes an hyperparathyroidism as a cause of both
hypercalciuria and low bone mass. This may be the reason why your doctor told you that your
osteopenia was "genetic".
Maybe to be sure that there is idiopathic hypercalciuria, more than 1 test on the 24-hour urine is
advisable. Maybe you could ask your doctor about your dietary requirements of calcium.
Source URL: http://www.physicianspractice.com/osteoporosis/osteoporosis-ask-expert-16
Links:
[1] http://www.physicianspractice.com/authors/maria-luisa-bianchi-md
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Osteoporosis Ask The Expert

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