Osteoporosis Ask The Expert

Transcription

Published on Endocrinology Network
(http://www.endocrinologynetwork.com)
October 14, 2007
By Michael Kleerekoper, MBBS, FACP, FACE [1] and Michael Kleerekoper, MBBS, FACP, FACE [1]
Questions this month have been answered by: Michael Kleerekoper, MB, BS, FACP, FACE, OBGYN.net
Editorial Advisor Harvey S. Marchbein, MD, USA, OBGYN.net Osteoporosis Chairman and Editorial
Advisor
Q: I am 46, pre menopausal, regular periods no symptoms of menopause, and have been suffering
from lower back pain for approx 2 months. I have however had discomfort in my left hip for about a
year,. I was sent for an x ray by my GP and the results this week indicated that I have some evidence
of osteoparosis and that my spine is slightly distorted, something I was unaware of. My doctor said I
may have been born with my spine in this position. I have an enlarged thyroid gland, I have had a
blood test previously and nothing showed. I have been given some anti-inflammatory tablets,
advised to take pain killers and asked to return to the doctor in a month's time. I also have slight
asthma. I was advised that when start the menopause I may have to have hormone replacement
treatment. I was wary of this because I attend a hospital for counseling and annual checks and
mammograms because there is a family history of breast cancer, my ! great grandmother,
grandmother and mother all developed breast cancer around age 60. I am estimated to have a one
in four chance of developing breast cancer. So I am between the devil and the deep blue sea here. I
suggested to my doctor that I perhaps should start to take calcium supplements and multi vitamins. I
go to a gym and exercise 3 times a week. Is there any advice you can give me. I am bewildered and
a little depressed about all this. Thanks.
A: Without a DEXA bone density, no real comments about your density status can be made. That
being said, if one were to have either osteopenia or osteoporosis at 46 while still getting periods,
most experts would recommend just what you have suggested to your doctor. If there is great
concern about osteoporosis at this time, a DEXA can be done. If you were to implement your own
plan above, a DEXA should be done in menopause and medications such as bisphosphonates
(Fosamax or Actonel) can be used along with your "own plan" delineated in your question. Hormone
replacement therapy is not approved for treatment of osteoporosis at this point.
Q: I am a white, 30 year old woman who sustained a stress fracture to the hip while running in early
August. My surgeon is more or less convinced that it was a repetitive stress injury as I had gone from
no running at all to 6 miles, three times a week, in only 3 months. Since then, I was referred to an
osteoporosis clinic. Initial ultrasound findings on my (injured leg!) heel were -2.0, osteopenia (10
weeks after surgery). I am only 5 foot 2, have nearly always weighed 98-104 pounds, and usually
been inactive. I was diagnosed with mild scoliosis at 12 and the hip fracture is the only broken bone I
have ever had. The only blood test so far measuring out of the expected range was PTH at 8 (it was
mentioned that normal is 12 or above).
I have tiny bones, and my questions are:
1. What are the relative risks of Lilly's Forteo (recombinant PTH) versus Fosamax for women of
childbearing age?
2. What are the chances that with small bones my DEXA scores would be significantly lower than
"normal" anyway?
3. I understand that BMD is only an indication, not a measure, of bone strength, and that younger
people with low BMD have lower risks of fracture than older people, because bone structure weakens
with age, just as bone density decreases with age. Is this accurate?
4. What is the best exercise to increase bone mass?
5. How soon should I have the PTH re-tested?
6. Is there anyone out there who is specializing on YOUNG cases of osteopenia/osteoporosis?
Thank you for your time.
A: Many questions, many problems. Your orthopedist is almost certainly correct in that you have
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sustained a repetitive stress injury. What you appear to have done is simply overloaded a normal
skeleton. The treatment of this is to avoid the overload situation, not use drug therapy.
Your small size probably accounts for a low bone density score in the heel. Additionally, studying the
injured side within 10 weeks of the injury probably reflects some of the acute unloading that
occurred while you were recovering from your injury and presumably not load bearing on that side.
Let’s leave the issue of Forteo and Fosamax aside for now. Forteo is not yet on the market to my
knowledge and has not been used in premenopausal women. Likewise, while alendronate is on the
market it has not been well studied in premenopausal women.
This brings me to an important question. What happened to your periods as you cranked up your
mileage? If they decreased in any way that is a sure sign that you are exercising too much and need
to cut back to the point where your periods become normal again.
For any given BMD younger people have a lower short-term (say 5 years) fracture risk than older
peoiple. However lifetime risk is probably greater.
There is probably no exercise that can increase bone mass in a 30 year old woman. Sorry, it doesn’t
work that way. Exercise is important for the growing skeleton and immobilization is bad for any
skeleton. However between those extremes exercise is good for your health but doesn’t build bones.
I can’t imagine why PTH was measured in the first place. The lab has a hard time distinguishing
between a value of 8 and 12. Unless you have a serum (blood) calcium that is either lower or higher
than the normal range I would not measure PTH again.
There are lots of people who take care of younger patients with osteopenia/osteoporosis. I am not
convinced you have either and don’t need a specialist.
I suggest you do the following:
Cut down your exercise.
Check your family to see if any of them (mother, aunts, grandmothers) have low bone mass,
osteoporosis, fractures.
Have your bone density checked at the heel on the uninjured side.
Have your bone density checked at your spine, hip, and forearm.
Q: I am 62 years of age and have osteo. I have also taken dilantin for seizures for 42 years. I am
presently taking 10 mg of fosomax daily and wearing the hormone patch. It has caused bleeding and
my gyn/ob wants me to consider Evista. My estrogen level is never high enough. In your opinion will I
need Fosamax and Evista?
A: Bleeding on hormones is an expected event. However there are many options for doses,
combinations, and regimens for estrogen and progesterone that can minimize and quickly (in most
cases) stop the bleeding.
I am not sure why you are taking both hormones and Fosamax. If this is only for your bones there is
some, but not much, advantage to combining hormones and Fosamax. If you are taking hormones
for other problems faced by 62-year-old women, I would stay on them. Otherwise Fosamax should be
fine on its own.
Talk to your doctor about once a week 70 mg Fosamax tablets. I see little need to add Evista to
Fosamax.
Q: During the last year I have been told by my Doctor that I have Osteoporosis. Since my teens I
have had thyroid disease and to take synthyroid. I am now 55. Last Jan I had an episode that started
with rapid heart rate (160 - 180 beats per minute) and extreme high blood pressure. I have not had
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either before. My Doctor said I was now hyperthyroid. My thyroid medication was too high and he
has lowered it twice. I have no thyroid (it was removed at the age of 22). Now I am on attenolol and
tiazac for the high blood pressure and rapid heart rate, celexa and lorezapam for the side effects of
tachyardia and hypertension. I take fosomax once a week for the bones and have had to discontinue
the hrt now because of the interaction with synthyroid. It has taken many months to bring down my
blood pressure and stabilize my heart rate. Do you think that someone with thyroid disease could
take forteo? Forteo is a thyroid derivative and I really don't want my bones to dissolve and get
fractures. My mom has already fractured her back and foot and hand and has lost 3 inches in height.
By the way, each time I have a thyroid test it always comes back as "normal" How can this be?
A: Several things to clear up. I don’t know any good reason why thyroid medication should
interfere with HRT.
Forteo is a brand name for a synthetic form of human PARAthyroid hormone. It has nothing to do
with the thyroid aside from being its “neighbor". Forteo is not yet on the market and no one is
certain who the best candidates will be for this medicine. If you are doing well on Fosamax once a
week stay on it.
I cannot address the “normal” thyroid test unless I know whether you are referring to a TSH test or a
free T4 test. The important one in your case is TSH.
Q:
I am 40 years old and had a low bone density scan 1 year ago. My Orthopedic surgeon put me on
Fosomax, 5 mg. for prevention. I feel better while on Fosomax. My body seems like it is on a more
even keel, not so nervous. What are the long term effects of Fosomax for someone of my age. The
only information I can find is about gastrointestinal upset, etc. I have had a few people tell me lately
that their Doctor would not put them on Fosomax for very long term because of the reported long
term liver & kidney problems. These people are my same age or a few years older and are having
the same low bone density problems. I have talked with my Physician, who says that he hasn't heard
of any long term effects. Thanks for your answer!
A: Where to begin? At 40 are you still having regular periods? How low was the bone density
result?
16% of all perfectly healthy, normal 40 year old women will have a bone density T score between
–1.0 and –2.0. In that case you are n ormal and don’t need Fosamax or any other medicine for your
bones.
There is no information from any other source that Fosamax makes people feel better. I am glad you
do feel better but it little to do with the Fosamax. Fosamax is known to be safe for at least 7 years
and probably for much longer. I know of no reports linking Fosamax to kidney or liver damage.
Q: Two years ago at the age of 56 I was diagnosed with severe osteoporosis of the Lateral Lumber
Spine (T score -3.67). My Lumber spine and left hip scores are -1.12 and -1.31 respectively. Three
years ago I had a complete hysterectomy because of endometrial cancer. Prior to that, I was on
hormone replacement therapy for six years. I now take Evista and Synthroid for hypothyroidism. My
obgyn wanted to wait two years for another scan, which is coming up in a few weeks, to see if my
exercise regimen and calcium intake was stabilizing the situation. From what I have been reading it
seems that I should have been taking Fosomax or similar these past two years. My doctor says if I
start Fosomax I should also take the Evista. Is it usual to take both? Would I be a good candidate for
Forteo?
A: With a spine T score of –3.67 and normal results elsewhere I have some reservations about the
quality of the spine scan. If the result is indeed correct I hope that you have had a thorough
investigation looking for secondary causes of bone loss.
Make sure that your thyroid hormone dose is not too high. Your TSH test should be normal if you are
taking the right dose.
If your bone density is stable on Evista and you are doing well I don’t see any reason to add either
Fosamax or Forteo. At the same time there is no harm taking both Fosamax and Evista aside from
the additional expense. Even if the drugs are covered by your medical insurance there is additional,
unnecessary expense incurred somewhere in the system.
Q: My mother is 85 years old. She has severe high blood pressure and has had spinal surgery for
bone spurs and narrowing of the spinal column. She also has intestinal problems. She has side
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effects to almost every medicine she takes. She has been diagnosed with osteopenia and the doctor
recommends that she take Actenol. She thinks that at her age, there is no time for the actenol to do
any good and so why should she put up with the side effects. Is she correct?
A: Mother always knows best! If your information is correct and at 85 your mother only has
osteopenia, not osteoporosis, then she probably does not need Actonel. However she should take
400-800 units of vitamin D a day as well as 1500 milligrams of calcium. She must also remain as
active as possible.
Quite frankly, knowing that mother had spinal surgery for bone spurs and narrowing of the spinal
column, the doctor might have anticipated that the bone density test was of limited value. (I am
making the assumption that the test was done on the spine).
Let me use your mother’s experience to remind any readers of this response that knowing when not
to do a bone density test is probably as important as knowing when to do the test.
In your mother’s case, by the time a patient has reached 85 the likelihood of osteoporosis is so high
that the test adds limited information. When the test does not show osteoporosis, as in your
mother’s case (it showed osteopenia) there is usually a good reason that can be identified.
At the other end of the age spectrum, too many healthy women are having bone density before they
have reached menopause or had any medical reason to expect that any bone loss has occurred.
Since 16% of these healthy younger women will have osteopenia no useful purpose is achieved by
doing the test, placing an unnecessary diagnostic label on a healthy woman, and worse yet
beginning unnecessary, probably expensive medication.
Why am I so confident that 16% of these healthy normal young women will have osteopenia? Easy!
Statistics 101 teaches us that 16% of any group will have a value that is more than 1 standard
deviation below the mean value for that group, provided the values are normally (evenly) distributed
about the mean. Bone density in healthy young women is normally distributed around the mean
value.
While I am still on statistics 101, remember also that 50% will be above the mean and 50% below
the mean. In terms of bone density and T scores, the 50% below the mean will have a negative value
for the T score result. This does not mean bone loss!
I sure hope this long answer to your very simple and straightforward question reaches the right
readership and that bone density tests will always be done when indicated and infrequently done
when not indicated.
Q: I am 28 years old and was diagnosed with osteopenia about 5 months ago. I have been taking
Fosomax 70mg since diagnosis. I also have ulcers, so I take Zantac 150 2x a day. The first 2-3 weeks
I was very sick (vomiting), but have overcome that. Now my hair is starting to break and fall out. I
have never had any problems with my hair until now. Is there anything else I can take other than
Fosomax that will help my bone density. Thank you for your time.
A: I suspect that you don’t have osteopenia and don’t need Fosamax. Because of the spread and
distribution of the normal values for bone density, 16% of all perfectly healthy, normal 28 year old
women will have a T score between –1.0 and –2.0. To label these healthy women as having
osteopenia is incorrect. This probably represents your maximum bone density. I am assuming that
you are otherwise healthy. I don’t know of any association between Fosamax and hair problems.
Please re-check with your doctor that you really need treatment for your bones, or consider getting a
second opinion from an expert in osteoporosis (endocrinologist or rheumatologist).
Q: I am 69 yrs. old and I have osteoporosis. I am on Evista, plus multi-vitamin and Caltrate and
Verapamil. I just found out I have another compression fracture in the lumbar section of my back.
This is the second one -- I had one 3 1/2 yrs. ago, and that particular one I knew how it happened.
This recent one I don't know how it happened. I did a lot of driving this past month and I slept on a
pull-out couch, and when I arrived home my back was really aching. I've had two bone density tests
and the last one was 1 1/2 yrs ago and it did show an improvement over the previous one. What I
would like to know is I should go on Evista and Fosamax...and should I see a specialist?
A: You need as immediate a reduction in fractures as possible. The biggest risk for a future fracture
is a previous fracture. Actonel has FDA approval for a claim of reduction in recurrent vertebral
fractures within 6 months, the most rapid FDA approved claim in the industry. You may wish to talk
to your doctor about this. With recurrent fractures, you may also wish to see an endocrinologist or
rheumatologist to evaluate other causes of the problem.
Q: I am 55 years old, I take actenol in the morning 1/2 hr. before eating with a full glass of water. I
thought I read somewhere calcium should not be taken for a certain period of time after I take
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actonel. I can't find the article now. I have cereal with milk every morning. Would that cause any
problems? Thank You.
A: The cereal and milk shouldn't be a problem at all. The deal with calcium and bisphosphonates,
such as Actonel and Fosamax, originated with some people complaining about gastrointestinal side
effects when taking Fosamax and soon thereafter taking their calcium (a necessary addition to the
therapeutic regime but timing is everything). To avoid various gastrointestinal complaints, the
calcium may better be taken at lunch and dinner time, since you need 1000 mg per day (plus
Vitamin D) and your body cannot absorb more than 500-600 mg per dose).
Q: I have been diagnosed with osteoporosis. I am 67 years old, had a dexascan a year ago was on
fosamax for one year, developed stomach pain, heartburn and ceased taking it. I had a second dexa
scan this year with my doctor informing me that the bone mass had decreased from 80% to 78% in
the year. I take 1500 calcium, 800 vit.D plus other vitamins, exercise daily including weights. Dr.
prescribed evista. My research indicates side effect may be clots. I have varicose veins. Am I at risk?
A: Several points to be taken here. The 2% difference in the DEXA results are NOT statistically
significant. At least a 3% change needs to be seen to confirm a REAL change and not just a statistical
variation. As far as what most experts consider first line drugs, they are the bisphosphonates,
Actonel and Fosamax. Fosamax is now weekly and this new method of taking Fosamax has
eliminated many of the earlier complaints. Actonel, although daily at this point, doesn't seem to have
the gastrointestinal complaints noted with it's cousin, daily Fosamax. Weekly dosing of Actonel is
expected and either of these medications may do very well for many who had problems on the daily
Fosamax.
The chance of serious clots with Evista is not common and even though Evista (and HRT) triple the
risk, the risk is STILL small. Depending upon the severity of the varicose veins, the risk may be
further increased in some patients.
Q: What kind of a doctor should I be seeing for osteopenia? My bone scans have varied from -2.6,
-2.3, -2.4 for the last three years. I take Fosamax and Evista. I am not please with the answers I get
from my primary care physician.
A: Many primary care doctors are well educated in the diagnosis and treatment of osteopenia and
osteoporosis. Depending upon the physician subspecialty availability in your area, internists,
gynecologists, rheumatologists and endocrinologists take care of this problem.
Q: I am 70 years old. My Doctor recently informed me my bone density results showed a 6%
increase in loss over the past 18 monthes. I started Didrocal 2 weeks ago. After only one week of the
white pills I began to feel bad pain in my joints. This pain was present during the sleeping hours and
would keep my awake or awaken me. The pain in my hip was the worst. My knees elbows and back
were almost as bad.
Q. Could this have been a result of Didrocal?
I do not have arthritus. But I do have a hiatus hernia. Therefore, I need to take Zantax each evening.
While on the white pills I would take my Zantax an hour or so after my meal then follow with the
white pill at least 2 or usually later after this Zantax.
Q Was it okay to take Zantax in this routine? Was afraid that the good of the Didrocal would be
wiped out. On the 12th night I could hardly climb the stairs. The pain in both the knee and hip was
that great. I had no strength in the leg at all. Could not believe it was my body. Also, now I expect to
complete the cycle with the blue pills.
Q Will it be okay to take the blue pill before breakfast so that I may keep taking my Zantac in the
evening.
Q. Should I take additional Calcium/Vitamin D with this blue pill?
Q. Will I experience the same pain in my joints on the second round as with the first round?
Q. Perhaps I should switch to a different osteoporosis remedy.
Thank you in advance for your interest.
A: Yes. Antiresorptive medications, like Didrocal, can have joint pain as a side effect.
Zantac shouldn't reduce the Didrocal efficacy. Some women take Zantac at night and take either
Fosamamx or Actonel in the morning and do well.
It should be OK to take the blue pill before breakfast.
Calcium/Vit. D.: You need a total of 1000 mg per day and 400-800IU of Vitamin D. Just make it add
up to the total recommended and not more than 500-600 mg of calcium at a dose.
You may experience the same joint pain. Some people find that re-testing for certain side effects
may NOT recur on subsequent dosing.
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Please discuss any change in your prescription choice with your doctor.
Q: My 86 year old neighbor has recently started having breathing problems. She has gone to
several doctors and has several tests. One doctor suggested that her breathing problem is possibly
related to having had Osteoporosis for so many years that her lungs are being squeezed. I took her
to dinner this evening. After dinner as she was getting into my car, she could not breath and began
to panic. This problem started a few months ago and seems to be getting progressively worse. Can
you give me any direction for getting her some relief from this problem?
A: She needs to be evaluated by a good, reassuring physician to determine if the problem is
osteoporosis alone, or at all. If it is osteoporosis, is it in combination with respiratory, cardiac or
gastrointestinal problems. A good, competent internist is her first step.
Q: I was diagnosed at age 50 after insisting I have a bone density test, with osteoporosis of the
spine and osteopenia of the hips. I have always been thin, lactose intolerant, and have taken
synthroid for a hypothyroid for about 8 years. I have been switched to Fosomax weekly after taking
the daily dose for a year. I have horrible backaches, uncomfortable to stand still, could this be the
osteoporosis? Do fractures show on the bone density test? I am due to have a repeat in a year.
Should it be sooner?
A: Osteoporosis usually has no symptoms unless a fracture is noted. Bone densities do not diagnose
fractures - Xrays are needed for that. Backaches and the like can be from a multitude of reasons arthritis, nerve pain, other orthopedic problems, etc. As far as repeating a DEXA, the National
Osteoporosis Foundation recommends every two years. There are, however, extenuating
circumstances that might move this timetable up in some. A specialist should evaluate for these
circumstances.
Q: Thank you. After reading the first two pages of ask expert I learned more about HRT in five
minutes than month of searching. Could you please tell me where I could research the compounded
tri=estrogens and if they have and results with treatment for osteopenia? Thank you.
A: I am not aware of any studies specifically with these compounded estrogens, such as
tri-estrogen. One might presume that with no other study material available, they might be
comparable to estrogen alone. On the latter topic, there is much information and much debate.
Q: My first DEXA scan test showed a -2.3 in the lower spine and a -1.5 on the hip. My doctor is
suggesting once a week Fosomax. I am 51 and have been on hormone replacement for 5 years, take
a daily 500 mg of supplemental calcium plus what I get in fortified soy milk and cereal and other
foods. I'm not terribly athletic but walk three miles a week when I am sticking to the exercise plan. I
have a history of chronic diarrhea, (bouts that can last for two to three months). My
gastroenterologist has done colonoscopies and thinks the bouts might be caused by irritable bowel
syndrome. I am worried about taking Fosomax because of the chronic diarrhea. Can a 51 yr. old
female deal with bone loss in any other way than taking medicine?
A: Fosamax shouldn't cause a problem with the chronic diarrhea. You may wish to discuss with your
gastroenterologist, the possibility of malabsorptive syndromes, such as sprue. This can cause GI
complaints as well as poor absorption of Vitamin D which would lead to poor calcium absorption and
osteoporosis. If there is a malabsorptive problem, correcting the problem may help with the
osteoporosis.
Q: I am a 31yr old smoker (I know...who needs to quit) with Osteoporosis. I rely on Depo Provera
shots to eliminate dibilitating periods. I also have hyperinsulinism. Would a hysterectomy cause
more bone loss than continuation of the Depo? What drugs are on the market for treatment and
what are their reputations?
A: As far as the drugs available, we have many responses on the various medications your doctor
can choose from and what the risks, benefits and alternatives are. With respect to your
gynecological complaints, The DepoProvera may not be helping your osteoporosis and possibly the
opposite. With hyperinsulinism and no further information, I might ask you to discuss insulin
resistance with your doctor. This may be part of a bigger picture known as polycystic ovarian
syndrome. If, however, you DO need a hysterectomy, hormone replacement therapy (presuming no
extensive endometriosis) may help maintain bone mass. The possible ramifications of antiresorptive
medications for osteoporosis in a 31 year old has too many facets to discuss with specifics in this
sort of forum.
Please check-out the OBGYN.net PCOS Pavilion and Hysterectomy & Alternatives for more
information regarding your question.
Q: I am a 37 year old african american woman who hasn't yet reached menopause and have
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healthy ovarian function. I have been diagnosed with Osteoporosis. I don't know the specifics, but
my doctor did a dexa scan to determine this after some x-rays for a cough came back looking "odd".
He stated that I have the bone density of a 70 year old woman with osteoporosis. I have been
lactose intolerant for the past 12 years and was not advised to take any calcium supplements. I am
also anemic and take niferex forte 150 twice daily. My doctor has stated that he does not know what
could have caused this for me. Could the lactose intolerance alone caused this? The only other
medical condition I have is endometriosis. I do not have a single person in my family with a history of
osteoporosis. My concern is what could have possibly cause this and the fact that the only treatment
i have received is recommendations to take fosamax, oscale, niferex and celebrex daily. Shouldn't I
have been counceled on diet and excercise? Should I be receiving some type of physical therapy?
Your response is appreciated.
A: As Dr. Kleerekoper has put it so succinctly this month, 16% of women will be out of the
statistical norm prior to menopause just by virtue of standard deviations in a population. Lack of
calcium can certainly be part of the reason you have osteoporosis. You may wish to discuss with a
gastroenterologist the possibility of malabsorptive syndromes, such as sprue. In some, it can also
cause poor absorption of such things as iron (leading to anemia), calcium and Vitamin D, which itself
would lead to poor calcium absorption and osteoporosis. If there is a malabsorptive problem,
correcting the problem may help with the osteoporosis. You need to see a specialist to tie everything
up in a package for you and have your specialists communicate with each other. A rheumatologist or
endocrinologist along with a gastroenterologist would be a great help. A hematologist may be helpful
for the anemia if no obvious cause was found. Appropriate diet, calcium, Vitamin D and weight
bearing exercise are things we've written about before as part of osteoporosis prevention and
treatment management.
References: **Note: Opinions expressed here are for educational purposes only and, as such, do
not constitute a physician patient relationship. This information is not intended to supplant the need
for you to consult with your physician prior to choosing therapeutic options and/or interventions.
Source URL: http://www.endocrinologynetwork.com/osteoporosis/osteoporosis-ask-expert-15
Links:
[1] http://www.endocrinologynetwork.com/authors/michael-kleerekoper-mbbs-facp-face
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Osteoporosis Ask The Expert

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