Osteoporosis Ask The Expert

Transcription

Published on OBGYN.Net (http://www.obgyn.net)
January 14, 2007 | Osteoporosis [1], Integrative Medicine [2], Pregnancy and Birth [3]
By Simon Kipersztok, MD [4]
Questions this month have been answered by: Simon Kipersztok, MD, OBGYN.net Osteoporosis
Editorial Advisor Alice Rhoton-Vlasak, MD, OBGYN.net Osteoporosis Editorial Advisor Barry L. Gruber,
MD, OBGYN.net Osteoporosis Editorial Advisor
Q: I am currently taking Fosamax to help prevent bone loss due to taking
prednizone. How soon do I need to discontinue taking Fosamax before it is
safe to become pregnant. I am currently tapering off on the prednizone and
have been told that that would not interfere with a pregnancy, but I am
concerned by the information I have found on Fosamax during pregnancy.
A: Unfortunately there are no data available that to my knowledge can help me answer your
question. Fosamax may remain in your bones for years and it is unknown if it could have an adverse
effect on a pregnancy after the drug is
discontinued.
I encourage you to discuss with your physician all the drugs available to
prevent bone loss. You both can then make a good evaluation of the risks and
possible benefits of each formulation.
Q: I am a 23 year old woman that has been diagnosed with osteopenia. I have 2 transverse process
fractures, L2&L3 with a Grade I spondylolisthesis
to L5. It has been ten months since the accident and my back still hasn't healed, what can I do? My
Doctor has me on Fosamax to build the bone and Vicodin/Hydrocodone for the pain. I can't sleep at
night because of the pain. Their is no comfortable position. Is their a chance my case may be
untreatable? None of the doctors I have seen have been able to help. Please, what can I do? A: It is
unlikely the osteopenia is related to the other spine problems. There may or may not be a potentially
treatable cause for your pain, but in order to figure it out you need to be seen at an expert
multi-disciplinary spine center with orthopedic surgeons and non-operative physiotherapists. Good
Luck!
Q: Can I take 7 fosamax 10mg tablets at one time?
A: The dosage for Fosamax when prescribed for the treatment of osteoporosis is 70 mg. weekly.
You can take each week one 70 mg. pill or alternatively seven 10 mg. pills. In both situations you
would ingest the same total amount of the drug.
Q: Two years ago I was sent for a bone density test as my sister has bones of an 85 year old. My
doctor did not tell me any numbers other than I tested at 65 years of age & he put me on 1500 mg
of calcium.
I exercise 3 times a week, quit smoking, take 1500 mg of calcium & 400 units vitamin D, eat a
healthy diet. Recently took bone density test again & nothing has changed so my dr. precribed
didrocal & told me only side effect may be heart burn. From the internet I discovered a variety of
possible side effects & long term effects are still unknown. I believe I am peri-menopausal, but from
the blood tests my dr. says no. My body tells me otherwise. I fear I will lose even more bone mass as
menopause approaches.
My questions are - will this drug help me & do I need to stay on it long term. At what risk am I to
have a fracture if I cannot live with the side effects. Is there anything else I could take if this does not
work?
Thank you for your time.
A:
You have low bone mass and you are perimenopusal given your age. Your doctor has
prescribed Didronel (I am not familiar with 'didrocal'...) and you take calcium and vitamin D. Your
bone density has not changed on a repeat test. If you are taking Didronel, the drug is safe an useful
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for bones if taken every 3 months. There are 2 other similar drugs commonly used for the prevention
and treatment of osteoporosis, risedronate (Actonel) and alendronate (Fosamax). If Didronel causes
side effects then you may want to try and see if one of the other drugs is better tolerated. Fosamax
can be given once a week. These drugs should be taken as long as the risk of fracture is increased
and that can be long term depending on the degree of low bone mass.
The increased risk of fracture depends on the T score (or % young adult) measured in your bone
densitometry study. It can vary in different sites of your body. Roughly, if the T score is less than -1
the risk of fracture increases by more than 2 fold. For a T-score of less than -2 the risk can increase
by more than 4 fold. For a T score of less than -3 the risk of fracture can increase by more than 8
fold.
Also, please be aware that no change in sequential bone density studies can still be good news since
it could mean that bone mineral density is not getting worse and whatever intervention was used it
is protectin g the bone from losing more density.
Q
:
My sister is 48 years old and premenopausal. Her only risk factors for osteoporosis are poor
dietary intake of calcium and lack of weight bearing exercise. Her recent DEXA showed her lumbar
spin to be at -1.24 SD and her femoral neck at -1.97 SD. Her physician started her on Calcium and
Vit D and Actonel and will repeat her DEXA in a yr. Is he being too aggressive using this medication
to prevent osteoporosis? Should my sister try Calcium, diet and exercise for a year and then see if
the DEXA improves or stays steady? I am concerned about the possible long term effects of Actonel.
Thanks.
A: The treatment recommended by your sister's physician is within the realm of what would be
reasonable given the information you provided. Often times, more than just the results of a DEXA
study go into making a decision to recommend medical treatment. Certainly risedronate (Actonel) is
a fairly safe drug to prevent and treat osteoporosis so your sister's risk of fracture will decrease after
its use.
Q: I am 44 years old, and recently diagnosed with Osteopenia. My OB/GYN increased my calcium
intake to 1200mg, and to do weight bearing exercises, along with prescribing fosomax. I am still
having periods. Is this safe?
A: The management plan as recommended by your physician is
safe. Fosamax is fairly well tolerated especially when taken once a week. As the drug is excreted by
the kidney, patients with severe kidney disease may need to have the dose adjusted.
Q: I am a 41 year old female, I have been on Actonel for four months now and seem to be on a
steady weight gain, 10 to 15 pounds with no change of eating habits and on the same exercise
program. Although I don't see weight gain on any of the info. on side affects I have read, I can't help
think that this drug seems to have slowed down my metabolsim not just my boneloss, is that
possible?, And if it is, is there anything I can do about it, short of stopping the RX. Thank you.
A:
There has been no evidence to support your concern that Actonel would be the cause of your weight
gain or that it might slow your metabolism.
Q: I am taking 30 mg of Actonel once a week. Bone density test found
osteoporosis in hip. I am 57 years old. When I take it on Sundays I get a
burning or pain in stomach. I am following all the directions of how to take
it. I hope this does not cause me to get ulcer later on or stomach cancer. I
am concerned.
A: It is unlikely that Actonel will lead to "cancer" of your gastrointestinal track,
but it is possible that esophageal irritation may be occurring as a cause of your pain as a result of
Actonel. Since you are using this product "off-label", which means different than the FDA approved
method (which is daily dosing) one other strategy which you might speak to your physician about is
taking a proton pump inhibitor, such as Prilosec or Prevacid, the evening before your weekly dose.
Using the drug as a weekly bolus rather than daily dosing is a general trend for these compounds
and in general has met with tremendous success; thus the idea of taking smaller doses daily would
not necessarily obviate the problem that you are encountering but might be tried nonetheless.
Q: I had a bone density test (do not remember number results) but my doctor prescribed
Fosomax. I took it daily for about a year. Then at my doctor's suggestion I changed to the
one-a-week Fosomax. After two weeks I coughed up blood three times one morning. A chest x-ray
showed my lungs were clear. I was afraid of Fosomax after that and have been taking nothing except
Premarin, which I have been taking for several years, and 1260 mg of Citracal and 800 IU of Vitamin
D. I also take Synthoid as I had my thyroid surgically removed. Do you think I am getting enough
calcium? I also drink soy milk. Thanks.
A: It appears you are getting sufficient calcium and
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vitamin D, which answers your only question. The premarin is also likely contributing to diminishing
your bone loss over time. The coughing up blood is a worrisome event and the relation to Fosamax
ingestion certainly was not established firmly in your case from the information you provided.
Perhaps there remains another explanation and further workup may be in order- please continue to
discuss this with your physician.
Q: Can you please explain the results of my Dexa? The T score is -2.7 and the Z score is -1.8 in the
spine. I am 53 yrs. old and in menopause. I know that the T score is compared to healthy young
women and the Z score to women of my age. What I am having trouble figuring out is which number
is most important. Thank you.
A: We believe that the T-score is more important with the
premise that normal bone mass is what we achieve as a young adult and every effort needs to be
made to maintain that optimal bone mass in effort to keep our stature and minimize fractures for the
remainder of our lives. Hence, the degree to which you measure up to that optimal young adult bone
mass gives you a more precise picture of your risks.
Q: I started to take medication for osteoporosis 6 months ago, and started Actonel 9 weeks ago. I
have fibrocystic breasts. After 2 weeks my breasts hurt so bad I could hardly touch them, they even
hurt when my clothes touched them. I called the Dr., they told me to wait two weeks and see. They
got better, but I called the company that makes Actonel and they had never heard of breast pain
when taking Actonel. They sent me a paper for the Dr. to fill out with information on me. I'm 72 years
old, and I had scleroderma 28 years ago. The Dr. told me in Jan. 2002 that it is coming back. I would
like to know if the medication I'm taking for osteoporosis is causing Scleroderma to come out of
remisson? My legs are getting hard so far to the middle of my calf. Could that be from the Actonel?
A: There is no clinical data or theoretical reason that Actonel would have any effect on your
breast tissue or your scleroderma. This drug rapidly binds to skeletal tissue at areas where calcified
bone is exposed to the blood or else gets excreted out of the body. The scar tissue in areas of
scleroderma involvement or in your breasts would not be areas that Actonel would bind and be
biologically active. That said, we always have more to learn and listen carefully to what our patients
tell us. Your physician(s) will need to help you sort this out further.
Q:
I am 34 years old and was diagnosed with osteoporosis 16 months ago. Upon diagnosis, my
doctor immediately put me on Fosamax. I was on it for 4 months when I began to see an
endocrinologist. That doctor said that if I wanted to have another child that I should immediately
cease taking Fosamax and get pregnant. I ceased taking the medication for almost 1 year, remained
on estrogen, and increased my bone density by 6%. I am now considering becoming pregnant. I am
concerned about the information my new doctor gave me regarding the fact that Fosamax stays in
your system for up to 10 years and is slowly released during that time. Have you heard about
premenopausal women taking Fosamax, stopping the medication, and then having healthy children?
Thank you for any information you are able to supply.
A: In response to your question, there has
been very little experience with
pregnancy in individuals who have taken Fosamax. Theoretically, and based on a large amount of
animal experimentation (including primates), the follwowing can be construed. Although Fosamax
does "hang around" for more than a decade in the body, most all of this is bound within the skeleton
and not "bioavailable". In other words, very small amounts enter the blood stream and thus
potentially pass through the placenta into a developing fetus. It has been estimated to be in the
"parts per million" range, which is highly unlikely to have any untoward effects on the fetus or its
development. Hope this is helpful and encouraging, even though there has been little actual
experience with this situation.
Q: I am 55 years old have just been diagnosed with osteopenia based on my first bone density
test. My mother also just had her first test at age 77 and also has osteopenia. I have not
menstruated for about 4 years. I took HRT for the first 3 but stopped due to lack of evidence for
cardiovascular health and concern about cancer. The bone density was done about 4 months after I
stopped the HRT.
I have severe GERD and am on Prilosec and therefore do not want to take Fosamax. I am reluctant to
take Actonel as well for the same reason. Evista is a concern for me due to the high level warnings
about blood clots - this does not seem to be a great trade off for a broken hip in 20 years. What do
you think about Miacalcin or other calcium products? thank you.
A: You do not provide information as to how severe your osteopenia as this
would factor into advising you (i.e., whether it is extremely mild or severe). Miacalcin would probably
not be a good choice as clinical trials have indicated it is ineffective within the first 5 years after
menopause (or in your case, after discontinuing estrogen). At best, it is a weak agent. Evista has an
incidence of blood clots about as frequent as estrogen itself and evidently that did not influence your
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initial decision to use it. More important, the incidence of blood clots is elevated only during the first
several months of use- then it is no more frequent an event than by chance in the general
population. So if you were to decide to use Evista, you need not worry for long about developing a
blood clot. Although you have "severe GERD", weekly dosing of bisphosphonates such as Fosamax or
Actonel seem well tolerated and only rarely cause additional problems. These drugs work well and
may be among the best agents currently available.
In summary, depending on your level of osteopenia, you do have many different reasonably safe and
effective options in addition to keeping adequate calcium and vitamin D intake. Hope this has been
useful.
Q: I am a 65 year old white female that has borderline osteoporosis of the spine. I have taken
"bone up" --- 500 mg daily--- this has a more adsorbable CA than regular CA and is extracted from
Australian bovine. For 1 year I took acetenol and then had a bone density test performed. The results
for my spine were identical to the 3rd decimal place from the bone density test performed a year
ago. However, my hip reading was down approximately 4 %. It is still osteopenic. I have been trying
to figure out where I went wrong. I took the actenol on a full quart of water (2 continuous glasses
then the remaining 2 within 20 minutes) and waited an hour before eating. I exercised 5 days a week
by walking approximately 2 miles each day. I put weights(1 1/2 pounds each) on my ankles when I
walked.
I have had 3 bone density tests. The second test showed a slight improvement from the first. During
this period, I used progesterone cream approximately 1/4 gm for 27 days per month. I took premarin
(.3 gm --- green pill) days 1 -25. I also took the "Bone Up" supplement and exercised 5 days a week.
I am switching to Citracal --- is it a good choice? My gynecologist has suggested fosamax for a year
then repeat the bone density test. What is your opinion?
A: Alterations in bone mass measurements from time to time as means of
monitoring the "success of treatment" are frought with serious limitations. It is always nice to see
steady, progressive gains. But frequently we note more undulating values which may relate to
limitations in the technology, calibration problems of the machine, different technicians, etc. It may
also reflect changes in bone density, but not necessarily bone strength. In clinical trials, patients who
lost bone while on these drugs still fractured less than their counterparts on placebo. It is also
conceivable that you might have lost more had you not been on Actonel. Progesterone cream or oral
preparations are unlikely to influence bone strength in any meaningful way, from data derived out of
good clinical trials. Calcium is important, but great differences among products are not supported
again by clinical trial data- most of this is marketing hype. Lastly, Fosamax is a well-tolerated and
effective approach to the problem and would not be a bad option to try.
Q: I am a lady 68 years old. I have been told I have Osteo in my hips. I was put on Fosomax. I
began to have chest pain and was put in the hospital for testing. I was told not to take any more of
the medicine. When I was dismissed my doctor told me if I needed him to call. I was not put on any
medication. I know I am not doing anything for my bones except taking calcium. They did not
recommend any other medication. Is there any I can take to help?
A: It is difficult to advise you,
when the results of your tests are not
described and specifically whether the cause of your chest pain was
determined to be esophagitis by endoscopy. In this case, then
sufficient concern would be raised concerning the possibility that
Fosamax was the underlying cause of this problem. But if that were not
the case, then resuming Fosamax once weekly or using Actonel seem
reasonable alternatives. Another less ideal option but still effective
would be to consider Evista.
In summary, without sufficient details about your case and your workup,
it is very difficult to advise you soundly. You might discuss these
factors in detail with your physician or seek a specialist in osteoporosis. Hope this is helpful.
Q: I would like to know if there is any difference between Fosamax and
Actonel and is one better than the other in treating osteoporosis. I have been diagnosed with
osteoporosis and brought it up to osteopina by taking Fosamax for several years. I started to get
some heartburn and decided to discontinue its use and the doctor stated that as long as I continued
with my HRT regimen that that should be OK. I have not used Fosamax for 2 years. I just had another
bone scan and it showed that it had returned to osteoporosis and the doctor prescribed Actonel. Will
I have to take this medicine for the rest of my life? Are there any other alternatives besides these
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drugs and weight bearing exercise? I am 60 and in excellent health otherwise. Thank you.
A:
There have been no "head to head" clinical trials comparing Actonel to Fosamax, so in reality it is
difficult to answer your question. The drugs are very similar in their mode of action and clinical
effects. Some experts are still more comfortable with Fosamax as a first line agent, since it has been
around longer and all trials have been quite sucessful while Actonel is newer to the market and at
least one study failed to show efficacy in reducing hip fractures compared to placebo (in the very
elderly).
Alternatives to drug therapy are beneficial but probably not sufficient to reverse your osteoporosis.
The major role of exercise in your age group (and important in itself) is to reduce your frequency of
falls and help you when you fall to land in a less hazardous manner. Hope this has been helpful.
Q: Hi, I am a 29 years old female who was recently diagnosed with osteoporosis. My t scores
were -2.6 with 26% bone loss in my spine and -1.6 with a 20% bone loss in my hip. I have also lost 3
inches in height in the last 10 years as well as broken my wrist 3 years ago along with numerous
arms and legs since I was little. I also have multiple sclerosis. Can you explain this diagnosis to me,
my doctor was a little vague. I was put on Didrocal once daily. Thank you for your time.
A:
Osteoporosis is currently defined as a condition of low bone mass leading to skeletal fragility and an
increased risk of fractures from relatively low trauma or impact. The reason for your having this
condition should be investigated. It may relate to medications being used for treatment of your MS
or possibly from inactivity if this applies. In any case, it may be important to first define the reason, if
possible, for your low bone mass. Then appropriate therapies can be considered. You would be best
advised to see an expert in the bone
field.
Q: My mothers side of the family has a history of osteporosis, I had a hysterectomy at age 32
and was not given hormones as the physician felt I still had an oveary that was working. Several
years later I was put on the Estraderm Patch but a few years later I was diagosed with Factor V
Leiden. Is Foxamax safe for me to take since I am on Coumadin for life? I am concerned about my
family history and the fact that I cannot take hormone therapy. Thank you.
A: There should be
no problem with utilizing coumadin and taking Fosamax
simultaneously; other than a theoretical concern that if you should have the rare complication of
esophageal ulcers then bleeding may be more excessive in your case and more difficult to control.
Suggest that you discuss this with your physicians.
Q: Hi. I am a 32yr. old female, 5'4" 105lbs. caucasian. I had a dexa scan and the results were as
follows: Quantatative T and Z scores for lumbar spine are -2.64 and -2.60. Quantatative T and Z
scores for left hip are -2.78 and -2.74. I was on miacalcin the first year and it was changed to
fosamax, due to more bone loss while on the miacalcin.
My questions are: How unusual is it for someone in their early 30's premenopausal, to develop
osteoporosis? How significant are my scores? What will happen when I do hit menopause, will I be in
trouble? I guess I mean what is the outlook for being in this situation? And what activities should I
avoid (skiing etc)
I should add that I cannot be on hormones because I have serious stroke risk due to atrial fibrillation,
and a whole between the atrium. I also have a pacemaker, and heart arrythmias. I take
antiarrythmics, and coumadin as well. Will I gain back all my bone loss with the fosamax?
Please, anything you can offer would be very helpful. Oh, just to add, I have had blood work to check
for calcium deficiency, and thyroid etc.
A: It is somewhat unusual to find low bone mass or osteoporosis at your age. You do not
mention whether you are menstruating regularly, which would have an impact on the rarity of your
situation. Assuming that you do, then you should have a complete work-up looking for other
potential underlying causes perhaps by an expert in the bone field (usually an endocrinologist or
rheumatologist with an interest in osteoporosis). The experience with drug therapy in
premenopausal women with osteoporosis is quite limited, and little can be stated based on the
literature or experience of the experts. Anecdotal cases suggest efficacy of Fosamax, but larger
series of cases have not been reported. Your prognosis really depends on whether an underlying
cause can be identified; thus it is difficult to comment further on this question of yours. As far as
activities, you might best avoid sports entailing high impact fall risks (e.g., skiing). Hope this has
been helpful.
Q: I am a student midwife and I am embarking on a case study on a lady who is a gravida 3,
parity 0. This lady has transient osteoporosis in the right hip. I am finding it very frustrating that this
lady is not all together being given the best care possible, as no one over here really knows much
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about it. The lady is 40 with 2 previous early miscarriages. Any information on how her care can be
enhanced, and what type of medication she should be on with relevant side effects would be
greatfully received by myself for use now and in the future. Thank you in anticipation.
A: Most
of the time, transient osteoporosis of the hip is just that - transient, and thus doesn't require any
specific intervention or therapy. It is an odd entity and very little in terms of pharmacologics have
been used in these cases. The major thing is to be sure this really is transient, and to monitor over
time.
Q: How effective is Actenol in either stopping, slowing down, or actual bone revitalization in
osteoporosis? Thanks.
A: Actonel is classified as an anti-resorptive agent, which actually means
that it primarily acts to prevent further dissolution of bone during remodeling. In essence, this will
restore the bone physiology back towards normal balance. Usually this means that bone mass will
increase to a certain degree (~10%) and then slowly level off- different that an "anabolic agent"
which would continue to build new bone. Hope this all makes some sense and is useful.
Q: I am 55 years of age, and last week had a bone density scan and a mammogram.
Appxoximately 3 years ago, the last bone scan showed osteopenia. Today, I had a call from the
doctor's office saying I now have osteoporosis. I have not wanted to take HRT due to previous
phlebitis after a surgery. My doctor has suggested taking the new drug, Actenol, and has prescribed
it for one year. Is there enough data out on this new drug to be safe? Are there any known reactions
to it? I am VERY healthy - no problems whatsoever. I breezed through menopause 3 year's ago, and
have had no mood swings or any other symptoms. My height is 5'5 1/2" and weight 101.5 lbs. I have
always been slight of frame. Also, in this mammogram, there was some possible calcification in my
right breast. Surgery was performed nearly 10 years ago on a breast lump- it was benign. Does this
new drug have any possible side effects such as causing breast cancer? Thank you in advance for
sharing any information as you wish.
A: Both Actonel (risedronate) and Fosamax (alendronate)
are members of a
class of compounds called bisphosphonates. These two are both approved
for treatment of osteoporosis in our country. They are not hormones and
target bone selectively; i.e. they do not act on any other organ and are quite well tolerated and safe.
Not being a hormone, they should not have any effect on breast cancer unlike estrogen hormonal
therapy. These drugs are quite effective for reducing the number of fractures and improving bone
strength along with bone density over a number of years. Thus, a commitment must be made to
taking the drug properly for an indefinite period of time monitored by bone density measurements
every one to two years. Hope this has been useful information.
Q: Can you please tell me after taking the fosamax tablet (once a week tablet) how long is it
before it reaches your bones? Do you get more side effects because you are taking a larger amount
at one time?
A: Fosamax (alendronate) will reach your bones within the first few hours
after ingestion. From all the clinical trials, it appears that taking a larger bolus of the drug once
weekly is associated with less not more side-effects, probably because of the six days of
non-exposure to the drug.
Q: I have been perscribed actonel for my osteoporosis, and I was wondering, is it ok to take
coversyl and aproxin tablets at the same time?
A: Coversyl is an ACE inhibitor and goes under
the name of Aceon in the US. The are neither major nor minor interactions with Actonel. After
searching for "aproxin" and being unable to find it on any search engine in English, I cannot
comment on that drug.
This question graciously answered by OBGYN.net Osteoporosis Chairman and Editorial Advisor
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.obgyn.net/osteoporosis/osteoporosis-ask-expert
Links:
[1] http://www.obgyn.net/osteoporosis
[2] http://www.obgyn.net/integrative-medicine
[3] http://www.obgyn.net/pregnancy-and-birth
[4] http://www.obgyn.net/authors/simon-kipersztok-md
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Osteoporosis Ask The Expert

Transcription

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