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OSTEOPOROSIS

Over 50% of your bone density is obtained in puberty. By 30 you should have obtained your peak bone mass. After that, bone is lost.  Children must have adequate calcium, vitamin D, exercise, and proper diet to have strong bones for life!!

Osteoporosis causes the body to remove more bone than it replaces. This means that bones get weaker. Weak bones are more likely to break. Osteoporosis is a bone disease that is quite common, especially in older women. However, young people and men can develop osteoporosis, too. Osteoporosis can be prevented, and with proper therapy it can be treated.
 
"Osteopenia" is thin bones that are not as badly affected as osteoporotic ones. Bone mineral density (BMD) can be measured and is an excellent predictor of fractures. The test is painless, with minimal radiation exposure. The DEXA (dual -energy x-ray absorptiometry) or BDT (bone density test) will show:  T score value of -1.5 to -2.5 (this is your score compared to a healthy young adult) if you have osteopenia.  More than -2.5 is osteoporosis. Many clinicians will not treat you until there is osteoporosis. Osteopenia is a warning sign much like prehypertension or borderline cholesterol.  Determining the cause of osteopenia and treating such things as low calcium intake or Vitamin D may be important to prevent osteoporosis. Getting exercise, decreasing alcohol to <2 drinks/day, quitting smoking and treating estrogen deficiency are other important measures. A vertebral fracture may be also noted on your bone density test. If so, treatment of osteopenia is warranted.
 
How can osteoporosis affect me?
  • You may not have any pain or other symptoms when osteoporosis begins --the "silent disease"
  • You are more likely to break (fracture) a bone especially if you fall because osteoporosis makes your bones weaker. Fractures in your back (spine), wrist, or hip are more frequent.
  • You may "shrink" (get shorter).
  • You may get a "hump" (curve) in your back.
  • You may have bad back pain that makes you stop some activities.
Who is at risk for osteoporosis?

Many things put people at risk for osteoporosis. The following people have a higher chance of getting osteoporosis.
 
Risk Factors:
  •  Asian or Caucasion race,  
  • menopause, early or premature  menopause, 
  • steroid usage (even in asthma), 
  • hyperparathyroidism, hyperthyroidism, long-term thyroid medication usage
  • malabsorption,
  • lactose intolerance,
  • renal or liver disease
  • cancer and chemotherapy
  • heavy  alcohol, or smoking
  • thin framed
  • excessive exercisers with poor nutrition and low body fat ( some marathon runners)
  • family history of osteoporosis, anorexia
  • low calcium intake or lack of  Vitamin D (patients not exposed to sun, i.e. nursing homes),
  • advanced age with decreased activity or any chronic disease with inactivity 
Desirable Blood Tests:
  • 25 OHD--hydroxy Vitamin D--levels should be 25 ng/ml or better (optimal around 50 ng/ml)
  • SPEP --measures abnormal proteins in the blood for cancers 
  • PTH --parathyroid hormone
  • TSH --thyroid imbalance is an important cause of bone loss
  • Urinary Cortisol
  • Testosterone
  • SMA20 --look at kidney function
  • CBC--blood count--look for other diseases
  • LFTS --liver function
  • 24-hour urine for cortisol and
    • 24 hr urine Calcium (<100 poor intake)
    • (>300 skeletal loss)
  • Dexamethasone supression - test
  • Antigliadin AB ( Celiac sprue--a disorder of intestinal absorption)
  • Carotene
  • Prolactin
  • LH/FSH --menopausal status
  • Estradiol
Evaluation:
 
Evaluate patients for risk factors for the following: i.e. neuromuscular diseases, nocturia (having to urinate at night), orthostatic hypotension (low blood pressure upon standing). Patients prone to falls might fracture something. With severe osteoporosis, just rolling over in bed or reaching for something can cause a fracture. To prevent falls-- pick things up off the floor and leave plenty of space to move around the house without tripping. A spinal X-ray may be indicated if there is back pain (suspected fracture).

Who gets a bone density?
 
Any woman who is 40 or greater who may be at risk for osteoporosis. Younger women with indications will also generally be approved by insurance. Medicare will cover it every 2 years for screening and, like other insurances, yearly if there is medication being given for treatment of osteoporosis.

Treatment of Osteoporosis:

Things that inhibit bone resorption:
  1. Bisphosphonates(Fosomax, Actonel, Boniva, Reclast... to name a few)
  2. Estrogen (hormone therapy)
  3. Calcitonin
  4. SERM's--Raloxifene for example
Things that build bone:
  1. Fluoride
  2. PTH --newer; Forteo, daily sub-cutaneous injection, used for 2 years
  3. Weight-bearing exercise, walking, calcium supplements, or dietary calcium 
  4. Vitamin D helps us to absorb calcium
Uncertain Action:
  1. Anabolic Steroids (testosterone) --likely builds bone as it does in men
  2. Ipriflavone
 
Interesting Facts About Calcium:

Calcium Carbonate:
Has 40% elemental calcium in a 500 milligram pill; may cause constipation.

Calcium Citrate:
Has 20% elemental calcium; you need 4 pills a day, but it gives less constipation and can be taken with or without meals. For older patients who may have problems with decreased acid production in the stomach (pernicius anemia), Calcium Citrate is the way to go!!

Vitamin D:
For older women; 400-800 units daily. 20 minutes in the sun with exposed skin will provide this amount of vitamin D.

Calcitonin: 
You need 200 IU per day via nasal spray. Nasal irritation may be a problem. This is excellent for the pain associated with spinal fractures.

Bisphosphonates - Fosamax, Actonel, Boniva: Decrease fractures;
  1. Low intestinal absorption (must be taken on empty stomach).
  2. Bind to hydroxyapatite (areas of bone where resorption is occurring).
  3. Have a long skeletal retention.
  4. May cause bone pain, reflux, bowel problems
  5. Do NOT put you at high risk for a jaw necrosis!!!When intravenous high doses of bisphosphonates are given to cancer patients for cancer-related bone problems--there are a very few cases of jaw problems
Taken weekly or monthly for at least one to three years to show effect, must be taken with water. Patient cannot lie down for at least thirty minutes, as it directly irritates the esophageal mucosa. Wait thirty minutes before any food or drink other that water is ingested.
 
There are some intravenous medications now such as Boniva or Reclast that you do not have to take orally. These are injected.

SERM

Selective Estrogen Receptor Modulator: The newest hottest area of interest. This refers to a medication which would be agonist on the cardiovascular system and bone, while being an antagonist on breast and uterus. One such drug, Evista (Raloxifene), decreases LDL, protects bones, and does not stimulate breast or endometrial cancer. Rx - Evista 60mg daily. This drug also decreases your risk of breast cancer!!
 
Bone Loss:
 
There a 1-3% bone loss per year in women during early menopause. Estrogen is a preventive treatment and needs to be taken over a lifetime. Don't forget to exercise and maintain a healthy lifestyle.
 
 
NEJM 5/2007 p2293




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