Osteoporosis (cont.)
Prevention of osteoporosis due to long term corticosteroids
The long term use of corticosteroids (such as
Prednisone, Cortisone, and
Prednisolone) can lead to osteoporosis. Corticosteroids cause decreased calcium
absorption from the intestines, increased loss of calcium from the kidneys, and
increased calcium loss from the bones. To prevent bone loss while on long term
corticosteroids, patients should:
- Have an adequate calcium (1000 mg daily if
premenopausal, 1500 mg daily if postmenopausal) and vitamin D intake. (Calcium
alone or combined with vitamin D cannot be relied upon to prevent bone loss
from corticosteroids unless other prescription medications are added.)
- Discuss with the doctor the use of either alendronate
or risedronate, both of which have been approved for the prevention and
treatment of corticosteroid-induced osteoporosis.
- Patients embarking on long term corticosteroids should discuss with
their doctor DXA bone density scan prior to beginning therapy and
careful monitoring for osteoporosis during therapy.
Monitoring osteoporosis therapy
The controversy of bone density testing in patients already taking osteoporosis medication
The American Medical Association and other reputable
medical organizations have determined that repeat bone density testing (DXA scans) is NOT indicated
in monitoring osteoporosis treatment or prevention on a routine basis. It is
scientifically premature to measure bone density as a way of monitoring
osteoporosis medications. Doctors simply do not know how to use these repeat
bone density measurements during therapy. A few of the most important reasons
are:
- Bone density changes so slowly with treatment that the changes are
smaller than the measurement error of the machine. In other words, repeat
DXA scans cannot distinguish between a real increase in bone density due to
treatment or a mere variation in measurement from the machine itself.
- The real purpose of osteoporosis treatment is to decrease future bone
fractures. There is no good correlation between increases in bone density
with decreases in fracture risks with treatment. For example, alendronate
has been shown to decrease fracture risk by 50%, but only to increase bone
density by a few percent. In fact, most of the fracture reduction with
raloxifene is not explained by raloxifene's effects on bone mineral density.
- One density measurement taken during treatment will not help the doctor
plan or modify treatment. For example, even if the DXA scan shows continued
deterioration in bone density during treatment, there is not yet research
data demonstrating that changing a medication, combining medications, or
doubling medication doses will be safe and helpful in decreasing the future
risk of fractures.
- An important note, even if bone density deteriorates during treatment,
it is quite likely that the patient would have lost even more bone density
without treatment.
- Recent research has shown that women who lose bone density after the
first year of menopausal hormone therapy will gain bone density in the next
two years, whereas women who gain in the first year will tend to lose
density in the next two years of therapy. Therefore, bone density during
treatment naturally fluctuates and this may not be relevant to the fracture
protection of the medication.
For all of these reasons, as surprising as it may sound
to many people (and even some doctors!), rechecking bone density is not at all
like checking blood pressure during treatment of high blood pressure
(hypertension). Routine bone density testing during
treatment is unlikely to be helpful. In the future, however, if ongoing research
brings new technology or new therapies, testing decisions will clearly change.
Next: Prevention of hip fractures in elderly persons with
osteoporosis »
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