Reports From National Arthritis Meeting

Dr. Shiel Gives Perspectives Of Interest On Osteoporosis From 2001 Annual Scientific Meeting Of The American College Of Rheumatology

Below are perspectives on key reports presented at the recent national meeting of the American College of Rheumatology:

• Introduction
• Medications
• Vitamins and Minerals
• Risk Factors

Introduction

Osteoporosis is a disorder of the skeleton in which bone strength is abnormally weak. This weakness leads to an increase in the risk of breaking bones (bone fracture).

Normal bone is composed of protein collagen and calcium. Osteoporosis depletes both the calcium and the protein from the bone, resulting in either abnormal bone quality or decreased bone density. Bones that are affected by osteoporosis can fracture with only a minor fall or injury that normally would not cause a bone fracture. The fracture can be either in the form of cracking (as in a hip fracture) or collapsing (as in a compression fracture of the vertebrae of the spine). The spine, hips, and wrists are common areas of osteoporosis-related bone fractures, although fractures can also occur in other skeletal areas, such as the ribs.

Osteoporosis can be detected by measuring the bone density. Bone mass (bone density) decreases after age 35 years, and decreases more rapidly in women after menopause. Risk factors for osteoporosis include genetics, lack of exercise, lack of calcium and vitamin D, lack of estrogen, cigarettes and alcohol, and certain medications. Patients with osteoporosis have no symptoms until bone fractures occur. The diagnosis can be suggested by x-rays and confirmed by tests that measure the thickness of the bone (bone density tests). Treatments for osteoporosis include stopping alcohol and cigarettes, weight-bearing exercise, calcium, vitamin D, estrogen, and medications to increase bone density.

Medications

Actonel (risedronate)

Risedronate is in a class of drugs called bisphosphonates, which also includes the drugs alendronate (Fosamax) and etidronate (Didronel). It is used for the treatment of Paget's disease of bone (a disease in which the formation of bone is abnormal) and to treat and prevent osteoporosis. It is traditionally taken as a 5mg tablet daily.

At this meeting, Actonel was reported to be as effective and well-tolerated in a once weekly 35mg dosing as with the traditional daily 5mg dosing.

Dr. Shiel's Perspective: I had heard of strong preliminary data about this a year ago and have been using the once weekly dosing in my practice. It does seem to be effective and is much more convenient for patients to take. This is especially so because this drug must be taken on an empty stomach in the morning with an 8 ounce glass of water, at least 30 minutes before any other medications, food, or beverage.

Parathyroid Hormone

Parathyroid hormone injections were demonstrated to significantly increase the bone density in men with osteoporosis.

Dr. Shiel's Perspective: This new treatment is not yet commercially available. It is good to see men being studied for these treatments as well as women. Parathyroid hormone treatment requires daily injections into the skin and has already demonstrated promising results in women with osteoporosis.

Parathyroid injections increased the height of the vertebrae in postmenopausal women with osteoporosis.

Dr. Shiel's Perspective: This is very impressive. Osteoporosis can lead to weakening of the bony building blocks of the spine (vertebrae). When this occurs, it can cause the vertebrae to compress, thereby leading to the loss of natural height. This study showed that the parathyroid hormone injections actually resulted in increased height of the vertebrae. The researchers contend that this is because the bone mass of the vertebrae is increased. If so, this would imply that this treatment has the capability of restoring some of the natural bone and bone anatomy (to a lesser degree).

Vitamins & Minerals

Vitamin D and calcium supplementation cut the risk of falling in half as compared to calcium supplementation alone!

Dr. Shiel's Perspective: What? Yes, that's right. These researchers studied 122 elderly women in long-stay geriatric care and recorded falls for 6 weeks before treatment and over a 3 month period after treatment. Half of the women were given vitamin D (800IU) plus calcium (1200mg) and half were given calcium (1200mg) alone. Before treatment, there were 22 falls in the vitamin D/calcium-assigned group and 20 in the calcium- assigned group. During the 3 month treatment, there were 25 falls in the vitamin D/calcium group and 55 falls in the group treated with calcium alone. The research stated that this effect on decreased falling may be a result of the Vitamin D combination on improving the function of the muscles and joints. I would like to see this study repeated on a larger scale.

Risk Factors

Low body weight shown to be a risk factor for fractures of the vertebrae in a European study.

Dr. Shiel's Perspective: This is not entirely earth-shaking. A thin body type is already a known risk factor for osteoporosis. What this study demonstrates is that the final outcome of this risk factor for osteoporosis is, indeed, dangerous and results in the compression fracture of the bony building blocks of the spine (vertebral compression fracture). Factors that increase the risk of developing osteoporosis are:

1. Female gender, Caucasian or Asian race, thin and small body frames, and a family history of osteoporosis. (Having a mother with an osteoporotic hip fracture doubles your risk of hip fracture.)

QUESTION

What is another medical term for osteoporosis? See Answer

2. Cigarette smoking, excessive alcohol and caffeine consumption, lack of exercise, and a diet low in calcium.

3. Poor nutrition and poor general health.

4. Malabsorption (nutrients are not properly absorbed from the gastrointestinal system) from conditions such as celiac sprue.

5. Low estrogen levels, such as occur in menopause or with early surgical removal of both ovaries. Another cause of low estrogen level is chemotherapy, such as for breast cancer. Chemotherapy can cause early menopause due to its toxic effects on the ovaries.

6. Amenorrhea (loss of the menstrual period) in young women also causes low estrogen and osteoporosis. Amenorrhea can occur in women who undergo extremely vigorous training and in women with very low body fat (for example, anorexia nervosa).

7. Chronic diseases, such as rheumatoid arthritis and chronic hepatitis C, an infection of the liver.

8. Immobility, such as after a stroke, or from any condition that interferes with walking.

9. Hyperthyroidism, a condition in which too much thyroid hormone is produced by the thyroid gland (as in Grave's disease) or is caused by taking too much thyroid hormone medication.

10. Hyperparathyroidism, a disease in which there is excessive parathyroid hormone production by the parathyroid gland (a small gland located near the thyroid gland). Normally, the parathyroid hormone maintains blood calcium levels by, in part, removing calcium from the bone. In untreated hyperparathyroidism, excessive parathyroid hormone causes too much calcium to be removed from the bone, which can lead to osteoporosis.

11. Vitamin D deficiency. Vitamin D helps the body absorb calcium. When vitamin D is lacking, the body cannot absorb adequate amounts of calcium to prevent osteoporosis. Vitamin D deficiency can result from the lack of intestinal absorption of the vitamin, such as occurs in celiac sprue and primary biliary cirrhosis.

12. Certain medications can cause osteoporosis, including heparin (a blood thinner), the anti-seizure medications phenytoin (Dilantin) and phenobarbital, and the long term use of corticosteroids (such as prednisone and prednisolone).

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Medical Author: William C. Shiel Jr., MD, FACP, FACR