- SECTION 1
- Calcium and Vitamin D
MEDICATIONS THAT PREVENT BONE BREAKDOWN
MedicineNet: Now that we know about prevention of osteoporosis, tell us about the medications in the treatment of osteoporosis.
Dr. Truong: Aggressive prevention and treatment of osteoporosis can involve medications that work by preventing natural breakdown of bone or medications that promote new bone formation. Examples of medications for the treatment of osteoporosis that prevent natural bone breakdown (anti-resorptive agents) include alendronate (Fosamax), risedronate (Actonel), etidronate (Didronel), and calcitonin. A medication designed to promote new bone formation is teriparatide (Forteo).
The bone is a living dynamic structure; it is constantly being removed (resorbed) and rebuilt. This process is an essential part of maintaining the normal calcium level in the blood. When the rate of resorption exceeds that of rebuilding over time, osteoporosis results. Anti- resorptive medications inhibit bone removal or resorption. This tips the balance toward bone rebuilding, thus increasing bone mass.
Alendronate (Fosamax) is an effective antiresorptive medication approved by the FDA for treating osteoporosis in women. Alendronate has been shown to increase bone density in the spine, and around the hips and arms. Alendronate also reduces the risk of fractures in the spine, hips, and wrists. The bone strengthening benefits of Fosamax can even be seen in elderly women over 75 years of age.
Fosamax is generally well tolerated with few side effects. One side effect of Fosamax is irritation of the esophagus (the food pipe connecting the mouth to the stomach). Inflammation of the esophagus (esophagitis) and ulcers of the esophagus have been reported infrequently with Fosamax use.
Risedronate (Actonel) is another bisphosphonate anti-resorptive medication. Like alendronate, this drug it is approved for the prevention and treatment of postmenopausal osteoporosis as well as for osteoporosis that is caused by cortisone-related medications (glucocorticoid-induced osteoporosis). Risedronate is chemically different from alendronate and has less likelihood of causing esophagus irritation. Risedronate is also more potent in preventing the resorption of bone than alendronate. Ibandronate is the most recently approved bisphosphonates, and is approved for prevention and treatment of postmenopausal osteoporosis. It is available in both daily and monthly formulas.
I generally avoid prescribing Fosamax and Actonel for patients with a history of inflammation, ulcers, or scarring of the esophagus. To reduce side effects they should be taken on an empty stomach, with at least 8 ounces (240 ml) of water, while sitting or standing. This minimizes the chances of the pill being lodged in the esophagus. Patients should also remain upright for at least 30 minutes after taking these pills to avoid reflux into the esophagus.
For those patients who cannot tolerate the esophagus side effects of Fosamax, estrogen, etidronate (Didronel), and calcitonin are reasonable alternatives.
The FDA first approved etidronate (Didronel) for treating Paget's disease. Paget's disease is a bone disease characterized by a disorderly and accelerated remodeling of the bone, leading to bone weakness and pain. But the FDA has not approved Didronel for the treatment of osteoporosis. For many years, doctors in this country have been using Didronel to treat osteoporosis "off label"-that is, using it without formal FDA approval, because of its effectiveness.
Didronel has been shown to increase bone density in postmenopausal women with established osteoporosis. Didronel has also been found effective in preventing bone loss in patients requiring long term steroid medications (such as Prednisone or Cortisone). Didronel does not appear to cause esophagus side effects like Fosamax, but it can cause nausea and diarrhea.
High dose or continuos use of Didronel can cause another bone disease called osteomalacia. Like osteoporosis, osteomalacia can lead to weak bones with increased risk of fractures. Therefore, Didronel is only prescribed in small doses and in a cyclic fashion. For osteoporosis, it is given two weeks every three months rather than on a daily basis.
Because of osteomalacia concerns and lack of enough studies yet regarding reduction in the rate of bone fractures, the United States FDA has not approved Didronel for the treatment of osteoporosis.
Teriparatide (Forteo) is a synthetic version of the human hormone, parathyroid hormone, which helps to regulate calcium metabolism. It promotes the growth of new bone, while the other osteoporosis medications improve bone density by inhibiting bone resorption. Teriparatide (Forteo) is self-injected into the skin. Because long-term safety is not yet established, it is only FDA-approved for 24 months of use. It reduces spine fractures in women with known osteoporosis, but reduction of hip fracture risk is currently unproven.
Calcitonin (Calcimar, Miacalcin) is a hormone
that has been approved by the FDA in this country for
treating osteoporosis and Paget's disease. Calcitonins come
from several animal species, but salmon calcitonin is the
one most widely used. Calcitonin can be administered under
the skin (subcutaneously), into the muscle
(intramuscularly), or inhaled nasally (intranasally).
Intranasal calcitonin is the most convenient of the three.
Calcitonin has been shown to prevent bone loss in postmenopausal women. In women with established osteoporosis, calcitonin has been shown to increase bone density and strength in the spine only.
One unique benefit of calcitonin is its short term relief of pain after a fresh osteoporosis-related bone fracture. Several studies have shown that calcitonin can decrease pain and decrease the need for pain medications in patients with recent painful fractures.
But experiences from my practice and from my review of the literature indicates that calcitonin is not as effective in increasing bone mass and strengthening bone as estrogen and the other anti-resorptive agents such as Fosamax and Didronel. Therefore, aside from the situation of a recent painful fracture, calcitonin has not been my first choice in the treatment of women with established osteoporosis. Nevertheless, calcitonin is a helpful alternative osteoporosis treatment for patients who are unable to tolerate Fosamax or Didronel.
Patients using Miacalcin Nasal Spray can develop nasal irritations, runny nose or nosebleeds. Injectable calcitonin can cause nausea with or without vomiting in 10% of patients. Injectable calcitonin can also cause local skin redness at the site of injection, skin rash and flushing.
MedicineNet: You have given us useful
information about osteoporosis prevention and treatment,
can you put it together for us? How do you define and
monitor osteoporosis in an individual patient?
Dr. Truong: Viewers must remember that knowledge in this area, interpretation of scientific data, along with medications and their uses are changing continuously.
Aside from a balanced diet, adequate calcium intake, regular weight bearing exercises, stopping cigarettes, and curtailing alcohol and caffeine intake, I like to have a base line measure of the patient's bone mass or density.
MedicineNet: How do you measure bone density? Who should be tested?
Dr. Truong: The best technique currently available in determining bone mineral density (BMD) is dual energy x-ray absorptiometry (DEXA). DEXA measures bone density in the hip and the spine. The test takes only 5-15 minutes to perform, uses very little radiation (less than one tenth to one hundredth the amount used on a standard chest x-ray), and is quite precise. DEXA can also be used repeatedly over a period of time to follow changes in BMD.
The BMD of the patient is then compared to the average peak BMD of young adults of same sex and race. Osteoporosis is defined as BMD of more than 25% below the average peak BMD of young adults of the same sex and race. Osteopenia (a milder form of bone loss than osteoporosis) is defined as BMD of between 10%-25% below the average peak BMD of young adults of the same sex and race.
Bone density measurements should be performed in patients at risk for developing osteoporosis. Persons at risk include women with a family history of osteoporosis and related bone fractures, early/surgical menopause, smoking, moderate to heavy alcohol use, malabsorption, over- active thyroid gland (hyperthyroidism), anorexia nervosa or bulemia, thin stature, scoliosis, history of stress fracture, Asian or Northern European origin, light skin, gastrectomy (surgical stomach resection), lack of childbirth in females, and sedentary lifestyle. Chronic use of certain medications such as corticosteroids (Cortisone, Prednisone, Prednisolone, etc.), excessive thyroid hormones, and anticonvulsant medications also increase the risk of osteoporosis.
MedicineNet: If the risk of osteoporosis
increases for women entering menopause, why not perform
base line bone density studies on all postmenopausal women?
Dr. Truong: I agree. I personally believe that all postmenopausal women should have bone density measurements. Bone density measurements can detect osteoporosis before fractures occur, predict the risk of future bone fractures, and measure the rate of bone loss over time as well as monitor effects of treatments. But it is not yet an official recommendation that every postmenopausal woman should have a bone density measurement.
MedicineNet: How do you use the bone density information in your practice?
Dr. Truong: For postmenopausal women with normal bone density, or with osteopenia, I would encourage starting estrogen replacement therapy to prevent bone loss. If they are unable or unwilling to take estrogen (usually because of concern over risks of uterus and breast cancers), I will ask them to consider Evista or low dose Fosamax.
In patients with moderate to severe osteoporosis, especially if they have already suffered osteoporosis related bone fractures, I will place them on anti-resorptive drugs such as Fosamax. If these patients cannot tolerate the esophagus side effects of Fosamax, I will use estrogen or Didronel.
MedicineNet:What about estrogen alone in the treatment of postmenopausal women with established osteoporosis?
Dr. Truong: Estrogen alone is an accepted treatment for osteoporosis in postmenopausal women. But in my review of the literature and in my personal experience, Fosamax is a more effective agent in building bone density and strength. Although it does not have the other benefits (such as lowering the level of blood cholesterol and risk of heart attacks) of estrogen. Therefore, when possible, I would not want to rely on estrogen alone in treating patients with severe disease and in those who already have suffered fractures.
MedicineNet: Do you use estrogen and Fosamax, or estrogen and Didronel together in some patients?
Dr. Truong: This is a difficult question. There is not enough long-term data on estrogen/Fosamax or estrogen/ Didronel combinations to determine whether the combinations are more effective than either agent alone in treating osteoporosis. I do have patients who are taking Fosamax for osteoporosis and who also take estrogen for other menopausal symptoms such as hot flashes and for the benefits to the heart.
MedicineNet: What about osteoporosis in patients on long term cortisone-related medications?
Dr. Truong: Patients with severe asthma, and those with chronic inflammatory conditions such as rheumatoid arthritis, may need conrticosteroids for prolonged periods of time.
Corticosteroids such as Cortisone, Prednisolone or Prednisone can cause osteoporosis in patients if taken chronically. Corticosteroids cause decreased calcium absorption from the intestines, increased loss of calcium from the kidneys, and increased calcium loss from the bones. Increasing dietary calcium intake is important but alone cannot stop the corticosteroid-induced bone loss.
Management of patients on long term corticosteroids should include:
- Adequate calcium (1000 mg daily if premenopausal, 1500 mg daily if postmenopausal) and vitamin D intake.
- Periodically reviewing with the doctor the need for continued corticosteroid treatment. (To find the lowest effective doses if continued treatment is necessary).
- For patients taking corticosteroids for more than 3 months, a bone density study may be helpful to measure the extent of bone loss. A bone density study can be repeated in the future to measure any further bone loss.
- Regular weight-bearing exercise, and stopping smoking cigarettes.
- In patients with moderate to severe osteoporosis as measured by a bone density study, or in patients already having suffered osteoporosis related bone fractures, anti- resorptive medications such as Fosamax, Didronel, or Calcitonin should be considered.
- It is important to remember that corticosteroids should not be stopped abruptly. If corticosteroids are to be stopped, they should be gradually tapered under a doctor's supervision.
MedicineNet: What about fluoride in treating osteoporosis?
Dr. Truong: Fluoride is unique in that it stimulates bone formation, while the other osteoporosis medications improve bone density by inhibiting bone resorption. However, the bone formed by fluoride stimulation appears to be weaker than normal bone and may be more prone to fracture. Fluoride also causes frequent side effects such as stomach upset and pain in the joints and lower extremities. Flouride is not an FDA approved treatment of osteoporosis in the United States.
Even though a recent study suggests that using a slow release fluoride preparation in lower doses may be better tolerated and more effective in building stronger bone and reducing bone fractures in the spine, there is still insufficient data to recommend fluoride as a treatment for osteoporosis.
MONITORING OSTEOPOROSIS TREATMENT SUCCESS
MedicineNet: After prescribing estrogen (or Evista or low dose Fasomax) for the prevention of osteoporosis, is it necessary to monitor bone density in postmenopausal women periodically? How do you know whether preventive measures are effective?
Dr. Truong: There are no official guidelines yet regarding monitoring bone density in postmenopausal women.
In postmenopausal women with normal bone density, who chose not to take long term estrogen, Evista or low dose Fosamax, I recommend repeating a bone density study in one to two years to determine whether there is any bone loss.
In postmenopausal women with normal bone density who are on estrogen, Evista, or low dose Fosamax, I generally do not repeat bone density studies. Although a case can be made for studying bone density in 3 to 5 years to see if preventive measures are effective.
MedicineNet: In postmenopausal women with established osteoporosis or osteopenia, how do you determine whether treatments actually benefit the bones?
Dr. Truong: In patients with osteoporosis or osteopenia on medications such as Fosamax or estrogen, I recommend repeating a bone density test in 1-2 years to monitor progress. In patients on chronic cortisone related medications, I will repeat the bone density test in 6 months or a year. Keeping in mind, of course, these are my practice patterns, not official guidelines.
MedicineNet: What about osteoporosis in men?
Dr. Truong: Osteoporosis can also occur in men, though less commonly than in postmenopausal women. Causes and treatment of osteoporosis in men is another discussion in itself, let us set up another interview in the near future regarding osteoporosis in men.
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