If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions via e-mail.
Previously, I commented on the diagnosis and potential courses of both osteoporosis and osteopenia. This installment focuses more on actual prevention and treatment options for those patients so affected.
Calcium has long been recommended for prevention of osteoporosis. Doses of at least 1200 mg per day have been suggested, but effectiveness at reducing fractures is unclear. Calcium carbonate is inexpensive but should be taken with meals to enhance absorption. Calcium citrate, though more expensive, can be taken without food. Commonly, dosing may be limited by constipation or stomach issues. Absorption can be impaired when used in conjunction with thyroid medications, blood pressures medications (specifically ACE inhibitors like lisinopril) or iron, and dosing should be separated by several hours at a minimum.
Vitamin D is critical, as I have mentioned in previous articles. Doses of 800-1000 IU per day are needed. The number needed to treat to prevent one hip fracture is 45 over 2-5 years of treatment. Given its benefit at potentially decreasing risk of stroke and certain cancers, there is no reason that patients should not supplement. This is one of the few supplements that I take personally!
For the most part, therapy revolves around a group of medications known as the bisphosphonates. Included in the class are fosamax, boniva and actonel. These medications inhibit bone turnover and therefore increase bone mineral density and strength. Trials demonstrate a reduction in spine and hip fractures with both actonel and fosamax. The number needed to treat over three years to prevent one fracture is 91 for fosamax and 79 for actonel. Despite weekly and monthly dosing schedules that are now available, noncompliance remains an issue with many patients stopping the medication entirely. Problems surround use of bisphosphonates in that they can cause significant problems with heartburn and esophageal symptoms. They must be taken with a full glass of water and patients must remain upright for at least 30-60 minutes after dosing. A newer option is once yearly intravenous infusion with reclast. Many patients like the convenience of once a year administration and the decreased likelihood of side effects. Cost can be problematic, but we have found that any patient with medicare and a supplemental insurance (i.e. AARP) will have near complete 100% coverage.
Concern has arisen over the potential for destruction of bone at the jaw. The complication is rare and has generally only been noted after intravenous use in patients diagnosed with cancer.
Other medications exist as far as treatment goes, but they are less commonly used and not worth discussing given constraints of space and for fear of completely losing any or all readership I may have secondary to boredom. What about hormones like estrogen? The Women’s Health Initiative trial did report that estrogen did reduce the risk of vertebral and hip fractures with a number needed to treat of 385 over five years. The benefits, however, do not outweigh the risks of estrogen therapy which include increased likelihood of breast cancer, stroke and heart disease. Generally, I do not recommend hormone therapy for treatment of osteoporosis unless the patient has compelling reasons to do so, like horrible hot flashes.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at scripna@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
Osteoporosis
Dr. Spence:
Please tell me all about Osteoporosis.
Thanks,
Imma Bender
Osteoporosis I – Definitions and Evaluation
Osteoporosis remains a significant health risk in this country. Estimates suggest that nearly eight million women and two million men in the United States have osteoporosis and another 34 million may have osteopenia, considered a precursor to osteoporosis. It is characterized by low bone mass and structural deterioration of bone strength resulting in an inherent increased risk of fracture. Shockingly, about 1 in 2 white females will suffer an osteoporotic fracture in her lifetime. Should you fracture your hip, mortality increases 10-20% at one year. Twenty five percent of patients with hip fractures will require long-term nursing home care.
It is suggested that all women greater than 65 years of age and all men greater than 70 should be screened for osteoporosis. Other patients that should be screened are those adults who have had a previous fracture or have certain clinical factors that place them at increased risk. These factors include low body weight, history of falls, excessive alcohol use or use of certain medications (i.e. steroids like prednisone, or anti-seizure medications like dilantin).
Screening is traditionally done by bone mineral density testing (DEXA scan) which measures bone strength at the hip and lower spine. Heel testing, as done in some offices, is reasonable, but follow-up on abnormal screens is recommended. A so-called "T-score" is generated that arbitrarily compares your bone strength with that of a 30 year old female. Any T score less than -2.5 meets the definition of osteoporosis whereas scores of -1.0 to -2.5 represents osteopenia.
There are various secondary causes of osteoporosis that should be note. Though most elderly patients have pure osteoporosis as a result of age and loss of estrogen production, there are secondary issues that may require different treatments. For example, reversal of a patient’s vitamin D deficiency may improve bone mineral density and may be all that is required for formal therapy. Other common conditions that may cause osteoporosis include hyperthyroidism, diabetes, emphysema, kidney failure and rheumatoid arthritis. Again, many prescribed drugs may ultimately result in loss of bone mass.
Treatment should generally be initiated for any patient with a calculated bone mineral density of less than -2.5 or any patient who has suffered a hip or vertebral fracture. Guidelines further suggest treatment for those with osteopenia. My experience has shown, however, that insurance companies are less to apt to cover the costs of therapy in cases of osteopenia. Given that treatment may very well prevent progression to overt osteoporosis, it seems ludicrous that insurance companies would block access to potentially valuable medication, but this is typical of our spiraling healthcare system. This is a topic for a whole separate discussion!
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at scripna@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
Please tell me all about Osteoporosis.
Thanks,
Imma Bender
Osteoporosis I – Definitions and Evaluation
Osteoporosis remains a significant health risk in this country. Estimates suggest that nearly eight million women and two million men in the United States have osteoporosis and another 34 million may have osteopenia, considered a precursor to osteoporosis. It is characterized by low bone mass and structural deterioration of bone strength resulting in an inherent increased risk of fracture. Shockingly, about 1 in 2 white females will suffer an osteoporotic fracture in her lifetime. Should you fracture your hip, mortality increases 10-20% at one year. Twenty five percent of patients with hip fractures will require long-term nursing home care.
It is suggested that all women greater than 65 years of age and all men greater than 70 should be screened for osteoporosis. Other patients that should be screened are those adults who have had a previous fracture or have certain clinical factors that place them at increased risk. These factors include low body weight, history of falls, excessive alcohol use or use of certain medications (i.e. steroids like prednisone, or anti-seizure medications like dilantin).
Screening is traditionally done by bone mineral density testing (DEXA scan) which measures bone strength at the hip and lower spine. Heel testing, as done in some offices, is reasonable, but follow-up on abnormal screens is recommended. A so-called "T-score" is generated that arbitrarily compares your bone strength with that of a 30 year old female. Any T score less than -2.5 meets the definition of osteoporosis whereas scores of -1.0 to -2.5 represents osteopenia.
There are various secondary causes of osteoporosis that should be note. Though most elderly patients have pure osteoporosis as a result of age and loss of estrogen production, there are secondary issues that may require different treatments. For example, reversal of a patient’s vitamin D deficiency may improve bone mineral density and may be all that is required for formal therapy. Other common conditions that may cause osteoporosis include hyperthyroidism, diabetes, emphysema, kidney failure and rheumatoid arthritis. Again, many prescribed drugs may ultimately result in loss of bone mass.
Treatment should generally be initiated for any patient with a calculated bone mineral density of less than -2.5 or any patient who has suffered a hip or vertebral fracture. Guidelines further suggest treatment for those with osteopenia. My experience has shown, however, that insurance companies are less to apt to cover the costs of therapy in cases of osteopenia. Given that treatment may very well prevent progression to overt osteoporosis, it seems ludicrous that insurance companies would block access to potentially valuable medication, but this is typical of our spiraling healthcare system. This is a topic for a whole separate discussion!
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at scripna@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
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