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Osteoporosis Ask The Expert

Osteoporosis Ask The Expert

Q: I am 37 and have been taking Fosamax for a couple of months. I took the osteo test because it was free. I was shocked to find I already have osteoporosis. My dexa scan showed mainly -3s with the worst being -3.97. My blood work was normal. I've never smoked or drank. I have always been thin. Would having four pregnancies and breastfeeding within the last eight years be a reason for my condition? I've read that breastfeeding weakens bones,but in normal women their bones come back stronger helping to prevent osteo. Will my bones get stronger when I stop nursing or am I out of luck since I already have the disease? I also asked my Dr. at what T-score number does a bone just break without a fall? She didn't know. She said my numbers were the worst she'd seen. Has anyone had -4s, -5s. . .? She wants me to have 1800 mg calcium daily and lift weights in addition to the Fosamax. Lastly, will I dissolve after menopause? I assume I will be put on HRT then.

 

A: Women who breastfeed will experience decreases in bone mineral density. Changes in bone mineral density during breastfeeding are reversible to the pre-pregnancy bone density. If the bone mineral density remains low 6 months after breastfeeding is discontinued, it warrants consideration for therapy.


Q: I have osteoporosis in my hips and osteopenia in my spine. I am an aircraft electric mechanic, which means I have to crawl inside the hole of the plane and I am climbing stands ect. I am wondering if i am at risk of fracturing myself. I fall alot, my hips go out from under me and I just fall. so I am worried if I should change my job? This is a deep concern of mine.

A: Both osteoporosis and osteopenia increase the risk of fractures. Avoiding activities that could lead to falls lessens the risk of a fracture.


Q: Have I been prudent to stop HRT after 11 years when I found out I had T-4 level osteoporosis? Since estrogen clearly did not prevent bone density loss, is the drug of choice alendronate? And if it is, what are the chances an HMO would be forced legally to permit its use at their expense? I am 71 years old, white, do not drink or smoke and am not overweight. I am still working.

 

A: When hormone replacement therapy is discontinued or no longer useful to prevent bone loss, the initiation of a bisphosphonate such as alendronate is both appropriate and useful.


Q: I was diagnosed with MS in 1994. Due to 6 past treatments with solumedrol and prednisone my neuro ordered a recent bone scan "just for a baseline," and to my shock it came back positive for osteoporosis. Now, I am on Fosamax 70mg. weekly. Was there anything I could have done to prevent this from happening, and shouldn't prescribers of high dose steroids inform patients of this risk and ways to prevent it? I am 43 with no family history. A: Based on your history you have 2 risk factors for osteoporosis-immobilization and prolonged steroid use. Fortunately, bisphosphonates such as Fosamax are capable of markedly protecting bones.

Q: I am 68 years old. my bone mineral densiity test reads as follows:
DEXA study of A P spine and proximal femurs on a Norland 798 bone densitometer. Bone mineral density in the lumbar region is 1.74 consistent with osteopenia. Bone density in ;the area of the right femoral neck is 3.95 consistent with osteoporosis. Area of the left femoral neck is 3.77 consistent with osteoporosis. Conclusion: Findings of osteopenia in the lumbar region and osteoporosis of both femoral necks.

What does all this mean ? Will I get a hump in my back as I have seen on some older women? I am unable to take fosamax. What are other treatments? Thank you for your time.

A: Unfortunately, no one can predict whether you will develop a "hump" or not, but based on your bone density you are at increased risk for a fracture. There are a variety of treatment options available. The first choice would be to try another bisphophonate called risendronate (Actonel) once weekly which may be better tolerated. Other potential options to discuss with your physician include estrogens, raloxifene, or nasal calcitonin. Neither raloxifene or calcitonin seem to offer protection in the hip. Another option that will be available at some time in the near future is recombinant parathyroid hormone.


Q: As a radiologist we do many self-referred DEXA scans. What should we recommend for therapy if any for premenopausal women with -1. to -2 t scores?

A: Our office does many self-referred DEXA scans and we interpret results without offering therapeutic recommendations. The treatment is deferred to the clinicians who treat osteopenia and osteoporosis. Our clinical practice also includes treating pre-menopausal women on whom we perform DEXA scans and diagnose osteopenia. Current treatment options include estrogen replacement (depending on the clinical situation) or bisphosphonates such as Fosamax 35mg weekly or Actonel 35mg weekly.


Q: I am taking Fosomax in response to osteopenia. Should I be taking calcium + vitamin D along with it?

A: You should be consuming adequate Calcium and Vitamin D to ensure optimal bone health. Daily requirement for Vitamin D is 400-800IUs. The amount of calcium depends on your age but would be 1000-1200mg daily. These amounts include dietary intake and supplements if needed. A good source to get these guidelines is www.fore.org/prevention.html.


Q: I am a 46 year old female with sever osteoporosis. I have been on fossamax for 8 months and I have been taking my 1500 mg. of calcium a day. My question is I am getting the hump on my neck and its getting worse. And there is quite abit of back pain. Is there a way to correct or stop the compression of my vertebrae. I have been doctoring with just my family doctor? He has only sent me to a pain management clinic for shots. I am getting shorter and my legs and arms are getting thinner. I am very worried about what is to come. Thank you for any help you can give me.

A: You should continue your Fosamax and calcium as well as avoiding any activities that could lead to falls which would increase your fracture risk. You should consider consultation with either a neurosurgeon or orthopedic spine surgeon to further evaluate your spine.


Q: I was diagnosed in February with osteoporosis (minus 4.2), and I am taking Fosamax. What is your opinion of ipriflavone (in addition to Fosamax)?

A: Ipriflavone is an over the counter nutritional supplement that has not been shown to be beneficial for bone health. Fosamax (alendronate) and other bisphosphonates are effective in treating osteoporosis.


Q: Is there evidence to support what I recently heard that anti-seziure drugs such as gabapentin and clonazepam can cause or exacerbate osteoporosis? These days anti-seizure drugs are prescribed more and more as psychotropic aids as well as for seizure control. Would you recommend that a 60 ish woman with mild osteoporosis who is on substantial doses of Neurontin 600-1200mgs per diem) and clonazepam (6mgs per diem) for anxiety be switched over to Valium or other sedative type medications? Your input will be greatly appreciated.

A: To my knowledge neither of the anti-seizure drugs mentioned affect bone density. Your osteoporosis should be treated independently of any of you psychiatric conditions.


Q: I have been on FemHrt recently, and in total about 5 years of hormone
replacement. Prior to that I took Fosomax for about a year. I saw both my primary physician and my gyn. today, and they have differing opinions on medication changes in light of the new studies. One wants me to take Fosomax- 70- one time weekly The other suggests Fosomax 35 and evista. I am 54 years old, through menopause, and do have osteoporosis. Which would you suggest, and why? Thank you, as I am very confused

A: It is difficult to deliver an intelligent opinion based on the limited information given. Clear indications for hormone replacement now include vasomotor symptoms, treating uro-genital atrophy, and preventing /reducing fractures in women at high risk. Hormone replacement reduces the risk of fractures in the spine and hip, but not to the same extent as bisphosphonates. If you are using HRT for the above reasons and your bone density is worsening then a bisphosphonate (alendronate or risedronate) should be added. Raloxifene (Evista) is not recommended with osteoporosis in the hip as it has only proven useful in the spine.


Q: I am a postmenopausal woman 48 yrs old, have been told I have osteoporosis in my hip and spine. I don't remember the T scores but I have just below the line between osteopenia and osteoporosis. I weigh 140 lbs and am 5 ft 7 in tall. My problem is my primary care physcian told me to take Fosamax, Oscal 1000 mg a day and work out with weights, my orthopedic Dr told me it is not bad to do all the things my primary care Dr said to do, told me I can lift any weights I want, snow ski, etc just be active and do anything I want to. I went to a endrocronologist and she told me it was real bad, not to lift over 10 lbs, not to do crunches, not to wear high heels, etc. She has me scared to death whereas the other two Drs have told me to not change anything I do. I wear the Vivelle Dot patch for estrogen replacement. Is the Vivelle Dot sufficient to help me to keep from losing more bone and what do you think I can do as far as activity? Also! , I have acid reflux and the Fosamax makes me sick, have tried Actonel also. I can take the Fosamax and be sick that day and feel fine the rest of the days. I just want to make sure the Fosamax is not going to cause me to have bad problems in my stomach because of the acid reflux. Please advise. I am so confused and know no other person that has this.

A: It is difficult for me to give an accurate answer without more information and without knowing your medical history in more detail. I suggest you check some websites, of reputable organization, with a lot of information about your problem. In the web sites you should be able to learn what advice most experts in the field of osteoporosis give to their patients. The web sites are:

  1. www.nof.org this is the site of the National Osteoporosis Foundation

  2. www.nams.org the site for the North American Menopause Society

  3. www.acog.org the site for the American College of Obstetricians and Gynecologists

  4. www.aafp.org the site of the American Academy of Family Practice

Good luck!


Q: I am 47years old and have osteoporosis.I was diagnosed last year,and now taking fossamax with my premarin and calcium. I have been loosing weight, it started in my ankles and now seem to be loosing size every where. I am in a lot of pain all of my bones are so sore and throb And i am getting that hump..And my stomach is always upset. My doctor gave me prilosec for that. I just dont know where to try next. Any information or direction would be greatly appreciated.

A: You have a number of complaints that are difficult to address without a proper history and physical examination. I recommend that you discuss your concerns with a primary care physician you feel comfortable with. Also, some changes in our body are expected as we age. Your physician hould be able to tell if he changes you notice are acceptable as normal or are a sign of disease.


Q: I had a DEXA scan done yesterday and was told by the technician that I was in the "yellow" and should be in the blue???? I was given Fosomax (once/week). I am a 43 year old premenopausal woman with regular periods. I have never smoked, fairly active(aerobics & weights), smallboned(5'4" 118 lbs.). I have two questions 1. I nursed 3 children on the average 8 months, but I have never been a milk drinker, would this cause this? 2. I have not been able to get a Doctor to believe that anytime I take calcium my blood pressure goes up and I do not feel well, I have tried viactiv, tums(makes my chest feel tight) and caltrate & citracal, why is this? And have you heard of others that have a problem with blood pressure when they take calcium?

A: Answers to your questions-

1. Possibly if your calcium intake from all foods was low. Dairy products are an excellent source of dietary calcium but other sources are adequate as well. These include green vegetables, meat, poultry, fish, etc.

2. I do not know and have not heard about it either. In fact the study below shows that increasing amounts of calcium ingested from dairy products causes a decrease in blood pressure.

Am J Clin Nutr. 2001 Mar;73(3):659-60.

    Calcium from dairy products, vitamin D intake, and blood pressure: the Tromso Study.

    Jorde R, Bonaa KH.

    Department of Medicine, the University Hospital of Tromso, Tromso, Norway. medrj@rito.no

    BACKGROUND: The present epidemiologic study was conducted in Tromso, Northern Norway, in 1994-1995. OBJECTIVE: The objective was to evaluate the relation between calcium intake from dairy products and the intake of vitamin D on systolic and diastolic blood pressure. DESIGN: Subjects who were taking drugs for hypertension or heart disease, those taking calcium tablets, subjects reporting cardiovascular disease, and pregnant women were excluded, leaving 7543 men and 8053 women aged 25-69 y for analysis. Calcium and vitamin D intakes were calculated from a food-frequency questionnaire. RESULTS: After correction for age, body mass index, alcohol and coffee consumption, physical activity, cigarette smoking, and vitamin D intake, there was a significant linear decrease in systolic and diastolic blood pressure with increasing dairy calcium intake in both sexes (P < 0.05). However, the difference in blood pressure between subjects with the highest and those with the lowest calcium intake was </=1-3 mm Hg. Similarly, with increasing blood pressure there was a significant (P < 0.001) linear decrease in age-adjusted calcium intake from dairy sources; the difference between the highest and the lowest blood pressure groups was 3-10%. Vitamin D intake had no significant effect on blood pressure. CONCLUSIONS: There is a negative association between calcium intake from dairy products and blood pressure. However, although the effect of calcium on blood pressure appears to be small, calcium could have a significant effect on primary prevention of cardiovascular diseases.

3. No.


Q: I am a 60 year old and I have tried taken Fosamax and it tears by stomach up. I am trying the once a week Actenol. In 3 weeks time I have noticed a burning stomach, neck ache and headache for 2 to 4 days after I take the medication. I do take a considerable amount of calcium and have for the past 30 years. I was taking the actenol due to the fact that my Mom is 91 and is totally disabilitated with osteoporosis and has had it since she was 27. My bone dentistry test showed very small amount of osteoporosis. My question is, do I have to take Actenol if I am taking calcium and other supplements? I don't want to tear up my stomach and keep having these pains. I would appreciate an answer when possible.

A: The medical term that is used for the upset stomach is dyspepsia. The neck ache and headache are very unusual side effects for this medication class and may be related to something else. The dyspepsia has been well described however and may be symptomatically improved by using an anti-acid medication such as Prilosec or Prevacid the evening before your weekly dose. You would be best advised to discuss this with your physician. Occasionally we note that the calcium supplement itself is causing the gastrointestinal problems. Good luck and hope this has been useful.


Q: I am 40 years old and I have a wedge compression fracture of my T6 vertabrae. A bone scan has shown no tumours or disease, and it was not caused by a trauma.I am awaiting a DXA scan. The thing that causes me extreme discomfort is constant pain in both my breasts and under my right arm. The pain also comes in intense pulses and I cannot get any relief from it. I have been told that the vertabrae could be pressing on a nerve. I would be very grateful if you could tell me which nerve or nerves this coulld be, and whether I will get some relief from the pain either through the nerve healing, or medication/exercise? Is this something that usually happens with a fracture in this area? Many thanks for your time.

A: It is certainly conceivable that the pain you are experiencing is related to the compression fracture at the 6th thoracic vertebrae from a phenomenon that has been termed "referred pain", even if a nerve cannot be identified as being compressed. As you mention, it will be important to perform a DEXA to determine if low bone mass or osteoporosis is responsible for this situation. If so, and you are still premenopausal, then a careful evaluation would be important to exclude secondary disorders which might be leading to osteoporosis at your age. If the DEXA is normal, then you might consider an MRI of the spine to exclude any other causes directly affecting this particular vertebrae. You might look into vertebroplasty or kyphoplasty as a measure to obtain more pain relief. These are procedures which stabilize the compression fracture by injecting a type of cement directly into the vertebral body. Results of these procedures are generally quite satisfying. Hope this is helpful.


Q: Do you have any compiled/summarized data on the comparison between Fosamax and Actonel? I am interested in the compared results of BMD and prevention of fractures. Is Actonel as effective as Fosamax? Which areas benefit more from taking one or the other? I would appreciate your assistance very much

A: There have been no published head to head trials comparing these agents, which would be the only scientifically valid method to answer your question. Otherwise, the data with these drugs suggest they are more similar then different. Nonetheless, we await further research trial results to address the issue as to which is more effective. Hope that is helpful.


Q: I am almost 50 years old and just diagnosed last week with osteoporosis. I hit menopause a year ago. My DEXA results for spine and hip were 2.6 and 2.8. I guess that means -2.6 and -2.8. Is this a mild or moderate case? Also, am I at risk now for fractures? I just started taking Actenol, 35 mg once a week. Should this help? I also plan on doing some weight bearing exercises with a trainer. I have been very, very active going to the gym daily, although mostly aerobics. My job requires that I travel a bit so I am always on the go. I am afraid I must change my lifestyle, now or down the road. This is causing me much concern. I have an underactive thyroid and been on thyroid supplement (currently generic Synthyroid) since my mid-thirties, having gotten Chronic Fatigue Syndrome. With the CFS was Candida, so I did very little dairy for a while but did take Calcium supplements, although not daily in recent years. I have had blood work to make sure I still needed the thyroid supplement all along and at the right dose. Would taking the thyroid supplement be a contributing factor in me developing this disease? No one in my family ever had it. I've had no fractures.

A: Your bone mass, based on the DEXA results, is just over the WHO threshold for the diagnosis of osteoporosis. Therefore, it is not "very" severe and, at your age, low trauma fractures would be unlikely. Actonel is a potent drug which should be quite helpful. You are doing everything else right; keep up the good work. If your thyroid supplement is being dosed correctly, then this should not be detrimental to your skeleton.


Q: I am advised by a friend whose doctor has told her there is a connection between the use of Fosamax for osteoporosis and possible eye damage or disease; she has stopped the dosage of Fosamax. I am very concerned about this since I have been on Fosamax for about two years (now prescribed both Fosamax at 70 mg weekly plus Evista). My doctor says no. Is there a connection between the use of "heavy metal antagonists" like disulfiram and calcium regulating agents like Fosamax and eye diseases like uveitis or uticaria or angioedema or other? I will really appreciate your response to this.

A: We are not aware of any reports of eye damage from Fosamax, nor any theoretical reason to be concerned.


Q: I am a 46-year-old healthy white female who was recently diagnosed with severe osteopenia. I have no serious medical problems, have never had children, and apparently am in the midst of menopause (two periods in the last year). I am on no prescribed medications. My mother and sister have both been diagnosed with osteoporosis/penia. My ob-gyn said my options were Evista, Fosamax, or Actonel. My question (finally!) is – is it absolutely necessary I take a drug at this point, which I really hate to start if I can keep from it because of all the possible side effects. I thought I might just get on a weight-bearing exercise program, cut back on caffeine and alcohol (I’ve been a heavy coffee drinker, an occasional wine/beer drinker), maybe take some extra calcium (although I’ve found it tends to constipate me). Would this be a safe reasonable approach for me to begin with at 46? Is it possible it could help me enough?

A: Choices to start medications are always your choice. Unless you have the diagnosis of osteoporosis you may elect to attempt a more healthy lifestyle. This is done with the knowledge that in the first 3-5 years of menopause the women destined to be osteoporotic tends to lose 3-5% of bone mass/year. This is regardless of lifestyle changes. You did not give T scores so I don't know what "severe osteopenia" means exactly. Clearly BMD t-scores less than 2.0 are at risk for incrrease fracture, although this doesn't mean a fracture will occur. Certainly if a conservative approach is taken followup bone density in 2 years is warranted.


Q: I am a small-framed mother of 5 and I have osteoporosis in my hips and osteopenia in my spine. I'm too young to have such old bones! My grandma and mother both have the same disease, too. The most frustrating thing about this is that there is no information out there for younger women with osteoporosis. Everything is geared for the older generation. My gynecologist put me on estrogen therapy and Fosomax and told me to come back in 2 years for another bone-density test. I took the Fosomax for about 6 months, but then quit because it was irritating my stomach. I want to go to a specialist to find out exactly WHY I have this disease at such a young age, but I haven't been able to find anyone who specializes in this area. My regular family doctor said that my gynecologist is the one to go to. But I don't really think he knows a whole lot about it. I'm worried that I might have a "mal-absorption" problem. I also have Fibromyalgia, which makes me think that maybe I just don't absorb the vitamins and minerals like I'm supposed to. I realize that Osteoporosis is a painless disease (unless you break a bone), yet my bones ache terribly! Especially the bones in my legs. Can you tell me what kind of doctor I should go to? I don't want to lose any more bone mass!

A: I would suggest that you contact the National Osteoporosis Foundation and locate an expert in the area of bone diseases to thoroughly evaluate your situation. I agree wholeheartedly with your concern that some disorder may be overlooked which might contribute to your having low bone mass, and that a careful evaluation should be undertaken. Good luck.


Q: I have been faithfully taking actonel for 2 years. My bone density test showed that my spine was the same , but my femur had lost 1%. I take calcium supplements with D and K and eat the right foods. My calcium supplements are viactive (2 per day) and Cal-Mag citrate with Vit. D. All these total 1500 mg per day. Why has my osteopinea not improved? What should I do to make it more effective? Does alcohol interfere with absorption? I do have a cocktail or 2 and that is the only thing I can think of that might be bad for me. Thank you for your time.

A: The response to Actonel or other such osteoporosis therapies is not always reflected by enhancement in bone density measurements, in part because of variability in the instrumentation and other related factors (making these tests good but not perfect), as well as the biology of drug response. It may take several years to see a difference in bone density measurements. Lastly, even in the absence of measurable changes, there is likely a benefit occuring with therapy which should lessen your risk of future fractures. You are doing everything right; so keep it up and good luck.


Q: I am 44 years old and recently had a bone scan which indicated -2.43 on the density scale. Yes, I have a family history of severe osteoporosis (grandma, mom, sis). I just started taking Fosamax (70mg) once a week (second week) . I had a complete hysterectomy a couple years ago, so I was taking Premarin (1.25). Recently, my gynecologist switched me to 2mg. of Gynodiol. In addition, my TSH (thyroid) test came back with a number of 17 (normal 1.0-4.7), so I am currently on a dose of Levoxyl (.05) until my next blood test this month. My question is that I am concerned about drug interaction. I seem to be gaining weight daily (padded), especially in my face, and I am very hot. I had expected to lose the unexplained 10 pounds when I started on the Levoxyl, not gain more. On the one hand I have felt very energetic (which is good), but I also feel like I am hyper, and crash and burn. I am concerned about the weight gain in spite of my life long exercising and proper eating habits, and wonder if these drugs are effective together.

A: These are very complex issues. Weight gain tends to be easier at menopause and with the adjunct of hypothyroidism it is compounded. All in all these medications do not interact to any significant degree. As in all cases, lifestyle issues need to be addressed. The transition through menopause should be accompanied with healthy living to include proper dietary habits, exercise, water intake, vitamins, calcium, minimum alcohol, caffeine, tobacco. Generally, if everything is in order this type of program helps maintain weight during this transitional time.


Q: Will taking fosamax cause a problem with my eyes, as I have glucoma?

A: To date I don't believe there is an interaction in this setting.


Q: I am 37 years old and 5 years ago my doctor told me that I have osteopenia (my mean T score is -2 in the lumbar area, for L5 is -2,5. During my first pregnancy at 26 years old I did not get any weight (I was 52 Kg for 1,68 m. My gynecologist didn't tell me nothing because the baby was healhy (at birth he was 3,2 kg, me, I was 44 kg!) Until my youngest age I disliked milk and chease, it is evident that I needed more calcium. After the birth of my son I came back to 49 kg but I had a lot of periodontitis desease.At 31 I had my daughter after one miscariage and I had some painful in the hip area but I did not loss weight and my alimentation was better (yogurt and milk). Some of my teeth broke so I decided to check my bones. Now my diet is much better and I take calcium supplement and sometimes vit D. My osteopenia is very stable. Sometimes I have some pain in my back when I seat down.Nothing particular and I have less problem in my teeth. Do you thing that it is dangerous for my health to have a third kid?

A: It sounds as if you have low bone density for a variety of reasons. Pregnancy certainly removes calcium from the mother's bones to support the growth of the fetus. For this reason it is important to take appropriate calcium to support the baby and the mother during pregnancy.


Q: My physician has diagnosed me as having ostopina after ordering a bone scan. He's told me to take, on a daily basis: 1200 mg calcium (which I have been doing for the past 3 years), 800 iu Vitamin D, 400 mg Vitamin E. I also am currently taking a women's multivitamin daily. My concerns are with the Vitamin E which in excessive doses, causes liver problems. Should I be concerned? Is the dosage/types of vitamins my physican is prescribing warranted? Thank you.

A: Osteopenia is best treated with calcium, vitamin D, exercise, refraining from excessive caffeine, alcohol, tobacco exposure, and avoiding medications that increase bone loss. The doses your physician recommended are appropriate.


Q: I am 52 years old, fair skinned and of Eurpean descent. My mother has osteoporsis in her spine, with multiple fractures - first symptoms appearing when she was in her late 70's. She is now 87 and has a severly limited life due to back pain.

I was diagnosed with estrogen sensitive breast cancer in August of 2001, began chemotherapy in September, and have not menstrated since October 2001. I had a modified radical mastecomy in Dec. 2001. I was recently told the results of my bone density exam - my scores were -2.8 for the spine, and ranged from -2.7 to -3.5 for the hip. I was put on Fosomax, but given no other instructions, told that I would be tested again in 2 years.

I don't smoke or drink, have walked and exercised regularly since I was in my early 20's, always eaten a healthy diet, and only been menopausal for about 11 months. I generally take a calcium supplement, with Vitamin D. I am concerned by the level of bone loss I have already sustained. I have asked my oncologist and my gynecologist if I should have further tests to determine if there is any other cause for the bone loss, or if the chemotherapy is implicated. Their responses have been, "we don't know." I worry that if I have a continued rapid loss of bone mass, my life will be compromised in the manner of my mother's life, only much earlier.

Would you recommend that I push for referral to an endocrinologist? Any information that you can give me would be appreciated.

A: I would recommend visiting with an endocrinologist who specializes in bone diseases. there are test that can be done to look for secondary causes of osteoporosis. You do seem a little young for such scores. Your family history suggests however that you are at significant risk in any event. The tests to have done, in my opinion, are CBC,. TSH, Vit D 25-hydroxy level, Intact PTH, Full chemistry, Serum Protein electrophoresis, 24 hour urine for calcium excretion.


Q: Good day - I am a 49 year old woman with osteopenia. Have been on Fosomax for three years and just recently was prescribed ACTONEL. I take it once a week (15 mg). I have regular periods and am on no other medication. Should I be concerned about taking medication for post-menopausal women? I also take 1200 mg of calcium daily. My bones have shown strengh on Fosomax but my doctor thought Actonel taken once a week would be easier to take - and it is. She also indicated that there was a Fosomax that I could take once a week but because I had been on it for three years it was probably wise to switch. Should I consider Miacalcin?? Thanks very much!

A: Fosamax and Actonel have similar profiles on bone. Miacalcin generally reduces fracture but show minimal change in bone density. Switching from Fosamax to Actonel is not really necessary. Both have 1 week dosing. I believe the dose on Actonel is 35 mg/week.


Q: I'm 56 years old and a 7 year survivor of breast cancer. At age 49, I went into menopause due to chemotherapy. I had my first dexa scan and I was found to have osteopenia, with a score of -2.2. My gynecologist is saying now that he is going to PUT me on Fosamax, 70 mg weekly, the highest dose. There is no osteoporosis in my family. I am very upset by this, given the information I have read. First of all, osteopenia is really just a variant of normal and quitecommon for women in their 50's. Secondly, I have read that it is not a DISEASE to be treated with drugs. I've also read that Fosamax does not provide benefits for women who don't have osteoporosis and that the risk of hip fracture is either equal or slightly HIGHER! I am not a doctor, but am very worried about my gynecologist's move and possible misinformation. Everything I've read has said that lifestyle modifications might do the trick, hence increase my calcium intake and start doing weight bearing exercises. Please help clear up my confusion. Thanks.

A: The National Osteoporosis Foundation recommends beginning treatment when bone density is less than -2.0. You are at slight risk of fracture by you score and therefore may benefit. It is true you are not osteoporotic. Lifestyle issues are appropriate and should include exercise, calcium and vitamin D intake, minimize alcohol, caffeine, tobacco. The data on fosamax supports a reduction in hip fracture in the very low bone density group (less than -2.5). Importantly, women tend to lose bone at an accelerated rate in the early menopause. This bone loss can be significant. At this point in your life you will loose approximately 1% bone mass/year. At present this may take 5-10 years for you to become osteoporotic.


Q: I am 65 years old and had a hysterectomy when I was 37 and was totallly done with the menopause by 42. I did not take any hormones but calcium and vitamins plus exercised until I was 55years old and the obgyn insisted I take a bmd test and be put on estrogen. At that time, 1992, it was discovered that I had osteopenia in by spine and hip. My t score for the neck of the hip was -3.36 and total for the hip was -2.58. for the spine -2.01 at 5'5" and 120 pounds and a past smoker. I was re-tested in 1997 with no significant considerations. I have been on estrogen patch for 10 years reluctantly, when the recent articles show it may cause worse side effects than previously anticipated. I stopped the replacement and demanded another bmd test and be put on fosamax. also, I have degenrative disk disease and am in chronic pain and scoliosis. My mom and grandmother had osteoporosis heart disease, strokes and my mom had a bad blood clot after a procedure once. My obgyn at my hmo is now telling my that I cannot have fosamax because there had been studies about the effectivness after 5 years and some possible new adverse side effects from usage. she also say my bones are just fine and will review when reading my last report if she ever gets it. Do you know of any new studies in the last few months which she is referring to? if not, don't you think I should be on fosamax? My only prescribed drug is trasadome for sleep.

A: Fortunately for women there are many options to take care of the same problem these days. HRT recently was confirmed to both maintain BMD as well as reduce fracture risks. Fosamax, Actonel, Evista also effectively maintain and reduce risk to fracture. Finally, Miacalcin has been shown to reduce fracture. These are your options for treatment


Q: I am 25 years old, Asian, no kids yet, and already diagnosed with ostopenia. My physician just recently prescribed me to take Fosamax, 70mg weekly. Now I'm concerned with this drug, since several have reported that it caused stones in the kidneys and salivary glands. Do you think this was a proper prescription given my case and age?

A: It would be quite unusual for a 25 year old to even get a bone density so one must wonder why this test was done. In addition, the exact numbers of the bone density were not listed. Osteopenia can range from -1.0 (just a bit worse than normal) down to -2.49 (just a bit better than osteoporosis). There is quite a difference between these two. That being said, if you happen to have moderate or severe osteopenia, it should be determined why this had occurred. Possibilities include insufficient calcium intake, insufficient Vitamin D intake, inadequate absorption of these items and related gastrointestinal problems, long term steroid therapy, extended periods of time in the teenage years being amenorrheic (without periods) and untreated or inadequately treated thyroid abnormalities. This needs to be determined before therapy and may be easily corrected. Fosamax therapy in a 25 year old is rarely needed once further testing is concluded. Adequate calcium, vitamin D and weight bearing exercise are usually the mainstays of therapy at your age.


Q: I was wondering if you could offer some input to share with my physicians as they have differing opinions. Several years ago following a drug reaction developed diffuse sensory neuropathy,tremors, joint muscle pain, treated with steroids one month to counteract reaction which escalated condition. Placed on Neurontin for nerve pain caused acute bone pain so was discontinued after a few months. Due to this asked for a Dexa Scan. Dexa Scan Spine -1.5 Hip -1.9 ( still menstruating) Late 40's. NTX 147 ( range 14-78), 24 Hr., Urine Calcium, Creatinine, Phos., Bun Glucose, PTH, Magnesium, normal. Vitamin D 1.25 was 50 on a range of(15-60) 25 Vit D. 13 range 10-68. Prior doctor placed me on Oscal plus D but advised to discontinue after two weeks due to slightly elevated ionized calcium, still slightly elevated ionized calcium so advised to get Calcium and D in diet only. Second Doctor did NTX test. Since the NTX reading was elevated I am wondering if this could be related at all to thyroid hormones as I thought they played a role in resorption? while Thyroid readings are in normal range since the onset of this chronic illness TSH has gone up over time and T4 down consistently over time. I am wondering what further tests may be needed to determine if there is a primary or secondary cause for bone loss? I cannot take hormone therapy due to fibroids and family history of Ovarian Cancer/also have Gastroparesis due to nerve damage so am concerned about Fosamax or biophosphate. While my mother has osteopenia her T scores are better then mine. Any input welcome?

A: The bone density itself is not all that low and may statistically just fall in a range that reflects the maximal bone mass that accrued by early adulthood as your skeleton matured (early 20's). About one out of eight from the population will have similar DEXA values as your test. What is more troubling is your markedly elevated NTX levels and perhaps it would be best to repeat that measurement to confirm it. If still high, then the 25 OH-vitamin D level is on the low side (most consider at least 20 as a cutoff point despite what the commercial labs list). Thus a work-up should focus on why your vitamin D levels are low, such as any malabsorption (gastrointestinal) problems which may not be causing any other symptoms. Suggest a specialist in bone and related metabolic disorders help you sort this out, if indeed the NTX level is confirmed. Good luck.


Q: I am a 52 year old female. My last mentrual cycle was in February of 1997. Menopausal symptoms began in 1994. In 1998, one year after cessation of my menses, I had my first Dexa Scan of the spine proximal femur. It was normal. The femur Tscore was -0.1 and the spine was a Tscore of-0.3. I chose not to embark on HRT. In 2000, I had the Dexa Scan repeated. The spine showed a T score of -1.01 and the hip a T score of -.47. Still choosing no HRT and feeling great. I started on 1200mg of calcium and continued with a life long pattern of weight bearing excercises only now adding weights in addition to cycling, walking, hiking. (4 or more times a week at 45 minutes or longer, weights 3 times a week at 20 minutes each). In 2002 I had the Dexa Scan repeated as I have heard the first five years after cessation of menses is when the most significant bone loss takes place. The most recent results show a spine T score of -1.2 and a hip T score of -1.1. My doctor, who knows I have never taken drugs or been sick suggests I retest in 15 months, continue calcium and exercise and hope that my major bone loss is now over. If loss is continued, she would like to treat the loss aggressively with one of the three drugs apparently available. No family history of osteoporosis per se but an 85 year old grandmother did break her hip on a bad fall? I have concerns about fosamax, evista, and actinal. Any suggestions? Surely there is a specialist somewhere that has studied ways to stimulate bone growth through specific exercises? Thank you for any assistance or recommendations.

A: It appears that you are doing everything correctly with respect to adequate Calcium, Vitamin D and appropriate exercises. You are still in the range not requiring medical therapy. No specific exercise has been elucidated to help your bones other than weight bearing exercises which you are already doing. Although the DEXA is recommended in 2 years, you may wish to get a serum NTX to evaluate your present bone turnover rate. That might help your doctor gauge the followup tests and possible therapy in the future.


Q: I am a 37 year old white female with Neurocardiogenic Syncope, and being treated by an electrophysiologist. A back x-ray and DEXA results showed mild scoliosis of the spine and osteoporosis of the lumbar spine. Could the two conditions be related? Should I request particular testing?

A: There is no indication that the two conditions are related. In addition, since osteoporosis is usually a global disease, it is a bit unusual (but not unheard of) to have it in the spine with a normal hip. The one thought may be alterations in activity due to the scoliosis resulting in spinal changes. This may very well be hereditary in nature and the rheumatologist will no doubt do a thorough workup to delineate the problem and the appropriate therapy. Remember that osteoporosis may represent a lack of having fulfilled the maximum potential of that bone rather than any loss.


Q: I had a hysterectomy when I was 25. I am 33 now, and have been diagnosed with osteoporosis. My score from my last bone density test was -2.8 in my hip and femur. One doctor tells me that I need to stop doing things, and another one of my doctors says I just need to slow down. Which one should I be doing? Slow down, or just stop completely? I am not on medication due to the cost of it all. What is another way I can get some benefits to strengthen my bones without the medicine.

A: At age 33, it is not clear why you need to change your activity at all unless there is more information not listed above. If you have your ovaries (a hysterectomy means uterus and cervix only) and they are functioning, many might recommend adequate Calcium and Vitamin D along with weight bearing exercises and appropriate followup with bone densities and anti-resorption blood tests as needed. If this has been done with no effect, absorption problems leading to this problem may need to be investigated. After this has been carried out, other therapies should be discussed as needed.


Q: Can you possibly enlighten me to what may be called hard bone vs. soft bone? My mother's internist feels fosamax is not right for her (even though her bone density test reveals severe osteoporosis) because she has hard bones. His explanation to her suggests that fosamax would make her hard bones harder and therefore be more brittle and much more susceptible to fractures.

A: This is not terminology I have ever seen. You need to ask your doctor for references.


Q: My 78-year old mother has been advised to take Fosimax or Actenol to prevent osteoporosis. We think this is a bit strange because she has normal bone density, she is physically very active (works out with weights in a gym five times a week and walks frequently). She also takes calcium and has a very good diet. There are no family risk factors in a family of very long-lived women. Her doctor wants her to take this prophylactically-- do you think this is necessary?

A: The National Osteoporosis Foundation and the World Health Organization have recommendations for treatment and prevention but unless your mother has another medical condition we are not aware of, bisphosphonates (Fosamax and Actonel) are not recommended for women with a normal bone density.


Q: I am 62 years old. I was diagnosed with breast cancer in 1989, had mastectomy with chemotherapy, and five years of tamoxifin. I took fosomax for a few years and then the PA put me on miacalcin and evista. I have been on these for about 5 years. My cholesterol is controlled with zocor and I take prilosec for acid reflux. I take a calcium supplement and also take vitamin e. I had a bone density test that showed a small amount of bone loss. Are these drugs appropriate ? I moved to another state and my new doctor raised her eyebrows when I told her what prescriptions I take but so far has not changed anything.

A: Although Miacalcin has some bone advantages, increasing bone density is usually not one of them. The Evista is a good drug but most experts agree that bisphosphonates such as Actonel and Fosamax are superior bone density builders. If one experiences a bone loss on a particular drug, it is important to find out why and switch medications as needed.


Q: I'm a 50 year old female diagnosed with osteopenia premenopausally at 49 (Spine T Score=-2.1, Hip=-1.9), weight 140, height 5'7". I've since had surgical menopause and am using estrogen via Vivelle Dot 0.1 transdermally. I also take 1200mg Calcium + Vit D and get regular exercise. I have an Hx of Hashimoto's thyroiditis with episodes of hyperthyroidism for about 4 to 6 wks once every couple years for the past 20 years. I'm careful not to take too much Levoxyl during hypothyroid periods. I'm curious if there's anything else I could do to prevent osteoporosis which my mother now has and my grandmother succumbed to? Would there be any benefit of testosterone replacement in osteoporosis prevention?

A: Although testosterone is an anabolic steroid and will help to build bone, there are many side effects from such therapy including male pattern baldness, cliteromegaly, deepening voice and others. With menopause and moderate to severe osteopenia, the usual recommendation is a bisphosphonate such as Actonel or Fosamax. These medications have been shown to have an additive effect with the estrogen you are already on.


Q: I am concerned about these drugs causing adenomas. My family history has breast cancer, leukemia,brain cancer, lung cancer and colon cancer. I am afraid to take fosamax or actonel because of this. I have osteoporosis, and was started on actonel 35 mg once a week, had severe cns symptoms after 3 doses, had to discontinue. Wondered about the 5 mg, if this would be as bad, and the tumors from these drugs?

A: These medications are not associated with adenomas.


Q: I am 47 years old very small framed 105 lbs and have just been diagnosed with osteoporosis. I had a hysterectomy 10 year ago and have been on 2mg of Estradoil since my surgery. My bone density test indicted that I have 10% loss in my spine and 40% loss in my hips. My doctor has put me on Fosomax 70mg once a week and 1500mg of calcium a day. I have just had blood test done to check for the lack of mineral absorption to explain why the large difference in the loss. I guess my question is why? I don't understand how there can be such a large loss in such a short amount of time. I told my doctor that since I was a child I have always had soreness in my bones and joints especially when it is cold. Also my hip joins have always popped when I walk. Two month ago my left knee swelled up and was very painful, this lasted a week. Two days later my knuckle on my hand popped while I was putting sheets on the bed and has been very swollen and painful. I had x-rays taken to see if anything was broken, they came back normal, but my hand is still very swollen and sore. My joints in my toes and hands will all of a sudden start to hurt and swell for awhile and then stop. I have told my doctors and they just dismiss it and say there is no connection. I am at a loss, I don't understand and would like to know what question I should be asking and are there doctors that specialize in this field? Any information you can share with me I would appreciate.

A: Your bone complaints are many and varied. It is likely that the osteoporosis is unrelated to your other bone and joint complaints. This may very well be matter of never having gained the bone rather than a differential loss in different areas. A rheumatologist might just be the right person to help you with all of your problems.


Q: I have only been on actenol for three weeks but am experiencing trouble swallowing for several days after I take actenol for osteoporosis. Is this normal and how dangerous is it?

A: Although this is unusual with Actonel, it can certainly happen. In some, it is a matter of drinking more water with your weekly pill. Drinking 12-16 ounces may make the difference instead of 8 ounces. Alternately, you may need to either discontinue the medication temporarily and then restart it or you may need to discontinue it and get checked out for esophageal erosions. Since this happens at the same rate as placebo, you may have a gastrointestinal problem you were not previously aware of. You need to contact your doctor and discuss this.


Q: What type of specialist should my mother see, she was recently diagnosed with Osteoporosis, she had her uterus remove and ovaries 20 years ago, had being on hormone replacement since then. Should she see a specific doctor?

A: She can be treated by any one of a number of medical specialties, presuming they have an interest in osteoporosis patients. The list includes gynecologists, internists, endocrinologists and rheumatologists.


Q: I am age 45 and menopausal since age 40. I have been taking HRT for the last 5 years and have had Dexa's the last 3 years. The first year baseline was "osteopenia" in both the spinal and hip area indicating a "high risk". Last year there was improvement in both areas (Dr. attributed it to the HRT). However, this year my spinal area is still in the high risk category and but my hip area has now moved into the osteoporosis arena. I have recently stopped taking the HRT and started taking Actenol 5 weeks ago. I now have moderate (to extreme at times) joint pain, particularly in my hands. I have tried taking aleve and other OTC medications to no avail. Is there something else to try? I don't know that I can live with the joint pain for the rest of my life. Thank you in advance for considering my question.

A: The joint pain is likely NOT related to the osteoporosis and more likely arthritis or other such related disorders. You may wish to consult your physician, an orthopedist or a rheumatologist to make the diagnosis and clarify the appropriate therapy for this seemingly separate problem.


Q: I'm 31 years old, 120 pounds, 5 feet 4 inches tall, and in good health. I workout regularly, both cardio and weights. About 3 years ago I was diagnosed with primary hyperparathyroidism. A bone density scan at that time showed that I had osteopenia. After a parathyroidectomy, my endocrinologist said that my body would probably make up for the lost bone. A recent bone density found mild bone loss in my spine (T score of -1.1) and better readings in my hips, however, I was upset about it not being back to 100%. I eat a very well balanced diet and take a multivitamin. Should I be taking any calcium supplements? Is it unrealistic to think that my bone density should be up to 100%? Any info would help.

A: You do not mention how severe the osteopenia was initially. If your spine T score is -1.1 where 0 to -1.0 is considered normal and your hips are better (presumably normal) then you are essentially normal. These numbers indicate that there is normal variation in people and the range of normal is noted above. Exercise, adequate calcium and Vitamin D and a healthy lifestyle should keeep you in the normal range and at your age may still continue to improve somewhat.


Q: I am a 49 year old woman (premenopausal) who has had GERD and has been taking prilosec for a year and a half. For the last 6 months or so I have had pain in my sacroiliac joints--enough to wake me up several times at night. Also, in the last year, my teeth have developed nicks and pits that snag dental floss. I understand that calcium is absorbed best in an acidic environment and that prilosec prevents that acidic environment in the stomach. I am concerned that prilosec may be affecting my calcium absorption and that I may be headed for osteoporosis. What can you tell me about prilosec and osteoporosis? What can I do to enhance calcium absorption while on prilosec?

A: Although there should be no practical problem with Prilosec and development of osteoporosis, in order to absorb calcium in an environment of reduced acidity (including being elderly), calcium citrate may be better absorbed than calcium carbonate is because it doesn't require an acid medium for absorption. In addition, Vitamin D is an important factor in the absorption of calcium.


Q: My 83 yr. old mother has osteoporosis with 2 compression fractures of the spine (C 6 & 7). She has been recently introduced to Coral calcium from a nutrician. Are there any findings on this "new" calcium? We are aware that it comes from the coral beds of Japan and are concerned about the purity of the drug. Also, she has taken calcium all of her adult life and we can't help wonder why this wasn't absorbed. Any info about absorbtion of calcium would benefit her as well as myself.

A: I have no scientific data on the source of calcium you refer to other than a small study from Tokyo in 1999. Since the coral calcium has calcium to magnesium is a 2:1 ratio and the calcium carbonate it was compared to did not, it may not be a fair comparison but "on average, the coral calcium was somewhat better absorbed in this study with very few subjects". No comparison was made to calcium citrate, a source better absorbed in the elderly because of lower acid levels in the stomach.


Q: I am a postmenopausal white female, 53, hypothyroid (25 mcg synthroid once daily), borderline osteopenia/osteoporosis. I cannot tolerate Fosamax because of joint pain. Evista (60 mg, once daily) worked fine for a while, but I began having numb left leg overnight. The numbness disappeared upon discontinuing the Evista. I had been taking Actonel with no problems at all before the Evista. I have restarted Actonel (5 mg once daily) in place of Evista. Since restarting I have frequent minor burping that continues all day. There is no pain or discomfort associated with the burping. I occasionally take aspirin, usually enteric, at the opposite end of the day from the Actonel. My hypothyroid was diagnosed while I was taking Evista. Is the burping an "adverse effect" of Actonel and should I be concerned about it? Is it the result! of interactions with other drugs? Should I return to Evista? Why would I have the burping now, when I did not have it earlier?

A: The cause of your complaints cannot be determined on such a forum and needs to be addressed to your physician. If it were the Actonel, and this should be no different than placebo, one option might be to go to the once a week, 35 mg Actonel.


Q: I have GERD and have taken Prilosec daily for 3 years. I am 55 and recently had a bone density test result of mild to moderate loss (osteopenia); my GYN prescribed Fosamax. Since I have GERD, is Fosamax advisable? Thanks!

A: Many people do quite well with GERD and weekly Fosamax, especially if they also take Prilosec. Others find that they do better with weekly Actonel. The real question is why, (with mild to moderate osteopenia indicating a T score of between -1.0 and -2.0), you are being treated. With no other risk factors, the National Osteoporosis Foundation recommends treatment once the T score is worse than -2.0, the cutoff between severe osteopenia and mild osteoporosis. You may wish to discuss this with your doctor.


Q: My gyn recently put me on both Evista and Fosamax. I am 51 years old. I have not had a period for a year and a half. I took FEMHRT for about two months (May and June) then the study came out and scared me off it. ( I have an older sister who had breast cancer. ) I had a bone density test in Aug. and it revealed I have osteopenia. She said my score was -1.5. She said that my hip was slightly worse than my spine. (I broke my hip in my 30's by falling off the top of an extension ladder.) I questioned her about putting me on two drugs and she said it was warranted. Should I be concerned about being on two drugs used for the same purpose? I am not having any side effects other than hot flashes from the Evista. I am 5'4" and 120 lbs. I do not smoke or drink. I try to do free weights every day for upper arm strength, and I started a brisk walking regiment after my test came back, but now my knee is hurting so bad, I am not walking. I take 1500 units of calcium per day along with various vitamin supplements. What else can I do to be proactive in my overall health? My main question is taking two drugs at once for the same problem.

A: With a T score of -1.5, that is the cut-off between mild and moderate osteopenia. Most of the literature states that in certain circumstances, this is the earliest that treatment with medications should be initiated. Of course, calcium in divided doses (not more than 500-600 mg per dose) and Vitamin D are essential. The usual treatment initiation starts with single drug therapy. Although studies have shown that two drugs do work better than one, for the most part, an indication for two drug therapy is not obvious from your email. If your doctor's answers are not sufficient, you may wish to consult an osteoporosis expert to be evaluated.


Q: I am a 49 year old woman with Complete Androgen Insensitivity Syndrome. I have been on HRT for 30 years, mostly Premarin 1.25. I recently changed to full-strength Estratest. Last week, I had a bone scan. Helical axial tomographic sections of L1, L2, L3, and the hip showed mean bone density computed at 134 mg/cc. My T-score is -2.1 What treatment should I be on? I know that I should be taking calcium and doing weight-bearing exercise. Should I be taking Fosomax or Evista? My general practice physician doesn't seem to have a clue.

A: You have several options. One would be to see if the addition of testosterone to the estrogen (Estratest) builds more bone than estrogen alone. Since testosterone is an anabolic steroid, it may very well help build bone. Alternatively, a bisphosphonate such as Actonel or Fosamax can be used based solely on the T score of -2.1. If you are contemplating Evista, this would be something to discuss with a gynecologist since you are presently on Estratest and a decision would have to be made as to the pros and cons of each "hormonal" therapy".


Q: At age 29 I fractured my hip while running. After a long series of tests it was judged a stress fracture helped along by low bone density resulting from idiopathic hypercalciuria that is being treated with chlorthiazide.

  1. Is it true that at age 29 my low bone density may not be the same condition called “osteoporosis”?

  2. What treatments are there to improve bone density at my age? Are bisphosphonates recommended?

  3. I intend to have my hardware out in the spring, but this will leave a large hole and weak bones in its wake (since the pin has been taking a lot of my stress load since it was inserted), should I start bisphosphonate therapy to aid recovery after the hardware is removed?

A:

1. By definition, low bone density consistent with osteoporosis, regardless of the cause, is osteoporosis.

2. Many low bone density problems in premenopausal women can be reversed by correcting the absorption or metabolic problem or with estrogen therapy, depending upon the actual cause of the low bone density. Bisphoshonates are usually not used for premenopausal women, especially those in the childbearing years.

3. This must be discussed with your orthopedist in conjunction with an osteoporosis specialist for the correct answer for you.

References

**Note: Opinions expressed here are for educational purposes only and, as such, do not constitute a physician patient relationship. This information is not intended to supplant the need for you to consult with your physician prior to choosing therapeutic options and/or interventions.
 
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