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Osteoporosis Ask The Expert |
| Q: Why does Osteoporosis occur more in Asian women? |
| Answer from Dr. Gruber |
| The answer to your question is not entirely known, although certain factors probably
contribute. First however, it is important to recognize that the data indicate that among Asians the rate of hip
fractures varies considerably whether one is speaking of Japanese, American-Asians, Koreans, New Zealand, Hawaii,
etc. In general, Asian women have higher fracture rates than African-Americans but lower than Caucasians. Presumably
racial and ethnic influences on risk for developing osteoporosis and fragility fractures depends on (undefined)
genetic factors which govern bone mass, geometry, and size of bones (all contributing to strength), bone turnover
rates, overall body composition (both muscle mass and fat lessen fracture rates), and calcium metabolism. In addition,
lifestyle issues such as physical activity, smoking, etc. probably play a role although this has not been well
studied in terms of its relationship to race and ethnicity. In summary, a wide range in fracture incidence worldwide
suggests that many factors enter into the determination of skeletal health. Bone mass itself (i.e., bone density)
is only a portion of the risk profile.
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| Q: Osteo sonogram versus DEXA |
| Dear Dr. I want to know about the osteo sonogram of the heel versus DEXA of the forearm. Which is better? What is the advantages of the QUS screening method? What is your opinion about AQUILLES Express today? |
| Answer from Dr. Gruber |
| The heel has become a valuable tool for screening populations to determine higher
risk individuals for future fracture. It may be slightly advantageous over forearm measures in that no radiation
is involved, and bone "quality" in some fashion is being assessed at a site of bone which is not predominantly
cortical as in the forearm. At predicting hip fractures, hip bone density remains the gold standard. The problems
with heel ultrasound and forearm measurements is the inability to detect a significant change with therapy and
hence it is not particularly useful for monitoring therapy. The other general problem about all peripheral measurements
is that at this point in time the "T-score" is poorly defined and rates of bone loss as we age differ
considerably from one site to another. These issues are currently being addressed by a group of experts in the
field. Barry L. Gruber, M.D. OBGYN.net Osteoporosis, Editorial Advisor |
| Q: How to interpret DEXA scan information for juveniles. |
| 13 year old with JRA for 9 years; has been on several short bursts of prednisone for flares of arthritis as well as flares of asthma; also had 1 year of tapering prednisone for arthritis control. Now on Methotrexate and Tolectin. Has been taking supplemental calcium of 1500 mg/day, but recently had to decrease that to 1000mg/day due to development of bilateral renal calculi. Was also placed on a thiazide diuretic (Naqua) to decrease calcium excretion in urine. Ca levels in blood (10.4), P (4.3). DEXA scan last month showed 1.) right femoral neck BMD value of 0.747, left femoral neck BMD value of 0.725, L1-L4 BMD value of 0.762 (Z value of -0.91). X-rays of bones frequently contain comments about osteopenic appearance of bones. Was active physically until this year (dance class, swimming, horseback riding). My question is how to interpret DEXA scan information for this age group. Also any data or experience on the use of Miacalcin, Fosamax or other bone sparing meds for JRA patients? |
| Answers from Dr. Bianchi and Dr. Gruber |
| 1. The calcium supplement should be given considering the actual dietary
intake of calcium. The RDA for this age is about 1200 mg/day. 2. Given the renal calculi and the thiazidic diuretic it is essential that she drinks at least 1-1.5 liters of water a day. 3. Re DEXA. Z-score makes reference to a sex and age-matched group of healthy. On most DEXA machines (Lunar, Hologic) the reference population is North American. There are no internationally agreed-upon thresholds for osteopenia and osteoporosis in younger patients. However, in my experience, - 0.91 can be considered a non-pathological deviation from normal, requiring a follow-up and the following therapeutical measures: - adequate calcium intake (dietary + supplement if needed); - evaluate vitamin D levels, which can be low after steroids, and give a supplement if needed (be careful, as she has kidney stones); - keep steroids as low as possible or avoid them: - have a regular physical activity within the patient's capabilities. Comments to X-rays are not significant, as X-rays are not precise in evaluating osteoporosis. 4. Methotrexate at dosage used for JRA seems not to induce bone loss (see Bianchi M.L. et al. Bone mass change during methotrexate treatment in patients with JRA. Osteoporosis Int (1999) 10:20-25). 5. Alendronate (Fosamax) and calcitonin (Miacalcin) are not used for the PREVENTION of osteoporosis in children, but only in the TREATMENT of a severely reduced bone mass (Z-score < -2) or in the presence of a history of fragility fractures. There are some studies on the use of alendronate in young patients for bone loss secondary to different diseases. Data on the use of calcitonin are very scarce.
|
| The BMD score (and bone mineral content) should be normalized for this
child's body size and compared to a normative data base for children of this
age (i.e., Z score) for hip and spine. The normative data base is
available commercially from the major manufacturers and also available at centers who see a lot of childhood bone disease (Shriner's Hospital, St. Louis; Riley Hospital in Indianapolis, etc). Ideally you need to consider gender, ethnic, pubertal stage, and bone size to match with these BMD values to determine how abnormal your individual patient is. Follow-up bone scans and height measurements are obviously also crucial. The statement on radiographs of "osteopenia" is generally not very accurate. Other considerations; the calcium supplement should be in the form of calcium citrate to inhibit stone formation. The use of Fosamax in children is gradually gaining in experience, especially in Europe and Canada (and particularly with osteo genesis imperfecta and its variants)- the results look quite good. No info on Miacalcin or other agents. Hope this is useful.
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| Q: Are calcium supplements and exercise enough? |
| I am a 46 year old premenopausal female who just had a bone density and it was -1.2. My physician put me on a weight bearing exercise program, a calcium supplement, and said he would recheck in 1 year. Does this seem like appropriate treatment? |
| Answer from Dr. Gruber |
| Perfectly appropriate. Your bone mass is near normal. Regards, Barry L. Gruber, M.D. OBGYN.net Osteoporosis, Editorial Advisor |
| Q: Breastfeeding with osteoporosis. |
| I am 28 years old and was diagnosed with osteoporosis about two years ago. Tests revealed that I have already lost about 25 percent of my total bone mass. I have since changed my diet in addition to taking calcium supplements and doing weight bearing and 'impact' exercise. I was also prescribed a medication named 'Miacalcin (calcitonin)' which I discontinued when I tried to get pregnant. I am now 3 weeks away from my due date and I would like to know your opinion on breastfeeding with this pre-existing condition. Thank you very much . |
| Answer from Dr. Bianchi |
| First of all, did you try to discover the cause of your early osteoporosis? Dietary
calcium (supplements are OK if you can't eat enough milk and dairy food) should ALWAYS be adequate, throughout
life. Vitamin D is important for intestinal absorption of calcium, but it should not be a problem if you stay outdoor
in the daylight with some skin exposed (many foods in the U.S. are enriched with vitamin D). During pregnancy and
lactation, you should take about 1.5 grams of calcium a day, as you will give much calcium to your baby. Up to
9 months of breastfeeding, with a correct diet, a healthy woman will recover all the calcium passed to the baby
within 18 months - that is, the calcium loss from the mother's skeleton in this period will not be permanent. In
your condition, I think that you should limit breastfeeding to about 3 months. Physical exercise (weight bearing)
is always good for bones. Maria Luisa Bianchi, MD OBGYN.net Osteoporosis, Editorial Advisor |
| Q: what kind of exercise I should do to strengthen the spine area |
| I an a 62-year-old woman and have just been diagnosed with 9-fold lower lumbar osteoporosis. The test was done because I fractured my fibula after falling. My femoral density is normal. I would like to know what kind of exercise I should do to strengthen the spine area but not injure it. I also have a family history of breast cancer and would prefer not to take ERT. What is the difference between fosamax and raloxifene, are there other drugs for this condition. Finally what about diet - I am 5'4" and weigh 140 pounds so I intend to lose about 15 pounds but should I eliminate caffeine and alcohol. I stopped smoking about 12 years ago. Thanks so much for your answer. |
| Answer from Dr. Bianchi |
I hope to have been informative. |
| Q: How risky would a pregnancy be for someone in whom osteoporosis is caused from Empty Sella Syndrome and a growth hormone deficiency ? |
| I am 31 yrs. old and have been diagnosed with osteoporosis due to having Empty Sella Syndrome and a growth hormone deficiency. My husband and I would like to start a family. How risky would a pregnancy be for me? |
| Answer from Dr. Gruber |
| I see no reason that pregnancy should be a risk, but would suggest that you
discuss this with your endocrinologist. Barry L. Gruber, M.D. OBGYN.net Osteoporosis, Editorial Advisor |
| Q: How effective is Miacalcin Nasal Spray? |
| I am a 65 year old female who was just recently diagnosed with osteoporosis of my left hip. Bone loss is not evident anywhere else. I have some problems with GERD so Miacalcin nasal spray was prescribed. After reading the insert I am questioning whether this medication will be of any benefit, it seemed like that drug studies showed it was only beneficial for the type bones in the vertebrae. |
| Answer from Dr. Gruber |
| Generally speaking, the bisphosphonates such as alendronate (Fosamax) are considered
more potent in terms of both increases in bone density and fracture data (especially at the hip). You are correct
that Miacalcin has only been proven to provide fracture efficacy in the vertebrae.
|
| Q: A 23 year old woman asking questions after being diagnosed with Osteoporosis. |
| I am a 23 year female who was just diagnosed with osteoporosis in my lower back and both hips. I also have osteopenia in the rest of my body. I was diagnosed with severe endometriosis at age 16 , I had a laparoscopy done at 16 and that's how I was diagnosed. I was then put on Lupron shots for 6 months to put me in premenopause. I had terrible side affects and was taken off after the 6 months. I was then put on Megace and have been on the Megace for the past 7 years. I'm not sure if you are familiar with the Megace or not , but it also put me into a premenopausal state. So I haven't had a period in 7 years. I had the bone scan done about three weeks ago and just found out the results today. I am very upset that I am only 23 and have this awful diagnoses. My Dr. isn't sure what kind of route she wants to take with me yet. She is going to consult some of her colleges first. One option is to take me off the Megace, but if we do that my endometriosis will cause me debilitating pain. So it's a no-win situation. If you have any information you could share with me I would appreciate it very much. Do you know of anyone my age with osteoporosis? |
| Answer from Dr. Gruber |
|
You have several options available. We do have experience with others like yourself with low bone mass (osteoporosis)
at such a young age. One option would be to consider "add back" therapy with a hormone, particularly
a selective estrogen such as raloxifene (Evista). You might discuss this with your gynecologist. There has been
experience with the use of Fosamax in individuals your age with reasonable good success and that is another consideration.
I would advise you to see a bone specialist
(in some areas that may be an endocrinologist, rheumatologist, primary care
physician/gynecologist). Good luck and keep in mind that treatments are available and effective! Regards, Barry L. Gruber, M.D. OBGYN.net Osteoporosis, Editorial Advisor |
| Q: Do Asthma medications decrease bone strength? |
| I am 34 years old and have had asthma all my life (diagnosed at 6 months old). Approx. 1.5 yr. ago I started taking Serevent, Aerobic, Singulair, and Rhinocort for my asthma and allergies. In the past month or so I have noticed pains in my hands (below the thumb on both hands) and periodically other places. Could the Rx I am taking have this kind of side effect? If so, can I do anything to increase my bone strength? Can I do anything to keep it from getting worse? The asthma Rx really has made a wonderful difference in my breathing, but I don't want to fall apart. |
| Answer from Dr. Gruber |
| I am not aware of any causal effect of the medications that you are using with these
sort of symptoms, although it may be wise to have x-rays taken and seek consultation with a rheumatologist or other
such specialist. Barry L. Gruber, M.D. OBGYN.net Osteoporosis, Editorial Advisor |
| Q: Help me understand these numbers |
| Hello, my question is in relation to my mother, age 75, who has had multiple fractures. Her BMD test score in 1999 was "9.8". After much hassle with her HMO, she was allowed to go on Fosamax and HRT; however, she could not tolerate the side effects of the HRT. She sub- sequently had a spontaneous break of the hip and later was switched to Evista. This year her BMD test score was "2.75". The nurse at the primary care physician's office is unable to interpret these scores for us, so we don't know what the scores mean or whether she is doing better. The primary care physician is not available to answer questions. Can you throw some light on what the scores mean? I thought the measurements were supposed to be in terms of deviations (T + or -), not a single number. |
| Answer from Dr. Gruber |
| Something sounds very strange; I am not sure what the 9.8 value represents
and thus am unable to render sound advice to you. The 2.75 value probably
is her T-score of -2.75 and suggests low bone density sufficient to
diagnose osteoporosis. Thus the use of Fosamax seems appropriate. You
might want to seek consultation from a specialist in your area or discuss
this more fully with your primary care MD.
|
| Q: Can Fosamax or Evista be taken prior to menopause, and would you recommend this? |
| I am 48 years old and am perimenopausal. I recently had a bone density scan which revealed a dist. T-score of -2.58 and prox. T-score of -3.41, consistent with a diagnosis of osteoporosis. My doctor says my blood tests all look fine and does not seem concerned. She advised me to exercise (I walk 40 minutes every day) and take calcium citrate with vitamin D. Because I am not even menopausal yet, I am very concerned about further bone loss. My question is whether Fosamax or Evista can be taken prior to menopause, and would you recommend this? The drug company's information states that their intended use is for "postmenopausal" women only. Also, the scan that I had done was of the forearm only, should I have more extensive testing done? |
| Answer from Dr. Gruber |
| I would advise a more complete evaluation with a central DEXA device and perhaps seek
consultation with a specialist. These values for a forearm seem quite low, but the major issue is whether this
represents bone "loss" or "never gain" (i.e., your bones were never normal at their peak values
in your 20's). This is an important distinction and may only be determined by following your bone mass over the
next year (although some bone marker turnover tests can be done now). But first I would suggest that you have these
numbers confirmed. Fosamax is sometimes used premenopausal in the
appropriate setting, but little clinical testing has been done to date. Barry L. Gruber, M.D. OBGYN.net Osteoporosis, Editorial Advisor |
| Q: Is
Fosamax still useful for an 86 year old female that has been diagnosed with osteopenia? |
|
My mother is in good physical shape and quite active but has osteopenia (see
below) and her doctor has recently prescribed Fosamax, 5mg/day.
She has shrunk several inches in the last 20 years. The Lunar Achilles+solo
ultrasonometer test showed the following: sample: USA female (Caucasian) %young adult = 65 T score = -2.2 %age matched = 118 Z score = 0.6 I do not know the actual result of the urine test performed (collagen Xlink N telopep) but it was summarized as (unspecified degree) osteopenia, thus the 5mg/day prescription. 1) The bone density chart typically show a baseline curve (normalized density or stiffness index versus age) that asymptotes to a constant value after about age 80. Is this because there is no significant data after that age or because bone is no longer lost (or lost very slowly) after that age? 2) Is the prescribed dosage sufficient? 3) Is there a significant difference between "normal" bone density curves for samples of anglo/American Caucasians and those of north-Mediterranean origins? |
| Answer from Dr. Gruber |
| Yes, Fosamax does not lose any efficacy in the elderly and appears
to
provide a benefit within a relatively short period of time (i.e., 18
months) Very little to no data on this topic, but recent evidence suggests that systemic bone loss may accelerate after age 80. Since the bone mass values are not that low, probably this is a reasonable choice to offset risk of adverse events. A lateral spine X-ray may shed additional light if there are any vertebral compression deformities (silent fractures) which would cause most to use full dose at 10 mg per day. A complex question for which we have incomplete data to determine how major a factor this really is. Barry L. Gruber, M.D. OBGYN.net Osteoporosis, Editorial Advisor |
| Q: In search of optimal health. |
| I am 52 years young and find myself faced with a decision to change medication or not. For one year I have been under my doctor's care with the use of Miacalcin, the last reading of my densitometry test showed continued bone loss in my spine. I understand that one year is a short time, but it's my bones that are being affected or not! My career of doing water therapy 5 hours a day , 5 days a week may be a factor, but I do yoga and eat well. Please help a young women in search of optimal health. I don't take estrogen by choice. Thank you. |
| Answer from Dr. Whitted |
| The treatment of low bone mass (osteopenia/osteoporosis) is three tiered. Lifestyle
factors should be addressed such as nutrition, exercise, habits (caffeine, alcohol, tobacco). If you are menopausal
the consideration of hormone replacement therapy or Evista (a selective estrogen receptor modulator), and an antiresorptive
agent (Miacalcin, Fosamax). Generally speaking, if one therapy is not working to satisfaction than an alternative
therapy should be chosen. In your setting there may be several areas that need to be addressed. R. Wayne Whitted, M.D., M.P.H OBGYN.net Osteoporosis, Editorial Advisor |
| Q: Information on the trials of parathyroid hormone used to build bone. |
| Brittle bones was the eye catcher of this article of March 28, 00, USA TODAY I would like more information on the trials of parathyroid hormone used to build bone. |
| Answer from Dr. Whitted |
| Parathyroid hormone in pulsatile fashion cause bone loss and is responsible, in simplistic
terms, for maintenance of appropriate calcium levels in the body. In non-pulsatile fashion, it stimulates osteoblastic
function and causes bone to be built. To date this medication is in investigational stage only and is expensive. R. Wayne Whitted, M.D., M.P.H OBGYN.net Osteoporosis, Editorial Advisor |
| Q: Fosamax and a eating disorder. |
| Hi, I am 27 years old and have been amennorheic for almost 2 years. I had a bone density scan done and my T scores showed my hip at -1.88 and my spine -1.89. My question is regarding Fosamax. I am starting OCP's now for supplemental estrogen and getting help with my eating disorder. Reading up on eating disorders and bone loss --- studies show that the bone loss is tough to reverse, would you recommend taking Fosamax as well as the pill? |
| Answer from Dr. Whitted |
| Your BDS suggests osteopenia. The underlying cause suggests an eating disorder producing
an hypoestrogenic state. This needs to be corrected, weight-bearing exercise started and appropriate calcium and
vitamin D taken. Fosamax is a reasonable alternative for improving bone density but can be difficult to take. BCPs
probably increase bone density to some degree. To take Fosamax or not in your setting is not absolutely clear.
It is important whatever you do to have follow up BDS in 2-3 years to look at trends. Other questions to ask yourself
are: do you have other risk factors for osteoporosis other than eating issues? R. Wayne Whitted, M.D., M.P.H OBGYN.net Osteoporosis, Editorial Advisor **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. |
