Osteoporosis Ask The Expert

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Questions this month have been answered by:


Barry Lee Gruber, MD OBGYN.net Editorial Advisor	Maria Luisa Bianchi, MD, OBGYN.net Osteoporosis Editorial Advisor

Q: Dilantin, Vitamin D and Osteoporosis?

As I have recently been diagnosed with osteoporosis at age 65, I need to know if there is any reliable information available for someone who responds best to very conservative treatment for any health problem. I take Dilantin for epilepsy, AzthmaCort for asthma, have a very low tolerance for even correctly prescribed allopathic medicines (presumably because of complete liver shutdown for about 24 hours from Seldane/Erythromycin administered about 6 years ago), compromised kidneys (which have not been tested recently). I am currently doing 1 1/2 hours daily of weight-bearing exercise. I take 200 IU's of Vit. D3 as cholecociferol but I find that if I get over 1,000 mg. of calcium, it prevents my getting any sleep because of interference with the Dilantin. I have had several dangerous challenges to my liver and am afraid to take Fosamax or any of the bisphosphonates, hormones, or Miacalcin. I notice that many studies seem to yield conflicting conclusions. Please discuss any treatment modality you feel appropriate for a case such as mine. No one in my family has ever had osteoporosis.

A: It is difficult to properly advise you as to what might be the best treatment in your individual case without a full history, examination, and potentially further work-up and evaluation to exclude other causes of osteoporosis. For example, you mention that you are taking Dilantin which may be a major contributory factor and raises the possibility that Vitamin D metabolism is abnormal because of using this anticonvulsant and causing "apparent low bone mass" which is on the basis of faulty mineralization of the bones. In this case, we sometimes recommend higher doses of vitamin D or active forms of vitamin D under careful physician guidance. Hope this is helpful.

Barry Lee Gruber, MD OBGYN.net Editorial Advisor

Q: Fosamax and heartburn?

I took Fosamax for 3 months--the last month I took two pills on Mondays and Fridays to avoid having to take the medicine on weekends. Twice--each time on Saturday-- I developed chest pain--like heart burn or indigestion--I don't have a history of heart burn so I discontinued taking the medicine and the pain went away and has not returned. My first question is why would the pain occur the day after I took the medicine? Also, I know this is a side effect, but what about the few people who had serious side effects. How did theirs become serious? Was it because they continued to take the medicine? I do worry about serious side effects and wonder how I can assure they don't occur. I have now been prescribed Actenol, but I haven't started taking it yet, because I am afraid the same thing will occur. (note--I was taking the medicine exactly as directed) Since I know I must take it, I have 3 questions: (1) Can I take it two hours after lunch instead of first thing in the morning. I understand they do this in Canada. It is very hard not to bend down while getting ready for work in the morning. (2) What exactly are the serious non reversible side effects and will I have symptoms before any side effect becomes serious so that it can be prevented? (3) I have read that taking the medicine less often (once or twice a week at a higher dose) can help prevent the esophageal problems. Is this true?

A: Alendronate (Fosamax) and Risedronate (Actonel) have the capacity to cause esophageal irritation and in some individuals the more serious problem of esophageal ulcers and bleeding. The incidence of this occurring is quite low, but is probably increased in those individuals taking it with little to no water and assuming a supine position after taking it (lying down). I personally believe that the "bending over" is taking this advice and concerns a bit too far and probably is irrelevant. Whether Actonel is less offensive remains a debate with very little good data which is not tainted with much commercial or capital interests by the manufacturers of these agents. Likewise, I am not convinced that there is enough data to support the use of Actonel on a flexible dosing schedule (i.e., at other times of the day). To minimize your risk, I would suggest using either of these agents in larger doses once weekly with an antacid regimen the night before (such as Prilosec or Prevacid) and otherwise take as directed with at least 4 ozs of water and don't lie back down (and preferably wait 60 minutes before eating). Hope that is helpful advice for you.

Barry Lee Gruber, MD OBGYN.net Editorial Advisor

Q: Lunar BMD or Ultrasound?

What are the differences in accuracy between Lunar BMD measurements and Ultrasound measurements? Which method to chose?

A: Both of these methods are accurate but quite different in technique and information gleaned. The Lunar (or any manufacturer's) DEXA will basically provide an accurate assessment of the quantity of bone, while ultrasound potentially will provide some insight into both quantity and quality of bone. Although at first glance, the ultrasound measurement seems therefore advantageous, we still have much to learn and refine to optimize the information gained by passing ultrasound waves through a portion of our skeleton. Plus it may not be appropriate to detect the average of sound wave velocity and attenuation over the entire heel bone as is currently being done, it may be necessary to deliver sound waves over thin sections of a bone one section at a time (similar to a CAT scan) and detect the changes individually and then interpret the meaning (something being considered for the future). Another limitation of ultrasound right now is that one can only measure peripheral sites of the skeleton such as the heel bone, whereas dEXA can be used for hip and vertebral quantitative assessments.

Barry Lee Gruber, MD OBGYN.net Editorial Advisor

Q: What's the latest information you have on treating osteoporosis with ipraflavone?

A: Not much good info on ipraflavone; most of the bone experts are convinced that this product has positive effects on the skeleton probably by exerting an "estrogen-like" effect. Some refer to it as "estrogen-light" in fact. But good double blinded prospective trials that are designed with large enough numbers of volunteers to determine the optimal dose and whether fractures are reduced are lacking.

Barry Lee Gruber, MD OBGYN.net Editorial Advisor

Q: Should I start Fosamax after these BMD results?

I have recently been diagnosed with osteopenia and am a 53 yr. old female-post menopausal. Family doctor ordered a wrist bone density-results were bone density of 0.427 g/cm equivalent to -0.7 numerical T score. Please explain. She also wants me on Fosamax 10 mg. immediately. I then went to an orthopedic for a different problem and as family doctor would not do a full body scan and was not going to recheck me for two years, he ordered a Bone Mineral Density. Results were equivalent of 129 MGS per CC. This was taken through the mid portions of the L1, L2, L3 and L4 vertebral bodies, averaged and compared to a national norm. The orthopedic says no to Fosamax. I have contacted the Osteoporosis Center in this area and they suggested I see an endocrinologist for a third opinion and to make a decision on treatment. I have an appointment next month. In the meantime I am very concerned, I do not understand my test results and as there is a history of osteoporosis (severe) in my family, I would appreciate your input?

A: You have not provided the T-score for the central DEXA that you had done measuring the lumbar spine, but assuming that this is within normal limits then the decision to start Fosamax or alternatively estrogen replacement therapy would be predicated on the concept of "prevention of developing osteoporosis" in the future. Since you state that you have a family history of this disorder and, not knowing what other risk factors you have for this disease, then you might be served well to see an expert in the field to assist you in this decision since you seem to be at increased odds for future skeletal fractures. Hope this is useful to you.

Barry Lee Gruber, MD OBGYN.net Editorial Advisor

Q: HRT or Fosamax with Osteopenia?

I am an active, healthy 60-year-old who is taking low dose estrogen and progesterone (approx. 10 years). I have been diagnosed with osteopenia. While my mother didn't have bone thinning problems I do have an aunt with osteoporosis. I eat moderately well, take calcium supplements, do weight bearing exercise and fast-walk on a tread mill. My doctor recently suggested that I reconsider my HRT (because of recent research on the link between estrogen replacement and breast cancer) but the choices are not clear. Fosamax is one possibility but now I am hearing of risks with long term use. Any opinions?

A: The difficulty in giving advice like this over e-mail is that all information is not available. For example, osteopenia covers a wide range from mild to quite advanced and a comparison with prior tests (or future tests) to gain insight as to whether you are stable or losing bone all are important bits of information used to develop an education opinion. If you were losing despite estrogen and had advanced osteopenia, then that might call for adding or replacing the estrogen with Fosamax (depending on your level of concern about the breast cancer issue, which is still unsettled in the medical field). Most bone experts are not particularly concerned about long-term effects of Fosamax at this point with the data available. Hope this is useful.

Barry Lee Gruber, MD OBGYN.net Editorial Advisor

Q: Telopeptide with creatine test accurate?

Is the blood test telopeptides with creatine accurate for testing bone density? Is it more accurate than DEXA, etc. I have had DEXA tests in past and have osteoporosis.

A: The test that you ask about is a quantitative measurement of a fragment of bone collagen (the major protein of bone) which is released from bone and ends up in the blood and urine when the bone dissolving cells are active. It provides you with no information about how much bone is present, i.e. bone density but is a marker that gives some information about the rate of bone loss. Some experts refer to this test as an analogy to a pilot landing a plane, where bone density represents the altitude you are at and the N-telopeptide (NTX) as the rate of descent- both being useful parameters but quite different. On a practical level, the NTX test gives a relatively short term (2-3 month) response (or insight) as a way to monitor effectiveness of therapy.

Barry Lee Gruber, MD OBGYN.net Editorial Advisor

Q: Will Fosamax and Tums work?

I recently had a bone density test and found that I was on the bottom scale. I'm 79 years old and am taking Fosamax 5mg. a day and calcium. Is there a good possibility that it will help and what are the side effects? What kind of calcium is best to take, my doctor suggested two Tums a day.

A: In response to your questions, yes Fosamax at a dose of 5 mg should affect your bones in a positive manner, both by increasing the quantity of bone and its strength. For individuals with very low bone mass, we usually prescribe 10 mg but there may be reasons why your physician is using the lower dose. The lower dose works but not quite as well as the standard 10 mg dose. The exact type of calcium that you take probably is not all that important unless you have problems absorbing it or have a history of kidney stones and in those cases calcium citrate is advantageous.

Barry Lee Gruber, MD OBGYN.net Editorial Advisor

Q: Is ERT more effective than Fosamax?

After reading some of the info on the web site, it seems that estrogen replacement therapy is put forth as more effective in preventing bone loss than fosamax. I am 52 years old and takes herbs that in effect give support to my female glandular system and contains plant estrogen from black cohosh. I do not have vaginal dryness or other difficulties and will still have a period on occasion. My gyn put me on 5mg of Fosamax and no ERT as she felt that since I was not experiencing signs of low estrogen that it was not necessary. (What are the indications of low estrogen?) My worst number on the bone density test was -2.0. I have thinning in both the hips and spine. Do I need a higher dose of Fosamax and when do you think that it should be used in my case?

A: First, you may not yet be in full menopause (absence of periods for at least 6 consecutive months). Low estrogen levels give the characteristics symptoms of menopause, and of course can be measured in blood. "Plant estrogens" act exactly like animal or synthetic estrogens - the problem is determining what dosage you can take from an herb. Estrogens have a much wider range of effects on menopause than alendronate (which acts only on bone), therefore they may be preferred. However, regarding prevention of osteoporosis, reduction of bone loss, and prevention of fractures they are not more effective than alendronate (fosamax). Probably your gyn has chosen to give you fosamax (5 mg is enough) because you have osteopenia, and are not yet in full menopause.