Posts Tagged ‘dryness’

•    Exercise regularly to keep bones strong
•    Take vitamin D along with your calcium supplements
•    Experiment with Menostar (estradiol) instead of hormone replacement therapy
•    Consider Evista (raloxifene) to reduce risks of spinal fracture and breast cancer
•    Ask your doctor about the benefits and risks of Fosamax (alendronate)
•    Make Miacalcin (calcitonin) an option if back pain from fractures is an issue
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We tend to think of our bones as hard and unchanging, like the bones we find on our dinner plate. But actually, they are living tissues that undergo constant change and renewal, just like our other organs. Cells called osteoclasts break bone down, and cells called osteoblasts build it back up, just as if you were remodeling your house a room at a time. The osteoblasts build up living tissue and reinforce it with minerals like calcium, magnesium, boron, and manganese.
Normally, these two processes—resorption and formation of bone—are closely linked so that bone stays strong. Quite a few factors can upset the balance, though. If the osteoclasts race far ahead of the osteoblasts, bone density can drop and eventually the bones are not strong enough. A minor fall can result in a broken hip, which can be catastrophic for an older person.
OStevporosis a condition of weakened bone, is responsible for 1.5 million fractures each year, including 300,000 hip fractureS.71 The National Institutes of Health (NIH) estimates that 10 million Americans currently have osteoporosis. Two million of them are men. While osteoporosis is thought of as a women’s issue, it is not limited to women.
There’s no shortage of controversy surrounding osteoporosis. Perhaps the first issue is just how many people should be RISK FACTORS
•    Female
•    Increased age
•    Shortness and thinness
•    White or Asian
•    Family history of bone loss
•    Sedentary lifestyle
•    Irregular menstrual periods
•    Early menopause
•    Low testosterone (men)
•    High level of thyroid hormone
•    Low-calcium diet
•    Low level of vitamin D
•    Cigarette smoking
•    Alcohol consumption
•    Prednisone or similar drugs (long-term use)
•    Certain anticonvulsants
•    Celiac disease
concerned about it. According to the NIH, 34 million people have low bone density. Add that to the 10 million who have been diagnosed with osteoporosis, and you come up with 44 million Americans for whom “osteoporosis is a major public health threat .,,767 That’s more than half of the population over 50 years of age.
Lumping those 34 million who have low bone density together with those who have already been diagnosed with osteoporosis certainly makes for a larger potential market for the drugs that have been developed to prevent or treat bone loss. Some public health researchers have criticized this tactic by calling it “disease-mongering.’,768 Instead of characterizing osteoporosis or low bone density as a risk factor for fracture, calling it a disease implies that it requires treatment. 769 The critics claim that this tactic mobilizes fear (and helps sell IS IT CELIAC DISEASE?
Anyone can break a bone by falling off a horse or out of a tree. But some people break bones without even trying. If you have experienced fractures for no logical reason, you and your doctor may want to figure out why your bones are not as strong as they should be.
One possible explanation is celiac disease. It should be investigated in young people with low bone density measurements. Celiac disease is due to gluten intolerance. If it is not diagnosed and a gluten-free diet is not followed, the resulting damage to the small intestine can interfere with proper absorption of the nutrients needed to build bone.
drugs) rather than promoting understanding and positive action.
The availability of bone density screening is a two-edged sword in this respect. On the one hand, it is helpful for those who are truly at risk to find out before they break a hip or develop debilitating back pain from vertebral fractures. Unfortunately, many of those being screened are not those who need it most. An analysis of nearly 44,000 women on Medicare found that the oldest women, ages 81 to 85, were only half as likely to be screened as women ages 66 to 70.770 The older women, however, are far more likely to have reduced bone density, even osteoporosis, putting them at risk of a fracture.
Increasingly, middle-aged women are being screened for bone density. The scoring system is a bit complicated, since it is based on standard deviations below the bone density of a young person at peak bone mass. Most of us don’t have the grounding in statistics to make much sense of “standard deviations,” so if the doctor does not explain carefully what the numbers mean, women often end up confused and alarmed. Critics point out that defining osteoporosis as bone density that is 2.5 standard deviations (T score –2.5) below the mean for a young person practically guarantees that approximately 30 percent of postmenopausal women will be diagnosed with this condition, whether they are truly at risk for osteoporosis or not.”Reducing the Risk of Fracture with Nondrug Approaches
Although osteoporosis treatment now includes many more options than it did just 10 years ago, each drug that is prescribed for weakened bones has some drawbacks. That’s why it makes sense to start with nondrug approaches and see how far they will take you. If you begin early enough, you may be able to slow bone loss and prevent a fracture. But even if you already have osteoporosis, these tactics may be a good addition to pharmacological treatment to make it more effective.
Exercise
Your doctor may not be accustomed to prescribing a walk around the block,. but getting more exercise should be just what the doctor orders. In so many cases nowadays we must go out of our way to work up a sweat. Few of us do manual labor to earn a living; walking to our jobs or just to the store is almost as rare, especially in many suburbs. So instead of incorporating physical movement into everyday life, we need to find time—and funds—to go “work out” somewhere.This may be too inconvenient for many people.
It has become clear that our bodies adapt to the demands we make of them. Weight-bearing exercise like walking, running, or mowing the lawn encourages bones to grow stronger.
***** Exercise
Moving your bones helps strengthen them. Doing something enjoyable on a regular basis—walking, gardening, dancing, or another weight-bearing activity—acts to delay bone loss as well as strengthen muscles, benefit cardiovascular health, improve mood, and reduce the risk of dementia. Exercise alone may not be enough to reverse bone loss, but it can improve the effectiveness of other treatments.773
Side effects: Sore muscles
Downside: If the exercise program is overly ambitious or too dangerous, a person with reduced bone density may experience injuries, including fracture.
Cost: Too variable to estimate Sitting in front of a computer screen, sadly, does nothing to stress our bones in a healthy way. In fact, differences in traditional patterns of activity may explain why women usually have less bone mass than men, even as young, healthy adults. In the past, boys were expected and encouraged to be active by playing sports and helping with strenuous chores. Girls, by and large, were not. Although these differences are diminishing among today’s children, physical activity has been declining across the board.
A lifetime of activity is ideal for the strength of the skeleton, but it may never be too late to benefit from more exercise. Anyone who has already experienced fractures from osteoporosis should check first with his or her physician, but appropriate weight training or walking may be helpful even for those who are quite elderly or a bit debilitated. The, exercise program should be carefully designed, of course, so that it does not put the person at a higher risk for fracture from a fall or injury.
The Calcium Craze
Calcium supplements are the first thing most people think of for preventing or treating osteoporosis. Although an adequate calcium intake is necessary to maintain strong bones, just taking calcium doesn’t seem to help very much once bone density has begun to decline. Calcium supplementation can make a difference in young people, whose bones are still developing. But in postmenopausal women, the evidence is murky. Some studies have shown that 500 to 1,000 milligrams of calcium a day together with 700 to 800 IU of vitamin D can reduce the number of fractures (though this benefit does not extend to
the spine ).774,175.776
The results of the Women’s Health Initiative on this issue were less encouraging. The study was very large, involving more than 36,000 postmenopausal women. Though supplements of 1,000 milligrams of calcium and 400 IU of vitamin D daily improved the density of bone in the hip, it did not
3    777
reduce the number of hip fractures, Scientists have tried to explain the disappointing results: The women were not in the oldest age category at highest risk for fracture; the women on placebo pills could take calcium on the side if they chose to; many of the women in the active supplement group did not take their calcium and vitamin D, every day.
Calcium is important for preventing and treating osteoporosis—but by itself it isn’t enough. Taken together with adequate vitamin D, it may help reduce the risk of falling as well as improve bone mineral denSity.77,44
Most of the experts who do research on osteoporosis agree that a calcium-rich diet (or a supplement of around 1,000 milligrams daily) and 15 to 20 minutes of sun exposure 3 or 4 days a week (or a supplement of 800 to 1,000 IU of vitamin D3, also known as cholecalciferol) are a sensible approach. Take no more than 500 or 600 milligrams of calcium at a time for better absorption.
Calcium also works with dietary protein to benefit the skeleton.779 Make sure you are getting enough protein.
Side effects: Gas, intestinal bloating, constipation Downside: Too much calcium increases the risk of kidney stones.
Cost: $6 to $10 per month for a supplement that contains both nutrients
In addition, 400 IU of vitamin D, just may not be enough. An analysis of a number of studies concluded that it takes at least 700 IU of vitamin D, a day to make a difference in fracture risk .780 Lower dosages simply aren’t effective.
Human skin can make vitamin D when it is exposed to sunlight. but older people are often careful not to go out in the
VITAMIN D PARANOIA
The recommendation for supplementing with vitamin D. has been set at 400 IU a day because of worries that a person could get too much. Vitamin D in excess is toxic, so taking more than 2,000 IU a day would be foolish. Most people don’t need a lot more than 1,000 IU daily, but that seems to be a more sensible level to aim for than the currently sanctioned 400 IU. That is especially true for older people at risk for osteoporosis, who may be avoiding sun exposure for fear of skin cancer.
sunshine without their sunscreen. Aging skin is less efficient at making vitamin D, so a health-conscious older person may actually be making very little of it. If this is true for you, a supplement may be advisable.
We weren’t as surprised as others may have been at the lackluster results seen with calcium supplements in the Women’s Health Initiative. Walter Willett, MD, DrPH, MPH, the Frederick J. Stare Professor of Nutrition and Epidemiology and chair of the department of nutrition at the Harvard School of Public Health, had told us years earlier that calcium is not the whole story. Women in Scandinavia have the highest calcium intake in the world, but they also have the highest rates of osteoporosis. Women in some parts of Africa get very little calcium in their diets yet rarely have trouble with fractures as they age. Sun exposure is one obvious difference that might account for women having relatively low levels of vitamin D in Scandinavia.
Clearly, other factors are at work here. That doesn’t mean you should cut down on calcium. But don’t count on it to do the job alone.
If you do choose a calcium supplement, keep in mind that calcium citrate may be taken with or without food, but calcium carbonate is absorbed best if taken at mealtime. 783 Many sources recommend taking 300 to 500 milligrams of magnesium with the calcium supplement.
Drugs to Treat Osteoporosis
Calcium supplements may be necessary but not sufficient against bone loss. Joel Finkelstein, MD, of Massachusetts General Hospital, has suggested that supplements of calcium plus vitamin D should be thought of as the ante for a poker game: It’s the bare minimum if you are going to play.784 Most of the drug treatments for osteoporosis work best if a person gets adequate amounts of these nutrients as well.
Low-Dose Estrogen (Menostar)
Women used to be told that once they reached menopause, they needed to take hormone replacement therapy to keep their bones strong. The idea was that they would be on estrogen (plus progesterone, unless they had undergone a hysterectomy) for decades and that this would prevent osteoporosis and the resulting fractures.
The findings of the WHI threw the wisdom of that simple approach into question. Although hormone replacement therapy (HRT) did cut the risk of hip fracture by more than 30 percent, it increased the risk of coronary heart disease, stroke,
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and breast cancer. After these findings were released, many women decided that they were more concerned about heart attacks and strokes than broken bones. So they stopped taking their HRT.
Since then, clinicians have been trying to find a way to get the benefits of HRT without all the risks. One way to do that is Menostar is a relatively new ultra-low-dose transdermal estrogen patch. It can increase bone mineral density and has been approved for preventing osteoporosis in postmenopausal women. Menostar comes as a patch applied to the belly. Each one lasts a week.
Side effects: Redness or irritation under the patch. Estrogen has a number of side effects, such as blood clots, stroke, increased risk of breast or endometrial cancer, and gallstones. It is not clear to what degree Menostar will cause estrogenic side effects.
Downside: No evidence that Menostar will prevent fractures; no long-term data on cardiovascular safety
Cost: About $50 a month
with an estrogen-receptor modulator such as Evista (see page 517). Another way might be with a different form of estrogen. In 2004, the FDA approved a low-dose estrogen patch to prevent osteoporosis, This transdermal patch, called Menostar, releases 14 micrograms of estrogen as (17-beta)-estradiol a day. This form of estrogen is different from the mixture found in Premarin or Prempro but the same as that found in some other estrogen pills for postmenopausal women. Estrogen is absorbed well through the skin, so the dosage delivered in a skin patch can be a lot lower than the dosage in a pill.This dose is quite a bit lower than those of other commonly prescribed estrogen patches used to treat menopausal symptoms.”
Menostar is not for treating menopausal symptoms such as hot flashes or vaginal dryness. It is not for use by women who already have osteopOCOSis with vertebral fractures. But for women whose bone mineral density is low or who are at risk for developing osteoporosis, Menostar might be one way to try to get the bone benefits of estrogen while sidestepping the cardiovascular risks.
The research done on Menostar indicates that it is not likely to cause problems in the uterus, even though there is no progesterone in the regimen to protect the uterine lining.” It does increase bone mineral density, particularly in the spine, better than placebo. 718 There are not enough data to indicate whether women using Menostar are less susceptible to fractures, either of the spine or of the hip.
The bottom line on Menostar is that women who choose to use it at this time should recognize that in some respects they are experimenting. There are still some important facts about its potential long-term benefits and risks that need to be clarified.
Raloxifene (Evista)
Raloxifene (Evista) was specifically designed to be as much like estrogen as possible in its effects on bone and unlike estrogen in many other ways. The researchers who developed this selective estrogen receptor modulator, or SERM, were hoping that it would strengthen bone and prevent fractures as hormone replacement therapy seems to, but that it would not increase the risk of uterine or breast cancer as HRT does. They were largely successful in their efforts. This medication does reduce the risk of fractures in the spine, although it does not seem to have much impact on hip fractureS.719
Because any osteoporosis drug must be taken for many years, a study considered the safety of raloxifene over a period of 8 years and found that it did not increase the risk of heart attack, stroke, uterine cancer, or ovarian cancer.7 90 Like HRT, raloxifene increases the risk of blood clots forming in
.,
**** Raloxifene (Evista►
This pill strengthens bone and is especially effective at preventing fractures in the spine. It is approved both for preventing and for treating osteoporosis. In addition, raloxifene can reduce the risk of invasive breast cancer in high-risk (postmenopausal) women by approximately 50 percent.
Side effects: Blood clots, vaginal dryness, hot flashes, joint pain, leg cramps
Downside: Raloxifene does not appear to have a significant effect on hip fractures. In addition, it does not reduce the risk of noninvasive breast cancer.
Cost: Approximately $75 for a month the veins. In fact, this drug increases the risk of fatal strokes as well as dangerous blood clots.19′ As a result, doctors and patients need to weigh its benefits—reducing the risk of spinal fractures and of invasive breast cancer—against the possibility of a blood clot or a stroke.
In the spring of 2006, scientists announced that Evista had performed well in the STAR trial, the Study of Tamoxifen and Raloxifene for preventing breast cancer.The women who had volunteered for this National Cancer Institute–sponsored study were at increased risk of developing breast cancer. Both drugs reduced their likelihood of a breast cancer diagnosis by about 50 percent. Women who took raloxifene were less likely to experience blood clots, cataracts, or uterine cancer than those given tamoxifen.
‘Me investigators concluded that women who had already taken tamoxifen for 5 years following treatment for breast cancer would get no further benefit from taking raloxifene. Women who had not taken tamoxifen but were at high risk of breast cancer could get two benefits—breast cancer prevention and osteoporosis treatment—in one pill if they took raloxifene instead.
Actonel, Boniva, and Fosamax
All three of these osteoporosis drugs fall into the category called bisphosphonates. Alendronate (Fosamax), ibandronate (Boniva), and risedronate (Actonel) work by slowing down bone resorption. They zip to places where bone remodeling is going on and mess with the osteoclasts so that these bone-wreckers work more slowly. Usually, that is enough to give the osteoblasts a chance to catch up a bit on bone formation.
Fosamax was the first bisphosphonate to be developed and approved by the FDA for treating osteoporosis. It has been available for more than 10 years in this country. Women who have taken it for that long have Continued to increase their bone mineral density. Although it was originally prescribed as a once-daily pill, the inconvenience of getting up early enough to take it an hour before breakfast or even coffee and juice, as advised, cut down on its popularity.Taking Fosamax with anything other than plain tap water reduces the amount that is absorbed and lessens its effectiveness. Changing the regimen so that it is taken only once a week, and only half an hour before breakfast, has made it easier for women to follow the doctor’s orders.
The effectiveness of all of the bisphosphonate medicines is clearest in people who are at highest risk: those who already have osteoporosis, particularly those who have experienced one or more fractures. The bisphosphonates are not hormones and don’t work through the same mechanisms as hormones. As a result, presumably they would be equally effective for men and women with osteoporosis.
Many of the studies that have been done on the bisphosphonates involved only women. Among a group of women who’d already had one vertebral fracture, Fosamax cut the number of hip fractures in hal E792 A head-to-head trial of Fosamax against Actonel showed that Fosamax had a slight edge. Subjects taking once-a-week Fosamax had higher bone
*** Alendronate (Fosamax)
Alendronate works by slowing bone resorption. It is commonly given once a week. It must be taken with 8 ounces of plain tap water, not mineral water, at least 30 minutes before eating or drinking anything else. The patient must remain standing or sitting during that time to keep the pill from lodging in the throat, where it can cause damage.
Side effects: Digestive disturbances, including heartburn, esophageal irritation or inflammation that can become severe, stomachache, and diarrhea; severe bone, joint, and muscle pain; osteonecrosis of the jaw, a rare but serious complication following tooth extraction, root canal, and other significant dental procedures; inflammation of the eye, resulting in blurred vision, eye pain, conjunctivitis, uveitis, or scleritis
Downside: Although alendronate has been around for more than 10 years, some of the more worrisome side effects are just now coming to light. No one knows how this drug will affect bone in the long term. Could the increased mineralization of bone end up making bones more brittle instead of stronger? As yet, there are no good answers to this ques- tion.’93
Cost: Approximately $77 per month, a little more than Actonel ($72) and Boniva ($74)
mineral density scores and were less likely to have lost bone than subjects taking once-a-week Actonel. ‘9′
A 3-year study of more than 9,W) women with osteoporosis found that Actonel reduced hip fractures significantly, from 3.2 percent in the placebo group to 1.9 percent in the Actonel group!95′Ibis study found no significant benefit among women who did not actually have osteoporosis but were included because of their age or other risk factors. Boniva, which is given just once a month rather than once a week, can increase bone mineral density. In a study that included nearly 3,000 women with at least one vertebral fracture, Boniva significantly reduced the number of new vertebral fractures.7 It did not reduce the rate of hip fractures or fractures elsewhere besides the spine, however.
A few complications of bisphosphonates that are especially worrisome have been getting significant attention lately. Some people taking Actonel or Fosamax have developed osteonecrosis of the jaw, a condition in which part of the jawbone dies. This seems to be an uncommon side effect, but it is frightening because there is no good treatment for it. Most of the cases reported so far have occurred after tooth extraction or some other major dental procedure. There is no indication that Boniva would be exempt from this issue.
If you are taking any of these drugs for osteoporosis, be sure to tell your dentist and your endodontist about it. We don’t know yet if discontinuing the medication for some months before a dental intervention would reduce the risk of this unusual adverse reaction.
TWo other concerns that have come up with the bisphosphonates are severe joint, bone, or muscle pain, and eye inflammation. ‘Me eye inflammation may affect vision. In one case, 7 the only way to control it was to discontinue the medica- tion. 97 Be sure to discuss your osteoporosis medication with your eye doctor, particularly if you notice any problems with ynx VWion.
The joint or muscle pain required narcotic pain relievers in some cases. The confirmation that it was related to the osteoporosis drug came when drug treatment was stopped and the pain went away—but when the drug was restarted, the pain returned.
Teriparatide (Forteo)
Currently, there is no other osteoporosis drug like teriparatide (Forteo). It is a genetically engineered copy of the active part of parathyroid hormone. This hormone, which is produced by a gland in the neck right next to the thyroid, governs the body’s utilization of minerals such as calcium. Like most of the human endocrine glands, it operates on a feedback system and shuts down when it senses there is enough calcium in circulation. If it senses too little, it stimulates bone breakdown to liberate calcium.
If the hormone stimulates bone breakdown, how can it help treat osteoporosis? Forteo—which is given by injection—is active for only a short time, reaching maximum concentration after about 30 minutes and disappearing completely within about 3 or 4 hours. 799 When the hormone is administered in this kind of short pulse, the body responds by building bone. Forteo is the only osteoporosis drug currently in use that stimulates bone formation.
Studies have shown that Forteo can increase bone mineral density in the spine and the hip. It also reduces fractures in the spine and elsewhere. It performs significantly better than placebo in men as well as women. In a small head-to-head trial against Fosamax, Forteo increased the bone mineral density of the spine by about twice as much and reduced fractures in places other than the spine significantly more than Fosamax did.8w
The FDA has approved Forteo to treat osteoporosis in men and women. It sounds great, but of course there are drawbacks. Side effects with Forteo are mostly mild: nausea, dizziness, headache, and leg cramps. It is given by injection, so redness and swelling may rarely occur at the injection site. A patient just starting on Forteo may experience “orthostatic hypotension,” or dizziness if she stands up suddenly. Fortunately, this side effect usually goes away within a couple of hours.
The big worry with Forteo involves its long-term use. Studies in rats have shown that this drug increases the rate of a bone cancer called osteosarcoma. This may have factored in to the FDA’s decision to limit use of Forteo to 2 years. The medication is so new that no one has a good handle on what the long-term. effects will be, but so far no cases of osteosarcoma have been reported in humans using the drug. 801
Another disadvantage of Forteo is that it must be in-jected every day. It comes in a self-injectable “pen,” and the shot is administered in the thigh or belly. Each pen lasts for a month and needs to be kept in the refrigerator.
In comparison to other treatments for osteoporosis, Forteo is extremely expensive. A single month’s treatment can cost $750 to $800. Given all these negatives, we think Forteo might best be reserved for people whose risk for adverse events with other osteoporosis treatments is too high.
Calcitonin (Miacalcin)
Another hormone that may be prescribed to treat osteoporosis is calcitonin. It, too, is made by the thyroid gland. It binds to osteoclasts and slows down their bone munching. It also helps regulate the action of vitamin D and works together with parathyroid hormone to control the balance of calcium and phosphorus within the body.
Salmon calcitonin can be given either as an injection or in a nasal spray. It can reduce fractures of the vertebrae significantly more than placebo. Some scientists have suggested that it may relieve back pain, which is frequently a serious problem for women whose osteoporosis has caused numerous fractures of the vertebrae. There is no solid consensus on this issue, however. 802,803
** Calcitonin (Miacalcin)
Calcitonin is given not to prevent but to treat osteoporosis. In women who already have at least one fractured vertebra, Miacalcin is significantly better than placebo at preventing additional spinal fractures. Some studies suggest that it helps alleviate back pain by stimulating production of beta-endorphins, the body’s natural opiates.
Side effects: Nausea and vomiting, flushing, redness or soreness at the injection site, rash, reduced appetite, severe allergic reaction; runny nose and nosebleed may occur with the nasal spray
Downside: Expensive. It does not appear to have a substantial effect on preventing hip fractures.
Cost: Nasal spray, $95 per bottle; injection, $45 for 2 milliliters (a 4-day supply)
Conclusions
When it comes to preventing broken hips and painful spinal fractures, there is no single treatment that stands head and shoulders above the rest. Each has benefits and disadvantages. People at risk for osteoporosis will need to think about the issues that might affect their treatment and their ability to stick with the program.
Even when the primary goal is prevention by getting adequate calcium and vitamin D together with exercise (and we strongly encourage that for everyone who can do it), the studies show that nutritional supplements are effective only if people actually take them all the time. Surprise! So consider whether you will take a pill or an injection every day, or if you’re better off with once-a-week or even once-a-month therapy.