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Osteoporosis Answers

Online Health Chat with Johnny Su, MD and Andrea Sikon, MD, FACP

May 9, 2014

Description

An estimated 10 million Americans have osteoporosis. Another 34 million have low bone mass. If left untreated, osteoporosis can be both debilitating and painful. Fortunately, there are steps you can take to prevent osteoporosis from ever occurring. Or, if you already have the disease, early detection and proper medical care can help you slow or even reverse its progress and prevent fractures.

Osteoporosis is a disease that weakens bones, making them more susceptible to sudden and unexpected fractures. Literally meaning “porous bone,” it results in an increased loss of bone mass and strength.

Although we do not know the exact cause of osteoporosis, we do understand how the disease develops. When osteoporosis occurs, the bone’s architecture is altered resulting in a weakened internal structure of the bone. Fortunately, osteoporosis can be prevented, detected and treated.


About the Speakers

Johnny Su, MD, is an associate staff physician in Cleveland Clinic’s Department of Rheumatologic and Immunologic Disease. He is board-certified rheumatologist and internal medicine. He has specialty interests in osteoporosis, general rheumatology and related conditions. Dr. Su completed a fellowship in rheumatology at University Hospitals of Cleveland following his residency in internal medicine was at Case Western Reserve University – University Hospitals of Cleveland. He graduated from medical school at University of Michigan Medical School, Ann Arbor, Mich. Dr. Su sees patients at Cleveland Clinic main campus and Twinsburg Family Health Center.

Andrea Sikon, MD, FACP, is the Chairman of Cleveland Clinic’s Department of Internal Medicine and Geriatrics within the Medicine Institute. She is board-certified in internal medicine. She also has an appointment with the Women's Health Institute, practicing in the Center for Specialized Women's Health. Dr. Sikon was named in Best Doctors in America from 2007-2013. She was the Inaugural Director of Primary Women’s health in the Medicine Institute from 2008-2010, and Director of Cleveland Clinic Staff Mentorship 2008-present. She received the National Committee for Quality Assurance Diabetes Recognition Award in 2010, and Scholarship in Teaching Award from Case Western Reserve University School of Medicine in 2011. Dr. Sikon completed her residency and internship in internal medicine at Mercy Hospital of Pittsburgh, in Pa. She graduated from medical school at Northeastern Ohio Universities College of Medicine, in Rootstown, Oh. In addition to her work around practice redesign and making care truly patient centered, Dr. Sikon has had a longstanding interest in quality improvement with clinical special interests within Women's Health. In the Center, she specializes in osteoporosis, menopause, irregular bleeding, preconception planning, and contraceptive management. Her other specialty interests include diabetes, hyperlipidemia and hypertension.


Let’s Chat About Osteoporosis Answers

Moderator: Welcome to our chat today with Dr. Johnny Su and Dr. Andrea Sikon. We are thrilled to have them here with us to share their knowledge about osteoporosis.

Let's start with your questions.


Osteoporosis Diagnosis

smilesun: Beside bone fractures, what are other medical risks are considered after being diagnosed with osteoporosis? Can osteoporosis be reversed?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: Breaking a bone is the most important and worrisome consequence of having osteoporosis. Indirect consequences of breaking bones, like altered gait, blood clots, bed sores, lung conditions and gastrointestinal issues— and even death, can all occur as well as depression that comes from a loss of independence and mobility. Osteoporosis can be treated very effectively. As bone density is the major way in which we "measure" osteoporosis objectively, we are limited in knowing if it is actually treated or reversed, since bone density is only a component of what makes up bone strength. People can break bones due to osteoporosis despite a normal bone density, a condition known as "clinical" osteoporosis. Furthermore, the risk of breaking a bone while taking bisphosphonates goes down disproportionally with only slight relative improvements in bone density.

Kronos: I am a 65-year-old man who has had a heart transplant three years ago. I currently take 7.5 mg prednisone daily, and I have osteoporosis. I am currently on Reclast® (zoledronic acid). My last bone density test score for right femoral neck was T-score -1.7 and Z-score -0.6. I have neck pain. Could it be caused by the osteoporosis?

Johnny_Su,_MD: Osteoporosis is likely not the cause of the neck pain. Osteoporosis does not cause any pain symptoms unless a person has fractured a bone in that area. You should follow up with your primary care physician regarding the neck pain.


Bone Loss Due to Other Medical Conditions, Medications and Treatment

megr: What medical conditions lead to bone loss?

Johnny_Su,_MD: Common medical conditions that lead to bone loss include hyperparathyroidism, hyperthyroidism, vitamin D deficiency, inadequate calcium intake, and lack of weight-bearing activity (i.e., patients in bed or in wheelchairs), and use of medications such as steroids (i.e., prednisone).

donnarush: What does it mean if a reading suggests secondary bone loss?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: This is very important for your doctor to pursue. Secondary causes are many and mean osteoporosis that is being caused by another condition or medication, rather than primary osteoporosis that is caused by genetics, aging, etc. Without identifying and treating secondary causes, continued bone loss is likely to occur. There are many examples of secondary causes, some common and some more rare conditions. Examples are inflammatory conditions like rheumatoid arthritis, premature menopause, testosterone deficiencies, kidney failure, etc.

megr: I use an elliptical six days a week for 50 to 60 minutes on level 18 on the random setting. I am still losing bone mass in my hips and spine. I also use eight and five lb. weights daily. I take calcium called Bone Strength Take Care® daily and drink one glass of almond milk daily that has 45 mg calcium. What else can I do? I eat a green salad almost daily and eat Brazil nuts to get magnesium. I had radiation treatments for breast cancer in 2005 and then I took an aromatase inhibitor for five years. I have had knee surgery, so it was suggested that I not use a treadmill. I thought the elliptical was just as good as my primary care physician said it was. I am willing to use a treadmill if that is what it takes to build bone mass. Can you help, please? Oh, I'm also 69 years old and very active.

Johnny_Su,_MD: If you are still losing bone mass despite everything that you are doing, medical evaluation needs to be done for other medical conditions that contribute to bone loss other than postmenopausal osteoporosis and decrease in bone mass due to aromatase inhibitor.

donnarush: I was diagnosed with squamous cell cancer of my anal canal last May. I went through 25 radiation treatments and two rounds of chemotherapy. A few years ago, my vitamin D level was 49. Now it is at 28. Two years ago, I was diagnosed with osteopenia. I have gone through menopause over six years ago. I am now diagnosed with severe osteoporosis with a Z score of -3.4. I also have a compression fracture of L5. Given the fact the radiation treatments surrounded this area, could radiation and chemotherapy be contributing factors for this drastic bone loss? I am 56 years old and very active. I don't understand all of this. Please help.

Johnny_Su,_MD: I am assuming your diagnosis of osteoporosis is based on a T-score of -3.4 and not a Z-score of -3.4. Radiation exposure of bone could contribute to abnormalities of the bone—including a decrease in bone mass. Your decrease in bone mass may be more related to the accelerated bone loss that women go through within the first five years after menopause (cessation of periods) rather than radiation exposure. A medical evaluation for other health conditions that may contribute to accelerated bone loss is also warranted.

MsFit123: I have been told my bones are very deficient in calcium. Yet I have been an avid exerciser (weight lifting and “cardio” aerobic exercise) for decades and eat a good diet. I am unable to take any more Boniva® (ibandronate sodium) or Fosamax® (alendronate) as I had a bad reaction in my jaw. I am currently taking 1,000 units of vitamin D and 1,200 to 1,500 mg calcium daily. Is there anything else I can do to strengthen my bones? I am very frustrated by my poor test results.

Johnny_Su,_MD: If your bone density shows that your bones are weak and your calcium intake and exercise regimen are both adequate, there may be other medical conditions present that may contribute to weak bones, such as hyperparathyroidism, hyperthyroidism, and low vitamin D level. Conditions such as these and others can be evaluated initially through the performance of blood tests. Before excluding the possibility of taking medications in the same family as Fosamax® and Boniva®, I would make sure to confirm that the reaction you had in your jaw was truly related to the medication and not coincidence. If it was truly a reaction to the medications, there are other medication families that can be used to treat weak bones.

Uncertain: How does one balance bone loss from taking Arimidex® (anastrozole) with a diagnosis of osteoporosis?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: I realize that being diagnosed with breast cancer can be devastating and the last thing anyone in that circumstance wants is to get another medical condition from treatment. However, bone loss can be easily prevented and/or treated with bone medication during treatment with Arimidex®. Additionally, bone density usually comes up after Arimidex® therapy is finished. I always advocate doing whatever you need to do to treat the cancer and we can easily treat your bones.

clara: Does calcium channel blockers such as verapamil and the blood thinner Plavix® (clopidogrel bisulfate) harm bones?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: Not that I know of. However, there are indeed a long list of medications that can impact bone, including commonly used medications like strong antacids (proton pump inhibitors, PPIs), SSRIs (serotonin specific reuptake inhibitors, which are antidepressants) and certain diabetes medications. A review of your medications with your doctor is a good idea and eliminating the use of any that are not critical should be considered at least annually. Some medications end up on our medication lists and never fall off. Some medications should be weaning off of, like long term PPIs, if appropriate.

mollie73: I take Keppra® (levetiracetam) and Vimpat® (lacosamide) for seizures. Do either of these drugs have an impact on your bone density?

Johnny_Su,_MD: Anti-seizure medications such as Keppra® and Vimpat® may potentially contribute to decreased bone density. However, if these medications are needed to treat seizures, the usual course of action is to treat low bone mass or osteoporosis if the patient has a problem with bone density on these medications rather than stopping the medication.

percussion: I have been taking Synthroid® (levothyroxine) and warfarin since 1995 and will continue for the rest of my life. How is calcium and vitamin D3 uptake affected by these drugs? I have been diagnosed with osteoporosis and do not take any medication at this time.

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: Hyperthyroidism (overactive thyroid) is a known cause of osteoporosis. Theoretically, if you were on too high of a dose of Synthroid® and /or required a suppressive dose due to treatment for a history of certain types of thyroid cancers, this could reduce bone density. Heparin therapy, but not necessarily warfarin, has been linked to decreasing bone density. If you have osteoporosis, you should have a tailored secondary evaluation, medical history review, and initiation of appropriate bone agents.

Yolandalmeyda: I have systemic lupus erythematosus for over 20 years. I am taking 5 mg prednisone, and sometimes I take up to 20 mg. My bone mass reduced to -1.5. I am getting my second Reclast® (zoledronic acid) injection. Do you have any other recommendation?

Johnny_Su,_MD: Reclast® infusions annually can be an effective medication to prevent further bone loss in someone with your medical history. It is also important to maintain adequate calcium intake between 1,200 to 1,500 mg daily for postmenopausal women and maintain adequate vitamin D levels based on blood test along with getting 45 minutes of weight-bearing exercise four to five times per week. If your prednisone dose is regularly over 7.5 mg daily, Reclast® may not be strong enough to maintain bone mass. Repeat bone density test annually is needed to determine trend in bone mass.


Osteopenia

pilatesgirl: What is the current thinking about osteopenia? What bone density numbers are signals for which treatment protocols?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: Some bone experts do not consider osteopenia a medical condition because it simply reflects low bone density. However, most individuals who break a bone have bone densities in the "osteopenic" range, as there are simply more patients who fall into this range than that of osteoporosis. Decisions to initiate bone medication need to be individualized for every patient. However, there is an online internationally available tool developed through the World Health Organization, called the FRAX® (fracture risk assessment tool), which helps to guide when and in whom therapy should be started in patients with osteopenia. It has limitations though in how it was created. Thus, it must be interpreted as a guide and not a definitive answer for every person nor a replacement for clinical individualized judgment.


Bone Density Testing

Gail Ann: I have a family history of severe osteoporosis. I would like to have a bone density test done yearly. My doctor disagrees. What time frame would you suggest for having this test? I am willing to pay out-of-pocket for the test, if necessary.

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: It is great to be proactive. However, bone densities usually change a small amount annually, thus more frequent testing is not necessarily better testing. This is why bone density testing is not recommended more than every two years for most patients unless you have certain high risk conditions (like long-term steroid use). I would concentrate mostly on reducing the modifiable risk factors that you can control, i.e. not smoking, exercising, limiting alcohol, etc.


Osteoporosis T-Scores

Uncertain: Is T-score always a measure of bone density, or does it also indicate bone strength? Which most predicts future fractures?

Johnny_Su,_MD: T-score is a measure of bone density which we use as an approximate measure of bone strength. Currently, we use a combination of a bone density measurement at the femoral neck along with risk factors to predict risk of future fracture using a WHO (World Health Organization) tool called FRAX® (fracture risk assessment tool), which allows us to predict risk of major osteoporosis fracture and hip fracture over next 10 years.

Uncertain: How severe is bone loss with T-scores in the -2.8 range?

Johnny_Su,_MD: When discussing osteoporosis, we generally categorize osteoporosis into regular osteoporosis and severe osteoporosis (i.e., a T-score less than or equal to -2.5 and fracture related to osteoporosis). In looking at T-score of -2.8, your bone mass is less than lowest 1.25 percent of normal healthy population with regard to bone mass.

cyn3: Is a T-score age adjusted? If I have a -2.5 in my 60’s and my mother has the same -2.5 in her 80's, are we at equal risk or is her risk of bone fracture higher?

Johnny_Su,_MD: T-score is not age adjusted. T-score compares a person's bone density to a health normal individual. An older individual with the same T-score as a younger individual has a higher risk of fracture.


Medications for Osteoporosis

Gail Ann: In your opinion, which of the prescription medications for osteoporosis is the safest (with the least number of side effects)?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: I honestly think that this is a highly individualized answer and cannot be answered in a blanket way. Most of them are incredibly safe even compared to medications used to treat blood pressure, cholesterol, etc. with very few side effects. Direct comparative head-to-head trials are extremely limited and thus limit our ability to say which one is more effective than the other. I recommend an individualized review of your full medical history to determine what is best for you.

Marie1: I am a patient with lots of allergies and sensitivity to drugs. Regarding the osteoporosis for which I have been treated for many years. I have tried Fosamax® (alendronate), but it caused esophagus problems. Actonel® (risedronate sodium) caused burning in my chest area and upset stomach. Intravenous Boniva® (ibandronate sodium) caused jaw and ear problems. Forteo® (teriparatide) caused my pulse rate to go up to 152, and Miacalcin® (calcitonin-salmon) which I returned to taking, and now I am told I cannot take it as it causes cancer. I am wondering if you have any suggestions except for calcium and vitamin D? My medical history at this time includes POTS (postural orthostatic tachycardia syndrome), chronic lymphocytic leukemia (CLL), heart valve problems and bronchiectasis.

Johnny_Su,_MD: Possible treatment options include Prolia® (denosumab) if you are not currently undergoing chemotherapy for treatment of leukemia. Intravenous Reclast® (zoledronic acid)—another bisphosphonate like Boniva®, Fosamax®, and Actonel®—is also a possibility since adverse reaction with one medication in one family does not necessarily imply same reaction with another medication in the same family.

Uncertain: How common are the severe side effects of Prolia® (denosumab) injections? Are there alternative medications after using Fosamax® (alendronate) and Actonel® (risedronate sodium) for 10 years?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: In my experience with Prolia®, side effects related to it are very rare. I personally generally avoid using it though in patients who have frequent infections or have suppressed immune systems. There are several other treatments for osteoporosis available and choosing between them requires a personalized approach with a review of your specific medical history to choose the best option for you. Additionally, you may qualify for a drug holiday after 10 years of a bisphosphonate without the need for any prescription medication for a number of years. You would need to be monitored during that time to ensure you are not experiencing significant bone losses and/or breaks.

Uncertain: Is Prolia® (denosumab) considered the "preferred" treatment after using Fosamax® (alendronate) and Actonel® (risedronate sodium). If so, why?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: Not necessarily. The concepts of drug holidays have been discussed in this health chat. Sometimes, patients can be followed completely off of any bisphosphonate after three to five years of use. Sometimes they need to go back on a bisphosphonate after that interval of being off of it if their density starts to drop again and/or they break a bone. Sometimes they should be switched to an alternative form if they are thought to need another agent after a holiday and/or are on it and thought to be failing therapy.


Medications for Osteoporosis (Prolia®)

Elizabeth: Can you kindly address the safety of Prolia® (denosumab)? Isn't it likely to cause problems—even cancer—if it allows the building of bones, but prevents the elimination of old bone?

Johnny_Su,_MD: Overall, Prolia® (denosumab) is a safe medication. It works mainly by reducing the resorption of bone, but does not prevent its elimination altogether. Over time, there is an increase in bone mass. The most common side effects of Prolia® are joint pain, back pain and arm and leg pain, which occur in up to 12 to 14 percent of individuals. Cancer risk for the medication is three to five percent.

Uncertain: I have osteoporosis of the spine (-2.9 T-score), left and right femoral necks (-2.6 T-score) and total hip -2.0. I have already been on Fosamax® (alendronate) for more than five years, and then Actonel® (risedronate sodium) for more than five additional years. Following breast cancer surgery and radiation, I was put on Arimidex® (anastrozole) for the past six years, which further compromises bone health. My oncologist wants to put me on an injection of Prolia® (denosumab), but I am afraid of all the terrible side effects it can cause. Can weight-bearing exercise, diet and calcium supplements alone—without Prolia®—arrest further bone loss? Can I wait to see if my bone density numbers worsen before taking Prolia®? Is there any alternative drug that is safer with fewer side effects? Breast cancer recurrence prevention vs. osteoporosis prevention is a dual edged sword.

Johnny_Su,_MD: Given that you have already been on treatment with either Fosamax® or Actonel® for more than 10 years, as long as your bone density is stable and you have not broken any bones related to osteoporosis, additional treatment may not be necessary. If you are remaining on Arimidex®, consideration can be given to initiation of Prolia® even if bone density is stable and you have not broken any bones. Exercise, diet and calcium supplement help to prevent bone loss, but sometimes are not enough.

Valpat: What is the latest research on the half life of Prolia® (denosumab) and its long-term effects on one's immunity health and bone health, including osteonecrosis of the jaw (ONJ) and brittle bones that result in abnormal thigh fractures?

Johnny_Su,_MD: The half life of Prolia® is about one month. Currently, there are patients on Prolia® for more than eight years without any long-term implications with regard to immunity and brittle bones with atypical fractures of the hip and ONJ. There is no consensus opinion that Prolia® needs to be stopped at any time due to this risk in terms of the patient population as a whole. Obviously, if one of these adverse effects occurs in an individual patient, the medication would need to be discontinued if it was believed to be a possible cause.

Uncertain: Will exercise, diet and calcium supplements stop bone loss? Are the serious side effects of Prolia® (denosumab) common, and are there alternative medications to arrest the progression of osteoporosis?

Johnny_Su,_MD: Exercise, diet and calcium supplements are important to preventing bone loss but by itself may not be sufficient to stop bone loss. The most common side effects with Prolia® occur in up to 15 percent of individuals who use the medication. Serious side effects generally occur in five to 10 percent of individuals who use the medication. Alternative medications for the treatment of osteoporosis include bisphosphonates i.e. Fosamax® (alendronate), Actonel® (risedronate sodium), Boniva® (ibandronate sodium) and Reclast® (zoledronic acid) along with Forteo® (teriparatide) (daily injectable medication for osteoporosis).


Medications for Osteoporosis (Bisphosphonates)

JuneLa: We know that in patients with osteoporosis who are taking bisphosphonates, the bone is less thin, but it does not have the same quality as new bone because more old bone cells remain. What are the implications of this for healing after any surgery that involves the breaking of bone? And specifically, what are the implications for open heart surgery in which the sternum is cut open?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: Bisphosphonates have definitively have been shown to reduce fractures. I believe that studies show that treatment of osteoporosis, including treatment with bisphosphonates, can accelerate healing after fractures, i.e. breaks. Discuss these specific concerns with your surgeon.

Bones75: I was on Fosamax® (alendronate) for four years and I was then taken off the medication. After two years, my bone density numbers declined substantially. I am back on Fosamax®. What are the risks of being on this medication for longer periods of time? I am currently taking calcium with vitamin D, and exercising. Are there other things I can do to prevent this continued decline. I am 57 years old.

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: It is common and often recommended now to consider a drug holiday after three to five years of bisphosphonate therapy, as this particular class of osteoporosis medications incorporate into the bone for a long period of time. Drug holidays, which mean stopping the drug for some interval of time—usually years, came about due to growing evidence that the extremely uncommon untoward conditions of osteonecrosis of the jaw and atypical femur fractures become more common with longer durations of treatment. Monitoring should occur, as it sounds like it did in your case, during such drug holidays to ensure that you do not begin to lose too much bone off of the medication. Whenever there is recurrent loss, testing to exclude other causes of the loss, for example secondary causes of osteoporosis, should be considered, even if they were done years prior at the time of the original diagnosis. Additionally, sometimes switching the form of bisphosphonates, such as to the intravenous form, may ensure better absorption of the medication and or switching to an alternative class of osteoporosis medication.


Medications for Osteoporosis (Forteo®)

cosmona: What are the side effects to taking a daily injection of Forteo® (teriparatide) for osteoporosis? Is this drug covered by Cleveland Clinic insurance?

Johnny_Su,_MD: The most common side effects to taking a daily injection of Forteo® is muscle aches, joint aches and bone pains. Most of the time, these symptoms are tolerable and treatable with Tylenol® (acetaminophen). Other side effects include high calcium level and high uric acid level. The most concerning side effect leading to a “black box warning” regarding osteosarcoma has never actually been confirmed to have occurred in patients on Forteo® and attributed solely to the medication. It is a warning because during the drug trials, the rats on Forteo® got bone cancer. However, doses the rats received were three to 60 times more potent than that being used currently to treat humans. Forteo® is covered by Cleveland Clinic insurance depending on your medical history and other drugs that have been tried or failed.

Valpat: I had surgery to remove a parathyroid adenoma in January and now have normal calcium and parathyroid hormone (PTH). Does the previous adenoma disqualify me from taking Forteo® (teriparatide)?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: Technically, if your PTH and calcium levels truly remain normal for extended periods of time, then you might qualify. However, two considerations come to mind. First, your bone density might come up significantly having treated the cause of the osteoporosis and low bone density—the hyperparathyroidism—and you may not need medication at this point. Secondly, sometimes parathyroid levels may increase again later on, and thus it would likely be avoided.

 

pilatesgirl: If someone has a family history of multiple myeloma, and bone and cartilage cancers, wouldn't Forteo® (teriparatide) be contraindicated?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: Teriparatide is not recommended for use in patients with bone cancer or those at higher risk for bone cancer, such as a history of Paget disease.

clara: I was on Fosamax® (alendronate) for 13 years. I went off of it two years ago, and now I am only taking Evista® (raloxifene). I did not get worse in the 15 years. Now I am on Forteo® (teriparatide). Can a person go back to or Evista® after Forteo®?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: Technically, you could return to any antiresportive medication after taking Forteo®. It is important to follow therapy with Forteo® with an anti-resportive, or you will likely lose the gains in your bone density from that treatment in the years after you stop it. However, Evista® has been found to be effective mainly at the spine and not to work as well at the hip. So if you have a low bone density in your hips, then it may not be the best medication. Additionally, a recent study did not necessarily support prolonged use of raloxifene beyond five years.

Valpat: What is your advice about the sequence of taking Forteo® (teriparatide) for three months followed by Prolia® (denosumab) and returning to Forteo® for another three months followed by another Prolia® injection to prevent the typical bone density loss when Forteo® is ended?

Johnny_Su,_MD: I would not recommend taking Forteo® and Prolia® in the sequence described in the question since it was not studied for use in that manner. I would recommend taking Forteo® for two years followed by Prolia®. Taking Prolia® following Forteo® should help prevent bone loss upon completion of Forteo®. Prolia® also helps build bone after two to three years of use and right now is being used indefinitely.


Treatment of Osteoarthritis with Rheumatoid Arthritis

cyn3: Background: I am a 60-year-old woman diagnosed with juvenile rheumatoid arthritis at the age of 13 years old. I have been on methotrexate and Synthroid® (levothyroxine) for years, and currently take Humira®, but no steroid usage. I was recently diagnosed with osteoporosis. I suffered 15 percent breakage of L1 about three years ago from a bad fall. In 2009 a front tooth broke and when I was getting an implant, bone resorption was noted. I have slightly elevated IgG but my calcium level is fine. With each doctor I get a different recommendation. Who should I trust, and who is the real expert? I started with a bisphosphonate when I reminded my rheumatologist of upper palate bone resorption and swallowing issues. With my gynecologist it was estrogen. I reminded him that my sister had estrogen-dependent breast cancer. With my endocrinologist it was Forteo® (teriparatide), but all my other doctors said not to use it as my osteoporosis was early stage. Now my new rheumatologist recommends Prolia® (denosumab). Plus, how does one know about side effects of combined drugs. Can Humira® cause additional risks? What about methotrexate or Synthroid®? Does calcium affect the heart?

Johnny_Su,_MD: Based on the available information, I favor treatment with Prolia®. There is theoretical concern about an increased infection risk with a combination of Prolia® and Humira®. Methotrexate does not increase the risk of osteoporosis. Synthroid® is fine as long as dosage is appropriate and not too high. Excessive calcium intake can increase cardiovascular risk. The recommendation is for a calcium intake of 1,200 to 1,500 mg daily between diet and supplements. If you would like a full evaluation, I recommend making appointment at Cleveland Clinic’s Metabolic Bone Center.


Medication Forms and Generic

megr: Is it better to get intravenous (IV) bisphosphonates rather than pills?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: That depends on a number of factors. Certainly, pills are much less expensive and thus more readily available than IV forms. Many of the bisphosphonate (BPS) pills can be taken at extended intervals, i.e. once a week and some once a month, to make them more convenient. There is also a once a year IV form that is considered more convenient by some, but some patients prefer the idea of taking a pill than getting something intravenously. BPS pills are unfortunately poorly absorbed, with less than one percent per dose, which is why they require patients to take them on a completely empty stomach with nothing else than water. Additionally, IV forms may be better for patients with relative contraindications to oral forms, such as esophagus or stomach ulcers, strictures, etc.

megr: Do you trust generic medication to treat bone loss?

Johnny_Su,_MD: Generic medications such as Fosamax® (alendronate) and Boniva® are both effective in treatment of bone loss in the form of low bone mass or osteoporosis.

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: I generally prescribe generic medications as these are the ones that most all insurance plans cover and are most affordable thus accessible for patients. Most do work, although generics only have to be as effective or equivalent to brand names by a percentage, which is not 100 percent. Thus, I personally start with generic medications most times. If a patient does not seem to be responding appropriately, I would either consider an alternative form (i.e., intravenous vs. oral), a different brand or using the brand name.


Osteoporosis Prevention and Improving Bone Health

health4me: I am a 38-year-old female with a strong family history of osteoporosis that at least dates back to my great-grandmother. I have rheumatoid arthritis (RA) and fibromyalgia as well, but have not entered menopause yet. I have only had one short course of prednisone in my life. All females in my family have had multiple fractures. My mom broke her hip when she was 64 years old and had full-blown osteoporosis at 50 years old. I do all the right things in terms of working out, vitamins, and diet. I already have degenerative conditions noted in my back with two herniated discs and in my hips. Is there anyone doing research on the prevention of osteoporosis before menopause or other more aggressive monitoring techniques that can be suggested? My gynecologist indicates that insurance will not pay for a bone density before the age of 50 years old, even with known risk factors.

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: It is great that you're being proactive. Unfortunately, rheumatoid arthritis is an inflammatory condition that in and of itself increases the risk for osteoporosis outside of the prednisone that is often used to treat it as well. Minimizing other risk factors, such as not smoking, doing weight-bearing exercise, and minimizing alcohol, as you are already doing, may be some prevention you can do. Adding activities that maximize your balance to minimize falls will become increasingly important as you age. So, staying physically active as you get older despite your medical conditions will be critical. Remember, thankfully not everyone who has osteoporosis breaks a bone, which is the end result that we really care about related to osteoporosis. If genetics trumps your prevention efforts, it does not necessarily mean that you will suffer the consequences of osteoporosis, i.e. fracture. Insurance may well cover a bone density premenopausally if you have RA. However, sometimes the results can be challenging to interpret at this time. You may also consider hormone therapy if appropriate upon menopause transition to help prevent bone loss typical with menopause. Also, be careful not to take too much calcium in the form of supplements. Some studies suggest that it could be harmful, although these are not definitive. Eating a calcium-rich diet is likely the best option. Taking vitamin D supplements is likely a good idea as it is not found readily in most foods.

Hershey09: I am a 20-year-old male with a complex health history. I was diagnosed with osteoporosis after being on hydrocortisone for 20 months. I was misdiagnosed with secondary adrenal insufficiency. I have been off hydrocortisone since August 2012, but my latest DEXA (dual-energy x-ray absorptiometry) scan in September 2013 showed no improvement. I have suffered two back injuries since September 2012 that have been attributed to my bone health. I am on 1,000 mg of calcium and 5,000 IU of vitamin D. I am exercising with weights and doing “cardio” (aerobic) exercises. What more can I do to improve my bone health? When should I expect improvement? What is the most important thing I can be doing to help my bones?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: It sounds as though you have been through a lot at such a young age. Your desire to be proactive is wonderful! It sounds as though you are doing a lot already to help improve your bone health. Bone density is not the whole contributor to breaks, so don't get too discouraged if you have not yet seen changes in bone density. Also, stability of density can be interpreted as treatment success at times too. Not smoking and minimizing alcohol to no more than one to two drinks per day are also other things you can do. You might consider seeing a physical therapist who specializes in osteoporosis to ensure that you are doing exercises and activities that will not harm your spine and bones, as some may need to be modified if you have had back issues in the past related to osteoporosis. They can give you a modification of your home program that ensures you can continue to be active, but in a safe way. Also, it sounds as though you should be following with a bone specialist who knows the details of your medical history and can provide more tailored recommendations for you through the years.

xdwl: How can a male prevent osteoporosis? Some articles say calcium supplements may increase heart attack risks, and milk may increase the risks of prostate cancer for males. My husband is over 60 years old. He only takes vitamin D3 400 IU daily now. He feels intermittent mild back pain. His doctor said men have a lower risk than women for the development of osteoporosis. Would you recommend a calcium supplement to men over the age of 60 years old? Would 600 mg of daily calcium supplement cause coronary artery or aorta calcification? How does one balance the benefits and risks?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: I applaud you for thinking about how to prevent osteoporosis in men, something we all often forget about! Men can get osteoporosis too and suffer similar consequences. In fact, men who break their hip die more frequently in the year following the break. The recommendation for calcium sufficiency in men is 1000 mg/day total, meaning total calcium taken in from one's diet and supplements. There is not definitive data to prove that calcium supplements cause heart disease or strokes. However, since calcium is readily available in many dietary foods, I generally recommend that everyone try their best to get their calcium intake through their diet, when possible, and save supplements only for those who cannot achieve this to make up the balance (as dietary sources have not been linked in any of the studies to increased risks.) I recommend searching the many online calcium calculators that are available to assess how much calcium is in your husband's current diet and seeing if you can make up the difference by eating more calcium-rich foods.

MGD: Are there any treatments or suggestions to help avoid deformities from osteoporosis?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: Deformities related to osteoporosis come from fractures, like the dowager's hump (hyperkyphosis) or stooped over stature that can result from vertebral (spine) fractures. Recall that osteoporosis is a completely different condition than osteoarthritis and other forms of inflammatory arthritis like rheumatoid arthritis, which can cause joint destruction and related deformities. All of the treatments we have discussed today would apply.

blw973: I had bilateral joint replacements done when I was 40 years old. I am now 59 years old and have had both hips revised. How can I maximize the strength of my femurs in order to keep my femoral stems intact?

Johnny_Su,_MD: I recommend getting a bone density test to assess bone mass to determine the strength of your bones to see if treatment is needed for low bone mass or osteoporosis. Otherwise exercise to maintain strength and conditioning of your leg muscles would also be beneficial. Additionally, getting enough calcium in the diet and maintaining adequate vitamin D levels are also important.

pilatesgirl: If someone has celiac disease from childhood, which led to lower bone density from the beginning, how might one improve bone health? Would better nutrient absorption be too late?

Johnny_Su,_MD: If absorption is an issue, improving nutrient absorption at any time is always better than having poor absorption. Maintaining adequate calcium and vitamin D intake (including taking in higher amounts to make sure that enough is absorbed as long as there are no side effects) and exercise play even bigger roles. You also need to make sure that no other medical conditions are contributing to low bone mass. Obviously, if bone mass is low enough, treatment is indicated.


Nutrition, Calcium and Supplements

xdwl: I am a 56-year-old post-menopausal female. I used to take a calcium supplement 550 mg and drink milk daily. I stopped calcium two years ago because of calcification in my coronary artery and aorta. In addition, I read articles which said calcium may increase heart attack risks in women. I only drink and can tolerate skim milk now and take vitamin D3 400IU/day. My recent bone density shows femur average 0.928 g/cm2 (0.3 in same age group), and L1-L4 0.961 g/cm2 (-0.3 in same age group). Occasionally I have mild back pain. Should I resume calcium supplement and dosage? How do I balance the risks to my heart and benefits to osteoporosis in using a calcium supplement?

Johnny_Su,_MD: The recommendation for calcium intake is between 1,200 to 1,500 mg daily for bone health without increasing cardiovascular risk in terms of dietary and supplement sources combined. This means that between what you get in your diet and in the form of supplements should add up to 1,200 to 1,500 mg daily.

percussion: How much calcium is too much calcium? If you are eating greens daily, is a supplement necessary?

Johnny_Su,_MD: The recommendation for calcium is 1,200 to 1,500 mg daily between diet and supplements. Eating enough greens such as collard greens, spinach and broccoli may get you enough calcium if you eat enough. One cup of each of the greens mentioned is equivalent to 300 mg of calcium.

lucylou14: I have osteopenia. I have been on low-dose prednisone for many years to keep systemic lupus erythematosus in remission. Other than a dip at menopause, my bone density is stable. The treatments I had gave me side effects. Is Citracal® Maximum 630 mg with vitamin D 500 IU contraindicated for someone with kidney stones recently discovered upon checking a cyst in the kidney?

Johnny_Su,_MD: Taking Citracal® is not contraindicated for kidney stones unless there is too much calcium being excreted through the kidneys. This can be assessed based on a 24-hour urine test for calcium excretion. If there is too much calcium excretion, calcium supplements would be contraindicated.

Hershey09: What is the difference between liquid calcium and calcium tablets? Does one absorb better? Is one better for the stomach?

Johnny_Su,_MD: Liquid calcium is probably easier to take than calcium tablets for someone with difficulties swallowing. Calcium in the form of calcium citrate is better absorbed than in the form of calcium carbonate regardless of whether liquid or tablet form. Calcium citrate is also easier to absorb for those patients with stomach issues such as reflux or ulcers, and for those who are on medications such as Prilosec® and the like to treat those conditions.

lucylou14: Does drinking a lot of tea contribute to bone loss?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: Some studies have suggested a correlation between caffeine and osteoporosis, mainly in adolescents, but I do not believe those have been definitively linked. In general, for other health reasons, limiting any caffeinated beverage to two cups or less a day may be optimal.

sw4health: Is there any difference in the quality of calcium in dairy products (e.g., milk, yogurt, cheese, etc.) versus plant-based foods (e.g., broccoli, kale, soy/almond milk, etc.)?

Johnny_Su,_MD: At this point in time, I do not routinely make a differentiation between recommending calcium from dairy sources versus calcium from plant sources. Often times other medical conditions that a person is being treated for dictates which calcium source is better. For example, someone being treated for high cholesterol should not eat excessive cheese because this may increase cholesterol, so plant-based sources of calcium may be better in this type of patient.

Hershey09: What are the benefits of a gluten-free diet in terms of osteoporosis?

Johnny_Su,_MD: As far as I am aware of, there is no specific benefit to a gluten-free diet in terms of osteoporosis.

blw973: Are there nutritional supplements that can help increase bone density?

Johnny_Su,_MD: The only nutritional supplements that are recommended to the general population to maintaining or improving bone density is adequate calcium intake between 1,200 to 1,500 mg daily for post-menopausal women and men over 50 years old, and 1,000 to 1,200 mg daily for premenopausal women and men under 50 years old. Also, providing adequate vitamin D intake based on vitamin D level on blood test. No other nutritional supplements have been tested in a rigorous enough manner to warrant recommendation as routine care for increasing bone density.

health4me: What is the recommended dose of vitamin D?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: The Institute of Medicine has recommended a daily allowance of 800 IU daily for the generic general population. However, that amount was studied to get a majority of people to a low normal level of vitamin D—lower than what many healthcare providers believe is in a sufficient range. Vitamin D absorption and sufficiency is impacted by a number of factors, including advancing age, darker pigmentation, lack of sun exposure, and obesity all lowering levels and many people who fall into these categories need supplements. I advocate for monitoring blood levels of vitamin D, at least periodically, in patients who have osteoporosis and/or are on /were on osteoporosis medications.

cyn3: I use almond milk on my cereal (which is wheat based). Recently I read that wheat may alter the intake of calcium in the body, if the two are combined together. Is this true, and are there other situations, combinations of foods or other medications that would prevent proper calcium intake?

Johnny_Su,_MD: I am not aware that combination of wheat and calcium taken together would impact the absorption of calcium. The most common medications that impact the absorption of calcium are the proton pump inhibitors such as Prilosec® (omeprazole), Prevacid® (lansoprazole) and Nexium® (esomaprazole) that reduce amount of acidity in the stomach.

megr: Is calcium from algae effective?

Johnny_Su,_MD: Calcium from any source including algae can be effective in terms of calcium supplement.


Strontium Supplements

Valpat: I am considering strontium citrate and would like to know if its side effects outweigh its bone building benefits.

Johnny_Su,_MD: A medication called strontium renelate is available for use in Europe for treatment of osteoporosis. There have not been any large studies to test the effect of other forms of strontium supplements such as strontium citrate. Therefore it is not possible to comment whether it has bone-building benefits that outweigh its side effects. Also need to keep in mind that although strontium may increase bone density, it does not necessarily mean a reduction in the risk of fracture which is the goal of treatment.


Weight and Osteoporosis

cyn3: I always hear that thinner women are more at risk for osteoporosis. I could stand to take off 20 to 30 pounds. Will my weight reduction increase bone density loss?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: It is true that having a long-term low body weight can increase the risk of osteoporosis. However, studies have shown that unfortunately, excess weight does not necessarily protect women and men from getting osteoporosis. Additionally, as there are numerous other health reasons and conditions that can be improved/prevented from maintaining a healthy body weight, I advocate for the latter. In the end, it is about our overall health, quality of life and longevity.


Exercise Benefits

pilatesgirl: Can you provide a more complex understanding of weight-bearing exercise? I understand how walking might help feet and leg bones and hips, but for wrists would push ups be more appropriate? Does stretching movements that pull on sections of bone benefit bone health?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: This is a very insightful question. Bone density in the bones on one’s dominant side is usually higher than the non-dominant side. Weight-bearing exercise includes anything in which your skeleton is supporting your weight. Weight-bearing stimulates positive bone turnover. Scientists first discovered this when astronauts rapidly lost bone density when they traveled into space. However, I believe that some studies have shown that higher impact activities such as jumping have a greater impact than things like walking. Other types of activities, like tai chi and exercise that develops muscular strength and balance, are also incredibly important to reduce fracture risk as they reduce falls, but not necessarily from their ability to stimulate bone density.

paul5w: I have heard that jumping up and down for a few minutes several times a week helped to increase bone density. Is there any evidence to prove this works?

Johnny_Su,_MD: Any activity where a person is supporting their own body weight i.e. standing, walking, jumping up and down helps to increase bone density. However, if bone density is not normal, jumping up and down may lead to compression fractures of the spine. Usually this form of exercise is not the primary or only method recommended to maintain or increase bone density.

paul5w: I have osteopenia. I take calcium with vitamin D. I have been off Actonel® (risedronate sodium) for two years. I took it and Fosamax® (alendronate) for a total of 10 years). I do elliptical or treadmill six days a week. If I am in good shape and do jumping exercises landing softly on a mat, would that be okay? Would it strengthen my bones?

Johnny_Su,_MD: Weight-bearing exercises on the elliptical or treadmill is preferred to jumping exercises. Sometimes the pressure on the spine from jumping exercises can lead to compression fractures. You also need to make sure that your bone mass is remaining stable off Actonel®. Since you have already been on treatment for 10 years, drug holiday is warranted if bone density shows stable bone mass and no interval history of fractures while on treatment and since off treatment.


Novel Therapies and Research

Valpat: What new osteoporosis medications appear to be the most hopeful and when do you think they will be available to patients? What about romosozumab, cathepsin K inhibitors, and glucagon-like peptide 2?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: There are several potentially up and coming new therapies in the pipeline for osteoporosis. In fact, there have been more new medications for osteoporosis in the last decade then there were in the prior two decades. I do not think that any of these new ones are in the final FDA approval stages though. We are still waiting for them to pass through final phase studies before they are available for widespread clinical use. Additional studies are investigating the benefits of combinations and optimal serial use of existing osteoporosis therapies—another exciting new development.

Valpat: What is the latest research on which form of vitamin K2 is most effective for healthy bones—MK-4 or MK-7?

Johnny_Su,_MD: I do not know the answer to that question. My reason for a lack of an answer is that it is not fully established that everyone would benefit from vitamin K supplementation from a bone health perspective. All of the studies that looked at reducing fractures with vitamin K supplementation were done in Japanese patients, so applicability to the general population is questionable.

Valpat: What is the latest research with nitrates as a treatment for osteoporosis? I had read about a study that showed promise with a topical nitrate gel.

Johnny_Su,_MD: Based on preliminary studies, nitrates showed promise in terms of improving bone density. However, no studies have been done to show that it reduces risk of fracture. Therefore, currently it is not being used as a treatment for osteoporosis.

cyn3: In looking at what is available in terms of treatment, I see four areas: anti-resorptive drugs, anabolic-increase drug, proper calcium and vitamins D and K (nutritionals) or weight-oriented exercise. Are there any other areas of treatment in the pipeline of research for treatment?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: I would not necessarily see these as four separate areas, as ensuring calcium and D sufficiency and weight-bearing exercises are critical to treatment, regardless of which bone specific agent is also used. There are some medications in the research pipeline of drug development. The one I believe that is closest to market is another anabolic agent that works through a different mechanism than the only other currently available drug in the United States (i.e., teriparatide). Studies of other medications are in various phases of trials.

Valpat: Please comment about the effect of rebounding and also vibration plates to help bone density.

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: I have heard about the use of vibration plate studies, but am not aware about the very latest data on these. This brings me to my notion that weight-bearing exercise is good for bones, but some exercises may be better than others. Jumping exercises involve higher rhythmic impact to our bones vs. simply walking.


Osteoporosis Support Group

cosmona: Is there a support group for people under 50 years old diagnosed with osteoporosis in Cleveland Clinic or in the Cleveland area?

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: We have shared medical appointments at Cleveland Clinic that may be a resource to share ideas and experiences with other patients with similar health concerns. Additional resources can be found through the National Osteoporosis Foundation.


Closing

Moderator: I am sorry to say that our time with Dr. Johnny Su and Dr. Andrea Sikon is now over. Thank you for sharing your expertise and time to answer questions today.

Andrea_Sikon,_MD,_FACP,_NCMP,_CCD: Thank you.

Johnny_Su,_MD: Thank you.


For Appointments

To make an appointment with Johnny Su, MD or any of the other specialists in our Department of Rheumatologic and Immunologic Diseases at Cleveland Clinic, please call toll-free at 866.275.7496. You can also visit us online at clevelandclinic.org/rheum.

To make an appointment with Andrea Sikon, MD, please call 216.444.3024 or call toll-free at 800.223.2273, ext. 43024. You can also visit us online at clevelandclinic.org/obgyn.


For More Information

On Osteoporosis
On Cleveland Clinic

Cleveland Clinic’s Center for Osteoporosis and Metabolic Bone Diseases is a national leader in osteoporosis research, and we provide early identification and treatment of osteoporosis. We offer evaluation with a Dexa (DXA) scan to assess your risk of fracture. We will combine this information with your health history and laboratory results to develop an individualized treatment plan for you that may include:

  • changes in diet and vitamin intake
  • an exercise program to stimulate bone formation
  • elimination of risk factors for bone loss
  • use of bone-building medications

If your disease is advanced, or if you already fractured a weak bone, we may integrate pain management and physical therapy into your treatment. We also may offer you the opportunity to participate in a clinical trial of a new medication.

Cleveland Clinic’s Department for Rheumatologic and Immunologic Diseases is ranked second in the nation by U.S.News & World Report and top ranked in Ohio.

At Cleveland Clinic’s Center for Specialized Women’s Health, patients are seen in a caring environment that emphasizes technological excellence as well as emotional well-being. The Center offers a full range of state-of-the-art services for testing the unique and changing medical needs of women. We use an interdisciplinary approach to evaluate your problem and arrive at the best treatment for you.

In addition to wellness exams, professionals within the Center for Specialized Women's Health offer a variety of services, including evaluation and/or treatment of osteoporosis. We provide evaluations of bone density and treatments, which include yearly infusion therapy.

As part of Cleveland Clinic’s Center for Specialized Women’s Health, our gynecology program is ranked third in the nation by U.S.News & World Report and top-ranked in Ohio.

On Your Health

MyChart®: Your Personal Health Connection, is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 866.915.3383 or send an email to: mychartsupport@ccf.org.

A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult.


Contact Information

If you need more information, click here to contact us, chat online or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272 ext. 43771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!

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Reviewed: 05/14

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