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Osteoporosis: The Silent Thief of Bone

Online Health Chat with Dr. Bruce Long & Dr. Andrea Sikon

April 8, 2011


Introduction

Cleveland_Clinic_Host: Learn how osteoporosis, the “silent thief of bone,” can be prevented, detected, and treated. Our experts will discuss how both men and women are affected by this metabolic bone disease. They will address early detection and prevention strategies that focus on balance and falls, vitamin D intake, and the amount of calcium in your diet, along with the variety of osteoporosis medications available.

Osteoporosis is a common, preventable, and treatable form of metabolic bone disease. Ten million Americans have this condition. Four-fifths of them are women. Early identification and treatment of low bone density is most effective in increasing bone mass and avoiding painful fractures.

Evaluations, which combine DXA bone scans with a thorough health history and lab testing, are used to develop treatment plans, including:

  • physical therapy to improve balance
  • fall prevention strategies
  • dietary changes and calculating the amount of calcium in your food
  • vitamin D supplementation
  • exercise programs to promote strong bones
  • eliminating risk factors for bone loss, such as smoking
  • medications to build or maintain bone density

When osteoporosis is advanced or if weak bones have fractured, pain management is incorporated into treatment. New approaches to osteoporosis prevention and treatment are under investigation. Cleveland Clinic patients are often able to participate in trials of medications that are as good as — and hopefully better than — current alternatives.

Bruce Long, MD, is a staff physician in the Department of Rheumatic and Immunologic Diseases. He is active in the Center for Osteoporosis and Metabolic Bone Disease. Prior to Dr. Long’s appointment at Cleveland Clinic, he was Chair of the Department of Rheumatology at Fairview and Lutheran hospitals. He is board certified in rheumatology and internal medicine, and his specialty interests include osteoporosis and bone disorders, vitamin D, autoimmune disorders, and pharmacology. Prior to entering the profession of medicine, Dr. Long practiced pharmacology in his home state of Illinois.

Andrea Sikon, M.D., F.A.C.P., N.C.M.P., C.C.D. is Chair of the Department of Internal Medicine at Cleveland Clinic. She is a National Certified Menopause Practitioner (NCMP) through the North American Menopause Society (NAMS) and a Certified Clinical Densitometrist (CCD) through the International Society of Clinical Densitometry (ISCD), practicing in both Internal Medicine and the Center for Specialized Women’s Health. Dr. Sikon’s clinical interests are in Women's Health, osteoporosis, and menopause. She started the Primary Care Women’s Health program of the Medicine Institute at Cleveland Clinic as its first director in 2008.

Dr. Sikon has published with ongoing research in her special interests of osteoporosis and menopause. She is a member of the National Osteoporosis Foundation Osteoporosis Clinical Updates editorial board, an outgoing member of the 2009-2010 Professional Education Committee of the North American Menopause Society, and a member of the Women’s Health Task Force of the Society of General Internal Medicine.

To make an appointment with Bruce Long, MD, or any of the specialists in the Department of Rheumatic 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.

Many women have questions about their health care. Now there's a resource for answers. Simply call 216.444.4HER and speak with a nurse who has special training in women's health issues. This free service of the Center for Specialized Women's Health is available Monday through Friday, 8:30 a.m. to 4:30 p.m. (EST) or visit clevelandclinic.org/obgyn for further information.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Drs. Bruce Long and Andrea Sikon. We are thrilled to have them here today for this chat. Let’s begin with some of your questions.


Osteoporosis

firebird56: Can you please help me understand why so many of us, young and older, have osteopenia/osteoporosis and so many respected physicians miss hyperparathyroidism as the underlying condition for the bone loss? Is it because of strict adherence to the NIH guidelines set forth? Thanks!

Dr__Bruce_Long: I'll try but I have the same concerns. There are so many different causes of osteopenia/osteoporosis. Hyperparathyroidism is one of them. In its early stages, hyperparathyroidism may not have any symptoms. It may be picked up routinely on a lab test by noting elevated calcium levels. In the early phases of hyperparathyroidism, the elevated calcium sometimes returns to normal. So it can be easily missed unless you are searching specifically for it. A common cause of hyperparathyroidism is vitamin D deficiency.


Diagnostic Test

songcanary: I currently have a T score of -2.3, which is a 10% loss from two years prior. Both of these were during perimenopause, I am now menopausal for 18 months. Do you find that these results tend to level out after menopause? I am physically active and eat a healthy diet, although not a lot of dairy. I do supplement with vitamin D3 2200 i.u. daily. Is this enough? Thank you.

Dr__Andrea_Sikon: Usually, T-scores are not used prior to the onset of menopause. For most women, accelerated bone loss often occurs within the four to seven years following the onset of menopause and tends to slow beyond that period. It is more important to determine if a woman is losing bone and at what rate, in combination with additional history and possibly even blood and urine testing, to help determine if this is "enough" vitamin D. A calculation tool called the FRAX exists that physicians can use to help them determine if additional bone-specific medication is needed based on a woman's specific information. In general, if your bone density is low and declining, I personally would consider having a blood test done to determine if the amount of vitamin D you are taking is enough. I also recommend completing an online calcium calculator survey to determine if you need calcium supplements in addition to the vitamin D supplement you are taking (Google "calcium calculators" to locate one of these) or to make sure you are getting enough calcium through your diet.

zfern: Can you comment on the use of FRAX to identify risks for bone mineral density (BMD)?

Dr__Andrea_Sikon: The FRAX is a calculation tool that has been validated to help determine a patient's risk of breaking a bone in the following 10 years. It is used only for patients who are NOT on bone medications already and who do NOT have osteoporosis. As evidence is fairly clear to recommend additional therapies for those with osteoporotic-range bone density, there is less evidence to guide recommendations for adding medications when the bone density falls into a low or "osteopenic" range. This additional FRAX score can add information to the decision-making process. Bone density is not the sole determinant in making a diagnosis of osteoporosis, so this is yet another piece of information in making such decisions more tailored for an individual patient.

gabbyme3: I was using Actonel® (risedronate sodium) for about 10 years, and my last DXA scan went from -2.6 to -2.9 spine and hip: -2.3 to -2.2

Dr__Bruce_Long: That may be a significant change, but we go by changes in the bone density number rather than T-score when analyzing significant change.


Medications

gabbyme3: Would Reclast® help a male, 75 years old, with osteoporosis?

Dr__Bruce_Long: Reclast® (zoledronic acid) is approved for use in men with osteoporosis.

gabbyme3: Are there any bad side effects with Reclast®?

Dr__Bruce_Long: There are potential side effects with any medication. Reclast® is generally well-tolerated, but in the clinical trials, about 15% of people had a 'flu-like' illness after the infusion that eventually cleared. There have been reports of osteonecrosis of the jaw (ONJ) and atypical femoral (thigh bone) fractures but these are rare.

Msfit123: I was on Fosamax® (alendronate) and Boniva® (ibandronate) from 2003 through 2010, when I developed the beginnings of osteonecrosis of the jaw (ONJ). I had a gum irritation and was diagnosed as having it. The cause! The bisphosphonate drugs I was taking! I was floored! Now I am forbidden by my gum specialist to ever take Boniva® again. So what can I do now to help my ongoing osteopenia and, soon to be, osteoporosis? Thank you.

Dr__Bruce_Long: ONJ is a rare association with bisphosphonates. Available alternative FDA-approved therapies include estrogen, Evista® (raloxifene) and Prolia® (denosumab).

Athena: I am a 53-year-old woman with osteopenia. I have been on Actonel® for four years. My mother has had osteoporosis since a young age. I am concerned about the side effects of Actonel® and would really like to stop taking it. I take calcium and vitamin D, and I exercise daily, including resistance exercise. Can I stop taking the Actonel® if I continue these things? Is there anything else you can suggest that would enable me to stop the Actonel®? I am VERY concerned about the side effects. Thank you!

Dr__Andrea_Sikon: First, I applaud you for doing all of the non-medication measures that are so important for bone health, but that often go overlooked, so keep these up! The medications for osteoporosis are extremely safe overall, although just like with anything we take -- including herbs and supplements -- there are potential risks with everything. Additionally, some of the recent evidence suggests we might recommend a "drug holiday" from medications such as Actonel® (or Fosamax®, Boniva®, etc.) after patients have been on them for more than 5 to 10 years, as these medications incorporate into our bones for a long period of time and could potentially start to cause some deleterious effects if used for too long. However, it is not well proven to make any decision to stop such medications without a careful discussion about your specific risks with your doctor.

clara: I have taken Fosamax® for 14 years. I stopped taking it more than a year ago because of reading about the femur bone. My hip score is -2.7 and the spine is -2.1. I am due for a bone scan in May of this year. My question is about stopping Fosamax®. I am not sure I did the right thing. I would also like to know you opinion about Forteo® (teriparatide) and strontium.

Dr__Bruce_Long: Your hip score is low and there may be concerns about high fracture risk. Femoral shaft fractures seem to be more likely due to inadequately treated osteoporosis rather than the drugs used to treat osteoporosis.

The complication of atypical femoral shaft fractures is rare, and other factors besides Fosamax® have been implicated. You should bring up the details with your doctor. Forteo® is the only osteoporosis medicine that we have that will build bone. We have found it very useful. There are many uncertainties with strontium so I do not use that in my practice.

eastside: Can we alternate Fosamax® and Actonel®?

Dr__Andrea_Sikon: There is no real reason/benefit to alternate between these.

MARTINL86: Bisphosphonates have recently been depicted in news articles as potentially dangerous. What is your opinion?

Dr__Bruce_Long: My opinion is that they are among the safer groups of medicines we have, but they do have potential side effects. Like all medicines, they should be used cautiously. Fortunately, the incidence of osteonecrosis of the jaw (ONJ) and atypical femoral shaft fractures are rare.


Minerals

zfernz: My doctor recommended two TUMS® in the morning to get extra calcium. I have been doing it for several years now. I am 53 with normal bone mineral density (BMD). Is it worth continuing this the in morning?

Dr__Andrea_Sikon: The best way to get your daily recommended amount of calcium is through your diet. However, the average American diet is deficient in calcium by 500 mg or more. This is especially true if you are lactose intolerant or avoid dairy, as these are the richest dietary sources of calcium. The easiest way to get your calcium daily is to drink 3 eight oz. glasses of skim milk daily. If you can't or don't like this, I recommend supplements to make up the difference. Consider finding a calcium calculator on the Internet to determine how many calcium supplements are needed. Also, know that TUMS® do not have vitamin D, which is difficult to find in natural food sources, so you need an additional vitamin D supplement if you are going to take TUMS® to get your calcium.

Spacely: What is your opinion regarding the use of strontium for osteoporosis? Do you know of any side effects or contraindications for its use?

Dr__Bruce_Long: Strontium may cause more dense bones, but it has not been approved for use in the treatment of osteoporosis. We do not know if there are future problems by making bones more dense with strontium. In the past, high dose fluoride was used to make the bones more dense, but the structure was not normal and some people had more broken bones.

johnnnita: My doctor indicated that a past test suggested "osteopenia." He recommended I take 1200 mg/day of calcium citrate and 1000 i.u. vitamin D3 daily. Does this sound right? Should I be worried? Otherwise, I'm in excellent health.

Dr__Andrea_Sikon: It's more important to know if you are losing bone over time rather than have a single reading of osteopenia, which in and of itself is not worrisome nor even considered a disease. Certainly, calcium and vitamin D are the building blocks of bone and making sure you have enough is important to ensure you maintain the bone you have.

MARTINL86: Besides calcium, what other bone minerals exist?

Dr__Bruce_Long: Calcium and phosphorous are the major bone minerals.

kiddies: I read somewhere that proton pump inhibitors decrease calcium absorption. What do you recommend for GERD treatment?

Dr__Andrea_Sikon: This is a potential concern as proton pump inhibitors (PPI) decrease the acidity in the stomach, and the most common form of calcium supplements is calcium carbonate, which requires an acidity to be absorbed. If you are using a PPI, you can simply take a calcium citrate formulation instead. Just remember to look at the serving size, which is often TWO pills instead of one.

MARTINL86: Is it possible that phosphorous may be needed as a supplement to treat osteoporosis?

Dr__Andrea_Sikon: Most individuals are not deficient in phosphorous, and thus would not require a supplement, unless you have a coexisting condition that causes significant malabsorption.

Jacqueline: Regarding menopause and calcium, do you need to automatically start taking it? What is the best source?

Dr__Andrea_Sikon: Having enough calcium is very important for bone health, and as our bone density increases from the time we are born and then peaks in our 20s to 30s, it is critical to make sure we have enough calcium in our daily intake starting from childhood, not just at menopause. There are many sources of calcium. Certainly, it is best to get it from our diets; however, the average American diet is deficient, and many need to take supplements to get enough. Please consult a calcium calculator (you can find one on the Internet) to determine how much you need in the form of supplements versus diet. Calcium always comes linked to another substance, and the two most common forms are calcium carbonate and calcium citrate. Carbonate has more calcium per pill, but needs an acid environment to be absorbed, so not likely the best formulation if you are taking antacids or do not take them with food. Calcium citrate can be taken at any time, but there is less per pill, so the serving size per dose is two pills.


Side Effects

clara: I read that the percent of osteonecrosis of the jaw and femoral factures was higher with once-a-year Reclast®.

Dr__Andrea_Sikon: In the largest study with once yearly Reclast® done to treat postmenopausal osteoporosis, there was one case of osteonecrosis of the jaw (ONJ) in the placebo group and one in the treatment group, so there was no increase seen. Overall, cases of ONJ have been more common in those who have metastatic cancer in their bones and were on IV forms of such a medication. Although this is a potential associated condition, it is extremely rare, and less than the risk of being struck by lightning. This extremely low risk should be balanced against the risk of breaking a bone due to osteoporosis, which is 1 in 2 for some postmenopausal women and as frequent in older men with osteoporosis as well.

wilderland: I have taken steroids for my MS. I now have osteoporosis but I cannot take biophosphonates because of osteonecrosis of the jaw (ONJ). What else can I do to help my bones?

Dr__Bruce_Long: If you have actually not had ONJ, you may want to consider a bisphosphonate. I am not sure from your question if you have had ONJ or are concerned about it as a side effect.

wilderland: I have had ONJ several times while trying different medicines.

Dr__Bruce_Long: Other approved treatments for osteoporosis include Forteo® and Evista®.


Exercise

MARTINL86: Some physicians have indicated that yoga practice without medication can help to reduce osteoporosis. What is your opinion?

Dr__Bruce_Long: Yoga is a great activity that helps improve balance and strength, which is very important in the treatment of osteoporosis. However, adequate vitamin D and calcium are also needed. We usually also need a medication to help balance the cells that are removing and building bone. Yoga alone would not do this.

trunko: I have had a laminectomy/fusion. Do you have any advice on exercise with this? I am always concerned about hurting my back.

Dr__Bruce_Long: After skeletal surgery, exercises are usually prescribed. It is best to consult with your physician or physical therapist for appropriate exercises.

oxford: I have osteoporosis in the spine, but also have fibromyalgia. Would I do the same type of exercise (treadmill=up to 1.2 miles)?

Dr__Andrea_Sikon: Walking is a wonderful way to exercise and would be fine to do whether you have osteoporosis and/or fibromyalgia.


General Questions

Lynne2: Do you recommend any particular non-dairy sources of calcium?

Dr__Andrea_Sikon: Dark green leafy vegetables are rich in calcium; however, dairy sources do have the most per serving. Overall, diets rich in fruits and vegetables are important for our overall health. Other foods may also be enriched with calcium, such as breads and cereals. Look for calcium on the label. Search the Internet for calcium sources in food to learn more about the variety of foods with calcium amounts in each.

ljkmer: I have been diagnosed with osteoporosis in my left hip and left lower back. How can I best treat this without medication?

Dr__Bruce_Long: The way you are phrasing your question makes me wonder if you are meaning osteoarthritis. Osteoporosis usually does not affect one side of the back. However, depending on the other circumstances, osteoporosis is treated with calcium, vitamin D, exercise, and often a medication to prevent further bone loss or to help rebuild bone.

Athena: I would like to hear more about taking "a drug holiday." I know there is not much research about this, but would like your opinion. Thank you.

Dr__Andrea_Sikon: There are some studies that are accumulating regarding this concept. In general, there have been studies evaluating stopping Fosamax® and Actonel® after 5 and 10 years of therapy. The different bisphosphonate medications bind to bone variably, some more strongly than others. All bisphosphonates incorporate into bone for a prolonged period of time, which is different than medications used for other reasons, such as blood pressure medications that are gone if not taken that same day. This allows us to consider the notion of stopping the medication after some years on it. There are not many studies yet to know how long such a drug holiday should last, and often your doctor might consider following blood/urine tests of bone turnover markers and bone density over time to help determine if and when such a medication might need be restarted- at least until we learn more of an answer from further studies.

cranny: Does the use of caffeine affect your bone density?

Dr__Bruce_Long: It is listed as a risk factor but may be clinically important with high use. You should attempt to keep it to less than four beverages per day.

speller: I was diagnosed with osteoporosis in my 30s. My only risk factor is a positive family history.. Are there clinical trials looking at the genetic aspects and earlier prevention?

Dr__Bruce_Long: I personally do not know of any. You may wish to check out clinicaltrials.gov to see if there are any studies in your area.

MARTINL86: What is your opinion of the "Achilles Bone Ultrasonometer"?

Dr__Bruce_Long: I do not know of that product, but heel DXA is used as a screening tool for osteoporosis. You will see those kinds of instruments at health fairs.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Drs. Bruce Long and Andrea Sikon is now over. Thank you again Drs. Long and Sikon for taking the time to answer our questions about osteoporosis.

Dr__Bruce_Long: Dr. Sikon and I would like to thank all of you for your excellent questions. We are sorry that we did not have a chance to answer every question. We are happy to have an active interest in bone health. Keeping your bones strong and preventing breaks are very important.


More Information

  • To make an appointment with Bruce Long, MD, or any of the specialists in the Department of Rheumatic 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.
  • A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit www.eclevelandclinic.org/myConsult.
  • 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!
  • Some participants have asked about upcoming web chat topics. If you would like to suggest topics, please use our contact link www.clevelandclinic.org/webcontact.

Many women have questions about their health care. Now there's a resource for answers. Simply call 216.444.4HER and speak with a nurse who has special training in women's health issues. This free service of the Center for Specialized Women's Health is available Monday through Friday, 8:30 a.m. to 4:30 p.m. (EST) or visit clevelandclinic.org/obgyn for further information.

A Parathyroid Disorders chat is scheduled for July 14th at noon EST. Dr. Krupa Doshi will be discussing this topic: Osteoporosis, Fatigue and Kidney Stones: What is My Parathyroid Doing? For additional information please go to clevelandclinic.org/webchats.


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