Monday, January 12, 2015

Osteoporosis Medications -- Do they really help?

An 88 year old patient arrived at my office today after a hard fall from a ladder to the ground onto her right hip.  She was very sore and bruised, but I was surprised that there was no fracture.  She is a feisty woman, and said, "I take all kinds of things for my bones except medicine, because I don't want to die like my mother.  She had osteoporosis and they gave her Fosamax.  She had a spontaneous fracture in her thigh bone, one of those strange ones that those drugs cause, and she went downhill from there, dying soon after."

Why not take osteoporosis medication?  This blog will tell both sides of the story.

Osteoporosis a progressive bone disease that is characterized by a decrease in bone mass and density which can lead to an increased risk of fracture.  Fractures in the elderly are often devastating and increase risk of death, but more than that is the debility from the pain of spinal compression fractures.

Osteoporosis in and of itself causes no pain or other symptoms.  The pain associated with osteoporosis is usually related to spinal vertebral compression fractures or other fractures, most often rib, hip and wrist.  They happen in situations in which a normal person would not get a fracture, so they are called "fragility fractures." 
The most important risk factors for osteoporosis are advanced age (in both men and women) and female sex; estrogen deficiency following menopause or oophorectomy is correlated with a rapid reduction in bone mineral density, while in men, a decrease in testosterone levels has a comparable (but less pronounced) effect.  There are higher levels in those of European or Asian ancestry, and it can be hereditary.

 There are several things that are modifiable that can increase the risk of osteoporosis:
  • Excessive alcohol consumption
  • Vitamin D deficiency
  • Tobacco smoking
  • Eating disorders, underweight and malnutrition
  • Inactivity and the opposite--endurance training
  • Heavy metals, especially cadmium and lead
  • Excessive soft drink consumption
  • The extensive use of steroids such as prednisone
  • Long term use of proton pump inhibitors (antacids used for GERD and ulcers)
  • Other medicines such as lithium, anti-epileptics, too high levels of thyroid medication, anticoagulants, some diabetic medications
There are two major types of bone remodeling cells:  osteoclasts, which remove old or injured bone (bone resorption), and osteoblasts, which build new bone (bone formation). They are both very important for the maintenance of strong, healthy bones.  In osteoporosis there is an imbalance of bone formation and resorption.  Either peak mass was never reached because of malnutrition, etc., or there is decreased formation and/or increased resorption.

The osteoporosis medications called bisphosphonates work by suppressing a key enzyme in osteoclasts, causing these cells to die.  Without osteoclasts to clean out old or injured bone cells, the osteoblasts build new bone on the old sick bone, creating an unhealthy foundation.  The bones are thicker, which is what is measured by bone density exams, but not necessarily always stronger.  The use of bisphosphonates increases the risk of atypical femoral fractures (the thigh bone).

Other side effects you may experience from bisphosphonates.  Many doctors do not do the proper follow up care, and are not even aware that they should be watching for these effects:

  • Lower levels of calcium in your blood (hypocalcaemia) – This is because it takes calcium and other minerals from your blood to build the bone more rapidly.  You need blood tests to check the levels of calcium and other minerals such as potassium and magnesium
  • Bone and joint pain can be controlled by a mild painkiller such as paracetamol
  • Changes in your bowel movements (constipation or diarrhoea) that usually only last for a few days – it is important to drink plenty of fluids (6 to 8 glasses a day)
  • Tiredness and low energy levels may occur with some types of bisphosphonates but are usually mild
  • Feeling sick is usually mild and gets better after a few days – if it continues or is severe, your doctor or nurse can give you anti sickness tablets
  • Kidney damage – you will have regular blood tests to check how well your kidneys are working
  • Damage to the jaw bone (osteonecrosis) is a rare side effect that may happen if you take bisphosphonates for longer than a year. You should have a dental check up before you start treatment. Always tell your dentist that you are having bisphosphonate therapy or tell your doctor if you need dental treatment
  • Esophagitis. Tell your doctor If you already have a condition of your esophagus or if you develop new symptoms such as pain or difficulty swallowing.  It is important to follow directions on when to take the medication, how to take it, when to eat, etc.

  • If you choose to take one of these medications, it is important to ask your doctor to watch for these problems.

    If you choose to not take these medications, luckily there are other things you can do which often work as well or better than the medications without causing abnormal bone to grow.

    1. Calcium -- ideally from foods such as eggs, fish, meat, almonds, liver, bone meal, dairy (not the best source of calcium), potatoes and green vegetables.  If supplementing don't take more than 800 mg because the body doesn't absorb more than that, if that much.  Taking more than 1000 is associated with an increase level of atherosclerosis (hardening of the arteries).
    2. Vitamin K2 -- fermented dairy foods and soy contain vitamin K.  Vitamin K2 assists in moving calcium around in the body--such as to your bones rather than lining your arteries.
    3. Magnesium -- vital in helping your body absorb calcium.
    4. Vitamin D3 -- test your Vitamin D, 25-hydroxy levels, you want the levels to be between 50-80 ng/mL.  Vitamin D is essential to the bones--low levels can cause Ricketts, a softening of the bones.
    5. Boron -- supports the function of Calcium, Magnesium, and Vitamin D.
    6. Vitamin C and vitamin E are also important for bone health.
    SpringTree SuperMulti Plus contains all of these at optimal levels, plus much more.

    Of course, regular light to moderate exercise, including weight bearing exercise, signals your bone cells to keep working to remodel and rebuild healthy bone with the natural nutrients you are giving your body.

    Bio-identical hormones are necessary for some women and men who have severe osteoporosis to assist in building bone.

    If you have arthritis remember that it is important to also support the bones, which provide a healthy foundation while controlling the inflammation in the joints.

    The summary of this is that bisphosphonate medications DO increase the density of bones, but do not create normal bone, and there is increased risk for atypical hip fractures.  There are also side effects from the medications that you don't get from the natural supplements.  However, each person gets to decide for themselves what course of treatment to follow.

    Until we meet again,
    Dr. Judi

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