Gettysburg Medical Center
The Clinical View
by P.E. Hoffsten, MD
5 December 2007 

WHY WORRY ABOUT YOUR BONES?

            The gentleman had been an executive with a great deal of responsibility for 30 years.  During that time, he had been a two pack a day smoker.  Cigarettes interfere with Vitamin D metabolism and cause bone demineralization.  While he had been a high school athlete, he gave up drinking milk when he graduated from high school.  He didn’t take a calcium supplement and he didn’t exercise.  He said he just didn’t have time.  And then at 64 years of age, he slipped on some winter ice and broke his left hip.  This is relatively common in woman but not so much so in men.  A bone mineral density was done and showed that his bones had far advanced demineralization with a disease called osteoporosis. 

            As he was recovering from his fractured hip, he was a little too proud to be using a walker and he had another accidental fall landing on his buttock.  This fall fractured two thoracic vertebrae.  These are treated with “kyphoplasty” whereby some putty like material is injected into the squashed vertebra, reinflating them and stopping the pain.  That is when he came to my attention as to what he should do to prevent further broken bones. 

            For those of you who would like to avoid an experience such as this, the problem begins at birth.  Bone mineral density increases progressively through age 22 and is totally dependent upon how much Vitamin D, how much calcium and how much weight bearing exercises the person experiences.  Those kids that drink their milk, take their vitamin pill and participate in gymnastics have the hardest bones of all.  Today’s couch potatoes who sit in front of a computer and don’t drink milk never really get up to full compliment of bone mineral density and are in jeopardy at an earlier age.  By age 28, bone mineral density begins to deteriorate in all of us, slowly at first and then more rapidly at age 45 to 50 when menopause occurs in women.  Men don’t know it but they have a similar “change of life” event, too.  Fifteen to twenty years of loss of bone mineral from age 45 to age 65 then leads to the epidemic of fractured hips that is going on at this time.  This epidemic is undoubtedly going to get worse in the future as our children who like Coca-Cola better than milk mature. 

            So what are the alternatives?  Step 1 is to get an adequate calcium intake and that means 1200 milligrams a day of elemental calcium which is 2 of the 600 milligram calcium pills daily.  Alternatively a quart of milk per day will take the place of the calcium pills.  The next most important step is adequate Vitamin D.  We used to think that 400 units per day were enough but that is really not enough.  For our adult population, it should be about 2,000 units a day of Vitamin D and this requires a dietary supplement.  Until recently, I was content to advise 800 units of Vitamin D but I think that the data now show that that the Vitamin D deficiency in our older population requires 2,000 units a day of Vitamin D.  The 3^rd component to maintain bone health is adequate weight bearing exercise.  The national prescription is to walk 3 miles per day.  I know a lot of people can’t do that or won’t do that.  As much walking as a person can get done up to that level is very beneficial.  Jogging for the over 50 age group is probably more detrimental than help because the osteoarthritic factor degrades joints.

            And then come the medications that might be used to treat osteoporosis.  There are two types.  One type makes bones build up and there is only one product in this class.  That is called Forteo.  It is an injectable form of a hormone called parathyroid hormone.  I have used this in several patients with very gratifying results.  Unfortunately, the expense is huge at about $8,000.00 per year which depresses the insurance company or the patient whoever has to pay it.  An assistance program for those who have trouble with expense is available.

            All of the rest of the osteoporosis medicines prevent the breakdown of natural bone.  Every day a small amount of bone is eaten up by a natural process and then new bone is laid down in its place. This is called bone remodeling.  Unfortunately as a person ages, the lay down process can’t keep up with the eating up process and the bones become demineralized.  One way to treat this is to slow down the eating up cells and let the bone lay down cells catch up.  This does result in a 6-10% increase in bone mineral in a 5 year period.  This has very dramatic effects on preventing hip, wrist and back fractures.

            The first product that was noted to be effective in this context was estrogen replacement therapy.  This has become so controversial that many physicians no longer recommend.  The advantages of estrogen replacement therapy for women include relief of the symptoms of menopause in addition to maintaining bone mineral density.  There is however, a definite increase in carcinoma of the uterus and a still controversial effect upon carcinoma of the breast.  For that reason, many physicians will not recommend estrogen replacement therapy for the prevention of osteoporosis.

            A second hormonal type of medication used to treat osteoporosis is called raloxifene

(Evista).  This product has the advantage of preventing breast cancer, treating osteoporosis somewhat, but having the risk of deep vein thrombosis and causing blood clots.  The use of this product is not as effective as the ones listed below called bisphosphonates.

            The family of drugs called the bisphosphonates work by incorporating into the person’s remodeled bone.  The bisphosphonate can not be eaten up by the remodeling cells and therefore the rate at which bone mineral is eaten up, is markedly decreased.  There are now 5 products on the market in this class.  The one with the best track record is Fosamax.  When it first came out, it was to be taken 10 mg daily.  Very soon thereafter, it came out as a 70 milligram pill taken once a week.  It needed to be taken on an empty stomach early in the morning and the person remained erect for a half an hour at least after that, not eating or drinking anything else.  It was recommended to put a half a glass of water in with it to help dissolve the product and lead to better absorption.  Unfortunately, this 70 milligram pill caused irritation of the esophagus of some people and the method of administration is inconvenient for some people.  But the product has very good evidence demonstrating decreased fractures of hip, wrist and back.  Recently Fosamax added Vitamin D to its preparation and Fosamax with Vitamin D is a new patented product.  The original Fosamax alone will go off patent next year and price may drop substantially. 

            The second product of this class was called risedronate (Actonel) and it worked in an entirely similar manner.  This product has the advantage of new recommendation that it be taken as two pills every two weeks as opposed to one pill every week.  That is slightly more convenient.         

            A third product called Boniva has the advantage of being used only once a month.  It is taken with a glass of water on an empty stomach and the person then remains erect with nothing else to eat or drink for an hour after taking the pill.  This once a month ritual seems to satisfy many people.

            All of these products are quite expensive costing $70-$80.00 per month.  But in my professional opinion, that is a small price to pay compared to the expense, misery and 20% six month mortality that comes after a broken hip. 

            A new product called Reclast (Zoledronic acid) is available as a once a year intravenous preparation.  It takes about 15 minutes to infuse this material and it is much more effective than the oral preparations in preventing fractures.  This product is relatively new on the market but it is probably the best long term solution available at this time for the problem.

            People often ask what the most important step in taking care of osteoporosis might be and I ask them back what is the most important leg on a three-legged stool.  The person needs to (1) exercise, (2) they need to get their Vitamin D and calcium in and (3) they need to get something in to prevent the resorption of the bone mineral.  That is expensive but well worth the investment.  The answer to the opening question is, “To prevent a whole lot of grief and pain!!”

This and other columns available at www.macpierre.com.