OSTEOPOROSIS (BONE THINNING) INFORMATION

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OVERVIEW:

Bone is living tissue constantly undergoing remodeling; when all is perfectly well, there exists a dynamic equilibrium between breakdown of bone by osteoclasts and build-back of bone by osteoblasts. By closely considering risk factors plus results of two tests, physicians are now able to assess (and categorize) patients as to the presence or absence of osteopenia/ osteoporosis at Lexington Medical Center. Osteoporosis and osteopenia are the most common metabolic bone diseases in the developed countries of the world, being responsible for an estimated 275 thousand new osteoporotic hip fractures each year in the United States. These and other fractures lead to considerable morbidity and mortality in later life. Similar to the previously dreaded polio prior to the vaccine, it now appears that most of these crippling complications are entirely preventable.

The immediate medical financial consequence of only those annual USA hip fractures is estimated at eight billion dollars per year; and, 12-20% die within one year...over 50% are unable to return to independent living.

PREVENTION IS THE KEY:

The Osteoporosis Program at Lexington Medical Center will be predicated on patients themselves and clinical physicians being aware of, and identifying, those who are at risk for osteoporosis. The emphasis is on early risk identification, early diagnosis, and early therapeutic intervention in order to prevent bone loss to the degree that the incidence of fractures escalates.

DIAGNOSIS:

The assessment of presence or absence of osteoporosis will revolve around radiographic imaging analysis with the Lunar DPX-IQ DEXA-scan bone densitometer (dual-beam...dual energy x-ray absorptiometry). This is a rapid and convenient examination which will include risk assessment. Bone mineral density (BMD) is compared to age-matched BMD and the average BMD at about age 35, a BMD least subject to bone fractures. A low BMD value includes osteomalacia (poor bone formation) and/or osteoporosis (bone thinning). The radiologist’s report will consultatively delineate the bone status as well as the interview-identified risk factors.

EVALUATION, URINE TEST:

IF the risk interview and further questioning are not clear as to whether a DEXA-scan bone densitometer determination of osteoporosis/osteopenia is due to high bone turnover or not, the most cost effective initial clarification is likely to be possible with the urine test (see below).

While not currently considered NECESSARY, the urine test can also be utilized to rule in or rule out secondary causes and to optimize treatment and avoid delays in therapeutic response (14% of women fail to respond to estrogen replacement, for example). Sometimes the cause is absolutely clear, my medical history and/or physical examination. Upon a clinical decision to institute treatment, the urine test for the bone-specific NTx osteolytic (degradation) product is ordered (if not previously already done) in order to determine a baseline pretreatment test result and to categorize whether the current skeletal state is one of high bone turnover (most of the secondary causes) versus one of low or normal bone turnover (genetic/familial/constitutional pre-disposition versus younger-age situations which prevented normal building of peak bone mass). About six weeks following this baseline test and the institution of therapeutic intervention, a repeat urine test is performed in order to assess the success of both patient compliance and modes of intervention. The test result indicating success is encouraging to both the patient and the physician; a result indicating intervention failure allows early modifications of treatment.

Specimen (urine) Collection:

The most consistently successful programs utilizing urinary monitoring base it on a system where the patient empties the bladder into the toilet on awakening (for example, at 7:00 a.m.), intakes ordinary liquids, and then obtains the urine specimen for the lab approximately 2 hours later (in the manner of a "spot" specimen rather than an actual timed specimen). Patient reassessment for therapeutic success with bone densitometry is ordinarily not performed in less than 18 months following institution of interventional maneuvers.

Urine Test Results Reporting:

1. Above normal result: "this result suggests an elevated rate of bone turnover of uncertain etiology."
   
2. Normal or decreased test result: "this result is compatible with low-turnover or normal-turnover osteoporosis versus a favorable response to treatment versus normal bone status."
   

Other Tests:

While urine testing for the marker of osteolysis (osteoclast activity) is the conventional laboratory monitor, one can also check the status of osteoblastic participation through serum tests of either or both of osteocalcin and bone-specific alkaline phosphatase. Any changes in a patient’s status are rapidly reflected in the markers for bony degradation while markers of osteoblastic activity typically lag that marker, reflecting any status change by some 3 to 6 months later.

TREATMENT:

The therapeutic strategy is to halt the net loss (inhibit the osteoclasts) of bone by hormone replacement or therapeutic medication, to enhance mineralization and reduce any sporadic occult normal and common compensatory elevation of parathyroid hormone (due to sporadic occult hypocalcemia) by calcium supplementation, and to use load-bearing exercise to add some skeletal stress, such stress leading to a net reduction in bone loss. American diets tend to be calcium deficient, and intestinal absorption of calcium is less effective in older age. When purchasing calcium supplement preparations, one can gain an idea of probable effectiveness by placing the tablet in a glass of either warm water or household vinegar for 30 minutes. According to the National Osteoporosis Foundation, the majority of the best supplements will dissolve within 30 minutes. Load-bearing exercise can be as simple as going up or down stairs, jogging, or walking; the idea is to regularly add some weight strain to the hip joints and spinal column. Additional measures (hormone replacement, medications) may be taken in proper situations. Regular exposure to sunlight (remember the home-bound or nursing home patient) is required for proper utilization of vitamin D. Smoking has an adverse effect by accelerating the degradation of estrogen. Excessive alcohol use produces overt or regularly recurring occult hypophosphatemia which leads to accelerated urinary loss of calcium. One in seven women fails to adequately respond with estrogen replacement. Since many of the calcium supplements require the presence of significant stomach acid for dissolving the tablet so that it can be properly absorbed, calcium citrate supplements are said to represent an advantage for the numerous persons who are already taking medications to reduce stomach acid. Calcium citrate intestinal absorption may be more effective in older age.

While there is some evidence that therapeutic intervention can rebuild some bone mass, there has been essentially no success at rebuilding the broken microscopic connections between bony trabecular struts which have undergone the osteoporotic process to the point of osteolytic division of the struts. It may, therefore, be urgent to begin treatment if the DEXA-scan study declares a state of osteoporosis.

Families should be encouraged to make efforts toward "fall-proofing" the homes of mobile elderly parents or others to whom they are closely associated. Among the most important adaptations to be made are: sturdy handrails for bathroom, bathtub, walk zones, and stairs (of any type). Loose rugs are dangerous, and stumble-causing clutter is dangerous. Stumble-liable footwear is dangerous. Over-medication to the point of fall-proneness is dangerous.

INFORMATION:

Information is readily available for patients, physicians, and other interested individuals in the Lexington Medical Center Library, particularly in the Community Health Information Library, therein. A number of information sites are available on the Internet, and Internet access is available to those who do not personally have it in the above Community Health Information Library. The site particularly recommended for physicians is that of the American Association of Clinical Endocrinologists: AACE

RISK FACTORS

GENETIC AND/OR PRIMARY CAUSES - * Old age/elderly
* White or Asiatic ethnicity
* Positive family history (especially if a female’s mother had a hip fracture)
* Small body frame
@ Juvenile osteoporosis
@ Idiopathic osteoporosis of young adults
@ Genetic diseases:

1. Osteogenesis imperfecta (occult/overt)
   
2. Homocystinuria
   
3. Ehlers-Danlos syndrome
   
4. Marfan’s syndrome
   
5. Menkes’ steely hair disease
   
6. Riley-Day syndrome (familial dysautonomia)
   
7. Gaucher’s disease & other glycogen storage diseases
   
8. Sickle-cell anemia
   
9. Thalassemia
   
10. Hypophosphatasia
    

LIFESTYLE - *** * Smoking
Inactivity
* Postmenopausal
Nulliparity
Excessive exercise (producing amenorrhea)
* Early natural menopause
* Early surgical removal of ovaries
Late menarche
* Had a low-trauma bone fracture after age 40

NUTRITIONAL FACTORS - *** Malnutrition
* Milk/dairy-products intolerance
* Life long low dietary calcium intake
Vegetarian dieting
Vitamin D deficiency
* Excessive alcohol intake
Consistently high protein intake
Alternative diets,? Watch out?

MEDICAL DISORDERS - *** Anorexia nervosa
Hyperthyroidism
Hyperparathyroidism
Cushing syndrome
Chronic depression
Alterations in gastrointestinal
hepatobiliary function, chronic
Mastocytosis
Rheumatoid arthritis
"Transient" osteoporosis
Prolonged parenteral nutrition
Hemolytic anemia, chronic
Chronic debilitating illnesses of other types
Males with low testosterone levels
Hypogonadism (testis or ovarian)
Diabetes mellitus, type I
Hemochromatosis
Amyloidosis
Renal tubular acidosis
Acromegaly
Multiple myeloma
Hyperprolactinemia, chronic
Porphyria

MEDICATION-RELATED - *** * Excessive level of thyroid hormone replacement (e.g.Synthroid)
Glucocorticoid drugs (cortisone)
@ Anticoagulant (heparin), chronic
Chronic lithium therapy
Chemotherapy (breast cancer or lymphoma)
* Gonadotropin-releasing hormone agonist or antagonist therapy
Anticonvulsants
Chronic phosphate-binding antacid use
Extended tetracycline use
Diuretics producing calciuria
Phenothiazine derivatives
Cyclosporin A
Anti-estrogen drugs
Vitamin D toxicity

REGIONAL OSTEOPOROSIS - Immobilization osteoporosis
Reflex sympathetic dystrophy
Transient osteoporosis of the hip
Regional migratory osteoporosis
Osteolysis syndromes
* Commonly problematic risk factor
@ rarely problematic risk factor or rare disorder
*** Secondary causes

3/18/97 (reviewed 6 June 2002)

Algorithms

DEXA-scan has determined presence of osteopenia/osteoporosis.

Three Lines of Evidence:

DEXA-scan radiological densitometer evaluation makes diagnosis of osteopenia/osteoporosis
NTx test gives a result proportional to osteoclast (bone resorption) activity
Bone-specific alkaline phosphatase (or osteocalcin) results are proportional to osteoblasts (bone build-up)

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