Internal Medicine Of Southwest Florida Newsletter
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Upper Respiratory Illness
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If after reading about osteoporosis, you feel you are eligible for bone density testing or Reclast infusion go to our website to request service.

IMSWF recommends regular exercise for stress management.

But for immediate relief, Dr. Kordonowy recommends this terrific tune courtesy of Mark Knopfler.
Issue: February 2010 02/2010

There are 3 featured articles this month. The first is about osteoporosis-a common bone disorder.  Internal Medicine of Southwest Florida does provide a yearly infusion medication, FDA approved for the treatment and prevention of this condition.  The next article is about diverticulosis and diverticulitis- the two terms are frequently misunderstood by patients and I try to clear this up. The final article deals with a common complaint this time of year- upper respiratory illness. I hope you find the articles interesting and helpful.
Weakened BonesThinning of the bones, more common in women than men.


Internal Medicine of Southwest Florida was one of the first medical groups in our community to provide the diagnostic modality of DEXA scanning to help document the presence of osteoporosis and osteopenia.


DEXA scanning stands for Dual-Energy X-ray Absorptiometry. It is a simple low radiation x-ray technique that can be used to establish a baseline bone density and risk for fracture.  Serial testing over time can help confirm and monitor therapy. There are other techniques sometimes used for various reasons to evaluate bone mass including quantitative CT. Blood or urine lab tests to monitor bone turnover are not agreed upon as a useful method of monitoring the disease or treatment of osteoporosis.


DEXA scanning is the only agreed upon modality that can be used to define osteoporosis or osteopenia.  Osteoporosis is defined as a skeletal disorder characterized by compromised bone strength that predisposes a person to an increased risk of fracture.  Osteopenia is the condition of low bone mass - it is not as significant as osteoporosis but indicates a person is at risk to progress to osteoporosis. Both conditions can affect women or men.  In the United States more than 44 million people have either osteoporosis or osteopenia.  Approximately 2 million men have osteoporosis and 12 million are at risk.  Men who have hormone blockade treatment for prostate cancer are at particular risk in the men's category.  DEXA scanning is recommended for women age 65 and over and all men aged 70 and older. If a patient is under these recommended ages but has one or more risk factors, testing is recommended. Any adult presenting with fractures may benefit from DEXA testing as well.  Patients who have taken steroid medication for more than 3 months are at significant risk and should be tested.  Patients on treatment should be tested approximately every 2 years. Persons on steroids chronically may need every 6 month monitoring.


Besides hormone blockade in men other medications associated with osteoporosis includes corticosteroids (prednisone and others) and anticonvulsant medications. Nearly all women 80 years and over have osteoporosis.  There are medical conditions that accelerate osteoporosis and physicians are always considering these possibilities when facing a patient with osteoporosis, especially if the problem is severe or not responding to treatment.

There are lifestyle issues that affect risk for osteoporosis. Low calcium intake in the diet, low vitamin D levels, cigarette smoking, excessive alcohol or caffeine use, significant weight loss in men, low body weights and inadequate exercise are all areas where improvements can help osteoporosis. Historical facts as they relate to a patient can predict risk for fracture. Using DEXA testing results carry predictable risk for fracture. If a person has a history of a diagnosed vertebral (spine bone) fracture they have a 4 times increased risk for a future fracture. If low bone density is also noted in such patients, the risk is even higher.


Appropriate calcium and vitamin D intake are important to preserve bone health.  More recent recommendations include 1500 mg elemental calcium for postmenopausal women not on estrogen as well as for men over 65 years of age. Requirements are slightly less for women who are still menstruating or men under age 65.  Vitamin D intake is recommended to be 800-1000 IU for adults 50 and older.   Our December Newsletter discussed vitamin D in more detail.  In that article readers learned that despite general supplementation recommendations, doctors are seeing a very high rate of vitamin D deficiency in the general population -especially the elderly. Our group is now monitoring vitamin D levels in our patients every 1-2 years.


Treatment for osteoporosis allows for several options. The main medication class used for treatment as well as prevention is known as bisphosphonates.  Prevention is indicated if a patient has osteopenia and additional risk factors.  These medications affect bone cells known as osteoclasts which are involved in bone turnover and remodeling.  We routinely recommend all of the medications in this drug class. Name brand medications FDA approved for treating postmenopausal osteoporosis include: Fosamax®, Actonel®, Boniva® and Reclast®.  More recent data suggests breast cancer metastasis is lower in patients using these medications. Another medication type indicated for treating osteoporosis in both men and women is called Forteo®.  This medication is used when disease is very severe or if a patient can't tolerate or isn't responding to the preferred line of therapy.  This medication is a subcutaneous injection given daily and is indicated to be taken for 2 years.  There is a hormone like medication called Evista® which has appeal in early menopause and in women at increased risk for invasive breast cancer as this product is FDA approved for invasive breast cancer reduction in women at high risk for this disease.  Finally there is a nose delivered hormone called Miacalcin® considered a second line option as it doesn't have as good of data for reduction of fracture rates. It can be helpful for pain control for acute vertebral fractures (FDA approved).


The bisphosphonates are usually given by mouth either daily, weekly or monthly. The optimal duration of treatment with bisphophonates is not known. There is one trial that has shown perhaps 5 years of continuous therapy can allow a 4 year medication holiday without increasing fracture risk. Other data shows continuous use for 5-7 years results in ongoing improvement in bone density and no increased complications. Boniva® is available by mouth or intravenously every 4 months. It is not approved for osteoporosis in men or corticosteroid induced osteoporosis. Boniva® hasn't shown hip fracture reduction data although it is approved for osteoporosis treatment based upon spine fracture reduction data and bone density improvement data. Reclast® is a once a year IV bisphosphonate. It is the only bisphosphonate FDA approved for all patient groups , both for treatment and prevention.Internal Medicine of Southwest Florida has provided this option for our patients for over 2 years.  Our experience with this product has been very positive overall.  It is a Medicare part B approved treatment and thus its cost is covered per part B rules.  The Medicare patient or their secondary is responsible for the 20% allowable charge.  We are excited about this treatment option because compliance is 100%, cost is neutral overall as the infusion is about the cost of an annual prescription of the by mouth bisphosphonates and there are no stomach side effects.  This treatment is not for everyone and there are conditions where it can't or shouldn't be used- specifically poor kidney function.


There has been a lot of controversy especially in our local community about the potential for a condition known as osteonecrosis of the jaw to arise as a complication of bisphosphonate treatment.  This is an exceedingly rare condition that has existed before bisphosphonates were ever developed. It is plausible that patients with cancer and who are nutritionally deficient, receiving radiation treatment and intravenous bisphosphonate therapy for certain cancer treatment protocols do have increased risk for this problem.  This group of patients is not the same as patients being provided therapy for the conditions we reviewed in this article. I would submit that when physicians are recommending bisphosphonates for treatment and prevention of osteoporosis we have weighed the potential risks of such a complication against the scientifically documented benefit of treatment.  This risk benefit analysis is usually overwhelmingly in favor of treatment.  If your dentist or oral surgeon has concerns regarding your treatment I would encourage them to consult the treating physician with their concerns.  I would also recommend patients to read the ADA (American Dental Association) guideline document regarding this issue. 

Diverticulosis or Diverticulitis

Colon Diverticula These two diagnoses are connected.  Diverticulosis is a "condition" more than a disease.  Diverticulitis is a complication of having diverticulosis.  Diverticulosis occurs in the large bowel (also known as the colon).  Diverticulosis is when a weakness or "pouch" develops in the colonic wall where the blood vessels enter the muscular layer of the colon.  A single pouch would be called a diverticula.   Blood vessels enter and exit the bowel every few inches and therefore a person can have numerous diverticuli (plural of diverticula). 

This condition was rare prior to the 20th century and it appears this is related to the drastic cut in the amount of fiber we now take in as compared to prior to the 20th century.  The occurrence of diverticulosis increases with age, affecting 50% of persons 60 and older who live in the western industrialized nations.  In Asian countries the condition is noted in less than 1% of the population. A high fiber diet is recommended for persons with diverticulosis  unless they get the complication of diverticulitis (see low residue diet in the paragraphs that follow).   Patients are often told to avoid popcorn, nuts and seeds although this recommendation has no scientific evidence to support it. We have seen many reports during colonoscopy of both diverticulosis and diverticulitis and there is never a comment of any of these food sources being seen blocking the diverticula.

Most people with diverticulosis have no symptoms but some can have irritable bowel syndrome (intermittent gas, bloating  and swings between constipation and diarrhea). Patients can also develop painless bleeding from injury to the artery that penetrates a diverticulum and ruptures on the inside of the bowel.  Usually the patient will either be passing bright red blood or perhaps maroon colored stools with clots.  Patients can bleed severely and this can become life threatening or require blood transfusions. Bleeding will usually stop on its own but occasionally intervention is required including embolizing a bleeding artery if the source of bleeding can be isolated or even surgical removal of a segment of the colon.  Colonoscopy is often the test of choice to evaluate sudden diverticular bleeding.

Diverticulitis is an inflammatory response following obstruction of a diverticulum (picture a mini-appendicitis).  Diverticulitis occurs in up to 25 % of persons with diverticulosis.  Diverticulitis usually presents with  change in bowel (usually constipation), abdominal pain (usually in the left lower quadrant, and fever. This condition is diagnosed by history and physical examination.  Complications can be looked for by urine testing -the inflammation can penetrate the urinary bladder.  Special x-ray imaging specifically CT scanning (Computerized Tomography) can reveal complications of abscess in the abdomen or pelvis. CT can show classic xray findings to rule the condition in as well as rule out conditions that might mimic this disease.  Treatment includes changing the diet to a low residue diet and starting antibiotics usually taken by mouth.  If a patient is very ill or unable to tolerated antibiotics by mouth, then the medication can be delivered by vein.

Usually this problem can be managed at home but sometimes hospital admission is necessary- especially if abscess might require surgical draining.  Up to 30% of persons who have an episode of diverticulitis will have a recurrence. If a second episode occurs the odd s of recurrence are 50% and surgical removal of the affected colon is recommended.  If the disease is in the right side of the colon surgery with the initial episode is recommended as the problem is more aggressive in this group of patients.

Upper Respiratory Illness


Fall, winter and early spring is the typical season for respiratory illness.  I have already discussed at length influenza vaccination and especially the H1N1 virus in the November newsletter . Most URI's present as cough and or head congestion with sore throat.  Most are  caused by a virus for which there isn't an antibiotic to treat it. Many patients are under the impression that the wonderful "Z-pak" is curing them of their infection.  The truth is most respiratory illnesses have no effective medication to kill the infectious agent and the patient is going to get better on their own. Further in this article I will recommend some simple symptomatic options most patients can safely take to make themselves feel better as their problem runs its course. No, I don't take antibiotics myself when I get one of these illnesses. Before the home remedies, I do wish to provide signs and symptoms for which you should request a same day or next day evaluation.

Symptoms that should prompt your immediate concern include: teeth- chattering chills(rigors), sudden onset of local rib or localized chest pain, bloody sputum, fever over 101, shortness of breath or resting heart rate over 100, confusion or wheezing. Remember signs of true influenza include invariably a temperature over 100 degrees, sudden and severe muscle aches (especially back/large muscles) followed by or associated with frontal headache/clear nasal discharge, sore throat and nonproductive but intense cough.  We have the ability to test for this illness in the office using a nose or throat swab and treatment is helpful especially if diagnosed in the first 1-3 days of symptoms.  Doctors can also offer preventive medication to persons living with the patient if an actual influenza case can be confirmed.  Strep throat is also a readily treatable condition with a simple throat swab- this testing is also available on site at our office.
Clues for a typical viral illness (most commonly this is the common cold virus) include:  occurring in outbreaks (family or neighbors have had it), mild fever (under 100.5), sudden onset of nasal stuffiness.  Yellow or green sputum is actually typical for viruses and is not a red alert for antibiotics- this is a common myth. Most viral illnesses will last 3 days to 2 weeks.  You should be trending to an improved condition by 14 days. If you are not this would be an indication to request an appointment with the doctor.
Things you may do from the over-the-counter shelf include:
1) Antihistamines such as Loratadine®, Alavert®, Claritin®, Tavist®, Zyrtec®.
2) Acetaminophen/Tylenol®, 2 every 6-8 hours for fever and/or aches and pains.
3) Zinc gluconate lozenges (Coldeez® brand especially) 13.3 mg dissolved every 2-3 hours per day will shorten the length of symptoms from cold virus.
4) Nasal saline sprays, menthol rub, guafenesin or dextromethorphan cough formulas.
5) If you are not allergic and Tylenol® isn't working well enough you may use ibuprofen (Motrin® and others) or aspirin 2 tablets every 6 hours with a snack for fever or aches.  Don't' take these options if you are on blood thinners or have an allergy to this type of medication.
6) High doses of vitamin C may help when acutely ill (1000 mg 3 times daily) but this is a very soft call.  Taking vitamin C to prevent a cold virus does not work.
I and my partners appreciate your patronage and interest in health. I hope these articles were helpful and informative for you.  Feel free to leave me feedback if there are topics of interest that you wish us to cover in future newsletters.  The plan is to provide this service bi monthly.

Raymond Kordonowy MD
Internal Medicine Of Southwest Florida
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