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.