Ramsey R. Hachem, M.D.                                               
Washington University School of Medicine

Barnes-Jewish Hospital

Division of Pulmonary and Critical Care 

 

 

Osteoporosis in lung transplantation

 

          Osteoporosis is a skeletal condition characterized by a reduction in bone mineral density and alterations in bone architecture and consistency resulting in an increased risk of fractures, including spontaneous ones.  Osteoporosis is an important medical complication for the transplant patient because the immunosuppressive regimen, particularly prednisone and steroids in general, contribute to bone loss.  The World Health Organization (WHO) defines osteoporosis as bone mineral density 2.5 standard deviations below peak bone density.  Normally, the bony matrix is continually being remodeled, but the fundamental problem in osteoporosis is an imbalance between bone formation and resorption that results in decreased bone density over time.  The diagnosis of osteoporosis is established by measuring bone mineral density using a radiology test called dual energy x-ray absorptiometry, or DEXA scan.  

In general, post-menopausal women have the highest risk of osteoporosis, but the disorder can affect men and women of all ages.  A significant proportion of patients have osteoporosis before transplantation because of chronic steroid use, low body weight, smoking history, physical inactivity, and vitamin D deficiency.  Other predisposing factors include malnutrition and malabsorption of vitamin D, especially in patients with cystic fibrosis.  In severe cases, osteoporosis may sometimes be a contraindication to transplantation since it is expected to worsen after transplantation.  This is especially true if the patient has had multiple vertebral compression fractures or a hip fracture since these can be very disabling.

 Therefore, prevention and treatment of osteoporosis are critical to better bone health.  Non-medical therapy is a straightforward but essential component of treatment.  This includes a healthy diet with adequate supplies of calcium and vitamin D.  The total recommended amount of calcium is 1500 mg daily; this includes dietary intake and supplemental calcium.  The recommended amount of vitamin D is 800 IU daily, but higher doses are necessary if the patient has malabsorption or is vitamin D deficient.  Weight-bearing exercise is another important non-pharmacologic treatment of osteoporosis.  The minimum recommended exercise regimen to derive a beneficial effect is 30 minutes three times weekly.  In a large study of post-menopausal women, those who exercised 4 hours per week had a 40% lower risk of hip fracture than those who exercised less than an hour a week.  Smoking cessation is strongly recommended for everyone in general, but smoking also accelerates bone loss.  This is an additional risk factor for osteoporosis among past smokers.  These measures should be adopted for all patients who have osteoporosis or are at increased risk for the disorder.  However, these lifestyle modifications alone are not sufficient for those who have osteoporosis and an increased risk of fractures.  Such patients require pharmacologic therapy for osteoporosis.

          Bisphosphonates are a class of drugs that inhibit bone resorption and are widely used for the prevention and treatment of osteoporosis.  This class of drugs includes alendronate, risedronate, and ibandronate, among others.  By inhibiting bone resorption, they increase bone mass and reduce the risk of fractures.  Numerous randomized controlled trials have demonstrated significant reductions in the risk of fractures for these drugs when compared to placebo.  Bisphosphonates are poorly absorbed when taken orally and must be taken on an empty stomach.  Additionally, the drug should be taken with at least 8 ounces of water, and the patient should stay upright for 30-60 minutes to reduce the risk of esophagitis.

           Many patients have hypogonadism before transplantation as as result of chronic illness, malnutrition, or prednisone use, and this contributes to the risk of bone loss.  Unless contraindicated, hormonal replacement with testosterone for men and estrogen-progestin for women can alleviate bone loss.  However, the use of estrogen is no longer considered a first-line treatment for osteoporosis among post-menopausal women because of an increased risk of cardiovascular disease and breast cancer.  Another class of hormonal agents, known as selective estrogen receptor modulators, include raloxifene and tamoxifen.  These do not have the same risk profile as estrogen, but can be effective for osteoporosis prevention although their efficacy is inferior to bisphosphonates.  Unlike other agents that inhibit bone resorption, teriparatide (Forteo) is a parathyroid hormone that stimulates bone formation and reduces the risk of fractures.  It is administered as a daily injection.  However, its use is limited to a maximum of two years because an increased risk of bone cancer was noted in animal studies, although this has not been observed in humans.

          Osteoporosis is a serious condition that can result in disabling symptoms and adversely affect quality of life after lung transplantation.  However, lifestyle modifications and medical therapy can improve bone health and mitigate the impact of osteoporosis on outcomes after transplantation.

We Remember

We Remember

      She was born on February. 15, 1969, in Carthage, Missouri. Cindy was the daughter of Richard Capps and Sarah "Bryant" Capps and the late "James" Jim Klice. Cindy enjoyed participating and attending antique car shows with her husband showing off their 1971 Chevelle, fishing and gardening.

      Cindy is preceded in death by her dad James "Jim" Klice and mother-in-law Jean Curtis. 

      March is notorious for "in like a lamb, out like a lion" or visa versa, but for those that received their transplant in March the wind and weather takes a back seat to breathing easier and enjoying all the joys of Spring.  Happy anniversary!

       

IPF gains SSA recognition

By Joshua Stegeman

Do you know what IPF is?  It stands for idiopathic pulmonary fibrosis.  Why is it important to know about this?  The Social Security Administration recently added IPF to its list of "Compassionate Allowances".

What does this mean for sufferers of IPF.  It means being approved for benefits in a matter of days rather than months or years.  It also means that since applicants with these diseases will be "fast-tracked" for benefits, it affords examiners more time to closely evaluate other applications, especially determining applications involving respiratory conditions.  Beginning March 1, 2010, the Social Security Administration will begin screening for these new conditions.  Applicants will still need to wait the full 24-month period for Medicare benefits, but will at least receive disability benefits almost immediately.

The Coalition for Pulmonary Fibrosis, which is a member of the National Organization of Rare Diseases, played a vital role in supporting the inclusion of IPF on the Compassionate Allowances.  You can visit their website for more information at www.coalitionforpf.org.  

The Compassionate Allowances list was created by the Social Security Administration in October 2008 to expedite claims for 25 rare diseases and 25 cancers.  In addition to including IPF, Social Security also added 37 other conditions.  For more information about the diseases and conditions included on the list you can visit www.socialsecurity.gov/compassionateallowances. 

      This is the time to change the scenery.  Go to the mall and walk a bit then sit and people watch.  What an education in styles and the new hair colors!  Grab a to-go sandwich, eat in the car and watch the drivers as they go on their merry way.  I tried to count cell phone users but gave up -- there were too many! How about going to the library and look over the latest books, checking out the most interesting ones? 

      But my favorite mood shifter is to get my hair done.  Many feel they can do it themselves just as well and probably they can.  But there's just something relaxing about the water pouring over your head as you lie back and relax and let someone else massage those worries away.  And this is good for guys and gals alike!    Pamper is the word here and that's a mood picker upper for sure.

     Email me at LKwasigroh@aol.com and let me know what ways you use to keep the moody blues at bay!