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Populations at Risk

The following sections describe certain populations who are especially at risk for low bone mass and fracture:

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I. Advancing Age/Prior Fracture/Family History of Fracture/Weight

- These parameters could be the strongest predictors for low bone mass and future fracture. In some cases, these factors have more predictive value for the development of future fractures than bone mineral density values. This is why our center makes it a priority to obtain this valuable information from our patients.

a. As we age, our bones generally get "thinner" or become less dense. This is particularly true for women after menopause. Depending upon the interplay of risk factors, having a prior fracture can quadruple the risk for a future fracture. At our center, after appropriate testing, we strongly consider treatment in patients who have fractured.

b. The old saying, "like father, like son; like mother like daughter" certainly applies when it comes to bone health. If an individual has a strong family history of osteoporosis, especially a parental history of hip fracture, then this is a significant risk factor for the development of low bone mass in that individual.

c. Low body weight is a risk factor for low bone mass, especially at weights below 127 lbs and Body Mass Indexes (BMI) less than 19 kg/m2.

II. Rheumatoid Arthritis/Lupus

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a. These conditions, which are quite familiar to rheumatologists are associated with the development of low bone mass. Although part of this risk has to do with the disease itself, medications (like corticosteroids) commonly used to treat these disorders often has a large impact. In this population, our center is extremely aggressive with regards to bone health.

III. Smoking / Excessive Alcohol Use

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a. Smoking reduces calcium absorption, slows the production of bone producing cells, and may impair blood supply to the bones. Older men and women who smoke cigarettes have significantly lower bone mineral density than those who do not. Smokers are generally weaker and have poorer balance, gait, and physical function. It is no surprise that older men and women who have smoked for years are more likely to sustain fractures after minimal trauma than are nonsmokers. At our center, we aggressively attempt to educate patients about the adverse effects of smoking and assist them with smoking cessation. In this regard, we often refer patients to local smoking cessation classes and offer drug therapy when indicated.

b. Excess alcohol consumption can adversely affect bone strength by interfering with the absorption/production of Calicum/Vitamin D and by causing a variety of hormone irregularities. In addition, since alcohol has a strong negative impact on balance and gait, patients who consume excess alcohol are at a greater risk for falls and, subsequently, have higher rates of hip and vertebral fractures.

IV. Medications that can adversely affect bone strength

a. Corticosteroids

i. Corticosteroids (sometimes referred to as Glucocorticoids, steroids, "cortisone pills") have been used by a variety of physicians in multiple fields to treat a wide spectrum of illnesses for over 50 years. When used judiciously, these medications can positively impact and even save the lives of patients with a range of conditions (including Rheumatoid Arthritis, Lupus, Vasculitis, Asthma, Chronic Obstructive Lung Disease, inflammatory skin diseases, inflammatory bowel diseases, inflammatory neurologic diseases, organ transplant recipients). Our experts are well versed in the therapeutic use of these medications but are aware of the long term potential bone weakening effects of this treatment.

ii. The exact reason why corticosteroids weaken the bones is complex, but is thought to be mainly caused by injuring the bone producing cells and changing calcium absorption and elimination.

iii. A DXA scan is recommended for any individual who has taken or is planning to take corticosteroids at a dosage more than 5mg/day of prednisone. Our providers aggressively screen patients with DXA scans who use chronic steroids and know that treatment thresholds for these patients are considerably lower than for average patients not using these medications. Since patients who take corticosteroids often have complicated bone problems, other specialists who prescribe these medications often call upon our center's providers to manage their patient's bone health.

b. Anti-convulsants (Seizure Medications)

i. Osteoporosis is increased in both and women with epilepsy. The risk has been linked to several medications used to treat epilepsy, including Carbamazepine (Tegretol®, Carbatrol®) Phenytoin (Dilantin®, Phenetyk®), Phenobarbitol, Primidone (Mysoline®) and Valproate (Depakote®).

ii. Studies have documented lower bone density measurements in patients (especially postmenopausal women) who take long term seizure medications. The mechanism of the increased risk appears to relate to medication-induced abnormal Calcium and Vitamin D metabolism. Any patient who has been on seizure medications for long periods of time should have their bone density checked. Our providers often work closely with neurologists to help improve the bone health of epilepsy patients.

V. Male Osteoporosis

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a. Contrary to the belief that osteoporosis is a woman's disease, osteoporosis in men is becoming increasingly recognized. Men in their 50s don't develop the rapid bone loss that women do in the years after menopause; however, by about age 65, men and women lose bone at about the same rate. After the age of 50, 6 percent of all men will experience a hip fracture and 5 percent will have a vertebral fracture related to osteoporosis. Most professional societies and the International Society for Clinical Densitometry recommend screening DXA scans for males over the age of 70 years.

b. At our center, we are aggressively screening and treating men for osteoporosis, especially those who have additional risk factors for fracture including advanced age, smoking, frequent falls, taking medications associated with bone loss, or prior fracture.

VI. Cancer

a. Breast Cancer

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i. In addition to the typical risks of osteoporosis associated with being post-menopausal, women who have breast cancer are at increased risk for osteoporosis and fracture as a direct result of their cancer therapy. This is particularly true if they have received agents that cause early menopause, affect hormone levels, or have a direct antiestrogen-like impact on the bone. Methods to lower estrogen levels in breast cancer survivors are important, since many breast tumors rely upon estrogen for growth.

ii. Perhaps the most well recognized agents to cause low bone mass are the same agents that have dramatically reduced the incidence of cancer recurrence in breast cancer survivors: Aromatase Inhibitors (AIs). Aromatase is a body enzyme that makes estrogen. AIs [some examples include Letrozole (Femara®), Exemestane (Aromasin®), Anastrozole (Arimidex®)] effectively inhibit this enzyme, thereby decreasing the body's estrogen, which helps keeps breast cancer in remission. It appears that women who have low bone strength to begin with are particularly susceptible to the Aromatase-Inhibitor induced bone loss.

iii. At our center, we strive to work with oncologists to help prevent the bone loss from Aromatase inhibitors so that these medications can be used to battle breast cancer. We not only aggressively treat low bone mass in breast cancer patients who take AIs, we follow well accepted guidelines that generally dictate that postmenopausal women who are planning to start an AI should have a baseline DXA scan.

b. Prostate Cancer

i. Prostate Cancer happens to be extremely testosterone-dependent. The treatment of Prostate Cancer often involves reducing testosterone levels. This type of treatment is known as "hormone therapy", or "Androgen Deprivation Therapy (ADT)." Examples of this treatment include medications like GnRH agonists (Lupron, Zoladex®, Viadur®, Trelstar®).

ii. Low levels of testosterone, however, are associated with bone loss, osteoporosis, and fracture. At our center, we strive to work closely with urologists and oncologists to help screen (with DXA scans) and treat low bone mass so that treatments directed at curing prostate cancer don't have ill effects on the bones.

VII. Gastrointestinal Implications

a. Normally, a variety of important nutrients from food (especially calcium) are absorbed through the intestine. Gastrointestinal issues can impair the ability to absorb calcium and vitamin D through the intestines (particularly small intestine); Calcium and Vitamin D are crucial to bone strength. Therefore, patients with Celiac Sprue, Inflammatory Bowel Disease (IBD - Crohn's and Ulcerative Colitis), Cirrhosis, and even those patients who have undergone gastric bypass are at risk for low bone strength and osteoporosis. In addition, many patients with IBD have required corticosteroids for the treatment of their bowel problems.

b. Our center recognizes these issues and works closely with Gastroenterologists, Bariatric Surgeons, and Primary Care Physicians to help screen and treat low bone mass in this vulnerable patient population.

VIII. Vertebral Fractures/Vertebroplasty

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a. Although osteoporotic fractures of the spine (vertebral fractures) are often silent, a proportion of these fractures cause deformity, height loss, or severe back pain.

b. Some patients with severe pain from a recent spine fracture undergo a procedure called vertebroplasty (a related procedure is called kyphoplasty). Simply put, this procedure involves placing small needles under x-ray guidance into the collapsed vertebrae and subsequently inserting a specially formulated bone cement. In many cases this procedure can instantly relieve the pain associated with a fractured vertebra.

c. Patients who have an osteoporotic vertebral fracture instantly meet criteria for a diagnosis of osteoporosis and are at a high risk of future fracture at many different bone sites, including further vertebral fractures.

d. At our center these patients are aggressively treated for their osteoporosis with both drug and non-drug treatments. We often consider the strongest osteoporosis treatments available for this vulnerable population.

IX. Metabolic Bone Disease / Chronic Kidney Disease Mineral and Bone Disorder (CKD-MBD)

a. Osteoporosis is not the only cause of impaired bone strength causing a tendency to fracture. The following conditions are just a few examples of other conditions that can cause bone weakness: Osteomalacia, Rickets, Paget's Disease of Bone, Primary and Secondary Hyperparathyroidism, Renal Osteodystrophy (CKD-MBD). As part of every workup, our bone experts routinely test for these and other conditions that can cause low bone mass prior to committing any patient to treatment for osteoporosis.

b. Chronic kidney Disease Mineral and Bone Disorder (CKD-MBD)

i. Chronic Kidney Disease refers to decreased kidney function. Declining kidney function is an unfortunate consequence of aging. Of those aged 70 or older, about 75% of patients have some degree of kidney impairment.

ii. Moderate to severe chronic kidney disease is associated with more than a 2-fold increase in the incidence of hip fracture. CKD-MBD is the broad term that defines a disorder of bone and mineral metabolism that is manifested by abnormalities in calcium, phosphorus, parathyroid hormone, vitamin D, and ultimately, bone strength.

iii. Our specialists are well versed on properly measuring bone mineral density in patients with Chronic Kidney Disease. In addition, we are familiar with the unique biochemical abnormalities which can be seen in Chronic Kidney Disease and often work closely with nephrologists to help prevent fractures in this vulnerable population.

X. Stroke/Bed Rest/immobilization

a. The process of weight bearing and walking/running allows our bones to remain healthy. In order to maintain strength, our bones depend upon the normal daily stresses, strains and compressive mechanical forces of the surrounding muscles and tissues.

b. Immobilization, whether it is a result of severe medical illness, stroke, respiratory failure, traumatic paralysis, or other neurodegenerative disorder results in severe, rapid bone loss. Many patients who have been immobile for long periods of time will experience bone fractures with little or even no trauma.

c. Stroke patients have been found to have a 2-4 fold increase in the risk of fracture.

d. It is crucial that these patients get aggressively evaluated/treated for low bone mass and our specialists are well trained to assess the risk and provide appropriate treatments.


References:

  1. Ad Hoc Committee on GIO. Recommendations for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. (2001) 44: 1496-1503.
  2. Eastham J. Bone Health in Men Receiving Androgen Deprivation Therapy for Prostate Cancer. The Journal of Urology (2007) 177:17-24.
  3. Epstein et al. Disorders Associated with Acute Rapid and Severe Bone Loss. J Bone Min Res (2003) 18: 2083-2090.
  4. Gnant M. Management of Bone Loss Induced by Aromatase Inhibitors. Cancer Investigation (2006) 23:328-330.
  5. Nicholas et al. Chronic Kidney Disease and Bone Fracture: a Growing Concern. Kidney International (2008) 74: 721-731.
  6. Quaseem A. Screening for Osteoporosis in Men: A Clinical Practice Guideline from the American College of Physicians (2008) 148: 680-684.
  7. Komaba et al. Treatment of Chronic Kidney Disease Mineral and Bone Disorder (CKD_MBD). Inter Med (2008) 47: 989-994
  8. Clinicians Guide 2008, National Osteoporosis Foundation
  9. The NIH Osteoporosis and Related Bone Diseases ~ National Resource Center. "Conditions and Behaviors that Increase Osteoporosis Risk". Accessed 2/2009
  10. The NIH Osteoporosis and Related Bone Diseases ~ National Resource Center. "What Breast Cancer Survivors Need to know about Osteoporosis". Accessed 2/2009