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In February, our guest expert in Le Club's Ask the Expert segment was Dr. Alexandra Papaioannou, B. Sc.N., M.Sc., M.D., FRCP(C), Associate Professor of Medicine at McMaster University in Hamilton, Ont., and Geriatrician at Hamilton Health Sciences.

Dr. Papaioannou is also Research Director at the Division of Geriatric Medicine, Faculty of Health Sciences, McMaster University, and an Associate Member of the Centre for Evaluation of Medicines, St. Joseph's Healthcare, and the Co-Director of The R. Samuel McLaughlin Centre for Research and Education in Aging and Health.

She is a fellow of the American College of Physicians and the Royal College of Physicians and Surgeons of Canada in Geriatric and Internal Medicine, as well as Diplomat of the American Board of Internal Medicine (ABIM). She has served as the Chair of the Board for Osteoporosis Canada (OC) and is the Vice-Chair of the Scientific Advisory Board and Chair of the Clinical Practice Guidelines task force for the OC.

Dr. Papaioannou was recently awarded the Lindy Fraser Award for recognition of her commitment to education, research and leadership in osteoporosis.

Dr. Papaioannou served on the Ontario Women's Health Council and participated in the development of osteoporosis guidelines for the Prevention of Osteoporosis (OPOT). She also served as the Co-Chair of the Ontario Ministry of Health and Long Term Care's Osteoporosis Strategy for Ontario.

She is the Hamilton Co-Director of the Canadian Multicentre Osteoporosis Study (CaMos). She has most recently completed the American College of Physicians Screening Guidelines and Osteoporosis and Dementia (PIER).

Here are Dr. Papaioannou's answers to your questions about Osteoporosis:


Q: Is an ankle scan as effective as a total bone scan in determining whether one is showing signs of osteoporosis?

A: No, it isn't. A total bone scan is recommended.


Q: I have a question regarding Fosamax. If a person has a very low calcium level and very low vitamin D should you use this medication, or should you first improve the levels of calcium and Vitamin D? If a person cannot tolerate calcium supplements such as pills, are there other forms of calcium available?

A: You should first increase your vitamin D (800-1000 IU daily) and calcium intake (1500 mg) per day. In addition to calcium carbonate, there is also calcium citrate, and fortified orange juice with calcium. I suggest speaking to your pharmacist. There are also good resources on the Osteoporosis Society website.

Q: Over the years, I took several bisphosphenates (Didrocal, Fosamax, Actonel) for osteopenia/osteoporosis and hated their side effects (esophagus irritation, overall body dryness, joint pain - Fosamax was the worst) as well as being concerned about the possibility that they may weaken my bones in the long term, as some studies suggests.

Then my endocrinologist and I discovered the non-prescription European-tested drug strontium, that builds up bone while it reduces its breakdown (bisphosphonates only do the latter), with little or no side effects or possibility of long-term consequences.

My first question is, why aren't safe(r) drugs like strontium being researched and promoted here, instead of bisphosphonates and dangerous parathyroid drugs like Forteo that may cause cancer (as it did in animal tests)?

The only reason I can see for the lack of progress on strontium research and marketing here is that drug companies can't make money with it (because it's an element and can't be patented). My second question is: How can the drug-development process be improved to better promote the needs of patients?

A: An application to Health Canada is currently underway for strontium. The process is lengthy, and is not related to the drug companies, but the government's concern that all the research is evaluated on a product prior to release in Canada.


Q: Which drug is better in restoring bone density in a 70-year-old woman with osteoporosis? My grandmother's family doc FINALLY agreed to switch her Didrocal to Actonel. Would Fosamax be more effective? Are the weekly preparations effective? Is one better tolerated than the other?

A: Both actonel and fosamax reduce the risk of spine and hip fractures. Weekly preparations are as good as the daily ones, and both drugs can be associated with nausea, abdominal pain and loose bowel movements.

Q: Please comment on the opinion of Dr. Ethel Siris, Director of the Osteoporosis Center at New York Presbyterian Hospital. She suggests that patients take a one-year vacation from bisphosphonates after five years because of the marked suppression of bone turnover. This would apply to people with advanced osteopenia. This information was part of an article in the
Globe & Mail on July 15, 2003.

A: Patients without fractures, family history of fractures, or personal use of prednisone like drugs and who have osteopenia are at low risk for fracture. A one-year vacation or re-evaluation of the use of bisphosphonates is appropriate. To date there is over 10 years of research with these drugs, and bone suppression or abnormal bone formation has not been shown.

Q: Would you please comment on the 'bone builder' pharmaceuticals, such as Didrical, Fosomax and Actonel? Are they effective? Should I take them with or without calcium supplements? How do diet and/or exercise impact the effectiveness? And, is a daily glass of wine a deterrent, or helpful? Thank you.

A: These drugs prevent bone breakdown and reduce the chances of spine and hip fractures. Didrocal has been only shown to reduce spine fractures. Calcium and vitamin D should be taken with all osteoporosis medications, but not at the same time. Your diet is an important source of calcium


Q: Is a calcium supplement made with oyster shells safe and readily absorbed?

A: Calcium carbonate from oyster shells may contain variable amounts of lead. Products made from calcium carbonate or calcium citrate are often recommended because they contain the highest percentage of elemental calcium per mg of calcium source.

Q: I am a 50-year-old woman who has just had a total hip replacement. I was diagnosed with osteoporosis last June and have been taking Actonel since then. Should I also be taking additional calcium supplements? Is there anything else I should be doing? Thanks!

A: You should have a total of 1500 mg of calcium from your diet or supplements and 800 IU of vitamin D per day. Supplements should be taken in divided doses, for example one with lunch one with dinner.

Q: There are so many different calcium products on the shelf that range from inexpensive 250/tabs to highly priced 60/tabs. How does one make a decision about the right product? Is there any difference between liquids, pills or chewables?

A: Osteoporosis Canada suggests taking the following factors into consideration:

1) The amount of calcium per tablet or dose: The amount of elemental calcium is the figure you use to calculate your true daily intake. This is usually found on the side of the bottle.

Products made from calcium carbonate or calcium citrate are often recommended because they contain the highest percentage of elemental calcium per mg of calcium source

2) Price: The most expensive is not necessarily the best. Speak to your pharmacist.

3) Tablet size: Some calcium tablets are very large and difficult to swallow; ask your pharmacist about chewable or effervescent tablets, they may be easier to take and as good as the tablets.



Q: Does having rheumatoid arthritis put you at greater risk of osteoporosis?

A: Yes. Rheumatoid arthritis is associated with higher risk due, in part, to the use of prednisone-like drugs, as well as the inflammation caused by the disease itself.

Q: I would like to know if it is true that women whose hair has greyed significantly prior to their mid 30s are at a higher risk for osteoporosis? I had read that there was a very high correlation.

A: This area has conflicting research; grey hair may be also associated with other pigmentation disorders, such as whitening of the skin. There are some articles that have shown a very small risk, and others that have shown no risk at all.

Q: My doctor tells me that thyroid pills may cause bone loss. Is this generally known? Are there other routinely prescribed drugs that my cause or exacerbate osteoporosis?

A: An overactive thyroid can be associated with an increased lifetime risk of fractures and bone loss. The effect of thyroid hormone treatment is somewhat controversial. The patients with suppressed thyroid stimulating hormone (TSH - one of the blood tests the doctor monitors) appear to lose bone. For example, they may be receiving a higher dose of their thyroid replacement.

Q: Are the chances of getting osteoporosis greater if one does not take vitamins, cannot drink milk and has menopause in early 40s? How does one reduce the risk of osteoporosis?

A: Premature or early menopause prior to age 45 is a major risk factor for osteoporosis. I would suggest you follow-up with your family doctor, and ensure that you are taking 1500mg of calcium and 800 IU of vitamin D in addition to exercise.



Q: I am 33, have a strong family history of osteoporosis, skipped a few periods and started my menstruation late. I'm healthy, eat well, watch what I eat and exercise every day. I'd like to know more about osteoporosis in young women and learn of research. What do you suggest?

A: Currently the Ontario Ministry of Health has funded a project through Osteoporosis Canada to examine what are the risk factors for osteoporosis in younger women. Stay tuned to the Osteoporosis Canada website, where the results will be released.

Q: I am a menopausal woman with a family history of severe osteoporosis (my mother has suffered hip and vertebral fractures), but normal bone density myself. In this situation, are lifestyle measures (diet, exercise, not smoking, minimal alcohol) enough, or should medication be considered? If so, what medication would this be?

A: You should ensure that you are taking 1500 mg of calcium and 800 IU of vitamin D from your diet or supplements. Medication is not necessary at this time. As you have strong risk factors, a bone mineral density should be repeated in two to three years

Q: I know three sisters who are around 70 to 80 years old. Two sisters drank milk and developed osteoporosis. The sister who couldn't drink milk has very strong and healthy bones. They all exercised and took care of themselves. I am also a person who, until recently, grew up drinking milk but found that the stomach problems I had was from milk. I also developed osteoporosis. So has my own family, who were avid milk drinkers. Why is it those who don't drink milk have healthier bones?

A: There is no research supporting that individuals who don't drink milk have healthier bones. Children need both exercise and dietary calcium to build bones; one or the other is not enough. Bone health can be affected by a number of factors including menopause. Sometimes, despite all the best prevention, bone loss can still occur with aging and menopause, and is not always predictable.


Q: How does the Curves workout measure up as an exercise program for a 66-year-old woman with osteoporosis?

A: The kinds of activity that affect bone mass include weight bearing and resistance exercise. Weight bearing exercise is one where bones and muscles work against the force of gravity such as walking, or aerobics, or stair climbing. Resistance exercise involves moving objects or our own weight to create resistance. The use of free weights and weight-training machines are examples. I cannot comment on the specific programmes such as Curves.

Q: How long does it take for my bones to show an improvement while taking Actonel? I have been taking it for two years. I exercise a fair bit with weights and aerobics. I also do the treadmill twice a week.

A: The goal of therapy is to maintain, or slow, bone loss. This can result in a 50 percent reduction in your risk of a bone fracture within one year of therapy. So from there, if your bone mass is stable, this is considered successful.


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