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 Our guest experts in May 2010 were Dr. Sandra Kim and Ina R. of the Multidisciplinary Osteoporosis Program at Women’s College Hospital.

Dr. Sandra Kim is the medical director of the Multidisciplinary Osteoporosis Program at Women’s College Hospital. She is an assistant professor in the department of medicine at the University of Toronto and a clinical teacher active in both undergraduate and postgraduate education. She completed the Master Teacher Program at the University of Toronto department of medicine and is the recipient of several teaching awards including the 2009 Women’s Health Award. Her clinical interest is in metabolic bone disease and endocrine disorders in pregnancy.

Ina R., BScN RN M.Ed., is a clinical nurse specialist. As an advanced practice nurse, she sees all new patients referred to the Multidisciplinary Osteoporosis Program and works with a large caseload of patients with osteoporosis or osteoarthritis who have complex needs. She is an educational resource for patients as well as co-ordinator of care, linking patients to services and supports, and helping them to understand their condition. She also provides information and community outreach for those interested in learning more about osteoporosis and osteoarthritis.

Here are their answers on Osteoporosis.

Q: When people are taking osteoporosis medications, should they still be ingesting higher amounts of calcium in diet and supplements?

A: Individuals who take medications for osteoporosis often have the misconception that the medications alone are enough to stabilize their bone loss. In order to ensure that these medications work effectively it is important to ensure that the body receives an adequate amount of the key building blocks of bone, calcium and Vitamin D, daily. Sources of calcium include diet and supplements. There is some variation between the recommended amounts of daily calcium intake (total from all sources: diet and supplements), but the general range for women up to the age of 70 years is 1,200 milligrams daily, and from 70 years and older 1,000 milligrams daily. Individuals who have experienced kidney stones or hyperparathyroidism should consult with their doctor regarding recommended calcium and vitamin D intake.


Q: I am 77 years old and have osteoporosis. I read somewhere that if a person takes Fosamax, it should not be taken for longer than 10 years. Is this true, or does a person keep on taking it indefinitely if their numbers are not good?

Q: I have been taking alendronate for osteoporosis for more than 10 years, and want to know if I should stop. My doctor says to keep taking it but I have read many conflicting opinions on the subject. Most think that a break of at least a year would be a good idea. Could I please have your opinion? Why do so many people recommend taking a break from the medication?

A: There has been some controversy over the subject of long-term bisphosphonate therapy. Even amongst osteoporosis specialists, there is currently no clear consensus on how long bisphosphonate agents such as Fosamax (alendronate) and Actonel (risedronate) should be continued, and whether a break from the medication (“drug holiday”) should be considered.

Bisphosphonate agents work by inhibiting bone loss by slowing down bone turnover. Presently, the largest and longest randomized clinical study we have on bisphoshonate use was for 10 years. This study demonstrated long-term safety of bisphosphonates and ongoing effective fracture risk reduction in women with osteoporosis. Nevertheless, due to the theoretical concern of possible over-suppression of bone turnover with long-term bisphosphonate use, some doctors are recommending a drug holiday (a temporary break off bisphosphonate medication for one or more years) in certain people who have been taking the drug for a long period of time. This is being considered only in people who have responded well to bisphosphonate therapy with stabilized bone mineral density results and no recent occurrences of fragility fractures. Currently there is no evidence-based research to support whether there is any clear benefit or potential harm from practicing drug holiday.

It is important to have regular assessments and discussion with your doctor on how you are responding to bisphosphonate treatment and whether or not there is an ongoing need for continued bisphosphonate use. Each individual is different and many factors are taken into account such as your bone density result, age, history of fragility fractures, risk for falls, other medical conditions and medications that you may be taking, and family history of osteoporosis. If you are considered to be at high risk for fractures then in most cases you will require ongoing bisphosphonate treatment long-term. Depending on your risk factors and overall assessment, your doctor might consider a drug holiday but close monitoring is recommended with a reassessment by your doctor the following year. If there are any uncertainties then you may request to be referred to an osteoporosis specialist for assessment.


Q: I had been on Fosamax for about six years and was told by a physician to take a break from it for a bit. I stopped taking it last fall and have just been running, lifting weights and taking lots of calcium and vitamin D as well as hormone therapy. I am waiting for Denosumab to come on the market. Should I go back on Fosamax in the meantime? I am 57 years old with two forearm fractures (2007 and 2009) and a strong family history of OP.

A: Whether you should restart Fosamax or not will depend on your overall risk for fractures. Your fracture risk is estimated based on several factors such as your current age, bone density result, prior history of low trauma fractures, other medical conditions and medications that you may be taking, risk for falls and family history of osteoporosis. Your doctor may recommend that you go back on Fosamax if there has been a significant decline in your bone mineral density since you stopped taking the medication. If you are considered at high risk for fractures, it is usually recommended that drug holiday from bisphosphonate therapy be only one to two years even if your bone density result has not changed during that period.

Based on your history provided (prior fractures and strong family history of OP), you may possibly be at high risk for future fractures, but I do not know your bone density result to say for certain. However if you are taking hormone replacement therapy, which is also an effective anti-resorptive treatment for osteoporosis, then you may not require Fosamax. You should be reassessed by your family doctor or osteoporosis specialist.


Q: Is Matrix energetics beneficial for osteoporosis?

A: Matrix energetics is described on its website as “a system of healing, self care and transformation.” There is currently no scientific research or evidence in the field of osteoporosis to demonstrate that it is beneficial for osteoporosis.


Q: If you have been diagnosed with osteoporosis, and your bone density improves with treatment, is it still accurate to say that you have osteoporosis? Or do you get to step back down to osteopenia?

A: The World Health Organization (WHO) criteria for the diagnosis of osteoporosis is defined as having a T-score of -2.5 or less on bone mineral density in either the lumbar spine or hip sites. WHO defines osteopenia as a T-score between -1.0 and -2.5. If your bone density improves with treatment such that your T-score is now higher than -2.5, then by the WHO definition you would no longer be classified as having osteoporosis but instead osteopenia. However, if you have a history of a low trauma fracture (fragility fracture), then you are diagnosed with osteoporosis regardless of your bone density result, even if your bone density improves with treatment.

It is important to know that bone strength is not only dependent on bone density (quantity of bone mass), but also the bone quality. Unfortunately, it is not easy to directly evaluate bone quality as this requires histomorphometry studies from bone biopsies. Instead, bone quality is indirectly assessed by a person’s history of fractures and family history of osteoporosis. Therefore it is not accurate to define osteoporosis by bone density information alone.

Rather than using the terms “osteoporosis” or “osteopenia” to make clinical decisions on whether treatment is required, it is more correct to determine a person’s overall 10-year risk for fractures. This is determined by assessing several factors such as age, bone density result, history of fragility fractures, use of steroids, family history of osteoporosis, risk for falls and other co-morbidities associated with risk for fractures.


Q: Is there any correlation between salt and osteoporosis and osteoporosis medication?

A: The major component of salt is sodium. For many different health reasons, current recommendations are that individuals limit their sodium intake to less than 2,300 milligrams per day. Sodium intake in amounts greater than 2,300 milligrams per day has been shown to contribute to calcium loss through the urine. As we know, calcium is one of the key building blocks of bone. Loss of calcium through the urine can have a negative effect on bone.


Q: Can measures such as weight-bearing exercise, diet and medication reverse bone loss or merely slow it down?

A: Stabilization of bone loss requires many different pieces of a large puzzle. No one single piece of this puzzle is effective on its own. Weight-bearing and strength training/resistance exercises, diet, fall-prevention – are all elements of a “bone healthy” lifestyle that have a positive impact on bone health, improve posture and balance, and contribute to the prevention of falls and fractures. Although they may play a role in slowing down that rate of bone loss they are not able to reverse bone loss on their own. Osteoporosis medications work at the level of the bone cells and have the ability to reverse bone loss and provide protection from fractures.


Q: Are there any natural alternatives to medication for osteoporosis?

A: Currently there are no natural alternatives to medication for osteoporosis that are supported by scientific research and evidence. Some individuals have mistakenly assumed that the nutritional supplement “strontium” is the same as “strontium ranelate,” a prescription medication used for osteoporosis. The prescription medication strontium ranelate has been approved and in use in the European Union since 2004, and has yet to be approved for use in Canada and the U.S. Individuals need to be aware that little is known about the risks and benefits of strontium nutritional supplements.


Q: I have recently been diagnosed with osteoporosis. I am only 55 years old and have no notable risk factors. Medical causes seem to have been ruled out. There is a suggestion that I should start taking medication to prevent bone loss or build bone, in addition to calcium supplementation. There has been a recent flurry of negative reports about the use of the drugs that have commonly been prescribed. How much testing has actually been done on their negative effects? How can one make a safe decision?

A: It is important to remember that all medications have potential side-effects and osteoporosis medications are no exception. The most commonly prescribed medication for osteoporosis treatment and prevention are the bisphosphonate agents such as Fosamax (alendronate) and Actonel (risedronate). The overall safety and effectiveness of bisphosphonates in reducing the risk of osteoporotic fractures have been confirmed by many large clinical studies, and these medications have been used worldwide by millions of people.

Bisphosphonate treatment may have been recommended to you if you are considered to be at high risk for fractures, or have low bone density scores and are in a rapid phase of bone loss (for example from recent menopause). Osteoporotic fractures are linked to additional fractures, altered quality of life, worsening of other health conditions and in some case, death. In starting any medication, it is important to be aware of the potential side-effects (both the common mild negative effects and the extremely rare severe effects). You and your doctor should carefully weigh the risks and benefits of taking a medication for your unique situation every time a medication is recommended and prescribed. In addition, media reports on drugs should be interpreted with caution as they may be based on anecdotal rare case reports or poorly designed studies. Any concerns about medications should be addressed and discussed with your doctor.


Q: I am in my 15th month of treatment with Forteo. I have had no side-effects and the treatment is going well. I have a bone density test soon so I am hoping that I have a significant improvement in my bone density. My question is, could I do another session of Forteo in the future if my bone density numbers warrant that? Are there other 'boosters' (other than Actonel, Fosamax, etc. which I do not do well with) which have proven effective in staving off bone loss?

A: Currently, Forteo (teriparatide) is only approved for one continuous treatment course of 18 or 24 months. There are ongoing studies assessing the efficacy and safety of using Forteo (and other similar parathyroid hormone analogs) in a cyclical fashion with or without other osteoporosis medications. Whether there are any benefits to a repeat continuous course of Forteo awaits further research.

Other than Actonel and Fosamax, there are many other osteoporosis medications that are available, such as intravenous bisphosphonates (aclasta and pamidronate), hormone replacement therapy, Evista (raloxifene), and miacalcin. Each of these drugs has different mechanisms of action in treating osteoporosis, different efficacies in reducing fracture risk, and different side-effect profiles. It is important to review the different treatment options with your doctor weighing both the risks and benefits for your unique situation. There are many potential new drugs that are currently being developed and studied for the treatment of osteoporosis that we will see in the future.


Q: I am presently taking Fosavance once a week, and am also taking the thyroid medication Eltroxin. I take the Fosavance as soon as I get up in the morning. Can I take the Eltroxin at the same time without negative effects, or should I wait a while?

A: Bisphosphonate agents such as Fosavance are poorly absorbed medications, and therefore it is recommended that they be taken alone on an empty stomach in the morning with plenty of water. To help maximize Fosavance absorption, we recommend that you avoid eating food for at least one hour and avoid any calcium-rich foods or calcium supplements and multivitamins for at least two to three hours. Other prescription medications (such as Eltroxin) can generally be taken one hour after taking your bisphosphonate.


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