Men`s Osteoporosis Support Group
Volume II, Issue IV	October 1, 1998

The newsletter on the Net

What`s new?

I`m excited to report that we now have an expert to support the group with answers for our questions about bone densitometry and radiology. Dr. James A. Schuster, a radiologist from Rochester, NY has very graciously volunteered to support the group. Additionally, he will be providing editorial and review support for future issues of the newsletter. If you have questions about bone density equipment, methods or techniques, radiology, or about your own bone mineral density (BMD) test results, please e-mail Dr. Schuster directly at schuster@rochester.rr.com. If the answer is specific only to you, he will respond directly to your question. If your question is of general interest, he will respond via the next newsletter.

This is the last newsletter that I will be mailing to members of the Men`s Osteoporosis Support Group. Future issues will be posted on the Internet at http://www.maleosteoporosis.org/ where they can be viewed or printed. I will be mailing this issue to everyone who is listed on the July 1998 Linking Up Roster from the National Osteoporosis Foundation since several men are new members that have never received an issue. If you write or call to let me know that you have no access to a computer and the Internet yourself, or through friends or family, I will continue to mail issues to you. Otherwise, I hope everyone will look for the issues at the Web site as they are published in January, April, July, and October of each year.

I want to remind members that no one should be more interested in your health than you are. This means you need to be as knowledgeable as possible about osteoporosis or other conditions that you have or might have. Don`t blindly accept everything that your medical practitioner says. Don`t be afraid to ask questions and to offer suggestions. Here is something that happened to me this month that I still don`t know the outcome of, but that vividly shows the importance of the previous reminders. I have recently changed clinics and care providers, going from an endocrinologist out of town, to a more local internist. When the internist got the results of my latest dual X-ray absorptiometry (DXA), he gave me a copy and pointed out that the results were abnormal. I don`t think he has copies of all my previous results and couldn`t check to see what changes had occurred since last year`s DXA. Since I`m vitally interested in my health, I did check for changes since last year. Oddly, and somewhat alarmingly, I noted that the hip neck BMD is down almost one standard deviation in a little over one year`s time. The current hip BMD is -2.25 S.D. from the young adult standard. I`m aggressively following up these results with a request to see a local endocrinologist and, after consulting with Dr. Schuster, our bone densitometry consultant, will also ask for a repeat hip DXA. I consider my local internist to be an excellent physician and I`m extremely happy with him. That doesn`t mean that I don`t double check his results and recommendations or look for possible oversights. It is my health and I don`t want to take an unnecessary chance that a busy physician overlooked something. So I`m never too busy to keep track of my health. I suggest that all our members should do the same. You`ll see from one of our case history profiles in this issue that not all sources of low BMD are benign.

Here is a follow-up on the topic of testosterone patches that was mentioned in last quarter`s newsletter. One of our members has had a chance to try both the Androderm and Testoderm(R) TTS patches. Please realize that this is not a scientific study with controls and adequate numbers to draw valid conclusions. If other members have similar or different results with either of the patches I would be glad to publish the results in a future issue. Anyway, this member was using the Androderm patch with no great problems, but was unable to maintain adequate serum testosterone levels. He thus volunteered to try the Testoderm(R) TTS when it became available. He found this also unable to get his serum levels of testosterone to acceptable levels and went back to the Androderm patch. Unfortunately, he then developed a very uncomfortable allergy to the vehicle in the Androderm patch which forced him to stop using it. He had found that his serum testosterone levels were still inadequate while on it, too. So, he is now taking 200 mg I.M. injections of testosterone cypionate every two weeks and reports normal serum levels with this method. He mentioned that his endocrinologist thinks that he might be able to use 400 mg once a month, and will report on that dosage results in a later issue if he tries it. The obvious conclusion here is that you should be sure you have periodic blood tests done to monitor serum testosterone levels if you are using one of the patches. Just because you can wear it comfortably doesn`t assure you that it is functioning adequately.

I have reported on ultrasound of the heel as a potential fast, inexpensive alternative to DXA in previous newsletters. Although they had only limited experience with the heel sonometry unit, and a controlled study was not undertaken, Dr. Schuster and his group were not impressed with the correlation between heel sonometry and DXA studies on randomly selected patients they scanned over the last several months. They have, therefore, elected to return the heel unit to the manufacturer.

Member case history profile

When you read the bulk of the literature on osteoporosis, you would think that it is strictly confined to postmenopausal women. As those of us in this support group know, that is not true. This case shows that very young men are also subject to the perils of osteoporosis. Additionally, this case shows how good fortune and early diagnosis can prevent a silent condition from developing into a painful and even debilitating one. There are a lot of men who could benefit from early diagnosis. So, we hope to start seeing such tests as heel sonometry eventually become reliable and effective.

This member is a 37-year-old white male physician previously in excellent health. He is very active with biking and is the captain of a group bicycling team that rides in the MS 150 tour each year. Additionally, he rows and uses the multi-station gym. He eats a well-balanced diet including an occasional wine or beer in moderation, is normal weight, was taking no medications, and doesn`t smoke.

Two years ago he fractured three ribs falling from a boat ride in a local lake and suffered a comminuted intra-articular glenoid fracture of the left shoulder 18 months ago after slipping on ice in a parking lot. The orthopaedist commented at the time that this was an unusual fracture, and he was surprised that it did not dislocate the shoulder instead.

He was evaluating a new DXA unit for his clinic and, during acceptance testing, he volunteered to be scanned. To his surprise, the test showed osteopenia with the following measurements: Lateral lumbar spine measured 0.725 g/cm2 (T-score unavailable, probably less than -2.5), Anterior-posterior (AP) lumbar spine was 0.842 g/cm2 (T-score -2.27), hip was 0.815 g/cm2 (T-score -1.45), and forearm was 0.558 g/cm2 (T-score of -2.25). He scanned another volunteer immediately who was normal, and did a repeat AP lumbar spine on himself that showed a BMD of 0.829 (T-score -2.38). He also did heel sonometry that measured 0.534 g/cm2, and a quantitative computed tomography (QCT) of 150.9 mg/cc, a T-score of -1.9.

He was completely shocked, and immediately contacted his physician who reviewed the reports, his chart, and the labs. They discussed possible causes and embarked upon a major laboratory work up. After 14 tubes of blood, 24-hour urine collection, and a complete physical, all labs results were completely normal except leutinizing hormone (LH) and testosterone. Pertinent normal values included serum and urinary calcium, chem 7 and 12, all thyroid functions, parathyroid, liver functions, prolactin, and cortisol. Repeat testosterone, free testosterone, and LH were confirmed as abnormal at a different lab. A pituitary MRI with gadolinium was negative.

After referral to an endocrinologist, results were reviewed and testosterone therapy (Androderm patch, 5 mg/day), and Fosamax, 10 mg/day were started. He was advised to get adequate calcium, vitamin D, and to exercise. There are no follow-up results yet to verify how well therapy is working, but there are no problems either.

Nonmember case history profile

I`m presenting a second case history in this newsletter because it is such an important one. The individual in the following case history is not a member of the group, but e-mailed his history to me after viewing our Web site. His name has been changed to protect his identity. There are many secondary causes of osteoporosis that can increase fracture risk and present complex treatment issues of their own. These include such causes as: Hypogonadism, endogenous and exogenous thyroxine excess, hyperparathyroidism, malignancies, gastrointestinal diseases, medications, vices, and connective tissue diseases. This case history shows the importance of looking beyond the obvious for all possible causes of low BMD.

One of the perils of an osteoporosis diagnosis is the possibility of confusing it with a far nastier disease, as the following illustrates. Arnaud is a 62-year-old man who enjoyed perfect health until recently. He is an ex-runner with many miles behind him. In 1993, he had back pain that was a little different from any he had before. It did not go away, and it grew worse with time. No unusual results were seen with MRI or X-ray so a few epidural cortisone injections were given. This left Arnaud pain free until April 14, 1998, five years later. At this point, the pain started again, following the same strange course. It was not attributable to any injury, but started with a gentle twist, as had the first bout of back pain. In both cases the pain was relatively mild in the beginning, only to become excruciating in a few weeks. An orthopaedist prescribed pain killers, and, when that did not help, scheduled an MRI on June 2. The MRI suggested that Arnaud had multiple myeloma (MM), a disease that destroys bone, especially in the spine and hip.

Arnaud`s primary physician, an internist, immediately scheduled a bone scan with technetium, and did blood work. The blood tests results appeared to rule out MM since this form of cancer usually produces a peak in the level of immunoglobulin protein that the cancerous cell produces. The peak was absent, however, the immunoglobulin profile was abnormal. That is, two of the other proteins normally present were not found. The internist, however, was convinced that Arnaud did not have cancer, and did not further question the abnormal profile. He ordered several other tests: Thyroid function, parathyroid hormone tests, 24-hour urine calcium (30% above normal levels), pH of first morning urine, a blood gas test, high resolution lumbar CT scan, and a chest X-ray. Additionally, he ordered urine protein analysis, an additional test for MM. Then, a prostate biopsy and sigmoidoscopy were done to look for cancers elsewhere. Arnaud had suddenly developed a protruding abdomen, so an MRI of the abdomen was also done. While all these tests were conducted, Arnaud had three epidural cortisone injections, but they did not completely relieve the pain. He was unable to lie down without pain or walk normally. Finally, the internist ordered a DXA scan to determine BMD on July 8. During the pre scan procedure, it was discovered that Arnaud had lost four inches of height. He also had a profile that indicated he was at risk for osteoporosis: Caucasian, drinks a lot of Pepsi, little calcium in the diet, and gets little sunshine. The scan results showed Arnaud`s BMD was -3 standard deviations from the normal young adult. He started taking large amounts of calcium in the form of milk, sardines, and collard greens. On August 11, Arnaud started to exercise by taking a short walk, but he broke a vertebra almost immediately.

On August 15, Arnaud started taking Fosamax, Miacalcin, and a thiazide diuretic to reduce calcium excretion in the urine. He discovered that the thiazide diuretic had distressing sexual side effects. Additionally, he was still worried about the pain and was concerned that his internist was not really a specialist in osteoporosis. He went to see a neurologist who felt the pain was greater than he would predict on the basis of examination of the X-ray. He recommended that Arnaud rule out cancer with a spinal biopsy. So, Arnaud called a specialist about the biopsy but was told that he could not be seen until November. Arnaud pleaded with the receptionist to get him in earlier. Finally, she said that if Arnaud could fax the test results, she would have the specialist look at them. Almost immediately she called back and said that the specialist would see him in two days.

Arnaud went to the specialist`s office in New York City where it was explained that sometimes cancerous cells do not produce abnormal proteins. When the cells become cancerous, they sometimes lose the ability to produce that particular protein. He did say, however, that the cells always suppress the production of other proteins. Based upon the appearance of Arnaud`s tests, the specialist felt he did not have primary osteoporosis, but rather it was secondary to a non protein producing form of MM. A spinal biopsy was ordered immediately since it is specifically diagnostic for MM. Arnaud reports that the spinal biopsy was not fun, but neither was it terribly painful. It is done with a local anesthetic injection to ease the pain, and the worst part is the hammering that the physician does to force the needle into the spine. The spinal biopsy unequivocally revealed that Arnaud was suffering from MM.

This case history once again reinforces the importance of knowing as much about your medical condition as possible. In this case, the diagnosis was suggested in early June but not final until mid-August. A thorough review of the picture of the lab results for MM should have shortened the diagnosis considerably and saved Arnaud pain and aggravation. He reports that he will be receiving therapy at the Memorial Sloan-Kettering Cancer Center. They will treat the cancer with chemotherapy and the bone loss with Fosamax. We wish him the best and a rapid recovery.

Osteoporosis reference book

In June of this year the Endocrinology and Metabolism Clinics of North America published an issue devoted entirely to osteoporosis. This journal is directed to the medical profession, but it can be an excellent information source for the layman, too. Expect to find some material difficult to understand or interpret unless you have an extensive medical background, and some information is cryptic even with a medical background. If you are, however, interested in having the latest information about osteoporosis in one handy book, this would be the one to have. W. B. Saunders publishes many Clinics of North America medical books in many medical, dental, and paramedical specialty areas. They are intended to be purchased in subscription form with each issue covering various treatment or diagnostic issues related to that specialty. If you contact the publisher, it might be possible to buy just a single issue or reprints from the issue. For more information about obtaining a copy write W. B. Saunders Company, West Washington Square, Philadelphia, PA 19105, see their Web site at http://www.wbsaunders.com/, or visit a medical library.

Here are the chapter titles and author`s names to see the scope of the book:

Pathophysiology of Osteoporosis by Dr. Robert P. Heaney

Applications of Bone Densitometry for Osteoporosis by Glen M. Blake and Ignac Fogelman

Risk Factors for Osteoporotic Fracture by Philip D. Ross

Biochemical Markers of Bone Turnover: Applications for Osteoporosis by Patrick Garnero and Pierre D. Delmas

Secondary Osteoporosis: Diagnostic Considerations by Kristine D. Harper and Thomas J. Weber Osteoporosis in Men by Eric S. Orwoll

The Roles of Exercise and Fall Risk Reduction in the Prevention of Osteoporosis by N. Kathryn Henderson, Christopher P. White, and John A. Eisman

The Roles of Calcium and Vitamin D in the Prevention of Osteoporosis by Ian R. Reid

The Role of Estrogen in the Prevention of Osteoporosis by Dr. Robert Lindsay

The Role of Calcitonin in the Prevention of Osteoporosis by Louis V. Avioli

Treatment of Osteoporosis with Bisphosphonates by Nelson B. Watts

The Role of Fluoride in the Prevention of Osteoporosis by Michael Kleerekoper

Therapy for Osteoporosis: Miscellaneous and Experimental Agents by Jean-Yves Reginster, Anne Noel Taquet, and Christiane Gosset

The Science and Therapy of Glucocorticoid-Induced Bone Loss by Nancy E. Lane and Barbara Lukert

Managing Patients with Complications of Osteoporosis by Deborah T. Gold, Kathy M. Shipp, and Kenneth W. Lyles

As you can see, there is virtually no osteoporosis topic that isn`t covered in the book, including osteoporosis in men. The authors note what we are so well aware of concerning osteoporosis in men: "Unfortunately, effective diagnostic and treatment strategies are not well developed, and current recommendations are derived by extrapolation from similar clinical situations in women."

Literature review

One of my personal pet peeves is the often indiscriminate use of glucocorticoids (prednisone and similar corticosteroids) by physicians. I`m convinced that my own osteoporosis is in someway related to or worsened by the prednisone I was given in my twenties while getting allergy injections. Thus, I found the recent article by Gram and others (1) very interesting. They randomized 48 normal male volunteers to receive treatment for 7 days with either (A) prednisolone, 10 mg twice daily, (B) prednisolone, 10 mg twice daily, and calcitriol (active vitamin D), 1 microg twice daily, (C) calcitriol 1 microg twice daily, or (D) placebo. The results of the 7-day treatment were followed for 28 days. They found that prednisolone promptly caused a decline in the serum markers of bone formation. It also caused an increase in renal calcium excretion and an increase in serum parathyroid hormone (the body`s attempt to prevent calcium loss). If calcitriol was added to the prednisolone, there was less of a decline in the serum markers of bone formation. Among markers of bone degradation, prednisolone suppressed one of them, but two others were unchanged. Calcitriol had no effect on any markers of degradation. The authors conclude, "...short-term administration of prednisolone to healthy men leads to fast and protracted suppression of biochemical markers of bone formation and extraosseous connective tissue metabolism. The effect on bone was partially antagonized by simultaneous calcitriol treatment, and points toward a potential role of calcitriol in the prevention of steroid-induced osteoporosis." My interpretation is that anyone receiving steroid therapy of any duration should be getting vitamin D supplements. Additional studies should be done to see if alendronate could prevent bone breakdown if used during and following short-term steroid treatment. This research is more important because of a recent article by Saag and others (2) who found that alendronate increases bone density in patients receiving long-term glucocorticoid therapy. Since corticosteroids block normal bone breakdown and formation when given for virtually any time frame, why not give medications to minimize the deleterious effects on bone whenever corticosteroids are given?

Diamond and others(3) showed the importance of serum vitamin D levels in a recent study comparing Australian men with and without hip fractures. The study group included 41 men in St. George Hospital for treatment of hip fracture and compared them to 41 hospital inpatient and 41 outpatient controls without hip fractures. They looked at the osteoporotic risk fracture criteria of age, body weight, comorbid illnesses, alcohol intake, cigarettes smoked, and corticosteroid use. Additionally they compared serum concentrations of several compounds, such as, vitamin D, testosterone, etc. One key finding that was significantly different in the men with hip fractures was a subclinical vitamin D deficiency (less than 50 nmol/L). This involved 63% of hip-fracture patients vs. 25% for controls. The authors conclude, "Subclinical vitamin D deficiency in Australian men may contribute significantly to the development of hip fracture through the effects of secondary hyperparathyroidism, resulting in increased bone loss." There is a strong emphasis on calcium supplementation in this country, but less is said about the need for vitamin D supplements. These studies mentioned here, show there may be more need for vitamin D supplements than is commonly thought. Particularly for older men, they might request that their physician do a serum vitamin D level to see if additional vitamin D intake is needed. The taking of vitamin D supplements could be a minimal price to pay to avoid the trauma of a fractured hip.

The recent study by Mackay and others (4) sheds considerable light on the issue of gastric irritation when taking Fosamax. This United Kingdom study found 20/1523 patients (1.3%) experienced esophageal events that were considered to possibly be related to alendronate. This number hardly seems worthy of the press this side effect of alendronate often gets. Additionally, most studies attribute the esophageal problems to patients not following directions. So, if you follow directions for taking Fosamax (drink an 8-oz. glass of water, and don`t lie down until you eat the next meal which is at least one-half hour after taking the pill), gastric side effects should not be worthy of worry.

1. Gram J and others, Bone 1998 Sep;23(3):297-302

2. Saag KG and others, NEJM 1998 Jul;339(5)

3. Diamond T and others, Med J Aust 1998 Aug 3;169(3);138-141

4. Mackay FJ and others, Br J Gen Pract 1988 Apr;48(429):1161-1162

EDITOR

Jerry Donnelly
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