Thanks again to a member. Last
newsletter I mentioned that Denis Neumann had recommended The
Prostate Cure by Harry G. Preuss, M.D. and Brenda Adderly, MHA. I want to thank Denis for mailing the
book to me after the July newsletter was published. I just want to agree with Denis` recommendation, and
suggest that this book should be required reading for all men, especially those over 40 years old.
A clarification from the last newsletter. In the review of The Osteoporosis Book, A guide for
Patients and their Families, by Nancy E. Lane, M.D., I mentioned her comment on diuretics. She stated on
page 31, "However, although thiazides may prevent bone loss, a woman must take them for over 10 years to
achieve this effect." This 10-year time period may be true for women, but apparently is not always the case for
men as noted in a study in Annals of Internal Medicine 1999 Apr 20;130(8):658-60, MEDLINE UI:99213902,
Adams JS and others, report rapid recovery of bone mass in hypercalciuric, osteoporotic men treated with
hydrochlorothiazide. Five males aged 42-66 with hypercalciuria, as determined by fasting urine calcium
testing, and osteoporosis were given hydrochlorothiazide, 25 mg twice daily, for approximately eight months.
They found, "Hydrochlorothiazide treatment in hypercalciuric and osteoporotic men was associated with a
rapid rebound increase in bone mineral density." This bone mineral density (BMD) increase amounted to 8%
and 3% in the spine and hip, respectively. The patients received no other medications such as calcium or
vitamin D during the study, thus attesting to the efficacy of the thiazide. Other studies have found a beneficial
effect of thiazides on BMD and fracture risk in men. Other diuretics, however, did not seem to have the same
positive effect. So, hypercalciuric and osteoporotic men have another effective option to increase BMD and
reduce fracture risk with thiazide diuretics.
If the urine calcium is determined in the fasting state, this helps differentiate resorptive from absorptive hypercalciuria. The resorptive variety indicates that the skeleton is the source of the calcium. For someone with osteoporosis, this would appear to be an important distinction since osteoporosis involves a loss of skeletal calcium. So, you may want to discuss this article with your physician since this is the second study I have reviewed recently where fasting urine calcium determination appeared important to the diagnosis and treatment of patients with
osteoporosis. See http://www.maleosteoporosis.org/10nl.htm which discusses the article by Giannini S et al, Clin Nephrol 1998 Aug;50(2):94-100. UI 98391619. Also,
for a description of the test for absorptive vs. resorptive hypercalciuria, see Pak CY et al, N Engl J Med 1975 Mar 6;292(10):497-500. MEDLINE UI:75118765.
Osteoporosis in Men. Thanks to Larry Schindler for faxing me information on the excellent and very
thorough article entitled Osteoporosis in Men by Orwoll ES and Klein RF. It can be found in Endocrine
Reviews, Vol. 16, No. 1, 1995, 87-116. If you want only one reference for osteoporosis in men, this would be
the one to have. If you have access to a medical library, you will want to get a copy of this article.
IV Pamidronate. I was informed by one of our members that he has started IV pamidronate (Aredia)
once every three months. He reports that the IV took about three hours and there were no side effects at all. He
has tried Fosamax several times but has been unable to tolerate it due to gastrointestinal problems. Since he
has severe osteoporosis and multiple vertebral fractures, his physicians decided to use the IV bisphosphonate at
this time. The effectiveness of this treatment method was confirmed in a study by Sarli M et al, Medicina (B
Aires) 1998;58(5 Pt 1):446-52. Treatment of post menopausal osteoporosis with intravenous pamidronate in
patients with esophagogastric pathology. They found, "In conclusion, intravenous pamidronate is an effective
and safe treatment for postmenopausal osteoporosis, especially in those patients with esophageal or gastric
disorders." In this study, as with almost all bisphosphonate studies, the drug trials generally include only
women. The action of all bisphosphonates is not dependent upon the gender of the patient, so expect equal
effectiveness with men or women. Men will just have to use them as an off-label prescription until the FDA
finally approves them for men. The important thing to remember is that an alternative bisphosphonate therapy
is now available for men or women unable to tolerate oral Fosamax.
Fosamax for men. Speaking of including males in Fosamax studies, Doctors Guide to the Internet
recently reported the first year results of a German clinical trial comparing Fosamax and alfacalcidol in 122
men with established osteoporosis. They report after 12 months of treatment with Fosamax, there was a 7.7
percent improvement in spinal BMD compared to 0.9 percent in the alfacalcidol group. The study is on going
with additional results to be reported later. These are excellent results and are similar to what members of the
Men`s Osteoporosis Support Group who are taking Fosamax have been finding. This report can be read at
MEDLINE Plus. If you`re a regular reader of this newsletter, you`ll realize that I refer to
MEDLINE often. It is an outstanding source of medical research information. To quote the
National Library of Medicine from their Web site, it is the". . .premier bibliographic database
covering the fields of medicine, nursing, dentistry, veterinary medicine, the health care system, and
the preclinical sciences. The MEDLINE file contains bibliographic citations and author abstracts
from approximately 3,900 current biomedical journals published in the United States and 70
foreign countries." The URL for MEDLINE is http://www.ncbi.nlm.nih.gov/PubMed/ which will
bring you to the PubMed search page where you can look up medical information. What I want to
point out is that there is a lot of other valuable information available on this Web site. You may
not be aware of it, and I have only recently discovered it myself. If you`ll click on Consumer
Health from the PubMed page, this brings you to http://www.nlm.nih.gov/medlineplus/ the site for
MEDLINE Plus. Whereas PubMed is dedicated to medical professionals, MEDLINE Plus is
meant for consumers. From here you can get information on the following topics: Health topics,
Dictionaries, Databases, Clearinghouses, Directories (of doctors and hospitals), MEDLINE,
Organizations (providing consumer information), Publications/news (of health interest to
consumers), and Libraries (that are online with health information). So don`t overlook this
excellent source of medical and health information for consumers. Whether you are looking for
osteoporosis-related information or anything else concerning your health, MEDLINE Plus should
be a priority Web site for your search.
Ask the experts
Ask the Experts. I would like to welcome Dr. Karen S. Kolba as one of our medical experts that
support the members of the Men`s Osteoporosis Support Group. Dr. Kolba is in the private practice of
Rheumatology in Santa Maria and San Luis Obispo, California. She is a Wisconsin native who went to the
Medical College of Wisconsin in Milwaukee. Her internship was at Akron (Ohio) General Medical Center in
Family Practice and this was followed by her residency in Internal Medicine, at the same center. Her
fellowship in Rheumatology was at the University of Arizona Health Sciences Center in Tucson, AZ. She has
served as the Senior Staff Physician, Divison of Rheumatology, Scott & White Clinic, Temple, TX, as Hospital
Consultant at the VAMC, Temple TX, and Assistant Professor of Internal Medicine, Texas A&M University,
College of Medicine, Temple, TX. Dr. Kolba is specialty certified by the American Board of Internal Medicine
and the American Board of Rheumatology.
First, I would like to thank Dr. Kolba for mailing me Part 1 and Part 2 of Managing Osteoporosis.
These booklets are part of the American Medical Association (AMA) education program for primary care
physicians. Part 1 is titled Detection and Clinical Issues in Testing, and Part 2 is Glucocorticoid-Induced
Osteoporosis. Additionally, there is a part three to this series, Prevention and Treatment. These are an
excellent source of information about osteoporosis for your primary care physician. Or, you might be interested
in them for yourself. Your physician can get more information at the Division of Continuing Medical
Education, Attn: Managing Osteoporosis, 515 N. State Street, Chicago, IL 60610. (312) 464-2588. Although
there is a lot of excellent information in these booklets, I did feel that Part 1 was particularly lacking in its
coverage of osteoporosis in men. I have written the AMA to express my concern about this problem. This
problem nothwithstanding, I highly recommend these booklets for someone interested in a greater
understanding of osteoporosis than you might get from typical handouts or brochures on osteoporosis.
Question. Some of the most devastated men I`ve communicated with recently are those with
osteoporosis-related problems after corticosteroid use. Some of these men did not have long-term, high-dose
corticosteroids either. I`ve also seen a couple of recent studies implicating short-term, relatively low-dose
corticosteroids as suppressors of bone formation (1,2). Exactly what do we know about the long-term effects
on bone formation of short-term, low-dose, or intermittently used corticosteroids? Have good quality studies
using densitometry been done comparing the BMD of test and control populations? Preferably, using large
populations of men and women several years after they received several intermittent short-term doses of
Answer. I can give you a general answer about the use of steroids and their side effects, but no one has
actually looked at this in a orderly fashion for low and intermittent doses. First of all, side effects of steroids
are felt to be related to the total "life-time" dose. That is, 10 mg for 10 days has the same risk as 1 mg for 100
days, or 100 mg for one day. But, of course, in a biologic system, that can`t possibly be true. If you shut down
a particular metabolic pathway for a day, the organism is likely to snap right back, as opposed to being shut
down for weeks or months. (I`m not talking about the adrenal glands here, I`m talking about the pathways
inside the cell that are affected by steroids). So, if someone takes 10 mg of prednisone for 10 days for poison
oak or asthma, it`s unlikely to cause any permanent damage anywhere. We can probably get away with using it
10 days out of 100, or once every three months without any big deal. But, if that cycle is repeated too often-say
once a month (roughly one-third of the days of the month)-that`s too much, and we start to see problems.
Immediate effects can be seen in diabetics with high sugars, and in hypertensives with increased blood
pressure. So, it is LIKELY that that dose will eventually effect bone. Rheumatologists tend to feel (and I use
"feel" rather than "think" on purpose) that any more than 2.5 mg per day on the average is bad for bone. (Of
course, don`t try to go even a single day with breathing! Asthmatics need steroids, sometimes, and they should
This is complicated by the fact that young bodies recover better than old bodies. Acute bone loss (really
calcium loss) under the age of 30 is PROBABLY completely reversible, but after the age of 60 it most certainly
is not. Here I`m talking acute loss-not the slow loss over years and years. We don`t know the "threshold dose"
for kids/teens where steroids will actually inhibit attainment of peak bone mass. I HOPE someone is looking at
this-but it is a tough project! At least now there are some fairly decent bone metabolism markers that could be
1. Robinson RJ et al, Aliment Pharmacol Ther 1997, Feb;11(1)201-4. Rectal steroids suppress bone formation
in patients with colitis. MEDLINE UI:97195621.
2. Gram J et al, Bone 1998 Sep;23(3):297-302. Effects of short-term treatment with prednisolone and
calcitriol on bone and mineral metabolism in normal men. MEDLINE UI:98407371.
Update from Dr. Kolba. She attended a Merck meeting on osteoporosis last weekend and sent a
summary that follows.
1. While steroid-induced osteoporosis use of Fosamax is listed at 7.5 mg/day of
prednisone or greater amounts, the Merck studies clearly showed excess bone loss at doses above
2.5 mg/day. Physicians need to become more sensitive to this when prescribing low-dose
2. It is her understanding that the Merck study on Fosamax in men has just been
completed with the expectation that about a year will be needed for data analysis and submission to
the FDA. Rumor has that it confirms that Fosamax works in men.
3. Merck just submitted their data on 30 mg once-a-week dosing of Fosamax. They aren`t
releasing the data, but Dr. Kolba understands it is positive since Merck submitted it to the FDA for
approval. This is similar to the 40 mg once-a-week dose recommended by Lunar News that was
mentioned in this newsletter quite some time ago. This may become an option for people who
can`t or won`t take Fosamax daily. Discuss this option with your physicians if it applies to you.
4. Another suggestion for making Fosamax more tolerable is to take a proton-pump
inhibitor such as Prilosec or Prevacid the night before taking Fosamax. This seems to decrease
5. IV pamidronate is indeed an effective way to go. Since it is an off-label use, most
insurance companies will not pay for it-and it is not cheap. Her understanding is that cost for the
drug and infusion is about $200, about equal to three months of Fosamax. Dr. Kolba will be using
this medication in her office.
Post fracture pain control. Vertebral compression fractures can cause pain that ranges
from slight to extremely severe. I have had e-mail from several men that have had great difficulty handling
their pain after compression fractures. One of our members is just now having great difficulty weaning himself
off the narcotics he has been given to try to relieve the pain. So, it is important to have ways to handle the
extreme pain without using strong drugs or narcotics. A recent study done in Sweden reports excellent results
on three patients suffering "refractory" pain. This study by Dahm PO et al, is reported in Reg Anesth Pain Med
1999 Jul-Aug;24(4):352-7. Intrathecal infusion of bupivacaine with or without buprenorphine relieved
intractable pain in three patients with vertebral compression fractures caused by osteoporosis. The MEDLINE UI
is 99372948. Intrathecal (i.t.), literally means to be ensheathed. Bupivacaine is a long-acting local anesthetic
and buprenorphine is an opioid derived from thebaine that is 25-50 times more potent than morphine.
Buprenorphine is addictive like morphine and patients can have similar withdrawal problems after its use.
When given in very small doses via pain pumps, the narcotic complications are of less concern.
In this study, the 18-gauge nylon i.t. catheter was inserted in a lumbar interspace with the tip positioned
at the level of the fractured vertebra. On one patient, bupivacaine was infused through the i.t. catheter from an
external electronic pump. In two other patients, buprenorphine was also infused along with the bupivacaine.
Satisfactory pain relief was obtained with daily doses of i.t. bupivacaine ranging from 10 to 70 (mean
approximately 25) mg and buprenorphine from 0.02 to 0.2 (mean of 0.15) mg. [Editor`s note: For comparison,
the normal IV dose of buprenorphine would be from1.8 to 2.4 mg/day.] Treatment lasted for 37, 387, and 407
days. One patient died of other causes, and the other two stopped treatment when it was no longer needed.
They are still pain free after 1,074 and 1,476 days after stopping treatment. The authors concluded,
"Continuous intrathecal infusion of bupivacaine, with or without buprenorphine, appeared to be an effective
method for the long-term treatment (months to > 1 year) of `refractory` pain from vertebral compression
fractures in this small group of patients." The small numbers makes this study less exciting. But, the pain
control with relatively safe medications (especially if only bupivacaine is needed), and the long-term relief after
stopping the treatment, are very encouraging. Those men who might benefit from this treatment should discuss
this study with their physicians.
Reduced fracture risk after Fosamax. A recent study confirms the effectiveness of Fosamax to reduce
fracture incidence. This study is by Hochberg MC et al, Arthritis Rheum 1999 June;42(6):1246-54. Larger
increases in bone mineral density during alendronate therapy are associated with a lower risk of new vertebral
fractures in women with postmenopausal osteoporosis. Fracture Intervention Trial Research Group. The
MEDLINE UI is 99292240. Women in this study received 5 mg/day of alendronate for two years followed by 10
mg/day for the remaining 12-30 months of the study. The authors state, "Women who had larger increases in
total hip BMD during the first 12 months had a lower incidence of new vertebral fractures during the entire
followup period." In fact, 3.2% of the women with increases of > or =3% in total hip BMD experienced new
vertebral fractures, whereas twice as many women (6.3%) whose BMD declined or stayed the same
experienced new fractures. It is always reassuring to see increased BMD after taking a medication such as
Fosamax. However, the most important factor is whether fracture risk is decreased by this increased BMD-and
that is not always the case with some medications. This study is important in that it found that, ". . .greater
increases in BMD are associated with lower risk of new vertebral fractures." Although men were not included
in this study, there is no reason to expect any different results for them since Fosamax is not gender specific in
Vitamin D insufficiency and osteoporosis. Vitamin D supplements are routinely recommended for
people with osteopenia or osteoporosis. Generally, the vitamin D is considered an adjunct to the alendronate or
calcitonin that is given as the primary treatment medication. A recent study shows that there are times when
vitamin D alone is adequate therapy. Adams JS et al J Clinc Endocrinol Metab 1999 Aug;84(8):2729-30.
Resolution of vitamin D insufficiency in osteopenic patients results in rapid recovery of bone mineral density.
MEDLINE UI 99371268. The authors evaluated 118 consecutive, free-living patients with osteopenia or
osteoporosis and identified 18 subjects with depressed serum 25-hydroxyvitamin D. These subjects received
50,000 IU vitamin D2 twice weekly for five weeks. This vitamin D repletion was associated with a significant
4-5% annualized increase in bone mineral density at both the lumbar spine and femoral neck. This study is a
reminder to look for the true cause of the decreased BMD. Just because you have bone densitometry that shows
low BMD, it doesn`t necessarily mean that alendronate or calcitonin is definitely needed. It means a thorough
work up is needed with multiple blood and urine tests (and other tests, if needed) to find the cause of the
problem. In the case of a patient with low vitamin D levels, other lab values will tend to be abnormal, too. For
example, the fasting urinary calcium/creatinine excretion ratio, serum parathyroid level, and osteocalcin level
should also indicate a problem is present.
High milk intake and osteoporosis. In much of the lay press there is often mention of the fact that
some of the countries with the highest milk consumption (and therefore the highest calcium intake), also have a
very high incidence of osteoporosis. Particularly in the vegetarian literature, this fact is used to promote the
vegetarian lifestyle-especially one free of milk products. This appears to be a case of "shooting the messenger"
rather than finding the root cause of the problem. This point is made in a recent study by Whiting SJ and
Lemke B in Nutr Rev 1999 Jun;57(6):192-5, Excess retinol intake may explain the high incidence of
osteoporosis in northern Europe. MEDLINE UI 99368487. The authors conclude, "Retinol [vitamin A] in
fortified milk could explain also the association of high calcium intake and hip fracture incidence in northern
Europe because milk is an important source of both nutrients." The problem occurs from a chronic intake of
greater than 1.5 mg/day of vitamin A, which in Northern Europeans comes from milk supplemented with
Vitamin A in the same manner we supplement ours with vitamin D. I have warned of this relationship between
high vitamin A intake and osteoporosis before. Be careful if you take lots of vitamins and supplements as this
relationship appears quite strong. You could be going backwards in your goal to attain higher BMD in spite of
taking all your prescribed medications if you are overriding them with too much vitamin A. See the January
1999 newsletter, http://www.maleosteoporosis.org/9nl.htm.
Calcaneous Ultrasonometry. Although dual X-ray absorptiometry (DXA) is the standard diagnostic
test to determine osteoporosis of the spine or hip, there has been considerable research into the use of
quantitative sonography of the calcaneus (the heel). This method is approved by the FDA and there are almost
5000 units in use around the world. The latest edition of Lunar News (to download this edition go to
http://www.lunarcorp.com/ or call 608-828-2663 to subscribe) has an extensive discussion of the Lunar
ultrasonometry unit, the Achilles, and indicates that it is comparable to DXA in diagnostic ability. Indeed the
graph in their advertisement shows a virtual exact duplication of the diagnostic capability of DXA. These units
are light, fast, very mobile, and relatively inexpensive to operate compared to DXA, so comparable diagnostic
results would be quite a plus for patients and physicians. There is an August 1999 abstract in MEDLINE (UI
99357198) where the authors tested just this ability of the calcaneous ultrasonometer to match the diagnostic
results of DXA. They were unable to get agreement between the two as often as Lunar News suggests is
possible. The study by Grampp S et al is in Am J Roentgenol 1999 Aug;173(2):329-34, Diagnostic agreement
of quantitative sonography of the calcaneus with dual X-ray absorptiometry of the spine and femur. They
concluded, "The considerable diagnostic disagreement between quantitative sonography and DXA could cause
confusion in the daily practice of radiology and make establishing the correct diagnosis a difficult task. The
choice of imaging technique influences which patients are diagnosed as osteoporotic." The are several
manufacturers of heel ultrasonography units, and the MEDLINE abstract doesn`t tell if they used the Lunar unit or
another brand. But, it indicates that there are still questions as concerns using these devices as diagnostic tools
for osteoporosis. They may also be useful for monitoring the effects of treatment, as Lunar suggests is an
acceptable capability of the Achilles unit. To my knowledge, the DXA is the method of choice, however, when
it comes to assessing how effective osteoporosis treatment has been. Should testing ultimately prove the
ultrasonography equivalent to DXA for this purpose, it would be a great boon to patients, and maybe more
so to the HMOs, and Medicare in reduced fees for the diagnostic tests. The figures I have seen show
ultrasonography is about 3.6 times cheaper than a central DXA, which is the standard diagnostic DXA.
Corticosteroids and osteoporosis. One of the most frustrating areas of osteoporosis for me is the
relationship between corticosteroid use and low BMD. I had corticosteroids given to me in my twenties which
I feel are somehow related to my osteoporosis. And, many of the e-mails I get are from men with a history of
steroid use before finding they had osteoporosis. Here`s a quote from an e-mail I got not too long ago from a
34-year-old man to give you an idea about the problems with corticosteroids and osteoporosis. "In retrospect,
I`m as you would expect, devastated when I consider that my doctor, who is recognized as an expert in the field
of allergy and asthma, never once mentioned to me the effects that prednisone has on bones in all the times I
have seen him. What happened to me is that I was playing basketball and went to suddenly run down court and
heard a pop in my foot. When it was X-rayed, they said there were no breaks but that I had a rupture of the
plantar fascia. Everyone thought this was quite odd and when I asked my orthopedic doctor could this be
related to steroid use, he said probably no. That is when I started to read more about the effects of prednisone.
I was shocked to find out that almost all of the literature clearly states that this medication causes osteoporosis.
I then called my doctor and after being told, `Oh, don`t worry yours will be normal,` he ordered a DXA for me.
Anyhow, after getting the test results, my doctor says he doesn`t remember what all the numbers mean but that
I`m not in any danger now. He says I have plenty of calcium in my bones." This man`s DXA results showed T-scores of -1.67 S.D. for the hip and -2.76 S.D. for the spine. I can tell you from our correspondence that he was
highly concerned by these numbers and by the fact that he wasn`t forewarned of the possibility of getting
osteoporosis from the use of corticosteroids-and rightfully so. Here is some of the latest research that applies
to corticosteroid use and its relationship to low BMD.
A patient survey. There are very interesting results of a telephone survey done by Buckley LM
et al, Arthritis Rheum, 1999 Aug;42(8):1736-9, Prevention of corticosteroid-induced osteoporosis: results of a
patient survey. MEDLINE UI 99374541. The authors contacted 147 patients receiving a mean prednisone dose of
10 mg per day for an average of 1-2 years. Twenty-nine percent reported having a bone density test, 29% were
taking calcium supplements, and 45% were receiving vitamin D. Forty percent of postmenopausal women
were receiving hormone replacement therapy and 14% bisphosphonates. Patients who were evaluated by
primary care physicians and rheumatologists were more likely to have undergone bone density testing and
preventive treatments than other specialists. The authors conclude, "Many patients receive inadequate
treatment to prevent corticosteroid-induced osteoporosis, and physician specialty is an important predictor of
bone density testing and treatment." Note that the American College of Rheumatology has published
recommendations for prevention and treatment of glucocorticoid-induced osteoporosis. A pretreatment bone
densitometry is the foundation of this recommendation and should be part of the early work-up of patients who
are initiating glucocorticoid treatment. This establishes a baseline BMD and determines what type of
preventive or treatment therapy is needed. From this study it is obvious that more than 70% of patients are not
getting the standard of care when starting glucocorticoids. Once again, it is important that patients educate
themselves so they can be partners with their physician in their medical care. Don`t trust your health only to
your physician, it is your life and your health, no one should care more about your health than you. Don`t be
like the 34-year-old man above who had to ask for a DXA six years after treatment started. Get the DXA at the
beginning and then get proper preventive therapy to avoid the problems he is having now.
Inhaled corticosteroids. This paper suggests the safest inhaled corticosteroids to use for
asthma to prevent side effects with long term use and is by Jackson LD et al, Can J Clinc Pharmacol Spring
1999;6(1):26-37, Comparative efficacy and safety of inhaled corticosteroids in asthma. MEDLINE UI 99395357.
The authors suggest that regular treatment with the following drugs in adults and children is unlikely to result
in any clinically significant effects on the parameters of growth retardation in children, adrenal suppression,
reduction in bone mineral density, and cataract formation. They list the safest inhaled corticosteroids as (the
first figure is for adults, the second for children`s dosage, all in micrograms): beclomethasone dipropionate less
than 1500 and 400, budesonide less than 1600 and 400, flunisolide less than 2000 and 1000, fluticasone
propionate approximately 500 and 200, and triamcinolone acetonide less than 1600 and 1200. They also
suggest that, "Patients requiring continued high doses by the inhaled route should be monitored for systemic
effects and be considered for osteoporosis prevention therapy if appropriate."
Vitamin D as a preventive for corticosteroid-induced osteoporosis. If something as cheap
and readily available as vitamin D plus calcium is effective in preventing osteoporosis in steroid therapy
patients, then why not use it in all such cases-even when using corticosteroid inhalers? Vitamin D with
calcium was moderately effective as shown in a meta-analysis of studies posted on MEDLINE from 1966 to 1997
according to Amin S et al, Arthritis Rheum 1999 Aug;42(8):1740-51, The role of vitamin D in corticosteroid-induced osteoporosis: a meta-analytic approach. MEDLINE UI 99374542. The authors looked at all studies of
randomized controlled trials lasting at least six months for patients receiving oral corticosteroids and that
compared vitamin D with either 1) no therapy or calcium alone, or 2) bisphosphonates, calcitonin, or fluoride.
The outcome measure of interest was the change in lumbar spine bone mineral density. Vitamin D plus
calcium was better than no therapy or calcium alone. It was similar to calcitonin, but worse than
bisphosphonates or fluoride. In view of the cost and safety, it would appear that all patients receiving
corticosteroids should be on vitamin D and calcium supplements as a preventive measure for osteoporosis.
This doesn`t preclude additional therapy as determined by the condition of the patient and the opinion of the
physician. And, it doesn`t mean that initial and follow-up DXAs aren`t needed to evaluate the baseline BMD
and effectiveness of the treatment to prevent or reduce the loss of BMD. But, this meta-analysis suggests there
is evidence that it is better than taking no preventive measures at all.
An additional study by Reginster JY et al confirms the value of vitamin D or its metabolites in
corticosteroid patients. It can be found in Osteop Int 1999;9(1):75-81, Prophylactic use of alfacalcidol in
corticosteroid-induced osteoporosis. MEDLINE UI 99295108. In 145 patients taking an average of about 46
mg/day of prednisolone, it was found that 1 microgram/day of alfacalcidol was significantly better than placebo
at maintaining BMD after one year. There was +0.39% change in BMD in the alfacalcidol group and -5.67%
change in the placebo group. Alfacalcidol is a metabolite of vitamin D and is not the form normally found in
vitamin D supplements. But, it appeared relatively effective at these high doses of corticosteroids, so it could
be an important medication for people on this steroid dosage. If you feel this study relates to your condition,
you may want to discuss it with your physician. There are other alternatives as well for men now in treating
Fosamax gets FDA approval for glucocorticoid-induced osteoporosis. This summer the FDA
approved Fosamax (alendronate sodium) for the treatment of glucocorticoid-induced osteoporosis in men and
women. This is important for those with steroid-induced osteoporosis and because it is the first time Fosamax
has been approved by the FDA for treatment of men for any form of osteoporosis. It is one step closer to
approval for its use (without an off-label prescription) in men for all forms of osteoporosis.
The FDA-approved indication is for men and women receiving glucocorticoids is a daily dosage
equivalent to 7.5 mg or greater of prednisone and who have low BMD. You can read more about this on the
Doctor`s Guide to the Internet at http://www.pslgroup.com/dg/10c15a.htm and get additional information about
the studies done that led to acceptance by the FDA. There is a lot of osteoporosis-related information at this
Web site that you will want to read, too. If you do some surfing around there, it will be educational.
Disclaimer. Diagnosis and treatment of osteoporosis are the responsibility of the patient and his or her physician. Nothing in this
newsletter is to be interpreted as a recommendation for treatment or to change treatment that your physician has prescribed. Although we attempt to
assure that information in this newsletter is factual, errors will occur. It is the responsibility of the reader to verify that information they are acting
on is factual. There is no relationship between this newsletter and any national osteoporosis group, including the National Osteoporosis Foundation.
All references to any such groups are for informational purposes only.