SIX CASE HISTORIES

At 65, Mildred's plans for an active retirement came to an abrupt halt.  She and her husband were about to set off on a trip around the United States in their new motor home when disaster struck.  One morning, while Mildred was opening a window she had opened a thousand times before, a searing pain shot right through the middle of her back.  Her husband rushed her to the doctor's office.  An X-ray taken in the doctor’s office showed that one of her backbones had collapsed.  The doctor said that Mildred had osteoporosis.

Mary’s problems began while at college.  There she developed an eating disorder called anorexia nervosa.  "I felt fat even though I knew I wasn't".  Once the disease got the upper hand, she ate less and less.  Her weight fell from the 121 pounds she weighed as a high school senior to a low of 78 pounds during her junior year in college.  "That's when my periods just stopped!" says Mary.  Six more years passed and still she had no period.  Finally, at age 28, Mary went to see a gynecologist and told him about the menstrual problems she was having.  A bone density test showed she had osteoporosis.  "Your bone density is reduced to the same level of a 65-year-old women,” said the doctor.  Mary couldn't understand how this could be.  The doctor explained that when Mary's weight dropped down to below a certain level, her body stopped making female sex hormones.  At this point, her periods stopped and Mary entered a menopause-like state.  This is when she began losing bone rapidly.

Harriet, a 45-year-old public school teacher felt an excruciating pain in her back when her family’s boat bounced over a wave on Lake Lanier.  Over the course of the day, Harriet's pain got worse and her husband, took her to the hospital where an orthopedic surgeon found that one of her backbones had collapsed.  Harriet saw her Internist for an evaluation.  The doctor referred her for a bone density test.  This test showed that the bones of her spine were very thin.  She was shocked when the doctor told her she had osteoporosis saying, "I've always thought that was an old persons disease".  She couldn't believe this had happened to her.  "It's so unfair”.

Lynn, a 53-year-old homemaker, recently entered menopause.  Her doctor told her that her bones appeared "very thin" on a chest X-ray she had as part of a physical examination.  She was referred for a bone density test.   The scan confirmed that her bone density was low.  This devastated Lynn.   Her mother and grandmother had suffered from osteoporosis, so she knew what this meant.

Laura felt and looked great at 55.  Most people would have said she was at least 5 years younger.   She attributed her good health to a balanced diet, regular exercise, and faithfully taking vitamins and mineral supplements.  After playing tennis last month, her foot began to hurt.  It didn’t get better and began to swell.  She saw her doctor who found a stress fracture had occurred.   A bone density test was ordered that showed a 30% loss of bone in the hip and 20% in the spine which was diagnostic of osteoporosis.  Laura was shocked!  “How could this happen to me.”

At 63, Jim looked forward to a secure retirement with full benefits in a little less than one year.  He worked long and hard and was ready to retire.  Jim had been smoking cigarettes and drinking beer since joining the Army at age 19.  On average he smoked about one pack of cigarettes and about one six pack of beer each day.  One Saturday morning, while cutting the grass, Jim felt a twinge of pain in this lower back.  As he kept going the pain got worse.  The pain didn't go away with rest so he visited his doctor the following Monday.  An X-ray showed a compression fracture of the 12th thoracic vertebra.  Jim was sent for a bone density test, which showed marked loss of bone from both the hip, and the spine, which confirmed osteoporosis as the cause of Jim's fracture.

What all these patients have in common is that they all had osteoporosis and none of them knew it before they suffered a bone fracture.  Fortunately today, we are able to quickly and simply diagnose osteoporosis years before a fracture occurs with a bone density test.  Better yet, several very effective fracture preventive therapies are available for treatment of osteoporosis.  Starting therapy for osteoporosis early is the best way to prevent fractures from occurring in the first place.   A bone density test is the only method for accurately detecting osteoporosis in its early phase. 

THE HARD FACTS

Osteoporosis afflicts 28 million Americans.  It is the silent thief that robs many otherwise healthy people of bone strength.  Last year alone, 60,000 people died within one year of after suffering hip fractures due to osteoporosis.   Of course, hip fracture tends to occur in the frail elderly who usually have other medical problems.  Given their advanced age, statistical analysis reveals that many hip fracture victims would probably have died from one cause or another anyway during this year even if they had not fractured their hip. However, careful study has shown that at least 15% of hip fracture patients die prematurely due to a complication of the fracture.  Fatal complications of hip fracture include pulmonary embolism, heart attack, stroke, pneumonia and other infections.

Table 1:  2001 Georgia Osteoporosis Statistics

In addition, each year, 1.2 million people fracture their wrists and spine and suffer the pain and crippling of this preventable disease.  In 2000, we spent about 20 billion dollars to treat osteoporosis in the US. Because of the growing number of persons attaining advanced age in our society, the number of hip fracture cases will double between now and the year 2020 unless we take measures soon to deal with this condition.   If nothing is done to prevent more people from developing osteoporosis, the annual cost of caring for these patients will exceed 80 billion dollars by the year 2020.  

INTERVIEW WITH DR. WOODSON

Grattan Woodson, M.D., Medical Director of the Osteoporosis Center of Atlanta, is an Internist who has specialized in the diagnosis, prevention and treatment of osteoporosis.  His clinical work is devoted to caring for patients with osteoporosis and conducting clinical research studies on methods of treating and preventing osteoporosis.  He also maintains a small primary care Internal Medicine practice in Decatur, GA.

Q: Dr. Woodson, what is osteoporosis?

A: Osteoporosis is a bone disease caused by the loss of calcium mineral from previously healthy bones.  As calcium is lost, the bones begin to weaken and become brittle.  These thin bones break easily with slight stress - like a china cup.  The disease, however, begins years before the fractures occur.  We diagnosis osteoporosis with a bone density test as being present once the bone calcium is more than 25% lower than theaverage level found in young healthy adults.  Osteoporosis primarily affects Caucasian and Asian women later in life.  One third of white women over the age of 50 have osteoporosis

Q: How does osteoporosis develop? 

A: After age 25 or so, everyone begins to lose bone at a slow, steady rate.  Some people destined to develop osteoporosis, however, lose bone much faster than normal.  These people are known as "fast bone losers."  This rapid bone loss can be genetic or due to another disease or even treatment for some other medical disorder.  Fast bone losers can be identified with a urine test, which reflects the bone loss rate.  These tests are for collagen crosslinks and are known commercially as NTx, Osteomark, or Pyrilinks D.  If steps are not taken to halt this rapid loss of skeletal calcium, these people are very likely to suffer from fractures later in life.  Other patients diagnosed with osteoporosis lose bone normally but have the disease because they never formed an adequate amount of bone during growth and development.  Both groups of patients can be diagnosed before fractures occur with a bone density test.

Q: Why should young women or men worry about osteoporosis if it's older women's disease?

A: While it is true that fractures due to osteoporosis don't usually develop until about age 65, bone loss begins some 20 years before.  Osteoporosis has a long silent period when there are no symptoms at all.  It is important for young and middle-aged adults to become aware of osteoporosis while it is still soon enough to do something about it.  If you wait until a fracture has already developed, your best opportunity for prevention is long past.  Osteoporosis is a disease that is much easier to prevent than treat. 

Q: What are the consequences of osteoporosis?

A: It's the main cause of fractures in the hip, wrist, and spine.  In fact, thousands of people die from osteoporosis each year, mainly due to complications from hip fracture.  Many others never regain the ability to walk naturally again.  The “dowager's hump" deformity of the spine seen in older women and men is usually due to osteoporosis.   Osteoporotic fractures are painful, often disfiguring, and can lead to loss of independence.      

Q: Why are women more affected by osteoporosis than men are?

A: Women lose the bone-protecting effect of estrogen (the female sex hormone) when they pass through menopause.  This causes an increase in the bone loss rate. Men on the other hand, usually maintain production of sex hormone throughout life.  Also, because women have a smaller skeleton than men do, they have less bone to spare-making osteoporosis more likely in them.  Finally, women are more likely than men to suffer from certain diseases, such as an over-active thyroid, which increases the likelihood, that osteoporosis will develop.       

Q: What about African-Americans? Are they at risk for this disease too?

A: Yes, postmenopausal African American women are at risk for fractures due to osteoporosis.  The risk is about 40% lower than for age-matched whites but this still represents a very large number of women.  In a study completed recently at our center, risk factors for osteoporosis in black postmenopausal women was similar to those for whites.  Treatment for osteoporosis in black women is the same as for white women but in general much less is known about this disease in black women that their white sisters.  African American men have the lowest risk for osteoporosis and fractures due to osteoporosis than any other sex or racial group. 

Q: How can osteoporosis be detected before it causes fractures?

A: We know that people destined to develop osteoporosis experience a long period of greater than average bone loss.  These people, mainly white and Asian women, have much to gain from being identified early.  Measuring bone density between 45 and 65 years of age with a bone density test is the best way to predict who is at highest risk. 

Q: What is the best way to treat osteoporosis?

A: Calcium, multiple vitamins, and exercise are the cornerstones of any osteoporosis treatment program.  Hormone replacement therapy with various estrogens or the non-estrogen raloxifene (Evista) are widely used drug for prevention and treatment.  The bisphosphonates, [alendronate (Fosamax), risedronate (Actonel), and etidronate (Didronel)] are very effective drug for prevention and treatment of osteoporosis.  Calcitonin nasal spray is also an effective treatment for osteoporosis.  Parathyroid hormone (Forteo) is the first bone building drug for osteoporosis that is expected to add a new dimension to treatment of this disease especially for the most severely affected patients as well as those who have failed treatment with usual therapy.  All these therapies are known to prevent fractures due to osteoporosis.   Many new drugs are also on the horizon, some of which are expected actually stimulate formation of new bone.

Q: I've heard several press reports about hormone replacement therapy lately.  Is this drug safe?

A: In July, 2002 results for the largest and most important study of estrogen and progesterone therapy for postmenopausal women was reported.  The NIH sponsored Women’s Health Initiative (WHI) showed that use of hormone replacement therapy (estrogen plus progesterone) was associated with an increased risk for heart attack, stroke, breast cancer, and blood clots.  These findings are definitive.  They came as a surprise to many physicians providing care to postmenopausal women.  I now recommend that women not routinely use HRT and if she does use this hormone combination that she use it at the lowest effective dose for the shortest time possible.  In my opinion, HRT has no roll in prevention of any chronic disease for the usual patient.  As for use of estrogen by itself, the jury is still out.  The WHI has a sister study still looking at this issue.  The results are expected in 2005. 

Q: Can calcium, vitamins, and exercise alone prevent osteoporosis?

A: Yes and no. Research shows that while calcium is important for bone growth and development, especially in young people, it will not prevent bone loss in middle-aged people.  Calcium and vitamin supplements in people over age 60 do help prevent fractures.  Exercise also helps people build strong bones and helps to keep them strong.  Unfortunately, exercise will not prevent bone loss. For patients with established osteoporosis, estrogen, raloxifene, one of the bisphosphonates, or calcitonin should be considered to prevent fractures due to osteoporosis.  This is not to say that calcium and exercise are not important, because they are.  It’s just that they are not enough by themselves.         

YOUR RISKS FOR OSTEOPOROSIS

Your skin color, gender, body build, and family medical history play a limited but important role in predicting whether you will have osteoporosis.  More important, however, are the bone-weakening habits you actually can control, such as smoking cigarettes and drinking alcohol.  Below is a list of characteristics and behaviors that place you at greater risk for osteoporosis:

The Hormonal Transition: Menarchy-Premenopause-Perimenopause-Menopause

Girls experience menarchy when they have their first period.  Menses are often irregular at first in girls but within a six to twenty four months they usually regulate.  Young and middle aged women are considered premenopausal.   It is during the premenopause that women are most likely to bear children.  A premenopausal woman’s periods are usually but not always characterized by regularity.   This is followed by a newly recognized transitional time called perimenopause.    The perimenopause is a period characterized by hormonal changes that lead to menstrual cycle irregularities and symptoms of hormone deficiency or relative excess.  The perimenopause often lasts approximately 5 to 7 years before the last period occurs.  This transition period in a woman’s life is known as the perimenopause.   Perimenopausal symptoms include intermittent hot flushing, mood swings, depression, irregular periods, skipped periods, and sometimes heavier than normal periods.  When appropriate estrogen and progesterone supplementation can help control these unpleasant symptoms.   Recently, the selective seratonin re-uptake inhibitor (SSRI) class of drugs has been FDA approved as the first non-hormonal therapy that effectively relieves these symptoms.  The menopause, which physicians officially define as beginning one year after the last menstrual period, follows this.  Menopause, especially when it occurs early, is one of the most important risk factors for osteoporosis.

The bone protecting effect of the female sex hormone, estrogen begins to be lost in the early to mid-forties at the onset of the perimenopause.   Bone loss is accelerated above the normal slow steady rate that begins in everyone at about age 30.   Women who start the perimenopause with lower than average bone density is at highest risk of developing osteoporosis later on. 

Table 2: Osteoporosis Risk Factor Checklist

Family History of Osteoporosis

Scientific evidence has established that osteoporosis is at least in part an inherited disease.  Studies show that about 60% of a persons bone density is determined genetically and, therefore, is inherited from ones parents.  This data suggests that life style factors, diet, exercise, illness, and habits (alcohol and tobacco) affect the remaining 40% of a persons bone density.  While we cannot change our genetic factors, we certainly can influence our lifestyle choices for the better and lower risk for osteoporosis.         

Body Build

Thin, small-framed women are higher risk for osteoporosis than their heavier, large-boned peers.  Scientists are not sure why this is so but have suggested that heavy, large-framed women may build a stronger skeleton during their early growth years and have relatively higher levels of estrogen through adult life.  All these factors protect against osteoporosis.

Tobacco Use

Smoking can increase your chances of developing osteoporosis.  Smoking hurts bone growth during the time when most calcium is stored in the skeleton.  Teen-aged girls who smoke fail to develop adequate bone strength during the growth years and so are especially likely to suffer from osteoporosis later on.  Smoking also affects adult women, causing them to enter menopause about two years earlier than women who don't smoke.  Once a woman enters menopause, her levels of estrogen falls.  Even if a woman who smokes takes estrogen therapy after menopause, she does not benefit as much as a woman who does not smoke.

Alcohol

Drinking more than two alcoholic beverages a day can cause osteoporosis.  Alcohol reduces sex hormones in both women and men.  These sex hormones are necessary for the body to absorb calcium needed for building bone.  Excessive use of alcohol interferes with normal bone growth and makes the skeleton more likely to fracture.

Certain Drugs

Osteoporosis is a side effect of treatment with steroid hormones, like cortisone and thyroid hormone.  Cortisone-like drugs can cause much more bone than normal to be removed from the skeleton while at the same time can inhibit bone growth.  Although occasional treatment with these drugs for short periods of time is not very harmful, prolonged therapy can be.  Thyroid hormone tablets are given to people who have lost the ability to make this necessary hormone for themselves.  The amount of hormone used to treat this condition varies greatly from one person to the next.  In fact, too large a dose can cause osteoporosis.   

Immunosuppressive drugs used to prevent the rejection of a transplanted organ like cyclosporin are suspected of promoting bone loss.  The use of Imuran and methotrexate for the treatment of rheumatological disorders like lupus and rheumatoid arthritis may also cause osteoporosis.  There is experimental evidence to suggest that use of lithium for depression; aminophylline for asthma, bronchitis, or emphysema; and Coumadin or heparin for treatment or prevention of blood clots may also cause osteoporosis.  The National Osteoporosis Foundation has published an excellent review on drugs and osteoporosis.  For ordering information, call NOF at 201-223-2226.

BONE DENSITY TESTS FOR EARLY DETECTION

You know the saying... "You can’t judge a book by its cover."  Neither can you easily predict whether your bones are healthy.  Although people with certain characteristics or habits may be highly likely to develop osteoporosis, many other people without these characteristics or habits can develop the disease, too.  The only way to detect osteoporosis accurately before fractures have occurred is by a test called a bone density test.

Bone density tests measure how dense the bone is.  Research shows bone density is the best way to predict whether a person will suffer a fracture due to osteoporosis.  A bone density test allows your doctor to detect bone loss early when fractures are preventable.  Because osteoporosis most commonly develops in the bones of the wrist, spine, and hip, it makes more sense to measure bone density in these areas of the body to detect early signs of the disease.   The bone testing X-ray devices, called bone densitometers, use a very low dose of radiation.  Once osteoporosis is detected, several effective treatment measures can slow, or even halt, bone loss and prevent osteoporosis.      

Who Should Have a Bone Density Test?  "Change of life" can also mean a change in bone density.  Women who are undergoing menopause should consider getting a bone density scan.  This is especially so for women who will not take estrogen after menopause.  For most women, menopause usually begins around age 50. There is little reason to test for bone loss in normal young women before menopause or age 45, unless they have medical conditions associated with osteoporosis.  Some of these conditions include an overactive thyroid, early loss of the menstrual period, and eating disorders like anorexia and bulimia.   Many experts agree that bone density tests are not necessary for everyone.  They are most useful to help decide if someone should be treated for osteoporosis to prevent the fractures caused by this disease.  The generally agreed upon indications for a bone density test are listed below.

1) Is treatment needed?  A bone density test can help identify people with low bone density who are most likely to benefit from treatment to prevent osteoporotic fractures.                                 

2) Abnormal Back X-rays: A bone density test can help separate abnormalities due to osteoporosis from those due to other causes not associated with bone loss.  The information from the test can help the doctor decide if any treatment or tests are needed.

3) Long-term Steroid Therapy: A bone density measurement can help the doctor avoid causing osteoporosis as a side effect of this treatment.          

4) Hyperparathyroidism:  This is a disease of calcium regulation that leads to osteoporosis in some but not all patients.  A bone density scan can help detect bone loss before fractures develop.                                    

5) Monitoring Therapy: Patients being treated for bone loss need to be followed objectively to help determine if they are benefiting from therapy.  Comparing the results of a follow-up bone density scan with the initial scan is the best method of doing this.

WHAT TO DO IF YOU THINK YOU MAY HAVE OSTEOPOROSIS

If after reading this monograph, you think that you or someone you know is at risk for or may have osteoporosis don't panic.  The disease can be prevented in most people.  Here's what you can do:                         

             1) See your doctor and talk it over                     

             2) Learn all you can about osteoporosis                 

             3) Get a bone density test to see if there is bone loss  

             4) Consider beginning one of the effective treatments for this condition              

             5) Get plenty of calcium                                

             6) Practice weight-bearing exercise on a regular basis  

MEDICAL EVALUATION OF PATIENTS WITH OSTEOPOROSIS

Patients suspected of having osteoporosis need a medical evaluation to establish the diagnosis, determine the severity of the disorder, and to serve as the basis for making a treatment plan.  This suspicion can arise for a variety of reasons.  Common reasons include the presence of thin looking bones on a plain x-ray, a family history of osteoporosis, a medical history of a disease or treatment with a medication known to cause osteoporosis, or the development of a fracture in the absence of trauma (stress fracture).  In those with a low likelihood of osteoporosis being present, a bone density test can often resolve the issue.  If the test shows bone loss, additional tests are usually advised while if the bone density is normal, no further testing is recommended for osteoporosis. 

In all patients, the medical evaluation begins with a thorough history of the illness and all related conditions.  This is important because many patients with osteoporosis have more than one cause for this condition, which is often uncovered in the process.  An in-depth knowledge of the patient's medical history is also important to avoid prescribing a treatment, which might be unsafe because of an unrelated medical problem.  At the physical exam, the doctor looks for signs of disorders known to cause osteoporosis, as well as, establishing the degree to which the patient has been affected by osteoporosis. 

The initial laboratory exam includes a complete blood count, a blood chemistry analysis, an erythrocyte sedimentation rate, a dip stick urinalysis, kidney and liver function tests, and a urine examination for collagen crosslinks.  A 24-hour urine collection is analyzed for calcium and magnesium to help determine if the diet is adequate in minerals and to look for signs of a calcium leak from the kidney.  Other blood tests are sometimes ordered when a clue is turned up sometime during the medical evaluation or even during the course of treatment suggesting one of the many secondary causes of osteoporosis.  Many patients also need a plain x-ray of the upper and lower spine to look for signs of osteoporosis and to have available for comparison in case new problems develop later on.  The evaluation always includes a bone density scan of both the spine and the hip to establish whether or not there is bone loss or frank osteoporosis and to serve as a baseline from which to measure the effect of treatment in the future.

Once the above information is available, it is analyzed for patterns, which fit specific diseases known to cause osteoporosis.  When a secondary cause is found for osteoporosis, if specific treatment is available for it, this can often halt the bone loss.  The results of the medical evaluation also help the doctor and patient decide which treatment to try first. A variety of treatments are presently available for osteoporosis and many more are being investigated in research studies.

PREVENTION AND TREATMENT OF OSTEOPOROSIS

The best way to stop the silent thief of osteoporosis?  Build the strongest possible skeleton and prevent bone loss before it occurs.  That means getting enough calcium during childhood and adolescence.  During these growth years, most of the bone mineral is deposited in the skeleton as bone is formed into its adult shape.  A calcium-rich diet and weight-bearing exercise are the two most important building blocks for a strong skeleton.               

Diet

Eat a well-balanced diet throughout life to both prevent and treat osteoporosis - as well as many other diseases.  Choose foods that are low in fat, cholesterol, sugar, and salt; high in vegetables, grains, beans, and fiber; and moderate to low in animal protein.  Too much fiber, however, can reduce calcium absorption and lower estrogen levels, so don't over do it.

 Table 3: Recommended Daily Calcium Intakes By Age*

*Optimal Calcium Intake. NIH Consensus Statement 1994 Jun 6-8; 12(4): 1-31.

A well-balanced diet usually has all the vitamins, minerals, and trace elements needed for healthy growth and development.  On the other hand, people who limit their diet to only a few foods should probably take a multiple vitamin every day.                                                                 

Children and young adults need three or four servings from the dairy group or the high calcium vegetable group each day.  Tasty low-fat dairy foods include 1/2% milk, frozen and regular yogurt, cottage cheese, low-fat cheese, buttermilk, and ice milk.  Calcium-rich vegetables include green leafy vegetables and the broccoli-cabbage family.  Other good sources of calcium are sardines, salmon, oysters, and shrimp. 

Calcium Supplements

Although a daily diet of calcium-rich foods is the best way to maintain healthy levels of calcium, some people simply cannot eat the types or amounts of food that are required.  For those unable to get enough calcium otherwise, calcium supplements can help.  The supplements vary greatly in quality, price, and calcium content.  Many contain calcium carbonate, which is the most economical form of calcium and is usually well tolerated.  Some other forms of calcium available include calcium gluconate, calcium lactate, calcium citrate, and calcium phosphate.  They are also well tolerated but generally are more expensive than calcium carbonate.    Calcium citrate (Citracal) is the best absorbed calcium but is bulkier and costs more than calcium carbonate.  I usually reserve recommending Citracal for patients who seem to have problems absorbing calcium carbonate or who are a risk for kidney stones.     

Daily calcium requirements are the same whether you are getting your calcium from the diet, a supplement, or a combination of both.  Studies show that there is not much difference in how well these different sources of calcium are absorbed from the intestine.  Calcium from supplements is absorbed into the body better if it is taken with meals or a snack than on an empty stomach.  The reason for this is that acid released from the food during digestion helps break up the calcium-containing compound, which is necessary for calcium absorption.  As some people get older their stomachs fail to make as much acid as in the past.  Without acid, the calcium stays in a form that cannot be absorbed.   Citracal can be absorbed in patients whose stomach lacks acid or who take certain medications (Zantac, Tagamet, Pepsid, Prilosec, Nexium, etc.) that reduce stomach acid.  In these patients, Citracal may be the preferred option.

How do you decide which supplement to take?

There may be an important difference in the way that some supplements are made.  Some tablets, especially some of the generic products, have been pressed too tightly during manufacture.  This can make it impossible for them to break up in the intestine and release their calcium.  Since these generic products are unregulated by the government, no testing is required to make sure that they dissolve in the stomach as they are suppose to do.  Calcium-containing liquids and chewable tablets have the advantage of already being in solution by the time they reach the stomach.  This increases the likelihood that the calcium in them will be absorbed.  You can do a simple test at home to see if your calcium supplement will break up.  Place your calcium pill in an 8-oz glass of water and wait 30 minutes.  If the product breaks up in the bottom of the glass, it will probably dissolve in your intestine, too.  Since sellers of generic calcium supplements have a number of different suppliers, you should test your supplement every time you buy a new bottle to be sure that the pill will dissolve.  Another option is to choose a quality brand name over a generic product.  By paying more, you are depending on the reputation of the pharmaceutical company making the product to guarantee that it has been manufactured properly.

Calcium supplements do cause side effects in some people.  These include constipation, upset stomach, and, rarely, kidney stones.  People with a personal medical history of kidney stones should consult their doctor before using calcium supplements.  Adding some fiber to the diet can usually prevent constipation.  Taking calcium with meals often prevents upset stomach.           

Table 4 Selected Calcium Rich Foods

Exercise

Get off your tailbone or lose it!  Physical activity helps children and young adults develop and maintain a strong sturdy skeleton (including your tailbone).  When muscles pull on bone during physical activity, the bone cells add more bone to the skeleton.  To be effective, exercise must be weight bearing, in other words, done against gravity.  Examples of weight- bearing exercise include walking, running, dancing, and jumping.  Although swimming, bicycling, and rowing are good exercises for the heart and muscles, they don't help prevent osteoporosis since they are not weight bearing.  Studies show that moderate regular weight-bearing exercise is one of the ways to increase bone density and thereby strengthen the skeleton. 

The beneficial effect of exercise though, lasts only as long as you remain active.  This means that consistency is key to benefiting from exercise.  For this reason, it is a good idea to begin slow and work your way up gradually to a level of exercise, which fits well into your lifestyle.  If you try to do too much, too soon, you may get hurt or simply give up gaining nothing but frustration.  Simple walking is one of the best exercises for osteoporosis and is also an excellent way of developing cardiovascular fitness as well.  Walking with hand and/or ankle weights is one way to increase the benefit.  Walking with a lightly weighted (1 LB to 5 LB) knapsack on the back is thought by some observers to improve balance thereby lessening the risk of falling.  It is probably better to walk around your neighborhood if this can be done safely.  The variable surfaces and walking up and down hills improves fitness more than walking on a flat track.  Use of an indoor treadmill is a good option for those without a good place to walk.

Exercise clubs usually have weight machines (Nautilus) which can also be used as part of a program to strengthen the skeleton.  Use of these machines should first be discussed with your physician.  Most studies of their use recommend exercising with light weights (5 LB to 15 lb.) in repetition, which means repeating the exercise many times over.  This type of exercise is designed to place stress on the skeleton and improve the endurance strength of the muscles.  It is not designed to build bulky muscles.  The YMCA and YWCA often have these exercise facilities available to their members at a cost that is often lower than the exercise clubs.                                    

Drug Therapy for Prevention and Treatment

After about age 25, everyone loses a little bone from the skeleton each year.  In most people, this small loss doesn't cause any problems.  In those who get osteoporosis, however, bone loss occurs much faster than normal.  Taking estrogen, the female sex hormone, is one of the best ways to slow bone loss.  Estrogen also improves the body's ability to use calcium from the diet and causes less calcium to be passed out of the body through the kidney.  

Hormone Replacement Therapy

The surprise announcement by the Women’s Health Initiative (WHI) investigators of the termination of the hormone replacement (HRT) wing of the study after an average follow-up of 5.2 years because the risks of therapy outweighed the benefits has had a major impact on care of postmenopausal women.   Both the public and the medical community was shaken by the sudden ending of what has been widely regarded as one of the most important randomized clinical trials of HRT and primary prevention in postmenopausal women.  The WHI is a program of the National Institutes of Health with the National Heart, Lung and Blood Institute responsible for this arm of the study. The participants in the study were sent a letter dated June 2002 entitled “Important Notice About Your Study Pills”. The WHI Data and Safety Monitoring Board (DSMB) recommended that women who had not had a hysterectomy and were on estrogen plus progestin (Prempro®) stop their study pills but they could continue their participation in other WHI programs such as the calcium and Vitamin D Program. The DSMB felt in their judgment that the health risks of taking estrogen plus progestin now exceeded the benefits. In the June letter, WHI told women that the number of women who developed breast cancer, heart attacks, strokes and blood clots was higher in women taking the estrogen plus progestin pill than in those taking placebo. The letter also informed them that there were benefits of taking estrogen plus progestin in that the number of women who had fractures or colorectal cancer was lower. 

It is of note that the DMSB did not stop the estrogen only protocol in 10,000 women who were status post hysterectomy.  As this information was forwarded to the medical and patient community, many immediate questions developed. Some of these questions were answered on the WHI website (http://www.whi.org). Very few patients not involved with the study were aware of this information and many people taking HRT or estrogen replacement therapy (ERT) do not have ready access the WHI website.  

The data indicates that the downside risks and upside benefits are small in either direction but add up when one considers that 38,000,000 American women are on these medications.  Specifically the risk compared with placebo for heart attack was increased by 29%, breast cancer was increased 26%, stroke was increased 41%, and blood clots were 41% more common.  On the good side was a 36% reduction in risk for colon cancer and a 34% decrease in risk for hip fracture.

Recently a meeting of Atlanta Area physicians specializing in Rheumatology, Internal Medicine, Endocrinology, Obstetrics and Gynecology, and Oncology was held to discuss the WHI results.  I had the privilege of attending and participating in this conference.  The physicians developed a consensus addressing two questions.  First, what is the role of HRT in management of postmenopausal women?  We concluded that HRT use after menopause should be restricted to management of patients with menopause symptoms that significantly impaired the patient’s quality of life.  This determination should rest principally with the patient’s own self-assessment of how her quality of life was affected by estrogen deficiency.  Furthermore we recommend that HRT use should be limited to 5 years after menopause except in unusual cases and that use of the lowest effective dose of HRT for symptom control but not necessarily symptom elimination be instituted.   For those patients currently on HRT, we concluded that patients be advised to stop treatment and suggest that this be accomplished by slowly withdrawing the patient from HRT over several months.  An empirically based recommendation from the conferees for discontinuing HRT begins with discontinuing the progestin and instituting unopposed ERT and half the patient’s prior dose.  The ERT dose is gradually decreased over the next 3 months and finally discontinued altogether.  If the patient is unable to withdraw from unopposed ERT then we recommend maintaining the patient on the lowest tolerated dose of estrogen and adding back cyclical progestin for 14 days every one to three months. 

With respect to the second question, what is the role of ERT in management of postmenopausal women, we concluded that ERT should not be started routinely in women without significant postmenopausal symptoms and that its use should be governed by the same guidelines outlined above for HRT.  For patients established on ERT, we concluded with dissent that patients should be encouraged to withdraw from therapy.  The specific withdrawal method would be slowly reducing the dose over several months finally discontinuing ERT.  If the patient was unable to tolerate complete withdrawal, use of the lowest effective dose was advocated.  The minority opinion was that since the ERT wing of the WHI was not terminated, the long-term use of long term ERT might still be on balance beneficial and therefore could be continued if the patient so desired. 

Of paramount importance to the conferees was that the physician assess the specific needs and medical conditions of each patient individually rather than subscribe to a single solution for all patients.  In our opinion, the accomplishment of this goal requires the physician to determine the wishes and views of the patient on use of HRT or ERT and then devote the time necessary for a thorough discussion of this important and complex issue with them.

So in summary and in contrast to what was commonly held to be the case before the WHI results were released, in my opinion, HRT should not be routinely used in postmenopausal women for prevention of chronic disease.  When its use is necessitated by severe hot flashes or other menopausal related symptoms, then it should be used in the lowest effective dose and for the shortest time possible. 

Calcitonin nasal spray (Miacalcin)

Another drug that successfully treats osteoporosis is salmon calcitonin, a synthetic hormone that is similar to the human hormone made by the thyroid gland.  Calcitonin slows down the skeleton's loss of calcium and increases bone density at least temporarily.  After about 18 months of treatment, some people begin to lose bone again, but more slowly than they would if they were not taking calcitonin.   Long-term studies of calcitonin show that it prevents spine fractures but not hip or wrist fractures.  Calcitonin nasal spray side effects are limited to nasal irritation and congestion and there are no serious problems with use of the drug.  It is well tolerated by most patients.  Calcitonin is approved by the US Food and Drug Administration for treatment of postmenopausal women with osteoporosis.  It is not approved for the prevention of osteoporosis.

Alendronate (Fosamax) and Risedronate (Actonel)

Alendronate and risedronate are potent new osteoporosis drugs that are members of the bisphosphonates class.   These agents are very effective drug therapy and are US FDA approved for treatment and prevention of osteoporosis.   These drugs act to preserve bone.  Use of these drugs lead to a build up of bone for at least three years but probably for much longer in many patients.    Studies show these drugs are some of the strongest agents presently available for osteoporosis.  In numerous studies, these drugs have been shown to increase bone density in the hip and spine and prevent fractures in the hip, spine, and wrist.   These drugs are given by mouth either every day or once weekly, the first thing each morning on an empty stomach.  The reported side effects are mild and not serious.  The most common complaint is upset stomach or indigestion, which is no more common that that occurring in the matched placebo group.   Both drugs have been proven to prevent osteoporosis caused by corticosteriods.  They can also be used successfully in combination with hormone replacement therapy and Evista.   In September 2000, Fosamax was approved by the US FDA for treatment of osteoporosis in men.

Raloxifene (Evista)

Estrogens use for prevention of osteoporosis is declining especially in light of the WHI data on HRT released in July 2002.  A new class of anti-estrogens known as selective estrogen receptor modulators (SERMs) were first developed and used as an anti-breast cancer drug.  Tamoxifen (Nolvadex) is the only drug currently approved for prevention of breast cancer by the US FDA.  Raloxifene (Evista) was the second SERM approved by the US FDA and the only SERM indicated by the US FDA for treatment and prevention of osteoporosis.  Evista does not cause breast pain, swelling, or vaginal bleeding that occurs in some patients treated with estrogen.  Raloxifene studies showed that while this drug blocks estrogen's effect in the breast and uterus, it acts like estrogen in the bone, liver, and blood vessels.  Evista has been proven to prevent fractures of the spine due to osteoporosis but not the hip or wrist.  In the Evista research studies so far, there was a 68% decrease in risk for developing breast cancer compared to the control group.  Raloxifene is presently being investigated in a long-term comparison study with Tamoxifen for the prevention of breast cancer.  Evista lowers the bad LDL cholesterol about as well as estrogen but has no beneficial effect on the good HDL cholesterol as is seen with estrogen.  In a recent analysis of the patients participating in a major Evista study (MORE) showed that those at high risk for heart attack or stroke experienced a 40% decrease in these conditions over the four years of the study.  A new larger study is underway to confirm this benefit of Evista.  Despite early enthusiasm, it is still too early to be certain how much or in fact if Evista will lower risk for breast cancer or cardiovascular disease.   This information will be forthcoming as the results of ongoing studies become available over the next few years.  Evista is taken by mouth as a 60mg tablet once daily.  It can be taken with or without food and rarely causes any gastrointestinal side effects.  Side effects associated with raloxifene are mild especially after age 60.  Common side effects experienced by a minority of women include hot flushing, leg cramps, and weight gain.  The only serious side effect is a slightly increased risk for blood clots like that with estrogen. 

Parathyroid Hormone (Forteo)

Parathyroid hormone (PTH) is a natural human protein that plays a critical role in bone health and disease.  In recent studies, small quantities of PTH given by subcutaneous injection once daily markedly increased bone density in the spine and hip and reduced fractures of the spine.  The increases in bone density with PTH was greater than that seen for any prior treatment and the fracture rate was decreased more than with any other treatment.  The drug must be given by a daily injection under the skin.  It is approved for use in men and women with sever osteoporosis (low bone density and fractures).  It has been shown effective for treatment of idiopathic osteoporosis, a rare form of the condition that is difficult to treat with past therapy.  PTH is the first bone growth factor approved by the US FDA for treatment of osteoporosis.   It can be used in combination with estrogen and Evista but it is not currently know whether or not it can be used together with bisphosphonates or calcitonin.  PTH is labeled for use by the US FDA for 18 to 24 months.  After that time, experts recommend discontinuing PTH and using a second agent to maintain bone health.  For this purpose, one can use Evista, Fosamax, Actonel, or estrogen.    

Side effects of PTH are minimal and include minor aches and pains and a slightly high blood calcium level in some patients.  In early studies of the PTH, rats given the drug developed bone tumors.  However, the dose used in the rats was extremely high compared with the dose used in humans.  Also, there is no indication that the very low levels of PTH used in humans intermittently is likely to cause human bone disease.  Some patients object to giving themselves a daily injection.   Lilly, the manufacturer of PTH is one of the most experienced drug companies when it comes to patient self-injectable drugs.  After all they discovered insulin in 1925!  Lilly has developed a very simple PTH filled pen that makes it very easy for patients to give themselves a daily shot.   Our staff is experienced in giving these injections and are prepared to help our patients learn to give themselves these shots. 

Treatment of Fractures of the Spine and Hip

The treatment goal of patients with a recent vertebral compression fracture is to relieve back pain.  Once accomplished, therapy focuses on returning the patient to a normal activity level and prevention of new fractures.  Seldom do these patients require hospital treatment.  Bed rest at home for the first week to ten days is the main treatment in the immediate post-fracture phase.  An ice pack or cooled gel pack placed on the back at the site of pain are often helpful.  This decreases muscle spasm and pain.  Some patients prefer a heating pad.  Initially, use of a liquid diet can prevent constipation, which often complicates spine fractures or its treatment.  Some doctors prescribe salicylate (aspirin), NSAID (Aleve), acetaminophen (Tylenol), Vioxx, Celebrex, cyclobenzaprine (Flexoril), propoxyphene (Darvocet) or codeine or hydrocodone (Lortab) to help control pain and muscle spasm.  Treatment with calcitonin nasal spray is reported to relieve pain due to osteoporosis.  After five to seven days, most patients can begin limited physical activities. These medications are often used in combination.  Capsaicin (Zosterix), sold as a topical anesthetic skin cream, is a chemical found in hot peppers.  It is a very effective method of relieving pain due to new or old osteoporotic fractures.  Capsaicin causes the nerve tissue to become deleted of the pain message chemical, substance P.  This leads to block the pain impulse.  It is sold over-the-counter without a prescription in several strengths.  To work best, it should be applied very sparingly directly to the painful area 3 times daily.                

Patients with hip fracture are always admitted to the hospital so the broken bone can be stabilized.  Today, most hip fracture patients are treated surgically by pinning or replacing the hip. Patients usually require several months of physical therapy beginning while they are still in the hospital for rehabilitation.  Even with these efforts to recover fully, one half of hip fracture victims never walk normally again.        

THE OSTEOPOROSIS RESEARCH PROCESS

The osteoporosis research studies conducted by the staff of the Osteoporosis Testing Center are governed by the US Food and Drug Administration's rules for Good Clinical Practices.  We strictly follow these published guidelines.  The goal of the studies we perform here is to determine if a new drug treatment is an effective means of preventing or treating osteoporosis.  In general, only those patients not presently taking treatment for osteoporosis are eligible to participate in research.  Studies are usually funded by a research grant which covers the cost of the research related medical expenses including the physician's fees, x-rays, blood and urine tests, and the bone density scan.  In addition, calcium supplements and the study drug are provided to the patient free of charge.  These studies usually last for 3 to 5 years because it takes this long to see a significant effect on osteoporosis.   While it varies from study to study, patients are asked to come to our office about 4 times each year.  About half the time, patients have blood and urine tests, back x-rays, a bone density scan, or a physical exam during an office visit.  The other visits are to pick up new study medication and calcium.  At every visit, our staff checks to see how the patient’s health is in general and specifically inquire about any new ailments.         

Osteoporosis research studies usually compare the effect of an investigational new drug plus calcium with that of calcium alone to see which is better.  To be proven effective, new drugs must show that they significantly contribute to patient improvement over and above an effect, which might result from chance alone.  To do this, some patients in the study must be given a placebo treatment instead of the active ingredient.           

OSTEOPOROSIS PREVENTION AND TREATMENT AFTER THE YEAR 2000 

Bisphosphonates and SERMs will remain the mainstay of osteoporosis prevention and treatment with some fading of estrogen and calcitonin.   A host of exciting new bone forming drugs will become available early in the century that will allow us to treat patients that have not responded well to present therapy.  Use of estrogen containing regimens will continue to decline in the wake of the WHI findings despite ERT’s effectiveness for osteoporosis. 

Growth Factors

Soon the osteoporosis research process will yield the first products that increase bone formation.  The first of these products to be approved for treatment of osteoporosis is Parathyroid hormone (Forteo).  A number of other factors are being investigated worldwide.  Much of the recent basic bone research has been aimed at identifying and understanding the bone growth factors, which serve to stimulate skeletal growth.  The task ahead will be to learn which ones work best and how to deliver them to the bone surfaces where they are needed most.  These studies are well underway and will soon produce results.          

Gene Therapy

The development of gene therapy for osteoporosis will probably make its debut within the first decade of the new century.  The areas holding the most promise include repair of defective genes found to cause osteoporosis or the replacement of these genes with new healthy ones.  These are very exciting times in osteoporosis research which has seen a virtual explosion in new information.

MALE OSTEOPOROSIS

In the United States, about 4 million men have osteoporosis and most of them do not even know it!  Tragically, each year 100,000 men suffer hip fracture with 20,000 of these dying within the first year of the fracture due to complications.  Many more men suffer annually from fractures of the spine and limbs due to osteoporosis.  Male osteoporosis usually begins silently in late middle age progressing to fractures in later life. 

Common Causes of Male Osteoporosis

A few conditions cause the most cases of osteoporosis in men such as loss of the male sex hormone, testosterone.  Failure of the male testicle to make testosterone is sometimes at fault.  These men often have a history of impotency.  Heavy use of alcoholic beverages and tobacco smoking both lower serum testosterone levels, thus increasing the risk for osteoporosis.  Alcohol is harmful to the skeleton in several ways.  It decreases male sex hormone production and increases its breakdown by the liver.  This results in lower testosterone blood levels, which can promote male osteoporosis.  Both acute and chronic heavy alcohol drinking directly cause toxic effects on bone cells leading to a decrease in bone growth. 

Long term treatment with cortisone-like drugs is another important cause of osteoporosis in men.  They damage the skeleton by increasing bone breakdown while decreasing bone growth.  They promote loss of calcium from the kidney and block vitamin D's ability to increase calcium absorption from the diet.  Together, these actions have devastating effects on the skeleton. 

Idiopathic hypercalciuria is a treatable cause of osteoporosis seen in some men.  It is due to a calcium leak from the kidney.  These patients sometimes have a medical history of kidney stones.  Measuring a 24-hour urinary calcium level in men following a low calcium diet can help identify persons with hypercalciuria.  Disease states resulting in high body acid levels cause osteoporosis.  Common examples include emphysema, chronic bronchitis, chronic renal failure, and renal tubular acidosis.  

Idiopathic osteoporosis, much more common in men than women, accounts for a large group of men with osteoporosis.  This disorder has no known cause.  The syndrome should be suspected when men in their fifth or sixth decade develop osteoporosis with no clear cause.  All other causes of osteoporosis should be excluded before this diagnosis is made.  A bone biopsy can be of diagnostic value in this group. 

There are many other causes of osteoporosis in men, which occur infrequently.  No one cause dominates male osteoporosis to the same degree that sex hormone deficiency does in females.  This can make the diagnostic evaluation in men with osteoporosis complex and prolonged.

The Diagnostic Evaluation in Men

The diagnostic evaluation of a man with osteoporosis should first be directed at the common conditions.  If a strong clue suggesting one of the rare causes develops, it can then be pursued.  A thorough patient history and a physical examination are the usual starting point in determining the cause of osteoporosis in men.  The laboratory exam looks for disorders of one or more of the bodies organs or hormone producing glands, that can cause of osteoporosis. A spine X-ray helps show the presence or absence of vertebral compression fractures.  This information helps confirm the diagnosis.  It is also useful for determining the cause of new back pain. 

A patient's bone density is the most reliable indicator of risk for fracture due to osteoporosis.  Moreover, the effect of the treatment can be measured precisely by comparing the follow-up bone density test with the initial scan.   A common reason for a bone biopsy in men is when idiopathic osteoporosis is suspected.  The biopsy can help confirm the diagnosis of idiopathic osteoporosis and rule out other bone diseases, such as osteomalacia.  Several special laboratory tests are used when one of the rare causes of osteoporosis is suggested by the initial evaluation. 

Prevention of Male Osteoporosis

Avoiding use of tobacco products and the heavy use of alcoholic beverages are two ways to reduce risk for osteoporosis.  Following a well-balanced diet and moderate regular exercise are the cornerstones of osteoporosis prevention.  Before beginning an exercise program, discuss it with your doctor.  If your diet is low in dairy products, consider using a daily calcium supplement.  Up to age 65, men need about 1000 mg of calcium daily but afterward need 1500 mg of calcium daily to help prevent osteoporosis.  A daily multiple vitamin is recommended for men over 65 years that do not absorb minerals and vitamins from their diet as well as in their youth. 

General Treatment of Male Osteoporosis

A well balanced diet is important to insure good general nutrition.  An adequate calcium intake of 1000 mg to 1500 mg daily is essential.  A daily multiple vitamin is also recommended for men with osteoporosis.   A walking program consisting of a brisk 30-minute walk four to five days per week should be started as soon as the patient is able.  Upper body exercises are useful to relieve back pain due to muscle spasm.  Braces have a limited role in pain management.

Men with osteoporosis due to sex hormone deficiency benefit from testosterone replacement therapy.  Testosterone is now available as a patch and in gel form which are useful for treatment of testosterone deficiency related osteoporosis.   Alendronate (Fosamax) was approved by the US FDA in September 2000 for treatment of male osteoporosis.  PTH (Forteo) was approved for treatment of male osteoporosis in 2002.

THE NATIONAL OSTEOPOROSIS FOUNDATION

The National Osteoporosis Foundation (NOF) is a non-profit voluntary health organization formed in 1984.  The Foundation's primary aim is to eliminate this disease.   The Foundation provides patients and their families with information on osteoporosis detection, prevention, and treatment.  NOF sponsors educational seminars for the public as well as for medical professionals.  They advocate increased governmental support for osteoporosis research and the Foundation directly funds osteoporosis research.

Research into the causes, prevention, and treatment of osteoporosis has begun to produce results.  But this new information is not getting to the public or the doctors who need it most.  For instance, estrogen replacement therapy after menopause prevents most of the fractures of the spine and hip. At present however, only one in seven women at risk for osteoporosis are on this bone-sparing hormone.  Another new finding shows that three daily servings of milk during childhood is an excellent way to prevent osteoporosis later in life. These important findings deserve more attention.  Providing this type of information to doctors and the public are examples of how the Foundation can help prevent osteoporosis.

Osteoporosis is a serious disease challenging our society.  In this century, the number of years we can expect to live has increased dramatically.  For us to remain healthy in our older years will require that our society practice preventive medicine to avoid disease rather than to try to cope with disease once it has taken its toll.  We want to be vigorous older citizens rather than crippled victims unable to care for ourselves.

Research and education sponsored and funded by The National Osteoporosis Foundation are critically important.  By supporting NOF, you can help put a stop to this disease in our lifetime.  We cannot afford to let a new generation of victims fall prey to osteoporosis.

Can You Help NOF?

The Osteoporosis Foundation needs your support.  NOF is the only non-profit organization dedicated to reducing the incidence of this preventable disease.  Your tax- deductible donation will be used to help us get the word out to thousands of potential victims (like you!) on how they can avoid this crippling disease.  NOF is wholly supported by our contributions, so please give generously.  Your donation will be used to help provide educational materials, programs, and urgently needed research.  Join NOF’s growing family of contributors and become a member today.

Additional Resources of Interest

The National Osteoporosis Foundation's Information Center can be reached by calling 201-223-2226.  The center is staffed by NOF personnel to help provide you with answers to your questions.  They can also help you order any of the very informative publications produced by the foundation.

The Osteoporosis Report is a quarterly newsletter published by The National Osteoporosis Foundation in Washington, DC.  It provides a national prospective on osteoporosis including the legislative developments affecting treatment, diagnosis, and research.  Current members of the Foundation receive the Osteoporosis Report free of charge.  To join NOF, complete the membership application at the end of this handout and mail it to NOF with your check.

Boning Up On Osteoporosis is published by the National Osteoporosis Foundation.  This monograph is written for people who want more information on this disease and its treatment. New members in NOF are mailed one complimentary copy.  Otherwise, it may be ordered from the Foundation for a small fee by calling NOF at 202-223-2226.

THE OSTEOPOROSIS CENTER OF ATLANTA

 “A Center for the Comprehensive Evaluation and Management of Osteoporosis and Related Diseases”

Osteoporosis is a bone weakening disease effecting one out of three Atlanta women after age 50.  Most people with osteoporosis don’t even know it until they break a bone.  Today, an exciting array of new diagnostic tools and treatment options have become available that allow us to effectively treat as well as prevent osteoporosis in most patients.   In the near future, a number of new treatment choices are on the way that will permit us to stimulate the growth of healthy new bone.  These new bone growth stimulators hold the promise that treatment of osteoporosis will become so effective that it will be virtually curative.   Known as the silent thief, osteoporosis is usually present for many years with no symptoms at all.  All the while, bone is getting slowly weaker.  During this time, a bone density test is the only reliable way to catch the thief in time to stop it.

Osteoporosis Evaluation is necessary only after the diagnosis has been made with a bone density test or a fracture typical of the disease has occurred (hip, spine of wrist).  The purpose of a careful osteoporosis evaluation is to identify unsuspected conditions that causes bone loss and determine the effect that known conditions are having on the rate of bone loss.  Once these are known, appropriate therapeutic action directed at these other conditions can be taken to lessen their impact on the skeleton.

Bone Density Testing has revolutionized the diagnosis and management of osteoporosis.   Testing of bone with this device permits us to tell how much bone is present at important skeletal sites.  Common measurement sites include the fracture prone  lumbar  spine,  hip,  and wrist.   Studies show that the lower the bone density in these key areas, the higher the risk for fracture.  Now we can detect bone loss before fractures occur.  Bone density testing also allows us to follow a patient’s response to treatment in an objective way not possible before the development of this new technology.

Bone Markers are a new biochemical approach to the diagnosis and management of osteoporosis.  These blood and urine tests allow us to begin to understand the physiology of bone.  Specifically, we can use these tests to tell how fast the skeleton is losing bone and to determine if the present therapy is working as expected. 

Biochemical Evaluation of the patient diagnosed with osteoporosis is used to exclude common causes of the bone loss such as thyroid disease, kidney or liver disease, and mineral malabsorption in the intestine or excessive loss from the kidney.   A series of simple blood and urine tests are used to get an indication if any of the common causes of bone disease is present.  If theses initial tests suggest an underlying disorder, further testing to confirm or refute its presence may be needed.

Fracture Management of the spine has been improved by the use of a new class of anti-inflammatory medications that are much less likely to upset the stomach.  A new surgical procedure, kyphoplasty, has also become available recently which involves the internal stabilization of the fractured vertebra by the injection of bone glue into the bone.  This procedure has resulted in considerable pain relief for select patients with unstable vertebral fractures.  Improved physical therapy techniques for the acute management of back pain as well as for rehabilitation after fractures is available at the center.

Insurance Coverage Our center professionals are providers for most of the major Atlanta PPO insurance networks and Medicare. Please call us to see if we are a provider for your plan.

 ABBREVIATED CIRRICULUM VITAE: GRATTAN WOODSON, M.D., FACP

 Academic Background

Oglethorpe University, Atlanta, Ga. BS 1976

Medical College of Georgia M.D. 1980 

Internship & Residency MI Bassett Hospital, Cooperstown, NY  1980-83

Clinical Fellow in Medicine, Columbia University College of Physicians and Surgeons, New York, NY 1980-83

Clinical Instructor of Medicine, Emory University School of Medicine, 1983 - present

Professional Organizations

Certified by The American Board of Internal Medicine 1983 - present

Fellow of the American College of Physicians 1993 -present

Member, The American Society for Bone and Mineral Research 1986 - present

Member, The Paget’s Disease Foundation 1989 - present

Member, The Osteogenesis Imperfecta Foundation 1991 - present

Life-time Member The National Osteoporosis Foundation, 1986 – present

Member, The Clinical Society for Bone Densitometry 1993 - present

Principal Hospital Affiliation

DeKalb Medical Center, Decatur, Georgia since 1986-present

 Osteoporosis Research Experience

1) 1985-1990 Proctor and Gamble Pharmaceuticals: Coherence (ADFR) therapy of osteoporosis with phosphate and etidronate: A  multicenter, randomized, double-blind trial.

 2) 1990-1998 Sandoz: A multi-centered, double-blind, placebo-controlled study to investigate the efficacy of salmon calcitonin nasal spray in the prevention of  osteoporotic vertebral  fractures (The PROOF Study).

 3) 1992-1997 Sanofi Winthrope: A study of tiludronate in the treatment of established post-menopausal osteoporosis.

 4) 1992-1996 Sanofi Winthrope: A  study of tiludronate in the treatment of post-menopausal women with low bone mineral mass and no vertebral fractures.

 5) 1993-1999 Proctor and Gamble Pharmaceuticals: A study to determine the efficacy and safety of risedronate in the treatment of osteoporosis in elderly women. (The HIP Study)

 6) 1993-1995 Proctor and Gamble Pharmaceuticals: A study to determine the efficacy and safety of risedronate in the treatment of postmenopausal osteopenic women.

 7) 1995-1998 Merck Human Health: A study to evaluate the safety, tolerability and effect on bone mineral density of 10mg of alendronate sodium for the treatment of postmenopausal osteoporosis in elderly female long term care facility residents.

 8) 1996-2000 Roche: A study on the efficacy and safety of ibandronate during 3 years’ treatment in patients with postmenopausal osteoporosis and vertebral fractures.

9) 1997-1999 Merck Human Health:

A study to compare efficacy of oral alendronate sodium to intranasal calcitonin-salmon for treatment of postmenopausal osteoporosis (IN-FOCAS).

 10) 1998-2000 Pfizer: Safety and efficacy of droloxifene for preventing bone loss in normal, early postmenopausal women.

 11) 1998-2000 Parke Davis: A Study Assessing the Safety and Protective Effect on the Endometrium of 4 Dosage Combinations of Norethindrone Acetate Plus Ethinyl Estradiol.

 12) 1997-98  Novartis: A Safety and Efficacy Trial with Transdermal Zolendronate in the Treatment of Postmenopausal Osteoporosis.

 13) 1998-99 Berlex: A study to evaluate the safety and efficacy of two doses of estradiol given by continuous transdermal administration in prevention of osteoporosis in postmenopausal women.

 14) 1999-2000 Merck Human Health: A  study to evaluate upper gastrointestinal tolerability upon rechallange in postmenopausal women with osteoporosis who previously discontinued alendronate due to upper gastrointestinal symptoms.

Publication  Highlights

1)  NB  Watts, S. T. Harris, H. K. Genant, R. D. Wasnich, P. D.  Miller, R. D. Jackson, A. A. Licata, P. D. Ross, G. C. Woodson, M. J. Yanover, W. J. Mysiw, L. Kohse, M. B. Rao, P. Steiger, B. Richmond, C. H. Chestnut, Intermittent cyclical etidronate treatment of postmenopausal osteoporosis. N Eng J Med 1990;323;73-79.

 2) Susan M. Ott, Grattan C. Woodson, William E. Huffer, Paul D. Miller, Nelson B. Watts, Bone histomorphometric changes after cyclic therapy with phosphate and etidronate disodium in women with postmenopausal osteoporosis. J Clin Endocrinol Metab 1994;78:968-972.

 3) Woodson,G., Adequate screening for axial osteoporosis with densitometry requires measurement of the hip and spine.  Poster presentation at the ASBMR, Baltimore, MD September 1995. J Bone Min Res 1995;(supp 1):

 4) M McClung, W Benson, M Bolognese, S Bonnick, M Ettinger, S Harris, H Heath, R Lang, P Miller, E Pavlov, S Silverman, G Woodson, K Kalkner, P Bekker,. Risedronate treatment of postmenopausal women with low bone mass: Preliminary Data. Osteoporosis Int 1996; (suppl 1):PTu 700

 5) Woodson, G.,.  An effectiveness study of etidronate therapy with and without estrogen. J Bone Min Res 1996;(supp 1):M651  

 6) P Beeker, M McClung, W Benson, M Bolognese, S Bonnick, M Ettinger, S Harris, H Heath, R Lang , P Miller, E Pavlov, S Silverman, G Woodson,  K Kalkner,  D Axelrod,. Risedronate is effective in increasing BMD in both early and late postmenopausal women with low bone mass.  J Bone Min Res 1997;(suppl 1): S474

 7) McClung, M, W Benson, M Bolognese, S Bonnick, M Ettinger, S Harris, H Heath, R Lang, P Miller, E Pavlov, S Silverman, G Woodson,  K Kalkner, P Bekker, D Axelrod,. Risedronate increases BMD at the hip and spine in postmenopausal women with low bone mass. J Bone Min Res 1997;(suppl 1): P269

 8) Woodson, G., The supine lateral site is more sensitive for the diagnosis of osteoporosis than other axial DXA sites.  J Bone Min Res 1997;(suppl 1): F614

 9) Woodson, G., An interesting case of osteomalacia due to antacid use associated with stainable bone aluminum in a patient with normal renal function. Bone 1998; 22:6;695-985.

 10) Silverman S, Genant HK, Kiel DP, Maricic MJ, Peacock M, Woodson G., Salmon-Calcitonin nasal spray prevents fractures in established osteoporosis.  Additional interim fracture analysis of the “PROOF” study. 1998 Bone; 23(suppl 5)

 11) Chestnut C, Maricic MJ, Silverman S, Woodson G., Are bone mineral density and biomarkers good predictors of efficacy for prevention of osteoporotic fractures? – Salmon-calcitonin nasal spray and alendronate. 1998 Bone; 23(suppl 5)

 12) Rosen CJ, Bonnick SL, Miller PD, McClung MR, Wasnich RD, Weiss SR, Woodson GC, Schnitzer TJ, Lenihan JP, Ross RP, Wang L, Smith ME, Gormley GJ, Melton, ME., Treatment of osteoporosis in postmenopausal women: alendronate vs intranasal spray calcitonin (effect on bone markers). 1999, J Bone Min Res 14;suppl 1:# SA 364, S399.

 13) Rosen CJ, Bonnick SL, Miller PD, McClung MR, Wasnich RD, Weiss SR, Woodson GC, Schnitzer TJ, Lenihan JP, Ross RP, Wang L, Smith ME, Gormley GJ, Melton, ME., Treatment of osteoporosis in postmenopausal women: alendronate vs intranasal spray calcitonin (effect on BMD) 1999, J Bone Min Res 14;suppl 1:# S365, S400.

 14) Fogelman I, Moreland L, Woodson G, Mellstrom D, Boling E, Riskin W, Strauss D, Stevens K, Manhart M., Gastrointestinal side effects and endoscopic findings similar between risedronate and placebo-treated patients.  2000 Osteoporosis International (Suppl 2)1179;459

 15) Woodson G., Once Weekly Risedronate Therapy. 2000, Osteoporosis International (suppl 2)s204, 550

 16) Hooper M, Hanley D, Eastell R, Boling B, Ribot C, Woodson G, Barton I., Sustained Effect of Risedronate in the Prevention of the First Vertebral Fracture in Women.   2000, J Bone Min Res  (suppl 1) su400, S438

 17) Woodson, GC., T-score concordance and discordance between the hip and spine measurement sites.  J. Clinical Densitometry, 2000;3:319-324.

 18) Miller P, Woodson GC, Licata AA, Ettinger MP, Mako B, Smith ME, Wang L, Yates J, Melton ME, Pamisano JJ,. Rechallange of patients who had discontinued alendronate therapy because of upper gastrointestinal symptoms. 2000, Clinical Therapeutics 22;1433-1422.

 19) WoodsonGC., Liao Y,.  A Case Control Study of Osteoporosis in Postmenopausal African American Women: Risk Factors, Bone Density, and Fractures.  2002, (In Press)

  COPYRIGHT 1991-2002 By Grattan C. Woodson, M.D., FACP