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Osteoporosis—A Silent Disease

Duquesne UniversityMylan School of Pharmacy

March-April 2003

UPDATEfrom thePharmacy CareAwarenessProgram

All events take place in the Center forPharmacy Practice, Room 432 Mellon Hall,unless otherwise stated.

MARCH – National Poison Prevention Month• March 12, 2003, 11:30 a.m.-12:30 p.m.

Blood Pressure Check-Up

• March 19, 2003, 12:00-12:50 p.m.“Osteoporosis: Are You At Risk?” Christine O’Neil, Pharm.D.

• March 26, 2003, 11:30 a.m.-12:30 p.m.Blood Pressure Check-Up

APRIL – Alcohol Awareness Month• April 2, 2003, 12:00 -12:50 p.m.

“Osteoporosis: How to Select a CalciumSupplement”

Did you know that one in every two women and one in eight men over 50 will have an osteoporosis-related fracture in their lifetime? Approxi mately 10 million U.S. individuals

have been diagnosed with osteoporosis, and18 million are at increased risk for the diseasedue to their low bone mass. Nearly 80 percentof these people are women. More than 1.5million fractures are attributed to osteoporosiseach year.

Osteoporosis is characterized by low bonemass and deterioration of bone tissue, both ofwhich increase the risk of various types offractures. Osteoporosis is often referred to asthe “silent disease” because bone loss occurswithout symptoms, until bones become sofrail that any abrupt strain, bump, or fall causesa fracture.

Bone tissue is constantly formed andremoved (resorption). Through the teenageyears, new bone is added faster than old bone isreplaced. Peak bone mass is reached aroundage 30, and shortly thereafter, resorption beginsto exceed bone formation. Osteoporosisdevelops when resorption progresses tooquickly or replacement occurs too slowly. The

most rapid bone loss occurs in the first fewyears following menopause, placing women at ahigher risk of developing the condition.

Body frame size, ethnicity, and family historyalso play a major role in the risk of developingthe disease. Small-framed women are morelikely to develop osteoporosis. Asian andCaucasian women are at highest risk, whileAfrican-American and Latino women have alower, but still significant, risk of osteoporosis.

Some risk factors can be controlled todecrease the chance of developing osteoporosis.A long-term diet low in calcium and vitamin Dalong with poor eating habits can contribute tolow bone mass, as well as smoking, excessivealcohol, and an inactive lifestyle. The use ofcertain medications such as glucocorticoidsmay have damaging effects on the skeleton.Other medications that may cause bone lossinclude anticonvulsants, methotrexate,cholestyramine, and cyclosporine. On theother hand, weight-bearing exercises can helpincrease bone density.

So how do you know if you are at risk ofosteoporosis? Your doctor may recommendthat you have your bone mass measured by abone mineral density (BMD) test. The “gold

standard” for the diagnosis of osteoporosis isthe central measurement of bone mass by aprocess known as dual X-ray absorptiometry(DXA). This safe and painless test can beperformed in the spine, wrist, hip, heel, orhand. By determining bone mass, the DXA canconfirm a diagnosis of osteoporosis, determinethe rate of bone loss, and predict chances offuture fracture.

For more information on osteoporosis, visitthe following Web sites:

• National Institutes of Healthhttp://www.osteo.org

• National Osteoporosis Foundationhttp://www.nof.org

• April 9, 2003, 8 a.m. -2 p.m.Lipid (Cholesterol) Screening – Call for an appointment (x1093)Blood Pressure Check-UpAlcohol Awareness Information Table Union-fourth floor

• April 23, 2003, 9 a.m. –noonOsteoporosis Risk AssessmentComplimentary Heel Ultrasound Screening – Call for an appointment (x1093)Blood Pressure Check-Up

MAY – National Osteoporosis Prevention Month!

The Role of Calcium in Osteoporosis

A publication of the Duquesne UniversityMylan School of Pharmacy

Pharmacy Care Awareness Program (PCAP)& Pharmaceutical Information Center (PIC)

Additional information on any of the topicsdiscussed may be obtained from thePharmaceutical Information Center by calling412-396-4600 or sending an e-mail topic@duq.edu.

Questions about screenings or programs:Christine O’Neil, Pharm.D, B.C.P.S.412-396-6417

03/03 1.5M DIH

Newsletter ContributorsJohn G. Lech, Pharm.D.

Christine O’Neil, Pharm.D.

Stacey L. Bergamasco, Pharm.D. Candidate

Conni M. McGrath, Pharm.D. Candidate

Treatment and Prevention

Calcium is essential for the maintenance of healthy bone. Table 1indicates the amount of calcium found in a variety of foods.

Depending on age, an appropriate calciumintake falls between 1000 and 1300 mg per day(Table 2). A calcium supplement may be usedif you are not getting enough calcium from thefoods you eat. Calcium supplements areavailable in a variety of salts such as calciumcarbonate, calcium citrate, etc. Each of theseproducts contains varying concentrations ofelemental calcium. They differ in the amountof calcium that may be absorbed as well aspotential adverse effects. In most individuals,calcium carbonate preparations such as OsCaland Tums are adequate. Patients withdecreased concentrations of gastric acid mayabsorb calcium less efficiently. People who takemedications that suppress gastric acidproduction such as Tagamet or Prilosec shouldpreferably take calcium citrate products. Also,those who experience gastric effects such asconstipation or bloating from calciumcarbonate preparations may better tolerate thecalcium citrate.

Vitamin D is necessary for optimal absorptionof calcium. Only about 20-30% of calcium isabsorbed when taken alone. A daily intake of 400and 800 IU of vitamin D is usually recommended.

A discussion of the drug treatment and prevention ofosteoporosis is included in the Duquesne Daily version ofthis newsletter. Please access the Duquesne Daily site foradditional information on this topic.

Visit www2.duq.edu/publicaffairs/news/news.cfm.

Table 2: Recommended Calcium Intake*

Ages Amount mg/day

Birth – 6 months 210

6 months – 1 year 270

1 – 3 years 500

4 – 8 years 800

9 – 13 years 1300

14 – 18 years 1300

19 – 30 years 1000

31 – 50 years 1000

51 – 70 years 1200

70 or older 1200

Pregnant and lactating

14 – 18 years 1300

19 – 50 years 1000*Based on guidelines from the National Osteoporosis Foundation

Table 1: Calcium Content of Some Foods*

Food Serving Size Calcium (mg)

Milk, skim 1 cup 302

Yogurt (low fat, fruit flavored) 8 ounces 300

Swiss cheese 1 ounce 272

Figs, dried 10 figs 269

Tofu, raw, firm ½ cup 258

Calcium-fortified cereals ¾ cup 250

Cheddar cheese 1 ounce 204

Calcium-fortified orange juice 6 ounces 200

Mozzarella cheese, part-skim 1 ounce 183

Collards, cooked from frozen ½ cup 179

American cheese, processed 1 ounce 174

Creamed cottage cheese 1 cup 126

Sardines, canned in oil 2 sardines 92

Parmesan cheese, grated 1 tablespoon 69

Mustard greens ½ cup 52

Kale, boiled ½ cup 47

Broccoli, boiled ½ cup 36*Adapted from: Treatment Guidelines from The Medical Letter. 2002;1:13-8.

Medications for the Treatment and Prevention of Osteoporosis

Management of osteoporosis

usually includes proper

nutrition and exercise along

with safety precautions to

prevent falls. Prescription

medications can also slow the rate of bone loss,

increase bone density, and reduce fracture risk.

Presently, medications classified chemically

as “bisphosphonates” (alendronate, risedronate,

zoledronic acid, and pamidronate), calcitonin,

estrogens, raloxifene, and parathyroid are

prescribed for the prevention and/or treatment

of osteoporosis. Bisphosphonates work by

decreasing bone resorption. As a result, new

bone formation continues and subsequently

increases bone density. Specific drugs in this

class include the oral formulations Fosamax

(alendronate) and Actonel (risedronate).

Common adverse effects of these agents

include abdominal pain, heartburn, and

irritation of the esophagus. The patient is

advised to take these medications on an empty

stomach, preferably first thing in the morning.

It is also important to take the drug with eight

ounces of water (no other liquid) at least 30

minutes before eating or drinking. Patients

must remain upright during this 30-minute

period to prevent damage of the esophagus.

Calcitonin is a naturally occurring

hormone involved in calcium regulation and

bone metabolism. In most women who are

more than five years past menopause,

calcitonin has been shown to slow bone loss,

increase spinal bone density, and relieve pain

associated with fractures. Calcitonin is

available as an injection or nasal spray; its

prescription name is Miacalcin. In the

injectable form, Miacalcin may cause flushing

of the face and nausea, whereas the nasal

preparation may cause rhinitis.

Estrogen Replacement Therapy (ERT)/

Hormone Replacement Therapy (HRT) has

been shown to increase bone density and

decrease fractures in postmenopausal women.

Side effects may include vaginal bleeding,

breast tenderness, and mood disturbances.

The Women’s Health Initiative (WHI) has

confirmed that synthetic HRT is associated

with a modest increase in the risk of breast

cancer, strokes, heart attacks, and blood clots.

Evista (raloxifene) is similar to estrogen in

terms of its effects on bone, but it is considered

an anti-estrogen on the uterus and breast.

Raloxifene has been shown to decrease the risk

of estrogen-dependent breast cancer by 65

percent over four years. Even though adverse

effects are not common, those reported include

hot flashes and deep vein thrombosis.

Parathyroid hormone increases bone

density by stimulating new bone formation.

Forteo (teriparatide) is a form of parathyroid

hormone recently approved by the FDA for the

treatment of osteoporosis in postmenopausal

women and in men who are at high risk for

fractures. This drug is self-administered as a

daily injection. Adverse effects may include

nausea, headache, dizziness, and leg cramps.

It is very important for men and women to

be aware of the common risk factors associated

with osteoporosis. Knowledge about the

disease and recognition of risk factors are two

methods to prevent osteoporosis or to slow its

progression. As discussed, there are many ways

to treat this disease. It is never too early or too

late to start your prevention program. Please

contact your physician or pharmacist if you

have any questions regarding osteoporosis or

the drugs used in its management.

In order to gain optimal

results from any of these

treatment options, they must be

taken with adequate calcium

(1000 mg-1500 mg/day)

and vitamin D

(400 IU-800 IU/day).