Osteoporosis Update 2017

Osteoporosis Update
New information continues to emerge in helping us to decide the best treatment for osteoporosis. We still encourage weight-bearing exercise, smoking cessation and moderation in alcohol intake. Vitamin D supplementation (when vitamin D levels are low) is helpful. Taking calcium in foods high in calcium such as dairy products is desirable, but supplementation with calcium pills can be done on a more limited basis than in the past. 600 mg of supplemental calcium is probably as much as should be taken. In patients who have a history of kidney stones, that can be a problem. 

Medications fall in two major categories: antiresorptive medications including such drugs as Fosamax, Actonel, and Boniva along with Reclast given intravenously and. drugs such as Forteo and Tymlos,that stimulate new bone growth and are discussed below.

Reclast can be given for 3 years in a row and then should be stopped for at least 1 year. We tend to not use much Boniva in our practice, as the hip data for preserving bone with this drug is not impressive. We administer a lot of Prolia in our practice, an antiresorptive with a slightly different mechanism of action, than the previous drugs. This drug is given subcutaneously in the office, every 6 months. All of these drugs have extremely rare side effects including jaw necrosis and long bone fractures (i.e. in the femur). Of the thousands of patients whom we treat with osteoporosis, we have not seen these side effects in the last 13 years. Hopefully, we are more attentive to these potential problems, and have been able to avoid them.

The length of time one can be on Prolia is not entirely clear. Studies have demonstrated continued benefit from Prolia on bone structure, out to 10 years. There are studies showing that stopping Prolia may be accompanied by an increase in fractures in the year following Prolia cessation. Some experts advocate stopping Prolia after about 8 years, and using Reclast in its place for 1-2 years, since there is still the concern that prolonged use of Prolia, like the bisphosphonates (i.e. Fosamax) might be associated with long bone fractures. This probably seems confusing as there are reasons to continue Prolia, and for reasons to stop (even temporarily) while substituting a different drug option. Time, and more studies will settle this issue. In the meantime, a new bone building drug has been released, called Tymlos. Like Forteo, it is a daily injection. Unlike Forteo which is used for 24 months, Tymlos it is used for 18 months, and it does not need to be refrigerated. The pen which contains 30 injections, is a bit unwieldy compared to the Forteo pen; depending on the hand agility of the patient, ease of use could be an issue. These drugs are used when the anti-resorptive drugs fail, or if the patient has a fragility fracture (i.e. falling from a standing position) and results are encouraging. Patients who have had previous radiation (for cancer) generally cannot use Forteo or Tymlos, but exceptions are sometimes considered.

Pain Treatment

Pain Treatment
As rheumatologists, we see a steady stream of patients in pain. Some patients respond quite well to anti-inflammatory medicines, but unfortunately there is no perfect solution. Some patients have kidney disease, ulcer history or are on anti-coagulants and cannot tolerate these medications. After the drug, Darvocet, was taken off the market, the only non-narcotic drug remaining was Tylenol and Ultram (tramadol). Tramadol has since been reclassified as a controlled substance. It joined the narcotics, Tylenol with codeine, Vicodin, Percocet, dilaudid, Fentanyl patch and morphine sulfate as controlled substances.

For years, doctors were encouraged to treat pain; postoperative pain as well as pain related to malignancy. More than anything, this has led to our current opioid epidemic. Currently, more Americans die each year from drug overdoses than all the American soldiers killed in Viet-Nam, Iraq and Afghanistan, combined.

We are now in a major dilemma trying to alleviate pain without habituating our patients. In addition, it is no surprise that giving narcotics to the elderly is associated with an increase in hip and compression spine fractures.

We are desperate for solutions. Acupuncture can be helpful in the right hands. Anti-depressants can sometimes help control pain but can cause sedation, among other problems.

In Colorado and California, it is fairly easy to prescribe marijuana for pain. Medical marijuana can be made so that the “buzz” or high is not as severe as when marijuana is smoked, administered rather in pill form (i.e. Marinol). It may not be as powerful as many narcotics, but it is less addicting. Our understanding is that in Pennsylvania with some exceptions, marijuana is generally not approved unless the patient has vomiting resulting from chemotherapy administered for cancer. That limits the number of potential patients who could benefit significantly from marijuana treatment.

Given Harrisburg’s conservative bent, I doubt our elected officials are going to see the light in the near future. Trying to stop the influx of narcotics at the border is not a solution to the opioid epidemic. As is often the case, the patients get the short end.

AWARDS!

Main Line Rheumatology’s Gary V. Gordon, MD, FACP, FACR and Thomas Harder, MD have been named 2018 “Top Doctors” by Philadelphia Magazine and Main Line Today Magazine. Also Amy Lundholm, DO was named a 2018 “Top Doctor” by Main Line Today Magazine. 

Dr  Gordon was awarded “Top Doctor” by Philadelphia Magazine for years 2018, 2016, 2015 and 2014, and by Main Line Today Magazine for years 2018, 2017, 2016, 2015, 2014 and 2013.

Dr. Harder was awarded “Top Doctor” by Main Line Today Magazine for years 2018, 2017, 2016 and 2015.

 

 

 

 

Weight and Arthritis

It probably comes as no surprise that being overweight aggravates arthritis. Certainly, weight bearing joints such as the low back, hips and knees are aggravated by excess weight. However, all joints including upper body joints, are also impacted by fat. Fat stimulates Omega 6 which is contained in beef and fatty foods. Omega 6 is an inflammatory mediator, and since inflammation is at the core of arthritis and cardiovascular diseases, this presents a problem. For those reasons among others, rheumatologists advocate diets high in Omega 3s, such as fruit, vegetables, fish and tree nuts like walnuts and almonds. This diet is the mainstay of the Mediterranean Diet which has been critically tested and acclaimed, reported first in the New England Journal of Medicine.

For years, low fat diets have been popular. In addition to the Mediterranean type diets, we try to get patients to avoid sugar as much as possible. Refined sugar stimulates insulin which alters metabolism by storing fat, and making us hungry. Low fat diets usually translate into high carb diets, and in patients who are insulin resistant, weight gain is even more of a problem.  Simple diet changes like avoiding sugary beverages (i.e. Coke and Pepsi) can be accomplished with good results. 

The value of exercise seems fairly obvious, but there are complications in our understanding.  Average exercise burns about 400 calories an hour- that is about the same amount of calories as a single hamburger patty. Unless you are exercising several hours a day, it becomes clear that you still need to control caloric intake, and avoid eating a lot of processed foods. Unfortunately, food manufacturers employ food chemists who are constantly searching for foods with the right amount of sugar, fat and salt to stimulate the sugar receptors in your brain, and you become addicted. This combination works on the positive smell and “mouth feel”. It takes a lot of discipline to avoid foods perceived as “delicious” and highly caloric.

Exercise is very important for weight loss, and both weight lifting activities, as well as aerobic exercise, is vital. You need to perspire to help burn calories, and reduce some of that “belly” or midriff fat.

One of the latest advances in our understanding of what makes some people fat relates to our gut bacteria. Our bodies mostly live in harmony with billions of bacteria in our gut that help digest food.  There are at least 2 populations of bacteria. One set of bacteria can cause fattening, and the other is associated with leanness.  So does that mean we should have skinny bacteria transplanted into our guts?  Maybe, but there is one significant catch.  The skinny bacteria work only with a balanced diet. According to Jeffrey Gordon, director of the Center for Genome Sciences and Systems Biology at Washington University in St. Louis, the microbes associated with leanness only succeed with a diet high in fruit and vegetables, and low in saturated fats.  Proper nutrition and a healthy diet are optimum for good health and a healthy weight.

Vasculitis

When blood vessels become inflamed for any reason, it is called vasculitis. The diagnosis is usually insufficient, by itself. As rheumatologists, we have to determine which size vessels are involved and what part of the body, in addition to blood vessels are involved, as it makes a considerable difference in diagnosis and treatment. For example, when large blood vessels are involved, it could be giant cell or temporal arteritis. Typically patients may have scalp tenderness and difficulty chewing. One blood test that shows a sedimentation rate is typically, but not always elevated. If the diagnosis is considered at all likely, corticosteroids need to be started soon, and the temporal arteries need to be biopsied by a surgeon. Time is of the essence in this diagnosis, as blindness can (although rare) be a consequence. In addition, sometimes the aorta may be involved with vasculitis, and appropriate imaging studies can help determine the diagnosis.

Another type of vasculitis we see less of, formerly called Wegener’s granulomatosis, is now called granulomatosis with polyangitis (quite a mouthful) after it was discovered that Wegener was a Nazi. In this disease, patients may initially have sinus infections or cellulitis around their eyes. Subsequently, they may develop pneumonia and cough up blood. Joints can be involved, and kidney involvement can also be severe. Making the diagnosis can be very difficult. Blood studies (i.e. ANCA) can help, as can imaging studies of the sinuses and chest. Ultimately, biopsies are often necessary. Treatment entails high dose corticosteroids and Cytoxan. More recently we have had significant success with Rituxan, a drug rheumatologists  “borrowed” from hematologists. This drug was originally used for a type of lymphoma. We have found it to be quite successful in treating rheumatoid arthritis, and we now know it can make a considerable difference in stopping the disease progression, even reversing much of the disease process of granulomatosis with polyangiitis.

The most common type of vasculitis involves small blood vessels and can be caused by the use of medications. Usually stopping the offending medicine is sufficient, although corticosteroids may also be needed. Other diseases involving small blood vessels include Henoch-Schonlein purpura which may also present with abdominal pain, blood in the urine, and blotchy rashes on the legs. Steroids are often used in these cases as well.

Osteoarthritis

As we naturally age, osteoarthritis is the most common arthritis for sufferers. Unfortunately, many people can develop osteoarthritis at younger ages. Typically, trauma can be a major factor in causing cartilage to wear down in any part of the body. Loss of cartilage, particularly in a weight-bearing joint such as the low back, hip or knee, will be most painful. Wear and tear clearly play a role, but does not explain why we see osteoarthritis in the cervical spine, hands and shoulders. We do not know all the factors involved in causing cartilage to deteriorate, but there are some interesting drugs currently in research that may help prevent it.

Low back pain is most commonly associated with osteoarthritis, and virtually everybody gets it sooner or later. X-rays are usually not that helpful, unless the pain is particularly severe with radiation down one leg, or pain that keeps a person up at night. Compression fractures of the spine can be confused with osteoarthritis, but typically compression fractures are more localized and more acute, in onset. MRIs show the surgeon or the anesthesiologist conducting an epidural, where the problem is located. Fortunately, very few people need back surgery for osteoarthritis and its associated problem of spinal stenosis. In spinal stenosis, bone spurs grow around the exiting nerve roots or the spinal cord, causing pressure on the nerve which can be painful and cause weakness in the legs.

For most people, therapy, including muscle strengthening exercises for the back and intermittent use of either muscle relaxers or anti-inflammatory drugs, can be helpful. The role of manipulation is difficult to quantify, but may be helpful in some instances, as well.

Occasional injections of corticosteroids or  visco-supplementation drugs, such as Synvisc or Orthovisc, can be helpful for the knee, delaying surgery. Muscle strengthening exercises and weight reduction are part of the treatment, as well. Nonsteroidal anti-inflammatory medication can be helpful but cannot be used in people who have pre-existing kidney disease, a history of peptic ulcers, or true aspirin allergies.

There are now 1-million total hips and joints implanted every year in the United States. When all else fails, joint replacement in the appropriate patient can make a significant difference in their quality of life  

The role of the rheumatologist is to guide patients through the tortuous course of therapeutic options to get appropriate relief.

Lupus

Systemic lupus erythematosus is the classic “autoimmune disease”. The cause is still unknown but genetic factors play a significant role. For reasons not yet understood, the immune system in lupus patients perceives some of the body as being foreign, attempting rejection.The immune system is stimulated, which reacts against many body parts including the lining of joints, heart and lungs. Skin is often involved, as well as parts of the central nervous system. Kidney involvement can be severe but fortunately strong medications are available to help prevent otherwise, serious deterioration.

Anyone can be affected with lupus, although it is typically more common in African American women of childbearing age. The presentation can be mysterious as lupus can involve so many different parts of the body. Patients may have unexplained fevers or rashes, and bruise easily due to low platelet counts (clotting factors). Patients can present with joint inflammation which may look like rheumatoid arthritis or chest pain, which can masquerade as a heart attack. As in so many diseases, having a high index of suspicion leads to getting the right blood tests to rule out or confirm a lupus diagnosis.

Lupus often requires physicians from different specialties to be involved; nephrologists need to carefully follow the kidney involvement. Sometimes early intervention prevents lupus kidney disease from advancing. On the other hand, patients who have received kidney transplants are doing generally well.

Prednisone is one of the medications used to treat lupus.This drug is a double-edged sword as it can be lifesaving but at the same time, can cause significant side effects including weight gain, diabetes, and compression fractures. Another drug used more for  skin and joint involvement, is Plaquenil. For severe kidney involvement, drugs such as CellCept and Cytoxan, can be quite helpful. In the last few years, a new intravenous drug, Benlysta, was FDA-approved. This was the first new FDA-approved lupus drug in 50 years and appears to be more helpful in the non-kidney aspects of lupus. The intention is that all these drugs may allow medical practitioners to manage lupus with a lower level of prednisone.

Osteoporosis

Osteoporosis has become the most common medical problem that rheumatologists treat. Although it is more common in women, men over the age of 65 can develop osteoporosis at almost the same rate as women. Risk factors include use of corticosteroids, smoking, lack of exercise, being underweight (yes, you can actually be too thin!) inadequate calcium and vitamin D intake, and a history of previous fractures. Blood tests tend to be somewhat unreliable. We depend on DEXA bone density tests, which also have their shortcomings. However, a DEXA scan is relatively  inexpensive, with less radiation than a chest x-ray.

The benefits and risks of the available drugs for osteoporosis are often in the news. Most  medications slow down the breakdown of old bone, and are effective. Long-term use has potential hazards  (i.e. mid-femur fractures) and rheumatologists currently limit treatment with any one of these drugs, to 5 years. On the other hand, there is ample data to indicate the bisphosphonates prevent many more fractures than they cause.  An alternative medication such as Denosumab (Prolia) is given as an injection every 6 months. It also works by slowing down the breakdown of old bone. Forteo is currently the only drug which builds new bone and is given as a daily injection for 2 years. It cannot be given to patients who have had previous radiation therapy for cancer. Newer drugs are a few years from being available.

Supplemental calcium (i.e. Citracal, Caltrate) for osteoporosis is somewhat controversial. Previous recommendations were to take 1000-1500 mg/day, but there have been recent studies which imply that too much supplemental calcium intake, besides increasing the risk of kidney stones, may be a cardiac risk.  These studies have some flaws, and opinions may change as we learn more.  Foods that are high in calcium, such as dairy products, anchovies, and kale are a better choice over supplements.

Gout treatment

Gout, once considered the disease of the rich (as they over-consumed foie gras, washed down with port wine) is a commonly seen rheumatologic problem today. Any joint can be involved, in addition to the classic big toe pain in the middle of the night. There are genetic factors, but the most common risk factors are diuretics which raise levels of uric acid. Other risk factors include alcohol, beef, organ meat and sometimes, shellfish. Diagnosis often requires aspirating fluid from a joint to analyze if urate crystals are present. It takes an experienced doctor to identify these crystals under a polarizing microscope.  Having an elevated uric acid by itself, does not necessarily confirm a diagnosis.

Treatment requires addressing the acute inflammation, either with an injection of cortisone, prednisone or an anti-flammatory medication by mouth. The drug, Colchicine, has been used for hundreds of years, but unfortunately, the cost rose dramatically  when the FDA unfortunately gave exclusive rights to its production to one drug company. After inflammation subsides, decisions are made whether or not long-term therapy (drugs) is indicated to prevent bone destruction and kidney stones; these drugs include allopurinol or febuxistat (Uloric). One size does not fit all and the timing and dosage of these medications need individual attention with a treatment plan.  Newer drugs are being developed as well for more severe types of gout.

Treatment of rheumatoid arthritis

Rheumatoid arthritis remains a crippling illness to treat, but new medications are making significant inroads into what used to be a crippling illness for almost everyone given his diagnosis. It has been 20 years since the advent of biologic drugs, starting with Enbrel and Remicaide. There are now more than 9 drugs which can help stop the disease and prevent further bone destruction. A new oral medication was released a few years ago, and rheumatologists are still sorting out the order of which medications work best for which aspect of rheumatoid arthritis, as well as psoriasis, psoriatic arthritis and ankylosing spondylitis. In addition, off label studies with these drugs show promise for other diseases such as sarcoid, reactive arthritis and polymyositis, among others. Drug side effects include infection and anyone who has seen TV drug commercials knows that although the list of side effects is long, infection is the greatest concern in 3-4% of patients. Nevertheless, there is not much more gratification than seeing a patient who previously could hardly move before starting these medications, regain their ability to work and enjoy life, again.