Did You Know That Certain Medications You Take Can Cause Osteoporosis, Fractures or Bone Loss?

This could be a wake-up call to action!

Glucocorticoids  or steroid medications taken for many medical conditions to help you feel better, can end up creating a serious bone fracture and disease problem for many adults. The question to ask yourself, and your family doctor or rheumatologist is, “Am I exchanging one problem for another?”

What are glucocorticoids, and why does my doctor prescribe them, if they lead to bone fractures and osteoporosis?  Your body has naturally-occurring glucocorticoids, or steroid hormones, that have many important functions. They help to interrupt or suppress inflammation, help your body respond to stress, and regulate how your body uses fat and sugar.

Many health problems involve inflammation, and if your body’s natural glucocorticoids are not performing well, drug assistance may be indicated. Glucocorticoid drugs are man-made, or synthetic versions of natural glucocorticoids, and can help suppress inflammation from autoimmune reactions, reducing pain, swelling, cramping, and itching. They are prescribed to treat autoimmune diseases like arthritis, rheumatoid arthritis or lupus; skin conditions like psoriasis or eczema; allergic reactions; breathing disorders like COPD and asthma; inflammatory bowel disease like Crohn’s or ulcerative colitis; various cancers, multiple sclerosis; surgery recovery, or sepsis. These drugs are effective in stopping damaging inflammation, but are more potent than the naturally occurring steroids and can cause serious damage.

According to the January 2, 2019 New England Journal of Medicine (NEJM), approximately 1% of all adults and 3% of adults older than 50 years of age receive glucocorticoids for allergies, inflammatory conditions, or cancer. Long-term use of glucocorticoids is associated with clinically significant toxic effects. Fracture, followed by diabetes, is the most common serious and preventable adverse event associated with these agents. The risk of fracture increases with age and with the dose and duration of glucocorticoid use. Here are the facts.

Vertebral fractures are the most common fractures associated with glucocorticoids; the risk of vertebral fracture increases within 3 months after initiation of treatment and peaks at 12 months. The relative risk of clinically diagnosed vertebral fracture doubles and the risk of hip fracture increases by approximately 50% among patients who receive 2.5 to 7.5 mg of prednisolone daily. In a study with a follow-up of 6 months to 10 years, glucocorticoids taken at very high doses significantly increased the risk of vertebral fractures.

Glucocorticoids have direct and indirect effects on bone remodeling. Bone loss can lead to an early increased risk of fracture and osteoporosis. Bone formation also decreases early in glucocorticoid treatment. Indirect glucocorticoid effects predispose patients to reduced muscle mass leading to an increased risk of falls, decreases in renal calcium resorption and levels of sex hormones, and alterations in parathyroid hormone functioning.

The risk of fracture rapidly decreases when glucocorticoids are discontinued. A prospective study showed clinically significant improvement in bone mineral density at the lumbar spine within 6 months after discontinuation of glucocorticoids. A large retrospective study showed an increased risk of a major osteoporotic fracture among patients with recent prolonged glucocorticoid use but not among those with intermittent or past use of these drugs.

What you need to know from this NEJM Report

  • Risk factors for glucocorticoid-induced fractures include age (>55 years), female sex, white race, and long-term use of prednisone at a dose of more than 7.5 mg per day.
  • Screening for fracture risk should be performed soon after the initiation of glucocorticoid treatment. The risk of fracture among patients who are 40 years of age or older can be estimated with the use of bone mineral density testing and the fracture risk assessment tool (FRAX).
  • Patients who receive glucocorticoids should be counseled about adequate intake of calcium and vitamin D, weight-bearing exercise, and avoidance of smoking and excessive alcohol intake.
  • Pharmacologic treatment is strongly recommended for anyone who has had a fracture and for patients who are at least 40 years of age if, according to the FRAX tool, the risk of major osteoporotic fracture is 20% or higher or the risk of hip fracture is at least 3%. Among patients who are receiving glucocorticoids and have a bone mineral density T score of −2.5 or less (indicating osteoporosis) at either the spine or the femoral neck, pharmacologic treatment is also recommended for men who are 50 years of age or older and for postmenopausal women.
  • Bisphosphonates (i.e. Fosamax, Actonel) are recommended as first-line treatment of osteoporosis because of their low cost and safety.
  • The risk of fracture decreases rapidly when glucocorticoids are discontinued. Exposure to glucocorticoids should be minimized as much as possible.

Non-drug options that can help (with or without taking glucocorticoids) bone loss, osteoporosis and fractures

  • Weight-bearing exercise, maintenance of normal weight, smoking cessation, limitation of alcohol consumption, and the assessment and management of fall risks.
  • Calcium and Vitamin D: Adequate dietary intake of 1,000 mg calcium per day and 600-800 IU of vitamin D (600 to 800 IU) is routinely encouraged in patients who receive glucocorticoids.
  • Bisphosphonates increase bone mineral density, help strengthen bone preventing further weakness, and slow down further bone loss.

Be an informed consumer! Talk to your doctor about glucocorticoid drugs that include beclomethasone, betamethasone, budesonide, cortisone, dexamethasone, hydrocortisone, methylprednisolone, prednisolone, prednisone and triamcinolone.

Make every effort to reduce your chance of disabling osteoporosis, fractures and bone loss. Discuss all medication and potential side effects with your primary care doctor, rheumatologist, and/or endocrinologist and together, make the best choices for your overall health and well-being.







Don’t Let Arthritis Stop You from Enjoying Sex

This original story, seen here, can now be seen on philly.com 1/4/19 as a Health & Science, Q&A column,  and in the Philadelphia Inquirer, Health & Science, Sunday 1/6/19.

“Doc, I’m having trouble at home. You know…?” Not a great conversation starter in an office visit with a rheumatologist, but common to hear from patients suffering arthritis.

According to health.clevelandclinic.org, patients with various forms of arthritis talk about how it affects their feelings of sexuality and their sex lives. Close intimate, sexual relationships are part of a healthy, quality of life. Working on achieving that might take a little extra work, but the benefits are worth it!

Arthritis sufferers say the following issues affect the quality of their sexual identity and sex lives: pain, exhaustion, fatigue or decreased endurance, loss of self-esteem and feelings of sexual attractiveness, decreased sexual desire and satisfaction, difficulty with sexual arousal, decreased sensation, erectile dysfunction or impotence, vaginal dryness, extreme sensitivity to touch, limitation of movement/flexibility, effects of surgery, depression, and side effects from medication.

Inflammatory arthritis is a group of diseases characterized by inflammation of the joints and tissues, and include rheumatoid arthritis, psoriatic arthritis, lupus and ankylosing spondylitis.

How do these conditions affect sex and relationships? Inflammatory arthritis can cause joints to be tender or painful, and when it hurts to move, sex feels like the last thing on your mind or agenda. Swollen or misshapen joints or weight gain can make you feel older, and less attractive and confident. Offshoot immune disorders like Sjögren’s syndrome, can decrease women’s lubrication. Often men’s’ penile blood vessels are affected, causing arousal and erectile dysfunction. So, who wouldn’t be depressed from all of this, which can then further exacerbate the problems?

There’s hope. We’re bringing sexy back.

Having sex can help your pain and your brain! Pleasurable touching and sex releases those blessed endorphins that bathe your brain in happy feelings, and holistically lubricate parts of your body. We’re not kidding!

There is no sex czar to make arthritis complications disappear, nor one magic bullet. But here are some RECOMMENDATIONS AND OPTIONS that can help.

  • Boost open and honest communication; allow yourself to be more vulnerable about fears, sexual needs, desires and difficulties
  • Accept change; we’re all in process at every age!
  • Plan ahead: Take medication or muscle relaxants beforehand, nap with a heating pad, take a warm shower or relaxing hot bath, use an electric blanket to relieve joint stiffness and add more pillows
  • Connect: Hug, kiss, cuddle, massage
  • Be spontaneous; there are more times than bedtime when you are naturally more tired
  • For improved intimacy – more kissing, and experiment with new positions, oral or manual stimulation, visuals, lubricants and sex aid devices
  • Make sure to stay active with exercise to increase stamina, strengthen muscles and improve range of motion
  • Recognize and address any depression and sadness; seek professional help
  • Following joint replacement surgery, discuss recovery and safe positions for sexual activity, with your doctor

Sex and all forms of arthritis can coexist. It’s the journey and destination to achieve satisfaction, happiness and peace in your life, so GO FOR IT!

A Main Line Rheumatology Patient With Rheumatoid Arthritis Runs Her Own Race

Rheumatoid arthritis can be a miserable disease for the millions of people who suffer from it.  Patients live with pain, stiffness and disability which can last for many years.  As rheumatologists, we always rejoice for those who manage to overcome the inherent difficulties living with a chronic illness.  Most of us would probably hang our heads and suffer the outrageous bad fortune, while a few others manage to rise above it.

A hero in rheumatology, and his face graces the cover of a standard text book of rheumatology, is the famous French painter, Pierre Auguste Renoir.  Renoir, as most know, had a unique impressionistic painting style beloved around the world.  His luscious paintings of his female models might suggest that the painter was some kind of Don Juan with a paintbrush.  The reality is that Renoir suffered, and was crippled by rheumatoid arthritis (RA).  He had to be physically carried on a chair, transferred from room to room.  Paintbrushes were either pushed into his hand and fingers, or taped to the back of his hands.  Renoir lived at a time when there was precious little medication to take for his pain and inflammation, other than narcotics, yet he managed to find the determination and will to overcome the enormous difficulties he suffered.

Every rheumatology practice has their own “Renoirs” and the doctors at Main Line Rheumatology are privileged to have a few.  One such patient is Susan M. She is a   52-year-old nurse who has rheumatoid arthritis (RA) that required ankle fusion, and elbows that do not bend much, which is a major factor as she enjoys running as a hobby and sport.  Her life has been further complicated by breast cancer.  In spite of these significant physical roadblocks, Susan M. runs marathons!  Not only does she run marathons, but she runs fast enough to have qualified for the Boston Marathon in April, 2019.  Given the number of runners to attempt to qualify for this 26-mile race, this was no small accomplishment.

Susan M. comes to Main Line Rheumatology for infusions of the drug, rituximab, under the care of our outstanding nurse practitioner, Cheryl Wieczorek.  Under Cheryl’s attentive care, Susan M. continues to do reasonably well controlling the inflammatory part of her RA.  The mechanical issues, including her elbow and fused ankle, cannot be helped by any medication, but Susan M. perseveres, nonetheless. Grit and determination come from deep within her determined, athletic and competitive spirit; she is a role model for many, and a marvel to observe and experience.  As her health partners and advocates, we are proud of her accomplishments.  Good luck in April, Susan M.!  In our estimation, you’ve already won the race.

Men and Osteoporosis. It’s Real, and Might Affect You!

To all men over age 50: At your next annual physical checkup visit, ask your doctor to check your height. If you have lost about one inch or more in the past year, you may have male osteoporosis, and is a very noticeable sign.

Osteoporosis is not just a “woman’s disease”. Although osteoporosis is typically associated with women, it is also diagnosed in men who account for an estimated one in five Americans who have osteoporosis. It is the major cause of fractures in the older population, where bones become thin and brittle, and as a result become weaker and more fragile. Women traditionally experience bone and spine issues after menopause and receive a confirmed diagnosis with a Dexa (bone) scan. However, men are normally not screened for osteoporosis, and don’t learn they have the condition until they experience a fracture. People who have rheumatoid arthritis or who smoke, consume more than three alcoholic drinks a day, have had prolonged prednisone treatment or previously experienced a fracture from only minimal impact should talk to their doctor about starting screening earlier.

Be proactive and don’t wait until you experience pain or height loss, before seeking help. Here are some questions to ask yourself.

  • Have I broken a bone since age 50?
  • Do I have a family history (female or male) of osteoporosis?
  • Do I appear shorter, or have a change in posture?
  • Do I have low levels of testosterone?
  • Do I consume more than three alcoholic drinks every day?
  • Have I had any prolonged steroid treatment?

According to a recent article published by the National Institutes of Health (NIH) Osteoporosis and Related Bone Diseases National Resource Center, here is important osteoporosis information for men.

Risk factors linked to osteoporosis in men:

  • Chronic diseases affecting the lungs, kidneys, stomach and intestines, or altered hormone levels
  • Undiagnosed low levels of testosterone
  • Unhealthy lifestyle habits including smoking, excessive alcohol use, low calcium intake, and inadequate physical exercise
  • Age: Risk increases with age
  • Heredity: A son is almost four times as likely to have low bone mineral density (BMD) if his father has low BMD; nearly 8 times as likely if both parents have it
  • Race: All men can develop the disease but Caucasian men at high risk

Osteoporosis can be effectively treated if detected before significant bone loss has occurred. A medical work-up to diagnose osteoporosis includes a complete medical history, x-rays, and urine and blood tests. The doctor may also order a BMD (bone mineral density of DEXA scan) test, which can be used to detect low bone density, predict the risk for future fractures, diagnose osteoporosis and monitor the effectiveness of treatments.

Primary and Secondary Osteoporosis
There are two types of osteoporosis: primary and secondary. Primary osteoporosis is either caused by age-related bone loss (men age 70, and over), or have an unknown cause.

At least half of men with osteoporosis have at least one secondary cause (sometimes more). In cases of secondary osteoporosis, the loss of bone mass is caused by lifestyle behaviors, diseases or medications. The most common causes of secondary osteoporosis in men include exposure to glucocorticoid medication, hypogonadism (low levels of testosterone), alcohol abuse, smoking, gastrointestinal disease, hypercalciuria and immobilization.

Causes of Secondary Osteoporosis in Men

  • Glucocorticoid excess (Asthma and rheumatoid arthritis medications)
  • Immunosuppressive drugs
  • Hypogonadism (Low testosterone levels)
  • Alcohol abuse
  • Smoking
  • Chronic obstructive pulmonary disease and asthma (COPD)
  • Cystic fibrosis
  • Gastrointestinal disease
  • Hypercalciuria (Loss of too much calcium)
  • Anticonvulsant medications
  • Thyrotoxicosis (Excess thyroid hormone)
  • Hyperparathyroidism (Enlarged parathyroid glands)
  • Immobilization (Prolonged bed rest or immobilization)
  • Osteogenesis imperfecta (Genetic disorder called “Brittle bone disease”)
  • Homocystinuria (Metabolism disorder)
  • Neoplastic disease (Benign or malignant tumor growth)
  • Ankylosing spondylitis and rheumatoid arthritis
  • Systemic mastocytosis (Accumulated mast cells in organs)

What You Can Do!
Make an appointment with your rheumatologist or endocrinologist for an evaluation and diagnosis. It’s your continued committed partnership in treating your osteoporosis.

Osteoporosis management includes eating foods high in calcium (i.e. dairy products) and taking vitamin D (1,000 mg daily for men age 50-70; 1,200 mg over age 71), regular weight-bearing exercise, no smoking, limitation of alcohol and caffeine consumption, and fall-prevention.


Main Line Rheumatology News

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Can Stem Cells Regenerate Damaged Cartilage in Osteoporosis?

If you have arthritis, you know about the term “bone on bone”. We tell patients that you cannot grow new cartilage once it is destroyed, whether from over or repetitive use, the natural aging process, or injury. Stories about stem therapy being used to treat osteoarthritis, an aggressive degenerative form of arthritis, are popular on the internet. But, can stem cells regenerate damaged cartilage with this disease? Maybe one day we can be cautiously optimistic, but for today, I am still skeptical.

Our understanding is that stem cells are the building blocks of all human tissue. Arthritis, or joint degeneration, is due to loss of the cartilage that cushions bones and the stem cell goal is to treat arthritis to regrow cartilage.

Stem cells that come from your own body and are harvested through a medical scientific procedure, are then injected back into your body (stem cell therapy) in a desired location, addressing a specific medical condition, movement or pain problem. A newborn baby’s umbilical cord is rich in natural stem cells, and there has been a movement over the last 5-10 years to freeze and save these stem cells for that baby’s (or natural family member) possible health needs.

The human body is a remarkable repair machine. Skin can regenerate, and a small piece of liver transplanted in a human body, grows miraculously to accommodate the body’s needs. But damaged cartilage causing osteoarthritis, does not naturally regenerate. Making degenerated and damaged bones and joints “almost good as new” is more often than not, only the outcome of surgery.

Dr. Shane Shapiro, at the Mayo Clinic Orthopedic Surgery and Center for Regenerative Medicine, published an article in May, 2018 describing how efforts and studies in stem cell regenerative medicine could treat degenerative conditions such as osteoarthritis, changing the course of orthopedic surgery over the coming years. Although research and studies show promise, stem cell treatment for arthritis is not widely available at this time, as is still being researched.

When discussing stem cell therapy, it’s important to understand that pure stem cells are not currently available to U.S. patients outside of a clinical research study. Stem cell therapies currently used outside clinical studies do not contain pure stem cells; they are a mix of a variety of cells with only a very small percentage, stem cells.

A handful of clinical research trials, monitored by the U.S. Food and Drug Administration (FDA), are ongoing at this time to study stem cell treatment for arthritis. The early findings are encouraging for the future. Many stem cell therapies now marketed to patients are conducted without a required FDA biologics license. Also, some forms of stem cell therapies are mislabeled, and do not contain actual living stem cells. These practices cause concern among rheumatologists as these treatments may mislead, or even harm the public.

Research into stem cells and arthritis shows that there are opportunities for stem cell treatment resulting mostly in pain relief and improvement in function, or quality of life. But only a few limited early studies have demonstrated improvement in new cartilage   or bone formation needed to cure arthritis, so I am skeptical. Exactly how that cartilage regrowth occurs, or even how pain relief is achieved, is still unknown.

To conclude, here is my opinion. Stem cell therapy, particularly with fetal stem cells, offers great promise for many diseases, including regenerating the damaged cartilage of osteoarthritis. Free standing stem cell clinics that offer treatment, giving you back a few of your mature stem cells for a high cost. As a cautionary tale, The New York Times reported, October 15, 2018, that Harvard University is retracting data that had implied that stem cells had improved cardiac function, when stem cells were placed in the heart. The odds of success currently are minimal, and insurance does not cover this expensive procedure. The “Religious Right” has prevailed upon the last three administrations to toss umbilical cords into the trash instead of utilizing them to save or improve lives. We hope this will change one day, or maybe other countries can lead the way.