Corticosteroid-Induced Osteoporosis

Symptoms

Because this type of osteoporosis can start quickly after a patient begins taking the drugs, it is better to measure bone density levels and monitor them regularly than wait until the patient starts having frequent fractures.

Causes and Risk Factors

The body's ability to produce strong, dense bones is a juggling act between natural processes that build up bone and ones that break it down. Corticosteroids tend to both reduce the body's ability to absorb calcium and increase how fast bone is broken down. The more of these drugs you take and the longer you take them, the greater your risk of developing osteoporosis.

Diagnosis

The best way to diagnose osteoporosis is to use dual energy X-ray absorptimetry (DEXA), (a special scan to measure bone density) when treatment with corticosteroids starts. One year later, a second test should be done to see if significant losses of bone density have occurred. Monitoring bone density levels should be ongoing while the patient is taking corticosteroids.

Treatment

Persons with low bone mass, postmenopausal women who are not taking estrogen and others at high risk for osteoporosis should be identified before being given corticosteroid drugs. To lessen the risk of this condition, a patient should use the lowest possible dose for the shortest possible time or switch to a non-corticosteroid drug, if medically advised. The same treatments used for osteoporosis should be applied in the case of corticosteroid-induced osteoporosis.

Hormone replacement therapy (HRT) is often used to prevent osteoporosis in women. HRT does have side effects, including an increased risk of blood clots and gallbladder and heart diseases. Taking HRT as a combination therapy - estrogen with medroxyprogesterone acetate (such as Prempro) - for several years or more may increase your risk of breast cancer. All combination HRT regimens can cause patchy vaginal bleeding, particularly during the first year of use. More study is needed to learn if estrogen-only therapy increases the risk of breast cancer. The long-term benefits of HRT are, therefore, under intense study.

If HRT isn't for you, other prescription drugs can help slow bone loss and may even increase bone density over time. They include:

• Bisphosphonates. These can reduce bone breakdown, preserve bone mass and even increase bone density in the spine and hip. The best known of these drugs is alendronate (Fosamax). Studies show it may cut the risk of hip and spine fractures in half. Etidronate (Didronel) is also sometimes given to help prevent bone loss.
• Raloxifene. This imitates estrogen's good effects on bone density, without some of the increased cancer risks. Hot flashes are a common side effect. You shouldn't use this drug if you have a history of blood clots.
• Calcitonin. Produced by the thyroid gland, calcitonin may slow bone loss and prevent spine fractures, but not hip fractures. It's given as a nasal spray, and about 12% of those who use it develop nasal irritation. It is usually given to those who are at high risk of fracture but cannot take estrogen or bisphosphonates.
• Tamoxifen, a synthetic hormone used to treat breast cancer. Although it blocks estrogen's effect on breast tissue, it has an estrogen-like effect on other cells, including bone cells. It may have serious side effects.
• Statins. Ordinarily this class of drugs is used to lower cholesterol levels, but some studies have shown that women who take statin drugs for at least a year may also lower their risk of bone fractures. Because research is ongoing, the drugs are not routinely given for osteoporosis. Side effects include potential reversible liver damage and, rarely, muscle inflammation.

Prevention

Preventing bone density loss is helpful no matter what your age or condition:

• Get enough calcium and vitamin D. Premenopausal women and postmenopausal women on HRT should have at least 1,200 milligrams (mgs) of calcium and 400 international units (IU) of vitamin D every day. Postmenopausal women not on HRT and those at risk of getting osteoporosis from taking steroids should get 1,500 mgs of calcium and 800 IU of vitamin D daily. Men under age 65 should consume 1,000 mgs of calcium every day and men over age 65, 1,500 mgs. Good sources of calcium include milk; low-fat plain yogurt; Swiss, cheddar and ricotta cheese; broccoli; canned salmon with the bones; orange juice and tofu. If you find it hard to get this much calcium from your diet, try calcium supplements.
• Exercise, which helps build strong bones and slow bone loss. It is helpful no matter when you begin, but it has the greatest benefits when you start young and do it throughout your life. Strength training lets you build the muscles and bones in your arms and upper spine. Weight-bearing exercise (walking, jogging, running, stair climbing, skipping rope, skiing and impact-producing sports) helps the bones in your legs, hips and lower spine.
• Don't smoke. Smoking speeds bone loss, perhaps by lowering how much estrogen a woman's body makes and by reducing the calcium absorbed by the intestine.
• Consider HRT. HRT is the best way to reduce a woman's risk of osteoporosis during and after menopause.
• Avoid drinking too much alcohol. Having more than two alcoholic drinks a day may cut bone formation and the body's ability to absorb calcium. There's no clear link between limited alcohol intake and osteoporosis.
• Limit caffeine.

If you already have osteoporosis, you may also want to consider the following:

• Maintain good posture. Keep your head held high, chin in, shoulders back, upper back flat and lower back arched to avoid stress on your spine. When you sit or drive, put a rolled towel in the small of your back. Don't lean over while reading or doing handwork. When lifting, bend at your knees, not your waist. Lift with your legs, keeping your upper back straight.
• Prevent falls. Wear low-heeled shoes with nonslip soles, and check your house for electrical cords, throw rugs and slippery surfaces that might cause you to trip or fall.
• Manage pain. Discuss pain management with your doctor. Don't ignore chronic pain. Left untreated, it can limit your mobility and cause even more pain.

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