Risks to Bone Health in Treating Chronic Disease in Younger Patients; Secondary osteoporosis is a risk with celiac disease, cancer, reflux medicines and after bariatric surgery

Risks to Bone Health in Treating Chronic Disease in Younger Patients

Secondary osteoporosis is a risk with celiac disease, cancer, reflux medicines and after bariatric surgery

LAURA LANDRO

March 3, 2014 7:16 p.m. ET

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Osteoporosis, a loss of bone strength that raises the risk of fractures, is one of the most common and crippling ailments associated with aging in women. Increasingly, it is striking younger patients who have a host of other medical problems.

Researchers call it secondary osteoporosis. They are identifying a growing list of factors that contribute to bone deterioration, including chronic diseases and some of the powerful drugs used to treat them. Alone or in combination, disease and medication can interfere with the way the body naturally breaks down and rebuilds bone tissue, and how well it absorbs bone-building nutrients like calcium and Vitamin D.

Because there often are no symptoms as bone weakens, osteoporosis often hasn’t been diagnosed until a patient suffers a fractured bone.

Now, bone health experts are calling for greater efforts to identify patients earlier who are at risk for secondary osteoporosis, before their bones become more fragile and further raise their risk of injury and disability.

Recommended measures include bone mineral density scans for patients who wouldn’t ordinarily get routine screening, treatment of underlying diseases that contribute to bone loss, lifestyle changes and calcium and vitamin D supplements. Doctors also are prescribing osteoporosis medicines shown to slow bone loss or build new bone.

Secondary osteoporosis is increasingly being diagnosed in younger patients with cancer, celiac disease, rheumatoid arthritis and inflammatory bowel disease, as well as in people taking reflux medications, blood thinners and some depression drugs, researchers say. Patients are at risk of secondary osteoporosis after bariatric surgery for weight loss, as are those receiving hormonal treatments to prevent the recurrence of breast or prostate cancer.

Adverse effects of diabetes on bone health are starting to be recognized. Smoking, excessive alcohol use, eating disorders like anorexia nervosa and inactivity are also linked to declining bone mass.

Stages of Bone Strength

Bone mass may diminish with age and certain treatments for disease.

The balance of bone formation and lossbegins to change when people reach their early 20s. After that age, they may start to slowly lose more bone than they gain.

Osteopenia is the stage when bone mass or bone mineral density is lower than normal but not yet considered osteoporosis. Healthy diet, getting daily recommended amounts of calcium and vitamin D and regular exercise can help slow or stop bone mass loss and prevent fractures.

Osteoporosis is the stage of severe bone loss, when bones thin and lose structure. There is no cure, but osteoporosis medications may slow or stop progress of the disease. Studies suggest that among adults age 50 and older, about one in two women and up to one in four men will break a bone due to osteoporosis.

Source: National Osteoporosis Foundation

Anyone taking corticosteroids, such as prednisone, is at risk, according to the American College of Rheumatology. The drugs, prescribed to suppress inflammation in a wide range of illnesses and to prevent organ rejection after transplants, have a direct negative effect on bone cells and can interfere with the body’s handling of calcium.

According to the National Osteoporosis Foundation, nine million adults in the U.S. have osteoporosis and an additional 43 million have low bone mass, or osteopenia, which increases their risk of osteoporosis and broken bones. The foundation projects that by 2030, the number of adults over age 50 with osteoporosis and low bone mass will grow by more than 30% to 68 million.

Primary osteoporosis is most commonly caused by women’s loss of estrogen after menopause. Age-related bone loss affects men starting in their 70s.

Last year, a review by researchers at Loyola University Medical Center in Maywood, Ill., found secondary causes of bone loss are reported in up to 60% of men, more than 50% of premenopausal women and some 30% of postmenopausal women who are diagnosed with osteoporosis.

“When I find a younger patient with osteoporosis, there is likely to be a secondary cause, and if that cause isn’t treated, they will continue to lose bone even if they are on osteoporosis medications,” says Pauline M. Camacho, an endocrinologist at Loyola and co-author of the study.

Mary Ellen Fahey, who lives on Chicago’s South Side, was diagnosed with osteoporosis at the age of 50, 11 years ago. She had taken the drug prednisone for five years in her 20s for severe asthma; although bones can recover after steroids are stopped, the drug may have been a contributing factor.

Her doctor prescribed a bone-building oral drug in the class known as bisphosphonates—alendronate, sold under the brand name Fosamax. Ms. Fahey began seeing Dr. Camacho in 2000 and says the doctor was surprised to see her bone density was declining despite the medication. Mrs. Fahey’s blood tests indicated she had low levels of calcium and Vitamin D.

Further testing showed Mrs. Fahey had celiac disease, which involves inflammation in the lining of the small intestine because of a reaction with gluten found in wheat, barley and rye. The disease can prevent the absorption of nutrients such as calcium and Vitamin D, and it also was preventing Mrs. Fahey’s body from getting the benefits of her osteoporosis drug.

Ms. Fahey says she got her celiac disease under control with a gluten-free diet. In 2008 and 2009, Dr. Camacho prescribed a newer bisphosphonate, drug, Reclast, or zoledronic acid, given intravenously once a year. Then the doctor gave her a year-long break from medication, a recommended strategy because of risks associated with the drugs. In 2011, the doctor started Mrs. Fahey on a twice-yearly injection of Prolia, or denosumab, a biologic therapy approved in 2010 that inhibits bone loss and fracture risk.

Even though Mrs. Fahey maintained her bone density on the earlier drug, Dr. Camacho says the response to denosumab led to a larger increase in bone mineral density. Now 61, Mrs. Fahey says she takes Pilates and Zumba classes to stay in shape and help keep her bones strong.

“There are 100 different reasons you could have low bone density, and often it is difficult to say whether it is the disease itself or the treatment that is causing bone loss,” says Kenneth Saag, director of the Center for Education and Research on Therapeutics of Musculoskeletal Disorders at the University of Alabama at Birmingham.

“The good news is, if osteoporosis is identified early, the medications used to fight it in older women have been shown to improve bone density” in patients with secondary causes, Dr. Saag says.

If patients need to be on a high dose of steroids such as prednisone, and if they have developed osteopenia but haven’t yet progressed to osteoporosis, it may be advisable to prescribe a medicine that increases bone density to protect their bones from fracture, Dr. Saag says.

Doctors often have to make decisions that balance treatment of underlying diseases with bone health, says Andrea Singer, clinical director of the National Osteoporosis Foundation and chief of the division of women’s primary care at Medstar George Washington University Hospital in Washington, D.C. With reflux disease, for example, it may be possible to stop proton pump inhibitor drugs linked to bone loss and instead rely on alternative treatments and dietary changes.

A patient who has a severe gastrointestinal disease might have difficulty swallowing. If that patient develops osteoporosis, Dr. Singer might avoid oral medications in favor of an injectable drug.

Aromatase inhibitors, which are hormonal drugs used for breast cancer, can also cause bone loss. “If that is the best treatment for cancer to reduce risk of recurrence, then that takes priority,” Dr. Singer says. Osteoporosis medications given at the same time can help combat bone loss. “If you have an underlying disease, ask your health care provider if you need to discuss risk factors and bone health,” Dr. Singer says.

 

About bambooinnovator
Kee Koon Boon (“KB”) is the co-founder and director of HERO Investment Management which provides specialized fund management and investment advisory services to the ARCHEA Asia HERO Innovators Fund (www.heroinnovator.com), the only Asian SMID-cap tech-focused fund in the industry. KB is an internationally featured investor rooted in the principles of value investing for over a decade as a fund manager and analyst in the Asian capital markets who started his career at a boutique hedge fund in Singapore where he was with the firm since 2002 and was also part of the core investment committee in significantly outperforming the index in the 10-year-plus-old flagship Asian fund. He was also the portfolio manager for Asia-Pacific equities at Korea’s largest mutual fund company. Prior to setting up the H.E.R.O. Innovators Fund, KB was the Chief Investment Officer & CEO of a Singapore Registered Fund Management Company (RFMC) where he is responsible for listed Asian equity investments. KB had taught accounting at the Singapore Management University (SMU) as a faculty member and also pioneered the 15-week course on Accounting Fraud in Asia as an official module at SMU. KB remains grateful and honored to be invited by Singapore’s financial regulator Monetary Authority of Singapore (MAS) to present to their top management team about implementing a world’s first fact-based forward-looking fraud detection framework to bring about benefits for the capital markets in Singapore and for the public and investment community. KB also served the community in sharing his insights in writing articles about value investing and corporate governance in the media that include Business Times, Straits Times, Jakarta Post, Manual of Ideas, Investopedia, TedXWallStreet. He had also presented in top investment, banking and finance conferences in America, Italy, Sydney, Cape Town, HK, China. He has trained CEOs, entrepreneurs, CFOs, management executives in business strategy & business model innovation in Singapore, HK and China.

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