Osteoporosis: Overview of Osteoporosis

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Osteoporosis:  Overview of Osteoporosis




Guest:  Dr. Kathie Hermayer - Medicine/Endocrinology, Diabetes & Medical Genetics

Host:  Dr. Linda Austin – Psychiatry


Dr. Linda Austin:  I’m Dr. Linda Austin.  I’m interviewing Dr. Kathie Hermayer, who is Professor of Medicine and an endocrinologist at the Medical University of South Carolina.  Dr. Hermayer, I know you have a very strong interest in osteoporosis.  Many people might not think of that as being within the realm of endocrinology because we think of endocrinology as being about hormones.  What is the connection between hormones and osteoporosis?


Dr. Kathie Hermayer:  Osteoporosis is a degeneration of the bones.  It usually can be seen with aging, particularly postmenopausal women.  However, it also occurs in men.  And it can occur younger in life.  However, normally, if it occurs younger in life, there may be a very strong family predisposition.  It can also be medication-induced.  But, endocrinology actually encompasses diseases of the bones.  So, that is why osteoporosis is also included in the scope of endocrine diseases.  However, osteoporosis can be, also, under other diseases, such as in the rheumatologic realm.


Dr. Linda Austin:  And it’s included because the hormones have a profound impact on how bone is formed, is that right?


Dr. Kathie Hermayer:  Correct. 


Dr. Linda Austin:  You mentioned, in passing, that medications can cause osteoporosis.  Which medications can do that?


Dr. Kathie Hermayer:  The major ones to think of are steroids, corticosteroids, which can lead to progressive bone loss.  So, frequently, if we see people who have been treated for lupus or rheumatoid arthritis with a long standing history of steroids, they can have, sooner than expected, osteopenia, which then leads to osteoporosis. 


Dr. Linda Austin:  Let’s define those terms.  Osteopenia is?


Dr. Kathie Hermayer:  The national standards for bone densitometry are set forward by the World Health Organization (WHO).  Bone density is probably one of the most common measurements we use for osteoporosis.  The reason we use bone density, it’s something we can all put our fingers on and it’s tangible, and we can discuss it with our patients.


We use something called the T-score for measuring osteoporosis, whereby we compare the standard deviation of the patient’s bone density to a standard deviation of a 30-year-old healthy bone.  And then we look at the degree of deviation from that 30-year-old healthy bone, and that’s called the T-score.  Anything less than -1.0 to -2.5 is considered osteopenia.  Anything less than -2.5 is considered osteoporosis by WHO criteria. 


Dr. Linda Austin:  Okay.  So, just to translate that, is it fair to say that osteopenia is mild loss of bone density, and osteoporosis is more severe loss?


Dr. Kathie Hermayer:  Correct. 


Dr. Linda Austin:  So, you would pass through those stages, presumably start out normal, then you might become osteopenic, which is a little bit of change or loss of bone density, and then osteoporotic, have osteoporosis when it becomes more severe?


Dr. Kathie Hermayer:  Correct.


Dr. Linda Austin:  At what age should a woman start to be concerned about osteoporosis?


Dr. Kathie Hermayer:  Generally, most of my patients are postmenopausal, or they can be perimenopausal.  And, certainly, men, also, have issues about bone concerns, particularly if they’re at high risk, say, if they have low testosterone levels, something like that, or they’ve taken prolonged steroids.  So, men are also at risk, but probably not quite as high risk as women. 


Generally, women, Caucasian, Asian women are about one out of two risk of being osteoporotic by the age of 70, and for men it’s about one out of seven.  For some reason, African-Americans are a little bit more protected against osteoporosis, but African-Americans are also at risk for osteoporosis. 


Dr. Linda Austin:  So, let’s say for a woman who has no particular risk factors for osteoporosis, at what age should she get her first screening, bone density study?


Dr. Kathie Hermayer:  The current recommendation from the National Osteoporosis Foundation is that all women should have their first bone density by the age of 65.  If they are younger than 65, and if they have one or more risk factors for osteoporosis, that would be family history, low milk, dairy, intake as a child, on medications which can predispose people for osteoporosis, such as steroids, maybe premature menopause, having a hysterectomy at a young age and not being put on estrogen therapy afterwards, smoking.  These can all be considered risk factors for osteoporosis. 


Dr. Linda Austin:  And, is there a recommendation for when men should first be screened for osteoporosis?


Dr. Kathie Hermayer:  The guidelines for men are not as clear-cut as for women.  There is actually no national osteoporosis foundation chapter for men that I’m aware of.  So, I think, for men, it’s more per the discretion of the physician.


Dr. Linda Austin:  I’m sure the most important question on everybody’s mind is, how do you prevent osteoporosis?


Dr. Kathie Hermayer:  The best preventative measures we have for osteoporosis, and, actually, the thing we’re trying to prevent, when we treat osteoporosis, is the first fracture.  And that could be a fracture to the hip, to the pelvis, or to the back.  Those are probably your three main fractures we’re trying to avoid.  So, that’s what all of the prevention is really about.  And, fractures can be very subtle.  People can have compression fractures to their back and they can have some pain, but they can occur spontaneously.  So, the person may experience pain, but it was not from a fall or any type of trauma.  It just can occur at the flip of a switch, so to speak.  So, in other words, trying to prevent that first fracture is paramount.  And the way that we can prevent osteoporosis is through our diet.  We do endorse good calcium and vitamin D intake, and weight-bearing exercises, where you take a good walk everyday.


Dr. Linda Austin:  Are people in northern climates who do not have as much year-round exposure to the sun at greater risk for osteoporosis?


Dr. Kathie Hermayer:  They may be at heightened risk for vitamin D insufficiency.  But, in terms of osteoporosis, there are certain geographic predilections, but I think it’s more a factor of genetics than a lot of other issues when it comes to geographic versus genetics.


Dr. Linda Austin:  There are medications, Dr. Hermayer, for treating osteoporosis.  Can you describe some of those meds?


Dr. Kathie Hermayer:  There are mainly two categories of medications we use for osteoporosis.  One is the antiresorptives, and the other is the anabolic bone builders. The antiresorptives, essentially, prevent bone loss.


Dr. Linda Austin:  And, what are some examples of those?


Dr. Kathie Hermayer:  The major types we have that are antiresorptive are bisphosphonates.  Common trade names for those are Fosamax, Actonel, Boniva, which is now available once a month; the others are more weekly.  Then we have estrogens, and Evista, which is an estrogen-like type agent, and Miacalcin, which can be given by a nasal spray or a daily injection.  Then we have the anabolic bone builders, which is a daily injection for a maximum period, during someone’s lifetime, of two years, and that’s an agent called Forteo. 


Dr. Linda Austin:  Wow, a lot of choices.  How do you, as a doctor, decide which medication for which patient?


Dr. Kathie Hermayer:  Generally, when I’m deciding on which medication is proper for somebody, I look at, first of all, the severity of their bone disease.  Are they, at this point, osteopenic?  Are they osteoporotic?  Have they, in fact, had a previous hip or back fracture?  So, that will basically determine what type of agent I’m heading towards.  And, again, the goal of therapy is to prevent that first fracture, which, in certain situations, can be fatal.


Dr. Linda Austin:  There certainly has been a lot of directed consumer advertising about these agents.  And there’s a lot of hype, I think, out there about the advantages of the once-a-month preparations.  In your view, is there credibility to those sorts of issues or, really, does it more have to do with clinical characteristics that you, as a doctor, need to make a decision about.


Dr. Kathie Hermayer:  Generally, with the bisphosphonates, if we’re going to give them orally, we do need to review somebody’s GI history, in other words, whether or not they have any tendency for stomach upset or gastritis, because those can become worse if you take a bisphosphonate and have a hiatal hernia or GE reflux, or gastritis. 


In terms of Miacalcin, it’s, overall, a pretty good agent.  However, what I point out to my patients is it does not seem to do as much for the hip as it does the back.  So, if, say, somebody’s scores are worse in their hip, then I may not use that agent first-line.


In terms of estrogens and Evista, there are issues regarding those agents regarding venous thromboembolic events, the event rate being increased with those agents.  So, you do need to find out if somebody’s had a prior clotting history, such as a pulmonary embolism or a deep venous thrombosis; they are contraindicated in those circumstances.


And then, again, with the different thoughts about estrogens, one needs to be careful at where somebody may be in their lifetime and whether or not estrogens are indicated for that individual.  And that’s a decision that, usually, the gynecologist or primary care provider makes with their patient.


In terms of Forteo, as I mentioned earlier, it’s really to be used for a two-year maximum span in someone’s lifetime.  And those are usually reserved for patients that are more advanced in their bone degeneration and you’re trying to prevent that first fracture or a recurrent fracture.


Dr. Linda Austin:  So, it sounds like it is a clinical decision that you really have to make very thoughtfully.  It’s not just a question of seeing a movie star who is taking a particular agent and has made an ad about it, but it’s something you have to really carefully talk over with your doctor, take a lot of different issues into consideration.


Dr. Kathie Hermayer:  Absolutely. 


Dr. Linda Austin:  The bone density studies, how often should one get that repeated?


Dr. Kathie Hermayer:  Getting a follow-up bone density has sort of evolved over time.  Currently, Medicare will only allow payment of a bone density every 23 months, unless there’s been a major change in therapy.  So, in other words, if I put a patient on Forteo this year then, perhaps, I could have their bone density covered by insurance next year, if they had a bone density this year as well.  So, you do need to discuss with your physician the intervals and frequencies you need to get your bone density studies done.   As I mentioned earlier, they are a very tangible marker we use to follow progression of one’s bone density, a bone density analysis.  However, they’re to be used with scrutiny because there are issues with insurance companies and their willingness to cover the cost of paying for one if it’s done on more of a frequent basis than allowable by that insurance carrier. 


Dr. Linda Austin:  If a person has a baseline normal bone density study, at what interval should that be repeated?


Dr. Kathie Hermayer:  A normal baseline bone density in a postmenopausal woman should probably be repeated at about a two to three-year interval.  If you have a normal baseline bone density in a premenopausal woman who doesn’t have any significant risk factors, then she may not need one for several years, unless there’s some major change in her lifestyle.


Dr. Linda Austin:  Dr. Hermayer, thank you so much for talking with us.


Dr. Kathie Hermayer:  You’re welcome.


If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection:  (843) 792-1414.


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