Osteoporosis: Overview of Osteoporosis
Transcript:
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.
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