Natural Ways to Treat Osteoporosis

The Osteoporosis Reversing Breakthrough

eres just a few things youll learn about how to get back into health. and conquer Osteoporosis. Those not-so innocent yet everyday substances that are currently attacking your body, perpetuating and aggravating your Osteoporosis. What to do and what Not to do to overcome your Osteoporosis effectively and permanently. How to create the energy you need to be able to work full time and feel confident you will be able to take care of your loved ones. How the pharmaceutical and food industry are conspiring to poison you and make you sick (Hint: American medical system is now the leading cause of death in the US). Which food industries use advertising to encourage doctors to tell you that their food is good for you just like those cigarette ads in the 1950s! The single most effective fruits and vegetables in cleaning up excess acidic waste and how to cleanse your inner terrain completely from systemic acidosis. Why, what your Doctor has told you is wrong, and why many medications actually increase the side effects and complications of Osteoporosis (primarily by depleting vital vitamins, minerals and nutrients from your body). Which supplements every patient must take to stop the symptoms and boost your body's ability to reverse Osteoporosis. How to naturally reduce your cravings for toxic foods. Lifestyle and food choices to reverse your Osteoporosis fast, naturally, and for good. Why treating the symptoms of disease is like using an umbrella inside your house instead of fixing the roof. The most powerful creator of health (Hint: its not a food or vitamin!) The best way to simplify the task of making a health-conscious lifestyle adjustment. A miraculous scientific discovery that jump-starts your body to do its natural work, which is to heal itself and restore your Health.

The Osteoporosis Reversing Breakthrough Summary


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Author: Matt Traverso
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Why is it important to know about osteoporosis

First, osteoporosis is the most common bone disease. While osteoporosis is painless, it is still important for you to understand how it can affect your personal health, Figure 1 Comparison of normal bone with osteoporosis. A, normal bone. B, osteoporotic bone. Courtesy of the National Association of Nurse Practitioners in Women's Health (NPWH). From Dempster DW et al. J Bone Miner Res 1986 1 15-21. Figure 1 Comparison of normal bone with osteoporosis. A, normal bone. B, osteoporotic bone. Courtesy of the National Association of Nurse Practitioners in Women's Health (NPWH). From Dempster DW et al. J Bone Miner Res 1986 1 15-21. family, finances, and lifestyle. A recent report from the U.S. Surgeon General says that by 2020, half of all Americans over the age of 50 will be at risk for fractures as a result of osteoporosis. Current estimates indicate that osteoporosis is an expensive health care problem, costing Americans 18 billion per year. Osteoporosis is costly not only in dollars...

What is osteoporosis and what does it look like

Osteoporosis is a disease in which bones become less dense, lose strength, and are more likely to break (fracture). Some people describe bones with osteoporosis as Swiss cheese. Even the word, osteoporosis, is derived from the Greek osteo, meaning bones, and porosis, with holes. Osteoporosis happens mainly to women at midlife and later, but also can happen to men and children. In children, new bone forms more quickly than it breaks down so that bone is actually growing all the time. In adults, bone goes through a constant and normal process where new bone is formed and old bone is broken down simultaneously and at relatively even rates. When more bone is lost than is being formed, osteopenia and osteoporosis develop. Figure 1 compares normal bone with osteoporotic bone.

How does osteoporosis occur

Osteoporosis, or bone loss, occurs when the process of bone breakdown and bone formation gets out of balance. The cells that cause bone breakdown (osteoclasts) start to make canals and holes in the bone faster than the cells that cause bone formation (osteoblasts) can make new bone to fill in the holes. The bone becomes When bone has to give up some of its calcium to ensure that blood levels of calcium stay normal, bone is weakened by the loss of calcium. The weakening of bone by its loss of calcium also leads to osteopenia and osteoporosis. Taking in extra calcium and vitamin D alone will not prevent osteoporosis. Because of the way bone develops, the mechanical stress on bone caused by exercise is also important for preventing osteoporosis. The less you exercise, the less the osteoblasts work to make new bone. You need both weight-bearing and resistive exercise to promote strong bones (see Questions 43 and 44). is also termed osteoporosis or osteopenia, depending on how frail the...

What are the risk factors for osteoporosis

Unless you break a bone, osteoporosis is painless. It's therefore important to know if you are at risk for developing it. While men and women have many of the same risk factors for osteoporosis and osteopenia, a few are gender-specific. The following factors put you at risk for osteopenia and osteoporosis Age. Bone mass decreases as you age. So as you get older, you are more likely to develop osteoporosis. While osteoporosis can affect women and men at any age, it most commonly affects postmenopausal women and older men. The National Osteoporosis Foundation reports that 75 of all cases of osteoporosis are diagnosed in white women over the age of 50. As men age, they too can develop osteoporosis, but it's much more likely to occur in men who are well into late life. Gender. Eighty percent of those with osteoporosis are women. Although men account for approximately 20 of cases, they develop osteoporosis much later if they get primary osteoporosis. Men can develop secondary osteoporosis...

How will I know if I have osteoporosis Are there any signs or symptoms

Because osteoporosis and osteopenia are not painful conditions, you will not know that you have either one unless you break a bone or you have bone mineral density testing. A fracture of the body of a vertebra (spine bone) that collapses it and makes it thinner and weaker. Usually results from osteoporosis but can also result from complications of cancer or some injuries. It was only a little fall I couldn't have broken a bone. While not common, it is important to discuss such injuries with your clinician. Back pain that comes on suddenly in the spine can mean that you have one or more vertebral fractures resulting from osteoporosis. This is different from the back pain associated with a muscle spasm. Even if you have just bent forward to reach for something or slipped in the bathtub, you can still get a fracture in your spine if you have osteoporosis. One physical sign indicating that you have osteoporosis is loss of height. So, if you shrink in height as measured in your annual...

How will my clinician use my test results to determine whether I have osteoporosis

A T-score, expressed in standard deviations, will be reported to your clinician, and your score will most likely be evaluated using the WHO guidelines. Most machines are calibrated with special software to determine your scores. Based on the guidelines (see Question 32), your results will indicate normal bone density, low bone mass (osteopenia), or osteoporosis. If you have osteoporosis with a fragility fracture, you will have a diagnosis of severe osteoporosis. Because the T-score not only reflects bone density but also your risk of fracturing a bone, your clinician should discuss specific ways of not only increasing your bone mass but also lowering your fracture risk (see Question 79). A Z-score is usually not helpful in making the diagnosis of osteoporosis. However, if it is particularly low (lower than -1.5), it is important for your clinician to evaluate you for conditions and illnesses that may be causing your bone loss associated with secondary osteoporosis. Such causes of...

What does menopause have to do with osteoporosis Are there different kinds of osteoporosis

There are actually two types of osteoporosis primary osteoporosis and secondary osteoporosis. Either type can affect men, women, and children. Primary osteoporosis is age-related and affects women more severely and earlier in life than men. Secondary osteoporosis is caused by other disease processes or medications used to treat various diseases or problems. Secondary osteoporosis is also more common in women because the illnesses that cause bone loss or the problems that require medications that affect bone remodeling more often affect women. Primary osteoporosis, although occurring in both men and women, is age-related and tends to occur mostly in women and about 10 years earlier than in men. This is because the rate of bone loss is different in women than men. Women rapidly lose bone in the four to eight years after menopause, and then continue with the slower rate of bone loss like men, who also experience bone loss over many years. Bone loss from primary osteoporosis is most...

Im 60years old Is it really worth it to start exercising now Will exercise at my age help prevent osteoporosis

Absolutely Exercising will help you no matter how old you are. Although exercise has been encouraged for many years as part of a healthy lifestyle, we are just beginning to quantify its positive effects on heart disease, obesity, diabetes, menopausal symptoms, and of course osteoporosis. It is never too late to incorporate regular exercise into your lifestyle. It's easy for us to say that we're too old to begin exercising at our age, but that is not true. If you don't already have osteoporosis or osteopenia, exercise is still important even though exercise alone doesn't prevent bone loss. When you are well past the first 4 to 8 years after menopause, during which the greatest amount of bone loss occurs, and if you don't have osteoporosis, you are less likely to develop osteoporosis. If you are only a few years into post-menopause, you may still lose enough bone to be diagnosed with osteoporosis later. Regardless of how many years you are past menopause, get moving And if you're a man,...

How is osteoporosis diagnosed

Conventional x-rays are not used to diagnose osteoporosis however, osteoporosis can sometimes be seen on x-rays. The x-rays used to diagnose a fracture can show osteoporosis, but only if you have a significant amount of bone loss, that is, 30 to 40 . There are, however, other tests that can be used specifically to evaluate your bone health. All bone mineral density (BMD) tests are safe, painless, and noninvasive. Most of the tests subject you to no more radiation than that received from the atmosphere during a crosscountry airplane trip. One of the BMD tests uses ultrasound technology. The gold standard (best test) for diagnosing osteoporosis or identifying osteopenia is dual-energy x-ray absorptiometry (DXA). Because your hip, spine, or whole body may be evaluated using DXA, you will need to lie down on an x-ray type of table while a machine takes measurements of your bone density. The measurements and images of your bones are sent to a computer nearby, usually in the same room....

If osteoporosis doesnt hurt what impact does it have on my health

Osteoporosis can affect your health in many ways, directly and indirectly You become more much more susceptible to fractures. Fractures, depending on which bone you break, can cause physical immobility and impairment of your general health, as well as financial problems and social isolation. Fractures can lead to death. If you are 50 or older with osteoporosis, you have a 1 in 2 chance of having an osteoporosis-related fracture during the remainder of your lifetime. Vertebral fractures caused by osteoporosis can severely affect the quality of your life in many areas, such as social functioning, overall health, emotional health, bodily pain, and vitality. The acute back pain associated with vertebral fractures and the healing process can be very debilitating. Being unable to do activities of daily living without pain can cause you to stop moving physically and mentally physically because of pain or physical impairment, and mentally because of fears of further injury and resulting...

When should I be tested for osteoporosis Will my tests be covered by insurance

The National Osteoporosis Foundation recommends bone mineral density (BMD) testing on the following individuals If you are a women aged 65 or older, you should be tested for osteoporosis even if you have no other risk factors. low trauma Family history of osteoporosis Genetic factors Sedentary lifestyle Nutritional deficiencies Excessive alcohol intake Cigarette smoking You will note that few of the above recommendations refer specifically to men. Male patients and their clinicians should discuss their risk factors for osteoporosis, just as women should. Insurance coverage for testing are estrogen deficient (postmenopausal) women with a clinical risk for osteoporosis are being monitored for effects of or response to approved osteoporosis treatments (see Part Three).

How long will I be treated for osteoporosis How will I know if the treatments are working

Osteoporosis is beginning to get the scrutiny and concern that it deserves. Up to now, osteoporosis has received little attention, possibly because it causes no pain unless you break a bone or because many people associate it with normal aging. Few therapies for osteoporosis have been tested for use for longer than 10 years, except estrogen, which was approved for the prevention of postmenopausal osteoporosis in 1972. Despite this, treatment for primary osteoporosis is usually ongoing unless some contraindications to treatment arise. In the case of secondary osteoporosis, treatment continues until the secondary cause of osteoporosis is remedied or the medication causing osteoporosis is discontinued and bone density testing reveals stable bone mass over time. The American Association of Clinical Endocrinologists (AACE) recommends the following monitoring schedule In those with normal results (a T score > -1.0), further BMD testing is not needed for 3 to 5 years. In those who are...

Its hard not to think about my bones being weak How do I keep osteoporosis from interfering with my life

Being told you have low bone mass or diagnosed with osteoporosis can represent an opportunity for change. Rather than letting the news interfere with your life, think of it as an opportunity to make positive changes. Rather than feeling deprived or feeling old, let osteoporosis be a life-changing moment. Because osteoporosis is a silent disease, you probably did not know you had it. But some of the changes you make now can positively affect the rest of your life. Get organized. If you are on many medications and you are taking medication to prevent or treat osteoporosis, get yourself a pill-minder to make sure that you are taking your medication in the appropriate amount, on the correct day, and at the right time. Even if you only take a couple of medications, it's worth it to your peace of mind to get organized and use a pill-minder so that by lunchtime, you don't have to worry about whether you took your morning dose of osteoporosis or blood pressure medication. Resolve to get...

Can my clinician tell if I have osteoporosis during my annual checkup

It is very important that your clinician take a good history during your annual check-up. The history is particularly important because osteoporosis is not painful unless you break a bone. Your clinician should ask you about the following Family history of osteoporosis Medications that can cause secondary osteoporosis (see Question 16) History of illnesses that are associated with secondary osteoporosis (see Question 17) After taking a thorough history, your clinician will examine you. For the purposes of detecting osteoporosis or for conditions that put you at increased risk of developing osteoporosis, your clinician should pay particular attention to the following Even after collecting all of this information, your clinician cannot determine if you have osteoporosis. They use this information to determine your risk for osteoporosis and then will order testing if needed (see Question 24). Since age 65, I have had a complete yearly physical, blood work,, urinalysis, and so forth. When...

If my clinician does not discuss screeningfor osteoporosis at what age should I make sure that I am screened

You and your clinician should discuss your bone health during every annual exam, regardless of your age. Your calcium and Vitamin D intake, your level of physical activity, and your lifestyle factors such as smoking and drinking alcohol can affect bone health at any age. If you believe that you have one or more risk factors for developing osteoporosis, it is important to discuss being screened with your clinician (see Question 13). The Surgeon General, in his 2004 report on bone health, advises that the following red flags at any age should warrant further assessment for osteoporosis or other bone diseases If you believe that you have one or more risk factors for developing osteoporosis, it is important to discuss being screened with your clinician Presence of disease that is associated with secondary osteoporosis (see Question 17)

Im worried that my daughter who is 40 will get osteoporosis How can she prevent this from happening to her

If you have already been diagnosed with osteoporosis, you are right to be concerned. Family history is certainly a risk factor for osteoporosis. But what you have learned from your own diagnosis can truly help your daughter. Women beginning midlife should make themselves aware of all the risk factors for developing osteoporosis. First, at the age of 40, unless she is one of the 1 who experience premature menopause (natural and total cessation of menstrual periods before the age of 40), she is likely to still be making the necessary estrogen to protect her bones. She should continue to take adequate calcium and Vitamin D for her age, which means 1,000 to 1,200 mg of elemental calcium and 400 IU of Vitamin D per day. This may mean assessing her diet and supplementing it if she does not get enough calcium through dairy products and other foods (see Table 4 in Question 48). If she smokes, she should stop. If she drinks excessive alcohol, she should stop that, too. Equally important, she...

Drug Induced Osteoporosis Glucocorticoids

Glucocorticoid-induced osteoporosis occurs as a result of multiple mechanisms. Corticosteroids have multiple effects on bone including direct inhibition of bone formation, impaired calcium absorption across the intestine, and increased renal calcium excretion, all of which result in a negative calcium balance. As a result of calcium wasting, secondary hyperparathyroidism results and increases bone resorption. Corticosteroids induce a myopathy, which reduces the bone-stimulating effects of muscle activity. In animal models, corticosteroids have been shown to induce apoptosis of osteoblasts and osteocytes thereby resulting in diminished bone formation. More recently, cortico-steroids have been shown to regulate bone metabolism through their effect on members of the TNF receptor family, the OPGs. Osteoclasts express the RANK receptor. Binding of RANKL to RANK activates osteoclastic activity, which can be blocked by a soluble receptor OPG (discussed above). Corticosteroids decrease OPG...

What about the new lowdose hormone patch Menostar estradiol that is used to prevent osteoporosis

Menostar (estradiol) was FDA-approved in 2004 for the prevention of postmenopausal osteoporosis. It is a dime-sized transdermal patch that delivers about 14 micrograms of estrogen per day. A new patch is applied every week. Because your body absorbs the estrogen from the patch through the skin, you can avoid the liver first-pass effect, meaning that the hormone is not metabolized through your liver. Instead, it can go directly into the bloodstream. If you are postmenopausal and want to prevent osteoporosis, or if you have osteopenia and you want to prevent further bone loss, Menostar may be appropriate for you. Menostar is not FDA-approved for osteoporosis treatment. Other treatment options are used instead. Menostar Osteoporosis Has half of the estrogen used in other transdermal patches is successful in the prevention of osteoporosis but does not prevent vasomotor symptoms Significantly increases bone mineral density after two years Although MHT can prevent postmenopausal...

What types of medication are usually prescribed for osteoporosis

If you are told you have osteopenia or are diagnosed with osteoporosis, calcium and Vitamin D supplementation with appropriate exercise may not be enough to decrease bone loss or build bone. You may need a prescription medication. Some medications are only prescribed for women and others are prescribed for both women and men. The North American Menopause Society (NAMS) advises that the following women receive prescription medication as part of their treatment for osteoporosis Postmenopausal women who sustain a fracture of a vertebra as a result of osteoporosis. trying to break down old bone. Estrogen therapy (ET) is one of these types of medications and for post-menopausal women has been found to be very effective in the prevention of osteoporosis. ET is appropriate for preventing osteoporosis in postmenopausal women who are experiencing significant menopausal symptoms (see Questions 64-66). Other medications that fall into the group of drugs intended to prevent further loss by...

Thought osteopenia was also bone loss What is the difference between osteoporosis and osteopenia

Although the words sound somewhat alike, osteoporosis and osteopenia are a little different from one another. Both relate to bone loss, but the difference is in how much bone is lost. Osteopenia, like osteoporosis, means that the process of bone development has become unbalanced and the rate of bone loss exceeds the rate of new bone growth. With osteopenia, some bone has been lost but not as much as with osteoporosis. Although osteope-nia slightly increases your risk of breaking a bone, the Osteopenia In Greek, literally meaning bone (osteo) that is lacking (penia) the process of bone development has become unbalanced and the rate of bone loss exceeds the rate of new bone growth. With osteopenia, some bone has been lost but not as much as with osteoporosis. Poor Bone Health is Common and Costly Poor Bone Health is Common and Costly Fractures from osteoporosis 1.5 million Fractures from osteoporosis 1.5 million Figure 2 Impact of osteoporosis. Courtesy of the U.S. Department of Health...

What should I tell my family about osteoporosis Will it curtail activities with them

If you have been diagnosed with osteoporosis, you should definitely discuss the diagnosis with your partner. First, your partner should know if you are on any new medications, so he or she can help support you in following the new regimen and watch for reactions. Second, you and your partner should discuss how your lives might be affected by osteoporosis. If your clinician has restricted your activity, discuss these restrictions with your partner or spouse. It is unlikely that you will be restricted from specific activities unless they are new to you (e.g., ice skating, skiing, skydiving). If you don't exercise regularly, this is a good time to discuss a new routine of exercising with your partner. Osteoporosis should not limit your activities or your thinking. Consider taking a class together for dancing, yoga, or tai chi. A diagnosis such as osteoporosis also gives you the opportunity to discuss other lifestyle changes that may be helpful to both you and your partner's bone health...

After Im diagnosed with osteoporosis or told that I have osteopenia what happens next

Once you have been sent for BMD testing, it's a good idea to investigate management options for osteopenia and osteoporosis. If your results are abnormal, you and your clinician can select the regimen that you both feel is best suited for your individual case. If your testing results come back in the normal range, you will still need to discuss prevention of osteoporosis to keep your bones healthy. If your T-score shows that you have osteopenia or osteoporosis, secondary causes of osteoporosis should be ruled out before treatments are suggested. It is very difficult to fully reverse osteoporosis once it is present. You might think that after you are told you have osteopenia or diagnosed with osteoporosis, your only goal should be to get rid of it. That is not the case. It is very difficult to fully reverse osteoporosis once it is present. But there are several important goals that you will want to work with your clinician to achieve It is important to remember that your goals toward...

What are isoflavones Are they effective for treating osteoporosis

Because isoflavones have been found to act like estrogen in the body, isoflavones are being studied not only for their effects on the hot flashes associated with menopause, but also for their effects on bone health. Several small studies have shown some promise in reducing bone loss and increasing bone mineral density without some of the side effects of estrogen observed in other scientific studies. For example, isoflavones don't seem to increase breast density, increase endometrial thickness, or exert the same negative effects on your heart health. Further study is needed to confirm the bone findings reported when isoflavone supplements are taken. Isoflavones are considered safe when taken with other medications, such as the prescription medications described in Questions 56 to 67.

What is Evista raloxifene What is a SERM and why is it effective in the treatment of osteoporosis

Evista (raloxifene) is the only FDA-approved selective estrogen receptor modulator (SERM) for the prevention and treatment of osteoporosis in postmenopausal women. You may be more familiar with tamoxifen, a SERM used in the treatment of breast cancer. A SERM binds with some estrogen receptor sites around the body. Although raloxifene is not a hormone, it has an estrogen-like effect in some body tissues such as bone and has an estrogen-blocking effect on other tissues such as breast and uterus. Evista increases bone mineral density, decreases the risk of fractures, and is FDA-approved for the prevention and treatment of osteoporosis in post-menopausal women. The dosage of Evista for both osteoporosis treatment and prevention is 60 mg per day taken as one tablet. Evista, unlike the bisphos-phonates, may be taken with or without food. In addition to Evista's positive effects on bone, it also decreases low-density lipoprotein (LDL) cholesterol (the bad cholesterol) as well as total...

Which bones are affected by osteoporosis

Bisphos Fracture

Although the hipbones and the vertebrae (bones of the spine) provide the best measurements of bone loss, osteoporosis occurs in all bones. The osteoblasts and osteoclasts are most active in the bones of the body's central region, that is, bones of the hip and vertebrae, and the long bones of the arms and legs. The skull bone is very rarely affected by osteoporosis. Fractures of the hip and vertebrae are also the most common fractures. Because all bones can be affected by osteoporosis, clinicians usually recommend that individuals with weakened bones, like those caused by osteoporosis and osteopenia, avoid playing certain sports or engaging in certain activities that will increase the likelihood of falls, which, of course, increases the risk of fractures of any bones, but particularly the hip (see Question 45). Individual bones of the spine. Fractures of these bones are the most common fractures in people with osteoporosis. In primary osteoporosis, women lose 5 to 10 of cortical bone...

Could I be taking any medications that affect bone health

There are several types of medications that can put you at greater risk for developing osteopenia and osteoporosis. These types of medications are believed to decrease bone mass either by accelerating bone breakdown or by interfering with new bone formation. Some drugs may also interfere with the body's use of Vitamin D and parathyroid hormone. However, certain medications cause bone loss and we just don't know why. Glucocorticosteroids (prednisone, prednisolone, cortisone, glucocorticoids, steroids, adrenocorticotropic hormone ACTH , Orapred , Pediapred , Prelone ) are the main group of medications associated with secondary osteoporosis. They cause more osteoporosis than any other medication. The glucocorticosteroids, also called corticosteroids or more commonly, steroids, can be taken orally, inhaled, injected, or used topically (through the skin) or intravenously. The oral, intravenous, and injected forms of steroids are the most damaging to bones. The long-term effects of inhaled...

What if Im told I that have osteopenia but not osteoporosis

If you have osteopenia, then your T-score is 1 to 2.5 standard deviations below the bone density of the average healthy young adult. Given a score in that range, your bone mass is somewhere between 10 and 30 below normal for a young adult. And your risk of fracture, based on your T-score alone, is as much as 2 to 5 times that of a healthy young adult with normal bone density. Therefore, it's still important to prevent falls. Although your T-score may indicate that you have osteopenia, it is best to assume that your bone loss will continue if you do not embrace the goals and behaviors intended to improve your bone health. Sometimes clinicians don't use the term osteopenia. Instead, they prefer to tell patients that they have low bone mass. Some clinicians may suggest prescription medications specifically intended to prevent further bone loss or to increase bone density. However, management options for osteopenia are controversial, and some clinicians think prescription medications for...

Are there other tests that are used to diagnose osteoporosis

While other tests can be used to diagnose osteoporosis, the World Health Organization (WHO) has established the guidelines for diagnosis based only on the results of DXA testing. So most other methods for identifying osteoporosis or osteopenia are used for screening, and then if the screening test suggests reduced bone density, a DXA is ordered to make a diagnosis. The following are the other tests that are available but less widely used Type of radiograph where the bone mineral density test is done on the wrist or heel while the body part is submerged in water. In addition to BMD tests, there are also biochemical markers that are measured in blood and urine to determine if specific therapies for osteoporosis are working. Biochemical marker measurements are not used for the purpose of diagnosing osteoporosis but sometimes for monitoring the progress of treatments (see Questions 40 and 69).


Celiac disease patients are at high risk for developing a low bone mineral density and bone turnover impairment. Persistent villous atrophy is associated with low bone mineral density. Of 86 consecutive newly diagnosed, biopsy confirmed celiac disease patients, 40 had osteopenia and 26 osteoporosis (Mora et al, 1999). There were no differences between males and females, or fertile and postmenopausal women. Bone mineral density in adult patients responsive to diet did not differ from that in healthy controls. Children maintained on a gluten-free diet for at least 5 years had nor mal bone mineralization and bone turnover. Even in postmenopausal women, a gluten-free diet led to a significant improvement in bone mineral density. In these cases, supplement treatment with vitamin D and calcium is indicated.

Ivy M Alexander PhD Canp Karl a A Knight RN MSN

100 Questions & Answers About Osteoporosis and Osteopenia 100 questions and answers about osteoporosis and osteopenia by Ivy M. Alexander and Karla A. Knight. p. cm. 1. Osteoporosis Prevention. 2. Osteopenia--Popular works. I. Title One hundred questions and answers about osteoporosis and osteopenia. II. Knight, Karla A. III. Title. RC931.073A42 2006 616.7'16--dc22 Part 1. An Overview of Osteoporosis and Bone Development 1 Questions 1-11 describe the physiology of bone development and how osteoporosis and osteopenia occur, including What is osteoporosis, and what does it look like Why is it important to know about osteoporosis What does menopause have to do with osteoporosis Are there different types of osteoporosis Questions 12-40 address the risk factors associated with osteoporosis, who should be tested, and how osteoporosis is diagnosed, including Who gets osteoporosis Could I be taking any medications that affect bone health Can my clinician tell if I have osteoporosis during...

Are there other vitamins and minerals that contribute to bone development

In addition to Vitamin D, the following vitamins play a role in bone health Vitamin B6 indirectly helps with bone development by lowering levels of homocysteine, a body substance associated with fractures due to osteoporosis. High homocysteine levels may also increase your risk of heart disease. Vitamin K can also help prevent bone from being broken down and calcium from being excreted in urine. Research is currently under way studying the long-term effects of Vitamin K on bones. Getting insufficient amounts of Vitamin K may lead to an increase in the risk of hip fracture. Folate, or folic acid, is a vitamin known to prevent spinal defects in developing fetuses, and like Vitamin B6 is also important in reducing homocys-teine levels, which have been associated with an increase in osteoporosis-related fractures. Calcium is probably the most well known mineral associated with bone health. However, magnesium and phosphorus play important roles as well. Magnesium and phosphorus contribute...

What do my results say about my future risk for fracturing a bone

Because fractures are the biggest problem associated with osteoporosis, it is important to know what your results say about your risk for fracture. It's also important to know that there is risk to fracturing your bones whether you are diagnosed with osteoporosis or not (meaning you may have it but don't know it). The lifetime risk of fracturing your hip, spine, or forearm is 40 in white women and 13 in white men. If you include the potential for fracturing other bones, your risk is increased even further. Your lifetime risk of fracturing your hip is equivalent to or more than your combined lifetime risk of developing breast, uterine, or ovarian cancer. If your T-score indicates that you have osteopenia, you could be four times more likely to fracture a bone. But, low bone mass as defined by your T-score is not the only factor that puts you at increased risk for a fracture. Your clinician should help you understand that your age, family history of osteoporosis, previous fractures,...

Where can I go for more information

While many of your questions have been answered in this book, you likely will want to look for additional information on osteoporosis, osteopenia, and other health-related topics. Refer to Appendix B and the bibliography for a listing of research and resources that may be helpful as you continue to improve your overall health as well as that of your bones.

What if I live in a rural area and I cant get to a place with a DXA machine Are there further tests that I would need

DXA machines are the most widely available of all machines used for testing bone mineral density. However, some areas of the United States do not have access to DXA machines. Because it is important to have your bone density evaluated, particularly if you have risk factors for osteoporosis, you should still be evaluated using one of the screening tests that may be available in your area. While it is preferable to have a test of your spine or hip to confirm a diagnosis of osteoporosis or determine if you have osteopenia, your clinician can still recommend preventive options and counsel you about nutrition and exercise for improving your bone health (see Part 3). If you do not have access to any bone mineral density testing, it is still important to adhere to a regimen of weight-bearing exercises as well as a diet with sufficient calcium, Vitamin D, and other nutrients to maintain healthy bones. You should also make every effort to prevent falls (see Question 79). 29. If I'm x-rayed for...

Conditions Leading to Calcium and Vitamin D Deficiency

Decreased absorption of vitamin D may result in osteomalacia (failure to mineralize new bone matrix). In conditions of malabsorption, both osteoporosis and osteomalacia may coexist. Bone biopsy is required to distinguish these entities but is generally not necessary for treatment. Given this background, it is clear that GI diseases resulting in inflammation or pathology of the upper small bowel are particularly susceptible to osteoporosis. Examples of these include celiac sprue, Crohn's disease (CD), pancreatic insufficiency (PI) (Moran et al, 1997) and postgastrectomy (Vestergaard, 2003). CD patients are especially at risk if they have had extensive surgical resections or have diffuse intestinal disease. With improved medical and surgical therapy for CD, extensive surgical resections are thankfully the exception. Patients with jejuno-ileal bypass are also at risk for osteoporosis. It remains to be seen whether less drastic weight loss surgeries, such as...

Nutritional Deficiency

Calcium and Osteoporosis Another common nutritional problem in patients with SB CD is calcium and vitamin D deficiency. Calcium deficiency is usually caused by a combination of malabsorption from the SB disease and low dietary intake. Factors contributing to the development of vitamin D deficiency include inadequate dietary intake, lack of sun exposure, fat malabsorption, and disruption of the enterohepatic circulation of vitamin D metabolites. These nutritional deficiencies may result in a number of metabolic bone complications, including osteopenia, osteoporosis, and osteomalacia. Patients with SB CD, particularly if they have metabolic bone disorders, are recommended to take supplements of calcium 1.5 g d and vitamin D 800 U d. There is a separate chapter on metabolic bone disease (see Chapter 55, Metabolic Bone Disease in Gastrointestinal and Liver Patients).

How soon are test results usually available Should I get a copy of the results ofthe testing

For results Some clinicians do not call if results are normal, so you need to be certain that your clinician has the right contact information and that no news is good news. If your testing shows low bone mass or osteoporosis, will you need to have a follow-up visit with your clinician Or does your clinician want to discuss treatment options over the phone Some people like to have copies of their test results so that they can track their own progress, but it's not necessary to get a copy of the results of your testing. It's more important for you to know if you have osteope-nia or osteoporosis so that if you must seek medical care from other providers or if you have a fall and are taken to a hospital emergency department, you will be able to inform the new providers of your diagnosis and if you are being treated. 36. If my BMD test results are normal, when should I be screened again If my test results show either osteopenia or osteoporosis, when should my test be repeated illness...

Cyclosporine and Tacrolimus

Cyclosporine and tacrolimus are calcineurin phosphatase inhibitors used in a variety of GI disorders. It is used in patients with severe ulcerative colitis (UC) to prevent colectomy. It is also commonly used post-OLT. Cyclosporine and tacrolimus both cause osteopenia and osteoporosis by increasing bone turnover, which is reflected in high levels of osteocalcin (Epstein et al, 1995 Inoue et al, 2000). Renal transplantation patients given cyclosporine alone, however, did not have sig- FIGURE 55-3. Determinant of bone mineral density. IL interleukin TNF tumor necrosis factor. FIGURE 55-3. Determinant of bone mineral density. IL interleukin TNF tumor necrosis factor.

Inflammatory Cytokines

Several lines of evidence suggest that factors other than glucocorticoids contribute to bone loss in inflammatory conditions of the bowel. Patients with recently diagnosed inflammatory bowel disease (IBD) do not have decreased bone mass density compared with age-matched controls however, those with symptoms of > 6 months duration have lower bone mass density than age-matched controls (Stockbrugger et al, 2002). A variety of cytokines are overproduced in IBDs and celiac disease and may have detrimental effects on BMD. The inflammatory cytokines IL-1 p, IL-6 and TNF-a are elevated in the systemic circulation of patients with CD. In patients with celiac disease, there is increased IL-1p and IL-6 in the systemic circulation which correlates with osteopenia. TNF-a expression is also increased in the mucosa of celiac patients, and, recently, treatment with infliximab has been shown beneficial in a patient with gluten-insensitive, refractory disease (Gillett et al, 2002). TNF-a has a...

Indications For Surgery

Because of better diagnostic tests and routine blood calcium determination, PHPT is diagnosed sooner and few patients have severe symptoms or dramatic associated metabolic problems. This, however, does not alter the need for treatment to prevent metabolic complications such as decreased bone density with osteopenia and osteoporosis, decreased creatinine clearance, and hypercalciuria. One reason why fewer patients present with severe metabolic problems is that most patients are easily treated.13 Currently, parathyroidectomy is the only definitive treatment for patients with PHPT. (The National Institutes of Health NIH consensus meeting in 2002 recommended parathyroidectomy for patients with evidence of the symptoms seen in Table 5-4. At previous consensus conferences, the need for a prospective randomized trial to define the disease's multisystem effects and to assess the long-term incidence and progression of complications in asymptomatic PHPT patients over 50 years was recognized.14)...

Older Children and Adults

A concern for both growing children and adults with lactose intolerance is getting enough calcium in a diet that includes little or no milk. Patients with lactose restriction are at risk for osteoporosis, osteopenia, and fracture (Infante and Tormo, 2000). Age-dependent recommendations for required daily calcium intake is shown in Table 62-3. Many nondairy foods are high in calcium, such as green vegetables and fish with soft, edible bones (Table 624). In patients who need a complete restriction of lactose, calcium supplementation is often recommended. Absorption of calcium from the diet is promoted by vitamin D, which is adequately supplied in a balanced diet. Sources of vitamin D include eggs and liver sunlight helps the body to naturally absorb or synthesize vitamin D.

Why should I take drugs that have side effects

What are the side effects of the drugs that are used for treatment of MS attacks Are cataracts a result of steroid use Is osteoporosis a complication of MS Bone damage The use of steroids results in the loss of calcium from bones that underlies the development of osteopenia and osteoporosis. Subsequently, this may lead to the collapse of vertebrae and an increased risk of fracture of the long bones. Even more serious is the increased likelihood of ischemic (aseptic) necrosis of the hips and other joints. When diagnosed early, treatment can reverse or limit permanent damage. Con

Radiographic Synopsis

Diffuse osteoporosis multiple telescopic fractures, with predominant involvement of the lower extremities rib fractures hyperplastic callus formation bowing deformities pseudarthrosis (os-teogenesis imperfecta) 2. Decreased bone mass in the axial skeleton and proximal portions of the appendicular skeleton vertebral collapse Colles' fractures fracture of the femoral neck (senile and postmenopausal osteoporosis)

Can I change any of my risk factors

You cannot change your age, gender, sex, race, fracture history, family history, menstrual history, time of menopause, genetic factors, and most medical conditions. You can, however, change some risk factors because most of them are related to lifestyle. Here's what you can do to lower your risk of developing osteoporosis or low bone mass If you drink alcohol, use moderation. More than two drinks per day increases your risk of osteoporosis as well as your risk of falling and breaking a bone. If you have any medical conditions that put you at greater risk for bone loss, discuss with your clinician how your condition could be managed to reduce the risk of jeopardizing your bone health. For example, if you have an eating disorder, discuss getting the help you need to resume eating a healthy diet. Or if your BMI is less than 18 (meaning you are underweight), get the help you need to gain enough weight to have a healthier BMI. Although having a BMI of < 22 increases your risk for...

How do I know which type of test should be ordered

Tests for osteoporosis are either done to screen an individual to detect the presence of bone loss or done to monitor the progress of previously diagnosed bone loss. You may recall from Question 24 that the only tests used to diagnose osteoporosis are those that test the bone density of your spine or hip. Tests that are performed on peripheral limbs (hands, forearms, wrists, lower leg, and feet) are primarily used for screening. However, if you are obese, peripheral bone mineral density testing at the forearm is often used for diagnosis because most DXA machines are inaccurate for and cannot accommodate individuals who weigh more than 250 pounds. Peripheral bone mineral density testing Bone mineral density tests of the non-central bones, usually heel, wrist, forearm, or fingers. If you attend a health fair where you are screened for bone loss using a portable machine, there is not likely to be a choice of tests. And if the portable testing shows bone loss, your clinician may advise...

Reason for steroid therapy

These are well known and no different in the pregnant state to those in the nonpregnant state, and they may be of relevance to the anaesthetist (e.g. electrolyte disturbance, osteoporosis). In general, hydrocortisone and prednisolone are about 90 metabolised by the placenta and therefore little reaches the fetus. However, maternal dosage above 10 mg prednisolone per day has been associated with neonatal adrenal suppression, and similar effects are theoretically possible in breastfed neonates, although reported measured concentrations of steroids in breast milk have been extremely low. There are unlikely to be adverse maternal effects of short-term administration of steroids given for premature delivery, although transient reductions in fetal heart rate variability have been reported.

Benefits Of Estrogen Replacement Therapy

Over the last two decades, overwhelming evidence has been accrued demonstrating that postmenopausal estrogen replacement protects against ischemic heart disease, osteoporosis, deterioration in cognitive function, colorectal cancer, and provides relief from vasomotor symptoms and urogenital atrophy. Multimodal-ity screening has resulted in an increase in the incidence of breast cancer diagnoses this increase, however, reflects more frequent detection of early-stage breast cancer. Because breast cancer survival is inextricably linked to early diagnosis, there are now more breast cancer survivors than ever. Morbidity and mortality associated with estrogen deprivation present serious health concerns. The risk benefit ratio of estrogen replacement therapy (ERT) is an appropriate consideration for all patients.

Are there blood and urine tests that can be used to determine if I have bone loss

In the case of osteoporosis, biochemical markers are chemical substances that indicate bone turnover. When osteoclasts (the cells of bone resorption see Question 5) break down the collagen in bone, byproducts of this breakdown (for example, N-teleopeptide crosslinks NTx ) are released into the bloodstream and excreted in the urine. When new bone is formed, byproducts such as osteocalcin and other substances also find their way to the bloodstream and get excreted in the urine. Currently, blood and urinary biomarkers are not used to diagnose osteoporosis, but they can be helpful in assessing how fast bone is formed and broken down. BMD testing, while important for assigning fracture risk and measuring bone mass, does not provide information about bone turnover or bone quality. Tests for biomarkers do not give any information about bone mass however, there is some evidence that the presence of bone breakdown biomarkers in urine is associated with an increased risk of hip fracture. While...

What is Actonel risedronate Is it like Fosamax alendronate

Actonel (risedronate) is another bisphosphonate prescribed to reduce bone turnover to treat or prevent osteoporosis. It can be taken either daily as 5 mg tablets, or weekly as 35 mg tablets. Like other bisphosphonates, Actonel is FDA-approved for the treatment or prevention of postmenopausal osteoporosis in women. It is also approved for the treatment and prevention of glucocorticoid-induced osteoporosis (GIO) in adults who are initiating or continuing oral glucorcorticoid medications at doses of > 7.5 mg daily. Actonel has also been approved for the treatment of Paget's disease (see Question 60). In a recent study that compared the effect of weekly Fosamax on bone mineral density with the effect of weekly Actonel on bone mineral density, Fosamax showed a greater increase in BMD and a greater decrease in bone turnover. But those taking Actonel had fewer fractures than those taking Fosamax. We already know that both Fosamax and Actonel are effective in reducing fracture risk, which...

Introduction And Case History

There was little success with tacrolimus, azathioprine, mycophenolate mofetil, thalidomide, cyclophosphamide, and alpha interferon. He developed many problems including weight gain, renal impairment, hypertension, osteoporosis and avascular necrosis of his hip and knee joints requiring hip decompression surgery and bilateral knee replacements. He has also required bilateral cataract surgery.

Chronic Bacterial Sinusitis Antiinflammatories

Long-term, low dose macrolide therapy represents one attempt at controlling the inflammation associated with chronic sinusitis (80). Medicines that have anti-inflammatory properties and are well tolerated are sought to help ease the reliance on systemic corticosteroids that affect both the number and function of inflammatory cells. When used in a topical form, nasal steroid sprays have been shown to be safe and effective in reducing the symptoms of alleric rhinitis (81). Their use in patients with chronic sinusitis can decrease the size of nasal polyps, and diminish sinomucosal edema (82). There are no set guidelines for the duration of use, and the expected side effects from long-term use are not yet known. Experience in using oral steroids for the treatment of chronic sinusitis is only anectodal. The extended use of oral steroid may result in serious side effects that include muscle wasting and osteoporosis. Because of the side effects, steroids are tapered and given in short...

Why Is Tnfa So Important In Inflammatory Diseases

With other cytokines to drive the inflammatory process. Inhibition of this key mediator has been demonstrated to have a potent anti-inflammatory effect in several models. The role of this cytokine in the pathogenesis of osteoporosis and loss of bone in inflammatory conditions is currently under intense investigation.

Preoperative abnormalities

A review of 31 patients with Cushing's disease showed that the commonest clinical features, in order of frequency, were weakness, thin skin, obesity, easy bruising, hypertension, menstrual disorders, hirsutism, impotence, striae, proximal muscle weakness, oedema, osteoporosis, mental disorders, diabetic GTT, backache, acne, hypokalaemia and fasting hyperglycaemia (Urbanic & George 1981). Fractures occur, and wound healing is poor.

Treatment of thromboembolism in pregnancy

Treatment of thromboembolism is with intravenous heparin initially (although subcutaneous low-molecular weight heparins (LMWHs) are increasingly used) and should not be delayed whilst awaiting investigation. Warfarin is associated with fetal abnormalities and in particular should be avoided in the first trimester and after 36 weeks' gestation. Acute treatment is followed by subcutaneous prophylactic heparin. It had been thought that prophylactic heparin caused stillbirth, prematurity and haemorrhage but more recent reviews controlling for maternal comorbidity have cast doubt on this assertion. Prophylaxis with LMWHs is now recommended because their use is associated with a lower incidence of osteoporosis and thrombocytopenia than unfractionated heparin, they require less monitoring, and they may be given as a once daily dosage. However, LMWHs have a prolonged action and are only partially reversible with protamine, meaning that LMWH prophylaxis may delay administration of regional...

Biology of Aging and its Clinical Implications

Underlying loss of entropy and fractality is a chronic and progressive inflammation that represents the biologic hallmark of aging (11). Seemingly, this inflammation originates from the interaction of individual genetics, diseases, and environment. Increased concentrations of inflammatory cytokines, especially interleukin-6 (IL-6) have been associated with increased mortality, functional dependence, and with a number of geriatric syndromes including dementia and osteoporosis (10, 11). In this perspective, it is not far-fetched to hypothesize that anemia may be both a consequence and a cause of aging (Fig. 2.1). Correction of anemia may break this vicious circle and delay the complications of aging. Geriatric syndromes are conditions that are typical, albeit not unique, of aging. Approximately 20 of cancer patients aged 70 and older had some form of early dementia or sub-clinical depression when screened for these conditions (18). Early detection of dementia may allow prompt...

GI Disorders and ARF Functional Disorders

There are many studies that have examined the role of diet in inflammatory bowel disease (IBD) but there is no evidence that specific immune-mediated reactions to food play a role in the majority of patients with either CD or ulcerative colitis. Elemental enteral feeding and parenteral nutrition can assist in the management of IBD patients with benefits that appear related to improved nutrition and bowel rest (and decreased fecal flow) rather than removal of specific allergens from the diet. Patients in remission should be encouraged to eat a nutritionally balanced diet without restrictions unless they experience intolerance to specific foods. It is typical for IBD patients to be instructed to avoid dairy products but this is unnecessary in most cases. Apart from those with symptomatic lactose intolerance (in which case they should still be able to eat most cheeses and yogurts) or rare instances of cow's milk protein allergy, IBD patients should be encouraged to consume dairy products...

Reducing Behavioral Risk Factors

Over the past few decades, the health benefits of physical activity have been well documented through epidemiologic studies (US DHHS 1996). Physical inactivity is increasingly recognized as a major risk factor for coronary heart disease and is also a risk factor for a variety of other chronic diseases including colon cancer, non-insulin-dependent diabetes, and osteoporosis (US DHHS 1996). Policy changes show promise in reducing physical inactivity (King et al. 1995). Organizational policies in the workplace can influence physical activity without passage of any type of law or regulation. For example, employers can enact policies that encourage walking during coffee breaks or can provide on-site exercise facilities.

Cross Sectional Studies

The main problem with cross-sectional study designs in etiologic research is the difficulty of sorting out temporal relationships. For example, a cross-sectional study of the relationship between calcium consumption and osteoporosis might find that those with high calcium consumption were more likely to have osteoporosis than those without, but this finding might be because people who know that they have osteoporosis increase their calcium consumption when told of this diagnosis. Interpretation of cross-sectional studies in terms of etiology is clear only for potential risk factors that will not change as a result of the disease, such as ABO blood groups or HLA antigens.

What Information Is Provided by Imaging

Noninvasive imaging technologies have become increasingly important over the past 20 years in the management of human diseases. Diagnostic radiology is the medical specialty that is responsible for imaging, providing critical information in three general areas, namely (i) anatomy blood flow, (ii) metabolism, and (iii) receptor expression. The first area is the most widely applied in terms of the number of studies. This type of imaging affords an opportunity to detect the abnormality, since many conditions result in the disruption of normal anatomy, function, or blood flow. One example is the detection of a mass in an abnormal location on a chest radiograph, which, with further tests leads to a diagnosis of cancer. Another example is the identification of fractures following traumatic injury, or decreased bone density resulting from osteoporosis. These basic radiology techniques remain an important component of disease management. They are routinely accomplished by radiography and...

Estrogen Replacement Therapy for Breast Cancer Survivors

Agents and other drugs that cause amenorrhea in 84 percent of women aged 35 to 44 years. Other studies indicate that this treatment causes permanent ovarian failure in 86 percent of women > 40 years of age.2 As a result, a larger number of women will potentially be rendered menopausal in the fourth, and fifth decades of their lives, which has serious consequences in terms of the risk of cardiovascular disease and osteoporosis.

Managing Age Related Disorders

The most common disorders of the elderly are dementia, cardiovascular disease, osteoporosis, and incontinence. It is not unusual for elderly patients to suffer from all these disorders simultaneously. OSTEOPOROSIS Diminished bone mass can be determined most conveniently with special X-ray machines (dual energy X-ray absorptiometry) or with ultrasound densitometry. Both procedures determine the density as g cm2, which is compared to normal values from a younger population and is used to estimate the likelihood of fracture. The first attempts to manage this disease involve a diet rich in calcium and vitamin D, along with regular weight-bearing exercises. Hormone replacement therapy has also been recommended, for men and women, but as discussed in a previous chapter, this approach can lead to dangerous side effects. An alternative drug therapy involves the use of bisphosphonates, antiresorptive drugs that are known to increase bone mass. The bisphosphonate, alendronate, was shown to...

Mutants Who Live Longer

The wild-type animals developed such tumors. Surprisingly to the authors, the mutant mice lived shorter by about 20 . Shortening of the life span proved to be a result of the fact that in the mutants, aging started 20 earlier than in control. On the other hand, when started, aging developed in the same time scale in two groups of animals studied. Aging of the mutant mice showed many traits similar to those in the wild type, namely, reduction of body weight loss of mass of liver, kidney, and spleen lymphoid and muscle atrophy osteoporosis and hunchbacked spine. It proved to be difficult to diagnose the reason of death for the old mutants. An impression arose that total living strength of the organism was slowly decreased and, after all, becomes lower than some critical level required to maintain the life. Just these symptoms should accompany a death caused by massive apoptosis of cells in important organs.

Mild Moderate Acute Crohns Colitis

Corticosteroids are effective inductive therapies for patients with moderate-severe Crohn's colitis or for patients with mild-moderate disease that has not responded to amino-salicylates and or antibiotics. Controlled release budesonide formulations are also efficacious for mild-moderate CD involving the right colon, but are not effective for more distal colonic disease. Doses of 40 to 60 mg daily of prednisone (or up to 1 mg kg d) are initiated until a clinical response has been established. Subsequent tapering is individualized according to the rate of response. Generally, the dosage is gradually reduced by 5 mg week until the drug can be ceased or symptoms flare. In the NCCDS, 78 of patients responded to steroids given in this way. The response to budesonide is somewhat less and neither systemic nor nonsystemic steroids are efficacious at preventing relapse. Indeed, after a course of corticosteroids, approximately 75 of patients will either have a flare of disease activity or...

Hepatic Osteodystrophy

The mechanism of metabolic bone disease in patients with liver disease is multifactorial. The liver is a source of factors involved in bone remodeling and these factors are reduced in chronic liver disease. Patients with liver disease have impaired osteoblast proliferation and thus decreased bone formation. The liver is a source of insulin-like growth factor (IGF)-1, which is important in bone remodeling. Animal data suggest that the decrease in IGF-1 in cirrhosis results in decreased bone formation. In humans, however, the correlation between IGF-1 and osteopenia is less clear. OPG is also produced by the liver, and reductions in this may result in increased osteoclast activity. In general cholestatic liver diseases are associated with lower BMD than noncholestatic liver diseases. In particular patients with PBC appear to have decreased BMD but this may also occur because patients are generally older, postmenopausal women. There are also data to suggest that patients with PBC or...

Supplemental Reading

Caballeria L, Pares A, Castells A, et al. Hepatocellular carcinoma in primary biliary cirrhosis similar incidence to that in hepatitis C virus-related cirrhosis. Am J Gastroenterol 2001 96 1160-3. Corpechot C, Carrat F, Bonnard AM, et al. The effect of ursodeoxycholic acid therapy on liver fibrosis progression in primary biliary cirrhosis. Hepatology 2000 32 1196-9. Corpochet C, Carrat F, Poupon R, Poupon RE. Primary biliary cirrhosis incidence and predictive features of cirrhosis development in ursodiol-treated patients. Gastroenterology 2002 122 652-8. Dickson ER, Grambsch PM, Fleming TR, et al. Prognosis in primary biliary cirrhosis model for decision making. Hepatology 1989 10 1-7. Gluud C, Christensen E. Ursodeoxycholic acid for primary biliary cirrhosis (Cochrane Review). Cochrane Database Syst Rev 2002 1 CD000551. Guanabens N, Pares A, Monegal A, et al. Etidronate versus fluoride for treatment of osteopenia in primary biliary cirrhosis preliminary results after 2 years....

Osteogenesis imperfecta

The general term given to a heterogeneous group of inherited disorders of collagen, caused by mutations of one of the two genes encoding collagen type 1, COL1A1 and COL1A2. Predominant features are osteopenia, multiple fractures, severe bony deformities, and short stature. Four broad types have been identified, but increased knowledge of the large number of genetic mutations suggests that further expansion of groupings will be needed (Cole & Cohen 1991,Marini 1998). In less severe cases, diagnosis may be delayed, but the resultant bony fragility, and propensity to fractures, may result in

Prophylactic Oophorectomy andor Hysterectomy

It has been postulated that hysterectomy may have some secondary effects by affecting ovarian blood flow and ovulation. Schairer and colleagues evaluated 15,844 women undergoing surgery in the Uppsala health care region of Sweden and found a 50 percent reduction in breast cancer risk in those women who underwent bilateral oophorectomy prior to age 50 years, compared with the risk of the background population.146 Hysterectomy alone had no consistent association with change in breast cancer risk. In a case-control series from Italy, women who underwent premenopausal oophorectomy with hysterectomy or hysterectomy alone had reduced relative risk of developing breast cancer (0.8 and 0.7, respectively).147 However, given the importance of the ovarian function in maintaining cardiovascular and bone health, there are presently no indications for recommending these procedures as prophylaxis against breast cancer in any subset of patients.

Prominent Occiput Infant

Osteogenesis Imperfecta Type Skull

Radiograph of the skull in an infant with osteogenesis imperfecta. Note the lack of mineralization with wormian bones. Clinically one feels multiple small bones over the skull. There is a thin cortex with minimal skull ossification and generalized osteoporosis.

Climacteric and Menopause

With age, the ovaries have fewer remaining follicles and those that remain are less responsive to gonadotropins. Consequently, they secrete less estrogen and progesterone. Without these steroids, the uterus, vagina, and breasts atrophy. Intercourse may become uncomfortable, and vaginal infections more common, as the vagina becomes thinner, less distensible, and drier. The skin becomes thinner, cholesterol levels rise (increasing the risk of cardiovascular disease), and bone mass declines (increasing the risk of osteoporosis). Blood vessels constrict and dilate in response to shifting hormone balances, and the sudden dilation of cutaneous arteries may cause hot flashes a spreading sense of heat from the abdomen to the thorax, neck, and face. Hot flashes may occur several times a day, sometimes accompanied by headaches resulting from the sudden vasodilation of arteries in the head. In some people, the changing hormonal profile also causes mood changes. Many physicians prescribe hormone...

Fifth metatarsal head resection

This procedure is well suited for older sedentary individuals, and for patients with osteopenia or osteomyelitis of the metatarsal head, where a transpositional osteotomy is not appropriate. Although transfer lesions (callus or ulcer) have been reported to occur beneath adjacent

Fractures and Their Repair

Bone Fractures And Broken Blood Vessils

There are multiple ways of classifying bone fractures. A stress fracture is a break caused by abnormal trauma to a bone, such as fractures incurred in falls, athletics, and military combat. A pathologic fracture is a break in a bone weakened by some other disease, such as bone cancer or osteoporosis, usually caused by a stress that would not normally fracture a bone. Fractures are also classified according to the direction of the fracture line, whether or not the skin is broken, and whether a bone is merely cracked or broken into separate pieces (table 7.3 fig. 7.17). Inhibits osteoclast activity, but if secreted in excess (Cushing disease) can cause osteoporosis by reducing bone deposition (inhibiting cell division and protein synthesis) Stimulates osteoblasts and prevents osteoporosis Essential to bone growth enhances effects of growth hormone, but excesses can cause hypercalcemia, increased Ca2+ excretion in urine, and osteoporosis Fracture of the distal end of the radius and ulna...

Diets and Specific Nutrient Requirements

Patients with excessive fecal volume losses are also losing significant amounts of bicarbonate, magnesium, and selenium. Replacement of bicarbonate can be accomplished with sodium bicarbonate tablets. This may be necessary to maintain normal acid-base status, and help prevent development of osteoporosis. Magnesium replacement may be difficult because of the cathartic effect of all currently available oral supplements and the poor bioavailability of the enteric-coated tablets. Replacement via injection is painful. Therefore, periodic IV replacement may be required. Because the vast majority of magnesium is found intra-cellularly, measurement of serum concentration may not accurately reflect magnesium status. Therefore, 24-hour urine magnesium should be routinely followed. Values above 70 mg daily suggest adequate magnesium stores. Selenium status can be followed by measurement of the plasma selenium concentration by a laboratory experienced in the measurement of this trace metal. It...

What is the difference between a DXA and a pDXA

The pDXA testing is only done for screening purposes. A diagnosis of osteoporosis can only be made using DXA. So if your pDXA shows some bone loss, your clinician would likely recommend a DXA to evaluate your hip and spine. pDXA testing is not considered appropriate for monitoring bone density in patients undergoing treatments for osteoporosis because response to treatments is not as evident in the bones of your hands, arms, and feet. pDXA testing on your forearm, usually your nondominant arm (for example, your left forearm if you are right handed), is not recommended if your forearm has been previously fractured, if it has a dialysis graft site, if it has been subject to prolonged immobilization, or if there is severe weakness or paralysis of that arm.

Inflammatory Bowel Disease

Osteoporosis In addition to its harmful effect on CD, tobacco also contributes to the development of osteoporosis among patients with IBD. The combination of a chronic inflammatory disease, frequent use of corticosteroids, and smoking increases the risk of osteoporosis dramaticially. This is especially true for women. This is another reason for cessation of smoking in IBD. Physicians should also look for osteoporosis early because effective therapies are available and it is usually asymptomatic before serious complications occur.

Nucleotide Reverse Transcriptase Inhibitors Tenofovir Disoproxil Fumerate Viread

When taken with efavirenz and lamivu-dine, tenofovir was more likely to cause bone mineral density decreases than stavudine taken with efavirenz and lamivudine. Over time, this could lead to osteoporosis with bone breakage of the hip, spine, wrist, or other small bones.

Hutchinson Gilford Progeria Syndrome

- Skeletal alterations include macrocephaly with craniofacial disproportion (frontal bossing, ectropion, small, low-set ears, micrognathism, long beaked nose, persistent fontanels, hypoplastic clavicles, generalized osteopenia osteoporosis with repeated pathologic fractures (Khalifa 1989), acro-osteolysis of distal phalanges or clavicles, progressive joint stiffness, coxa valga with horseback-riding stance

What is kyphoplasty Would it help my spinal fractures

Spine Exercise

Spinal (or vertebral) fractures are a major concern for men and women with osteoporosis because they can lead to severe pain and disability (see Question 84). These fractures can also lead to kyphosis (see Figure 13 in Question 83). The spine deteriorates and curves due to fractures in individual vertebrae. Most osteoporotic vertebral fractures are traditionally treated with pain medications and a gradual return to normal activities. Although back braces to prevent twisting and support the spine were used in the past, they are infrequently Figure 16 Exercises to prevent or improve deformity and reduce pain. Source Duke University Medical Center's Bone and Metabolic Disease Clinic. Reprinted with permission. Gold DT, Lee LS, Tresolini CP, eds. Working with Patients to Prevent, Treat, and Manage Osteoporosis A Curriculum Guide for the Health Professions, 3rd ed. Durham, NC Center for the Study of Aging and Human Development, Duke University Medical Center 2001. Figure 16 Exercises to...

Have early menopause What does this mean for my bones and will I need treatment

When you are trying to cope with the treatments for cancer, it's hard to think about your bones and the possibility of developing osteoporosis so early in life. But the fact is that when you stop having your menstrual periods for whatever reason, your risk of bone loss increases. When you experience a natural menopause around the average age of 51, you can expect to lose bone most rapidly in the 4 to 8 years following menopause (starting one year after your last period). There are several reasons why you might experience menopause much earlier than that and, therefore, need to cope with a larger stretch of your life without estrogen, an important hormone for bone growth. Surgically-induced menopause (removal of both ovaries) will cause you to lose bone fairly rapidly. It is important for you to prevent bone loss by getting the appropriate amounts of calcium (1,200 to 1,500 mg), Vitamin D (400-800 IU), other necessary nutrients (see Table 6 in Question 54), and exercise. You should...

Subclinical Cushings Syndrome

Preclinical or subclinical Cushing's syndrome is caused by autonomous glucocorticoid secretion in patients who may have no overt, or only minimal, clinical signs and symptoms of full-blown Cushing's syndrome. Subclinical hypercortisolism has been reported in 5 to 20 of patients with adrenal inci-dentalomas. Depending on the amount of glucocor-ticoid secreted by the tumor, the clinical spectrum can vary considerably. Diagnostically, patients often have a slightly attenuated diurnal rhythm of cortisol secretion. They may also have a suppressed contralateral adrenal gland. Removing the hypersecret-ing adrenal gland, even without removing the normal gland, may result in life-threatening acute adrenal insufficiency. The natural history of this condition is unclear because long-term prospective studies are lacking. Subclinical Cushing's syndrome may progress to overt Cushing's syndrome. Some patients with subclinical Cushing's syndrome have subtle biochemical abnormalities that are reversed...

What is Boniva ibandronate Is it also calledBonviva

Boniva (ibandronate) was recently approved by the FDA for once-a-month dosing. It is the first and only bisphosphonate that can be taken once a month. Although currently only available in the United States, Boniva will be marketed under the brand name Bonviva when it is approved in other countries. Monthly Boniva, taken as one 150-mg tablet, and daily Boniva, taken as 2.5-mg oral tablets, were recently approved for the prevention and treatment of postmenopausal osteoporosis. The daily dose is available in the United States on a limited basis because the monthly dose is more effective and it is easier to remember a monthly pill. Both the daily and monthly dosages increased BMD at the lumbar spine and other bones, but after one year of treatment, bone mineral density of the lumbar spine had increased more with the monthly dose as compared to the daily dose. Although the long-term effects of Boniva are not known yet, the half-life of Boniva is measured in days and therefore does not stay...

Clinical Manifestations

Bones refer to the skeletal manifestations of hypercalcemia, which range from myalgias and arthralgias to osteopenia and severe osteoporosis, seen in 40 to 70 of cases of persistent hyperparathyroidism. The radiographic manifestations of prolonged hyperparathyroidism, subperiosteal bone resorption (Figure 7-1), salt and pepper skull, dif- fuse spinal osteopenia, or osteitis fibrosis cystica (abnormal calcium deposits in soft tissue or muscles), are seen in 41 to 91 of patients with parathyroid carcinoma, compared with 5 of benign hyperparathyroidism.911 The concurrent development of skeletal and renal manifestations of hypercalcemia is also seen much more commonly in the presentation of parathyroid carcinoma than in benign hyper-parathyroidism. It is a distinguishing feature of the higher level of hypercalcemia and hyperparathy-roidism associated with parathyroid carcinoma.

Exercise and Senescence

There is no clear evidence that exercise will prolong your life, but there is little doubt that it improves the quality of life in old age. It maintains endurance, strength, and joint mobility while it reduces the incidence and severity of hypertension, osteoporosis, obesity, and diabetes melli-tus. This is especially true if you begin a program of regular physical exercise early in life and make a lasting habit of it. If you stop exercising regularly after middle age, the body rapidly becomes deconditioned, although appreciable reconditioning can be achieved even when an exercise program is begun late in life. A person in his or her 90s can increase muscle strength two- or threefold in 6 months with as little as 40 minutes of isometric exercise a week. The improvement results from a combination of muscle hypertrophy and neural efficiency.

Examination of the Gastroenterology Patient for Metabolic Bone Disease

The diseases discussed in this chapter are all associated with inappropriately low BMD resulting from a variety of distinct mechanisms. Given that the causes of bone loss are distinct, the examination of the patient with GI-related metabolic bone disease should be tailored to the particular situation. Figure 55-2 presents an algorithm that is useful in various scenarios. Diseases such as celiac disease commonly cause osteoporosis. Indeed, in studies of asymptomatic osteoporotic women, 10 demonstrate antitissue transglutaminase antibodies suggesting that celiac disease may be a contributing factor for osteoporosis in the general population (Nuti et al, 2001). Diseases such as UC and, to a lesser extent, CD result in decreased BMD because of cumulative corticosteroid use therefore tests of BMD such as dual-energy x-ray absorptiometry (DXA) are more important following steroid exposure. In addition to DXA testing, other tests such as quantitative (usually calcaneal) Osteoporosis...

Ciclesonide Asthma Copd [69

Ciclesonide, a new inhaled corticosteroid (ICS), is indicated for the prophylactic treatment of persistent asthma. ICS treatment is a widely accepted standard of care for maintenance therapy of chronic asthma, and the currently available agents include fluticasone propionate, budesonide, triamcinolone acetonide, flunisolide, and beclomethasone dipropionate. These agents exert their potent anti-inflammatory effects via modulation of the glucocorticoid receptor (GR). Although ICS drugs are generally safe and well tolerated compared with oral corticosteroids, many have measurable systemic exposures, and concerns over potential side effects resulting from it severely limit the dose at which they can be administered for long-term therapy. Systemic adverse effects associated with corticosteroids include HPA axis suppression, osteoporosis, abnormal glucose metabolism, cataracts, and glaucoma, some of which could potentially occur with the long-term use of high dose ICS. The key...

Should I stop exercising if I break a bone

Hip Fracture Locations

I always hear about older folks fracturing their hips. Is this because of osteoporosis or because of the frequency offalls How are broken hips repaired Breaking a hip may be the first sign that someone has osteoporosis. Because 95 of hip fractures occur as a result of falls, it is important to look at ways of preventing them (see Question 79). Breaking a hip may be the first sign that someone has osteoporosis. If you have already lost 30 to 40 of the bone in your hip, then bone loss may be visible on the x-ray. If your hip fracture occurs from a low level of trauma (like falling out of bed), you may be diagnosed with osteoporosis without having a bone density test done. If not, then you may not be officially diagnosed with osteoporosis until a bone mineral density test confirms it, although it's unlikely that BMD testing would be done while you're in the hospital. As part of your hip fracture management, you may be placed on a medication to treat osteoporosis (see Question 74). I...

How are MS attacks treated Why are there different drugs to treat attacks of MS

Any opacification (loss of transparency) of the lens or its capsule. Osteoporosis trast, oral steroids had no effect except to double the risk of relapse of optic neuritis as compared with IV Medrol. There often is a rapid response to either drug in patients with acute, severe relapses, but there are no good studies of either IV compared with any dose of oral steroids to evaluate this in MS. The side effects of steroids include an increased risk of infection, including viral, bacterial, yeast, fungal, and parasitic types. This includes progressive multifocal leukoen-cephalopathy (PML), which has been recently reported in two study patients treated with Avonex and Tysabri. Other complications include psychiatric problems, cataracts, osteoporosis, and ischemic necrosis of hips and other joints (as well as others).

Small Arteries and Arterioles

Aging and disease modify vascular structure and function. Hypertension is associated with vasoconstriction, VSM hypertrophy and rarefaction in the microcirculation. Pulse volume, pressure, and velocity are important physiological variables that may function as biologic signals to the endothelium and VSM of the microcirculation. The capillary pulse volume modifies and in turn is modified by microcirculatory structure and function. For example, both MAP and PP affect glomerular filtration rate independently, presumably through direct effects on glomerular filtration pressure 61 . Increased systolic BP or PP is associated with a variety of disorders related to aging, including atherosclerotic cardiovascular disease 62, 63 , heart failure 64 , stroke 65, 66 , cognitive disorders 67-69 , white matter lesions 70, 71 , macular degeneration 72 , renal dysfunction 73 , osteoporosis 74 , and glucose intolerance 75-77 . Abnormal microcirculatory pulsation may participate in the pathogenesis of...

Coronary Artery Disease

Osteoporosis Postmenopausal women are at risk for loss of cancellous bone in the vertebrae and other long bones, which places them at increased risk for fracture. Bone mineral density decreases rapidly within 5 years of menopause due to estrogen deficiency. This ultimately results in microarchitectural deterioration and a progressive increased fracture risk. Postmenopausal untreated women may lose 35 percent of their cortical bone and up to 50 percent of their tra-becular bone. It is estimated that 1.2 million major fractures per year in the United States in women are related to osteoporosis. Fifteen percent of postmenopausal women will suffer wrist fractures, and an even larger number will incur spinal compression fractures. Compression fractures of the vertebral bones may result in loss of stature, pulmonary restriction, and

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A clinical trial has just recently begun to evaluate Forteo as an effective treatment option in women who have used either Fosamax or Actonel without success. In a study of women who had taken either Fosamax or Evista for almost three years, the women who had been on Evista and switched to Forteo built more bone mineral density, and more quickly, than the women who were switched from Fosamax to Forteo. Table 13 contains further information about Forteo. manufactured forms of calcitonin with action essentially identical to those made in the body but with greater potency and longer duration. They have the same amino acids as the calcitonin found in salmon, which is why they're often designated as calcitonin-salmon. Calcitonin is one of the earliest discovered treatments for osteoporosis. Formerly given as a subcutaneous injection, Miacalcin NS is now taken as a once-a-day nasal spray. Fortical is also a once-a-day nasal spray, but has never been available as a subcutaneous injection....

What is a dowagers hump Can it be reversed

Figure 15 Osteoporosis can cause irreversible damage to the spine, leading to significant disability. Courtesy of the National Association of Nurse Practitioners in Women's Health (NPWH). Figure 15 Osteoporosis can cause irreversible damage to the spine, leading to significant disability. Courtesy of the National Association of Nurse Practitioners in Women's Health (NPWH). Once you reach a certain point in the curving of the spine, the kyphosis is not reversible. Figure 15 shows the progression from a spine unaffected by osteoporosis to the point at which the kyphosis resulting from osteoporosis cannot be reversed. After your fractures are healed, it is important to begin an exercise program to prevent kyphosis and to even reverse some of the curve before it reaches the point where it cannot be reversed. Figure 16 shows exercises that can be done to stretch the muscles around the spine, increase flexibility, and reduce the likelihood of more fractures. These are great exercises to do...

Selective Estrogen Receptor Modulators

Preclinical data have shown that raloxifene, an antiestrogen with no estrogen-agonist effect on the uterus, inhibits mammary carcinogenesis in a rat model of breast cancer in a manner similar to tamoxifen when raloxifene is used in combination with 9-cis retinoic acid.97 Clinical trials have been started in an attempt to establish the role of raloxifene in preventing osteoporosis in postmenopausal women, and preliminary

Second Edition

Braverman, 2003 Developmental Endocrinology From Research to Clinical Practice, edited by Erica A. Eugster and Ora Hirsch Pescovitz, 2002 Osteoporosis Pathophysiology and Clinical Management, edited by Eric S. Orwoll and Michael Bliziotes, 2002 Challenging Cases in Endocrinology, edited by


Reflex sympathetic dystrophy (RSD) is a burning pain in the extremity associated with autonomic changes, allodynia, and trophic and motor abnormalities. It is associatied with local osteoporosis (Sudeck's atrophy), and the pain causes a reduced range of motion and leads to contractures.


12q12-14 chromosome, near the gene for the 1-a-hydroxylase enzyme. The VDR is found in the intestinal epithelium, parathyroid cells, kidney cells, osteoblasts, and thyroid cells. VDR also can be detected in keratinocytes, monocyte precursor cells, muscle cells, and numerous other tissues. The allele variations for the vitamin D receptor. Two allele variations exist for the vitamin D receptor (VDR) the b allele and the B allele. In general, normal persons with the b allele seem to have a higher bone mineral density 9 . Among patients on dialysis, those with the b allele may have higher levels of circulating parathyroid hormone (PTH) 7,9,10,11 . COOH carboxy terminal NH2 amino terminal. (From Root 7 with permission.)

Figure 639

Pathophysiology of the milk-alkali syndrome. The milk-alkali syndrome comprises the triad of hypercalcemia, renal insufficiency, and metabolic alkalosis and is caused by the ingestion of large amounts of calcium and absorbable alkali. Although large amounts of milk and absorbable alkali were the culprits in the classic form of the syndrome, its modern version is usually the result of large doses of calcium carbonate alone. Because of recent emphasis on prevention and treatment of osteoporosis with calcium carbonate and the availability of this preparation over the counter, milk-alkali syndrome is currently the third leading cause

Maria T AbreuMD

Clinicians caring for patients with gastrointestinal (GI) or liver diseases focus primarily on the intestinal or hepatic manifestations of the disease but there are several silent extraintestinal complications that merit attention. one of these systemic consequences is bone loss. osteopenia is defined by a WHO group as a decrease in bone mineral density (BMD) by > 1 standard deviation compared to a control population (Table 55-1), and osteoporosis is defined as a decrease in BMD by > 2.5 standard deviations compared to a control population. These cut offs were chosen to reflect an increase in fracture risk with diminished BMD, but other factors, in addition to BMD, may increase the likelihood of a fracture. Table 55-2 lists the GI or liver disorders associated with premature or excessive bone loss and the estimates of osteopenia and osteoporosis in these patients. Perhaps more important is the increased risk of vertebral or other skeletal fractures. There are morbid complications,...

Preventive Therapy

Because PBC is a progressive disease that often eventually results in the need for liver transplantation, it is particularly important that patients remain as healthy as possible to improve their long-term outcome. The major preventable complications of PBC include osteoporosis and variceal hemorrhage. However, it is important to counsel patients on other modifiable lifestyle choices as well. Particular attention should be paid to smoking and obesity because both have the potential to modify transplantation outcome. Osteoporosis It remains somewhat controversial whether osteoporosis is truly a complication of PBC. Although it is common among patients with PBC, this disease affects predominantly middle-aged women who are at risk for osteoporosis for other reasons. In any case, patients should be screened for osteopenia or osteoporosis using bone densitometry. All patients with PBC should take calcium and vitamin D, either as a supplement or as part of their regular diet. The...


An under-appreciated cause ofosteoporosis in patients with GI or liver disease is hypogonadism. Patients treated with glucocorticoids for any reason suppress gonadal and adrenal sex hormone production via suppression of the hypothalamic-pituitary axis. Women with CD, celiac disease or severe weight loss from any cause often do not menstruate and must be treated as if postmenopausal (Sher et al, 1994). Women that are postmenopausal and have coexistent GI diseases such as CD or celiac disease are at very high risk for osteoporosis and fractures (Clements et al, 1993). Similarly women with primary biliary cirrhosis (PBC) who are postmenopausal are at significantly higher risk than younger women for osteoporosis and fractures (Solerio et al, 2003). Estrogen replacement, especially in younger women who are not postmenopausal, should be considered. Estrogen replacement therapy has been shown to be safe and effective in patients with PBC (Monegal et al, 1997). Men with CD, celiac disease,...

Treatment Strategies

In spite of the variety of mechanisms leading to metabolic bone disease, there are several treatment strategies that are broadly applicable. The best strategy is prevention (eg, avoidance of glucocorticoids to treat IBD whenever possible). Effective treatment of the underlying GI disease (eg, gluten-free diet in celiac disease) can improve BMD within a year (Mora et al, 1998 Szathmari et al, 2001 McFarlane et al, 1995). Of course, even at the time of diagnosis, bone loss may be well on its way. Low BMD is a result of decreased bone formation and or increased bone resorption. Most therapies for osteoporosis aim to inhibit bone resorption (eg, bisphosphonates Table 55-4 ). Bisphosphonates are highly effective for both prevention (Saag et al, 1998 Cohen et al, 1999 Reid et al, 1998) and treatment of glucocorti-coid and postmenopausal osteoporosis (Reid et al, 1998 Adachi et al, 1996) (see Table 55-4). As a class of drugs they are more effective than vitamin D, fluoride or calcitonin for...


The first patient was a 42-year-old female, with a 20-year disease duration, who presented with severe orogenital ulcerations, oligoarthritis, and low-grade fever. During the past years her orogenital ulcerations responded only to moderate-to-high doses of steroids, which had resulted in severe, steroid-induced osteoporosis. Any attempt in the past to reduce the daily dose of methylprednisolone below 8 mg using cyclosporine A and or azathioprine was unsuccessful. At the initiation of infliximab treatment, which was decided mainly to treat severe genital ulcers, she was on methylprednisolone 0.2 mg kgr day and colchicine.