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“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Friday, February 27, 2009
    "Snap" Isn't Good

    OK. What shall we talk about today?

    I know. Let's start with the telephone call I got yesterday from the ER. They were seeing a patient of mine, an elderly woman who's been bed bound for several years following a stroke. Yesterday while bathing her, the caregiver raised her (the patient's) arm so as to do a better job - and heard a loud SNAP.

    That's how bad osteoporosis can get. You snap someone's humerus in two, just by raising their arm.

    Granted, it usually isn't that bad. If you're immobile and non-weight bearing that really accelerates the process, and no, calcium supplement isn't going to be enough to fix that. Bone is like muscle in the sense of "Use it or lose it"; it reacts to being stressed by strengthening itself. Bones are active, not static; bone matrix is constantly being revised to respond to stress. This is why astronauts are at extra risk for osteoporosis. If you spend time in a zero gravity environment, bone strength decreases. Weight bearing exercise like walking, jogging, weights are all helpful in maintaining bone structure but swimming and stationary bicycling are not.

    I spend a lot of time trying to convince patients to take medication for osteoporosis. Most patients, at least in my experience, think that calcium alone is enough. It's not, not if you are on that slippery slope of bone loss. But you should take calcium, and these days I recommend calcium citrate with vitamin D. Calcium citrate is more easily absorbed than calcium carbonate (the kind you get in antacids). Also, you need stomach acid to absorb calcium properly. There is evidence that long-term PPI or H2 blocker use (i.e., meds like ranitidine or omeprazole) can be a risk factor for osteoporosis because it means that you're absorbing less calcium.

    We have lots of great new medications to treat bone loss now. Probably the most commonly used are the biphosphonates like alendronate and risedronate. (US brand names: Fosamax and Actonel.) These are the ones that can irritate the esophagus and have to be taken on an empty stomach, but they work the best. I also use raloxifene (Evista), mostly if someone can't tolerate a biphosphonate.

    Why do we treat? It turns out that fractures are much more of a health risk than you'd think. Here's an article about mortality risk associated with hip fractures: in this study, a cohort of 120 elderly patients were followed after sustaining a fracture. Six months out, 18% had died and another 29% were institutionalized. That's 47 percent - nearly half - who never made it home.

    Other risks for osteoporosis include being thin (hah), heavy caffeine intake, smoking and alcohol. Lifestyle does make a difference here, but the main risks are age and genetics. If osteoporosis runs in your family it means you have a higher risk of getting it.

    My patient isn't a candidate for surgery. She's too frail and her bone quality is so bad the surgeon wouldn't be able to pin the bone. So she's in an immobilizer and she's lost the use of her good arm (the other one is the stroke-affected arm).

    Take your calcium, exercise and cut back on the coffee.




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