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WELL Duquesne University Mylan School of Pharmacy

UPDATE from the Pharmacy Care Awareness Program

March-April 2003

Osteoporosis—A Silent Disease


id you know that one in every two women and one in eight men over 50 will have an osteoporosis-related fracture in their lifetime? Approxi mately 10 million U.S. individuals have been diagnosed with osteoporosis, and 18 million are at increased risk for the disease due to their low bone mass. Nearly 80 percent of these people are women. More than 1.5 million fractures are attributed to osteoporosis each year. Osteoporosis is characterized by low bone mass and deterioration of bone tissue, both of which increase the risk of various types of fractures. Osteoporosis is often referred to as the “silent disease” because bone loss occurs without symptoms, until bones become so frail that any abrupt strain, bump, or fall causes a fracture. Bone tissue is constantly formed and removed (resorption). Through the teenage years, new bone is added faster than old bone is replaced. Peak bone mass is reached around age 30, and shortly thereafter, resorption begins to exceed bone formation. Osteoporosis develops when resorption progresses too quickly or replacement occurs too slowly. The

most rapid bone loss occurs in the first few years following menopause, placing women at a higher risk of developing the condition. Body frame size, ethnicity, and family history also play a major role in the risk of developing the disease. Small-framed women are more likely to develop osteoporosis. Asian and Caucasian women are at highest risk, while African-American and Latino women have a lower, but still significant, risk of osteoporosis. Some risk factors can be controlled to decrease the chance of developing osteoporosis. A long-term diet low in calcium and vitamin D along with poor eating habits can contribute to low bone mass, as well as smoking, excessive alcohol, and an inactive lifestyle. The use of certain medications such as glucocorticoids may have damaging effects on the skeleton. Other medications that may cause bone loss include anticonvulsants, methotrexate, cholestyramine, and cyclosporine. On the other hand, weight-bearing exercises can help increase bone density. So how do you know if you are at risk of osteoporosis? Your doctor may recommend that you have your bone mass measured by a bone mineral density (BMD) test. The “gold

standard” for the diagnosis of osteoporosis is the central measurement of bone mass by a process known as dual X-ray absorptiometry (DXA). This safe and painless test can be performed in the spine, wrist, hip, heel, or hand. By determining bone mass, the DXA can confirm a diagnosis of osteoporosis, determine the rate of bone loss, and predict chances of future fracture. For more information on osteoporosis, visit the following Web sites: • National Institutes of Health • National Osteoporosis Foundation

Upcoming Events Mark Your Calendar MARCH – National Poison Prevention Month • March 12, 2003, 11:30 a.m.-12:30 p.m. Blood Pressure Check-Up • March 19, 2003, 12:00-12:50 p.m. “Osteoporosis: Are You At Risk?” Christine O’Neil, Pharm.D.

All events take place in the Center for Pharmacy Practice, Room 432 Mellon Hall, unless otherwise stated.

• March 26, 2003, 11:30 a.m.-12:30 p.m. Blood Pressure Check-Up APRIL – Alcohol Awareness Month • April 2, 2003, 12:00 -12:50 p.m. “Osteoporosis: How to Select a Calcium Supplement”

• April 9, 2003, 8 a.m. -2 p.m. Lipid (Cholesterol) Screening – Call for an appointment (x1093) Blood Pressure Check-Up Alcohol Awareness Information Table Union-fourth floor • April 23, 2003, 9 a.m. –noon Osteoporosis Risk Assessment Complimentary Heel Ultrasound Screening – Call for an appointment (x1093) Blood Pressure Check-Up MAY – National Osteoporosis Prevention Month!

The Role of Calcium in Osteoporosis Calcium is essential for the maintenance of healthy bone. Table 1 indicates the amount of calcium found in a variety of foods. Table 1: Calcium Content of Some Foods* Food Milk, skim Yogurt (low fat, fruit flavored) Swiss cheese Figs, dried Tofu, raw, firm Calcium-fortified cereals Cheddar cheese Calcium-fortified orange juice Mozzarella cheese, part-skim Collards, cooked from frozen American cheese, processed Creamed cottage cheese Sardines, canned in oil Parmesan cheese, grated Mustard greens Kale, boiled Broccoli, boiled

Serving Size 1 cup 8 ounces 1 ounce 10 figs ½ cup ¾ cup 1 ounce 6 ounces 1 ounce ½ cup 1 ounce 1 cup 2 sardines 1 tablespoon ½ cup ½ cup ½ cup

Table 2: Recommended Calcium Intake* Calcium (mg) 302 300 272 269 258 250 204 200 183 179 174 126 92 69 52 47 36

*Adapted from: Treatment Guidelines from The Medical Letter. 2002;1:13-8.

Depending on age, an appropriate calcium intake falls between 1000 and 1300 mg per day (Table 2). A calcium supplement may be used if you are not getting enough calcium from the foods you eat. Calcium supplements are available in a variety of salts such as calcium carbonate, calcium citrate, etc. Each of these products contains varying concentrations of elemental calcium. They differ in the amount of calcium that may be absorbed as well as potential adverse effects. In most individuals, calcium carbonate preparations such as OsCal and Tums are adequate. Patients with decreased concentrations of gastric acid may absorb calcium less efficiently. People who take medications that suppress gastric acid production such as Tagamet or Prilosec should preferably take calcium citrate products. Also, those who experience gastric effects such as constipation or bloating from calcium carbonate preparations may better tolerate the calcium citrate. Vitamin D is necessary for optimal absorption of calcium. Only about 20-30% of calcium is absorbed when taken alone. A daily intake of 400 and 800 IU of vitamin D is usually recommended.

Ages Birth – 6 months 6 months – 1 year 1 – 3 years 4 – 8 years 9 – 13 years 14 – 18 years 19 – 30 years 31 – 50 years 51 – 70 years 70 or older Pregnant and lactating 14 – 18 years 19 – 50 years

Amount mg/day 210 270 500 800 1300 1300 1000 1000 1200 1200 1300 1000

*Based on guidelines from the National Osteoporosis Foundation

Treatment and Prevention A discussion of the drug treatment and prevention of osteoporosis is included in the Duquesne Daily version of this newsletter. Please access the Duquesne Daily site for additional information on this topic. Visit

Newsletter Contributors

A publication of the Duquesne University Mylan School of Pharmacy

John G. Lech, Pharm.D. Christine O’Neil, Pharm.D. Stacey L. Bergamasco, Pharm.D. Candidate Conni M. McGrath, Pharm.D. Candidate

Pharmacy Care Awareness Program (PCAP) & Pharmaceutical Information Center (PIC) Additional information on any of the topics discussed may be obtained from the Pharmaceutical Information Center by calling 412-396-4600 or sending an e-mail to Questions about screenings or programs: Christine O’Neil, Pharm.D, B.C.P.S. 412-396-6417 03/03 1.5M DIH

Medications for the Treatment and Prevention of Osteoporosis


anagement of osteoporosis usually includes proper nutrition and exercise along with safety precautions to prevent falls. Prescription medications can also slow the rate of bone loss, increase bone density, and reduce fracture risk. Presently, medications classified chemically as “bisphosphonates� (alendronate, risedronate, zoledronic acid, and pamidronate), calcitonin, estrogens, raloxifene, and parathyroid are prescribed for the prevention and/or treatment of osteoporosis. Bisphosphonates work by decreasing bone resorption. As a result, new bone formation continues and subsequently increases bone density. Specific drugs in this class include the oral formulations Fosamax (alendronate) and Actonel (risedronate). Common adverse effects of these agents include abdominal pain, heartburn, and irritation of the esophagus. The patient is advised to take these medications on an empty stomach, preferably first thing in the morning. It is also important to take the drug with eight ounces of water (no other liquid) at least 30 minutes before eating or drinking. Patients must remain upright during this 30-minute period to prevent damage of the esophagus. Calcitonin is a naturally occurring hormone involved in calcium regulation and bone metabolism. In most women who are more than five years past menopause, calcitonin has been shown to slow bone loss, increase spinal bone density, and relieve pain associated with fractures. Calcitonin is available as an injection or nasal spray; its prescription name is Miacalcin. In the injectable form, Miacalcin may cause flushing of the face and nausea, whereas the nasal preparation may cause rhinitis.

Estrogen Replacement Therapy (ERT)/ Hormone Replacement Therapy (HRT) has been shown to increase bone density and decrease fractures in postmenopausal women. Side effects may include vaginal bleeding, breast tenderness, and mood disturbances. The Women’s Health Initiative (WHI) has confirmed that synthetic HRT is associated with a modest increase in the risk of breast cancer, strokes, heart attacks, and blood clots. Evista (raloxifene) is similar to estrogen in terms of its effects on bone, but it is considered an anti-estrogen on the uterus and breast. Raloxifene has been shown to decrease the risk of estrogen-dependent breast cancer by 65 percent over four years. Even though adverse effects are not common, those reported include hot flashes and deep vein thrombosis.

In order to gain optimal Parathyroid hormone increases bone density by stimulating new bone formation. Forteo (teriparatide) is a form of parathyroid hormone recently approved by the FDA for the treatment of osteoporosis in postmenopausal women and in men who are at high risk for fractures. This drug is self-administered as a daily injection. Adverse effects may include nausea, headache, dizziness, and leg cramps. It is very important for men and women to be aware of the common risk factors associated with osteoporosis. Knowledge about the disease and recognition of risk factors are two methods to prevent osteoporosis or to slow its progression. As discussed, there are many ways to treat this disease. It is never too early or too late to start your prevention program. Please contact your physician or pharmacist if you have any questions regarding osteoporosis or the drugs used in its management.

results from any of these treatment options, they must be taken with adequate calcium (1000 mg-1500 mg/day) and vitamin D (400 IU-800 IU/day).