Many lung diseases require steroid medications for treatment. Although these medications can be life-saving for some patients, they can cause many side effects, including osteoporosis. Additionally, many older patients who are not taking steroid medications are at risk for osteoporosis because of age or smoking history. Early screening for osteoporosis and use of medications to prevent bone loss can greatly reduce the chance of bone fractures.
All patients with bone loss or who are at risk of bone loss should stop smoking and exercise regularly. Both of these lifestyle modifications can increase bone density and reduce the risk of fractures. Aerobic exercise (walking, treadmill, exercise bicycle) is best and should be done for a minimum of 30 minutes three times per week.
Patients taking glucocorticoid steroids should consume 1,000 to 1,500 mg of calcium per day. This can be in the form of calcium tablets or food. An 8 oz glass of milk, calcium-fortified orange juice, or yogurt contains about 300 mg of calcium. Calcium supplements are available as either calcium citrate or calcium carbonate. Of the two, calcium citrate (for example, "Citracal") is probably the better since it is more easily absorbed from the intestinal system by most people. Calcium carbonate is less expensive than calcium citrate but is less easily absorbed by the intestinal system, especially in persons who lack sufficient stomach acid including patients taking H2 blocker medications (such as Pepcid or Zantac) or taking proton pump inhibitor medications (such as Nexium or Prevacid). A typical calcium carbonate replacement tablet has 600 mg of calcium but these tablets can be large and difficult for some people to swallow. Chewable calcium antacid tablets (for example, ‚"Tums") contain 200 mg of calcium and are easier for most persons to take. Calcium supplements are generally safe but can cause constipation in higher doses. Persons with previous kidney stones or with family members with kidney stones should take their calcium supplements with meals in order to reduce their risk of developing stones related to calcium supplements. Vitamin D should also be taken in adequate amounts (400 - 800 units per day); for most people, a general multivitamin or vitamin D fortified milk is sufficient.
These drugs help prevent osteoporosis by slowing bone resorption (dissolving). There are 2 drugs commonly used, both of which are effective. Bisphosphonates can be given once per day or once per week. The once weekly dosing has fewer side effects in many people. In most patients requiring treatment for osteoporosis, bisphosphonates are preferred over calcitonin or estrogens.
Alendronate ("Fosamax") is normally taken once a day. Men, pre-menopausal women, and post-menopausal women taking estrogen should take 5 mg per day. Post-menopausal women not taking estrogen should take 10 mg per day. Alendronate can also be taken once a week (70 mg one day each week). It must be taken first thing in the morning on an empty stomach with 8 oz of water. You should not eat or drink anything for 30 minutes after taking alendronate and you should not lie down for 30 minutes after taking the drug. The most common side effect is gastrointestinal (heartburn, stomach pain, or nausea).
Risedronate ("Actonel") works very similarly to alendronate. It can be taken as 5 mg once per day or 35 mg once per week. It should also be taken first thing in the morning on an empty stomach with 8 oz of water 30 minutes before eating or drinking anything. Do not lie down for 30 minutes after taking the drug. Gastrointestinal symptoms are the most common side effects.
This is a natural hormone that can reduce bone loss and is effective in osteoporosis. The form of calcitonin available by prescription comes from salmon and is most commonly given as a nasal spray. The usual dose is 200 units per day. Side effects can include allergic reactions, flushing, and nausea. The first dose of calcitonin should be given in your doctor's office because severe allergic reactions can rarely occur.
Men with low levels of testosterone may benefit by testosterone replacement to help reduce osteoporosis. It can be given by a patch ("Androderm" - 5 mg per day) or by a gel that is rubbed into the skin ("Androgel" - 50 mg per day). Because testosterone can worsen prostate cancer, men should have the PSA level checked before beginning testosterone to screen for prostate cancer.
In post-menopausal women, estrogen treatment can prevent osteoporosis. However, there are risks with estrogen that out-weigh the benefits in most women. Some of these risks include heart disease, stroke, dementia, blood clots, and breast cancer. At present, we do not recommend starting estrogen treatment for the treatment or the prevention of osteoporosis except in rare situations.
All persons should be sure that their intake of calcium and vitamin D is adequate. Whether to take additional medications (such as a bisphosphonate, calcitonin, or testosterone) usually depends on the result of bone densitometry (DEXA scan). The following are the indications for DEXA scans:
1. All women over age 65 yrs with no risk factors
2. All postmenopausal women under age 65 yrs with additional risk factors for osteoporosis
3. All postmenopausal women under age 65 yrs with fractures
4. All women considering therapy for osteoporosis
5. All women on estrogen therapy for a prolonged period
6. Individuals with primary hyperparathyroidism
7. Individuals receiving chronic glucocorticoid therapy
The DEXA scans will report the density of the bone by a "T-Score". The lower the T-Score, the less dense the bone. Because the T-Scores are given as negative numbers, a bigger the negative number means a lower T-Score. A moderately reduced T-Score is called osteopenia and a severely reduced T-Score is called osteoporosis. All persons with T-Scores less than -2.0 should be treated with a bisphosphonate (preferably) or calcitonin. Persons with osteoporosis risk factors (such as steroid medications) with T-Scores less than -1.5 should also be treated with a bisphosphonate. Persons with osteoporosis who continue to worsen despite a bisphosphonate may need to take a second drug (such as calcitonin) in addition to the bisphosphonate. A new treatment for osteoporosis called parathyroid hormone may be an option for difficult cases but will likely be too expensive for first line treatment.