Monday, October 18, 2004

Margaret Lucas of Northeast has pain in her bones. Her discomfort started after eight months of chemotherapy for colon cancer.

Since her doctors are concerned that the treatment may have caused osteoporosis, Ms. Lucas, 76, recently underwent a dual emission X-ray absorptiometry (DEXA) scan, also known as a bone density test, at Washington Hospital Center in Northwest.

“Some days my bones don’t hurt. Some days they do,” she says. “If I try to walk a block, I’ll have to stop, but it doesn’t hurt when I’m sitting or laying down.”

Last week, Dr. Richard H. Carmona, U.S. surgeon general, issued the first-ever report on the state of bone health in the nation, “Bone Health and Osteoporosis: A Report of the Surgeon General.” By the year 2020, one in two Americans older than age 50 will be at risk for fractures from osteoporosis or low bone mass, according to the U.S. Department of Health and Human Services in Southwest.

Currently about 10 million Americans over the age of 50 suffer from osteoporosis. In addition, another 34 million people are at risk for getting the disease. Although the majority of the people suffering from the illness are women, men also suffer from the condition.

It can be an extremely disabling if a person has a fracture, says Dr. Jack Wilkenfeld, attending physician with privileges in rheumatology at Inova Fairfax Hospital. Patients that suffer hip fractures may never be able to walk again. Spinal and wrist or forearm fractures also are common.

“For the longest time, osteoporosis and fracture were considered a normal consequence of aging,” he says. “We’ve highlighted that this is an illness and something that we should treat… instead of just accepting that you’re just getting older.”

Although osteoporosis is usually a disease of older-aged women and men, choices people make in their younger years will affect their chances of having the condition, says Dr. David Downing, resident program director for OB/GYN at the Washington Hospital Center.

People most likely to get osteoporosis are small and thin, or Caucasian or Asian women who smoke. Having a family history of osteoporosis or a personal history of fractures also increases the risk of illness. Per day, people should limit themselves to one alcoholic drink and no more than two 8-ounce cups of coffee.

Consuming enough calcium and vitamin D throughout life is important to prevent the disease, Dr. Downing says. People should also take part in weight-bearing exercises.

“Normal bone is chock-full of calcium,” he says. “When there’s a lack of calcium, it looks like there’s a bunch of little holes in the bone…. As you get older, you lose the calcium.”

Osteoblasts are cells that put calcium in the matrix of the bone, while osteoclasts are cells that take the calcium away and diminish the internal strength of the bone, Dr. Downing says. Since estrogen tends to stimulate osteoblasts, when women experience menopause and lose estrogen, they usually lose calcium and bone structure diminishes.

However, even those in perfect health need the osteoclasts to redistribute bone mass during different times of life. Bone mass and mineral adjust to support the places where the most outside force occurs.

For instance, people on bed rest lose calcium because of the lack of weight-bearing exercise. Signs that the osteoclasts are overactive could include a fracture, the curving of the back or pain.

“You don’t want a teenager going through a growth spurt to sit on the couch all day,” Dr. Downing says.

The bone mass of women and men peaks at age 30, says Dr. Nahrain Al-Zubaidi, assistant professor of endocrinology and metabolism at Georgetown University Hospital in Northwest.

“It’s like a bank account. You bank until you’re 30,” she says. “From there, you decrease on bone mass.”

Women who had amenorrhea in their life, which is the loss of their menstrual cycle even though they aren’t pregnant, are at a greater risk for osteoporosis, Dr. Al-Zubaidi says.

For instance, sometimes women or girls who are anorexic or bulimic lose their periods, which means they lack the estrogen needed to keep their bones strong.

“If you don’t have a regular cycle, identify the reason for it,” she says. “If there is no identifiable reason, oral contraceptive pills will help bone loss.”

Also, often times, vegetarians don’t get enough calcium or vitamin D, Dr. Al-Zubaidi says.

Further, many medications can contribute to loss of bone mass and mineral, Dr. Al-Zubaidi says. For instance, glucocorticoids are anti-inflammatory drugs, such as prednisone, used to treat lupus, a chronic autoimmune inflammatory disease.

Some anti-seizure drugs, certain cancer treatments, heparin and cyclosporine are known to increase the chances of someone having osteoporosis. Unfortunately, patients could take the drugs for a long time before seeing a side effect.

“Osteoporosis is a silent thing,” Dr. Al-Zubaidi says. “The first sign can be a fracture.”

Thankfully, there are many medications that can treat and prevent the disease, says Dr. Felicia Cosman, clinical director of the National Osteoporosis Foundation in Northwest.

Evista has been approved by the Food and Drug Administration for the prevention and treatment of osteoporosis.

Also, Forteo is a drug for patients with severe forms of the condition, who have usually already had a fracture. It increases bone density and quality by enabling the osteoblasts.

Further, a class of drugs called bisphosphonates, such as Fosamax and Actonel, inhibit the osteoclasts so that the osteoblasts can make bone.

Since today, doctors can improve bone architecture at any stage of the disease, Dr. Cosman says patients should undergo DEXA scans, which are usually an accurate predictor of osteoporosis.

“A DEXA scan is painless and nonevasive,” she says. “It only takes about five minutes.

Dr. Cosman says all women by age 65 should have the test done, and it should be done earlier for anyone with risk factors.

Since there have been more studies on how to interpret the results of the DEXA scan for women than men, research is currently under way in “Mr. Os,” a study on 6,000 men older than 65, says Joan McGowan, director of Musculoskeletal Diseases at the National Institute of Arthritis and Musculoskeletal and Skin Diseases in Bethesda. She holds a doctorate in biomedical sciences.

Currently, doctors don’t know what the results mean from the DEXA scans of men, she says. Therefore, male scans are generally compared to the scans of women, where research has already been done on bone density and fractures.

Ms. McGowan also is hopeful that genetic research in humans and mice will lead to greater understanding of the disease.

“Right now, we don’t know the genes causing osteoporosis,” she says. “We are identifying the genes. There will be multiple genes, each contributing a little bit, that are involved in building a strong skeleton.”

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