It’s interesting that the USPSTF is publishing new guidelines for screening of osteoporosis just as more questions develop about the long term treatment of osteoporosis with bisphosphonates. In the first USPSTF recommendation update that’s been released after the new protocol for posting anticipated updates for public comment, the task force now gives a Grade B recommendation for osteoporosis screening for all women age 65 or older, as well as for younger women who are estimated to have a risk as high or higher than a 65 year old woman with no additional risk factors.
The statement specifically recommends DEXA screening of the hip and lumbar spine, but and even recommends a tool to use to assess risk in younger women called the FRAX Risk Assessment Tool.
No recommendation (Grade I: insufficient evidence) is given to screening for men.
There has been a lot written about the risks of atypical femur fractures and osteonecrosis of the jaw in long term treatment with bisphosphonates. The benefits of these drugs seems to outweigh these risks in general. Still it is not clear how long we should use these drugs, and whether the benefits are lasting after a several year course of treatment, or only last as long as treatment continues. Clearly there is more research needed to answer these questions.
The task force also gives no specific guidelines as to how to assess the risk for women age less than 65. Generally considered risk factors for osteoporosis include smoking, thyroid therapy, corticosteroid treatment, thin body habitus, poor calcium intake, sedentary lifestyle, and prior fractures.
My practice has been to try to screen women in the 50-65 age range if they have multiple risk factors or at 65 if not. I’ll continue this routine, but it’s good to have the new recommendation as it will make Medicare coverage for DEXA a preventative service, I believe with no co-pay or deductible. Comments as to experience with this issue are welcome on this medical blog.
In the 1950’s vitamin D was added to most milk products and many bread products to address a nationwide concern of vitamin D associated rickets. At the time this seemed to prevent rickets, the concern at that time. Now we are seeing vitamin D deficiency problems again. This is a problem with multiple causes:
-Less skin exposure, more time indoors, more use of sun screen. (The natural precursor of the active form of vitamin D requires sunlight exposure in the skin to change into its active form)
-Concern that many more medical problems may possibly related to low levels of Vitamin D. (Multiple sclerosis, depression, fatigue, osteoporosis, fibromyalgia, … there is much debate about most of these concerns)
-The optimal level of vitamin D is being questioned, is 20mcg/dl OK, should it be 40, 50. or even higher for optimal levels?
As I was thinking about a recent post on the concerns of using Depo-Provera I wondered about an alternative progesterone delivery technique and its effect on bone density. Implanon is an implantable cylinder containing etonogestrel, a different progestin hormone than is used in Depo-Provera. It was approved for use in the USA in 2006, but has been fairly slow to gain popularity, probably because of the problems that arose with the last implantable contraceptive rod device Norplant. Implanon is a single rod implanted just under the skin that slowly releases the hormone and gives up to 3 years of very effective contraception. It appears that Implanon use is not associated with bone mineral loss, as documented in several European studies. Implanon has been used in Europe for about 10 years. The Mayo Clinic patient education site has a good discussion of whether Implanon may be a good choice for you.
One good thing about both Depo-Provera and Implanon is that they avoid the reduction in effectiveness seen as well known side effects of many antibiotics. Reduced contraceptive efficacy is listed under Doxycycline side effects, Levaquin side effects as well as under the side effects of many other antibiotics.
We have known for some time that use of the injectable contraceptive Depo-Provera can lead to mineral loss in young women. Here is even more frightening information. Young women tend to feel this is a concern for old women, but I believe this contraceptive is a poor alternative to birth control pills, patches, or the nuva-ring intravaginal device for most young women. See the article by Roni Caryn Rabin in Friday’s NY Times.
If you have been using prednisone, you should be aware also that osteoporosis is one of the most common prednisone side effects with prolonged use.
Osteoporosis is a common problem in women and sometimes in men as we get older. Normally after menopause there is a gradual loss of calcium from the bones in women. There are a number of things you can do to reduce your risk of osteoporosis, and the fractures of the spine, hip and wrist that can happen in people with osteoporosis. Most important are getting good calcium intake as a young person to build strong bones up front by getting regular exercise, enough calcium in your diet, and not smoking. Dr. Oligario in Health Today outlines this pretty well. One thing some people don’t think of is that prolonged use of the injected contraceptive Depo-provera can lead to osteoporosis in young women, so that just when they should be adding bone mineral they are losing it. Any kind of long term corticosteroid use (prednisone or similar medications used for serious health problems like arthritis, lupus, and auto-immune disorders) is another common cause of bone mineral loss and osteoporosis. This is a well known prednisone side effect. If you think you are at risk for osteoporosis discuss this with your physician and consider a DEXA scan to test your bone density.
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