BONE HEALTH AND OSTEONECROSIS JOINTS
Dr. Charles E. Myers
In this lecture, Dr. Myers reviewed how bone is created and the factors that can impact on bone health. Reduction in testosterone also tends to reduce bone density and increases the risk of fracture. This is because the drop in testosterone creates a drop in the level of estradiol which means less new bone formation and increased bone breakdown.
Bone formation and breakdown
are integral parts of the bone formation process. When conditions favoring breakdown predominate, bone density diminishes and fracture risk increases.
Because bone is like muscle in that loading bone tends to favor increasing bone strength (and the
converse), Myers suggested that men at risk for osteoporosis follow exercise regimens that include bone loading forms as well as muscle stressing forms.
Vitamin D is important in maintaining bone health because it facilitates the gut’s absorption of calcium. And calcium phosphate (with magnesium) is a major component of the “cement” that fills in the spaces between the bone’s lattice-work collagen structure.
In addition to Vitamin D3, Myers suggested taking 800 mg of calcium per day and 500 mg of magnesium. He reported that bone metastases tend to be denser regions of the bone because they have increased levels of calcium. There is, he said, a tendency for calcium to move out of healthier bone into the diseased bone regions.
He cited the results of a small study that compared the fracture risk after 7 years between a group of men who had had orchiectomies and a “controls” group. The orchiectomy group had a 28% higher risk of fracture than the control group. Dr. Myers then discussed the Bisphonsphonates and their utility in reducing osteoporosis.
Under the general class of Bisphosphonates are found: Fosamax, Actonel, Aredia, Zometa, etc. Fosamax is heavily advertised, as are some of the others, for preventing osteo in women and also for “slowing” bone metastasis formation in men who have failed hormonal blockade therapy. Myers also included estrogens like DES and trans-dermal estrogen for preventing osteo.
He made the statement that “with adequate calcium and Vitamin D, the bisphosphonates are nearly 100% effective”. They can also be administered both orally and intravenously.
[Ed. Note: Dr. Myers claim of “bisphononates being nearly 100% effective” should be examined in light of the reality that no drug (other than perhaps aspirin) ever comes close to being 100% effective. ]
He did discuss some of the side effects of these drugs including the recently announced jaw necrosis problem. Men with gum disease or who have to undergo dental procedures of significance, have been reported to develop serious jaw bone necrosis while on a bisphosphonate.
Fosamax can produce GERD. All of them can cause hypocalcemia with or without severe leg cramps. He identified the typical characteristics of men he sees in his clinic who develop jaw necrosis: they have some kind of bone trauma or abscess, low testosterone/estrogen, low serum calcium, and were taking Zometa every 3-4 weeks.
[Ed. Note: Coincidentally while writing this section, the most recent edition of the NEJM (355:22, 2279-2281, 11/30/06) crossed my desk. In it is an article by Dr. John P. Bilezikian, a Professor of Pharmacology and Medicine at Columbia that discusses this very subject.
One of his highlighted conclusions was that “patients should see their dentists before beginning intravenous bisphosphonate therapy so that dental hygiene can be optimized”. In other words, if you’re on something like Zometa for prostate-related bone problems, be sure to see your dentist and look into preventing jaw necrosis from developing. Dr. Bilezekian reported receiving lecture and
consulting fees from several of the major pharmaceutical companies who produce these bisphosphonate products.
He concluded his article discussing the issues created by this class of drugs for men who also have to have dental procedures by writing: “As always, physicians and patients must carefully weigh the benefits and risks when considering drug treatment. For patients with recognized indications for nitrogen-containing bisphosphonates, using these agents is likely to do far more good than withholding them”. Caveat emptor!]
Dr. Myers concluded this lecture by stating that effective management with bisphosphonate use is doable because there is a “wide range of treatment options” applicable to most men.
Intl Prostate Cancer Conference, October 2006, Reston, VA
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