Ice hockey and bone density in young players
A constant issue that we read in the press or on the Net is the importance of building strong dense bones early in life as protection from osteoporosis as we age. This study, PMID: 14606508, by Gustavsson A, Olsson T, and Nordstrom P, J Bone Miner Res 2003 Nov;18(11):1964-9, appears to fault that idea, at least as concerns ice hockey as the form of exercise. When the authors compared ice hockey players to controls over a six-year period, they found significant gains of bone mineral density (BMD) at the femoral neck in the hockey players at the first follow-up at 30 months. Twenty-one players stopped their active sports at the 30-month time period. When their BMD was compared to players who stayed active, there was significant loss of BMD at the femoral neck and total body compared to active players. And, at the second, 70-month follow up, only players who had remained active had significantly improved femoral neck, total body and spine BMD compared to controls. The authors state: "We conclude that ice hockey training during childhood and adolescence may not prevent the development of osteoporosis of the femoral neck later in life if the activity is not maintained." These results are completely logical and it is a fairly safe assumption that they apply to all types of exercise, not just ice hockey. This is because bone is in a constant state of flux as it is continually being remodeled, increased, decreased, etc., based upon exercise, diet, and other factors. Thus, it is highly probably that early efforts to build a "bone bank" that will protect you later in life are a pipe dream. In reality building and maintaining BMD is a life-long project that requires proper diet, adequate exercise and caution with medications or lifestyle changes that are destructive of BMD. The truth is that you probably have a "normal" BMD for whatever your current lifestyle indicates. If that lifestyle changes, so too will your BMD. Witness the rapid loss of BMD in astronauts, but also note that soon after their arrival back on earth they rebuild the lost BMD as they get back to a new normal lifestyle for them. So, you can build a good solid bone structure to help prevent osteoporosis, you just can't rest on your laurels assuming the gains are permanent. You have to continually do whatever it was that improved your BMD or expect to lose out on your improvement.
Teriparatide's effect on cortical and cancellous bone structure
There are several articles on the bone-building ability of teriparatide, recombinant human parathyroid hormone (1-34), Forteo, on this Website. I suggest a search of the FreeFind search engine at the home page using the terms: "parathyroid hormone," "Forteo," "(1-34)," "Pth," etc., to locate all the information. And here are a couple of updates on that topic: Teriparatide vs. alendronate, Forteo with Fosamax and Teriparatide after medications. There is a new study on teriparatide in J Bone Miner Res 2003 Nov;18(11):1932-41, by Jiang Y and others, PMID: 14606504. The authors used two-dimensional histomorphometry and three-dimensional micro CT scans to view 51 paired iliac crest bone biopsy specimens in women taking teriparatide for 19 months and compared them to 19 women taking placebo. Results with 2D histomorphometric analysis showed 14% increase in cancellous bone volume in women taking teriparatide compared to a 24% loss of volume in the placebo group. Using 3D cancellous and cortical bone structural analyses, teriparatide significantly increased cortical thickness by 22% compared to placebo of 3% while significantly increasing the cancellous connectivity density by 19% compared to -14% for placebo. The authors conclude: "These data show that teriparatide treatment of postmenopausal women with osteoporosis significantly increased cancellous bone volume and connectivity, improved trabecular morphology with a shift toward a more plate-like structure, and increased cortical bone thickness. These changes in cancellous and cortical bone morphology should improve biomechanical competence and are consistent with the substantially reduced incidences of vertebral and nonvertebral fractures during administration of teriparatide." These results are interesting because they reinforce the effectiveness of teriparatide both on cancellous (interior softer spongy) and cortical (outer hard dense) bone. Remember that the bisphosphonates, such as Fosamax and Actonel, work primarily on cancellous bone. The spine is made up of considerably more cancellous bone than the hip, which accounts for the generally greater increase in BMD there when compared to the hip for people taking the bisphosphonates. This is objective evidence to back the effectiveness of teriparatide in treating osteoporosis and for preventing fractures of the hip or spine. Note that the authors paired the data for the teriparatide groups: One took 20 microg injections/day and the other 40 microg injections/day. The 20 microg dose was later approved by the FDA, so the pooled results would be greater than expected for that lower dose if you are using Forteo.
Guidelines for treating glucocorticoid-induced osteoporosis
This study in Arch Intern Med 2003 Nov 24;163(21):2619-24, by Adler RA and Hochberg MC, PMID: 14638562, suggests guidelines concerning osteoporosis for male U.S. veterans who are being evaluated for or treated with glucocorticoids. In summary:
For patients taking glucocorticoid therapy and those starting it for at least three months, use a DXA to evaluate fracture risk.
If there is low BMD, treat patients with bisphosphonates.
All patients about to start prednisone treatment at a dose of 7.5 mg/d or more also need bisphosphonates.
In facilities without DXA capability, most patients should receive bisphosphonates.
Urine calcium measurement is recommended to determine which patients might benefit from vitamin D and calcium supplements.
If these recommendations will be followed by all who are on or about to start corticosteroids a lot of misery from osteoporotic fractures can be avoided.
Intermittent IV ibandronate for glucosteroid-induced osteoporosis
NOTE: Ibandronate, (Boniva) a later generation bisphosphonate, was approved by the FDA for treatment of postmenopausal osteoporosis in the 2.5 mg/day oral dosage in May 2003. But, its real power rests in the possibility of using it IV in intermittent doses every three month or so, and, in fact, I have heard that it might even work in a once-yearly IV dose. This study in Osteoporos Int. 2003 Oct;14(10):801-7, by Ringe JD and others, PMID: 14610641, used the IV injection of 2 mg ibandronate every three months and compared it to the effect of 1 microg alfacalcidol daily in men and women with established corticosteroid-induced osteoporosis. All patients had 500 mg/day calcium supplements, too. After three years the ibandronate group had 13.3% increase in lumbar spine BMD vs. 2.6% in the alfacalcidol group, and the femoral neck was improved 5.2% vs. 1.9%, respectively. The authors note that both treatments were well tolerated and they state: "In conclusion, intermittent i.v. ibandronate injections are efficacious, well-tolerated, and convenient, and promise to offer physicians an important therapeutic advance in the management of osteoporosis. Note that in a newsletter I have also referred to research that showed that women who were nonresponders to alendronate had improved BMD when given once-weekly ibandronate injections. With the added research since that study, the time interval between injections would surely be increased. For anyone not responding to other bisphosphonates, remember that IV ibandronate offers another effective means of increasing BMD.
Incidence of osteoporosis in men with advanced prostate cancer
In a newsletter I have discussed androgen deprivation therapy (ADT) for men with advanced prostate cancer and noted that it is often associated with osteoporosis. This study, in BJU Int 2003 Nov;92(7):690-4 by Hussain SA and others, PMID: 14616447, however, notes that there can be a high incidence of osteoporosis in men with advanced prostate cancer even before ADT begins. In fact, virtually the entire study group of 174 patients had osteoporosis ( t-score <= -2.5) or osteopenia (t-score -1 to -2.4), whereas a control group had a 27% incidence of osteoporosis. Thus men with advanced prostate cancer need to have bone density testing and many need to be on some type of osteoporosis therapy even before they begin ADT.