San Antonio Express-News (Sunday)
Severe osteoporosis requires infusion
Q: I am a 71-year-old woman who still works full time as a teacher. I have osteoporosis and have had two bone scans. My latest scan showed a slight deterioration from the first two years ago. My T-score in my spine went from -2.2 to -2.6. It was recommended by my endocrinologist that I get the Reclast infusion because I have acid reflux and the other choices wouldn’t be
good.
I’m wondering your thoughts and if you know of any natural ways to avoid the infusion. I currently take many supplements, including calcium and vitamin D, and I eat 1,200 mg of calcium per day. I also started taking 1 scoop of collagen powder. The infusion scares me, but I don’t want any more bone loss!
A:
Osteoporosis doesn’t generally cause symptoms until a person develops a fracture, but fractures can be devastating. That’s why screening for osteoporosis is widely recommended and why treatment is indicated when a person has severe osteoporosis.
Initial treatment consists of lifestyle changes: stopping smoking, adequate vitamin D and calcium intake, regular exercise and avoiding heavy alcohol use. Often, these are adequate to slow or reverse bone loss. However, when a person has a T-score of -2.6, they are at a high enough risk for a fracture that medication has more benefits than harms.
Using some assumptions, I put your information into the FRAX calculator (frax.shef.ac.uk) and got an estimate that 16% of women like yourself would develop a major osteoporotic fracture in the next 10 years, including a 4.5% risk of a hip fracture. Your T-score of -2.6 and your risks of fracture are all in the range where medication is recommended.
A bisphosphonate drug, like alendronate (Fosamax) or risedronate (Actonel), is generally the first-line medication that is recommended. Zoledronic acid (Reclast) is in the same class but is given by IV
infusion, usually yearly. Most people with well-controlled acid reflux can take pills, but those with esophageal disorders are at risk for damage from the pills. So, IV is then preferred.
Since your osteoporosis is severe enough to warrant treatment and has been worsening in the last two years, I agree with your endocrinologist. Normally, the medicine is given for three to five years before reassessing whether it is still necessary. Using these medicines for too long can lead to other issues.
Q: I was diagnosed with osteoarthritis of the knee. What are your thoughts on a shot in the knee?
A:
Orthopedic surgeons generally recommend two kinds of shots. One is a steroid and the other is hyaluronic acid. The evidence on steroid injections is that they cause benefit for some people but, in long-term trials, aren’t any better than placebo injections. After a long period of time, they can even damage the cartilage in the knee. That being said, I have occasionally had patients with such a dramatic response to a steroid
injection that they get months or even a year of immense relief. So, I do try it once in a while.
The data on hyaluronic acid injections is that they are very expensive and do not work well at all. There is minimal improvement compared to a placebo injection. Regular exercise, topical treatments like diclofenac gel, or oral anti-inflammatories like ibuprofen or naproxen remain the mainstays of treatment for mild to moderate osteoarthritis.
Q: Are cancers and COVID considered to be autoimmune diseases? Someone said this to me recently, but I have never heard this before.
A:
No, both cancers and COVID-19 infections are essentially failures of the immune system. The job of the immune system is to keep us safe from invaders — either outside invaders like bacteria, viruses, fungi and parasites, or inside invaders like cancer — when the body’s own cells start growing uncontrollably.
The immune system is amazingly good at its job, but unfortunately, the pathogens
we encounter are also very good at escaping the immune system. Cancers also have many ways of bypassing the immune system’s control. An autoimmune disease, such as Type 1 diabetes, multiple sclerosis and lupus, occurs when the immune system mistakenly recognizes part of the body as an invader. The immune system then attacks and damages the body.
The target for Type 1 diabetes are the beta cells of the pancreas, with the result being that a person is unable to make insulin. Joints, the kidney and the skin are all targets for lupus; whereas for multiple sclerosis, it’s the cells making myelin in the central nervous system that are the targets of attack. I’m simplifying things because the issues are complex. What triggers the autoimmune response isn’t always known.
Vaccines give the immune system help ahead of time and can prevent many infections and a few cancers. There is much active research being done now to make better vaccines to both treat and prevent other cancers.
Q: I am 70. Due to breast
cancer history in my family and a diagnosis of atypical ductal hyperplasia in a lump that was removed, I get MRIs with and without imaging agents annually.
Do I have to be concerned about gadolinium being retained in my body? With annual MRIs, how long does it take to build up in the brain, bones and organs? Would it make sense to get the MRI without an imaging agent every other year? How do I decide the risk versus the benefit?
A:
The MRI contrast material is based on gadolinium. Although some people can have retention of gadolinium in the brain, it is not clear that this leads to any clinical symptoms. Similarly, gadolinium can be found in the skin, bone and liver, but it’s not clear whether these lead to problems. After decades of using these agents, the risk of clinical disease seems to be very low.
The bigger issue is the kidney. Some gadolinium agents, which are no longer used in the U.S. or Europe, are associated with a condition called nephrogenic systemic fibrosis. It is only found in people with advanced kidney disease, and it may also be associated with older gadolinium contrast agents. The risk of gadoliniuminduced kidney disease is minimal with newer agents and in people without preexisting kidney disease.
In my opinion, for people without kidney disease, gadolinium toxicity is not a significant risk, and you should get the recommended screening test ordered by your specialist. In people with mild chronic kidney disease (called CKD stage 2 or 3), gadolinium is probably safe, but in people with stage 4 CKD, it should probably be reconsidered. There are times when an MRI is so important that it is worth the risk, in which case we use the agents with the best safety record, but the oncologist still needs to consider other ways of screening.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med .cornell.edu or send mail to 628 Virginia Drive, Orlando, FL 32803.