Hip Fracture Risk and Antihypertensive Drugs

Are you taking strontium citrate or one of the osteoporosis medications to increase your BMD and decrease your bone fracture risk? Here is something else to consider if you are at least 66 years of age. 
 
Initiating antihypertensive drugs in the elderly has been associated with an immediate increased risk of falls. The most likely mechanism is orthostatic hypotension, which is associated with dizziness and fainting. The effect is acute, occurs over a relatively short time, and may lead to falls, some of which can result in hip fractures.

The following study was undertaken to determine whether initiation of antihypertensive drugs (e.g., thiazide diuretics, angiotensin II converting–enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, or β-adrenergic blockers) was associated with an immediate increased risk of hip fractures. Health care administrative databases were used to identify patients initiating an antihypertensive drug in Ontario, Canada. Elderly  people who began receiving an antihypertensive drug had a 43% increased risk of having a hip fracture during the first 45 days following treatment initiation.

http://archinte.jamanetwork.com/article.aspx?articleid=1392493

http://www.medscape.com/viewarticle/774769?src=mpnews

 

Facebook

This blog www.strontiumforbones.com has a link on facebook. You can post questions or comments on my blog or on my facebook page at http://www.facebook.com/?sk=welcome#!/pages/Strontium-for-Osteoporosis/462179087156676. I hope to hear from you soon! You have to sign in to use facebook, but it is free and simple.

Case Study on Strontium Citrate for Osteoporosis with Fragility Fractures

Sara S. DeHart, MSN, Ph.D., is an 80-year-old woman who was diagnosed with osteopenia at age 63. She was treated initially with Fosamax 10 mg. daily and Estraderm patches twice weekly.  She discontinued the patches after about two years, and Fosamax after about three years. Following a fragility fracture of the sacrum, she was prescribed Actonel 5 mg five times a week. Her vitamin D blood level was found to be very low, although she had supplemented with 400 IU vitamin D3 throughout her adult life.

She followed “standards of care” medical recommendations until she developed a second fragility fracture at T9 while taking Actonel.  At that point, she stopped using Actonel and began taking strontium citrate. She increased her vitamin D3 supplementation. Today, she is 80 years old and her BMD is normal. More importantly, she has not fractured, even after a recent fall onto an asphalt driveway! Follow this link to read her amazing story:

http://www.intrepidreport.com/archives/7529

 

Methods for Assessing Bone Quality

Bone mass, geometry, and tissue material properties contribute to bone structural integrity. Thus, bone strength arises from both bone quantity and quality. Bone quality encompasses the geometric and material factors that contribute to fracture resistance. Although no single method can completely characterize bone quality, current noninvasive imaging techniques can be combined with ex vivo mechanical and compositional techniques to provide a comprehensive understanding of bone quality.

Methods for assessing mechanical properties include whole-bone, bulk tissue, microbeam, and micro- and nanoindentation testing techniques. Outcomes include structural strength and material modulus. Advantages include direct assessment of bone strength; disadvantages include specimen destruction during testing.

 Methods for characterizing bone geometry and microarchitecture include quantitative CT, high-resolution peripheral quantitative CT, high-resolution MRI, and micro-CT. Outcomes include three-dimensional whole-bone geometry, trabecular morphology, and tissue mineral density. The primary advantage is the ability to image noninvasively; disadvantages include the lack of a direct measure of bone strength.

 Methods for measuring tissue composition include scanning electron microscopy, vibrational spectroscopy, nuclear magnetic resonance imaging, and chemical and physical analytical techniques. Outcomes include mineral density and crystallinity, elemental composition, and collagen crosslink composition. Advantages include the detailed material characterization; disadvantages include the need for a biopsy.

Clinical Orthopaedics and Related Research, Volume 469, Number 8 (2011), 2128-2138.

Is Strontium Ranelate Safe?

“Clinical trials are designed to assess efficacy, not safety and so post marketing data is needed to evaluate safety. Jakob et al report the results of an observational cohort study to assess safety and treatment persistence with SR during 3 years follow-up in 12,702 postmenopausal women from 7 countries (29). Mean age was 69.0 years with 16.5% of patients being over 80 years. Mean follow-up duration was 32 months and mean treatment duration was 25.2 months (24,956 patient-years of treatment). VTE was reported in 55 patients, an incidence of 2.1/1000 patient-years (95% CI 1.6, 2.8), lower than that observed in patients treated with SR in the phase III studies (7.9/1000 patient-years; 95% CI 6.3, 9.7). No DRESS syndrome or Stevens-Johnson syndrome was reported. Persistence of SR treatment was 80%, 68% and 64% after 12, 24 and 32 months treatment, respectively.”

29. Jakob FJ, Palacios S, Audran M, et al. Final results of a 3 years prospective observational cohort study of patients treated with strontium ranelate. Osteoporos Int 2012;23(Suppl 2):S73.

http://www.iofbonehealth.org/volume-12-issue-2

Vitamins B6 and B12 and Folic Acid

Readers of my blog know that I advocate taking strontium citrate along with a combination of vitamins, minerals, and other supplements for bone health. Most people understand that calcium, magnesium, and vitamin D are essential for strong bones. Some people are adding vitamin K1 and/or vitamin K2 (MK4 or MK7) to their supplement lists. But did you know that you may also need vitamins B6 and B12 and folic acid?

“Some studies suggest high blood levels of the amino acid homocysteine may be linked to lower bone density and higher risk of hip fracture in the elderly. Vitamins B6 and B12, as well as folic acid, play a role in changing homocysteine into other amino acids for use by the body; so, it is possible that they might play a protective role in osteoporosis. Research is ongoing as to whether supplementation with these B vitamins might reduce fracture risk.” This paragraph is quoted from:
http://www.iofbonehealth.org/nutrition

The studies referred to are:

1. McLean RR, Jacques PF, Selhub J, et al. (2004) Homocysteine as a predictive factor for hip fracture in older persons. N Engl J Med 350:2042-49
2. Morris MS, Jacques PF, Selhub J (2005) Relation between homocysteine and B-vitamin status indicators and bone mineral density in older Americans. Bone 37:234-42

I take Nature's Bounty Sublingual Vitamin B12, 5000 mcg (5 mg) per microlozenge. I was using it three times per week, but I have recently increased my intake to the recommended dosage of one microlozenge daily. You dissolve these under your tongue for maximum absorption.

My multivitamin, Nature Made Multi For Her 50+, contains 6 mg of vitamin B6,25 mcg of vitamin B12, and 400 mcg of folic acid.

Effects of Strontium Citrate on Osteoblasts

The objective of this study was to assess the effects of strontium citrate on the proliferation and differentiation of osteoblastic cells obtained from human alveolar bone. Primary osteoblasts, obtained from human alveolar bone residues at the time of third molar extractions and explanted in culture, were seeded in BGJb media containing 10% FCS. After the cells reached a semiconfluent stage, strontium citrate (bibasic anhydrous, pure grade from Jost Chemical) at various concentrations (0.05-1.0 mM) was added.

The MTT test showed the cells to be responsive to strontium citrate with significant increases in cellular activity/proliferation at 24 and 48 hrs. Alkaline phosphatase activity was significantly enhanced at 48 and 72 hrs with strontium citrate concentrations in the test range.

The data support the hypothesis that strontium citrate increases the proliferative/alkaline phosphatase activity of human osteoblastic cells from alveolar bone. The results validate previous research that has been done with other forms of strontium in clinical studies and rodent calvarial cells and indicates that strontium citrate could be a promising agent in treating oral as well as systemic bone disorders.

http://iadr.confex.com/iadr/2007orleans/techprogram/abstract_89231.htm

Interpretation of BMD Scans in Patients Stopping Strontium Ranelate Treatment

“The oral administration of strontium ranelate causes a clinically significant overestimation of BMD because of the high attenuation of X-rays by strontium atoms in bone." GM Blake and I. Fogelman “performed a theoretical study to calculate the long-term effect of strontium treatment on BMD and establish the duration of past treatment for which the remaining bone strontium content (BSC) has a negligible effect on BMD.” “Estimates of the strontium BMD artefact after treatment has stopped were performed on the assumption that the BSC effect accounts for 75% of the total measured BMD change at 3 years.” “If 75% of the BMD changes are explained by BSC, in the average patient, 3-year treatment leads to a spine BMD artefact of 11.2%, decreasing to 3.8% 10 years after stopping treatment. The BMD artefacts at the total hip and femoral neck sites are smaller by factors of 0.65 and 0.53, respectively.” “On average, 6-month treatment is required for the spine BMD artefact to exceed 3%, the figure adopted as the maximum BMD change caused by bone strontium that has a negligible effect on scan interpretation.” The researchers concluded that “strontium ranelate treatment lasting for > 6 months can affect BMD measurements for many years afterward.” http://www.ncbi.nlm.nih.gov/pubmed/16939400 J Bone Miner Res. 2006 Sep;21(9):1417-24.

Minimum Effective Doses of Strontium

The aim of the PREVOS study (PREVention Of early postmenopausal bone loss by Strontium ranelate) and the STRATOS study (STRontium Administration for Treatment of OSteoporosis) was to determine the minimum dose at which strontium ranelate (SR) is effective in, respectively, the prevention of bone loss in early postmenopausal nonosteoporotic women and the treatment of postmenopausal vertebral osteoporosis.

The minimum dose at which SR is effective in preventing bone loss in early postmenopausal nonosteoporotic women and in the treatment of postmenopausal osteoporosis is 1 g/day and 2 g/day, respectively.

Strontium ranelate phase 2 dose-ranging studies: PREVOS and STRATOS studies, J. Y. Reginster and P. J. Meunier, Osteoporosis International, Volume 14, Supplement 3, 56-65, DOI: 10.1007/s00198-002-1349-0

The chemical structure of strontium ranelate is composed of two atoms of stable strontium combined with organic ranelic acid. Strontium is the bone active component and makes up 34% by weight of the whole molecule, so each 2 g dose of strontium ranelate delivers 680 mg of elemental strontium.

 Strontium ranelate: a novel treatment for postmenopausal osteoporosis: a review of safety and efficacy, Glen M Blake and Ignac Fogelman, Clinical Interventions in Aging, Dec. 2006, 1(4): 367-375

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699648/

Update On My Calcium And Magnesium Intake

For many years, I have been taking one tablet per day of KAL Calcium Magnesium Extra Strength, which contains 500 mg calcium (as calcium carbonate and calcium amino acid chelate), 250 mg magnesium (as magnesium oxide and magnesium amino acid chelate), 15 mg sodium, and 50 mg betaine HCl.  I was buying it at my local health food store, but I found a replacement that I think is even better and will be ordering it soon from www.iherb.com, an online distributor I've been getting my strontium and a couple of other supplements from.

The new product is Country Life, Gluten Free, Calcium Magnesium Complex 1000 mg/500 mg in two tablets, 360 tablets, $20.23. The calcium is in the form of calcium hydroxyapatite, citrate, aspartate, alpha-ketoglutarate, and lysinate. The magnesium is in the form of magnesium oxide, citrate, taurinate, alpha-ketoglutarate, and aspartate. Each tablet contains 500 mg calcium, 250 mg magnesium, and 250 mg phosphorus (as calcium hydroxyapatite).

In addition to a calcium/magnesium supplement, I take a multivitamin, Nature Made Multi For Her 50+, which I buy online at www.walgreen.com when the company has one of their frequent “buy one, get one free” offers. This multivitamin contains 200 mg calcium, 100 mg magnesium, 1000 IU vitamin D3, 80 mcg vitamin K, and many other key nutrients.

For breakfast, I have 12 oz fat-free milk, which gives me 450 mg calcium. At lunch, I take the 500 mg calcium/250 mg magnesium supplement. With supper, I take my multivitamin for 200 mg calcium and 100 mg magnesium. That comes to 1150 mg calcium, without counting other food sources. The RDA for women 50+ is 1200 mg calcium per day. I may cut back to 8 oz milk (300 mg calcium) on days when I know I’ll be having something calcium rich for supper.  

Combination of Micronutrients for Bone (COMB) Study

After 12 months of consecutive supplemental micronutrient therapy,repeat bone densitometry was performed. The results were analyzed in a group of compliant patients and demonstrate improved BMD in patients classified with normal, osteopenic and osteoporotic bone density.

Combination of Micronutrients (COMB) Protocol for Bone Health

1. Docosahexanoic acid or DHA (from Purified Fish Oil): 250 mg/day
2. Vitamin D3: 2000 IU/day
3. Vitamin K2 (non-synthetic MK7 form): 100 ug/day
4. Strontium citrate: 680 mg/day
5. Elemental magnesium: 25 mg/day
6. Dietary sources of calcium recommended
7. Daily impact exercising encouraged

After one year of therapy with the COMB protocol compared to published results for strontium ranelate and bisphosphonate medications, the percent changes in bone mineral density (z values) were as follows:

Femoral neck: 4% increase for the group on the COMB protocol vs. 2% for strontium ranelate, alendronate, and risedronate

Total hip: 3% increase for the COMB protocol vs. 3-4% for strontium ranelate, 2% for alendronate, and not calculated for risedronate

Total spine: 6% increase for COMB protocol vs. 5-6% for strontium ranelate, 4% for both alendronate and risedronate

This combined micronutrient supplementation regimen appears to be at least as effective as bisphosphonates or strontium ranelate in raising BMD levels in hip, spine, and femoral neck sites. No fractures occurred in the group taking the micronutrient protocol. This micronutrient regimen also appears to show efficacy in individuals for whom bisphosphonate therapy was previously unsuccessful in maintaining or raising BMD. Prospective clinical trials are required to confirm efficacy.

This study by Stephen J. Genuis and Thomas P. Bouchard was published in the Journal of Environmental and Public Health, Volume 2012 (2012), Article ID 354151,doi:10.1155/2012/354151 COMB Protocol

Spinal BMD And Scoliosis

On June 15, 2006, Ioannis P. Pappou, MD et al published a retrospective study entitled “Discordantly High Spinal Bone Mineral Density Values in Patients With Adult Lumbar Scoliosis.” The purposes of this study were: 1) to investigate the validity of bone mineral density measurements with DEXA in patients with adult lumbar scoliosis and 2) to investigate the association between osteoporosis and adult lumbar scoliosis. The study concluded the following: Cobb’s angle measurements on DEXA scans are reliable and comparable to conventional radiographs. Spinal BMD values are less valuable for monitoring osteoporosis than hip values in scoliotic patients; an increasing discrepancy with age was noted. Scoliotic patients exhibited discordantly high spinal BMD values, despite significant hip osteoporosis. The discrepancy correlated with aging and curve magnitude. Scoliosis was common among the osteoporotic population (9.47%). Lumbar scoliosis is a useful clinical marker for osteoporosis, irrespective of scoliosis history and magnitude. Viable alternatives for osteoporosis evaluation of adult patients with lumbar scoliosis are hip DEXA values, in conjunction with other BMD measurements. http://journals.lww.com/spinejournal/Abstract/2006/06150/Discordantly_High_Spinal_Bone_Mineral_Density.19.aspx