Lupus and Osteoporosis: What You Need to Know

Although bone seems hard as a rock, it is living tissue, just as our skin is. Cells in bone are constantly being broken down (also called bone turnover or resorption), while new cells are being built up. When an imbalance between break-down and build-up occurs, bones can lose their density more quickly, and the resulting disease is called osteoporosis. Bones become fragile and are at greater risk of breaking (fracture). Often, the vertebrae (small bones in the spine) fracture, leading to pain and loss of height. One of the most threatening fractures is hip fracture, which can lead to serious disability. (Note: osteoporosis, a disease of bone, has nothing to do with osteoarthritis, which is a disease of joints.)

How Lupus May Increase Your Risk of Osteoporosis

People with lupus may be at special risk for osteoporosis due to four factors:

• use of corticosteroids, which are known to increase bone breakdown if doses equivalent to 7.5 mg of predinisone daily are taken for more than six weeks;
• lupus fatigue, which may lead to lack of sufficient exercise, increasing risk because the stress of the body against gravity is needed to promote maintenance of bone density;
• on-and-off use of corticosteroids, which may cause ups-and-downs in your weight, leading to a negative impact on bone density;
• certain cytokines, byproducts of the inflammatory process, which can have a negative impact on bone density.

Therefore, it's important that your bone density level be monitored and that you help prevent and treat the osteoporosis with adequate calcium, vitamin D, exercise and, if necessary, prescription medications.

Monitoring Bone Density

Here at Hospital for Special Surgery, we believe that everyone taking long-term steroids should have a bone density evaluation. The "gold standard" for bone density measurement is a form of X-ray called DEXA, which stands for dual energy X-ray absorptiometry. Your doctor may recommend this test every one to two years.

In addition, a simple urine test measures the rate of bone turnover by assessing the rate of loss of bone cells in the urine. It's called NTX, which stands for cross-linked N-telopeptides of bone type I collagen. You can discuss with your doctor having this test on a yearly basis or more frequently, especially if you are on corticosteroids or to monitor treatment effects if you are taking medication to prevent or treat osteoporosis.

Getting Enough Calcium and Vitamin D

Calcium is an important building-block of bone, and vitamin D transports calcium from the intestines and gets it into the blood, where it gets picked up and used for bone-building. Adequate calcium and vitamin D can help preserve bone density in people taking corticosteroids. Clinical trials in those who already have osteoporosis have shown that calcium and vitamin D supplements reduce the risk of fracture by 25% - but not necessarily in those using corticosteroids.

How much do you need? The National Institutes of Health recommends that (non-pregnant) adults receive 1000 mg. of calcium daily, with that dose boosted to 1200 mg. in women over 50, and to 1500 mg. in men and women over 65.

Although food is your best source of nutrients, most Americans do not get enough calcium in their diets - especially those who have problems with dairy products, such as lactose intolerance or absorption problems due to sprue. Calcium-fortified foods and calcium supplements can fill the gap. The amount of supplementation you need depends on how much calcium is consumed in food. Try to figure out how much you are getting in your diet and then supplement to get it up to your bone requirements. If you have little or no calcium in your diet, you can rely totally on supplements.

Three to four servings each day of dairy foods will give you about 1200 mg of calcium. A serving is: 1 cup of milk or yogurt; 1-1/2 ounces of hard cheese; or 2 cups of cottage cheese. Low-fat and non-fat foods have the same amounts of calcium as non-fat foods. The amount of fat does not affect the calcium content.

Other good sources are: canned fish with bones you can eat, such as sardines and salmon; dark-green leafy vegetables, such as kale, collards, and broccoli; and calcium-fortified foods, such as orange juice, soy milk, and breads that are so labeled.

Various types of calcium supplements are available. One of the most popular is calcium carbonate (found in Viactiv, Caltrate, Oscal, etc.); carbonate must be taken at the end of a full meal because the calcium is not broken down effectively when there is no digestive activity. The other popular preparation is calcium citrate (such as in Citrical); it does not need to be taken with food, but you usually need to take more pills to reach your requirement. Foods that are fortified with extra calcium usually contain calcium phosphate, which may be better absorbed than supplement pills. (Magnesium offsets the constipating effects calcium carbonate, which is why it may be recommended for people who take that form of calcium supplementation.)

Make sure to read the side of the bottle to determine how many milligrams are in each pill so that you know how many need to be taken each day. When you see calcium expressed as a percent of the product, i.e. "35% calcium" (which most often occurs on food labels), this is a percent of 1000 and, thus, each serving gives you 350 mg. of calcium.

If you use supplements, don't take your entire daily calcium requirement in one dose. Divide it into two or three doses over the course of the day. Your body can't use 1000 mg. of calcium all at once and will simply excrete the excess in urine.

Don't take more than 2000 mg of calcium a day. Although your body tends to excrete the excess, overdoses may increase the chance of developing kidney problems in some people.

Some medications interfere with calcium absorption. Do not take calcium with prescription high-dose iron nor with a bisphosphonate. Allow an hour or two between these products.

Getting your vitamin D is equally important. We need 400 to 800 units of vitamin D daily. If you drink milk, you get 100 units in 8 oz of milk. You also get it in egg yolks, fatty fish, and cereal and milk fortified with vitamin D. Although D is known as the sunshine vitamin because your body converts sunlight into D, we know that sun is not good for many people with lupus. However, even if you are able to go in the sun, using a sunscreen with an SPF 8 or above eliminates the ability of the skin to make the conversion. So don't look to the sun to give you vitamin D. Make sure to get it in your food or supplements. This may be easy because 400 units are in almost every multivitamin preparation sold

Many calcium preparations also contain D. Unlike calcium, your D can be taken all at once because it is a fat soluble vitamin that hangs around in the body - or it can be taken in with your calcium.

Getting Enough Exercise

Although fatigue can affect your ability to maintain a regular exercise program, exercise is a critical component of osteoporosis prevention. Exercise must be weight-bearing, such as walking, aerobics, dancing, running, or walking down stairs (but not the use of a stairmaster, which can stress the knees).. What strengthens the skeleton is the impact of your body weight against gravity - so swimming doesn't work. It is the impact of your body weight against the ground that sends a message to the skeleton. (Tai chi increases balance and reduces the risk of falls, which decreases the risk of fracture, but does not increase bone density.) Of course, any new exercise regimen should be discussed with your physician before starting.

Hospital for Special Surgery has an excellent Osteo Fitness exercise program. To participate, you have to be cleared by your physician and evaluated by our Rehabilitation Department. The program focuses on weight-bearing, strength, flexibility, posture, and balance. It is conducted at our Integrative Care Center on Madison Avenue at 60th Street. For information, call the Community Education Department at 212-606-1057.

However, exercise doesn't require getting into sneakers and sweats and going to a club. With attention and extra effort, you can turn your regular daily activities into exercise. For example, try this: barefoot, keeping your knees straight, and holding on to a chair for balance, rise up on your toes and then come down on your heels with a thud. Repeat multiple times and throughout the day, building up to a total of about 10 minutes. By not bending your knees, the stress is going throughout the body - but avoiding stress on your knee or hip joints.

For more exercise tips, order a free booklet called "Exercise" from the National Institutes of Aging by calling (800) 222-2225. And visit their website at www.nihseniorhealth.gov/exercise/toc.html

Prescription Medications

If you are losing bone density too fast, your doctor is likely to prescribe a medicine to slow the loss - although taking such drugs does not replace taking calcium supplements because calcium is needed to create bone matrix and the drugs then lower the rate of bone turnover. Four types of drugs are currently available.

• Bisphosphones include alendronate (brand named Fosamax) and risedronate (Actonel), which have been shown to reduce the risk of fracture of the spine and hip by 40 to 50%. Side effects may include nausea, heartburn, and pain in your stomach, muscles, or bones. These drugs must be taken in a certain way-when you first get up, before you have eaten, and with a full glass of water. You should not lie down or eat for at least one-half hour after taking the drug. Some doses are taken daily, while others are taken once a week.
• Raloxifene (Evista) is a SERM (selective estrogen receptor modulator) that is somewhat less potent in reducing bone loss than the bisphosphonate. Like estrogen, this SERM slows bone loss, but may cause blood clots in some women. Unlike estrogen, it does not prevent hot flashes and should not increase your chance of developing cancer of the endometrium (the lining of the uterus or womb). It is not known whether raloxifene poses other the other risks that were recently identified in long-term estrogen users.
• Calcitonin (Miacalcin) is a naturally occurring hormone that also is less effective in increasing bone mass than the bisphosphonates, although it has a positive impact on the microarchitecture of bone. It also may lessen the pain of fractures in the spine. Originally prescribed as a daily self-injectable treatment, it is now more commonly prescribed in the nasal spray form. Side effects of the nasal spray form may include a runny nose or nasal polyps in some people.

In the future is another drug treatment, teriparatide (Fortéo) which is a synthetic parathyroid hormone (PTH). It will be the first drug that actually builds bone, rather than just slowing bone loss, which will be of special benefit to people with severe osteoporosis who have already experienced fractures. It will be available as a daily self-injection, similar to the way people with diabetes self-administer insulin.

The Osteoporosis Center at HSS

The Osteoporosis Center at Hospital for Special Surgery is dedicated to the prevention, diagnosis and treatment of osteoporosis. Services provided include: DEXA testing with the most advanced equipment; individual counseling and education from specialist nurses based on the results of the DEXA, risk factors, lifestyle, and medical history; comprehensive treatment plans for patients with osteoporosis; and referrals to physicians, physical therapists, and nutritionists, as indicated. The HSS Osteoporosis Center is unique in its provision of these extended nurse education and counseling services; further, at the end of your visit, you receive the phone number of your nurse in case you have any questions in the future.

Ours is the only Center of its kind in the New York area, and we have been cited by Congress as a model for the development of other centers. We train physicians from all over the world. Coverage of these services varies depending on your insurance plan; the Center does accept Medicare. For more information, call (212) 606-1588.

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