OrthoDoc

Its strange how one thing leads to another, especially when you are browsing the web. Is this what they call serendipity?

One of my neighbors’ father in a close by flat had back pain troubling him for a week. Apparently he had slipped in the bathroom and was now refusing to get up from bed. His son was worried and had called me in to check if anything was wrong. I made a courtesy call …anxious to prove my competence. I declared that there was nothing serious and rest should be enough. I thought that would suffice but soon the specifics were enquired into, and I knew I couldn’t get away so easily. Clinically he seemed to be comfortable with no weakness in his limbs. This time around I announced that there could be a fracture in one of the several back bones (vertebrae). Knowing how worried they could get, I added that this is quite common at his age, 75 years, and it requires an x-ray for confirmation. Out came the x-ray!! He had it all along!

I held it up against the tube, furrowed my brows and made a note of the compression fracture of the D12 vertebrae. So there you are, he has a fracture. No, but his doctor told him that there was a scratch in the bone. Did he really have a fracture, enquired his wife, her eyes about to fall of her sockets! Of course there was one. I struggled to explain. This is not like the usual fracture where the bone breaks into two or more pieces. Here the height of the bone decreases as the walls of the square-shaped bone collapses making it look wedge-shaped. This is because …the bone is weak, interjected the son. I nodded my head in agreement. The doctor prescribed some painkillers and …he also asked us to take this. He handed over a packet with a vial inside it. Salmon Calcitonin was the name of the drug. He said this will make his bones stronger in a week but I do not know the dosage. He mentioned 200 but there’s so little of it …and how do we give it to him. Well, well …this is administered as nasal puffs and each puff is metered to deliver 200 units. Oh! Ok.

There are so many drugs introduced in the market these days that makes keeping up with all the information very difficult. So what did we have about Osteoporosis and its treatment in the web? I decided to do a Google search. And this is what I came up with.

Osteoporosis

In simple words, osteoporosis refers to loss of density of bones. What that means is that the bones become weak and break easily from minor falls, necessitating a visit to the doctor. It is commonly seen in the elderly and women in particular after menopause. Bones also become less dense and weak after prolonged immobilization as in fractured bones treated in plaster casts or in paralyzed limbs. But the medical term for this is osteopenia. Osteoporosis refers to the specific disease process rather than the mechanical condition or radiological appearance of bone. In other words it is a quantitative and not a qualitative defect.

There are several web sites dedicated to Osteoporosis. But there’s one that took my breath away. Osteoporosis and Bone Physiology is a site maintained by Susan Ott, who is an Associate Professor in the Department of Medicine at University of Washington. The site details every aspect of osteoporosis. Overall the site looks old-fashioned, but hides a lot of information, if you cared to look for it. Some excellent images and animations supplement the information available. The language is lucid and clear. This would be a one stop reference for everything on Osteoporosis. There is also information available for Patients and a corner for kids. To top it all she manages to keep it updated.

Salmon Calcitonin

Susan Ott does mention calcitonin as one of the many drugs available to treat osteoporosis. Calcitonin can be administered as an injection or as a nasal spray. As a nasal spray, salmon calcitonin was first used to treat Paget’s disease. Its ease of use as a nasal spray was then exploited for treatment of osteoporosis. Its use significantly reduces the occurrence of spinal fractures and there is a modest improvement in vertebral bone density. Calcitonin is a hormone produced normally in the human body by the thyroid gland. Salmon calcitonin is a synthetic form that has the same amino acid sequence as in the calcitonin of salmon origin. The drug is not of salmon origin. This is marketed as Miacalcin by Novartis. Emisphere technologies has developed an oral form of Salmon Calcitonin in conjunction with Novartis and the drug is yet to complete its phase III clinical trials.

The Facts

The presence of a vertebral fracture is more an evidence than an indication for osteoporosis. Vertebrae can have micro fractures invisible to the naked eye that are probably the cause of back pain in an elderly with osteoporosis. They do not suffer from any kind of scratches!! Vertebrae also collapse in the center when they are referred to as codfish vertebrae. Fractures in the elderly around the hip, spine and wrist in a low-energy trauma situation indicate the presence of osteoporosis, and necessarily require to be treated for the same.

Each puff of the calcitonin spray, indeed delivers 200 IU of the drug (0.09 ml to be exact) and it doesn’t have to be inhaled. Each bottle contains 3.7 ml and that usually lasts for a month. Opened bottles need to be stored in temperatures not exceeding 25 ºC. And unused bottles need to be stored in the refrigerator but not in the freezer. The drug has no gastric side effects but can, in a few patients, irritate the nasal lining. In addition to using the spray a patient also needs to use calcium and Vitamin D supplements.

Other drugs available for treating osteoporosis are:

Anabolic (Bone forming) agents

• Intermittent Parathormone (PTH) injection. Low doses of parathormone helps build bone mass. Abnormally high secretions of the hormone, on the contrary, causes bone resorption.

Anti-resorptive agents

• Hormone Replacement therapy (HRT) in the form of estrogen. There have been concerns of increased risks of breast and endometrial cancer, strokes, pulmonary embolism and coronary heart disease. Low dose therapy may be appropriate.
• Selective Estrogen Receptor Modulators (SERM) - Raloxifene (Ralista, Evista). These drugs bind to estrogen receptors and have estrogen-like and anti-estrogen actions depending on the tissue of action. Though they help control osteoporosis like estrogens, they do not carry the same risk factors as HRT is normally associated with. The effect on the cardiovascular system, whether desirable or undesirable is still under debate. Along with HRT, SERMs are best considered for post-menopausal osteoporosis.
• Biphosphonates are Alendronate (Fosamax, Restofos) , Rrisedronate (Actonel) and Ibandronate (Boniva). They are known to reduce the incidence of fractures. Of late there have been reports about Osteonecrosis (bone death) of the jaw bone in the literature, and so the drug needs to be used with caution.
• Calcitonin.

Further reading

1. Pharmaceutical Treatment of Osteoporosis by Susan Ott.
2. Osteoporois - Preventiion and Treatment at Endotext.com
3. Pharmacotherapeutic Implications of Osteoblast and Osteocyte Apoptosis at Endojournals .org
4. Alendronate for treatment of Osteoporosis in men at NEJM.
5. Article on Salmon Calcitonin in American Journal of Medicine (pdf format).
6. Miacalcin at novartis website.
7. Diseases of Bone and Calcium Metabolism at Endotext.

Tags: osteoprorosis, salmon calcitonin, treatment of osteoporosis, vertebral fractures

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