Drugs Used to Improve Bone Density

May Actually Increase Risk of Fractures

Bisphosphonates are a class of drugs commonly used to treat osteoporosis, and include alendronate, etidronate, risedronate, and zoledronic acid. Bisphosphonates are designed to slow or stop the bone loss that occurs during the body’s natural process that involves removal and replacement of bone tissue. In March 2010, at the annual meeting of the American Academy of Orthopaedic Surgeons, reports suggested that if bisphosphonates are used for four or more years, they may actually impair bone quality and increase the risk of certain bone fractures. Two separate studies by researchers from the Hospital for Special Surgery (HSS) and Columbia University Medical Center revealed data suggesting that long-term suppression of bone remodeling with bisphosphonates may alter the material properties of bone, potentially resulting in brittle bone and contributing to the risk of atypical fractures.

http://www3.aaos.org/education/anmeet/anmt2010/podium/podium.cfm?Pevent=339

Accessed March 22, 2010

Bisphosphonates have also been associated with osteonecrosis of the jaw (ONJ), an uncommon but potentially serious condition that can cause severe destruction of the jaw. Initially, it was thought that the greatest risk was in patients with cancer who received treatment with intravenous bisphosphonates. However, a recent study at the University of Southern California found that ONJ caused by oral aledronate was more common than previously suggested. The jaw problem was found in 9 of 208 patients receiving oral alendronate, or approximately 4% of the population. The findings from this study indicated that even short-term oral use of alendronate led to ONJ in a subset of patients after certain dental procedures were performed.

J Am Dent Assoc. 2009 Jan; 140(1):61-6.

Concerns about bisphosphonates have prompted many people to search for other forms of therapy to improve bone density and prevent osteoporosis.

Declining estrogen levels after menopause result in bone loss and increased fracture risk. Estrogen levels can be increased with transdermal estradiol, which is well tolerated and similarly effective to raloxifene (a drug approved for the prevention and treatment of postmenopausal osteoporosis) in preventing bone loss.

Menopause. 2009 May-Jun; 16(3):559-65.

In addition, we recommend that both men and women utilize a broad-spectrum bone support program beyond the basic calcium/magnesium/vitamin D in order to optimize bone density and quality and to reduce the risk of osteoporosis.

Your questions are welcome.

Clearing Up Fungal Nail

The first sign of a fungal nail infection is discoloration - yellow or white opacity - of the nail, most commonly on the big (great) toe. If left untreated, toenails can become thick, causing pressure and irritation, and thus act as a trigger for more severe complications. This can be particularly problematic in elderly patients and patients with diabetes, because fungal nail (clinically known as onychomycosis) is among the most significant predictors of foot ulcer, which can ultimately lead to severe infection and even amputation. As the severity of onychomycosis may be associated with the length of time the individual has had the infection, early intervention is advisable.

Conventional therapy involves taking oral antifungal drugs for several months. When these medications are taken orally, the patient must have baseline and regular lab work to monitor liver function, as these medications can be harmful to the liver. The reason that topical antifungals typically are not used to treat fungal nail is that most commercially available topical creams are unable to penetrate the nail to reach the site of infection. Our compounding pharmacy can solve this problem by preparing customized formulations containing a penetration enhancer to increase the extent of absorption through the nail. When selecting the best form of treatment, the practitioner needs to consider the cause of the infection, other medications that the patient is taking in order to avoid drug interactions, and the potential for adverse events associated with antifungal therapy. Topical treatment of onychomycosis offers a distinct advantage to oral therapy. Because topical preparations can be applied directly to the affected area and therefore result in lower drug levels in the blood, the potential for serious problems associated with oral antifungal therapy, such as drug interactions and liver problems, is decreased. Ask our compounding pharmacist for more information on customized therapies for fungal nail.

Am J Clin Dermatol. 2009;10(4):211-20.

J Dermatolog Treat. 2005 Feb;16(1):52-5

J Cutan Med Surg. 2004 Jan-Feb;8(1):25-30.

Prescrire Int. 2009 Feb;18(99):26-30.

Pure Sesame Oil for Treatment of Dry Nasal Mucosa

Many people experience problems with dryness of the tissue lining the inside of the nose, which is worse during the winter, in warm and dry inland climates or deserts, and after nasal irradiation. Complaints of nasal dryness may occur in situations involving low humidity including long journeys by airplane and air-conditioned environments. Normal saline (Isotonic sodium chloride solution; ISCS) has long been the most commonly used therapy for nasal dryness. But, it has been shown that normal saline produces little change and pure pharmaceutical grade sesame oil has been shown to be significantly more effective than normal saline for treatment of nasal dryness.

Our compounding pharmacy can place pure pharmaceutical grade sesame oil in a nasal spray. The recommended dose is 1 to 3 sprays in each nostril 3 times daily.

In studies, a few patients reported allergies to sesame seed. However, when they received oral 1-ml doses of pharmaceutical quality pure sesame oil, no allergic reactions were observed. Pharmaceutical grade pure sesame oil does not contain the proteins that typically cause allergic reactions.

Sesame oil contains a high concentration of tocopherols (vitamin E) that might neutralize oxidants and prevent tissue damage and inflammation that would otherwise occur.

Rhinology 2000 Dec;38(4):200-3

Arch Otolaryngol Head Neck Surg 2001 Nov;127:1353-1356

Medication Changes Needed after Gastric Bypass

Bariatric surgery is done to help patients lose weight, control diabetes, and improve cardiovascular risk. Roux-en-Y gastric bypass reduces the stomach size and bypasses part of the small intestine to limit absorption, and therefore medication form and doses may need to be adjusted after surgery. For example, patients should use liquid or non-oral meds (such as a transdermal gel) for weeks to months after bypass surgery to allow healing. It is important to avoid medications that contain sugar, sucrose, corn syrup, maltose, fructose, lactose, honey, mannitol, and sorbitol to reduce symptoms of dumping syndrome (nausea, pain, diarrhea, sweating, rapid heart rate, or fainting). We can compound medications that are free of these problem-causing additives.

After bypass surgery, absorption is unpredictable due to the shortened intestine, and medications should be switched to “immediate release” versus extended-release or enteric-coated forms. Our compounding pharmacist will work together with patients and their physicians to customize medication doses to meet each patient’s specific needs.

When people lose weight, medications for problems such as diabetes and hypertension may no longer be necessary. Birth control may need to be changed.

Due to decreased absorption of nutrients, patients who have had a Roux-en-Y procedure may need to increase their consumption of calcium, fat-soluble vitamins (especially vitamin D), folic acid, iron, thiamine, and vitamin B12. Ask our professional staff to recommend quality supplements.