Thread by @moreyraortho

Medications and Bone Health:
A Thread 🦴🧵

Let’s discuss some medications that can have harmful effects on your bone health

(Not medical advice. Consult first with your physician prior to changing your medications)

Let’s start with the common anti-acids …
#Osteoporosis

Proton Pump Inhibitors (PPIs)

These are commonly used in patients with gastroesophageal reflux disease (GERD). Examples include omeprazole, esomeprazole, lansoprazole, pantoprazole, etc.

PPIs basically inhibit the formation of acid in the stomach. As such, they can affect nutrient absorption, including calcium.
The body then starts breaking down its own bone in order to obtain calcium for bodily functions

It’s possible that H2 blocker antacids (Histamine-2 blockers) could also affect bone density but the association is not clear or as clear. I would certainly consider PPIs to be worse than H2 blockers for🦴 health, at least based on available info.

Recent data also suggests that PPIs could lead to autoimmune disorders 😳

Note: Some folks see improvement of GERD in a low carb diet, so that could be a way to ameliorate that.

Next, some diabetes medications that can lead to ⬇️🦴 density include the thiazolidinediones (AKA glitazones) such as pioglitazone and rosiglitazone. Others include SGLT2 inhibitors, such as empagliflozin.

Next, corticosteroids are well known to be detrimental to 🦴 health. As mentioned earlier, this is NOT medical advice. If U R on a corticosteroid you must talk to UR provider prior to any changes. Suddenly changing a stable dose can lead to adverse outcomes, including death ☠️

Next, loop diuretics can also be detrimental to 🦴 health. These can include hydrochlorithiazide (HCTZ), furosemide, bumetadone, etc

Next, psychotropics can be detrimental to bone health. This broad category includes hypnotics, benzodiazepines, lithium, and antidepressants such as SSRIs and SNRIs.

Again, talk with your provider first prior to any changes.

Note: Lithium deleterious effect is suspected at a psychotropic dose. I am not aware of any data for a very low dose of lithium as some folks could be using as a supplement to possibly help prevent dementia.

Lastly, a word on the bisphosphonates:

These medications are used to treat osteoporosis but, at the same time, they’re bad for 🦴 health🤯. What gives?

Mechanism of action for most of these include inducing programmed cell death (AKA apoptosis)

They induce apoptosis on the osteoclasts, which are the cells responsible for bone resorption.

As we age the 🦴 forming cells (osteoblasts) are less active in comparison to the osteoclasts. This leads to ⬇️ing 🦴 density over time. The purpose of the bisphosphonates…

…is to slow down or halt this process. The end result is a net ⬆️ in 🦴 density. However, this is not the same quality bone as someone who never took these medications.

Let’s look at an analogy:

Suppose your bone is a paved road. Occasionally will you have some potholes that need to be patched up. This job gets done by the osteoblasts.

Over time, however, the road has too many cracks and too many patched up potholes.

So, over the long run, the only way to improve the quality of the road is to remove the asphalt completely and re-pave it. The removal of the road would be the job of the osteoclasts.

If the osteoclasts are not working, then they patched up road with cracks cannot be removed.

In order to have a better road you will need to have the osteoclasts remove the patched up road so that the osteoblasts can come in and lay down new pavement.

Thus, as you can see, the QUALITY of the 🦴 in someone who takes bisphosphonates is not as good as somebody who does not. In some rare cases (after 5 years) it could even lead to fractures (atypical femoral fractures).

Other adverse effects of these 💊 incl. jaw osteonecrosis.

I do believe that bisphosphonates have a place in medicine.

We do know that the elderly with hip fractures are prone to a shorter lifespan. This involves a roughly 30% mortality at 1 year after a hip fracture.

Bisphosphonates have been shown to DECREASE ⬇️osteoporotic fracture incidence. However in a meta-analysis they have NOT been shown (at least yet) to improve overall mortality.

Thus, it is my personal belief that the prescription of bisphosphonates should be individualized and should based on a thorough discussion between pt and physician after a fragility fracture (e.g., hip fracture after ground level fall) or DEXA scan showing osteoporosis

It is certainly my strong belief that any discussion of osteoporosis MUST include a discussion on diet/nutrition and lifestyle. To simply jump into prescribing medications without discussing diet/nutrition and lifestyle is a complete disservice to the patient. For more on this:

Osteoporosis Prev
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🍹Max 2/d
😴 x7-8hr
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🏋️‍♂️💪🏻
❌ Sugar
❌ Processed 🥘
❌ Cola w/phosphoric acid
☕️ Max 2/d in 🚺
✅🥫Wild salmon/sardines w/🦴s
⬆️ 🥩&🍳
Ferment: L reuteri
☀️ UV B
⬆️ Vit D3 🏁25OH-Vit D: 60 ng/ml
Vit K2
Mg
Ca (w/👆🏻3, not by itself)
Vits C,E,A
Zn,P,Se,B