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Corticosteriods:
Patients with arthritis who are treated with glucocorticoids face a highly increased risk of developing osteoporosis.
Belgian researchers at the 64th Annual scientific Meeting of the American College of Rheumatology (ACR) in Philadelphia Pennsylvania,stated
that pamidronate,as a primary preventive therapy can help arthritis patients maintain bone mineral density and fight off glucocorticoid-induced
osteoporosis.
Yves Boutsen,MD,Clinical Adjunctive Chief of Rheumatology,St-Luc University Clinic of Mont Godinne Belgium,led a team
of researchers in a prospective,controlled,one-year study comparing single-infusion pamidronate,
three-month therapy with pamidronate and calcium therapy alone in patients requiring first-time treatment with glucocorticoids.
Patients were examined at one year to determine differences in bone mineral density (BMD).
Thirty-two patients requiring first-time,long-term glucocortoids (at least 10 mg predisonolone daily) were studied. With
initiation of glucocortcoid therapy, patients all received 800 mg of elemental calcium daily,given as calcium carbonate. More
importanly,patients were also randomely allocated to receive one of the following; Group A received a single infusion of pamidronate
90 mg; Group B received a first infusion of pamidronate 90 mg followed by a 30-mg infusion of pamidronate every three months;
Group C received the calcium supplement alone.
Lumbar spine and hip (total and subregions) BMDs were measured at the onset and repeated at six-month intervals by dual-energy
x-ray absorptiometry (DEXA). Bone turnover was assessed by measurement of total and bone-specific serum alkaline phosphatase
activity,serum osteocalcin and serum C-telopeptide crosslinks of type-1 collagen.
After one year, results showed that the mean BMD changes for groups A,B and C were 1.7 %,2.3 % and-4.6 % respectively,at
the lumbar spine. BMD changes at the femoral neck were 1.2 % and-3.1 % respectively; and at the total hip refion were 1.0
%,2.6 % and-2.2 %.respectively.
No significant difference was observed between the pamidronate groups (A & B),but a significant difference was observed
between both pamidronate groups as compared to the calcium-alone regions. The researchers concluded that intravenous pamidronate
effectively achieved prevention of glucocortoid-induced osteoporosis.
Patients at high risk of steroid-induced osteoporosis should start bone-protective therapy at the same time they begin
glucocorticoids, Britain's Royal College of Physicians (RCP) recommends.
In a guidance document issued Monday, the RCP, the Bone and Tooth Society of Great Britain and the National Osteoporosis
Society update their 1999 advice on treating and preventing osteoporosis, which did not include steroid-induced disease.
High-risk patients include people over 65, and those who have had a previous fragility fracture.
"Glucocorticoids are an important but still relatively neglected cause of osteoporosis," said Dr. Juliet Compston, chair
of the RCP's guidelines development group. "There are now effective prevention measures and these guidelines provide an evidence-based
approach to the manage ment of glucocorticoid-treated patients," she said.
At any one time, about 1% of the adult population in the UK is taking oral glucocorticoids, most commonly prednisolone.
As many as 350,000 people in the UK could be at risk of glucocorticoid-induced osteo porosis, according to the RCP.
Patients receiving glucocorticoids should also have their bone mineral density measured with dual energy X-ray absorptiometry,
the physician group adds.
Measures to reduce bone loss include reduction of glucocorticoid dosage to a minimum, consideration of other formulations
or ways of administering the drug and prescription of alternative immuno suppressive drugs, the guidance says.
Patients should also be encouraged to cut back on alcohol and tobacco, and to maintain good nutrition, an adequate dietary
calcium intake and appropriate physical activity
The Story About Alice and her perspective:
Alice was in such bad shape that she thought she was going to die. There were times she prayed to die,because it was
so,so painful. She didn't really think of taking her life.she just prayed that one day she'd sleep and not wake up. What kept
Alice 39,going was her daughter theresa,who turned sixteen in early 1975. Alice said,"When I'd think that way,I'd say,no I
want to see my daughter grow up. I want to know she's going to be able to take care of herself".
Alice was a young college student and new single mom when her arthritis began,with swelling and pain in her right elbow.
A couple of month's later,the joints of two fingers on her left hand started to swell up.. by the time she finished school
and landed a job as a telephone operator with Bell Canada,an ankle was also affected. Then she had her really bad flare: "Practically
all my joints were involved. I woke up one morning and I couldn't get out of bed",recalls Alice.
A rheumatologist had some fluid from her elbow tested and diagnosed her with rheumatoid arthritis. He gave her cortisone
injections in her elbow for the pain,but he didn't really explain what she was facing. "In the early stages they jusy say
this is what you have,RA,"Alice says looking up at the ceiling.,"and I want you to take some of this,a coated form of Tylenol,and
I want you to come to my office once a week. They would inject my joints with cortisone,maybe once in three months (hands),different
joints like knee once a year. Some joints he repeated,others he did not. This continued for a while,and the pain just kept
progressing and I would be taking off time from work all the time."
The physiothapist kept telling her to keep her joints moving,because if she didn't,she wouldn't be able to move them.
Alice didn't quite understand the full impact of the therapist's words. "Exercise with all that pain,and I can barely walk
?,thought Alice. The occupational therapist made a special support for her hands and arms so she could sleep at night. She
would roll over and pin her hands under her body and according to Alice,"The pain was unbelievable".
Later,a new rheumatologist closer to her home had her hospitalized. For three weeks,she was prodded and poked, tested
and injected. In her condition,they finally concluded,Alice shouldn't even be working,a daunting prospect for a single mom
with a toddler to take care of. Fortunately,Alice's sister ccame from her family home and stayed to help out,and the initial
treatments,a combination of gold injections,water therapy,splints for her hands,more Acetaminophen, and lots of rest,seemed
to be helping.
Over the next several years,Alice was up and down,mostly down,with flares and remissions,but the RA was taking over.
The pain was becoming consistently bad,she was still on regular gold injections and taking a lot of Acetaminophen, she suffered
periods of deep depression,and her mobility was slowly eroding. She couldn't handle a few light chores,but she relied on her
sister for help with her daughter. She couldn't even comb her own hair,because her shoulders were so bad.
For another two years her conditioned worsened. Nothing seemed to help,and she landed in hospital again. This time she
saw a friendly,and interested physiotherapist who asked if she'd been in touch with The Arthritis Society. "You've been sick
for fourteen years,and nobody told you about them ?" the physio asked. "Well no",Alice replied. And he said,"I'm going to
sign you up right now"and Alice thanked God,she didn't know they had social workers you could sit and talk to,and physiotherapists
and occupational therapist. (One may have problems getting through at times,because they are very busy } That was what Alice
needed,to really understand what was happening with her arthritis,to be educated about it. ( Alice was also cautioned
about some members and staff,after all,people are people . I experienced some real bad ones.) She seen a local nurse,but
she didn't really understand Alice's disease,at all.
That same year,Alice was referred to an orthopedic surgeon for her knees. He took x-rays and gave her the news
in no uncertain terms "He said."You have to make up your mind. You have no cartilage left in your knees. You're too young,but
you can have surgery done now or wait till later,and be in a wheelchair and go through all the pain". (things have changed
now)
"By then"says Alice,"my arthritis was so bad I couldn't comb my hair,I couldn't wash myself,I couldn't feed myself,let
alone walk. Just to take one step was agnonizing." She decided to go with total joint replacements,both knees,four months
apart.
"After the first operation it was very painful,but after I started going on it I felt better. I didn't have all that
pain I'd experienced before. I was able to put my foot down and walk with a walker,then a cane". The second operation, though,wasn't
as good. Alice's right knee doesn't bend as much as it should,making it difficult for her to sit comfortably,for example,in
the back of a car. "My patella doesn't move at all in the right knee,but it doesn't pain".
Alice still has arthritis "all over",and since the operation her right ankle has been very painful. She walks with a
limp,but she can walk,and the pain in her knee,while it isn't totally gone,is bearable. "Before I had to think when I got
up," she explains. "Now I can just get up,OK,ther's going to be a little discomfort,but not like before,when I fell I wanted
to faint because the pain was so bad.
Without a doubt,the results would have been better if the operations had been performed earlier,something Alice's going
to have to consider as she contemplates the continuing deterioration of her other joints. Her right hip is "acting up a little
bit",and the other hip may eventually be affected,too,either by the progression of the disease,or because of the uneven wear
her hips are subjected to because of her mismatched knees.
"I don't even want to think about having my hips replaced right now,"she says,"but it's a possibility. My hands are still
the same,my elbows,my shoulders,it's affected my shoulders,real bad,and my elbows have gotten worse".
Overall,though Alice is better than she was. Her knee surgery has given her a measure of independence she didn't have
before, and The Arthritis Society occupational therapists have helped set her up with a labour-saving devices to make her
domestic tasks easier,and have given her instruction in how to perform those tasks with the least possible stress on her aching
joints. "I have to make ways of doing things",she says,"but I feel much better that I'm doing things for myself,because before
my sister and my daughter used to be doing everything."
She's even doing occasional volunteer work for the Arthritis Society,attending meetings to talk about her arthritis and
she agreed to attend a meeting of medical students and talk about the real world of arthritis.
" You can't help but think about the future,"Alice says"but I try not to. I say,whenever I reach the river,then I'll
cross over the bridge,but now I don't want to think about it. I just want to thank God for what I have and try to make it
better,if I can."
I met and talked to Alice,and I wonder,sometimes,if she had gotten better medical treatment earlier and got a better
understanding about her disease ,things may be a lot of different. Alice started treatment 25 years ago. I hope this story
may help some patients about dropping conventional therapy,to reconsider,and think about Alice and her story. Complementary
therapy if it helps,yes !,but total,Alternate threapy No !!
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