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  1. 1. Cindy Johnston, MDChief Fellow, Division of RheumatologyAlbert Einstein College of Medicine
  2. 2.  Your bones may feel rock hard, but they are living tissue. Bone-building cells (osteoblasts) and cells that break downbone (osteoclasts) are always at work.
  3. 3.  During your teenage years, tremendous bone growth takes place with bonebuilding out pacing bone breakdown. Most adults reach their peak bone mass by age 20, with only a smallamount more of bone mass added by the time you reach age 28. Hormones—estrogens in females and testosterone in males—play a majorrole in this rapid bone growth during the first 25-30 years of life. Around age 28, the same amount of bone that is removed is replaced.However, bone loss is a normal part of aging in both men and women. In women, the hormone estrogen decreases sharply after menopause,which causes bone breakdown to speed up. Men start out with more bone mass than women but as they age, theirtestosterone levels slowly go down. This leads to a gradual loss of bone.
  4. 4.  Bones need Vitamin D and calcium as well asprotein and other nutrients to grow andbecome strong, but genes play a big part inhow thick your bones are. If one of your parents had thin bones, youare more likely to have them. Other things, like diet, exercise, co-existingmedical conditions and medications alsoinfluence the thickness of your bones.
  5. 5.  Osteopenia is the term used to describemild thinning of the bones. In osteopenia, bone build up is not enough tokeep up with bone breakdown. People with osteopenia are at risk fordeveloping osteoporosis as well as fractures. Osteopenia is more common in women thanin men.
  6. 6.  It is known as a silent disease because, if undetected, bone losscan progress for many years without symptoms until a fractureoccurs.
  7. 7.  Studies have found an increase in bone lossand fracture in individuals with SLE. In fact, women with lupus may be nearly fivetimes more likely than those without thedisease to experience a fracture fromosteoporosis.
  8. 8.  Individuals with lupus are at increased risk for osteoporosis for manyreasons. To begin with, the glucocorticoid medications often prescribed to treat SLE cantrigger significant bone loss. In addition, pain and fatigue caused by the disease can result in inactivity, furtherincreasing osteoporosis risk. Studies also show that bone loss in lupus may occur as a direct result of the disease. Inflammation increases bone breakdown and decreases new boneformation in all people. Lupus, like other autoimmune disorders, causes inflammation. This probably is the major reason why people with lupus haveincreased bone loss. Of concern is the fact that 90 percent of the people affected with lupus arewomen, a group already at increased risk for osteoporosis.
  9. 9.  Objective. To determine the association between race/ethnicity andbone mineral density (BMD) in women with systemic lupuserythematosus (SLE). Methods. Women with SLE (n 298), including 77 African Americans and 221 whites, completed this cross-sectionalstudy conducted from 1996 to 2002. Hip and lumbar spine BMD were measured by dual-energy x-rayabsorptiometry.Study participants completed a self-administered questionnaire and a physician completed theSystemic Lupus InternationalCollaborating Clinics/American College of Rheumatology Damage Index (SDI). BMDresults were expressed asZ scores. Analyses were performed to identify factors, including race/ethnicity,associated with low BMD defined as a Zscore 1.0 or less at the hip or lumbar spine. Results. African Americans compared with whites were younger at study visit (mean SD 39.7 8.4 years versus42.9 11.6 years) and had higher SDI (mean SD 1.8 2.0 versus 1.0 1.6), but similar proportions of women werepostmenopausal (31.2% versus 38.0%). African Americans had significantly lower mean BMD Z scores at the hip(0.49versus 0.07; group difference 0.41; 95% confidence interval [95% CI] 0.70, 0.13) and at the lumbar spine(1.03versus 0.10; group difference 1.13; 95% CI 1.48, 0.78) compared with whites. African Americanrace/ethnicity wasstrongly associated with low BMD at the lumbar spine (adjusted odds ratio 4.42; 95% CI 2.19,8.91) but not at the hip,adjusting for factors associated with low BMD. Conclusion. African American women compared withwhite women with SLE had lower BMD at the hip andlumbar spine.
  10. 10.  thinness or small frame family history of the disease being postmenopausal and particularly having an early menopause abnormal absence of menstrual periods (amenorrhea) prolonged use of certain medications, such as those used to treatlupus, asthma, thyroid deficiencies, and seizures low calcium intake lack of physical activity smoking excessive alcohol intake.
  11. 11.  Decreased Physical Activity Weight-bearing physical activities, such as walking andjogging, exert force on our bones. Your bones respond by increasing their mass in orderto spread the load over a larger amount of bone. Physical activity also improves balance andcoordination, which reduces the risk of falling that cancause broken bones. The pain and fatigue that accompany lupus can makeit difficult to be physically active, adding to the riskfor osteoporiosis.
  12. 12.  Hormonal changes Estrogen and testosterone play important roles inkeeping your bones thick. Women with autoimmune disorders often go throughmenopause a few years earlier that those womenwithout such conditions. This earlier loss of estrogen can trigger osteoporosis.
  13. 13.  Low Vitamin D level Vitamin D is needed to absorb calcium. Vitamin D is formed in the skin when the skin is exposedto sunlight. Some people with lupus avoid sunlight since it cantrigger flares. This may explain in part why some peoplewith lupus have low Vitamin D levels but notcompletely. Scientists are just discovering the importance of VitaminD to the immune system and have found that manypeople with autoimmune diseases have low Vitamin Dlevels.
  14. 14.  Kidney disease The kidney is one of the major places in the bodywhere vitamin D is changed to its active form. Kidney diseases can affect the kidney’s ability tochange vitamin D to its active form. Some people with lupus develop lupus nephritis,a form of kidney disease. When lupus nephritis becomes chronic, itincreases the risk for osteoporosis.
  15. 15.  Medications Steroids are powerful anti-inflammatory medications thatsuppress the immune system in high doses. However, they also have an effect on bone. They increasebone breakdown by upsetting the calcium balance. Steroids also reduce the activity and life span of the bone-building cells. Cyclophosphamide (Cytoxan) and methotrexate arechemotherapy drugs used to suppress the immune system insome lupus patients. They can cause a woman’s ovaries to shutdown. This causesless estrogen, which indirectly increases the risk forosteoporosis.
  16. 16.  Even though your genes mostly determinehow strong your skeleton will become, yourlifestyle also plays a big part in your bonehealth. Ways to prevent and treat osteoporosis inpeople with lupus are not very different fromthose for people without lupus.
  17. 17.  Bone mineral density tests measurebone thickness at different places inthe body. These tests can detect osteoporosisbefore a fracture occurs as well aspredict the chances that you willbreak a bone.
  18. 18.  Bone loss in people with lupus is most common in thespinal bones of the lower back, therefore, the best placefor measuring bone density is the lower back spine. There are no guidelines for bone density screening inpeople with lupus, but there are some generalrecommendations. All of the following should have routine bone densityscreening, like a DEXA scan Postmenopausal women with lupus and a previous fragilityfracture women age 60 years or older with a risk factor for osteoporosis(such as lupus) any woman older than 65 years
  19. 19.  There are no guidelines for premenopausal women orpostmenopausal women younger than 65 years withoutrisk factors for osteoporosis. A DEXA scan every two years is a good idea for both menand women with lupus under the age of 50 if they haveother risk factors for osteoporosis, if they have had highlevels of disease activity, or if they are or have takensteroids. If you receive treatment for osteoporosis, it is usually notuseful to have another bone scan done to see if it isworking until after 2 years of treatment.
  20. 20.  Calcium is the most abundant mineral in the body. About99% of the body’s calcium is stored in the skeleton. Calcium needs change as you age. People in their teensand early 20s need more calcium because of the rapidbone growth that occurs during this time. For women, calcium requirements remain stable untilmenopause when estrogen decreases and bone breakdownincreases.
  21. 21.  Research shows that calcium plus vitamin D canreduce bone loss in postmenopausal women, especiallythose who take at least 1,200 mg of calcium per day andtake part in weight bearing activities. Calcium is absorbed in the small intestines but you absorbless as you get older. By the time you are 65, you absorb only 50% of the calciumthat you did when you were a teenager.
  22. 22.  It is recommended that both adult men andwomen with lupus have a total daily calciumintake of 1500 mg. Sources of Calcium Diet is the best source more easily absorbed 2 or 3 cups of milk or milk products per day willmeet the daily requirements for most adults.
  23. 23.  Calcium supplements are available without a prescription,but not all calcium supplements are equal. Think about the following when choosing your supplement: Purity When picking a calcium supplement, look on the label for “purified” or theUSP (United States Pharmacopeia) symbol. Dose When buying calcium supplements, check the label for the elemental calciumcontent, not the total content. Elemental calcium is the amount of calcium your body actually can use. For example, a tablet containing 500 mg of calcium carbonate provides 200mg of elemental calcium. Therefore, one tablet provides only 200 mg ofcalcium, not 500 mg.
  24. 24.  Type Calcium carbonate (Tums or Caltrate) most common type of calcium tablets the least expensive on the market Calcium carbonate requires extra stomach acid for best absorption, so itshould be taken with meals. Calcium citrate (Citracal or Solgar) Calcium citrate does not require extra stomach acid for absorption, so youcan take it anytime, even on an empty stomach. Calcium citrate, however, usually provides less elemental calcium per pill, soyou may need to take more tablets per day depending on your needs. Calcium citrate is also more expensive than some other types of calciumsupplements. Calcium gluconate and calcium lactate have a low amount of elemental calcium so you may end up taking severaltablets to meet your calcium needs
  25. 25.  Tolerance Calcium supplements may cause side effects indigestion, gas or constipation in some people. People with acid reflux or GERD may have difficulty,especially with calcium citrate. When you begin taking calcium, start with 500 mg/dayfor a week and then gradually add more calcium. Taking calcium with meals can decrease the chance itwill upset your stomach. Tea may interfere with calcium absorption. You maydrink tea but not with your calcium supplement
  26. 26.  It is currently recommended that adults with lupus have atotal daily vitamin D3 intake of 800 – 1,000 IU. Vitamin D is a fat-soluble vitamin. This means that anyVitamin D your body does not need immediately can bestored for later use in your fat tissue. Unlike calcium, there is a blood test to see if you areproducing enough vitamin D. Although there is no worldwide accepted normal vitamin Dlevel, the general consensus is that your 25(OH)D levelshould be at least 32ng/mL to reduce your risk of fracture.At a level of 32ng/mL, calcium absorption is at itsmaximum.
  27. 27.  Vitamin D is found in some foods but it is mainly producedin your skin after your skin is exposed to ultraviolet raysfrom the sun. Wearing a sunscreen with an SPF of 8 or higher decreasesthe skin’s ability to produce vitamin D by 95%. People with low vitamin D levels do not absorb calciumwell. Without enough vitamin D, only 10-15% of calcium in yourdiet is absorbed.
  28. 28.  Vitamin D occurs naturally in only a fewfoods. fatty fish, such as mackerel, salmon, sardines, codliver oil, and eggs from hens that have been fedvitamin D. Milk fortified with vitamin D contains 100 IU per 8 oz.cup. Orange juice fortified with vitamin D is now availableas is vitamin D-fortified cereals and breads.
  29. 29.  Limit soft drinks Soft drinks contain high levels of phosphorous. Phosphorus is an important mineral in the body, buttoo much phosphorus can actually cause calcium to bedrawn from your bones and teeth. Phosphorous is contained in fizzy soft drinks. You donot need to give up soft drinks completely, but limithow much you drink.
  30. 30.  Treatment with anti-inflammatory drugs isoften needed to control lupus symptoms. While the use of steroids is a risk factor forbone loss, if these drugs are used for shortperiods of time and drugs that can reducesteroid doses (Cellcept, Plaquenil) arestarted along with them, the bone loss mightbe minimized.
  31. 31.  Men and postmenopausal women withosteoporosis Oral alendronate (Fosamax) risedronate (Actonel) ibandronate (Boniva) IV Zolendronic Acid (Reclast) Side effects include nausea, abdominal pain,difficulty swallowing, and the risk of aninflamed esophagus or esophageal ulcers.
  32. 32.  Long-term bisphosphonate therapy has beenlinked to a rare problem in which the upperthighbone cracks, but doesnt usually breakcompletely. Bisphosphonates also have the potential toaffect the jawbone. Osteonecrosis of the jaw is a rare condition occurringafter a tooth extraction in which a section of jawbonedies and deteriorates.
  33. 33.  Estrogen when started soon after menopause, can help maintain bone density. However, estrogen therapy can increase a womans risk of blood clots,endometrial cancer, breast cancer and possibly heart disease. Raloxifene (Evista) mimics estrogens beneficial effects on bone density in postmenopausalwomen, without some of the risks associated with estrogen. Taking this drug may also reduce the risk of some types of breast cancer. Hotflashes are a common side effect. Raloxifene also may increase your risk of blood clots. In men, osteoporosis may be linked with a gradual age-related decline in testosterone levels. Testosterone replacement therapy can help increase bone density.
  34. 34.  Teriparatide (Forteo) This powerful drug uses parathyroid hormone tostimulate new bone growth. Its given by injection under the skin. Long-term effects are still being studied, sotherapy is recommended for two years or less.
  35. 35.  Denosumab (Prolia) Compared to bisphosphonates, denosumabproduces similar or better results while targetinga different step in the bone remodeling process. Denosumab is delivered via a shot under the skinevery six months. The most common side effects are back andmuscle pain.
  36. 36.  Prevent falls Wear low-heeled shoes with nonslip soles Check your house for electrical cords, area rugsand slippery surfaces that might cause you totrip or fall. Keep rooms brightly lit, install grab bars justinside and outside your shower door, and makesure you can get in and out of your bed easily.
  37. 37.  Dont smoke. Smoking increases bone loss perhaps by decreasing the amount of estrogen awomans body makes by reducing the absorption of calcium in your intestine Avoid excessive alcohol. Consuming more than one alcoholic drink a daymay decrease bone formation and reduce yourbodys ability to absorb calcium. Being under the influence also can increase yourrisk of falling
  38. 38.  Like muscle, bone is living tissue that responds to exerciseby becoming stronger. The best exercise for your bones is weight-bearingexercise that forces you to work against gravity. Walking climbing stairs weight lifting Dancing Exercise alone will not make your bones thick but it canstop you from losing bone.
  39. 39.  These exercises should be done 3-5 times/week. You should also do some weightlifting 2-3 times/week. Weight-bearing, jumping and weight-lifting activitiesshould be done in combination for 30-60 minutes at atime. This seems like a big order when you have fatigue or pain. Start out slow and work your way up. Exercise has anti-inflammatory effects and once you start,you might notice a gradual improvement in how you feel.
  40. 40.  Irene Blanco, MD Yasmin Santiago Our Audience!