Osteoporosis Treatment Gains Made
New research is underway to find the most effective medication
combinations for persons with advanced osteoporosis, according to two new reports
in the New England Journal of Medicine (NEJM).
"This combination of two very expensive drugs is trying
to fine-tune the best therapy for people who already have severe osteoporosis
and are at the end of the road," says Dr. Steven R. Goldstein, professor of
obstetrics and gynecology at New York University School of Medicine in New
York City.
"The more important aspect of bone health for me and for
most physicians is in preventing our patients from getting to the point where
they might be candidates for this kind of therapy," he emphasizes.
According to an accompanying editorial in the NEJM,
five medications have been approved for the treatment or prevention of osteoporosis
in the US in the last decade.
The medications fall into two main categories: those that
reduce bone remodeling (such as alendronate) and those that stimulate bone
formation (such as parathyroid hormone).
While each class has been shown to reduce the risk of fractures,
it has been unclear how they work together.
According to the National Osteoporosis
Foundation, 80 percent of those affected by osteoporosis are women.
Twenty percent of non-Hispanic Caucasian and Asian women
aged 50 and older are estimated to have osteoporosis, and 52 percent are estimated
to have low bone mass.
Five percent of non-Hispanic African-American women over
age 50 are estimated to have osteoporosis; an estimated additional 35 percent
have low bone mass that puts them at risk of developing osteoporosis.
Ten percent of Hispanic women aged 50 and older are estimated
to have osteoporosis, and 49 percent are estimated to have low bone mass.
Osteoporosis is under-recognized and under-treated not only
in Caucasian women, but in African-American women as well, the Foundation states.
Many experts stress that the key to osteoporosis is to start treating people
at earlier stages of disease, or perhaps even before they have developed the
disease.
"These are people way at the end of the line, who come into
the care of bone specialists," Dr. Goldstein explains. "The relevance of such
a study to the overwhelming majority of women at risk for future fragility
fractures is low.
"Every day, we're trying to prevent women from getting to
the point where they would possibly think about such a combination of two such
potent and expensive drugs," Dr. Goldstein says.
One study found that delivering a parathyroid hormone medication
on three-month cycles may be a more efficient way to strengthen bone quality.
A second study found that gains in bone density achieved
after taking parathyroid hormone are lost if that regimen is not followed by
alendronate - Fosamax®, a bisphosphonate medication.
Both studies looked at people with severe cases of the disease.
The authors of the first study sought to discover whether
parathyroid hormone would work just as well on women who have been on other
therapies and whether cyclic (as opposed to daily) therapy was more effective
for bone formation.
One hundred twenty-six women with severe osteoporosis who
had been taking alendronate for an average of three or more years were randomly
assigned either to continue alendronate alone, to take alendronate plus parathyroid
hormone daily, or to take the combination in three-month cycles.
"We saw better maintenance of bone formation effect with
repeated cycles," says Dr. Felicia Cosman, lead author of the study and director
of the clinical research center at Helen Hayes Hospital in West Haverstraw,
New York.
"It does look like cyclic therapy is a rational approach
but we need to test it further at this point," she says. "If further testing
confirms the findings, this means that with less patient effort and better
tolerability, we may be able to get a better effect."
The study also confirmed that, even with patients who have
been on alendronate long-term, parathyroid hormone works.
X-ray data suggests that parathyroid hormone may reduce
the risk of further vertebral fractures but the results were not statistically
significant.
"It's suggestive that maybe the increase in bone density
is associated with expected improvements in bone strength and bone fractures," Dr.
Cosman notes.
Along similar lines, the second study found that alendronate
therapy given after parathyroid hormone therapy led to significant increases
in bone mineral density. When alendronate was not given, increases in bone
density were rapidly lost.
The editorial, however, stresses that the results of both
trials were preliminary.
Always consult your physician for more information.
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Pain relief may just be mind over matter, says a new report
in the Journal of Neuroscience.
The new research states that the belief that a pill will
relieve pain is enough to cause the brain to release its own natural painkillers.
According to the American Chronic
Pain Association, chronic pain is pain that continues a month or
more beyond the usual recovery period for an injury or illness or that
goes on for months or years due to a chronic condition. The pain is usually
not constant but can interfere with daily life at all levels.
The Association states that
this question is often asked by people who have been told that they will
have to learn to live with their pain. At times, it is difficult to pin down
a specific physical cause for the pain. But that does not lessen the suffering.
When pain is experienced, it is in both our bodies and
minds, the Association explains. Persons cannot
separate the physical and psychological effects any situation has.
The finding is the first direct evidence that the brain's
own pain-fighting chemicals, endorphins, have a role in the phenomenon known
as the placebo effect - and that this response corresponds with a reduction
in feelings of pain.
"This is telling us that placebos are powerful," says
study lead author Dr. Jon-Kar Zubieta, an associate professor of psychiatry
and radiology at the University of Michigan.
"When there is a belief that something may take place,
this belief actually activates systems in your brain that are directly modifying
experience," Dr. Zubieta says. "If you receive a drug and you believe it
is active, the drug itself might not be doing very much.
"We looked at the response of pain control systems in
the brain," Dr. Zubieta explains. "We observed that a placebo that was believed
to be an agonistic agent was able to enhance the release of these anti-pain
endogenous opioids."
In the study, the researchers were able to show the power
of the placebo effect.
"There was more relief in response to this inactive medication
as a function of belief," Dr. Zubieta says. "In fact, in some areas of the
brain, the release was related to how much they believed the drug was going
to be effective."
Dr. Zubieta believes these findings tell us something
about how humans function.
"Understanding these mind-body connections are important," he
says. "There are many treatments that are believed to be effective, when
in reality they may not be more effective than placebo."
One expert thinks the findings are important, but miss
the larger point.
"It's clearly another step in elucidating these mechanisms,
which is really terrific," says Daniel E. Moerman, the William E. Stirton
Professor of Anthropology at the University of Michigan in Dearborn, and
the author of Meaning, Medicine and the Placebo
Effect.
"It's only the technology that has made this an interesting
area to study," Dr. Moerman adds. "You can scan this stuff now. You can see
it, so there it is, and therefore it's sort of real."
Always consult your physician for more information.
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