Rectal Bleeding – A discussion about possible causes

Colon-Endoscopes
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Photo credit:  http://www.naturalhealingsolutionsllc.com/learn-about-colon-hydrotherapy.html

Photo credit:  http://www.thenurseslockerroom.com/2013/03/sigmoidoscopy-screening-test-for.html

One of the more common problems that bring patients into the doctor believe it or not is seeing blood in the toilet, on the stool or on the toilet paper after having a bowl movement.  Since I’ve had a few patients recently who have come in because of this problem, I thought I’d discuss some possible causes.

Healthcare providers take this issue seriously because sometimes blood noticed after having a bowl movement can be a sign of colon or rectal cancer.  Fortunately, most of the time the causes of rectal bleeding is not cancer however.

Causes of rectal bleeding:

1)  Hemorrhoids:  Swollen blood vessels can occur in the rectum or anus and cause itching and/or pain and can sometimes bleed.  Usually hemorrhoids produce a blood that is described by patients as being a “bright red color.”  It may sometimes coat the surface of the stool or may drip into the toilet and turn the water red or be noticed on the toilet paper.  Hemorrhoids do not have to be painful – in fact painless rectal bleeding at the time of having a bowl movement is common in hemorrhoids.

2)  Anal Fissure:  If the lining of the anus has a tear, it can cause bleeding and sometimes there may be pain with having a bowl movement.

3)  Other causes such as infection, colitis (which could be due to an auto immune disease such as ulcerative colitis or Crohn’s disease), colon polyps or colon cancer can also cause bleeding.  If the bleeding comes from higher in the digestive system such as in or above the stomach, the blood may look dark black or have a tarry appearance.

Diagnosis/Testing:  In order to find out the cause of the bloody stools, your healthcare provider may perform some tests or refer you to a specialist to help determine the cause.  They will take into account the information you provide, your past history and symptoms as well as your age.

1)   Rectal exam:  Your healthcare provider will usually examine the rectum and look for a source of bleeding such as a hemorrhoid or anal fissure.  This may also include a digital rectal exam (where to doctor inserts a gloved and lubricated finger into the rectum to feel for possible rectal cancers).

2)  Anoscopy:  Your doctor may use a small plastic device with an attached light to get a better look for the source of bleeding.  Most of the time this is not painful (although perhaps a bit uncomfortable) and can be done in the office.

3)  Sigmoidoscopy:  This is a procedure that is usually done in an outpatient treatment center and the patient is usually not sedated.  There are rigid or flexible sigmoidoscopes.  Usually a flexible sigmoidoscope is used.  A flexible tube (it is approximately 70cm long and 1cm wide) with a tiny video camera and a light is inserted into the anus and gently into the colon while air is inserted into the colon to enlarge the area and help the doctor get a better view.  Often a biopsy (small sample of colon tissue) is taken with the use of a tiny biopsy tool.  The sigmoidoscopy allows visualization of the anus, rectum, sigmoid colon and top of the descending colon.  It does not allow visualization of the entire colon so it may miss seeing cancers, polyps or sources of bleeding in some areas.

4)  Colonoscopy:  This procedure is similar to the sigmoidoscopy but allows the doctor to examine the entire colon using a longer flexible tube. The Colonoscope (about 140cm in length) is able to reach the areas seen by the sigmoidoscope and also allows visualization of the transverse colon, ascending colon and cecum.  The patient is usually sedated during this procedure.

When to seek help:  It is impossible to know the cause of rectal bleeding without an examination, therefore everyone who has rectal bleeding should talk to their healthcare provider to help determine the cause and what examination is needed.  Even though there are common causes of rectal bleeding that are not cancerous, bleeding can be caused by cancer or precancerous conditions.

Precancerous polyps may be present in the colon for years before they become cancerous and may be removed safely from the colon, preventing them from becoming cancer.  These polyps may cause symptoms which are very similar to an innocent hemorrhoid.

I’ve met patients who have ignored rectal bleeding for years because they thought it was because they had a hemorrhoid and it turned out to be cancer.  With increased age comes an increased risk for polyps and colon cancer .

Colon Cancer Screening:  For patients who is at average risk, colon cancer screening is started by checking the stool for small amounts of blood (which may be hidden) each year starting at age 50.  It is also recommended to have your first colonoscopy at age 50 (unless you have other risk factors for colon cancer) and every 10 years thereafter unless you are at increased risk based on your family history or a previous diagnosis or biopsy result.

People at increased or high risk:

If you are at an increased or high risk of colorectal cancer, you should begin colorectal cancer screening before age 50 and/or be screened more often. The following conditions make your risk higher than average:

1)  A personal history of colorectal cancer or adenomatous polyps

2)  A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s)

3)  A strong family history of colorectal cancer or polyps

4)  A known family history of a hereditary colorectal cancer syndrome such as familial adenomatous polyposis (FAP) or hereditary non-polyposis colon cancer (HNPCC)

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

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What is a Pressure Ulcer (AKA Pressure sore)?

shutterstock_89421025bed-soresPhoto credit:  http://diseasespictures.com/bedsores/

A patient came in to see me today with a sore on his heel that’s been bothering him for the past few months.  He’s diabetic and has lost feeling in the bottom of his feet.  He’s had these pressure sores in the past but has trouble getting them to heal up.

Pressure sore:  Areas of skin that have been damaged by pressure such as sitting or lying in one position for a very long period of time.  They can also be called “bedsores.”  The are more commonly found in areas of the body where the bone is near the surface of the skin such as on the hips, elbows, ankles and back/buttocks. The skin and soft tissues become damaged because not enough oxygenated blood can get to the area to promote healing usually due to the compression of the damaged skin and soft against hard bone tissue.

Appearance:  The sores change in the way they look depending on how long they’ve been present and how much damage has been done.  In the beginning, the sore appears as a small red patch of skin, and if not treated, the skin will break down and cause a hole or crater to form (we call this an ulcer).

Stage 1:  The skin is intact without ulcers but when you push on the skin it does not change colors to indicate good blood flow.  Usually, healthy tissue will be pink and when you push on the area with your finger you can notice it will become less pink and in a couple seconds the pinkness will return.  This does not happen in the damaged skin at this stage – it may have a darkly pigmented color.

Stage 2:  There is an open, shallow ulcer with a red-pink color at the base of the wound.  Sometimes there may be blisters present which are either intact or ruptured.

Stage 3:  Structures beneath the skin such as fat may be exposed but at this stage, you should not see bone, tendons or muscle tissue.

Stage 4:  Structures beneath this skin including bone, tendon and muscle may be seen in the bottom part of the ulcer

People at Risk:  Some patients are more at risk than others of getting pressure sores.

1)   Patients who cannot move very well because they have a medical problem.  These people may sit or lay in one position for a long time.  They need help to move to a different position so that the skin doesn’t form sores.

2)   Older people are more prone to pressure sores because they often don’t move around as much and their skin is more fragile and thinner than a younger person.

3)   Patients who have diabetes or nerve problems in their feet may not feel when a small pebble or area gets into their shoe or pressure pushes on the foot causing injury.

4)   Patients in the hospital or nursing home are at especially high risk for many of the factors noted above – increased age, decreased mobility, and other complicated medical problems.

Prevention:  Some things can be done to lower the chances of getting pressure sores

1)   Repositioning the patient’s body every two hours so that they are not lying on one area where the skin is being crushed, pinched or pressure is building

2)   Putting pillows between the ankles and knees to decrease the pressure on the skin over these boney areas

3)   Raising the head of the bed when the patient is lying on their side to decrease the pressure on the hip bone

4)   Getting special foam or soft mattresses that decrease the pressure on the areas of the body that have the most pressure on them

For patients in wheelchairs:

1)   Use a special cushioned seat if possible to prevent pressure on the sacrum

2)   Every hour tilt forward or to the side to release pressure on the seat

3)   If ankles or heels press on the chair, use foam padding to protect against sores

4)   Check skin regularly for signs of pressure or ulcers

Treatment:  Pressure sores are treated differently depending on the stage of ulceration and how severe the damage to the skin is.

1)   If there is mild erythema, the treatment is generally off-loading the area but decreasing the amount of time that this area is compressed by body re-positioning, and/or using pillows to cushion the area.  We also use transparent films over the ulcers to protect the areas.

2)   In patients who have diabetes, adequately managing blood sugars to keep them under good control is very important.  Elevated blood sugars impede wound healing.

3)   If there is dead or dying skin or soft tissues, this often needs to be removed to help prevent infection.

4)   Special bandages may be needed to keep the healing tissue moist but prevent tissue maceration (from being too moist). Sometimes the dressings that we use to treat wounds can be very expensive.

5)   Antibiotics may be prescribed if there is a wound infection

6)   Medication for pain may also be prescribed

There are some tools to score the pressure and grade the healing process.  These are helpful for patients who come back for repeat visits to wound care clinic or their primary care provider and there is a need to grade the healing by giving them a score.  Some clinical features that are examined include:

1)   Amount of Exudate

2)   Skin color surrounding the wound

3)   Peripheral tissue swelling

4)   Peripheral tissue firmness around the wound

5)   Amount of granulation (healing) tissue

6)   How much epithilization is present

It’s important to optimize the nutritional status of patients with wounds.  Particularly for patients who have Stage 3 and 4 ulcers, they need enough protein and calories to help heal these wounds.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Diabetes Foot Care

shutterstock_110360354Patients who have diabetes need to pay extra attention to their foot care to help prevent infections.  I’ve had numerous patients with diabetes need foot or toe amputations that could have been prevented with excellent foot hygiene.  Small scrapes in the skin or ingrown nails can become extremely bad very quickly with diabetes because patients who have diabetes often don’t have as much sensation (due to damage to the nerve endings and blood vessels in your feet).  This can make it difficult to detect sores and once an infection is present it can be very difficult to treat.  I thought I’d put together some tips to help you keep your feet healthy and decrease the risk for infections.

1)      Stop smoking:  If you smoke, this can decrease the blood flowing to your feet and make foot problems worse.

2)     Inspect your feet everyday:  Look for blisters, cuts, cracks or sores.  If you cannot see your feet well then use a mirror or have a family member help you.

3)     Wash your feet everyday:  Use warm (not hot) water – be sure to check the temperature with your hands rather than your feet.

4)     Dry your feet well:  Pat them dry and do not rub the skin on your feet too hard.  Dry between each toe.  If the skin on your feet stays moist, bacteria or fungus can grow and that might lead to a foot infection.

5)     Keep your feet soft:  Use a skin moisturizer such as Aveeno, Dove or Cetaphil on your feet to keep your skin soft and prevent calluses and cracks.  Don’t put the cream between your toes unless you are treating athlete’s foot with a fungal cream.  Make sure to wear socks or traction on your feet after applying the cream so you don’t slip and fall.

6)     Clean under your toenails carefully:  Don’t use sharp objects under your toenails.  Instead use the blunt end of a nail file or other rounded tool to decrease the chance of piercing the skin.

7)     Trim and file your toenails straight across:  This helps prevent ingrown nails.  Use a nail clipper instead of scissors.  Then use an emery board to smooth the edges.  If you need help trimming your nails, schedule an appointment with your medical provider.

8)     Change your socks everyday:  Socks should have a thick cushion and fit loosely around your feet.  Socks without seams are best because seams often rub the feet.  Do not wear stockings, socks, or garters that come up to the thigh or knees unless your medical provider advises you to do so because they can decrease the blood flow to your feet.

9)     Look inside your shoes before putting them on:  Check them every day for gravel, torn linings, or thorns that can cause blisters or sores.

10)  Do not go barefoot:  Don’t wear sandals or shoes with thin soles because these types of shoes are easy to puncture.  They also do not protect your feet from hot pavement or cold weather.

11)  Have your medical provider check your feet during each visit:  If you notice a problem with your feet, see your medical provider right away rather than trying to treat it with a home remedy.  Some home remedies or treatments that you can buy without a prescription (such as corn removers) can be harmful.

12)  Keep your blood sugar down:  Watch what and how you eat, monitor your blood sugar, take your medications and get regular exercise.

When to seek medical help:

A)      If you cannot do proper foot care

B)     If you have a foot sore or ulcer that is not healing after 3 days (including corns, calluses or ingrown nails)

C)     If you have black and blue areas in your toes or feet

D)    If you have peeling skin or blisters between your toes

E)     If you have a fever for more than 24 hours and a foot sore

F)     If you have new numbness or tingling in your feet that does not go away after you move your feet or change positions

G)    If you have unexplained or unusual swelling of your foot or ankle

H)    Anytime you have questions about your feet or concerns it is best to contact your medical provider

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Testosterone Deficiency – aka “Low T”

shutterstock_148300076Low testosterone is a hot topic right now in primary care.  Recent advertisements are on television discussing various testosterone treatments available to men with “Low T.”  I’ve recently had quite a few patients asking me to check testosterone levels and then they usually have questions about testosterone treatments if the blood levels are abnormal.

Testosterone is a hormone that is produced in both men and women, but it is usually present at higher levels in men.  The consequences of low serum testosterone are not known for certain but there are several possible symptoms of low levels including (research is still being done):

  1. Low sex drive, erectile dysfunction, poor morning erection
  2. Fatigue
  3. Being slow to go through puberty (if it is too low during childhood)
  4. Decreased bone mineral density
  5. Decreased muscle mass
  6. Decreased muscle strength
  7. Anemia
  8. Decreased mood
  9. Decreased cognitive function

Of course there are other, more common causes of low sex drive and fatigue that can affect grown men instead of low testosterone levels.  Experts believe that the current trials have demonstrated weak and indirect inferences about the usefulness of testosterone for osteoporosis in men.

Testosterone levels naturally decrease as men age.  This normal decline in testosterone however has not had established clinical consequences.  We are still studying the effect that the natural decline of testosterone levels have in the body.  Elderly men often ask if they should be prescribed supplemental testosterone to keep their levels from decreasing.  The answer is difficult because we currently do not entirely understand whether the changes in body generally associated with aging (decreased muscle mass, decreased energy) may be related to naturally decreasing testosterone levels or even if treatment with testosterone reverses the decreasing muscle mass and energy we see in the average person with increasing age.  We’re also concerned about adverse consequences of testosterone with diseases that are testosterone dependent such as prostate cancer.

Controversy regarding testosterone whether to prescribe testosterone therapy:  A committee of the Institute of Medicine of the National Academy of Sciences Committee reviewed available studies and concluded that no beneficial effects of administering testosterone have been well established.  The Endocrine Society however has published evidence based guidelines for testosterone therapy in adult men with deficiency of testosterone.  The guidelines from the Endocrine society are:

  1. Testosterone therapy should be prescribed only for men with low serum testosterone levels on more than one test and who have symptoms of testosterone deficiency and have no known pituitary or testicular disease.
  2. In order to minimize the potential risk of causing testosterone-dependent diseases, the target level of testosterone level in the blood should be between 300-400 ng/dL (10.4 to 13.9 nmol/L)

The Institute of Medicine’s committee on testosterone concluded that there is insufficient evidence to conclude that testosterone treatment of elderly men has any well-established benefit thus far on improving muscle strength, physical function, vitality, sexual function, cognition and quality of life.  They recommended further investigation.

Potential to cause harm:  High testosterone levels has the potential to cause cancer of the prostate but data are limited.  The common practice in treating prostate cancer is to lower serum testosterone levels with medications.

Screening for low testosterone:  One approach has been the following:

  1. If a male has symptoms of possible testosterone deficiency such as decreased sex drive, energy, mood or osteoporosis or anemia a serum testosterone level can be checked early in the morning (before 8am when normal testosterone levels are highest).  If the level is low, it should be repeated for confirmation.
  2. Free testosterone levels should only be evaluated in men who have obesity.
  3. If testosterone levels (both times) is less than 200 ng/dL (6.9 nmol/L) evaluation for causes of hypogonadism can be performed. If there is no pituitary or testicular disease, discuss  with the patient about possible treatment with supplemental testosterone (ie. Benefits vs risks).

Testosterone treatment:  One approach to treatment has been the following:

  1. If treatment is started and the symptoms that led to measuring the testosterone are not corrected (improved energy, sex drive, anemia, etc.)  within a few months then discontinuing the testosterone treatment can be considered.
  2. Before starting treatment, a digital rectal exam should be performed and a PSA (prostate specific antigen) measured.  If a man has higher than normal PSA with no identifiable risk factors a urological evaluation should be performed before any testosterone therapy is started.
  3. 3 months after starting the testosterone treatment, a digital rectal exam and PSA should be repeated.  If there is a prostate nodule or the PSA has increased more than 1.4ng/mL (and confirmed) urological consult should be sought.  If the PSA and digital rectal exam is not considered abnormal, the digital rectal exam and PSA should be performed once a year  (just as with any man).

References:  Bhasin S, Cunningham GR, Hayes FJ, Matsumoto AM, Snyder PJ, Swerdloff RS, Montori VM, Task Force, Endocrine Society. Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2010 Jun;95(6):2536-59.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Sexual Dysfunction in Men – Erectile Dysfunction and Beyond

shutterstock_136970978Purchasing medications for erectile dysfunction:  I first want to comment the issue of purchasing medication on the internet, through mail order , magazine articles or television ads that claim to sell medications such as Viagra, Cialis or Levitra or some herbal supplement for erectile dysfunction without the need for a prescription and at a low cost.  I highly recommend that you do not purchase these products this way because the sources are not known to be safe or reliable.  Would you purchase your blood pressure or diabetes medicine from someone you don’t know but who claims to be legit?  I sure wouldn’t!  It is not known if these drugs sold without prescription through ads like this are counterfeit or contain toxic chemicals which could be damaging to your health.

Men often come to talk with me about medications that may help with sexual problems such as inability to acquire or maintain an erection for sexual intercourse.  Since this is a popular topic in the primary care office, I thought I might discuss male sexual dysfunction, possible causes and some treatment options.

Some male sexual complaints may include:

1)     Premature ejaculation

2)     Delayed or inhibited ejaculation

3)     Lack of interest in sex (decreased sex drive)

4)     Unable to become erect or maintain an erection for satisfactory sexual intercourse (we also call this impotence or erectile dysfunction)

Erectile Dysfunction (ED):   Your doctor may diagnose erectile dysfunction if the man cannot acquire or maintain an erection during 75% of attempts to have sexual intercourse.  If a man has only occasional inability to have an erection and this improves later, they do not have erectile dysfunction (ED) as defined by the American Urological Association.

Possible causes of male sexual dysfunction:

1)      Limited blood flow to the penis can be caused by:

  1. Cigarette smoking
  2. Uncontrolled diabetes (high blood sugars)
  3. High blood pressure (hypertension)
  4. Alcoholism
  5. Illicit drug use
  6. Aging
  7. Depression
  8. Common medications prescribed by your doctor

2)     Psychological causes:  Performance anxiety, stress or decreased mood can lead to impotence.  Many patients explain that they accept a decrease in sexual function as being normal due to aging.  Often times there are reasons for decreased sexual function in men that once addressed can improve sexual function and increase the satisfaction with their sexual health.  One of the possible reasons such as performance anxiety is when the focus of the sexual act shifts from a romantic experience to one filled with anxiety about the ability to acquire or maintain an erection.  It’s also true in some men that as they mature, their interests and concerns may expand.  If he’s preoccupied with concerns about money or business matters, he may lose the sexual focus needed to maintain an erection.

How to determine the cause of male sexual dysfunction:   When a man expresses concern about sexual dysfunction, I usually start off by trying to determine the cause by asking some questions, performing an exam and then ordering some laboratory tests.  If you will be visiting your doctor and have concerns about sexual dysfunction, I recommend that you think about the following and be ready to discuss these items with your doctor:

1)      Do you get erections at night or in the morning when you first wake up?

2)     Are you having any personal problems with your sexual partner?

3)     Did the sexual dysfunction come on gradually or all the sudden?

4)     Do you have medical problems such as diabetes, high blood pressure, tobacco use, alcohol or illicit drug use or other psychological factors that could contribute to the dysfunction?

What to expect during a physical examination:  Some men may be resistant to come to their doctor to discuss sexual dysfunction because they’re not sure what to expect during the physical exam.  Your doctor may do the following:

1)     Check your blood pressure – it’s very important to get your blood pressure at goal

2)     Examine the penis, testicles and blood vessels in the groin

3)     Examine the chest for signs of abnormal breast swelling in men

Laboratory testing:  Your medical provider will often check several lab tests that can influence a man’s sexual ability.

1)     Testosterone (hormone) level – hormone

2)     Blood sugar tests – a fasting blood glucose or an A1c

3)     Thyroid hormone test (TSH)

4)     Prolactin (hormone) level

5)     Home nocturnal penile tumescence (NPT) is a test that measures how many erections the man is getting during the night when sleeping.  Men who have damage to the blood vessels or nerves involving the sexual organs usually have decreased nocturnal erections and we call this “organic” impotence.  Men with normal night-time erections are more likely to have psychologically related impotence although there may be a combination of the two factors involved.

6)     If the nocturnal penile tumescence test is abnormal, your doctor may ask you to have some special tests such as a ultrasound test to examine the deep arteries of the penis and groin to make sure they are getting enough blood flow.

Treatments for male sexual dysfunction:  Men often come in to the clinic and ask for medication without understanding that medication may not help if the cause of the problem is not discovered.  It’s very important to determine the cause of the sexual dysfunction because the improper use of medications can have serious side effects and may not actually cure or help the problem.

Medications to treat erectile dysfunction:

Testosterone therapy:  If your testosterone level is too low, correcting this by taking testosterone medication can improve sex drive, erectile dysfunction, increase muscle mass and reduce the risk of osteoporosis.  Men who do not have low testosterone levels do not benefit from additional testosterone and may actually have unhealthy side effects if they take testosterone inappropriately.  Treatment options may include testosterone injections that may be given every 1-2 weeks, testosterone gels (Androgel is a commonly prescribed example), a testosterone skin patch (Andoderm is a popular example) or a testosterone lozenge that remains in the mouth for 12 hours are the most common treatment options for low testosterone.

Counseling:  We realize that depression, anxiety and increased social stresses can cause erectile dysfunction. Sexual therapy is often helpful in these cases.  The great thing about counseling is that there are no medical side effects because this does not involve taking a medication.  Counseling can actually fix the problem which is often more desirable than relying on a medication which must be used repeatedly.  Some examples of where psychotherapy can be useful are:

1)      Performance anxiety, when a man suddenly experiences one or more failures during sex.   Often this is not due to the inability to perform but more related to anxiety about failure.

2)     Men who have depression or anxiety often have a lowered sex drive.  Counseling can help improve both while improving sex drive and function without the need for medication.

3)     Couples where one partner has a serious medical condition might be worried about possible the safety of sexual activity.  It is often helpful to discuss this with a medical professional or counselor who can help with these concerns.

Phosphodiesterase-5 inhibitors (PDE-5) – Viagra, Levitra and Cialis:  These medications work by increasing the natural chemicals in the body that allow the penis to become erect.  The do not increase sexual desire.  These medications are effective in restoring the ability to have an erection in about 70% of men and work best in men with psychological erectile dysfunction problems (in combination with treating the underlying psychological component).  In men with damage to the blood vessels or nerves of the pelvis/penis due to high blood pressure or diabetes, these medications help about 55-60% of the time.  For men who have sexual dysfunction after prostate surgery, these medications help in only 25%.   The main difference between Viagra, Levitra and Cialis is the cost of the medication and amount of time that the medication takes to begin working and how long the effects last.  Some people may find the one particular medication works better for them than another but all three work in a medically similar way.

Possible side effects:  PDE-5 medications such as Viagra can cause headache, dizziness, indigestion and flushed (red colored) skin or blurred vision.  Most side effects only last a short time, but because Cialis has a longer duration than the others, the side effects may also last longer.  There is also a possibility of drug interaction with nitroglycerin if a patient uses that for chest pain or blood pressure.  Using PDE-5 medications and nitroglycerin can cause dangerously low blood pressure.  If a man is taking nitrate medications we generally do not recommend Viagra, Levitra or Cialis.

Drug interactions:  In addition to nitroglycerin, patients who take doxazosin or terazosin (which are used to treat enlarged prostate and hypertension) should not take PDE-5 medications because the combination can cause a dangerously low blood pressure.   Other medications such as erythromycin, ketoconazole, rifampin, phenytoin and grapefruit juice can alter the time that these erectile dysfunction drugs remain in the body and subsequently can cause more side effects.

Safety:  We are unsure if Viagra is safe for patients who have had a heart attack, stroke or life-threatening heartbeats (arrhythmia) within 6 months.  We are also not sure if it is safe for men who have had untreated high or low blood pressure or a condition called retinitis pigmentosa which is a medical condition of the eye that can lead to blindness.

Penile self-injection:  Patients may inject a medication into an area of the penis called the corpora cavernosa and this causes an erection by allowing the blood vessels within the penis to expand.  No sexual stimulation is needed to create the erection.  The common medications used are alprostadil or papaverine.

Possible side effects:  many men stop doing penile self-injections because of pain at the injection site.  There is also a risk that the penis may remain erect after intercourse.  Prolonged erection is called priapism.  If it lasts longer than 4-6 hours it may be a medical emergency and those patients should be seen in an emergency room.  If blood stays inside the penis for more than 48 hours permant scarring of the tissue inside of the penis may result.

Insertion of a pellet into the urethra:  MUSE (Intraurethral alprostadil):  The same medication used for penile self-injection can be inserted into the urethra (opening where the urine comes out) and the medicine is absorbed and causes an erection.

Possible side effects:  There can be some pain in the penis as the blood vessels enlarge to create the erection.  There is less chance of prolonged erection with this than with self-injection.

Vacuum-assisted erection devices:  A rigid ring is placed at the base of the penis (near the body) to hold the blood in the penis and then vacuum pressure is used to draw blood into the penis to create an erection.  About 67% of patients are able to achieve and erection with a vacuum assisted device but only about 25-50% of people who use them are satisfied with them.

Possible side effects:  Although the man will be able to have an orgasm, he is usually not able to ejaculate with a vacuum-assisted device because the ring that holds blood in the penis also compresses the urethra and that prevents semen from exiting.

Inflatable implant:  With an inflatable implant, an erection is produced by squeezing a small pump that has been implanted surgically in the scrotum.  The pump causes fluid to flow from a reservoir (also implanted surgically) in the lower pelvis to two cylinders residing inside the penis.  The cylinders expand to create the erection.

As you can see, there any many possible reasons that can lead to male sexual dysfunction and multiple treatment options.

For more information, you may check out the web resources below:

American Urological Association

The Hormone Foundation

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

High Blood Pressure (Hypertension) – A discussion about the condition, causes and treatment options

shutterstock_117887302What is blood pressure anyway?  Blood pressure is a measure of the force of the blood against the walls of your arteries. Blood pressure readings include two numbers, such as 120/80 (say “120 over 80”).  The first number is the systolic pressure and is the force of blood on the artery walls as the heart pumps.  The second number is the diastolic pressure and is the force of blood on the artery walls between heartbeats, when the heart is at rest.

What is hypertension/high blood pressure?  Your blood pressure normally goes up and down depending on what you are doing. You’ve probably heard that a normal blood pressure is less than 120/80 but it is normal for it to go up when you’re exercising or under stress.  It’s normally higher for example when you’re exercising than when you’re sleeping.  If you’re rushing to make it to your doctor’s appointment, it might be higher when it’s measured in the doctor’s office then when you’re relaxed right before you go to bed. Despite what a lot of people think, high blood pressure usually does not cause headaches or make you feel dizzy or lightheaded.  It usually has no symptoms, but it does increase your risk for heat attack, stroke, kidney and eye damage.  The higher your blood pressure, the more your risk increases. Your doctor will probably look at several variables when trying to determine whether your blood pressure is elevated abnormally and whether your blood pressure needs to be treated.  If you have diabetes, kidney disease, an aneurism or if you’ve had a heart attack or a stroke we usually try to keep the blood pressure lower than for other patients because they are at higher risk of developing additional health related problems if their blood pressure is high.

If a patient is normally healthy without any health related problems, we usually don’t consider them to have hypertension unless their blood pressure is 140/90 or higher.  For a patient with diabetes, we consider their blood pressure to be too high if it’s 130/80 or higher.

Why should you care if your blood pressure in high?  Most of the time when people have high blood pressure they don’t have any symptoms so they aren’t even aware that it’s elevated!  High blood pressure is sometimes called a “silent killer” because even though you don’t have symptoms from it being elevated, it can do damage to the arteries in the heart, brain, kidneys, eyes and other organs.

Men are often most interested to know that having hypertension can cause a form of sexual dysfunction called erectile dysfunction (ED).  That’s right, if your blood pressure is elevated, your sex life may be negatively affected as a consequence.  Read my article on male sexual dysfunction in men here.

It may take years to develop symptoms from this damage but it is usually permanent and can make patients more likely to have a heart attack or stroke, kidney damage (sometimes requiring dialysis), vision problems, and even lead to early death.

Some patients might not have thought about why they would want to stay healthy, so I usually ask them to make a list of what’s important in their life.  For some people it’s important for them to be alive and healthy so they can spend time with their family members (wife/husband, children, siblings, pets, etc.)  Some people enjoy traveling and they may not have considered that it’s much more difficult to travel if you have problems with your heart, brain, kidneys or eyes for example.  I think it’s important to think about what your short term and long term goals are, and use this as motivation for keeping healthy.

Who is at risk?  High blood pressure is a very common problem!  Elevated blood pressure is more common as we get older but can affect anyone.  Among people over age 60, hypertension occurs in 65 percent of African-American men, 80 percent of African-American women, 55 percent of white men, and 65 percent of white women.

I’ve had patients who are children with abnormally elevated blood pressures.  Oftentimes high blood pressure runs in the family, so if your father, mother or siblings have hypertension it’s important to be aware that you are at higher risk of developing hypertension yourself.  High blood pressure is also more common in people who have diabetes, drink more than two alcoholic drinks/day, are overweight, eat an unhealthy diet or don’t exercise regularly.

If you have sleep apnea, you are also at greater risk of high blood pressure.  Until correcting the sleep apnea, it may be very difficult to control your blood pressure.

High Blood Pressure Treatment:  There are certain lifestyle modifications that can help get your blood pressure in the normal range and also medications that your doctor might prescribe.  Usually a combination of both medications and lifestyle changes achieves the greatest success in achieving a blood pressure that is within the healthy range for you.

Lifestyle modifications:

1)     Reducing the amount of salt in your diet

2)     Losing weight if you are not at your goal

3)     Avoiding excessive amounts of alcohol

4)     If you smoke, decreasing or stopping

5)     Exercising for at least 30 minutes on most days

Reducing sodium intake is important because with increased salt (or sodium chloride) intake from food that we eat, our bodies naturally absorb more wate.  The increased water absorbed into the body then contributes to an increased amount of fluid in the blood vessels and heart and that in tern leads to hypertension.  Diuretic medications (discussed below) work in almost an exact opposite way to decrease the amount of salt and water in the bodies and lower blood pressure.

Medications:  If lifestyle changes alone are not successful in getting the blood pressure under control, your doctor may prescribe certain medications to help decrease the strain on the heart and arteries. The constant stress from the elevated blood pressure that may lead to organ damage if not treated adequately.

With such a variety of blood pressure medications available, medical providers try to make the best decisions based on the latest scientific research as well as an individual patient’s past medical history and other medical conditions.  The Joint National Committee on Prevention, Detection, Evaluation, and Treatment (JNC) has had seven publications that have been released based on scientific research about blood pressure since 1976.  The guidelines are constantly changing as we acquire new data from scientific data.

Most blood pressure medications are tolerated well, but just like any medication, there is the possibility of side effects.  I will discuss some of the possible side effects of the various classes of blood pressure medications.  If you experience side effects, allergies or just don’t like the medication prescribed, I recommend discussing this with your doctor right away rather than just stopping the medication because there might be some reason (other than the medication) that could be causing an undesired effect.  It’s also true that you might not notice an immediate drop in blood pressure right after starting some types of blood pressure medications.  It can take a few days or even weeks to achieve the full effect with certain medications.

You should know that it often takes more than one blood pressure medication to get blood pressure under control.  These medications are often used together and work in different ways to reduce blood pressure.  We might use 1, but often use 2, 3 or 4 different blood pressure medications to achieve the blood pressure goal (less than 140/90 for example).

ACE (angiotensin converting enzyme) inhibitors block a hormone in the body that causes narrowing of the blood vessels.  By allowing the blood vessels to widen, it lowers the blood pressure and improves the heart output.  This is usually the first type of medication that is prescribed for someone who has high blood pressure because it usually works so well and because there are usually not many side effects.  Some of the common ACE inhibitors are lisinopril, benazopril, enalopril, captopril and ramipril.  There are many more ACE inhibitors available that are not named here.  We also prescribe ACE inhibitors to patients who have chronic kidney disease, heart failure or diabetes.  Usually these patients also have hypertension, but not always.  If they don’t have high blood pressure, the ACE inhibitors are usually used because they protect the kidneys from damage due to elevated blood sugar.

Possible side effects:  The most common complaint of patients who cannot tolerate an ACE inhibitor is a persistent, dry, hacking cough.  About 10% of people who are prescribed an ACE inhibitor may experience a cough (that goes away after stopping the medication), and if that happens to you, we can use another similar medication – see ARB (angiotensin II receptor blocker) medications.   A very small percentage of people can have an allergic reaction to ACE inhibitors that causes swelling of the lips/mouth (angioedema).  If you develop swelling of the lips, tongue or mouth you shouldn’t take this medication and talk to your doctor right away.  We don’t see it happen very often but severe allergic reactions to any medication can be life threatening so it’s important that if you have trouble breathing after taking any medication, you call 911 (an emergency/ambulance team) instead of trying to drive to a hospital yourself.

 

Angiotensin II Receptor Blockers (ARBs):  These medications work similar to ACE inhibitors to reduce blood pressure but have their effect at a different site in the kidney than the ACE inhibitor.  These are newer medications than ACE inhibitors and are generally more expensive.  Since they work in a similar way to ACE inhibitors, we usually use these mostly in patients who cannot tolerate and ACE inhibitor or have chronic kidney disease.  They also work to widen the blood vessels to lower the blood pressure.  Some examples of ARBs include losartan, valsartan, and candesartan.  Not all ARBs are mentioned here.

Possible side effects:  The main difference between the ACE inhibitor and the ARB is that patients who cannot take the ACE inhibitor due to cough, can usually tolerate the ARB.  Angioedema (allergy) is also less common in ARBs.

 

Diuretics:  These medications lower your blood pressure by causing your kidney to produce more urine (which contains water, sodium and potassium).  You might notice that you have to get up to go to the bathroom more frequently when you take a diuretic blood pressure medicine.  Having less water/fluid in the blood vessels decrease the pressure inside the vessels (like having less volume of water running through a garden hose decreases the pressure inside of it).  There are different classes of diuretic medications to discuss:

1)      Thiazide diuretics:  Usually these medications are taken once a day.  Common examples are chlorthalidone and hydrochlorothiazide (HCTZ).

2)     Potassium-sparing diuretics:  Spironolactone, triamterene or amiloride are diuretics which do not cause as much loss of potassium in the urine as some of the other diuretics.

3)     Loop diuretics:  Lasix is an example of a stronger diuretic that lasts only 6 hours (so it has to be taken multiple times each day) but is used for patients who have high blood pressure and congestive heart failure.  We don’t use loop diuretics as often with high blood pressure because they we have to be very careful to monitor the potassium closely in patients who take loop diuretics.  This means that patients taking these medications may be asked to get blood work done fairly frequently.

Possible side effects:  Diuretics are usually very well tolerated and the main complaint that I hear people complain about is having to urinate more frequently.  I usually recommend taking a diuretic in the morning rather than the evening so that if they do have to urinate more frequently, they get most of the effect in the day when they’re awake.  We need to check kidney function and electrolytes when patients take diuretics to make sure that the sodium and potassium do not get too low.  People who have gout sometimes have more attacks if they take thiazide diuretics.

 

Calcium channel blockers:  These medications reduce the amount of calcium that enters the cells of the heart thereby causing the cells of the heart to relax and dilate and reduce the pressure as well as reducing the force and rate of the heart.  There are two categories of calcium channel blockers:

1)      Dihydropyridine – examples include amlodipine, nifedipine, and felodipine.  There are many others  as well.

2)     Nondihydropyridines – examples include diltiazem and verapamil

Possible side effects:  Sometimes patients who take calcium channel blockers may develop headache, dizziness, flushing, nausea or swelling of the gum tissue (gingival hyperplasia).  It the dose of medication is too strong, it can cause the heart rate to slow too much and lead to dizziness or falling.

 

Beta blockers:  These medications lower the blood pressure by decreasing the rate and force of the heart when it pumps blood.  Some examples of common beta blockers include metroprolol, atenolol, carvedilol and labetalol.  The last two beta blockers listed here also cause relaxation of the blood vessels (alpha blocking effect).

Possible side effects:  Beta blockers have a higher chance of causing side effects than some of the other blood pressure medications that are commonly prescribed so they are often reserved for patients who have resistant hypertension or have had a heart attack or heart failure.  We often give beta blockers to patients who have migraine headache because the medication helps to reduce the frequency of migraine we believe by affecting the nervous system/blood vessels.  People with panic disorder or anxiety may also benefit from taking beta blockers because patients often feel more relaxed while on this medicine, perhaps because of the effect on the sympathetic nervous system.

Patients who have asthma sometime get worsening symptoms from their asthma if they use beta blockers.  We are careful with the use of beta blockers in patients who have diabetes (and who sometimes get low blood sugar from their insulin) because the beta blockers can sometimes make it difficult for patients with a low blood sugar to feel symptoms of it coming on.  Beta blockers can also cause fatigue, dizziness, sleepiness, and decreased ability to exercise in some patients.

Alpha blockers:  These medications relax the blood vessel s in the body and thus allow the diameter of the vessels to widen.  Since vessels are wider, the pressure is decreased – think about how a nozzle works on a hose.  If you widen the nozzle and amount of water that is able to go through the hose, the pressure will decrease.  Some common alpha blockers are doxazosin, prazosin and terazosin.

Possible side effects:  The most common side effect of alpha blockers is dizziness, especially when standing up quickly.  We usually don’t use alpha blockers as a first medication for treating high blood pressure because of this possible side effect.  Men with an enlarged prostate and high blood pressure however may benefit from one of these medications because they can help to shrink the prostate and help increase the urine flow and decrease blood pressure.

Direct vasodilators:  We sometime prescribe medications that directly relax the blood vessels quickly, especially in patients who come into the hospital with severe hypertension.  These medications are short acting and as they wear off they can lead to an increased heart rate so we usually only use these medications in combination with a medication such as a beta blocker.  Common direct vasodilators include hydralazine or minoxidil.

Possible side effects:  headache, weakness, nausea and rapid heartbeat or possible side effects.  We also use minoxidil topically (Rogaine) for hair growth because it increases the blood flow to the hair follicles.

My recommendations:  Patients who have high blood pressure and are motivated to get their blood pressure controlled can do so but it might take some time and effort on their part.  After consulting with their primary physician and coming up with a treatment plan, I next recommend obtaining a blood pressure cuff and measure blood pressure twice a day.  The first measurement should be done first thing in the morning after getting up and before having any coffee (or other caffeinated beverages).  Write this number down and also record another blood pressure right before going to bed.  If you have diabetes, it’s important to get your blood pressure less than 130/80 consistently.   If you don’t have diabetes or a history of heart attack, stroke, chronic kidney disease or aneurism then your goal blood pressure should be less than 140/90.

I have a tendency to value the home blood pressure records more than what we measure in the office because there is often some stress with getting to the doctor’s office on time, parking , waiting in an exam room, etc. all of which may not be a pleasant experience.  We can check your blood pressure cuff in the office and see how it compares to our cuff and ensure that it is accurate.  If your blood pressure is consistently higher than it should be, we may make changes in your medications by adding additional medications or increasing the dosage of medications that you are already taking.

Again, do not stop taking your medications without telling your doctor.  If you don’t take your medications, medical providers cannot help you with your blood pressure.  We need to know if you cannot take them and we can even work with you to help you remember to take your medications if you forget.

Tips on checking your blood pressure at home:

1)  Sit in a chair that supports your back.  Rest your arm on a table so that your upper arm is at the same level as your heart.

2)  Sit with your arm slightly bent with your palm up.  Keep your feet flat on the floor and your legs uncrossed.

3)  Use the same arm every time you check your blood pressure

4)  Make sure that you can put the blood pressure cuff directly on the skin of your upper arm.  You may need to remove any sweaters or pull up your sleeves. Be sure that your sleeves are not too tight around your arm.

5)  Wrap the blood pressure cuff snugly around your upper arm, palm facing up.  The lower edge of the cuff should be about 1 inch (2.5 cm) above the bend in your elbow.

6)  Press the on/off button on the electronic monitor.  Follow the manufacturer’s instructions for using the device.

7)  The blood pressure cuff will automatically inflate to about 180mmHg (unless the monitor decides you need a higher number).  Then the cuff will begin to delate automatically and the numbers on the screen will begin to drop.

8)  Wait at least 5 minutes before taking another blood pressure readings working properly.

9)  Look often at blood the blood pressure cuff and rubber tubing.  Make sure that they are in good condition and do not have any holes or cracks.

9)  When you purchase a blood pressure monitor, bring it to the doctor’s office to compare the reading you get with the reading that is taken in the office.  They should be close. Repeat this check yearly to make sure your machine is working properly.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Keeping your Bones Strong and Healthy – All about Osteoporosis Prevention and Treatment

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Osteoporosis:  A medical disorder that causes the bones to become weak, thin and fragile.  Bones that are weaker are more likely to break (fracture).  Women are more commonly affected by this disorder because after menopause lower levels of estrogen are produced by the body.  Estrogen is a hormone that helps keep the bones strong.

It is very important to detect low bone density (weak bones) because there are treatments available which can protect and actually help build up bone and prevent bone fractures in those people who are at the greatest risk.

Why do we care?  Bone fractures, especially in the hip cause a huge change in lifestyle and lead to decreased mobility, decreased ability for patients to care for themselves, and increased risk of death due to physical deconditioning, increased risk of infection (from surgery and also from decreased mobility respiratory illness).   In fact, people who sustain a hip fracture are more likely to die than a person of the same age who does not experience this injury. About 20 percent of people who have a hip fracture die within a year of their injury. It is estimated that only one in four persons have a total recovery from a hip fracture.  Most people spend from one to two weeks in the hospital after a hip fracture. The recovery period may be lengthy, and may include admission to a rehabilitation facility. People who previously were able to live independently will generally need help from home caregivers, family, or may require the services of a long-term care facility. Hip fractures can result in a loss of independence, reduced quality of life, and depression, especially in older people.

Fractures that occur in the spine due to osteoporosis can lead to pain and cause changes in the curvature of the spine.  We’ve all seen older folks who have difficulty walking due to having abnormal curvature of the spine and these patients often have osteoporotic fractures in the vertebra of the back.

Risk factors for osteoporosis:

1)  Sex – women are more likely to get osteoporosis than men

2)  Age – risk of osteoporosis is higher with increasing age

3)  Race – there is a higher risk of osteoporosis in people of white or Asian descent

4)  Family history – you are at higher risk of osteoporosis if you have a parent or sibling with osteoporosis, especially if there is a family history of bone fracture

5)  Body frame size – men or women who have a smaller body frame size are at higher risk because they have less bone mass to draw from as they age

6)  Hormone levels – osteoporosis is more common in patients who have too much or too little of certain hormones  (estrogen, testosterone, thyroid, parathyroid or adrenal hormones for example)

7)  Low calcium in the diet – a lifelong lack of getting enough calcium increases the risk of developing bones that are thinner and more fragile.

8)  Eating disorder – Patients with anorexia are at increased risk of osteoporosis due to decreased nutritional intake of calcium

9)  Weight loss surgery – those patients who have surgery to help them lose weight are at higher risk of osteoporosis because of a reduction in the size of the stomach or a bypass of some of the intestines.  This may decrease the absorption of calcium or vitamin d.

10)  Certain medications – see below

Prevention:  Several important steps to maintaining proper bone formation and density can be done without the need of medication.  These include proper diet, exercise and not smoking.

A)  Diet:  Preventing the bones from thinning involves getting enough nutrients, especially calcium and vitamin D.

  1. Calcium:  Most experts agree that men and women who have not reached the age of menopause yet consume at least 1000 mg of calcium each day (combination of diet and supplements).  Women who have already gone through menopause should consume at least 1200mg of calcium each day (combination of diet and supplements).   Foods that have calcium include dairy milk, cottage cheese, yogurt, hard cheese, green vegetables (especially kale and broccoli).  A way to calculate the amount of calcium from food is to multiply the number of servings of calcium rich foods by 300 mg.  One serving size of dairy milk or yogurt is 8 oz.  1oz of hard cheese or 16 oz of cottage cheese is one serving size.
  2. Vitamin D:  Most experts also agree that men over age 70 and women who have gone through menopause consume at least 800 international units (IU) for vitamin D each day.
  3. Alcohol:  Drinking more than 3 drinks per day can increase the risk of fracture due to increased risk of falling and poor nutrition.

B)  Exercise:  We understand that our bones maintain their strength if we continue to use them.  Patients who become immobile are at increased risk of bone fractures because their bones tend to become thinner with decreased use and activity.  Patients who are more physically active are generally stronger and less prone to falling as well.  Exercising 30 minutes or more three times per week or more is recommended to maintain bone strength.

C)  Smoking:  Smoking cigarettes is known to speed bone loss.  One study suggested that women who smoke one pack per day throughout adulthood have a 5-10% reduction in bone density by menopause.  If you smoke, I suggest you get help with stopping to help prevent osteoporosis.

We can reduce the risk of bone fractures by reducing falls.  Several ways to reduce falls in older adults include:

1)  Avoiding (as much as possible) medications that can cause dizziness

2)  Provide adequate lighting to areas both inside and outside the home

3)  Ensure there are no loose rugs or electrical cords that could lead to tripping or falling

4)  Avoid walking in areas outside that are unfamiliar

5)  Avoid slippery surfaces such as ice or wet/polished floors

6)  Ensure good eye care by visiting an eye doctor regularly

Screening for Osteoporosis:  There are several different recommendations for when to start screening for osteoporosis.  The U.S. Preventative Service Task Force (USPSTF) recommends screening women who are age 65 or older who has no increased risk of fracture as compared to a 65 yo women of Caucasian decent.  If a woman has a previous bone fracture or an early family history of osteoporosis (especially a mother with an early bone fracture) or has thyroid disease or take medications that can increase the risk of thinning the bones, screening earlier is generally recommended.

Assessment tools:  There are several tools that have been developed by the WHO (World Health Organization)  – (see FRAX) to help assess risk for osteoporotic fractures.  These tools ask questions that relate to risk factors for osteoporosis and attempt to calculate a probability of hip fracture even without knowing exact measurements of bone density measured by special x-ray tests.

DXA Bone Mineral Density Test:  A bone density test uses special x-rays to determine how many grams of calcium and other bone minerals are packed into a bone segment.  Bones that are commonly tested include the spine, hip and forearm.  We do this test to identify patients who are at higher risk for bone fracture, as well as to monitor the progress of therapy for patients who are being treated.   Bone density tests are not the same as bone scans.  Bone scans usually require the patient to get an injection before the procedure and are used to detect bone fractures, bone cancer or bone infections.

Medications that increase the risk of bone thinning:  If you take any of these medications, ask your doctor about whether you should have your bone density tested:

1)  Glucocorticoids such as prednisone or dexamethasone

2)  Anti-Seizure medications such as Dilantin, Tegretol, Phenobarbital or Primadone

3)  Heparin – medication to treat abnormal blood clotting

4)  Acid reducing medications called proton pump inhibitors (PPIs) such as Prilosec may increase the risk of osteoporosis or fractures but more research is needed.

Treatment for osteoporosis:  The treatment really depends on the reason for the decrease in bone density.  We might change the patient’s current medications to different medicines that are safer and have less risk for decreasing bone mineral density.  Correcting a patient’s thyroid, parathyroid or testosterone imbalance may improve their bone density without the need for other medications.  We usually try to ensure that they are getting adequate dietary intake of calcium and vitamin D and may due some lab tests to look for excessive loss of calcium in the urine.  We might test the patient’s vitamin D levels along with the hormone levels mentioned above.  If there has already been a hip or vertebral compression fracture we will also usually check a bone mineral density (DXA or DEXA) scan to confirm the level of osteoporosis.

The DEXA scan gives us a numerical value that corresponds to the degree of osteopenia (low bone density) or osteoporosis (greater risk of fracture).  A normal bone density is when the T-score (measured on the bone density test) is between 0 and 1 standard deviation below the mean.  A normal T score may be reported as a T-score of +1 to -1.  If the T score is -1 to -2.4 the patient is said to have osteopenia which means that they have a risk of developing osteoporosis if not treated.  If the T score is -2.5 or less, the patient is diagnosed with osteoporosis.  The lower the T score (higher the negative number), the greater the risk of fracture.

Medical treatment of osteoporosis:

1)  Calcium – at least 1200 mg of calcium/day but no more than 2000 mg/day.

2)  Vitamin D – at least 800 international units/day – sometimes very high doses such as 50,000 IU/week may be prescribed if your levels are measured to be very low.

3)  Bisphosphonates such as Fosamax , Actonel  or Boniva are medications that slow the breakdown and removal of bone (bone resorption).  These are taken first thing in the morning on an empty stomach with an 8oz glass for still water.  There has been some concern about the use of bisphosphonates in people who require invasive dental work – it may lead to avascular necrosis or osteonecrosis.  Most experts do not think that it is necessary for most people to stop bisphosphonates before invasive dental work (tooth extraction or implant) because the risk is very small for those people who take bisphosphonates for osteoporosis treatment or prevention.  People who take a bisphosphonate as part of a treatment for cancer should consult their doctor before having invasive dental work however.

There is some concern about atypical (stress) hip fractures associated with long-term use of bisphosphonates.  Patients who have been taking them for more than 5 years may need re-evaluation to see if further continuation of the medication is recommended.

4)  Selective Estrogen Receptor Modulators (SERMs) produce estrogen-like effects on the bone.  They include Evista and tamoxifen.  In addition to osteoporosis treatment/prevention there is a decrease in the risk of breast cancer in women who are at high risk.  These medications are not recommended for women who have not started menopause.

5)  Calcitonin is a hormone produced by the thyroid gland that, together with parathyroid hormone, helps regulate calcium concentrations in the body.  This may be administered via nasal spray or injection.  Nasal administration is usually preferred due to ease of use and less chance of nausea and/or flushing.  It’s not clear if calcitonin improves bone in places in the body other than the spine.

6)  Parathyroid hormone (PTH) – (prescription preparation name Forteo) produced in the parathyroid glands(non-prescription form) stimulates bone resorption and new bone formation.  Clinical trials suggest the PTH therapy is effective in both prevention and treatment of osteoporosis in post-menopausal women and men.  It has been proven to reduce spine fracture risk more than any other treatment that we know about.  It does, however require a daily injection and is expensive so it’s usually reserved for patients with severe hip or spine osteoporosis with a T score of  less than -2.5 (higher number) and osteoporosis-related fracture.

When taking Forteo, we often check a blood uric acid and calcium level at the start of the medication, after 6 weeks, 6 months later and then after 12 months of therapy.

We generally do not use this medication in pediatric and young children whose bones are still growing or in patients with bone cancer,  Paget’s disease of the bone and extreme caution is needed in patients who have a history of recent calcium kidney stones.

7)  Prolia is a medication that helps improve bone mineral density and reduce fracture in postmenopausal women with osteoporosis.  It is an injection under the skin once every 6 months.  It’s usually well tolerated but can have side effects such as skin infections or eczema.  It should not be given to patients who have a low blood calcium level.

For more information, please check out the following resources:

National Library of Medicine

Osteoporosis and Related Bone Diseases National Resource Center

National Osteoporosis Foundation

National Women’s Health Resource Center (NWHRC)

Osteoporosis Society of Canada

The Hormone Foundation

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com