Medication and Older Adults

Osteoporosis is a disease in which bones become fragile. With decreased strength, bones have an increased tendency to break or fracture. The most common osteoporosis fracture sites are the small bones of the back (vertebrae), wrists, upper arms, pelvis and hips. Once a fracture occurs, there is greater chance for more fractures, resulting in pain, loss of mobility and possible need for surgery.

Who gets osteoporosis?

Osteoporosis affects more than 25 million Americans. Older individuals, especially women who have reached menopause, are most at risk. In addition to gender, other factors increase the risk of osteoporosis, including:

• Family history.
• Race. Caucasians and Asians are at a higher risk than African Americans.
• Inadequate calcium and vitamin D intake.
• Lack of physical activity.
• Cigarette smoking or excessive drinking of alcohol.
• Low body weight.
• Certain menstrual irregularities that are associated with estrogen deficiency.
• Some medications, including oral cortisone-like medications (glucocorticosteroids) or anti-seizure medications.

What does osteoporosis have to do with asthma?

Since asthma is an inflammatory disease of the lung, continuous use of anti-inflammatory medications is important for most patients with asthma. Cortisone-like medications, called glucocorticosteroids, are the most potent anti-inflammatory medications to treat asthma. Glucocorticosteroids can be administered systemically by oral, intravenous, or intramuscular route, or topically by inhaler, nasal spray, eye drops, or skin creams. Long-term use of oral glucocorticosteroids, such as the pill prednisone, has been associated with adverse effects, including osteoporosis. In contrast, inhaled or topical glucocorticosteroids are effective in treating asthma and have few adverse effects. Your allergist/immunologist is trained to consider the risks and benefits of using specific types of glucocorticosteroids. He or she will always prescribe the lowest effective dose of prednisone or other oral glucocorticosteroids, if required, and inhaled rather than oral medication whenever possible.

What can I do to help prevent osteoporosis?

Get adequate calcium. Calcium is best absorbed if taken with meals in small amounts throughout the day. The most concentrated calcium sources are dairy products, which sometimes also contain vitamin D. For example, one glass of skim milk has 302 mg of calcium and 85 calories. Four ounces of low-fat plain yogurt has 415 mg of calcium and 145 calories.

The recommended daily allowance for calcium is:

• 800 mg/day for one to 10 years of age
• 1,200 mg/day for 11-24 years of age
• 1,200 mg/day during pregnancy and lactation
• 1,200 mg/day adults greater than 24 years of age
• 1,500 mg/day for postmenopausal women
• 1,500 mg/day for adults at risk of osteoporosis

Some people lack an enzyme, called lactase, required to digest the milk sugar lactose. These people, who are lactose intolerant, may not be able to drink milk. However, some of these individuals may be able to eat yogurt or hard cheese, as well as acidophilus milk or other milk products to which lactase has been added. Good non-dairy sources of calcium include tofu (150 mg/4 oz), broccoli (freshly cooked, 136 mg/cup), collards (150 mg/cup), turnip greens (200 mg/cup), and sardines with bones (375 mg/3 oz).

For people who do not consume enough calcium in their regular diets, calcium supplements are recommended. But make sure to pay attention to the amount of elemental calcium-the actual amount of calcium present-in supplements. Taking more than 500 to 600 mg of calcium at one time or ingesting calcium with high fiber foods should be avoided, as either reduces calcium absorption. Supplements containing bone meal should be avoided, because of excess phosates. It is best to discuss calcium supplementation with your physician.

Make sure vitamin D intake is adequate but not excessive. The usual recommended amount for vitamin D is 800 International Units (IU) per day. Most multivitamins contain this amount. Doses up to 1,000 IU have improved calcium absorption and bone metabolism, but higher doses are not recommended unless prescribed by a physician. Vitamin D is found in egg yolks, salt-water fish, cow's liver and can be activated by sun exposure. Vitamin D 2 (ergocalciferol) is more effective than Vitamin D 3 (cholecalciferol).

Exercise. Weight-bearing exercises such as walking, hiking, stair climbing or jogging are recommended. The goal is to exercise every other day, or four times a week. The length of time depends on the intensity of the exercise. For walking, 45-60 minutes is recommended. If you have been inactive, consult your physician before beginning any exercise program.

Avoid cigarette smoking or excessive alcohol use. Smoking cigarettes and drinking alcohol in excess contributes to the risk of osteoporosis in addition to other health problems.

Female hormone replacement. If you are a woman who has reached menopause, estrogen replacement therapy can reduce the risk of osteoporosis. However, recent data suggest that this benefit may be outweighed by other risks. Discuss this with your physician.

Monitor your testosterone levels. If you are a man taking oral glucocorticosteroids such as prednisone, your blood testosterone level may need to be measured to be certain your testosterone level is not low.

See your physician. Discuss osteoporosis and any concerns you may have with your physician or other health care providers. If you have several risk factors for osteoporosis or you need daily prednisone which increases urinary calcium loss to control asthma, your physician may need to determine your bone density by a simple measurement with a densitometer. Your doctor can provide further assistance, such as prescribing medication to improve your bone health.

The AAAAI's How the Allergist/Immunologist Can Help: Consultation and Referral Guidelines Citing the Evidence provide information to assist patients and health care professionals in determining when a patient may need consultation or ongoing specialty care by the allergist/immunologist. Patients should see an allergist/immunologist if they:

• Need to confirm the diagnosis of asthma
• Need education on asthma and guidance in techniques for self-management.
• Need for daily asthma reliever medications.
• Are not using medications as prescribed, and this is limiting their ability to control their asthma.
• Would like to try to minimize their need for medications
• Your allergist/immunologist can provide you with more information on asthma medications and osteoporosis.