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Bone Growth

HSB
  • By HSB
  • Posted July 7, 2008 at 5:20 pm · 18 replies
  • Shared with the public
5 Recommendations

Does bone continue to grow while you're taking fosamax or any of the others? I've read that it is the process of bone breaking down that actually spurs the new growth.

Explore topics in this journal entry and replies:

Cancer Chondrosarcoma Boniva Forteo Fractures Alendronate Fosamax Actonel Pain Osteomalacia Bone cancer Osteoporosis Stress fractures Evista Stress

18 replies

windblown

Hi HSB: The bisphosphonate drugs, Fosomax, Boniva, Actonel etc only slow bone loss. The only drug I know that stimulates bone growth is Forteo.

Please do some reading on this to make sure I'm correct. I'm sure the NOF has an article on how these drugs work. You can also look up remodeling, and see how this all is explained.

Check out the link below to the Univ of WA Bone Physiology course. This link has videos and animations that should answer your question. I'm not sure how long it is, but try to read the whole course on remodeling. I just added the link to the NOF's page on remodeling at (6:31 p.m. pst)

Good Luck...

http://depts.washington.edu/bonebio/ASBMRed/growth.html

windblown

Hi HSB: Here's the NOF's page on remodeling:

http://www.nof.org/patientinfo/medications.htm#Bone%20Remodeling%20Cycle

SaraMeeks

It is my understanding that all of the medications, except Forteo, slow down the osteoclast action in bone remodeling--that is they slow down the tearing down of bone which is necessary for the building up of bone. Forteo, alone, apparently affects the osteoblast action or the building up of bone.
I've also always understood that one process depends upon the other and the two are linked-in other words, you have to have the tearing down to have the building up and osteoclastic action is necessary to stimulate osteoblastic action.
Along that line, I have read that slowing down bone loss will also slow down bone re-building as one depends upon the other. So, the increase in bone density that occurs with bisphosphanates is really a "relative" increase in bone density, not a true one.

duranee1

You're right, Sara, the bisphosphosphonates only slow down resorption.
First the bisphosphonate is attached to the bone surface.
Then, when a section of bone needs to be replaced, the osteoclast consumes the bisphosphonate while breaking down the bone.
The bisphosphonate kills the osteoclast, so the bone resorption is minimized.
This may work for a while, but check out the low impact fractures that are being seen with long term bisphosphonate use:
http://content.nejm.org/cgi/content/full/358/12/1304
Be sure to look at the x-ray pictures. Low impact means from a standing height or lower - no severe trauma. This was published in the New England Journal of Medicine in April.

windblown

Hi Duranee1: Interesting article... Do you agree there is a link between BP use and this atypical type of frax? I noticed that they didn't check the study participants for other metabolic bones diseases, so I'm wondering can we say that the BP's actually caused the unusual frax, or could it be some undisclosed bone disorder?

My Dr seems to think this is a possibility, due to the fact that they are seeing similar frax's at their research lab, but I never asked her if these conditions could be related to some other contributing factor, that could cause this atypical type of bone frax. Do we know why there were only femur frax's and no vertebral?

If the participants PTH, vit D and bmd wasn't checked, doesn't that mean there *could* have been some undisclosed bone disorders, that may have contributed to this?

This analogy is very interesting, but I wish we had a more clear cut answer to it. I'll have to ask my Dr if those they have seen with this problem were checked for any metabolic bone disorders, or if the BP's were the sole contributor. At some point I may have to go back to BP's for treatment, and I would like to know if I'm looking at a possible brittle bone issue. I've finished my two years on Forteo and need to maintain my gains, but I'm using a drug that works slower than the Bisphosphonates (Evista), so if I have to switch back to Actonel I would like a concrete answer on this question. I went from -3.6 (spine) pre-forteo to -0.9 (spine) post forteo, and would like to hang onto that how ever I can, and I'm not sure Evista will do that alone.

Thanks for posting this Duranee1 it's very interesting:)

Jacqueline

Here is a blog that appeared in the Wall Street Journal:

http://blogs.wsj.com/health/2008/06/04/side-effect-watch-femur-fractures-in -fosamax-patients/

windblown

Hi Jacqueline: Thanks for this article, it gives me another piece to the puzzle :)

duranee1

Hi Windblown,
Valid questions. Except that it's not the only report of these fractures and they're overwhelmingly associated with long term BP use. One article that I've read in its entirety is Kwek. They state, "This particular fracture pattern has not been previously associated with any form of osteomalacia or mineral disorder, and very likely represents a new pattern of pathological fractures." This would lead me to infer that the other possible disorders you mention are not the cause of these fractures. The reference is: Kwek EB, Goh SK, Koh JS, Png MA, Howe TS. 2008. An emerging pattern of subtrochanteric stress fractures: A long-term complication of alendronate therapy? Injury. [Epub ahead of print]

All these patients show increased cortical bone at the same area. Many of the patients had prodromal pain from 2 months to 2 years before the break and bone scans showed a corresponding area of increased stress on the unfractured bone in the other leg. Kwek actually did have BMD and co-morbidities for most of the patients reported.

Let me know how the Evista does at maintaining the gain you got from the Forteo. Good luck.

If you're interested, the other references in the Kwek paper are:
Armamento-Villareal R, Napoli N, Panwar V, Novack D. 2006. Suppressed bone turnover during alendronate therapy for high-turnover osteoporosis. N Engl J Med. 355(19):2048-50.

Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt MC, Bauer DC, Genant HK, Haskell WL, Marcus R, Ott SM, Torner JC, Quandt SA, Reiss TF, Ensrud KE. 1996. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet. 348(9041):1535-41.

Black DM, Schwartz AV, Ensrud KE, Cauley JA, Levis S, Quandt SA, Satterfield S, Wallace RB, Bauer DC, Palermo L, Wehren LE, Lombardi A, Santora AC, Cummings SR; FLEX Research Group. 2006. Effects of continuing or stopping alendronate after 5 years of treatment: the Fracture Intervention Trial Long-term Extension (FLEX): a randomized trial. JAMA. 296(24):2927-38.

Currey JD. 1984. Effects of differences in mineralization on the mechanical properties of bone.
Philos Trans R Soc Lond B Biol Sci. 304(1121):509-18.

Goh SK, Yang KY, Koh JS, Wong MK, Chua SY, Chua DT, Howe TS. 2007. Subtrochanteric insufficiency fractures in patients on alendronate therapy: a caution. J Bone Joint Surg Br. 89(3):349-53.

Mashiba T, Mori S, Burr DB, Komatsubara S, Cao Y, Manabe T, Norimatsu H. 2005. The effects of suppressed bone remodeling by bisphosphonates on microdamage accumulation and degree of mineralization in the cortical bone of dog rib. J Bone Miner Metab. 23 Suppl:36-42.

Schneider JP. 2006. Should bisphosphonates be continued indefinitely? An unusual fracture in a healthy woman on long-term alendronate. Geriatrics. 61(1):31-3.

Odvina CV, Zerwekh JE, Rao DS, Maalouf N, Gottschalk FA, Pak CY. 2005. Severely suppressed bone turnover: a potential complication of alendronate therapy. J Clin Endocrinol Metab. 90(3):1294-301.

Wasserman N, Yerramshetty J, Akkus O. 2005. Microcracks colocalize within highly mineralized regions of cortical bone tissue. Eur J Morphol. 42(1-2):43-51.

windblown

Hi Duranee1: Thanks very much for all the articles. I'm will definitely read all of them, and pass them along to my Dr.

I'll let you know how my next NTx test goes, since I won't be having another dxa for one year. This last dxa was included in a study at LLU, and I had the scan done twice (calibration/accuracy test). Both scans came up with the same result (t-score). I'm still amazed that I could improve as much as I have from the Forteo.

I have another question for you but will start a new thread on it. I hope you can shed some light on the topic.

HSB

Hi Windblown,

Did you use any of the Bisphosphonates before you used Forteo? Thanks to everyone, it's very useful information.

Helene

windblown

Hi HSB: Yes I took Actonel for about 15 months. Are you taking Fosomax, or just considering it? My t-score went up by .2, on Actonel, but my Dr wanted me to switch to Forteo since I still was at a -3.4, and I agreed. I've had 6 frax's so I wanted to try something that worked faster and that builds new bone.

HSB

Hi ,
I took Fosamax for 5 years, then stopped for a year. My spine and left hip stayed the same, -1..9 and -2.5. My right hip got worse, -2.1 to -2.5. However, all of my labs are good. I'm really hesitant about going back on Fosamax based on everything mentioned above...plus, (and very relevant per my Dr.), I haven't fractured. Frankly, I'm making myself nuts since obviously all of these drugs are relatively new The reason I asked about you BP use is that I'd heard that Forteo worked best if you hadn't used them. My thoughts are sort of running to not taking anything and waiting. If I fracture, then consider Forteo. (However, 5 years ago I had a chondrosarcoma removed from my leg which makes me not ideal.) However,, if everything is breaking, it might be worth the risk Right now the worst part is it's all I'm thinking about which is becoming extremely stressful. I need to make up my mind and live with it. Again, thanks for the feedback.

windblown

Hi HSB: Firstly, please don't panic. I too have read that if you took BP's prior to Forteo, then Forteo *may* not work as well, but I didn't have the luxury of waiting to start it. I believe I made the correct decision, because my improvements on it have been incredible, so that completely contradicts what I've read, which means you may have to take everything you read with a grain of salt, since there are still things we DON'T know about these drugs. If the statement of waiting to take Forteo after a BP is correct, then I shouldn't have seen the increases I did. My experience has established you can still see t-score improvements on Forteo after taking a BP.

Don't let the discussion we've had in this thread deter you in your decision. I *was worried* you might be put off by our discussion, and I'm truly sorry for that! If you read these scientific articles, it clearly states that NOT all patients on these meds have this type of reaction, in fact it's a very small number compared to those who have benefited, without getting into the other probs some have with these meds (GI etc). I believe that those who have benefited from BP's greatly outweighs the number who had these unusual frax's or other serious side effects. I know so many that haven't had the brittle bone prob or the atypical frax's with BP's, all you have to do is look at the stats on BP's which have been used for much longer in cancer than osteo, so it's been around quite a long time, just look up cancer use of BP's and you'll see what I'm talking about with Fosamax.

These studies have to cover the negatives, but they don't apply to all. I believe there might be other contributing factors that cause these phenomenons imho.

This is a perfect example of the theory that not all patients experience the same side effects.

I don't know your age, but it seems one of the common denominators was ages ranging in the 70's of the participants. As we age, we develop other comorbid factors that could have contributed to this.

One very important thing is if you've had bone cancer, and radiation to the bone you can't take Forteo. Check this with your Dr or in the Cleveland Clinic article below.

Good Luck with your decision, and please don't let our conversation worry you or put you off of a potential treatment, since there aren't that many available. Maybe we should have discussed what we did on some other thread.

With each of my frax's I was laid up for over a year, not being able to drive for months and had great difficulty with walking, sitting and standing. Of course there are different types of frax's the silent and more serious ones, but with all my other spinal probs the recovery time was extremely long and almost unbearable, because it affects every aspect of your daily life making the simplest task very hard to do. Silent frax's don't involve the long rehab I had to go through to walk, sit and stand again; until the frax progresses to a much more aggressive type of frax, then you have the much more involved and sometimes long recovery.

One thing that worries me, is when people say they will wait till they have a frax and then decide what to do, believe me you don't want to wait to have a frax, you want to prevent it.

Good Luck, and I hope you continue to be frax free.

I wish you all the luck in your decision and treatment.

http://www.ccjm.org/pdffiles/DEAL703.PDF#search=%22forteo%20and%20osteosarc oma%22

MotherGoose

Very good reply, Windblown.
Sensible and well-advised sharing of your thoughts and concerns. Reading the research means much more than reading -- it means understanding statistics and comparing the types of studies -- and being skeptical, too.
Lucy Buckley PT aka Mother Goose

mj2

My doctor told me that all the medications for osteo stopped bone recycling except Forteo. I could not take Forteo, so he said I was too young to stop recycling of bone, so he suggest I take nothing except the calcium and D at this point (even though my scores are 4's).

HSB

HI All,

Please don't ever apologize for sharing knowledge, we all need to know everything we can in order to make a decision. I'm so sorry about all of your frax. Have you fractured since the forteo?
The other reason I've decided to stop the Fosamax is that the increase had pretty much tapered off. And 2 of the 3 points stabilized. I can't help but be concerned that my bone isn't turning over as I'm 57. I know I am contraindicated for Forteo. My, probably not so good, reasoning is that it was a contained tumor which was removed, with the bone. No chemo, no radiation. mj2, I'm curious, are you post menopausal? And why can't you take Forteo? (I'm a bit obsessed with Forteo!). Have you fractured? You might get something out of a book I've just finished, "The Myth of Osteoporosis". It's not what it sounds like. It just give s a different perspective, particularly if you've been diagnosed with low BMD but have not fractured.

Take care, Helene

windblown

Hi Lucy: Thanks for your kind words. One of my problems is I am a true skeptic most of the time, and I spend a lot of time over analyzing most things, so I can't just read something (research and editorials) and take what is put across as gospel without disecting every aspect of the facts and overlooked issues.

I don't want to disaude anyone from their beliefs, so my eagerness to discuss these issues requires walking a fine line between education and understanding-for me-and possibly changing someones else's belief system in a negative way while going through my growth process. I just have to be careful that some don't get tangled up in my constant analysis, of these ever-growing issues.

windblown

Hi HSB: I'm glad that our discussion didn't put you off in some harmful way. I agree that it is necessary to share knowledge, both the pro and the con, so we can make our own informed decision, but I'm constantly amazed how some react to news, research etc., etc., whether it's factual or not. Of course I'm not including you in this group of seekers of negative medical publications, to use as their final decision on tx. If some could put just as much faith in positive research, as they do the negative, it would eliminate a lot of problems.

To answer your question, no I haven't fractured since I've been on Forteo, knock on wood. How are you doing with your chondrosarcoma? The ccjm article says along with the Dr.'s I've discussed this with, that if you've had cancer, Forteo is contraindicated, *but* it seems the reasoning is if you had radiation to the bone. So, I don't know maybe there are some exceptions to this rule, regarding cancer that is in remission, that didn't utilize rad to the bone.

I understand now what you are doing with your tx, so I hope you continue to do well with this particular decision.

Best of luck to you!!!

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