Lupus

Tuesday, October 2, 2012

SLE, Osteoporosis and Avascular Necrosis etc..

     Bone issues in lupus patients are caused by a few things, limited movement and exercise due to being and feeling ill, medications such as steroids, and from a direct result from the disease, and low vitamin D levels.

http://www.bclupus.org/reference_library/Articles%20-%20Lighthouse%20&%20other%20sources/20070401-Weinstein%20Patricia%20K%20MSN%20ARNP-Lupus%20and%2

Lupus and Bone Health 

By: Patricia K Weinstein, MSN, ARNP 

Your bones may feel rock hard, but they are living tissue. Bone-building cells (osteoblasts) and cells that break down bone (osteoclasts) are always at work. During your teenage years, tremendous bone growth takes place with bone building out pacing bone breakdown. Most adults reach their peak bone mass by age 20, with only a small amount more of bone mass added by the time you reach age 28. Hormones—estrogens in females and testosterone in males—play a major role in this rapid bone growth during the first 25-30 years of life. Around age 28, the same amount of bone that is removed is replaced. However, bone loss is a normal part of aging in both men and women. In women, the hormone estrogen decreases sharply after menopause, which causes bone breakdown to speed up. Men start out with more bone mass than women but as they age, their testosterone levels slowly go down. This leads to a gradual loss of bone. Men are at a greater risk of developing osteoporosis than they are of getting prostate cancer. 

Bones need Vitamin D and calcium as well as protein and other nutrients to grow and become strong, but genes play a big part in how thick your bones are. If one of your parents had thin bones, you are more likely to have them. Other things, like diet, exercise and medications, also influence the thickness of your bones. 

Osteopenia is the term used to describe mild thinning of the bones. In osteopenia, bone build up is not enough to keep up with bone breakdown. People with osteopenia are at risk for developing osteoporosis as well as fractures (broken bones). Osteopenia is more common in women than in men. By age 80, many women have lost 30% of their bone mass. Men usually begin to have bone loss due to aging after age 60.  

Osteoporosis, which means “porous bones,” is a loss of bone thickness to the point that applying very low forces can cause bones to break. These breaks, called fragility fractures, occur without any obvious injury, often by something as simple as sneezing. One in two women by age 75 have osteoporosis, which places them at a high risk for breaking their bones. Osteoporosis also can increase your chances of dying. About 20% of people who break a hip die within a year because of the problems caused by limited movement. People who break spinal bones (vertebrae) are at an even higher risk of death. When spinal bones near the ribs break, the chest becomes squeezed. This prevents the lungs from filling completely causing pneumonia or a collapsed lung. Breaks in the spinal bones of the lower back can affect the abdominal area causing constipation, abdominal pain, distention and poor appetite. Spinal fractures may also weaken muscles, cause pain, and upset balance, all of which increase your chances of falling and breaking other bones. 

Osteonecrosis is death of bone tissue caused by a poor blood supply to the bones. This loss of blood supply can be temporary or permanent. Without blood, the bone tissue dies and eventually the bone may collapse. Osteonecrosis is also known as avascular necrosis, aseptic necrosis, and ischemic necrosis. Osteonecrosis is an unfortunate complication of lupus and/or steroid use. The most common places that osteonecrosis occurs are the hip, shoulder and spinal bones of the lower back. At this time, there is no known treatment for osteonecrosis. Frequently, patients have hip pain that worsens with walking. Pain medications and crutches to reduce weight on the jointmay help lessen the pain. One small study found that bisphosphonates (see page 7) also might help. Surgery that smooths out the joint surface or joint replacement may decrease joint pain and improve quality of life. 

Lupus and Osteoporosis
Some conditions besides menopause and aging are associated with high levels of bone 
breakdown. Lupus is one of those. Having lupus increases your risk of osteoporosis for a number 
of reasons in both men and women. Some of these can be changed by medication or changing 
your lifestyle. Others, like a family history, body build, and race, cannot be changed.  
Traditional risk factors
People with lupus may have some of the same risk factors for osteoporosis that affect people in 
general. These include Caucasian or Asian race, being thin or having a small frame, having a 
blood relative with osteoporosis, drinking too much alcohol, smoking, and not enough calcium in 
the diet. Once you have a fragility fracture, that is a bone that breaks without obvious injury, you 
are at risk for having another one.  
Inflammation increases bone breakdown and decreases new bone formation in all people. Lupus, like other autoimmune disorders, causes inflammation. This probably is the major reason why people with lupus have increased bone loss.
Decreased Physical Activity 
Weight-bearing physical activities, such as walking and jogging, exert force on our bones. Your bones respond by increasing their mass in order to spread the load over a larger amount of bone. 
Physical activity also improves balance and coordination, which reduces the risk of falling that can cause broken bones. The pain and fatigue that accompany lupus can make it difficult to be physically active, adding to the risk for osteoporiosis. 
Hormonal changes 
Estrogen and testosterone play important roles in keeping your bones thick. Women with autoimmune disorders often go through menopause a few years earlier that those women without such conditions. This earlier loss of estrogen can trigger osteoporosis.  
Low Vitamin D level 
Vitamin D is needed to absorb calcium. Vitamin D is formed in the skin when the skin is exposed to sunlight. Some people with lupus avoid sunlight since it can trigger flares. This may explain in part why some people with lupus have low Vitamin D levels but not completely. 
Scientists are just discovering the importance of Vitamin D to the immune system and have found that many people with autoimmune diseases have low Vitamin D levels. 
Kidney disease 
The kidney is one of the major places in the body where vitamin D is changed to its active form. 
Kidney diseases can affect the kidney’s ability to change vitamin D to its active form. Some people with lupus develop lupus nephritis, a form of kidney disease. When lupus nephritis becomes chronic, it increases the risk for osteoporosis.

Osteoporosis

Osteoporosis is a condition in which the bones become less dense and more likely to fracture. Fractures from osteoporosis can result in significant pain and disability. Osteoporosis is a major health threat for an estimated 44 million Americans, 68 percent of whom are women.
Risk factors for developing osteoporosis include:
  • having a family history of the disease
  • for women, being postmenopausal, having an early menopause, or not having menstrual periods (amenorrhea)
  • using certain medications, such as glucocorticoids
  • not getting enough calcium
  • not getting enough physical activity
  • smoking
  • drinking too much alcohol.
Osteoporosis is a silent disease that can often be prevented. However, if undetected, it can progress for many years without symptoms until a fracture occurs.

The Lupus – Osteoporosis Link

Studies have found an increase in bone loss and fracture in individuals with SLE. In fact, women with lupus may be nearly five times more likely to experience a fracture from osteoporosis. Individuals with lupus are at increased risk for osteoporosis for many reasons. To begin with, the glucocorticoid medications often prescribed to treat SLE can trigger significant bone loss.
In addition, pain and fatigue caused by the disease can result in inactivity, further increasing osteoporosis risk. Studies also show that bone loss in lupus may occur as a direct result of the disease. Of concern is the fact that 90 percent of the individuals affected with lupus are women, a group already at increased osteoporosis risk.

Osteoporosis Management Strategies

Strategies for the prevention and treatment of osteoporosis in people with lupus are not significantly different from the strategies for those who do not have the disease.
Nutrition
A diet rich in calcium and vitamin D is important for healthy bones. Good sources of calcium include low-fat dairy products; dark green, leafy vegetables; and calcium-fortified foods and beverages. Also, supplements can help ensure that the calcium requirement is met each day. Vitamin D plays an important role in calcium absorption and bone health. It is synthesized in the skin through exposure to sunlight. While many people are able to obtain enough vitamin D naturally, excessive sun exposure can trigger flares in some people with lupus. These individuals may require vitamin D supplements in order to ensure an adequate daily intake.
Exercise
Like muscle, bone is living tissue that responds to exercise by becoming stronger. The best exercise for your bones is weight-bearing exercise that forces you to work against gravity. Some examples include walking, climbing stairs, weight lifting, and dancing.
Exercising can be challenging for people with lupus who are affected by joint pain and inflammation, muscle pain, and fatigue. However, regular exercises such as walking can help prevent bone loss and provide many other health benefits.
Healthy lifestyle
Smoking is bad for bones as well as the heart and lungs. Women who smoke tend to go through menopause earlier, triggering earlier bone loss. In addition, smokers may absorb less calcium from their diets. Alcohol can also negatively affect bone health. Those who drink heavily are more prone to bone loss and fracture, both because of poor nutrition and an increased risk of falling.
Bone density test
Specialized tests known as bone mineral density (BMD) tests measure bone density at various sites of the body. These tests can detect osteoporosis before a fracture occurs and predict one’s chances of fracturing in the future. Lupus patients, particularly those receiving glucocorticoid therapy for 2 months or more, should talk to their doctors about whether they might be candidates for a bone density test.
Medication
Like lupus, osteoporosis is a disease with no cure. However, there are medications available to prevent and treat osteoporosis. Several medications (alendronate, risedronate, ibandronate, raloxifene, calcitonin, teriparatide, and estrogen/hormone therapy) are approved by the Food and Drug Administration (FDA) for the prevention and/or treatment of osteoporosis in postmenopausal women. Alendronate is also approved for use in men. For people with lupus who develop or may develop glucocorticoid-induced osteoporosis, alendronate has been approved to treat this condition and risedronate has been approved to treat and prevent it.
Related Information

What People With Lupus Need to Know About Osteoporosis

January 2012

What Is Lupus?

Lupus is an autoimmune disease, a disorder in which the body attacks its own healthy cells and tissues. As a result, various parts of the body—such as the joints, skin, kidneys, heart, and lungs—can become inflamed and damaged. There are many different kinds of lupus. Systemic lupus erythematosus (SLE) is the form of the disease that is commonly referred to as lupus.
People with lupus can have a wide range of symptoms. Some of the most commonly reported symptoms are fatigue, painful or swollen joints, fever, skin rashes, and kidney problems. Typically, these symptoms come and go. When symptoms are present in a person with the disease, it is known as a flare. When symptoms are not present, the disease is said to be in remission.
We know that many more women than men have lupus. Lupus is two to three times more common in African American women than in Caucasian women and is also more common in women of Hispanic, Asian, and Native American descent. African American and Hispanic women are also more likely to have active disease and serious organ system involvement. In addition, lupus can run in families, but the risk that a child or a brother or sister of a patient will also have lupus is still quite low. It is difficult to estimate how many people in the United States have the disease, because its symptoms vary widely and its onset is often hard to pinpoint. Unfortunately, there is no cure for the disease.

What Is Osteoporosis?

Osteoporosis is a condition in which the bones become less dense and more likely to fracture. Fractures from osteoporosis can result in significant pain and disability. In the United States, more than 40 million people either already have osteoporosis or are at high risk due to low bone mass.
Risk factors for developing osteoporosis include:
  • thinness or small frame
  • family history of the disease
  • being postmenopausal and particularly having had early menopause
  • abnormal absence of menstrual periods (amenorrhea)
  • prolonged use of certain medications, such as those used to treat lupus, asthma, thyroid deficiencies, and seizures
  • low calcium intake
  • lack of physical activity
  • smoking
  • excessive alcohol intake.
Osteoporosis often can be prevented. It is known as a “silent disease” because, if undetected, bone loss can progress for many years without symptoms until a fracture occurs. Osteoporosis has been called a childhood disease with old age consequences because building healthy bones in youth helps prevent osteoporosis and fractures later in life. However, it is never too late to adopt new habits for healthy bones.

The Link Between Lupus and Osteoporosis

Studies have found an increase in bone loss and fracture in individuals with SLE. In fact, women with lupus may be nearly five times more likely than those without the disease to experience a fracture from osteoporosis.
Individuals with lupus are at increased risk for osteoporosis for many reasons. To begin with, the glucocorticoid medications often prescribed to treat SLE can trigger significant bone loss. In addition, pain and fatigue caused by the disease can result in inactivity, further increasing osteoporosis risk. Studies also show that bone loss in lupus may occur as a direct result of the disease. Of concern is the fact that 90 percent of the people affected with lupus are women, a group already at increased risk for osteoporosis.

Osteoporosis Management Strategies

Strategies for the prevention and treatment of osteoporosis in people with lupus are not significantly different from the strategies for those who do not have the disease.
Nutrition. A well-balanced diet rich in calcium and vitamin D is important for healthy bones. Good sources of calcium include low-fat dairy products; dark green, leafy vegetables; and calcium-fortified foods and beverages. Supplements can help ensure that you get adequate amounts of calcium each day, especially in people with a proven milk allergy. The Institute of Medicine recommends a daily calcium intake of 1,000 mg (milligrams) for men and women up to age 50. Women over age 50 and men over age 70 should increase their intake to 1,200 mg daily.
Vitamin D plays an important role in calcium absorption and bone health. Food sources of vitamin D include egg yolks, saltwater fish, and liver. Many people obtain enough vitamin D naturally, but some individuals may need vitamin D supplements to achieve the recommended intake of 600 to 800 IU (International Units) each day.
Exercise. Like muscle, bone is living tissue that responds to exercise by becoming stronger. The best activity for your bones is weight-bearing exercise that forces you to work against gravity. Some examples include walking, climbing stairs, weight training, and dancing.
Exercising can be challenging for people with lupus who are affected by joint pain and inflammation, muscle pain, and fatigue. However, regular exercise, such as walking, may help prevent bone loss and provide many other health benefits.
Healthy lifestyle. Smoking is bad for bones as well as the heart and lungs. Women who smoke tend to go through menopause earlier, resulting in earlier reduction in levels of the bone-preserving hormone estrogen and triggering earlier bone loss. In addition, smokers may absorb less calcium from their diets. Alcohol also can have a negative effect on bone health. Those who drink heavily are more prone to bone loss and fracture, both because of poor nutrition and an increased risk of falling.
Bone density test. A bone mineral density (BMD) test measures bone density at various parts of the body. This safe and painless test can detect osteoporosis before a fracture occurs and predict one’s chances of fracturing in the future. Lupus patients, particularly those receiving glucocorticoid therapy for 2 months or more, should talk to their doctors about whether they might be candidates for a bone density test. The BMD test can help determine whether medication should be considered.
Medication. Like lupus, osteoporosis is a disease with no cure. However, several medications are available for the prevention and/or treatment of osteoporosis, including: bisphosphonates; estrogen agonists/antagonists (also called selective estrogen receptor modulators or SERMS); calcitonin; parathyroid hormone; estrogen therapy; hormone therapy; and a recently approved RANK ligand (RANKL) inhibitor.

Resources

For more information on osteoporosis, contact:
NIH Osteoporosis and Related Bone Diseases ~ National Resource Center
Website: http://www.bones.nih.gov
Phone: 202-223-0344
Toll free: 800-624-BONE (2663)
For more information on lupus, contact:
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Information Clearinghouse
National Institutes of Health

For Your Information

This publication contains information about medications used to treat the health condition discussed here. When this publication was produced, we included the most up-to-date (accurate) information available. Occasionally, new information on medication is released.
For updates and for any questions about any medications you are taking, please contact:
U.S. Food and Drug Administration
Website: http://www.fda.gov/
Toll free: 888–INFO–FDA (888–463–6332)

http://www.medicinenet.com/aseptic_necrosis/page4.htm
Aseptic necrosis facts

  • Aseptic necrosis is a bone condition that results from poor blood supply to an area of bone, causing localized bone death.
  • Aseptic necrosis can be caused by trauma, damage to the blood vessels that supply bone its oxygen, poor blood circulation to the bone, abnormally thick blood (hypercoagulable state), and atherosclerosis or inflammation of the blood vessel walls (vasculitis).
  • Steroid medications (cortisone, such as prednisone [Deltasone, Liquid Pred] and methylprednisolone [Medrol, Depo-Medrol]) are the most common medications to cause aseptic necrosis.
  • Risk factors for aseptic necrosis include alcoholism, cortisone medications, Cushing's syndrome, radiation exposure, sickle cell diseasepancreatitisGaucher disease, and systemic lupus erythematosus.
  • Aseptic necrosis may or may not cause pain.
  • The treatment of aseptic necrosis is critically dependent on the stage of the condition.

What is aseptic necrosis?

Aseptic necrosis is a bone condition that results from poor blood supply to an area of bone, causing localized bone death. This is a serious condition because the dead areas of bone do not function normally, are weakened, and can collapse. Aseptic necrosis is also referred to as avascular necrosis or osteonecrosis.
Reviewed by Catherine Burt Driver, MD on 10/17/2011

What causes aseptic necrosis?

Aseptic necrosis can be caused by trauma and damage to the blood vessels that supply bone its oxygen. Other causes of poor blood circulation to the bone include a blockage by air or fat (embolism) that obstructs the blood flow through the blood vessels, abnormally thick blood (hypercoagulable state), atherosclerosis (hardening of the arteries), or inflammation of the blood vessel walls (vasculitis). Steroid medications (cortisone, such as prednisone[Deltasone, Liquid Pred] andmethylprednisolone [Medrol, Depo-Medrol]) are the most common medications to cause aseptic necrosis. Typical bones affected by steroids include the femur bone of the hip, the humerus bone of the shoulder, and the tibia bone of the knee, sometimes in combinations and frequently affecting both sides of the body (bilateral). Aseptic necrosis of the jawbone has been associated with the use of medications (bisphosphonates) used to treat high blood calcium levels from cancer.

What are risk factors for aseptic necrosis?

Conditions that are risk factors associated with aseptic necrosis includealcoholism, cortisone medications, Cushing's syndrome, radiation exposure,sickle cell diseasepancreatitisGaucher disease, and systemic lupus erythematosus. Aseptic necrosis of the jawbone has been rarely reported in association with the use of bisphosphonate medication, particularly intravenously including zolendronate (Zometa) and pamidronate (Aredia).
Reviewed by Catherine Burt Driver, MD on 10/17/2011

What are symptoms of aseptic necrosis?

Aseptic necrosis begins as a painless bone abnormality. It can remain painless. The involved bone often later develops pain, especially with use. For example, if a hip joint develops avascular necrosis in the ball of the hip joint, pain can be noted, especially upon weight-bearing. As the ball of the hip joint collapses from the degeneration of the bone from aseptic necrosis, pain in the groin can be felt with hip rotation and pain can sometimes be noted with rest after weight-bearing.

How is aseptic necrosis diagnosed?

The diagnosis of aseptic necrosis can often, but not always, be made with plain film X-rays. By the time changes are apparent by plain film X-ray testing there has been substantial damage to the bone affected. Bone changes visible on plain film X-ray are, therefore, considered a later-stage finding. Earlier signs of avascular necrosis can be detected with an MRI scan image or suggested by a nuclear bone scan image.

What is the treatment for aseptic necrosis?

The treatment of aseptic necrosis is critically dependent on the stage of the condition. Early aseptic necrosis (before X-ray image changes are evident) can be treated with a surgical operation called a core decompression. This procedure involves removing a core of bone from the involved area and sometimes grafting new bone into the area. This allows new blood supply to form, preserving the bone. Weight-bearing or impact of the involved joint is restricted.
Later stages of aseptic necrosis (when X-ray image changes are apparent) typically lead to seriously damaged bone and joints, requiring joint replacement surgery. For related information, please read the following articles: Total Hip Replacement and Total Knee Replacement.
Reviewed by Catherine Burt Driver, MD on 10/17/2011

What is the prognosis of aseptic necrosis?

Aseptic necrosis causes a serious injury to affected bone. Frequently this leads to permanent destruction of the adjacent joint. Early core decompression is generally necessary to prevent collapse of affected bone.

Can aseptic necrosis be prevented?

Aseptic necrosis can be prevented by minimizing the use of steroid medications when possible and by treating underlying medical conditions, such as those described above, that can increase the risk of developing aseptic necrosis.


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