Osteopenia & osteoporosis?
 

Hi everyone,
I received a call from my GYN this morning. I had a bone density test last week and she said it showed osteopenia in my left hip and osteoporosis in my lumbar spine. I am shocked by this. I had the test done is 2008, right before I got sick, and it showed a little bit of something in my left hip. Nothing to be worried about.

I'm shocked because I never thought I would get osteoporosis due to many many years of exercising and being very healthy about my life.

Just another thing to add to my list!

My meds are
Cymbalta
Tramadol
Synthyroid

Supplements:
Krill oil
R lipoid acid
Coq10
Probiotic

I gave up calcium and vitamin D two years ago after the results of my hair analyses showed my calcium levels were really high. I had that test done by my shiatsu therapist. As for D, I drink a a glass of almond milk every morning. I am outside all the time when it is nice out. I stopped this when my doctors at Hopkins told me to stop all vitamins they were not necessary. I know I had my levels checked several times and D was good.

My questions:
Could any of my meds or supplements cause this?
Could this have anything to do with me getting neuropathy? Could this be caused my having neuropathy?

Any answers will be appreciated.

I'm also going to do research just thought I check with those I consider the experts first! :confused:

SSRIs and osteoporosis: (relatively new finding)...

http://www.ncbi.nlm.nih.gov/pubmed/22659406

If your thyroid medication is too high, there can be bone loss too.

B12 if low will result in bone loss too.

Article:
http://depts.washington.edu/druginfo...iles/V34N8.pdf

Thanks Mrs. D.
I'm going to get an appt with my GP and ask for a blood test for B12,

calcium, magnesium, thyroid, Vit D.

I'm also going to speak with my rheumatologist about the cymbalta and whether

it should be changed. I just don't know what to change to. It was really the first

Thing that worked for me. I'm afraid to stop.

Is there anything else you can think o f that I should ask about?

Thanks for your help! Hopeful

Hi Hopeful
I have had Osteopenia for quite some years, mostly in my hips. I have had bone densety tests done fairly routinely. My PCP years ago, and a rheumatologist 2 years prescribed meds for this, but I never took it. And just very recently I have developed Inflamatory Arthritis, and X Ray of wrists and hands now are showing Osteopenia and Degenerative Joint Disease. My rheumatologist thinks perhaps the neuropathy is coming from this arthritis.

I think that all this " bone conditions" like osteopenia ( which is pre-osteoporosis),osteoporosis and arthritis can have close relation to peripheral neuropathy.


Well Mrs D, thanks so much for the information. I just read the article from University of Washington on " Drug Therapy Topics".
This was very interesting and informative.
I had no knowlege that all those meds could cause osteoporosis. The worst part of it ( for me) is that I take most of them I take antidepressant Amitriptyline for neuropathy ( I do not know if this one is included?), I take Synthroid Methatrexate, and some times Prednisone. Of course, I did know that Prednisone can cause, and perhaps mostly always will, cause boneloss.

By the way, Prednisone can also cause cataract, BIG TIME!! I just had a very fast growing cataracts in both eyes just after a course of high dose Prednisone. Now I have to have cataract surgery.
I wish we did not have to take all these meds.

All the best
Synnove

Doc

Haha very funny Dr. Smith!!!

Hi Synnove,

It seems like you are on a lot of the same meds I am. I also get 20mgs of solumedrol with my IVIG Rx every month. Not sure if that is enough to cause bone issues.

I always check the side affects of any medication before I take it. I don't remember ever seeing bone loss as a s/e. I looked up the s/e of cymbalta on several sites today and they still have not listed bone loss. You would think once they find something like that out they would insist the drug company make it known. I suppose it all comes down to money. :(

Thanks for the info on the prednisone too. I didn't know about the cataracts.
Hoeful:)

And, it's alwasy a good idea
 

--when calcium levels have been recorded high in the past, but there is evidence of bone loss, to check the functioning of the parathryroid glands as well--these are the little glands embedded in the thyroid whose function is to regulate calcium metabolism.

It's certainly not uncommon, due to the action of medications or hyperplasia, for the parathyroids to produce too much hormone and cause blood levels of calcium to rise--and often, in response to the dysregulated hormone feedback, the body will leach calcium from bone to restore the serological balance. (And yes, this was me--despite all the weightlifting and such I do, at one point due to high parathyroid hormone I had high ionized calcium levels and a degree of osteopenia; last year I finally had surgery to remove two hyperplastic glands.)

You may want to look at vitamin K2. Here's a link on the connection to K2 and bone loss.

http://www.thorne.com/altmedrev/.fulltext/14/3/284.pdf

Make sure you are not taking any B vitamins when you get tested or it will ruin the results.

Also, the MMA test is better than ONLY a serum B12 test.

I wasn't being sarcastic. I don't recall ever hearing/reading that PN could come from, or be caused by arthritis (may have glossed over or forgotten), and I think that's an interesting statement! Goggling arthritis cause peripheral neuropathy I see that rheumatoid arthritis can lead to PN. Not sure about osteo yet—still reading....

It seems strange that while all of my doctors have been aware of the severe osteoarthritis in my spine, no mention of a possible connection—let alone cause/effect relationship—to my PN has ever been mentioned. The spine issues definitely began years before the PN first reared it's ugly tuchus/tukhus(sp?)/dupa.

Kinda makes me go, "Hmmm...." :Ponder: And gives me yet something else to delve into (like I have't got enough already!) :eek:

Doc

The pre-release studies Big Pharma does on its meds are usually comprised of a relatively small segment/cross-section of the general population. Many side effects don't show up until the medication has been on the market (and available to a much larger/wider number of guinea pigs) for months to years later, and then SOMEONE has to report them. Patients can do this directly (if they know how, and make the effort to do so), but often (usually?) opt for telling their doctors, who may or may not listen/take them seriously/dismiss them, and whether or not those doctors ever report those side effects is anyone's guess—they're as likely as anyone else to leave it up to someone else/the next guy. So when we see statistics on side effects, there's a good chance that we're seeing only a fraction of reality, and possibly just the tip of the iceberg.

What does your doctor hear when you talk?

Doc

Yuh, what does a doctor hear when you talk? :Dunno: Not much. :( :Scratch-Head: Just the way it is.

The interference with bone by the SSRIs is relatively new information.

Probably won't make it into inserts for a long time.

http://en.wikipedia.org/wiki/Serotonin

Scroll down to Bone Metabolism in this wiki article. It is pretty complicated. But when added to situations involving glucocorticoids like medrol or prednisone, it may have more of an impact. It takes many years to discover post marketing information on these sophisicated drugs. Sometimes decades!

Thanks everyone for your responses.

Stacy I'm not going to start any supplements until I can see my GP and get a script for blood work. I want to have a baseline.

Dr. Smith I just thought the look on the dogs face was really funny! I know what you mean by none of your doctors bringing up the connection to you. I was just thinking this morning that doctors of different specialities should work in one office and share each patients information. Think of all the time it would save people like us. They need to focus on the whole person not just their piece of the puzzle.

Mrs. D. That is interesting. Who knows maybe their will be a way to stop the destruction of bone.

I left a message for my rheumatologist today. I emailed my neurologist last night. He said it is concerning but not something he works on to call rheumo. I'm hoping he calls soon. I need to speak with him about this.

Thanks again to all of you. Don't know what I'd do without the people on this site! You are all angels!!!

Hi Hopeful, that is a good idea. It is nice to have a doctor one can comunicate with in modern technology. ( that way a patient do not have to wait weeks on end and pay costly fee for frequent visits)

Dr. Smith: I too, thought the big picture of the dog, and it's expression was halerious. I interpreted it in this way: as if the dog was saying " yes, I know!!!! All the things we have to go through!!

and I thought it fit you for a comment like that, due to all the "stuff" you have to deal with.

To be more serious. I think that a lot of doctors in general out and around in the medical community, do not know a lot about neuropathy, let alone it's causes.
And it is actualy dangerous, because diagnosis and treatment can be delayed.

I can still remember the day I went to this particular neurologist in my search for answers, and the doctor said" I have never in my 30 years of practice heard of such a symptom you are describing" I was trying to explain the very unpleasant experience/symptom of sensory nerves , the ever so active small fiber nerves constantly "vibrating in my tissue.

The next neurologist thought I was anxious ( who wound not be??!! after trying to get relief from this discusting condition) and he did not find any sign of neuropathy.

I was referrfed by ny own regular neurologist ( he is actually an interventional neurologist who embolized fixed my brain aneurysm) to a specialist in neuropathy at the medical school at a university. He has become my local guy, but he refers me out. He has now also refered me to another neurosurgeon regarding something else.

It was my rheumatologist that has diagnosed again the inflamatory arthiritis. She says now that it has presented with a furious polyneuropathy and small fiber neuropathy. She is treating the joint inflamations and the vasculitis with immunosupressive and the neuropathy symptoms with other meds like Lyrica and Amitripthyline.
I have had degenerative discss and cervical spondylosis in my cervical for 10 - 12 years, and have had flares of radiculopathy on and off. needed Medrol dose pack treatment sometimes. Pins and needles and numbness. BUT, ALL THESE YEARS, we did not think in the terms like "NEUROPATHY"

Dr. Smith, it was not until I was lucky to find this good young rheumatologist that is realy smart, that I was told the connection between arthritis and neuropathy. She is on that treat the patient, not the blood tests. She does hundreds of blood tests, a lot negative. But I have plenty symptoms and I have plenty positive diagnostic tests like MRI, X RAY EMG NCS, Skin biopsy, POsitive GI tests for autonomic neuropathy

I can not remember where I read it but I did resd: A lot of entrapment neuropathy can be caused by arthritis and possibly also osteoporosis??

This was just my thoughts, and I know I am rambeling Sorry

Dear Doc,

That was cute. Is that a photo of your dog? Gorgeous dog. I am a HUGE dog lover, especially of the larger breeds.

Thanks,
Hopeless

Syvonne,
I'm surprised to hear you say read you red that nerve entrapment caused by osteoporosis may cause neuropathy. I wish I had seen that. When I spoke to my neurologist today he said osteoporosis doesn't have any connection to neuropathy. Go figure!!

I think so many things are connected and the doctors have not discovered a lot of this yet. They are only currently at the tip of this iceberg.

True. A couple of our doctors have told us that doctors (in general) typically hear ~25% of what patients tell them; not because they're inattentive or ambivalent, but because they're thinking—going over things in their minds from their training or experience. IOW, they're absorbed in thought.

Similarly, patients typically hear ~50% of what doctors tell them due to anxiety, pain/symptoms, other distractions.

Good reasons to:

1.) Make/Take a list of points to make/cover; make sure the doctor hears/absorbs/comprehends what you want her/him to, and

2.) Take notes or bring someone to pick up on what may be missed.

Doc

I agree, but I don't think it'll happen. I'd be delighted if they'd just talk to/communicate with each other about us beyond sending reports back & forth. Maybe it's a game of CYA. :Dunno: I'll be very surprised if/when it ever does happen.

Doc

We must have vastly different doctors, because almost all of mine—including the neuropathy specialists at the medical center—have freely admitted that they don't know much about neuropathy.

Some have said they do learn things from savvy patients who do their own research (that the doctors don't have time to do), while others (the institutional variety) have tunnel vision, and can't/won't admit/acknowledge anything that isn't endorsed/blessed by the institution (like the medical center specialist who dismissed RLA because, "I read they're doing something with it in Europe, BUT... yadda, yadda, yadda..."

Relax—I can ramble with the best of 'em! ;) :D

Doc

Nope. Just a funny pic I came across. I was going to link to a clip af Arte Johnson saying, "Verry interesting..." but it seemed a bit tired.

Doc

Just a few quickie points--
 

It's certainly possible for osteoarthritis, through shifting of bone position and compression on nerves, to cause neuropathies, or to exacerbate existing ones. In fact, much of what is termed radiculopathy--neuropathies of the spinal nerve roots--would be caused by osteoarthritis in the spine overgrowing the spinal foramen, the openings the nerve roots pass through as they exit the spine (look, on imaging reports, for terms like "hypertrophy" or uncinate process"). This type of neuropathy is usually confined to the dermatome of the affected nerve roots, though, and would feel "different" from a more diffuse neuropathy.

Now, rheumatoid arthritis is certainly associated with neuropathy (as, indeed, are all the vascultic/connective tissue autoimmune conditions), but this is much more likely to be inflammatory in nature or due to blood vessel compromise. I suppose, though, with sufficient inflammatory swelling nerves might also be mechanically compressed.

See:

http://neuromuscular.wustl.edu/antib...max.html#rheum

http://neuromuscular.wustl.edu/antib...html#vascassoc

:Hum: I must be of the very few who hear what the doctor is saying. I know much more about my problem than any GP so I try to educate them some but not that much as they probably will never see another patient with what I have and they don't have time anyway. Besides they are busy keying in anything else and not really listening. If they do see someone else with my problem, they would not know it. :Noooo: And they surely do not have much time nowadays with a patient. :(

In saying that, a neurologist who knows CMT very well is great to have. :) They can understand the problem.

Hi everyone.
I went to my rheumo today. We spoke about the osteoporosis and cymbalta ( Mrs D I took the research you sent me) turned out he did know about this s/e.

He said I need to come off,the cymbalta. I spoke with him about trying Wellbutrin (also info from this site). He agreed.

I have to taper off the cymbalta within the next two weeks then start the Wellbutrin. Needless to say, I am nervous about the withdraw from cymbalta. My doctor didn't seem to think it should be any problem. I take 90 mgs now and he wants me to decrease it by 30 every couple of days.

I will start the Wellbutrin after I'm finished tapering off the cymbalta.

Has anyone come off of cymbalta before? The articles on line make it seem awful.

Hopeful;
I wish you all the best in switching these medications.
Symbalta was once prescribed for me by my PCP, that is when I was on Neurontin for neuropatht. He said the combination of the two would work. I only took one pill, and I got so sick for the rest of the day with nausea etc.

Hope you get to the right combination treatment that work for you.
Synnove

Glenntaj,
I read your post in this thread with interest. I have printed out your link and studied it. Think I have seen it before too.

Do you have any comments on the use of Rituxan for the treatment of Rheumatoid arthritis/vasculitis/and neuropathy.??

Thanks
Synnove

Please don't shoot yourself in the foot—that's not "hopeful"! ;)

IF you encounter problems, you have a support network here that will do their best to help you through it.

BUT it's no biggie, and you're going to come through it fine, RIGHT? ;)

Doc

Your so right Dr. Smith. No sense in worrying! I do have a wonderful support system here.

I was wondering though, I dropped my cymbalta by 30 mgs today and I am really jittery. My nursing head says that can't be possible my blood levels could not have come down yet.

Am I right? Maybe I drank more caffine than usual.( I know I'm not suppose to drink caffeine I was trying to clean up my house and needed it)!

Duloxetine (Cymbalta) has a half life around 12 hrs (8-17). Does that fit the time frame? If not, it was probably the caffeine, or maybe the two in... combination(?) (that's not the word I'm searching for, but it gets the idea across).

Doc

Yes it does fit the time frame. I was on a high dose of 90mgs. I went to 60 mgs yesterday. That was 24 hours after my last dose of 90 mgs. Today I stayed on the 60 mgs. I was suppose to go out with people I use to work with today. I had to cancel. I feel really exhausted and sick at my stomach.

I was also up a lot last night in pain but that happens to me at times. I'm hoping it is just a fluke that this happening at the same time I'm tapering off cymbalta.

What also happens with SSRI type drugs, is that they change the production and metabolism of serotonin.

When the cell senses the serotonin still in the synapse, the serotonin in the cell declines, as it is not needed.

When you go off the drugs it takes time for the cells to reactivate the synthesis of the needed serotonin under the new conditions of how the synapse works normally.

Taking some l-tryptophan is sometimes helpful in tapers, off SSRIs.. some doctors use it now. Mark on the TBI forum used it to get off long term high dose Paxil.

But early in a taper, it is best not to use l-tryptophan. This amino acid is the precursor to serotonin manufacture using B6 and magnesium as cofactors.

I think 2 day tapers off of the high dose Cymbalta, is way too fast. Most people would have adjustment problems at that schedule. Near the end of the taper, using the tryptophan may be helpful. You can search online "tryptophan SSRI withdrawal" and read what others have used. Some suggest 5-HTP, but I don't like that, as it is basically a drug, and can be harsh. The tryptophan is more natural and slower.

Hi Mrs. D.
When you wrote two days tapering off high dose cymbalta is too fast. Did you mean too soon for side effects or too much to lower my dose by?

I don't think there is really any other way to lower it. I was taking 1 60 mg and 1 30 mg. now I'm taking 60 mgs. Then the doctor told me go to 30 one and 60 the next. The to to 30 for a few days and stop. He said I should be done in a week and a half to two weeks.
What do u think?
As always thanks for your advice!

My wife just came off citalopram (Celexa) and she's been snarfing meclizine (same as Dramamine Less Drowsy, but stronger) daily. That's just about over too. If this continues, you might call your doctor about this, s/he may be able to prescribe some & call it in to your pharmacy.

Doc

Well I thought I saw in your last post that he wanted you do go down 30mg every 2 days? I thought that was way too fast.

Depending on how long you were on them.... the withdrawal may be different. Also some people seem more likely to have problems than others. So this variability seems to make tapers more difficult.

I'd say at least 7 days on each new dose. It is unfortunate that the capsules are not made for this eventuality... Lilly is known for putting capsule only for drugs that may cause problems coming in contact with the mucus membranes of the mouth and throat. Strattera by Lilly, has to be in a capsule because the drug itself is irritating.

Some people open the 30mg Cymbalta and put 1/2 the capsule contents in a empty capsule to get the taper lower than 30mg... down to 15. It is at the very end where most of the undesireable symptoms occur.

Here is one example of Cymbala taper:
http://www.health.harvard.edu/newsle...antidepressant

If you Google "Cymbalta taper" you'll find more.

Hi Mrs. D.,
I am going to lower my dose once a week as the Harvard chart suggest. As I said my doctor suggested I taper off in a two week period.

You had said the symptoms don't usually appear until the end of tapering. If that is the case I'm going with having a stomach virus. I had to cancel my IVIG today because I'm so nauseous I was afraid I would vomit during it. I'm also so exhausted. I rescheduled for tomorrow. Hopefully, I'll feel better!

Would it be useful after the taper is complete? DW has been off of citalopram for a couple weeks now (taper wasn't off that high a dose, and stepped down a week at a time). At first, as previously mentioned, the nausea & motion sickness were the nemesis, and meclizine helped. Now that that's over, there are severe incapacitating emotional swings.

I've been reading the suggested, but they seem to be talking about taking the l-tryptophan during the taper, as opposed to after.

Also, this article gets cited more than once
http://www.supplements-and-health.co...e-effects.html

Doc

Yes, I think the tryptophan might be very helpful, for even weeks or months after. It requires the cofactors of B6 and magnesium.

B-right by Jarrow has a moderate dose or she could get the P5P, from NOW and use one a day.

Some people get insomnia after SSRIs...because they are not making serotonin properly yet. Serotonin is the precursor for melatonin . So using melatonin for a while might help. Methylcobalamin the cofactor for the conversion of serotonin to melatonin.

Is this trading dependencies? Eventual taper off the tryptophan?

Doc

No there should be no dependency.... tryptophan is in food too.

It just boosts synthesis in the direction of serotonin. Tryptophan has trouble getting into the brain, as other amino acids compete with it. So it is best to take alone away from protein meals.

Precursors are controlled by enzymes, cofactors in synthesis.
There are checks and balances in the body, to only do what is needed. But if enough tryptophan is scarce, less serotonin will be made in the brain.

There should be no let down, unless your wife has some genetic problem with amino acids etc.

5HTP however is only one step away from serotonin, and could give a mild withdrawal. This is why I prefer tryptophan over 5HTP.

Tryptophan is mildly sedating at least for me, so I took it at night.