Super summary: What are the drugs that cause osteoporosis?

*It is only for medical professionals to read and refer to the fifteen categories of drugs that cause damage to bones.

In the previous tweet, I introduced the osteoporosis caused by warfarin, and some friends left a message in the background to ask: In addition to warfarin, what other drugs can cause osteoporosis? Drug induced bone loss (Drug induced Bone Loss) is often ignored by us.

In addition to the well-known glucocorticoids as the main cause of osteoporosis, some other drugs may also cause damage to bones.

01.
Glucocorticoid Glucocorticoid therapy is the main cause of drug-induced osteoporosis.

The use of glucocorticoids can cause a significant risk of bone loss, especially in the first few months of medication.

For elderly men, postmenopausal women, people with a low body mass, a history of falls, fractures, or smoking, the incidence of fractures using glucocorticoids increases.

Generally speaking, when 2.
5-7.
5 mg/d prednisone or equivalent treatment is used, the risk of fracture can increase.

Patients who take 7.
5 mg or more of prednisone a day have a 5-fold increase in fracture risk.
For at least 3 months, patients who take prednisone 10 mg or more a day have a 7-fold to 17-fold increase in fracture risk.

Therefore, all patients receiving glucocorticoid therapy (any dose, and the expected course of treatment is 23 months) should maintain a total calcium intake of 1000-1200 mg/d and a vitamin 600-800 U/d through diet and/or supplements D intake.

02.
Aromatase inhibitors Aromatase inhibitors can reduce the concentration of estrogen in the circulation, thereby increasing bone loss, reducing bone density, and increasing the risk of fractures.

There are two types of aromatase inhibitors, one is non-steroidal drugs such as anastrozole and letrozole; the other is steroidal drugs such as emracetam.

The study found that breast cancer patients with bone mineral density T value less than -2.
0 can still be treated with aromatase inhibitors.
It is recommended to supplement calcium + vitamin D at the same time, regularly assess the risk of fractures, and use zoledronic acid under the guidance of a doctor.
, Bisphosphonates and other drugs have a protective effect on bones.

03.
Gonadotropin releasing hormone agonist, gonadotropin has a powerful effect on bones.

During puberty, the increase in gonadal hormones stimulates the activity of osteoblasts, leading to a significant increase in bone density.

For people treated with gonadotropin-releasing hormone agonists (such as gonarelin, goserelin), the drug suppresses estrogen levels, increases bone resorption and causes rapid bone loss.

In premenopausal women receiving gonadotropin releasing hormone agonists, zoledronic acid can be used to prevent bone loss.

04.
A small dose of medroxyprogesterone (5-10mg/d) combined with estrogen will not affect the ability of estrogen to prevent bone loss.

But if you use its long-acting contraception (injection once every 3 months), it is recommended to use medroxyprogesterone to supplement enough calcium and vitamin D at the same time.

In addition, the patient should change his life>
The use of bisphosphonates or other drugs is not currently recommended.

05.
Anti-androgen drugs Anti-androgen drugs (such as flutamide, bicalutamide, nilutamide) can cause osteoporosis and/or the risk of fractures due to lower testosterone levels.

For long-term treatment patients, it is recommended to supplement the intake of calcium and vitamin D.
If necessary, oral alendronate or intravenous zoledronic acid can be used to increase bone mass.

06.
Anti-epileptic drugs Long-term anti-epileptic treatment is associated with low bone density and increased fractures.

Most antiepileptic drugs (such as phenobarbital, phenytoin, carbamazepine, primidone) can increase the activity of P450 enzymes, promote the catabolism of vitamin D into inactive metabolites, and increase bone calcium mobilization and bone turnover.

It is currently recommended to supplement calcium and vitamin D for patients taking antiepileptic drugs.

07.
Antidepressants Tricyclic antidepressants and selective serotonin reuptake inhibitors (such as fluoxetine, paroxetine, sertraline, fluvoxamine, and citalopram) are all associated with an increased risk of fragility fractures.

Selective serotonin reuptake inhibitors accelerate bone loss in postmenopausal women in a dose-dependent manner.

Prescribing antidepressants for postmenopausal women should take into account that they may increase the risk of osteoporosis.

08.
Warfarin & Heparin Warfarin: Warfarin can antagonize vitamin K and inhibit the γ-carboxylation of osteocalcin.
Uncarboxylated osteocalcin cannot effectively combine with calcium to reduce bone calcium deposition.
Inhibit bone mineralization, leading to osteoporosis or fractures, especially for elderly patients.

However, there is currently no recommended specific treatment for bones for patients receiving warfarin.

Heparin: Heparin is generally used to prevent thrombosis after surgery.
It can reduce bone formation and cause bone loss.

Usually short-term use will not cause changes in bone mass.

Some pregnant women may need to use heparin for a long time, and calcium supplementation should be paid attention to during this period.

09.
Loop diuretics Loop diuretics (such as furosemide, torasemide) are often used to improve the symptoms of patients with edema and heart failure.

It inhibits the absorption of calcium ions by inhibiting the reabsorption of sodium ions and chloride ions, causing an imbalance in the metabolism of sodium, potassium, and calcium ions in the body, resulting in excessive calcium loss.

Osteoporosis caused by it often affects the whole body, especially non-spine parts such as the marrow.

If you have leg cramps during the use, you should pay attention to it.

Studies have found that appropriate calcium supplementation (daily intake of 1000 mg) and vitamin D can reduce the incidence of fractures.

10.
Antiviral drugs such as ritonavir and indinavir are used for antiretroviral infections.

The proportion of patients who use this type of osteoporosis is much higher than that of those who have not used the drug.
In addition, the increase in cytokine levels caused by chronic malnutrition and chronic infection of HIV-infected patients may itself cause osteoporosis. It is recommended that men and women over 50 years of age with HIV infection be screened for osteoporosis on a regular basis.

11.
Calcineurin inhibitors Calcineurin inhibitors (such as tacrolimus) induced bone loss and fragility fractures in transplant patients depend on the dose and duration, underlying disease and age.

Bone loss occurs in the first few months of use, and corrective treatment should be taken as soon as possible (if the T score is -2.
0 or below, calcium and vitamin D and bisphosphonates should be supplemented).

12.
Gastric mucosal protective agents, proton pump inhibitors (such as omeprazole, rabeprazole, etc.
) and antihistamine H2 receptor blockers (such as cimetidine) affect calcium absorption by reducing gastric acid secretion.

However, some poorly soluble calcium (such as calcium carbonate) requires an acidic environment for optimal absorption.

If the elderly and postmenopausal women use these two types of drugs for a long time, they need to increase the calcium in their diet, and they can also choose the easily absorbed calcium citrate instead of calcium carbonate.

13.
Chemotherapeutic drugs Some specific chemotherapeutic drugs also damage bone.
For example, long-term high-dose methotrexate can cause methotrexate bone disease.

Ifosfamide can damage the proximal tubules, leading to metabolic acidosis, renal phosphate loss, hypercalciuria, and in severe cases, it can lead to hypophosphate chondrosis.
When using these drugs, follow the doctor’s advice and pay attention to follow-up blood.
Calcium level, regular assessment of bone nutrition level.

14.
Levothyroxine Thyroid hormone and growth hormone have a synergistic effect, which can promote the growth and development of bones.

However, excessive use of thyroid hormone can cause an imbalance of calcium and phosphorus in the body, causing bone decalcification and increased bone absorption, which in turn leads to osteoporosis.

Elderly patients with osteoporosis need to take levothyroxine in combination with calcium and vitamin D supplementation, and patients at risk of fracture need to be treated with anti-bone resorption drugs.

15.
Vitamin A Insufficient or excessive intake of vitamin A may increase the risk of fractures.

Excessive vitamin A will inhibit the activity of osteoblasts and stimulate the formation of osteoclasts, leading to accelerated bone resorption and fractures.

Studies have found that women who consume more than 1500μg of vitamin A daily have a doubled risk of hip fracture.

Common food sources of vitamin A include liver, milk, egg yolks, butter, and some fruits and vegetables; people who eat a lot of these foods should not use vitamin A-containing supplements.

Summary There are also differences in the effects of the drug characteristics, the disease itself, the treatment cycle, the treatment dose and other factors on the bone.

For long-term drugs that may have adverse effects on bone quality, combined calcium and vitamin D supplementation is recommended.
However, drugs that inhibit bone resorption (such as bisphosphonates, denosumab, raloxifene, etc.
) are not recommended For patients who need to take long-term warfarin, heparin, proton pump inhibitors, medroxyprogesterone, loop diuretics, antidepressant and antiepileptic drugs.

Medical staff should reassess the need for drugs and use the lowest dose and shortest duration possible.

It is recommended that when using drugs with potentially harmful effects on bones, especially in high-risk patients, life>
References: [1] Liu Chen, Wang Yuqin: Causes, pathogenic drugs and prevention and treatment of drug-induced osteoporosis[J].
Journal of Adverse Drug Reactions, 2011.
13(6):367-372[2]https://www .
uptodate.
cn/contents/zh-Hans/antiepileptic-drugs-and-bone-disease? [3] Lancet Diabetes Endocrinol.
2018 Nov;6(11):901-910.
[4] Nguyen KD, Bagheri B, Bagheri H.
Drug-induced bone loss: a major safety concern in Europe.
Expert Opinion on Drug Safety, 2018, 17(10): 1005-1014[5] SourceResponsible Editor of Doraemon MedicineCard Scan Code Download Doctor Station App5w+Drugs are free to inquire about copyright declaration This article is reproduced, welcome to forward to the circle of friends -End-