Autoimmune rheumatic diseases are often accompanied by long-term use of high dose corticosteroids. Through the suppression of osteoblasts (bone-building cells) and an increase in bone degradation, bone loss occurs shortly after commencing treatment. Bisphosphonates (ex. Actonel, Fosamax) are one family of medications used to prevent corticosteroid-induced osteoporosis.1

Bisphosphonates exert their benefits by incorporating into new bone and slowing its degradation through the interference of osteoclastic activity. Given that these medications can reside in bone for years, even after the cessation of the medication, the long-term consequences are of interest and quite paradoxical. It has been observed that the prolonged use of bone-building bisphosphates can actually cause weaker, more brittle bones. In rare cases, this can result in atypical femur fractures and osteonecrosis of the jaw (i.e. dying and disintegrating bone of the jaw). As such, there is great controversy around the recommended duration of use for achieving and maintaining protection against fractures. With these raised concerns, the Food and Drug Administration (FDA) completed a systematic review of the long-term benefits of bisphosphonates. The results were alarming—there is little, if any benefit with use beyond three to five years. The FDA continued by saying that after three to five years of use, those with a low fracture risk, or with a near-normal bone density could probably stop taking the medication. It was stated, however, that the decision to maintain or cease treatment should be evaluated on a case-by-case basis, and at the discretion of the patient and doctor. 2

Another article published in the New England Journal of Medicine elaborated on the ideal candidates for long-term use of bisphosphonates. Black et al. concluded that the following demographics should be considered for prolonged therapy: women with a history of spinal fracture, with a current fracture, or who continue to have low bone density (i.e. T score less than -2.5) after three to five years of using bisphosphonates. Conversely, those with osteopenia (decreased bone density but not yet osteoporotic) should cease treatment after the recommended three to five years. 3

Regardless of whether bisphosphonates are applied, any course of long-term high dose corticosteroids should be accompanied by natural supportive measures for the maintenance of healthy bone mass. When possible, this should include regular weight-bearing exercise, an alkaline diet, and daily intake of calcium (1,000mg/day), vitamin D (400-800IU/day) and vitamin K2 (50-100mcg/day). Avoiding smoking and excessive consumption of alcohol is also advised.1

Bone density is of paramount concern with the use of long-term high dose corticosteroids. With that said, a well-informed and discerning patient may bend under the pressure, but will not break.

References

  1. Picado, C. & Luengo, M. (1996). Corticosteroid-induced bone loss. Prevention and management. Drug Safety, 15(5):347-59.
  2. Whitaker, M., Guo, J., Kehoe, T. & Benson, G. (2012). Bisphosphonates for Osteoporosis—Where Do We go From Here? New England Journal of Medicine, 366:2048-51.
  3. Black et al. (2012). Continuing Bisphosphonate Treatment for Osteoporosis—For Whom and for How Long? New England Journal of Medicine, 366:2051-53.

Recipe

To reduce bone loss, an alkaline diet is where to start. Fruit and vegetables are metabolized to bicarbonate, which is alkaline. So the easiest way to adjust the body’s pH is by increasing produce in your diet. The general rule of thumb is to consume 80% of your food from alkaline sources.

Once you have a handle on curbing bone loss, shift focus to increasing bone density with the following vitamins and minerals:

  • Calcium ex. Salmon, trout, sardines, sesame seeds, almonds
  • Vitamin D ex. Salmon, egg yolks
  • Vitamin K ex. Dark leafy greens, broccoli, Brussels sprouts, cauliflower, cabbage

Finally, stimulate the production of bone-building osteoblasts with these powerful phytochemicals:

  • Lycopene ex. Tomatoes, watermelon, pink grapefruit
  • Polyphenols ex. Cloves, peppermint, cocoa powder, dark berries, cherries, apples with the peel

Bone is a dynamic tissue, constantly being broken down and rebuilt—with that said, it is never too late to support the development of strong and healthy bones.

BONE-BUILDER KALE & SALMON SALAD

Servings: 4

Salad Ingredients

1 bunch Kale, stems removed
2 Tbsp Lemon juice
2 cloves Garlic, minced
2 Tbsp Extra virgin olive oil
Sea salt
2 Tbsp Avocado oil
4 Salmon fillets, skin on
½ cup Roasted almonds, crushed
¼ cup Unsweetened dried cherries or blueberries
1 Tbsp Hemp seeds (optional)

Dressing Ingredients

¼ cup Tahini
½ cup Water
1 Tbsp Lemon juice
¼ – ½ tsp Sea salt
1 clove Garlic, minced (optional)

Instructions

  1. In a large bowl, combine the kale, lemon juice, garlic, 2 Tbsp of extra virgin olive oil and ½ tsp of sea salt. Toss.
  2. In a frying pan, heat 2 Tbsp of avocado oil over high heat. Pat the salmon dry and season with a pinch of sea salt. Cook the salmon skin-side-down until nicely browned (2-3 minutes). Carefully flip the fish and cook for another 2 minutes until opaque up the sides.
  3. While the salmon is cooking, whisk together the ingredients for the dressing. Add more water as needed.
  4. Plate the kale and sprinkle with the roasted almonds, dried fruit and hemp seeds. Serve the salmon on top with a drizzle of dressing.