Osteoporosis diuretics

Thiazide diuretics decrease urinary calcium excretion and may decrease bone turnover. However, their effects on bone mineral density and fracture rates have not been studied in controlled trials. Thiazide diuretics are not recommended solely for potential beneficial effects in osteoporosis. 

Prescribing thiazide diuretics solely for osteoporosis is not recommended but is a reasonable choice for patients with osteoporosis who require a diuretic and for patients on glucocorticoids with a 24-hour urinary calcium excretion >300 mg. 

Uses Chronic asthma Actions Topical steroid Dose Two inhalations tid-qid or 4 inhal bid Caution [C, ] Contra Component aU gy Disp Met-dose inhaler SE Cough, oral candidiasis Interactions T Risk of GI bleed W/ ASA, NSAIDs T effects W/ sakneterol, troleandomycin -1- effects W/barbiturates, hydantoins, pheny-toin, rifampin T effects OF diuretics, insulin, oral hypoglycemics, K supl, salicylates, somatrem, live virus vaccines EMS May affect glucose(hyperglycemia) monitor ECG for hypokalemia (flattened T waves) concurrent ASA/NSAID use may t risk of GI bleeding OD Acute OD unlikely to cause life-threatening Sxs, chronic OD may lead to S/Sxs of muscle weakness, and osteoporosis symptomatic and supportive... 

Use with caution in older patients with Hepatic impairment Patients taking diuretics, NSAIDs or with nephropathy Sinus node dysfunction or Heart block, Osteoporosis, Unsteady gait, Urinary incontinence... 

The primary roles and the recommended daily intake of major and trace minerals are listed in Table 38-3. Similar to vitamins, these minerals are typically obtained from dietary sources. Specific minerals may likewise be included in various multivitamins and other dietary supplements, with the intent that these minerals will promote good health and prevent disease. Again, there is generally no need for mineral supplements for most people eating a reasonably balanced diet. On the other hand, mineral supplements can be helpful in specific situations where the body s need for a mineral may exceed dietary supply. Some examples of appropriate supplementation include calcium supplements for people with osteoporosis (see Chapter 31), potassium supplements for people on diuretics (see Chapter 21), and iron supplements for people with certain anemias. Hence, mineral supplements may be helpful in certain individuals, but the dose and type of supplement should be adjusted carefully. 

The American Cancer Society states that there does not seem to be any relationship between caffeine and cancer. However, other adverse effects for women remain a concern, such as the possibility that large amounts of caffeine could contribute to osteoporosis (thinned and fragile bones), particularly in elderly women. As caffeine is a diuretic, which increases loss of fluids and electrolytes in the urine, it could rob the body of calcium. Nevertheless, a study published in 2001 concluded that the net effect of carbonated sodas on the body s calcium is negligible, and that the loss of calcium in urine due to carbonated drinks is too small to affect calcium balance. 

Several studies have shown that thiazide diuretics prevent calcium loss in bones, which may improve bone density and protect against osteoporosis. Preliminary research also suggests that diuretics are helpful in preventing stroke. Lurther studies are needed to confirm these findings. 

Locomotor Beta-blockers, diuretics, Fatigue, gout, osteoporosis,... 

Glucocorticoid treatment for arthritis or other ailments can very quickly produce a form of osteoporosis caused by the inhibition of bone formation [334]. In such cases, the decrease in bone mass may be as much as 10-20%, but examination of trabecular bone reveals a much greater (30-40%) decrease in this component of bone [335]. Combination therapies with vitamin D and bisphosphonates, calcitonin or fluoride can be effective [336]. Therapy employing vitamin D or 1,25-(OH)2D3, the latter being highly calcaemic, should also include serum calcium monitoring and the use of thiazide diuretics as appropriate. 

Metabolic changes over a long period may induce disease, e.g. thiazide diuretics (diabetes meUitus), adrenocortical hormones (osteoporosis), phenytoin (osteomalacia). Drugs may also enhance their own metabolism, and that of other drugs (enz5mie induction). 

Drinka PJ, Nolten WE. Hazards of treating osteoporosis and hypertension concurrently with calcium, vitamin D, and distal diuretics. J Am Geriatr Soc 1984 32(5) 405-7. 

B Unlike other diuretics, furosemide at high infusion rates is associated with ototoxicity. Ototoxicity may occur with all loop diuretics, but the frequency is less with bumetanide and it has not been reported with torsemide. In addition, hypocalcemia is a side effect also experienced with loop diuretics and not with thiazide diuretics. In contrast, hydrochlorothiazide decreases urinary excretion of calcium, which may result in an elevation of serum calcium levels. Thus, thiazide diuretics may potentially reduce the risk of osteoporosis and be beneficial in postmenopausal women. 

Women receive the same benefits from antihypertensive therapy as men. However, ACE inhibitors and ARBs are contraindicated in women who intend to become pregnant because they are teratogenic. Thiazide diuretics may be especially beneficial in postmenopausal women with osteoporosis because they cause retention of calcium and have been shown to positively affect bone mineral density. Women tend to have higher rates of drug-related adverse effects than men. 

Thiazide diuretics increase urinary calcium resorption. A 10-year retrospective study of 83,728 women demonstrated fewer fractures among patients currently taking thiazides." A prospective trial demonstrated maintenance of BMD at the spine and hip over a 3-year period with low-dose hydrochlorothiazide, with a greater effect seen in women." Prescribing thiazide diuretics solely for osteoporosis is not recommended, but is a reasonable choice for the patient with osteoporosis who requires a diuretic. 

A diet with sufficient potassium can reduce the risk of stroke, slow the progress of kidney disease, and control blood pressure. Americans consume on average 30-40 percent less potassium than has been the norm for the human race over the course of its history. The behavior is attributable to the lowered consumption of fresh fruits and vegetables—a consequence of the easy availability of processed foods. The new trends in diet have produced a potassium deficiency in large segments of the population, which has in turn led to an increased incidence of hypertension, cardiovascular disease, kidney failure, diabetes, arthritis, and osteoporosis. The use of diuretics, laxatives, and steroids also contributes to a deficiency, as too much potassium can be flushed out of the body. 

Thiazide diuretics, which reduce urinary excretion of Ca, sometimes are employed to treat calcium nephrolithiasis and may be useful for the treatment of osteoporosis see Chapter 61). Thiazide diuretics also are a mainstay for treatment of nephrogenic diabetes insipidus, reducing urine volume by up to 50%. The mechanism of this paradoxical effect remains unknown. Since other hahdes are excreted by renal processes similar to those for Cl", thiazide diuretics may be useful for the management of Br" intoxication. 

ADVERSE EFFECTS AND PRECAUTIONS Adverse effects of diuretics see Chapter 28) determine tolerance and adherence. Erectile dysfunction is a troublesome adverse effect of thiazide diuretics physicians should inquire specifically regarding its occurrence. Albeit uncommon, gout may be a consequence of the hyperuricemia induced by these diuretics. Either of these adverse effects is reason to consider alternative therapies. Hydrochlorothiazide may cause rapidly developing, severe hyponatremia in some patients. Thiazides inhibit renal Ca " excretion, occasionally leading to hypercalcemia although generally mUd, this can be more severe in patients subject to hypercalcemia, such as those with primary hyperparathyroidism. The thiazide-induced decreased Ca excretion may be used therapeutically in patients with osteoporosis or hypercalciuiia. 

Following initiation of anti hypertensive therapy with thiazide diuretics, transient hypercalcemia has been seen in over one-third of patients (87). Two percent of patients receiving long-term thiazide diuretics administration had persistent hypercalcemia (68). In the elderly (especially women), combined administration of thiazides with vitamin 0 supplements (for osteoporosis) can have synergistic effects on the elevation of serum calcium levels resulting in severe hypercalcemia (69). Similarly, if the patient is predisposed to hypercalcemia (IHPT, 2HPT or immobilization), thiazides can precipitate significant and sustained hypercalcemia (68,70). 

Tolerance to the diuretic action of caffeine was demonstrated more than 50 years ago and was shown to develop on chronic caffeine intake so that the clinical significance of hypokalemia and calciuria is difficult to evaluate. Although controversial, some epidemiological studies have implicated caffeine in the increased risk for poor calcium retention. For calcium intakes lower than 750 mg per day, increased rate of bone loss and lower bone density were reported. However, it has been suggested that the effect on bone of high caffeine intake requires a genetic predisposition toward osteoporosis. In individuals who ingest calcium recommended daily allowances, there is no evidence of any effect of caffeine on bone status and calcium economy. 

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