BONE DISEASES AND JOINT PAINS



Marshall Kaplan, M.D.
Chief, Division of Gastroenterology
New England Medical Center
Boston, MA
September 9, 1999

Question
What is your opinion of Naproxin for joint pain? Are these type drugs safe for the liver?

Answer
It's ok. NSAID's are usually safe if used in moderation.

Melissa Palmer M.D.
Specialty: Gastroenterology and Hepatology
Medical advisory board of the ALF New York Chapter
ALF National Chapter Nutrition Education Subcommittee
January 2000

Question
What is the effect on someone with PBC who has an extremely low "D" level?

Answer
Vitamin D is a fat soluble vitamin which is often poorly absorbed by individuals with PBC. Vitamin D supplementation with calcium is important as patients with PBC are prone to bone problems, including bone loss, bone pain, and bone fractures. These bone disorders are often a source of great suffering and can severely disable a person. In fact, sever bone disease coupled with recurrent bone fractures in people with PBC may be an indication that liver transplantation is warranted.

Melissa Palmer M.D.
Specialty: Gastroenterology and Hepatology
Medical advisory board of the ALF New York Chapter
ALF National Chapter Nutrition Education Subcommittee
January 2000

Question
I was diagnosed with osteoporosis, and understand it is common in PBC. I was told to be careful of breaks because it will take longer for bones to heal. What are your suggestions for someone with osteoporosis. Would you discourage bouncing activities such horseback riding?

Answer
Osteoporosis (a decrease in bone quantity) is the most common bone disorder in PBC. The hip and spine are the areas of the body most commonly affected. Thus, people with osteoporosis are susceptible to hip fractures and often suffer from bad backs. Bouncing activities should be avoided. Instead it is important to strengthen bones with weight bearing exercises using light weights. This should be incorporated with an aerobic exercise. Full discussion of these topics are beyond the scope of this chat, but entire chapters are devoted to these issues - osteoporosis sand exercise, in my book. I will incorporate these issues in my website- www.liverdisease.com on the next update.

Howard Worman, M.D.
Division of Digestive and Liver Diseases
Departments of Medicine and of Anatomy and Cell Biology
College of Physicians & Surgeons
Columbia University
New York, NY 10032
April 2000

Question
Is there evidence that Motrim used for joint pain & swelling is safe for those with PBC or other liver disease? Please give an update on other current treatments for joint pain/swelling in the states.

Answer
Depending upon the reported series, between 4% and 50% of people with PBC have arthropathies (joint problems). The causes are many and include rheumatoid arthritis, psoriatic arthritis, neuropathic joint pain, polymyalgia rheumatica, CREST syndrome and mixed connective tissue diseases. In short, many different conditions can cause the joint problems in people with PBC. The appropriate treatment could be different depending upon the cause of the joint pain and swelling. I can't begin to give an update on the current treatment for joint pain and swelling, as there are literally hundreds of different available drugs. A notable recent advance is the "COX-2" inhibitors that have fewer side effects than the older anti-inflammatory drugs.

Ibuprofen (Motrin) is safe for most people with liver disease as long as it is used as directed by an experienced physician. The major side effects associated with ibuprofen and this class of drugs are on the stomach and kidneys. As with all other drugs, they should be used only as necessary and, if used for the long-term, only under the guidance of a doctor.

Howard Worman, M.D.
Division of Digestive and Liver Diseases
Departments of Medicine and of Anatomy and Cell Biology
College of Physicians & Surgeons
Columbia University
New York, NY 10032
April 2000

Question
Could you explain the difference between osteoporosis, osteomalcoa, and osteopenia. Why are so many with PBC diagnosed with these bone diseases?

Answer
Osteopenia - metabolic bone disease characterized by reduced bone mass which can result from many causes.

Osteomalacia - defective bone mineralization characterized by softening of the bones; it usually results from deficiency of vitamin D and calcium.

Osteoporosis - reduction of bone mass per unit volume with no modification in the ratio between the mineral and organic phases of the bone.

In PBC, osteopenia (reduced bone mass) is mainly due to osteoporosis. This is the same condition that causes decreased bone mass in older women. Less commonly, osteomalacia can be the cause or a contributing factor to osteopenia in PBC. The loss of bone mass in PBC is about twice as high as age and sex matched controls. The exact reasons why patients with PBC develop osteopenia are still not known. Treatment with vitamin D and calcium may slow the rate of bone loss.

Howard Worman, M.D.
Division of Digestive and Liver Diseases
Departments of Medicine and of Anatomy and Cell Biology
College of Physicians & Surgeons
Columbia University
New York, NY 10032
April 2000

Question 
What are your thoughts of a person with PBC taking Tylenol, Advil, Aleve or plain aspirin for arthritis pain.

Answer
Patients with PBC must consult with their doctors regarding the use of any medications, including over-the-counter ones. Anyone using an over-the-counter medicine must also carefully follow the directions on the label and discuss and questions with their doctors and call their doctors if symptoms persist.

Regarding these particular drugs, acetaminophen (Tylenol) is an extraordinarily safe drug when used as directed and is associated with very few side effects.

Ibuprofen (Advil) and naproxen sodium (Aleve) are also very safe when used as directed but can be associated with stomach upset, an increased incidence of gastrointestinal bleeding and in rare cases kidney problems.

Again, I strongly emphasize that patients with persistent arthritis pain should use medications only as directed by their physicians.

Dr. Nathan Bass
Professor of Medicine, Medical Director, Liver
Transplantation Program,
University of California
San Francisco
Show 2000-2001

10.) Why is it that so many with PBC have terrible bone aches and pains? Is it just PBC or all liver diseases? What do you recommend we take for the pain?

Answer
Many types of liver disease may be complicated by bone thinning, but this problem is clearly worst in PBC. The loss of mineral (calcium) from bone in PBC is the main cause of bone pain, and is most incapacitating when this leads to fractures or collapse of vertebra from the weakening of bone structure. Rarely, an inflammation of the fibrous cover of the bone may also occur (periostitis). The factors causing bone loss in PBC include postmenopausal hormone changes in women, poor absorption of calcium and vitamin D from the digestive tract, and factors that accumulate in the blood stream in cholestasis that inhibit the cells that form the bone, while there is increased activity of the cells that remodel or remove bone tissue. Other genetic factors that determine the way an individual responds to vitamin D may also play a role. The bone pain in PBC can be tremendously disabling, and fortunately, can be prevented by well-timed liver transplantation. Further bone loss should be prevented by appropriate treatment with calcium, vitamin D, hormone replacement and bone-building medications such as alendronate.

The pain should be treated with painkillers as strong as needed, but not non-steroidal anti-inflammatory drugs (e.g., Ibuprofen), as these can cause gastrointestinal bleeding in patients with portal hypertension. Some of the newer so called COX-2 selective drugs like Celebrex or Vioxx may be effective and safer, but are untested in this situation and are considered contraindicated in patients with liver disease. They, occasionally have caused serious internal bleeding. Opiate pain killers will help, but are habit forming and sedating and worsen encephalopathy. This is a difficult problem to treat satisfactorily once it has progressed to an advanced stage.

Howard Worman, M.D.
Associate Professor of Medicine and Anatomy and Cell Biology
College of Physicians and Surgeons Columbia University
July 2003

Question
Have there been any studies done on post-TX medications like Prograf and Rapamune causing Joint and Muscle Pain? Or leading to osteoporosis?

Answer
I am not aware of any studies that have specifically looked at tacrolimus (Prograf) or sirolimus (Rapamune) causing joint and muscle pain. However, in clinical trials of these drugs, patients have reported these symptoms. Osteoporosis is known to occur at an increased frequency after organ transplantation and is probably aggravated by anti-rejection medications. A few studies in laboratory animals suggest that bone loss may be faster with cyclosporine A, somewhat less with tacrolimus and even less with sirolimus. I am not aware of similar studies in human subjects but it is possible that they have been done. If you are interested in published studies, you may want to know about the National Library of Medicine resource Pub Med. You can search the medical literature using Pub Med on the Internet. The URL is:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed



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