Osteoporosis Prevention

Prevention of Osteoporosis :

Osteoporosis, characterized by low bone mineral density, is common and associated with an increased risk of fracture. The lifetime risk of an osteoporotic fracture is approximately 50% for women and 30% for men. Osteoporotic fractures can cause significant pain and disability. As such, research has focused on means of preventing osteoporosis and related fractures. Primary prevention strategies include calcium supplementation, vitamin D supplementation, and exercise programs. A recent systematic review and meta-analysis found that calcium supplementation of 1200 mg per day or more (with or without vitamin D) could decrease fracture risk for adults (mainly women were studied) over age 50. Screening for osteoporosis on the basis of low bone mineral density is also recommended for women over age 60, based on indirect evidence that screening can identify women with low bone mineral density and that treatment of women with low bone density with bisphosphonates is effective in reducing fractures. The effectiveness of screening for osteoporosis in younger women and in men has not been established. In addition, real-world adherence to pharmacologic therapy for osteoporosis is low: one-third to one-half of patients do not take their medication as directed. Vitamin D deficiency is common and can increase the risk of fracture. Screening to detect vitamin D deficiency in older adults has been proposed, but has not yet been rigorously evaluated.

Chemoprevention

Chemo :
As discussed in Heart Disease and Nervous System Disorders, regular use of low-dose aspirin (81–325 mg) can reduce the incidence of myocardial infarction in men. Low-dose aspirin reduces stroke but not myocardial infarction in middle-aged women. Based on its ability to prevent cardiovascular events, aspirin use is cost-effective for men and women who are at increased risk. Nonsteroidal anti-inflammatory drugs may reduce the incidence of colorectal adenomas and polyps but may also increase heart disease and gastrointestinal bleeding, and thus are not recommended for colon cancer prevention in average risk patients. Antioxidant vitamin (vitamin E, vitamin C, and beta-carotene) supplementation produced no significant reductions in the 5-year incidence of—or mortality from—vascular disease, cancer, or other major outcomes in high-risk individuals with coronary artery disease, other occlusive arterial disease, or diabetes mellitus.

Smoking Treatments

Smoking Treatment :

Smoking Treatments.

Component Examples Encouragement of the patient in the quit attempt Note that effective cessation treatments are now available. Note that half the people who have ever smoked have now quit.   Communicate belief in the patient's ability to quit. Communication of caring and concern Ask how the patient feels about quitting. Directly express concern and a willingness to help. Be open to the patient's expression of fears of quitting, difficulties experienced, and ambivalent feelings. Encouragement of the patient to talk about the quitting process Ask about   Reasons that the patient wants to quit.   Difficulties encountered while quitting.   Success the patient has achieved.   Concerns or worries about quitting. Provision of basic information about smoking and successful quitting Inform the patient about   The nature and time course of withdrawal.   The addictive nature of smoking.   The fact that any smoking (even a single puff) increases the likelihood of full relapse.

Clinical Guidelines For Prescribing Nicotine Replacement Products.

1. Who should receive nicotine replacement therapy?    Available research shows that nicotine replacement therapy generally increases rates of smoking cessation. Therefore, except in special circumstances, the clinician should encourage the use of nicotine replacement with patients who smoke. Little research is available on the use of nicotine replacement with light smokers (ie, those smoking 10–15 cigarettes/d). If nicotine replacement is to be used with light smokers, a lower starting dose of the nicotine patch or nicotine gum should be considered. 2. Should nicotine replacement therapy be tailored to the individual smoker?    Research does not support the tailoring of nicotine patch therapy (except with light smokers as noted above). Patients should be prescribed the patch dosages outlined in Table .   Research supports tailoring nicotine gum treatment. Specifically, research suggests that 4-mg gum rather than 2-mg gum be used with patients who are highly dependent on nicotine (eg, those smoking > 20 cigarettes/d, those who smoke immediately upon awakening, and those who report histories of severe nicotine withdrawal symptoms). Clinicians may also recommend the higher gum dose if patients request it or have failed to quit using the 2-mg gum.

Suggestions For The Clinical Use Of The Nicotine Patch.

Parameter of Clinical Use Suggestions Patient selection Appropriate as a primary pharmacotherapy for smoking cessation. Precautions Pregnancy: Pregnant smokers should first be encouraged to attempt cessation without pharmacologic treatment. The nicotine patch should be used during pregnancy only if the increased likelihood of smoking cessation, with its potential benefits, outweighs the risk of nicotine replacement and potential concomitant smoking. Similar factors should be considered in lactating women. Cardiovascular diseases: While not an independent risk factor for acute myocardial events, the nicotine patch should be used only after consideration of risks and benefits among particular cardiovascular patient groups: those in the immediate (within 2 weeks) post-myocardial infarction period, those with serious arrhythmias, and those with severe or worsening angina pectoris. Skin reactions: Up to 50% of patients using the nicotine patch will have a local skin reaction. Skin reactions are usually mild and self-limiting but may worsen over the course of therapy. Local treatment with hydrocortisone cream (2.5%) or triamcinolone cream (0.5%) and rotating patch sites may ameliorate such local reactions. In fewer than 5% of patients do such reactions require the discontinuation of nicotine patch treatment. Dosage1   Treatment of 8 weeks or less has been shown to be as efficacious as longer treatment periods. Based on this finding, we suggest the following treatment schedules as reasonable for most smokers. Clinicians should consult the package insert for other treatment suggestions. Finally, clinicians should consider individualizing treatment based on specific patient characteristics such as previous experience with the patch, number of cigarettes smoked, and degree of addiction. Brand  Duration (weeks)  Dosage (mg/h)  Nicoderm and Habitrol 4 21/24 then 2 14/24 then 2 7/24 Prostep 4 22/24 then 4 11/24 Nicotrol 4 15/16 then 2 10/16 then 2 5/16 Prescribing instructions Abstinence from smoking: The patient should refrain from smoking while using the patch.   Location: At the start of each day, the patient should place a new patch on a relatively hairless location between the neck and the waist.  Activities: There are no restrictions while using the patch.  Time: Patches should be applied as soon as patients awaken on their quit day.

Suggestions For The Clinical Use Of Nicotine Gum.

Parameter of Clinical Use Suggestions Patient selection Appropriate as a primary pharmacotherapy for smoking cessation. Precautions Pregnancy: Pregnant smokers should first be encouraged to attempt cessation without pharmacologic treatment. Nicotine gum should be used during pregnancy only if the increased likelihood of smoking cessation, with its potential benefits, outweighs the risk of nicotine replacement and potential concomitant smoking. Cardiovascular diseases: Although not an independent risk factor for acute myocardial events, nicotine gum should be used only after consideration of risks and benefits among particular cardiovascular patient groups: those in the immediate (within 2 weeks) post-myocardial infarction period, those with serious arrhythmias, and those with serious or worsening angina pectoris. Adverse effects: Common adverse effects of nicotine chewing gum include mouth soreness, hiccups, dyspepsia, and jaw ache. These effects are generally mild and transient and can often be alleviated by correcting the patient's chewing technique (see "Prescribing instructions" below). Dosage Dosage: Nicotine gum is available in doses of 2 mg and 4 mg per piece. Patients who smoke less than 25 cigarettes per day should be prescribed the 2-mg gum initially. The 4-mg gum should be prescribed to patients who express a preference for it, have failed with the 2-mg gum but remain motivated to quit, and/or smoke more than 25 cigarettes per day. The gum is most commonly prescribed for the first few months of a quit attempt. Clinicians should tailor the duration of therapy to fit the needs of each patient. Patients using the 2-mg strength should use not more than 30 pieces per day, whereas those using the 4-mg strength should not exceed 20 pieces per day.  Prescribing instructions Abstinence from smoking: The patient should refrain from smoking while using the gum.   Chewing technique: The gum should be chewed slowly until a "peppery" taste emerges, then "parked" between cheek and gum to facilitate nicotine absorption through the oral mucosa. Gum should be slowly and intermittently chewed and parked for about 30 minutes. Absorption: Acidic beverages (eg, coffee, juices, soft drinks) interfere with the buccal absorption of nicotine, so eating and drinking anything except water should be avoided for 15 minutes before and during chewing. Scheduling of dose: A common problem is that patients do not use enough gum to get the maximum benefit: they chew too few pieces per day and do not use the gum for a sufficient number of weeks. Instructions to chew the gum on a fixed schedule (at least 1 piece every 1 to 2 hours) for at least 1 to 3 months may be more beneficial than ad lib use.

Suggestions For The Clinical Use Of Bupropion SR.

Parameter of Clinical Use Suggestions Patient selection Appropriate as a first-line pharmacotherapy for smoking cessation. Precautions Pregnancy: Pregnant smokers should be encouraged to quit first without pharmacologic treatment. Bupropion SR should be used during pregnancy only if the increased likelihood of smoking abstinence, with its potential benefits, outweighs the risk of bupropion SR treatment and potential concomitant smoking. Similar factors should be considered in lactating women (FDA Class B). Cardiovascular diseases: Generally well tolerated; infrequent reports of hypertension.  Side effects: The most common side effects reported by bupropion SR users were insomnia (35–40%) and dry mouth (10%). Contraindications: Bupropion SR is contraindicated in individuals with a history of seizure disorder, a history of an eating disorder, who are using another form of bupropion (Wellbutrin or Wellbutrin SR), or who have used an MAO inhibitor in the past 14 days. Dosage Patients should begin with a dose of 150 mg every morning for 3 days, then increase to 150 mg twice daily. Dosing at 150 mg twice daily should continue for 7–12 weeks following the quit date. Unlike nicotine replacement products, patients should begin bupropion SR treatment 1–2 weeks before they quit smoking. For maintenance therapy, consider bupropion SR 150 mg twice daily for up to 6 months. Prescribing instructions Cessation prior to quit date: Recognize that some patients will lose their desire to smoke prior to their quit date, or will spontaneously reduce the amount they smoke.  Scheduling of dose: If insomnia is marked, taking the evening dose earlier (in the afternoon, at least 8 hours after the first dose) may provide some relief.  Alcohol: Use alcohol only in moderation.