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Senior Citizen Health & Medicine
Antidepressants Like Prozac, Zoloft Linked to Lower
Bone Density in Senior Citizens
For many, the benefits are likely to out
weight the risks: editorial
 June 26, 2007 - The class of antidepressant
medications known as selective serotonin reuptake inhibitors, which
include the well-known drugs Prozac and Zoloft, may be associated with
an increased rate of bone loss in older men and women, according to two
articles in the June 25 issue of Archives of Internal Medicine, one of
the JAMA/Archives journals.
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Selective serotonin reuptake inhibitors (SSRIs)
treat depression by inhibiting the protein that transports serotonin, a
neurotransmitter involved in sleep and depression, according to
background information in the articles. This protein has recently been
discovered in bone as well, raising the possibility that SSRIs may
affect bone density and the risk of fracture.
SSRIs account for about 62 percent of
antidepressant prescriptions in the United States, and are often
prescribed to the elderly. (Read more from Mayo Clinic below article.)
Susan J. Diem, M.D., M.P.H., University of
Minnesota, Minneapolis, and colleagues studied 2,722 older women
(average age 78.5 years) beginning in 1997 through 1999. At that time
and again an average of 4.9 years later, researchers measured women’s
total hip bone density and also that of two subregions.
At each visit, the participants were asked to bring
in all the medications they had used within the past two weeks,
including SSRIs and tricyclic antidepressants, which work through a
different mechanism.
A total of 198 (7.3 percent) of the women were SSRI
users, 118 (4.3 percent) took tricyclic antidepressants and 2,406 (88.4
percent) took neither (those who took both were not included in the
analysis).
After the researchers adjusted for other factors
affecting bone density and antidepressant use, including depression
severity and calcium supplement use, bone mineral density at the hip
decreased 0.82 percent in SSRI users.
This compared with a decrease of 0.47 percent among
those who used tricyclic antidepressants and also in those who did not
take any antidepressants. Higher rates of bone loss were also observed
at the two hip subregions among SSRI users.
“One potential explanation for our findings is that
SSRI use may have a direct deleterious effect on bone,” the authors
write.
“This theory is supported by findings of in vitro
and in vivo laboratory investigations.”
Some data suggest that SSRIs may interfere with the
function of osteoclasts and osteoblasts, cells responsible for the
regular breaking down and rebuilding of bone in the body.
“Our findings suggest that, in this cohort, use of
SSRIs is associated with increased rates of hip bone loss,” the authors
conclude. Although some of this association may have occurred because
women who were prescribed SSRIs were different from those who were not
prescribed SSRIs, “further investigation of SSRI use and rates of change
in bone mineral density in other populations with longer follow-up is
warranted given the recent description of serotonin transporters in
bone.”
Related study looked at male senior citizens
In a related paper, Elizabeth M. Haney, M.D., of
Oregon Health & Sciences University, Portland, and colleagues conducted
a similar study with 5,995 men age 65 and older (average age 73.7). The
men’s bone density at the hip, including subregions, and at the base of
the spine were measured between 2000 and 2002. Participants were asked
to bring all medications to their clinic visit, where they were also
given a physical examination and asked about other health and lifestyle
factors.
A total of 160 (2.7 percent) men reported using
SSRIs, 99 (1.7 percent) reported using tricyclic antidepressants and 52
(0.9 percent) reported using trazodone, a third type of antidepressant.
Total hip bone mineral density was 3.9 percent
lower among SSRI users than among men who didn’t use any
antidepressants. Similarly, spine bone mineral density was 5.9 percent
lower among SSRI users than among non-users. There was no significant
difference in either hip or spine density between men who took tricyclic
antidepressants or trazodone and those who did not take antidepressants.
“These associations are biologically plausible and
clinically important,” the authors conclude.
“Because SSRI use is prevalent in the general
population, our findings have a potentially important public health
impact. If confirmed, people using SSRIs might be targeted for
osteoporosis screening and preventive intervention.”
Editorial: Physicians Must Balance Between
Treating Minds, Sparing Bones
Although these studies do not prove definitively
that SSRIs cause a reduction in bone mineral density, they do raise
concerns that physicians must consider when they write prescriptions for
antidepressant medications, writes Kenneth Saag, M.D., M.Sc., of the
University of Alabama at Birmingham in an accompanying editorial.
“The SSRI risk-benefit ratio should be compared
against traditional antidepressants as well as alternative approaches
such as newer drugs, psychotherapy and even electroconvulsive therapy,”
Dr. Saag writes.
For many patients, the benefits of SSRIs are likely
to out weight the risks, Dr. Saag continues. “Although it is not
appealing to use a second medicine to ‘chase’ the adverse effects of a
first one, if needed, there are many good options that exist to prevent
bone loss.”
As medicine advances, it is not surprising that
physicians are finding new ways to improve one health problem while
worsening another, he concludes. “The astute clinician individually
tailors therapies, tries to balance benefits against potential risks and
provides appropriate and informed consent for all drugs prescribed. In
the case of the depressed patient, good clinical acumen and thoughtful
adverse event monitoring can help avoid having healthier minds at the
expense of sicker bones.”
(Arch
Intern Med. 2007;167:1231-1232. Available to the media pre-embargo
at
www.jamamedia.org)
Editor's Note: Dr. Saag has served as a consultant
to, or speaker for, or has received grant funding in the area of
osteoporosis from Merck & Co, Aventis, Eli Lilly and Co, Novartis,
Roche, Arngen and GlaxoSmithKline. He is partially supported by a grant
from the Agency for Healthcare Research and Quality and a grant from the
National Institutes of Health.
Mayo Clinic
Selective serotonin reuptake inhibitors (SSRIs)
Selective serotonin reuptake inhibitors (SSRIs) are
a newer class of antidepressant medications. The first drug in this
class was fluoxetine (Prozac), which hit the U.S. market in 1987.
How SSRIs work
It's not clear precisely how SSRIs affect
depression. Certain brain chemicals called neurotransmitters are
associated with depression, including the neurotransmitter serotonin
(ser-oh-TOE-nin). Some research suggests that abnormalities in
neurotransmitter activity affect mood and behavior. SSRIs seem to
relieve symptoms of depression by blocking the reabsorption (reuptake)
of serotonin by certain nerve cells in the brain. This leaves more
serotonin available in the brain. As a result, this enhances
neurotransmission — the sending of nerve impulses — and improves mood.
SSRIs are called selective because they seem to affect only serotonin,
not other neurotransmitters.
SSRIs approved to treat depression
Some SSRIs are available in extended-release form
or controlled-release form, often designated with the letters XR or CR.
These forms are intended to provide controlled release of the medication
throughout the day or for a week at a time with a single dose.
Here are the SSRIs that have been approved by the
Food and Drug Administration specifically to treat depression, with
their generic or chemical names followed by available brand names in
parentheses:
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac, Prozac Weekly)
Paroxetine (Paxil, Paxil CR)
Sertraline (Zoloft)
Some of these medications may also be used to treat
conditions other than depression.
>>
Read more, including side effects, at Mayo Clinic
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