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Tuesday, May 14, 2013
Q: I am an 80-plus-year-old man with rheumatoid arthritis. My doctor has reduced my methotrexate dosage due to his concern about kidney damage. He prescribed Tylenol. My question is whether Tylenol also has a potential problem for my kidneys.
A: Rheumatoid arthritis is a serious form of arthritis that can cause severe damage to joints if not aggressively treated. Methotrexate is a powerful medicine, often used as chemotherapy for some cancers. It is effective for many people with rheumatoid arthritis, even though RA isn’t anything like a cancer. It does involve cells growing rapidly, which the methotrexate can control.
All medicines — whether they are prescribed by a physician, found over the counter or sold as supplements — have the possibility of side effects, but some effects are more likely than others. Tylenol, if taken excessively, is well-known to cause damage to the liver. However, long-term use of Tylenol can cause kidney damage as well.
I estimated that methotrexate is about 500 times more likely to cause kidney damage than Tylenol. Even that is an understatement, since that’s the risk when people take high doses of Tylenol every day for years or decades, against the risk of a few weeks’ worth of high-dose methotrexate.
Fortunately, the risk of kidney disease from methotrexate is much lower with the smaller doses used for rheumatoid arthritis.
Q: I am a 67-year-old female. I recently went to my gynecologist for my annual checkup. When I asked about scheduling a bone-density test, she said I only have to have one every 10 years! I thought my endocrinologist said I should have one every two years.
Who is correct? Has the change come about because of the new health-care law?
A: Osteoporosis, the loss of mineralization of bones, leads to an increased risk of fracture. Osteoporosis happens in both men and women, but more quickly and more completely in women. Because of this, and because women start off with a lower bone density than men do, on average, women are much more likely to have osteoporotic fractures.
Women lose bone density the fastest right after menopause, but the bone loss slows down after a few years. The U.S. Preventive Services Task Force recommends initial testing for all women over 65, and for women younger than 65 who have additional risk factors.
The optimum time to wait between screenings in women over 65, after the first test, hasn’t been clear, until a recent study looked at this very issue. The study found that the results of the previous bone density determine when you should look again. If the bone density is normal, then a 10-year or even 15-year interval is safe. However, if the first study showed low bone density (osteopenia) but not osteoporosis, then a five-year or a one-year follow-up is necessary, depending on how serious the bone loss is.
Who is right? It depends on your results. But the decision of when to do the follow-up bone density test, like all tests, should be based on science, by scientists, and not on the economy, by politicians.
Doing fewer unnecessary tests leads to better outcomes for patients. It also saves money, but that is secondary.
You can estimate your fracture risk with the FRAX tool at http://www.shef.ac.uk/FRAX/tool.jsp. Pick your country under “calculation tool.” The USPSTF recommends screening for a major osteoporotic fracture risk above 9.3 percent.
Dr. Keith Roach’s column runs in Tuesday’s Extra.
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