Expert: Ivan Goldberg, M.D. - 4/29/2010

Question
I am 50 and have osteoporosis in my spine (top and bottom) and osteopenia in my hip. Repeated bone density test and loss of 6% bone in less than a year.  I have successfully been on lithium for 30 years to treat bipolar (no other drugs are needed), but am concerned that lithium is causing my lack of calcium absorption in my bones. I am under the care of a naturopath in addition to an internist. I had a vit. D deficiency,now under control. Other tests, i.e. thyroid appear to be generally normal.  Please help me- I am scared to go off lithium- anyway to neutralize its affect on my bones?

Answer
Hi Deborah . . .

I think I have some good news for you. It seems as if someone has been giving you some incorrect information. It is true that lithium treatment has an effect on the bones and calcium metabolism, but the effect is to increase bone density and reduce the likelihood of developing osteoporosis. The following abstracts support that point of view:

1. Bone. 2009 Feb;44(2):331-4. Epub 2008 Oct 18.

Lithium's effect on bone mineral density.

Zamani A, Omrani GR, Nasab MM.

Division of Endocrinology and Metabolism, Department of Medicine, Shiraz
University of Medical Sciences, Iran.

Lithium salts are widely used in treating psychiatric patients. Lithium may be
associated with hyperparathyroidism, a risk factor for osteoporosis. However, the
data on the effect of lithium on bone mass are conflicting. We assessed bone
mineral density with dual-energy X-ray absorptiometry at the hip and lumbar spine
in 75 lithium treated outpatients and 75 normal subjects matched for age, sex and
body mass index. Serum total calcium, intact parathyroid hormone (PTH),
estradiol, osteocalcin, total alkaline phosphatase (ALP) and C-telopeptide (CTX)
in addition to fasting urinary calcium excretion were also determined in both
groups. The mean (+/-SD) bone density in lithium treated patients was 4.5% higher
at the spine (P<0.05), 5.3% higher at the femoral neck (P<0.05) and 7.5% higher
at the trochanter (P<0.05). In addition, lithium treated patients had lower serum
total ALP (P<0.005), lower serum osteocalcin (P<0.005) and lower serum CTX
(P<0.05) but the total calcium, PTH and urinary calcium excretion did not differ
significantly between patients and controls. In conclusion, our results suggest
that maintenance therapy with lithium carbonate may preserve or enhance bone
mass. These data also suggest a lower bone turnover state in those receiving
lithium.

PMID: 18992857 [PubMed - indexed for MEDLINE]


2. Horm Metab Res. 1998 Sep;30(9):594-7.

Lithium carbonate therapy is not a risk factor for osteoporosis.

Cohen O, Rais T, Lepkifker E, Vered I.

Institute of Endocrinology, Sheba Medical Center, Tel Hashomer, Israel.

Lithium carbonate is a widely used drug for affective disorders. It may effect
calcium metabolism and alter parathyroid physiology by causing hypersecretion of
parathyroid hormone. Patients treated with this medication might therefore be
predisposed to osteoporosis. The purpose of this study was to evaluate the effect
of either short- or long-term lithium carbonate therapy on parameters of bone
metabolism. Parathyroid function and indices of bone metabolism were assessed in
23 patients treated for affective disorders. 10 patients were treated for 0.4-1.0
year (Group 1), and 13 patients were treated for more than 3 years (Group 2). In
all subjects, bone mineral density measurements in the hip and lumbar spine
regions were performed using dual energy X-ray absorptiometry. Serum thyroid
hormone, PTH, LH, testosterone and urine OH-proline, free cortisol, calcium and
phosphate excretion were measured. The two groups were well matched for sex,
weight, calcium intake, lithium levels and smoking habits, although Group 2 was
slightly older. No differences between the two groups were noted in either bone
mineral density or other parameters that were assessed. Urinary OH-proline was
elevated similarly in both groups. Our results did not detect any effect on bone
density after short- or long-term lithium carbonate therapy, although the data
does suggest an increase in bone turnover associated with this treatment. Thus,
short- or long-term treatment with lithium is not associated with increased risk
for osteoporosis.

PMID: 9808330 [PubMed - indexed for MEDLINE]


3. Curr Drug Saf. 2008 Sep;3(3):185-9.

Skeletal effects of central nervous system active drugs: anxiolytics, sedatives,
antidepressants, lithium and neuroleptics.

Vestergaard P.

Department of Endocrinology, Aalborg Hospital, Aarhus University Hospital,
Aalborg, Denmark. p-vest@post4.tele.dk

Many central nervous system active drugs can alter postural balance, increasing
the risk of fractures. Anxiolytics and sedatives include the benzodiazepines, and
these have been associated with a limited increase in the risk of fractures, even
at low doses, probably from an increased risk of falls. No systematic differences
have been shown between benzodiazepines with long and short half-lives. Although
the increase in risk of fractures was limited, care must still be taken when
prescribing for older fall-prone subjects at risk of osteoporosis. Neuroleptics
may be associated with a decrease in bone mineral density and a very limited
increase in fracture risk. Antidepressants are associated with a dose-dependent
increase in the risk of fractures. The increase in relative risk of fractures
seems to be larger with selective serotonin reuptake inhibitors (SSRIs) than with
tricyclic antidepressants. The reason for this is not known but may be linked to
serotonin effects on bone cells and the risk of falls. With the wide use of
SSRIs, more research is needed. Lithium is associated with a decrease in the risk
of fractures. This may be linked to its effects on the Wnt glycoprotein family,
which is a specialized signalling system for certain cell types.

PMID: 18690999 [PubMed - indexed for MEDLINE]


4. Ugeskr Laeger. 2008 Apr 28;170(18):1550-5.

[Osteoporosis and fractures associated with drugs]

[Article in Danish]

Vestergaard P, Rejnmark L, Mosekilde L.

Arhus Sygehus, Osteoporoseklinikken, Arhus C. p-vest@post4.tele.dk

Drugs can affect the skeleton in different ways. Antiepileptic drugs were not
associated with any major fracture risk. Lithium was associated with a decreased
fracture risk. Insulin, sulphonylureas and metformin were associated with a
decreased risk, whereas glitazones were associated with an increased risk. Blood
pressure lowering drugs, thiazide diuretics and nitroglycerin were associated
with a decreased risk of fractures, whereas amiodarone and loop diuretics were
associated with an increased risk. Pain medication varied from no effect to an
increased fracture risk.

PMID: 18454925 [PubMed - indexed for MEDLINE]

I think it would be a good idea to show these abstracts to any doctor who advises you to switch from lithium toi another mood stabilizing medication.


The most common risk factors for bone los are heredity, smoking, hyperthyroidism and lack of exercise..

Best regards . . .

Ivan
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