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Bone Death and Destruction

Part of A Practical Guide to HIV Drug Side Effects


Avascular Necrosis

(necrosis = death)
The thigh bone's (no longer) connected to the hip bone. That could be your problem if you develop the tongue-trippingly named avascular necrosis (AVN) of the femoral head, a bone disease in which a lack of blood flow results in tissue death in the top end of the thigh bone, the section that creates part of your hip. Studies have indicated that protease inhibitors may contribute to this hip-destroying problem. Researchers theorize that elevated blood fats -- particularly the high triglyceride levels often caused by these drugs -- might be blocking the blood supply to the bones, thus leading to tissue death, but note that this is definitely still theory, not a proven fact. Even in PHAs not on HAART, triglycerides are often too high and might be a factor in the development of bone problems.

The following are additional risk factors because each of these can contribute to decreased blood supply to the bone:


  • long-term use of corticosteroid drugs
  • alcohol abuse
  • bone injury (such as fractures)
  • bone infections
  • scuba diving
  • Addison's disease -- an adrenal gland condition that some PHAs develop, which results in reduced production of the steroid hormone called cortisol. It is usually treated with low doses of hydrocortisone (30 mg or so daily), a dosage level that is not usually thought to cause AVN but might contribute (via the same process as any chronic corticosteroid use).

The hip is usually the first place where avascular necrosis of the bone shows up, but it may also develop in the shoulder, knee or hand. Common early symptoms include:

  • pain in the hip joint or groin area, which may radiate down the leg to the knee, and may in some cases be quite excruciating
  • stiffness in the hip area (often particularly noticeable upon awakening)
  • occasional aching (especially after long periods of walking or standing)
  • a decreased range of motion

With any such symptoms, getting a comprehensive physical exam is a must, followed, if appropriate, by an MRI (magnetic resonance imaging) scan of the bone.

Tips for Handling Avascular Necrosis (AVN)

If detected early on, small holes can sometimes be drilled in the bone to increase blood flow and allow new blood vessels to grow (a process called core decompression surgery), thus helping to slow worsening and reduce pain. However, there are no known curative measures that will permanently prevent a downhill slide toward bone death. If it has progressed too far in the hip bone, the only thing that works is hip replacement. It may be useful for PHAs who are concerned about AVN to avoid the following activities that could increase the pressure on the hip joint:

  • some weight-lifting exercises
  • squats
  • running on concrete
  • carrying heavy weight on the shoulders

Osteopenia and Osteoporosis

(osteo = bone; porosis = thin)
The other bone problem being seen in PHAs is osteopenia, or its more advanced stage, osteoporosis. These are the gradual loss of bone tissue that occurs when the body's normal constant loss of bone cells is not equaled by constant replacement, resulting in gradually thinning and weaker bones that may become brittle and break easily. Postmenopausal women are inherently at greater risk than men for osteopenia and osteoporosis. As with AVN, it is not fully understood what all the causes may be, although it appears that protease inhibitors may be contributing, as well as HIV disease itself, hepatitis co-infection, nutritional deficiencies, smoking and lowered sex hormone levels. It is theoretically possible that the osteoporosis in some PHAs might actually be contributing to the development of AVN, a known complication of severe osteoporosis, although studies to date have not shown this.

A DEXA scan is the best way to diagnose bone mineral loss, whether it is still at the stage of osteopenia or has developed into the more severe osteoporosis. A baseline scan (done before starting HAART) can be compared to later readings. Without a baseline scan, doctors can compare the current results with standard values based on the person's age, weight and build, thus estimating the probable bone loss.

Tips for Handling Osteoporosis

Until all the causes are well defined, advice on specific curative or preventive measures will be lacking. However, in the meantime, what we do know to help prevent or reverse osteoporosis in general may certainly help, including:

  • weight-bearing exercise
  • cutting down or quitting smoking
  • a nutrient-rich diet
  • additional supplementation with calcium (1,000 mg daily for men, and 1,000-1,500 mg for women)
  • magnesium (500-600 mg daily; excess magnesium can cause loose stools so watch for this)
  • vitamin D3 (400-800 IU daily). Vitamin D has been shown to be deficient in many PHAs and is important to ensure good uptake and use of your calcium.

For more info on nutrition for healthy bones, see "Good to the Bone" in the fall / winter 2001 issue of CATIE's Positive Side magazine, available at or by calling 1.800.263.1638 [if you're in Canada].

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This article was provided by Canadian AIDS Treatment Information Exchange. Visit CATIE's Web site to find out more about their activities, publications and services.
See Also
Bone Health and HIV Disease
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