Another study on how “docs” rate caught my eye. This one compared ratings as collected on behalf of offices and hospitals to those on social media sites on the same providers.
Formal ratings focused on the courtesy, communication skills, perceived medical or surgical skills, nursing staff, wait times, etc.
Social media ratings tended to focus more on front desk staff, office décor, TV channels, pleasantness or not of others in the waiting area, etc.
Interesting dichotomy. Looking at both should give a better picture.
And then there are ratings done by insurers. These tend to focus on factors such as did I prescribe a generic oral bisphosphonate to everyone, rather than did I counsel the patient on improving nutrition.
Understanding ratings is not as easy as it looks.
Jay Ginther, MD
I was asked about treatments for Fibromyalgia. Pain clinics have injections and pharmaceuticals that often help, but not always enough. I approach from a different angle.
Fibromyalgia is a collection of many different maladies that are magnifying each other. They are very difficult to untangle. Treating all aspects of the pain is the key to success.
I have actually “cured” fibromyalgia only 4 times, but usually I can decrease the pain enough that other measures will work better than before.
The key is understanding that pain often is nerves misbehaving, magnifying the intensity of unpleasant stimuli. This is neuropathy or neuralgia. These conditions are made much worse by nutritional deficits.
B1, B6, B12 and Folate are key nutrients for nerve function. Controlling diabetes is also important. Low calcium, potassium or magnesium cause cramping and pain. These should ALL be checked.
Vitamin D is often overlooked as essential for nerve function. Low vitamin D will cause depression, malaise, nerve malfunction and increased pain. I aim for a vitamin D level of 70 ng/ml – higher than needed for bone health, but completely safe. If your level is very low you may need megadoses, well above 5000 IU daily.
Take Control Naturally with Vitamin D3, as well as B1, B6, B12, Folate, Calcium, Potassium and Magnesium.
Jay Ginther, MD
Our goal is NO NEW FRACTURES. Therefore, Treat to Target means a FRAX score of <20% for “major osteoporotic” and <3% for hip fracture. Alternately, T-score of better than -1.5 if there are any fractures.
Antiresorptives do not substantially increase bone mass or BMD. While a 3-5% BMD improvement can be seen when a long term deficiency in calcium absorption is corrected, the function of an antiresorptive is to maintain current bone mass.
If you want to substantially increase bone mass, you must use an anabolic medication. We now have 2. Forteo (teriparatide) has been available for 15 years. Tymlos (abaloparatide) was approved late last spring, but has only achieved good coverage by a majority of insurance companies in the last month.
Both can be given for up to 24 months. Both must be followed by an antiresorptive to avoid loss of gains. Both will show continued improvement in BMD for up to 3 years after switching to an antiresorptive because calcium takes up to 3 years to fully accumulate in new bone matrix formed by an anabolic.
Both should NOT be given to anyone with open growth plates, Paget’s, radiation to bone, cancers which have or could spread to bone, elevated bone specific alkaline phosphatase other than from fracture healing, or pregnant or nursing women.
Tymlos is approved for postmenopausal women only. It does not stimulate bone turnover significantly and therefore shows faster BMD increase initially in the hip. It has not been tested for use after antiresorptives.
Forteo is approved for men and women with osteoporosis which is “age-related”, or from steroid use, or from idiopathic hypogonadism. Forteo significantly increases both osteoblast and osteoclast activity, thereby stimulating bone turnover, which is often suppressed after long-term antiresorptives. Forteo is the default treatment for ONJ and AFF.
If you are dealing with vertebral fractures on VFA, or really low BMD on DXA, or with multiple fragility fractures, you need an ANABOLIC FIRST, to decrease fracture risk. Then follow with antiresorptives to maintain a low enough fracture risk.
Remember, even these medications will fail without proper nutrition.
jay Ginther, MD
Treat to Target of NO NEW FRACTURES. How do we find that target? DXA >-2.5 is a start. Fragility fractures increase new fracture risk. FRAX adds many more risk factors to the calculation and TBS refines FRAX.
Vertebral Fracture Assessment (VFA) looks at the spine from the side and independently identifies additional fracture risk. This can be done on a DXA machine or by x-ray. A single vertebral compression fracture of 25% or more pre-empts DXA, BMD, and FRAX in diagnosing Clinical Osteoporosis and recommending treatment.
VFA should be done because the majority of vertebral compression fractures are first noticed by x-ray or DXA VFA imaging. If you do not personally view the images, be sure the radiologist specifically checked for vertebral deformities as described by Genant.
I recently published my retrospective review of 1259 sequential first time VFA patients in Endocrine Practice 2017:23:1375-8.
VFA identified many patients not identified as high fracture risk (Clinical Osteoporosis) by DXA or fragility fracture or height loss or kyphosis or FRAX.
We should consider including VFA in every first time Complete Bone Health Evaluation.
And how should we treat? Next time…
Jay Ginther, MD