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Archive for the ‘Osteoporosis’ Category

True in the 1960’s – even more true today.  We expect to live into our 80’ and 90’s.  We expect to enjoy those extra years.  We can, with a little planning and action NOW.

If YOU don’t take care of your body, where ARE you going to live?  That is the real question.  Women start to rapidly lose bone at Menopause.  This is totally natural and used to be unavoidable.  Without action on your part, you could develop Clinical Osteoporosis and Fractures and wind up in a nursing home.  You can avoid these complications of natural aging.

Cedar Valley Bone Health Institute of Iowa offers a Complete Bone Health Evaluation.  DXA, VFA, specific blood tests not usually done in annual check-ups, full history, an examination and full consultation usually take 30 minutes focused on bone health alone.  We can Prevent Osteoporosis if we start early enough.  Prevention is far better than treatment, and ideally should start decades before menopause.

You must be prepared to Take Control of those issues you can control:  Calcium, Vitamin D, Protein, Vitamins & Minerals, and Exercises for Balance, Strengthening and Posture.  Everyone should do these Natural measures for best results, whether taking Osteoporosis Medications or not.  For younger persons and for some individuals over 50, they are enough all by themselves.

Calcium is best absorbed when eaten in foods.  You want to consume 400-500 mg  in each meal to get 1200 mg every day.  If you do not get enough calcium in your diet alone, Calcium Citrate pills are much better absorbed than Calcium Carbonate pills, if you take antacids or are over 50.  Adora Premium Chocolates are a delicious way to get 500 mg calcium in only 30 calories.

Your skin can make Vitamin D3 from the Sun at mid-day in the summer.  Doing that risks Skin Cancer because you cannot use sun block if you want to make Vitamin D.  The sun is high enough above the horizon only 5 months of the year in Iowa.  Plus, we lose our ability to make enough Vitamin D as we grow older.  Over half of Iowans are low on Vitamin D as summer ends in September.  7 out of 8 Iowans are low by mid April when we can first get a few minutes a day of Vitamin D.

New studies presented at National Osteoporosis Foundation and American Society for Bone & Mineral Research meetings in the last 3 years have shown we need much more Vitamin D than we thought just 3 yers ago.  The easiest and safest move is to take extra Vitamin D3.  The amount of D3 in your multiple vitamins and minerals, in your calcium supplements, and in your milk combined are rarely enough.  Test for 25-hydroxy Vitamin D Level, in order to tell if you are taking enough to get between 40 and 80 ng/ml in your blood.

Bones and muscles are both well over 80% Protein.  (Calcium is added for stiffness in bone.)  Protein need not be from animals, but getting enough protein in a vegetarian diet takes constant attention.  Most people should get 1 gram of protein for every kilogram of their body weight.  An easy calculator and advice on where to get protein, as well as calcium and vitamin D3 can be found on my blog site www.BoneDocBlog.com.

Vitamins & Minerals from a diet of many different fresh fruits and vegetables is tedious and difficult.  I prefer a Multiple Vitamin & Mineral Supplement as an easy way to be certain I have optimal levels of all those trace nutrients.

Daily Exercises for Balance, Strengthening and Conditioning of your whole body, are important.  Include specific Postural Exercises to maintain upright posture of your spine.  This decreases the chance of developing “humpback” or kyphosis in later years.  A minimum of 20- to 30 minutes daily standing and walking is needed, along with specific exercises for balance.

While women are more likely to have bone health issues and fractures, you are not alone.  One-quarter of all Clinical Osteoporosis patients are men.  Talk to the men in your life about bone health.  Make sure they, and your daughters, are following the guidelines above.

Take Control of your Bone Health.  Start today by getting a Complete Bone Health Evaluation.  I have never evaluated anyone for bone health and not found at least one detail that we could improve upon.  Go to www.BoneDocBlog.com, www.CVBoneHealth.com, or call 319-233-BONE (2663) for further information.

Treat to Target #6 – Treatment

February 27, 2018 @ 7:07 pm
posted by Dr Ginther

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 #5 – VFA

February 25, 2018 @ 7:45 pm
posted by Dr Ginther

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

Treat to Target #4 – TBS

February 16, 2018 @ 7:05 pm
posted by Dr Ginther

Our goal is NO NEW FRACTURES.  Cancellous (spongy, like the ends of the drumstick) bone should be a strong latticework of struts called trabeculi.  Clinical Osteoporosis, an increased fracture risk, occurs when some of the struts disappear.

Trabecular Bone Score (TBS) evaluates the spongy bone in the DXA images of the vertebrae (spine) looking for irregularities.  When TBS finds uneven bone mineral density within the spine DXA, that indicates a higher fracture risk, regardless of the total BMD.

Adding the TBS feature to a DXA machine allows the quality of bone in the spine to influence the FRAX score, just like the BMD in the femoral neck part of the hip influences the FRAX score.  Adding TBS detects more patients at high fracture risk who should be treated to avoid fractures.

Diabetes increases a person’s fracture risk for any given DXA BMD or T-score.  Controlled diabetes adds about the same risk as rheumatoid arthritis, so we usually check that box in FRAX.  Uncontrolled diabetes is more serious requiring further adjustment to FRAX.

FRAX is pre-empted by a hip fracture.  “Do not pass GO, do not collect $200, start a pharmaceutical”  Vertebral (spine) Fracture is the same, but the majority of spine fractures are not noticed clinically.  “Morphometric” (first noticed on x-ray) vertebral fractures count, but how to find them?

VFA next time

Jay Ginther, MD