Archive for the ‘Osteoporosis’ Category
This week I had a patient who has decided that she does not need to treat her Osteoporosis because she does not yet have symptoms. This could be a problem for her. The first symptom of Osteoporosis usually is a Fracture. Ouch!
Actually she has had symptoms. She has 5 Vertebral Compression Fracture Deformities in her thoracic spine. As is usually the case, she had aching, but not sharp pains, from these “crumble-type” fractures. Therefore she doesn’t really believe that they are “real” fractures.
Vertebral Fractures generally occur about a decade before Hip Fractures. They are the early warning that much more obvious, and much more inconvenient, fractures may be coming. You ignore that warning at your peril.
Clinical Osteoporosis is a Silent Disease until the first major Fracture (Bone Attack). Heart disease may be silent until the first Heart Attack. High Blood Pressure may be silent until the first stroke (Brain Attack). Each of these can change your whole life.
Osteoporosis with Fracture is far easier to prevent than to treat – for the patient as well as the doc. Why wait for a fracture? Why not start treatment before ruining your life for a few weeks – or forever.
Take Control of Your Life.
Jay Ginther, MD
Patients, Primary Care Docs, and Orthopedic Surgeons all worry about bone surgery while on Osteoporosis Medications. They also worry about Atypical Fractures of the Femur (AFF). There is one medication that actually helps bone healing and is routinely used to treat AFF. That is the Anabolic, Forteo.
Atypical Fracture of the Femur is quite rare. AFF has become less rare since we started treating osteoporosis with Antiresorptive Osteoporosis Medications. Typical Femur Fractures are still about 100 times as common – and we can prevent over half of those with Antiresorptive Osteoporosis Medications.
AFF is a Stress Fracture, usually just below the hip, that starts on the lateral side of the Femur. It is a small crack, which can gradually spread across the bone.
The best treatment for a stress fracture is stimulating the cells that make new bone (OsteoBlasts) and also stimulating the cells that gobble up bone (OsteoClasts). This increases bone turnover, which is needed for healing a fracture, especially a stress fracture.
Forteo is the only Anabolic we currently have in the USA. Forteo is routinely used to treat AFF before, as well as after, the fracture. It is also used to treat other stress fractures such as metatarsals in the feet and “shin splints” in the proximal shaft of tibia.
Forteo is also commonly used to enhance healing in osteoporotic patients in spine fusions and in total joint replacement.
Jay Ginther, MD
You have started taking Osteoporosis Medication. You think you have entirely eliminated your Fracture Risk. Then, WHAM – you have a Fracture! What went wrong?
It is time to re-evaluate. There are many possible reasons for your fracture.
First, all osteoporosis medications gradually become effective over months. Therefore, if you fracture within the first few months, there has not been enough time for it to become fully effective.
By two to three years, all osteoporosis medications Decrease Fracture Risk by 1/2 to 2/3. That is very good, but not perfect.
Second, you need to be sure you are getting enough Absorbable Calcium in 3 doses of 400-500 mg In Foods or With Foods – every day. You need to have a high enough Vitamin D level to absorb the Calcium. You need Magnesium too – a Multiple Vitamin and Mineral (taken with a full meal) should be enough. You also need Protein (1gram per kg of body weight). If you had Secondary HyperParathyroidism, it must be resolved.
Third, Bisphosphonate pills are sometimes not absorbed adequately. When they work, we actually absorb less than 1% of the drug taken. If this is a problem, Reclast or Prolia can get around the absorption issue. Of course, skipped doses do not work at all.
Fourth, there may be other issues causing fragility. A Complete Bone Health Evaluation will usually identify Diabetes, HypoThyroidism, Colitis, Irritable Bowel Syndrome, Lactose or Gluten sensitivities, etc. These need to be fixed too.
Finally, your Osteoporosis may be too severe to be ideally treated with Antiresorptives. Very low BMD and T-scores, multiple Fragility Fractures, Vertebral Fracture Deformities (especially multiple) are all indications that you probably should start with the Anabolic, Forteo, to build up your Bone Matrix enough that a Antiresorptive can then be the best treatment.
Fracture while on medication? Time to re-evaluate. Then modify your program if needed.
Jay Ginther, MD
Patients with poorly controlled Diabetes and high blood sugar levels often have bone with above average Bone Mineral Density (BMD). This is good? WRONG !!
High blood sugars lead to glycolization of the Bone Matrix, which is the protein part of the bone – collagen. This means that glucose (sugar) molecules are incorporated into the collagen protein chains. This distorts and stiffens the Bone Matrix.
Normally, stiffer is better, Calcium stiffens the bone matrix, which strengthens the bone. But too much of a good thing is bad. Too stiff becomes brittle. Brittle bones break more easily than “stiff enough” bones.
Persons with diabetes who routinely run high blood sugars fracture more easily than non-diabetics. Therefore, at the same BMD and T-score, diabetics have a higher Fracture Risk.
We knew that high blood sugars in diabetics are bad for kidneys, eyes and nerves. Now we know that high blood sugars in diabetics are bad for bones too.
Take Control of Your Future. If you have diabetes, work with your primary doc to get your blood sugars under control.
Jay Ginther, MD