Posts Tagged ‘BMD’
Clinical Osteoporosis 2017, NOF and ISCD joint meeting had a different emphasis this year. Fracture Risk, rather than Bone Mineral Density (BMD) is now the key metric. Several speakers emphasizd the importance of VFA in making the diagnosis of Clinical Osteoporosis. This is something I have presented in poster exhibits 2015, 2016 and 2017. I am now mainstream!
“Treat to Target” was the big new message this year. We should set a target of decreased Fracture Risk for each patient and alter treatment until we reach it. This has been routine for years in diabetes, hypertension, cholesterol, etc. This is recognition that Osteoporosis is a chronic disease that we can control, but never cure, just like many others.
Take Control Naturally is the necessary first step, as I have outlined over the last few months. This is often sufficient for prevention and in mild disease.
Advanced Osteoporosis, especially after fragility fractures, or vertebral compression fractures seen on VFA, is usually beyond nutrition and exercise only. This will usually require medications to significantly reduce fracture risk.
The huge change is the recommendation to use an Anabolic medication first, to markedly reduce fracture risk, when BMD is very low or multiple fractures have already occured. Then follow up with an Antiresorptive to maintain a low fracture risk. Traditionally Medicare and other insurances have demanded we try Antiresorptives first to maintain bone as it is, even when multiple fractures have proven the bone to NOT be good enough at curent BMD.
We are entering a new age of Fracture Prevention!!
Jay Ginther, MD
The National Osteoporosis Foundation (NOF) and the International Society for Clinical Densitometry (ISCD) are meeting together later this week. This will be my 10th attendance at each group. They are both always interesting.
I will be presenting a new research project this year – “Vertebral Compression Deformities in Patients with Normal Bone Mineral Density”.
This is a further study of the 79 patients with Normal BMD by DXA alone, who were changed to Clinical Osteoporosis because of vertebral compression fractures found on VFA from last year’s study of 1259 consecutive patients with first-time VFA at our facility.
I look forward to seeing what else is new this year.
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