Posts Tagged ‘Calcium’

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

Diabetes + High BMD = Brittle Bone

August 11, 2015 @ 8:50 pm
posted by Dr Ginther

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

Determining the correct 25-hydroxy Vitamin D level is still a work in progress.  In the 8 years I have been attending meetings, we have made considerable progress.  NOF 2007 was the first time any society proposed an intake above 400 IU daily and a 25-hydroxy Vit D level of more than 20 ng/ml.

At the 2015 U. Wisconsin “Bare Bones Symposium” the latest recommendations were discussed.  I have summarized them here.

Take Vitamin D3.  D3 is Cholecalciferol (what we make in sunshine).  Vitamin D2 is Ergocalciferol (what plants make and use).  D3 works much better in people than D2 becuse it is the right stuff.   It lasts 5 times longer and the assay is more accurate.

Test for 25-hydroxy Vitamin D level and aim for between 40 and 80 ng/ml.  At 40 ng/ml over 98% of people can absorb and utilize Calcium fully.  You want to have some margin of safety since lab test results vary by at least 20%.  If you are seriously deficient, we give 50,000 IU of D3 every M, W, F based on your level and size, to correct the level quickly.

If you do not want to test your level, and you are the “average person” of 154# or 70 kg, you should take 3800 IU daily.  This should achieve the 40 ng/ml level – eventually.  If you are very deficient, this could take a year or more.  If you are larger than the old average, or you have digestive issues, you will need more.

Finally, some cancer researchers believe that 70 ng/ml is better for preventing and treating cancers.  If they are right, you should go for the higher level.  If they are wrong, you have done no harm by going for the higher level.

Take Control of your Bone Health.  Take enough D3.

Jay Ginther, MD

Several patients have concerns about oral surgery while taking Prolia.  This is not a problem – if you follow guidelines.

Prolia is different from other Antiresorptives.  Prolia does not accumulate in bone.  5 to 6 months after your last dose, Prolia has lost its effect of slowing bone turnover.  Therefore, it is safe to proceed with surgery on bone (including dental surgery) 6 months after your last dose.

Patients worry about OsteoNecrosis of the Jaw (ONJ), but this is very rare.  In fact ONJ virtually never occurs without a tooth extraction or serious periodontal disease.  Even then, it is rare unless you also have cancer,  have poorly controlled diabetes, or are seriously Deficient in Vitamin D3, or Calcium, or Protein intake.

Elective Orthopedic Surgery timing is the same.  If you need a Total Hip Replacement (THR) or Total Knee Replacement (TKR), schedule the surgery for 6 months after your last dose of Prolia.

Any time you plan to have surgery on bone, you should Optimize Your Bone Health First.  Get a Complete Bone Health Evaluation.  Optimize your Vitamin D level (at 40 to 80 ng/ml).  Optimize your Calcium intake in foods and supplements combined (at 400 to 500 mg at all 3 meals daily).  Optimize your daily Protein intake (1 g Protein for every kg body weight).

Sometimes you will also need the Anabolic, Forteo, to increase bone matrix and improve healing.  More about that another time.

Get the best possible result from orthopedic or dental surgery.  Wait 6 months after Prolia, and do your part to optimize your bone health.

Jay Ginther, MD