Posts Tagged ‘Calcium’
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 means aiming for NO NEW FRACTURES. As discussed last time, the original target was to maintain Bone Mineral Density (BMD) at the level first tested. 25 years ago that was amended to be a T-score of -2.4 or higher, since “osteoporosis the test result” was set at -2.5.
But what if you already have fractured? Clinical Osteoporosis the diagnosis is a T-score of -1.5 plus a “Fragility Fracture” acquired in any fall from standing height, even on ice. That is because for the first year after a fracture your risk is 5 times normal. Your risk decreases to 2 times normal after 5 years, but always is higher after a fragility fracture.
If your Fragility Fracture was a Hip Fracture, you have Clinical Osteoporosis regardless of DXA BMD and T-score. You are at high risk of future fracture, especially of the other hip. You should start treatment to prevent a new fracture. At the very least you need to optimize calcium, vitamin D3, protein, and multiple vitamins & minerals intake.
If you also need a pharmaceutical, it should be one which can raise your T-score above -2.5 if you have no fractures, and above -1.5 if you already have a fracture. That usually means considering an anabolic. Your goal is NO NEW FRACTURES.
FRAX next time.
Jay Ginther, MD
Once again we have been treated to statisticians mushing together multiple disparate previous studies to “prove” that calcium alone, or vitamin D alone, or both together in one of many different combinations will not prevent fractures. All mushed together in a carefully selected meta-analysis, you can prove anything depending on which studies are included.
More important, asking if adding a specific dose of calcium, or vitamin D, or both, will prevent fractures, misses the entire point. Most studies did not properly account for the nutrients in each day’s diet in individual test subjects – or in individual control subjects, many of whom also consumed the nutrients being studied.
And how can you ethically ask a patient to limit their diet in a way you believe will put them at risk for fractures? You have to settle for encouraging patients who are inadvertently short on some nutrients to improve their diet. But then they do not fracture and you cannot prove that they would have if only you had withheld the information!
We help individuals improve their bone health. One size does not fit all. We do a Complete Bone Health Evaluation. Then we adjust nutrition and lifestyle as needed for that individual. In about half of women and three-quarters of men, this is enough.
Jay Ginther, MD
Choose your parents well. Their genetics mix to form your genetics. Your genetics play a large role in determining your potential strengths and weaknesses. However, what you do with your potential is up to you.
We all wish we could be something we are not, and never can be. That is completely natural, but not helpful. You have to play the hand you were dealt. You have to take control of your future, and you can.
If your parents had great bones, you probably will too – as long as you take care of them with Calcium, Vitamin D, Protein, Exercises, Balance, and Avoid Smoking.
If your parents crumbled into kyphosis (humpback) or broke a hip, due to osteoporosis, you better get working on what you can control as early as possible. You will probably need medications eventually, but starting on natural treatments early enough can delay that need for years.
If you Take Control Naturally of what you can control early enough, you can achieve many years of fracture free life. That’s as good as it gets.
Jay Ginther, MD