Posts Tagged ‘Fracture’
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
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
The FDA approved Tymlos (Abaloparatide) in June for use in women diagnosed with osteoporosis. Unfortunately most patients are unlikely to obtain insurance coverage for Tymlos until January or February 2018.
Tymlos is an anabolic, which means that it can stimulate osteoblasts, the cells that make new bone matrix. Until now only Forteo (Teriparatide) has been available to do that. Having a second option will be helpful.
Tymlos is similar to Forteo, yet there are distinct differences. Tymlos is almost pure osteoblast stimulation which means that BMD rises faster in areas with cortical bone, such as the hip. This potentially makes it a better choice for women never exposed to antiresorptive bisphosphonates like Fosamax (Alendronate), Actonel (Risedronate), Boniva (Ibandronate), and Reclast.
Tymlos is a daily shot (like insulin), but does not require refrigeration. It is approved for up to 24 months use and must be followed by an antiresorptive in order to not lose the benefits gained.
Patients with a single fracture of hip, or multiple fractures of other bones including spine, or with a BMD well below -2.5, or a FRAX score well above 20%and 3.0%, should be considered for an anabolic. Now we have another choice available.
For now Tymlos is approved for women only and osteoporosis only. We look forward to the FDA adding men and other indications in coming years.
Meanwhile, we wait for insurance coverage to make it affordable.
Jay Ginther, MD
Smoking is a major risk factor for fractures. Smoking suppresses the osteoblasts (the cells that make new bone). The osteoclasts (cells that eat away bone) then can easily outdo the osteoblasts, and you lose bone mass. Lower bone mass = more fractures.
Stopping smoking altogether is the best for your bone health. That is really tough to do. E-cigarettes have not proven less harmful to bone. Nicotine patches help only if they eventually lead to less nicotine intake than with smoking.
The damage smoking does to your bones (and lungs, and heart) is dose related. Therefore, cutting way down is almost as good as quitting, and often much easier to do.
Especially if you are trying to heal a fracture, stopping smoking, even for a few weeks, is really important. 1 ppd smokers are 5 to 10 times as likely to not heal a fracture. The same is true for infection rate after surgery.
Steroid Inhalers also suppress osteoblasts and bone formation. Unfortunately many cannot get off their steroid inhalers, even after they quit smoking. Major bummer.
Take Control Naturally of your bone health. Stop Smoking. Or at least cut way back.
Jay Ginther, MD