Posts Tagged ‘osteoclasts’
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
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
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
Dentists and Oral Surgeons are sometimes wary of their patients being on ANY Osteoporosis Medications when they undergo tooth extractions or other dental proceedures. One osteoporosis medication is different from all the others. Forteo is the only Anabolic medication currently available in the USA. Forteo does not cause dental and jaw problems. Forteo can be used to treat ONJ and other bone problems of the jaw.
OsteoNecrosis of the Jaw (ONJ) is a rare complication of tooth extraction. If you have cancer, are on chemotherapy, have uncontrolled diabetes, or are on the higher doses of Antiresorptive Osteoporosis Medications used in Cancer Patients with Metastases, ONJ is less rare.
ONJ is the result of too slow bone repair by the OsteoBlasts (the cells that make new bone matrix). Antiresorptive medications slow down both OsteoClasts (the cells that resorb bone) and OsteoBlasts.
Forteo cannot cause ONJ. Forteo (Teriparatide) stimulates OsteoBlasts. That increases new bone matrix formation. Therefore, Forteo can prevent and treat ONJ.
Forteo has been shown to improve bone healing in dental surgery, including implant osseointegration and healing alveolar defects. Ref: Batshutski JD, Eber RM, Kinney JS, et al. Teriparatide and osseous regeneration in the oral cavity. N Engl J Med. 2010, 363:2396-2405. Ref: Kuchler U, Luvizuto ER, Tangl S, et al. Short-term Teriparatide delivery and osseointegration: a clinical feasibility study. J Dent R. 2011:90(8):1001-1006.
As a former orthopedic surgeon, I have discussed these issues with several of our local oral surgeons and dentists.
If you are facing oral surgery or tooth extraction, discuss your osteoporosis medications with your dental surgeon. Most osteoporosis medications should be held for your surgery. Forteo is the exception. Forteo actually helps your jaw heal after dental surgery.
Jay Ginther, MD