Posts Tagged ‘Reclast’
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
Recently a patient asked me to review all osteoporosis medications for her to consider and choose from. We had already optimized her Calcium intake, 25-hydroxy Vitamin D level, Protein intake, Multiple Vitamins & Minerals, and Exercise program. These had all helped substantially, but not enough for her peace of mind. She feels that she needs osteoporosis medication too. Here they are:
Anabolic medication for osteoporosis actually increases bone thickness and strength! Antiresorptive medications for osteoporosis (Fosamax, Alendronate, Actonel, Atelvia, Boniva, Evista, Reclast, Prolia) only preserve bone.
We have talked about all of the Antiresorptive medications over the last 2 months. They are excellent treatment if slowing down the OsteoClasts (cells that eat away your bone) is sufficient. That is not always the case.
Now it is time to talk about something completely different. Anabolic medication stimulates the OsteoBlasts (cells that make new bone matrix). OsteoBlasts can rebuild your bones. If you have Fractures, your bones may need to be rebuilt.
Forteo (Teriparatide) is the only Anabolic medication for osteoporosis in the USA. Close cousins of Forteo are available in other countries.
You may need the Anabolic, Forteo, if you have a hip fracture, multiple other fractures, or if VFA testing reveals a Vertebral Compression Fracture. A DXA T-score well below -2.5 can be reason enough without fracture.
Glucocorticoid (Cortico-Steroid) medications (Prednisone, Steroid Inhalers) specifically supress OsteoBlasts (cells that make new bone). Stimulating the OsteoBlasts with the Anabolic, Forteo, can offset the bone loss from Steroid medications. Smoking also supresses OsteoBlasts, leading to bone loss. Stopping Smoking would be best, but Forteo can help.
Not everyone needs an Anabolic, but some individuals do. A Complete Bone Health Evaluation will tell you if an Anabolic is right for you.
More about Forteo (Teriparatide) next time.
Jay Ginther, MD
Denosumab (Prolia) mimics the natural process that keeps OsteoClasts (the cells that gobble up bone) under control before menopause. OsteoCytes release Osteoprotegrin (OPG) when Estrogen (or Testosterone) is on board. OPG controls the formation and activation of OsteoClasts by blocking RANK-Ligand, which is necessary for OsteoClast formation and activation. This decreases fracture risk.
Prolia mimics OPG and blocks RANK-Ligand, thus blocking bone resorption by preventing OsteoClasts. It is a RANK-Ligand Antibody. It is like birth control for OsteoClasts. Prolia is given as a shot under the skin twice a year. Prolia is very effective at first, but begins to fade by 6 months. Without another injection , Prolia has totally lost effectiveness by 12 months after the last shot.