Osteoporosis: Prevention and Treatment

Osteoporosis: Prevention and Treatment



Osteoporosis is a condition in which bones lose mass and become weak and brittle. It affects 10 million people and causes two million fractures in the U.S. per year. Joy Wu, MD, Chief, Division of Endocrinology, discusses the testing, diagnosing, and treatment of osteoporosis. She describes the condition’s risk factors, who should get a bone density test (DXA), and what steps you can take to decrease your risk. Dr. Wu covers common medications such as Fosamax (Alendronate), Boniva (Ibandronate) and other osteoporosis medications, including the pros and cons of each. Finally, Dr. Wu answers many questions from the audience.

Joy Wu, MD, PhD, is a board-certified endocrinologist who specializes in treating osteoporosis and other bone and mineral diseases. Dr. Wu is Chief of the Division of Endocrinology, Gerontology and Metabolism and Vice Chair of Basic Science in the Department of Medicine at Stanford.

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good evening and welcome I'm Gene Johnson one of the Librarians at Stanford health library thank you for joining us for tonight's talk osteoporosis prevention and treatment it is my pleasure to introduce our speaker Dr Joy Wu Dr Wu is a board-certified endocrinologist who specializes in treating osteoporosis another bone and mineral diseases she is chief of the division of Endocrinology gerontology and metabolism and vice chair of basic science in the department of medicine at Stanford Dr Wu's laboratory is currently studying stem cell therapies for bone formation and the prevention of cancer metastases to bone throughout the program please enter any questions in the Q a box at the bottom of your screen and at the end of the talk doctor we will try and answer as many of those as possible okay doctor I turn it over to you thank you Gene for that kind introduction it's really a pleasure to be here it's always a pleasure to talk to people about their bone health and the Stanford health library is such a valuable source of information for the public so again really really grateful for the opportunity all right so the topics I'd like to cover today um include the definition of osteoporosis and who should be tested for this how what can we do as individuals to improve our bone health and finally a bit of a discussion about you know when is it that we need to think about medication and how can we do this safely all right let me start with the take-home messages and I would love for everyone to come away with the understanding that fractures are serious due toasty progresses but in fact are preventable um the osteoporosis affects not only women but also men the risk factors that influence your fracture risk there are many of them and we'll review some of those today lifestyle changes can certainly slow but usually not fully reverse bone loss and finally when used properly osteoporosis medications can in fact be very safe and effective so let's start with uh the definition of osteoporosis it's a disease of skeletal fragility here is a photograph rendering of what your bone looks like under the microscope and you can see normal bone has a lot of connections and plates and rods and I think you can appreciate in this rendering of osteoporosis about that the amount of bone is less and that these rods are thinner and in fact osteoporosis literally means porous bone and refers to a decrease in bone mass that leads to increased fragility and likelihood of fracture what do you process in perspective it's very common 34 million Americans are estimated to have low bone mass and compare this to a very similar number of individuals who have high blood pressure and just slightly less than those who have high cholesterol so very common public health problem what's not always appreciated is how devastating osteoporosis can be the most significant kind of fracture is a hip fracture of which there are about 250 to 300 000 cases per year and the one-year mortality is really shockingly high after a hip fracture it can be 25 or more and if you compare that to other diseases for which we think of as having serious impacts on health um you know they're about 700 000 heart attacks or myocardial infarctions a year in the U.S um for which the one-year mortality now is less than 10 because of the outstanding work in both prevention and treatment there are a similar number of invasive breast cancer cases Advanced Breast Cancer cases diagnosed each year 230 000 and this is a case in which the mortality is also pretty high after one year about 20 percent the lifetime risk for osteoporosis for women is 50 so one in two women will have uh an uh fracture due to fragile bones or osteoporosis um compare this to a 12 percent or a one in eight chance over a lifetime of being diagnosed with breast cancer I alluded to the fact that men are also at risk for osteoporosis about 20 percent of men can expect to sustain a fracture in their lifetime due to osteoporosis and this is more on par with the rate of diagnosis of prostate cancer which is quite common in them so this is a photograph of a fracture cast I think in the back you can see a person standing in there to give you some sense of How High this is this represents the 5500 fractures that occur every day in the U.S due to osteoporosis which is more than 2 million per year so osteoporosis is in fact a major public health burden affecting more than 10 million Americans 80 percent of whom are women on the previous slide I assure you they're more than 2 million fractures per year and this number uh representing the direct cost per year is now far outdated probably well exceeds 20 to 25 billion dollars in costs two per year the kinds of fractures that can occur with osteoporosis vary by a number of sites perhaps the most common is a vertebral fracture or a spine fracture I'm also common sites are risks especially I trained in Boston and it's quite common in the winter to slip on a patch of ice and land on your outstretched hand and so this can lead to wrist fractures we've talked about how hip fractures are particularly devastating um likewise pelvis fractures and other types of fractures the kinds of fractures that occur with osteoporosis can change over the lifetime so wrist fractures are most common in relatively younger women those in their early 50s and 60s and again I think that's because if you were to slip and fall on the sidewalk uh younger women are able to get their hands out they have their reflex time to put their hands out to break their fall and often will fall on their outstretched hands leading to a wrist fracture spine and shoulder factors are a little bit more evenly distributed across ages whereas hip fractures really are mostly limited to the elderly population over the age of 70 to 75 and I think as you get older the balance gets worse the Frailty gets worse and if somebody were to trip and fall they're less likely to be able to catch themselves less likely to be able to break their fall with their arm and more likely to fall directly on the hip leading to a hip fracture so a little more about osteoporosis in men about one-third of hip fractures do occur in men men suffer almost 600 000 fractures a year of which about 75 000 are hip fractures what's particularly aligning is that men are more than twice as likely to die after hip fracture but less than half is likely to receive treatment for osteoporosis so increasing public awareness that osteoporosis affects men is a high priority of mine um Gene mentioned in the introduction that my laboratory is very interested in breast cancer and bone metastases in my clinical practice I focus on osteoporosis in patients who have breast and ovarian cancer and in particular women mostly women there are men who have breast cancer in women who have breast ovarian cancer they can be at risk for bone loss for a number of reasons many women are treated with chemotherapy which is quite toxic and can be tough on the bones the chemotherapy can lead to premature menopause from the stress the biological stress of the process because many breast cancers are treated with endocrine therapy to block estrogen which leads to bone loss that can also increase the risk of fracture and finally many individuals with cancer are treated with radiation therapy which also can result in bone loss so this is just a figure showing in light grade survivors with breast cancer and comparing their fracture rates which are significantly higher than reference control individuals without breast cancer and to stay on the topic of cancer and bone loss again to make the point that those individuals who are treated with endocrine therapy are at particular risk so let me start by reviewing the normal rates of bone loss in men it's about 0.5 per year women have a period around menopause when the estrogen levels fall pretty abruptly and so the rates of bone loss during menopause and after it can be as high as one to two percent this is sort of naturally occurring bone loss here in green um but shown to the right in blue are bone loss that result from cancer therapies and highlighted in the red boxes are endocrine therapy relating particulated breast cancer so aromatase Inhibitors are a common way to block endocrine um block estrogen levels in individuals with breast cancer and you can see that the rate of bone loss is higher than naturally occurring bone loss after menopause the greatest bone loss comes in younger pre-menopausal women who either are put on aromatase therapy and ovarian suppression to prevent cancer recurrence or who have chemotherapy-induced premature menopause and you can see that these rates of bone loss are really dramatically higher than naturally occurring rates all right so let's talk about who should be tested who's at risk Frosty purses and who should be tested so there are a number of risk factors that increase a person's chance for having fractures probably the greatest is age the older we get the higher the risk of fracture for a number of reasons because bone density goes down because muscle strength goes down because people become more frail balance goes down and all of those things lead to increased risk of fracture a history of our previous fracture is also a very important risk factor so if you were to look at individuals who have a hip fracture and go back in time about half of those individuals previously had some other kind of fracture for instance a wrist fracture or a spine fracture I showed that risk wrist fractures happen more in younger adults around the ages of 50s to 60s and you know it's particularly sad when somebody comes in with a hip fracture or and and you learned that there was a history of a previous risk fracture and they say well but you know I I slipped on the ice and I fell really hard but the reality is you should not break a bone if you're falling from standing height or lower of course if you fell off a 10-foot roof or were involved in a motor vehicle accident that's certainly a higher level of trauma other things that increase your risk for having bone loss and fractures include medications particularly glucocorticoids so these are commonly known as steroids they include medications like prednisone prednisolone methylprednisolone Solu-Medrol a family history is important particularly if you've had a parent who had a hip fracture you know we in in the medical field we spend a lot of time discussing with patients how excess body weight can be associated with risks but osteoporosis is a case where being too thin actually raises the risk of bone loss smoking excessive alcohol intake rheumatoid arthritis and other inflammatory diseases and finally secondary osteoporosis which is osteoporosis relating to other conditions or medications it's important to identify those who have these risks for fractures because again if you look at all hip fractures they occur from a relatively small fraction of the population and many of these individuals have previously had a fracture whereas half of the fractures occur in the rest of lower risk individuals so our gold standard test for identifying individuals at risk for osteoporosis is called the bone density test it's also referred to as a dexa scan that stands for dual energy x-ray absorption geometry the general recommendations from a number of professional organizations devoted to bone health suggests that women who are 65 or older and men who are maybe 65 70 or older should be um referred for a screening bone density test in addition younger postmenopausal women or men between the ages of 50 and 69 who have significant risk factors like the ones we discussed before so medications that cause bone loss cancer treatment other conditions like rheumatoid arthritis history of tobacco or heavy alcohol use those would all be reasons to consider earlier screening and finally what's often missed is individuals who've had a low trauma fracture or what we call a fragility fracture after the age of 15. so not counting um you know broken arms that happened when you were a child or teenager um but as an adult after the age of 50 if you've had a fracture that really happened without a lot of trauma um that's an indication to get a screening bone density test and then finally as we talked about there are conditions like rheumatoid arthritis and medications like glucocorticoids that can also be associated with bone loss so what is abundant CD scan this is a photo taken with permission from our scanner here at Stanford um it's basically a bed with an arm around it and it takes pictures of the spine and the hip and calculates the bone mineral density sometimes on rare occasions we also measure the wrist thank you the rodency um is measured in terms of T scores which are standard deviations compared to reference adult populations excuse me for one second I'm going to take a drink so as you can see here adult bone density is highest in young adults matched for gender and perhaps race and ethnicity with age there's a gradual decline in women there's a more rapid decline around the time of menopause um and then it evens out again over time so in the hip we measure the ephemeral neck which is the thinnest part of the hip joint as well as the total hip and in the spine we measure the lumbar vertebra L1 to L4 and the world health definition World World Health Organization defines osteoporosis as the t-score that is two and a half standard deviations lower than that of a reference young adults if you have an intermediate bone loss something we call osteopenia that's a t-score of -1 standard deviation to minus 2.5 and if your mind density is greater than one standard deviation below the reference adult then your abundant city is considered to be normal this is a non-invasive test it doesn't hurt you lie on this bed for about 10 minutes and you can get these results so I'd like to spend a few minutes talking about the fact that your fracture risk depends not only on your abundant density which is measured by dexa but also on age so here is a chart showing um bone mineral density t-score decreasing towards the left so on this direction is the most severe you know a t-score of minus 3.5 and then on the um y-axis is your risk of having a hip fracture over the next 10 years as calculated by an algorithm we used called frax and this is for a woman who is 150 pounds five foot six inches and I've plotted her risk over uh different bone density scores at a variety of Ages so first let's look here at a t score of minus 2.5 which is what the World Health Organization defines as osteoporosis and the recommended threshold for treatment is when the 10-year risk of having a hip fracture is at three percent now that might sound like a very low number but again remember that I showed that the um effects of a hip fracture are really devastating at you know 20 mortality rate so we really want to set this threshold very low and try to prevent as many as we can so at a t-score of minus 2.5 a 65 year old woman shown here in this sort of dark blue black band um will cross the three percent threshold right at a t score of minus 2.5 so a 65 year old woman who has a t score of minus 2.5 for a diagnosis of osteoporosis by bone density would Merit treatment if you are younger than 65 your abundant City can be lower it can be almost as low as minus 3.0 before you reach that threshold so sometimes I see younger women in my clinic who for whatever reason have had a bone density and have been identified as having you know a t-score of minus 2.7 minus 2.9 technically in the osteoporosis range but if we calculate her risk because she is so young she's relatively protective they might say you know we don't need to treat right away we can watch for it but the converse is also true and what I want to show you here is on the far right a woman at age 80 can have a near normal bone density T square of minus maybe 1.31.4 and still reached that risk threshold of three percent and again that's because there are many other factors that go into your risk of fracture and these increase with age so often we'll see an older adult who has fallen and had a wrist fracture or maybe has had a spine fracture and the primary physician very appropriately orders abundant City Skin but then when the results come back as osteopenia the patient might be told oh everything is fine don't worry but in fact if you've had a fracture or if you are older than 75 or 80 um it could well be that you could be at risk for osteoporosis even without a very low bone density score the other point I'd like to make is the number of risk factors you have also significantly matters so again this is the same woman at age 65 for a given height and weight looking at the number of risk factors that she has and you can see that if she only had zero or one risk factor she might not reach the treatment threshold but at two and more that risk significantly increases so the more risk factors you have ferocity process the greater the chance of fracture all right it's also important to note that while having a very low t score is a risk for osteoporosis and fractures having osteopenia or osteoporosis doesn't mean I'm sorry having osteopenia or a more normal abundant city does not always mean that you're in the clear and that's because about half of fractures actually occur in individuals who have osteopenia and that's a function of the fact that a much larger percentage of the population has osteopenia and osteoporosis so even um when you have osteopenia you can be at risk for osteoporosis and that's the reason that we assess all the other risk factors to try to stratify those individuals who are greatest risk all right now we can talk about things that we can do to improve bone health so the surgeon general's Freeport has several recommendations getting enough calcium and vitamin D we'll talk on the next few slides about what that means being Physically Active reduce your risk of Falls so this means things like if you have loose throw rugs um throughout your house to make sure that they are either tacked down or stuck to the floor that you don't have loose rug Corners I wish you might trip things like having um good railings and banisters on the stairs at night having a nightlight to the bathroom a surprising number of Falls occur in older adults because they were getting out of the bed to go to the bathroom in the middle of the night it was dark it might be a little bit sleepy their balance isn't so great maybe the dog is lying on the floor next to the bed and so that is a very common scenario for older adults to trip and fall while going to the bathroom so having a nightlight to allow a little bit of visibility is important maintaining a health healthy weight that means not too thin or not too overweight don't smoke or stop smoking if you do limit alcohol use no more than a drink a day for women two drinks a day for men and finally we discussed that several medications and diseases can be associated with bone loss so bringing that to the attention of your physician to talk about bone health all right let's talk about calcium calcium is part of the mineral in your bone the reason your bones are so structurally hard is because they're largely composed of calcium and phosphate mineral deposited as something called hydroxyapatite and calcium is the part that we have some control over how much is deposited so a general guideline is that we should be aiming for a thousand to twelve hundred milligrams of calcium per day if you're at risk for bone loss and this can be from dietary sources or from supplements so if you want to take dietary sources you can see that dairy products milk yogurt cheese are really a wonderful source of calcium on average one serving of dairy so that's a cup of milk a cup of yogurt an ounce or two of cheese have almost 300 milligrams of dairy so if you were to have two to three servings of dairy a day you would really have very sufficient calcium intake calcium can also be found in other Foods many juices and cereals are fortified if you like canned salmon especially with the bones that's a good source um dark green vegetables broccoli kale are also a great source um just not as concentrated as dairy products now many adults especially on a western diet don't get three servings of dairy products a day and if that's the case you can also take supplements or maybe you have lactose intolerance um perhaps you're on a vegan diet and dairy is not part of your dietary intake and so that's fine you can do calcium entirely based on supplements the important thing to remember is you want a thousand milligrams a day but your body can really only absorb about 500 milligrams at a time so if you are taking only supplements you need to divide it into two doses of roughly 500 milligrams at a time if you happen to be taking medications for acid reflux Flex so things like proton pump inhibitors or H2 blockers then you should take a form of calcium called calcium citrate otherwise calcium carbonate is the most abundantly available it's over the counter it is less expensive and that's a perfectly fine supplement you also need vitamin D vitamin D acts on the intestines to help absorb calcium and a general guideline again for individuals who are at risk for bone loss is a goal of 800 to 1000 international units a day so to keep things simple I generally tell my patients to remember a thousand milligrams of calcium and a thousand units of vitamin D so vitamin D can come as a plant-based supplement which is vitamin D2 also known as ergocalciferol um probably more commonly you'll see vitamin D3 on the shelves of your Pharmacy choli calcifera this is the version that we produce in our skin when we are exposed to sunlight and it's an animal based form either of those is fine and you can take all one thousand all at once or you can buy calcium supplements that have the vitamin D divided into those Doses and take those as well next we have to talk about physical activity uh as you know when we send our astronauts up into space so they can rapidly lose bone and in fact I read somewhere that the astronauts on the International Space Station devote about three to four hours per day to rigorous activities so that they can maintain their bone health when they come back to earth so the American Heart Association recommends 150 minutes of moderate or 75 minutes of vigorous activity a week I tell my patients to aim for 30 minutes a day so that can be walking it can be tennis swimming anything that you enjoy the important thing is to do something an average of 30 minutes a day for per week every every week in addition for bones um specifically it can be very beneficial to do strength training and I recommend two to three times a week these can be with free weights these can be at the gym using weight machines they can be resistance bands you can get them on Amazon for a few dollars you can get a bag of resistance bands that have different degrees of stretchiness there are also many videos available online that have body weight exercises so things like squats push-ups uh there you know you can get a very effective strength training routine without any kind of equipment at all I also counsel my patients that balance and flexibility are very important things like yoga and pilates and stretching can be very beneficial so if you're looking for resources the bone health and osteoporosis Foundation is a patient-facing organization that has some great tips on osteoporosis in general but they have a nice guide to exercise and then I like this website melioguide.com which is written by a physical therapist who specializes in osteoporosis and provides some nice guidance on exercises all right sometimes lifestyle changes are not enough you can have all the calcium and vitamin D you can do all the right exercises that you might just have either such a low bone density or a calculated risk that is too high and we really have to think about treatment so how do we make those decisions who is at um at need for treatment so again we talked about how individuals who are women over the age of 65 men over the age of 70 or those who are younger with risk factors or fracture history should have a dexa skin those who have osteoporosis the t-score of minus 2.5 or who have had a previous fracture a hip spine and that can either be clinical which just means that you knew you had the fracture or radiographics sometimes spine fractures surprisingly are what we call silent people don't realize that they've had a spine fracture it's just visible on x-ray so this category should be considered for treatment if you have osteopenia then we recommend using that fax calculator I showed a few slides ago to calculate the 10-year risk of fracture and if it exceeds three percent for hip fracture or 20 for all major osteopotic fractures then also you fall into the group for which we should consider treatment so just a little bit on medications because that's really more of a discussion for your doctor but just so that you're aware of what exists out there as options so I tell my patients that the amount of bone that we have is really determined by the balance between how much bone is formed versus how much bone is broken down so we have cells called osteoblasts in our body that make bone and we have cells called osteoclasts that break down the bottom and I um use the analogies of the brick layer for bone formation and the Jackhammer guy for bone breakdown so really it's quite simple if we want to treat osteoporosis we can either stop the jackhammers we can block bone breakdown or we can promote bone formation Now by far the most medication prescriptions are written for these medications here which black bone breakdown what we call anti-resorptives the anabolics are really reserved for various severe cases this is a summary table of osteoporosis medications in pink on the top are the anti-resorptives these again are the most commonly prescribed medications they include oral bisphosphonates you may be familiar with um alendronate which is marketed as Fosamax resedronate marketed as actinel there's an intravenous form a zolodonic acid we class these are very very safe and effective medications they are our longest standing um osteoporosis medication for the oral medications they sometimes cause heartburn or GERD and gastroesophageal reflux disease they can't be used in individuals who have renal um kidney problems um and if somebody has heartburn or gerd then we recommend intravenous bisphosphonique also known as reclast again cannot be used in individuals with poorly functioning kidneys a newer medication in this sort of group approach is stenosamab marketed as Prolia the nice thing is it can be used in individuals whose kidneys are not functioning at 100 percent as the important thing to remember for Prolia is it cannot be stopped abruptly and there's a little bit of caution for those who are immune compromised the anabolic or bone building medications shown in green we have three options uh two of them are very similar forteo and timlos um and they're all very effective these two do require daily self-injections so you can imagine that's not a super popular option um and again why we reserve it for more severe cases the newest entrance on the market is ramasozumab marketed as a vanity causes very rapid reduction in Risk which is great if somebody is that high risk um it does carry a box warning a risk for some cardiovascular Adverse Events these are monthly injections highlighted in bold are the ones that are also approved for men so all osteoporosis medications are first tested and approved by the FDA in women with post-menopausal osteoporosis and then often the companies will seek approval for um osteoporosis cinnamon I do want to make the point that um since I discussed uh the risk of bone loss in cancer patients particularly those undergoing endocrine therapy that it's really the anti-resorptives that our preferred options for individuals with cancer and finally the sequence matters all you need to know is that if you are ever started on one of these anabolic agents in green um it can it must be followed by an anti-resorptive if you were to stop after this one to two year period the new bone would go away very quickly and considering that two of them require giving yourself injections every single day that would be very disappointing so you want to immediately switch to an anti-resorptive um it's also important to note that if that anti-resorptive is denasana which is Prolia which can be safely given for you know five to ten years it cannot be stopped abruptly so after that you also need to switch to one of the oral or intravenous bisphosphonates for maybe up to a year but again these are details to be discussed with your physician and finally in the last few minutes I want to discuss address the issue of whether osteoporosis medications are safe um I I see only osteoporosis patients in my clinic so I really heard all of the concerns and it's quite common for individuals to come to me and say I prefer natural remedies I'm sensitive to medication I read that they can be dangerous um or understandably I I know somebody a relative a friend who took the medication and had an unpleasant type effect so I I certainly appreciate that there's um a lot of uh concern about taking medication in general and um with some of the rare side effects of these medications one of which is a condition that affects the jaw called osteonecrosis of the jaw this has led to a great deal of uh worry uh um among patients and their dentists about whether they can safely take these medications and I just want to point out that the American Dental Association issued a statement that said that um you know discontinuing osteoporosis therapy might not eliminate the risk because this condition does occur even without these medications however it's important to remember that discontinuing osteoporosis treatment can have a very negative effect on the treatment of low bonus so essentially it can you know raise your risk of fractures so um just uh advising um some caution in in asking people to stop so I think a more helpful way to think about it is what are the benefits versus risks of treatment um so shown here in grade in the first three are spine wrist and hip fractures among patients treated for a hundred thousand patient years so this could be ten thousand women treated for 10 years you can see there would be several uh if they were untreated there would be several thousand spine fractures risk factors hip fractures combined but if they're treated with osteoporosis medication this difference is the reduction in the number of fractures and that's pretty significant compare that with the risk of the rare side effects osteonecrosis to the jaw and atypical fracture and and again these are extremely low and they're broken down by treatment duration so more than 10 years is what it takes to see any detectable rates of atypical fracture and you can see that's far less than your risk of being involved in a car accident I think this is also another way to visualize it which is um if you were to treat say a thousand women over 10 years these are the number of fractures that you would prevent again remember that one out of every two women is going to experience a fracture in their lifetime from osteoporosis so these are the number of fractures that we would prevent these are the number of cases that you might expect to see of osteonecrosis of the job and if treated for five years atypical fractures so I think the important take-home point is that in appropriate individuals the benefits of five years of treatment really far far outweigh the risk and with that I will come back to my take-home messages which are the factors due to osteoporosis are serious but preventable and in fact are not an inevitable part of aging I hear from many people that own you know my my mother my aunt my uncle fell and broke their hip or their wrist or something but they were older and they felt but that that really should not be an expected part of aging there's a lot we can do to mitigate that um remember the osteoporosis affects not only women but also men your risk of fracture depends on a number of factors Lifestyle Changes um Can indeed slow but usually cannot reverse severe osteoporosis or bone loss and when used properly osteoporosis medications are extremely safe and effective and with that I will thank you for listening and if I can figure out how to stop sharing okay we've got quite a few questions here Dr Wu um let's start how much milk do women over 70 need to drink so um it's about the amount of calcium so uh all individuals who are at risk for bone loss need to have um about a thousand milligrams of uh calcium here we go uh a thousand to twelve hundred milligrams of calcium a day and so milk is a very efficient source that provides about 300 milligrams so if you didn't want to take any supplements you could drink three glasses of milk a day all right um currently I'm receiving uh an annual re-class infusion okay what's the maximum number of times to receive this drug right so there's not a maximum lifetime number um I do recommend for my patients and again this is um a case-by-case determination but for most of my patients um after you know three to five infusions yearly infusions I will um recommend what I call a drug holiday so that means stopping the infusion for a year to two and the reason we do that is because we know that if you stop the medication for a year those already very very very low risks of osteoporosis of the jaw and atypical fracture get reset to Baseline after just one year of not having the infusion after two years the risk of having osteoporosis starts to rise again so for most of my patients I recommend a holiday of one to two years and then you can safely restart and you know continue with another say three to five infusions all right why are TBS scans more widely known and used that's what they have here well OTP skin right yeah so so TBS is um largely still investigative it's another you know everybody is trying to figure out ways to even better predict who is at risk um so TBS is um it's a trabecular bone score it's um it's a radiographic software that can be added onto dexa scans um and and you know may modestly improve the prediction rates so that is you know comes down the software is very expensive so every hospital has to decide whether or not it's worth it and um you know so far the data are encouraging but it's it's a pretty modest Improvement in the prediction of risk so I think um you know it's up to each Hospital whether or not they want to carry it all right could osteoporosis be the cause of shoulder elbow or hand pain so osteoporosis usually is not a cause of pain pain is more likely to be due to something going on in the joints so that would be osteoarthritis or maybe rheumatoid arthritis osteoporosis is silent which is why we need to screen for it because you really can't feel your abundance until of course you have a fracture which is then very painful and you don't want um you don't want to wait until then um what exercises should be avoided if you have osteoporosis so I don't um I try not to ever tell anybody not to exercise so I think uh you know the if you look at the websites that I recommended there are some guidelines about things um often you know individuals with newly diagnosed osteoporosis will ask me can I still ski can I go horseback riding um and usually what I tell those individuals is you know uh for instance I am a a big fan of skiing I assume a risk every time I ski that you know there there could be a fall there could be a fracture if somebody is a skilled experienced skier and they're willing to accept that risk then you know I think that's a personal decision um if you've been diagnosed with severe osteoporosis and you're wondering if you should learn to ski for the first time I would say maybe maybe get some management and treatment first but I try very hard never to tell anybody not to do exercise okay kind of related why do so many hip fractures lead to death yeah it's it's really quite shocking and the answer is not that the uh it's not the hip fracture itself that caused the death but often it's sort of um the final straw in an older individual who's frail so um being bedridden being in the hospital being um you know susceptible to infections or perhaps blood clots if you can't um can't get up and walk around it's sort of the cumulative effect of all of those um hits to the to the uh the body and the individuals so it is it is usually not the case that the hip fracture itself um caused the death but it's all of the downstream effects um and and when you talk to individ to people you know many people will say oh uh my parent or and you know my grandmother had a hip fracture and and then she died and and that really should not be an inevitable uh link so we of course want to try to prevent that okay are any of the newer medications for bone growth more effective than the older ones um so I mean I guess more by well no so um they're all effective they all significantly decrease fracture risk um the newest medication happens to be what we call an anabolic which is a bone building medication so it acts maybe more quickly but all of the medications are quite effective at lowering fracture risk overall and personally I prefer the medications that have been around the longest because we have the longest history of understanding how to use them the most safely um and and you know understanding what the side effects are and how they can be managed okay does having a hysterectomy at 50 increase your risk for osteoporosis so the hysterectomy itself which is removal of the uterus should not really influence your osteoporosis risk however it's quite common to remove the ovaries at the same time as the uterus was easy and removal of the ovaries does cause loss of estrogen and bone loss all right a t-score of 3.3 is that considered severe I I assume you mean a t-score of minus 3.3 so yeah standard deviations below um uh reference adult range um yes that would be getting towards the the range of severosity processes okay objective is weight-bearing exercise to prevent osteoporosis um I I think that a healthy lifestyle can certainly be very effective at slowing the rate of bone loss um you know certainly I gave the example of astronauts who lose a lot of bone um you know we also see counter examples so tennis players who start playing at a young age their dominant serving arm is noticeably stronger than the other arm so um it certainly can have some effect there was a study in Australia a number of years ago where they um took a group of women around the average age of 65 and subjected them to pretty rigorous weight lifting so um not you know not Ginger one to two pounds but sort of uh you know 80 of the maximum amount of weight they could live live for a given exercise with as you might imagine very very careful supervision and they had pretty substantial increases in bone density on the range of five to ten percent which is uh not that far off from what we can accomplish with medications but that was you know a very carefully done supervised and um quite rigorous training program so it may or may not be for everybody foreign okay does having a cortisone injections for that bursitis pain register as a risk factor that's a great question so many people get cortisone injections for joint pain and discomfort um for the most part those injections should be really localized to the Joint we worry more about systemic dosing of glucocorticoids or steroids so things that are taken orally or given intravenously and for the most part local steroid injections should not not be a significant contributor unless of course you're getting you know many many of them or very high doses all right uh is there the possibility of hip replacement as a protective treatment for someone with serious hip bone loss so um I'm not an orthopedic surgeon but hip replacement is really done more for arthritis or you know if you've had a factory then then of course there might be Hardware that is implanted but it is not done as a preventive measure for preventing hip fractures okay um is there a risk of too much calcium for heart for heart health so there have been some studies that have purported to show an association between high-dose calcium supplementation and worsening heart disease those um have not been very rigorously done studies uh you know they were sort of after the fact analyzes of data that was collected for other reasons which is not sort of the gold standard of how we do clinical research that being said if you look at those studies um and and you sort of take it you know on face value that there is the risk it really seemed to be associated with individuals who are taking very high doses of calcium more than three thousand milligrams a day and I would never recommend that because that will for certain raise your risk of kidney stones so um you know again the amount of calcium is you know roughly a thousand to twelve hundred milligrams okay all right um this might be are there problems if you get 1200 they don't say what from diet and still take 1200 in supplements I don't know if that's calcium or vitamin D well it's uh we don't really get vitamin D from diet so I'll assume that um the question is about calcium um so that means you're taking 2400 milligrams of calcium which is quite a bit um so it's if you're really getting 1200 milligrams in diet it's it's not necessary to take the supplements more is not always better okay someone is asking about Osteo strong a program that uses muscular skeletal strengthening have you do you know anything about that um so I don't endure specific programs um but I do endorse strength training so um if you you know if you assess the program and you find that it's a good strength training program that you think you might benefit from and that would be fine okay uh there's a question um about uh can you explain how much calcium can be absorbed at once right so um your body can absorb maybe five or six hundred milligrams so the point is that if you're going to take all of your calcium as supplements you need to divide it into two doses okay we can't absorb the full um 1200 all at once okay [Music] what is your thought on adding vitamin K to calcium supplement ation yeah so um there is quite a bit of work going on looking at the role of vitamin K it's quite common in supplements um it doesn't reach the level of rigorous clinical evidence for which calcium and vitamin D have so I don't specifically recommend it unless you have a vitamin K deficiency which is quite rare um I I don't I think it's unlikely to be harmful if it's in your supplement but I don't specifically recommend it okay um or an invasive dental procedure how long before the procedure must the biophosphonates be retired right so there isn't you know these these complications the osteenicris of the jaw are so rare that it's exceedingly difficult to do any kind of Trials and understand them um and so there is no data to guide us on this and in fact um again that you know the the estimates of um frequency are are very very low so um you know I think that's a question to discuss with uh your dentist or oral surgeon um if uh if it's a routine you know cavity or cleaning root canal that's really not um any indication to stop um I think the exception are procedures that will drill down into the bone so specifically implants um or maybe you might want to you know take into account and and often then um I've heard surgeons prefer anything from three months to a year so okay great uh um okay what is your opinion about the value of collagen and oral connective tissue and increasing bone density not sure what that means but maybe you should I'm not certain I wonder if this person's referring to things like uh well actually I've never heard of oh I don't know if there's such things as oral collagen I think I'm thinking of glucosamine kendritin um there's no um there's no strong evidence to support them okay and how do studies Define or validate that a fraction is due to osteoporosis so we Define osteoporosis fractures is those that occur with low trauma and so the formal definition is standing height or lower so if you tripped on the curb if you slipped on ice if you you know were just standing and fell um so you know anything at a if you fell from a higher height or if you were involved in trauma a motor vehicle accident you know skiing Sports Injury those would not be osteoporosis fractures but we Define them as for you know fragility fractures occurring without trauma all right um let's see what if one has different T scores for the spine a hip yeah that's a great question so um we we do most commonly measure spine hips sometimes the wrist and you'll get different t-scores so it's the lowest t-score guides the decision making and it predicts risk everywhere so I often the spine is typically lower than the hip um and that's because you have more surface area of bone in the spine and so it can rise and fall more quickly and so it's quite common that I can hear from patients that you know that they're concerned that they have a low spine bundensity and therefore that their risk for spine fracture that's a very logical assumption but actually a low bone density anywhere predicts risk of fracture everywhere okay if I had a dexy scan uh years ago that determine osteoporosis should I have another to see if the results have changed um sure if you if you've previously had osteoporosis on a abundant City Skin it's probably a good idea I I typically recommend most insurance companies will cover every two years so that's typically the window after which I repeat bone density scans okay uh do you still need to take calcium in some form while taking reclast yes the calcium again is what makes the bones strong the mineral that's what contributes to the the hardness of the bone and and its strength and so if you're you know on treatment Frosty process it's especially important to have plenty of calcium so that the treatments can work what type of milk is best to drink one percent two percent or whole it doesn't matter it's the amount of calcium okay in that so uh let's see what is your understanding of the effectiveness of bio-identical HRT to help prevent bone loss or improve bone density so um I'm not going to comment necessarily about bioidentical but hormone replacement therapy in general um although home we're referring here to estrogens um in progesterons are clearly beneficial for bone and that is the reason that women lose bone more quickly during menopause is because estrogen levels fall um and so while HRT is clearly beneficial for bone the Women's Health Initiative study now almost 20 years ago showed that there are other risks associated with HRT relating to cardiovascular disease breast cancer and because we have such effective treatments that treat bone loss themselves I I do not prescribe HRT for the treatment of bone loss you can speak with your um gynecologists there are indications for HRT particularly in women who have just gone through menopause so early post-menopausal women who are experiencing very uncomfortable symptoms relating to the menopause transition that is a a very reasonable indication um but specifically for the prevention or treatment of bone loss um HRT is is not a typical treatment okay um someone asked why is running not considered weight-bearing for osteoporosis prevention why is running running I mean I think running is a terrific exercise it certainly has great cardiovascular benefits it will um it will load a bit the lower body right because you're pounding on the pavement um if you're going to do running then it's important also to do upper body strengthening as well okay and I think this will be our last question what are your thoughts on bone excuse me bone marker tests in addition to dexa scan right so um in in certain certain circumstances they can be helpful um but the the challenge with bone marker tests is um they are not uniformly uh applied and they have quite a bit of variability so um I think the analogy that everybody thinks of is you know in cholesterol testing uh we prescribe medications to lower cholesterol and we can very accurately measure the cholesterol levels and um and they correlate with risk of heart disease and we would very much like something similar in um the osteoporosis world to correlate with fracture risk and to tell us whether our treatments are working um and and the current markers are are just not that sensitive uh and helpful but in certain cases they can be useful well I really want to thank you Dr Wu for sharing this great information I I only scratch the surface of some of these questions um I want to thank the audience for joining us and and for these great questions and also um if you didn't get your question answered um and you would like additional information or resources please contact the Stanford health library um this presentation will be available through the Stanford health library and also our YouTube channel soon very soon a couple weeks at most uh I hope you can join us for our next lecture thank you thank you so much for having me you're welcome good night

#Osteoporosis #Prevention #Treatment

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