Are you aware of the silent killer affecting over 10.2 million Americans? Join us for a riveting discussion with Patricia Donahue, an acute care nurse practitioner at the Kayal Orthopaedic Center, as we uncover the mystery of osteoporosis. Gain valuable insights on bone metabolism, the process of bone growth and turnover, and why it's crucial to build up our bone mass during our childhood and adolescent years.
Discover the various tests that can be done to assess for osteopenia and osteoporosis, including the gold standard, the DEXA imaging test. Learn the importance of regular testing, especially for high-risk groups, in order to prevent fractures and maintain bone health. Patricia also sheds light on the difference between Z scores and T scores and how they help to identify the risks of developing osteoporosis.
Finally, we explore the treatment options available for osteoporosis, including medications like bisphosphonates, RANKL inhibitors, and anabolic agents. Patricia emphasizes the need for monitoring vitamin D and calcium levels when starting medication treatment and the implications of stopping medications without proper transition. We also delve into the role of hormone replacement therapy and the use of the drug Evista in breast cancer patients with osteoporosis. Don't miss this informative conversation with an expert in the field of osteoporosis diagnosis and treatment.
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Transcript
Episode Transcript
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Robert A. Kayal, MD, FAAO (00:00):
Hello and welcome to another edition
of the Kale Ortho podcast.
Today is June 13th, 2023.
And today's guest is PatriciaDonahue.
She's an acute care nursepractitioner at the Kale
Orthopedic Center And shespearheads our osteoporosis and
bone metabolism center and runsour fracture liaison service as
(00:20):
well.
Welcome to the podcast,patricia.
Patricia Donohue, ACNP (00:23):
Thank you, Dr Kale.
Thank you for having me today.
Robert A. Kayal, MD, FAAOS (00:25):
Oh, i'm honored to have you here.
We're so happy to have you herebecause we're going to speak
today about a very, very common,ubiquitous problem, and that is
osteoporosis.
Osteoporosis is extremelyprevalent in the world.
Unfortunately, it's known asthe silent killer.
It is estimated that more than10.2 million Americans have
(00:46):
osteoporosis And an additional43.4 million people have low
bone density.
Two million new cases ofosteoporotic fractures per year
exceeds the annual number of newcases of myocardial infarction.
That is, heart attack, breastcancer and prostate cancer
(01:07):
combined.
Annual fracture incidence isexpected to increase 68% to 3.2
million by the year 2040.
It is no wonder we callosteoporosis the silent killer.
So we're going to just jumpright in right now and invite
(01:27):
Patricia Donahue to speak to ustoday about bone metabolism,
osteoporosis diagnosis,treatment and monitoring of this
wretched condition.
So let's first start and talkabout bone metabolism.
Let's just talk about the factthat our bones, our tissues and
these tissues are alive.
(01:48):
Can you elaborate on that forus, patricia?
Patricia Donohue, ACNP (01:51):
Sure.
So our bones are a livingtissue, as Dr Kale said, And we
basically build most of ourbones.
It's called the bone modelingyears during our childhood years
The very important duringadolescence, because that's when
we deposit most of ourmineralization into our bones.
Then we continue to grow upuntil around the age of peak
(02:15):
bone mass, When we stop growingadditional bone and that's where
our bone bank stops.
But it's very important inthose years to get our
mineralization, our calcium, ourvitamin D for any parents that
are out there or grandparentsfor their children to get the
adequate amounts, to put theadequate amounts in their bone
bank.
At the age of 27 to 30, we stopgrowing.
(02:38):
We make additional bonethroughout our lives But what we
do is we have these other bonecells and I call it plowing the
land It's almost like excavatingAnd then the new bone cell
growth just fills in thosedefects.
We never grow additional bonethroughout our life after the
age of 30.
So we really turn or turningover our skeleton.
(03:00):
We're making less bone as weage.
We're breaking down more boneas we age And certain conditions
that we work up and evaluatepatients for in the Metabolic
Bone Health Center are certainconditions that can affect bone
growth or bone turnover.
As Dr Kale said, this is asilent disease So we need to
(03:24):
recognize risk.
Factors are very important ingetting patients to get a bone
density test and an evaluation.
Robert A. Kayal, MD, FAAOS (03:32):
I always emphasize that with the
pediatric population that wetake care of at the Kale
Orthopedic Center.
Very often when children comein with their parents and they
break their wrist, i emphasizethat, that young age, that it's
incumbent upon us to enforce theneed to take calcium and
vitamin D during our growingyears, because we're
(03:53):
establishing our bone density,our bone stock, by the age of 30
.
That's when we really reach ourpeak bone mass.
So it's incumbent upon us toenforce to children that they
should be taking calcium andvitamin D, especially during
their growing years, becausethat is essentially the peak
bone mass that they're going tobe starting with And it's sort
of downhill after the age of 30for both men and women, but
(04:15):
especially from women after theyhit the age of menopause, and
we'll talk more about that in alittle bit.
So, as far as the biology ofbone metabolism, there are a lot
of things that we can do thatare important cellular
characters that we discuss, thatplay critical roles in bone
metabolism.
What are some of those players?
Patricia Donohue, ACNP (04:37):
So the bone growth cells are called
osteoblasts and we actually canmeasure them in blood tests to
see how much somebody isactually making.
And then there's osteoclasts.
The osteoclast takes the olderremnants of bone and clears out
the tissue in the bone, so newbone cell growth can come into
(04:58):
place.
and the osteocytes are aprecursor to osteoclasts.
So a lot of our medications,you'll see, are targeted at
these three areas.
Robert A. Kayal, MD, FAAO (05:07):
Right .
So these cells emanate from thebone marrow.
These undifferentiatedmesenchymal stem cells become
these osteoblasts and osteocytesand osteoclasts, and they all
play very, very important rolesin this bone metabolism.
So essentially, the good guysare the osteoblasts that make
(05:28):
the bone, the osteoclasts sortof break down the bone, but both
are necessary for normal bonemetabolism And it is the
interaction between these cellsthat allow bone to remodel and
form and break down throughoutour lifetime.
And that's what really accountsfor this bone remodeling and
(05:51):
the fact that we replenish orturn over our entire skeleton
approximately eight times in ourlifetime.
What are some of the tests thatwe can do in the office to
assess whether or not a patientpotentially can develop
osteopenia or osteoporosis?
Patricia Donohue, ACNP (06:09):
So still , the gold standard is the bone
density or DEXA test, and whatthe DEXA imaging is is a
two-view low radiation X-ray.
In fact, we are exposed to moreradiation from the natural
environment over a 48-hourperiod of time than what we get
exposed to in a bone densitytest, so it's very low radiation
(06:32):
.
It gives us the ability to lookat the mineralization in
specific areas in our hips andin our lower spine and in some
cases of the forearm, so itallows us to see what the
mineralization of the bone is.
Now there are certain testscores that we look at.
We look at Z scores in any malethat's less than the age of 50
(06:56):
or any premenopausal women, andwhat these scores do is they
tell us where your individualmineralization is compared to
somebody that's the same age,ethnicity and race.
So anybody that's lower themore negative you get in that Z
score, the worse that it is.
So anybody that's lower thanthe negative 2.0 is said to have
(07:21):
a lower bone mineralizationwhen compared to their age match
peers.
On the other hand, when we lookat the postmenopausal women and
men that are over the age of 50,we look at something called T
scores, as Dr Kaila and I justspoke about.
We peak our bone growth at theage of 30.
(07:41):
Our bone mineralization iscompared to that individual who
has peaked their bone mass atthe age of 30.
Again, the more negative thatwe get, the worse that the test
is.
So a negative 1.1 to a negative2.4 is osteopenia and negative
2.5 and lower is osteoporosis.
(08:02):
So we can see by this bonedensity test, our first test, to
see how much is osteopenia,normal osteopenia and
osteoporosis in our patients.
Robert A. Kayal, MD, FAAOS (08:15):
The bone density test that we do in
our office is probablyconsidered the gold standard
right Correct.
So why is it so important toeven do these tests and to
identify if somebody hasosteopenia and osteoporosis?
Patricia Donohue, ACNP (08:28):
So this is the problem out there and
it's become a public healthissue.
Public health issue is that ourdisease of osteopenia,
osteoporosis, is a silentdisease.
People don't know that theyhave the disease unless they
have a bone density test or ifthey have a fracture.
And that is a problem becauseonce you have a fracture, your
(08:50):
chances of having an additionalfracture goes up within that
first year.
So it's very important,especially in the high risk
group categories, that patientsdo have and individuals have
bone density testing.
There's the guidelines, say,for women over the age of 65 and
(09:11):
men over the age of 70.
But if there's a youngerindividual that has risk factors
such as taking long termsteroids, a history of a low
energy fracture, family historyof fracture, then it's, or going
through menopause, then it'simportant to get this bone
density test at an earlier ageto identify bone loss, with
(09:34):
possible rectifying andtreatment or even lifestyle
changes to help to correct andimprove their bone density
before they lose future bone.
Robert A. Kayal, MD, (09:45):
Absolutely , absolutely.
And it's unfortunate we call itthe silent killer, because the
orthopedic literature suggeststhat approximately 20 to 30
percent of patients that suffera hip fracture, which is a very,
very common problem in thisworld, 20 to 30 percent of those
(10:06):
patients that endure a hipfracture, will not make it one
year after that hip fracture.
Twenty to thirty percent ofthem will pass away the same
year after the suffering thathip fracture.
And the reason is notnecessarily from the fracture
itself, what the surgicalmanagement of the fracture, but
rather the complications thatare then associated with being
(10:27):
bedridden from that fracture.
So, for instance, pressuresores, pneumonia is blood clots,
pulmonary embolism, anothercomplications like that.
So it's incumbent upon us as ahealth care provider to make
sure that our patients that aresuffering and enduring low
energy fractures, insufficiencyfractures, are appropriately
(10:48):
worked up and treated To preventanother fracture.
But most importantly, it'simportant at the appropriate
time to assess our patientsearly on to see if they are at
risk for osteopenia orosteoporosis and ultimately
suffering one of theseinsufficiency pathological
fractures.
The numbers are staggering inthat approximately eighty to
(11:15):
ninety five percent of patientsthat endure an insufficiency,
low energy fracture are actuallydischarged from the hospitals
without any follow up care fortheir osteoporosis by a bone
metabolism expert such aspatrician.
So it's, it is a health carecrisis.
(11:35):
It is why we call it the silentkiller and is the reason we are
having this podcast today tobring attention to this silent
killer.
So, as far as the bone densitytest, the DEXA, are there other
things that we can do with thebone density test that can
assess the bone quality at all?
Patricia Donohue, ACNP (11:57):
So there is an additional test that we
do at Kali orthopedics and thatis looking at a lateral view of
the lower spine, called thelateral vertebral assessment, or
other institutions may call ita vertebral fracture assessment,
and what it does is it looks atthe height of the vertebrae in
(12:17):
the lower spine to make surethat the height is equal to the
adjacent vertebrae, above orbelow.
If there is a lower or decreasedheight, it makes us suspicious
that there may be a vertebralcompression fracture there.
So what's important to knowabout vertebral compression
(12:38):
fractures is a majority of thesefractures are asymptomatic.
patients don't have any pain.
In fact, we identify some thatare chronic and we don't even
know how long they've been there.
So it's important, when we seethis decreased height, to have a
full work up in evaluation forosteoporosis and treatment,
(12:59):
because there's a five fullchance and those individuals who
have a fracture of having anadditional vertebral fracture in
the next year and a two tothree full chance of them having
other fractures, such as a hipor pelvic fracture.
So that's a really importantmodality to do and to identify
these fractures proactivelybefore and treat them before an
(13:23):
additional fracture occurs.
Robert A. Kayal, MD, FAAOS (13:25):
I think we should probably take
this opportunity to show ourviewing audience a model of bone
.
We can describe the anatomicalstructures of this bone and we
can compare and contrast hownormal bone would compare and
contrast to compromise bone, onethat is compromised from
osteopenia or potentiallyosteoporosis.
(13:47):
This is a cross section throughbone and you can see the inner
network of bony architecture Wecall the cancellous bone or the
spongy bone, as opposed to theouter, structurally strong,
compact bone We call thecortical bone.
So the outside of our bone isthat strong, cortical, compact
(14:11):
bone.
That's, for instance, the boneyou can feel when you palpate
your shin or your wrist.
The inner aspect of the boneeveryone's familiar with is the
bone marrow and inside the bonemarrow you have a lot of fat and
another constituents of thebone marrow.
But the bony part of the insideof the bone is this spongy,
(14:35):
cancellous, trabecular bone Andthat is the bone that is
primarily compromised when wespeak about osteopenia and
osteoporosis.
This bone is alive.
As we said before, it'sconstantly breaking down and
building, breaking down andbuilding.
The osteoclast are breaking itdown, the osteoblast are
(14:56):
building it And over time thestructural architecture of this
bone changes in everyone suchthat the inner cancellous
trabecular bone tends to becomeless dense and the outer compact
cortical bone becomes thinnerand thinner and thinner And the
(15:17):
canals of the bone become moreand more capacious over time.
So here's an example now of achange of the inner and outer
aspect of this bone.
So we can see that now it's theouter cortical bone is
definitely thinner, the compactbone is definitely thinner and
(15:41):
more compromised And the innertrabecular network of bone is
certainly more porous and lessstructurally intact, comparing
and contrasting what happenswith osteopenia and osteoporosis
.
So, as we just mentioned, wespoke about trabecular bone.
So, patricia, why don't youelaborate on this concept of the
(16:03):
trabecular bone score for us?
Patricia Donohue, ACNP (16:06):
So trabecular bone, like Dr Kale
was just explaining about thespine in particular, is made up
of 75 percent of trabecular bone.
We just had spoke aboutvertebral fractures If that
trabecular network orscaffolding starts to thin out
because of an increased bonebreakdown we got a lot more
(16:28):
spaces in it, there's thinnerplates and rods and the
scaffolding is more likely tocollapse.
So a trabecular bone score isan addition that we can add on
to our bone density test thatwe'll just look at that inside
quality of the bone to tell usif we have a partial degradation
(16:48):
of full degradation of thetrabecular bone.
If there is, we may usemedications to help build up
that network and there arecertain medications that work
even better than othermedications to target those
areas to prevent that collapsingand that thinning of that bone.
So that's a very importantthing to look at.
Robert A. Kayal, MD, FAAOS (17:09):
And what about the frack score?
We hear a lot about this frackscore.
That's so important as well.
F-r-a-x.
Patricia Donohue, ACNP (17:15):
Yes.
So the frack score was designedby the World Health
Organization and what it does isit takes an individual's risk
factors such as their genetics,their history of fracture,
corticosteroid use, alcohol,smoking, and puts that
calculation in with one of theirhip scores And it then comes
(17:37):
out with a chance, a percentageof an individual having a major
osteoporotic fracture in thenext 10 years as well as a hip
fracture in the next 10 years.
So the World HealthOrganization suggests treatment
over 20% if patients come over20% in the first category, or in
over 3% chance of having a hipfracture in the next 10 years.
(18:00):
But we must keep in mind thatcalculated that risk factor is
just based upon what we'reseeing in the hip.
So if somebody has a normal orlow frack score or chance of
fracturing and they haveosteoporosis or a low trabecular
bone score in the spine, itreally preempts us to actually
(18:23):
treat those individuals beforethey get a spine fracture.
So very important to delineateand see which calculations work
with which part of the bonedensity testing.
Robert A. Kayal, MD, FAAOS (18:33):
Is there any blood work that you
can perform for patients toidentify whether or not they're
at risk of disorders of bonemetabolism, osteopenia,
osteoporosis, etc.
Patricia Donohue, ACNP (18:44):
Yes, so very good question, thank you.
And what we do is we put acomprehensive evaluation with
the bone density test and thenext step is to do some blood
work and to look at conditionsor look for conditions that may
be creating bone loss, such ashypocalcemia, low vitamin D
levels You need vitamin D toabsorb calcium other conditions
(19:08):
such as hyperparathyroid disease, hyperthyroid disease or other
disease processes,corticosteroids, adrenals
problems, other conditions thatare hemotological disease that
can be causing bone loss in ourpatients.
So we try to identify if there'sany disease processes and
(19:31):
collaborate with otherdisciplines or specialists in
that area If we do identifythose, to get those conditions
under control before giving thema medication.
And then, in addition to that,as we spoke about the osteoblast
, the bone growth, and theosteoclast class the bone
breakdown we can also checkmarkers that measure collagen in
(19:54):
the bloodstream.
Collagen is the end result ofbone breakdown.
So the higher your collagenlevel in your blood is, the more
bone you're breaking down.
So we can use that as a markerto see how much you're breaking
down and we can also use that inresponse to our treatment
modalities to make sure thatthey're working effectively for
(20:17):
our patients.
In addition to our bone densitytesting, Well, it's amazing.
Robert A. Kayal, MD, FA (20:20):
There's so much you can do to assess
this condition That's fantasticand probably monitor treatment
as well.
Patricia Donohue, ACNP (20:26):
Yes.
Robert A. Kayal, MD, FAAOS (20:28):
So I'm sure our viewing audience is
wondering when should I startassessing my bone quality?
When should I come in for abone density?
When do I need blood work?
So both men and women, andsometimes even in young
adolescents and athletes thatsuffer stress, fractures etc.
We know about the femaleathlete triad.
(20:50):
potentially You might want totalk about that as well, but
when should our viewing audienceconsider getting assessed for a
bone density and doing some ofthe blood work?
often would they need to followup after getting one.
What types of regular intervalsdo you recommend follow up?
Patricia Donohue, ACNP (21:10):
Okay, very good question.
So, starting out with ouradolescent population are
younger individuals that arechildren that are in sports,
anybody that has a stressfracture.
we don't routinely do bonedensity tests on individuals
that age, but if they've had astress fracture we need to
(21:30):
evaluate whether or not theyhave a deficit in their bone
quality, and it can, most of thetimes, can be related to
secondary causes, such as therelative energy deficiency
syndrome.
you know, eating disorders,anorexia, bulimia, not giving
enough protein to the skeletonbefore you're working out,
(21:51):
putting it into a negativebalance.
We also can look for cases thatthey may have fractures due to.
maybe they had asthma and weretreated with a large amount of
steroids.
They didn't have, as we spokeabout before, enough calcium and
vitamin D in their diet.
So it's important to assessthese individuals in getting
(22:13):
that Z score, but also lookingfor the secondary influences
that is causing bone loss inthis age group, and we've have
identified individuals maybewith celiac disease.
they have a malabsorptionproblem, that they're not
absorbing vitamin D than toabsorb the calcium that you're
giving to them.
(22:33):
So it's really important tolook for secondary causes within
this age group.
Then fast forward.
Robert A. Kayal, MD, FAAOS (22:39):
Just to interrupt you, if you don't
mind, for a second, about thisfemale athlete triad.
You know, in these youngfemales we talk about this
female athlete triad, whereyoung women in particular can
suffer from osteoporosis andfractures and what we call
amenorrhea.
You know, we always say inorthopedics, especially when
(23:00):
we're talking about bonemetabolism, estrogen is the
bone's best friend And it's soimportant for women, especially
at a young age, to have theirperiods every month.
Regular periods are veryimportant for the young
adolescent woman, especiallybecause of the estrogen levels.
The estrogen protects the boneAnd when patients are having,
(23:24):
for instance, some eatingdisorders that can deleteriously
affect their ability to have amonthly period, that will
translate into a conditioncalled osteoporosis in this
female athlete triad.
And sometimes these young womenwill suffer fractures because
of the osteoporosis And thetreatment is not necessarily to
treat the osteoporosis but totreat the underlying condition,
(23:47):
which is, in this particularcase, an eating disorder which
can contribute.
So that's also very, veryimportant to note.
Patricia Donohue, ACNP (23:54):
That's correct.
And the first question we doask is the menstrual cycle, how
irregular or regular it is.
And there's one statisticthat's out there that suggests
that the bone bank that youbuild and the amenorrhea can
affect that bone bank.
It can predictosteoporosis-related fractures
in women in their later yearspost-menopausal.
(24:15):
So really important to look atthis time period and relative
energy deficiency and secondarycauses.
Robert A. Kayal, MD, FAAO (24:23):
Great point, great point.
Patricia Donohue, ACNP (24:25):
So then fast forward to the
post-menopausal orperimenopausal women.
So it's said, around the 10years that women's going through
menopause, they're losingapproximately 2% of their bone
per year And, just as you hadexplained, it's due to that
estrogen loss that increasesbone resorption, increases bone
(24:47):
breakdown.
So it's really important toidentify these women, especially
if they've gone through theirmenopause at an earlier age, to
do bone markers and then maybesome hormonal markers to see
where they're at in menopauseand work in collaboration with
their gynecologist.
Some of these women, if theydon't have risk factors for
(25:09):
breast cancer, uterine cancer orblood clots, we may use
low-dose hormonal therapy onthem around the time of
menopause, five to 10 years, topreserve that bone from breaking
down further and preventingfurther bone loss.
If they're not a candidate, wecan use the bisphosphonates, and
(25:29):
that is when we've used them inthose circumstances before All
right.
Robert A. Kayal, MD, FAAOS (25:33):
So just going back to the testing
and the periodic testing,certainly the perimenopausal
woman.
And then, how often afterwardsis that dependent on the results
of their bone density tests andthe blood work?
Patricia Donohue, ACNP (25:46):
Yeah, so anybody that's being treated,
actively treating or monitoringwe're concerned about.
I would recommend doing a bonedensity test every year If
Medicare will pay for it.
Sometimes you have to write aletter to other commercial
insurances, but generally ifyou're actively treating those
patients and concerned aboutbone loss, i've never had a
(26:07):
commercial insurance or Medicaredeny having a bone density test
.
Along with that, we would checkthe bone markers every six
months to a year to make surethat our treatment is effective
in preventing further breakdown.
We can't have a bone densityany less than a year, but we can
use the lab certainly for alittle bit closer in time.
Robert A. Kayal, MD, FAAOS (26:28):
Does everyone get blood work, Or
just everyone that's beingassessed for osteopenia and
osteoporosis?
do we always get blood work?
Patricia Donohue, ACNP (26:35):
So for the very least, if you have a
normal bone density test, igenerally just check the calcium
and the vitamin D.
These are the buildingmineralization and you need for
your bones on a daily basis.
So everybody needs a calciumintake through their dietary
means or supplements.
So to check that and then tocheck the actual hormone called
(26:58):
the parathyroid hormone to makesure that you're absorbing that
calcium and getting it to yourbones.
When we check a normal calciumin the bloodstream it doesn't
tell us if that calcium.
It tells us maybe it's normalbut it doesn't tell us if it's
getting to the bones, maybewe're leaching.
If we don't get enough calciumin on a daily basis, we may
(27:19):
leach that calcium out of ourbones, demineralize our bones
and it looks great in ourbloodstream.
But doing a parathyroid hormonelevel will tell us whether or
not we're getting an adequateamount of calcium.
So that's really important todo on the patients of the very
least calcium, vitamin D and aparathyroid hormone level.
Robert A. Kayal, MD, FAAOS (27:41):
I'm sure everyone's wondering how
much calcium and vitamin D theyshould be taking, but we'll get
to that very shortly, so let'sjust talk about at this point
some risk factors for thiscondition.
What are some of the riskfactors for patients that may
ultimately end up gettingosteopenia or osteoporosis?
Patricia Donohue, ACNP (27:58):
Sure So low BMI.
you don't take enough proteinin.
it doesn't support your bones,So less than 18.5 of body mass
index is usually indicative ofpossible bone density issues.
On the other hand of thespectrum, obesity is.
vitamin D is a fat solublevitamin, So you may see lower
(28:22):
vitamin D levels in thoseindividuals and you may have to
give them extra vitamin D to getthem to a normal level so they
can absorb the calcium thatyou're having.
And then also, while we're onthe subject, for obesity, some
individuals may have undergone agastric bypass to ruin Y, and
it bypasses the area of oursmall bowel where most of our
(28:45):
intestinal absorption ofvitamins and minerals occur, and
so those individuals may needincreased amounts of vitamin D.
And what's important to know isvitamin D doesn't have to pass
through the small bowel.
There is a liquid form ofvitamin D.
It's a bucal form that you canput a drop or two under your
(29:06):
tongue, and it's usually onedrop equals a thousand
international units.
So if somebody hasmalabsorption issues, that's a
good way to get the vitamin Dinto their blood, to get them to
adequate amounts so they canabsorb their calcium.
We also, which is important todo in our patients, is to look
for a height loss.
(29:27):
Anybody that has a height lossof an inch and a half over a
lifetime.
I say to my patients so what'syour height now and where were
you when you were 30 years ofage?
If they lost more than twoinches, it behooves us to do
that vertebral fractureassessment, to look for a
vertebral fracture there.
And then we have our usuallyover the age of 65, the over the
(29:52):
age of 70, and doing the bonedensity test Now.
It's important to assessgenetics And a lot of our older
patients may not know theirparents or grandparents history
of osteoporosis because bonedensity testing wasn't done.
So you have to ask them iftheir grandparents fractured,
because genetics can beresponsible for 60 to 80% of
(30:13):
bone loss.
Robert A. Kayal, MD, FAAOS (30:13):
So that's really important.
It's just like everything else,exactly exactly.
Patricia Donohue, ACNP (30:17):
And then there's the modifiable risk
factors smoking, alcohol,whether or not they're having
more than three drinks a day.
if they're smoking, whether ornot they're exercising, you know
is a very important Boneloading exercises of just
walking in the older patients,it prevents not only bone loss
(30:38):
but what you suggested before asarcopenia or a loss of muscle
mass, which makes our patientsprone to falling and balance
issues.
So important to assess all that.
Robert A. Kayal, MD, FAAOS (30:48):
Yeah , i can't emphasize enough the
importance of the modifiablerisk factors.
As an orthopedic surgeon thatdoes a lot of joint replacements
, i could tell you I am privy tothe ability to actually inspect
the bone quality during surgery.
And on the patients I performknee replacement surgery on a
regular basis those that areavid long time smokers or
(31:13):
alcoholics, long time consumersof alcohol products the bone
quality is certainlytremendously compromised
relative to the non smokers andthe non alcohol consumers.
So it's really, reallyimportant to stop smoking and
excessive alcohol consumptionbecause it truly deleteriously
(31:34):
affects your bone quality andsignificantly increases your
risk for fracture.
So there's this concept inorthopedics called Wolf's Law,
and Wolf's Law is essentially,in layman's terms, bone response
to load.
So whenever you load a bone,bone response by getting
(31:54):
stronger.
So we typically find in ourclinical practice that patients
that live a sedentary lifestyleor are frail or emaciated those
are the patients that end upgetting osteopenia and
osteoporosis, whereas the veryactive patients, or typically
the heavier patients, very oftendo not get the osteoporosis
(32:18):
because their skeletons have tocarry the load of their body
weight for their lifetime.
And if there are runners ordoing a lot of high impact
aerobic activity, it reallyhelps to strengthen the bone
tremendously.
So it's just like anything else.
Bone is a tissue.
When you exercise it, when youwork it out, it gets stronger,
(32:41):
and when you live a sedentarylifestyle, it essentially
atrophies and becomes frail andbrittle and fractures.
I know we can get vitamin D inour diets, but is there anywhere
else we can absorb vitamin Dfrom?
Patricia Donohue, ACNP (32:54):
So we only absorb 10% from the sun,
And I have many patients thatsay I sit in the sun all day.
I go to Florida, I'm a sun bird, I'm a snow bird.
But the reality is, if you'reusing sunscreen and you're out
in the sun, you're onlyabsorbing 10%.
Robert A. Kayal, MD, FAAOS (33:08):
I tried.
Patricia Donohue, ACNP (33:10):
So definitely.
Calcium is in not only dairybut it's found in nuts and green
leafy vegetables.
So getting a nice calcium chartis the preferred way to get
calcium.
But if you have lactoseintolerance or you can't
tolerate these food groups, Imean there's.
Or if you're a vegetarian,there's soy products, there's
(33:32):
almond milk, there's other ways.
And then the calciumsupplements.
It's always recommended to takea calcium citrate tablet because
calcium is absorbed better inan acid environment than calcium
citrate comes in an acid.
So you don't have to take itwith food.
But what's important to realizeor know is that you don't want
(33:53):
to take more than 500 milligramsat any given time.
So I have patients that say I'mon 1,000 milligrams of calcium
and they're taking them both atone time, both the tablets.
You're not absorbing more than500 milligrams with each tablet,
so you need to divide thosedoses.
So the recommended calciumintake and diet in supplements
(34:14):
is 1,000 milligrams for men andfor children And for
post-menopausal women it's 1,200milligrams.
So I tell my patients startlooking at your labels, start
calculating out your calcium andyour diet and then we can start
to supplement with supplementsif needed.
Vitamin D, on the other hand,the maintenance is 800 to 1,000
(34:35):
international units And againyou need to get a vitamin D
level check to see if there'sany absorption problems that we
need to increase that amount ona daily or a weekly basis to get
you to where you need to be toabsorb the calcium.
Robert A. Kayal, MD, FA (34:49):
Vitamin D is very, very important for
our bodies in that it helps toabsorb the calcium from our gut.
So if your vitamin D levels arelow, you really won't even be
absorbing the calcium thatyou're taking, and I hope you
appreciated the fact thatPatricia said for women and
children.
So 1,200 milligrams 12 to 1,500milligrams of calcium every day
(35:12):
is important for women andchildren.
So when I have those kids comein with a broken wrist, i always
tell the parent that the childshould be taking the same amount
of calcium that you're taking,emphasizing to the mom that she
should be taking calcium andvitamin D as well.
So it's very, very important todo that.
I also favor calcium citratebecause of the fact that it is
(35:35):
water soluble, And I believe theliterature supports the fact
that there's a lower incidenceof kidney stones with the
calcium citrate as opposed tothe others that are more readily
found in the kidney stones,like the calcium oxalate and
carbonate.
Yeah, so now that we'respeaking about medications and
(35:58):
the treatment, what are some ofthe first of all classes that we
place these medications into inaddressing osteopenia and
osteoporosis, and then maybegive us some examples of each
and why they work?
Patricia Donohue, ACNP (36:15):
Okay, so , as we had spoken about, there
are either it's an increasedamount of bone breakdown that
people have and that's relatedto bone loss are not enough bone
building.
So there's a class called theanti-resortive agents, which are
the oldest medications thathave been around and many of you
(36:36):
probably remember the phosomaxand the actinol, which are oral
forms.
They are taken once a week orit can be once a month, but
they're not recommended forindividuals that actually have
some gastroesophageal refluxdisease or an older patient that
may not absorb tablets as well.
(36:57):
So there is an alternativecalled reclassazoleoginic acid,
which can be given theintravenous route And, if needed
, it can be given on a yearlybasis.
But again, we continue tomonitor to see if you actually
do need it on a yearly basis.
So that's a class ofanti-resortives.
It's the bisphosphonates, thenext class of anti-resortives.
Robert A. Kayal, MD, FAAOS (37:19):
So essentially they inhibit the
osteoclasts.
Patricia Donohue, ACNP (37:21):
That's correct.
Robert A. Kayal, MD, FAAO (37:22):
Those are the cells we talked about
that break down the bone, sothey inhibit osteoclasts.
Those are the anti-resortives.
Patricia Donohue, ACNP (37:29):
That's correct.
The next class ofanti-resortives is called rankl
inhibitors.
A rankl breaks again increasesthe osteoclasts that break down
cells.
And that's where prolia many ofyou heard about prolia.
It's an every six monthinjection So, unlike the
bisphosphonates that hold on tothe bone for a longer period of
(37:50):
time And, like I said, you onlymay need them every year, every
two years, i've even seen it upto every three years in infusion
, they prolia.
On the other hand, it wears offvery quickly.
So the injection has to begiven every six months And you
have to be pretty regimented toreally make sure that you make
(38:10):
it into the office to get thatinjection, because if it wears
off, it wears off very quicklyand your bone resorption goes up
very quickly and your chancesof fracturing can occur.
So this is really somethingthat we really drum home with
our patients And basicallytelling them that they have to
be regimented.
If we are going to stop it, wecan't just stop at cold turkey.
(38:33):
We need to give you abisphosphonate to seal it in so
this way you don't have thattype of side effect.
The prolia will diminish yourcalcium.
So, going into any of theirstarting treatment on any of
these medication regimes.
It was important for us to do acalcium and vitamin D to ensure
that these are workingeffectively.
(38:55):
Then you have an adequateamount of calcium and vitamin D
and especially prolia andevenity, which we're going to
talk about next, will drop yourcalcium level.
Evenity is the class ofmedication that has a dual
mechanism It slows down bonebreakdown It's been out for
about four years and it alsoincreases bone formation.
(39:18):
So it's a really nicemedication to use in patients
that have a very low T score orbone density test or at their
risk of fracturing or have ahistory of fractures.
But you have to make sure thatthey don't have any
cardiovascular risk factors.
The third class of medicationsis called the anabolic agents.
These anabolic agents areparathyroid, synthetically made
(39:42):
parathyroid hormone.
Parathyroid hormone, when givenin intermittent doses, actually
increase osteoblastic activity,so increases bone cells.
It's the only medication thatwe have that actually increases
by itself the bone cells.
It's very useful in treatingpatients that are on
glucocorticoid, trabecular bonedeficiencies, vertebral
(40:06):
fractures, other fractures andosteoporosis.
Again, if you just stop thatafter the course of that
medication, you need to seal itin because your body's going to
go back to its normalequilibrium and start to break
down all that good new bone thatwe just gained, and it would
have been moist at both fartimes.
Robert A. Kayal, MD, FAAOS (40:25):
So that's important.
So seal it in with anotherbisphosphonate.
Patricia Donohue, ACNP (40:28):
That's correct.
Robert A. Kayal, MD, FAAOS (40:29):
So these are the bone formation
agents that she's talking aboutnow, for instance the Forteo,
but the bisphosphonates that shetalked about earlier.
What are some of the examplesof those bisphosphonates?
Patricia Donohue, ACNP (40:41):
So Phosomax, Actinol, Atylvia
they're the bone oldest forms ofthe oral medication and then
reclass, to which is sublodronic.
Robert A. Kayal, MD, FAAOS (40:51):
Yeah , and what about hormonal
replacement therapy andderivatives of hormone, estrogen
for instance?
Patricia Donohue, ACNP (40:59):
Yeah.
so again, around that firstfive, seven years of menopause
is really important If thegynecologist and there's been a
lot of hesitancy ingynecologists in actually
recommending hormonalreplacement because of the
women's health studies thatwe've done in the past but even
the National Association ofMenopause Society recommends
(41:21):
treatment with low dose estrogenand progesterone if you have a
uterus around the time ofmenopause to prevent bone loss
and it prevents vertebralfractures and other fractures.
So it's a very useful way touse these hormone replacements
if they are individuals that cantake it in that period of time.
Robert A. Kayal, MD, FAAO (41:41):
Right and along the lines of hormonal
replacement therapy.
There's an agent called evistaright, which is an interesting
agent in that it can be usedspecifically in patients
potentially that have alsobreast cancer and osteoporosis
right.
That's good.
Why is that?
Patricia Donohue, ACNP (41:59):
So it's said to be breast protective in
those patients that have apretensivity to develop breast
cancer.
But it's the evista is the, anagent that actually attaches to
the estrogen receptors, so itacts like an estrogen but it's
not truly an estrogen.
It's really helpful in thoseindividuals that are further out
(42:20):
from menopause because if yougive it too close to menopause
it may cause breakthrough,bleeding and the
osteoarthopedics.
We don't know how to deal withthat.
So we don't want to give it tooclose to menopause, so we want
to use it later down the road,like maybe 10 years after
menopause.
But it specifically works thebest in the spine.
(42:41):
So this is a really importantagent If people don't want to be
on the other agents that canpreserve bones.
Specifically, it works betterin the spine and works less in
the hip.
So when I say we do this workup with the bone density and
blood test, then we look at theindividual and have a targeted
(43:01):
plan of care what agent we wantto use, appropriate agent where
the bone density is showing thebone loss and patient specific.
So that's really important.
Robert A. Kayal, MD, FAAOS (43:13):
Yeah , And with breast cancer it's
interesting because the Savistaagent apparently tricks the body
right.
It tricks the bone and ittricks the breast.
Breast cancer in general tendsto like estrogen.
It sort of grows potentiallyand becomes more aggressive with
estrogen Input.
Bone also loves estrogen.
(43:37):
Bone gets stronger withestrogen.
This Savista agent potentiallycan trick the body rather in
that it will bind to the boneand stimulate the bone formation
, but it will not bind to thebreast tissue and stimulate the
breast cancer growth.
So that is the conceptessentially behind the agent
(44:03):
Avista.
Why are we attacking thiscondition with so many different
agents if they all work?
There must be something I'mmissing here.
Are there potentialcomplications or side effects
with some of these medicationsthat we need to talk about,
which may potentially cause usto maybe change courses and
(44:25):
switch from one medication toanother?
Patricia Donohue, ACNP (44:28):
So that's a very good point, and
you had mentioned the statisticthat only 15% of patients that
have osteoporosis-relatedfractures are being treated, and
the bottom line is that thereis a fear out there with using
these agents.
Back in the 80s to 90s,specifically when Fasamax was
(44:49):
around, it was used for a longduration and period of time And
what they saw is they saw someside effects, such as a
bisphosphonate-related femurfracture that occurred in 1,000
patients, and then thewell-reported and publicized
osteonocroosis of the jaw, whichoccurs in 1 in 100,000 patients
(45:13):
.
So there's been this pandemoniaof fear in using these agents
and we can only think that maybethat's creating the hesitancy
in using these.
But like anything else inmedicine that we do, we must
weigh the risks and the benefitsAnd what we have seen with
these medications is a fewcommon factors Using
(45:36):
bisphosphonates for a longperiod of time.
In the 80s and 90s they used itfor over 10 years.
We know not to use the oralforms of these medications for
longer than five years without adrug holiday to let in the bone
recover In the IV reclass aboutthree years, let in the bone
recover And then to really notuse a long duration and then
(46:01):
also identify risk factors forthe osteonocroosis of the jaw.
It was many patients that hadsome radiation to the jaw from
cancer or had poor dentation.
Which brings me to my next pointis that anybody that's on any
of these agents, hygiene dentalhygiene is of utmost importance
(46:22):
Keeping up on your evaluation byyour dentist and having regular
exams, regular cleanings,mentioning to your dentist that
you're on these medications Sothis way they can watch you
carefully with us.
But the newest guidelines amongthe American Dental Association
doesn't even suggest taking youoff of these agents or
(46:46):
monitoring the bone turnovermarker when they're in fact
doing even implants or drillinginto the bone.
We like to time it a little bitfurther out from your last dose
, but you don't need to stopthese agents and those are the
newest guidelines that's put outby the American Dental
Association.
But any patient that's on theseagents, then they see a
(47:06):
non-healing ulcer in their mouthor if they have pain in their
thigh, then they need to get anx-ray done for their thigh and
see their dentist to make surethat it's not related to these
anti-resortive agents.
So that's really important.
Robert A. Kayal, MD, FAAOS (47:24):
Yeah , we certainly don't want to
miss one of those atypical femurfractures which have clearly
been associated with some ofthese medications.
What about the Avista?
Any concerns with respect toAvista and estrogen-like type of
agents?
Patricia Donohue, ACNP (47:42):
Good question.
So Rheloxaphen or Avista isprobably the only agent that is
out there that has an enhormonereplacement that is not
associated with theosteonecrosis of the jaw and the
atypical femur fracture.
So that's the beauty of thosemedications, but they bring
along with it the higher risk ofthromboembolic events.
Robert A. Kayal, MD, FAAOS (48:02):
So, everybody.
Patricia Donohue, ACNP (48:03):
Every medication has its trade-off and
we want to do, like I said,that comprehensive evaluation
and a plan of care according topatients' risk factors.
Robert A. Kayal, MD, FAAOS (48:12):
What you mean by that Thromboembolic
.
sometimes we get concernedabout cardiac issues, blood
clots, pulmonary embolism,strokes, things like that with
estrogen and hormonalreplacement therapy.
So certainly, besides talkingto Patricia, we would also
really invite you to speak toyour primary care physicians or
(48:32):
your cardiologists to get theirblessing before proceeding with
some of these agents.
Now, as far as monitoring, onceyou've diagnosed the patient
and treated the patient, wetalked about monitoring with
subsequent bone density testingand blood work.
Sometimes urine analysis isalso used as well.
(48:54):
What are you looking for inthat?
Patricia Donohue, ACNP (48:55):
Yes, The urine test is very helpful
because it can tell us if aperson has a urinary leak of
calcium.
So we're giving calcium to ourpatients, thinking that it's
getting to the bones.
Either they're not absorbing itor at the other end, they can
leak out urine.
There are certain medications,like the loop diuretics, that
can cause calcium loss as well,so we may see an increase in the
(49:19):
urine based upon that, andwe've changed and worked with
primary care doctors to changetheir diuretic regime around.
We also can have patients thattake large amounts of water and
the border is good for you butit makes you pull off sodium and
makes you pull off calcium inyour urine.
So if somebody has a very low orhypocalcemia and we're giving
(49:40):
you calcium supplements and it'snot working, then we'll check a
urinary calcium either a spottest or preferably 24-hour urine
.
We can also if there's an agentwe want to use we want to make
sure that there's no calciumoxalate crystals in the urine,
such as with kidney stones andthings like that.
So that's really important andalso identifying other diseases
(50:04):
that are related to phosphorusand calcium in the kidney and
kidney disease that we can helpto identify with these urine
tests A urine test or a bloodtest can also be used to measure
a bone resorption marker.
They actually, like I said, itmeasures the calcium, the
collagen remnants in the urineor blood.
(50:27):
So it can be used as a markerto see how our therapy is
working, for continuingmonitoring and then to see when
it starts to increase, when weneed to intervene with an
additional possible Medicaid.
Robert A. Kayal, MD, FAAOS (50:40):
Well , that was all so informative.
We're so honored to have you asour bone health expert at the
Kale Orthopedic Center.
We're just so privileged tohave you with us today.
I hope that you found thispodcast very informative.
I'm just going to ask Patriciato take a minute to summarize,
because this is such a veryimportant topic.
I definitely want to make sureour viewing audience gets the
(51:03):
message that osteoporosis andosteopenia is a ubiquitous
problem and is very prevalent inour society and is the silent
killer.
So, patricia, last words forour viewing audience, please.
Patricia Donohue, ACNP (51:18):
So, as Dr Kel had mentioned, it's very
important to have, starting atadolescence, calcium, vitamin D,
exercise And then, goingforward, the post-menopausal
woman needs to get a bonedensity test, screening around
the age of menopause.
And then individuals that haverisk factors and around the age
(51:40):
of 50, that are smokers, alcoholgenetics, some family history
of osteoporosis, their historyof a low energy fracture, which
is a fracture from a singlelevel, not from a height, and
then also any other sedentaryinvolvement, lack of exercise
due to maybe some illness orsomething that has not allowed
(52:02):
them to be active.
And then over the age of 65 forthe female in general and over
the age of 70 for the male ingeneral.
We need to identify these boneloss disease processes because
they are a silent disease and weneed to recognize them before a
person sustains a fracture, andthat's very important because
(52:26):
having a fracture like wementioned, having an additional
fracture, is very prevalent.
So it's important for us totake care of our bone health and
we're dedicated to do this atthe KL Orthopedic Center and we
hope to help you take care ofyour bone health as well 100%.
Robert A. Kayal, MD, FAAOS (52:45):
One last thing what is this fracture
liaison service that youspearhead at the KL Orthopedic
Center?
Patricia Donohue, ACNP (52:51):
So a fracture liaison service and we
mentioned that only 15% ofpatients after fracture are
actually being treated.
So we used to have a fractureliaison service that was
originally designed to go intothe hospital to meet those
patients.
But then we recognized that thepatients were sedated.
They didn't remember us.
(53:11):
They had no idea what we weretalking about after we called
after discharge.
So now it's spearheaded toactually identify those patients
, getting the word out to all ofour orthopedic surgeons to help
identify and let us know aboutthose patients when they come in
with a low energy fracture.
One in particular that wehappen to miss a lot is the ones
(53:33):
that are done at the ambulatorycare center, which many more
surgeries are doing there, butspecifically the wrist, the
distal radius fracture that canbe a red flag that there's some
underlying metabolic bonedisease or deficiency, and those
patients in particular need tohave a bone density test and
need to be appropriately sent tothe fracture liaison service.
(53:57):
So it's really identifyingpatients that have low energy
fractures and getting them intoan evaluation and possible
treatment.
Robert A. Kayal, MD, FAAOS (54:05):
Yeah , when Patricia's mentioning low
energy fractures, we considerthose pathological fractures,
insufficiency fractures,fractures that should not have
developed.
For instance, a fall from aheight of only three or four
feet should not result in abroken bone to your wrist in the
normal bone.
But when somebody hasosteopenia or osteoporosis we
(54:28):
call that a low energy fracture,very much different than
breaking your wrist in a caraccident, for instance.
So anyway, thank you so muchfor joining us today on this
Kail Ortho podcast.
It was so enlightening to meand so refreshing now to have
Patricia as part of the KailOrthopedic Center.
We're so privileged to have herwith us.
(54:48):
Thank you for spending the daywith us, patricia.
Patricia Donohue, ACNP (54:50):
Thank you so much.
Thank you for having me.
Hello and welcome to another edition
of the Kale Ortho podcast.
Today is June 13th, 2023.
And today's guest is PatriciaDonahue.
She's an acute care nursepractitioner at the Kale
Orthopedic Center And shespearheads our osteoporosis and
bone metabolism center and runsour fracture liaison service as
(00:20):
well.
Welcome to the podcast,patricia.
Patricia Donohue, ACNP (00:23):
Thank you, Dr Kale.
Thank you for having me today.
Robert A. Kayal, MD, FAAOS (00:25):
Oh, i'm honored to have you here.
We're so happy to have you herebecause we're going to speak
today about a very, very common,ubiquitous problem, and that is
osteoporosis.
Osteoporosis is extremelyprevalent in the world.
Unfortunately, it's known asthe silent killer.
It is estimated that more than10.2 million Americans have
(00:46):
osteoporosis And an additional43.4 million people have low
bone density.
Two million new cases ofosteoporotic fractures per year
exceeds the annual number of newcases of myocardial infarction.
That is, heart attack, breastcancer and prostate cancer
(01:07):
combined.
Annual fracture incidence isexpected to increase 68% to 3.2
million by the year 2040.
It is no wonder we callosteoporosis the silent killer.
So we're going to just jumpright in right now and invite
(01:27):
Patricia Donahue to speak to ustoday about bone metabolism,
osteoporosis diagnosis,treatment and monitoring of this
wretched condition.
So let's first start and talkabout bone metabolism.
Let's just talk about the factthat our bones, our tissues and
these tissues are alive.
(01:48):
Can you elaborate on that forus, patricia?
Patricia Donohue, ACNP (01:51):
Sure.
So our bones are a livingtissue, as Dr Kale said, And we
basically build most of ourbones.
It's called the bone modelingyears during our childhood years
The very important duringadolescence, because that's when
we deposit most of ourmineralization into our bones.
Then we continue to grow upuntil around the age of peak
(02:15):
bone mass, When we stop growingadditional bone and that's where
our bone bank stops.
But it's very important inthose years to get our
mineralization, our calcium, ourvitamin D for any parents that
are out there or grandparentsfor their children to get the
adequate amounts, to put theadequate amounts in their bone
bank.
At the age of 27 to 30, we stopgrowing.
(02:38):
We make additional bonethroughout our lives But what we
do is we have these other bonecells and I call it plowing the
land It's almost like excavatingAnd then the new bone cell
growth just fills in thosedefects.
We never grow additional bonethroughout our life after the
age of 30.
So we really turn or turningover our skeleton.
(03:00):
We're making less bone as weage.
We're breaking down more boneas we age And certain conditions
that we work up and evaluatepatients for in the Metabolic
Bone Health Center are certainconditions that can affect bone
growth or bone turnover.
As Dr Kale said, this is asilent disease So we need to
(03:24):
recognize risk.
Factors are very important ingetting patients to get a bone
density test and an evaluation.
Robert A. Kayal, MD, FAAOS (03:32):
I always emphasize that with the
pediatric population that wetake care of at the Kale
Orthopedic Center.
Very often when children comein with their parents and they
break their wrist, i emphasizethat, that young age, that it's
incumbent upon us to enforce theneed to take calcium and
vitamin D during our growingyears, because we're
(03:53):
establishing our bone density,our bone stock, by the age of 30
.
That's when we really reach ourpeak bone mass.
So it's incumbent upon us toenforce to children that they
should be taking calcium andvitamin D, especially during
their growing years, becausethat is essentially the peak
bone mass that they're going tobe starting with And it's sort
of downhill after the age of 30for both men and women, but
(04:15):
especially from women after theyhit the age of menopause, and
we'll talk more about that in alittle bit.
So, as far as the biology ofbone metabolism, there are a lot
of things that we can do thatare important cellular
characters that we discuss, thatplay critical roles in bone
metabolism.
What are some of those players?
Patricia Donohue, ACNP (04:37):
So the bone growth cells are called
osteoblasts and we actually canmeasure them in blood tests to
see how much somebody isactually making.
And then there's osteoclasts.
The osteoclast takes the olderremnants of bone and clears out
the tissue in the bone, so newbone cell growth can come into
(04:58):
place.
and the osteocytes are aprecursor to osteoclasts.
So a lot of our medications,you'll see, are targeted at
these three areas.
Robert A. Kayal, MD, FAAO (05:07):
Right .
So these cells emanate from thebone marrow.
These undifferentiatedmesenchymal stem cells become
these osteoblasts and osteocytesand osteoclasts, and they all
play very, very important rolesin this bone metabolism.
So essentially, the good guysare the osteoblasts that make
(05:28):
the bone, the osteoclasts sortof break down the bone, but both
are necessary for normal bonemetabolism And it is the
interaction between these cellsthat allow bone to remodel and
form and break down throughoutour lifetime.
And that's what really accountsfor this bone remodeling and
(05:51):
the fact that we replenish orturn over our entire skeleton
approximately eight times in ourlifetime.
What are some of the tests thatwe can do in the office to
assess whether or not a patientpotentially can develop
osteopenia or osteoporosis?
Patricia Donohue, ACNP (06:09):
So still , the gold standard is the bone
density or DEXA test, and whatthe DEXA imaging is is a
two-view low radiation X-ray.
In fact, we are exposed to moreradiation from the natural
environment over a 48-hourperiod of time than what we get
exposed to in a bone densitytest, so it's very low radiation
(06:32):
.
It gives us the ability to lookat the mineralization in
specific areas in our hips andin our lower spine and in some
cases of the forearm, so itallows us to see what the
mineralization of the bone is.
Now there are certain testscores that we look at.
We look at Z scores in any malethat's less than the age of 50
(06:56):
or any premenopausal women, andwhat these scores do is they
tell us where your individualmineralization is compared to
somebody that's the same age,ethnicity and race.
So anybody that's lower themore negative you get in that Z
score, the worse that it is.
So anybody that's lower thanthe negative 2.0 is said to have
(07:21):
a lower bone mineralizationwhen compared to their age match
peers.
On the other hand, when we lookat the postmenopausal women and
men that are over the age of 50,we look at something called T
scores, as Dr Kaila and I justspoke about.
We peak our bone growth at theage of 30.
(07:41):
Our bone mineralization iscompared to that individual who
has peaked their bone mass atthe age of 30.
Again, the more negative thatwe get, the worse that the test
is.
So a negative 1.1 to a negative2.4 is osteopenia and negative
2.5 and lower is osteoporosis.
(08:02):
So we can see by this bonedensity test, our first test, to
see how much is osteopenia,normal osteopenia and
osteoporosis in our patients.
Robert A. Kayal, MD, FAAOS (08:15):
The bone density test that we do in
our office is probablyconsidered the gold standard
right Correct.
So why is it so important toeven do these tests and to
identify if somebody hasosteopenia and osteoporosis?
Patricia Donohue, ACNP (08:28):
So this is the problem out there and
it's become a public healthissue.
Public health issue is that ourdisease of osteopenia,
osteoporosis, is a silentdisease.
People don't know that theyhave the disease unless they
have a bone density test or ifthey have a fracture.
And that is a problem becauseonce you have a fracture, your
(08:50):
chances of having an additionalfracture goes up within that
first year.
So it's very important,especially in the high risk
group categories, that patientsdo have and individuals have
bone density testing.
There's the guidelines, say,for women over the age of 65 and
(09:11):
men over the age of 70.
But if there's a youngerindividual that has risk factors
such as taking long termsteroids, a history of a low
energy fracture, family historyof fracture, then it's, or going
through menopause, then it'simportant to get this bone
density test at an earlier ageto identify bone loss, with
(09:34):
possible rectifying andtreatment or even lifestyle
changes to help to correct andimprove their bone density
before they lose future bone.
Robert A. Kayal, MD, (09:45):
Absolutely , absolutely.
And it's unfortunate we call itthe silent killer, because the
orthopedic literature suggeststhat approximately 20 to 30
percent of patients that suffera hip fracture, which is a very,
very common problem in thisworld, 20 to 30 percent of those
(10:06):
patients that endure a hipfracture, will not make it one
year after that hip fracture.
Twenty to thirty percent ofthem will pass away the same
year after the suffering thathip fracture.
And the reason is notnecessarily from the fracture
itself, what the surgicalmanagement of the fracture, but
rather the complications thatare then associated with being
(10:27):
bedridden from that fracture.
So, for instance, pressuresores, pneumonia is blood clots,
pulmonary embolism, anothercomplications like that.
So it's incumbent upon us as ahealth care provider to make
sure that our patients that aresuffering and enduring low
energy fractures, insufficiencyfractures, are appropriately
(10:48):
worked up and treated To preventanother fracture.
But most importantly, it'simportant at the appropriate
time to assess our patientsearly on to see if they are at
risk for osteopenia orosteoporosis and ultimately
suffering one of theseinsufficiency pathological
fractures.
The numbers are staggering inthat approximately eighty to
(11:15):
ninety five percent of patientsthat endure an insufficiency,
low energy fracture are actuallydischarged from the hospitals
without any follow up care fortheir osteoporosis by a bone
metabolism expert such aspatrician.
So it's, it is a health carecrisis.
(11:35):
It is why we call it the silentkiller and is the reason we are
having this podcast today tobring attention to this silent
killer.
So, as far as the bone densitytest, the DEXA, are there other
things that we can do with thebone density test that can
assess the bone quality at all?
Patricia Donohue, ACNP (11:57):
So there is an additional test that we
do at Kali orthopedics and thatis looking at a lateral view of
the lower spine, called thelateral vertebral assessment, or
other institutions may call ita vertebral fracture assessment,
and what it does is it looks atthe height of the vertebrae in
(12:17):
the lower spine to make surethat the height is equal to the
adjacent vertebrae, above orbelow.
If there is a lower or decreasedheight, it makes us suspicious
that there may be a vertebralcompression fracture there.
So what's important to knowabout vertebral compression
(12:38):
fractures is a majority of thesefractures are asymptomatic.
patients don't have any pain.
In fact, we identify some thatare chronic and we don't even
know how long they've been there.
So it's important, when we seethis decreased height, to have a
full work up in evaluation forosteoporosis and treatment,
(12:59):
because there's a five fullchance and those individuals who
have a fracture of having anadditional vertebral fracture in
the next year and a two tothree full chance of them having
other fractures, such as a hipor pelvic fracture.
So that's a really importantmodality to do and to identify
these fractures proactivelybefore and treat them before an
(13:23):
additional fracture occurs.
Robert A. Kayal, MD, FAAOS (13:25):
I think we should probably take
this opportunity to show ourviewing audience a model of bone
.
We can describe the anatomicalstructures of this bone and we
can compare and contrast hownormal bone would compare and
contrast to compromise bone, onethat is compromised from
osteopenia or potentiallyosteoporosis.
(13:47):
This is a cross section throughbone and you can see the inner
network of bony architecture Wecall the cancellous bone or the
spongy bone, as opposed to theouter, structurally strong,
compact bone We call thecortical bone.
So the outside of our bone isthat strong, cortical, compact
(14:11):
bone.
That's, for instance, the boneyou can feel when you palpate
your shin or your wrist.
The inner aspect of the boneeveryone's familiar with is the
bone marrow and inside the bonemarrow you have a lot of fat and
another constituents of thebone marrow.
But the bony part of the insideof the bone is this spongy,
(14:35):
cancellous, trabecular bone Andthat is the bone that is
primarily compromised when wespeak about osteopenia and
osteoporosis.
This bone is alive.
As we said before, it'sconstantly breaking down and
building, breaking down andbuilding.
The osteoclast are breaking itdown, the osteoblast are
(14:56):
building it And over time thestructural architecture of this
bone changes in everyone suchthat the inner cancellous
trabecular bone tends to becomeless dense and the outer compact
cortical bone becomes thinnerand thinner and thinner And the
(15:17):
canals of the bone become moreand more capacious over time.
So here's an example now of achange of the inner and outer
aspect of this bone.
So we can see that now it's theouter cortical bone is
definitely thinner, the compactbone is definitely thinner and
(15:41):
more compromised And the innertrabecular network of bone is
certainly more porous and lessstructurally intact, comparing
and contrasting what happenswith osteopenia and osteoporosis
.
So, as we just mentioned, wespoke about trabecular bone.
So, patricia, why don't youelaborate on this concept of the
(16:03):
trabecular bone score for us?
Patricia Donohue, ACNP (16:06):
So trabecular bone, like Dr Kale
was just explaining about thespine in particular, is made up
of 75 percent of trabecular bone.
We just had spoke aboutvertebral fractures If that
trabecular network orscaffolding starts to thin out
because of an increased bonebreakdown we got a lot more
(16:28):
spaces in it, there's thinnerplates and rods and the
scaffolding is more likely tocollapse.
So a trabecular bone score isan addition that we can add on
to our bone density test thatwe'll just look at that inside
quality of the bone to tell usif we have a partial degradation
(16:48):
of full degradation of thetrabecular bone.
If there is, we may usemedications to help build up
that network and there arecertain medications that work
even better than othermedications to target those
areas to prevent that collapsingand that thinning of that bone.
So that's a very importantthing to look at.
Robert A. Kayal, MD, FAAOS (17:09):
And what about the frack score?
We hear a lot about this frackscore.
That's so important as well.
F-r-a-x.
Patricia Donohue, ACNP (17:15):
Yes.
So the frack score was designedby the World Health
Organization and what it does isit takes an individual's risk
factors such as their genetics,their history of fracture,
corticosteroid use, alcohol,smoking, and puts that
calculation in with one of theirhip scores And it then comes
(17:37):
out with a chance, a percentageof an individual having a major
osteoporotic fracture in thenext 10 years as well as a hip
fracture in the next 10 years.
So the World HealthOrganization suggests treatment
over 20% if patients come over20% in the first category, or in
over 3% chance of having a hipfracture in the next 10 years.
(18:00):
But we must keep in mind thatcalculated that risk factor is
just based upon what we'reseeing in the hip.
So if somebody has a normal orlow frack score or chance of
fracturing and they haveosteoporosis or a low trabecular
bone score in the spine, itreally preempts us to actually
(18:23):
treat those individuals beforethey get a spine fracture.
So very important to delineateand see which calculations work
with which part of the bonedensity testing.
Robert A. Kayal, MD, FAAOS (18:33):
Is there any blood work that you
can perform for patients toidentify whether or not they're
at risk of disorders of bonemetabolism, osteopenia,
osteoporosis, etc.
Patricia Donohue, ACNP (18:44):
Yes, so very good question, thank you.
And what we do is we put acomprehensive evaluation with
the bone density test and thenext step is to do some blood
work and to look at conditionsor look for conditions that may
be creating bone loss, such ashypocalcemia, low vitamin D
levels You need vitamin D toabsorb calcium other conditions
(19:08):
such as hyperparathyroid disease, hyperthyroid disease or other
disease processes,corticosteroids, adrenals
problems, other conditions thatare hemotological disease that
can be causing bone loss in ourpatients.
So we try to identify if there'sany disease processes and
(19:31):
collaborate with otherdisciplines or specialists in
that area If we do identifythose, to get those conditions
under control before giving thema medication.
And then, in addition to that,as we spoke about the osteoblast
, the bone growth, and theosteoclast class the bone
breakdown we can also checkmarkers that measure collagen in
(19:54):
the bloodstream.
Collagen is the end result ofbone breakdown.
So the higher your collagenlevel in your blood is, the more
bone you're breaking down.
So we can use that as a markerto see how much you're breaking
down and we can also use that inresponse to our treatment
modalities to make sure thatthey're working effectively for
(20:17):
our patients.
In addition to our bone densitytesting, Well, it's amazing.
Robert A. Kayal, MD, FA (20:20):
There's so much you can do to assess
this condition That's fantasticand probably monitor treatment
as well.
Patricia Donohue, ACNP (20:26):
Yes.
Robert A. Kayal, MD, FAAOS (20:28):
So I'm sure our viewing audience is
wondering when should I startassessing my bone quality?
When should I come in for abone density?
When do I need blood work?
So both men and women, andsometimes even in young
adolescents and athletes thatsuffer stress, fractures etc.
We know about the femaleathlete triad.
(20:50):
potentially You might want totalk about that as well, but
when should our viewing audienceconsider getting assessed for a
bone density and doing some ofthe blood work?
often would they need to followup after getting one.
What types of regular intervalsdo you recommend follow up?
Patricia Donohue, ACNP (21:10):
Okay, very good question.
So, starting out with ouradolescent population are
younger individuals that arechildren that are in sports,
anybody that has a stressfracture.
we don't routinely do bonedensity tests on individuals
that age, but if they've had astress fracture we need to
(21:30):
evaluate whether or not theyhave a deficit in their bone
quality, and it can, most of thetimes, can be related to
secondary causes, such as therelative energy deficiency
syndrome.
you know, eating disorders,anorexia, bulimia, not giving
enough protein to the skeletonbefore you're working out,
(21:51):
putting it into a negativebalance.
We also can look for cases thatthey may have fractures due to.
maybe they had asthma and weretreated with a large amount of
steroids.
They didn't have, as we spokeabout before, enough calcium and
vitamin D in their diet.
So it's important to assessthese individuals in getting
(22:13):
that Z score, but also lookingfor the secondary influences
that is causing bone loss inthis age group, and we've have
identified individuals maybewith celiac disease.
they have a malabsorptionproblem, that they're not
absorbing vitamin D than toabsorb the calcium that you're
giving to them.
(22:33):
So it's really important tolook for secondary causes within
this age group.
Then fast forward.
Robert A. Kayal, MD, FAAOS (22:39):
Just to interrupt you, if you don't
mind, for a second, about thisfemale athlete triad.
You know, in these youngfemales we talk about this
female athlete triad, whereyoung women in particular can
suffer from osteoporosis andfractures and what we call
amenorrhea.
You know, we always say inorthopedics, especially when
(23:00):
we're talking about bonemetabolism, estrogen is the
bone's best friend And it's soimportant for women, especially
at a young age, to have theirperiods every month.
Regular periods are veryimportant for the young
adolescent woman, especiallybecause of the estrogen levels.
The estrogen protects the boneAnd when patients are having,
(23:24):
for instance, some eatingdisorders that can deleteriously
affect their ability to have amonthly period, that will
translate into a conditioncalled osteoporosis in this
female athlete triad.
And sometimes these young womenwill suffer fractures because
of the osteoporosis And thetreatment is not necessarily to
treat the osteoporosis but totreat the underlying condition,
(23:47):
which is, in this particularcase, an eating disorder which
can contribute.
So that's also very, veryimportant to note.
Patricia Donohue, ACNP (23:54):
That's correct.
And the first question we doask is the menstrual cycle, how
irregular or regular it is.
And there's one statisticthat's out there that suggests
that the bone bank that youbuild and the amenorrhea can
affect that bone bank.
It can predictosteoporosis-related fractures
in women in their later yearspost-menopausal.
(24:15):
So really important to look atthis time period and relative
energy deficiency and secondarycauses.
Robert A. Kayal, MD, FAAO (24:23):
Great point, great point.
Patricia Donohue, ACNP (24:25):
So then fast forward to the
post-menopausal orperimenopausal women.
So it's said, around the 10years that women's going through
menopause, they're losingapproximately 2% of their bone
per year And, just as you hadexplained, it's due to that
estrogen loss that increasesbone resorption, increases bone
(24:47):
breakdown.
So it's really important toidentify these women, especially
if they've gone through theirmenopause at an earlier age, to
do bone markers and then maybesome hormonal markers to see
where they're at in menopauseand work in collaboration with
their gynecologist.
Some of these women, if theydon't have risk factors for
(25:09):
breast cancer, uterine cancer orblood clots, we may use
low-dose hormonal therapy onthem around the time of
menopause, five to 10 years, topreserve that bone from breaking
down further and preventingfurther bone loss.
If they're not a candidate, wecan use the bisphosphonates, and
(25:29):
that is when we've used them inthose circumstances before All
right.
Robert A. Kayal, MD, FAAOS (25:33):
So just going back to the testing
and the periodic testing,certainly the perimenopausal
woman.
And then, how often afterwardsis that dependent on the results
of their bone density tests andthe blood work?
Patricia Donohue, ACNP (25:46):
Yeah, so anybody that's being treated,
actively treating or monitoringwe're concerned about.
I would recommend doing a bonedensity test every year If
Medicare will pay for it.
Sometimes you have to write aletter to other commercial
insurances, but generally ifyou're actively treating those
patients and concerned aboutbone loss, i've never had a
(26:07):
commercial insurance or Medicaredeny having a bone density test
.
Along with that, we would checkthe bone markers every six
months to a year to make surethat our treatment is effective
in preventing further breakdown.
We can't have a bone densityany less than a year, but we can
use the lab certainly for alittle bit closer in time.
Robert A. Kayal, MD, FAAOS (26:28):
Does everyone get blood work, Or
just everyone that's beingassessed for osteopenia and
osteoporosis?
do we always get blood work?
Patricia Donohue, ACNP (26:35):
So for the very least, if you have a
normal bone density test, igenerally just check the calcium
and the vitamin D.
These are the buildingmineralization and you need for
your bones on a daily basis.
So everybody needs a calciumintake through their dietary
means or supplements.
So to check that and then tocheck the actual hormone called
(26:58):
the parathyroid hormone to makesure that you're absorbing that
calcium and getting it to yourbones.
When we check a normal calciumin the bloodstream it doesn't
tell us if that calcium.
It tells us maybe it's normalbut it doesn't tell us if it's
getting to the bones, maybewe're leaching.
If we don't get enough calciumin on a daily basis, we may
(27:19):
leach that calcium out of ourbones, demineralize our bones
and it looks great in ourbloodstream.
But doing a parathyroid hormonelevel will tell us whether or
not we're getting an adequateamount of calcium.
So that's really important todo on the patients of the very
least calcium, vitamin D and aparathyroid hormone level.
Robert A. Kayal, MD, FAAOS (27:41):
I'm sure everyone's wondering how
much calcium and vitamin D theyshould be taking, but we'll get
to that very shortly, so let'sjust talk about at this point
some risk factors for thiscondition.
What are some of the riskfactors for patients that may
ultimately end up gettingosteopenia or osteoporosis?
Patricia Donohue, ACNP (27:58):
Sure So low BMI.
you don't take enough proteinin.
it doesn't support your bones,So less than 18.5 of body mass
index is usually indicative ofpossible bone density issues.
On the other hand of thespectrum, obesity is.
vitamin D is a fat solublevitamin, So you may see lower
(28:22):
vitamin D levels in thoseindividuals and you may have to
give them extra vitamin D to getthem to a normal level so they
can absorb the calcium thatyou're having.
And then also, while we're onthe subject, for obesity, some
individuals may have undergone agastric bypass to ruin Y, and
it bypasses the area of oursmall bowel where most of our
(28:45):
intestinal absorption ofvitamins and minerals occur, and
so those individuals may needincreased amounts of vitamin D.
And what's important to know isvitamin D doesn't have to pass
through the small bowel.
There is a liquid form ofvitamin D.
It's a bucal form that you canput a drop or two under your
(29:06):
tongue, and it's usually onedrop equals a thousand
international units.
So if somebody hasmalabsorption issues, that's a
good way to get the vitamin Dinto their blood, to get them to
adequate amounts so they canabsorb their calcium.
We also, which is important todo in our patients, is to look
for a height loss.
(29:27):
Anybody that has a height lossof an inch and a half over a
lifetime.
I say to my patients so what'syour height now and where were
you when you were 30 years ofage?
If they lost more than twoinches, it behooves us to do
that vertebral fractureassessment, to look for a
vertebral fracture there.
And then we have our usuallyover the age of 65, the over the
(29:52):
age of 70, and doing the bonedensity test Now.
It's important to assessgenetics And a lot of our older
patients may not know theirparents or grandparents history
of osteoporosis because bonedensity testing wasn't done.
So you have to ask them iftheir grandparents fractured,
because genetics can beresponsible for 60 to 80% of
(30:13):
bone loss.
Robert A. Kayal, MD, FAAOS (30:13):
So that's really important.
It's just like everything else,exactly exactly.
Patricia Donohue, ACNP (30:17):
And then there's the modifiable risk
factors smoking, alcohol,whether or not they're having
more than three drinks a day.
if they're smoking, whether ornot they're exercising, you know
is a very important Boneloading exercises of just
walking in the older patients,it prevents not only bone loss
(30:38):
but what you suggested before asarcopenia or a loss of muscle
mass, which makes our patientsprone to falling and balance
issues.
So important to assess all that.
Robert A. Kayal, MD, FAAOS (30:48):
Yeah , i can't emphasize enough the
importance of the modifiablerisk factors.
As an orthopedic surgeon thatdoes a lot of joint replacements
, i could tell you I am privy tothe ability to actually inspect
the bone quality during surgery.
And on the patients I performknee replacement surgery on a
regular basis those that areavid long time smokers or
(31:13):
alcoholics, long time consumersof alcohol products the bone
quality is certainlytremendously compromised
relative to the non smokers andthe non alcohol consumers.
So it's really, reallyimportant to stop smoking and
excessive alcohol consumptionbecause it truly deleteriously
(31:34):
affects your bone quality andsignificantly increases your
risk for fracture.
So there's this concept inorthopedics called Wolf's Law,
and Wolf's Law is essentially,in layman's terms, bone response
to load.
So whenever you load a bone,bone response by getting
(31:54):
stronger.
So we typically find in ourclinical practice that patients
that live a sedentary lifestyleor are frail or emaciated those
are the patients that end upgetting osteopenia and
osteoporosis, whereas the veryactive patients, or typically
the heavier patients, very oftendo not get the osteoporosis
(32:18):
because their skeletons have tocarry the load of their body
weight for their lifetime.
And if there are runners ordoing a lot of high impact
aerobic activity, it reallyhelps to strengthen the bone
tremendously.
So it's just like anything else.
Bone is a tissue.
When you exercise it, when youwork it out, it gets stronger,
(32:41):
and when you live a sedentarylifestyle, it essentially
atrophies and becomes frail andbrittle and fractures.
I know we can get vitamin D inour diets, but is there anywhere
else we can absorb vitamin Dfrom?
Patricia Donohue, ACNP (32:54):
So we only absorb 10% from the sun,
And I have many patients thatsay I sit in the sun all day.
I go to Florida, I'm a sun bird, I'm a snow bird.
But the reality is, if you'reusing sunscreen and you're out
in the sun, you're onlyabsorbing 10%.
Robert A. Kayal, MD, FAAOS (33:08):
I tried.
Patricia Donohue, ACNP (33:10):
So definitely.
Calcium is in not only dairybut it's found in nuts and green
leafy vegetables.
So getting a nice calcium chartis the preferred way to get
calcium.
But if you have lactoseintolerance or you can't
tolerate these food groups, Imean there's.
Or if you're a vegetarian,there's soy products, there's
(33:32):
almond milk, there's other ways.
And then the calciumsupplements.
It's always recommended to takea calcium citrate tablet because
calcium is absorbed better inan acid environment than calcium
citrate comes in an acid.
So you don't have to take itwith food.
But what's important to realizeor know is that you don't want
(33:53):
to take more than 500 milligramsat any given time.
So I have patients that say I'mon 1,000 milligrams of calcium
and they're taking them both atone time, both the tablets.
You're not absorbing more than500 milligrams with each tablet,
so you need to divide thosedoses.
So the recommended calciumintake and diet in supplements
(34:14):
is 1,000 milligrams for men andfor children And for
post-menopausal women it's 1,200milligrams.
So I tell my patients startlooking at your labels, start
calculating out your calcium andyour diet and then we can start
to supplement with supplementsif needed.
Vitamin D, on the other hand,the maintenance is 800 to 1,000
(34:35):
international units And againyou need to get a vitamin D
level check to see if there'sany absorption problems that we
need to increase that amount ona daily or a weekly basis to get
you to where you need to be toabsorb the calcium.
Robert A. Kayal, MD, FA (34:49):
Vitamin D is very, very important for
our bodies in that it helps toabsorb the calcium from our gut.
So if your vitamin D levels arelow, you really won't even be
absorbing the calcium thatyou're taking, and I hope you
appreciated the fact thatPatricia said for women and
children.
So 1,200 milligrams 12 to 1,500milligrams of calcium every day
(35:12):
is important for women andchildren.
So when I have those kids comein with a broken wrist, i always
tell the parent that the childshould be taking the same amount
of calcium that you're taking,emphasizing to the mom that she
should be taking calcium andvitamin D as well.
So it's very, very important todo that.
I also favor calcium citratebecause of the fact that it is
(35:35):
water soluble, And I believe theliterature supports the fact
that there's a lower incidenceof kidney stones with the
calcium citrate as opposed tothe others that are more readily
found in the kidney stones,like the calcium oxalate and
carbonate.
Yeah, so now that we'respeaking about medications and
(35:58):
the treatment, what are some ofthe first of all classes that we
place these medications into inaddressing osteopenia and
osteoporosis, and then maybegive us some examples of each
and why they work?
Patricia Donohue, ACNP (36:15):
Okay, so , as we had spoken about, there
are either it's an increasedamount of bone breakdown that
people have and that's relatedto bone loss are not enough bone
building.
So there's a class called theanti-resortive agents, which are
the oldest medications thathave been around and many of you
(36:36):
probably remember the phosomaxand the actinol, which are oral
forms.
They are taken once a week orit can be once a month, but
they're not recommended forindividuals that actually have
some gastroesophageal refluxdisease or an older patient that
may not absorb tablets as well.
(36:57):
So there is an alternativecalled reclassazoleoginic acid,
which can be given theintravenous route And, if needed
, it can be given on a yearlybasis.
But again, we continue tomonitor to see if you actually
do need it on a yearly basis.
So that's a class ofanti-resortives.
It's the bisphosphonates, thenext class of anti-resortives.
Robert A. Kayal, MD, FAAOS (37:19):
So essentially they inhibit the
osteoclasts.
Patricia Donohue, ACNP (37:21):
That's correct.
Robert A. Kayal, MD, FAAO (37:22):
Those are the cells we talked about
that break down the bone, sothey inhibit osteoclasts.
Those are the anti-resortives.
Patricia Donohue, ACNP (37:29):
That's correct.
The next class ofanti-resortives is called rankl
inhibitors.
A rankl breaks again increasesthe osteoclasts that break down
cells.
And that's where prolia many ofyou heard about prolia.
It's an every six monthinjection So, unlike the
bisphosphonates that hold on tothe bone for a longer period of
(37:50):
time And, like I said, you onlymay need them every year, every
two years, i've even seen it upto every three years in infusion
, they prolia.
On the other hand, it wears offvery quickly.
So the injection has to begiven every six months And you
have to be pretty regimented toreally make sure that you make
(38:10):
it into the office to get thatinjection, because if it wears
off, it wears off very quicklyand your bone resorption goes up
very quickly and your chancesof fracturing can occur.
So this is really somethingthat we really drum home with
our patients And basicallytelling them that they have to
be regimented.
If we are going to stop it, wecan't just stop at cold turkey.
(38:33):
We need to give you abisphosphonate to seal it in so
this way you don't have thattype of side effect.
The prolia will diminish yourcalcium.
So, going into any of theirstarting treatment on any of
these medication regimes.
It was important for us to do acalcium and vitamin D to ensure
that these are workingeffectively.
(38:55):
Then you have an adequateamount of calcium and vitamin D
and especially prolia andevenity, which we're going to
talk about next, will drop yourcalcium level.
Evenity is the class ofmedication that has a dual
mechanism It slows down bonebreakdown It's been out for
about four years and it alsoincreases bone formation.
(39:18):
So it's a really nicemedication to use in patients
that have a very low T score orbone density test or at their
risk of fracturing or have ahistory of fractures.
But you have to make sure thatthey don't have any
cardiovascular risk factors.
The third class of medicationsis called the anabolic agents.
These anabolic agents areparathyroid, synthetically made
(39:42):
parathyroid hormone.
Parathyroid hormone, when givenin intermittent doses, actually
increase osteoblastic activity,so increases bone cells.
It's the only medication thatwe have that actually increases
by itself the bone cells.
It's very useful in treatingpatients that are on
glucocorticoid, trabecular bonedeficiencies, vertebral
(40:06):
fractures, other fractures andosteoporosis.
Again, if you just stop thatafter the course of that
medication, you need to seal itin because your body's going to
go back to its normalequilibrium and start to break
down all that good new bone thatwe just gained, and it would
have been moist at both fartimes.
Robert A. Kayal, MD, FAAOS (40:25):
So that's important.
So seal it in with anotherbisphosphonate.
Patricia Donohue, ACNP (40:28):
That's correct.
Robert A. Kayal, MD, FAAOS (40:29):
So these are the bone formation
agents that she's talking aboutnow, for instance the Forteo,
but the bisphosphonates that shetalked about earlier.
What are some of the examplesof those bisphosphonates?
Patricia Donohue, ACNP (40:41):
So Phosomax, Actinol, Atylvia
they're the bone oldest forms ofthe oral medication and then
reclass, to which is sublodronic.
Robert A. Kayal, MD, FAAOS (40:51):
Yeah , and what about hormonal
replacement therapy andderivatives of hormone, estrogen
for instance?
Patricia Donohue, ACNP (40:59):
Yeah.
so again, around that firstfive, seven years of menopause
is really important If thegynecologist and there's been a
lot of hesitancy ingynecologists in actually
recommending hormonalreplacement because of the
women's health studies thatwe've done in the past but even
the National Association ofMenopause Society recommends
(41:21):
treatment with low dose estrogenand progesterone if you have a
uterus around the time ofmenopause to prevent bone loss
and it prevents vertebralfractures and other fractures.
So it's a very useful way touse these hormone replacements
if they are individuals that cantake it in that period of time.
Robert A. Kayal, MD, FAAO (41:41):
Right and along the lines of hormonal
replacement therapy.
There's an agent called evistaright, which is an interesting
agent in that it can be usedspecifically in patients
potentially that have alsobreast cancer and osteoporosis
right.
That's good.
Why is that?
Patricia Donohue, ACNP (41:59):
So it's said to be breast protective in
those patients that have apretensivity to develop breast
cancer.
But it's the evista is the, anagent that actually attaches to
the estrogen receptors, so itacts like an estrogen but it's
not truly an estrogen.
It's really helpful in thoseindividuals that are further out
(42:20):
from menopause because if yougive it too close to menopause
it may cause breakthrough,bleeding and the
osteoarthopedics.
We don't know how to deal withthat.
So we don't want to give it tooclose to menopause, so we want
to use it later down the road,like maybe 10 years after
menopause.
But it specifically works thebest in the spine.
(42:41):
So this is a really importantagent If people don't want to be
on the other agents that canpreserve bones.
Specifically, it works betterin the spine and works less in
the hip.
So when I say we do this workup with the bone density and
blood test, then we look at theindividual and have a targeted
(43:01):
plan of care what agent we wantto use, appropriate agent where
the bone density is showing thebone loss and patient specific.
So that's really important.
Robert A. Kayal, MD, FAAOS (43:13):
Yeah , And with breast cancer it's
interesting because the Savistaagent apparently tricks the body
right.
It tricks the bone and ittricks the breast.
Breast cancer in general tendsto like estrogen.
It sort of grows potentiallyand becomes more aggressive with
estrogen Input.
Bone also loves estrogen.
(43:37):
Bone gets stronger withestrogen.
This Savista agent potentiallycan trick the body rather in
that it will bind to the boneand stimulate the bone formation
, but it will not bind to thebreast tissue and stimulate the
breast cancer growth.
So that is the conceptessentially behind the agent
(44:03):
Avista.
Why are we attacking thiscondition with so many different
agents if they all work?
There must be something I'mmissing here.
Are there potentialcomplications or side effects
with some of these medicationsthat we need to talk about,
which may potentially cause usto maybe change courses and
(44:25):
switch from one medication toanother?
Patricia Donohue, ACNP (44:28):
So that's a very good point, and
you had mentioned the statisticthat only 15% of patients that
have osteoporosis-relatedfractures are being treated, and
the bottom line is that thereis a fear out there with using
these agents.
Back in the 80s to 90s,specifically when Fasamax was
(44:49):
around, it was used for a longduration and period of time And
what they saw is they saw someside effects, such as a
bisphosphonate-related femurfracture that occurred in 1,000
patients, and then thewell-reported and publicized
osteonocroosis of the jaw, whichoccurs in 1 in 100,000 patients
(45:13):
.
So there's been this pandemoniaof fear in using these agents
and we can only think that maybethat's creating the hesitancy
in using these.
But like anything else inmedicine that we do, we must
weigh the risks and the benefitsAnd what we have seen with
these medications is a fewcommon factors Using
(45:36):
bisphosphonates for a longperiod of time.
In the 80s and 90s they used itfor over 10 years.
We know not to use the oralforms of these medications for
longer than five years without adrug holiday to let in the bone
recover In the IV reclass aboutthree years, let in the bone
recover And then to really notuse a long duration and then
(46:01):
also identify risk factors forthe osteonocroosis of the jaw.
It was many patients that hadsome radiation to the jaw from
cancer or had poor dentation.
Which brings me to my next pointis that anybody that's on any
of these agents, hygiene dentalhygiene is of utmost importance
(46:22):
Keeping up on your evaluation byyour dentist and having regular
exams, regular cleanings,mentioning to your dentist that
you're on these medications Sothis way they can watch you
carefully with us.
But the newest guidelines amongthe American Dental Association
doesn't even suggest taking youoff of these agents or
(46:46):
monitoring the bone turnovermarker when they're in fact
doing even implants or drillinginto the bone.
We like to time it a little bitfurther out from your last dose
, but you don't need to stopthese agents and those are the
newest guidelines that's put outby the American Dental
Association.
But any patient that's on theseagents, then they see a
(47:06):
non-healing ulcer in their mouthor if they have pain in their
thigh, then they need to get anx-ray done for their thigh and
see their dentist to make surethat it's not related to these
anti-resortive agents.
So that's really important.
Robert A. Kayal, MD, FAAOS (47:24):
Yeah , we certainly don't want to
miss one of those atypical femurfractures which have clearly
been associated with some ofthese medications.
What about the Avista?
Any concerns with respect toAvista and estrogen-like type of
agents?
Patricia Donohue, ACNP (47:42):
Good question.
So Rheloxaphen or Avista isprobably the only agent that is
out there that has an enhormonereplacement that is not
associated with theosteonecrosis of the jaw and the
atypical femur fracture.
So that's the beauty of thosemedications, but they bring
along with it the higher risk ofthromboembolic events.
Robert A. Kayal, MD, FAAOS (48:02):
So, everybody.
Patricia Donohue, ACNP (48:03):
Every medication has its trade-off and
we want to do, like I said,that comprehensive evaluation
and a plan of care according topatients' risk factors.
Robert A. Kayal, MD, FAAOS (48:12):
What you mean by that Thromboembolic
.
sometimes we get concernedabout cardiac issues, blood
clots, pulmonary embolism,strokes, things like that with
estrogen and hormonalreplacement therapy.
So certainly, besides talkingto Patricia, we would also
really invite you to speak toyour primary care physicians or
(48:32):
your cardiologists to get theirblessing before proceeding with
some of these agents.
Now, as far as monitoring, onceyou've diagnosed the patient
and treated the patient, wetalked about monitoring with
subsequent bone density testingand blood work.
Sometimes urine analysis isalso used as well.
(48:54):
What are you looking for inthat?
Patricia Donohue, ACNP (48:55):
Yes, The urine test is very helpful
because it can tell us if aperson has a urinary leak of
calcium.
So we're giving calcium to ourpatients, thinking that it's
getting to the bones.
Either they're not absorbing itor at the other end, they can
leak out urine.
There are certain medications,like the loop diuretics, that
can cause calcium loss as well,so we may see an increase in the
(49:19):
urine based upon that, andwe've changed and worked with
primary care doctors to changetheir diuretic regime around.
We also can have patients thattake large amounts of water and
the border is good for you butit makes you pull off sodium and
makes you pull off calcium inyour urine.
So if somebody has a very low orhypocalcemia and we're giving
(49:40):
you calcium supplements and it'snot working, then we'll check a
urinary calcium either a spottest or preferably 24-hour urine
.
We can also if there's an agentwe want to use we want to make
sure that there's no calciumoxalate crystals in the urine,
such as with kidney stones andthings like that.
So that's really important andalso identifying other diseases
(50:04):
that are related to phosphorusand calcium in the kidney and
kidney disease that we can helpto identify with these urine
tests A urine test or a bloodtest can also be used to measure
a bone resorption marker.
They actually, like I said, itmeasures the calcium, the
collagen remnants in the urineor blood.
(50:27):
So it can be used as a markerto see how our therapy is
working, for continuingmonitoring and then to see when
it starts to increase, when weneed to intervene with an
additional possible Medicaid.
Robert A. Kayal, MD, FAAOS (50:40):
Well , that was all so informative.
We're so honored to have you asour bone health expert at the
Kale Orthopedic Center.
We're just so privileged tohave you with us today.
I hope that you found thispodcast very informative.
I'm just going to ask Patriciato take a minute to summarize,
because this is such a veryimportant topic.
I definitely want to make sureour viewing audience gets the
(51:03):
message that osteoporosis andosteopenia is a ubiquitous
problem and is very prevalent inour society and is the silent
killer.
So, patricia, last words forour viewing audience, please.
Patricia Donohue, ACNP (51:18):
So, as Dr Kel had mentioned, it's very
important to have, starting atadolescence, calcium, vitamin D,
exercise And then, goingforward, the post-menopausal
woman needs to get a bonedensity test, screening around
the age of menopause.
And then individuals that haverisk factors and around the age
(51:40):
of 50, that are smokers, alcoholgenetics, some family history
of osteoporosis, their historyof a low energy fracture, which
is a fracture from a singlelevel, not from a height, and
then also any other sedentaryinvolvement, lack of exercise
due to maybe some illness orsomething that has not allowed
(52:02):
them to be active.
And then over the age of 65 forthe female in general and over
the age of 70 for the male ingeneral.
We need to identify these boneloss disease processes because
they are a silent disease and weneed to recognize them before a
person sustains a fracture, andthat's very important because
(52:26):
having a fracture like wementioned, having an additional
fracture, is very prevalent.
So it's important for us totake care of our bone health and
we're dedicated to do this atthe KL Orthopedic Center and we
hope to help you take care ofyour bone health as well 100%.
Robert A. Kayal, MD, FAAOS (52:45):
One last thing what is this fracture
liaison service that youspearhead at the KL Orthopedic
Center?
Patricia Donohue, ACNP (52:51):
So a fracture liaison service and we
mentioned that only 15% ofpatients after fracture are
actually being treated.
So we used to have a fractureliaison service that was
originally designed to go intothe hospital to meet those
patients.
But then we recognized that thepatients were sedated.
They didn't remember us.
(53:11):
They had no idea what we weretalking about after we called
after discharge.
So now it's spearheaded toactually identify those patients
, getting the word out to all ofour orthopedic surgeons to help
identify and let us know aboutthose patients when they come in
with a low energy fracture.
One in particular that wehappen to miss a lot is the ones
(53:33):
that are done at the ambulatorycare center, which many more
surgeries are doing there, butspecifically the wrist, the
distal radius fracture that canbe a red flag that there's some
underlying metabolic bonedisease or deficiency, and those
patients in particular need tohave a bone density test and
need to be appropriately sent tothe fracture liaison service.
(53:57):
So it's really identifyingpatients that have low energy
fractures and getting them intoan evaluation and possible
treatment.
Robert A. Kayal, MD, FAAOS (54:05):
Yeah , when Patricia's mentioning low
energy fractures, we considerthose pathological fractures,
insufficiency fractures,fractures that should not have
developed.
For instance, a fall from aheight of only three or four
feet should not result in abroken bone to your wrist in the
normal bone.
But when somebody hasosteopenia or osteoporosis we
(54:28):
call that a low energy fracture,very much different than
breaking your wrist in a caraccident, for instance.
So anyway, thank you so muchfor joining us today on this
Kail Ortho podcast.
It was so enlightening to meand so refreshing now to have
Patricia as part of the KailOrthopedic Center.
We're so privileged to have herwith us.
(54:48):
Thank you for spending the daywith us, patricia.
Patricia Donohue, ACNP (54:50):
Thank you so much.
Thank you for having me.
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