Good evening. I'm Kelly Geer Ripken and I'm national chair
of A Woman's Journey. On behalf of Johns Hopkins Medicine and A
Woman's Journey, thank you for joining us this evening for our monthly webcast series,
Conversations that Matter. As you know, A Woman's Journey strives to
improve your wellbeing through health education. Globally, osteoporosis causes more than eight
point [inaudible 00:00:45] roughly one fracture every three seconds. As you age, your body may absorb calcium and
phosphate from your bones, leaving the bone breakdown. Unfortunately, this also makes your bone weaker
and more likely to break. When this process of bone breakdown reaches
a certain stage, it's called osteoporosis. Many times, a person will fracture a bone
before she, or he even knows there's been a significant bone loss. Tonight, we are so pleased to be joined by
Johns Hopkins endocrinologist and metabolic bone specialist, Dr. Kendall Moseley. So please use your Q&A on your screen to pose
your questions to Dr. Moseley, who will respond during the last 20 minutes of tonight's conversation. I want to take this opportunity to acknowledge
and thank Johns Hopkins University's program, Hopkins at Home, for their production assistance. And you can visit their website for additional
lectures and courses throughout the year. And now, I am pleased to introduce Dr. Moseley. Dr. Moseley? Thank you so much, Kelly. I really appreciate it. And I welcome everybody tonight. I hope everyone is doing well. I'm just very excited to give this talk tonight
about osteoporosis. The anecdote I often share prior to talks
like this for A Woman's Journey is that this is actually how my mom figured out what I
did for a living many years ago when she came to A Woman's Journey in Baltimore, where I
gave a lecture on osteoporosis and she sat right smack in the front row. Very proud of course, as a mother is, but
came up after me and said, "Oh, this is what you do every day. I guess I had no idea." And so this has really helped educate, not
only a lot of patients and a lot of people out in our community, but also my own family
members. So I always like to start with a definition
of osteoporosis. I think it's important to get us all on the
same page. And there are a lot of words here, but I promise
you I'll walk you through them. Osteoporosis defined as, "A systemic skeletal
disorder characterized by low bone mass and microarchitectural deterioration of bone tissue
with a consequent increase in bone fragility and susceptibility to fracture." And when we break that definition down, I
want to focus on three main parts. The first is the systemic skeletal disorder. We're going to see pictures in a little bit
of a bone density test or a DEXA scan where we talk about the hip, we talk about the spine,
sometimes there's a forearm, but remember that those images, those measurements are
actually a surrogate measure or an estimate for bone throughout the body. The second piece is the microarchitectural
deterioration. So oftentimes, the DEXA does not tell the
full picture. There are people who break bones even when
the DEXA is normal or it shows osteopenia. So we have to think about other things that
may be lurking underneath the surface that result in fracture. And then finally, the most important part
of this definition is the last part, the susceptibility to fracture. We talk all the time about T-scores and bone
density, but at the end of the day, those things don't matter because what we focus
on is the fracture and preventing that first fracture from ever occurring. Simply speaking, osteoporosis is a bone deficiency. Its thinning, its loss, its weakening. And you can see in the diagram here, normal
bone versus osteoporosis. There's major differences between the two
bones. This is microarchitectural change that you're
seeing here too. So again, getting back to the middle of that
last definition that I showed you, it's the bone changing over time and ultimately becoming
weak as it changes. So why do we care about osteoporosis? Well, I know why I care and I know why probably
you care because you're here today, but there's the big picture, which is we've all heard
about this little lady, or frankly, little old man, who maybe is living independently,
happily married, pets at home, visiting the grandchildren, pre-COVID, and living a nice
life. And all of a sudden there's a fall and there's
a fracture, maybe there's even a broken hip, leads to hospitalization, maybe leads to a
surgery, leads to physical therapy. And then, the determination that rehab is
needed. And then may be a blood clot and a rehospitalization
for pneumonia, and so on and so forth. And at the end of the day, these patients
oftentimes do not return back to their independent lifestyle. And sadly, many of these patients at the end
of the day, pass away from complications of their fracture. So absolutely we care about this disease,
even though it's terribly silent, we want to prevent that broken bone. The statistics that Kelly was alluding to,
are quite dismal, unfortunately. About 10 million individuals in the United
States have osteoporosis. About 8 million of them, women. 2 million of them, men. And I would probably argue two facts. One, this number will be increasing over time. Our population is getting older, our baby
boomers are developing osteoporosis, so that 10 million is very likely a higher number. Two, we don't screen as much as we should,
particularly our men. For some reason, we have it in our heads that
this is a woman's disease, but oftentimes men can get osteoporosis. And we'll talk a little bit about that. 50% of women and 25% of men will have a fracture
in her or his lifetime. That rivals cardiovascular statistics, strokes,
heart attacks, other disease states that we worry so much about. These are real statistics. Fracture is a real disease. 25% of individuals will die within the first
year following a hip fracture. So getting back to that picture earlier, again,
this is not only a disease associated with significant morbidity, but also mortality. And if you look at healthcare costs, that
we're all focused so much on these days, over $25 billion are estimated for the cost of
fractures by 2025. And again, with an aging population and the
disease that's only becoming more prevalent, that number is only expected to rise. So we have a few goals for our talk today. We're going to talk about the causes of osteoporosis. Why does this happen? We're going to talk about risk factors for
bone loss and how we screen for them. We're going to talk about things that you
can do to improve your chances of good bone health. What are some interventions you can start
today, tomorrow? And then obviously, things that I can do or
your doctor can do regarding specific treatments for osteoporosis. So we're going to do a little mini biology
lesson. Again, this is not to intimidate anybody,
but just to get us on the same page. And I'll start by saying, bone is not an inanimate
object. So your bones are not rocks that you carry
around with you all day long. They're actually constantly remodeling. They're building up, they're breaking down. And it's the fact that they can remodel and
renew themselves that keeps them flexible, it keeps them able to bend and twist without
breaking instantaneously like a spaghetti stick. It's that balance of bone buildup, however,
and that balance of bone breakdown, that determines how much bone you have. So obviously, if you're building up more than
you're breaking down, you're gaining bone. If you're breaking down more than you're building
up, you're losing bone. And then there's obviously steady states and
we'll get into a diagram of that in a second. So just remember your bone is always refreshing
and renewing itself. And it's only when that balance becomes disturbed,
that we see disease. These are the cells responsible for that building
up and that breaking down. And I put this on here, again, not to intimidate
anybody with a biology lesson, but to show you the types of cells that we then target
later on down the road, should you need medication for your osteoporosis. So bone breakdown actually starts with kind
of what I describe as a Pac-Man cell or the osteoclast. The osteoclast identifies a spot of old bone,
or maybe a bone that has a little fracture in it, and actually chews up a little resorption
pit, which is a normal thing. That then sends signaling molecules into the
bloodstream that call in the osteoblast, B as in build. It builds bone back. It identifies this pit of bone, fills it in
with unmineralized osteoid. And then, over the course of about three months,
that osteoid, that soft bone, becomes hard. And how does it become hardened? It becomes hardened with very important elements
like calcium, phosphorus, and protein, which we'll come back to. But remember, if you want to build healthy
bone, you need the building blocks. So again, it's this balance of the Pac-Man
cell, the osteoclast and the bone building cell, the osteoblast, that's going to dictate
how much bone you have. Now, this is a picture of the life cycle. And as you can see, the bone is always changing. In the first three decades of life, we are
building bone. I have younger children, I hope they're still
building bone, I hope they're getting taller. Until about the age of 30, we're building
more bone than we're breaking down. Between 30, and for women at the age of menopause,
there's generally a steady state. For men, it's between 30 and about 70, where
there's a steady state of bone building and breaking down. Women enter into menopause, where the breakdown
state far accelerates the bone building state. And then, after the perimenopause, there's
a slow decline thereafter. For men, it's mostly just a slow decline after
the age of 70. Now, as you can imagine, this is a normal
curve. The patients who wind up in my office are
not normal, or patients who break bones are not normal. There are things that happen along the lifestyle. It might be something in childhood, it may
be chemotherapy or Hodgkin's as a child, it may be smoking, it may be other disease states
that interfere with this normal curve. And so when we think about osteoporosis, we
never take it as a time zero, your DEXA scan shows osteoporosis, let's treat you. The first question is why, what has happened
along your curve that may have affected how much bone you have? And it's part of our screening process. How do we determine what your bones look like? So this is a picture of a DEXA scan. Hopefully some of you have had a DEXA scan. We'll talk about who should have a DEXA scan,
but typically, we look at different spots in the bone. We look at the lumbar spine, so vertebral
bodies, L1 through L4. We additionally look at the hip, we look at
the total hip region. We look at the femoral neck. It has nothing to do with this neck here. It's the neck of the hip, it's kind of where
the ball and socket attaches to the femur. And using those three sites, and even sometimes
a fourth site, which is a distal radius, we make a determination based on T-score, as
to whether or not an individual has osteoporosis. And you can see in this graphic here, what
the definition for osteoporosis is. Really it's a T-score less than or equal to
a negative 2.5. Osteopenia, or low bone density, is a negative
1 to a negative 2.4. And normal is anything greater than or equal
to a negative 1. Now, a T-score is just a standard deviation. And as I mentioned earlier, not everybody
who has a fracture has osteoporosis by T-score, but if you have a fracture, I don't even need
a T-score to tell you that you have osteoporosis. And I should clarify here. When I say fracture, I don't even mean a fracture
falling out of a three-story building or being hit by a tractor outside. I'm referring to a low impact fracture. So this is a standing height or less, fall
to the ground, bracing one's self with one's arm, slipping on the ice and hitting your
hip and having a broken bone. Things that are not normal, things you would
not expect a 30 year old to have necessarily. So who should be screened for osteoporosis? Well, at the bare minimum, women older than
65, and this is just kind of Medicare dictated at the end of the day, and men greater than
70. And men is pretty clear just based on that
graph that we looked at earlier, but more commonly, we see people screened earlier than
this. And why are they screened? Well, sometimes there's an X-ray, or even
a CAT scan, that might indicate there's low bone density or osteopenia. Or more commonly in my clinic and those of
my colleagues, it's the presence of one or more risk factors for low bone density or
osteoporosis that makes that little red flag go off in our heads to say, "Hmm, maybe we
should think about the bones in this particular patient." So getting a little bit more into the details. So I'll tell you age or postmenopausal status
is a risk factor for osteoporosis. Again, remember women have that very steep
drop off after the menopause in bone density, when estrogen levels decline. I would be challenged to find many women who
make it to 65 by the time they go through menopause. So again, many women come much older to clinic
after getting this diagnosis of osteoporosis, just because they're postmenopausal. Men greater than 70, family history of osteoporosis. So these are individuals with a mother or
a father with low bone density or fractures, or mother or father, brothers, and sisters
on treatment for osteoporosis oftentimes will come requesting an evaluation. Race is an interesting one. So originally, and certainly in some of our
calculators that we use, we consider a Caucasian race or an Asian race to be of higher risk
for fracture than those of Latino or African American descent. Much like kidney function, this particular
discrepancy is coming under additional evaluation right now, because some of the data that's
dictated that race is a major determinant of osteoporosis is being challenged. We don't have enough data necessarily, or
large enough patient populations to say definitively that Latinos and African Americans are not
at a big risk for fracture. And in fact, doing that may be a disservice
to those populations in terms of screening. So again, our societies are really looking
into this particular risk factor, so I urge all of you to take this with a grain of salt
when considering your own risk factors. Low body weight. So BMI anything less than 18. Medications, things like steroids or aromatase
inhibitors, androgen deprivation therapy in men for prostate cancer. All of these could impact bone. Alcohol, tobacco, lifestyle choices that maybe
aren't the smartest. Personal history of fracture. So I oftentimes will get in clinic people
who, "I slipped out on the ice, it was a wintry day and I broke my wrist, but it was really
icy and I took a bad slip." That's actually an osteoporotic fracture. It counts as a fragility fracture. You wouldn't expect your 25-year-old son or
your friend who's a bit younger to have the same fracture with normal bones. Testosterone deficiency, or estrogen deficiency,
vitamin and mineral deficiency, immobility. And then frankly, there is a laundry list
of additional medical conditions to add to this. This is far too short to talk to get into
all these different conditions, but they encompass rheumatologic disorders, not just for the
steroids, but because of that pro-inflammatory state. A number of endocrine disorders, so my background,
things like hyperparathyroidism, or Cushing syndrome, or vitamin D deficiency. Any sort of gastrointestinal disorder where
they may be malabsorption or weight fluctuations, or again, chronic inflammation. Liver disease is a big one. Bone marrow disorders, kidney dysfunction,
and then a whole list of medications as well. All of which may have important negative impact
on the skeleton. So what do we do for workup? Like I said, it is so rare that I see a patient
in my clinic where I look at a DEXA scan and write a prescription. The first thing I want to know is why are
your bones not perfect? And to get at that a little bit more after
I do a history and take a comprehensive physical exam, I order labs. Endocrinologists order a lot of labs, so we
always say, "Drink up before you go to the lab," because they're going to be taking a
lot of blood. I'm going to order a comprehensive panel,
I'm going to get a phosphorus. What am I looking for? I'm looking for your calcium levels, I'm looking
for phosphate levels, I'm looking for kidney and liver function. I want to see what's happening with your thyroid. Is it overactive? Which can cause bone loss. Vitamin D is so critical for good bone health. Let's make sure it's adequate. Parathyroid hormone, which really regulates
your balance of calcium and vitamin D in the body. Yes, I torture people with a 24-hour urine
calcium collection. It's a good way for me to gauge if people
are getting enough calcium in, or maybe they're putting too much out. And oftentimes I'll screen for multiple myeloma,
which is a blood cell disorder, which can cause slow and steady bone loss. If the level of suspicion is high enough,
we may order additional labs, including a celiac screen, which is a cause of malabsorption
and vitamin D deficiency in patients. And then some other fancier things, again,
based on physical exams. So let's talk a little bit about treatment. And I think it is so important to empower
my patients to give you something to do when you go home that you can actively work on,
that's not just taking a pill that I prescribe for you, or an injection, or an infusion,
because it's a partnership. And really to succeed, we both need to be
doing our part. So pillars of osteoporosis treatment are comprehensive. So we have diet, things that we could really
modify. Lifestyle, pharmacologic agents, which we'll
get a little bit into at the end. And then obviously, if I find anything in
your laboratory testing or pick up anything in talking with you or physical exam, we need
to treat those things too. There's no point in slapping a bandaid on
a problem if there's underlying causes that may be rectified before we start treatment. So what can patients do to strengthen their
bones? So calcium. Calcium goal. And we can talk more about this at the end. I'm sure there will be questions. Goal calcium for individuals at risk for bone
disease. I'm not talking about individuals who are
healthy, and have no risk factors, and have normal bones, but individuals at risk for
bone disease or with a diagnosis of bone disease should be getting calcium between 1,000 and
1,200 milligrams orally daily, total. This can be through diet, this can be through
supplement, this can be through a combination of both. Ideally, you're doing it through your diet. I think our cardiologist colleagues would
agree. Diet is always best, it's kind of the way
mother nature intended it to be, but we have a number of people who are lactose-intolerant
or have dietary restrictions for whatever reason, where oftentimes you just can't get
enough through your soy milk, or your almond milk, or your regular old cows milk or cheese. And sometimes a supplement is needed. Calcium citrate is the supplement of choice. It's better absorbed, it is easier on the
GI tract, comes in different formulations. And ideally, you want to spread your calcium
out throughout the day so that you don't get that GI upset. And again, that it's absorbed appropriately. Vitamin D is much harder to get through natural
sources. I would not encourage a lot of sun exposure
simply because our dermatologic colleagues would be very angry with me for recommending
that. And frankly, you need a lot of sun exposure
in a very sunny place with a lot of skin exposed kind of throughout the year to get the D necessary
to make your own for good bone health. Oftentimes therefore, we will prescribe an
over-the-counter supplement of vitamin D. Even though the Institute of Medicine would
recommend 600 to 800 a day, I think we all know that's oftentimes insufficient, particularly
in the dead of the winter or we cover up with sunscreen. So a lot of my patients will do about a 1,000
to 2,000 a day with a goal total calcium of greater than about 30 to 40 nanograms per
milliliter on blood testing. Supplements can be taken all at once. And De is the over-the-counter supplement. Sometimes patients need a prescription strength
vitamin D. And that formulation is vitamin D3, slightly more bio-available, but really
the two are equivocal at the end of the day. Protein. This is another big one. So there are so many fancy diets out there
these days. And I see patients eliminating entire food
groups in their quest to become healthy, but we can't forget about protein. Even if you're vegetarian, even if you're
vegan, there are sources of protein that could really nourish your bones with goals listed
here. So 0.4 grams per pound of body weight is really
what you should be reaching for. And then exercise. In the era of COVID, no one is encouraging
you to necessarily go out and join a gym and you don't have to. The good news is that walking counts. Three to four days per week, 30 minutes of
walking counts as resistance training, as do resistance bands or home weights that you
may have, exercise bicycles, ellipticals if you use the arms. Really all counts, with the exception of swimming,
where the water is doing most of the weight. So don't be intimidated by exercise, I should
say, because of these rules. Just do something you enjoy, that's the most
important thing. Obviously, quit smoking. I will be yet one more doctor who will say,
"Please quit smoking. It's not good for you." Limit your alcohol conception. That's oftentimes just one glass of wine per
night, depending on your body weight and other health factors. Maintain a healthy weight. So fluctuations in weight are not good for
bones, particularly weight loss. I'm all about healthy weight loss. If your BMI is elevated and you're doing it
in a sensible way, but losing 20, 30 pounds in a short amount of time only hurts the bones
at the end of the day. And then make sure you eat a healthy and well
balanced diet. I'd say reach for all the colors. There are not many foods that are off limits
when it comes to bones, it's really the elimination of certain foods or limiting your foods to
certain food groups that cause the most harm. What about when these lifestyle changes and
things that you're doing aren't enough? Well, start by saying you are not a failure. It is not a failure if the bones need a little
bit of extra help. We do not blame people when they have to go
on blood pressure medications, we do not blame people when they need to go on cholesterol
medications. We just say, "You need a little bit of extra
help." So I see a lot of dejected faces in my clinic
sometimes when the patients are just gold star students and the numbers still aren't
looking great, they just need a little bit of extra help. Osteoporosis is a disease and we treat diseases
in this country, so let's look at it as being proactive and you doing additional things
to help your bones versus us reacting to a fracture. So medications for osteoporosis have to be
taken in addition to your calcium indeed. Just because we're starting medications, does
not mean you get to stop the building blocks of bone. Remember that graph from way back when, where
we talked about the different cells. Remember how we talked about the osteoblast,
putting down this unmineralized soft bone that over three months has to harden? Well, this is how we harden it. It's with protein, it's with calcium phosphate
and vitamin D. So please don't stop your supplements or your dietary intake. And then there's medications that really fit
into two different bins. We have medications that reduce bone breakdown. So again, that osteoclast Pac-Man cell, where
we break down our bones and we really want to kind of stop them, paralyze them, pause
them. And then there's medications that really incentivize
the osteoblast or the bone building cell to build your bones back up again. And remember that no matter what we do with
our treatment plan, the goal will always be fracture prevention. The DEXA scan may not change. Again, so many dejected faces in my clinic
when the DEXA is kind of the same year after year, after year, but just know that underneath
the surface, again, if we took that microscope and we looked inside the bone, things are
changing and fracture risk is being reduced even if the DEXA tells a different story. Medications that stop your bones from breaking
down. So estrogen used to be a tried-and-true mechanism
for doing this, but in 2002, the Women's Health Initiative kind of put the kibosh on a lot
of the estrogen that was being prescribed for bone health. Certainly, if you need estrogen for other
reasons, and you've partnered with your primary care doctor, your gynecologist, on using estrogen
for other reasons, postmenopausal hot flashes or other challenges that you're having, we're
okay with that. We like estrogen in the bone world, we just
rarely start it as a primary agent for bones. There's selective estrogen receptor modulators,
like Evista, which is similar to Tamoxifen, which is a sister drug oftentimes used in
breast cancer. It's a daily pill. The challenge with that is it's not as strong
as some of the other medicines and it doesn't necessarily help the hip. So if you've got low bone density in your
hip or a family history of hip fracture, we generally don't reach for that agent. It does come with an increased risk of clotting
as well, so we always want to get a history that way. And then there's medications that probably
more of you are familiar with. We have a lot of medicines in the bisphosphate
category. So tried-and-true alendronate, which again,
when patients went through menopause back in the day, they also got a prescription for
alendronate, once a week pill. Risedronate, which is available either once
a week or once a month. Now, I did not include ibandronate on this
particular list, namely because it doesn't have hip fracture protection, so we don't
use much of that once-a-month medication. There's IV bisphosphonates. Again, all of these acting to stop the Pac-Man
cell. Reclast or zoledronic acid is the name of
that medication. And then there's the two-time-per-year injection
called Denosumab. Who are candidates for things that aren't
pills? Pills are certainly the easy way to start,
but there are many patients who really just aren't good candidates for that. So, number one, if you have challenges swallowing,
or you have malabsorption at baseline from gastrointestinal disease, if you have bad
reflux, these medicines tend to make them worse. So we may reach for a yearly infusion versus
a twice-a-year injection, or gosh forbid, you're taking the medication religiously every
week or every month, and you're still losing bone. Well, then it's time to kind of kick it up
a notch and move to something a little bit stronger with the zoledronic acid or the denosumab. Side effects of the bisphosphate class of
medicines and the denosumab all kind of are coupled into the same concept. So if you're not getting good calcium and
vitamin D, we can see bone pain. So we're really good about kind of teeing
you up before we start those medicines. Low blood calcium. Again, we want to do a complete lab panel
to make sure you don't have low blood calcium to start. With the once-a-year infusion or the zoledronic
acid for the first dose only, there's about a 20% risk that you can have an infusion reaction. So for about 24 to 48 hours, you just kind
of feel blah, some people had a similar reaction to the COVID vaccine where just you're out
of commission for a few days. Luckily, if you have subsequent infusions,
it shouldn't come back. I get a lot of questions about jaw osteonecrosis. This is a very rare complication of these
medications, about one in 300,000, where it's a mouth ulcer that can form along the gum
line, typically in the setting of an invasive dental procedure like extractions or implants,
and then atypical fracture. So I oftentimes in clinic will hear, "Well,
I read online these medicines cause fractures." And what this is referring to is that with
long-term use, again, we're talking 10-plus years of use without pause, we sometimes see
these strange thighbone fractures where the bones almost become brittle, because they
don't break down at all. Remember, they have to break down and build
up a little bit to keep them flexible. So again, there's one in 800,000 fractures
can occur with long term use. If I'm more worried about your spine fracture
or your real hip fracture, through the main part of the hip that I showed you on that
DEXA scan, this will be the least of my concerns. And then I really want to highlight this. This is critical that you be empowered with
the knowledge about, but denosumab, that twice-a-year injection I alluded to earlier, this medicine
has to be given every six months. You cannot quit without telling your doctor,
you can't delay a dose, you can't skip a dose. If a dentist tells you, "Hey, you need a root
canal, just hold off this month on that shot, you can get it later." Just say no, call your doctor, because there
is a rebound effect with this drug where the bones can go into a high breakdown state and
we've seen spontaneous vertebral compression fractures as a result. There are medications that help your bones
build up. They're a little bit more labor intensive. The two that used to be around for the longest
time until the new kid on the block at the bottom popped up, were these daily subcutaneous
injections, teriparatide and abaloparatide, where yep, at home, you are giving yourself
a nightly injection for up to two years. There's a newer medication approved in April
of 2019, called romosozumab, which is a monthly injection that's given in clinic for up to
one year. And these medicines, again, are designed to
build bones up, but so that you don't come down off that roller coaster and lose the
bone all over again, they have to be followed by one of these medications that promote or
prevent bone breakdown. So it's a coupled process there. We don't ever start one drug that bone builds
without knowing what we're going to transition to after that. There are a lot of questions that remain,
and I'm sure you have some good ones that are being sent to Kelly as I speak, but how
long should patients be on medication or drug holidays? There's no one good answer. And I will say that patients, everyone is
different. In general, for the bisphosphonate, we reconsider
therapy at about five years, but this is a very individualized decision based on you,
your preference, your risk for fracture, and many other factors. There are questions out there about the best
order to take these medications in. We're now learning more and more that maybe
bone-building drugs, those labor-intensive injections we talked about, we should start
those first and then finish with an anti-breakdown drug, because we get the most bang for our
buck when we start with bone-building drugs and finish with an anti-breakdown drug. We just have to convince the insurance companies
of that. And then finally, what in the world, there's
so much information out there right now. How do we choose? And this is the bulk of the referrals that
we get, where I feel as though primary care doctors and family practitioners get really
overwhelmed. We have so many different things out there
now. How do we pick which one is best? And again, that's an individualized discussion
based on you, your preferences, your workup, your history, and a lot of other factors that
go into that discussion. So again, that's the partnership that we work
on to decide on your osteoporosis care. So some final pearls before I turn it back
to Kelly. Number one, fractures aren't normal. So again, I hear so many times, "Well, yeah. I mean, my mom, she had a hip fracture, but
she was 80. It doesn't matter." That's not normal. We would never say that your mother's heart
attack was normal or that your father's stroke was normal. These are not normal phenomenon and we need
to take them seriously. Men get osteoporosis. I was delighted to hear that we have men on
this conference today too, because you need to hear this as much as others. And frankly, women out there, if you've got
spouses or partners who are male, they need to hear this too. So at least go with them to their appointments,
so you can ask the right questions for them. Please think about other osteoporosis causes
and make sure your doctor is working them up prior to just getting that prescription
handed to you. And please don't forget about your calcium
and your vitamin D. They really are as important and as anything that I would prescribe to
you, because again, those building blocks are really critical for optimal bone health. So with that, I will say thank you, I'm excited
to hear what you all have posted regarding questions. And I'll go back to Kelly. Great. Thank you very much, Dr. Moseley. We're going to jump right into the questions
if you don't mind. Sure. So, okay. The first one is from Trisha and she would
like to know, "Is there data available on the benefits of yoga to treat osteoporosis?" Good question. That is actually an excellent question. And I love that you've asked that, Trisha,
because I oftentimes get the counter question. So I have a lot of patients who do yoga, who
are worried about yoga and their bones, because some of the poses, there's a lot of hyper
extension of the spine and patients worry, "Gosh, am I going to break if I do these things?" The correct answer, it is highly dependent
on the type of yoga that you do, the intensity of the yoga that you do, and how accomplished
a yogi you are. So if you are someone who's been doing yoga
your entire life, where you know the poses, you have the flexibility, you have the core
strength necessary to do those poses, it's absolutely a wonderful exercise. It promotes strength, importantly, it promotes
balance. Remember, how do fractures occur? Well, they usually occur when we fall. So the more stability you have when you're
standing upright, that we get from yoga, and Pilates, and things like that, the fewer falls
we see. I love it, I think it's a great exercise. Now, if you're new to the field and you're
all of a sudden doing sun salutations and kind of bends and twists that maybe your body
is not used to, I worry about that a bit more, because your muscles aren't necessarily trained. Respecting data, there is some limited data. Again, more so in the fall prevention realm
than anywhere else, showing that it can be beneficial to bone health, but not necessarily
with DEXA outcomes. Thank you. I would imagine that really, it's like you
said in your presentation, exercise, really any type of exercise, is better than nothing. Get moving. Again, I know it's been hard at the pandemic. A lot of our gyms were closed, but there is
so much material now on YouTube. And a lot of instructors have Zoom availability
for things that they were previously doing in the studio, so utilize those resources
and just move. Your body, as a good colleague of mine said,
"If you don't move it, you lose it." So use it. That's true. Thank you. Our next question is from Diane. "Under supplements, you did not mention vitamin
K2. Do you recommend it? And if so, how much?" So another very common question we get. At the end of the day, if you have a healthy,
balanced diet, additional vitamin K is not necessary to promote good bone health. If we just get it in abundance from our fruits,
and our vegetables, and other sources, it does help with bone formation, but again,
a healthy diet should have enough K. I worry about too much vitamin K, because vitamin
K is actually involved in the clotting pathway in our blood. And so there are some studies showing that
if you get too much vitamin K, it actually can lead to blood clots and even stroke. So again, everything in moderation when it
comes to vitamins and supplements. Thank you. Pat would like to know, "Is osteoporosis hereditary?" Absolutely. So thank you for that very important question. To take us back to that original graph where
I showed kind of the acquisition of bone. So we gain bone until about the age of 30. Well, guess what? By the age of 30, your peak bone density,
that peak is up to 40% determined by your genetics. So if your mother, your father, had low bone
density or osteoporosis, there is a high likelihood that you too will be at risk for low bone
density or low bone formation by your peak. You maybe weren't destined to be here, but
rather you were destined to only be here. And sometimes that's the only thing we can
find despite a thorough workup. So since it is hereditary, is there a certain
age that you would recommend someone to go and get a bone density test? Because really in general, we're saying that
these things really don't happen till maybe menopause age. So how do you feel about that? It's a great question. So I will say there's no correct answer, but
in general, amongst the bone heads, we call ourselves, we believe that catching it early
is always better than catching it late. Once you've lost bone, it's gone. It's really hard to get back. If there is a strong family history of osteoporosis,
my clinical preference is to screen, at least we're talking about women, at the time of
the perimenopause. So I want to know, before that steep drop
off occurs, where you are. Because if you go into your menopause and
you already have, osteopenia or nearing osteoporosis, I will guarantee you, actually, there's no
guarantees in life, but very likely, at the end of menopause, you will already have osteoporosis. So in women with a family history of osteoporosis,
screening at the time of menopause is very important. Thank you. Good point. April would like to know, "Dr. Moseley, do
these drugs interfere with rheumatology drugs [inaudible 00:36:37] also with any of the
medications that people who have endocrine issues would have to take?" So if anybody really has a rheumatoid issue,
or has an endocrine issue, and they're taking medication for that, how does the osteoporosis
drugs interfere in general with these drugs? Yeah, that's a great question. Again, it's an individual thing. And it depends on the medication, but in general,
within the rheumatologic diseases, these drugs, osteoporosis drugs complement the rheumatologic
drugs, namely because we worry about the bones with rheumatologic disease. So rheumatoid arthritis or lupus, we worry
about the pro-inflammatory state, we worry about the steroids. So many of the osteoporosis drugs have actually
been studied in patients with rheumatologic conditions and have been shown to prevent
bone loss and even prevent fracture. So we actually use these drugs a lot in rheumatology
patients and they certainly don't interfere with the immunomodulator medications that
rheumatology patients are often on. Again, they're complimentary that way. With respect to the endocrine diseases, it
depends on the endocrine disease. We really want to treat the underlying endocrine
disease. And as long as we're treating the underlying
endocrine disease, the osteoporosis medication should not necessarily make a difference with
one small exception. I'll give you a nuance here, but if someone
already has high blood calcium from a condition known as hyperparathyroidism, those bone-building
drugs we talked about, those daily subcutaneous injections for two years, we don't go anywhere
near those, because they can only make your calcium go a little bit higher. Right. I guess it would really take an endocrinologist
to think to take the hyperthyroid blood test, correct? Correct. Although that's a simple test that a lot of
internists can quickly order, and looking at a blood calcium is always helpful as well,
but interestingly, with hyperparathyroidism or high blood calcium, high blood calcium,
high parathyroid hormone, we use osteoporosis medications to prevent bone loss, which can
be an outcome of that disease. Yeah. I guess I was trying to allude to also that
our viewers, that if you're going just to your internist and your health is fine, but
maybe it's hereditary with some endocrine issues or you can't seem to balance your vitamin
D and calcium, that be proactive and ask your internist, or family practitioner, or maybe
even go to an endocrinologist to get those tests done. Absolutely. Go armed with knowledge. Because again, there's so much out there now. I think that maybe your practitioner would
appreciate some guidance on this. There's a lot of other things they treat and
have to treat each day. Be proactive. Our next question, "Dr. Moseley," this is
from Ann. And she would like to know, "How do you know
that medications are working when the DEXA scan doesn't change?" Great question. So Ann, the first thing I want to know when
I walk into a clinic room is number one, I scan for any sort of crutches, or boots, or
casts. That's my absolute horror when I see that. But the first thing I want to know is, have
you had any falls and if you had any fractures? And if the answer is no, I consider it a victory. Unlike a cancer surgery, we don't know that
we've succeeded unless we prevent the fracture. So we don't see the outcome of our intervention
unless we fail and somebody has a broken bone. So if the DEXA is not changing and you don't
have a broken bone, it's a victory. I'll also point out too, the natural history
of bone is it kind of trickles down over time, even after the menopause, or in men, there
is a slow decline in bone density. So if you're actually steady state, year after
year, you've kind of avoided that slow bone loss that maybe someone who's not treated
for their osteoporosis may have. Great. Thank you very much. Dr. Moseley, we're getting a lot of questions
and concerns about the side effects from osteoporosis. So Charlotte asked, "Do the side effects from
osteoporosis medications cause fractures?" Which you briefly touched on and you can mention
that again, and along with that is just in general, that people are nervous and afraid
to take some of these drugs for osteoporosis, just because there can be some very serious
side effects. And with the bone pain, flu symptoms, etc.,
and feeling that way for a long time. Yeah. I think these are all extremely valid questions
and I think we all acknowledge that it would be great to have medicines that have zero
side effects, but we don't. We have aspirin that has side effects. We have acetaminophen that has side effects. We have vitamins and minerals that have side
effects. And so anytime we put something that's not
natural in our body, we are taking the risk of a side effect against the potential benefit
of whatever it is we're putting in our body. And when it comes to osteoporosis medications,
the risk that we are considering against the benefit, is the benefit, which would be, we
want to reduce the risk of fracture and then the risk of some of these more common side
effects and some of these more rare side effects. So that's the individualized discussion to
have is, what do your numbers look like? What does your fall risk? What is your individual risk for breaking
something? And are we willing to take on the risk of
a side effect to a medication? How easy is it to stop that medication? I mentioned that twice-a-year injection. If I have someone who's anxious about going
on medications in the first place, I'm not going to start something they can't stop. That would be insane of me to do. So we might start a little bit milder in that
particular case. Whereas I have many patients who come in and
they kind of want to do everything possible to get to the heart of their bone disease. I find it's often helpful before we even launch
into a risk or side effect discussion, to just remember that osteoporosis is a disease. It is something that should be thought of
as we think of diabetes, blood pressure, cholesterol, I've said earlier, cancer, it's a disease
that needs to be treated. We try to manage things conservatively as
much as we can, but you can only manage things conservatively so much before you start to
see the side effects of that, which again, would be fracture. Briefly, about the osteonecrosis of the jaw. I get that all the time. Again, it's a rare complication. If you're having a dental extraction or an
implant where there's invasive work being done on your jaw, there is a small chance
that that jaw can get infected and cause this mouth ulcer. And sometimes we can even treat through that. Sometimes we do have to stop the medication. Again, it's about one in 200,000 to 300,000. So quite rare. And again, the risk of one out of 200,000
to 300,000 to the risk of you falling and breaking your wrist, we have to weigh that
in clinic, or the risk of these atypical thighbone fractures. Again, very atypical, very rare. One in 800,000 with long term use. Generally in those cases, I'm far more worried
about a typical fracture, which would be of the spine, or the wrist, of the thigh. But again, that's the discussion to have with
your doctor. That is, "What are you concerned about? How can I talk you through that? And how can we work together to come up with
the treatment plan that you're comfortable with, but also that I'm comfortable with as
a bone head, getting you through the winter without falling and breaking something?" Great. Thank you very much. On that note too, with medications, when people
have... One of the questions from another Mary here
I see is, she wanted to know that a lot of the physicians, before they decide to do some
type of surgery, whether it's on a knee, or a shoulder, or something there, or you're
back even, they'll give them steroid injections. How do you feel about steroid injections in
general? Does that contribute later on to getting osteoporosis
or not, or...? No, I'm not as bothered by the three time
or four-time-per year steroid injections and knees, and backs, and necks, and things like
that. The main concern are the systemic steroids,
your prednisone, your dexamethasone. For three months or more is generally a cutoff
that we say for steroid exposure leading to bone loss. If you need it, you need it. And again, my personal bias is if that steroid
gets you walking more, if it gets you moving more, it gets you pain free where you're working
on your balance or can go to physical therapy, I'd far prefer that local steroid injection,
which has minimal bone effects than doing nothing at all. Great. That's a great answer. Thank you. This is a question from Katie she wanted to
know, "Is osteopenia/osteoporosis, a counter indication for knee replacements or other
joint replacements?" Great question. Yeah, so we get a lot of referrals from our
surgical colleagues to optimize bone health prior to these surgeries, because it would
make sense. If you're going to be putting hardware into
a softer bone, then they would worry about the success of that bone surgery. I would not say it is contraindication to
surgery, but again, we would want to make sure your calcium, your vitamin D status are
adequate so that you're healing that bone appropriately where the hardware is. And certainly, if you have osteoporosis, we
want to treat that to harden up your bone a little bit, so to speak, prior to the surgery. But again, going back to my last comment,
I want you moving. So if you need a new hip and a new knee, and
that's going to get you off the couch and out taking a walk on a beautiful day, let's
do that too. So again, a lot of times we'll optimize the
bones for a few months prior to surgery, patients will have the surgery. And then we'll continue to treat after that
with the medications for osteoporosis really having no impact on bone healing after the
fact, so you can stay on your osteoporosis medications. It certainly should not impair the healing
process of an orthopedic procedure. Great. Thank you. Our next question is from Melisha and she'd
like to know, "What is the difference or how do they differ between osteoporosis and arthritis?" Yes, so they're neighbors, but they don't
really talk to each other, at least not based on the current research. So osteoporosis, we're talking about the bones
thinning over time. And osteoarthritis is when the padding between
the bones starts to erode over time, so there's kind of a gelatinous cushion that lives between
the bones, and the spine, and then the knees, and then the hips. And over time, that gelatinous cushion can
become thinner for a variety of reasons, lead into bone-on-bone rubbing, which is why people
get pain. And almost a bone scar that can form along
the surface of the bone. So they don't really relate to one another,
other than maybe some artifacts we can see on DEXA scans, but they should not impact
one another. Great. So if you are diagnosed with some arthritic
issues, maybe you broke a bone in the past, or you just someone that hereditary happens
to have this or whatever, that you shouldn't necessarily panic that, "Oh my goodness, this
means I have osteoporosis." No, we see a lot of arthritis. Just as a side note, on DEXA scan, you can
see arthritis on those kind of poor woman's X-rays that we get in the spine and in the
hip, I see a lot of arthritis. And I pointed out to patients all the time
and they say, "Really? I had no idea. Should I do something about this?" I say, "Well, are you in pain?" And they say no. And I say, "Well, then you don't need to do
anything about it." So it's common and nobody likes to hear it,
but there is wear and tear with age. And so we do expect to see arthritis evolve
over time. And no, you should not panic unless you're
having extreme pain that takes you to the orthopedist office. Thank you. Our next question is from Anne. And she'd like to know, "Should you take a
magnesium supplement?" Anne, so this kind of falls into the category
of the vitamin K. And I would say, if you have a healthy balanced diet, you're getting
adequate magnesium. In fact, most of the time we get more magnesium
than we can even process and we excrete it. This is excluding those individuals who have
nutritional challenges. So if you are a gastric bypass patient or
someone who has a lot of intestinal challenges with absorption, or very limited diet due
to GI problems, then by all means, you may need additional supplementation to get the
nutrients you need. Great. Thank you. Our next question is from Kathleen. They're just rapid firely coming in here,
so I apologize [inaudible 00:49:49]. I told you we'd be busy tonight, Kelly. So this is from Kathleen and she would like
to know, "Is there evidence taking collagen that will help to prevent fractures?" No. I mean, the short of the long of it is no. I know there's a lot out there with powders,
and gummies, and certainly they seem attractive, but we don't know that collagen that goes
through the gut first actually makes it through the bloodstream and into the bone. Although, wouldn't it be nice, right? Yeah, that'd be really nice. That'd be very nice. It'd be much easier than some of these other
things I've been talking about. Take a little gummy. That would be great. Love them. Love them. Yeah. Our next, we have another question here and
we're going to wrap it up in a few minutes, but just we'll take a few more questions. So women are in general, they're concerned
about taking oral calciums like Tums. Does this increase the likelihood of calcium
buildup in the arteries of the heart? Right. No, I'm really glad you've asked this question,
Kelly, because we get this a lot. So the consensus between the American Heart
Association and the bone groups is that individuals at risk for bone disease, women and men, 1,000
to 1,200 milligrams of calcium total a day has no impact on cardiovascular disease, does
not increase your risk of stroke or heart attack. We prefer it be through the diet, because
the bulk of the studies that did maybe indicate a slight risk of adverse cardiovascular outcomes
without significance, but maybe a slight risk, were those taking supplements. And a lot of those studies were flawed. But again, we agree. In fact, I gave a great debate. It was not a debate, it was a lovely chat
with Dr. Pam Ouyang, who is here at Johns Hopkins, who does women's heart health, about
this exact topic. And we left good friends agreeing that 1,000
to 1,200 milligrams a day through supplement or diet preferred is perfectly fine. Great. Another, I guess a myth, actually I would
say. I think a lot of women think that, "Okay,
if I have bigger bones, I'm less susceptible to getting osteoporosis as opposed to maybe
a woman that's smaller boned." So is that truly a myth? It is. I mean, it is. We kind of went through, there's all sorts
of things that can lurk underneath the surface of the bone. And I actually do some research in type two
diabetes and bone. And we know that individuals with type two
diabetes actually have very normal bone density on DEXA scan. They look fine, we send them home comfortable
with their results, but then they go home and they fall and they break a hip. And so this speaks again to that underneath
the surface, that bone quality, it's a hot topic in osteoporosis nowadays, but deficiencies
in bone quality, whereas everything looks good on the outside, but you pull back the
curtain and the microarchitecture or how the bones remodel, may not be so great. Again, leading to fracture. So I would not say just because you're a big
boned, it's protective. So well, there are some of us that are saying,
"Darn." And so I'm going to take one more question
here. So can you maybe talk a little bit about what
research is being conducted on osteoporosis? Is there anything currently going on or any
new drugs on the horizon? Right. So I would love to say there are a lot of
new drugs on the horizon, but Romosozumab, the monthly injection, was kind of the last
one. The major challenge with pharmacologic or
pharmacotherapy for osteoporosis is that to do these clinical trials, to show that they
reduce the risk of fracture, you need huge studies. I mean, we're talking 5,000 participants or
more. And a lot of times, those participants have
to be what we call treatment naive, meaning they haven't been treated with osteoporosis
medications in the past. And so identifying those individuals and doing
these trials can be terribly expensive. They take up to five years or more to get
the fractures necessary to show that the drug is better than placebo. And so they take a long time to get up and
running, and a long time to complete, and a long time to get through the FDA. So there aren't really new medications under
investigation right now for osteoporosis. There's a few looking at a more rare bone
condition called hypoparathyroidism, where the parathyroids are underactive, but we're
waiting. We always want more treatments available for
our patients. And then what research is ongoing right now? I think they really get back to that clinical
piece that I was talking about on a prior slide, which is how do we know which medication
is best for a patient? How can we tailor our pharmacologic decisions
to our patients who come to us in the clinic? Are there certain traits that we should be
looking for in our patients? Are there certain genes that might predispose
someone to having a better reaction to one medicine than another? We don't know. And then again, looking at the order of therapy,
more and more, we're seeing that bone-building drugs, first and foremost, followed by an
anti-breakdown drug, works a heck of a lot better than going in the opposite direction. But how do we do that? Do we need to treat for five years? Can we do two and then off and then two and
then off? And then finally, this concept of a drug holiday,
which again, I spoke to a little bit earlier is, how do we know when it's time to stop
the drug holiday? We have just this nebulous space where we
leave patients sometimes, but how do we know when it's been too long off of your medication
and maybe your fracture risk has gone up again and we don't know until you come back in and
have had a new fracture? So those would be the points I'd touch on. Wonderful. Well, listen, I want to thank Dr. Moseley
very much. Thank you so much for your time this evening. And thank all of you for joining us this evening. Graciously, Dr. Moseley has agreed to respond
to any questions that haven't been answered this evening, so you'll receive an email with
her answers in approximately two weeks. And in the coming days, the video of tonight's
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