Osteoporosis: Causes, Symptoms & Treatment

hi thank you for joining us I'm your host natty Yousef and today we're talking about osteoporosis osteoporosis weakens bones making them susceptible to sudden unexpected fractures the disease often progresses without any symptoms or pain and is not found until bones fracture today we will talk to our Cleveland Clinic experts regarding steps you can take to prevent this disease and treatments that may be needed and here with us today we have two experts we have associate professor of medicine for the OBGYN and women's health Institute dr. palin but--or glad to have you and we also have with us head of the center for osteoporosis and metabolic bone disease and rheumatologist dr. Chad deal thanks having you as well I want to start first of all with dr. bitter when I explained to myself and to the audience why we need a woman's health aspect to this why it's important that you're here yeah hormonal treatments are can be very very helpful for bone because obviously for most patients with osteoporosis is gonna be postmenopausal women who have a loss estrogen and hormone therapy which we'll talk about a little bit more there's a better understanding of risks versus benefits and it's you know there was a scare many years ago that it's a lot of risk and not much benefit now we really understand that depending on the woman you can really get a lot of benefits from hormones bone health being one of them and sometimes we use hormonal treatments to minimize the duration of use of our other bone agents so we really worked closely together between women's health and the osteoporosis Center to help treat our patients excellent thank you and for our viewers who I was watching you can leave your questions in the comment section below if you have any questions we'll ask them live here and before we begin please remember this is for informational purposes only and it's not intended to replace your own physicians advice all right so let's start doctor deal with explaining what is osteoporosis so most people know osteoporosis as a disease that causes fractures prior to that though for a very long time you can have osteoporosis and not even know it and it's basically a what we call a micro Ketil deterioration of bone so think of a think of a skyscraper as it goes up with all these girders and as time goes on in your bone you're missing a few of those girders which creates weakness and the weakness gradually accumulates until you have a fracture so it's really important for both men and women to get a test for osteoporosis prior the fracture because in most cases we can actually prevent the fracture if we know that the patient has either osteopenia which is a little bit not quite as bad as osteoporosis in advance and use some of the drugs whether it's hormone replacement or bisphosphonate therapy or many of the other drugs that we have so before a fracture ever happens is are there any symptoms that the patients may be feeling and not knowing that could be osteoporosis right and that's why we've we've called it the silent thief so people generally they don't have any symptoms until a fracture occurs so that's very different than for instance arthritis tío arthritis where if you have it in your knee you're gonna have stiffness and swelling as an early warning sign that the joint is deteriorating but with osteoporosis know you have no symptoms and then was at risk I know women are definitely at risk I know it's called also a woman's disease correct some people refer to it there's a lot of men that are under diagnosed so it's not just a woman's disease but it is most common in women after menopause so we're really looking at anybody who's lost their sex steroids so that would be estrogen for women and testosterone for men also you know patients who have been thin throughout their life which we define as less than a hundred twenty seven pounds that's a risk factor certain medical conditions diabetes rheumatoid arthritis will increase risk those who've had a previous fracture all right at risk for another fracture and we also look closely at the medication list so for example women who've had chemotherapy for example for breast cancer and are now taking anti estrogen treatments people who are taking steroids so those would all be things that we look at at the Med list see if they're on a medication that could increase their risk is a big factor as long age is one of the biggest factors okay so if we look at any bone density and let's say somebody has a bone density that's an osteopenia range not quite osteoporosis and they are 50 years old their risk of fracture is going to be much lower as opposed to somebody with that same bone density who's now 65 so in fact for each five years that passes after age 65 you're essentially doubling your risk of fracture so age is one of the biggest things that we worry about for fractures okay and then so the cause is unknown but how does that disease develop well we do know a lot of the causes for low bone mass or osteoporosis about 70% of peak bone mass is genetically determined so by the time you're 25 or 30 70 percent of your bone mass is done Wow that's why it's really important to have a healthy lifestyle as a youth that includes not smoking and low alcohol intake and lots of exercise and normal body weight but there are environmental issues as dr. vittor has already mentioned that affect peak bone mass okay so there so so a lot of the times it's known but the the genetics of it are very complex they're at least a hundred genes or more that control peak bone mass bone loss so you might think of genes that control vitamin D metabolism or calcium absorption or osteoblasts function these are the cells that produce new bone or osteoclasts the cells that break down bone so there are lots of genes involved that we don't understand yeah sure are there certain diseases or medical conditions that contribute to bone loss more than others yeah so the reason I'm here I'm a Rheumatologist I got interested in this because many of my diseases can result in bone loss one would be rheumatoid arthritis in fact rheumatoid arthritis is a risk factor if you go to this fracks website if you just Google in fracks on your computer you can calculate your 10-year risk of a fracture and rheumatoid arthritis is is one of the risk factors in addition for all the inflammatory diseases that rheumatoid this tree with steroids that's a huge risk factor so we're talking about cortisone prednisone those types of medications they're very big risk factors but it's not only Rheumatology all subspecialties use steroids or prednisone as part of their treatments for various inflammatory diseases and the medications can also there's some medications that can cause well I think dr. bitter also already mentioned aromatase inhibitors and women with breast cancers those are anti-androgen therapy for men is anti anti estrogen anti-androgen therapy and men with prostate cancer for instance that's a really big risk factor but there are others like seizure medication dilantin that accelerate vitamin D metabolism and can cause low bone mass so there are lots of medications that can do this can accelerate the process sure ok and now like let's switch onto the dietary factors and you talked about that a little bit even when by your by the age 25 or earlier you should be healthy let's talk about diets their dietary factors that can contribute to this disease I'm glad you're asking me this question because I'm going to keep your whining this yeah I mean what you're doing throughout your youth and with your lifestyle it really makes a big difference so we want to make sure that patients are getting enough calcium we preferred dietary calcium as opposed to supplements whenever possible I realize that that's not always possible we have patients you know who have gastrointestinal issues or lactose intolerance they may not be able to get adequate dairy calcium or you know it's dairy is your best way of getting calcium there's other ways but if you're lactose and tartes gonna be hard for you to get that so getting enough calcium is probably one of the most important things and it truth be told nobody knows exactly how much calcium is required there's some controversy with that but we think somewhere around a thousand twelve hundred milligrams a day and I see people who are either getting way too little calcium or sometimes getting way too much because that amount at the thousand to twelve hundred should be everything including supplements and what's in your diet so there could be too much calcium mm-hmm that can also cause to bolus it won't cause bone loss but you know adding extra calcium is never going to help you to build your bone either you're gonna pee it out or there's some concern about whether you know it leeches out into the arteries you know calcium is a safe supplement overall but just like everything else too much is you want everything to be in moderation too much of anything isn't good plus it's constipating right most types of calcium right what about lifestyle traces so lifestyle includes exercise you're talking about things like that so the good example of exercise would be as if if you go into space you lose about one to two percent of your lumbar spine bone density every month so that's total weightlessness so obviously that's not something that our audience is going to experience but if you're a couch potato you know you can lose bone mass not to that extent - so weight-bearing activity is really important and when I say weight-bearing I'm not talking about lifting weights we're talking about heel strike so putting your foot to the floor and sending a mechanical stimulus through your skeleton we have cells in our body called osteocytes that are Meccano receptors and they take that vibration and they turn it into something that stimulates osteoblasts to produce new bones so that kind of lifestyles really important I think we've already mentioned calcium we've already mentioned smoking alcohol alcohol is a direct toxin to Ostia blasts the kind of the cut point for that for men is about three drinks a day 21 a week it may be less for women or toxic the cell smoking nicotine is really bad for your bones there's nothing nicotine is good for including the bone and even those guys in space have treadmills and they have certain things to do to keep their bones strong right yeah they do you know the Cleveland Clinic was involved in a project to try to do what we call counteract the the effects of weightlessness so that we can go to Mars and in order to do that you've got to do some kind of weight-bearing activity going to Mars and back otherwise you're in you're in real trouble and so that that's an experiment that's still ongoing at NASA and Johnson City but it started at the Cleveland Clinic Wow and I think it's important to emphasize it's not just about taking a supplement or getting half an hour for working out in a day it's really about lifestyle you know being eating nutritious foods taking good care of yourself I do see people who are taking bunch of supplements but they go on these fad diets and they lose a bunch of weights that you know of course we want you to be a healthy weight but they do it through eliminating of a lot of wholesome foods and then I see a huge decline in their bone density you know the year after so it's really there's there's a lot to be said for just taking plain old good care of your so it's kind of reversible like you can you can fix that if your few bones are starting to be weak you can fix it with your lifestyle and dietary choices yeah to a certain extent sure okay well we talked about how there is no signs or symptoms for osteoporosis but what yeah I know you mentioned earlier there's a test that people should take what age who should take it and what so kind of the guideline my guideline is a little bit different than the official guidelines so the official guideline is every woman at age 65 should have a bone density test but if you have clinical risk factors for bone loss you know so that would be low body weight or smoking her family history or previous fracture it really should be at menopause because so many women enter menopause with low bone mass already and there's a subset of women that can lose up to 5% of their bone mass every year for six years you can lose 1/3 of your bone mass in a six year period the only way to really attack that is to know if you need to treat it right away and a bone density test is the best way to do that for men the guideline is age 70 unless there's risk factors and in which case we do it at age 50 okay yeah and it's a hundred-dollar test it's part of welcome to Medicare so when you get a when you go get your Medicare insurance that's part of the test it's covered by Medicare but most commercial insurance will pay for it if you have risk factors and I think it's it's a it's a it's a test that's well worth the hundred dollars even if you had to pay for it yourself in order to maintain skeletal integrity and prevent fractures can you describe to the audience kind of like walk through what kind of tests look what does it look like what to expect going into a bone-density yeah it's it's really really easy it takes about five or ten minutes you lie on a table and there's a x-ray beam that sends a x-ray through your skeleton the hip and the spine and the amount of x-ray that gets through the bone and is detected on the other side is proportional to the amount of calcium in the bone okay and when I say x-ray remember this is a very low x-ray procedure it's about one tenth of the amount of x-ray of a chest x-ray it's about the same amount of radiation you get flying from Cleveland to San Francisco so it's not something you should worry about in terms of x-ray exposure okay let's jump on to treatments I want to talk to you about treatments what treatments there are and I know for women it's probably different for men so we'll kind of tag-team and talk about that yeah we have lots of treatments available so we have hormonal treatments which technically the hormone replacement therapy for the younger woman is meant to be for preventing osteoporosis and fractures but we do have great data many many years of data that suggests that actually helps prevent fractures and hip fractures this is which is important because not all medications available have been shown to prevent hip fractures which is one of the types of fractures that we really worry about because that's the one that you know can really impact you know affect disability in terms of putting you into a nursing home or increasing your chance of having a bad outcome and increasing death so that's where hormone therapy can be very helpful especially for the younger woman who's got pretty severe bone loss but we have not many many non-hormonal options available we have what we call also designer hormones so these are called selective estrogen receptor modulators CERN's or sometimes people call them estrogen receptor agonist antagonist but really what the name is trying to find is that it works like an estrogen in some body parts and as an anti estrogen at other body parts so for example the one that we have approved for bone health is an anti estrogen at the breast so it's also used for breast cancer prevention it's a I would define this a little bit of a weaker bone medication so this is probably a perfect idea ideal candidate for that one would be a younger woman that has significant bone loss and she has a family history of breast cancer okay and she wants to prevent that risk but her risk of fracture right now isn't that high because she's still younger and so what you can do is you can kind of insert that therapy for five years or so so you kind of postpone when she's gonna switch over to another therapy and I'm sure we'll talk about that there's bisphosphonates um these are the bone medications that come in pill form injectable form oftentimes just taken once a week or once a month and then we have also bone builders and other injectables would you be taking the same approach okay so the bone builders what dr. bitter was mentioning or our anabolic so we divide therapy and two anabolic or bone building and a knee resort 'iv and the anti resorbs prevent bone resorption or bone breakdown and those include estrogens and thus IRMS that were mentioned along with the bisphosphonates the bone builders we have two of them now we have for Te'o and Tim Lowe's and they're both PTH analogs PTH being parathyroid hormone and they're injections and they're expensive but for patients at high risk for fracture who've already had fracture we have very low t-score there are kind of go to drug for the severe osteoporosis case and I think they're underutilized and should be considered in patients with severe osteoporosis now yeah I was going to say for the bisphosphonates medications you you may have been asked we're going to ask me that there's a real fear of using these medications now and the two things that people think about as side effects are these atypical fractures or this brittle bone and osteonecrosis of the jaw so I always tell my patients there's no free lunch there's always a risk to everything you do you could take an aspirin tablet swallow and it could stick on your esophagus and you could burn a hole in your esophagus if you don't do properly so our job as osteoporosis specialists is hard to treat people at high risk for fracture so that the benefit of the drug outweighs the risk now having said that a typical fracture risk is with these drugs these are thigh bone or hip fractures that occur spontaneously with long term therapy they don't really occur in the first three years of bisphosphonates era P they're they're issues related to long term therapy and for that reason we have guidelines now for drug holidays with bisphosphonates so people with mild or moderate risk might be on the drug for three to five years and then they get time off for good behavior but it's not really time off because these drugs the bisphosphonates medications bind to bone they stay there a long time so I call it an administrative holiday but the drugs still actually working that's not true that's not true for estrogens that's not true for Serbs that's not true for anabolics because once you stop those the effect goes away very rapidly and then we also have another injectable called Prolia and that's actually helpful for our patients who have bad kidney you know kidney dysfunction and patients with weakly functioning kidneys oftentimes can't tolerate some of the other bits phosphonate medications and this injection done like a flu shot essentially getting it twice a year at the doctor's office and tends to be well tolerated so the point is we really have a lot of options and we use all of these medications regularly so it's about you know the individual person what's in their medical background what are their priorities what do they feel comfortable with and we take it from there and oftentimes we will change the medication that we're using over time so the long-term medication the side effects that you were mentioning the osteonecrosis of the jaw the unhealing wounds of the jaw and the femoral neck fractures so these seem to be an issue with longer term use so oftentimes if it's a younger woman we can use something hormonal for five to ten years and then we know that when we take her off the hormones that bone density is gonna drop and then now she's in her 60s and maybe she doesn't need the hormones anymore she's not having it half lashes then we can step in with our other phone agents and that way we're minimizing the duration of use so we're maximizing the benefit but minimizing some of those long-term risks and we're getting a lot of questions we'll get to them here in a second but first dr. Diehl I went out to talk about osteoporosis in men is it common was it more common more common than you think about 20% of all hip fractures are men 20% yeah so it's a substantial minority so there are two differences with men from women or maybe more but one is men have higher peak bone mass so about 10% more peak bone mass so that that means that they fracture later in life if they do fracture and the second thing is they don't have abrupt decline in hormones like women do at the menopause testosterone decline is much more gradual over time so that tends to protect them from fractures but not totally as I mentioned 20% of all hip fractures are men and they're same risk factors that we've talked about already for women apply to men so healthy lifestyle calcium vitamin D intake smoking alcohol they all apply to men and I don't think we touched on this there are primary and secondary osteoporosis can you explain these two main types and what causes second osteoporosis and money it's that's a kind of a nomenclature term primary is when there's no apparent secondary cause like rheumatoid arthritis or steroid use or vitamin D deficiency and those are mostly you know just the genetics of it and the secondary causes are those that we can identify a definite reason for the osteoporosis and and hopefully intervene and do something about it okay and then the risks don't differ for men correct the risks are both for women yeah there there there's almost total overlap and risk factors for osteoporosis between men and women okay great thank you guys well I'm gonna go ahead and head to some live questions that we're getting I have a Brandon Daly dairy calcium source versus non dairy calcium source which is better so as long as you're getting your calcium as through a natural food source that's okay I think one is necessarily better than the other I usually give a printout of how much calcium is in different foods and you can actually find that on our Cleveland Clinic website because I oversee a lot of the women's South Cleveland Clinic patient education materials for the hospital so if you google Cleveland Clinic patient education and you'll have a whole bones section that goes into a vitamin D and calcium and we try to update those every few years so that they're you know they're they're up-to-date with accurate information so I think it's important for everybody just to add up their typical average day calcium intake and you can do that with fancy Google calculators or apps or you could just do simple arithmetic and just seek is on our website lists different types of foods and how much calcium per serving on one thing to keep in mind some of the green leafy vegetables sometimes our body has a harder time extracting the calcium from those so I always tell people don't underestimate with those or don't over run don't overestimate so be accurate if you're saying oh that looks like about a half a cup of kale don't you know say that's half a cup of kale I would really look at the your intake because you might not be getting quite as much calcium from some of the green leafies oh that was Brandon right that he may be getting at weather you know if you go to a website a vegan website there's lots of information about calcium from dairy versus non-dairy source so there's a fair amount of controversy I think that dr. Butler and I agree that calcium food calcium for many sources probably good but there are there is controversy in that area and I think one important thing to bring up is that your body typically can only absorb about 500 milligram calcium at one time so what I see a lot of times is somebody who's sat down with their fortified cereal had their fortified orange juice put their milk took their mouth live item and they said I'm done for the day you know your body is very smart smarter than I said it controls how much calcium it's going to absorb so it's one thing if you're trying to make sure that you're getting the right amount of calcium and take break that up throughout the day so don't take a supplement of when you already took a multi of I just poop that out yeah great and then I surely what are things you can do if you already have osteoporosis as a result of Crohn's and other health issues so well Crohn's disease there are a couple of reasons that that people with Crohn's have low bone mass one is many of those folks with inflammatory bowel disease have been on steroids or prednisone which can cause bone loss second reason is that if they especially if they've had surgery they may have malabsorption and they may not absorb calcium and vitamin D very well at all many patients might have low body weight and that's another risk factor so when you talk about therapy for those folks you've got to address all those issues and correct to the extent you can all those issues and if if they still have low bone mass then that's where you step in and use one of the active drugs that we have to either prevent bone loss or build up bone now I wanted to ask you where do you go for that bone density exam tests do you go to your primary care physician do you need to see a specialist well so bone density machines used to be more prevalent and they used to be in many many primary care offices but over the last decade or so the reimbursement for bone density has declined rapidly and many bone density machines and private offices have gone away so often they're in hospital based radiology departments but there's still a very significant number in private offices it's the machines cost about fifty sixty seventy thousand dollars they're not too expensive but they're not too cheap and it's fairly easy to find what you do it's helpful to make sure that you're getting your bone density on the same machine so that you know when you in two years when you're following up on that that you can actually exactly so you can compare change because it's like otherwise getting on a scale and trying to determine you know one or two pounds difference on all different scales and we take great pride I mean both dr. diehl and I read thousands of scans per year and so at our institution we take great pride in making sure that we're all certified and that we're following the international society guidelines so you want to make sure that you're getting it from a professional place and following up on the results there thank you Chris for women who have been diagnosed with breast cancer and are taking estrogen blockers what are the natural therapies that they can use to prevent their bones from thinning so I'm assuming when they say natural Christy said was thinking about like supplements so let me address that first so because I get that question a lot in terms of soy supplements that's one of the most common questions that we get soy can't have estrogen like properties and so our oncologists get a little nervous about the use in supplement form because when we look at plants estrogen even though it's found in nature it's completely unnatural to our body chemistry we don't have estrogen that looks like that so on our on our website that I mentioned the calcium sheet it also talks about you know the hormone therapies and there we talked about different amounts of soya how much estrogen they have so if you're doing naturally through diet I think that's okay but when you're doing it in supplement form I get a little nervous people also take strontium sometimes for as a supplement and the you know the recommendation is to not use that people use fluoride in fact if you're just looking at bone density data you know fluoride is probably gonna help improve your bone density more than many other products that we have why don't we use it it probably increases the risk of fractures so we really the medications that we recommend have been really tested and we're looking at outcomes like fracture data so the problem with some of the supplements there although they're labeled as natural we don't really have safety data right yeah so I mean I recommend supplements in my practice but I'm a little nervous because I in terms of osteoporosis health has you know bone health outside of the calcium and vitamin D we don't have data about safety or effectiveness and others right so it's okay to eat soy diet and you're in your diet but not supplements probably stay away from you right and as long as you're not overdoing else yeah again some of our oncologist do it because depending on the type of breast cancer treatment you're receiving some like tamoxifen for example work by really competing for that estrogen receptor so how if you're getting a little extra estrogen from a lot of SOI it's probably okay but for medications like of aromatase inhibitors which function by really dropping that estrogen level the alcohol just really worry about any kind of estrogen seeping into the system that it may actually make it not work as well all right and then I have Gloria I have osteoporosis what can I take to relieve stiffness and pain as I am on warfarin so she she doesn't have stiffness and pain from the osteoporosis as we mentioned it's silent so her stiffness and pain is probably related to degenerative joint disease or I'm not sure where the stiffness and pain yes and that's a different issue for stiffness and pain other than physical therapy and stretching and heat and all the non-medical non medicine type of therapies we often use non-steroidal anti-inflammatory drugs for stiffness and pain but that's really not related to Ostia proces and that's why it's called silent bone thief right correct the big source of confusion is because they both have the term osteo in it which means bone but osteoporosis literally means porous bone so it's weaker and osteoarthritis which causes a lot of pain means inflammation okay right and then Bonnie I'm a kidney transplant patient and on prednisone and worked out and walk a lot what else can I do to stop the pain more pain questions more pain well I don't know why she has pain so that's a hard one their answer sorry yeah I needs an evaluation probably with Rheumatology okay great so I'm gonna go ahead and see here we got Lydia what are the pros and cons of tell me if I'm doing this right is it request infusion reclassed infusion so that reclass is one of the bisphosphonates that we mentioned well tolerated we have great data on the effectiveness it's given once a year and we use it for at least three to five years and then do a bone holiday for most people unless it's severe and really there's not many contraindications so that one of the reasons we wouldn't use it if somebody had significant kidney dysfunction we'd be constant about that but one of the nice thing about the injections is that we're guaranteeing that it's being absorbed so when a patient takes or like for example if they take oral Fosamax roughly about one one thousandth of that is absorbed so if they're not taking it properly on empty stomach they're drinking it with their coffee absorption might be an issue or if somebody has bowel issues that prevent absorption so at least we're bypassing all that and we're ensuring that it's absorbed and also if somebody does have issues with you know reflux esophagitis type of symptoms from the pills then the IV formulation helps bypass that and it's a simple yeah it's a simple infusion it takes about 20 minutes yep you do have to have an IV about 10 percent of patients get a post in fusion reaction we call it flu-like it's not the flu but they may have low-grade aches and pains low-grade fever for 24 to 48 hours yeah it's a Medicare B drug so it's covered very well by Medicare you the out-of-pocket expenses are usually very small actually went generic a few years ago and the price for instance of that drug is like $350 for an infusion once a year so it's really actually very cost effective medication they're actually using an oncology to some of these medications and bisphosphonates to prevent metastases to the bone so there's probably some other health benefits that need to be more studied medicine Allison wants to know what are the pros and cons of Prolia right I think dr. Becher mentioned Prolia Prolia so we've talked about bisphosphonates that are chemicals and they bind to bone and when an osteoclast comes along the bone surface to resorb the bone the bisphosphonates taken up and the osteoclasts function is inhibited Prolia or denosumab is completely different it is a monoclonal antibody against ranked like in rank ligand is a cytokine that's absolutely essential for osteoclasts function asti class being the cells that resort bone it's a shot given every six months when you stop this drug if that goes of it away very rapidly so we're not talking about drug holidays with this drug it's a very effective drug we actually have a ten year study now in 2,500 people showing its safety over a 10-year period it does have some of the same side effects as the bisphosphonates including rarely these atypical femur fractures or osteonecrosis of the jaw I should say something about onj osteonecrosis of the jaw 90% of patients who get that tend to be the cancer patients who are getting the high-dose medications dr. Pachauri mentioned if they have cancer they tend to get reclassed or Prolia in super high doses ten times the osteoporosis dose about five to 10% of these onj cases are in osteoporosis patients but in most cases these are patients who have dental procedures that involve exposed bone like a tooth extraction or very poor dental hygiene so that for that reason once we when we're starting one of these drugs on a patient and they have some dental issues we always like them to get those dental issues cleaned up and taken care of before we start the medication and one more plug in for the hormonal therapies so the hormone therapies and the Stern's that I mentioned they are not they have not been linked to some of these long-term risks such as of the jaw and the femoral neck so for women who are appropriate candidates or her stuffing suffering with a lot of menopausal symptoms that can't sleep vaginal dryness I mean a whole menopause complex mood concerns this is some way this is a way that you can avoid the long term use of one medication yeah and the anabolic drugs the bone builders Forte on Timo's they're not associated with atypical fractures or onj either questions about Fosamax so Terry wants to know are there natural treatments without taking drugs such as Fosamax so similar to what we talked about before there's there's really no natural supplement that we know that works and unfortunately you know if we lived in a country where there was more strict regulation of the supplement market I would feel so much more comfortable but we're seeing increased number of liver transplants from supplement cuz that you can make a lot of claims on supplements because you know everybody wants to be healthy and there's people with money in their pockets so if it's a business model built on very little oversight by any federal exactly and so there's people out there to make a buck they may have the best intentions of putting out a pure product but there's issues with impurities they found wrapped poison and chemotherapy agents and some of the supplements and without the data to show that there's any supplement that helps I'm a little nervous about recommending it and supplements you don't need a prescription for you could just go get it from wherever or online and some people they ask me can I do this with just calcium and vitamin D alone for instance and what I usually tell folks is that we have randomized control trials that led to the approval of all the drugs we've talked about today and the placebo group is calcium and vitamin D so we know that when you add an active medication to calcium and vitamin D that you reduce your risk for fracture calcium and vitamin D are important and when you are on one of these medications you still need calcium because calcium is the building block of bone Fosamax is not calcium you still need that calcium it's kind of a quirky analogy I mean it's not perfect but I like the way it feels in my head yeah you know I think of calcium and vitamin D as a bunch of bricks and I think of the medications that we're recommending when the bone disease is really bad as like a bricklayer and so when you have a wall that's falling apart and the bricks need to be put together dumping more calcium and vitamin D so dumping more bricks isn't going to fix the problem and having a bunch of bricks and no bricklayer isn't going to help or having the brick layer which is the medication without the adequate number of bricks the calcium and vitamin D isn't going to help so it's that delicate balance of both that you need and then Joanne wants to know of fosamax causes dropping well jaw pain so first of all there are lots of reasons for jaw pain we have patients who walk in the clinic and they've stopped their Fosamax because they have clicking and their jaw and that's TMJ that has nothing to do with omj there are many reasons for for jaw pain muscular pain grinding your teeth at night everything that that causes pain around in the jar the face is not related to Fosamax I've seen across of the jaw there's a definition for its expose bone that persists for more than six weeks so if you look in your mouth you'll see an area where the gums gone and where you can see exposed bone and that persists that's onj the rest of the causes for pain in the jaw or something else thank you for asking that because that comes up a lot and let's not forget onj and the atypical femoral fractures actually occur in people not on these medications oh okay so this is not just from these medications so in fact if you look at hip fractures it turns out a good number of them can be these atypical fractures and people not on meds it just we're just concerned that it may slightly increase the risk but the number of these slightly increased risks that we're talking about are in the rare category one out of a thousand or less and then Darlene wants to know should I take vitamin D or d3 and what is the difference d2 or d3 so there's two types of D there's d2 and that's usually the prescription that we write it's 50,000 unit D - it's plant-based d3 is U is over-the-counter so that's where you get four hundred a thousand two thousand five thousand you can just pick it up off the shelf that's that's a animal source product okay d3 maybe a little more potent than d2 not a huge difference so either either as fine tuesday vegetable consistency is the key and the nice thing about vitamin d is it's fat soluble so it's one of the only vitamins that you can take more in lump sum and so i always tell people if you forgot it for a week and you say oops then you can actually double up the next week and similar to taking it every day and you shouldn't do that with other vitamins but vitamin D is one that's reasonably safe as long as you're sticking to the lower over the doubt over-the-counter doses and not a high prescription dose and I'll follow up with Kathy's question she wants to talk about high dosage of vitamin D is it safe and you need to take calcium with it you know vitamin D you ask 20 different people you're gonna get 60 different answers so back in the day when we really didn't have as much data on vitamin D I would use the higher dose supplements in my practice the 50,000 units and I still have to in some women that have had for example bariatric surgery and have really hard time absorbing but I favor finding a lower dose that it could take regularly and that that way I can see because there's I've seen some people accidentally take we use the 50,000 unit sometimes one to two times a week but I've seen people accidentally taking it once a day so I think there's a lot more it's more predisposition so yeah to error with that so I've really tried to find what's the minimum that the patient can use and usually I don't recheck levels for about 3-4 months to get a real idea of the plateau your approach may be different no it's it's I agree with that and we we tend to use the 50,000 in patients who really have very low vitamin DS because we want to replete them very quickly because people who have really severe vitamin D deficiency don't have can have not osteoporosis but osteomalacia osteomalacia is a failure of bone mineralization and vitamin D is really required for that so somebody the typical patient would be patient who's had bowel surgery and they have what we call short bowel syndrome and they come in and they have a vitamin D level of 5 normal being 30 and those folks have a lot of unman er alized bone they have something we call osteo 8 in the bone and those patients need very quick repletion of vitamin d in order to get their bone density bone mineralized and that's where we tend to use the the bigger pills that dr. Peter was talking about the 50,000 and we should probably talk about the optimal level of vitamin D because that's also an area of confusion so the National Institute of Medicine say anything over 20 is adequate but really with bone health that's for a general population but for patients who are having a lot of achiness or those with osteoporosis many of us would feel that that's suboptimal and we try to strive for over 30 ideally 40 to 50 I'm a little nervous about too much vitamin D again since it's fat soluble you may not be able to pee it all out and you can't get toxic on it so although we have data on safety you know the higher ranges even more than a hundred and you know surfers and people who are out in the Sun getting it naturally we don't have that safety data for supplements so I try to stick to somewhere between 30 and 80 almost mostly in the 40 to 50 range really I don't know if your approaches - yeah and then the normals 30 to 80 and as I said there is controversy about whether you need 20 whether you need 30 nanograms per deciliter but most folks and the osteoporosis feel go with 30 nanograms or greater great and then Agnes wants to know I'm on the weekly medication for osteopenia / osteoporosis I followed the rule on an empty stomach and do not lie down would drink my coffee for 30 minutes to an hour how beneficial is the injection over the pills so so she's asking whether taking the injection which would be Prolia or the infusion which would be reclassed might be better than Fosamax now if you take your Fosamax properly as she's doing empty stomach big glass of water don't have anything to eat or drink for at least 30 maybe even longer it's going to be effective therapy the where I think where you get some improvement with either Prolia or reclass or in patients who are not quite as compliant with their oral medicines or forget their oral medicines or take it with a cup of coffee is dr. mature mentioned earlier so and in those cases the injection or the infusion may be a better choice great and then Gwendolyn what can you do about constipation due to calcium supplements yes that's a good question so sometimes just fixing the behaviors that worsen constipation is helpful so what do I mean really pushing the fluids especially when the weather starts to turn people don't realize they're getting relatively dehydrated because the heaters are kicking in so I really encourage patients who are constipated to really aim for six to eight glasses of water a day minimizing other agents that are constipating you always want to make sure that you know thyroid has been checked you don't have another reason to be constipated benef what yeah I don't advertise certain supplements but you know it's a fiber format benefiber is one of our favorites in our clinic I'm just staying regular with that there's some data that calcium phosphate might be a little bit better in terms of constipation you know personally I've seen that to be true and you can find that it's harder to find but you can find that in some you know gummies used to be able to find it as posture deep and I think they got rid of that a while ago I've seen it at Sam's and Costco as chewables right so calcium that brings up the point of calcium supplements come in calcium carbonate calcium citrate calcium phosphate calcium gluconate most patients the most common on the market is calcium carbonate so that's what's in tums or a scowl or Cal trait citracal I find a little bit less constipating - and the advantage of taking calcium citrate is it's absorbed independent of acid so you don't have to take it with a meal you can use it in patients who have a disease called pernicious anemia where they have no stomach acid it's absorbed very well to the disadvantage of the citracal is the the elemental calcium is less so you have to take a bigger pill and more pills often with citracal than you do with carbonate calcium carbonate manis a little bit more expensive - yeah and then uh I'm glad he mentioned about the acid because keep in mind that if you're on medications to block stomach acid like your prilosec your next scene which a lot of people are on then you really should stick to something like the calcium citrate as opposed to the calcium carbonates because you're not going to absorb the calcium carbonate as well okay well I'm gonna give you one more question before I let you guys go uh-huh Lin wants to know what things cause me to have a higher chance of getting osteoporosis and I'll kind of end it with that we can talk about because we've talked about that earlier lifestyle yes this dietary and then also I want to kind of touch on pain because if you like a lot of people were asking about pain management with this so we want to kind of clarify everything here as a kind of conclusion for today I think one thing I'll touch on for this question that we haven't touched on is women with premature menopause so those would be defined as laid before age 40 these women have accelerated not just bone aging but heart aging and brain aging so these women really should be on hormone therapy until the average unless there's a reason not to be until about age 52 51 52 the natural ages of menopause so that we really don't you know creates osteoporosis 20 years before favorite men - and you know we oftentimes do that if even if a woman went through menopause at age 43 a little earlier but not the definition of premature menopause so unless she has a compelling reason not to be she usually will feel better and she'll protect her bones great yeah and you asked about pain as we as we already have mentioned this is a silent disease until you have a fracture there's some folks who have vertebral fractures or spine fractures and they have a tremendous amount of pain and in many cases that pain will resolve over 6 or 12 weeks but in some some cases it may not there's a procedure called kyphoplasty where they actually insert a cement tight substance in the vertebral body and that sometimes helps resolve pain sometimes patients who have chronic pain end up in in medical spine centers and places that deal with chronic pain in the spine another common cause of pain with a fracture or sacral fractures or pelvic fractures they can be very painful and you know we do our best to treat them as we do many other pain patients well thank you both so much for taking educating us in our audience and thank you for watching we hope you enjoyed today's discussion and to download our free osteoporosis guide and learn more about prevention treatment options please go to Cleveland Clinic org slash osteoporosis and for more health news and information make sure you're following us on Facebook Twitter Instagram and snapchat at Cleveland Clinic just one word we will see you again next time thank you

Channel: Cleveland Clinic

Views: 41,625

Rating: 4.6318407 out of 5

Keywords: osteoporosis, dr. chad deal, dr. pelin batur

Id: fuMaTOFPu4I

Length: 47min 56sec (2876 seconds)

Published: Thu Nov 29 2018