Are you aware of the silent killer affecting over 10.2 million Americans? Join us for a riveting discussion with Patricia Donahue, an acute care nurse practitioner at the Kayal Orthopaedic Center, as we uncover the mystery of osteoporosis. Gain valuable insights on bone metabolism, the process of bone growth and turnover, and why it's crucial to build up our bone mass during our childhood and adolescent years.
Discover the various tests that can be done to assess for osteopenia and osteoporosis, including the gold standard, the DEXA imaging test. Learn the importance of regular testing, especially for high-risk groups, in order to prevent fractures and maintain bone health. Patricia also sheds light on the difference between Z scores and T scores and how they help to identify the risks of developing osteoporosis.
Finally, we explore the treatment options available for osteoporosis, including medications like bisphosphonates, RANKL inhibitors, and anabolic agents. Patricia emphasizes the need for monitoring vitamin D and calcium levels when starting medication treatment and the implications of stopping medications without proper transition. We also delve into the role of hormone replacement therapy and the use of the drug Evista in breast cancer patients with osteoporosis. Don't miss this informative conversation with an expert in the field of osteoporosis diagnosis and treatment.
Are you aware of the silent killer affecting over 10.2 million Americans? Join us for a riveting discussion with Patricia Donahue, an acute care nurse practitioner at the Kayal Orthopaedic Center, as we uncover the mystery of osteoporosis. Gain valuable insights on bone metabolism, the process of bone growth and turnover, and why it's crucial to build up our bone mass during our childhood and adolescent years.
Discover the various tests that can be done to assess for osteopenia and osteoporosis, including the gold standard, the DEXA imaging test. Learn the importance of regular testing, especially for high-risk groups, in order to prevent fractures and maintain bone health. Patricia also sheds light on the difference between Z scores and T scores and how they help to identify the risks of developing osteoporosis.
Finally, we explore the treatment options available for osteoporosis, including medications like bisphosphonates, RANKL inhibitors, and anabolic agents. Patricia emphasizes the need for monitoring vitamin D and calcium levels when starting medication treatment and the implications of stopping medications without proper transition. We also delve into the role of hormone replacement therapy and the use of the drug Evista in breast cancer patients with osteoporosis. Don't miss this informative conversation with an expert in the field of osteoporosis diagnosis and treatment.
Hello and welcome to another edition of the Kale Ortho podcast. Today is June 13th, 2023. And today's guest is Patricia Donahue. She's an acute care nurse practitioner at the Kale Orthopedic Center And she spearheads our osteoporosis and bone metabolism center and runs our fracture liaison service as well. Welcome to the podcast, patricia.
Patricia Donohue, ACNP:Thank you, Dr Kale. Thank you for having me today.
Robert A. Kayal, MD, FAAOS:Oh, i'm honored to have you here. We're so happy to have you here because we're going to speak today about a very, very common, ubiquitous problem, and that is osteoporosis. Osteoporosis is extremely prevalent in the world. Unfortunately, it's known as the silent killer. It is estimated that more than 10.2 million Americans have osteoporosis And an additional 43.4 million people have low bone density. Two million new cases of osteoporotic fractures per year exceeds the annual number of new cases of myocardial infarction. That is, heart attack, breast cancer and prostate cancer combined. Annual fracture incidence is expected to increase 68% to 3.2 million by the year 2040. It is no wonder we call osteoporosis the silent killer. So we're going to just jump right in right now and invite Patricia Donahue to speak to us today about bone metabolism, osteoporosis diagnosis, treatment and monitoring of this wretched condition. So let's first start and talk about bone metabolism. Let's just talk about the fact that our bones, our tissues and these tissues are alive. Can you elaborate on that for us, patricia?
Patricia Donohue, ACNP:Sure. So our bones are a living tissue, as Dr Kale said, And we basically build most of our bones. It's called the bone modeling years during our childhood years The very important during adolescence, because that's when we deposit most of our mineralization into our bones. Then we continue to grow up until around the age of peak bone mass, When we stop growing additional bone and that's where our bone bank stops. But it's very important in those years to get our mineralization, our calcium, our vitamin D for any parents that are out there or grandparents for their children to get the adequate amounts, to put the adequate amounts in their bone bank.
Patricia Donohue, ACNP:At the age of 27 to 30, we stop growing. We make additional bone throughout our lives But what we do is we have these other bone cells and I call it plowing the land It's almost like excavating And then the new bone cell growth just fills in those defects. We never grow additional bone throughout our life after the age of 30. So we really turn or turning over our skeleton. We're making less bone as we age. We're breaking down more bone as we age And certain conditions that we work up and evaluate patients for in the Metabolic Bone Health Center are certain conditions that can affect bone growth or bone turnover. As Dr Kale said, this is a silent disease So we need to recognize risk. Factors are very important in getting patients to get a bone density test and an evaluation.
Robert A. Kayal, MD, FAAOS:I always emphasize that with the pediatric population that we take care of at the Kale Orthopedic Center. Very often when children come in with their parents and they break their wrist, i emphasize that, that young age, that it's incumbent upon us to enforce the need to take calcium and vitamin D during our growing years, because we're establishing our bone density, our bone stock, by the age of 30. That's when we really reach our peak bone mass. So it's incumbent upon us to enforce to children that they should be taking calcium and vitamin D, especially during their growing years, because that is essentially the peak bone mass that they're going to be starting with And it's sort of downhill after the age of 30 for both men and women, but especially from women after they hit the age of menopause, and we'll talk more about that in a little bit. So, as far as the biology of bone metabolism, there are a lot of things that we can do that are important cellular characters that we discuss, that play critical roles in bone metabolism. What are some of those players?
Patricia Donohue, ACNP:So the bone growth cells are called osteoblasts and we actually can measure them in blood tests to see how much somebody is actually making. And then there's osteoclasts. The osteoclast takes the older remnants of bone and clears out the tissue in the bone, so new bone cell growth can come into place. and the osteocytes are a precursor to osteoclasts. So a lot of our medications, you'll see, are targeted at these three areas.
Robert A. Kayal, MD, FAAOS:Right. So these cells emanate from the bone marrow. These undifferentiated mesenchymal stem cells become these osteoblasts and osteocytes and osteoclasts, and they all play very, very important roles in this bone metabolism. So essentially, the good guys are the osteoblasts that make the bone, the osteoclasts sort of break down the bone, but both are necessary for normal bone metabolism And it is the interaction between these cells that allow bone to remodel and form and break down throughout our lifetime. And that's what really accounts for this bone remodeling and the fact that we replenish or turn over our entire skeleton approximately eight times in our lifetime. What are some of the tests that we can do in the office to assess whether or not a patient potentially can develop osteopenia or osteoporosis?
Patricia Donohue, ACNP:So still, the gold standard is the bone density or DEXA test, and what the DEXA imaging is is a two-view low radiation X-ray. In fact, we are exposed to more radiation from the natural environment over a 48-hour period of time than what we get exposed to in a bone density test, so it's very low radiation. It gives us the ability to look at the mineralization in specific areas in our hips and in our lower spine and in some cases of the forearm, so it allows us to see what the mineralization of the bone is. Now there are certain test scores that we look at. We look at Z scores in any male that's less than the age of 50 or any premenopausal women, and what these scores do is they tell us where your individual mineralization is compared to somebody that's the same age, ethnicity and race. So anybody that's lower the more negative you get in that Z score, the worse that it is. So anybody that's lower than the negative 2.0 is said to have a lower bone mineralization when compared to their age match peers.
Patricia Donohue, ACNP:On the other hand, when we look at the postmenopausal women and men that are over the age of 50, we look at something called T scores, as Dr Kaila and I just spoke about. We peak our bone growth at the age of 30. Our bone mineralization is compared to that individual who has peaked their bone mass at the age of 30. Again, the more negative that we get, the worse that the test is. So a negative 1.1 to a negative 2.4 is osteopenia and negative 2.5 and lower is osteoporosis. So we can see by this bone density test, our first test, to see how much is osteopenia, normal osteopenia and osteoporosis in our patients.
Robert A. Kayal, MD, FAAOS:The bone density test that we do in our office is probably considered the gold standard right Correct. So why is it so important to even do these tests and to identify if somebody has osteopenia and osteoporosis?
Patricia Donohue, ACNP:So this is the problem out there and it's become a public health issue. Public health issue is that our disease of osteopenia, osteoporosis, is a silent disease. People don't know that they have the disease unless they have a bone density test or if they have a fracture. And that is a problem because once you have a fracture, your chances of having an additional fracture goes up within that first year. So it's very important, especially in the high risk group categories, that patients do have and individuals have bone density testing. There's the guidelines, say, for women over the age of 65 and men over the age of 70. But if there's a younger individual that has risk factors such as taking long term steroids, a history of a low energy fracture, family history of fracture, then it's, or going through menopause, then it's important to get this bone density test at an earlier age to identify bone loss, with possible rectifying and treatment or even lifestyle changes to help to correct and improve their bone density before they lose future bone.
Robert A. Kayal, MD, FAAOS:Absolutely, absolutely. And it's unfortunate we call it the silent killer, because the orthopedic literature suggests that approximately 20 to 30 percent of patients that suffer a hip fracture, which is a very, very common problem in this world, 20 to 30 percent of those patients that endure a hip fracture, will not make it one year after that hip fracture. Twenty to thirty percent of them will pass away the same year after the suffering that hip fracture. And the reason is not necessarily from the fracture itself, what the surgical management of the fracture, but rather the complications that are then associated with being bedridden from that fracture. So, for instance, pressure sores, pneumonia is blood clots, pulmonary embolism, another complications like that.
Robert A. Kayal, MD, FAAOS:So it's incumbent upon us as a health care provider to make sure that our patients that are suffering and enduring low energy fractures, insufficiency fractures, are appropriately worked up and treated To prevent another fracture. But most importantly, it's important at the appropriate time to assess our patients early on to see if they are at risk for osteopenia or osteoporosis and ultimately suffering one of these insufficiency pathological fractures. The numbers are staggering in that approximately eighty to ninety five percent of patients that endure an insufficiency, low energy fracture are actually discharged from the hospitals without any follow up care for their osteoporosis by a bone metabolism expert such as patrician. So it's, it is a health care crisis. It is why we call it the silent killer and is the reason we are having this podcast today to bring attention to this silent killer. So, as far as the bone density test, the DEXA, are there other things that we can do with the bone density test that can assess the bone quality at all?
Patricia Donohue, ACNP:So there is an additional test that we do at Kali orthopedics and that is looking at a lateral view of the lower spine, called the lateral vertebral assessment, or other institutions may call it a vertebral fracture assessment, and what it does is it looks at the height of the vertebrae in the lower spine to make sure that the height is equal to the adjacent vertebrae, above or below.
Patricia Donohue, ACNP:If there is a lower or decreased height, it makes us suspicious that there may be a vertebral compression fracture there. So what's important to know about vertebral compression fractures is a majority of these fractures are asymptomatic. patients don't have any pain. In fact, we identify some that are chronic and we don't even know how long they've been there. So it's important, when we see this decreased height, to have a full work up in evaluation for osteoporosis and treatment, because there's a five full chance and those individuals who have a fracture of having an additional vertebral fracture in the next year and a two to three full chance of them having other fractures, such as a hip or pelvic fracture. So that's a really important modality to do and to identify these fractures proactively before and treat them before an additional fracture occurs.
Robert A. Kayal, MD, FAAOS:I think we should probably take this opportunity to show our viewing audience a model of bone. We can describe the anatomical structures of this bone and we can compare and contrast how normal bone would compare and contrast to compromise bone, one that is compromised from osteopenia or potentially osteoporosis. This is a cross section through bone and you can see the inner network of bony architecture We call the cancellous bone or the spongy bone, as opposed to the outer, structurally strong, compact bone We call the cortical bone. So the outside of our bone is that strong, cortical, compact bone. That's, for instance, the bone you can feel when you palpate your shin or your wrist.
Robert A. Kayal, MD, FAAOS:The inner aspect of the bone everyone's familiar with is the bone marrow and inside the bone marrow you have a lot of fat and another constituents of the bone marrow. But the bony part of the inside of the bone is this spongy, cancellous, trabecular bone And that is the bone that is primarily compromised when we speak about osteopenia and osteoporosis. This bone is alive. As we said before, it's constantly breaking down and building, breaking down and building. The osteoclast are breaking it down, the osteoblast are building it And over time the structural architecture of this bone changes in everyone such that the inner cancellous trabecular bone tends to become less dense and the outer compact cortical bone becomes thinner and thinner and thinner And the canals of the bone become more and more capacious over time.
Robert A. Kayal, MD, FAAOS:So here's an example now of a change of the inner and outer aspect of this bone. So we can see that now it's the outer cortical bone is definitely thinner, the compact bone is definitely thinner and more compromised And the inner trabecular network of bone is certainly more porous and less structurally intact, comparing and contrasting what happens with osteopenia and osteoporosis. So, as we just mentioned, we spoke about trabecular bone. So, patricia, why don't you elaborate on this concept of the trabecular bone score for us?
Patricia Donohue, ACNP:So trabecular bone, like Dr Kale was just explaining about the spine in particular, is made up of 75 percent of trabecular bone. We just had spoke about vertebral fractures If that trabecular network or scaffolding starts to thin out because of an increased bone breakdown we got a lot more spaces in it, there's thinner plates and rods and the scaffolding is more likely to collapse. So a trabecular bone score is an addition that we can add on to our bone density test that we'll just look at that inside quality of the bone to tell us if we have a partial degradation of full degradation of the trabecular bone. If there is, we may use medications to help build up that network and there are certain medications that work even better than other medications to target those areas to prevent that collapsing and that thinning of that bone. So that's a very important thing to look at.
Robert A. Kayal, MD, FAAOS:And what about the frack score? We hear a lot about this frack score. That's so important as well. F-r-a-x.
Patricia Donohue, ACNP:Yes. So the frack score was designed by the World Health Organization and what it does is it takes an individual's risk factors such as their genetics, their history of fracture, corticosteroid use, alcohol, smoking, and puts that calculation in with one of their hip scores And it then comes out with a chance, a percentage of an individual having a major osteoporotic fracture in the next 10 years as well as a hip fracture in the next 10 years. So the World Health Organization suggests treatment over 20% if patients come over 20% in the first category, or in over 3% chance of having a hip fracture in the next 10 years. But we must keep in mind that calculated that risk factor is just based upon what we're seeing in the hip. So if somebody has a normal or low frack score or chance of fracturing and they have osteoporosis or a low trabecular bone score in the spine, it really preempts us to actually treat those individuals before they get a spine fracture. So very important to delineate and see which calculations work with which part of the bone density testing.
Robert A. Kayal, MD, FAAOS:Is there any blood work that you can perform for patients to identify whether or not they're at risk of disorders of bone metabolism, osteopenia, osteoporosis, etc.
Patricia Donohue, ACNP:Yes, so very good question, thank you.
Patricia Donohue, ACNP:And what we do is we put a comprehensive evaluation with the bone density test and the next step is to do some blood work and to look at conditions or look for conditions that may be creating bone loss, such as hypocalcemia, low vitamin D levels You need vitamin D to absorb calcium other conditions such as hyperparathyroid disease, hyperthyroid disease or other disease processes, corticosteroids, adrenals problems, other conditions that are hemotological disease that can be causing bone loss in our patients.
Patricia Donohue, ACNP:So we try to identify if there's any disease processes and collaborate with other disciplines or specialists in that area If we do identify those, to get those conditions under control before giving them a medication. And then, in addition to that, as we spoke about the osteoblast, the bone growth, and the osteoclast class the bone breakdown we can also check markers that measure collagen in the bloodstream. Collagen is the end result of bone breakdown. So the higher your collagen level in your blood is, the more bone you're breaking down. So we can use that as a marker to see how much you're breaking down and we can also use that in response to our treatment modalities to make sure that they're working effectively for our patients. In addition to our bone density testing, Well, it's amazing.
Robert A. Kayal, MD, FAAOS:There's so much you can do to assess this condition That's fantastic and probably monitor treatment as well.
Patricia Donohue, ACNP:Yes.
Robert A. Kayal, MD, FAAOS:So I'm sure our viewing audience is wondering when should I start assessing my bone quality? When should I come in for a bone density? When do I need blood work? So both men and women, and sometimes even in young adolescents and athletes that suffer stress, fractures etc. We know about the female athlete triad. potentially You might want to talk about that as well, but when should our viewing audience consider getting assessed for a bone density and doing some of the blood work? often would they need to follow up after getting one. What types of regular intervals do you recommend follow up?
Patricia Donohue, ACNP:Okay, very good question.
Patricia Donohue, ACNP:So, starting out with our adolescent population are younger individuals that are children that are in sports, anybody that has a stress fracture.
Patricia Donohue, ACNP:we don't routinely do bone density tests on individuals that age, but if they've had a stress fracture we need to evaluate whether or not they have a deficit in their bone quality, and it can, most of the times, can be related to secondary causes, such as the relative energy deficiency syndrome. you know, eating disorders, anorexia, bulimia, not giving enough protein to the skeleton before you're working out, putting it into a negative balance. We also can look for cases that they may have fractures due to. maybe they had asthma and were treated with a large amount of steroids. They didn't have, as we spoke about before, enough calcium and vitamin D in their diet. So it's important to assess these individuals in getting that Z score, but also looking for the secondary influences that is causing bone loss in this age group, and we've have identified individuals maybe with celiac disease. they have a malabsorption problem, that they're not absorbing vitamin D than to absorb the calcium that you're giving to them. So it's really important to look for secondary causes within this age group. Then fast forward.
Robert A. Kayal, MD, FAAOS:Just to interrupt you, if you don't mind, for a second, about this female athlete triad. You know, in these young females we talk about this female athlete triad, where young women in particular can suffer from osteoporosis and fractures and what we call amenorrhea. You know, we always say in orthopedics, especially when we're talking about bone metabolism, estrogen is the bone's best friend And it's so important for women, especially at a young age, to have their periods every month. Regular periods are very important for the young adolescent woman, especially because of the estrogen levels. The estrogen protects the bone And when patients are having, for instance, some eating disorders that can deleteriously affect their ability to have a monthly period, that will translate into a condition called osteoporosis in this female athlete triad. And sometimes these young women will suffer fractures because of the osteoporosis And the treatment is not necessarily to treat the osteoporosis but to treat the underlying condition, which is, in this particular case, an eating disorder which can contribute. So that's also very, very important to note.
Patricia Donohue, ACNP:That's correct. And the first question we do ask is the menstrual cycle, how irregular or regular it is. And there's one statistic that's out there that suggests that the bone bank that you build and the amenorrhea can affect that bone bank. It can predict osteoporosis-related fractures in women in their later years post-menopausal. So really important to look at this time period and relative energy deficiency and secondary causes.
Robert A. Kayal, MD, FAAOS:Great point, great point.
Patricia Donohue, ACNP:So then fast forward to the post-menopausal or perimenopausal women. So it's said, around the 10 years that women's going through menopause, they're losing approximately 2% of their bone per year And, just as you had explained, it's due to that estrogen loss that increases bone resorption, increases bone breakdown. So it's really important to identify these women, especially if they've gone through their menopause at an earlier age, to do bone markers and then maybe some hormonal markers to see where they're at in menopause and work in collaboration with their gynecologist. Some of these women, if they don't have risk factors for breast cancer, uterine cancer or blood clots, we may use low-dose hormonal therapy on them around the time of menopause, five to 10 years, to preserve that bone from breaking down further and preventing further bone loss. If they're not a candidate, we can use the bisphosphonates, and that is when we've used them in those circumstances before All right.
Robert A. Kayal, MD, FAAOS:So just going back to the testing and the periodic testing, certainly the perimenopausal woman. And then, how often afterwards is that dependent on the results of their bone density tests and the blood work?
Patricia Donohue, ACNP:Yeah, so anybody that's being treated, actively treating or monitoring we're concerned about. I would recommend doing a bone density test every year If Medicare will pay for it. Sometimes you have to write a letter to other commercial insurances, but generally if you're actively treating those patients and concerned about bone loss, i've never had a commercial insurance or Medicare deny having a bone density test. Along with that, we would check the bone markers every six months to a year to make sure that our treatment is effective in preventing further breakdown. We can't have a bone density any less than a year, but we can use the lab certainly for a little bit closer in time.
Robert A. Kayal, MD, FAAOS:Does everyone get blood work, Or just everyone that's being assessed for osteopenia and osteoporosis? do we always get blood work?
Patricia Donohue, ACNP:So for the very least, if you have a normal bone density test, i generally just check the calcium and the vitamin D. These are the building mineralization and you need for your bones on a daily basis. So everybody needs a calcium intake through their dietary means or supplements. So to check that and then to check the actual hormone called the parathyroid hormone to make sure that you're absorbing that calcium and getting it to your bones. When we check a normal calcium in the bloodstream it doesn't tell us if that calcium. It tells us maybe it's normal but it doesn't tell us if it's getting to the bones, maybe we're leaching. If we don't get enough calcium in on a daily basis, we may leach that calcium out of our bones, demineralize our bones and it looks great in our bloodstream. But doing a parathyroid hormone level will tell us whether or not we're getting an adequate amount of calcium. So that's really important to do on the patients of the very least calcium, vitamin D and a parathyroid hormone level.
Robert A. Kayal, MD, FAAOS:I'm sure everyone's wondering how much calcium and vitamin D they should be taking, but we'll get to that very shortly, so let's just talk about at this point some risk factors for this condition. What are some of the risk factors for patients that may ultimately end up getting osteopenia or osteoporosis?
Patricia Donohue, ACNP:Sure So low BMI. you don't take enough protein in. it doesn't support your bones, So less than 18.5 of body mass index is usually indicative of possible bone density issues. On the other hand of the spectrum, obesity is. vitamin D is a fat soluble vitamin, So you may see lower vitamin D levels in those individuals and you may have to give them extra vitamin D to get them to a normal level so they can absorb the calcium that you're having.
Patricia Donohue, ACNP:And then also, while we're on the subject, for obesity, some individuals may have undergone a gastric bypass to ruin Y, and it bypasses the area of our small bowel where most of our intestinal absorption of vitamins and minerals occur, and so those individuals may need increased amounts of vitamin D. And what's important to know is vitamin D doesn't have to pass through the small bowel. There is a liquid form of vitamin D. It's a bucal form that you can put a drop or two under your tongue, and it's usually one drop equals a thousand international units. So if somebody has malabsorption issues, that's a good way to get the vitamin D into their blood, to get them to adequate amounts so they can absorb their calcium.
Patricia Donohue, ACNP:We also, which is important to do in our patients, is to look for a height loss. Anybody that has a height loss of an inch and a half over a lifetime. I say to my patients so what's your height now and where were you when you were 30 years of age? If they lost more than two inches, it behooves us to do that vertebral fracture assessment, to look for a vertebral fracture there. And then we have our usually over the age of 65, the over the age of 70, and doing the bone density test Now. It's important to assess genetics And a lot of our older patients may not know their parents or grandparents history of osteoporosis because bone density testing wasn't done. So you have to ask them if their grandparents fractured, because genetics can be responsible for 60 to 80% of bone loss.
Robert A. Kayal, MD, FAAOS:So that's really important. It's just like everything else, exactly exactly.
Patricia Donohue, ACNP:And then there's the modifiable risk factors smoking, alcohol, whether or not they're having more than three drinks a day. if they're smoking, whether or not they're exercising, you know is a very important Bone loading exercises of just walking in the older patients, it prevents not only bone loss but what you suggested before a sarcopenia or a loss of muscle mass, which makes our patients prone to falling and balance issues. So important to assess all that.
Robert A. Kayal, MD, FAAOS:Yeah, i can't emphasize enough the importance of the modifiable risk factors. As an orthopedic surgeon that does a lot of joint replacements, i could tell you I am privy to the ability to actually inspect the bone quality during surgery. And on the patients I perform knee replacement surgery on a regular basis those that are avid long time smokers or alcoholics, long time consumers of alcohol products the bone quality is certainly tremendously compromised relative to the non smokers and the non alcohol consumers. So it's really, really important to stop smoking and excessive alcohol consumption because it truly deleteriously affects your bone quality and significantly increases your risk for fracture. So there's this concept in orthopedics called Wolf's Law, and Wolf's Law is essentially, in layman's terms, bone response to load. So whenever you load a bone, bone response by getting stronger.
Robert A. Kayal, MD, FAAOS:So we typically find in our clinical practice that patients that live a sedentary lifestyle or are frail or emaciated those are the patients that end up getting osteopenia and osteoporosis, whereas the very active patients, or typically the heavier patients, very often do not get the osteoporosis because their skeletons have to carry the load of their body weight for their lifetime. And if there are runners or doing a lot of high impact aerobic activity, it really helps to strengthen the bone tremendously. So it's just like anything else. Bone is a tissue. When you exercise it, when you work it out, it gets stronger, and when you live a sedentary lifestyle, it essentially atrophies and becomes frail and brittle and fractures. I know we can get vitamin D in our diets, but is there anywhere else we can absorb vitamin D from?
Patricia Donohue, ACNP:So we only absorb 10% from the sun, And I have many patients that say I sit in the sun all day. I go to Florida, I'm a sun bird, I'm a snow bird. But the reality is, if you're using sunscreen and you're out in the sun, you're only absorbing 10%.
Robert A. Kayal, MD, FAAOS:I tried.
Patricia Donohue, ACNP:So definitely. Calcium is in not only dairy but it's found in nuts and green leafy vegetables. So getting a nice calcium chart is the preferred way to get calcium. But if you have lactose intolerance or you can't tolerate these food groups, I mean there's. Or if you're a vegetarian, there's soy products, there's almond milk, there's other ways. And then the calcium supplements.
Patricia Donohue, ACNP:It's always recommended to take a calcium citrate tablet because calcium is absorbed better in an acid environment than calcium citrate comes in an acid. So you don't have to take it with food. But what's important to realize or know is that you don't want to take more than 500 milligrams at any given time. So I have patients that say I'm on 1,000 milligrams of calcium and they're taking them both at one time, both the tablets. You're not absorbing more than 500 milligrams with each tablet, so you need to divide those doses.
Patricia Donohue, ACNP:So the recommended calcium intake and diet in supplements is 1,000 milligrams for men and for children And for post-menopausal women it's 1,200 milligrams. So I tell my patients start looking at your labels, start calculating out your calcium and your diet and then we can start to supplement with supplements if needed. Vitamin D, on the other hand, the maintenance is 800 to 1,000 international units And again you need to get a vitamin D level check to see if there's any absorption problems that we need to increase that amount on a daily or a weekly basis to get you to where you need to be to absorb the calcium.
Robert A. Kayal, MD, FAAOS:Vitamin D is very, very important for our bodies in that it helps to absorb the calcium from our gut. So if your vitamin D levels are low, you really won't even be absorbing the calcium that you're taking, and I hope you appreciated the fact that Patricia said for women and children. So 1,200 milligrams 12 to 1,500 milligrams of calcium every day is important for women and children. So when I have those kids come in with a broken wrist, i always tell the parent that the child should be taking the same amount of calcium that you're taking, emphasizing to the mom that she should be taking calcium and vitamin D as well. So it's very, very important to do that.
Robert A. Kayal, MD, FAAOS:I also favor calcium citrate because of the fact that it is water soluble, And I believe the literature supports the fact that there's a lower incidence of kidney stones with the calcium citrate as opposed to the others that are more readily found in the kidney stones, like the calcium oxalate and carbonate. Yeah, so now that we're speaking about medications and the treatment, what are some of the first of all classes that we place these medications into in addressing osteopenia and osteoporosis, and then maybe give us some examples of each and why they work?
Patricia Donohue, ACNP:Okay, so, as we had spoken about, there are either it's an increased amount of bone breakdown that people have and that's related to bone loss are not enough bone building. So there's a class called the anti-resortive agents, which are the oldest medications that have been around and many of you probably remember the phosomax and the actinol, which are oral forms. They are taken once a week or it can be once a month, but they're not recommended for individuals that actually have some gastroesophageal reflux disease or an older patient that may not absorb tablets as well. So there is an alternative called reclassazoleoginic acid, which can be given the intravenous route And, if needed, it can be given on a yearly basis. But again, we continue to monitor to see if you actually do need it on a yearly basis. So that's a class of anti-resortives. It's the bisphosphonates, the next class of anti-resortives.
Robert A. Kayal, MD, FAAOS:So essentially they inhibit the osteoclasts.
Patricia Donohue, ACNP:That's correct.
Robert A. Kayal, MD, FAAOS:Those are the cells we talked about that break down the bone, so they inhibit osteoclasts. Those are the anti-resortives.
Patricia Donohue, ACNP:That's correct. The next class of anti-resortives is called rankl inhibitors. A rankl breaks again increases the osteoclasts that break down cells. And that's where prolia many of you heard about prolia. It's an every six month injection So, unlike the bisphosphonates that hold on to the bone for a longer period of time And, like I said, you only may need them every year, every two years, i've even seen it up to every three years in infusion, they prolia. On the other hand, it wears off very quickly. So the injection has to be given every six months And you have to be pretty regimented to really make sure that you make it into the office to get that injection, because if it wears off, it wears off very quickly and your bone resorption goes up very quickly and your chances of fracturing can occur. So this is really something that we really drum home with our patients And basically telling them that they have to be regimented. If we are going to stop it, we can't just stop at cold turkey. We need to give you a bisphosphonate to seal it in so this way you don't have that type of side effect.
Patricia Donohue, ACNP:The prolia will diminish your calcium. So, going into any of their starting treatment on any of these medication regimes. It was important for us to do a calcium and vitamin D to ensure that these are working effectively. Then you have an adequate amount of calcium and vitamin D and especially prolia and evenity, which we're going to talk about next, will drop your calcium level. Evenity is the class of medication that has a dual mechanism It slows down bone breakdown It's been out for about four years and it also increases bone formation. So it's a really nice medication to use in patients that have a very low T score or bone density test or at their risk of fracturing or have a history of fractures. But you have to make sure that they don't have any cardiovascular risk factors.
Patricia Donohue, ACNP:The third class of medications is called the anabolic agents. These anabolic agents are parathyroid, synthetically made parathyroid hormone. Parathyroid hormone, when given in intermittent doses, actually increase osteoblastic activity, so increases bone cells. It's the only medication that we have that actually increases by itself the bone cells. It's very useful in treating patients that are on glucocorticoid, trabecular bone deficiencies, vertebral fractures, other fractures and osteoporosis. Again, if you just stop that after the course of that medication, you need to seal it in because your body's going to go back to its normal equilibrium and start to break down all that good new bone that we just gained, and it would have been moist at both far times.
Robert A. Kayal, MD, FAAOS:So that's important. So seal it in with another bisphosphonate.
Patricia Donohue, ACNP:That's correct.
Robert A. Kayal, MD, FAAOS:So these are the bone formation agents that she's talking about now, for instance the Forteo, but the bisphosphonates that she talked about earlier. What are some of the examples of those bisphosphonates?
Patricia Donohue, ACNP:So Phosomax, Actinol, Atylvia they're the bone oldest forms of the oral medication and then reclass, to which is sublodronic.
Robert A. Kayal, MD, FAAOS:Yeah, and what about hormonal replacement therapy and derivatives of hormone, estrogen for instance?
Patricia Donohue, ACNP:Yeah. so again, around that first five, seven years of menopause is really important If the gynecologist and there's been a lot of hesitancy in gynecologists in actually recommending hormonal replacement because of the women's health studies that we've done in the past but even the National Association of Menopause Society recommends treatment with low dose estrogen and progesterone if you have a uterus around the time of menopause to prevent bone loss and it prevents vertebral fractures and other fractures. So it's a very useful way to use these hormone replacements if they are individuals that can take it in that period of time.
Robert A. Kayal, MD, FAAOS:Right and along the lines of hormonal replacement therapy. There's an agent called evista right, which is an interesting agent in that it can be used specifically in patients potentially that have also breast cancer and osteoporosis right. That's good. Why is that?
Patricia Donohue, ACNP:So it's said to be breast protective in those patients that have a pretensivity to develop breast cancer.
Patricia Donohue, ACNP:But it's the evista is the, an agent that actually attaches to the estrogen receptors, so it acts like an estrogen but it's not truly an estrogen. It's really helpful in those individuals that are further out from menopause because if you give it too close to menopause it may cause breakthrough, bleeding and the osteoarthopedics. We don't know how to deal with that. So we don't want to give it too close to menopause, so we want to use it later down the road, like maybe 10 years after menopause. But it specifically works the best in the spine. So this is a really important agent If people don't want to be on the other agents that can preserve bones. Specifically, it works better in the spine and works less in the hip. So when I say we do this work up with the bone density and blood test, then we look at the individual and have a targeted plan of care what agent we want to use, appropriate agent where the bone density is showing the bone loss and patient specific. So that's really important.
Robert A. Kayal, MD, FAAOS:Yeah, And with breast cancer it's interesting because the Savista agent apparently tricks the body right. It tricks the bone and it tricks the breast. Breast cancer in general tends to like estrogen. It sort of grows potentially and becomes more aggressive with estrogen Input. Bone also loves estrogen. Bone gets stronger with estrogen. This Savista agent potentially can trick the body rather in that it will bind to the bone and stimulate the bone formation, but it will not bind to the breast tissue and stimulate the breast cancer growth. So that is the concept essentially behind the agent Avista. Why are we attacking this condition with so many different agents if they all work? There must be something I'm missing here. Are there potential complications or side effects with some of these medications that we need to talk about, which may potentially cause us to maybe change courses and switch from one medication to another?
Patricia Donohue, ACNP:So that's a very good point, and you had mentioned the statistic that only 15% of patients that have osteoporosis-related fractures are being treated, and the bottom line is that there is a fear out there with using these agents. Back in the 80s to 90s, specifically when Fasamax was around, it was used for a long duration and period of time And what they saw is they saw some side effects, such as a bisphosphonate-related femur fracture that occurred in 1,000 patients, and then the well-reported and publicized osteonocroosis of the jaw, which occurs in 1 in 100,000 patients. So there's been this pandemonia of fear in using these agents and we can only think that maybe that's creating the hesitancy in using these. But like anything else in medicine that we do, we must weigh the risks and the benefits And what we have seen with these medications is a few common factors Using bisphosphonates for a long period of time. In the 80s and 90s they used it for over 10 years. We know not to use the oral forms of these medications for longer than five years without a drug holiday to let in the bone recover In the IV reclass about three years, let in the bone recover And then to really not use a long duration and then also identify risk factors for the osteonocroosis of the jaw. It was many patients that had some radiation to the jaw from cancer or had poor dentation.
Patricia Donohue, ACNP:Which brings me to my next point is that anybody that's on any of these agents, hygiene dental hygiene is of utmost importance Keeping up on your evaluation by your dentist and having regular exams, regular cleanings, mentioning to your dentist that you're on these medications So this way they can watch you carefully with us. But the newest guidelines among the American Dental Association doesn't even suggest taking you off of these agents or monitoring the bone turnover marker when they're in fact doing even implants or drilling into the bone. We like to time it a little bit further out from your last dose, but you don't need to stop these agents and those are the newest guidelines that's put out by the American Dental Association. But any patient that's on these agents, then they see a non-healing ulcer in their mouth or if they have pain in their thigh, then they need to get an x-ray done for their thigh and see their dentist to make sure that it's not related to these anti-resortive agents. So that's really important.
Robert A. Kayal, MD, FAAOS:Yeah, we certainly don't want to miss one of those atypical femur fractures which have clearly been associated with some of these medications. What about the Avista? Any concerns with respect to Avista and estrogen-like type of agents?
Patricia Donohue, ACNP:Good question. So Rheloxaphen or Avista is probably the only agent that is out there that has an enhormone replacement that is not associated with the osteonecrosis of the jaw and the atypical femur fracture. So that's the beauty of those medications, but they bring along with it the higher risk of thromboembolic events.
Robert A. Kayal, MD, FAAOS:So, everybody.
Patricia Donohue, ACNP:Every medication has its trade-off and we want to do, like I said, that comprehensive evaluation and a plan of care according to patients' risk factors.
Robert A. Kayal, MD, FAAOS:What you mean by that Thromboembolic. sometimes we get concerned about cardiac issues, blood clots, pulmonary embolism, strokes, things like that with estrogen and hormonal replacement therapy. So certainly, besides talking to Patricia, we would also really invite you to speak to your primary care physicians or your cardiologists to get their blessing before proceeding with some of these agents. Now, as far as monitoring, once you've diagnosed the patient and treated the patient, we talked about monitoring with subsequent bone density testing and blood work. Sometimes urine analysis is also used as well. What are you looking for in that?
Patricia Donohue, ACNP:Yes, The urine test is very helpful because it can tell us if a person has a urinary leak of calcium. So we're giving calcium to our patients, thinking that it's getting to the bones. Either they're not absorbing it or at the other end, they can leak out urine. There are certain medications, like the loop diuretics, that can cause calcium loss as well, so we may see an increase in the urine based upon that, and we've changed and worked with primary care doctors to change their diuretic regime around.
Patricia Donohue, ACNP:We also can have patients that take large amounts of water and the border is good for you but it makes you pull off sodium and makes you pull off calcium in your urine.
Patricia Donohue, ACNP:So if somebody has a very low or hypocalcemia and we're giving you calcium supplements and it's not working, then we'll check a urinary calcium either a spot test or preferably 24-hour urine. We can also if there's an agent we want to use we want to make sure that there's no calcium oxalate crystals in the urine, such as with kidney stones and things like that. So that's really important and also identifying other diseases that are related to phosphorus and calcium in the kidney and kidney disease that we can help to identify with these urine tests A urine test or a blood test can also be used to measure a bone resorption marker. They actually, like I said, it measures the calcium, the collagen remnants in the urine or blood. So it can be used as a marker to see how our therapy is working, for continuing monitoring and then to see when it starts to increase, when we need to intervene with an additional possible Medicaid.
Robert A. Kayal, MD, FAAOS:Well, that was all so informative. We're so honored to have you as our bone health expert at the Kale Orthopedic Center. We're just so privileged to have you with us today. I hope that you found this podcast very informative. I'm just going to ask Patricia to take a minute to summarize, because this is such a very important topic. I definitely want to make sure our viewing audience gets the message that osteoporosis and osteopenia is a ubiquitous problem and is very prevalent in our society and is the silent killer. So, patricia, last words for our viewing audience, please.
Patricia Donohue, ACNP:So, as Dr Kel had mentioned, it's very important to have, starting at adolescence, calcium, vitamin D, exercise And then, going forward, the post-menopausal woman needs to get a bone density test, screening around the age of menopause.
Patricia Donohue, ACNP:And then individuals that have risk factors and around the age of 50, that are smokers, alcohol genetics, some family history of osteoporosis, their history of a low energy fracture, which is a fracture from a single level, not from a height, and then also any other sedentary involvement, lack of exercise due to maybe some illness or something that has not allowed them to be active. And then over the age of 65 for the female in general and over the age of 70 for the male in general. We need to identify these bone loss disease processes because they are a silent disease and we need to recognize them before a person sustains a fracture, and that's very important because having a fracture like we mentioned, having an additional fracture, is very prevalent. So it's important for us to take care of our bone health and we're dedicated to do this at the KL Orthopedic Center and we hope to help you take care of your bone health as well 100%.
Robert A. Kayal, MD, FAAOS:One last thing what is this fracture liaison service that you spearhead at the KL Orthopedic Center?
Patricia Donohue, ACNP:So a fracture liaison service and we mentioned that only 15% of patients after fracture are actually being treated. So we used to have a fracture liaison service that was originally designed to go into the hospital to meet those patients. But then we recognized that the patients were sedated. They didn't remember us. They had no idea what we were talking about after we called after discharge. So now it's spearheaded to actually identify those patients, getting the word out to all of our orthopedic surgeons to help identify and let us know about those patients when they come in with a low energy fracture. One in particular that we happen to miss a lot is the ones that are done at the ambulatory care center, which many more surgeries are doing there, but specifically the wrist, the distal radius fracture that can be a red flag that there's some underlying metabolic bone disease or deficiency, and those patients in particular need to have a bone density test and need to be appropriately sent to the fracture liaison service. So it's really identifying patients that have low energy fractures and getting them into an evaluation and possible treatment.
Robert A. Kayal, MD, FAAOS:Yeah, when Patricia's mentioning low energy fractures, we consider those pathological fractures, insufficiency fractures, fractures that should not have developed. For instance, a fall from a height of only three or four feet should not result in a broken bone to your wrist in the normal bone. But when somebody has osteopenia or osteoporosis we call that a low energy fracture, very much different than breaking your wrist in a car accident, for instance. So anyway, thank you so much for joining us today on this Kail Ortho podcast. It was so enlightening to me and so refreshing now to have Patricia as part of the Kail Orthopedic Center. We're so privileged to have her with us. Thank you for spending the day with us, patricia.
Patricia Donohue, ACNP:Thank you so much. Thank you for having me.