A Woman's Journey Presents: Bone Up - Osteoporosis

Good evening. I'm Kelly Geer Ripken and I'm national chair of A Woman's Journey. On behalf of Johns Hopkins Medicine and A Woman's Journey, thank you for joining us this evening for our monthly webcast series, Conversations that Matter. As you know, A Woman's Journey strives to improve your wellbeing through health education. Globally, osteoporosis causes more than eight point [inaudible 00:00:45] roughly one fracture every three seconds. As you age, your body may absorb calcium and phosphate from your bones, leaving the bone breakdown. Unfortunately, this also makes your bone weaker and more likely to break. When this process

of bone breakdown reaches a certain stage, it's called osteoporosis. Many times, a person will fracture a bone before she, or he even knows there's been a significant bone loss. Tonight, we are so pleased to be joined by Johns Hopkins endocrinologist and metabolic bone specialist, Dr. Kendall Moseley. So please use your Q&A on your screen to pose your questions to Dr. Moseley, who will respond during the last 20 minutes of tonight's conversation. I want to take this opportunity to acknowledge and thank Johns Hopkins University's program, Hopkins at Home, for their production assistance. And you can visit

their website for additional lectures and courses throughout the year. And now, I am pleased to introduce Dr. Moseley. Dr. Moseley? Thank you so much, Kelly. I really appreciate it. And I welcome everybody tonight. I hope everyone is doing well. I'm just very excited to give this talk tonight about osteoporosis. The anecdote I often share prior to talks like this for A Woman's Journey is that this is actually how my mom figured out what I did for a living many years ago when she came to A Woman's Journey in Baltimore, where I gave a lecture on

osteoporosis and she sat right smack in the front row. Very proud of course, as a mother is, but came up after me and said, "Oh, this is what you do every day. I guess I had no idea." And so this has really helped educate, not only a lot of patients and a lot of people Out in our community, but also my own family members. So I always like to start with a definition of osteoporosis. I think it's important to get us all on the same page. And there are a lot of words here, but I

promise you I'll walk you through them. Osteoporosis defined as, "A systemic skeletal disorder characterized by low bone mass and microarchitectural deterioration of bone tissue with a consequent increase in bone fragility and susceptibility to fracture." And when we break that definition down, I want to focus on three main parts. The first is the systemic skeletal disorder. We're going to see pictures in a little bit of a bone density test or a DEXA scan where we talk about the hip, we talk about the spine, sometimes there's a forearm, but remember that those images, those measurements are actually

a surrogate measure or an estimate For bone throughout the body. The second piece is the microarchitectural deterioration. So oftentimes, the DEXA does not tell the full picture. There are people who break bones even when the DEXA is normal or it shows osteopenia. So we have to think about other things that may be lurking underneath the surface that result in fracture. And then finally, the most important part of this definition is the last part, the susceptibility to fracture. We talk all the time about T-scores and bone density, but at the end of the day, those things

don't matter because what we focus on is the fracture and preventing that first fracture from ever occurring. Simply speaking, osteoporosis is a bone deficiency. Its thinning, its loss, its weakening. And you can see in the diagram here, normal bone versus osteoporosis. There's major differences between the two bones. This is microarchitectural change that you're seeing here too. So again, getting back to the middle of that last definition that I showed you, it's the bone changing over time and ultimately becoming weak as it changes. So why do we care about osteoporosis? Well, I know why I care

and I know why probably you care because you're here today, but there's the big picture, which is we've all heard about this little lady, or frankly, little old man, who maybe is living independently, happily married, pets at home, visiting the grandchildren, pre-COVID, and living a nice life. And all of a sudden there's a fall and there's a fracture, maybe there's even a broken hip, Leads to hospitalization, maybe leads to a surgery, leads to physical therapy. And then, the determination that rehab is needed. And then may be a blood clot and a rehospitalization for pneumonia, and

so on and so forth. And at the end of the day, these patients oftentimes do not return back to their independent lifestyle. And sadly, many of these patients at the end of the day, pass away from complications of their fracture. So absolutely we care about this disease, even though it's terribly silent, we want to prevent that broken bone. The statistics that Kelly was alluding to, are quite dismal, unfortunately. About 10 million individuals in the United States have osteoporosis. About 8 million of them, women. 2 million of them, men. And I would probably argue two facts.

One, this number will be increasing over time. Our population is getting older, our baby boomers are developing osteoporosis, so that 10 million is very likely a higher number. Two, we don't screen as much as we should, particularly our men. For some reason, we have it in our heads that this is a woman's disease, but oftentimes men can get osteoporosis. And we'll talk a little bit about that. 50% of women and 25% of men will have a fracture in her or his lifetime. That rivals cardiovascular statistics, strokes, heart attacks, other disease states that we worry so

much about. These are real statistics. Fracture is a real disease. 25% of individuals will die within the first year following a hip fracture. So getting back to that picture earlier, again, this is not only a disease associated with significant morbidity, but also mortality. And if you look at healthcare costs, that we're all focused so much on these days, over $25 billion are estimated for the cost of fractures by 2025. And again, with an aging population and the disease that's only becoming more prevalent, that number is only expected to rise. So we have a few goals

for our talk today. We're going to talk about the causes of osteoporosis. Why does this happen? We're going to talk about risk factors for bone loss and how we screen for them. We're going to talk about things that you can do to improve your chances of good bone health. What are some interventions you can start today, tomorrow? And then obviously, things that I can do or your doctor can do regarding specific treatments for osteoporosis. So we're going to do a little mini biology lesson. Again, this is not to intimidate anybody, but just to get us

on the same page. And I'll start by saying, bone is not an inanimate object. So your bones are not rocks that you carry around with you all day long. They're actually constantly remodeling. They're building up, they're breaking down. And it's the fact that they can remodel and renew themselves that keeps them flexible, it keeps them able to bend and twist without breaking instantaneously like a spaghetti stick. It's that balance of bone buildup, however, and that balance of bone breakdown, that determines how much bone you have. So obviously, if you're building up more than you're breaking

down, you're gaining bone. If you're breaking down more than you're building up, you're losing bone. And then there's obviously steady states and we'll get into a diagram of that in a second. So just remember your bone is always refreshing and renewing itself. And it's only when that balance becomes disturbed, that we see disease. These are the cells responsible for that building up and that breaking down. And I put this on here, again, not to intimidate anybody with a biology lesson, but to show You the types of cells that we then target later on down the

road, should you need medication for your osteoporosis. So bone breakdown actually starts with kind of what I describe as a Pac-Man cell or the osteoclast. The osteoclast identifies a spot of old bone, or maybe a bone that has a little fracture in it, and actually chews up a little resorption pit, which is a normal thing. That then sends signaling molecules into the bloodstream that call in the osteoblast, B as in build. It builds bone back. It identifies this pit of bone, fills it in with unmineralized osteoid. And then, over the course of about three months,

that osteoid, that soft bone, becomes hard. And how does it become hardened? It becomes hardened with very important elements like calcium, phosphorus, and protein, which we'll come back to. But remember, if you want to build healthy bone, you need the building blocks. So again, it's this balance of the Pac-Man cell, the osteoclast and the bone building cell, the osteoblast, that's going to dictate how much bone you have. Now, this is a picture of the life cycle. And as you can see, the bone is always changing. In the first three decades of life, we are building

bone. I have younger children, I hope they're still building bone, I hope they're getting taller. Until about the age of 30, we're building more bone than we're breaking down. Between 30, and for women at the age of menopause, there's generally a steady state. For men, it's between 30 and about 70, where there's a steady state of bone building and Breaking down. Women enter into menopause, where the breakdown state far accelerates the bone building state. And then, after the perimenopause, there's a slow decline thereafter. For men, it's mostly just a slow decline after the age of

70. Now, as you can imagine, this is a normal curve. The patients who wind up in my office are not normal, or patients who break bones are not normal. There are things that happen along the lifestyle. It might be something in childhood, it may be chemotherapy or Hodgkin's as a child, it may be smoking, it may be other disease states that interfere with this normal curve. And so when we think about osteoporosis, we never take it as a time zero, your DEXA scan shows osteoporosis, let's treat you. The first question is why, what has happened

along your curve that may have affected how much bone you have? And it's part of our screening process. How do we determine what your bones look like? So this is a picture of a DEXA scan. Hopefully some of you have had a DEXA scan. We'll talk about who should have a DEXA scan, but typically, we look at different spots in the bone. We look at the lumbar spine, so vertebral bodies, L1 through L4. We additionally look at the hip, we look at the total hip region. We look at the femoral neck. It has nothing to

do with this neck here. It's the neck of the hip, it's kind of where the ball and socket attaches to the femur. And using those three sites, and even sometimes a fourth site, which is a distal radius, we make a determination based on T-score, as to whether or not an individual has osteoporosis. And you can see in this graphic here, what the definition for osteoporosis is. Really it's a T-score less than or equal to a negative 2.5. Osteopenia, or low bone density, is a negative 1 to a negative 2.4. And normal is anything greater than

or equal to a negative 1. Now, a T-score is just a standard deviation. And as I mentioned earlier, not everybody who has a fracture has osteoporosis by T-score, but if you have a fracture, I don't even need a T-score to tell you that you have osteoporosis. And I should clarify here. When I say fracture, I don't even mean a fracture falling out of a three-story building or being Hit by a tractor outside. I'm referring to a low impact fracture. So this is a standing height or less, fall to the ground, bracing one's self with one's

arm, slipping on the ice and hitting your hip and having a broken bone. Things that are not normal, things you would not expect a 30 year old to have necessarily. So who should be screened for osteoporosis? Well, at the bare minimum, women older than 65, and this is just kind of Medicare dictated at the end of the day, and men greater than 70. And men is pretty clear just based on that graph that we looked at earlier, but more commonly, we see people screened earlier than this. And why are they screened? Well, sometimes there's an

X-ray, or even a CAT scan, that might indicate there's low Bone density or osteopenia. Or more commonly in my clinic and those of my colleagues, it's the presence of one or more risk factors for low bone density or osteoporosis that makes that little red flag go off in our heads to say, "Hmm, maybe we should think about the bones in this particular patient." So getting a little bit more into the details. So I'll tell you age or postmenopausal status is a risk factor for osteoporosis. Again, remember women have that very steep drop off after the

menopause in bone density, when estrogen levels decline. I would be challenged to find many women who make it to 65 by the time they go through menopause. So again, many women come much older to clinic after getting this diagnosis of osteoporosis, Just because they're postmenopausal. Men greater than 70, family history of osteoporosis. So these are individuals with a mother or a father with low bone density or fractures, or mother or father, brothers, and sisters on treatment for osteoporosis oftentimes will come requesting an evaluation. Race is an interesting one. So originally, and certainly in some of

our calculators that we use, we consider a Caucasian race or an Asian race to be of higher risk for fracture than those of Latino or African American descent. Much like kidney function, this particular discrepancy is coming under additional evaluation right now, because some of the data that's dictated that race is a major determinant of osteoporosis is being challenged. We don't have enough data necessarily, or large enough patient populations to say definitively that Latinos and African Americans are not at a big risk for fracture. And in fact, doing that may be a disservice to those populations

in terms of screening. So again, our societies are really looking into this particular risk factor, so I urge all of you to take this with a grain of salt when considering your own risk factors. Low body weight. So BMI anything less than 18. Medications, things like steroids or aromatase inhibitors, androgen deprivation therapy in men for prostate cancer. All of these could impact bone. Alcohol, tobacco, lifestyle choices that maybe aren't the smartest. Personal history of fracture. So I oftentimes will get in clinic people who, "I slipped out on the ice, it was a wintry day and

I broke my wrist, but it was really icy and I took a bad slip." That's actually an osteoporotic fracture. It counts as a fragility fracture. You wouldn't expect your 25-year-old son or your friend who's a bit younger to have the same fracture with normal bones. Testosterone deficiency, or estrogen deficiency, vitamin and mineral deficiency, immobility. And then frankly, there is a laundry list of additional medical conditions to add to this. This is far too short to talk to get into all these different conditions, but they encompass rheumatologic disorders, not just for the steroids, but because of

that pro-inflammatory state. A number of endocrine disorders, so my background, things like hyperparathyroidism, or Cushing syndrome, or vitamin D deficiency. Any sort of gastrointestinal disorder where they may be malabsorption or weight fluctuations, or again, chronic inflammation. Liver disease is a big one. Bone marrow disorders, kidney dysfunction, and then a whole list of medications as well. All of which may have important negative impact on the skeleton. So what do we do for workup? Like I said, it is so rare that I see a patient in my clinic where I look at a DEXA scan and write

a prescription. The first thing I want to know is why are your bones not perfect? And to get at that a little bit more after I do a history and take a comprehensive physical Exam, I order labs. Endocrinologists order a lot of labs, so we always say, "Drink up before you go to the lab," because they're going to be taking a lot of blood. I'm going to order a comprehensive panel, I'm going to get a phosphorus. What am I looking for? I'm looking for your calcium levels, I'm looking for phosphate levels, I'm looking for kidney

and liver function. I want to see what's happening with your thyroid. Is it overactive? Which can cause bone loss. Vitamin D is so critical for good bone health. Let's make sure it's adequate. Parathyroid hormone, which really regulates your balance of calcium and vitamin D in the body. Yes, I torture people with a 24-hour urine calcium collection. It's a good way for me to gauge if people are getting enough calcium in, or maybe they're putting too much out. And oftentimes I'll screen for multiple myeloma, which is a blood cell disorder, which can cause slow and steady

bone loss. If the level of suspicion is high enough, we may order additional labs, including a celiac screen, which is a cause of malabsorption and vitamin D deficiency in patients. And then some other fancier things, again, based on physical exams. So let's talk a little bit about treatment. And I think it is so important to empower my patients to give you something to do when You go home that you can actively work on, that's not just taking a pill that I prescribe for you, or an injection, or an infusion, because it's a partnership. And really

to succeed, we both need to be doing our part. So pillars of osteoporosis treatment are comprehensive. So we have diet, things that we could really modify. Lifestyle, pharmacologic agents, which we'll get a little bit into at the end. And then obviously, if I find anything in your laboratory testing or pick up anything in talking with you or physical exam, we need to treat those things too. There's no point in slapping a bandaid on a problem if there's underlying causes that may be rectified before we start treatment. So what can patients do to strengthen their bones?

So calcium. Calcium goal. And we can talk more about this at the end. I'm sure there will be questions. Goal calcium for individuals at risk for bone disease. I'm not talking about individuals who are healthy, and have no risk factors, and have normal bones, but individuals at risk for bone disease or with a diagnosis of bone disease should be getting calcium between 1,000 and 1,200 milligrams orally daily, total. This can be through diet, this can be through supplement, this can be through a combination of both. Ideally, you're doing it through your diet. I think our

cardiologist colleagues would agree. Diet is always best, it's kind of the way mother nature intended it to be, but we have A number of people who are lactose-intolerant or have dietary restrictions for whatever reason, where oftentimes you just can't get enough through your soy milk, or your almond milk, or your regular old cows milk or cheese. And sometimes a supplement is needed. Calcium citrate is the supplement of choice. It's better absorbed, it is easier on the GI tract, comes in different formulations. And ideally, you want to spread your calcium out throughout the day so that

you don't get that GI upset. And again, that it's absorbed appropriately. Vitamin D is much harder to get through natural sources. I would not encourage a lot of sun exposure simply because our dermatologic colleagues would be very angry with me for recommending that. And frankly, you need a lot of sun exposure in a very sunny place with a lot of skin exposed kind of throughout the year to get the D necessary to make your own for good bone health. Oftentimes therefore, we will prescribe an over-the-counter supplement of vitamin D. Even though the Institute of Medicine

would recommend 600 to 800 a day, I think we all know that's oftentimes insufficient, particularly in the dead of the winter or we cover up with sunscreen. So a lot of my patients will do about a 1,000 to 2,000 a day with a goal total calcium of greater than about 30 to 40 nanograms per milliliter on blood testing. Supplements can be taken all at once. And De is the over-the-counter supplement. Sometimes patients need a prescription strength vitamin D. And that formulation is vitamin D3, slightly more bio-available, but really the two are equivocal at the end

of the day. Protein. This is another big one. So there are so many fancy diets out there these days. And I see patients eliminating entire food groups in their quest to become healthy, but we can't forget about protein. Even if you're vegetarian, even if you're vegan, there are sources of protein that could really nourish your bones with goals listed here. So 0.4 grams per pound of body weight is really what you should be reaching for. And then exercise. In the era of COVID, no one is encouraging you to necessarily go out and join a gym

and you don't have to. The good news is that walking counts. Three to four days per week, 30 minutes of walking counts as resistance training, as do resistance bands or home weights that you may have, exercise bicycles, ellipticals if you use the arms. Really all counts, with the exception of swimming, where the water is doing most of the weight. So don't be intimidated by exercise, I should say, because of these rules. Just do something you enjoy, that's the most important thing. Obviously, quit smoking. I will be yet one more doctor who will say, "Please quit

smoking. It's not good for you." Limit your alcohol conception. That's oftentimes just one glass of wine per night, depending on your body weight and other health factors. Maintain a healthy weight. So fluctuations in weight are not good for bones, particularly weight loss. I'm all about healthy weight loss. If your BMI is elevated and you're doing it in a sensible way, but losing 20, 30 pounds in a short amount of time only hurts the bones at the end of the day. And then make sure you eat a healthy and well balanced diet. I'd say reach for

all the colors. There are not many foods that are off limits when it comes to bones, it's really the elimination of certain foods or limiting your foods to certain food groups that cause the most harm. What about when these lifestyle changes and things that you're doing aren't enough? Well, start by saying you are not a failure. It is not a failure if the bones need a little bit of extra help. We do not blame people when they have to go on blood pressure medications, we do not blame people when they need to go on cholesterol

medications. We just say, "You need a little bit of extra help." So I see a lot of dejected faces in my clinic sometimes when the patients are just gold star students and the numbers still aren't looking great, they just need a little bit of extra help. Osteoporosis is a disease and we treat diseases in this country, so let's look at it as being proactive and you doing additional things to help your bones versus us reacting to a fracture. So medications for osteoporosis have to be taken in addition to your calcium indeed. Just because we're starting

medications, does not mean you get to stop the building blocks of bone. Remember that graph from way back when, where we talked about the different cells. Remember how we talked about the osteoblast, putting down this unmineralized soft bone that over three months has to harden? Well, this is how we harden it. It's with protein, it's with calcium phosphate and vitamin D. So please don't stop your supplements or your dietary intake. And then there's medications that really fit into two different bins. We have medications that reduce bone breakdown. So again, that osteoclast Pac-Man cell, where we

break down our bones and we really want to kind of stop them, paralyze them, pause them. And then there's medications that really incentivize the osteoblast or the bone building cell to build your bones back up again. And remember that no matter what we do with our treatment plan, the goal will always be fracture prevention. The DEXA scan may not change. Again, so many dejected faces in my clinic when the DEXA is kind of the same year after year, after year, but just know that underneath the surface, again, if we took that microscope and we looked

inside the bone, things are changing and fracture risk is being reduced even if the DEXA tells a different story. Medications that stop your bones from breaking down. So estrogen used to be a tried-and-true mechanism for doing this, but in 2002, the Women's Health Initiative kind of put the kibosh on a lot of the estrogen that was being prescribed for bone health. Certainly, if you need estrogen for other reasons, and you've partnered with your primary Care doctor, your gynecologist, on using estrogen for other reasons, postmenopausal hot flashes or other challenges that you're having, we're okay with

that. We like estrogen in the bone world, we just rarely start it as a primary agent for bones. There's selective estrogen receptor modulators, like Evista, which is similar to Tamoxifen, which is a sister drug oftentimes used in breast cancer. It's a daily pill. The challenge with that is it's not as strong as some of the other medicines and it doesn't necessarily help the hip. So if you've got low bone density in your hip or a family history of hip fracture, we generally don't reach for that agent. It does come with an increased risk of clotting

as well, so we always want to get a history that way. And then there's medications that probably more of you are familiar with. We have a lot of medicines in the bisphosphate category. So tried-and-true alendronate, which again, when patients went through menopause back in the day, they also got a prescription for alendronate, once a week pill. Risedronate, which is available either once a week or once a month. Now, I did not include ibandronate on this particular list, namely because it doesn't have hip fracture protection, so we don't use much of that once-a-month medication. There's IV

bisphosphonates. Again, all of these acting to stop the Pac-Man cell. Reclast or zoledronic acid is the name of that medication. And then there's the two-time-per-year injection called Denosumab. Who are candidates for things that aren't pills? Pills are certainly the easy way to start, but there are many patients who really just aren't good candidates for that. So, number one, if you have challenges swallowing, or you have malabsorption at baseline from gastrointestinal disease, if you have bad reflux, these medicines tend to make them worse. So we may reach for a yearly infusion versus a twice-a-year injection, or

gosh forbid, you're taking the medication religiously every week or every month, and you're still losing bone. Well, then it's time to kind of kick it up a notch and move to something a little bit stronger with the zoledronic acid or the denosumab. Side effects of the bisphosphate class of medicines and the denosumab all kind of are coupled into the same concept. So if you're not getting good calcium and vitamin D, we can see bone pain. So we're really good about kind of teeing you up before we start those medicines. Low blood calcium. Again, we want

to do a complete lab panel to make sure you don't have low blood calcium to start. With the once-a-year infusion or the zoledronic acid for the first dose only, there's about a 20% risk that you can have an infusion reaction. So for about 24 to 48 hours, you just kind of feel blah, some people had a similar reaction to the COVID vaccine where just you're out of commission for a few days. Luckily, if you have subsequent infusions, it shouldn't come back. I get a lot of questions about jaw osteonecrosis. This is a very rare complication

of these medications, about one in 300,000, where it's A mouth ulcer that can form along the gum line, typically in the setting of an invasive dental procedure like extractions or implants, and then atypical fracture. So I oftentimes in clinic will hear, "Well, I read online these medicines cause fractures." And what this is referring to is that with long-term use, again, we're talking 10-plus years of use without pause, we sometimes see these strange thighbone fractures where the bones almost become brittle, because they don't break down at all. Remember, they have to break down and build up

a little bit to keep them flexible. So again, there's one in 800,000 fractures can occur with long term use. If I'm more worried about your spine fracture or your real hip fracture, through the main part of the hip that I showed you on that DEXA scan, this will be the least of my concerns. And then I really want to highlight this. This is critical that you be empowered with the knowledge about, but denosumab, that twice-a-year Injection I alluded to earlier, this medicine has to be given every six months. You cannot quit without telling your doctor,

you can't delay a dose, you can't skip a dose. If a dentist tells you, "Hey, you need a root canal, just hold off this month on that shot, you can get it later." Just say no, call your doctor, because there is a rebound effect with this drug where the bones can go into a high breakdown state and we've seen spontaneous vertebral compression fractures as a result. There are medications that help your bones build up. They're a little bit more labor intensive. The two that used to be around for the longest time until the new kid

on the block at the bottom popped up, were these daily subcutaneous injections, teriparatide and abaloparatide, where yep, at home, you are giving yourself a nightly injection for up to two years. There's a newer medication approved in April of 2019, called romosozumab, which is a monthly injection that's given in clinic for up to one year. And these medicines, again, are designed to build bones up, but so that you don't come down off that roller coaster and lose the bone all over again, they have to be followed by one of these medications that promote or prevent bone

breakdown. So it's a coupled process there. We don't ever start one drug that bone builds without knowing what we're going to transition to after that. There are a lot of questions that remain, and I'm sure you have some good ones that are being sent to Kelly as I speak, but how long should patients be on medication or drug holidays? There's no one good answer. And I will say that patients, everyone is different. In general, for the bisphosphonate, we reconsider therapy at about five years, but this is a very individualized decision based on you, your preference,

your risk for fracture, and many other factors. There are questions out there about the best order to take these medications in. We're now learning more and more that maybe bone-building drugs, those labor-intensive injections we talked about, we should start those first and then finish with an anti-breakdown drug, because we get the most bang for our buck when we start with bone-building drugs and finish with an anti-breakdown drug. We just have to convince the insurance companies of that. And then finally, what in the world, there's so much information out there right now. How do we choose?

And this is the bulk of the referrals that we get, where I feel as though primary care doctors and family practitioners get really overwhelmed. We have so many different things out there now. How do we pick which one is best? And again, that's an individualized discussion based on you, your preferences, your workup, your history, and a lot of other factors that go into that discussion. So again, that's the partnership that we work on to decide on your osteoporosis care. So some final pearls before I turn it back to Kelly. Number one, fractures aren't normal. So

again, I hear so many times, "Well, yeah. I mean, my mom, she had a hip fracture, but she was 80. It doesn't matter." That's not normal. We would never say that your mother's heart attack was normal or that your father's stroke was normal. These are not normal phenomenon and we need to take them seriously. Men get osteoporosis. I was delighted to hear that we have men on this conference today too, because you need to hear this as much as others. And frankly, women out there, if you've got spouses or partners who are male, they need

to hear this too. So at least go with them to their appointments, so you can ask the right questions for them. Please think about other osteoporosis causes and make sure your doctor is working them up prior to just getting that prescription handed to you. And please don't forget about your calcium and your vitamin D. They really are as important and as anything that I would prescribe to you, because again, those building blocks are really critical for optimal bone health. So with that, I will say thank you, I'm excited to hear what you all have posted

regarding questions. And I'll go back to Kelly. Great. Thank you very much, Dr. Moseley. We're going to jump right into the questions if you don't mind. Sure. So, okay. The first one is from Trisha and she would like to know, "Is there data available on The benefits of yoga to treat osteoporosis?" Good question. That is actually an excellent question. And I love that you've asked that, Trisha, because I oftentimes get the counter question. So I have a lot of patients who do yoga, who are worried about yoga and their bones, because some of the poses,

there's a lot of hyper extension of the spine and patients worry, "Gosh, am I going to break if I do these things?" The correct answer, it is highly dependent on the type of yoga that you do, the intensity of the yoga that you do, and how accomplished a yogi you are. So if you are someone who's been doing yoga your entire life, where you know the poses, you have the flexibility, you have the core strength necessary to do those poses, it's absolutely a wonderful exercise. It promotes strength, importantly, it promotes balance. Remember, how do fractures

occur? Well, they usually occur when we fall. So the more stability you have when you're standing upright, that we get from yoga, and Pilates, and things like that, the fewer falls we see. I love it, I think it's a great exercise. Now, if you're new to the field and you're all of a sudden doing sun salutations and kind of bends and twists that maybe your body is not used to, I worry about that a bit more, because your muscles aren't necessarily trained. Respecting data, there is some limited data. Again, more so in the fall prevention

realm than anywhere else, showing that it can be beneficial to bone health, but not necessarily with DEXA outcomes. Thank you. I would imagine that really, it's like you said in your presentation, exercise, really any type of exercise, is better than nothing. Get moving. Again, I know it's been hard at the pandemic. A lot of our gyms were closed, but there is so much material now on YouTube. And a lot of instructors have Zoom availability for things that they were previously doing in the studio, so utilize those resources and just move. Your body, as a good

colleague of mine said, "If you don't move it, you lose it." So use it. That's true. Thank you. Our next question is from Diane. "Under supplements, you did not mention vitamin K2. Do you recommend it? And if so, how much?" So another very common question we get. At the end of the day, if you have a healthy, balanced diet, additional vitamin K is not necessary to promote good bone health. If we just get it in abundance from our fruits, and our vegetables, and other sources, it does help with bone formation, but again, a healthy diet

should have enough K. I worry about too much vitamin K, because vitamin K is actually involved in the clotting pathway in our blood. And so there are some studies showing that if you get too much vitamin K, it actually Can lead to blood clots and even stroke. So again, everything in moderation when it comes to vitamins and supplements. Thank you. Pat would like to know, "Is osteoporosis hereditary?" Absolutely. So thank you for that very important question. To take us back to that original graph where I showed kind of the acquisition of bone. So we gain

bone until about the age of 30. Well, guess what? By the age of 30, your peak bone density, that peak is up to 40% determined by your genetics. So if your mother, your father, had low bone density or osteoporosis, there is a high likelihood That you too will be at risk for low bone density or low bone formation by your peak. You maybe weren't destined to be here, but rather you were destined to only be here. And sometimes that's the only thing we can find despite a thorough workup. So since it is hereditary, is there

a certain age that you would recommend someone to go and get a bone density test? Because really in general, we're saying that these things really don't happen till maybe menopause age. So how do you feel about that? It's a great question. So I will say there's no correct answer, but in general, amongst the bone heads, we call ourselves, we believe that catching it early is always better than catching it late. Once you've lost bone, it's gone. It's really hard to get back. If there is a strong family history of osteoporosis, my clinical preference is to

screen, at least we're talking about women, at the time of the perimenopause. So I want to know, before that steep drop off occurs, where you are. Because if you go into your menopause and you already have, osteopenia or nearing osteoporosis, I will guarantee you, actually, there's no guarantees in life, but very likely, at the end of menopause, you will already have osteoporosis. So in women with a family history of osteoporosis, screening at the time of menopause is very important. Thank you. Good point. April would like to know, "Dr. Moseley, do these drugs interfere with rheumatology

drugs [inaudible 00:36:37] also with any of the medications that people who have endocrine issues would have to take?" So if anybody really has a rheumatoid issue, or has an endocrine issue, and they're taking medication for that, how does the osteoporosis drugs interfere in general with these drugs? Yeah, that's a great question. Again, it's an individual thing. And it depends on the medication, but in general, within the rheumatologic diseases, these drugs, osteoporosis drugs complement the rheumatologic drugs, namely because we worry about the bones with rheumatologic disease. So rheumatoid arthritis or lupus, we worry about the pro-inflammatory

state, we worry about the steroids. So many of the osteoporosis drugs have actually been studied in patients with rheumatologic Conditions and have been shown to prevent bone loss and even prevent fracture. So we actually use these drugs a lot in rheumatology patients and they certainly don't interfere with the immunomodulator medications that rheumatology patients are often on. Again, they're complimentary that way. With respect to the endocrine diseases, it depends on the endocrine disease. We really want to treat the underlying endocrine disease. And as long as we're treating the underlying endocrine disease, the osteoporosis medication should not

necessarily make a difference with one small exception. I'll give you a nuance here, but if someone already has high blood calcium from a condition known as hyperparathyroidism, those bone-building drugs we talked about, those daily subcutaneous injections for two years, we don't go anywhere near those, because they can only make your calcium go a little bit higher. Right. I guess it would really take an endocrinologist to think to take the hyperthyroid blood test, correct? Correct. Although that's a simple test that a lot of internists can quickly order, and looking at a blood calcium is always helpful

as well, but interestingly, with hyperparathyroidism or high blood calcium, high blood calcium, high parathyroid hormone, we use osteoporosis medications to prevent bone loss, which can be an outcome of that disease. Yeah. I guess I was trying to allude to also that our viewers, that if you're going just to your internist and your health is fine, but maybe it's hereditary with some endocrine issues or you can't seem to balance your vitamin D and calcium, that be proactive and ask your Internist, or family practitioner, or maybe even go to an endocrinologist to get those tests done. Absolutely.

Go armed with knowledge. Because again, there's so much out there now. I think that maybe your practitioner would appreciate some guidance on this. There's a lot of other things they treat and have to treat each day. Be proactive. Our next question, "Dr. Moseley," this is from Ann. And she would like to know, "How do you know that medications are working when the DEXA scan doesn't change?" Great question. So Ann, the first thing I want to know when I walk into a clinic room is number one, I scan for any sort of crutches, or boots, or

casts. That's my absolute horror when I see that. But the first thing I want to know is, have you had any falls and if you had any fractures? And if the answer is no, I consider it a victory. Unlike a cancer surgery, we don't know that we've succeeded unless we prevent the fracture. So we don't see the outcome of our intervention unless we fail and somebody has a broken bone. So if the DEXA is not changing and you don't have a broken bone, it's a victory. I'll also point out too, the natural history of bone

is it kind of trickles down over time, even after the menopause, or in men, there is a slow decline in bone density. So if you're actually steady state, year after year, you've kind of avoided that slow bone loss that maybe someone who's not treated for their osteoporosis may have. Great. Thank you very much. Dr. Moseley, we're getting a lot of questions and concerns about the side effects from osteoporosis. So Charlotte asked, "Do the side effects from osteoporosis medications cause fractures?" Which you briefly touched on and you can mention that again, and along with that is

just in general, that people are nervous and afraid to take some of these drugs for osteoporosis, just because there can be some very serious side effects. And with the bone pain, flu symptoms, etc., and feeling that way for a long time. Yeah. I think these are all extremely valid questions and I think we all acknowledge that it would be great to have medicines that have zero side effects, but we don't. We have aspirin that has side effects. We have acetaminophen that has side effects. We have vitamins and minerals that have side effects. And so anytime

we put something that's not natural in our body, we are taking the risk of a side effect against the potential benefit of whatever it is we're putting in our body. And when it comes to osteoporosis medications, the risk that we are considering against the benefit, is the benefit, which would be, we want to reduce the risk of fracture and then the risk of some of these more common side effects and some of these more rare side effects. So that's the individualized discussion to have is, what do your numbers look like? What does your fall risk?

What is your individual risk for breaking something? And are we willing to take on the risk of a side effect to a medication? How easy is it to stop that medication? I mentioned that twice-a-year injection. If I have someone who's anxious about going on medications in the first place, I'm not going to start something they can't stop. That would be insane of me to do. So we might start a little bit milder in that particular case. Whereas I have many patients who come in and they kind of want to do everything possible to get to

the heart of their bone disease. I find it's often helpful before we even launch into a risk or side effect discussion, to just remember that osteoporosis is a disease. It is something that should be thought of as we think of diabetes, blood pressure, cholesterol, I've said earlier, cancer, it's a disease that needs to be treated. We try to manage things conservatively as much as we can, but you can only manage things Conservatively so much before you start to see the side effects of that, which again, would be fracture. Briefly, about the osteonecrosis of the jaw.

I get that all the time. Again, it's a rare complication. If you're having a dental extraction or an implant where there's invasive work being done on your jaw, there is a small chance that that jaw can get infected and cause this mouth ulcer. And sometimes we can even treat through that. Sometimes we do have to stop the medication. Again, it's about one in 200,000 to 300,000. So quite rare. And again, the risk of one out of 200,000 to 300,000 to the risk of you falling and breaking your wrist, we have to weigh that in clinic,

or the risk of these atypical thighbone fractures. Again, very atypical, very rare. One in 800,000 with long term use. Generally in those cases, I'm far more worried about a typical fracture, which would be of the spine, or the wrist, of the thigh. But again, that's the discussion to have with your doctor. That is, "What are you concerned about? How can I talk you through that? And how can we work together to come up with the treatment plan that you're comfortable with, but also that I'm comfortable with as a bone head, getting you through the winter

Without falling and breaking something?" Great. Thank you very much. On that note too, with medications, when people have... One of the questions from another Mary here I see is, she wanted to know that a lot of the physicians, before they decide to do some type of surgery, whether it's on a knee, or a shoulder, or something there, or you're back even, they'll give them steroid injections. How do you feel about steroid injections in general? Does that contribute later on to getting osteoporosis or not, or...? No, I'm not as bothered by the three time or four-time-per

year steroid injections and knees, and backs, and necks, and things like that. The main concern are the systemic steroids, your prednisone, your dexamethasone. For three months or more is generally a cutoff that we say for steroid exposure leading to bone loss. If you need it, you need it. And again, my personal bias is if that steroid gets you walking more, if it gets you moving more, it gets you pain free where you're working on your balance or can go to physical therapy, I'd far prefer that local steroid injection, which has minimal bone effects than doing

nothing at all. Great. That's a great answer. Thank you. This is a question from Katie she wanted to know, "Is osteopenia/osteoporosis, a counter indication for knee replacements or other joint replacements?" Great question. Yeah, so we get a lot of referrals from our surgical colleagues to optimize bone health prior to these surgeries, because it would make sense. If you're going to be putting hardware into a softer bone, then they would worry about the success of that bone surgery. I would not say it is contraindication to surgery, but again, we would want to make sure your calcium,

your vitamin D status are adequate so that you're healing that bone appropriately where the hardware is. And certainly, if you have osteoporosis, we want to treat that to harden up your bone a little bit, so to speak, prior to the surgery. But again, going back to my last comment, I want you moving. So if you need a new hip and a new knee, and that's going to get you off the couch and Out taking a walk on a beautiful day, let's do that too. So again, a lot of times we'll optimize the bones for a

few months prior to surgery, patients will have the surgery. And then we'll continue to treat after that with the medications for osteoporosis really having no impact on bone healing after the fact, so you can stay on your osteoporosis medications. It certainly should not impair the healing process of an orthopedic procedure. Great. Thank you. Our next question is from Melisha and she'd like to know, "What is the difference or how do they differ between osteoporosis and arthritis?" Yes, so they're neighbors, but they don't really talk to each other, at least not based On the current research.

So osteoporosis, we're talking about the bones thinning over time. And osteoarthritis is when the padding between the bones starts to erode over time, so there's kind of a gelatinous cushion that lives between the bones, and the spine, and then the knees, and then the hips. And over time, that gelatinous cushion can become thinner for a variety of reasons, lead into bone-on-bone rubbing, which is why people get pain. And almost a bone scar that can form along the surface of the bone. So they don't really relate to one another, other than maybe some artifacts we can

see on DEXA scans, but they should not impact one another. Great. So if you are diagnosed with some arthritic issues, maybe you broke a bone in the past, Or you just someone that hereditary happens to have this or whatever, that you shouldn't necessarily panic that, "Oh my goodness, this means I have osteoporosis." No, we see a lot of arthritis. Just as a side note, on DEXA scan, you can see arthritis on those kind of poor woman's X-rays that we get in the spine and in the hip, I see a lot of arthritis. And I pointed

out to patients all the time and they say, "Really? I had no idea. Should I do something about this?" I say, "Well, are you in pain?" And they say no. And I say, "Well, then you don't need to do anything about it." So it's common and nobody likes to hear it, but there is wear and tear with age. And so we do expect to see arthritis evolve over time. And no, you should not panic unless you're having extreme pain that takes you to the orthopedist office. Thank you. Our next question is from Anne. And she'd

like to know, "Should you take a magnesium supplement?" Anne, so this kind of falls into the category of the vitamin K. And I would say, if you have a healthy balanced diet, you're getting adequate magnesium. In fact, most of the time we get more magnesium than we can even process and we excrete it. This is excluding those individuals who have nutritional challenges. So if you are a gastric bypass patient or someone who has a lot of intestinal challenges with absorption, or very limited diet due to GI problems, then by all means, you may Need additional

supplementation to get the nutrients you need. Great. Thank you. Our next question is from Kathleen. They're just rapid firely coming in here, so I apologize [inaudible 00:49:49]. I told you we'd be busy tonight, Kelly. So this is from Kathleen and she would like to know, "Is there evidence taking collagen that will help to prevent fractures?" No. I mean, the short of the long of it is no. I know there's a lot out there with powders, and gummies, and certainly they seem attractive, but we don't know that collagen that goes through the gut first actually makes

it through The bloodstream and into the bone. Although, wouldn't it be nice, right? Yeah, that'd be really nice. That'd be very nice. It'd be much easier than some of these other things I've been talking about. Take a little gummy. That would be great. Love them. Love them. Yeah. Our next, we have another question here and we're going to wrap it up in a few minutes, but just we'll take a few more questions. So women are in general, they're concerned about taking oral calciums like Tums. Does this increase the likelihood of calcium buildup in the arteries

of the heart? Right. No, I'm really glad you've asked this question, Kelly, because we get this a lot. So the consensus between the American Heart Association and the bone groups is that individuals at risk for bone disease, women and men, 1,000 to 1,200 milligrams of calcium total a day has no impact on cardiovascular disease, does not increase your risk of stroke or heart attack. We prefer it be through the diet, because the bulk of the studies that did maybe indicate a slight risk of adverse cardiovascular outcomes without significance, but maybe a slight risk, were those

taking supplements. And a lot of those studies were flawed. But again, we agree. In fact, I gave a great debate. It was not a debate, it was a lovely chat with Dr. Pam Ouyang, who is here at Johns Hopkins, who does women's heart health, about this exact topic. And we left good friends agreeing that 1,000 to 1,200 milligrams a day through supplement or diet preferred is perfectly fine. Great. Another, I guess a myth, actually I would say. I think a lot of women think that, "Okay, if I have bigger bones, I'm less susceptible to getting

osteoporosis as opposed to maybe a woman that's smaller boned." So is that truly a myth? It is. I mean, it is. We kind of went through, there's all sorts of things that can lurk underneath the surface of the bone. And I actually do some research in type two diabetes and bone. And we know that individuals with type two diabetes actually have very normal bone density on DEXA scan. They look fine, we send them home comfortable with their results, but then they go home and they fall and they break a hip. And so this speaks again

to that underneath the surface, that bone quality, it's a hot topic in osteoporosis nowadays, but deficiencies in bone quality, whereas everything looks good on the outside, but you pull back the curtain and the microarchitecture or how the bones remodel, may not be so great. Again, leading to fracture. So I would not say just because you're a big boned, it's protective. So well, there are some of us that are saying, "Darn." And so I'm going to take one more question here. So can you maybe talk a little bit about what research is being conducted on osteoporosis?

Is there anything currently going on or any new drugs on the horizon? Right. So I would love to say there are a lot of new drugs on the horizon, but Romosozumab, the monthly injection, was kind of the last one. The major challenge with pharmacologic or pharmacotherapy for osteoporosis is that to do these clinical trials, to show that they reduce the risk of fracture, you need huge studies. I mean, we're talking 5,000 participants or more. And a lot of times, those participants have to be what we call treatment naive, meaning they haven't been treated with osteoporosis

medications in the past. And so identifying those individuals and doing these trials can be terribly expensive. They take up to five years or more to get the fractures necessary to show that the drug is better than placebo. And so they take a long time to get up and running, and a long time to complete, and a long time to get through the FDA. So there aren't really new medications under investigation right now for osteoporosis. There's a few looking at a more rare bone condition called hypoparathyroidism, where the parathyroids are underactive, but we're waiting. We always

want more treatments available for our patients. And then what research is ongoing right now? I think they really get back to that clinical piece that I was talking about on a prior slide, which is how do we know which medication is best for a patient? How can we tailor our pharmacologic decisions to our patients who come to us in the clinic? Are there certain traits that we should be looking for in our patients? Are there certain genes that might predispose someone to having a better reaction to one medicine than another? We don't know. And then

again, looking at the order of therapy, more and more, we're seeing that bone-building drugs, first and foremost, followed by an anti-breakdown drug, works a heck of a lot better than going in the opposite direction. But how do we do that? Do we need to treat for five years? Can we do two and then off and then two and then off? And then finally, this concept of a drug holiday, which again, I spoke to a little bit earlier is, how do we know when it's time to stop the drug holiday? We have just this nebulous space

where we leave patients sometimes, but how do we know when it's been too long off of your medication and maybe your fracture risk has gone up again and we don't know until you come back in and have had a new fracture? So those would be the points I'd touch on. Wonderful. Well, listen, I want to thank Dr. Moseley very much. Thank you so much for your time this evening. And thank all of you for joining us this evening. Graciously, Dr. Moseley has agreed to respond to any questions that haven't been answered this evening, so you'll

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