Taking Care of Your Bones: Critical Steps for Aging Strong

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[00:06] Moderator: Welcome to the workshop, Taking Care of Your Bones, Critical Steps for Aging Strong.

My name is Penina Seidman, and I will be your moderator for this workshop. I am thrilled to introduce today's speaker, Dr. Sara Cromer.

Dr. Cromer is an endocrinologist at Massachusetts General Hospital, where she treats patients with bone diseases such as osteoporosis, diabetes, and other endocrine disorders. She also conducts epidemiological research examining how endocrine medications are used, whether they are equally safe and effective across different groups, and how social and environmental factors affect health and healthcare.

She works to raise awareness about bone health, lifestyle modifications, and treatment options to help people maintain strong, healthy bones.

Please join me in welcoming Dr. Cromer.

[00:55] Dr. Cromer: Hello, everyone. Thanks for coming today. I'm excited to talk to you about bones and what you can do to help keep your bones strong.

So, we'll start out with a few learning objectives.

Today, we're going to talk about why bone health matters and the scope of the bone health problem in America.

[01:12] We'll talk about who's at risk for developing poor bone health, and then we'll talk about who should get tested and how to read a bone density test.

We'll talk about all the lifestyle changes that you can be doing even now to help keep your bones strong, and then we'll talk about medications that can be used to help prevent fractures.

[01:28] Starting out with the scope of the problem; osteoporosis is quite common and on any given day there are about two million Americans who are living with yearly osteoporosis related fractures. The risk for fracture is actually higher in people who are survivors of bone marrow transplants and may be somewhere between two to eight times higher; all those studies differ. The difference in risk between a survivor and someone who has not gone through a bone marrow transplant seems to be greatest in younger people who otherwise might not have reasons to have low bone health, so in the ages of 30 to 60, and it appears to be a little bit higher after an autologous stem cell transplant than an allogeneic one.

About one in every two women in the U.S. will break a bone in her life due to osteoporosis, and about one in every four men will break a bone. So again, very, very common.

This is, again, comparing autologous versus allogeneic stem cell transplant recipients. You can see that the rates are higher among those who've had an autologous stem cell transplant.

[02:27] When we think about how osteoporosis affects the bone, many people ask me, I'm having some pain in my knee, pain in my hip, pain in my back. Is that because of my osteoporosis? The answer is usually no, because osteoporosis is usually an asymptomatic disease, meaning that it causes no symptoms at all unless or until you break a bone.

[02:49] This is because osteoporosis affects the inside of the bone, meaning the quality of the inner contents of the bone, and there aren't many nerves there that are causing pain. But if someone does have an osteoporosis fracture, they can have many symptoms.

Pain, of course. In many cases, they may have decreased mobility or loss of their independence. In some cases, especially among the elderly who already had a number of factors limiting their independence, they may require long-term nursing care. In some cases, fractures can even significantly increase the risk of death. In fact, among the general population, having a hip fracture carries about double the risk of death in the next year as having a heart attack. So, it's something that can be very serious.

[03:30] When we think about bone strength, there are two kinds of concepts in how we can think about this.

The first is bone mineral density, which is by far the most commonly used, and it's a measure of the quantity of the inside of your bone.

I have these two pictures here. There's a healthy bone on the left, and you can see that in the center, it looks kind of like a sponge, but the holes are not very big. It has this dense mesh of what we call spicules that hold the bone together, and they can spread out force and any sort of trauma so that it spreads throughout the bone, and no single area gives a lot of impact and is less likely to break.

[04:05] In osteoporosis, that changes, and your bone density decreases. You get smaller spicules, bigger holes that are less able to absorb any sort of impact or trauma, and it's more likely to break.

When we measure this for osteoporosis, we usually measure it at the spine or the hip. It's pretty uncommon to measure it at other places.

The other thing that probably matters in terms of breaking bones is the quality of your bone, and there are ways to measure this. There's something called the trabecular bone score. There's another very special type of CT scan that can measure the quality of your bone. Neither one of these is routinely used in clinical practice, and in fact, the CT scan is only approved for use in the research setting.

Almost all of the data and the science that we have around this has to do with bone mineral density or the quantity of your bone.

[05:01] When we think about bone density across the lifespan, I want you to focus on the first, the top two lines here.

Most people have bone density that steadily increases until about the age of 25 to 30. The blue line is men and the red line is women. You can see that they're both reaching their peak bone mass between the ages of 25 and 30.

In both cases, bone density is relatively stable, maybe declining just a little bit until about age 50. At that point, women go through menopause. Of course, if you are a survivor, you may have gone through menopause much earlier, and this transition might happen earlier. But in that period where menopause begins and the estrogen levels can fall, most women lose something like 10 to 20% of their bone density over a 5-to-10-year period. So, there's a big drop for women, followed by a steady decline after you come through the loss of estrogen period.

[05:51] For men, first of all, the peak bone mass is higher in men, and then they don't have that menopausal transition where there's a sudden drop, but they do have a steady decline in bone density over time. When we think about reasons that someone might have an increased risk for fracture, if someone is at risk for low bone mass, there're two ways that can occur.

The first is the lower red line here, where you can see the pattern is very similar to what it would be in a woman who is not at risk, but she is all shifted downwards. This generally happens in someone who never attains their peak bone mass, so this could be someone who had poor nutrition as a child, it could be in someone who has just genetic risk for low bone mass, or it could be in someone who had a childhood cancer and who never achieved their peak bone mass.

[06:39] The other way that you could get a low bone mass is if you reach your peak bone density, but then as I mentioned, you go through some sort of transition, either menopause or exposure to other risk factors earlier than expected. You have a loss of bone density at that time, and it never recovers. Then it still steadily declines over time, again, both in women and men, and so you reach your peak bone mass, but then you lose it and you can never really recover without medication. Either one of those could result in loss of bone density over time.

In terms of risk factors for osteoporosis, there are some that are in our control. These include things like how much calcium we eat on a day-to-day basis, which I'll talk about a little more in a minute, low vitamin D levels can result in poor ability to build new bone and absorb calcium, the amount of exercise we do, and particularly weight-bearing exercise, can affect the bone health, and then both smoking and alcohol are very bad for the bones and can lead to accelerated bone loss.

[07:38] That said, there are also a lot of osteoporosis risk factors that are not in your control at all. Age is probably the strongest risk factor. As all of us age, our bones get weaker, and there's not a whole lot that we can do to change that. Being a woman decreases your bone density, lowers your peak bone density, and then you have all these transitions that can increase your risk. If you go through menopause early or even if you go through puberty late, both of those decrease how much estrogen you're exposed to in your lifetime and can result in lower bone density.

There's also family history. If you have osteoporosis and fractures in your family, you may be at higher risk.

If you have major other diseases like liver or kidney disease, then you may be at higher risk.

There's a number of hormone disorders that can affect your osteoporosis risk. These include overactive thyroid or overactive parathyroid disorders, as well as some other very rare hormone disorders.

[08:32] And then there's a list of inflammatory things. If you are severely ill for a long time, particularly if you're immobilized, that can lead to increased bone loss because your bones are no longer getting that kind of weight-bearing exercise that they need to stay strong.

 Autoimmune or inflammatory diseases can increase your risk of bone loss.

Poor nutrition, low weight, poor absorption of food, and eating disorders can all lead to low bone density.

Then there's a number of different medications that can lead to poor bone density, either from directly impacting the bone, including steroids like prednisone or dexamethasone, or through preventing absorption of medications, particularly proton pump inhibitors like omeprazole or pantoprazole, can limit how well you absorb calcium. So, even if you're taking calcium, you may need more if you're on one of those medications.

[09:21] If we think about risk factors that might be specific to people who are survivors of stem cell transplant or bone marrow transplant, then everything in bold here, I think, is more likely in this population. 

The timeline of someone's bone health, you know, cancer pretreatment phase, you may or may not have some of these risk factors. Some in your control, some out of your control, like bone loss. But then as you go through the diagnosis and treatment phase, and you may be exposed to a number of factors, including chemotherapy, steroids, prolonged illness and immobilization. Maybe poor nutrition, and maybe there's other medications that you needed to take at that time that could have affected your bone health. Then, in the recovery phase, of course, everyone's journey is different.

For some people, these risk factors may continue. Some people may need to take steroids in the long term, while some people may have more immobilization for a longer period than others. Some people in the recovery phase can move through and get and lose a lot of these risk factors for bone loss, but some people may still have some of these risk factors.

Then, in the survivorship phase, it really depends on where you are in that process.

[10:38]  Who should be tested? I'll start with the general population. We say that all women should be tested once they hit age 65. Some guidelines say that men should be tested once they hit age 70, although it's somewhat controversial.

Younger people with risk factors for bone loss should be tested. This includes any postmenopausal women with any risk factor at all. This includes smoking, alcohol, or prior prolonged steroid use; any of those might indicate you need an earlier screening. Then if you went through menopause very early, then that's another risk factor as well.

Anyone who's had what we call a fragility fracture, which I'll talk about, should be screened for low bone density. And again, there are many other reasons to consider it, including chronic illness, including steroids like prednisone, including chemotherapy, and then including early menopause.

[11:27] I mentioned fragility fracture as a reason to screen and often to treat for osteoporosis.

A fragility fracture is defined as a fracture that occurs with a trauma that is similar to or less than a fall from standing height.

If someone trips and falls over the corner of the rug in their living room, that's a fall from standing height. If they break a bone doing that, that's a fragility fracture. It's something that we think probably should not occur in someone who has really healthy bone density.

Whereas if someone fell down two flights of stairs and broke a bone, that's something that we would consider not a fragility fracture because it's something that probably would have happened even in someone with really good bone density.

We consider these to be osteoporosis defining if they occur at the hip or pelvis, which are, these two little red dots around the bottom of the spine, or if they occur at the shoulder or the wrist or in the spine.

[12:31] The test for screening bone density is called a DEXA scan, which stands for dual energy x-ray absorptiometry and this is it's a very very low radiation x-ray that looks at the quantity of bone, as we discussed, or the bone mineral density. We usually check it at the lumbar spine and at two different places in the femur which is the hip bone and if you get a printout you'll probably see something like this picture on the right. It shows a picture of the spine, a picture of the hip, and then it has these colorful little graphs that show where you are compared to your peers, which we'll talk about, and then it has some numbers at the bottom.

[13:07] To read it, we look at the spine, particularly the lumbar spine, which is the lower part of your back. Then we look at something called the total hip, which is the entire section of your femur or your hip bone that's inside this little blue square over here.  We also look at a very particular spot on your hip called the femoral neck, which is at the end of this arrow. There's a little tiny white box that you can probably see there, but it's in the middle of the hip bone.

[13:33] Some people get confused reading about the femoral neck. They think that it's their neck, but it's not. It's the neck of your femur, which again is your hip bone.

In some cases, we also check the bone density at what's called the distal radius. This is the end of your forearm very close to your wrist.

What you get in your printout that your doctor would be looking at is a couple of different numbers.

The first is the BMD or bone mineral density at each site. This is an absolute measure which is mainly useful to compare over time, and it's used to generate the T and Z-scores that I'll tell you about, and it's expected to be different at different bone sites. So, it's usually highest at the spine, in the middle at the hip, and lowest at the wrist.

[14:16] Next is your T-score and this is probably the most important number. This compares your bone density to a healthy 25-year-old of your gender. So, if you're a woman, it compares you to a 25-year-old woman. If you're a man, it compares you to a 25-year-old man.

Some machines will also use a race or ethnicity-specific comparison, and that's quite controversial, but you may see that. This tells you where your bone density is compared to a 25-year-old. We assume that you reached your peak bone density around age 25, and we're looking to see how much that's changed over time. 

If you have a score of zero, it means your bone density is the same as a 25-year-old man or woman, depending.

[15:03] If it's above zero, that means you're above average. We don't see too many of those in people who were screening for osteoporosis. And if it's below zero, it means that we think you've lost bone density over time.

How negative the score tells us how concerned we should be. If it's less than minus one, that's considered osteopenia, and if it's less than minus 2.5, that's considered osteoporosis.

Another way of looking at this is to imagine we have thousands of people, and we line them up based on their bone density. There would be a lot of people in the middle here with a T-score around zero, and then there would be people with lower T-scores. The osteopenia would be these light blue people who have a T-score between minus 1 and minus 2.4. Then osteoporosis would be people who have a T-score of minus 2.5 or lower.

You can see that there's maybe 20% of people who have osteopenia in this graph and a very small number of people who have osteoporosis over there.

[16:04] The last one that we look at is the Z-score. This is a very similar idea to the score, but instead of comparing you to a 25-year-old, we're now comparing you to other people your age. If you have a Z-score of zero, it means that you're exactly average for your age. If you have a Z-score that is above zero, it means you're above average. And if you have a Z-score that's below zero, it means you are below average compared to other people your age.

In this scenario, we don't get concerned about slightly negative numbers because, of course, half of people will have a Z-score below average, but we do start to get concerned if the Z-score is less than minus two. That tells us that something more serious is going on, and you're really at the bottom end of average.

As another way of looking at this, in the graph here, if you imagine the blue dotted vertical line is your cutoff for osteoporosis. It only represents a very small percent of people in the blue graph curve, in the blue line. That's your T-score, but it represents maybe half of people in the red line, which would be your Z-score, if you're an older age.

[17:19] One more way to look at this is if you have your T-score compares you to a non-moving target. This thick black line going across at zero is the average bone density of people who are 25. That number doesn't move because 25-year-olds always have the same density, but the Z-score compares you to a moving target, which is other people your age. So that one does move. People your age are aging, and then they have a steadily lowering Z-score.

In terms of things that you can do to help protect your bone density, the first is in terms of calcium intake. Everyone, regardless of whether you have risk factors for bone loss, should be targeting calcium intake somewhere around a thousand milligrams per day and the best way to get that is from diet. You can look at any food in your pantry, and on the nutrition facts on the back, it should tell you how much calcium is in each serving, but I've included a few examples here.

[18:29] Milk, for example, one glass of milk has about 300 milligrams. If you have a glass of milk with breakfast, lunch, and dinner, you're mostly done with your calcium for the day.

In terms of fortified drinks, including plant-based milks like almond milk, oat milk, and orange juice that have calcium added to them. Those often have as much or even more calcium than milk in them. Other dairy products like cheese and yogurt also have a fair amount of calcium.

Tofu is actually fermented with calcium, so it has a good source.

There are certain leafy greens that have calcium, but not all of them. So, the big ones are collard greens, kale, broccoli rabe, which is kind of the long skinny one, not broccoli, and bok choy all have a fair amount of calcium, but you usually have to eat something like 10 cups of them a day to get your full calcium intake. So that's not feasible alone as a calcium source for most people.

There are some processed foods that are fortified with calcium, including cereals, oatmeal, and macaroni and cheese that will have calcium added to them. Again, you can check through anything in your pantry, looking at the nutrition facts on the back.

[19:35] As I mentioned, we prefer to get calcium from the diet, but if needed, you can get calcium from supplements. I would avoid this if you have any history of kidney stones, because these supplements can slightly increase your risk of kidney stones. If you are going this direction, calcium citrate tends to be better absorbed than calcium carbonate. You would probably aim for a calcium citrate, which is commonly sold under the name Caltrate, but there are many, many different formulations.

 All right, other steps you can start now to protect your bones.

I generally recommend that almost everyone gets their vitamin D checked. Vitamin D deficiency is very, very common, especially if you live in a place that's cold where you bundle up most of the winter and don't actually have any skin exposure to the sun in the winter. So, I recommend that everyone have their level checked.

We're generally shooting for a level between 30 and 50. If your level is low, it's very easy to fix that. We can give you a vitamin D supplement.

The most common is a dose somewhere between 1,000 to 2,000 a day, but depending on your level and how well you absorb nutrients, you might need more or less.

I have some patients, for example, who have conditions that affect their ability to absorb nutrients who take 10,000 units a day, and that's just the right dose for them because they don't absorb it very well. So, everyone's a little different.

[20:57] The next thing is weight-bearing exercise. We get questions about this all the time, and the clearest evidence is that not exercising is very bad for the bone.

 So, you know, being immobilized in an ICU, for example, can lead to rapid bone loss, but anything that puts weight on the bones is good for them. That could be something like walking. Walking puts weight on the lower body and the spine.

For your upper body, you might also want to add something like body weight exercises like plank or push-ups, or you could use upper body just like hand weights. You could also go to the gym and do resistance training either on your own or with a trainer, if that's something that's of interest to you. But there are many ways to do this. 

This is just one example of ways that you can do weight-bearing exercise. You can do sit to stands, walking, squats, toe raises, but again, there are many, many things that count as weight-bearing exercises.

[21:50] The only thing that really does not is swimming because swimming, you are buoyant in the water and that actually takes weight off of your bones, which is not to say that you can't swim. It just doesn't count towards your weight-bearing exercise for the day.

Last, I would say, your steroid dose is not often in your control, but whenever possible, taking the lowest dose of steroids available is what's best for the bone. If there is an option to go down on steroids, that is a good thing. But of course, what you need to stay healthy otherwise can often take precedence of that.

[22:27] That leads us to our final topic; medications that can be used to prevent fracture. There's a very clear list of reasons why someone should take a medicine that is universally accepted across different guidelines.

 The first and the strongest is a fragility fracture. As I mentioned, that is a fracture that occurs with a fall from standing height or less.

If you have broken your hip, your pelvis, your back, your shoulder, your wrist with a fall on the way to the bathroom or something like that, then medication is probably best for you to help prevent your risk of fracturing again.

The second strongest reason is if you do have a diagnosis of osteoporosis, which again is a T-score that is less than or equal to minus 2.5. If you have osteopenia, the guidelines are a little more undecided about whether you want treatment or not.

[23:17] There are definitely studies that show that most of our medicines can decrease risk of fracture in people who have osteopenia, not yet osteoporosis. But the absolute risk of breaking a bone if you have osteopenia is not nearly as high as it is with osteoporosis, and so you still get benefit from the medicine, but your risk is already low enough that that benefit is fairly small.

Often it comes down to whether or not the patient wants to be aggressive about trying to prevent fractures and also whether or not you have other risk factors. If you have osteopenia, not osteoporosis, but you also smoke, still have to take steroids, and have gone through menopause, then maybe it may be a good idea to use a medication in that case.

[24:03] The last indication is if you are taking steroids for a prolonged period, it's generally recommended to take one of these medicines to blunt the bone loss that occurs with steroids. As an example of steroid doses that we worry about, even a small-ish dose of prednisone, like 7.5 milligrams a day can be really important if you have to take it for a long time, like six months or more. Then higher doses of prednisone, like 30 milligrams, are concerning to us, even if you only take them for a short time, like 30 days.

When we think about medications, they generally fall into two categories that work on two different types of cells.

So, every day of your life, your bones are constantly being broken down and remade by these two types of cells called osteoclasts and osteoblasts. Osteoclasts are the octopus-looking one, pink one on the left. They walk along dissolving old bone, and then the osteoblasts come behind it and lay down a new soft bone called osteoid that then has calcium and phosphorus stick to it over time to make it stronger.

This process is really important for helping your bones stay young, fresh, and supple so that they can wave in the wind like a healthy tree as opposed to snapping in the wind like a petrified tree. This process is important, but trouble happens when the balance is thrown off.

What you want is equal amounts of bone breakdown and bone buildup. So, you're not losing bone, you're just replacing old bone.

If you take a high-dose of steroid or have a number of other risk factors, the balance can shift and you can have too much bone breakdown by those osteoclasts and not enough bone build up by the osteoblasts. So, our medicines are generally geared towards one or both of these cells.

[25:47] There's a broad category that we call anti-resorptive medications, and their job is to turn off these osteoclasts and prevent further bone breakdown so that bone buildup can catch up a little bit.

There's another category that is called anabolic agents, kind of like an anabolic steroid. Their job is to activate these osteoblasts and encourage new bone creation faster than it would normally occur.

I break these down into two categories on the left, those anti-resorptives. There's a number of different ways you can take them. There are weekly pills that you may have heard of like Fosamax, Actonel, and Boniva or there's a yearly infusion called Reclast. That is once a year at some sort of infusion center. There's one other medicine in this category called Denosumab or Prolia which is an injection that you get in a clinic once every six months in your arm like a flu shot.

[26:37] In terms of anabolic agents, there are two ways to take those as well. There's a group that you take as a daily injection that you give yourself. It comes in a pen. So, for those of you who have taken insulin or any other injectable medication in the past, it would be very similar to that. It's a pen with pen needles, and then there's a monthly injection that you would get in the clinic called romosozumab or Evenity.

Notably, both of the anabolic agents you would take for one to two years, and then you switch over to an antiresorptive agent, which acts as, some people call it, bone glue to hold in all of the bone density increases that you got from the anabolic agent.

[27:15] If you did take an antiresorptive, you can expect a one to 3% increase in your bone density each year on average. There are people who get less, and there are definitely people who get a lot more. We always see more increases in the spine. That'll be a theme for all the medications.

In terms of the more important outcome, which is whether or not you're breaking bones, we generally see about a 50 to 70% drop in fractures at the spine and about a 30 to 50% drop in fractures at the hip.

This is just an example. This graph on the bottom shows clinical vertebral fractures, which is a fracture in your spine that causes pain.

You can see that the dotted line is placebo. People who weren't taking an active bone medication, in this case, they were taking calcium and vitamin D. The dark black line is people who took alendronate, which is called Fosamax, you can see that they had about half as many spine fractures as the people who did not receive alendronate.

[28:26] In terms of side effects, this depends on the mode of delivery. For the pills that are once a week, some people get some stomach symptoms like gastritis or reflux. I would say about 10% of people get those and then every once in a while, a patient tells me that they have some joint aches while they're on this medication. 

In terms of the yearly infusion medication, which is called zoledronic acid or Reclast, there is a very common flu-like reaction to the very first dose you get of that medication. When I say flu-like, it feels like you have the flu, fever, chills, body aches, joint aches, and severe fatigue. Again, that affects about one in three people, so, it's quite common.

[29:07] It can vary in severity. Some people, just feel under the weather for a couple of days, whereas others feel like they just have to be in bed for two to three days. Importantly, that happens almost exclusively with the first dose. Even if you get it with the first dose, it's pretty uncommon to get it with the second or third or fourth dose.

Receiving the injection in the arm, there can be an increased risk for low calcium levels, which can sometimes be dangerous, so that often requires monitoring. There does seem to be a slight increased risk in infections such as pneumonias. That's something to be very careful about.

Many, many, many people have questions about the rare side effects of all anti-resorptive medications. You may have heard of these if you've read about osteoporosis at all.

One of them is called atypical femoral fracture, and the other is called osteonecrosis of the jaw. Both of these happen because, as I mentioned, this process where your bones are constantly being broken down over time and replaced over time is actually really important. If you turn off this process for too long, your bones can become too stiff, too brittle and have trouble recovering even from very minor injuries.

[30:13] That results in atypical femoral fractures, a break in your femur or your hip bone that doesn't actually happen at the hip. It happens in the middle of the thigh.

Then the other one, osteonecrosis of the jaw, happens if you need a big dental procedure, usually something significant where the dentist has to drill into the bone, such as an extraction or an implant. Sometimes if you've been on these medications for a long time, they will not heal well after that big injury from the drill in your jawbone, so these are real risks that understandably people are very concerned about.

But I want to highlight this graph here, which was from a study about atypical femoral fractures. You can see that with that purple line down at the bottom shows you how many fractures occurred in this group, depending on how long they had taken one of these medications.

You can see at the five-year mark, the risk was about 8 per 10,000 people, so a little less. Now, because we know about this risk, we generally don't use these medications for that long.

We usually treat somewhere between 3 to 6 years and then do a drug holiday, where we stop all medication and let it wash out from your system, to really decrease the risk of these rare side effects.

[31:32] Just one more thing to highlight how rare these are. The study that looked at the rate of these side effects in people taking these medicines also looked at the number of fractures prevented by these medicines.

The purple line, again, is the risk of those rare atypical femoral fractures caused by the medicine. The blue line is the number of hip fractures prevented by the medicine, and the red line is the number of all fractures prevented by the medicine. Again, there is a risk of this complication with these medications, but the benefits clearly outweigh the risks.

[32:09] If you took an anabolic medication, you might expect your bone density to increase much more with these medications than it does with antiresorptives.

We generally see about a 5% to 20% increase in bone density over a 1to 2 year period, depending on which medication you take. That increase is always greater at the spine, just like it is for the antiresorptive medications. In terms of fracture risk, we see very dramatic decreases in fracture at the spine, somewhere between 80 to 85% in most trials. Depending on which drug you take in this medication group, some of them are proven to decrease hip fractures. Some of them are not because the trials were too small and too short to really see a difference in hip fractures, but for those that are proven, it seems to reduce the risk of hip fracture by about 40%.

[33:01] Here we have on the right side at the top, we have the changes in bone density over time.

This study showed about a 14% increase in bone density at the spine over one year, and then at the bottom we see the differences in clinical fractures, which is any fracture that caused symptoms and was not found by accidental x-ray, which is most fractures. You can see that they reduced significantly on this medication. Then, in terms of side effects, if you take the daily injection anabolic medication about 10% of people get palpitations and it looks like it doesn't seem to increase the risk of dangerous and abnormal heart rhythms. 

It doesn't seem to be of any danger to you at all, however it can be kind of anxiety provoking because usually immediately after taking the injection your heart will race for about 15 to 20 minutes. When I say race, it will be 130 beats a minute for no reason for 15 to 20 minutes which again we have no reason to believe that this is dangerous, but it can be very anxiety provoking.

[34:02] The other common side effect with this medication is meandering joint aches. For example, one day my elbow is a little sore, the next day my ankle is a little sore, and it moves over time.

In terms of the monthly infusion, which is called Evenity or Romosozumab, this is, they have really no common side effects aside from some soreness at the site that you get the injection, like if you had a flu shot and you were sore the next day.

But there's a lingering question about this medicine and heart disease and where that comes from. There were two very large trials, each about 5,000 women who looked at this medicine.

There was one trial where it was compared to a placebo or an inactive medication where it looks totally safe, and then there was another trial where it was compared to one of the weekly pills called alendronate or Fosamax. In that trial, about 1% of the alendronate group had a heart attack or a stroke, and 1.5% of the new medicine group had a heart attack or a stroke.

[35:02] That was not enough to be statistically significant, as we say in the research world, so it's possible that it was a fluke in the data. It's possible that this new medicine does slightly increase the risk of heart attack or stroke. Or the third possibility is that maybe the alendronate slightly protects people against heart attack and stroke. There are some studies that suggest an anti-inflammatory effect of medications like alendronate. So that's possible, and we just don't know.

The FDA has said that no one should get this medicine if they've had a heart attack or a stroke in the past year. I personally would not give this medicine to anyone who's had a heart attack or a stroke ever. When I talk about it to patients, I tell them that it really does do a lot of good things for the bone, but it's an unknown risk of whether there's a slight increase about five in a thousand risk of a heart attack or a stroke while on the medication. It's a decision that we make together based on priorities.

[35:56] In conclusion, healthy bones can really help improve both the length and the quality of your life, improve your chance of long-term independence, mobility, and lack of pain, but everyone is at risk for bone loss as they get older.

Everyone eventually hits that slope where their bone density is declining over time. The longer you live, the more bone density you lose unless you're actively fighting against that. Survivors of cancer and bone marrow transplant have more risk factors than the average population for early bone loss.

You may benefit from bone density screening if you've ever had a fragility fracture, if you have multiple risk factors, or if you take chronic steroids.

[36:37] Everyone can support their bone health by doing a variety of lifestyle things, including making sure they're getting adequate calcium in their diet, making sure their vitamin D level is normal, staying active with weight-baring exercise, and avoiding smoking and alcohol. 

In some cases when appropriate medications are generally quite safe and can be very effective at preventing fractures. With that I'm happy to take any questions.

[36:54] Moderator: Thank you so much Dr. Cromer for this excellent presentation.

We do have some really good questions in the chat already. There are a number of questions in the chat about how the right medication is chosen for each patient.

You had mentioned some reasons that you might not give a patient the anabolic agents, but how does a doctor figure out which one is right for which person?

[37:27] Dr. Cromer: It's a great question, and the fact is that it often comes down to the patient, at least in my practice, and how strongly they want to manage their bone density risk. The reason for that is that all of these medicines are fairly effective at preventing fractures.

 Antiresorptives will decrease spine fractures 50 to 70% and hip fractures 30 to 50%.

The anabolics, they decrease it a little bit more at the spine, 80 to 85%, but are fairly comparable at the hip, at least for those that had big enough trials.

So, I am generally comfortable with patients guiding their discussion on what is important to them and what leads them to choose one medication or another.

Some people have more concern about heart disease and might not be interested in the question of heart disease medicine at all.

Some people are not willing to do daily injections, understandably, so that medication is off the table. Some people have particular concerns about one medication or another in terms of side effects. So a lot of times the patient-specific factors guide what we choose in the end.

[38:29] Moderator: Great. Thank you.

We also have a number of questions about steroids. One question is from someone who has osteopenia from long-term steroid use in the past.

If that steroid use risk has now dissipated over time or they should consider that. We also have questions about steroid use in terms of cortisone shots for arthritis.

[39:00] Dr. Cromer: Good questions.

Starting with the, for those who used to be on steroids but are no longer taking them. The good news is that there is definitely bone density recovery and fracture risk recovery after you stop steroids. We don't think that it gets quite back to where it was, but it definitely gets better. Most people regain a lot of bone density when they stop that steroid. So that's the good news.

So if you're in a situation where you took steroids 10 years ago and haven't taken them since, I think the most important piece of information is your bone density testing now and then whatever risk factors you currently have ongoing, which might be that you're, you know, you're postmenopausal woman.

It might be that you smoke. It might be that you are not really able to do a lot of exercise. It might be family history. I think that bone density test is kind of the most important piece of information for you now.

Then, in terms of steroids in joint injections, most joint injections are designed right in joint space and don't get absorbed into the rest of your body. On the whole, those are fairly safe.

Even if they do get absorbed, which does sometimes happen, if any of you have diabetes and have had a joint injection, you may notice that your blood sugar is higher. Even in that scenario, it's a one-time dose of a steroid medication followed by a long break from steroid medication, and so that's probably not too high of a risk.

The other thing I do want to say about steroids, since we're talking about it, is that the bone density loss from steroids happens very quickly, almost right away.

If you are about to start a high-dose of steroid, I would talk to your doctorthe day that you're starting, even before then, should we anticipate that this is going to be a long course of steroids?

If so, should I get one dose of the once a year medication to protect my bones just to protect me while I'm on this steroid? That way you can actually blunt the early part, the big loss that happens right away. Because if you start a steroid and then six months later come in, a lot of the damage has already been done. You may not have a chance to protect yourself from that steroid.

[41:06] Moderator: Thank you. We have a few questions about drug holidays and when to go back.

One question, I'll get to the other ones after, is about after a drug holiday, is it recommended to go back to the same drug or to switch up the drugs?

[41:30] Dr. Cromer: After a drug holiday, I consider it to be a blank slate. My patients and I have the entire conversation as if we've never used a medication before. The reasons for that are that your health may have changed in that time, your priorities may have changed in that time, and what medications are safe for you may have changed in that time.

For all we know, a new medication might have been approved in that time, so we start fresh after a drug holiday.

[41:55] Moderator: Great. Thank you.

What about the impact of hormone replacement therapy on bone health?

Dr. Cromer:

[42:04] Dr. Cromer: Estrogen is definitely good for the bones. There was a large trial called the Women's Health Initiative in the early 2000s that many of you may be familiar with. That did show that hormone replacement therapy is protective to the bones.

Compared to any of the other medications that I talked about, hormone therapy is not as effective, which is why I probably should have included in this talk, but I did not. But it's certainly y protective. It's definitely a positive

[42:31] Moderator: Thank you. You had mentioned that there are drugs that affect your absorption of calcium, such as omeprazole.

For someone who is on omeprazole, how does that change the amount of calcium that they should be taking? And, as part two, from a different person, what other drugs might be recommended for GERD or the like?

[42:56] Dr. Cromer: Okay. These are great questions. So, in terms of your calcium intake, while you're on a proton pump inhibitor, like omeprazole, I honestly think the best thing to do is ask your doctor to check something called a parathyroid hormone or PTH level.

The reason for that is that PTH is a hormone that controls the calcium level in your blood. It will change much earlier than the actual calcium level in your blood will change because your body works very hard to make sure that your calcium level is in a good range.

If your body is struggling to absorb calcium from your food, your calcium level probably will not change. What will happen is your parathyroid hormone will go up, and it will start pulling calcium out of your bones, which is called secondary hyperparathyroidism and is bad for the bones.

You can check if your body is happy with the amount of calcium that it's getting by getting that parathyroid hormone level checked. When you do have that checked, you should also check your calcium level and your kidney function and your vitamin D because all of those can also affect the parathyroid hormone level.

The second question was other medications for GERD. By far the most effective is the proton pump inhibitors, omeprazole, pantoprazole, lansoprazole, dexlansoprazole. All of those are by far the most effective, and many people need them sometimes more than once a day. 

Other medications include things like famotidine or Pepcid. Those still probably affect your calcium absorption a little bit because it has to do with how acidic your stomach is, and those medicines do turn down the acidity, but they're not as detrimental as medicines like omeprazole, we think.

Other things, so diet change can go a long way if there are certain trigger foods that make your GERD worse or your reflux or your gastritis worse. Avoiding trigger foods, which are generally spicy foods, fatty foods, acidic foods like citrus, red wine, coffee, a lot of good things, but avoiding those can go a long way.

Then there's medicines like Tums, which actually is calcium carbonate, so it counts both as a treatment for gastritis and also a calcium supplement.

Then there's medicines like Pepto-Bismol or generally don't interact with your calcium absorption.

[45:20] Moderator: Great. Thank you.

There are questions about the frequency for which one should have a bone scan. Starting with how soon after steroid use or chemo should someone have a bone scan?

[45:38] Dr. Cromer: It's a good question and it's an area of much debate in the field, so I don't think I can give you the right answer.

It often depends on a lot of other factors that are specific to you, including where your bone density is at the beginning. For example, if the day you start chemotherapy, your bone density is very, very good.

Let's say your T-scores are plus two, then it's hard to make the argument that we should check your bone density a year later, because it's very unlikely that you'll have lost significant bone to the point that you need treatment.

That said, there are some guidelines based on people who already have some bone loss. Let's say you get your bone density screening at age 65, And if your bone density is in the normal range, we generally don't recommend another bone density for at least five years, in some cases, even 10 years.

If your bone density is in the osteopenia range, we generally rescreen in like three to five years. If it's in the osteoporosis range, we recommend starting medication, definitely, and then also rechecking more frequently.

When people are on medication, we usually check the bone density every two years, and the reason we don't do it more frequently is that even in scenarios where you already have osteoporosis and you're on medication; the actual bone mineral density change is very slow for something over years.

The DEXA machine also has a margin of error in it, so if your bone density went up by 1%, it's actually within the margin of error of the machine. The machine will just tell us that the bone density didn't change, so that's why we don't do it.

[47:13] Moderator: Thank you.

Similar to the earlier question about injected steroids in joints, how risky are topical steroids, for example, for eye problems?

[47:24] Dr. Cromer: Yeah, great question.

Both topical and inhaled steroids, which include things like Flonase or asthma inhalers or COPD inhalers, can lead to high levels of steroid in your blood if you take enough of them.

For topical steroids, you really have to slather it all over your body to get enough absorbed that it's similar to taking an oral dose of prednisone, but it can happen, especially if you're using the really strong steroids like clobetasol.

If you're using something like hydrocortisone topical, that's a much weaker steroid, and again, you'd have to pour it all over your body twice a day to get that high-dose of steroid in there. If it's something like prednisolone drops for your eyes, I wouldn't worry about that at all.

Then for inhalers, it's only the very, very high-doses of the inhalers and only if you're taking them more than once a day does it really reach those higher steroid levels.

[48:22] Moderator:

Does decreasing steroid use mean that osteopenia or osteoporosis will be reduced on their own?

[48:32] Dr. Cromer: As I mentioned, we often do see some improvement in bone density after coming off steroids. That is especially true in younger people who are still at a point where they could build some bone density naturally on their own. I would say that's under like age 35. For women, it's generally before menopause that you can really get that recovery well.

You would see some reduction, but I would not stop steroids and then stop screening. I would keep an eye on your bone density. If it's not improved after even a year, one to two years, then I would consider that's the best improvement that you're going to get.

Now if you're in the osteoporosis range still, you should probably be thinking about medications.

[49:09] Moderator: Thank you.

Someone wrote in that they know DEXA scans can also give information about lean mass and fat measurements. Is that something that's recommended alongside bone health, and how would that be used?

Is it the same machine? Is the process the same?

[49:32] Dr. Cromer: So, it is the same machine. The process is similar, not exactly the same, but it just goes over a wider portion of your body.

The order is different. If your doctor orders a DEXA for bone density screening, they are not going to give you body composition measures like fat or lean mass. It's something that you need to check differently. For the sake of bone health, it is not necessary.

There's not strong data saying that that would change our choices or help us guide you differently. It can be helpful in just trying to understand your metabolic health, so it's particularly helpful for people who have something called their colloquially fatty liver disease or otherwise called MASLD.

It's sometimes helpful for people with diabetes to try and understand what their distribution of fat is and whether major lifestyle changes could help that.

[50:22] Moderator: Thank you.

For someone who does have a fracture and x-rays do show osteopenia, should they wait to heal that fracture before starting bone density meds or should they start immediately?

[50:40] Dr. Cromer: These questions are all so good. Thank you all so much for these questions.

First of all, I'd say if you have a fragility fracture, it does not matter what your bone density is, you should be treated.

I mentioned early on there's this idea of quantity of bone versus quality of bone. If you have had a fragility fracture, which again is a fall from standing height or less that leads to a broken bone, then you should be treated. Because even if your quantity of bone is okay, that tells us that your quality of bone is not good.

That said, if the fracture you have is not a fragility fracture, let's say you were in a car accident and you had a fracture that anyone might have had, there is no evidence to really suggest that these medicines slow fracture healing.

In fact, some of them are studied for improving fracture healing, particularly these daily self-injections, teriparatide and avalaparitide, or Forteo and Tymlos, are shown to make fractures heal faster if you have something called non-union, which is a long-time non-healing fracture.

They're also studied for these kind of rare side effects, these atypical femoral fractures. They seem to make those heal faster. I think those absolutely would be safe.

The medicines like alendronate or Fosamax or zoledronic acid or Reclast have been tested in studies where they're given very soon after a hip fracture, and there does not seem to be any delayed healing.

In fact, zoledronic acid or Reclast in particular showed decreased risk of death after hip fracture in one of its studies, so I would not wait. I would just jump on that and try and prevent future fractures.

[52:20] Moderator: Great. Thank you.

We have time for one more question, and I'm going to move away from osteoporosis and osteopenia for a bit about infection, because that's something that certainly folks in this community are very concerned about.

What do people have to worry about in terms of infection risk for the bone? Particularly, we have one person who asked about her knee replacement or other orthopedic or bone health issues that might have infection rather than some of the other things we discussed.

Dr. Cromer:

[52:57] Dr. Cromer: Yeah. So, I do not manage a lot of post-knee replacement infections. I'm probably not the best person to ask about that.

The ones that come to mind for me are if you do have a fracture, if there's an infection in the bone, the bone heals slower and you can have this non-union problem I just mentioned.

The risk is certainly much higher if the fracture is open, meaning that it breaks in than if it's closed. But, if you if you have a surgery to fix the fracture, then there's a risk for infection as well.

There's also a complication called avascular necrosis that can occur in any bone. It is more common in people who take steroids, especially in people who take steroids for a long time, or in people who have chronic illnesses that might result in decreased blood flow to the bone.

How that happens is if you are getting this decreased blood flow to the bone, then there's less delivery of oxygen, less delivery of nutrients, and the bone can actually die even though it doesn't break. That can be very painful and that can become infected.

That's not really something that associates with osteopenia and osteoporosis, but it is something that can be a risk factor, for example, if you're on chronic steroids.

[54:14] Moderator: Thank you so much. On behalf of BMT InfoNet and all of our partners, I want to thank Dr. Cromer for this very helpful, very thorough presentation. And thank you to the audience for joining us and also for your very, very good questions.