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Breaking Bad: diagnosing and treating osteoporosis · 'Bone Up'

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Hello and welcome to the first episode of Bone Up, the podcast all about bones.
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How we make them, why we break them and if we fully understand them.
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I'm David Armstrong.
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Hi and I'm Richie Abel and over this series we're going to be exploring osteoporosis,
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bones, what we know and what we yet to discover and we hope you will join us on the journey.
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So for anyone keen to learn more about our infrastructure of calcified collagen, this
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is Bone Up.
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That's such a brilliant phrase.
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Well, yes, I was trying to get something other than bone, so I thought infrastructure of
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calcified collagen, that'll cover it.
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Okay so we've got a jingle.
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Well hello.
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Hi David, it's great to get started on the pod.
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It is, it is.
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So welcome to you, welcome to everyone to the UK's first podcast on osteoporosis and
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bones.
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Over the series we will be hearing from a whole range of hopefully well informed individuals
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about fragile bones from patients to scientists in the hope of learning more about osteoporosis.
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And I have to point out Richie, the first time that we met, in fact, maybe the first
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thing you ever said to me was, I don't believe in osteoporosis and yet here you are hosting
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an osteoporosis podcast.
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I do remember saying that.
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It was at the osteoporosis leadership training program and I remember we were in a room with
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a whole bunch of other clinicians and the hosts of the program asked what people thought
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about osteoporosis and if they put themselves in osteoporosis shoes, how would they feel?
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And I think I said I would feel insecure because people are about to realize that osteoporosis
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doesn't exist and I still remember the looks I got in the room.
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Everybody was in a sort of shocked, stunned silence at how the osteoporosis society had
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managed to recruit somebody that didn't believe in osteoporosis.
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Yes I do.
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I remember it well.
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But yet you have moved, have you, from your agnostic stance?
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I suppose so, yes.
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I think one of the nice things about coming together with lots of clinicians and talking
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about bone health and bone aging and bone disease is that I have slowly come to realize
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there's lots of different opinions about osteoporosis and I see that maybe there is a wider condition,
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bone fragility and that osteoporosis is part of that.
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It's one of the things that contributes to fragility but there's probably a lot more
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to learn about and the osteoporosis is a very useful concept as long as we use it correctly
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and I hope that one of the things we can do today to get this podcast started out is to
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sort of look at the consensus and give everybody a background to bone fragility and osteoporosis
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so we can all get started together.
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So when we did the leadership course together, David, one of the things that they taught
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us was that you should start building a consensus when you begin working with other people and
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it would be really nice if we could start building a consensus here because I'm sure
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a lot of the people listening have heard stuff about bone disease before.
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Yeah.
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And we need to get everybody on the same page.
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So I suppose the first and most obvious question is what is osteoporosis?
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Well the orthodox answer to that is to go straight to the World Health Organization
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and the World Health Organization fortunately have given us a definition.
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Now their definition involves having a test done called a bone density scan and if you
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produce a result on that of 2.5 standard deviations below a set marker then you have osteoporosis.
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And what does that test actually measure?
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The test measures bone mineral density.
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It essentially measures how dense your bone tissue is or if you want to be really simple
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just how much bone tissue you have.
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The test involves exposing your bone to a set amount of radiation.
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The more bone you have the more it will be absorbed.
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The less bone you have the less is absorbed.
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And we can then measure that and get quite a clear and accurate view of how dense your
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bone is in a number of different areas of the body.
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And there seems to be a related term which I see used quite often which is osteopenia.
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What is osteopenia?
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Yeah, osteopenia.
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Some people come to me and say they've had a diagnosis of osteopenia and the pedants
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among us and you will know that I am very pedantic about this sort of thing will say
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that osteopenia is not a diagnosis.
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Osteopenia is the description of an area on a graph.
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Essentially when you get the result of your DEXA scan you get what is called a T score.
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And your T score is usually negative because your bone density is compared against what's
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considered the peak bone density for human beings aged about 25.
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And we measure this and how many standard deviations below that you are.
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So as I said earlier if you're two and a half standard deviations and other words if you're
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quite a bit below average peak bone density then we say you have a T score of less than
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minus 2.5 and you have osteoporosis.
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There is this sort of yellow area in between the red and the green which we call osteopenia
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which means you have a T score of less than minus one but not yet less than minus 2.5.
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And it's sometimes described as people who have a slightly increased risk of having a
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fracture but in reality it's hard to define.
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So if you suspect somebody of having osteoporosis or low bone mineral density give them a DEXA
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scan and osteopenia is slightly low bone mineral density and osteoporosis is very low bone
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mineral density.
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That's true yes I think in lay terms that's a fair description.
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Does everybody who fracture have osteoporosis?
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No they certainly don't although you could say it depends how you define osteoporosis
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but certainly according to the World Health Organization definition that we've just discussed
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then no lots of people fracture with bone mineral density greater than minus 2.5.
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In fact at a population level the majority of people who suffer for example hip fracture
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actually have bone mineral density in the osteopenic range rather than in the range
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of osteoporosis.
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It's just that there are many more people within that range.
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So what are the other risk factors then that might also be contributing to the fractures?
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Well that's interesting because there are other what we call independent risk factors.
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So if your bone density machine is broken for the afternoon and you come to my clinic
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and say what are the chances of me breaking a bone there are questions I can ask you that
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will help make that decision.
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So for example if your mum or dad have fractured their hip during their lifetime then you're
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substantially more likely to break your hip.
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So I can divide the population into those who have a parental history and those who
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don't and that gives us a good idea or a good way of dividing up your risk and in fact there's
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a quite a long list of what we would call independent risk factors.
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And is there a way that you can record all of these for your patients?
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Yeah you can go through them and in fact people have done this and as you know our colleagues
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in Sheffield University have done this and produced an algorithm which is just a complicated
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calculation called the FRACS score and the FRACS score basically takes all those independent
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risk factors such as smoking tobacco, taking excessive alcohol, taking glucocorticoids,
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having diabetes, having an early menopause and a long list of other independent risk
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factors and puts them together and essentially divides people up into those who have lots
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of independent risk factors and those who have few and can give people an estimate of
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their 10 year risk of actually having a fracture without even doing a DEXA scan.
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For the DEXA earlier you mentioned there was kind of a grey area where people who have
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very low bone mineral density are perhaps more likely to fracture but still people who
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have only slightly low bone mineral density osteopenia might still fracture.
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Does the use of FRACS improve your ability to work out which of your patients might fracture?
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Absolutely, I mean that's one of the reasons that we use it at the clinic and you can,
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FRACS gathers up the independent risk factors but then you can also do a DEXA scan and you
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can put the bone mineral density from the DEXA scan into that calculation and you can
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get an even better or even more accurate figure for the risk of the patient in front of you
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suffering either a hip fracture or any sort of fracture although it still must be said
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it's not perfect and we do see people with relatively low FRACS scores who still go on
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to break bones and we see people with high FRACS scores who don't break bones and therefore
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we know we're still very much in the foothills of understanding why people suffer fragility
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fractures.
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So how do you decide which of your patients are going to get treatments for fragility?
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Well we use both the FRACS and the DEXA.
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There are certain groups of people who almost without doing any other estimation we feel
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do need treatment so for example if you're over the age of 75 and suffer a hip fracture
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almost by definition you have fragile bones and therefore that's a sort of patient I would
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be very quick to consider.
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So David from the description you're giving us there seems to be several ways in which
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you can assess a patient's bone health either using a DEXA scan or using the FRACS question
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there or perhaps the FRACS and DEXA together as you've described.
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How do you decide which of your patients need treatment?
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That seems a simple question but it actually gets to the very heart of what we're talking
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about.
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Ultimately what I want to do is reduce your risk of having a further fracture and therefore
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I want to decide which of my patients will get benefit from the intervention I give them
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in terms of making it less likely they will break something again.
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So for example if I see someone in their 80s or 90s who suffered a hip fracture then almost
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without any assessment without a DEXA scan or without FRACS I know that they have fragile
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bones and they will undoubtedly benefit from treatment on those fragile bones so there
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are some people who will benefit from treatment almost without any formal assessment.
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For most people however a DEXA scan and a FRACS helps us choose between those who will
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definitely get a risk reduction in terms of further fracture and those who won't.
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But really underneath that answer is the wide variety of treatments because not all treatments
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are pharmaceutical treatments some treatments involve alterations in lifestyle or habits
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or diet as well so when you ask me to choose a treatment what I tend to think of is more
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general management of patients and of course this is a long-term condition so management
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is also a good word because it refers to trying to improve someone's bone health over a long
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period of time.
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That's really interesting I've actually been quite shocked you know coming in to do medical
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research about how much doctors have to think when they're treating their patients.
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No two people are the same everyone's an individual there seems to be so much for doctors to consider
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about their patients and I hope some of the Imperial Medical students might tune into
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this podcast and that's a good lesson for them as well.
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So let's get let's get back to the treatments then I'm sure the people who are listening
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to the podcast have through some way found out they have osteoporosis either they've
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had the DEXA or FRACS or maybe they suffered a fracture and through one of those routes
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they've been offered treatments.
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What kind of treatments do you give to your patients and why?
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Okay I think there's a little basic science required here and this is something that I
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always explain to patients because I think if you understand how treatments work then
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you're more likely to take them and use them and benefit from them.
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There are two teams of cells within your bones there are cells called osteoblasts which build
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bone and cells called osteoclasts which remove bone and they take part in what you might
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call a bone turnover cycle.
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And most treatments we have either increase bone building or reduce bone removal and as
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a result you get a net gain in bone mineral density.
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For most people they have osteoporosis because they have excessive bone loss and therefore
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most of our treatments are aimed at reducing bone loss.
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Again I sometimes explain to people this is like filling up the bath with water and we
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can either block the plug hole or turn on the tap to run water in more quickly and most
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of the treatments that we have are ways of blocking up the plug hole and therefore the
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water fills up in the bath.
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So the standard treatment or the treatment that most people will be offered at some point
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are treatments called bisphosphonates.
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Bisphosphonates are usually taken as tablets once a week or sometimes once a month although
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if you have problems with your gastrointestinal tract you can get them as an infusion once
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a year.
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Bisphosphonates adhere to the surface of bone and they interfere with how the osteoclasts,
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the bone removal cells work and they reduce the risk, sorry they reduce the rate at which
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you lose bone.
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They block up the plug hole essentially and therefore the density of your bone, the density
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of the bone mineral tissue gradually increases over a period of time and they would form
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the mainstay of our treatment for osteoporosis.
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And what about the less invasive treatments I've heard about like calcium supplements,
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vitamin D?
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Yeah I maybe sort of jumped ahead to the pharmaceutical treatments.
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For many people then we start off with lifestyle, in fact for all patients we start off with
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lifestyle and diet.
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Calcium and vitamin D are essential.
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Bone tissue is made up of as you know collagen and calcium crystals and it's essential to
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have a good calcium intake in the diet and this is something we always ask patients.
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Most patients have reasonable calcium intake but you do encounter people fairly frequently
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who have very poor calcium intake over many many years.
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And although opinions differ a little on this there is no doubt that if you have taken practically
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no calcium in your diet for 30 or 40 years then your bones are going to suffer as a result
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of that and either you need to increase calcium in the diet or you need to take a calcium
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supplement.
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There is very good evidence however that taking a calcium supplement by itself doesn't help,
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you need to take vitamin D along with that and vitamin D is best thought of as a sort
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of passport to get calcium from where it is now closer to where you want it to be and
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that is in the bones.
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So for example vitamin D helps you get calcium from the stomach into the bloodstream, helps
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absorb calcium into the bloodstream.
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It reduces calcium loss in the kidneys and it encourages calcium to move from the blood
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into the bones.
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So again when I explain this to patients I often explain vitamin D is like a passport,
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it gets calcium more quickly to where it wants to be.
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There is good evidence that low vitamin D levels over a long period of time tend to
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be bad for bones as well.
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So again this all comes to the general assessment of the patient.
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If I find someone who has a very poor calcium intake for years who is severely deficient
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in vitamin D and who maybe is a heavy smoker I know from research that I can actually improve
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their bone mineral density and reduce their risk of fracture by altering those lifestyle
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changes and particularly for younger patients that is something that I would consider doing
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maybe before reaching for the prescription pad.
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However in some patients either their FRACS predicted score is so high or their bone mineral
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density is so low or they are an older patient and really making big changes to lifestyle
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at this stage are going to be difficult then you would move more towards the pharmaceutical
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end of the treatments.
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So all in all then the pattern you seem to be describing is that for people who are diagnosed
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with fragility you can prescribe lifestyle treatments, you can prescribe exercise, you
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can prescribe supplements and for maybe the people with more severe fragility you can
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move on to the pharmaceutical options, the medicines like bisphosphonates.
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One thing that struck me there was where you talked about younger patients and it occurred
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to me one thing we haven't really thought about yet so far is what type of people suffer
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from osteoporosis, what kind of age range are we talking about?
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The honest answer to that is that the majority of people are older and that the majority
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of people are older females that is after the menopause because while in clinics and
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while in research and while in the sort of learned journals we often discuss rare cases
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overwhelming majority of osteoporosis is post menopausal osteoporosis.
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Nevertheless there are other large and important groups of people who also have low bone mineral
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density, the first group that springs to mind certainly from a doctor's point of view are
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people who take steroids, glucocorticoids in the long term, that could be for chest
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disease such as asthma, it could be for conditions such as arthritis or inflammatory bowel disease
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and glucocorticoids they're bad for your bones in many ways but they certainly encourage
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bone loss, they encourage the cells that remove bone and they form a big group of patients
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who have low bone mineral density but who aren't post menopausal females.
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There are other groups of patients who have low bone mineral density, in the youngest
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age group patients I often get referred to the clinic are those with eating disorders,
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it's sometimes believed that's purely because they don't take enough calcium or vitamin
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D in the diet but in fact that's a multifactorial problem and having low weight is a big contributor
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to osteoporosis, weight bearing exercise is an important management tool or lifestyle
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change that you can make to encourage your bones to get stronger and you find that if
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patients are very underweight then they often have lower bone mineral density.
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The other issue with eating disorders is that it often affects the menstrual cycle and estrogen
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levels fall and so if I see someone who's 21 who maybe suffers from an eating disorder
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and has very low bone mineral density, the density you might expect from a 70 or 80 year
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old I wouldn't necessarily reach for the same drugs as I would for someone in an older age
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group because there are so many other lifestyle things that can be changed and often just
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restoring a normal menstrual cycle is very important for that group of patients.
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So what's coming across here is that bone fragility is a very very complex condition
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and if the people listening go on Google and Google osteoporosis or bone fragility what
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they'll probably see is some document that says well osteoporosis is a loss of bone mineral
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density perhaps a loss of bone mass that happens when you get older but actually there's a
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lot more to it than that.
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Yes older postmenopausal women and maybe much older men are at higher risk because of loss
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of bone mineral density but we have to think about how people's lifestyles affect their
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bone perhaps especially when they're very young treatments that people are receiving
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you mentioned glucocorticoids lots of cancer therapies for breast cancer and prostate cancer
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can also cause bone mineral density to drop.
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This is a much more sophisticated disease than you often hear or see about.
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It is and while we have talked primarily about bone mineral density and that's something
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which we know about and which is easy to measure there are other factors and I know this is
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something you've been involved in and there are other things we can measure about bones
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which may well predict who fractures and who doesn't aside from just how much bone tissue
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you have and I think that's looking at the quality of the bone.
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Yeah I think that on the whole certainly in the perception of the public and in a lot
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of professionals the view is that osteoporosis bone fragility whatever we're going to call
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it is something caused by loss of bone mass and bone mineral density but there's probably
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a lot more to it than that.
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You mentioned earlier on that a lot of people who fracture have osteopenia and not osteoporosis
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which is only slightly low bone mineral density as opposed to very low bone mineral density
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which begs the question why would people fracture when they have osteopenia and for the last
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decade or so a lot of scientists and a lot of clinicians have been talking about a concept
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called bone quality which is all about the quality of the material and maybe it doesn't
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matter if you don't have very much bone if that bone is of a very high quality I suppose
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an example you might give is concrete cancer.
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If you build a very sturdy looking building out of very poor concrete it's going to collapse
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and if you build a very narrow looking building out of very good concrete it's going to stay
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up and a lot of the research that's going on in bone at the minute is to try and isolate
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what this bone quality really is what aspects of bone material also contribute to the strength
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or also contribute to the fragility and it could open up whole new ways of diagnosing
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the disease and also treating it.
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I think that's very true I mean as a Welsh rugby supporter you will know that 14 men
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playing well can play just as well as 15 men not playing quite so well and indeed that's
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joking aside that that's a reasonable analogy you can have lots of players of reasonable
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quality you can have a small number of players of very good quality and certainly when we're
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at the clinic and when we're talking to patients and thinking about things we're simply thinking
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about the number of players you have in your team and we're good at increasing the number
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of players you have in your team but we're not that really we're not really that good
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at measuring or certainly the clinic at measuring how what the quality of the bone is like and
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we don't really know how to increase the quality of that bone certainly in terms of pharmacology.
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I really like your analogy there I hope England have a player sent off as well because it
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seems to be the Welsh way we'll solution to things yeah.
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I do really like your analogies I love the analogy about vitamin D being like a passport
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it sounds much more like an original I think that is one of mine I have to say but it is
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it gets you know vitamin D gets from your mouth into your bone and every time it reaches
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a barrier like the gut or the kidney or something the passport vitamin D says come on ahead
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calcium you know.
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I sort of feel like vitamin D is more like an EU passport than the UK passport.
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Oh we want to we want to avoid controversy yeah yeah calcium gets to the Irish seaboard
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or in the west of Scotland and just can't get over to Northern Ireland.
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So a lot of my research is about trying to identify those properties and I hope that
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in some of the other podcasts as we as we move through the topic of bone fragility we
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can break down a little bit more you know why people fracture what are the risk factors
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how does osteoporosis i.e. low bone mineral density contribute to this wider idea of bone
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fragility what else is going wrong you know you mentioned right at the beginning of the
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podcast that bone is collagen and mineral and one of the things that strikes me is that
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in all the things we've been talking about today with the diagnostics like Dexa for example
27:40
imaging the bone to measure the bone mineral density I kind of feel you're only getting
27:43
half the story you know if you're missing out the collagen as well there's a lot more
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there and I know there's some groups in the UK and around the world who are doing things
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to look at the collagen etc as well so hopefully hopefully we can pick up all that as well
27:57
but yeah and to bring that right back to you know to the clinic I mean I know from really
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good research that giving people bisphosphonate reduces their risk of having another fracture
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compared to not getting the bisphosphonate and I can share that with patients and say
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this is the drug for you however if I see someone who's had a Dexa scan and they maybe
28:17
have an osteopenic value and in fact maybe not a very low osteopenic value and I've said
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to them you know you fractured and actually your bone density is not that bad and I'm
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going to give you a drug which functions to increase your bone density further and the
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patient with some justification I think can say to me but look my bone density is not
28:38
that bad to start off with what evidence have you got that making that even higher will
28:44
reduce my risk of having a further fracture when having quite good bone density in the
28:49
in the first place didn't actually reduce my risk of fracture and I think that's a that's
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a good question and I think those are often patients who have some problem with the quality
28:59
of their bone and while bisphosphonate and other treatments like that may still be an
29:05
important part of their of their management it's always in the back of my mind that I'm
29:12
giving them more bone material which is maybe not of great quality.
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So I can imagine right now there's people hopefully who are listening to this podcast
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who are shouting at the speaker should I take collagen supplements that's the question that
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I'm always getting asked so I'll put that to you now.
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Do collagen supplements work is it just a figment of the internet's imagination?
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Yeah I mean I think this it's almost in in future episodes I think we're going to have
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a I'll have a fake news category it's important to remember that lots of things that you take
29:48
into your mouth going to go into the stomach they hit the they hit the hydrochloric acid
29:53
in your stomach and they get taken apart and and a lot of a lot of the stuff doesn't get
30:00
absorbed some does get absorbed there's no evidence that the body will necessarily take
30:05
that collagen that you put in the top end and use it to strengthen your bones.
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Now it must be said there is evidence that increasing protein in the diet can be of benefit
30:16
to some patients if you've had a relatively low protein content in your diet and if you
30:21
take extra protein particularly if you exercise and possibly if you take calcium and vitamin
30:26
D as well that can be of benefit but it can be of benefit in the sense that it tends to
30:32
increase your bone mineral density.
30:35
I can't necessarily tell you that taking protein will improve the quality of your bone in any
30:42
way.
30:43
Well there's also a lot more going on there isn't it I can imagine that if somebody is
30:47
inclined to change their diet to improve their bone health they might also be inclined to
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exercise more smoke less and drink less so to try and pin down one effect among many
30:58
must be really hard.
30:59
Well absolutely and I think it's something else we will cover in that muscles and bones
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muscles and bones are similar you always find muscles and bones together they they develop
31:11
from the same mesenchymal stem cell and therefore you find things that are good for muscles
31:17
for example exercise are good for bones because exercise increases the density of your bone
31:24
things that are bad for bones for example taking steroids steroids are also bad for
31:29
muscles and that they they cause muscle atrophy so many things so for most most risk factors
31:36
for low bone density are also risk factors for for low muscle mass and vice versa.
31:44
So let's get back to the the treatments for a minute because I know people always have
31:51
questions about the treatments and earlier when you mentioned bisphosphonates and you
31:56
described how they work by turning the tap plugging the bath so you stop the lot yeah
32:03
that's a good example that so you plug the bath and you allow the bone mineral to increase
32:12
how effective are bisphosphonates at reducing somebody's risk of fracture?
32:20
The answer to that is you could go through a hundred different papers and find a hundred
32:25
different figures but in general terms I say to people they will reduce your fracture risk
32:32
by somewhere between 30 to 50 percent across the board across different age groups and
32:38
in different conditions that of course is a relative reduction so if you have a very
32:44
very high risk of fracturing then reducing it by 30 percent is really important if you
32:49
have a very very low risk of fracturing then even reducing it by 50 or 60 or 70 percent
32:56
isn't actually doesn't make that much clinical difference to the risk of further fracture
33:01
but in general terms if your doctor has looked at your dexa has calculated a fraction and
33:07
has correctly decided that you should take a bisphosphonate then the relative risk reduction
33:13
from taking that is worthwhile and as I said somewhere between 30 to 50 percent across
33:18
the board in most patients.
33:23
And how often do people take the treatment how long should they take the treatment for?
33:29
Yeah well that's another good question it's a slow treatment it's not something you can
33:34
take for six months and see an immediate improvement you have to gradually slow down the activity
33:40
of these osteoclast cells and allow the osteoblasts to gradually increase bone mineral density
33:47
so we really think in blocks of five year treatment sometimes people say three to five
33:52
years but I have to be honest and say I'm not sure if there's any point in taking the
33:56
treatment for three years so we think of this in five year blocks of treatment and if you've
34:01
taken your bisphosphonate for five years and you haven't had a fracture and usually if
34:06
we see a modest increase in your bone mineral density on a dexa scan then for many patients
34:11
now we recommend having a holiday from taking that drug.
34:16
For other people if they've reached the five year mark and maybe they've had a fracture
34:21
or their bone mineral density is still quite low then we recommend that they continue to
34:25
take it for a little longer but now there's generally a ceiling of 10 years because once
34:32
you reach 10 years on a bisphosphonate it appears that in general terms you've got most
34:37
of the benefit you're going to get from it but you do run into greater risk of some relatively
34:43
rare side effects which do start to increase from about five years onwards.
34:50
Would you have any advice for anybody listening now who has been diagnosed with osteoporosis
34:57
via a dexa scan or been identified as somebody who is at high risk of a fracture through
35:04
the FRAX questionnaire and has been offered bisphosphonate?
35:12
What advice would you give those patients?
35:14
Yeah I mean I would say to them if they have seen a specialist or if you have seen your
35:20
GP and you've had a proper assessment done and the bisphosphonate has been recommended
35:25
then for most people I would advise that you take it because it's an effective drug.
35:31
There are tens of thousands of people in the UK today who would have had serious fractures
35:38
who have not had those fractures because they've taken the bisphosphonate.
35:42
I think the two biggest issues that come up in terms of bisphosphonates are people take
35:48
them for a period of time and then stop taking them so they have a painful fracture and they're
35:54
worried about having a further fracture and they maybe have a dexa scan done and they're
36:00
told they have osteoporosis and they faithfully take that tablet for six months or nine months
36:05
or a year but after 18 months or two years the pain of the fracture has gone away, they
36:12
have other things to worry about and often you find the compliance with the medication
36:17
drops off and there's this figure that we often hear that after one year well under
36:25
50% of people are still taking their bisphosphonate who are prescribed it and in fact people often
36:31
quote figures as low as 30 or 33% of people continue to take their bisphosphonate in the
36:37
long term.
36:38
Now for some people that's because of side effects but for many it's just because they
36:42
haven't bothered getting the repeat prescription and unfortunately this is a drug you need
36:46
to take, it's a commitment in the longer term to get the benefit from it and those figures
36:52
that I've quoted about reducing the risk of fracture those come from research studies
36:56
where people take their drug for the full length of time.
37:00
I suppose the other thing I would say to people is that the one issue that stops people taking
37:07
the drug is concern about side effects and usually concern about two rare side effects,
37:13
one called osteonecrosis of the jaw or ONJ and another called atypical femoral fracture.
37:22
It must be said that the risk of both those things is substantially less than the risk
37:26
of you having another fracture in almost all cases or indeed you wouldn't have been prescribed
37:32
the drug.
37:34
Atypical femoral fracture is an unusual type of fracture that occurs at the top of the
37:39
leg and it's usually associated with having been on one of those treatments for a very
37:45
very long time, certainly more than five years and sometimes we would have found in the past
37:50
people more than 10 years.
37:52
My analogy about the bath is useful in that instance in that it's important to block up
37:56
the plug hole but if you let the bath run for a very long time eventually the water
38:01
starts to spill over and you do have to take the plug out and let it run out a bit.
38:07
It seems that inhibiting those osteoclast cells from working is good to strengthen your
38:14
bone initially but if you inhibit those cells for a very very long time then you stop them
38:20
doing some of the important repair work that they have to do and you run the risk of some
38:25
of these rather unusual sudden fractures.
38:28
But the risk of that it must be said is low and it's not something if you've been properly
38:35
assessed the risk of you having what you would call a normal fragility fracture will be much
38:41
higher than one of these rare fractures but it's important once you get to five or six
38:45
or seven years that you assess the need to keep going.
38:49
The other risk I mentioned the osteonecrosis of the jaw is a condition in which you get
38:55
inflammation and infection down in the root of a tooth.
39:00
It is very rare it is associated with having taken bisphosphonates for a long time and
39:05
it tends to occur mainly in people who have very bad dentition who have a previous history
39:11
of abscesses or dry sockets or other major dental problems to start off with.
39:21
It's more common in smokers and more common in people who have a treatment for for mouth
39:25
cancer or cancer around the skull.
39:28
We recommend people get a checkup with the dentist regularly as we all should do if you
39:33
haven't had a check with your dentist for six months before starting a bisphosphonate
39:37
you should do that just to make sure things are okay with the teeth but otherwise the
39:41
risk of that happening is still relatively very rare and it's not something I would let
39:46
people interfere with the decision to start a bisphosphonate in most cases.
39:53
That's a really lovely description of the treatment there and it was interesting how
40:00
you described the side effects.
40:04
I've never really heard of bisphosphonate being described as a commitment before but
40:10
that's really interesting because it does take a long time for the treatment to work.
40:16
What kind of discussions do you have with your patients when you begin prescribing them
40:23
the bisphosphonate and do you have any follow-up or discussions with the patients further down
40:30
the line?
40:32
Yeah I mean it's not unusual and it's disappointing to find someone who has been prescribed a
40:39
bisphosphonate but who has quite simply been prescribed the drug.
40:44
They've had a phone call from the GP receptionist to say there's a new drug here for you there's
40:50
little explanation as to why you're being prescribed it there's little explanation as
40:55
to how you take it because it's important that a bisphosphonate is taken on an empty
40:59
stomach first thing in the morning with a glass of water not not with milk or tea or
41:04
any food and that about half an hour is left before you eat anything.
41:09
So it is a commitment we talk about lifestyle changes it's almost a lifestyle change and
41:13
that you need to commit to that in the long term but it's something we get certainly in
41:21
in secondary care we hopefully have a little more time to spend to talk to patients and
41:28
actually maybe I shouldn't say that about secondary care because that sounds if I'm
41:30
criticizing primary care I'll go back and say I think the key here is to spend a little
41:36
time explaining to patients so for example the way I explained about bone building cells
41:42
and bone removing cells about the plug in the bath and how taking this tablet plugs
41:47
up the bath and let your bones gradually become stronger if you explain to a patient that's
41:52
how it works patients will buy into that and they will know why they're taking it if by
41:58
contrast a patient simply receives a phone call from a GP receptionist to say there's
42:03
a new tablet here for your bones without any explanation then they may take it for a period
42:09
of time thinking it will help the pain in my bones they may take it until they next
42:13
see the orthopedic surgeon who says your fractures healed you can now go and they won't actually
42:18
buy into that longer term commitment knowing that their bones will be gradually getting
42:24
more dense and stronger and less likely to fracture over a long period of time.
42:30
There is good evidence that a call from a nurse even at six months or 12 months to check
42:35
how you're getting on makes a difference it's the sort of thing which overall isn't that
42:39
expensive but it's sometimes overlooked and it's sometimes difficult to organize so I
42:45
would say if you ask me to pick one thing about how we manage osteoporosis that we could
42:50
improve upon it's probably that follow-up at four months six months 12 months just to
42:56
check the patient is still taking the tablet because in financial terms that's a lot cheaper
43:02
than someone in two or three years having a hip fracture or shoulder fracture or spinal
43:07
fracture and ending up back in hospital.
43:10
It's that feeling too that we haven't forgotten about the patient there are some conditions
43:15
where people have to come to the hospital regularly and they face-to-face contact with
43:19
doctors and nurses on a regular basis often with osteoporosis we're starting a treatment
43:24
and we're saying this is a treatment that that goes on for three to five years or longer
43:27
and I think that regular contact just to check that you're doing okay is really important.
43:33
Now that can be done by pharmacists can be done by nurses it can be done by a whole range
43:37
of people it certainly doesn't have to be done by the doctor and going forward that's
43:43
something that is a change in the way we're thinking about things and that's something
43:48
that that we encourage very much at a local level that we work as a team now and that
43:54
if the community pharmacist knows that a patient has stopped picking up their prescription
43:59
then I want to hear about that because that is knowledge that is out there and if then
44:04
a phone call from my nurse to that patient to say you've stopped picking up your prescription
44:09
is there a problem then that can get the ship back on an even keel again and the treatment
44:14
goes forward and five years down the line the patient hasn't suffered a fracture.
44:19
What we don't want is the patient giving up the medication the local pharmacist knowing
44:23
that they've stopped picking it up the GP record showing that they're not picking it
44:27
up but no communication there between all those groups and the patient then turning
44:31
up next year with with a hip fracture which which is a disaster.
44:38
So I suppose that's something that we haven't really picked up on very much yet is what
44:42
actually are the consequences of a fracture.
44:47
So what are the what are the common fractures and what happens to somebody when they do
44:51
fracture?
44:52
Well the immediate as someone who has suffered a number of fractures myself the immediate
44:56
consequence of course is the pain of a fracture but we tend to think we tend to think in the
45:02
longer term of I suppose the the time it takes up in hospital and the cost of being in hospital
45:10
and then also of course the mortality associated with fractures and people sometimes don't
45:14
realize this that the fractures particularly major fractures are associated with significant
45:20
mortality.
45:21
So the figures which are relevant really across the Western world and I don't think have changed
45:27
much in the last 20 years are that around 20 percent of people are dead within one year
45:33
of suffering a hip fracture and for some groups of people like men for example that rises
45:38
to 25 percent or more.
45:40
So if you consider a hip fracture as a condition that has a 25 percent one-year mortality that
45:46
immediately makes it a much more fatal condition than most types of cancers nowadays and that
45:52
most forms of myocardial infarction or stroke or other serious conditions.
45:58
It must be said as well that even fractures of the vertebrae in the spine are associated
46:03
with significantly increased risks of mortality.
46:07
So really all types of fracture are not good for you and make it more likely that you will
46:12
or so I should say all types of fragility fracture are not good for you and can be shown
46:17
to increase your risk of mortality at the end of the year.
46:23
One of the things I would really love to do is raise people's awareness about bone fragility
46:33
and it was interesting there what you said about the mortality and how severe the disease
46:37
is even in comparison to some cancers.
46:42
There does seem to be a general attitude that bone fragility is something that occurs to
46:49
everyone as we age particularly postmenopausal women loss of bone and a fracture is inevitable
46:57
and that there's nothing really that we can do about it and it would be really wonderful
47:03
if we could change that perception because there are effective treatments.
47:07
There are diagnostics.
47:09
I guess there's always room for improvement in the treatments.
47:12
If we could get from 50% reduction to 100% reduction in the risk that would be wonderful.
47:17
If we could identify more people or identify them early and get them on treatments like
47:21
calcium and vitamin D, get them exercising, stopping smoking, that would be wonderful.
47:27
And I really hope that through this podcast we can reach out to people and try and raise
47:33
the profile of fragility and get a general discussion going about what we can do about
47:38
it, how it's not inevitable and if we can put more money and more research time in things
47:44
like bone quality.
47:47
When you talk about preventing this from happening if there was one age group I would concentrate
47:54
on to prevent osteoporotic fractures in 75 year olds, it's teenagers and people in their
48:01
20s, it's achieving peak bone mass because the higher peak bone mass you get the further
48:08
you have to fall if you want to put it like that when you get older and you start to lose
48:14
bone.
48:15
So while it's really important to treat people who already have osteoporosis in their 60s
48:20
and 70s, if we could prevent osteoporosis developing by getting people as high bone
48:26
mass as they could get when they're 25 then that would actually save us so much money
48:32
time and effort and disease later in life.
48:36
So bone fragility then is not just a factor of aging but it's also a factor of development
48:42
and if we could encourage better and healthier development people would have a lot further
48:46
to fall as they age before they suffered a fracture.
48:50
I think that's absolutely true, I mean you were saying is this just an aging condition,
48:54
there's no doubt about it once you get to your 90s you tend to have lower bone mineral
48:59
density and you're more likely to fracture but that does not mean that there's lots and
49:03
lots of people between the age of 40 and 90 let's say that we could do so much to improve
49:10
their bone mineral density, so much to reduce their risk of recurrent fractures.
49:15
So I feel this is a really positive note to end the first episode on and I hope that in
49:22
the future episodes of the podcast we're going to be able to explore some of those ideas,
49:28
what we can do to improve people's development, what we can do to slow aging, how we can encourage
49:33
people to have healthier and longer bone lives and I'm really excited about finding out.
49:40
Yeah we've touched on so many things right from new research at the cellular level, things
49:46
you're doing to look at elasticity and quality of bone right down to how we could get community
49:51
pharmacists to let GPs know if the patient's not picking up their prescription and everything
49:57
in between to improve bone and reduce the risk of fractures.
50:04
You know the holy grail if I can put it like that of osteoporosis treatment is seeing a
50:10
patient who's fractured their hip today and knowing that if I had seen them last week
50:16
I would have a test that would have shown me that they were almost certain to fracture
50:21
their hip today and also have a treatment that I know if I'd given it to them last week
50:27
would almost certainly have prevented them from fracturing their hip today and those
50:32
are the two the two sides of the coin being really good at spotting who's going to fracture
50:38
and we're well away from that now and having really effective treatment that prevents that
50:44
fracture and if we can move those two things forward then we'll be a lot closer to curing
50:52
osteoporosis.
50:55
Fantastic so that gives us a good scaffold going forward we know what we're looking for.
51:01
Excellent I'll see you next time on the next episode of Bone Up.
51:05
Bone Up I love that title.
51:09
Thanks everyone for listening we hope you enjoyed it and we hope you come and tune in
51:14
for future episodes where we'll unpack some of these concepts a bit more and delve deeper
51:19
into the world of bone fragility.
51:23
Thank you.