Support For Those Quitting Prolia

Hey Formisc,

I believe your transition from Prolia to alendronate had perfect timing and will hopefully allow you to avoid any type of rebound. Might be a good idea to check your calcium in the next 30-60 days just to be sure CTX stay low but you're probably good. Many people that transition like you did after just 18 months will continue to gain bone mass on alendronate after Prolia. You might also have a low CTX baseline, which again, helps with the transition. I would not worry about the low CTX markers. Low is good and it will continue to be suppressed on alendronate. For reference, my CTX after one month on Prolia was 37pg/mL. It will be higher by month 6 before my next shot.

Not sure what to tell you on dental surgery other than tell your surgeon that you are on alendronate so they can get the job done quickly to minimize risk. Exposed bone seems to be what you want to avoid.

So the low calcium needs to be addressed. I to saw my calcium drop when I started Prolia and have bumped up my intake. I have hypercalciuria as well which means I have to take even more than the average just to have a chance at building bone. Low calcium can cause all kinds of side effects so you need to make sure you're getting enough in your diet + supplements. Prolia and alendronate will make it more difficult for your body to borrow calcium from your bone bank (so to speak). You REALLY want to get close to the 1200mg/day range to ensure you have enough calcium to support your bodies set point as well as to have enough for your bones to build. You can't build bone without calcium.

25(OH)D looks perfect. To low or too high is not good for bones. I'm a bit surprised your PTH is only at 3.5 pmol/L (33pg/mL). PTH will typically go high when serum calcium is low. I would have expected numbers closer to 60-70pg/mL. I can't explain that one. Maybe my conversion is off.

Albumin looks great too. No calcium correction required.

My two cents.

Hi Mayblin,

Sure. A little background first. The form of calcium in your body that is considered physiologically active is called calcium ion or free calcium (Ca2+). When you read the "calcium" on your blood test, it's total calcium. Total calcium is roughly 45% calcium ion, 45% calcium bound to albumin, and 10% other calcium compounds (like calcium phosphate, calcium sulfate...).

Since measuring calcium ion is a bit tricky and more expensive, most doctors just use total calcium and assume the percentages listed above. When you use total calcium, you should adjust the number based on the blood albumin when albumin is less than 4. The equation for the adjustment is: Corrected calcium (mg/dL) = measured total Ca (mg/dL) + 0.8 (4.0 - serum albumin [g/dL]). If you like, here is a link to a calculator https://perinatology.com/calculators/Corrected%20Calcium.htm .

I'm putting together a presentation on Calcium and Vitamin D for Osteoporosis now. Below is the draft slide on corrected calcium.

Thank you very much for your explanation. I got the conversion part. Is the corrected calcium level a better indication of calcium deficiency (or overage)? If so, whats the reference range?

Overall I'm still not quite getting how a blood calcium level would indicate whether or not a person is calcium difficient. It's said that our own PTH, if at normal functional level, would fine tune our blood calcium level to normal range for vital functions such as nerve, heart and muscle. And the biggest reservoir in the body for calcium is bone. That is, if we are truly difficient in calcium, our bones will be sacrificed to maintain a normal blood calcium level. How do blood level of free calcium ion, albumin bound calcium or other calcium salts reflect whether or not a person is actually difficient of calcium, if at all?

Thanks, Michael, for your very helpful and encouraging remarks. And thanks for posting your CTX score - it is reassuring that my low CTX may not be a cause for worry. Without any baseline BTM tests, i can only speculate that my baseline CTX was relatively low because Prolia did not increase my bone density much over the 3 injections. Which would hopefully mean that there are less "pre-mature" osteoclasts floating around

Yes, i plan to do another BTM in 2-3 months to monitor my CTX and calcium level. My PCP had prescribed 900mg calcium carbonate daily but i was concerned about overly high level of calcium causing calcification of arteries so i opted for 500mg of calcium hydroxyapatite instead. Will now supplement this with 200mg and 400mg of calcium citrate on alternate days. Not sure if that will be sufficient to lift up the calcium level into the recommended range. Btw, the 8.3 is the "corrected" calcium number by my doctor - the original number was 8.4.

I didn't really look at the PTH number as it fell within the recommended range. Your conversion is correct but trying to understand why you think it should be 60-70 pg/mL because from my googling, the normal range is between 15-65 pg/mL:
https://my.clevelandclinic.org/health/articles/22355-parathyroid-hormone
Unless you are saying that the PTH should have increased to compensate for the low calcium. Perhaps something to discuss with my doctor.

Thanks again, Michael for sharing your wealth of knowledge and all the best

Hi formisc - Yes, the standard range for PTH is 15-65 pg/mL, however, it will go higher and even out of range when your body has a low calcium level. This is the signal to your bone, kidneys, and intestines to gather more calcium into your blood. My last blood test where my calcium dropped to 8.7 (normally around 9.5), my PTH jumped to 70 (normally 45). So I increased my calcium to get it back up. Prolia (or bisphosphonates) can make it tough for your body to get calcium from your bones when it needs it, which is good for bones, but bad for your bodies ability to control calcium without adequate diet calcium.

Now let's talk about calcium intake and supplements. I'm actually working on a presentation for next month on Calcium and Vitamin D for Osteoporosis for Bone Buddies. Calcium is a sensitive subject because there is a lot or religious beliefs surrounding types of calcium.

First, calcium intake. Dr. Fred Coe, who is recognized by many doctors as the worlds best nephrologist, did a study showing the average normal person needs ~700mg of calcium just to break even on bone balance. If you have elevated urine calcium, it's REALLY tough to get enough calcium to get to bone balance. If you cannot get to bone balance, you will lose bone, full stop. The body cannot manufacture calcium, it has to come from your diet or bones. Below is a draft slide from my presentation that shows the study outcome. I'm actually not surprised you did not gain much bone mass on Prolia if you were not getting adequate calcium.

Second, calcium supplements. Now I know I'm going to get pushback here, but calcium is calcium. When you take a calcium supplement like calcium citrate, calcium carbonate, calcium phosphate (hydroxyapatite) or others, it will be broken down into it's components before it is absorbed from the intestine into the blood stream. Calcium Ion (aka "free calcium") is what will be absorbed into the bloodstream. Now if you're low in some other mineral, then for convenience, you could take calcium with magnesium or vitamin D or whatever. They do not have to be taken at the same time. As long as your blood levels of magnesium or vitamin D are good, you don't need to take them with calcium. Here is a link to Dr. Bilezikian outlining this point https://youtu.be/fTEvmkxTG1g?si=ZRA0kKLlJ3kmdPb1 . Watch for two slides. I will have more details to share next month on calcium and vitamin D. It's too hard to put it all it text on a message board so you will have to wait for the video 🙂

Finally the disclaimer. I'm not a doctor, I'm a researcher trying to help others, based on my experience, be better prepared to talk to their doctors. While you should ensure your doctor is up to speed on current research, never take some random persons position over your doctors. It's just too risky.

Yes, the corrected calcium level is a better indication of calcium level and it uses the same range as total calcium listed on your calcium test (high-low range). The Mayo Clinic Calcium reference value is 8.8-10.2 mg/dL for people over 60.

Great job on your explanation of the calcium control system. You are spot on. Your body will do everything it can to maintain a set point your body wants to be at. However, if your body cannot get calcium from your bone fast enough (like when your on a drug like Prolia or alendronate) then you need to ensure you are getting enough from your diet. For me, I'm on Prolia and have hypercalciuria (peeing out too much calcium), so I really have to be consistent on calcium intake. Prolia just go a new block box warning for hypocalcemia for kidney patients for this reason I believe.

The corrected calcium number really only comes into play if you have an albumin problem and your calcium numbers look off, or if you are investigating hyperparathyroidism. Most people don't have to worry about corrected calcium. Perhaps I should not have mentioned it without a better explanation.

Yes, the corrected calcium level is a better indication of calcium level and it uses the same range as total calcium listed on your calcium test (high-low range). The Mayo Clinic Calcium reference value is 8.8-10.2 mg/dL for people over 60.

Great job on your explanation of the calcium control system. You are spot on. Your body will do everything it can to maintain a set point your body wants to be at. However, if your body cannot get calcium from your bone fast enough (like when your on a drug like Prolia or alendronate) then you need to ensure you are getting enough from your diet. For me, I'm on Prolia and have hypercalciuria (peeing out too much calcium), so I really have to be consistent on calcium intake. Prolia just go a new block box warning for hypocalcemia for kidney patients for this reason I believe.

The corrected calcium number really only comes into play if you have an albumin problem and your calcium numbers look off, or if you are investigating hyperparathyroidism. Most people don't have to worry about corrected calcium. Perhaps I should not have mentioned it without a better explanation.

Hey Formisc,

I believe your transition from Prolia to alendronate had perfect timing and will hopefully allow you to avoid any type of rebound. Might be a good idea to check your calcium in the next 30-60 days just to be sure CTX stay low but you're probably good. Many people that transition like you did after just 18 months will continue to gain bone mass on alendronate after Prolia. You might also have a low CTX baseline, which again, helps with the transition. I would not worry about the low CTX markers. Low is good and it will continue to be suppressed on alendronate. For reference, my CTX after one month on Prolia was 37pg/mL. It will be higher by month 6 before my next shot.

Not sure what to tell you on dental surgery other than tell your surgeon that you are on alendronate so they can get the job done quickly to minimize risk. Exposed bone seems to be what you want to avoid.

So the low calcium needs to be addressed. I to saw my calcium drop when I started Prolia and have bumped up my intake. I have hypercalciuria as well which means I have to take even more than the average just to have a chance at building bone. Low calcium can cause all kinds of side effects so you need to make sure you're getting enough in your diet + supplements. Prolia and alendronate will make it more difficult for your body to borrow calcium from your bone bank (so to speak). You REALLY want to get close to the 1200mg/day range to ensure you have enough calcium to support your bodies set point as well as to have enough for your bones to build. You can't build bone without calcium.

25(OH)D looks perfect. To low or too high is not good for bones. I'm a bit surprised your PTH is only at 3.5 pmol/L (33pg/mL). PTH will typically go high when serum calcium is low. I would have expected numbers closer to 60-70pg/mL. I can't explain that one. Maybe my conversion is off.

Albumin looks great too. No calcium correction required.

My two cents.

Two things @michaellavacot:

I have been told to take calcium and magnesium at least two hours apart, because they compete.

My blood calcium is always 10.2-10.3. I usually take 600-1000mg in a supplement with dairy allergy. Your blood level, you said, was 0.5 but it dipped to 8.7. Yet you have hypercalcemia that is bad enough that you are avoiding Forteo and Tymlos.

I have stage 3 kidney disease (eGFR as low as 36 and as high as 51). But my kidneys do not leak calcium. What is the significance of your high calcium in urine vs normal/low normal in blood?

My PTH is always normal. Doctors have not commented on my 10.3 calcium blood test. I know there are deeper tests for PTH function but I have responded well to Tymlos so leaving that issue for now.