Confused by doctor options to choose, including Keith McCormick

bluebonnet, most patients are taking bisphosphonates after Forteo or Tymlos. Even before the black box was lifted, my prescribing endocrinologist knew about the Wister rat and the flaw in the studies. Now, some patients are extending Forteo use without a bisphosphonate in between.
My suspicion is that the idea of "sealing the gains" is a hang-over from the days where there were no anabolics. Now, the understanding is that sealing the gains prevents the important process of remodeling. Look at this though from 2005
The amino-bisphosphonates strongly inhibit osteoclastic bone resorption. During normal bone remodeling, osteoblastic bone formation follows resorption and occurs within the eroded cavities, so inhibition of bone resorption also results in inhibition of bone formation. Bone biopsy studies using double tetracycline labels show that the bone-forming surface is suppressed by 60–90% with usual doses of the bisphosphonates (4, 5). These drugs are certainly not anabolic! The volume of bone does not increase. The bone density as measured by dual-energy x-ray absorptiometry, however, does increase. This is because the bone is no longer remodeling, and so there is not much new bone. The older bone is denser than the newer bone; there is less water and more mineral in the bone, and the radiographic techniques thus measure the higher density.
https://academic.oup.com/jcem/article/90/3/1897/2837115
The article clarifies that there is no known way to remove bisphosphonates from bone and it can persist in preventing remodeling for ten years. Which is why the effect of Forteo is blunted when taken after a bisphosphonate.

Does staying on Forteo longer than 2 years maintain the bone that was previously built? If we need to build more bone how does this work? I still need to read the article you attached.

@bluebonnet242,
the article may not even interest you. It's just some speculation about bisphosphonates.
Clinical trials on Fotteo were limited to 24 months. I don't know of any trials ensuing after the cancer warning was removed. Physicians are left to determine which patients would benefit from extended use.
Ten year follow-up of women who stopped Forteo after 18 month indicates a sustained fracture protection while BMD returned to baseline gradually over those ten years. Though those women took either HRT or alendronate.
After taking Forteo the cells that build bone proliferate. Their activity stimulates the cells that break bone down. Eventually the osteoclasts can dominate in number though there isn't evidence of disadvantage in this.
The assumption comes from a time before Forteo when the only pharmaceutical control was to reduce osteoclasts.
But we can use bone markers to determine the relation between osteoclasts and osteoblasts on an individual basis in our own treatment.
So far it appears as though continued use of Forteo doesn't just maintain gains but advances them.

Now that there is generic Forteo, the cost for this is much less. Do you know if generics (bio similar?) are as effective?

@gently my bone marker tests showed that Tymlos stopped working before 18 months. At this point I don't think my doctors would recommend continuous use for more than 2 years for that reason.

@windyshores, this is so interesting. Thanks. I'd be curious about the numbers and if you repeated the tests. One problem with CTX is that it is easy to mishandle. It has to be refridgerated but can only be refridgerated for a short period then it has to be frozen and remixed before being examined.
You know all the rest: time of day, quality of sleep, food intake
Was it the CTX was too high or P1NP too low. I'm excited ( you can see) about this piece of information.
When I stopped Forteo for a month the CTX dropped appreciably. I should have retested after resuming for a month. But I think the month was too long. I'll try for two weeks and then three weeks in the coming year and be more organized with the bone markers. Was your md orchestrating; mine won't be.

babbs, not to interrupt, but my prescribing physician told me that they are exactly the same in effect. I used them interchangeably my first year.
The physician could be misinformed.

Even more interesting that it was Tymlos. Tymlos is thought to raise CTX as much as Forteo, but maybe it was P1NP that had declined.

@gently the surprise was that me P1NP was low. My CTX was too. But at that point I had excellent gains. I was told by two doctors and McCormick that the effect had waned as it usually does at some point. I stayed on Tymlos another 6 months to complete the 2 years and was told I was probably safe to do that, but I also wanted to really explore the next steps, which ended up being Evenity before Reclast. My P1NP was low with Evenity too. Timing of testing has never been ideal for me. My doctor doesn't do bone marker testing so I have to arrange myself.
ps I thought it was pretty well-known that these drugs peter out over a year or year and a half...the question now, as you well know, is if and when we can again get a boost from them, especially after bisphosphonates short term

@gently @windyshores - I am sooo curious to hear what you all continue to discover in this line of thinking. As I just started Forteo , but obviously already looking ahead!!!!