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Reclast vs ?

Posted by maloc @maloc, 6 days ago

Hello!

Does anyone have any insights on my dilemma?

My past 2 dexa scans done a year apart show very mild osteopenia in hip and spine but osteoporosis (-4.1) in forearm. My TBS score shows normal bone structure, no osteopenia or osteoporosis. My doctor is telling me I need to do the Reclast infusion. She is not offering any pill form whatsoever and told me Reclast is basically the only way to go.

I am a very active, fit 65 year old. I am considering a REMS scan to sort out what is going on with my forearm. My endo didn’t have any good info on it and said DEXA is the way to go when diagnosing and prescribing. I have never fractured a bone. I am not looking to bring on new problems due to side effects. In the past I have reacted to a booster for whooping cough- full body rash for over a year, terrible experience that I have no desire to repeat.

I am hypothyroid and have been on synthroid for many years now. My calcium intake has not been great, sporadic at best, but committed now to improvement.

If anyone has any thoughts or past experiences that might help in my decision I thank you in advance!

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frog100 | @frog100 | 5 days ago
In reply to @kfhoz "@maloc There are several research papers and presentations/videos by doctors and researchers about osteoporosis drug sequencing..." + (show)
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@maloc There are several research papers and presentations/videos by doctors and researchers about osteoporosis drug sequencing or order to take them. I don't want to post them all here, but search YouTube for Dr. Michael Lewiecki or Dr. Benjamin Leder for lots of detailed information.

For a quicker overview of sequencing try this one:
Osteoporosis Treatment: Best Order for Medications Explained


This video from Douglas Description: "Lucas ... explains that drug sequencing matters, with evidence showing the best results come from starting with anabolic (bone-building) drugs before transitioning to other therapies. ... "

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@kfhoz
This was very helpful video. My husband always asked me “what is the source”. Thus, the doctor is boarded in Orthopedic Surgery and Regenerative Medicine. He specializes in OP.
Thank you for sharing this very informative video.

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maloc | @maloc | 4 days ago
In reply to @cat1203 "@maloc Sequencing is a little complicated, at least I find it so. If you start with..." + (show)
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@maloc Sequencing is a little complicated, at least I find it so. If you start with a bisphosphonate such as Reclast, it will blunt the effectiveness of an anabolic drug, such as Tymlos, Forteo or Evenity, that might be prescribed later. Those drugs are bone-builders. They usually are prescribed for more severe cases of osteoporosis. The conundrum is that if your T-scores worsen or you fracture while on the bisphosphonate and you/your doctor want to use a bone builder for improvement, the bisphosphonate you tried first will blunt the effectiveness of a bone-builder. I have two conflicting thoughts on this: (1) if T-scores are osteopenia or just mildly osteoporotic, take no drugs at this point. If/when things worsen, start with one of the anabolics. (2) take an anabolic even if T-scores are osteopenia or just mildly osteoporotic and build as much bone as you can while still in the early stages with the likely outcome (IMHO) of getting back into normal range. Then a bisphosphonate for maintenance afterwards, duration of which to be determined by monitoring by DEXA and/or blood turnover markers, The second course may not be possible though because insurance companies generally want to try the less expensive "little guns" before approving the much more costly "big guns."

In my case, I was diagnosed with severe osteoporosis at -3.9 in my spine (hip numbers osteopenia or just mildly osteoporotic). I was diagnosed after my second wrist break. I was prescribed alendronate, which I took for 3.5 years. In the interim I learned about the other drugs on my own. Had I known about them at the time, I would have asked to be put on a bone builder from the get-go. I am now in month 20 of teriparitide (Forteo). My DEXA in March showed 4.6% improvement in spine which is OK but still leaves me at -3.5 with a still degraded bone structure. I think I would have had better results had I not been on alendronate first.

You might find this article useful
https://medshadow.org/conditions-treatments/osteopenia-osteoporosis/osteoporosis-treatment-screening-medications/

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@cat1203 thanks so much! I have do my due diligence about Reclast vs actonel. Your info is very helpful.

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maloc | @maloc | 4 days ago
In reply to @gently "hi, you might want to be tested for hyperparathyroidism. Low bone density in the distal forearm..." + (show)
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hi, you might want to be tested for hyperparathyroidism. Low bone density in the distal forearm is often the first sign. Though they are completely different glands hypothyroidism often occurs with hyperparathyroidism. I would want serum PTH, calcium, ionized calcium, phosphorus and magnesium.

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@gently thanks. Yes, i am low end of hypoparathyroidism blood test, in the normal range tho. Others tested bu not magnesium. I do supplement with mag glycinate tho. Thank you tor the insight!!!

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gently | @gently | 4 days ago

maloc, high doses of synthroid can suppress levels of parathyroid hormone confounding a hyperparathyroid diagnosis.
On the other hand the distal third is the area most susceptible to misreading on dexa. The forearm is a small bone area because of this if a patient moves at all even a tremor or supressed cough during the scan, blurring leads to an underestimation of BMD.
Positioning is tricky. Your arm has to be positioned perfectly flat to avoid rotational artifacts and to recognize anatomical reference points ( radial endplate, the ulnar styloid), BMD varies vastly from the wrist to the elbow.
Finally if you have a small arm, because dexa doesn't account for volume a small arm will register a lower bmd.
I really like that your doctor measured your forearm. Forearm measurements are usually reserved for those who can't be measured elsewhere. But they are wonderful for catching a damaged parathyroid gland.
I'd be reluctant to take Reclast with mild osteopenia, partly because of the possibility of side effects, but more because of its mechanism of action. It slows down bone turnover first by blocking the cells that carry away damaged bone that slow down the cells that rebuild bone. Was your forearm -4.1 on both dexas.

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mayblin | @mayblin | 3 days ago
In reply to @cat1203 "@maloc Sequencing is a little complicated, at least I find it so. If you start with..." + (show)
Profile picture for cat1203 @cat1203

@maloc Sequencing is a little complicated, at least I find it so. If you start with a bisphosphonate such as Reclast, it will blunt the effectiveness of an anabolic drug, such as Tymlos, Forteo or Evenity, that might be prescribed later. Those drugs are bone-builders. They usually are prescribed for more severe cases of osteoporosis. The conundrum is that if your T-scores worsen or you fracture while on the bisphosphonate and you/your doctor want to use a bone builder for improvement, the bisphosphonate you tried first will blunt the effectiveness of a bone-builder. I have two conflicting thoughts on this: (1) if T-scores are osteopenia or just mildly osteoporotic, take no drugs at this point. If/when things worsen, start with one of the anabolics. (2) take an anabolic even if T-scores are osteopenia or just mildly osteoporotic and build as much bone as you can while still in the early stages with the likely outcome (IMHO) of getting back into normal range. Then a bisphosphonate for maintenance afterwards, duration of which to be determined by monitoring by DEXA and/or blood turnover markers, The second course may not be possible though because insurance companies generally want to try the less expensive "little guns" before approving the much more costly "big guns."

In my case, I was diagnosed with severe osteoporosis at -3.9 in my spine (hip numbers osteopenia or just mildly osteoporotic). I was diagnosed after my second wrist break. I was prescribed alendronate, which I took for 3.5 years. In the interim I learned about the other drugs on my own. Had I known about them at the time, I would have asked to be put on a bone builder from the get-go. I am now in month 20 of teriparitide (Forteo). My DEXA in March showed 4.6% improvement in spine which is OK but still leaves me at -3.5 with a still degraded bone structure. I think I would have had better results had I not been on alendronate first.

You might find this article useful
https://medshadow.org/conditions-treatments/osteopenia-osteoporosis/osteoporosis-treatment-screening-medications/

Jump to this post

@cat1203, i didn’t respond 'well' during my 1st yr on Forteo either: at 13mo, my lumbar gain was "only" 4.9% with a slight but insignificant bmd loss at the hip and femoral neck, and that was without any prior bisphosphonate treatment. Given your 3.5yrs on Fosamax, a 4.5% gain is actually a strong biological signal.

Have you done a BTM lab recently? If they still show a robust turnover state - especially when compared to your previous labs if you had them, it may be worth discussing an extended 3rd year of Forteo with your doctor. Considering your current TBS of 1.224, staying the course could allow for continued architectural reinforcement and mineralization.

FWIW, I was actually prescribed and approved for a 3rd year of Forteo due to my seemingly "delayed" response, though I ultimately chose not to pursue it because my BTMs were too high at the time. In the end, I had wonderful gains.

Just a thought!

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2121 | @leslie2121 | 1 hour ago

Weighing in here again:
I just had my yearly bone density scan (same facility and machine) and I had a 10% increase in almost every area! Hips stayed the same but one spot worsened in one femoral neck, oddly.
Only thing I did was increase my cardio exercise and added strength training. I am now at -2.5 so still osteoporosis but better.

Going to try Tymlos with the exercise to see if I can get more density. I think it was adding weights, increasing intensity and consistency that helped.

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