Is it really necessary to take Alendronic Acid with these results?

[NowandAgain]

I am 72 years old and have been diagnosed with osteoporosis/osteoporotic (Iam not sure which as the report refers to both). The results of my tests and recommendations are as follows:-

Indication: PTH

Risk Factor: Excess alcohol, fractured

wrist age 64, maternal hip fracture,

Secondary Osteoporosis (PTH)

Medication: OTC Vit D just started

Falls in the last 12 Months: 0

Weight: 58.8kg

Height: 159.5cm

Ethnicity: white

Age: 72

Bone mineral densitometry hip Lt :

Scanned Region:

AP Spine (L2, L3, L4)

BMD(g/cm2) = 0.676

T-score = -3.7

Z-score = -1.3

Classification = osteoporosis

Femoral Neck

BMD(g/cm2) = 0.467

T-score = -3.4

Z-score = -1.5

Classification = osteoporosis

Total Hip

BMD(g/cm2) = 0.531

T-score = -3.4

Z-score = -1.7

Classification = osteoporosis

WHO Fracture Risk Assessment Tool

10 - Year fracture Risk:

Major Osteoporotic Fracture =60%

Hip Fracture = 46%

Reported Risk Factors: previous

fracture, parental fracture, Secondary

Osteoporosis, alcohol use

UK, Neck BMD = 0.467, BMI = 23.

FRAX Version 3.08. Fracture probability

calculated for an untreated patient.

Fracture probability may be lower if the patient has received treatment.

Interpretation:

No technical difficulties reported withthe hip or spine scans. On analysis no

artefacts seen.

L1 has been excluded due to being > 1 SD

different to adjacent vertebrae appearing small and bright on the AP.

The non dominant forearm could not be scanned due to previous fracture.

At present due to BMD and risk factors

for osteoporosis, the patient has a high risk of fracture in the next 10 years.

Possible dental issues have been recorded and must be fully resolved

before starting any bisphosphonate treatment.

The patient has not lost any height but as L1 has been excluded due to appearing

small and bright a VFA scan was performed today. No fracture identified.

Chronic degenerative changes noted but grossly unchanged to CT 07/09/2021.

Recommendation:

The patient is osteoporotic.

Based on the referral information and DEXA results, treatment is indicated

with Alendronate, Risedronate or Binosto for 5 years provided there are no

contraindications, and it can be tolerated. If the patient is unable to

take an oral bisphosphonate or they are not tolerated, the current recommended

second line agent is Denosumab 60mg subcutaneous injection, every 6 months

for 5 years. (NICE T161 \T\ 204)

Denosumab can be prescribed and administered in the primary care

following this recommendation, but prior to doing so, please consult the drug

prescribing information/summary of product characteristics, patient information leaflets and risk materials

available online at the Electronic Medicines Compendium) medicines.org.uk/emc/

In particular, the similar cautions regarding dental treatment / risk of

osteonecrosis of the jaw and atypical femur fractures exist for Denosumab as

oral (or IV) bisphosphonates. Denosumab should be used with caution in patients

at risk of recurrent or severe respiratory / urinary or skin or other

infections and in this situation (or if it is not tolerated), IV bisphosphonates

may be an alternative or Strontium Ranelate could be considered (please see

BNF for risk factors)

If treating with Denosumab for up to 5 years do not just stop as there have

been cases of an increased rebound fracture risk shortly after stopping.

Discuss with Rheumatology in all cases after a repeat DEXA scan to assess bone

density before stopping Denosumab.

If the patient fractures after 1 year of treatment with a T-score -3 aged 65 or

a T-score of -4 refer to rheumatology to consider future treatment options in the

osteoporotic clinic HUTDG/OST.

The patient has been given lifestyle

advice on bone health. They have been advised to reduce their alcohol

consumption to within the daily recommended limits.

If vitamin D deficient and treating with

a Bisphosphonate recommended treatment regimen is based on:

A fixed loading regimen to provide a total of \R\300 000 IU vitamin D, given

either as separate weekly or daily doses over 6 - 10 weeks.

Followed by maintenance therapy comprising vitamin D in doses equivalent

to 800 - 2,000 IU daily (occasionally up to 4,000 IU daily), given either daily

or intermittently at higher doses.

Adjusted serum calcium should be checked one month after completing the loading

regimen or after starting vitamin D supplementation in case primary

hyperparathyroidism has been unmasked.

Calcium Supplementation: Under normal circumstances calcium supplementation is

given alongside vitamin D supplementation, however, if the patient

has a dietary intake of calcium that is equivalent to the proposed calcium

supplementation; vitamin D supplementation is available without a

calcium component. There may be rare ircumstances where there is a

contraindication to calcium and or vitamin D supplementation. Always check

with the treating specialist if there are any concerns.

Follow-up: Refer back for reassessment of fracture risk in 5 years.

**************

I am at present taking prescribed Vitamin D Adcal calcium carbonate and have also been prescribed Alendronic Acid 70mg to be taken once a week, but to date I am not taking this since I am loathe to take more medication than is absolutely necessary since my husband seems to take so many to counter-effect others.

My fractured wrist over 10 years ago was due to me being silly failing to leap over something of height!

I am active in the garden carrying heavy barrel loads of garden material and laying heavy garden slabs, etc. and this seems never ending.

I have recently had a masectomy to one breast and have hyperthyrodism due to a small biateral goitre but as I have no symptons to date I am not taking the 5mg carbimazole prescribed for this.

The only other medication I am taking at present is10mg rivaroxaban for the thrombosis of the leg (this may have been caused by the Astra Zeneca vaccine)

I believe I may have arthritus in one knee.

I am sorry if I have given more of my health details than may be necessary but maybe it will assist and any comments as to whether it is considered the Alendronic Acid prescribed is necessary will be greatly appreciated since I am loathe to take more medication than is absolutely necessary since my husband seems to take so many to counter the effect of others.

[t1gernidster]

Does the ‘secondary osteoporosis- PTH’ indicate hyperparathyroidism?

[NowandAgain in reply to t1gernidster]

Thank you t1gernidster. Someone else has suggested this and I will look into it.

[t1gernidster in reply to NowandAgain]

With diagnosed hyperparathyroidism no drugs will make your bones stronger until the offending gland/s has/have been surgically removed. I do hope it isn’t that.

[scd2211]

With your osteoporosis scores and your high risk factor of future breaks I would definitely start the weekly alendronic acid treatment as soon as possible. I have taken it for nearly 7 years without any side effects, it is just one tablet a week and I don’t know I’ve taken it. I have seen an improvement in my Dexa scores as a result of taking it.

I don’t think your results should be left untreated. Wishing you well with your decision.

[NowandAgain in reply to scd2211]

Thank you scd2211 it is good to read you don't have any side effects from taking the alendronic acid treatment. I hope you can see my reply to PeepBo. It appears I should go back to the dentist before starting the medication but your reply is encouraging. Thank you

[walk21]

With Tscores of -3.4 and -3.7 you probably would be wise to take the alendronic acid to reduce the risk of getting a hip fracture like your mother's. That letter is quite wonderful and full of very useful advice about the different medications. I would keep it to refer to in the future and take note that you should get your teeth looked after before you start medication.

[NowandAgain in reply to walk21]

Thank you walk 21. Indeed I was very impressed with the comprehensive report I was given. I have signed up to see all my medical records which is a bonus now. I hope you can see my reply to PeepBo.

[walk21 in reply to walk21]

I am pleased you will get help from an endocrine specialist. I would pursue that before taking alendronic acid. I hope you get sorted and have peace of mind about it Best wishes

[Met00]

What a detailed report! Whether or not to take medication has to be your decision, but bear in mind that you have a very high risk of fracture: in the next 10 years you have a 60% chance of any major fracture and a 46% chance of a hip fracture. Taking a bisphosphonate would reduce that risk to around 30% and 23% respectively. So there are no guarantees of preventing fractures, but less chance of it happening compared to no medication. If you go on denosumab, that should reduce the risk a little more, BUT if you ever stop taking denosumab you have to go straight onto a bisphosphonate to reduce the risk of rebound fractures. For that reason I personally wouldn't accept denosumab before being sure there was an alternative relay medication I could tolerate if I had to stop the denosumab.

I'm puzzled by the reference to PTH. Do you have hyperparathyroidism? If so, that needs to be treated, as it stops calcium reaching the bones; once treated, bone density will sometimes improve naturally. Also, have you been offered support to reduce your alcohol intake? Unfortunately too much of that also has a negative effect on the bones.

By the way, osteoporosis is the condition, osteoporotic is simply another way of saying you have osteoporosis. It's like saying someone is diabetic, meaning that they have diabetes.

[NowandAgain in reply to Met00]

Thank you Met00 for the useful information given in your reply.. Indeed I was very impressed with the comprehensive report I was given. I have signed up to see all my medical records which is a bonus now. I hope you can see my reply to PeepBo.

[Met00 in reply to NowandAgain]

I've seen your other replies and fully understand your reluctance to take AA. You mention thyroid, but PTH refers to parathyroid, which is a different hormone regulated by the 4 parathyroid glands. However, if your calcium level is low and your parathyroid high, that sounds like secondary hyperparathyroidism, where your parathyroid glands have released more hormone to try to raise your blood calcium to normal levels (that's part of their function). If that's the case, it should be a priority to find out why your calcium level is low. This could be poor absorption (due perhaps to low blood vitamin D or something like coeliac disease), or it could be because your diet doesn't contain enough calcium. Unfortunately alcohol can also have a negative impact on all of this, so it could well be a combination of different factors. I hope they're checking everything rather than just making assumptions.

[NowandAgain in reply to Met00]

Thank you Met00. I will look into this. Unfortunately although I have access to my medical reports for some reason I can't at present!

[PeepBo]

I was on Alendronic Acid tablets for 3 years, fortunately with no serious side effects. The only drawback was that half way through the treatmnt I needed extensive dental wotk which my NHS dentist would not do and I had to have it done privately (and expensively). My scores were much lower than yours and in fact I only had osteopaenia (not osteoporosis) so in fact doubt whether I needed to be on it at all. Everyone is different however, so do please discuss this thoroughly with your consultants and have a look at the Royal Osteoporosis website. Good luck.

[1000Miler in reply to PeepBo]

You confused me there for a while by saying that your scores were lower than the OP's yet you only had osteopenia. I think you probably meant to say that your scores were higher, not lower?

[NowandAgain in reply to PeepBo]

Thank you PeepBo and for your dental experience. I was advised to have a dental checkup which I did about a month ago. As I had not done so for about two years (18 months being covid related and for the remaining 6 months I was concerned with other problems) one of my teeth needed a large filling. I am however experiencing a little pain from this (I believe my pain threshold is high) so I should go back to the Dentist again. I have a telephone appointment with the Endocrine Specialist Nurse on Friday and it appears my hyperthyrodism and calcium deficiency are related. Although my blood tests and scans results are not good, I do not feel they are having any adverse effect on my everyday life and I am able to carry on as normal and I fear, from what I read, that if I take carbizamole for my hyperthyrodism and the Alendronic Acid for my bones, if I was to get the side effects some people experience, my lifestyle could change dramatically especially as my husband is disabled and cannot do the things I have to do. I have been very fortunate that my breast masectomy has not prohibited me, to date, of carrying out heavy tasks.

[PeepBo in reply to NowandAgain]

Please investigate fully with your nurse. I wish you all the best.

[NowandAgain]

Thanks AHEvergreen. That was a very interesting read and although my bone loss is related to my hyperthyrodism as I have no symptons of either and certainly do not suffer from depression I can't help feeling at 72 I would prefer to live a short happy life than a long one. Whilst it could be argued that without drugs it will not be a long healthy one, when the time comes that I cannot do what I can do now, I may have to take a different type of drug! I certainly don't want to be a burden on anyone. In the meantime I will continue taking the Vitamin D, and try and improve my diet. The heavy work I do in the garden on a very regular basis should help strengthen my bones.

[NowandAgain]

Further to my previous post looking at my medical report it shows I have a nodular on the right side of my thyroid.. Repeat Tfts show persistent mild hyperthyriodism and there is no mention of hyperparathyroidsim although when I have a telephone appointment with the Endocrine Specialist Nurse in a couple of weeks time I will ask about this. (I thought it was today, but I was wrong)

I have now spent nearly all day going through my records and have learnt a lot with the help of google athough I very much doubt I will remember all the medical terms!

It looks like I have had a full MOT and have itemised the main bone and serum calcium results recently given in case these are of interest, but if not, please do not bother to respond.

Normal ranges are given in bold.

My full blood count is normal.

Total white cell count 4.8 10*9/L 3.9 – 11.1 – normal

Total 25-hydroxy Vitamin D 61 nmol/L - normal range 25 – 9999

XVDXA DXA Vertebral morphometry - normal

XPDEX Bone mineral densitometry per - normal

XLDEX Bone mineral densitometry lum - normal

XHDXL Bone mineral densitometry hip - ABNORMAL.

Serum calcium 2.4 mmol /L 2.2 – 2.6 Normal

Serum adjusted calcium conc 2.5. mmol/L 2.2 – 2.6 Normal

Serum inorganic phosphate 1.1 mmol/L 0.8 – 1.5 Normal

Serum alkaline phosphatase 155 iu/L 30 – 130 ABNORMAL.

Serum total protein 65 g/L 60 – 80 Normal

Serum albumin 38 g/L 35 – 50 Normal

Serum globulin 27 g/L20 – 35 Normal

Comments made MED Stable.

My Thyroid Blood Result are as follows:-

Serum free T4 level 16.9 pmol/L 9.0 – 19.0 Normal

Serum TSH level < 0.008 miu/L 0.35 – 4.94 ABNORMAL. (this has been tested 4 times in the past year and has remained constant.

Serum free T4 level 16.9 pmol/L 9.0 – 19.0 Normal

Serum free T3 level 9.3 pmol/L 2.5 – 6.0 ABNORMAL (not taken recently and only taken once in June 2022) when I was diagnosed with thyroid issues.

QRISK2 cardiovascular disease 10 year risk score 13.4

As mentioned before I have no symptons.

I am very graetful to those who have contributed to my first post, but please don't feel obliged to respond further. I will however post a follow up after my appointment with the Endocrine Specialist Nurse.

[Met00 in reply to NowandAgain]

Just one quick comment. Your Vitamin D is within the NHS range, but increasingly consultants are saying it should be at least 75nmol/litre (in the US you're considered deficient if it's below this), and many experts say 100.

[NowandAgain in reply to Met00]

Thank you Met00. I expect that is why my Dr prescribed the Vitamin D Adcal calcium carbonate. Will await my appointment with the Endocrine Specialist Nurse before making my next move