Osteoporosis/Osteopenia Treatment , Vit D, Testosterone, Bisphosphonates
Why and Diagnosis - Last November I crashed and fractured my left hip , 3 years ago I crashed and broke my right clavicle , over that same time frame I broke 2 teeth (both cavity filled molars biting down on something hard). I know maybe I should stop crashing :-) and be careful what I eat on my old weakened teeth? With 4 bone/teeth incidents in 3 years, even though all of these happened as a result of trauma, I decided to get a Bone Density Scan. None of the doctors I saw (2 orthopedics', and 2 primary care) thought it was necessary but said it couldn't hurt. At the radiology lab I even had to sign a statement agreeing to pay if the insurance did not cover( they did). Diagnosis was Osteoporosis in the left femoral neck (Note: this was the fractured hip which is a whole other discussion since general consensus is they should have done the right hip which I did bring up at the time) the remainder of that hip was Osteopenia, and the spine was Osteopenia... Patient at a high risk of fracture was the last thing written on the report... That surprised the doctors and it was the last thing I expected... Osteoporosis only showed up in one place but Osteopenia is serious as well, so this really has my attention, I should be able to hit the ground pretty hard without breaking anything :-) I'm only 54!
Research and Tests - So I went to Dr. Google to search out causal factors. Turns out when searching Osteoporosis on the internet everything comes up is for women. You must specify for men. With consultation and orders for tests from the real Doc's , I was able to rule out some of the more scary and least likely causal factors like bone cancer, hyperthyroidism, hypothyroidism, pituitary/thyroid issues (my Mother had) .... There were no definitive causal factors.... What we did find is I tested very low for Vitamin D and Testosterone... Calcium , kidney, liver all good....Small men with low BMI are at much higher risk for osteoporosis than larger men... Running is the absolutely best thing you can do for your bones...
Initial Treatment - Suggested by all Doc's and obviously agreed to by me.... Take supplements and retest, Calcium 1000mg per day (even though its good) , big Vitamin D 4000mg per day (already retested and improved)....Weight bearing exercise (running I'm on that)... In one year get another Bone Density Scan including both hips this time to compare the injured to uninjured hips.
Future Treatment - When I went over all of this with my NH primary care physician , I said I cant afford to hit the ground while riding my bike anymore. He suggested if I was interested a 1 year treatment of Bisphosphonate's (drugs to treat osteoporosis) or more specifically an injection of Boniva every 3 months for 1 year. He then went on to say if it were me I would wait 2 years and get another bone density scan but I understand your concern. So initially I agreed to the prescription for the 4 injections. After doing some more internet research on the side effects etc of bio I have decided to wait . The testosterone at this point is not even on the table , however its a huge concern going forward, I have tested low for Testosterone twice now. I do not suffer from any Low T side effects. But if it came down to having healthy bones I would absolutely have to consider it. Nothing would be off the table at that point , I may even consider adding some animal protein back into my diet if need be in the future but will wait out the supplements and next bone density scan.
@ Doc's - Looking for comments specific to bisphosphonates or any osteoporosis/osteopenia treatment ????
@ All - stories, thoughts , comments, on bone health? Low T ?
Comments
Tim, no surprise in the findings, given your history, and body type. I think I already talked to you about Calcium and D3. Maybe a reminder about the value of weight lifting, in particular squats, to help sustain bone mineral content. There's also the issue of the value of getting yourself down to 120# - you might run a little faster, but at what cost to the rest of you. I myself feel much better @ 148#, even though I know I race better @ 145; and when I'm down to 143, I get really worried.
Even young cyclists (pros) have a risk of osteoporosis and increased fractures. Probably due to their un-natural body weight - look at Bernard Hinault, greg Lemond and Eddy Merckx today compared to racing days - coupled with lack of strength training. You've got 30 more years to go, don;t want to spend them pushing a walker.
I've found in the past five years I've gotten more cautious when on my bike. Part may be unconscious worry about risk of falling, and part may be unconscious worry about slower reaction times. Whatever the reason, I don't see the upside of going 55 mph down hills/mountains anymore.
My prescription: 1000 mg Calcium a day, along with 500 mg in your diet, along with D3. Serious attention to thrice weekly weight room work. despite any perceived impact on bike/run training.. Hold off on drugs for now.
I disagree with the concept that running is the best thing for bones, especially not the way we tri-geeks run (high mileage). I agree with Al again, weight lifting is key. And not the 20-30 rep type stuff. The weight needs to be heavy, aiming for 6-15 reps-type heavy, good form, rest in between 3-5 sets, emphasis on lower body - squat, deadlift, lunge, core. Chest/back focus on upper body. Endurance athletes chronic neglect this and we pay for it.
I am no expert when it comes to animal vs plant protein. I am sure there are arguments both ways. I am reminded of a study in a archeology journal recently that one proposed reason we prevailed was bone strength due to animal protein intake. But that is not good enough to change. Probably important again to remember you are a crazy endurance stud. If anybody needs above average protein intake, it is you.
Re: Testosterone. Disclaimer - the entirety of my expertise in management of osteoporosis is in men whom I render castrate to treat prostate cancer. I don't know how low your T is, but will tell you that a man who is very low (<50) has no hope of improving his bone health with all of the Ca/Vit D/weight lifting in NH without T supplementation (which they cannot have) or bisphos. So all men in my practice, in the castrate zone, get bisphos. Every one of them, doing otherwise is malpractice IMO. It is doubtful you are castrate, but I consider low-T complications on a continuum - the lower it is, the risk of osteoporosis (and other maladies) incrementally rises (the higher it is the more risk of CV disease). I am also no expert on low T in endurance athletes, but I continue to be of the opinion that our athletes, esp at the pointy end of the spear/volume curve, suffer from low T as a result of our efforts, no different than when a female becomes hypogonadal by excess exercise/diet and stops menstruating. As this is a true hobby for you (though you are a PRO in my book!), with your DEXA results and an eye on your long term health, it may be best to reduce volume, focus on short races, lift, etc. Ryan Hall's experience would be a case study in my research on this topic: <br /> http://www.nytimes.com/2016/01/17/sports/ryan-hall-fastest-us-distance-runner-is-retiring.html?_r=0
As far as the vit. D supplementation, what was your level at? Lab ranges go pretty low...usually around 30...and a good range IMO is 50-80. I usually start people at 10,000 IU/day if under 30. It is a fat soluble vitamin and can be overdosed, but people get unnecessarily tweaky about it. You can safely take 10,000 IU/day for months, and some studies go even higher. Also, I'm a big fan of an "emulsified" form....think making the fat molecules much smaller so its much better absorbed....quicker results and more "bang for you buck"
Glad to see your taking it daily rather than once/week which is usually what the MD's recommend, for what reason I don't know. I've had a TON of people see me who were taking it this way and we're still low.
@Al- Calcium- Yes we spoke about calcium right after my crash as that was the number once concern many had over my diet. I religiously tracked my calcium intake via myfitness pal and easily exceeded the 100% everyday , followed up with blood work which confirmed good levels of calcium. None the less I started to take 1000mg per day split am/pm and became even more aware of calcium foods. Weight- It has always been my opinion that race weight is not healthy, but it sure does feel good and work. I've always got to within 2-4lbs of race weight for most of my IM training and then drop down to race weight for a month prior and then I dont stay there very long. Consider I raced KONA/IMAZ at around 120 and have spent the winter at 128 currently at 126... Strength Training- while I was a bit limited due to the shoulder/hip injury in early winter I was 3x per week religious all winter long for the first time in years, now the season is hear I am 2x per week but have cut down some... Jaw Necrosis was one of the concerns I had , specially since recently going thru some dental work including an implant.... The doc did reassure me that one year prescription should be a non issue.
@Doug- Lifting- Well I have never been able to pack on muscle ever, even at my fattest in my previous life I dont think I ever tipped the scales over 145. My last sport pre-triathlon was rock-climbing which I took very serious and was quite good at it , my lean rock climbing fitness weight was around 130lbs and I could do pullups until the cows came home (took a while this winter to build up to a measely 10 pullups)... With a bad lower back squats/dead lifts have never agreed with me , I do body weight squats, one of the orthopedic docs I went to said lunges/core/planks best things you can do for your hip (keep in mind this was for fracture and torn labrum)... This winter I did go for heavy short sets in my lifting. Protein- currently rethinking reanalyzing the amount of protein I may need as an IM athlete, tracking everything to see changes over the next 6months to a year, if need be I will reincorporate some animal protein back into my diet but holding off for now... NOOOO I dont wanna go shorter I wanna go longer... I'm signed up for UMFL in February :-)
My Testosterone numbers- What is the difference between total serum testosterone and free testosterone?
3/16 6/3
total 436 ng/dL total 297
free 4.0 pg/mL free 3.7
@Steve- Great explanation I had an aha moment in understanding. What is your opinion of 1 year prescription bisphosphonate vs. longterm? Do the osteoclasts come back or start working again after the 1yr? Seems most of the side effects and studies are all longer term.
My Vitamin D levels- I have been taking 4000mg 2 x 2000mg am/pm
3/16 6/3
26ng/mL 39
Do you think I should up the dosage or wait to see when it levels off? Going to get tested again in August. Funny thing is I spend the winter in Tucson , outdoors every single day in the sunshine. Truly amazing the number of people in general who test low for vitamin D.
Tim- You were wise to get tested, and I hope you find what works best for you. As meticulous as you are, I'm sure you will find what works and what doesn't.
They are all convinced the doctors are the problem, you are definitely on the right path here.
Please keep us updated!!
~ Coach P
Considering T in isolation does not help much. Need LH measured. LH is the hormone made by the brain that tells the testicles to make T. If your T is low and LH is low, which is most likely, then the dx is "hypogonadal hypogonadism" - i.e. for some reason your brain is not doing its job, the testicles are fine. Anorexia/malnutrition, excessive exercise are the typical causes of this condition, unless you banged your brain during your fall. If your LH is high however (and T low), that means the brain is working but the testicles are not
@Paul- What are they?
I rotate through a variety of WADA legal natural testosterone boosters as a precaution and to ensure that I don't get used to any of them.
@P- Thanks....Yep a lot of junk food vegans, and IM athletes out there ....The crap we eat when training/racing is tough to avoid... Gotta focus on eating healthy the rest of the time!
Tim- Glad you are finding your way through this. Just wanted to point out that despite being in sunshine and all that you are using sunscreen and covering up with high SPF clothing which will decrease your actual vit D production. Unfortunately at some point it becomes a tradeoff between vit D supplementation and skin cancer. I would choose the former.
Another option for management of Osteoporosis or osteopenia is daily injection of Human Parathyroid hormone (Forteo). For many folks, this is the best way to actually increase bone density. The benefits are that it is one of the only treatments that actually increases bone mineral density, it does NOT involve testosterone supplimentation (which avoids the doping question), and it is basically just increasing a natural hormone to stimulate bone growth. The down side is that one can only take it for about 12-18 months, a daily injection is needed (similar to insulin), and there is a very small risk of certain rare types of bone cancer. For most younger folks, it is certainly worth considering as a first line treatment to increase the bone density and then consider bisphosphonates to maintain the new, higher bone density.
http://www.dartmouth-hitchcock.org/endo/parathyroid_hormone_therapy.html
I use this a treatment frequently and the daily shot is the thing that most folks find most annoying but it can make a significant difference in just a year of therapy.
Good question about the return of osteoclast activity after discontinuing bisphosphonates, and I don't have an answer, nor do I know of any study addressing it. If you're leaning toward using bisphosphonates I would say the shorter the better, but I'm not a big fan given that IMO they're a myopic approach to the problem. Like Ralph said above, the bone isn't actually stronger, and a good argument could be made that it's actually weaker overall, despite the "improvement" that some follow-up bone density studies will show. It's one of those things that seems counter-intuitive on the surface, but makes sense when the whole picture is looked at.
Not a bad jump in the Vit D...not great though and you want to get to that 50-80 range ASAP (and maintain it there) given the issue. Soooo, I would bump it to 10,000 IU/day (better absorption if split that into am and pm dose like you have been doing....good job!) until the retest in August. Usually 2000 IU/day is then a good maintenance dose but you'll want to keep a close look at that with regular retests.
@Paul- thanks for the supplement data... will do some reading on them
@Satish- I know I cover up long sleeve and use sunscreen (when training) but its still kinda funny when you think about it as I still spend 30-60 minutes outside everyday in the full sunshine of Tucson walking dogs, swimming, etc with at least partial unprotected exposure to the sun. Way more than the average person in the winter time. Thanks for your thoughts and opinions on my MRI and reports.
@Ralph- Thanks for your thoughts and the informative link on Forteo... Sounds like a very reasonable first step alternative and will be suggested or considered in future treatment if any.
@Steve- Doubled the Vitamin D up to 8000 (2 x 4000 AM/PM) till my next test in August. BTW I have read and had suggested by other doctors that you can go as high as 12000 per day.
@Doug- It seems most Doc's dont test SHBG until they have determined chronic low T or other issues. The SHBG test I have came from insidetracker and they use the tested SHBG and total Testosterone to calculate the Free Testosterone.
So my plan going forward.
1.Hold off on my current prescription for Bisphosphonates.
2.Continue strength training, current supplements with the increase in Vitamin D.
3.Test again in August (middle of IM training and not optimal) and again in late October (3 weeks after my IM and huge reduction in training volume/intensity).... Serious evaluation after the October Tests and giving the body a rest...
4. Get another Bone Density Scan (both hips this time) 1st one was 2/16/16.... I probably need to wait until after that date next year if I want insurance to pay... But they are relatively inexpensive... Any opinions of how soon I should get the followup Bone Density Scan?
5. Before taking the next step based on these results will consult current doctor's and make appt. with endocrinologist specialist?
6. Any other thoughts or ideas on how I may proceed?
Thoughts on testing...just from personal experience, and not as an MD here. Over the past 15+ years as I;ve been doing relatively strenuous and nearly year-round training in S/B/R, I would routinely schedule an exam with my MD at the "end" of the season. I would usually get blood tests of varying sorts, along with BP, etc. What I discovered is that within 2-4 weeks, such tests (including BP) are not as reliable as ones done 6-8 weeks after my final race, which was always either an Ironman, or the Xterra WC on Maui - both of which would have 3+months of strenuous training, and then a draining race day. I suspect there's a lot of re-equilibration that goes on over time beyond simply gaining weight back and re-adjusting body water distribution, plasma volume etc. Like the replenishment of tortured muscle protein, neurotransmitters, abused hormone production cycles, etc.
I've become a big believer now in the need for some serious attitude and activity adjustment annually in the winter months, say Nov-Feb, which affects my approach to the OS. But the need to re build and re-group physically is getting stronger (and longer?) every year, and I'm determined (as my sig line says) to "have fun with my fitness" as long as I can. Meaning I have to be able to be fit, and be well enough to have fun.
Conclusion - hold off on any re-testing until just before you intend to re-start serious deep training, hopefully 6-8 weeks after your last big race of the year. Repeat DEXA scan? bone change is a slow process, so a year after the first one makes some sense.
Prolia injection another non-bisphosphonate medication to consider. some similar bad potential side effects though.
measuring calcium in your blood does note really reflect your calcium intake or reflect if you are consuming enough calcium.
you might consider increasing calcium supplement intake further. you might know better than me, but is it hard to get the needed absorbable calcium without consuming dairy products ? vegan types argue otherwise, but I think that is one good thing about dairy.
not sure that repeating a bone density within a year will be useful. takes a while to reflect the changes.
yes good idea to see a good younger endocrinologist.
Why not? How bad do you want to beat this thing? If you weened yourself off of caffeine over say the course of a month, you wouldn't miss it at all. I know caffeine is a drug, but just like any other drug, after the initial withdraw shocks, it's not so bad. I NEVER take in caffeine and I wake up in the morning just fine and don't feel any need for it anytime throughout the day. I know if you're addicted to it, you might "think" differently, but c'mon man... That is something that should be soooo simple to change. Seriously. That would be like someone with celiac's disease saying "I know wheat gives me headaches and belly cramps, but I just really love spaghetti..." Or a full blown alcoholic saying "yeah, I know I have 3 DUI's and my wife left me, but I just need a little something to take the edge off 2-3 times a day..."
Yeah, then we can put you in the "Kona, No Coffee" club, which we discovered in CO includes John, Jeremy, Teri, and me.
Tim..
The supplement company I get many of my supplements from recently came out with a new D formula that also has Vit. K in it ( both phytonadione and menaquinone forms). I have to admit I was a little ignorant of the whole Vit. K thing, but after doing a little reading about it I thought you may be interested in doing the same. I think the above above Mercola article is a good place to start.