Episode Transcript
Speaker 0 00:00:00 Okay. Hi everybody. I'm Steve Spencer. I'm the founder of the Birmingham Medical News. We, since 2004, we've been providing the Alabama healthcare community with, uh, all sorts of information on healthcare. And this is our initial podcast. This is not only for healthcare professionals, but also for, uh, regular folks, whether you're an insurance salesman, a lawyer, or a carpenter. And, uh, hopefully you'll learn some things about healthcare conditions that you might be worried about or you may just wanna learn about. So, with that said, we're sponsored by kas and Company. Kassouf and Company is an accounting firm in Birmingham that actually was founded in the 1930s, so it's almost a hundred years old. And while Kassouf works across all industries for our purposes, they have a really great experienced healthcare, uh, consulting practice. Anyway, we are actually in their studios today. They're just fantastic for us.
Speaker 0 00:01:07 They've, uh, uh, allowed us to use their studios. Russ Dorsey, who's head of it here, is actually gonna do everything for us. I couldn't even begin to do this. Russ is gonna edit and put the whole thing together. Anyway, today we're talking about osteoporosis, and we have Dr. Chris Heck, who's an orthopedic surgeon with, um, with Southlake Orthopedics. Dr. Heck, after earning his medical degree, um, uh, did his, uh, residency with the University of Kentucky and then went on and got a, did a spine fellowship with Duke. And, um, so to start out today, Dr. Heck, I know that you've really, uh, come to do a lot of work and focus on osteoporosis. And I wondered for starters, how, how did you, how did that even get started with you?
Speaker 1 00:02:01 Yep. So, um, we're on the front lines of osteoporosis. Um, when we take call, uh, or even some patients may walk into our office with fractures. Mm-hmm. Um, we then, as orthopedists are gonna take care of the fractures. Mm-hmm. <affirmative>. But the issue is why did the fracture occur? Obviously, some fractures occur for very generic reasons. Somebody twisted their ankle playing soccer or got in a car wreck and had, you know, multiple injuries, including broken bones. But when you have a low energy injury, so car wreck, high energy is, is put into the body and that can cause regular healthy bones to break. But when you have low energy injuries, especially in the older patient population, that is a suggestion that there's an underlying cause. Um, when grandmama falls down and breaks her hip, that's most likely due to osteoporosis. If grandson did that, he wouldn't break his hip.
Speaker 1 00:02:55 And so, number one, we're on the front lines. We see these patients in the emergency room, in the hospitals and, and less frequently in our office, and we fix the broken bone. But then they still have the underlying problem, which is the weak bones, the brittle bones, the osteoporosis, technically mm-hmm. <affirmative>. And, um, uh, we would see for patients who would come back in with re repetitive fractures, um, the most common risk factor for an osteoporotic fracture, osteoporotic fracture is a prior osteoporotic fracture. So, uh, the studies on this show that, uh, if, if grandmama falls and breaks her hip 20%, so one in five of those patients who break their hip from osteoporosis will break it again within 12 months. One year they'll be back in the hospital, back in bed, increased risk for blood clots, pneumonia. And so now the issue is when you break both hips, guess what?
Speaker 1 00:03:49 You got no more hips to break. You think you're out of the woods. But you can break your ankle, you can break your wrist, you can break around a prior knee replacement or hip replacement, cuz your bones are very brittle. So, um, the way I got into it was patients would come and I'd see repetitive fractures. And even in our orthopedic academy, we, uh, there was the, there was a decade in the first decade of this century, uh, 2000 to 2010 said it was called Own the Bone. It was a, uh, you know, a program put by forth by our, uh, academy, uh, orthopedic academy to try to not just treat the fracture, but treat the whole patient. And the whole patient here was osteoporosis. And they would recommend, Hey, uh, you know, get your patient after you fix them, they get 'em outta the hospital and they're recovering.
Speaker 1 00:04:35 Get 'em a bone density test, also known as a DEXA scan, D E X a mm-hmm. <affirmative>. Um, and then that will demonstrate that they have bad bones and then send 'em to their medical doctor and let's get 'em on osteoporosis treatment. Um, and so as a conscientious doctor, I thought, you know, that's a great idea. Let me start doing that and let's treat the whole patient from an orthopedic standpoint. And, uh, one time I had a patient come back like six months after I fixed her broken hip, assuming she was having more hip problems. And so I walked in and I said, Hey, uh, your hip hurting you? And she's like, no, my hip feels great. I said, well, what brings you back in? She said, well, you sent me to my doctor. And he said, well, I, osteoporosis as an orthopedic, it's a bone problem.
Speaker 1 00:05:13 Go see your orthopedist. And I was kinda at that point thought, if I'm not treating them and I sent 'em away to another doctor and they're not treating 'em, then the patient's just getting lost. Right. They're following into a never ending loop that they'll never get out of. So, um, uh, that combined with some of the, uh, uh, the representatives for the drug companies that make osteoporosis were saying, Hey, you know what? You see a lot of osteoporotic patients, you should probably treat 'em. Mm-hmm. And I said, you know, I'm a surgeon. I'm not a medical doctor. I don't treat patients with medicines except for very short periods of time. It's usually pain control if they have a broken bone or a injury. And, um, but because this one patient really just kind of felt bad for this patient, just getting the run around in the medical system, I said, let's start it. So along with my physician assistant, uh, gosh, we started this, I bet you, 10 to 12 years ago, and, uh, have been running it ever since. Okay.
Speaker 0 00:06:05 Um, and, and one, one of the things I just, uh, you mentioned, um, so when a patient comes in to you, he or she has, has their medical doctors sent 'em, maybe they've had surgery for a fall or maybe not. What's the first thing you do
Speaker 1 00:06:21 To value 'em for osteoporosis? Yeah. Um, so if, uh, some, um, primary care doctors, uh, OBGYNs, uh, rheumatologists, those are kind of the three specialties outside of orthopedics that will start to look at this. Okay. Um, obviously the OBGYNs, they treat women, uh, from, you know, young age all the way up to, to late in life. And this is a problem typically, and we can get into this more, but typically of older women mm-hmm. <affirmative>, um, and so we do get a lot of referrals from those specialties, uh, to treat these patients. Uh, the first thing is get a bone density test. Mm-hmm. <affirmative>, uh, the bone density test is a risk assessment for fracture. Usually it'll state that you are at low risk, immediate risk or moderate risk or high risk for a future fracture. Mm-hmm. <affirmative>, it lets us know how thin your bones really are.
Speaker 1 00:07:09 Mm-hmm. <affirmative> mm-hmm. <affirmative>. Um, and then two, we get some blood work. We get blood work for a variety of reasons. One is, uh, some of the medical management for osteoporosis, you can't give people if they have bad kidneys. Well, if you have underlying kidney disease and we don't check that, then I can hurt your kidneys even worse. Mm-hmm. <affirmative>, mm-hmm. <affirmative> two is, let's just look at, uh, some of the other hormones that may be due to, we found a couple tumors, not, not not cancer tumors, but tumors that nonetheless were, uh, secreting, uh, hormones that, uh, cause the bones to be weak. And so if you don't correct that problem and you try to treat them, uh, it's, it's like spraying, you know, water in the wind, it just comes right back at you. It's not gonna do anything. And so, um, uh, so you gotta correct that underlying problem first.
Speaker 1 00:07:57 And so if we do find those tumors, then we will send the patient to, uh, an endocrinologist or to a surgeon if they have a small tumor to pop the tumor out, usually in the parathyroid gland, which is in your neck. Okay. Um, so once we can get control of that, uh, and then for men even, we'll test their, if we have a man who has osteoporosis mm-hmm. Less frequent, it may be acau, it may be a sign that they have low testosterone. Mm-hmm. Again, get 'em into endocrinology. So we wanna look at labs, we wanna get a bone density. And if all of those are just your generic run of the mill osteoporosis, then uh, there's about a 30 minute consultation at our office, uh, with our, with our providers. And, um, uh, we'll go through personal history, family history, which is another significant risk factor for osteoporosis.
Speaker 1 00:08:40 You know, hey mom, I broke her hip and now I broke my hip. Um, and then there are different, um, there are different categories of osteoporosis medicine and we'll, if you truly have osteoporosis are at high risk for fracture or have had a prior fracture, we'll get you on the medical management and mm-hmm. <affirmative>, the medic, the medications are usually classified into two groups. One is anti-resorptive medications, and those were the early osteoporosis drugs. Osteoporosis drugs have been around for decades. Okay. Um, the early osteoporosis drugs, things like Fosamax, um, Boneva, uh, Sally Fields was on TV pushing Bon nva. Mm-hmm. They have proli, well, Prolia kind of gets a different classification, but the early osteoporosis drugs, um, were anti-resorptive. And basically they prevented your body from resorbing minerals out of your bone, anti-resorptive. Okay. So I guess, you know, maybe we should go back a little bit. What is osteoporosis?
Speaker 0 00:09:33 Right? Because I wanna ask you exactly when you mentioned your body absorbs mineral minerals outta your body. I, yeah, please. Let's
Speaker 1 00:09:39 Get, so what is osteoporosis is a condition where your body, uh, resorbs the minerals outta your bone. Your bone is strong because it's a lattice work of minerals and bone. Okay. Uh, without the minerals, the bones have nowhere to grow. Um, but, um, if you don't have the bone, you don't have the strength. So it's a combination of minerals and bone mm-hmm. <affirmative>. And so, um, when we are born, our bones are not as strong as they're ever gonna be. Mm. Right. Kids' bones break a lot easier than adult bones do. Sure. So when we're born, our bone density, the strength of our bone increases up to about age 30. Okay. Unfortunately, everybody in this room is over the age of 30. Yeah. We are all on the down slope now. Okay. Okay. All of us, after 30 to 40 in that decade start to lose bone density. Little bit 3% per year.
Speaker 0 00:10:30 And what I don't wanna break into your teammates. Yeah. But why is that? Why do we start losing bone density?
Speaker 1 00:10:35 Uh, your body is, you're not, uh, bringing in the type of minerals that you used to from either poor diet, uh, is also your body is wanting, um, different minerals than it did when you were younger. Right. They, they, your, your body is basically saying, I need this out, I need this, I need more calcium. Okay. And if you don't put the calcium in your bloodstream, it's gonna say, I know where to find calcium. Where do I find calcium? The bones in the bones. Yeah. Okay. So then they put in their cells in there that will, uh, dissolve the, the bone and the minerals and release it from the structure out into the body.
Speaker 0 00:11:13 So, so then alright. As we start losing bone density, our thirties and forties, so some of it is simply we're not getting the minerals that we need, which are different than when we're younger. Yep. Right, right, right. But, but so that would be diet
Speaker 1 00:11:26 And it's our metabolism too, you know. Okay. You, you can't eat the same thing now that you did when you were 15. Sure. Right. So it's, it's a metabolism, it's a, it's your innate body's development. So it's not all just diet, um, but some of it can be. Yeah. Um, some of it's our lifestyle mm-hmm. <affirmative> mm-hmm. <affirmative> typically we're outside more when we're young. Yeah. We're inside more when we're older. Uh, sunlight, uh, helps to our sunlight and our skin helps to, uh, convert, uh, vitamin D in vitamin D helps us absorb calcium out of our gut. So when we're outside getting vitamin D all or getting sunlight, we have a lot of vitamin D in our system. Mm-hmm. <affirmative>, when we're adults sitting inside working and operating all day long, I don't see the sun sunlight very much. Right. Um, and so I don't get as much vitamin D in my body, so I would have to supplement it with, uh, pill, you know, pills, medications, herbal supplements mm-hmm. <affirmative> diet. Mm-hmm. And there are diet, there are, uh, foods that are high in vitamin D and high in, uh, calcium, but so, uh, as I mentioned earlier, uh, thirties and forties, it starts to then go into downswing. Mm-hmm. <affirmative> 3% per year, we lose our bone density mm-hmm. <affirmative> until menopause. Okay. Menopause only affects the females. Right. And so when they hit menopause because of the hormonal changes, um, they start losing it 10% per year. And,
Speaker 0 00:12:45 And I hate to get too in the weeds, but what is it about menopause that, that makes that
Speaker 1 00:12:50 Happen? Yeah. That I, I'm not educated enough. Oh, I, I couldn't even, oh, sorry. That's all right. I'd probably get into the endocrinology side of things and I'm not trained on that. Okay. But, uh, okay. Uh, having done my research, that's what I've learned. Uh, okay. I don't wanna overspeak my bounds, if you will. So, but better
Speaker 0 00:13:03 Line is that's when it
Speaker 1 00:13:04 Gets worse. Menopause. Yeah. It has to do with the hormonal changes, but nonetheless, they start losing at about 10% per year. Okay. So if you've got a, you know, if you've got a building, building building up to age 30 mm-hmm. <affirmative>, and then men and women are going down at the same rate until menopause and then menopause, the women start dropping at a much higher rate than the men. Mm-hmm. <affirmative> men will eventually get osteoporotic. They usually get it 20 years after women do. Okay. So the most frequent female osteoporosis patients we see mm-hmm. <affirmative> are sixties or older. Okay. The most common men osteoporosis patients we see are eighties and older. Mm-hmm. <affirmative>. Okay. Uh, because men's bones stay stronger on average longer than a woman's does. And so that's why if you look on tv, all the osteoporosis medications, the commercials are all geared towards women.
Speaker 1 00:13:50 And it's not that men don't need it, it's not that men don't get osteoporosis. It's not that men don't need medications for it, but if you're gonna target your, your your mass audience, the mass audiences are female, there's, there's, uh, family history, there's genetics, uh, there's, there's, uh, and take even, uh, uh, on, on, uh, kind of, uh, I guess on the genetic side, there's, there's, uh, increased rates based on, um, your, your racial background, um, um, Caucasians and, and mm-hmm. Japanese specifically have a much higher rate of osteoporosis. A lot of the literature that is, uh, written about on osteoporosis is, uh, American and even Japanese. Oh, okay. Um, blacks, Hispanics, they get it as well mm-hmm. <affirmative>, but, uh, they have a much lower weight as well. Huh. So, and that goes to genetics. Okay. There's just the genetic makeup, and again, I couldn't tell you why those, uh, demographics have different rates, but they do.
Speaker 1 00:14:54 Okay. Um, so men will get it, um, again later in life. And then so we get to the treatment as a dimension. A moment ago, I guess I kind of jumped to it. So now we know what osteoporosis is. Mm-hmm. What do we, how do we treat it? Anti-resorptive, the early medications were me geared towards keeping your bones from, or keeping your body from resorbing minerals outta your bones. Okay. So, um, those showed a statistically decreased risk of future fractures. They did tests where they had this group of patient gets osteoporosis medicines, antiresorptives. This group of patient did not. And the group of patients that got the medicine had much lower rates and they thought, oh, this is great. This is how we're gonna treat it. Mm-hmm. <affirmative>. Mm-hmm. <affirmative>, the problem is antiresorptives, as the name implies, prevent you from losing more bone. They prevent you from resorbing, more me more minerals outta your bones.
Speaker 1 00:15:39 Okay. What if your bone density is already really, really low? You like, what's, if it's, what if it's in the toilet? Okay. And now you're just preventing it from getting worse. Right. You're preventing it from going down the toilet. Mm-hmm. <affirmative>, but you're still in the toilet. Mm-hmm. <affirmative>. Mm-hmm. <affirmative>, those patients will typically break. We have patients who are on Fosamax or Boneva or Reclast. Uh, these medicins are in a group called BIS phosphates. That's their category. Okay. Patients who are still breaking, um, they're not on the right drug analogy. Okay. Um, if you have high blood pressure, you go to your doctor and you get put on a blood pressure medicine and you come back six weeks later, two months later, and your blood pressure's still up. Mm-hmm. <affirmative>, you're either not on a strong enough dose or you're not on the right medicine.
Speaker 1 00:16:19 Right. And your doctor's gonna tinker with it for a while until it gets it where your blood pressure is good. Mm-hmm. <affirmative>, if you're on Fosamax and old school anti-resorptive mm-hmm. <affirmative> and you're not breaking bones. Perfect. The goal of osteoporosis medical management is to prevent a fracture. It's not to treat pain. Mm-hmm. <affirmative>, broken bones do hurt, but osteoporosis as an entity, it's not a painful condition. It's a silent problem disease. So, um, um, if you put 'em on the medicine and they break, then they're not on the right medicine and they'll say, well, you know, I broke my hip, but I'm on Fosamax. I'm fine. Well, well you're on Fosamax, but you're still breaking. So then there's the newer class of drugs. Newer class of drugs have been around probably 15 years plus mm-hmm. <affirmative> and, uh, now we're into anabolic, kinda like anabolic steroids, you know, builds muscles and bodybuilders. Right. Anabolic, just mens growth. Okay. And so anabolic osteoporosis, drugs grow bone. Oh, that's, see, so now we made that trend. We go up until your 30, 40, then you drip down uhhuh, antiresorptives keep you flat, maybe you get a little increase. Okay. Okay. You go up, you go down. Now you hit anabolic drugs cuz you either you're so low or you've broken so many times, it actually makes your bone quality go back up. That's
Speaker 0 00:17:34 Fantastic. I didn't know that was
Speaker 1 00:17:35 Existed. Anabolic drugs now. So you can actually improve it. You can Wow. The, they're a little bit more high maintenance. Mm-hmm. <affirmative>, they're typically injectable drugs, not pills. Okay. They typically are done daily. Mm-hmm. <affirmative>, uh, kinda like an insulin shot. Patient has to give themselves their own injection at home. There are some newer medicines now that are anabolic that they get, uh, once a month. But anabolics are only approved for anywhere from one to two years. You can't just take anabolics forever. Uh, FDA studies and the FDA approval process, they're only quote, approved for anywhere from one to two years depending on which drug you're on. Okay. So at the conclusion of making your bone density go back up with the anabolics, then you get on an anti-resorptive for life
Speaker 0 00:18:19 And you, you hope that to hold it there as best
Speaker 1 00:18:21 You can. That's right. And that's the kicker. It's it is for life. Yeah. Osteoporosis is a condition where your body pulls these minerals out. And if you stop taking your osteoporosis drug, if you think, oh, I was on embolic for two years, I'm great, now all of a sudden they're gonna go back down
Speaker 0 00:18:36 As it starts pulling the
Speaker 1 00:18:38 Minerals out. So it is a lifelong disease. It is lifelong treatment. Mm-hmm. <affirmative>, but it can prevent some serious problems, fractures. And you people say, well, it's a broken bone, you're not gonna die from it. Mm-hmm. <affirmative>, you're right, you're probably not gonna die from your broken bone. Mm-hmm. <affirmative> your hip fracture, but you're gonna die from a pneumonia, you're gonna die from a blood clot. Mm-hmm. You're gonna die from sepsis. Um, the other studies they've done on geriatric over over 65 mm-hmm. <affirmative>, geriatric patients who have a hip fracture mm-hmm. <affirmative>, um, what is the number? It's, uh, one in three will die within 12 months of a hip fracture. Oh my God. And they didn't die from the hip fracture. Wow. They died from the complications of the hip fracture. So,
Speaker 0 00:19:18 So essentially 33%
Speaker 1 00:19:20 Of patients geriatric patients with a hip fracture will be dead within a year still.
Speaker 0 00:19:24 That's amazing. Because, you know, what you just said was you don't die of a hip fracture, but in a way you kind of do, I mean, essentially if 33% of folks with hip fractures mm-hmm. Die within a year,
Speaker 1 00:19:34 This is the That's pretty incredible. This is the epitome of preventative medicine. Yeah. Right. And especially if you get the warning shot across the bowel mm-hmm. <affirmative>, if you fall, if grandmama falls and breaks her hip mm-hmm. <affirmative>, we know she has osteoporosis mm-hmm. <affirmative>, let's, and let's get her through this and she survives mm-hmm. <affirmative>, let's not have it happen again. Yeah,
Speaker 0 00:19:51 Sure. So you'd probably want to get her on the antibiotic. I guess
Speaker 1 00:19:55 It depends if it's her first fracture, uhhuh <affirmative> and her bone density says, you know, maybe she's kind of got borderline. So the, the, the step below osteoporosis is osteopenia, which just means Okay. A, a paucity a a a less bone osteo is bone. So osteoporosis is just like, uh, no bone. Okay. Uh, a little bit more than that, but osteopenia is a loss of bone and then there's normal, which is, you know, normal bone density. Right. And so, um, if, if somebody has a first time fracture and, uh, their bone density is maybe on the border of osteopenic or osteoporotic or maybe they're just barely into osteoporosis, I think an anti-resorptive is good. It's been shown to decrease your risk for future fracture very well. Okay. Okay. Um, however, if, uh, this is your second hip fracture and you broke your knee above a knee replacement five years ago and Oh yeah. Three years ago you broke your ankle stepping off the curb. Mm-hmm. <affirmative>, man, this is just a never ending snowball unless you get on probably an anabolic.
Speaker 0 00:20:58 And one question a little bit aside, but on the ana, why does the FDA only prove it for two years? Is there some kind of, go ahead.
Speaker 1 00:21:04 Yep. Yep. So, um, if I remember correctly, the first one that came out was a drug called Forteo. Okay. Uh, that was the very first one. And, um, you know, they studied these in animal models and I believe there was some concern about increased risk of cancer, uh, with prolonged, because, you know, cancer is growth of cells. Oh. And here you're growing bone and bone growth comes from bone cells. Mm-hmm. <affirmative> mm-hmm. <affirmative>. So, uh, I believe it had something to do with, um, with, with a concern for cancer, although it's never been, been demonstrated in the human population. Mm-hmm. <affirmative>. Mm-hmm. <affirmative>, you know, we, we infer a lot from animal studies and so, uh, the Forteo was the first anabolic drug on the market, and it did wonders, I mean mm-hmm. <affirmative>, the, the, the, not only for the studies on that, but also, um, they show patients who were having either spine surgery or uh, joint replacement surgery.
Speaker 1 00:21:55 Uh, when we put large pieces of metal in patients' bodies, uh, sometimes their bone can't support it. Mm-hmm. And they would fracture around their hip replacement, they would pull their screws from their spine surgery, would not hold their spine together anymore. Mm-hmm. <affirmative> and actually patients who were placed on Forte at the time had a much, uh, lower rate of complications around the time of that surgery because it helped make their bones stronger to support mm-hmm. <affirmative>, you know, these pieces of metal that we're hoping your body incorporates into the bone. Mm-hmm. <affirmative> mm-hmm. <affirmative>. But anyway, but yeah. So you're allowed to, some of the medicines and the most recent one had such good results. They, at one year they were like, you know, we don't need to keep going on this.
Speaker 0 00:22:33 Okay. Okay. Thank you so much. Great information. How can people find out more?
Speaker 1 00:22:39 Yep. So, um, they can call our office, uh, air Code 2 0 5 9 8 5 4 1 1 1. Go to our website south lake orthopedics.com. Uh, we have information there if they call our office, uh, just say, I want to get an evaluation for osteoporosis, and we have people who can take care of 'em from there.
Speaker 0 00:22:56 Uh, we're going to end it only temporarily. This is the end of part one. We'll be back next week with part two. Uh, thank Casso again. My, this is Casso Studio. They've been incredibly generous to us. And don't forget the Birmingham medical News, giving you all the information you can ever ask for about healthcare in Alabama. And just because you don't live in Alabama doesn't mean you can't learn about osteoporosis. So thank you everybody.
