Amanda Wilde (Host): This is Community Connect presented by Tampa General Hospital. I'm Amanda Wilde. Joining me is Dr. Yevgenia Usheva, medical director of the USF Adult Osteoporosis Program. Join us as we explore the essential aspects of bone health. Dr. Usheva welcome.

Yevgeniya S. Kushchayeva, MD, PhD: Thank you so much. It's a great pleasure. To be here and thank you for your invitation.

Amanda Wilde (Host): Well, This is something That is personal to me and many other women. When do we need to think about checking our bones?

Yevgeniya S. Kushchayeva, MD, PhD: This is a very good question. Unfortunately, awareness about osteoporosis is not as good as we would like it to be, and many people are not aware when even to think about this. So the major US guidelines provide a clear recommendations for osteoporosis screening initiation. The US Preventive Services Task Force usually recommends screening all women who are 65 and older using.

DEXA study or dual energy x-ray absorptiometry. So also young, women might need to be screened if they have risk factors for bone loss and some of them, some select previous fracture. Parents with hip fractures, low body mass index, smoking, chronic, glucocorticoid therapy or other chronic disorders for men. it is a little bit different, situation here, the US.

Preventive Services Task Force state that current evidence is insufficient to recommend routine screening for men. But other organizations such as Our National Bone Health and Osteoporosis Foundation and International Society for Clinical Cytometry suggest considering screening in men who are 70 years and older and even younger men with a significant risk factors for bone loss.

So in general, screening for bone loss is very important, and initiation screening depends on age and risk factors that a, a person might have.

Amanda Wilde (Host): Are there any clinical symptoms or signs of bone loss along with those risk factors? If there are symptoms, that would be something we need to consider.

Yevgeniya S. Kushchayeva, MD, PhD: This is a very good question. So, maybe This is the reason why we don't know so good about osteoporosis, because This is usually silent, asymptomatic disease until fracture occurs. Fracture is the initial presentation of osteoporosis. We call those fractures, frag agility fractures because they can occur, from minimal trauma, from false, from standing, position even without trauma.

And of course, symptoms will depend which bone, has been fractured, but usually it is pain. However, sometimes with vertebral fractures. a patient might not have a classical clinical presentation and, up to two third of vertebral fractures will be unrecognized by the patient due to really absence of, symptoms like acute pain or misattribution to other chronic back conditions.

So just chronic back pain that many of us might have as. Especially with aging, and This is very important to know that if the first fracture happened, so the risk for recurrent fracture will be significantly higher during the next two years after the first fracture. That is why screening for the primary prevention and if fracture already happened.

Evaluation of bone density is very critical to avoid the recurrent fracture.

Amanda Wilde (Host): It sounds like you diagnose bone loss due to fragility fractures, which might lead you to the screening with the dexa. And the dexa itself is a diagnosis tool or do you have any other tools to diagnose bone loss?

Yevgeniya S. Kushchayeva, MD, PhD: Yes, absolutely. This is another great question. so we have couple of ways how to diagnose osteoporosis. First of all, This is based on bone mineral density when T-B-M-D-T score is minus 2.5 OMFS in spine or heap. This is osteoporosis also, when patient had already fragility fracture. Regardless what DEXA shows.

It's also, osteoporosis already. And the third way how we can use this, we have a specific calculator that called frax. So this calculator we use for patient's with osteopenia, but this calculator, has multiple questions. Uh, about risk factors that can tell us the 10 year probability for fracture, and That is the third way.

How we can diagnose, osteoporosis. We also can use opportunistic images, something like, a CT that done for any reason, not for a bone reason. You also can use this to predict, bone mineral density and to clarify if patient might need additional evaluation.

Amanda Wilde (Host): You mentioned aside from risk factors. That screening should apply to women 65 and older and men over 70. Those are the guidelines, but I'm wondering, I always hear about women and bone loss is bone loss, a women disease or women and men both get this disease at the same rate.

Yevgeniya S. Kushchayeva, MD, PhD: osteoporosis is not only disease, in women, of course, the prevalence of osteoporosis. And men is substantially lower than in women. It sounds like 4.4% versus close to 20%, but estimated number of men with osteoporosis, about one two millions in the United States and interesting based on literature one. Three women and one in five men over 50 will have osteoporotic fracture in their lifetime.

And men even, they, have lower incidences of osteoporosis. They have multiple risk factors, including, Low body mass index, the same prolonged steroid use, previous fractures, sometimes smoking, sometimes alcohol consumption, hypogonadism, androgen deprivation therapy for patient's with prostate cancer, let's say history of strokes, diabetes. All of those disorders will affect, bone loss in men and exactly like in women.

And the most important what we need to remember that men who experienced hip fracture have mortality rates approximately twice that of women. and let's say if we are talking about hip fractures that happened in men and women. One-year mortality will be 37.5% in men compared to 2018 women, most likely the success of mortality occurs at least partially because male fractures usually happened about 10 years later in life than in women when comorbidities are more prevalent.

But osteoporosis is disease for both women and men.

Amanda Wilde (Host): And you have described many conditions that can. Cause bone loss. So That is something for us all to be aware of and, And also aging.

Yevgeniya S. Kushchayeva, MD, PhD: Exactly, exactly. Osteoporosis is considering, disease of aging right now. Osteoporosis, I would say, became younger. and This is because of secondary osteoporosis, because primary osteoporosis, it's usually in women because of estrogen deficiency. When we became menopausal, we lose our estrogens That will accelerate bone resorption and reduce bone formation.

So we will be losing more bone than we can. But secondary causes will include a lot of chronic disorders. on top what I mentioned, it also can be chronic kidney disease, liver disease, a lot of endocrine disorders, overactive thyroid, overactive parathyroid glands, cushion syndrome, growth hormone deficiency, or let's say disorders that cause malabsorption like, Crohn disease, ulcerative colitis, celiac disease, multiple rheumatological conditions because they usually have chronic inflammation.

And plus those patient's, often on glucocorticosteroids and of course lifestyle. I mean life lifestyle factors are also very critical against smoking alcohol. Poor nutrition, especially with low calcium and vitamin. The low level of physical activity, everything will lead to low bone mineral density and multiple medication that can cause this, including steroids, aromatase inhibitors, androgen deprivation, agents, multiple chemotherapies, so you can see variety of risk factors that can affect bone mineral density.

Amanda Wilde (Host): Now medication is usually the go-to when people do have osteoporosis. What are some of the side effects of those osteoporosis medications and how do we minimize the risk?

Yevgeniya S. Kushchayeva, MD, PhD: yes. I think This is one of the, of the, really important questions because there are, uh, many beliefs in society that those medications really have multiple side effects. I mean, Osteoporosis medications as any other medications can have side effects, but commonly, the prevalence of those side effects are exaggerated and sometimes even not supported by current literature.

and, please, we also all need to remember that those side effects, and I'm going to. talk about them, in details in the moment that they are very rare And the overall risk profile of those drugs is favorable compared to their benefits in fracture prevention, for example, everybody is afraid about osteo necrosis of the jaw.

but. The patient's. For patient's treated, for example, with bisphosphonates or denosumab, the absolute risk of osteonecrosis of the two, it's typically between 0.01 to 0.05% over five years. In contrast. Lifetime risk of dying in the motor vehicle accident in US is approximately 0.9, which is 11 deaths per 100,000 population.

You can see the difference. Another example, let's say annual mortality from upper respiratory infections like influenza and respiratory syn virus. So an influenza alone can cause over 10,000 deaths per year. And, RSV about 6,000 deaths per year. So, it means it's several hundred, uh, people per 100,000 population. Of course who most predisposed, even This is extremely rare complication.

Elderly people, people with poor dental health or people who are going to have, invasive dental procedures. That is why we always recommend our patient's before we can see the treatment. Talk to your dentist before initiation of those medications to check if you might need any procedure that should be done before we start treatment.

Amanda Wilde (Host): So. Fairly look at and weigh the risk. is it fair to say that complications are rare?

Yevgeniya S. Kushchayeva, MD, PhD: Yes, absolutely. Uh, it's very rare. Another, a side effect that people are afraid. Oh, This is atypical femoral fracture, with bisphosphonates. But again, it's about 0.022 0.1%, and it's related for duration of treatment. So you can see that if you can see the correct medication, the correct, duration of treatment, we can absolutely minimize side effects.

Even they extremely rare right now, one of the very important information about side effects that, community needs to know about This is discontinuation of denosumab. Denosumab is, very potent anti resor medication that cannot be stopped. Any follow-up treatment because if denosumab is stopped without any consolidation therapies, the patient will develop activation of resorption until the point of rebound vertebral fractures.

So This is something that. Every single patient who started on denosumab should remember. So it's very critical information for all of people to know. and of course, other medications like anabolic medications, ide abide. they were known to cause osteosarcoma. It was a warning box, but the risk is theoretical and was based on animal studies only.

There is no risk in human that has been absorbed for a long period of time. and. The last medications, the newest, which is romosozumab with a black warning box, increased cardiovascular risks. But this was only seen in active controlled trial and not in placebo controlled trials. But still, if we see a patient with high cardiac risk, usually it should be a discussion with cardiologist about safety, to proceed with this medication.

Amanda Wilde (Host): Dr. Keva, can you explain why treatment for osteoporosis is important?

Yevgeniya S. Kushchayeva, MD, PhD: yes. because benefits of treatment, Really overcome all of possible side effects. Treatment for osteoporosis is important because it significantly reduces the risk of fractures which are associated with substantial morbidity, mortality and loss of quality of life. And we are dealing mostly with. Elderly people, so osteoporotic fractures, especially hip and spine, can lead to disability.

Increased risk for next fractures, even premature deaths. Hip fractures, for example, carry a one-year mortality risk of 21 to 24% in all the people, and often result in long-term loss of independence. And let me tell you even more for hip fracture studies consistently showed that 40 to 60% of patient's will not recover their pre fracture, mobility or ability to perform a daily living activities for one-year after fracture.

And I will tell you only 26% in the year will continue living. Independently. So the same for vertebral fracture. It's a chronic pain after vertebral fracture. It'll be a chronic pain disability limitation in function, limitation in daily living act activities. so That is why it is very important to, prevent those fractures because consequences are quite devastating, especially for elderly people.

Amanda Wilde (Host): After hearing this. If someone wants to get screening, what's the first step they should take?

Yevgeniya S. Kushchayeva, MD, PhD: so it's quite easy to do so the person can talk with their primary care physician or any specialist they are going to, to screen them for osteoporosis if they are eligible. It's very easy to do just with DEXA scan. DEXA scanners are widely available in almost all. All radiology departments, it is simple x-ray based test with very low radiation exposure.

but important to know that unlike other imaging modalities, the bone mineral density monitoring needs to be done on the same scanner since comparison results from different DEXA scanners. Is not recommended So, It means you need to choose the DEXA scanner That is most convenient for you and go there on regular basis, for bone mineral density monitoring.

Amanda Wilde (Host): Well, Dr. Keva, Thank you so much for sharing your knowledge And this important information about a disease that really can affect any of us and really appreciate you also highlighting the risk factors.

Yevgeniya S. Kushchayeva, MD, PhD: Thank you so much for having me here. It was a pleasure.

Amanda Wilde (Host): That was Dr. Yevgenia Keva. Medical Director of the USF Adult Osteoporosis Program.

Speaker: For more information, please visit tg.org/endo.

Amanda Wilde (Host): If you enjoyed this episode, be sure to like, subscribe, and follow Community Connect presented by TGH on your favorite podcast platform. This is Community Connect presented by Tampa General Hospital. Thanks for listening.