22. Five years

Five years is the usual course for alendronate, the drug that dampens the enthusiasm of osteoclasts, the bone cells that dismantle bone structure, a process followed by osteoblast remodeling/rebuilding.  Why just five years? Well, there are side effects--gastritis, osteonecrosis of the jaw, possible increase in femur fractures, all very rare but harder to ignore with each passing year.  Also, the effect of alendronate lingers, so my osteoclasts remain inhibited--or so they say.  But before deciding whether to continue alendronate or perhaps consider other approaches, some form of assessment is in order.  A bone density test obtained two years after the start of alendronate showed marked improvement; let's see if that progress has been maintained. \

21. Bucket List

It was one my bucket list, I explain, when I'm asked about the cast on my left forearm (non-displaced distal radial fracture). I've never broken a bone before, but you'd think that with osteoporosis, I'm at risk.  OK, but how much risk?  Well, not that much.

The FRAX algorithm uses bone density measurements and also family/personal history and height/weight. FRAX says over the next 10 years I have a 10% risk of a major osteoporotic fracture (which includes my broken wrist) and a 2.5% risk of hip fracture.

That's a fairly low risk, but for me it was 100%.  

So I do anything about it?

As planned I will continue the alendronate for the five year course.
And I will continue HCTZ which diverts calcium from urine to bones.
I should step up my self-designed yoga routine which emphasizes balance, core strength, and posture, the first two particularly important for fall prevention.

And of course, more caution when pruning tall trees

20. Annual Exam 2017

Met with my endocrinologist who who agree with the plan to continue alendronate for another couple of years.  She was not surprised that my bone density improved, both because that is not an uncommon finding with alendronate (despite official statements to the contrary) and because the HCTZ may be shifting some calcium to my bones.  The latter would also explain no new kidney stones.

19. Success!

Three years into alendronate therapy (the bone strengthening pill), I repeated the "DEXA" (bone density) scan of my spine, neck of the left thigh bone, and total hip.  The spine was the most affected before (3.8 standard deviations from the normal of a mature adult), and remains osteoporetic now--BUT ONE STANDARD DEVIATION BETTER!--only 2.8 SD.

At 5-9 and a fraction, my height is right at the mean of the American male.  If I were 3.8 standardard deviations below the mean, I would be about 4 ft, 10.5 inches.  2.8 SD would be around five foot, one and a half inches.  So taking alendronate for three years has been the equivalent of adding about three inches to my height (actually 2.8 inches). Not bad.

The plan is to continue taking alendronate for 2 years, then stop.  Somehow the bone densifying effect of alendronate continues long after stopping.  And continuing would increase the risk of jaw necrosis or spontaneous femur fractures that are rare side effects. Five years seems to be the Goldilocks balance between risks and benefits.

18. Osteroporosis by xray

Here are some computerized xrays (CT or CAT scans) of osteoporetic vertebrae (normal on left, osteopenia in middle, real-live osteoporosis on right).  No wonder they break (but why hasn't mine?). 

Impressive, eh?

17. Boring

I did get a call to come in. I thought about if for a few days, not really thinking it was necessary, but then again why not. First some "upper and lower abdominal X-rays, then a call from the urologist.  I had a regular appointment later that day, but he said a phone call should be sufficient since the X-ray showed no changes, as long as I was feeling okay, no need for further evaluation/treatment.

The X-ray showed : "abnormal calcifications: The evidence of bilateral nephrolithiasis appears stable on this exam.  No calcifications identified in the course of the ureters.  Bones: Mild degenerative change lower lumbosacral spine."

So, the stones are in the kidneys, just where the ureters take off (the "renal pelvis"), not in the ureters.  And the doc observed, the stones are small enough so that if they did enter the tubes (which would require a little uphill travel), they be able to pass (instead of obstruct). 

As for the spine, the previously noted arthritis, apparently not worse than on prior exams, and no side mention of osteoporosis, which had started the whole process three years ago.

16. Yearly Check-up?

A year ago I got a call from my urologist's office suggesting that I come in for an xray, which as I noted in post 13, showed no changes (no new stones and no change in the position of the pre-existing stone on the left).  

This year no such call, and I have been without symptoms of stones, so I'll let things pass.  I suppose that if were imaging to happen, and it showed movement of that left stone, it could be removed before it caused any problem--acute kidney stones aren't just the cause of pain, but can damage the kidney as urine builds up behind the stone.

Still, though, let sleeping dogs or stones or babies lay.

15. Microarchitecture

On the left are the rail-less granite slabs that serve as steps leading away from my back door (the steps continue unseen to the left). This angle demonstrates the steep drop from the top step to the bottom of the window well outside a basement window, about six feet.  

So there I am on the that step, standing on one leg while I put on a shoe, when I lose balance and fall into the well.  It's a slow fall and I think as I fall, "shit, I'm probably going to break the window; a real pain to fix."

I should have been more worried about breaking me, given the state of my bones.  A few months later, the hinge on my folding bike breaks and down I go.  But again I remain unbroken. Many people with osteoporosis break a bone just standing up or sitting down. Why didn't that happen to me with two hard falls?

The answer may be a concept called microarchitecture.  I may not have density, but there is something protective about what little structure I do have.  Sounds like a theory made up to explain something that can't really be explained.  Whatever it is, I'm grateful for it.

14. Update

Now about half-way through the recommended 5 yr course of alendronate, which increases bone density.  Some studies have suggested that for the first five years, bone density increases, with minimal benefit thereafter but continuing (though very low) risk of side effects such as jaw osteonecrosis ("death" of jaw bone cells)--some dentists refuse to do oral surgery on patients taking alendronate.

Question:  when should I repeat a bone density test to see if the alendronate is working?  At least 2-3 years--got to give it time to work.  I'll probably wait for the 3yr option, and if no improvement consider alternatives.

13. Steady As He Goes

The six month repeat x-ray shows no changes in the size or position of the stones.  Good news, I guess, but I am a little disappointed, hoping that some the changes that I've made would have made a difference.

Mainly, I'm trying to drink more water, easier said than done.  I've been taking low dose hydrochlorothiazide (HCTZ), a mild diuretic that in higher doses is used as an anti-hypertensive. HCTZ also decreases calcium concentration in urine, which I hope also means increased calcium availability for my bones.

I added a magnesium supplement that has been associated with decreased kidney stone formation, and greatly decreased drinking sodas with phosphoric acid (root beers, colas, dr pepper).

For the new year, I will try to add 4oz of lemon juice to my drinking water every day because its high levels of citrate may even dissolve stones already present (though I should think of it as more of a preventative strategy.

I don't think I'll try to decrease dietary levels of oxalic acid (my stones are probably calcium oxalate); high oxalic acid foods include chocolate, nuts, berries, grapes, and leafy greens, all of which have advantages that I think outweigh the oxalate factor.

12. Second Opinion

I met Dr. Hank, a urologist, at a retreat; we and our wives had a pleasant talk but it seemed unlikely our paths would cross again; they live 50 miles or so away, and at the time I wasn't looking for a urologist.

Fast forward a few years, and I need a second opinion, to explain if nothing else.

So last spring I talked with Hank who provided a real insight and recommended repeating an X-ray after six months or so. 

He said that the remaining large (8mm?) right stone, as well as the small stones on the left appear to be residing in ureteral ducts downhill from the ureter's kidney exit. On the diagram, the black dot presents the right stone.

So for the stone to enter the ureter proper where it cause mischief (obstruction), it has to first go uphill.  No gravity boots for me.

11. Mixed Message

A couple of months ago I underwent a renal scan to further determine the extent of this damage. I was given a tiny dose of a radioactive isotope and then for almost an hour I had to lay still while a medical geiger counter tracked the flow of this isotope as it passed through the kidneys.  I was watching the screen and it looked like my right kidney was not processing as quickly as the left.  

This is what my urologist emailed me about the scan:

"Your renal scan showed 62% function in the left kidney and 38% function in the right kidney. The right kidney has some sluggish drainage, but no obstruction.  It is likely from the chronic dilation of the ureter and collecting system."

And this is from the radiologist's interpretation:

"The arterial phase reveals prompt perfusion of the left kidney but diminished perfusion of the right kidney.  Split renal function at two minutes reveals 62% of the total perfusion to be present in the left kidney and 38% and [sic] the right kidney.  There is prompt unobstructed excretion by the left kidney. There is somewhat delayed and prolonged clearance of activity from the right collecting system."

The urologist would have me believe that both kidneys are functioning below normal--"function" being the key word here.  In fact, since 62 + 38 = 100, it would appear that my renal system operates as the equivalent of one healthy kidney. Doesn't sound good, does it?

But the radiology report suggests a different interpretation, that the left kidney is responsible for 62% of the total work done during that hour, and the right for 38%.  A normal left ovary, in other words, and a problematic but unobstructed right ovary. Here the key word is "perfusion." Is there a difference between perfusion and function?  

I'll go with the radiologist and schedule a second opinion with a second urologist.

My family practice doctor is more interested in a blood test called creatinine and the "glomerular filtration rate" derived from creatinine level, are the usual markers used to define kidney health.  My creatinine level measured in January was significantly elevated, raising concern about permanent kidney damage. But that was before any procedure, when hydronephrosis was present; a few weeks after the stone was removed, the creatine returned to normal levels.

10. 24, 46, 49, 53, 65

So, what happens to the calcium that has been leaking out of my bones--or the dietary calcium that isn't being getting into the bones in the first place? Parathyroid (PTH) and calcitonin hormones dictate a narrow range for blood calcium levels, critical for calcium's numerous roles, which include clotting mechanisms, hormone release, and muscular nerve transmission.  

Extra calcium would interfere with these tasks, so the kidney diverts extra calcium into the urine, too much in my case. When the concentration of dissolved urine calcium gets too high, the opposite of dissolve occurs: precipitation. Stalagtites, crystals, hail, kidney stones, all examples of precipitation.

Kidney stones can block the ureter, leading painful or not so painful spasms, and causing a back-up of urine upstream to the kidney--not good because that back-up creates pressure on cells, a potentially deadly process.  

24, 46, 49, 53, 63, 65: ages when I experienced kidney stones, all spontaneously passed until the most recent, which required a laser blasting. Done under general anesthesia, the most difficult part of the procedure was the temporary (about two weeks) placement of a stent: a tube inserted inside the ureter to prevent kinking and blockage by postop swelling or by a remnant of the stone.  More annoying than painful, and associated with markedly increased frequency, I decided to have it removed before a 3 week overseas trip. Been okay in the 9 months since then. I did okay

9. Yoga: Let's Get Specifical

I want a yoga routine that emphasizes poses helpful for kyphosis and osteo in general while excluding poses that might be harmful (forward bends, impact, twisting).  More than just a list of poses, yoga practice needs a sequence that allows one pose to flow into the next, critical for maintaining a meditative mindset.  Bryn Kest's original power yoga series, for example, has great sequencing, but yoga guru Rodney Lee appears oblivious to this concept.

The study cited in post # 7 promised "detailed" description of poses and sequence, but when I emailed the lead author, her reply just noted, "the future report never came to be.  Sorry that I am unable to provide more detail about the poses."

I suspect that's a common issue with research.  A "preliminary" study gathers interest ("breaking news") but really needs more patients, longer follow-up, and/or refined methodology, all which require more intense work (i.e., time and money) than available.  Initial interest wanes, researchers move on, but achieves an almost mythical status, the preliminary status left by the wayside.

That happened with a study of 12 (yes, just a dozen) adults comparing weight management with and without a nutritional breakfast.  The preliminary finding suggested that skipping breakfast was a bad idea, and has been incorporated into the conventional wisdom of modern nutrition.  All without follow-up confirmation.  For some people, sure, but not a panacea.

Same thing with yoga and kyphosis: Does it really help in the long-term for a wide range of osteoporosis patients?  Don't know and perhaps never will.

8. Power Yoga

So what about yoga and reversal of kyphosis?

Could be simple as the cobra pose, or any backward bend, opening up compressed vertebrae, giving space for remodeling, a few minutes to reduce forward pressure, promoting growth of osteoclasts, and an influx of calcium and other matrix material.  

Really? 10-20 minutes a day of a handful of specific poses will do this? 

Or maybe it's the stretching, loosening of ligaments.

Or yoga breathing: a deep, slow, rhythm that restores.... 

7. Yoga and Osteo

Bones cycle between breakdown (aka resorption) and repair (ossification).  Ossification can follow both internal resorption and external fractures.  So what about spinal wedge fractures that lead to kyphosis: can natural bone "remodeling" heal these fractures, reversing kyphosis along the way?

A recent study divided one hundred eighteen women and men aged 60 and older with kyphosis into two groups. The experimental group attended hour-long yoga classes 3 days per week for six months.  The control group attended a monthly seminar and received mailings.  The active treatment group demonstrated a 5% improvement over the control group based on measurements of the kyphotic angle.

What is it about yoga (or any other exercise) that would promote natural healing and the reversal of kyphosis?  When, if ever, is it too late to embark on an exercise regime designed for osteodudes ? (.

6. Kyphosis, aka, Dowager's Hump

Vertebrae are well supported posteriorly (the "facet" wings), but not so much anteriorly (the vertebra body).  Plus the anterior is subjected to more stress when bent over (heavy lifting), or impact stress (riding horseback). Continuous stress can cause multiple small fractures in the vertebral body, leading to compression and forward bend.

This is not bad posture--a problem of past or current weakness or discipline-- not tight ligaments that just need loosening, and not subluxation fixable by chiropractic manipulation, but an irreversible spinal curve.  Really irreversible? Completely?  Well, maybe not, as my next post will suggest.

5. FRAX

It's all about fractures.  Osteoporsis means increased risk of broken bones.  A niece recently broke her arm when her ATV rolled.  I supposed if I had been there instead of her, I might have had several, more serious fractures.  But who's to say?

Well, FRAX says something.  FRAX is the Fracture Risk Assessment tool developed by WHO and British researchers in 2008, using large populations, linking known fractures with demographic and clinical data.  

I went to the FRAX website, entered the requested information, and came up with a prediction that within the next 10 years I have a  27% risk of a major osteoporotic fracture and 16% risk of a hip fracture.  

Not bad, that means this year I have a 1 out of 37 chance of a major fracture. Returning to the tool and plugging in a normal bone density result, I would have only a 1 out of 167 risk of a major fracture.  To be dramatic, my osteoporosis means almost a 500% increase in risk of a major fracture this year. 

But frankly, it's not so much the major fracture I'm worried about, but rather the insidious microfractures that I'll talk about in my next post.

4. Non-Compliance and Faith

A couple of headlines from the past few days:
     "NASCAR will not penalize teams with noncompliant roof flaps"
      and "Forty percent of miners' technical reports are non-compliant"

More than just not following recommendations, "non-compliance" suggests a serious breaking of rules or laws.

Doctors use non-compliance to describe patients who don't take their meds, or don't quit smoking or don't exercise or don't have lab tests done.  For some, the law-breaking insinuation of the term is distasteful and "nonadherent" has been suggested instead, but nonadherent has its own problems.

You can read that some 50% of patients do not take prescribed medications, not unexpected in the 70 year old on 5-10 meds, each with different schedule (morning or night; before or after meals, etc.).  But I just have a once weekly self-injection for arthritis, and a couple of daily supplements (calcium, vitamin D, omega-3 pill) and now the weekly alendronate.  

No big deal if I forget the supplements a couple times a week, but I forgot alendronate dose 2, taking it couple days late, and this morning forgot dose 3; we'll see if I take it tomorrow. No wonder that 30% of osteos on alendronate stop taking it within several months.  I don't and won't feel better taking it--same goes for blood pressure or cholesterol lowering meds, among others--I just take it on faith.

3. Primary Osteo

Many factors disrupt the active bone remodeling described in the previous post.  

Muscles attach to bones.  Pull the muscle hard enough and the bone also gets pulled. Specialized nerve receptor cells in the bones recognize these pulls and respond by stimulating osteoclast activity.  Ergo, bones become stronger (more dense) with weight-bearing exercise.  I don't have an answer why inactivity has the reverse effect (loss of bone density) but it does.

Steroids such as prednisone used by asthmatics, or recipients of organ transplants.  These steroids may keep calcium from reaching bones or may disrupt the osteoclast/osteoblast balance.  The body can overproduce it's own steroids, yielding the same results

Excessive alcohol use and smoking are associated with osteoporosis; alcohol because it inhibits calcium and vitamin D absorption and may directly kill osteoblasts; the smoking link is unclear, perhaps just because smokers are more likely to abuse alcohol and to have poor nutrition.

Too much parathyroid hormone, not enough thyroid hormone, any eating disorder (including the simple deficiency of calcium), and certain cancers and renal disease also increase the risk of osteoporosis. Decreased bone density attributed to one or more of these factors is labelled "Secondary Osteoporosis."

I tested negative for all known risk factors, so I have "Primary Osteoporosis," which means an as yet undiscovered factor, or an acceleration of the inevitable bone loss that occurs with aging, has led to my bone loss.