Live Lecture: Bone Health, featuring Dr. Kannen

Hannah Vargo:

Good evening, and welcome to the second Florida Orthopedic Institute Live Lecture. Thank you for joining us. My name’s Hannah Vargo, and I’m a physician liaison at Florida Orthopedic Institute. Tonight, I’m proud to present Dr. Jeff Kannen, one of our primary care sports medicine doctors. He’ll be talking about bone health, osteoporosis, and its treatments.

Hannah Vargo:

Dr. Kannen is board certified by the American Board of family medicine. He’s a member of numerous organizations, including the American Medical Society for Sports Medicine, the American College of Sports Medicine, and the American Academy of Family Physicians. Dr. Kannen cares for all musculoskeletal conditions in pediatric and adult populations.

Hannah Vargo:

He has special interests in overuse injuries and upper and lower extremities, endurance sports injuries, diagnostic ultrasounds, and regenerative medicine treatments. Before we get started just a few housekeeping notes first, we’ll be sending everybody a link to the webinar.

Hannah Vargo:

Second, you can comment or ask questions directly on zoom. I’ll be monitoring those questions. You can also send questions to our Instagram or our Twitter at FL_Ortho. Third, if you don’t have a sound or your slides are not moving, please try refreshing your browser. With that, I’m pleased to turn it over to our speaker, Dr. Jeff Kannen.

Jeff Kannen:

Thank you, Hannah, for that introduction. Thank you and welcome everyone tonight for today’s live lecture for bone health. I have no disclosures for this presentation tonight. So our objectives tonight, we’re going to review key topics in bone health. We’re also going to review concepts of fracture risk assessments in the population, as well as different treatment options for low bone density and osteoporosis.

Jeff Kannen:

First, we’re going to start with an introduction to bone health and what that means. So bone health plays a critical role in maintaining a health level of function within the body. So bones are very important for maintaining different aspects of your function and day-to-day life. Certain imbalances within the body can lead to poor bone health, and you can develop osteoporosis or low bone density from these imbalances.

Jeff Kannen:

And this increases the risk of having a fracture, traditionally with bone health we’ve tried to target the older populations because these are more at risk traditionally, but there’s been a trend more recently with screening younger and younger people because we found that there’s also a risk in younger people for having low bone density. And this may include younger populations with certain diseases as well as athletes.

Jeff Kannen:

So what is osteoporosis? Well, it’s a major health issue and it seems to be underdiagnosed and undertreated in the general population. And that’s why we’re going to focus on that tonight. The aging population in the United States is generally getting older, and this is contributing to an increased population that is going to have low bone density. And that’s why it’s very important to focus on this population.

Jeff Kannen:

So osteoporosis is preventable and it is treatable, but only about one in four people or a quarter of the population that has low bone density is either treated or even diagnosed. And that’s a pretty small number, many patients who have a fracture, and what I’m talking about is a fragility fracture, and that’s a fracture secondary to low bone density. Many of these patients aren’t treated, or they’re not assessed for having a low bone density.

Jeff Kannen:

Next, we’re going to talk about the kind of bone structure and how bones are important for function in the body. So when we’re looking at a bone, this is an example of a long bone, and this is how most bones are in the body. There are different types of bones within the body. Traditionally, when we’re looking at a bone, we have different parts of the bone. You have the outer portion of the bone, which we call the cortex or the cortical surface, and that’s kind of the outside hardened layer of the bone.

Jeff Kannen:

And then within the bone, there’s this inner layer and we call that spongy bone or medullary bone. And this bone is important, kind of for the whole structure of the bone. And this inner portion of the bone is most affected by low bone density. And this is where you can develop osteopenia, which is a low bone density or osteoporosis. And generally, that occurs within the shaft of the bone.

Jeff Kannen:

Like here, we can see, and then there are different parts, you have the ends of the bone, which make up the particular surface. And that’s the point that goes into the joints. And then you have other different aspects of the bone as well. And that’s kind of the primary structure of bones.

Jeff Kannen:

So what do bones do? They provide the structure to the body. They help protect the organs within the body, there are an area for mineral storage within the body, specifically calcium and phosphorus. Those are the major minerals within bones that are important. Another thing they do is produce red blood cells within that inner portion of the bone. And that’s very important for providing red blood cells within the body.

Jeff Kannen:

And those are the kind of the major functions of bone within our bodies. So what is low bone density mean? We’re going to talk about that next. So the major kind of disease affecting low bone density is called osteoporosis. And this is a disease process within the body where bones start to lose their density. And this makes them very brittle. It makes them at an increased risk of having a fracture or breaking.

Jeff Kannen:

Osteoporosis is categorized by an imbalance of bone formation, as well as bone breakdown. And most people up until older ages tend to not have a significant imbalance in their bones unless they have certain underlying diseases. And then what happens in low bone density or osteoporosis, you get an increased bone breakdown and that leads to lower bone density.

Jeff Kannen:

So osteoporosis, you can see in this figure on the top portion, this is what normal bone looks like. And this is a figure for that. So you have this nice kind of structure within the bone here, and then in osteoporosis, which is lower, you can see that you develop these bigger gaps within the bone. And that’s what it happens when the bone starts to lose its density.

Jeff Kannen:

And so it’s not as strong and you get not as much structure within it, and that makes it an increased risk for breaking. So what is osteopenia? Osteopenia and osteoporosis are similar disease states, osteopenia is kind of a less severe form of osteoporosis. We consider it low bone density, but it’s very important to know that it still carries an increased risk of having a fracture.

Jeff Kannen:

So it’s very important, even if you have osteopenia that you still manage and treat that osteopenia may progress to osteoporosis as well. So in the United States, about 10 million people have osteoporosis and they’re diagnosed each year about 40 million Americans will have osteopenia, and that’s a pretty significant number. And like I said earlier, only about one in four of these is actually diagnosed or treated.

Jeff Kannen:

So there are many people out there in the general population who are not being treated for this. And about 1.5 to two million Americans will have fractures secondary to osteoporosis each year. And that’s a fairly significant number. So a question I often get is, is osteoporosis similar to osteoarthritis? And these are actually two different disease states.

Jeff Kannen:

So osteoporosis affects low bone density and it decreases the density of the bone. Whereas osteoarthritis affects the joints and those are the areas on the ends of the bone. And these are completely separate. They are not caused by the same thing. And it’s important to know that distinction whenever you’re being treated or seeing your doctor so that you can ask about that.

Jeff Kannen:

So next, we’re going to talk about certain fractures and we’re going to kind of overview some of the fractures that can be related to osteoporosis. And there are three main ones that we’re going to talk about now, most severe is a hip fracture. You, then you can also have a spine fracture, a vertebral fracture, and then you can also develop a wrist fracture.

Jeff Kannen:

And these are the three most common fractures related to low bone density. Hip fracture, so like I said, this is kind of the more severe one that we focus most of our attention on in order to prevent and treat. About 300 people each year in the United States will develop a hip fracture. Most of these occur after a fall, and this can be a fall if you’re standing, or if you slip and fall.

Jeff Kannen:

And most of these occur in elderly patients, older than 65, you can also develop a hip fracture if you have certain disease states or you can develop it in a young person who has a more major injury, such as a car accident, or a fall off of a ladder. Hip fractures carry a significant risk of complications, most important things and complications that we focus on are you’re at risk for developing a blood clot.

Jeff Kannen:

You can get lung infections and pneumonia. You can get muscle wasting, and then it also increases the risk of death. And that’s very important because there’s an increased risk of death associated with hip fracture. So we want to be able to avoid that if possible, most of these hip fractures occur kind of in a certain area within the hip.

Jeff Kannen:

So here on the right here, we have a picture of the hip and you have a certain part of the hip. You have the femoral head where the joint connects. Then you have the neck which attaches the rest of the bone and the thigh called the femur. And most of these fractures occur either in the femoral neck or this inner intertrochanteric area. And it causes the hip to be unstable.

Jeff Kannen:

Most patients aren’t able to walk on a broken hip and they usually require hospitalization and surgery to fix. The next type of fracture that we’re going to talk about is what’s called a spine fracture or a vertebral compression fracture. These are actually the most common fracture out there related to low bone density and osteoporosis.

Jeff Kannen:

Up to about half of people over age, 80 years old will develop a vertebral fracture. And that’s a very significant number when you think about that. Most of these occur kind of in the lower area of the spine called the lumbar spine. And they can also occur up in the upper portion of the spine, which is called the thoracic spine. Risk factors for these are low bone density, having a fall, either from a standing height or slipping on an object, or if you have a history of a vertebral fracture, that’ll also increase your risk of having another fracture.

Jeff Kannen:

Most of these are treated, trying to control the pain as well as restoring their function with day to day activities and then treating their osteoporosis. The next fracture we’re going to talk about is a wrist fracture. And these are most commonly in younger patients, usually right around menopause in females or postmenopausal female.

Jeff Kannen:

And menopause is right around the age of 50. So usually we see these right around the age of 50 or older and these occur after a fall typically. When you look at the wrist, most of these occur at the distal radius, which is one of the bones in the wrist. You also have the ulna which is the second bone in the wrist. And usually, the treatment will involve either splint or cast for about six or eight weeks or sometimes if the fracture is unstable, you’ll require surgery.

Jeff Kannen:

So why do we worry about fractures? Well, there are several different adverse consequences to having a fracture. It may involve admission to the hospital or a nursing home you’ll have increased pain, and decreased function at the side of the fracture or above and below. You might have more complications related to your hospitalization or with the rehab afterward.

Jeff Kannen:

And this puts a greater burden on patients, as well as their families and caregivers. And these are the most significant adverse effects of fractures. So when we’re looking at bone density, we want to kind of talk about risk factors for having low bone density.

Jeff Kannen:

So next, we’re going to talk about certain things that you may have or certain things that you can modify that may increase your risk of having a fracture. So the biggest ones that we’re going to talk about are having tobacco use, drinking alcohol, and that’s excess alcohol, more than the recommended limit per day, not exercising, and they’re not getting regular exercise.

Jeff Kannen:

There’s a population that’s at risk for having a fracture or low bone density. And that’s Caucasian females and usually of European descent. Having a lower body weight as well as not eating enough protein in your diet will increase the risk of having low bone density, having premature menopause as well. Certain athletes such as long-distance runners. And those tend to be a little bit leaner and low body weight. That’ll increase your risk of having low bone density, as well as certain sleep disorders.

Jeff Kannen:

Certain medicines may increase the risk of having low bone density. This is a list here of the most common ones that are related to having bone density. Phenytoin is one, certain treatments for cancer may increase the risk of osteoporosis, being on certain antidepressants or SSRIs, being on long-term antiretroviral therapy for HIV or aids may increase the risk of low bone density.

Jeff Kannen:

Being on Lasix or cyclosporine, methotrexate, which is used to treat rheumatoid arthritis may increase the risk of having low bone density. Certain thyroid medicines may increase the risk, being on omeprazole or medicines to treat acid reflux may increase the risk as well as oral steroids for a prolonged time. If you’re on heparin, which is a blood thinner that may also increase the risk.

Jeff Kannen:

Having certain diseases may increase the risk of having low bone density, liver disease, hyperthyroidism having diabetes specifically type one diabetes. Having certain cancers might increase the risk. And that’s usually related to the treatments, having end-stage kidney disease or renal disease, COPD. Rheumatoid arthritis has been related to low bone density having sarcoidosis, which is an autoimmune disease, which targets the lungs as well as other parts of the body.

Jeff Kannen:

And then in athletes having what’s called relative energy deficiency, which is a, not a very common topic. And I’m not going to address that very much today, but it’s important to know that if you have an athlete who has low bone density, then they might be at risk for having osteoporosis.

Jeff Kannen:

So how do we screen you for osteoporosis? There are two main ways. One is performing at what’s called a bone mineral density test. And this is also known as a DEXA scan. We’re going to talk about this a little bit. This is typically a test that’s done to screen patients, and we’ll talk about certain guidelines that can be used to screen patients.

Jeff Kannen:

Once you have a screening test and that test is normal. We typically don’t repeat that test unless you develop risk factors or have a fracture in the future that might be related to bone density. Then we might, we might test you again. So what do we use screening for? It’s used to screen patients who are at higher risk for having a disease within the population.

Jeff Kannen:

And there’s not a universal guideline. There are several different organizations that have developed guidelines and some of these use the same criteria and some are a little bit different and I’m going to go over kind of the guidelines that I usually recommend for patients. So in terms of screening, typically we recommend all women greater than the age of 65 to be screened for osteoporosis.

Jeff Kannen:

If you’re postmenopausal and a female, and you have certain risk factors that might increase your risk. And these are several risk factors here listed. If you have a history of a fragility fracture, and that’s one of those three fractures that I mentioned, the hip fracture, spine fracture, or wrist fracture, and you’re between ages of 40 and 45, you might want to consider being screened for osteoporosis.

Jeff Kannen:

If you’ve had osteopenia or osteoporosis identified on an x-ray, that’s another reason you should have a bone density test. If you’ve been on long-term oral steroids and that’s usually greater than three months, and that’s usually typically every day, then you’d want to be screened for osteoporosis. And then if you have rheumatoid arthritis, that’s another reason to be screened.

Jeff Kannen:

The third criteria here is usually a woman who’s right around menopause or postmenopausal with certain risk factors. If you’re a current smoker, if you drink more than two drinks of alcohol per day, if you have a family history of having an osteoporotic fracture, then you want to get screened. If you’ve had an early menopause, or if you have low body weight, you might want to consider being screened for osteoporosis.

Jeff Kannen:

So how do we diagnose osteoporosis? So before we talked about screening, which is used to identify people who might be at high risk, now we want to diagnose osteoporosis. And like I said, this is done with a bone mineral density test or a DEXA scan. And that’s the most common way that we diagnose you with osteoporosis.

Jeff Kannen:

The second way is if you’ve had a fragility fracture and that’s one of those three fractures that I mentioned, a hip fracture,  vertebral fracture, or a wrist fracture, then regardless of your bone density test results, then we automatically typically diagnose you with osteoporosis. So next I’m going to talk about what a bone mineral density test is.

Jeff Kannen:

So kind of the medical term for this is a Dual Energy X-ray Absorptiometry or a DEXA scan is the most common phrase we use. And it’s a very simple test. It’s usually performed at an imaging facility, it’s an outpatient, and it’s very noninvasive. It typically uses kind of two x-ray waves and it scans the body here. So in this picture, you can see, we have a gentleman here laying on this table and this kind of bar above him will move across his body.

Jeff Kannen:

And it’s going to measure his bone density by using these low-energy x-ray waves. So once we perform this test, we get certain results. And the most common result we get is what’s called a T score. And this T score compares the results of an individual patient to that of a 30-year-old healthy person in the population. The lower your T score, the lower your bone density is. And the more at risk you’re having for either osteopenia or osteoporosis.

Jeff Kannen:

There’s another kind of result that will show up typically on some bone density tests, and that’s called a Z score. We don’t use this too often. It’s usually more in pediatric populations or younger patients, and this compares your result or an individual’s result to that of a person at the same age and body composition. And that’s usually the same kind of height or the same weight.

Jeff Kannen:

So when we’re looking at the results, so typically a T score of minus one or higher is considered normal. If you have a T score of a minus one, minus 2.5, that’s considered low bone density or osteopenia. And then if your T score is less than 2.5, we consider this osteoporosis. And those are the typical numbers that we use, and these do not change.

Jeff Kannen:

So once we get your bone density test, or regardless of a bone density test results, we can use what’s called a fracture risk assessment. And this helps us also determine if you’re at high risk for having a fracture. So your bone mineral density test may be used to calculate this risk score. It considers and estimates the risk of having a fracture in the next 10 years.

Jeff Kannen:

And this is a general estimate. It’s not completely accurate, but it’s very good, and it can help us determine the kind of your risk and it can help us determine the right type of treatment for you. We recommend typically treatment if your hip fracture risk is greater than or equal to 3%, or if your major osteoporotic fracture risk. And thas fracture, that’s either a hip fracture, a vertebral fracture, or a wrist fracture is greater than 20% and that’s within the next 10 years.

Jeff Kannen:

So how do we monitor your risk of having a fracture? Well, if, once you have a bone density test performed and you’re diagnosed with either low bone density or osteoporosis, you typically want to repeat the test every two to five years, depending on your treatment, as well as your decision with your doctor. And regardless of changes in your bone mineral density test results, you will still want to continue treatment regardless of those results.

Jeff Kannen:

So if your results improve, you’ll still want to continue on your treatment that you’ve been on. And you’ll want to talk to your doctor about kind of when you would continue that and when you would stop. So next, we’re going to talk about treatment options for osteoporosis. So the goals of treatment, there’s really one main goal, it’s to reduce the risk of having a major fracture, and that’s having a hip fracture, a vertebral fracture or wrist fracture.

Jeff Kannen:

And then kind of a secondary goal is to prevent, stop and reverse the disease because once you have osteoporosis, you may be at risk for having further fractures. So kind of the approach values and most clinicians will use in terms of preventing and treatment of osteoporosis is kind of a multi-component approach. Typically, we’ll focus on weight-bearing exercise and falls prevention. We’ll focus on tobacco and alcohol cessation.

Jeff Kannen:

You’ll want to supplement with certain vitamins, such as calcium and vitamin D and then you might want to consider certain prescription medicines to treat the low bone density. So next, we’re going to talk about kind of what weight-bearing exercise is and how this is important for the treatment of osteoporosis.

Jeff Kannen:

So why do we talk about exercise and why is that important for osteoporosis? Well, we found that kind of exercise will affect the bones, and the more that you’re exercising and putting weight that changes the density of the bones. And that can be very effective in either preventing or maintaining your bone density. So usually we recommend a multi-component program that you uses weight-bearing exercise or balance training.

Jeff Kannen:

In most patients, you’ll want to avoid strictly aerobic exercise and you’ll want to incorporate certain resistant exercise or balance training. And that’s been shown to help the most with low bone density. So what are some examples of certain exercises that you can do to help with your low bone density? So we’ll talk about aerobic exercise and that’s more of a kind of cardio exercise. So you can do things like walking, jogging, or hiking.

Jeff Kannen:

You can do step aerobics, you can do racket sports, such as tennis, which is more dynamic. You can use a stair climber, you can do dance exercises, then you can also use an elliptical if you have access to a gym. And typically you’d want to aim for about 30 minutes of this type of exercise, about four or five times a week if you’re able to, and that will give you the most benefit for your own health.

Jeff Kannen:

The next exercise you want to consider doing is resistance exercise and that’s weight-bearing resistance exercise. And some examples of this are doing certain bodyweight exercises, such as pushups, squats, or lunges using free weights. Using elastic exercise bands can be very effective using certain weight machines where you’re putting weight on can be very effective.

Jeff Kannen:

And you typically want to aim for resistance exercise about two or three times per week if you’re able to. The next thing that we’ll focus on is what’s called falls prevention. And falls are kind of more directly related to having a fracture than bone density test results. And that’s very important to kind of recognize because even if you have low bone density and you’re having frequent falls or frequent accidents, that will increase your risk of having a fracture significantly.

Jeff Kannen:

And we typically recommend certain weight-bearing exercises, you can do physical therapy and then supplementation of vitamin D and calcium patients who are at risk or older will be able to help with falls prevention. So certain things that you can do around your home or for a family member to help kind of make your home safe, would be to remove obstacles around your house, which may increase your risk of having a fall.

Jeff Kannen:

You’d want to wear supportive footwear, you’d want to avoid walking barefoot or having a kind of a, I guess, a kind of a surface that makes it more increased risk of having a fall. You’d want to use rubber mats in your shower because that will help with gripping. You’d want to avoid using rugs on a hard floor. And that’s because these, the rugs can slip easily, unless you have something underneath the rug to hold them down, then they might slip and they can increase the risk of having a fall.

Jeff Kannen:

You’d want to consider installing handles around your bath or shower. And that can be helpful. And then you’d want to consider using a cane or a walker if you need to in order to help with your balance. So the next thing we’ll talk about is treatment with supplements. So really two main supplements that would be used in having low bone density is calcium and vitamin D

Jeff Kannen:

And most people want to aim for about 1200 to 1500 milligrams of calcium per day. You want to aim for about 800 internet national units of vitamin D per day. And these numbers will vary depending on your risk and your certain situation. Sometimes we’ll test you for having calcium or vitamin D and that’s a blood test that we would perform and most patients would want to supplement each day with these vitamins. You’d want to consider this in a younger patient who might be at risk as well.

Jeff Kannen:

Some examples of calcium and vitamin D intake in your daily diet would be foods that are high in dairy. So that’s such as milk or cheese. Certain yogurts will be high in calcium and then certain vegetables such as broccoli, bok choy or almonds. Those are some examples of foods that are high in calcium.

Jeff Kannen:

So next we’re going to talk about prescription treatments for low bone density and osteoporosis. So who needs a kind of prescription treatment? I get this question a lot. A lot of times we’ll focus on those other preventative measures, such as weight-bearing exercise and supplementation, but sometimes you’ll want to consider using prescription treatments.

Jeff Kannen:

Typically, patients who’ve had a history of having a fracture such as a hip fracture or spinal fracture will want to consider being treated just because your risk of having another fracture in the future is very high. If you’ve had osteoporosis confirmed by a bone mineral density test you’ll want to consider being treated. If your total fracture score is greater than 20% or your hip fracture risk is greater than 3% and that’s in the next 10 years, then you’ll want to consider being treated.

Jeff Kannen:

If you’re high at risk for falls, despite your low bone density test results, you’ll want to be treated. And then if you’ve had a fracture or are on long-term steroids for a certain diseases, then you’d want to consider being treated because the steroids will increase the risk of having low bone density.

Jeff Kannen:

So there are really two main classes of prescription treatments. And I’m going to touch on primarily this first class, which is called the antiresorptive class, and these are the most common. And what these do is they prevent new bone loss within the bones themselves. The second class and which is less commonly used, are called anabolic medicines and these tend to build up new bone within the body.

Jeff Kannen:

So the antiresorptive medicines that we typically use, and these are all approved for use in low bone density and osteoporosis, the most common is what’s called bisphosphonates. The second most common would be denosumab. Then you have estrogen hormone therapies. You have a medicine called raloxifene, and then you have this combination medicine below with estrogen.

Jeff Kannen:

So the first class that we’re going to talk about is called bisphosphonates. And these are the first-line treatments for osteoporosis. They’re recommended in patients who are diagnosed with osteoporosis or at high risk for having a fracture. And these basically target cells that break down bone, and that’s how they work. And it reduces your risk of having a hip fracture or spinal fracture by about 50 to 90%.

Jeff Kannen:

And that’s a very significant number. These are taken either daily or weekly, most commonly I would prescribe this weekly. And usually, you’d want to be on the treatment for approximately five years. Some patients want to take it longer, and if you’re unable to tolerate this by mouth or a pill, sometimes you can take it by an IV form and that’s not very commonly done.

Jeff Kannen:

The most common formulations used in this class, you have alendronate, risedronate, you have ibandronate, those are the most common forms. And then you have several others here. Typically, you’ll want to take these on an empty stomach first thing in the morning, you’ll want to avoid using them in certain chronic kidney diseases, as well as if you have certain esophageal disorders.

Jeff Kannen:

Some of the adverse effects of these, or they can cause joint and bone pains, it can irritate the lining of the stomach and esophagus, which is your food pipe. It can cause typical femur fractures, and it can also cause what’s called osteonecrosis of the jaw. I wanted to talk about osteonecrosis of the jaw because this is a kind of a question I get a lot from patients regarding the side effect.

Jeff Kannen:

This is a rare adverse consequence of having oral bisphosphate or IV bisphosphate therapy and nearly all the cases of having this occurred in patients who are on IV doses and high doses of oral bisphosphate that were being treated for cancer-related osteoporosis. And usually, the risk of having this is extremely low if you’re on oral therapy.

Jeff Kannen:

And I usually recommend talking with your doctor about this risk and typically the risk is very low and the benefit of being on the treatment would outweigh the risk of having this. The next treatment we’re going to talk about is called Denosumab. And this is another first-line treatment. It’s recommended for patients who have been diagnosed with osteoporosis or have a high risk of having a fracture.

Jeff Kannen:

And again, this helps target cells within bone that break down bone. And by that way, it kind of increases the bone density and this will increase the risk pretty similar to the other therapy I talked about with oral bisphosphate it’ll decrease the risk of having a fracture by about 40 to 70%. And that’s very significant.

Jeff Kannen:

This is given every six months, it’s used as a subcutaneous injection, which goes under the skin, will typically give this in the office, but some patients can take this at home if they’ve been instructed, you’ll want to check your calcium level as well as your kidney function prior to administering this because it may decrease your level of calcium within the blood, or if you’re at risk for having low calcium, you may want to avoid this medicine.

Jeff Kannen:

And typically once you start this medicine, you’d stay on this for the rest of your life, indefinitely, some patients may consider coming off of it. And then you should consider switching to another medicine because once you stop this medicine, your risk of having a fracture will go up again. The two main forms that are approved are called Prolia and Xgeva.

Jeff Kannen:

The next treatment and I’m going to of briefly talk about this and is called estrogen hormone therapy. This isn’t a very common therapy used. Typically, we use this only in kind of postmenopausal or menopausal women who are having hot flashes or symptoms secondary to menopause. And I typically don’t recommend using this in older patients because it can increase the risk of having a heart attack or a stroke.

Jeff Kannen:

It’ll increase the r