Osteoporosis controversies and promising treatment options
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Osteoporosis – Controversies and Promising Treatment Options. Keith R. Holden, M.D. Ponte Vedra Beach, FL www.Dr-Holden.com. Osteoporosis Controversies. Guidelines for prevention and tx vary Bone quality versus bone quantity Same BMD can have different fx risk (age)

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Osteoporosis – Controversies and Promising Treatment Options

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Osteoporosis controversies and promising treatment options

Osteoporosis – Controversies and Promising Treatment Options

Keith R. Holden, M.D.

Ponte Vedra Beach, FL

www.Dr-Holden.com


Osteoporosis controversies

Osteoporosis Controversies

  • Guidelines for prevention and tx vary

  • Bone quality versus bone quantity

  • Same BMD can have different fx risk (age)

  • Cumbersome dosing requirements

  • Drug side effects


Bisphosphonate side effects

Bisphosphonate Side Effects

  • Esophagitis

  • Esophageal stricture

  • Esophageal cancer

  • Osteonecrosis of jaw

  • Atypical Femur Fracture


Atypical femur fracture aff

Atypical Femur Fracture (AFF)

  • Bisphosphonates ↓ osteoclast fxn & induce osteoclast apoptosis

  • Suppress bone resorption = hard, brittle bone

  • Path: ↓ bone heterogeneity = ↓ bone quality

    • Complete lack of TCN labeling = severe ↓ bone formation

    • Stress injury-like cortical hypertrophy in other femur with unilateral AFF


Limitations of bmd tests dexa

Limitations of BMD Tests (DEXA)

  • ↑ BMD does not always = ↑ bone strength

  • T-score not consistent predictor of osteoporosis outside of elderly postmenopausal white♀

  • Other populations, Z score may be better predictor of low bone density


Fracture risk tool

Fracture Risk Tool

  • www.shef.ac.uk/FRAX/tool.jsp

  • FRAX estimates 10-yr. fx risk based on BMD femoral neck + osteo risk factors


Bone quality vs bone quantity

Bone Quality vs Bone Quantity

  • Bone quality = bone strength (cortical bone structure/quality of collagen) + rate of remodeling

  • Bone densitometry measures BMD (quantity), helps assess fx risk, aids in dx of osteo, but does NOT measure bone quality


Living matrix of bone

Living Matrix of Bone

  • Healthy bone requires a balance of:

    • Bone building by osteoblasts

    • Resorption by osteoclasts


Osteoid matrix of bone

Osteoid Matrix of Bone

  • 90% collagen (majority Type 1)

  • Osteoclast degradation & osteoblast synthesis create circulating peptides of Type 1 collagen

  • Type I collagen is cross-linked by deoxypyridinoline (DPD)

  • DPD provides rigidity and strength (quality) to bone


Usefulness of bone biomarkers

Usefulness of Bone Biomarkers

  • Reflects bone remodeling yrs. before BMD ∆

  • ↑ T score + ↑ biomarker → fx risk (odds 4.1)

  • Allow tracking of response to therapy

  • May improve adherence to therapy


Urinary deoxypyridinoline udpd

Urinary Deoxypyridinoline (uDPD)

  • Cross-link Type IC (relatively selective)

  • Measure of bone resorption - ↑ urine level > bone loss

  • Unaffected by diet

  • Easy to measure spot AM urine

  • Recheck within 30-90 days after initiating therapy

  • Covered by Medicare


Effective supplements for bone

Effective Supplements for Bone

  • Calcium

  • Vitamin D

  • Magnesium

  • Boron

  • Strontium ranelate

  • Ipriflavone

  • Vitamin K

  • Choline stabilized orthosilicic acid (ch-OSA)


Choline stabilized orthosilicic acid

Choline stabilized orthosilicic acid

  • Ch-OSA = bioavailable silicon

  • RDBPC trial: added to calcium and D3 showing improved bone biomarkers and BMD ↑ 2%

  • RDBPC trial: ↑ tensile strength of hair

  • RDBPC trial: + effects of skin surface changes, mechanical properties, ↓ brittleness hair/nails


Biophysics and bone health

Biophysics and Bone Health

  • Pulsed Electromagnetic Field (PEMF) therapy has shown promise in clinical trials for tx and prevention of osteoporosis

  • Mediates process via cell signaling proteins – growth factors, cytokines, and prostaglandins


Pemf clinical trials and osteoporosis

PEMF Clinical Trials and Osteoporosis


Pemf improves bmd

PEMF Improves BMD

  • PEMF 72Hz 10 hrs daily for 12 wks to radius of “osteoporosis prone” ♀

  • BMD showed sig. inc. in exposed areas 36 wks

  • Similar but weaker response in non-treated arm

    (Tabrah, et. al., 1990)


Pemf suppresses bone loss in dop

PEMF Suppresses Bone Loss in DOP

  • Evaluated rats with surgically induced DOP

  • After 8 wks, PEMF sig. ↑BMD, ↑ TGF-beta 1, ↓IL-6 in proximal femur

  • Conclusion: PEMF efficiently suppresses bone loss in DOP via local factors

    (Shen, et al., 2010)


Pemf chronotherapy in ovx rats

PEMF Chronotherapy in (OVX) rats

  • Evaluated CR with PEMF in ovariectomy-induced osteoporosis in rats

  • 12 weeks, (OVX-DPEMF) group had better prevention against OVX-induced bone loss

  • ↑BMD, ↑osteoblast activity, ↑ trabecular health markers; ↓bone markers of resorption (uDPD)

    (Jing, et. al., 2010)


Pemf dm induced bone loss

PEMF ↓ DM Induced Bone Loss

  • Rats with streptozotocin-induced DM bone loss

  • PEMF daily 8 hrs x 8 wks

  • PEMF improved biomechanical bone quality DM bone

  • PEMF partially reversed DM-induced bone deterioration

  • Conclusion: PEMF might become an additive method for inhibiting DM osteoporosis

    (Jing, et al., 2011)


Pemf affects osteoblasts

PEMF Affects Osteoblasts

  • Study on in-vitro osteoblastic cell culture

  • PEMF ↑osteoblastic growth, ↑ TGF-beta 1

  • PEMF ↓ prostaglandin E2

  • Conclusion: Study sheds light on mechanism of action of PEMF in non-union fx & prevention of osteoporosis

    (Li, et al., 2007)


Pemf prevents osteoporosis

PEMF Prevents Osteoporosis

  • Studied rats subjected to bil ovariectomy

  • PEMF augmented/restored trabecular bone mass/architecture in PEMF groups

  • PEMF attenuated higher serum PGE(2) of OVX rats and restored levels to that of controls

  • Conclusion: PEMF may be useful in prevention of osteoporosis resulting from ovariectomy

    (Chang, et al., 2003)


Pemf modulates osteoblast cells

PEMF modulates osteoblast cells

  • PTH used to tx osteoporosis; Insulin & IGF-1 anabolic roles in osteogenesis

  • Cell signaling proteins IRS-1, S6 RSK, & eNOS were phosphorylated by PTH, Insulin, & PEMF to the same extent in osteoblast-like cells

  • Conclusion: Anabolic affects of PEMF may be mediated through these proteins

    (Schnoke, et. al., 2007)


Summary pemf physiologic effects

Summary PEMF Physiologic Effects

  • ↑ BMD

  • ↑ TGF-beta 1

  • ↓ IL-6

  • ↓ PGE(2)

  • ↑ osteoblast growth

  • Phosphorylation of IRS-1, S6 RSK, eNOS


Clinical approach to osteoporosis

Clinical Approach to Osteoporosis


Use food as medicine

Use Food as Medicine

  • Alkalinizing plant based diet

  • Address food sensitivities

  • Mineral rich foods


Optimize gut health 5rs

Optimize Gut Health – 5Rs

  • Remove

  • Replace

  • Reinnoculate

  • Repair

  • Rebalance


Address regulatory blockades

Address Regulatory Blockades

  • Foci of interference (ANS)

  • Stress

  • Inflammation

  • Toxins

  • Allergy

  • Infection (occult, dysbiosis, dental)

  • Heavy metals


Supporting factors

Supporting Factors

  • Resistance training

  • Nutritional supplementation

  • Hormonal balance

  • PEMF


Osteoporosis case studies

Osteoporosis Case Studies


Case study 1

Case Study #1

66 y.o ♀ with osteoporosis (T-score -3.1)

  • Baseline: mostly plant based diet, resistance training, Ca, Mg, and D

  • (1/27/11) uDPD 9.7 nM/mM Cr (NL < 6.5)

  • Weekly 1 hr PEMF sessions x 2 mos

    • (3/16/11) uDPD 4.5 (53% drop!)

  • Maintenance: Monthly 1 hr PEMF

    • (7/21/11) uDPD 5.5

    • (10/24/11) uDPD 4.5


Case study 1 urine dpd

Case Study #1 Urine DPD


Case study 2

Case Study #2

63 y.o. ♀ osteoporosis (‘09 T-score LS -3.9; ‘11 T-score LS -4.1)

  • Hx FMG, CFS, IBS, MCS & hx multiple fxs

  • Baseline: BHRT, Ca, Mg, D

  • Added ch-OSA + tx gut dysbiosis

  • Started PEMF (3/26/11) monthly; (7/26/11) inc. freq. to weekly; (9/12/11) 2-3 X week

  • (4/13/11) uDPD 9.7; (10/4/11) uDPD 5.0 (48.45% drop!)


Case study 21

Case Study #2


Case study 22

Case Study #2


Case study 23

Case Study #2


Case study 24

Case Study #2


Contact information

Contact Information

Keith R. Holden, M.D.

822 A1A North, Suite 310

Ponte Vedra Beach, FL 32082

(904) 473-4954

[email protected]

www.Dr-Holden.com


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