The following points summarize the key topics and information shared during todays meeting:
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1. **Pharmaceuticals for Osteoporosis**
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Dr. Lucas acknowledged that traditional medical practitioners often prescribe drugs as the primary treatment for osteoporosis because that is the main tool available to them. Their goal is to prevent fractures, and they may not be fully aware of the downsides of these medications. Dr. Lucas emphasized the importance of individualized treatment while also discussing general trends and considerations.
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2. **Hormones and Bone Markers**
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Questions about bone markers and DHEA sulfate were discussed and the need to wait for stabilized hormone levels before taking action. The conversation also covered the use of commercial testosterone products for women, noting the challenges of dosing and the preference for compounding creams to achieve the correct dosage.

3. **Oxytocin**

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Dr. Lucas described oxytocin as a drug, hormone, and peptide with applications in sexual health and potential benefits for bone density, although there are no studies directly linking oxytocin to increased bone mineral density.

4. **Breast Cancer and Hormone Replacement**

Dr. Lucas discussed the complexities of hormone replacement therapy for breast cancer survivors, especially those with estrogen-positive cancer. The conversation highlighted the need for a collaborative approach with oncologists and the exploration of alternative options if estrogen is not advisable.

5. **Peptides**

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Dr. Lucas mentioned the regulatory challenges with peptides, such as abutamoren (MK-677), which have been removed from the market due to FDA actions influenced by pharmaceutical companies.

6. **Bisphosphonates**

Dr. Lucas expressed concerns about the over-prescription of bisphosphonates like Fosamax, Reclast, and Boniva. He discussed their mechanism of action, potential side effects like atypical femur fractures and osteonecrosis of the jaw, and the long-term implications of suppressing bone metabolism.

7. **Denosumab (Prolia)**

Prolia, an anti-resorptive drug that is popular due to its convenience and effectiveness in reducing vertebral fractures, was discussed. However, there is an increased risk of vertebral fractures after stopping the drug, which requires careful management.

8. **Romosozumab (Evenity)**

Dr. Lucas briefly touched on Evenity, which is used for a maximum of 12 months and has both anabolic and anti-resorptive phases. It is not considered a long-term solution.

9. **Anabolic Drugs (Forteo and Tymlos)**

Dr. Lucas spoke about anabolic drugs for patients with severe osteoporosis or high fracture risk, as they promote bone building without suppressing bone metabolism. He discussed the removed black box warning for osteosarcoma and the challenges with insurance coverage.

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Dr Doug: really was to just kind of hit some of the major.

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Dr Doug: The major drug points give people kind of my perspective on them, because I think we've had just again a lot of questions on different drugs when to use them when not to use them. And obviously there's every case is different.

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Dr Doug: But there's some generalities that I think we can talk about for those that have their video on or for those that are willing to turn their video on when you were diagnosed with osteoporosis, assuming you have osteoporosis when you were diagnosed with it, whose doctor told them to take a drug, a pharmaceutical for it.

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Dr Doug: everybody, except for Tom. Oh, Nope, Tom, too.

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Dr Doug: And I got some thumbs up awesome as well. Kim. Okay, Jim. So yeah. And so let me just start off by saying that that's totally normal and totally fine, because the the medical doctors, the Dos, the Mds. That are in the traditional medical system. It's the only tool they have.

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Dr Doug: so their goal is to help prevent fracture, so their goal, their their hearts are generally in the right place, and they have a tool that they feel like they can use, and their education probably hasn't really told them all of the downsides. And so they use the tools that they have access to. And that's generally gonna be pharmaceuticals, and they don't have the training to really talk about anything else.

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Dr Doug: So

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Dr Doug: Before I really dive in, I'm going to wait until it actually turns

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Dr Doug: 12 here on the east coast.

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Dr Doug: as everybody else is filtering in I'll just kinda reiterate that we're hey, Alan? That, we're gonna talk about drugs today. But if anybody has any questions about hormones, go ahead and drop those in the chat. So I wanna make sure we follow up on that from last week.

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Dr Doug: So, David, great question about Tim Loz.

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Dr Doug: yeah. Great question from Liz. That's a great question. I'll cover that.

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Dr Doug: Oof.

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Dr Doug: that's a complex and anatomy question, Susan. I'll see if I'll see if I can answer that. All right, let's start with Liz's question. We'll talk about that from a

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Dr Doug: a hormone perspective, and then I'll talk about oxytocin as well. Since that sort of bleeds in between drugs and hormones. So so? Liz asked. She said she had her bone markers and dhas sulphate done a few weeks ago. I assume I need to wait on hormone levels before acting on this

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Dr Doug: and then she has a question about commercial testosterone. So, Liz, I'm not sure I totally understand that question about Dha, meaning that, are you concerned that it was low and your bone turnover markers weren't weren't where you wanted them to be. If you give me more on that, and then, as far as the commercial testosterone. So

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Dr Doug: there are commercial testosterone products that are made from men, and Androgello is a product that's made from men. So you can use variations of dosing to work for women.

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Dr Doug: The challenge with a product like Android gel is, although it's actually not really strong enough for men either. But usually the the men's products are gonna be too strong. Right? So men have 10 x the the testosterone levels of women. And so if you were to use a a very small dose of a male strength product, it gets kinda difficult to use. So the amount of androg you'd wanna use would be very, very small. Same thing with like testosterone injections.

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Dr Doug: we can use an injection of testosterone, but the lowest strength you can get is 100 milligram per ml. So you're doing.

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Dr Doug: you know, point one, or you know, point O 5 Ccs of a of an oil which is just. It's there's almost more waste in the syringe than there is actually injected into the the muscle or sub queue. So it's just kinda challenging to do. And that's why we compound it and cream instead. Cause cream you can compound in whatever strength you want. So for men, we use 200 milligrams per milliliter for women. We would use 2, 4, 6, 8, 10,

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Dr Doug: and you know, somewhere around that range. So again, like.

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Dr Doug: like, you know, a tenth or a twentieth of the dose, if that makes sense.

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Dr Doug: And then Susan, ask a question about kind of some some tough anatomical stuff around the thyroid. I don't know that I can actually answer that in a logical way, Susan. So I'm gonna defer that to.

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Susan Jaye: I just wanted to know. I just wanted to know. I didn't make it clear. I just wanted to know if you have a thyroid ultrasound, and they tell you that you have a certain measurement of that. It's miss, or whatever, if that's the same as having a heart and heart test? Are they 2 different.

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Dr Doug: Those those are, yeah, those are gonna be different measurements altogether. Yeah.

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Susan Jaye: That's what I want to know. Thank you.

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Dr Doug: And problem.

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Dr Doug: Alright. So let's talk about oxytocin real quick. So oxytocin is a kind of a fun drug slash hormone, slash peptide that we use. So it kind of fits into the category of all 3,

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Dr Doug: because it is made technically kind of by a pharmaceutical company. But it's compounded generally is how we get it. So it is a drug. It is a hormone cause. It's made endogenously in both women and men, but more in women, and then it is short enough. I believe it's under 20 amino acids in length. So it then is also technically a peptide. So oxytocin is kinda cool because it's been used in the sexual health space for a long time. So

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Dr Doug: if you were to look at, you know, go back for decades where

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Dr Doug: researchers have been looking for different tools that both women and men can use to increase. We'll just call it desire intimacy. It's not like an erectile dysfunction drug, or the the same, but for women. But it does help to improve relationships between people. So it's kind of been leveraged in that space and sexual health for a long time, which is why I'm comfortable using it because it's been used in, you know, millions, and probably tens of millions of doses without reported side effects.

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Dr Doug: Oxytocin, naturally, is a hormone that's secreted in premenopausal women and higher levels

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Dr Doug: during the the period of time. Kind of right before ovulation, so sort of just naturally secreted in in an attempt for the brain to help the the body to become more attracted both to and from a partner, so to increase the likelihood of making babies

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Dr Doug: postpartum. So after a woman delivers a baby, she has a large increase in oxytocin, which potentially also helps with the delivery.

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Dr Doug: but helps with the letdown of milk, and then also helps with bonding of the baby. So for those of you that have had children, you might remember that screaming, pooping, biting monster that entered into your life. And it's amazing that we choose to love these things. I have 3 of them, so I can kinda say that, at least from the father perspective. But women are disappointed, secreted, so that they then are kind of

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Dr Doug: pushed into having a better relationship with this little thing right out of the gate.

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Dr Doug: So it's kinda cool that in that same postpartum period oxytocin bonds to osteoblasts and has a receptor there, so women will reliably lose bone mineral density during pregnancy, because the baby is sort of sucking it all out of you like a parasite, and then your body helps to put it back by using a a hormone like oxytocin, so we can leverage that and the postmenopausal timeframe to again encourage Osteoblast to make more bone.

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Dr Doug: There are no studies, and I say this every time I I recommend it to a patient. There are no studies looking at Bulmer density and oxytocin. But it is a fun drug slash hormone with pleasurable side effects that also should be increasing Bulmer density. So it's sort of a fun little hack, if that makes sense

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Dr Doug: hoop

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Dr Doug: any questions on that

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Dr Doug: great, it comes in a nasal spray.

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Dr Doug: So it's also not a

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Dr Doug: not another capsule

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Dr Doug: which we're always trying to avoid. Alright. So this is actually a great in between Sally. So thank you for putting this in here and being open to saying that out loud. So Sally put in the chat. She says, I'm a breast cancer survivor. Estrogen positive took Electrazole for 5 years. Cancer was stage one surgery, irradiation, how to decide if some form of hormone replacement is worth the risk.

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Dr Doug: boy, that's a really really tough question. And I have that exact same clinical scenario 2 h from now.

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Dr Doug: So I have this.

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Dr Doug: I have this conversation more often than I'd like to. It's really really tough.

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Dr Doug: it's tough, because we have to get buy in from oncology and oncology in general doesn't like hormones. So I never wanna just steer somebody, especially a breast cancer survivor to say, look, estrogen is safe. We don't need to worry about it. Let's just go do it. That would be irrational, and probably malpractice, technically.

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Dr Doug: because the truth is is that if you are at high risk, and I said this last week with with hormones.

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Dr Doug: if you're at high risk of developing breast cancer and a woman who has had breast cancer is at higher risk than a woman who has not. So if you're at high risk of developing breast cancer, and you're on estrogen, especially if it was estrogen positive. The recurrence of the same cancer is more likely than a different cancer.

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Dr Doug: If you're on estrogen, then you are more likely to have a new cancer grow faster. So it's sort of like throwing fuel on the fire, thinking that the fire is out and the fire wasn't out.

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Dr Doug: You know what I mean. So that's that's the risk. Now there are plenty of women, and if anybody remembers you know Suzanne Summers, who died, I think, last year. She was such a huge advocate for biochemical hormone replacement, wrote books about it. She had breast cancer. She survived. She was in remission. She went back on hormones, and then she died of breast cancer, recurrence.

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Dr Doug: super unfortunate

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Dr Doug: for her cause, because that was kind of her whole thing. She was such a big advocate for hormones. And then, unfortunately, that ended up killing her.

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Dr Doug: But it's an example of you know. It is risky, and there is risk. And so the question is, is, what do you have more risk of? We know that it's gonna improve your bone marrow density. We can say that confidently. If you have severe osteoporosis, and you're likely to fracture. You know your spine or your hip. What are you more afraid of what's what's a better option. And that's a very individual question.

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Dr Doug: So, Sally, that that question for us we would have to get. We'd have to get buy-in from your oncologist. Talk about estrogen! And if the answer was a hard No.

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Dr Doug: then we talk about other options. What about Progesterone? Was it progesterone positive? If not, can we consider Progesterone? What about testosterone? We know testosterone aromatizes to estrogen. But we can use testosterone and an aromatase inhibitor, and then you get the benefits of testosterone. And you don't have any estrogen. Would they be okay with that? And so we try to take a team approach. Sometimes oncologists are not open to anything at all. And then we just have to use other options. Right?

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Dr Doug: Hormones are a powerful tool, but they are not the only tool.

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Dr Doug: So then you can other also leverage other things like oxytocin and other peptides, and then really lean on the lifestyle stuff.

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Dr Doug: So hope that all makes sense.

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Dr Doug: And then, Beth, I will let me just mention this one Peptide, and then we'll get into the drugs.

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Dr Doug: So Beth asked about the peptide of Butamorin.

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Dr Doug: So a beauty more. And also it goes by the name MK. 6, 7, 7

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Dr Doug: is a Peptide that we were using for a while. And, Beth, if you if you haven't heard this yet. So the FDA went through and kind of wiped out a bunch of the different Peptides that we use.

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Dr Doug: not because they're dangerous. Not because there's any patient related issues with the Peptides purely because the FDA has a strong affiliation with pharmaceutical companies. Pharmaceutical companies don't like peptides because they can't patent those things, and they can't make money off of those things. So they strongly encouraged the FDA to eliminate them whenever possible. So they went through and eliminated some really really good Peptides

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Dr Doug: that had lots of human evidence, and again, millions of doses with no side effects or no bad outcomes associated with them.

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Dr Doug: So abutamorum was one of those, and the reason why we used it is that it increases. Igf one igf, one stands for insulin like growth factor. If you've never measured it, it's essentially how I describe it to my patients. Igf, one is like the anabolic catabolic switch. So if you are trying to gain muscle mass, you're trying to build bone. You want Igf one to go up. If you wanted to potentially lose weight, you want Igf one to go down

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Dr Doug: right? So it's this, like catabolic antibiotic switch in the Igf, one Peptides like abutamor, and Mk. 6, 7, 7. Storlin, Cjpamoral and testimoral all these different Peptides all function through the Igf one receptor.

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Dr Doug: if that wasn't too techy.

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Dr Doug: Okay.

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Dr Doug: alright. So let's talk about drugs, because this is a really, really it's a really important topic that I don't like to talk about, because I don't prescribe the drugs for the most part, but who in here has been told to take. You don't have to answer this if you don't want to. But who has been told to take abyssphosphenate? So Phosmax reclast Boniva, all those so like

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Dr Doug: about a quarter third of people on the call, right

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Dr Doug: when they recommended those drugs. So put your hands down when they recommended those drugs?

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Dr Doug: Did they do any testing to show that you were rapidly losing bone? Was your Ctx elevated? Did they have any any indication whatsoever that that was the right drug to use

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Dr Doug: no one. Right? So here, raise your hand. If they did do that

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Dr Doug: one.

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Susan Jaye: Phone density.

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Dr Doug: Right. It's all about bone density. But we don't know what that means. Right?

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Dr Doug: So here's the thing with the bisphosphonates. They're popular because they're cheap. They're oral. They, in theory, are low risk. And it's so easy to write right. If I'm a doctor and I have 5 min and your T scores less than negative. 2.5, or your frax is above, you know, whatever

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Dr Doug: it's so easy to just say bit. Let's just put you on a bisphosphony. What's the harm? It'll improve your bone mineral density, and it will

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Dr Doug: but

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Dr Doug: the bisphosphonate drugs in general, I think, are woefully overprescribed, and there are some potential risks.

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Dr Doug: So most of you have probably heard me talk about this. But

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Dr Doug: there's basically 2 categories drugs. So there is the

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Dr Doug: the antresruptive drugs. So the drugs that act mostly on osteoclasts. And then there's the anabolic drugs, the drugs that act mostly on the osteoblasts and build up bone. I'll talk about those last. So the anti-resive drugs include the bisphosphonates

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Dr Doug: prolaa, and to some extent of entity we'll talk about that one in the middle. The bisphosphony is the most popular. They've been around the longest, and there's so many different forms, you know, oral ib, you know, monthly and yearly infusions with reclast.

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Dr Doug: And so the Bisphosphonates literally poison the osteoclasts. So they stop working.

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Dr Doug: and then the Osteoblasts continue to work, some in as a result of that imbalance, that sort of uncoupling, of bone metabolism, you will see an increase in bone mineral density. Usually not always. I have a patient. Later today she was on fossil Max, I think, for 2 years, and her bone density continued to go down so clearly that wasn't the right drug for her.

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Dr Doug: But what I see in the labs. And when we look at the bone turnover markers is that when you squash ctx, so you push Ctx into the ground.

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Dr Doug: That's the breakdown marker. We expect that P. One and P. The Bone building marker, gets squashed, too. Now there must be some residual p. One. And P. That's why people continue to increase bone mineral density.

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Dr Doug: but we see them both very, very low, and that's why you run into problems with bone metabolism. So you run into the atypical femur fractures and osteone of the jaw, that if you've if you've ever looked up images of either of those things, you don't want either one.

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Dr Doug: And so that's why there are now restrictions on how long you can take the Bisphosphonates. So

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Dr Doug: if you are on depending on which one it could be 3 years 5 years. I think there's one that's in theory out to 7 years.

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Dr Doug: But you can't take them forever. Because if you squash bone metabolism indefinitely, you will eventually run into issues because you need to turn over your bone. Otherwise you end up with dense, fragile bone. So it looks good on Dexa. But you still have fractures, and that's the atypical femur fractures. And I can tell you that the

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Dr Doug: the they say that that's that's low risk. I just think they're under reported

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Dr Doug: cause we saw as an orthopedic surgeon is some all the time, you know. Obviously, we're in a biased space, and you know we're seeing femur fractures. But I saw a lot of atypical femur fractures. It was really common for women that have been on bisphosphonates, and were those ever reported? No.

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Dr Doug: so I think we don't. We don't really know what that risk is, but that's why I I really don't like these drugs osteosis of the jaws terrible. If you've ever seen videos of that, or experience somebody talking about their experience with it is terrible. And I think the likelihood of you know somebody as they age, you know, and you get into your sixties, seventies, and eighties and needing dental work is pretty darn high. So putting yourself in a situation where, you know doctors, the the dentists. They don't even wanna work on you. If you're on a bisphosphony. Has anybody experience that

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Dr Doug: right? They they'll literally be like, I'm not. I'm not touching you. I'm not gonna do anything for you.

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Dr Doug: And that's that's a problem, because we need our teeth to eat food.

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Dr Doug: So so in general, I don't like the Bisphosphonates. Those 2 side effects really scare me. There's other side effects like the oral ones. There's, you know. There's nausea. There's esophageal issues, you know. You upset stomach, or whatever. I'm not as worried about that. Usually you can do something about that or switch to Iv there's some reports about esophageal cancer. So I don't really know what to think about those reports. But for the most part it's the bone metabolism issues. If you squash bone metabolism forever, I think you're gonna run into issues.

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Dr Doug: So if you were 90 years old and you didn't have a choice, and you were mostly refined to a wheelchair, anyway.

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Dr Doug: Maybe that's the right scenario, right? You don't know what your life expectancy is. It might be 5 to 10 years. Then maybe it's okay. But if you're 50, if you're 60, even if you're 70,

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Dr Doug: I mean, you have too long. There's too much time left

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Dr Doug: to use a drug like that, because on the back end of that, what are you gonna do?

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Dr Doug: So I'll talk about that in a second.

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Dr Doug: So all right. So then that's bisphosphony. That's why I don't like it, and I don't think we should use it pretty much for the most part for anyone.

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Dr Doug: There are scenarios, though, where it makes more sense. So those scenarios would be like this breast cancer question. Right? So

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Dr Doug: let's say, a woman is on

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Dr Doug: whatever what, Sally, what'd you say you were on

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Dr Doug: electrosol? So that's a aromatase inhibitor. Right? So you're on a drug that will reduce estrogen and essentially take it to 0 for a kind of Perry, or even especially premin of causal woman. If you haven't gone through menopause yet, and you're put on a drug that blocks your estrogen

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Dr Doug: man. It is, I hear, terrible because your body is eliminated. Your body has been ripped off of estrogen instantaneously.

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Dr Doug: Menopause kinda does this right? Like you have it. You don't have it. You have it. You don't have it. Your body sort of get used to it, but you can adjust over time to some extent you still have symptoms, or most women will have symptoms, but you can adjust to it over time when you remove it completely

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Dr Doug: immediately. Women are really symptomatic, and as a result, the bone loss, not to mention the other stuff. But the bone loss is rapid. So in that scenario where you say, well, I know from the neurontologist says you're gonna be on this drug for the next 2 years or 3 years or 5 years.

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Dr Doug: You're gonna be on this drug for the next 5 years.

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Dr Doug: Why don't we use something temporarily that can help to shunt that blow, that, or slow down that bone loss right like that makes sense to me, and that's why there, one of the drugs reclass? There's a my cancer version of it. I can't remember the name of it. But use that same drug.

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Dr Doug: It's a an annual infusion. Slow down bone loss, poison your osteoclasts temporarily. That kind of makes sense. Right? So then you can maintain your bone mineral density while you treat the breast cancer, assuming you survive the breast cancer, then you're on the other side of it, and you add a much better starting point to maintain your bone density potentially without drugs.

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Dr Doug: So that's where I think that really makes sense. Other scenarios. If you have a rapid bone loss. Your ctx is really high and you can't slow it down.

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Dr Doug: We go through a program. You're doing all the things you're like. Shoot. My ctx is still 800. What do I do? Maybe it's time to actually put one of those things in place. I still probably wouldn't use it. Bisphosphony.

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Dr Doug: But before I move to the next drug, I would say Prolaa would be next any questions on bisphosphonates.

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Dr Doug: No, great. I'm not a fan case. You couldn't tell.

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Dr Doug: So the next probably most popular drug would be prolia who here has been recommended. Prolaa

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Dr Doug: some, not as many. I'm surprised, actually, because it seems really popular. So

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Dr Doug: yeah, Liz, do you have a question about bisphosphonates? Nope.

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Dr Doug: do you have a question about Perlia?

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Dr Doug: Do you have a question about something else.

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Dr Doug: You can ask your question if you want.

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Liz’s iPhone: I was recommended folia.

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Dr Doug: Okay, gotcha. Gotcha.

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Dr Doug: Yeah. So Prolaa has become more popular, I think, for 2 reasons. One is, it's just more convenient. So doctors have this problem with pills because patients don't wanna take them. So if you wanted to increase the likelihood of your patient being compliant, you can give them an injection once a month and then as long as they show up for their appointment, then you're good.

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Dr Doug: So that's a real thing. And doctors deal with compliance issues, especially in the bisphosphonates, because people don't wanna take them so it's popular with doctors because it gives them more control. Also, they can bill for the injection. So there's a financial incentive to using an injectable drug. It's an office visit, and you get a procedure code. So take that for what it is. Prolia is different than the bisphosphonates. It is also an anti resorive drug. It just works a little bit in a different pathway. I just recorded a new video on this.

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Dr Doug: So it's kind of a cool drug. It it works at the the rank Ligand receptor.

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Dr Doug: Or actually, I rank, laying it individually. So it sort of activates your immune system, tells your immune system to go after this thing that acts on the Osteo sites

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Dr Doug: downstream, impact osteoclasts it also downstream impacts part of your immune system.

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Dr Doug: which is why one of the side effects is increases risk of infection. But it works differently than this phosphinates, so it doesn't necessarily poison the Osteoclax, but it slows down their function, and we still see that same drop in. Ctx. We see that same drop in p. One. And P.

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Dr Doug: And they loved it, though, because it was so effective. And if you look at the numbers, it's really effective, especially for vertebral fracture. Right? So the the, I think, the original trial, the freedom trial. I wanna say, it was like a 40% higher than that 60% reduction in vertigo fractures which sounds really high. But that's a relative risk. And if you've heard me talk about these statistical things, there's relative risk, there's absolute risk.

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Dr Doug: It was still not insignificant. It was like a 4% reduction, absolute risk reduction for vertebral fractures. So that's not nothing.

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Dr Doug: It doesn't really do as much for hip. I think that just has to do with the mechanism. So the reduction in hip fracture was about 0 point 5% absolute risk reduction, which is not super impressive.

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Dr Doug: but what they liked about it is they didn't see in the initial three-year trial. They didn't see atypical femur fractures or osteonicrosis of the job like not a one. So that's cool.

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Dr Doug: So then they did a 7 year extension to that that initial 3 year trial that they got FDA approval from, and that 7 year extension took them out to 10 years. So they took everybody in the 3 year trial, and then they took all the people on placebo, and they added them. So then they had people that had been on it for potentially up to 10 years, or up to 7 years, and then some people that had gotten off of it.

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Dr Doug: and they show that again that it was actually pretty darn safe. I think they had one atypical femur fracture in in that trial.

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Dr Doug: and I don't think they reported any cases of osteonicrosis of the jaw. Now remember, these are all funded by Amgen. So take that for what it is. But they didn't report any of those complications. So they're sort of, you know, they're celebrating. They're like, Hey, now we have this long term solution that looks to be safe

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Dr Doug: for 10 years, and who knows how long? Right we can use this drug forever, but

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Dr Doug: is interesting. I don't know really where this came about, but Amgen also funded a look at another study, and this seems like a bad business move, responsible. But poor business choice. So they looked at another study

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Dr Doug: and funded it, and where they got X-rays, or they looked at who had X-rays of people that were on the drug, and people who had come off the drug. So people who had stopped prolee after, either before or after 3 years.

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Dr Doug: And what they found is that it wasn't that many. It was like 350 patients that had X-rays. There was an increased risk of vertebral fracture after stopping the drug

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Dr Doug: and the risk of multiple retrieval fractures in the group of people that had been on the drug for over 3 years that were stopping the drug.

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Dr Doug: So now you sort of find yourself in the situation where, like shoot.

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Dr Doug: I'm on a drug, and I can't get off of it, because if I get off of it. Then I'm gonna have a vertebal fracture. So that was kind of the takeaway from that study. And so now you know, a lot of people will hop on the they get recommended to be on the drug. They take their first injection, then they go on Facebook, and they're in a like an Osteoprosis group. And the people are talking about these, this risk of increased fracture. And you know, and then I get these messages on

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Dr Doug: on Youtube. And people are freaking out. And so

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Dr Doug: I think that we have to take into context of what the risk was. It was not high, it was in the single digits.

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Dr Doug: What we're just what we're simply seeing is that if you suppress osteoclast function for long enough, when you come off the drug, you're gonna see it an increase in function, right? The body's gonna rebound. You've been holding it down forever, and as soon as you let go of it it's gonna go nuts.

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Dr Doug: and that's what happens. And so osteoclasts go crazy. They reserve a whole bunch of bone and put you at increased risk of fracture, and it kind of just makes sense.

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Dr Doug: So there's a lot of people that are on this drug that want to come off of it, that are scared to come off of it.

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Dr Doug: What I said in the video is, you have to remember that a the percentage of people that have fractures is very low. The percentage of people that have multiple vertebal fractures, which is what is, you know, really scary, right? Just keep fracturing, keep fracturing. They also had multiple vertebal fractures before they started the drug. So if you're you know, the 55 year old woman who's been on it for 3 years, who's never had a fracture? Who has reasonable bone quality. That's probably not gonna happen.

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Dr Doug: And also the people that were in that study were probably not doing anything else.

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Dr Doug: Right? So like, you guys are motivated. You're doing stuff. You're here. You're learning. You're doing resistance training. You're eating the diet. That's gonna help your bones. You're pushing. Igf one up like that's not gonna be the same group

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Dr Doug: that was seeing the vertebra fractures. Can I guarantee that somebody's not gonna fracture? Of course not. But we have several patients that were on Proleah that are coming off of Prolaa. And we're really pushing as hard as we can without drugs to see what we can do, and so far their their Ctx. And P. One and P. Look good. If you read this book. Mccormick's book, you guys haven't read this like Bible on Bone Hill.

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Dr Doug: I'm slowly making my way through it. He talks about monitoring people, monitoring Ctx.

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Dr Doug: And give some case examples of prolaa and and watching. You know how quickly it rises right, and considering he, he even talks about like he's kind of a I wouldn't say he's a drug advocate, but he certainly talks about using them potentially using Abyssin 8. If you see it get too high. I haven't seen that happen yet.

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Dr Doug: and that's why I think that you know what we do is so effective because we're pulling all the levers we can, you know, from the lifestyle, from the supplements, from the hormones, from the Peptides, if applicable, doing all the things. If you do that, we don't see this massive increase in ctx.

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Dr Doug: Does that make sense?

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Dr Doug: So it is possible. So if you hear anybody really freaking out about that, please tell them it is possible we just have to have a solid approach and test frequently.

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Dr Doug: like I would get Ctx and P. One and P like every month, you know, know what's happening. Don't stick your head in the sand on that one, because you will lose bone quickly.

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Dr Doug: make sense.

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Dr Doug: cool any questions about Prolaa.

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karendunham: No.

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Susan Jaye: I just sent one. I just sent one.

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Dr Doug: Oh, sorry I'm not watching my chat.

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Dr Doug: Well, there, I missed a lot of things in chat. Sorry, guys.

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Dr Doug: all right, Susan, Susan says recently a woman told me that she had a broken shoulder, and her rheumatologist recommended prolee.

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Dr Doug: I looked it up and saw on the Internet that Prolaa does not target the thoracic spine.

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Dr Doug: I know certain bone drugs, target different spine hips. Some of these drugs work on different parts of the spine.

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Dr Doug: Yeah. So if

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Dr Doug: hmm!

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Dr Doug: They weren't, they weren't looking at. Is that true?

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Dr Doug: I think they were looking at spine fractures. They were talking about spine fractures overall. So Perlilla does work better on the spine than it does on the hip.

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Dr Doug: So it might be.

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Dr Doug: It might be the drug of choice for that particular person. It just depends on her situation, proximal, humorous fractures, that shoulder fracture. It is a fragility fracture depending on the mechanism

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Dr Doug: so that that could make sense again depending on the situation.

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Dr Doug: but not good for hips as much. Let me just go back and look at these. Is Fossa Maxabis, Phosphorine? Mary asked. The answer. Is that. Yes, Fossa, Max is like the quintessential bisphosphony. I'll come back to Ppis Kim

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Dr Doug: Melody asks, How does a person decrease their ctx while increasing their P. One. And P. Oh, that's such a good question.

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Dr Doug: Let's talk about that.

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Dr Doug: So when I started this game a couple of years ago, and I learned about the bone. Health, the bone bio markers. I was super excited to prove that we could raise P. One and P. Which is the building marker and drop. Ctx turns out that doesn't work that way. So these are the things we learned. So

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Dr Doug: bone metabolism when manipulated naturally, and what I mean by naturally is with natural occurring things, not with drugs necessarily, although with drugs. Kinda 2, the Ctx and p. One and P are linked, meaning that they tend to go up and down together. So it is not common that we see Ctx drop in p. One, and P. Go up.

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Dr Doug: That would be cool, and I have seen that happen a few times, but usually we see them move together. That's why we switched from looking at the independent markers. So Ctx and P. One and P. What their absolute measures are. We switch to looking at the ratio of the 2?

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Dr Doug: So you've heard me talk about that P. One and P. Over Ctx. Divided by 1,000. We do that because.

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Dr Doug: let's say, just give a couple of examples. So

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Dr Doug: actually, Michelle is a great example. So Michelle gave us her numbers. Right? So Michelle said. Her Ctx. Is 1, 58, and her p. One, and P. Is 30, and she's been taking Allendron it for 5 years. All right. So let's do some math.

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Dr Doug: So if we do the math on that, and we say, p. One, and P. Is 30, so we're doing 30, divided by point 1 5 8.

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Dr Doug: Your ratio.

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Dr Doug: Michelle, is 1 89

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Dr Doug: now for somebody who's not on a drug, 199 is not bad. I would actually take 189.

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Dr Doug: The, I think, where this falls apart is when you're on drugs that falsely suppress both of them. The ratio doesn't mean as much, so there probably is a threshold, and I don't know what it is yet of P. One and P. That we need to maintain cause I've seen. I saw a woman recently who was on pro Leah, and these were squashed like Ctx, double digits, and P. One and P like at 10,

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Dr Doug: right? But her ratio was 300. It looked amazing, but we know that she's not building bone.

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Dr Doug: so there's gotta be a threshold. We just haven't. We don't have data to know what that is yet, but we switched to the the ratio instead of the absolutes because we know that they're gonna go up and down together. It's how much they go up and down together. So, for example, let's say, Michelle goes off of Allendron. So she goes off the drug.

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michellethompson: Off of it! Now.

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Dr Doug: There we go alright. So you're you're off of it now. How long have you been off of it?

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michellethompson: Since last October. Ish.

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Dr Doug: Okay. Same way.

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michellethompson: Now I'm doing diet all the stuff the heel drops, weight training and stuff, and I have another bone scan in August.

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Dr Doug: Beautiful. When were these laps drawn before that I would assume.

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michellethompson: These labs were drawn in December.

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Dr Doug: Oh, so actually, so these were. You were probably more suppressed

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Dr Doug: when you were on it.

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Dr Doug: because for Alan drawn a it would have worn off by then. So you were seeing some bone metabolism more than you were when you were on it, I bet.

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Dr Doug: So that's cool, and you're getting a scan when.

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michellethompson: August.

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Dr Doug: Okay, cool. So I would recommend repeating Ctx and P. One, and P around the same time, or sometime before then. I like, you know, if I could do it again, you know. Really, there's no downside to doing it frequently other than it's expensive to do on your own. The other thing I would say is, make sure we just had this conversation yesterday, and it was really frustrating. Make sure that you're getting them done at the same time, and that they're fasted cause they do change throughout the day.

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Dr Doug: So that can be a really annoying thing for people. But try to do it the exact same time of day. Try to mimic as many of the variables as you can, and then you're going to get the best sense of what's going on.

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Dr Doug: But yeah, we'll see what happens. Right? So we'll see what happens in the spring and the summer.

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michellethompson: Yup!

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Dr Doug: Do all do all the things that's great.

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Dr Doug: Diane asked. Do you use bisphosphonates to prevent rebound after Prolaa? Is it possible to get off without those, and that's kind of what I was talking about. I don't know when you wrote this, Diane, but most doctors, if people come off of Prolaa. They will use bisphosphonates. But here's the thing.

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Dr Doug: If we are worried about the fact that we were suppressing bow metabolism for a decade, why would suppressing bow metabolism for another 5 to 7 years make sense.

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Dr Doug: It does prevent the rebound loss.

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Dr Doug: But we're further poisoning osteoclast and preventing bone from doing what it does. So we need to let the bone

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Dr Doug: go through metabolism if we're going to get it better. So I think they're just kicking the can down the road potentially making it worse.

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Dr Doug: Kim real quick on PPI's. So proton pump inhibitors

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Dr Doug: used for acid reflux and other things. Proton pump inhibitors do increase fracture. Risk.

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Dr Doug: They don't. They don't decrease Bominaro density. And this is where a lot of doctors get confused. There's some big studies that looked at PPI use, and it did not show that there was a decrease in bone mineral density. But there is an increase in fracture risk. So this is one of those areas where fract, where bow mineral density is sort of detached from fracture risk to some extent

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Dr Doug: that makes sense, and doctors fight back on that. Now there are reasons to be on ppis, even if you have osteoporosis. So let's say, for example, if you have evidence of esophageal cancer, precancerous cells, hyetal hernia that can't be fixed surgically. Some other reason why you need to be on a acid suppressing drug. Then I would trade that increased fracture risk for not having a soft cancer is absolutely terrible.

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Dr Doug: So

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Dr Doug: I always tell people don't feel bad. If you need to be on a drug for the right reason, just make sure it's the right reason.

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Dr Doug: Angie said, that she needs a bisphosphonate because she had her last perlia injection yesterday.

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Dr Doug: Yep, that's pretty common

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Dr Doug: or romos ozzy map.

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Dr Doug: which

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Dr Doug: is a vanity. So

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Dr Doug: that's a good but great transition. So, Angie, just, we're going to transition to to identity

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Dr Doug: any other questions on prelima

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Dr Doug: cool. So aroma, sozumab, Orlia, I'm sorry, or identity these names Perlia is denossumab

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Dr Doug: chromosome identity. So identity hit the market. I don't remember how long ago. It hasn't been that long, and it was sort of hailed as like the miracle drug, because the trials were really positive in slowing down fracture. So if you were a patient with multiple vertebra fractures. This was sort of the godsend, right? Because it would stop people from fracturing. So that's cool.

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Dr Doug: But you can only take it for 12 months. So talk about a short lifespan. What's the next plan? You've got to have something that you can do after that. And so identity is kind of cool. It's another sort of immune-based drug.

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Dr Doug: and it works. It's been told to be both anabolic and anti-resorptive. But what it really does is, it starts out anabolic, but then it ends up being anti-resortive. And so when you look at the bone turnover markers that kind of start to go up, but then they come down.

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Dr Doug: and I think that's why you can't use it past 12 months, too, is because at some point they just kinda stop. It stops being effective. So it's a really short term solution. If I had a patient that was actively fracturing, I think it's reasonable to use the side effect profiles pretty good from what we know now, I don't think there are any long term studies on it, though, but again, people aren't using it after 12 months, anyway. So you're only gonna use it short term. And you have to have a plan after that.

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Dr Doug: realistically. If I were treating a patient with it, which I would never do. But realistically, you'd actually want to stop it sort of at the peak of the anabolic phase, which would be around 6 months.

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Dr Doug: so take it for 6 months, stop and then do something from there. To continue to push that up would be my preference of how to use that drug. That's really all I have to say about that, because again, it's just not a long-term solution.

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Dr Doug: Those aren't those aren't the people that I hear

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Dr Doug: any questions about that

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Dr Doug: cool? Alright. So let's talk about anabolic drugs. So anabolic drugs are my favorite. I've prescribed them. I can think 3 times, so I don't. I still don't use them a lot. But antibiotic drugs would be Forteo and Timlos.

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Dr Doug: The reason why I like them when we need a drug is because they don't squash bone metabolism. They elevate it. So p. One, and P. On Forteo and Tevlos will go from whatever the starting point is in the double digits. It'll hit, you know, 1, 5,200. 300. I've seen it over 300, right? So that's rapid bone building. That's why they work the way they do. But Ctx goes up too.

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Dr Doug: and so you still have to look at the ratio. But the ratio for the patients that I've seen on it is always positive. I mean, it's like the ratio is 300. 400. It looks amazing.

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Dr Doug: The so the benefit is, you rapidly build bone. I use it for patients where their T- score is terrible, and they're at very high risk. If they've already had a fracture, they're in a deep, dark hole, and I'm confident that the things that we're gonna do are going to help them. But I wanna help them faster, right? This is where we would use an anabolic really drive this?

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Dr Doug: it works, I mean, every time, and the only downside I see is it can mess with your calcium metabolism. So you see potential of the side effects of having hyper calculation

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Dr Doug: because you're again, you're building bone. Actually, it's hypo calciumia. You're pulling bone out of the bloodstream. But either way you have to check your electrolytes potentially, change your dose, change your frequency, whatever most people can get through that without an issue. The black box. Warning that's that's subsequently been removed is all about osteosarcoma bone. So that's a scary sounding cancer. And it is a terrible cancer.

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Dr Doug: But it's never been reported in an adult taking this drug ever. Not once.

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Dr Doug: So the reason why they got that black box warning was because in the original drug trials on mice or rats. I think it was rats.

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Dr Doug: The rats developed osteosarcoma, but if you go back and look at the rat model that they used, and it was like like all of them, it's like, but if you go back and look at the rat model that they used, it's a model that is prone to developing cancer. So you give a

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Dr Doug: a a rat model that's prone to developing cancer, a drug that rapidly turns over a single cell line. What's the likelihood that it's gonna develop cancer? It's pretty high. And so when you then took that to the human studies, they stopped them after 2 years because they tried to do the math on the rat lifespan. And when they developed cancer and what that relates to with humans, that's impossible. Math, by the way.

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Dr Doug: so they stopped it at 2 years. We don't have any data past 2 years. There was not a single case of osteosarcoma, and I think the reason why is that in adults

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Dr Doug: sorry in humans, in humans, osteoarcoma is a kid disease, and it is terrible. And I've treated it and it sucks.

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Dr Doug: but it's it's a disease of adolescence in young adulthood.

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Dr Doug: We don't see it in older adults. We don't see it in mature adults, so I just don't think that we're in a position with our bone growth and the the condosites, and how they're developing. We're not going to see osteosarcoma

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Dr Doug: in in older adults with this drug. I don't think ever

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Dr Doug: so. I think that they did a huge disservice to the drug and the potential benefit of the drug by putting that black box label on it. I think there is potential use of this drug again. We've used it a handful of times when we've really needed it. The challenge is, it's hard to get insurance to pay for it.

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Dr Doug: and they always refuse it. They kick it back every time.

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Dr Doug: So that's the insurance game which is really annoying any questions about the antibiotics

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Dr Doug: cool? I do have a list of questions. Actually, I should be looking at.

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David Callen: One quick question at your own time. Loss. Do

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David Callen: Can you work out and continue? You know, resistance, training that type of thing to

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David Callen: strengthen the bond.

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Dr Doug: You better?

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Dr Doug: Yeah. And so let me. Just that's a great comment. So the way that we use it is we don't change anything other than the fact that you're on this drug.

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Dr Doug: And when people come into the program and they say, Hey, I was told to take Forteo and my doctor's really pushing me to do this. This is my starting point a lot of times, we'll say, look, let's get your bone turnover markers now, before you start it, go ahead and start it if you have access to it, and then we'll just layer the program on top of it by the time you end up coming off of it in one to 2 years.

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Dr Doug: Then you're gonna have such a good program. You're gonna have a better chance of maintaining the bone that you've built than if you you know, did nothing, which, again, is what most of the population would do right. So absolutely do all the things put everything in place, and that way when you come off of it. It's just like you were shot up an escalator at the airport, and now you're on the next floor.

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Dr Doug: you know. It's just a much faster way to get there.

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Dr Doug: I have a question, too.

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Diane K Miller: I'm.

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Dr Doug: Yes, Diane! Hi.

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Diane K Miller: Are they still saying? You can only take it for 1, 2 year span, and not again.

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Dr Doug: I have heard that they lifted the 2 year restriction. I've not seen that in writing from any any one, any organization. So I've heard that the FDA. Will allow it, but I don't know that insurance companies would pay for it, and it is stupid, expensive.

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Diane K Miller: Okay. Thank you.

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Dr Doug: Yeah, cause I I had somebody I don't remember. I I don't think this was a patient or remember somebody on Youtube who like there was the same guy, one person who just kept saying, Just take foretail forever. I was like, I don't know. I don't know if that's a good idea.

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Diane K Miller: Well, I already took it once. It was a long time ago, but my insurance is through Eli Lily who makes it

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Diane K Miller: so? I.

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Dr Doug: You'd think, yeah, I bet.

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Diane K Miller: And make trouble getting it approved.

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Dr Doug: Yeah, can that be shared with other people? Can you get it for others?

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Diane K Miller: I wish.

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Dr Doug: Me too.

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Jennifer Doak: I have a question about Tim Wells.

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Dr Doug: Yeah. Hi, Jennifer.

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Jennifer Doak: About

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Jennifer Doak: I don't know electrolytes. And I mean, I'm assuming you're gonna end up with

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Jennifer Doak: probably higher calcium. Or is that only some people.

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Dr Doug: Yeah, it's it's only some people.

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Jennifer Doak: So would you.

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Jennifer Doak: Is that in your urine or in your blood to California, or both.

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Dr Doug: So what they're worried about is in blood, so it can mess with electrolyte balances in serum, which calcium is very tightly controlled. That's why we really like.

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Dr Doug: I don't often worry about what your blood calcium looks like, because your body's gonna control your blood calcium very tightly. You're gonna see it in urine, too. If you have hyper calcemia, it's gonna come out in urine, right? Cause your body's gonna get rid of it. But I don't really worry about that, either, because it's there's no downside to having calcium and urine as long as your bones continuing to get better right? It's just excreting calcium that you're using otherwise.

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Jennifer Doak: Does that tie into anything at all with like.

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Jennifer Doak: possibly too high of vitamin d.

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Dr Doug: Yeah, it's an interesting question. And I've not seen that studied because anytime the the women's health initiative basically demonstrated that calcium and vitamin d is the gold standard treatment for osteoporosis. So all of the drug trials are going to have calcium and vitamin d. 2.

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Dr Doug: Just depends on what dose. And what form? Right? But that's usually crappy calcium. So it's calcium carbonate or calcium citrate and not a lot of vitamin d. So in the studies. You're not gonna see that in our patient population and people that are coming, you know, they're coming to see us with 5,000 10,000 Iu or 50,000 iu of vitamin DA day. Could that impact calcium? Absolutely right? So now you have 2 really big tools that are manipulating calcium metabolism. And I think that's dangerous on both fronts.

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Dr Doug: Yeah. Vitamin d is, it's real. It'll impact your calcium absorption. We don't need that much vitamin d

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Dr Doug: a couple of questions I want to hit here that were submitted ahead of time.

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Dr Doug: Sandy Lane was, she said, that she's about to receive her fifth prola dose

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Dr Doug: she doesn't like the side effects. She's looking to get off of Prelima, but have been told to do so would need to take a drug like phosphor, Max Boniva reclass, etc. Those are all the Bisphosphonates.

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Dr Doug: So we already kind of covered that sandy. And then is this true? No.

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Dr Doug: hopefully, if so are there. Meds you recommend from research that have the least side effects. So my my preference would be actually. And I've not seen a study on this. But what I would love to see is somebody who is really at risk, or let's say they come off prelate, and they're starting to see a Ctx climb, and they're everything else is optimized rather than using. Anti-resorptive Lycabis phosphinate. See what happens with an anabolic

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Dr Doug: right? So instead of saying, Whoa, Whoa! Whoa, let's put the brakes on the osteoclass. Let's help out the other side of the equation. This is a simple math problem. So let's use an anabolic, and let's drive up P. One and P. And then if the ratio makes sense, then we're okay.

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Dr Doug: So I would love to see that I don't think it's been studied, but I think that would be a cool study to do, and you could do that clinically.

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Dr Doug: So that's the answer to that. But, Sandy, I haven't even seen the need for that. So I think if you have a solid plan you shouldn't see it go crazy.

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Dr Doug: And then I just answered that

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Dr Doug: same thing with Annette. She wants to stop Prola.

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Dr Doug: What is the worst I can expect?

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Dr Doug: We don't know

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Dr Doug: right? We just we just don't know. There's not enough data on that.

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Dr Doug: Lynn was asking, does reclast damage boom remodeling? Yes.

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Dr Doug: if so, for how long? Yeah. Good question. So this goes back to bisphosphonates a reclass being an Iv bisphosphonate. So once a year injection

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Dr Doug: and the half-life is years

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Dr Doug: years. So you'll see this drug stay in your system for you know, 5, 10 years. It depends on how you metabolize it, but it's gonna be there impacting your bone for a long time. I've had patients who've been on it, and their bone turnover markers are still suppressed 2, 3 years later. Right? Ctx is still super low. So it is. It's in there long time. And then how long does the rerun effect to last after

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Dr Doug: Forteo? That's a kind of a different question. So Lynn was asking, How long does the rebound effect last after Forteo. It's kind of like that's sort of using a prolia term and applying it to Forteo. So it doesn't. Really, it's not the same thing. What happens after you stop, Forteo, is that you're on this sort of like, rise right? And then when you stop, it's gonna plateau. And if you haven't changed anything, it's gonna drop. It's not really a rebound. There are not. There is not an increased risk of fracture. After stopping Forteo and timeline like there is afterlia. So? Not really the same thing.

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Dr Doug: Yes, Diane.

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Dr Doug: sorry to catch a mid swallow. There.

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Diane’s iPad: Hello! Put a little bit of it in the chat, but it was back to the eventity. But

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Diane’s iPad: so I, in September had an X-ray have a 6 bird with 6 end plate fractures in the thoracic and lumbar spine.

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Diane’s iPad: Verte Bay heights are maintained, with the exception of I believe it's Cl. 4, 5 so over 2 year period previous to that I was like, go on the Bisbos. No, go on the prolea.

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Diane’s iPad: I'm scared and then on that one get on end of eventity asap but I had pretty much already decided that I was gonna try

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Diane’s iPad: your route this route. So mostly. So I'm I'm I'm comfortable with not being on the drugs. But

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Diane’s iPad: my question, and the only thing that cause I'm in Canada. The only thing I can get is a dexa and a Ctx. So in 6 months my Ctx. Went from 1.1 4 0 to point 7 5 8.

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Diane’s iPad: So it's going down. I know that 1.1 was not good. I knew I knew that, but

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Dr Doug: What's the reference? So those are going to be different units. What's the reference range.

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Diane’s iPad: I I'd actually have to give that to you at some. But I I listen to you very. Oh, because you've repeated this many times, and I think I have it

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Diane’s iPad: once you do the the change from

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Diane’s iPad: once you move the decimal right, so that 1.1

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Diane’s iPad: 4 0 or point 7 5 8 is what you would be using when you would be calculating it against the.

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Dr Doug: I got it, yeah. And then.

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Diane’s iPad: Yeah.

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Dr Doug: If that's true, that is really high. Yeah.

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Diane’s iPad: And then I'm down to point 7 5 8, and next week I go for another one. I've been getting these tests every 6 months which I have to pay for. But anyways, I can't get a P. One. Np, I'm trying to find a place in Washington where I can get a. P. One np, and then our and around. But I'm coming up blank. So right now, my question is with regard to those end plate fractures, and I've had them describe to me are those Osteo productors.

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Dr Doug: Yeah, it's it's gonna depend on what they look like. The fact that you didn't lose

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Dr Doug: height is good.

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Dr Doug: But I was just. I just had this issue. It's so hard to actually get images and look at images. People try to send me desks all the time. The desk never work so aggravating.

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Diane’s iPad: Yeah, I'm.

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Dr Doug: A lot of times. Radiologists don't really get specific, especially on X-ray on Ct. It's usually a little bit more clear. If there's if there's an inplate fracture, especially if there's multiple. I would almost say we have to assume. Because why else would they be there?

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Dr Doug: I think we're

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Dr Doug: go ahead.

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Diane’s iPad: I had the X-rays in September, and then I then I and I've had 2 MRI's one I paid for, and then just a recent one that was through the hospital.

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Dr Doug: Yeah, well, that's what I was gonna say. So MRI MRI can over estimate.

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Dr Doug: Excuse me, MRI can overestimate. And depending on how much edema there was how much swelling in the bone there was. You can kinda get a sense of where these real or not.

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Diane’s iPad: None, none.

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Dr Doug: Yeah. So then, how old were they, you know, and if you could compare them to the previous MRI.

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Diane’s iPad: Send a little.

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Dr Doug: Yeah.

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Dr Doug: like, because it.

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Diane’s iPad: They explained that they're not acute, not then. It only goes from acute to old but there's been no change from September to like last week

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Diane’s iPad: at all. And one of the radiologists

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Diane’s iPad: I got to speak to, and he said, he's not so sure that this just isn't the way my spine is. Does that make it sense.

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Dr Doug: Yeah. And that's that's the challenge, right? So we we don't know and there's no way to know again. MRI can overestimate you could get a Ct. And you could look at them more clearly that way. But I don't know. It's it's really tough. So I think this is one of the reasons why in the studies on the drugs

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Dr Doug: they don't like to use even X-ray because it's going to over estimate.

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Dr Doug: Oh, there you are. Yaki just disappeared on me, Diane. There you are, so I'll get back up here. Oh, I know.

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Dr Doug: Let me move you, anyway, I can still see you. So yeah, so it's tough. I would just, I would pretend, like they're real.

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Dr Doug: because it's probably more important. It it probably makes more sense to pretend like they're at least real, and that you have some some concerning spine weakness.

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Dr Doug: because you're gonna treat it, anyway.

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Dr Doug: So let's just assume that this is what I would do

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Dr Doug: if you were my patient. So let's just assume that they're real. Let's do all the things we can do. But that doesn't mean we necessarily jump, jump on a drug?

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Dr Doug: Does that make sense.

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Diane’s iPad: Will share.

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Dr Doug: Factors is scary. But the fact that you haven't lost height

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Dr Doug: and they don't look like they're new.

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Dr Doug: Let's just move. Let's just move forward to be cautious. But you're doing all the right things getting the getting the labs.

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Dr Doug: One thing I wanted to say is, if you can get to Washington.

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Dr Doug: Look at life extension as a company that you can order the labs through.

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Diane’s iPad: Alright! Let's do that.

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Dr Doug: Life extension has a panel. Ctx. P. One. And P. You can do it without a doctor's order, and they should be able to draw it. In Washington State. There are some states where they have restrictions.

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Dr Doug: The more left coast States describe that, however you will, are more restrictive than the others.

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Dr Doug: If that made sense. Okay.

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Diane’s iPad: I mean my, my my spine is like negative 3.9, and it's an addictive. 6 months later was negative 3.7. Yes, I'm on strontium because I'm throwing everything up.

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Dr Doug: Do it? Yeah, go.

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Diane’s iPad: Right? So, okay, so.

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Dr Doug: Sink.

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Diane’s iPad: Yeah. And I mean, and I'm I'm I'm I'm a gym rap by nature, but I I am in there doing you know currently cause I've lost some weight. But I'm 115 pounds. I'm doing 100 pound dead list. So I'm I'm not hurting myself

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Diane’s iPad: right.

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Dr Doug: Good. Yeah. I mean, I I well, I don't. I mean, I can't say that you're not gonna have a fracture, but I think you're doing all the right things.

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Dr Doug: Yeah. So I would say, Diane, connect with David, because, David, you are. You live in Canada right?

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Dr Doug: Where'd you go?

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David Callen: No, I'm not.

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Dr Doug: Oh, you're not! Oh, there you are!

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David Callen: But let's see, is Lab Corp, in Canada.

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David Callen: Nab.

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Diane’s iPad: Poor!

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Dr Doug: Lab, core.

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David Callen: It's the Major, Us. Player.

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Dr Doug: I wouldn't be surprised if they weren't. Canadian. Canadian healthcare is tough to be a.

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Diane’s iPad: And you know.

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Diane’s iPad: When you say the left province I live in that left province of BC. And it is the worst. If I'm I, if I go to Alberta, or I go to Manitoba or Ontario I can get. I can get these things. So you know I am planning on winters, winter subsiding, and I'm planning to go wherever I've gotta go as far as I got. But yeah, so.

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Dr Doug: He is helpful. The Rems, though I don't think you're going to find a rems until you get from where you are. I mean the closest one, I think, would be in Chicago.

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Diane’s iPad: Actually, there's one in Alberta I call.

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Dr Doug: Oh! There is! Oh, cool and.

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Diane’s iPad: Yeah, so I will. I will like, I say, I wait until the roads are better. But.

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Dr Doug: It would be helpful. Yeah.

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Diane’s iPad: That identity is the reason why that identity was so. What I felt pushed was because it was going to do that increase the strength, so to speak, is that that's the given. My situation.

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Dr Doug: If I again, if I had a patient that was actively fracturing. So let's say you had 5

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Dr Doug: acute or subacute fractures on MRI.

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Dr Doug: Different story.

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Diane’s iPad: Okay.

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Dr Doug: Right? Different story.

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Diane’s iPad: Said.

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Dr Doug: It's tough, it's really tough. Let's answer a couple of questions. I do have to leave on time because I'm doing a talk on hormones for my wife's company.

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Dr Doug: hormones and weight loss. That's a fun conversation. Let's go, Lori.

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Lori Riggio: Hello, Dr. Doug, I have a question for you for the P. One Np. Minus 55.8, and my ctx. Is 3 47. You had explained how to do a ratio of that to kind of make meaning of those numbers. Can you share that with me again?

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Dr Doug: Yeah, same again, 55.8.

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Lori Riggio: 55.8 for the P. One Mp. And the Ctx. Is 347.

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Dr Doug: So the way that you do that is 55.8, divided by point 3 4 7, and that gets you 160. And so those are natural numbers. Right? You're not on a drug.

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Lori Riggio: Yeah. No drugs.

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Dr Doug: Yeah, so so that ratio where we find it. You're probably in sort of like, the yeah kind of middle to lower third somewhere around that rain. You know the the fortieth percentile. Maybe if we were to extrapolate statistics. So it's okay. But it could be better.

408

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Lori Riggio: Okay? Because my lumbar Dexa was negative 3.9, which is quite scary.

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Lori Riggio: So I'm trying to do all I can, you know from you know the exercise thing. But I saw that a weighted vest might be a good way to build bone, but I don't know which one, and I don't know how much weight to start with, and if you think that's not even worth it. I was looking into the vibration platforms, but they're so expensive. So can you give me a direct.

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Dr Doug: The low hanging fruit. I know. Yeah.

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Lori Riggio: That is great. This is the.

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Dr Doug: Challenge right? Cause there are. There are a lot of things

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Dr Doug: so weighted best. I've got a video on that. It's a little bit older, but there is evidence to support using a weighted vest. The studies would aim at getting to 10% of body weight, but start low. Go slow. Obviously they're loading your spine. That's why you're using them. But they can also put your spine at risk. So that's something that you could consider if you wanna drop if you go. And are you in the the slack community chat.

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Lori Riggio: No.

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Dr Doug: Get, get in slack and ask for some links to some Amazon products. Cause there's a number of people have put stuff like that in there we need to add one to our Amazon list. So maybe go to the the chat there, or slack rather, and put that in there, and we'll get some of the most popular items. We'll put them in the Amazon affiliate list. So you guys will all have access to that. So I think that's that's a re very reasonable. It's it's a you know, not particularly expensive thing to do.

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Lori Riggio: And up.

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Dr Doug: Plates, I think, are cool, because it's a way to do impact. There we go or anchor. Just put one in there for you. So if you look in chat.

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Lori Riggio: Thank you.

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Dr Doug: Assuming aranta. That's.

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Dr Doug: So

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Dr Doug: the vibration plates, I think, are cool, a way to stimulate or simulate, rather impact without doing impact. But you're right. They're expensive. If you're gonna get a good product, you're gonna spend some money.

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Dr Doug: And then what I would say, too, is, look at the video that I did on heel drops.

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Dr Doug: You know, as a as a free way to do impact. That's a no brainer.

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Dr Doug: Friday.

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Lori Riggio: Them, and then I was hurting my neck was killing me, so.

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Dr Doug: It's an incredible amount of.

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Lori Riggio: Later on.

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Dr Doug: Yeah, I I agree so easier way into it. Easier way.

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Lori Riggio: All right.

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Dr Doug: I will say, too, if you have issues. So people that can't do impact the vibration plate. I know they're expensive. But I mean, I I've really I. So I have a power plate. And I really enjoy using it as a way to warm up my joints. I have pretty significant arthritis in my knee.

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Dr Doug: and so like warming up my joints before I do squats. But do any of those things, I use it for my upper body. Now, too, I use it every time. I pretty much use it every day. Yeah, Lorna.

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Lori Riggio: Okay, just.

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Dr Doug: Sorry, Tom, I'll come back to you.

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Lorna Nichols: I just bought a power plate.

435

00:59:13.685 --> 00:59:14.665

Lorna Nichols: and

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Lorna Nichols: I was amazed when I first got on it.

437

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Lorna Nichols: I liked the way it felt, and it was actually relaxing, I thought, and I really craved doing it because of the way it feels. So I

438

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Lorna Nichols: I it was a huge investment for me, but I'm very, very happy with it, did it?

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Dr Doug: Yeah, I I like that company far away above the others, for sure.

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Dr Doug: All right. So, Tom, what do you have for us?

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Dr Doug: I can't hear you. I think you're still muted.

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Dr Doug: See if you can get there.

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Thomas Schellberg: Mute! Unmute! Hi!

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00:59:53.477 --> 00:59:55.175

Dr Doug: Hear me! I hear you, Buddy.

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Thomas Schellberg: What's your opinion of neuroma surgery? I hear your foot, doctor, or a foot doctor.

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01:00:01.015 --> 01:00:04.785

Dr Doug: Well, I'm still a foot doctor, still, an orthopedic surgeon.

447

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Dr Doug: And aroma surgery is a plus minus. You gotta have the right diagnosis. If you truly have a neuroma, then it helps. If you don't have an aroma, it doesn't help. So

448

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Dr Doug: it's I'd say it's about a 50 50, usually not in my hands, because I didn't do very many, because most times that pain wasn't coming from an aroma.

449

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Dr Doug: But on average, if you look at pediatric and orthopedic surgery combined. It's about a 50% success rate.

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01:00:31.045 --> 01:00:48.924

Thomas Schellberg: I'm gonna I'm gonna see another doctor to look at this going on for 4 or 5 years, and I'd like to do some backpacking, running, and even the the heel drops. Any of those would be a help, because right now I can't do much weights, because I've also got thumb pain.

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Dr Doug: Yeah, yeah, we talked about.

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Thomas Schellberg: I'm looking at a bunch of things here.

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Dr Doug: Yeah, we talked about using straps to help with the thumb pain.

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Thomas Schellberg: Yeah, it's not helping. But I'm gonna get 8 weeks off because I'm also having surgery for an inguyl hernia. So.

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Dr Doug: Oh, man. Yeah.

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Thomas Schellberg: Won't be doing any.

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Dr Doug: Don't live! Don't live forward from that! Oh, my gosh!

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Thomas Schellberg: Yeah.

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Dr Doug: Alright. Well, so, guys, I gotta run liz and Janet, drop your questions in the chat or in in slack, and we'll start with those next time, and then next week I am off grid my birthday is on Saturday, so I'm disappearing and I will be back at the end of the week. So Carrie is going to talk to you, I think, about

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