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A late breakfast

The first line drug for osteoporosis, Alendronic Acid (fosomax) comes with very precise instructions on how to take it.   It should be taken with a large glass of water (further research says this ‘large glass’ is 200ml / 7fl oz) after getting up in the morning.  No eating in the middle of the night….they really really want your stomach to be empty.  No eating for at least half an hour after taking the pill, and stay vertical (sitting upright or standing).

These pills used to be taken everyday, and I can see that this set of instructions, seemingly so simple, would be quite a hassle with a busy life and no respite.  With the one a week dosing it is pretty simple to manage.

But why the emphasis on not taking the pills with breakfast – the easiest time of day to remember to take pills?  So easy that I discovered Bestbeloved was taking pills he shouldn’t take with meals along with all the others he has  to take in one large handful with his breakfast.

The reason we need to avoid food as that very little of the drug gets absorbed into the bones.  Most of it just gets eliminated.

This is a quote from the MRHA – the Medicines and Healthcare Products Agency

“5.2 PHARMACOKINETIC PROPERTIES

Absorption

Relative to an intravenous reference dose, the oral mean bioavailability of alendronate in women was 0.64% for doses ranging from 5 to 70 mg when administered after an overnight fast and two hours before a standardised breakfast. Bioavailability was decreased similarly to an estimated 0.46% and 0.39% when alendronate was administered one hour or half an hour before a standardised breakfast. In osteoporosis studies, alendronate was effective when administered at least 30 minutes before the first food or beverage of the day.

Bioavailability was negligible whether alendronate was administered with, or up to two hours after, a standardised breakfast. Concomitant administration of alendronate with coffee or orange juice reduced bioavailability by approximately 60%.”

So, if you eat your pill with breakfast none of the drug gets into your bones.  If you eat it up to two hours after breakfast, none of it gets into your bones.  Taking your pill with coffee or orange juice instead of plain (low calcium) water means more than half of it is wasted.

It doesn’t help that almost all of the drug passes straight through anyways, however careful you are.  Being totally careful about taking the pill, overnight fast, two hours before breakfast and with plain water, you still only get to use less than one percent (0.64%).  This is halved if you have your breakfast half an hour later, which is what the packaging says is the amount of time you need to leave between taking the pill and eating breakfast.

Question is, given that the dosing is planned around people eating half an hour later, is it bad for me to wait an hour or two to get more of the bone hardening drug into my bones or not?

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Posture, posture, posture

yoga with Wii

The osteoporosis guides are full of exhortations to manage your posture to reduce your risk of fracture.  The aim is to prevent your back from curling forward (imagine cuddling a kitten/slouching on a sofa) as this increases the risk of spine fractures.  The spine is a series of stacked bones, and they get little fractures without people noticing, they crumble a little, form a wedge shape…and the wedge encourages curling forward, which increases the pressure and increases the fractures, and before you know it you are walking along unable to look at anything but the ground.

I’ve been teaching myself to put on my shoes with a straight back (don’t forget the neck!), but haven’t been able to figure out any way to cut my toenails without curving.  Maybe I’ll have to put up with lacquered toenails the rest of my life.  I got my nails cut by a nail salon person when I first broke my wrist as I could not do them myself, and the technician was so distressed at the idea of my just having my nails cut and no polish that I let her put polish on. Even though it was a nothing colour it was still weird, and I couldn’t open the very ancient pack of nail polish remover I had in the studio so it just wore off gradually over the next month.

A useful guide is to get a broomstick, place it along your spine, and learn to bend while keeping your vertebrae aligned with the pole.  At least it is a useful imaginary guide…it is actually really hard to tell what your back is doing in detail, and holding the pole top and bottom is difficult, especially with a fractured wrist.  Need a mirrored gym and a video camera and a physical therapist of my own.

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Ouch!  still haven’t figured out how to catch a sneeze ahead of it happening.  I’m supposed to support the small of my back or brace a hand against a thigh to reduce risk of fracture when sneezing…but my sneezes are unhelpful and they explode without enough warning.  Plus, of course, one should be grovelling for a tissue at the same time and not dropping whatever else is being carried and clenching (sorry) the pelvic floor muscles..

**

I looked into devices to help one to develop and maintain a good posture.  Most of them are things you strap on and wear a measuring and notifying device in the small of your back.  The straps look awkward to manage and rather obvious, and most of the devices make an audible sound, so not good for discretion.  One US version allowed a sound or a vibration.

While I was looking at these I came across a device called Lumo Lift.  With the wonders of modern technology and delivery systems I found out about it the 23rd of December, and on the 24th I was presented with it as my (slightly early) christmas present by Bestbeloved.  It is very easy to use, very discrete, can be told what posture you are aiming at.  Two little taps in a new position tells the device that is what you are aiming at.  I sit straight at my desk on my Swopper chair but my back angle is slightly different from walking, and you can tell it to ‘coach’ you, where the thing buzzes whenever you go out of the desired posture, or just to monitor.  In the monitoring mode the thing gives five short buzzes if you have been out of the target posture for a length of time you can set for yourself.

An extra benefit is that it also tells you how many steps you have done.  I got an email this morning congratulating me on having walked the equivalent distance to swimming the English Channel over the past nine days.  It synchronises with your smart phone, which records the data.

The whole thing is tiny, discrete, and just clips onto your shirt or bra strap with a little magnet.  So far I am impressed with it as a way to remind me all the time to think about the shape of my back.  It measures what it calls ‘slouchy’ posture, and it is based on the angle of the device, so if my back was very straight but at an angle to the floor – as in the straight back bend I’m supposed to be learning, it would give a warning buzz.  What would be very useful would be to have two, one on the lower back and one on the upper, and for it to give a warning if the distance between these two reduced, because that would mean that the spine was curling.  I’ll write to the company and see if there is any way to do this.

I’ve already written to the company to see if the sensitivity can be altered.  While I am sitting, actively, on my lovely red Swopper stool, I register steps when I bounce…ok, I don’t bounce that vigorously a lot, but it is fun to do now and then.  The stool has made a considerable difference to my neck pain as well as keeping me moving the whole time I am at my desk, so I am very pleased with it. Fortunately I can still use the foot control of my sewing machine while on the stool, so for those of you that are envisaging a very wobbly unstable thing, it isn’t like that.  Stable with movement, like those animals on springs in children’s playgrounds.

We also retrieved the ancient Nintendo Wii from the attic and set it up in the living room.  Reducing the risk of falls is a big thing with osteoporosis, as even a hardly noticeable fall (even turning over in bed!) can lead to fractured bones.  I’ve been having fun on the balance games.  It is difficult to be sure what activities are safe to do- I’d like to do the hula hooping as it gets me out of breath and makes me laugh, but, while my back in straight the hip rotation must alter the angles of the vertebrae…until I can get a definitive answer I’ve banned that from my activities.   I’m surprised, with the numbers of people with osteoporosis and the use of the Wii with the elderly to reduce falls that I couldn’t get a list of which activities to avoid and modifications on others.  I’ll keep hunting.  Plenty of research papers available on the impact on balance and whether these balance activities equate to the tests used in other research, but no basic guide.  I wrote to the National Osteoporosis Society about one of the exercises they recommend that everyone else says not to do, but just got a (Facebook) message back saying I should phone.  I like the use of Facebook for generalisable advice as lots of people can learn from queries.

Enough sitting…January is the time for group challenges on my fused glass Facebook groups, so I’m off to do a Sgraffito drawing a day and a painting a day.  Started these to get myself out of the frit frolics I’ve been doing the last few months when I couldn’t handle sheet glass.  Still tricky, but getting my dexterity and strength back…frayed thumb tendon not fully recovered so opening jars still difficult, but making progress.

 

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Water hardness and foolish instructions

I’ve been looking at a lot of issues around medication, posture, exercise and the psychological impact of a diagnosis of osteoporosis. One of the reasons given for poor compliance with medication (people stop taking their pills when the doctors think they should carry on) is the difficulty in coping with the specified way they have to be taken.

Note -alendronic acid or Alendronate is the generic name for this drug, Fosamax is a brand name.

“Taking alendronic acid
It is important that you take alendronic acid in the correct way, as otherwise it can cause irritation and damage as it is swallowed:

Take the tablet/medicine first thing after getting up in the morning. Take it before you eat any food or have anything to drink other than water.
You must drink a large glassful of plain water (not mineral water) as you take your dose. If you are taking tablets, swallow the tablet whole – you must not chew, break, or crush alendronic acid tablets.
It is important that you take your dose while you are standing or sitting in an upright position.
Continue to sit or stand upright for 30 minutes after taking your dose – you must not lie down during this time.
Do not have anything to eat or drink (other than plain water) during the 30 minutes after taking a dose .”  http://www.patient.co.uk/medicine/alendronic-acid-for-osteoporosis-fosamax

You’ll see it says you need to drink “a large glass of water”  – I’ll discuss what this means to the manufacturer and what it means to individuals reading it later.  I want to focus on the phrase not mineral water”.  Now, I grew up in India, where drinking water was boiled and carefully stored, so maybe I think more about water quality than many.  I also had my first job in London, where the water tasted so bad all I drank were tomato cup-a-soup as that was the only think I found that would disguise the flavour.  This predates the ready availability of water filter jugs and bottled water.

I’m also the kind of person that want to know “why not”  and “why do you think that” whenever I hear an instruction.

So why not mineral water?  It turns out that calcium in the water affects the absorption of the drug.

Calcium in water is good for your heart and bone health, and hard water is one of the major sources of calcium for many people.  Water hardness is a sufficiently big component of calcium availability that it has been recommended that GP’s should know the water hardness in their areas http://www.sld.cu/galerias/pdf/sitios/rehabilitacion-bal/how_much_calcium_is_in_your_drinking_water.pdf  .  This same report said that the manufacturers of the pills didn’t know what effect the calcium had on bioavailability of the drug so wouldn’t give a recommendation on the maximum level.

So, don’t take these pills with mineral water as it will reduce the availability and absorption of the drug.  BUT- tap water varies a lot.  Mineral water varies a lot.  I checked the calcium level of my tap water using my suppliers on-line ‘enter your postcode’ service.  I have medium hard water.  I checked the calcium level of the bottled water I keep for trips (very cheap stuff from the supermarket).  That had about one-tenth the amount of calcium in it.  I’d be better off using the mineral water rather than the tap water to take my pill.

I’m not the only one that thinks this is ridiculous.  R.Pelligrini of Bologna University wrote

 “the aforementioned formulation of the package insert is practically a nonsense, owing to the well-known huge differences among waters, both tap and mineral,”http://paperity.org/p/10789431/which-water-for-alendronate-administration

The amount of calcium in water to take the pill with should be specified, then people can make an informed choice.  I discovered that I could get calcium testing kits from the local aquarium/pet fish supply shop for a few pence a time.  I got sent a water hardness test strip with a dishwasher I bought a few years ago.  It is not difficult or expensive to test your water hardness.  Bottles of water specify their mineral content. Deciding which water to use would be easy if one knew the calcium level that didn’t compromise absorption.

Why does this matter?  People could be reducing the effectiveness of their medication by following this ruling.  If they dislike the flavour of their tap water this will make the whole process even less pleasant and possibly reduce compliance.  It also makes it feel arbitrary and controlling – instructions without clarity, a “must” without a reason.  Add to that, if you research the issue it turns out to be nonsense.  What else might one go on to mistrust?

There is also the issue of safety.  I read a query sent to an online help desk for arthritis sufferers.  The questioner said they were about to travel and how could they safely take their alendronate in places where they didn’t know if the tap water was safe to drink.  The reply was  to say tap water was safe in most European countries (the traveller didn’t say where in the world they were planning to go).  I didn’t keep a reference to that question and answer, but it has stuck in my head.  Go ahead, die of dysentery, but don’t take your pill for a long standing, possibly eventually disabling, ailment with bottled water.  Now that is a ridiculous piece of health advice.

 

 

Apologies for the references being such long links in the middle of the text.  I used Google Blogger for years and found shaping my links very easy but WordPress is defeating me for some unknown reason.  I’ll keep working on improving my knowledge and skill.

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BMD, fracture, Krege, Nature, prediction

numbers, numbers….and the mysteries of the invisibility of spinal fractures

The last post looked at the scores on the scans.  These show how my bones compare to other women’s bones, both young and fit, and the same age and fit.  If everyone had great bones and never got osteoporosis, someone would still be the worst.  They don’t tell you anything about what the risk of fracture is by themselves.  I’d like to know if my spine already has the small wedge fractures that lead to dowager’s hump, but I can’t tell that from anything in the current data.

The hip figures are used in an easy to use calculator called FRAX, which you can use at this link sitehttp://www.shef.ac.uk/FRAX/.  You do need to have your hip bone mineral density to work this out.  Based on my score I have a very low risk of fracture in the next ten years, even if I add in the chronic malabsorption caused by my problems with gluten (family history of coeliac disease, don’t know if I have it or one of the other gluten sensitivities).    Action for me would be some general lifestyle advice about eating well, reducing risk of falls by tidying the house, changing style of shoes etc.   With that as the sole bit of data I’d probably stop skiing (which I hardly do anymore) and try to be a bit less chaotic around the house. I already wear very sensible lace-up shoes and never wander around in my socks.

Malabsorption problems like coeliac disease are important in considering bone health.  If you don’t absorb nutrients properly, eating well and exercising properly in the bone building years to thirty will not be as effective in giving you long lasting strong bones.  I had a quick look at some current trials on osteoporosis drugs currently recruiting in the UK, and they all  excluded subjects with malabsorption issues.

So, if the spinal figures are so much worse for me, how likely am I to have a future spinal fracture?  Hard to say…the simple figure says high risk, and that is why I am taking the drugs and trying to learn to move in a way which protects my spine.  One thing that even a small amount of reading tells me is that these spinal fractures are strange and odd things.  I’ll write about what happens shortly, but for the moment a piece of research on the importance of spine imaging for identifying vertebral fracture and for identifying people at high risk for fracture makes an interesting point.

” Among 947 subjects with morphometric vertebral fracture, 66 reported a history of vertebral fracture by questionnaire and 881 did not. Thus, 93% of subjects with a morphometric vertebral fracture were unaware of the fracture. Additionally, among a total of 84 subjects with a history of clinical vertebral fracture by questionnaire, 66 (79%) were found to have a vertebral fracture by morphometric analysis of radiographs, whereas 18 (21%) were found not to have a vertebral fracture.”

http://www.nature.com/bonekeyreports/2013/130904/bonekey2013138/full/bonekey2013138.html

Fracture risk prediction: importance of age, BMD and spine fracture status

John H Krege, Xiaohai Wan, Brian C Lentle, Claudie Berger, Lisa Langsetmo, Jonathan D Adachi, Jerilynn C Prior, Alan Tenenhouse, Jacques P Brown, Nancy Kreiger, Wojciech P Olszynski, Robert G Josse, David Goltzman & on behalf of the CaMos Research Group)

What this shows is that people often don’t know if they have any spinal fractures.  That seems odd, but the individual bones in the spine are held in place by the other vertebrae, the ribs, other bits of tissue, and you can have a lot of fractures and still wander around getting on with life.  If you have ever seen those people, usually elderly women, who are out doing their shopping but walking along with a very bent back so they can only see the ground, they probably have spinal fractures that are visibly disabling but don’t prevent them from getting about.

I would like to know if I had spinal fractures already.  I’ve had years of back problems caused by my extremely pronating feet (flat feet) which I didn’t start correcting until my thirties, and I have used a programme of new prescription orthotics every year since then, combined with very controlling shoes (I found Ariat riding boots excellent, as the stiffness in place for the stirrups held my heel on the orthotics very well) and chiropractors and massage therapists helping to keep me aligned.  For the last six years or so it hasn’t mattered what podiatrist I have been to, I still can’t get rid of the neck pain, and the last two massage therapists I saw left me in pain for weeks.  Something has clearly changed.

It’s not a simple matter to know what state your spine is in.  You need access to complex imaging equipment, expert assessment of the images, and someone in the health system who decides you need to know.  It’s not like deciding to have a dental check up.  It is, of course, completely unnecessary to know if any of my spinal vertebrae are already showing compression fractures, but I’d like to see how the treatment and lifestyle choices I make now affect my spine over the next few decades.  A baseline measure would be good.

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Understanding the diagnosis

We asked the surgeon about a test for osteoporosis.  He said to ask the GP.  It looks as if, from the general reading I have done, that the bone team assume that bone density scans are initiated by GP’s and the GP’s assume that the bone team consider whether they are needed.  It is easy for a patient to slip through this assumption gap.

We asked for a scan. The GP agreed, and a couple of weeks later I was seen in a clean, calm, spacious room, and a week after that the GP had the results.  I have a vague recollection that the GP (who is really lovely and friendly), said she didn’t know what the numbers meant, but the single score prompts an osteoporosis drug and calcium and Vit D supplements if wanted (my scores on calcium and Vit D were fine but I always buy own – it seemed simpler to get the higher dose offered by prescription).

Got the pills, read all the data on the slip inside the packet, read around about side effects and effectiveness…more on that in another post.

 

We took a snapshot on a phone of the scores sent through by the DEXA people.   The hip scan shows that there is an increased risk of fracture (osteopenia) and the spine that there is a high risk of fracture (osteoporosis).  There are lots of numbers but you really only need to look for the summary at the bottom – WHO classification.

 

spine scan

hip scan

Of course, that is sufficient to decide to treat given the current guidelines, but I like to understand what is happening.  The first thing to bear in mind is that these scores are relative -they compare the amount of bone to a fit health thirty year old woman.  They tell you information about the likelihood of a fracture from a very minor fall, or, in the case of the spine, from normal activities like turning over in bed. These scores tell you how you differ from others, and I’ll write about the relative risks they indicate in another blog.

My sister sent me an excellent book called “Yoga for Osteoporosis” by Loren Fishman and Ellen Saltonstall.  The first few chapters of the book contain the best explanation of the statistical tools of Standard Deviation and T and Z scores that I’ve come across and I have three social science degrees and have spent a lot of time in statistics classes.  I’ll refer to this book several times- there’s a great section on how bones behave which I’ll write about later.

I was curious to understand the reports because I’m just generally curious, and the reading I did suggested that it was completely normal to be given a diagnosis of osteoporosis and a medical treatment without any form of explanation. Not surprising then that so many people stop taking the pills.  You get to find out about the side effects (they are described in every single packet of pills) even if you don’t experience them yourself, but you don’t know what is happening to your bones and what you might be able to do to help reduce the chances of disabling injuries. You also don’t get to know if you are improving your bones by the measures you take, unlike things like cholesterol lowering drugs where you can get almost immediate feedback on how effective you are being with lifestyle, diet and medication changes.

So, lets start with T scores.  Presuming the information in this source book (written in the USA) is the same as the UK, the T score tells you how many standard deviations your score is away from that of a healthy 25-30 year old woman.  So, that is how much you differ from someone in their prime.  The Z score tells you how many standard deviations you are away from healthy women of your age, height and weight.  We all lose bone mass from about thirty on- just some lose it a lot faster than others, and the menopause, with its change of hormone levels, makes the whole process speed up.  Men – you aren’t immune to this bone loss either, so don’t think you’re safe from fractures.  A positive score means you have denser bones than average, a negative score less dense.

So the next thing you need to know about is standard deviations – don’t worry, quick and simple explanation.  You need to know if almost everyone is about like you (say if you were an inch shorter than the average height) or if you are very different from the average ( your annual earnings if you are a top movie star).  One standard deviation around the mean includes 68.2% of people – so over two thirds of people will be in that group.  Two standard deviations include 95% of people. Only one percent of people are more than 2.5 standard deviation from the mean. If your bone density is over -2.5 standard deviations from the mean then you have osteoporosis – your bones are less dense than 99 percent of healthy young women.  Between -1 and -2.5 standard deviations from the mean indicates osteopenia – thinning bones but not yet at such a high risk of fracture.

So, peering carefully at my figures, I can see the Z and T scores for both the spine and hip.

Spine  T score    Z score

L1      -3.7            -2.8

L2      -3.0           -2

L3      -3.8           -2.8

L4     -3.9            -2.9

total  -3.6           -2.6

 

Hip

neck   -2.2        -1.2

total   -2.3        -1.7

The other numbers are the density readings the statistical comparison uses.  They would be meaningful to bone specialists.  I don’t need to know to figure out what the scans mean for me.

You’ll notice that the numbers in the second column are smaller than the numbers in the first column.  My bones are much less dense than those of young healthy women, and not quite so much worse than women of my age and build.  One of my lumbar vertebrae scored less than the minus 2.5 standard deviations worse than other women my age (yay!  Go lumbar vertebra 2!).  They average out to -2.6, which puts my lumbar spine in the osteoporotic range- only this area is scanned so I have no idea what the rest of my spine looks like. My lumbar vertebrae are less dense than about 99% of healthy women my age.

 

The hip bone is more dense- I score in the osteopenia range, where the bone has begun to thin and efforts should be made to reduce the onward thinning, but the risk of fracture is not so high. My hip bones are less dense than about 90% of healthy women my age and build.

 

So, why should I care what this means?  I got the pills- why not just take them and hope for the best?  Well, partly because the side effects listed are pretty gross.  Partly because compliance with the medication offered is so poor- so many people stop taking the drugs within the first two years when the risks will only get greater over the rest of their lives.  Partly because it looks as if  postural and exercise changes can make a significant difference, and partly because I’m just chronically nosy.

 

 

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Just a spoonful of sugar…

Read any list of the effects of osteoporosis – broken hips- only thirty percent of people fully recover and twenty percent die. Spinal fractures lead to a slow disintegration of the spine, compressing the torso and making it hard to breathe and eat, and making moving difficult as well as confining people to views of their feet, if you can see past your stomach which gets shoved out, and nothing much else.

I have found a wrist fracture has wiped out three months of my life, with some capacity returning as strength and grip return, though I still have very little flexibility. I also has a screw that sticks up on my wrist , with just a thin cover of skin over it. My first visit to a physiotherapist this week has led to an instruction to learn to love my wrist as it is – I was turning away to avoid looking at the angry purplish lumpy area as she worked it rather painfully- but I need to train all the new nerve endings to behave because at the moment they are reacting as if a tiger was in the room at the slightest touch. I failed to ask the surgeon if the screws were slot or Philips headed- and if I weren’t so reactive I’d be tempted to get a tattoo of a screw head.

So, wouldn’t people diagnosed with osteoporosis be glad there were drugs available to help prevent fractures, and take them assiduously for the rest of their lives if needed? Figures vary in different studies, but about half the people prescribed drugs for osteoporosis stop taking it- and they were giving up in the first year or two. So why would anyone skip a small weekly tablet (which is my prescription) when they might be reducing the impact of a disabling condition?

To start with, read the list of possible side effects. The ones that leap off the page are osteonecrosis of the jaw (rare, admittedly) and a weird seemingly spontaneous fracture of the femur. Add in a variety of digestive issues, ulceration of the oesophagus, diffuse joint pain and several other unpleasant things and the desire to take the medication definitely goes down. I thought this sentence from patient.co.uk was a pretty good indicator of the tone of the general information “A rare side-effect is osteonecrosis of the jaw. This occurs when the jaw bone does not receive enough blood, the bone starts to weaken and die. You must stop taking bisphosphonates if this happens.” It doesn’t explain how to tell this has begun to happen. Oh, and by the way, you can’t have dental implants while on the drug, so hope your teeth don’t fall out. Just as well I gave in and bought an electric flosser after weeks of trying to figure out how to floss my teeth one handed.

Next look at how to take the pills. Eat them first thing in the morning with a full glass of water (what size glass? Why can’t they tell you stuff like that- people are used to buying drinks in different size glasses) and then stay vertical for at least half an hour after this. The length of time to be vertical and foodless varied, with half an hour being the minimum. Don’t take it while still in bed. This is all to help you avoid that pesky oesophageal ulceration. Fine, can do that.

Then you just get four pills, one for each week. Tiny things really. Got to remember to get a repeat prescription every month. Got to remember to take them the same day each week. Are people better at once a day, once a week, once a month or once a year medication? One study I read said the yearly injection could be helpful for compliance but the problem was then that it was the doctors that would have to remember and would that work?

So I take the pills. Hope I don’t get the side effects. Can’t find any charts which show the interval after beginning the drug when the different side effects would be likely to occur if they did. I chose a day for the first pill when I had nothing else scheduled, just to add safety to the process. If I am fine for the first pill will I continue to be ok? If I make it past the first month will I be ok? The first year? No idea.

So now I’m taking these pills. Hoping I don’t get side effects. Hoping it is helping me reduce the bone loss. How can I tell if it is working? Lots of chronic conditions have drugs to help- pills for blood pressure, for arthritic inflammation etc. With all of those you get a programme of testing to make sure that the levels of medication are having the desire effect and are the right dosage. With the osteoporosis pills you are told it might help and that pretty much seems to be it. If there is a programme of monitoring bone density I don’t know about it. There also seems to be a urine test for bone breakdown products that I encountered in one paper, but it was suggesting that was complicated to administer and I didn’t find out anything else about it. It is normal human behaviour to be more dutiful when observed- just read up on any of the studies on hand washing after using the toilet. There are trial projects that show that having a specialist nurse explain your results and follow up a few weeks later (a few weeks!) increased compliance at this early stage.

And the people running the health services fret because compliance with the medication is poor!

Enough for today….wrist has worn out. Curiosity continues.

I have recorded the sources for the studies I have used in writing this blog, but haven’t done official references or any critical analysis of the research papers Please don’t regard this as a scientific report, it is just one curious person trying to figure out a way to manage to get maximum gain and minimum pain.

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Skeletons aren’t forever

I’ve started learning everything I can about osteoporosis, well, not the science but the living. What can I do to make my bones stronger? What can I do to reduce my risks? What are the risks? Why do so many people stop taking the drugs within a couple of year? There are lots of questions and it seems tricky to get all the answers, at least in an easy to understand and act on format. Where’s the local support group? Where’s the learning from others?

I’ve cancelled my Pilates class as the forward bending is bad…so that means I’m going to have more trouble with my pelvic floor not less, and now I learn that, before I sneeze, I need to support my back. So, I’m strolling down the street, with my handbag weighing less than 3lb and other weight of no more than 10lb evenly distributed, I feel a sneeze about to erupt, and I have to quickly and, hopefully discretely, cross my legs, brace my back, fumble for my handkerchief ( I should add I have a broken wrist, which is how the osteoporosis was discovered) and all before the sneeze happens. It seems that one of the main tools for living needed will be some form of slowing down time machine.

I’ve been trying to learn to move more magestically. I watched a bit of video of me and the grand-kid that had been filmed in slow motion. Got to do more of that but maybe not so slow- but need to give up the impetuous movements. I say to my friends when they marvel at some super-fast project I’ve completed that I only have two speeds, one and off. I’m going to have to learn steady.

If I learn stuff I like to share it, so here’s is the beginning of my offering to others in my position. As a side project I am writing this in WordPress rather than Blogger, so that I can learn about this too.

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