Ask the Expert: Dr. Rachel Pessah-Pollack, MD

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Dr. Rachel Pessah-Pollack, MD, is an endocrinologist and Clinical Associate Professor at NYU Langone Health, a bone health expert. She is Vice Chair of the International Society for Clinical Densitometry’s Annual Meeting and recently completed 6 years on the Board of Directors for the American Association of Clinical Endocrinologists (AACE). As part of her role at AACE, she co-authored the association’s clinical practice guidelines for osteoporosis.

Disclaimer: If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Well Guide contain information from peer-reviewed research, medical societies and governmental agencies; however, these articles are not a substitute for professional medical advice, diagnosis, or treatment.

1. Tell us about yourself and what led you to your work as an endocrinologist?

I first became interested in endocrinology during my residency when a close family member was diagnosed with thyroid cancer. I remember the close relationship she had with her endocrinologist after surgery and the very treatable nature of her disease. It seemed to me to be such an optimistic field to be caring for patients and having a long-term relationship. During my internal medicine and fellowship training at Mount Sinai one of my mentors, bone expert Dr. Donald Bergman, would have weekly “Bones and Breakfast rounds” where I immersed myself in the subject of osteoporosis. He was very involved in the American Association of Clinical Endocrinologists (AACE), and encouraged me to become involved nationally. I was a co-author on the 2016 AACE Postmenopausal Osteoporosis Guidelines, collaborating with experts nationally in osteoporosis, which we updated in 2020. I enjoy caring for patients with bone disease because our goal together is preventing fractures (and living long healthy lives!). 

2. How does menopause affect bone health?

Menopause (and perimenopause) are times associated with a lack of estrogen and we know there is a relationship between this loss of estrogen and the development of bone loss. Early menopause, and any other prolonged times during life where menstrual periods are absent, can contribute to bone loss. I always ask my patients about their history of periods during their adult life. If they have had prolonged times of missing menstrual cycles, this can be a sign that they may have low bone mass prior to menopause and this bone loss can be accelerated during menopause.

3. What advice would you give patients who have recently been diagnosed with osteoporosis and are hesitant to take medication for it?

With my patients with osteoporosis I try to help them understand the diagnosis of osteoporosis and the importance of bone treatment first, and then we discuss the details of the side effects (and, of course, the benefits). 

Osteoporosis is often called a “silent bone disease” because, initially, bone loss can occur without any symptoms. A T-score of -2.5 or lower on a bone density scan is considered osteoporosis. For many patients that receive this diagnosis, it can be hard to understand as they may not “feel” anything and because of this are reluctant to take medication for prevention. I find the best way to help these patients who may be hesitant is to go through the most likely side effects (reflux) of the medications and then the rare side effects (these are the ones that get the most attention in the news and in social media and are very rare), reviewing the actual data. And of course the big picture, a hip fracture can significantly affect quality of life and can be preventable with osteoporosis treatment.

I also have patients who come to me with fragility fractures, broken bones that occur after minimal trauma. These patients are the ones that, regardless of their bone density scan results, can be diagnosed with osteoporosis and are very high risk for future fractures. The role of treatment is to prevent their next fracture. In women who have had previous fractures, data shows that these women are much more likely to fracture again, particularly in that first year after a fracture making this a special window to initiate treatment. 

World Health Organization Criteria for Classification of Osteopenia and Osteoporosis

4. Should everyone with osteoporosis take medication to manage it?

There are a lot of factors that go into determining if treatment with medication is needed for osteoporosis. It is important to see a physician for evaluation to look for “secondary causes” of bone loss - these are underlying causes that if treated can actually help the bones improve. For example, we know that in patients that have a high calcium level due to parathyroid issues, if there is surgical treatment the bones actually improve. Another cause of bone loss can be undiagnosed celiac disease and in this case, the bone density significantly improves on a gluten free diet.  

If no underlying etiology of osteoporosis is diagnosed, there is an increased risk for fracture and a medication is indicated to reduce the risk for fracture. In our AACE 2020 Guidelines, we strongly recommended medication for patients with:

  1. Those with a T-score between − 1.0 and − 2.5 in the spine, femoral neck, total hip, or 1/3 radius and a history of fragility fracture of the hip or spine  
  2. Those with a T-score of − 2.5 or lower in the spine, femoral neck, total hip, or 1/3 radius 
  3. Those with a T-score between − 1.0 and − 2.5 in the spine, femoral neck, total hip, or 1/3 radius and  FRAX®  10-year probability for major osteoporotic fracture is ≥ 20% or the 10-year probability of hip fracture is ≥ 3% (in the U.S.)  

5. How effective are medications at preventing further bone loss and/or fractures?

Medications are very effective at reducing further bone loss, improving bone mineral density, and preventing fractures. The chance of reducing your fracture risk can vary between 50-70% or higher depending on the site (whether it’s the spine or hip or another bone in the body) and depending on which medication is chosen.

The most commonly used medications are bisphosphonates which work to reduce fractures in the spine, hip and outside the spine.  These are often used as a first line treatment for patients initially who are designated “high fracture risk” (eg no prior fractures, moderately low T-scores on bone density). It is also possible to consider some of our injectable treatments if there are contraindications to oral bisphosphonates. 

For our “very high fracture risk” patients we recommend stronger initial treatment. For example, if you have had multiple vertebral fractures or hip fractures or very low T-scores we may recommend taking an injectable bisphophonate or denosumab or a bone building anabolic agent. Anabolic medications must be followed by another medication and cannot be stopped suddenly. These medications are highly effective at fracture reduction and the choice of initial treatment depends on your DXA scan T-score, prior fracture history and risk factors for future fractures.   

6. What do you tell people who are concerned about medication side effects?

The main side effects of bisphosphonate pills are typically reflux and stomach upset. I encourage my patients to stay upright 30-60 min to try to prevent these symptoms and take the medication with a large glass of water on empty stomach. The intravenous bisphosphonates are better tolerated from a stomach perspective but can have mild flu-like symptoms typically after the first infusion. Sometimes taking acetaminophen before and after the infusion can help these symptoms. Many patients prefer this small potential for side effects with the yearly infusion since they do not need to remember to take it again for another year, and sometimes it has an even longer effect.

A very rare complication of bone treatment agents (bisphosphonates, denosumab, romosozumab) is a break or crack in the middle of the thigh bone. This injury, known as atypical femoral fracture (AFF), can cause pain in the thigh or groin that begins subtly and may gradually worsen.  Some of the bone medications can also cause osteonecrosis of the jaw (ONJ), a rare condition in which a section of jawbone is slow to heal or fails to heal, typically after a tooth is pulled or other invasive dental work. This occurs more commonly in people with cancer that involves the bone. These people take much larger doses of a bisphosphonate than those typically used for osteoporosis.

It appears that the risk for AFF and ONJ increases the longer you take these bone medications so we often recommend a drug holiday from bisphosphonates (drug holidays are not possible from the other bone medications). Because of the prolonged benefits after discontinuing bisphosphonates, it is reasonable to consider a “holiday” from bisphosphonates after extended treatment. 

Importantly while a drug holiday does exist after bisphosphonates, there is no “drug holiday” after denosumab or anabolic agents. What this means is it is very important to transition to a bisphosphonate after these medications and not stop it suddenly. We have lots of studies showing that if you stop denosumab suddenly you can not only lose all of your bone density gains but can be at risk for numerous spine compression fractures. During Covid, patients missed doses of denosumab and vertebral fractures occurred. If you have any issues getting your scheduled dose of denosumab, contact your physician to switch you to a bisphophonate.

The medications for osteoporosis are very effective, safe, and have been studied thoroughly in trials. Hopefully with this knowledge, patients feel more comfortable treating their osteoporosis.

 7. Do you encourage people to make lifestyle changes even when they take medication for their osteoporosis?

I always tell my patients there is value in lifestyle changes for osteoporosis.  Light weight-bearing exercises can be important and improve BMD as can ensuring adequate daily calcium and vitamin D intake. For patients with balance issues, I encourage them to engage in physical therapy.

8. If someone has been diagnosed with osteopenia, should they start medication to prevent a diagnosis of osteoporosis?

There are different factors we take into account with an osteopenia diagnosis. For example, are they also on a high risk medication for bone loss that will accelerate the osteopenia to osteoporosis if untreated? (eg, Certain breast cancer medications, long term steroid use.) On the bone density scan which shows osteopenia, we calculate out the risk for breaking a bone over 10 years. If the risk of a hip fracture is more than or equal to 3% over the next 10 years and/or risk of any major fracture is greater than or equal to 20% over the next 10 years, bone treatment is recommended. The FRAX score takes into account numerous risk factors including age, gender, weight, tobacco use, prior fractures, parent with fractured hip, and additional risk factors. Of course even if the DXA shows osteopenia and there is a history of osteoporotic fractures, treatment is recommended regardless of the bone mineral density. 

9. What advice would you give women who have not been diagnosed with osteopenia or osteoporosis but are aware of it as they enter menopause?

Osteoporosis is a disease that is treatable and preventable but only a small proportion of people at risk for fractures get this evaluation and treatment. It is very important to be screened by your physician to see your risk for osteoporosis and determine if you should have a bone density scan and/or see a specialist. I recommend to my patients 50 years old or above to have adequate daily calcium intake (1200 mg diet and supplement combined), normal vitamin D stores, and do light weight-bearing exercises. 

Finally, osteoporosis is treatable and it is important for women to seek out these treatments with a good understanding of the benefits, and personalized treatment to their individual situation and history.

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