Osteo Update

Published 10.21.2016
Today I saw my osteoporosis specialist. It was just the annual check up, she'd ordered a few blood tests and a urine test. All tests were normal according to the doctor, and as nothing in medical condition has changed over the past year, there was very little to discuss.

Except that is, until I asked specifically about my vitamin D level, which was measured at 54 ng/ml which corresponds to 135 nmol/iter. My target vitamin D level, as I've written previously, was 46 ng/ml, which means I overshot a bit. The doctor told me to back off the 4000 IUs dosage I've been taking because now that, "I'm replete" with vitamin D, there's no point in having excess.

I asked if excess vitamin D could be a problem, and her answer was yes, vitamin D increases the absorption of calcium (Ca), which can cause problems such as kidney stones. However, since I'm not taking Ca supplements, she allowed that that was less of a risk for me. I didn't say that I wouldn't cut back, but I did note that my fingernails are much stronger on the higher dose, and if I notice that they soften on a lower dose I'll jump it back up. Too much vitamin D can cause other problems as well, but I'm not taking anywhere near the amount of vitamin D that would cause toxicity.

What I'm actually thinking of doing is taking 4000 IUs every other day, with 2000 IUs on the other days. So an alternating pattern. This will lower my weekly intake 3000 of 4000 IUs. Basically, my average daily intake will drop to 3000 IUs. Then if my fingernails remain strong, I'll drop back to 2000 IUs a day, and see what happens then. It could well be that having established a level, 2000 IUs will be plenty to maintain that level. It's also possible that sticking with 2000 IUs would have yielded the same nail improvement, just over a longer time period. Please note: I am not any kind of medical professional. Absolutely nothing you read on this site should be considered any form of medical or nutritional advice.

As for my intake of Ca, she had no problem with my getting it from diet once I demonstrated that I know which foods contain it and I pay attention to the amount I'm getting. I don't track per se, but as with calories, I spent the time to educate myself as to the portion sizes required of various foods to reach the overall total desired. I never did write up my Ca-based diet, but the shorthand version is Beans, Greens, Seeds, Nuts and Cheese— pretty much in that order. If I get to the end of the day and I haven't had enough Ca, I'll eat a bit of cheese.

My blood Ca levels remained constant, but the doctor said that's not reflective of diet. The body manages blood Ca levels very tightly, and takes what it needs from the bones if enough isn't ingested. If serum Ca levels are off, then she'd have to go looking for a medical reason as to why they are. Mine aren't, so the discussion ended there. Her point, though, was that serum Ca levels do not reflect a diet adequate in calcium content.

A New Rabbit Hole

Everything else she measured remained that same, except for my level of alkaline phosphatase bone isoenzyme (abbreviated ALK PHOS BONE on the results sheet). We didn't discuss this particular result because I didn't know to ask about it. I only know that the level changed (it increased) because I always ask for a copy of my blood test results when I check out. When I got home I compared this year's test results to last year's and noticed the difference. Thus did alkaline phosphatase bone Isoenzyme become today's rabbit hole to disappear down instead of working on the other projects I have for this and other sites. An initial Google search yielded seemingly positive results:

Alkaline phosphatase (ALP) is an enzyme naturally present throughout your body. It comes in many variations called isoenzymes. Each isoenzyme of ALP is different, depending on where in your body it’s made.

Your bones make an isoenzyme called ALP-2. Levels of this enzyme increase when bones are growing or bone cells are active.

That to my non-medical practitioner eyes seems like precisely the result one would want to see: evidence that my bone making cells are well, making bones— or are at least active. I don't really know that site above, but here's what the Mayo Clinic says:

Bone alkaline phosphatase (BAP) is the bone-specific isoform of alkaline phosphatase. A glycoprotein that is found on the surface of osteoblasts, BAP reflects the biosynthetic activity of these bone-forming cells. BAP has been shown to be a sensitive and reliable indicator of bone metabolism.

Bone is not stagnant, it's constantly being made and then resorbed into the body. The alendronate (generic Fosamax) that I took for almost five years (and have been off now for 1.5 years) blocks the body's means of resorbing bone, but it doesn't increase the body's ability to make new bone.

Newer drugs, such as Forteo, act on both sides of the equation— meaning it increases the rate of bone creation and slows resorption. However, Forteo has to be injected daily. Forteo costs $3100 (retail) for a 4 week supply (28 doses) or about $111 per shot. In 2010, the price per shot was $947.20. In 2016, Forteo's wholesale price was 2551.77. Because of the price, insurers don’t like to pay for it, preferring Fosamax, which costs pennies a day. Researchers have also found that Forteo increases risk of bone cancer for rats. I’m not a rat, but I don’t like needles. That's why I'm trying to do as much as I can to maintain the bone that I have without drugs. In any event, based on the New York Times article, I'm not a candidate for the drug yet in any case.

However, the Mayo Clinic also says that if BAP is too high, that indicates that bone turnover is too fast. In fact, BAP is expected to decrease by 25% when patients are treated to block resorption— as I was. So maybe all I'm seeing is my levels returning to the pre-alendronate status. I don't know what my level was pre-treatment because I was diagnosed based on a bone mineral density (BMD) scan, nothing more. I also don't know what my BAP level was after being on the alendronate because I was off it for six months before I saw the specialist. She wasn't happy about that because she would have liked to see that data point, but it is what it is. Speaking of BMD scans, I didn't have one this year, but will have one next July, along with another set of blood tests.

My alkaline phosphatase bone isoenzyme in both tests are in the lower end of the normal range, which for post-menopausal women is listed as 14.2 - 42.7 mcg/L (microgram per liter). Two points aren't enough data to make any determination whatever, of course, but absent any new negative information I come across, I think this is a positive trend. I want my osteoblasts to be making more bone! Of course, if they are making more bone because my osteoclasts are working overtime to resorb my bones, that wouldn't be optimal.

Per this site, the urine sample is where evidence of bone resorption rate would be. I didn't get the urine results for some reason, only the blood results. I did ask the doctor about the urine test, and she said it was normal. But I have no way to compare last year's numbers to this. I suppose I could go back and ask for the urine numbers. Now that I know what's in them, I think I might. Though it doesn't look like I have last year's urine results either. Hmm…

Bottom Line

Except for telling me to back off the vitamin D, the doctor was pleased with the blood tests and the lifestyle changes that I've made. I really, really, really don't want to lose any more bone— and I really, really, really don't want to have to go back on alendronate or any other drug. She noted again that I am short and petite, and so the T-scores might not be the best benchmark for me. Rather, it will be more important to see how the numbers trend over time.


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