Episode Overview

Podcast: Run the List
Episode: Osteoporosis
Host: Walker Redd
Guest: Dr. Brooke Madsen, Endocrinologist
Date: June 30, 2025

This high-yield episode focuses on osteoporosis, one of the most common and important disorders in internal medicine. The discussion centers on practical approaches to screening, diagnosis, risk assessment, treatment decisions, and patient counseling. Special emphasis is given to interpreting DEXA scan results, using the FRAX calculator, nuances of osteoporosis treatment, and strategies for prevention, including lifestyle modification.

Key Discussion Points & Insights

1. Screening: Who and When?

(02:06)

• USPSTF Recommendation:

  • All women age 65 or older should be screened for osteoporosis with a DEXA scan.
  • Screen earlier if additional risk factors are present.

  "I typically think of 65 as being the time where we start screening people."
  — Dr. Brooke Madsen [02:20]

2. Interpreting DEXA Results & Diagnosing Osteoporosis

(02:40)

• Sites Measured:

  • Lumbar spine (L1-L4)
  • Hip (total hip and femoral neck)

• Scores:

  • T Score: Standard deviations from the mean of a 30-year-old woman
    • Osteopenia: T score -1.0 to -2.4
    • Osteoporosis: T score ≤ -2.5
  • Fragility Fracture: Diagnosis of osteoporosis can also be made if a patient sustains a low-trauma (fragility) fracture, regardless of T score.

  "A T score of -2.6, for example, and below that would be diagnostic of osteoporosis. Or you can throw all the T scores out the window and diagnose someone with osteoporosis if they've had a fragility fracture..."
  — Dr. Brooke Madsen [03:30]

• Practical Patient Conversations:

  • Show the images to the patient.
  • Explain the meaning and context of the comparisons.

3. FRAX Calculator: Risk Assessment

(05:36)

• Purpose:

  • Estimates the 10-year risk of major osteoporotic and hip fractures.

• Factors Included:

  • Age, prior fractures, parental hip fracture, tobacco/alcohol use, glucocorticoid use, chronic illnesses (e.g., diabetes, thyroid disease), lifetime estrogen exposure, height loss (possible occult compression fractures).

  "By going through these questions [in the FRAX calculator], you're also getting a lot of the history that you need to sort of assess someone's risk for fracture."
  — Dr. Brooke Madsen [06:21]

• Threshold for Treatment:

  • 10-year risk ≥20% for major fracture typically indicates treatment is warranted.

4. Therapy: Decision-Making and Medication Choices

(08:00–09:41)

• High Fracture Risk:

  • Anabolic Agents: (bone-building)
    • Teriparatide, Abaloparatide (daily injections for up to 2 years)
    • Romosozumab (monthly injection for 12 months)
  • Always follow with an antiresorptive agent after anabolic therapy.

  "The most important thing to remember is that all of these medications... need to be followed by antiresorptive therapy..."
  — Dr. Brooke Madsen [09:05]

• Lower Fracture Risk:

  • Antiresorptive Therapy:
    • Oral bisphosphonates (e.g., alendronate)
    • IV bisphosphonates (e.g., zoledronic acid/Reclast)
    • Denosumab (Prolia) – must also be followed by bisphosphonates to prevent rebound vertebral fractures

  "You just can't stop Prolia cold turkey. You always have to follow this with a bisphosphonate to consolidate that therapy."
  — Dr. Brooke Madsen [10:20]

• Patient Preferences:

  • Route of administration is important—work with the patient's preference.

5. Medication Side Effects

(10:28)

• Rare but much-discussed:

  • Osteonecrosis of the jaw
  • Atypical femur fractures

• Emphasize rarity and reassure patients.

  "These are side effects that many of these drugs carry, but they are very rare."
  — Dr. Brooke Madsen [10:46]

6. Monitoring and “Drug Holidays”

(11:14)

• DEXA Monitoring: Every 2 years, or longer if not needed to change management.

• Ultimate Goal: Prevent fractures—not just improve T scores.

• Therapy Duration: Strive for a break (“holiday”) from medication to minimize cumulative rare side effects.

  "No one's on these medications indefinitely, forever. So we're always trying to get to a break."
  — Dr. Brooke Madsen [12:00]

7. Lifestyle and Prevention

(12:41)

• Calcium:

  • 1200 mg/day recommended (diet preferred; supplement if needed)
  • Online calcium calculators can help estimate dietary intake.

• Vitamin D:

  • Target range: 30–50 ng/mL

• Fall Prevention:

  • Remove home hazards, minimize high-risk medications

• Exercise:

  • Weight-bearing and strength training are crucial (not just walking)
  • Online resources for resistance training (e.g., YouTube channel by PT Margaret Martin)

  "Many people, when asked, they'll say, 'Oh, I walk five miles a day.' That's great ... but it's really important that people are doing strength training and weightlifting as well."
  — Dr. Brooke Madsen [13:32]

Notable Quotes & Memorable Moments

• On Osteoporosis Diagnosis:

  "Or you can throw all the T scores out the window and diagnose someone with osteoporosis if they've had a fragility fracture..."
  — Dr. Brooke Madsen [03:45]

• On Shared Decision-Making:

  "Many times patients have strong preferences about what route of administration they'd like to receive their medication. So that helps us decide together too how to move forward with treatment."
  — Dr. Brooke Madsen [08:26]

• Medication Transition Pearl:

  "You just can't stop Prolia cold turkey. You always have to follow this with a bisphosphonate..."
  — Dr. Brooke Madsen [10:20]

• Ultimate Treatment Goal:

  "As long as we're not fracturing, that is the ultimate goal and generally we're doing okay."
  — Dr. Brooke Madsen [11:33]

• Reassurance on Medication Risks:

  "...They are very rare side effects and they're unlikely to experience."
  — Dr. Brooke Madsen [10:50]

Important Timestamps

| Timestamp | Segment | |---------------|-------------------------------------------------------| | 02:06 | Screening recommendations & risk factors | | 02:40 | DEXA interpretation and T score explanation | | 04:14 | Practical approach to reviewing results with patients | | 05:36 | FRAX calculator: use, questions, and implications | | 07:10 | FRAX result: Threshold for initiating treatment | | 08:00 | Treatment overview: high-risk and low-risk options | | 10:28 | Rare side effects of medications | | 11:14 | Monitoring and medication holiday | | 12:41 | Lifestyle modification and patient resources | | 14:20 | Three key take-home points |

Top Three Takeaways

(14:20)

1. Risk Assessment:
   • Use the FRAX calculator in treatment-naïve patients to estimate 10-year fracture risk and inform treatment decisions, especially if T scores are in the osteopenia range.
2. Specialist Input:
   • Endocrinologists can assist with evaluation for secondary causes of osteoporosis and consideration of anabolic agents not typically used in primary care.
3. Fall Prevention:
   • Fracture prevention requires attention to fall prevention measures, particularly resistance and strength training for balance and bone health.

This episode offers a practical, patient-centered framework for approaching osteoporosis in primary care and beyond, blending up-to-date clinical evidence with real-world strategies for patient engagement and shared decision-making.