Medical Report 5-8-12

Yesterday morning  (5/7) I saw Dr Anca Goller, an endocrinologist recommended by my GP.  The GP had put me on Calcium Citrate with Vitamin D and an extra dose of straight Vitamin D, but said a specialist should look into why I have such mushy bones.  Dr Goller went to medical school in Romania and did her residency at UMass Medical in Worcester.  One decision was whether to keep the appointment with Dr Goller, as Bridget (our doctor daughter-in-law) had set up an appointment with an endocrinologist at Beth Israel who is very respected.  I chose to keep the appointment so that we could start the tests that might reveal the underlying cause of my osteoporosis.  I told Dr Goller that I have an appointment in two weeks to see Dr Harold Rosen at Beth Israel.  Small world: she did a rotation while at UMass Medical at Beth Israel and had worked with Dr Rosen.

Dr Goller did a very thorough inventory of symptoms, conditions, history, etc.  She set out a series of blood tests that will indicate whether any of the most likely causes are in play.  She also prescribed a 24-hour urine collection regimen so that they can tell how much calcium my body is getting rid of.  There is another series of tests that they use to monitor how well any course of action is working.  She would normally have had me do that, but she knew that the tests available at Beth Israel are better than the tests available at Emerson, so she felt it was better to have Dr Rosen prescribe those.

Barbie had found a 2007 study on the internet that looked for a connection between Coumadin and osteoporosis.  It is logical that there might be a connection because vitamin K is crucial in blood clotting, and Coumadin works by interfering with vitamin K’s role in clot formation.  Similarly, vitamin K is key in bone building.  If vitamin K’s role is compromised, bone formation might also be affected.  The St Louis University study examined the medical records of 15,000 people who had been on Coumadin for more than a year.  The vast majority were women, and there was no correlation.  However, in the male subset, there was a 63% increase in bone fracture.  We asked Dr Goller about the study, and I can’t remember what she said.

Dr Goller set out a 5-point plan of attack:

1.       Blood diagnostic work.

2.       Urine collection + analysis

3.       Weight bearing exercise.  Walk.  No high impact or vibration, heavy lifting, ladders, etc.

4.       Calcium and Vitamin D.  Protein helps.

5.       Avoid falling.  Use a shower that has grab bars or a seat, so that you are not in danger of slipping on a wet surface.  Clean up things on the floor that can interfere with placement of the canes I walk with.  Turn on lights when getting up in the middle of the night for a bathroom run.

After seeing Dr Goller, I picked up the images from my bone density scan, as Dr Rosen had requested them.

That afternoon I saw Dr David Green, the pulmonologist who treated my 2 pulmonary emboli and who put me on Coumadin.  He reviewed the printout of the St Louis study, but I couldn’t tell if he had already seen it and whether it affected his opinion about prescribing it.  He had access to the medical records.  My first embolism was in 1998 and the second was in 2004.  Both occurred right after long plane flights during which I did not move about much.  Various blood tests were done in 2004 to determine if there were any cause other than inactivity during a long flight to suspect.  There were none.  So we concluded that medicating specifically for plane flights makes sense.  That can be done with an injection of Lovanox.  In fact, immediately after my hip surgery in December, 2010, I recall getting Lovanox in the stomach.  I believe I came home with a few syringes of Lovanox, and I self-administered some of the doses.  So in the future I am to inject Lovanox 1 hour before any long plane flight, wear compression socks, and move about on a regular basis.  Given all that, I can come off Coumadin!

There is an alternative to Coumadin that is available now.  I did not get the name.  It operates in a completely different way than Coumadin, and the dosage is very standard.  You just take a pill; there is no need for continual monitoring, as there is with Coumadin.  However, unlike Coumadin, there is nothing that can reverse the anti-clotting effects of the drug.  So, should you have an incident, such as a car accident, where you are bleeding profusely, there is nothing they can do to enhance your ability to clot.  They are working on drugs to reverse it, but none is available yet.  So Dr Green does not choose to prescribe it yet.  I had the feeling that if there were a way to reverse it, that Dr Green would have put me on that.  I am happier taking Lovanox only when flying, as presumably there are fewer side effects (assuming I am not gallivanting all over the globe).

Today I got all the way to Emerson Hospital to do the blood tests, when I realized I had left the list of tests Dr Goller gave me at home.  Mistakes still happen.