🎧 Friday Q&A: twice yearly Covid boosters?; top tips to prevent bone loss and osteoporosis

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Let’s try something new today! 🎉

We will stick with our regular Friday Q&As, but this time I’m answering your questions via audio AND you’ll get to hear the question right from your fellow community member - in their own voice.

Today’s subscriber questions:

• Why aren’t we all offered twice yearly Covid shots to protect us year-round?

• What are the best drugs and non-drug therapies to prevent bone loss and osteoporosis?

Today, these questions are available free for everyone so you can get a taste of what these future Q&As will be like. Starting next week, they’ll go back behind the paywall. Be sure to upgrade your subscription to continue to receive access!

Take a listen to the full questions and my responses in the audio below ☎️

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Prefer to read the Q&As? Transcripts are below!

QUESTION #1

Dr. McBride, my question is a fun COVID one. I know you don't get like any of those. As I sit here recovering from my second bout of COVID in a year, my question is why is the CDC or other relevant organizations not recommending that Americans get twice yearly booster shots in the spring, say, and in the fall? It seems that we simply cannot keep up with the evolving virus and its numerous mutations it would seem to me that this would be a much more effective way to prevent more Americans from contracting the virus. Thank you.

Okay. Great question. Why aren't we giving everyone a COVID shot every six months given the COVID is everywhere? Well, the short story is, I'm not sure it would make a difference in the outcomes that you're looking for, or put it more finely. I'm not sure that the benefits of giving everyone a COVID shot every six months would outweigh the downsides. You know, every public health decision we make and every individual medical decision we make has to make sense. It has to be that the benefits outweigh the downsides.

So if you think about why we give vaccinations in the first place against COVID, it's for two main reasons. First and foremost is to prevent people getting seriously ill from COVID enough that they need hospital care or supplemental oxygen. And we know that for most people at this point, having had COVID themselves and having had a number of shots, they have the accumulated immunity from the shots and getting COVID itself. And by the way, we do give mid-year boosters to patients at highest risk for serious outcomes. That is patients who are on oxygen, have lung disease, have underlying heart disease, who are on chemotherapy, have weakened immune systems and people who are elderly and frail.

But for all comers, the risk of going to the hospital from COVID is so low just for the general population. And those numbers are not increasing. Like sure cases rise every time there's a wave, but the share of hospitalizations isn't increasing. Meaning we have such accumulated immunity, the total immunity in the population, such that I don't think we're gonna get much more benefit from giving healthy people, young people a shot in the mid-year. Now, the other goal of the vaccine is to reduce the risk of infection from not getting sick at all. The problem is that ever since Delta, that variant landed on the planet in 2021, the vaccine no longer blocks transmission and it no longer blocks infection. In other words, you can get 10, 20 shots. You can get an IV drip of COVID shot and you can still get COVID. So when you're the CDC or another public health entity and it's expensive and administratively challenging and, you know, a pain in the neck to get vaccine doses into arms. And when people are getting COVID despite the shots, it doesn't really make sense to give people more shots as a public health recommendation.

And last, of course, it was meaningfully reducing the risk of hospitalization in the sickest and most frail category of patients, and in which case those people should get a mid-year shot. On an individual basis, it really depends on who you are as to whether you should get a second shot. But again, even my patients who qualify for a mid-year vaccine dose, I remind them that the vaccine isn't a panacea. It's not sterilizing. MMR is a sterilizing vaccine. COVID is not, it just takes the edge off. The best way to prevent serious outcomes from COVID is yes, to get vaccinated and boosted if you're at particularly high risk. But really it's on the patient, the individual to work on their underlying health conditions, to manage their diabetes, to manage their heart disease, to get exercise, to prioritize sleep, to manage their stress, to limit, if not discontinue alcohol, to quit smoking. Those are arguably the most meaningful health interventions to prevent serious outcomes of COVID-19 in this era.

The other thing I wanna recommend for people at higher risk is to have access to a doctor who can prescribe Paxlovid if needed and to make sure you're up to date with your other vaccines because a one-two punch from COVID and RSV, for example, can be really bad or from COVID and flu or any combination of viruses.

So the long story short is for all comers a twice a year COVID shot isn't evidence-based, isn't probably going to make a meaningful difference in hospitalizations in just all comers, but yes in high-risk patients and to try to reduce the risk of infection is a little bit of a fool's errand in this wildly contagious virus when you can get five shots a year, you can get 10 shots a year and you can still get COVID. I hope that makes sense and I hope you stay well.

QUESTION #2

Hi Lucy. I have fallen and I have broken both of my femurs in the past. I'm now looking at bone building protocols and there are many that I do not want to do. I would prefer doing alternative ways of building back my own bones. I do not have osteoporosis. I do have osteopenia in my left hip. In any event, can you recommend which bone building drugs are the best to use and what the alternative therapies are? I would really appreciate it. Thank you very much.

And thank you so much for this great question. I get it all the time from my own patients who are trying to reduce the risk for osteoporosis and falls and just generally optimize their bone health. I am so sorry to hear that you broke both of your femurs. That sounds exceedingly traumatic and I don't blame you one bit to want to do everything in your power to reduce the risk of that happening again. So people fracture for two main reasons. Number one, falls, accidents and two, osteoporosis. Osteoporosis puts people at higher risk for fractures. Osteoporosis is a thinning of the bones, and it is common in people who are older, and it's more common in women post-menopause. When women lose estrogen at their middle age, the bones tend to become more frail with time. But this is not an inevitability.

So let's talk next about how to prevent and treat osteoporosis and then falls on top of it. Osteoporosis is common, as I said, because of age and post-menopause. Those things you can't prevent, but you can do things to optimize your bone health in any phase of your life. So not smoking. Cigarette smoking puts people at higher risk for osteoporosis. Limiting, if not ceasing, alcohol consumption. Alcohol increases our risk for osteoporosis. Certain medications can increase our risk for osteoporosis, as can being underweight and having low muscle mass and low muscle tone. Those are a few things you can work on.

You can also work on your diet. So getting calcium and vitamin D in your diet is essential. It depends on who you are as to what goal of calcium you should have per day. For my post-menopausal women, I recommend getting 1,000 to 1,200 milligrams of calcium per day diet, not through supplements. I also recommend making sure your vitamin D level in your blood is optimized, whether or not you need a supplement is up to you and your doctor. We treat osteoporosis with pharmacology with prescription medications when and if people have osteoporosis and or they're increased risk for fractures for some other reason. Maybe they have osteopenia and a high FRAX score, which is a calculated risk of fractures. So either you broke your femurs because you have osteopenia and a high frac score or your bone density was falsely low and you actually do have osteoporosis or you just fell and had a bad trauma and you would have broken your bone for any reason because it was such a big bad fall.

Let's talk about pharmacology versus lifestyle in order to manage osteoporosis and fall risk. So usually I recommend a combination of things for patients. You should talk to your own doctor for specific recommendations. But in general, as a matter of course, I recommend to my patients who are post-menopausal, women at risk for osteoporosis or have osteoporosis to get 1,000 to 1,200 milligrams of calcium per day through diet, to check their vitamin D level at their checkup, make sure it's optimized and supplement as needed with vitamin D, and to get weight-bearing exercise. That is exercise that strengthens your muscles, which then helps bone density, 20 minutes, three times a week. That can be with Pilates, with yoga, lifting weights, wearing a weighted vest. Those are some of the examples of how to get weight-bearing exercise. The common medication to treat osteoporosis is Fosamex Boniva Actinel. Those are the bisphosphonates. These medications work by inhibiting the activity of cells called osteoclasts that break down bone. And they lead to a net increase in bone density. They're usually taken by mouth once a week or once a month. And the downsides can be gastrointestinal side effects and rarely pathologic fractures of the thigh bone, which is something you've already had, and jaw problems. Those are uncommon, but they are definitely real risks. The other common medication we use for osteoporosis is a medication called Prolia. It's a monoclonal antibody, and it's basically a chemical that blocks a protein receptor involved in the formation and activation of osteoclasts, those cells that break down bone. It is a shot that's given under the skin every six months, usually by a nurse. It can have side effects as well, like back pain, muscle aches, bladder infections, and there are rare occasions where people have developed serious infections and a slight increased risk for certain types of fractures. So as with any medical intervention, there are always risks and there are always benefits. And the way you should treat your bone density is nuanced and of course should be with your doctor.

I'll just say this though, and if you have osteopenia and not osteoporosis, and the fractures you had were not thought to be because of the bone density loss, but they were because of the impact of the accident itself or the fracture, you know, the fall, then you may not need to be on medication at all. And of course, that's your choice. Certainly patients who optimize their calcium intake through diet, optimize their vitamin D through a supplement or not, who get regular weight-bearing exercise, and then who work on fall prevention by working on their balance, their coordination, their muscle tone, and their vision can do beautifully. In other words, if you don't fall because you have such good balance and muscle tone in your legs and your vision is optimized, you may not fracture again. People don't often fracture without an impact. So if you don't have an impact, you're not gonna fracture, which is why I stress the importance of balance and coordination exercises over pharmacology in many cases.

So it's a long way of saying that like with most medical conditions, osteoporosis is one where I recommend prevention through lifestyle and through pharmacology as needed. I hope that's helpful. I wish you all the best.