Osteoporosis: The Silent Bone Thief
Online Health Chat with Chad Deal, MD and Lynn Pattimakiel, MD
Web Chat Description
Osteoporosis is a common, preventable and treatable form of metabolic bone disease. Fifty seven million Americans—mostly women—are affected by osteoporosis and low bone mass. According to the National Osteoporosis Foundation, ‘a woman’s risk of breaking a hip due to osteoporosis is equal to her risk of breast, ovarian and uterine cancer combined.’ Additionally, ‘a man age 50 or older is more likely to break a bone due to osteoporosis than he is to get prostate cancer.’ Early identification and treatment of low bone density is most effective in increasing bone mass and avoiding painful fractures.
Osteoporosis, the ‘silent thief of bone,’ can be prevented, detected and treated. Although there are uncontrollable risk factors, such as age and being a woman, there are ways to improve bone health. While various medications can treat osteoporosis, early detection of low bone density and prevention strategies that focus on balance and falls, vitamin D intake and the amount of calcium in your diet are the most important measures to ensure bone health.
About the Speakers
Chad Deal, MD, director of Cleveland Clinic’s Center for Osteoporosis and Metabolic Bone Diseases, is a board-certified rheumatologist. He has specialty interests in osteoporosis and related conditions. Dr. Deal completed a fellowship in arthritis and connective tissue diseases at Boston University School of Medicine after completing his residency and internship at Boston City Hospital, in Boston. He is a graduate of University of Arkansas for Medical Sciences College of Medicine, Little Rock, Ark.
Lynn Pattimakiel, MD is a clinical associate in the Department of Internal Medicine at Cleveland Clinic, and practices in the Center for Specialized Women’s Health. Her clinical interests are women's health, osteoporosis, menstrual disorders and menopause. Dr. Pattimakiel completed her fellowship in women’s health at Cleveland Clinic after completing her residency in internal medicine at St. Vincent Charity Hospital, in Cleveland. Dr. Pattimakiel earned her medical degree from the Medical University of Debrecen, in Debrecen, Hungary.
Let’s Chat About Osteoporosis: The Silent Bone Thief
Osteoporosis and Osteopenia Diagnoses
trudy: As a woman, what age should I be concerned about osteoporosis?
Lynn Pattimakiel, MD: As women, we should start thinking about our bone health at a very early age. We continue to build bone up until the age of 30 years old, so it is during these years it is very important to get an adequate amount of calcium and vitamin D to help increase our peak bone mass. After 30 years old, there is a gradual loss of bone, and this accelerates at the time of menopause (at an average age of 51 years old). Therefore it is very important that we monitor the strength of the bones in postmenopausal women.
wade: Can men get osteoporosis, too?
Lynn Pattimakiel, MD: Men are also at increased risk for developing osteoporosis as they get older, or if they are on medications that may decrease their bone strength. They should be monitored as well.
Mark911: I am 62 years old. I work out regularly for about one and one half hours at least every other day. Half of the time is spent on cardiovascular exercise, the other half is strength training to maintain strength as I age. I have not been tested for osteoporosis. However, recently I have heard unusually loud cracking noises particularly in my shoulders. The left shoulder is also quite painful and cracks the loudest by far. After cracking, the pain seems to be reduced by maybe 40 percent. The pain seemed to start after I had increased the weight used on my left arm in my workout, and has continued for over two months. It does not seem to be getting any worse. It is particularly intense when I first wake in the morning. It is much less intense during my workout. Can this combination of cracking noises and pain suggest bone weakening?
Lynn Pattimakiel, MD: It is great that you are leading such a healthy and active lifestyle. The weight-bearing exercises are definitely going to be beneficial in improving and maintaining the strength of your bones. The cracking sounds and pain that you are experiencing are most likely not due to bone thinning or osteoporosis. It may be related to arthritis or inflammation of the joint or tendon. Discuss with your health care provider if you have any risk factors or are on any medications that may increase your risk for osteoporosis. Otherwise, you should consider getting a bone density test at the age of 70 years old.
laura628: I am a 68-year-old old female. I was diagnosed with osteopenia about 10 years ago. I was on generic alendronic acid for several years, but it gave me joint pain in the hip area, so my doctor took me off that medication. I take vitamin D, calcium and magnesium every day. I also eat and drink dairy products daily. I am active, and enjoy walking and bike riding. I have a small build, and I am hoping that my lifestyle will help prevent my osteopenia from developing into osteoporosis. I get bone density tests every two years and they show no change. Am I safe to assume my lifestyle and eating habits will help prevent osteoporosis?
Lynn Pattimakiel, MD: If you have a small frame, you may have had a lower bone density to begin with. It is excellent that you are living a healthy and active lifestyle, including taking proper supplementation, vitamins and staying up-to-date with your screening bone density tests. Your health care provider may also be able to check a urine test to check the amount of bone breakdown (urine NTX [N-terminal telopeptide]). If there is any decline in your bone density test or an elevation in the bone break-down marker, it may be beneficial to start therapy for your bones.
Another excellent tool you can use is called the FRAX® score. You can Google this online, and answer the questions to determine your risk for fracture. If you are at higher risk, you may benefit from therapy. If you have questions, you may be able to complete this with your health care provider.
Estrogen and Bone Formation
SThomas: How important are estrogen levels in bone formation? How do you address specific ‘extras’ that enhance treatment, but are not part of the medication being used to treat the osteoporosis?
Lynn Pattimakiel, MD: Estrogen levels are very important in the process of bone formation. After menopause, when the ovaries are no longer producing estrogen, there is a more rapid rate of decline of bone loss for approximately five to seven years. This is because estrogen helps slow down or inhibit the activity of the osteoclasts (cells that break down bone).
The ‘extras’ are definitely needed to help treat osteoporosis, because if the body does not have the proper building blocks, minerals, and vitamins it needs to create a strong scaffold, the medication that we use to treat osteoporosis will not be as effective.
Effects of Caffeine on Bone
pw5: Does caffeine intake affect osteoporosis?
Chad Deal, MD: Patients who consume lots of caffeine can lose calcium in the urine—a condition called hypercalciuria. This is only a concern with high caffeine intakes, for example consuming 10 cups of coffee per day. One to three cups of coffee per day is not a risk factor for osteoporosis.
Bone Density Test
quelly: What is a bone density test and who should have one?
Lynn Pattimakiel, MD: A bone density test is an x-ray that is usually taken of the hip and spine. This is used to measure the density or strength of the bone. It is recommended that all women who are 65 years old have a bone mineral density. It may be beneficial to have a bone density test in postmenopausal women earlier if they have other risk factors, for example a previous history of stress fracture, low body mass index, or a history of chronic steroid use or other medication that may decrease bone strength.
DEXA (Dual Energy X-ray Absorptiometry) Scan
Griggs: Are DEXA (dual energy x-ray absorptiometry) scans reliable on people with very small, petite and thin frames?
Chad Deal, MD: Patients with small frames may have lower bone densities. It is hard to quantitate how much lower, but it should be a consideration in evaluation of fracture risk. Last week I saw a small person who was four feet tall with a T-score of -4.0. In anyone’s book, this is osteoporosis.
Hormone Replacement Therapy and Osteoporosis
jello: Can hormone replacement therapy help with osteoporosis?
Lynn Pattimakiel, MD: In postmenopausal women, hormone therapy is approved to help prevent further bone loss in women at increased risk for fracture or osteopenia (bone thinning). It is not improved for the treatment of osteoporosis.
Griggs: When is Forteo® (teriparatide) recommended as the first drug to take for treatment? Should bisphosphonates usually be prescribed first, before Forteo® to see if the problem can be reversed?
Chad Deal, MD: Forteo® can be a first-line agent when there is a high fracture risk. This is based on physician determination. High-risk patients could include patients with previous fractures, especially hip and spine fractures, and patients with multiple fractures. In addition, some patients with very low T-scores even without fracture could be high risk—such as patients with a T-score less than -3.0 or lower. Remember, we have a method to estimate fracture risk known as FRAX®, which can help evaluation fracture risk. National Osteoporosis Foundation guidelines recommend treatment if 10-year fracture risk is greater than three percent for hip and greater than 20 percent for major osteoporotic fracture. Patients with 10-year risks substantially higher than three percent and 20 percent could be considered high risk.
sky: What are the names of medications that increase bone density and not make the bones more brittle?
Chad Deal, MD: No osteoporosis medication makes bone more brittle in the first three years of treatment, and they all reduce the risk for fracture. Atypical femur shaft fractures occur after eight years of treatment. (The rate is about 1.20 per 1,000 per year). If your risk of hip fracture is about one percent per year (we use FRAX® to determine this), then your risk of a hip fracture with no treatment is 1 per 100. So, the benefit outweighs the risk. The risk of atypical fractures is why we discuss a drug holiday with patients after three, five or 10 years of treatment, depending on the patient’s underlying fracture risk.
cardinal: I was diagnosed with osteoporosis about one year ago. My T-score was exactly -2.5 at the hip. My primary care physician wanted to immediately put me on Fosamax® (alendronic acid). However, I asked for a vitamin D test and the results showed my vitamin D levels to be in the high-normal range. As a child I suffered from severe eczema that was attributed to an allergy to milk and wheat. I was prevented from participating in many activities by the scabby sores on my hands. I started to drink milk when I was 25 years old, and usually drink about two gallons a week. For the last several years I have been taking calcium, magnesium and vitamin D supplements. My diet is mostly fruits and vegetables. I have never broken a bone. I work out with weights for one to two hours per week and take step aerobics classes two to three times per week. I have never broken a bone.
I deferred starting Fosamax® (alendronic acid) as suggested by my primary care doctor until I checked out the possible side effects. The list of possible side effects scared me because my father suffered from stomach ulcers. Both a brother and a cousin have nearly died from esophageal perforations leading to severe internal bleeding without any known cause. The cousin had a second emergency perforation with severe bleeding last month.
Lynn Pattimakiel, MD: It definitely sounds like you are doing everything in your power with your diet, lifestyle and exercise modifications to help prevent further bone loss. If you are getting a lot of calcium in your diet, you may not need to take extra supplementation. There can be harm in getting too much of anything. The recommended total daily doses of calcium are 1200 to 1500 mg daily in divided doses (dietary sources preferred). It is understandable to have reservations about taking medications that may list multiple harmful side effects. When choosing a medication for you, it is important to weigh the risks vs. the benefits, and this needs to be individualized in each case. Discuss your concerns with your primary care doctor, if you are personally at risk for developing stomach ulcers, problems with your esophagus, or have swallowing difficulties. If you are at risk, there are other formulations available that are enteric coated or may be given through an IV or injection that you may tolerate better. The risk for fracture with osteoporosis is high, and can lead to higher morbidity and mortality. Therefore, we don't want to let your bones go untreated.
Retired Dan: After Forteo® (teriparatide), I use Fosamax® (alendronate sodium) and do weight lifting. What else should I do?
Lynn Pattimakiel, MD: Forteo® (teriparatide)—a bone building agent—is often used for two years in patients who have severe osteoporosis or have failed other bone therapies. Once this is completed, it is a good idea to continue treatment with a bone medication which decreases break down of bone, such as Fosamax® (alendronate sodium). It is very important to make sure that you are taking this medication properly. It should be taken as prescribed on an empty stomach with a full glass of water. Make sure to avoid eating or drinking anything else for at least 30 minutes (this includes other medications or vitamins) because this can interfere with the absorption of the medication. Also, make sure to stay upright for 30 minutes to avoid reflux. Weight-bearing exercise is excellent to help improve the strength of bones. However, it would be advisable to discuss with your health care provider the amount of weight you should use, and certain activities to avoid that may increase the risk of fracture. Remember to also get an adequate source of calcium and vitamin D in your diet.
eadler1220: Do the benefits of bisphosphonates (e.g., Fosamax® [alendronic acid]) outweigh the risks in the treatment of osteopenia? How about taking it preventively in postmenopausal women?
Chad Deal, MD: All drug treatments are risk-benefit decisions. Currently, we use an absolute fracture risk model FRAX® to make treatment decisions. This is web-based and you can Google it and take a look. The National Osteoporosis Foundation recommends treatment if your 10-year risk is greater than 35 percent for hip fracture and greater than 20 percent for all fractures. We use this mainly in patients with osteopenia with a T-score of -1.0 to -2.5, since the National Osteoporosis Foundations recommends treatment in patients with a T-score of less than -2.5.
clara: I was on Fosamax® (alendronic acid) for 12 years. I have been off of it now for three years. Last year my T-scores were as follows: spine at -2.2, hip at -2.5 and femur at -2.7. The doctor said there was a slight change but not much. He told me if I wanted to try it, he would offer me Forteo® (teriparatide). He did give me Evista® (raloxifene) to take. I am extremely concerned about hip fractures. I am going to have another bone scan soon.
Chad Deal, MD: After 12 years of Fosamax® (alendronic acid) it is usually appropriate to take time off as you did. We usually restart if bone loss occurs. This is based on how much decline you have had on your next bone density test, which is measured as grams/cm2 not by T-score. Usually, the decline has to be greater than 0.03 g/cm2 or 0.04 g/cm2. The choice of which drug to use if there is a loss of bone mass is individual, but Forteo® (teriparatide) is used in patients at high risk for fracture with low T-scores and/or previous fractures.
kaytee: What drugs can help to rebuild bone? If you have osteoporosis, will you eventually break a bone?
Lynn Pattimakiel, MD: Osteoporosis can increase your risk for fracture because the bones can become more porous (picture Swiss cheese), and you are not able to bear the same load. Fractures may even occur and go unnoticed. You may have seen elderly people lose height or develop a hump. This can be due to silent compression fractures of the spine. There are many options of bone therapies to help rebuild bone, which include:
- Bone-building agents (for example, Forteo® [teriparatide]).
- Antiresorptive agents, including bisphosphonates (for example, alendronate, risedronate and zoledronic acids), hormone therapy (in postmenopausal females), rank ligand inhibitors (Prolia® [denosumab]) and selective estrogen receptor modulators (Evista® [raloxifene]). You should discuss with your health care provider which therapy would be best for you.
keep going: Can you overtake medications for building bones (for example, Fosamax® [alendronic acid])?
Lynn Pattimakiel,MD: It is very important that when you start a bone therapy, you continue to be monitored and re-evaluated, because no medication should be taken indefinitely. If your bone density and bone resorption markers remain stable, some providers may consider taking a drug holiday because the medication can continue to work in your bones for some time.
Chad Deal, MD: There is only one anabolic drug—or bone builder—and that is Forteo® (teriparatide). The other drugs are ‘antiresorptive’ meaning they prevent bone resorption or break down. The antiresorptive drugs do increase bone mass since they prevent break down. For a year or two bone formation continues, but eventually formation slows down. Forteo® directly stimulates bone formation.b
bo: I am 82 years old with osteoporosis and experienced a loss of over two inches in height. Is there any new medicine to prevent further bone loss?
Chad Deal, MD: First, what is the cause for the two-inch height loss? If it is from osteoporosis, it is related to spine fractures? An x-ray will answer this question. If there are fractures, the use of Forteo® (teriparatide) should be considered. Forteo® is an anabolic agent for osteoporosis. It is given as a daily injection for two years. There are other causes for height loss, such as scoliosis and narrowing of the discs between the vertebral bodies. Again, an x-ray can answer these issues.
bbo: But I also have osteoporosis
Chad Deal, MD: Osteoporosis per se does not cause height loss unless you have had vertebral (spine) fractures.
Sky: I am a 76-year-old woman who has had kyphoplasty surgery twice for compression fractures in my back due to osteoporosis. What is the best medication for me to take? Also, what are the risks of taking this medicine, and would the benefits outweigh any risks?
Chad Deal, MD: If you have had fractures in the spine, you should be on Forteo® (teriparatide). It is the only anabolic drug for this indication, unless you have contraindications for its use (including previous x-ray therapy, Paget disease, bone tumors, etc.). The benefit outweighs the risk in someone how has had multiple vertebral fractures. Forteo® (teriparatide) can cause high blood calcium, but it is usually minor. There is a black box warning about osteosarcoma (a bone cancer) in rats. All experts feel that this is not an issue in humans. The benefit is preventing the next fracture, which can have a significant effect on your health.
Osteonecrosis of the Jaw: A Side Effect of Osteoporosis Medication
cookie27: I am a 55-year-old woman diagnosed with osteoporosis five years ago. I have tried several treatments, including Boniva® (ibandronic acid) and Fosamax® (alendronic acid), but experienced terrible jaw pain and side effects. My Ob-Gyn physician is now recommending Reclast® (zoledronic acid) or Prolia® (denosumab). My investigation of these two medications indicates that they also have same side effects. If I must choose from these products which do you recommend? Is there any new study on stem cell therapy for osteoporosis? I would be very happy to participate in such a trial. I have a fractured T-11 and pain in my back. For the past seven months I've been using Strontium Boost™, AlgaeCal® Plus, and vitamin D-3. Would this be enough without going to the Reclast® and Prolia®?
Chad Deal, MD: Jaw pain is usually not a side effect of these medications. Jaw problems occur after dental surgery when bone does not heal, a condition called osteonecrosis of the jaw (ONJ). They all can cause bone pain. Reclast®(zoledronic acid) is a bisphosphonate like Fosamax® (alendronic acid) and Boniva® (ibandronic acid). It is given in the vein, not by mouth. Prolia® (denosumab)is not a bisphosphonate. It is given by injection every six months. It, too, can cause ONJ after dental surgery. It does not usually cause bone pain. If you had a fracture of T11, you should consider taking Forteo® (teriparatide). This is our drug of choice for patients at high risk for fracture.
can too: Can you take Fosamax® (alendronic acid) and still safely receive a dental implant?
Chad Deal, MD: Dental implants are safe to have when taking Fosamax®. However, a problem can occur before the implant. If you have a tooth pulled while on Fosamax®,you can have delayed healing—a condition called osteonecrosis of the jaw (ONJ). This is rare (1 per 50,000 to 100,000 patients), so the American Dental Association recommends in their position statement that if you need emergency dental surgery and are on Fosamax®—you should go ahead with the surgery.
Medications and Low-Blood Calcium
monday3: I read that Fosamax® (alendronic acid) does not help if you have low blood calcium. So, what is low blood calcium if Fosamax® isn’t helping to improve bone density?
Chad Deal, MD: If you have low blood calcium, there is a reason. One reason is a condition that is a result of vitamin D deficiency call osteomalacia. In this situation the treatment is not Fosamax® (alendronic acid), but rather vitamin D. Low calcium is not a common condition since the body has many ways to regulate calcium to prevent this. Low calcium can be dangerous, for example it can cause cardiac arrhythmias.
marti: I have osteoporosis and I have been taking calcium supplements for years. However, I also have a body scan calcium score that is ‘off the charts.’ In addition I have had heart valve surgery for aortic stenosis (plaudits to Marc Gillinov, MD and Cleveland Clinic). I also have calcified arteries. I have spoken with several physicians and they all advise me to continue with the calcium supplements. To me, this does not make logical sense. What would you advise?
Lynn Pattimakiel, MD: It is understandable that you would have concerns about getting too much calcium. Too much of anything can lead to complications. It is also important that you have a sufficient amount of calcium to help maintain the strength of your bones. Your total daily intake should be 1200 mg to 1500 mg daily in divided doses. Your gut can only absorb 500 mg at one time. I would recommend that you get your servings of calcium in your diet first, including milk products. other dietary source of calcium, which include green leafy vegetables (spinach and lettuce), rhubarb, sardines, salmon, tuna, oranges and broccoli. If you are unable to get enough calcium in your diet, make up the difference with a supplement.
see it: Is plant-based calcium better than mineral base? Or is there no difference?
Chad Deal, MD: In general, calcium from foods may be better—it seems to be associated with less or no cardiovascular risk as that which has been reported for calcium supplements. Not all mineral-based supplements are the same. Calcium citrate (Citracal®) may be better absorbed in patients with low stomach acid than the calcium carbonate preparations (including Tums®, Oscal®, etc.)
There is some concern about calcium supplements and cardiovascular risk. The studies seem to show if you get your calcium from your diet, the risk is not there. So, I recommend dietary sources of calcium as safer.
Use of Strontium and Calcitonin for Osteoporosis
naturalist: Do you ever recommend taking strontium as a treatment for osteoporosis?
Chad Deal, MD: Strontium ranelate is approved for low bone mass in Europe. It is taken daily, comes in a packet and is dissolved in water or other liquid. This form of strontium is not available in the U.S. The strontium preparations you purchase in store in the U.S. have not been tested, and our recommendation is that it should not be used as therapy for osteoporosis.
Carie: What is your opinion of strontium for bone health? Since prescription strontium is not available in the U.S., can you recommend any foods that are high in it?
Chad Deal, MD: There are no foods that have strontium that have been tested for low bone mass. Strontium ranelate is a drug available only in Europe and not in the U.S., so there is no currently available strontium-based treatment in the U.S.
tabialex: Does long-term use of nasal calcitonin for osteoporosis increase your risk of cancer? How long should the nasal form be used? Does it protect the spine better than the hips?
Chad Deal, MD: Both the FDA and the EU equivalent (EMA) have ruled that because of a possible association of nasal calcitonin with cancer, the risk is not worth the benefit for osteoporosis. These are recommendations to the two agencies and not official policy yet. Nasal calcitonin has not been used for osteoporosis by experts for many years because of the data which shows it is minimally effective for osteoporosis. Still, the drug had four and one half percent of the market. The data on cancer association is based on a meta-analysis and is not definitive, but suggestive.
Lifestyle for Osteoporosis Prevention
roses: I’m 35 years old, what are some things I can do now to help prevent or deter osteoporosis? Do I need to worry about it this young?
Lynn Pattimakiel, MD: Make sure you get an adequate dietary source of calcium, (1200 mg daily in divided doses) and vitamin D. It is also important to engage in a healthy active lifestyle, with regular weight-bearing exercise and improvement of your balance. Avoid smoking and excessive amounts of alcohol because this can be harmful for your bones.
just starting: I’m lactose intolerant. How can I make sure I get the calcium I need to keep my bones strong?
Lynn Pattimakiel, MD: Consider taking lactose-free milk or other dietary source of calcium, which include green leafy vegetables (spinach and lettuce), rhubarb, sardines, salmon, tuna, oranges and broccoli. If you are not getting enough calcium in your diet, it is recommended that you make the difference up with an over-the-counter calcium supplement taken in divided doses.
Griggs: How difficult is it, in your experience, to reverse osteoporosis with diet, exercise, and lifestyle changes alone?
Lynn Pattimakiel, MD: It is important that everyone has the proper building blocks to improve the quality of bone strength. This includes an adequate dietary source of calcium and vitamin D, and avoidance of offending agents that may increase the risk of bone break down, including excessive alcohol, smoking or chronic steroid use. Weight-bearing exercises are also very important in stimulating new bone formation. Unfortunately, if someone already has osteoporosis, defined by either a low T-score (less than -2.5) or a clinical history of stress fracture, diet and exercise are not considered adequate treatment. Due to the higher risk of fracture, it is recommended that therapy for the bones is started to help further prevent bone loss or build new bone.
sc945: I’m 65 years old and I have osteoporosis. What can I do now to help my bones get stronger?
Lynn Pattimakiel, MD: There are many things that you can do to help improve the strength of your bones. The first step is making dietary and lifestyle changes to increase your dietary intake of calcium and vitamin D. Improve your daily exercise with small weight-bearing exercises. It is very important that you improve your balance as well, because with osteoporosis we want to prevent any falls. We also want to avoid any risk factors that may decrease your bone strength. These include excessive alcohol and smoking. You would also benefit from talking to your health care provider because you would benefit from starting therapy to help treat your bones in order to help prevent future fracture.
Stem Cell Therapy
cookie27: Is there any stem cell therapy coming upon the horizon for osteoporosis treatment? I'm a 55-year- old woman, who was diagnosed with osteoporosis about five years ago. I have taken several treatments with terrible side effects. I'm currently taking Strontium Boost™ and AlgaeCal® Plus and vitamin D. For the past two years I have had a fractured T-11, If I have to choose between Reclast® (zoledronic acid) and Prolia® (denosumab), which would you recommend? Is there another treatment that maybe I haven't heard of that you could recommend?
Lynn Pattimakiel, MD: Unfortunately, at this time there is no stem cell therapy that is FDA-approved for the treatment of osteoporosis. If your bone density test showed a low T-score, and you also suffered a spinal fracture, you are considered to have severe osteoporosis and definitely would benefit from therapy. Both intravenous Reclast® (zoledronic acid) and Prolia® (denosumab) are effective and well-tolerated medications that have been approved for the treatment of osteoporosis in postmenopausal women. It is important that you discuss with your doctor if there are any contraindications individualized to you that would prevent you from taking one versus the other, for example kidney disease.
Moderator: I'm sorry to say that our time with Cleveland Clinic experts Chad Deal, MD and Lynn Pattimakiel, MD is now over. Thank you, doctors, for taking your time to answer our questions today about osteoporosis.
Chad Deal, MD: Thanks for joining us today. Your questions were excellent.
Lynn Pattimakiel, MD: It has been a pleasure chatting with you today. Thank you.
To make an appointment with Chad Deal, MD or any of the other specialists in our Department of Rheumatic and Immunologic Diseases at Cleveland Clinic, please call toll-free at 866.275.7496. For an appointment with Dr. Deal at Solon Family Health Center, please phone 440.519.6800. You can also visit us online at www.clevelandclinic.org/rheum.
To make an appointment with Lynn Pattimakiel, MD, or any of the other specialists in our Cleveland Clinic Center for Specialized Women’s Health, please call 216.444.4HER or call toll-free at 800.223.2273, ext. 44437. You can also visit us online at clevelandclinic.org/womenshealth.