Food for thought Bisphosphonates in Osteopenia
I found this thought provoking especially when weighing whether or not to start a Bisphosphonate. I honestly never viewed it like this but with many Doctors rethinking their use of Bisphoshonates in Osteopenia I found this article food for thought.
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What's your view on menopausal asymptomatic osteopenic patients who already take calcium + vitamin D and live an active life. Should they take bisphosphonates or other antiresorptive therapy? If so, at what dosage?
Luis Gonzalez, MD
Professor, The University of Melbourne, Melbourne, Victoria, United Kingdom
The question you ask is very important. What is it we are trying to prevent? Are we trying to prevent bone loss after menopause or to restore bone mass in elderly persons? It is neither. We are trying to prevent fractures, and more specifically we are trying to prevent the morbidity, mortality, and cost associated with fractures. This emphasis is not just semantics, it has fundamental significance in understanding why treat, who to treat, which drug to choose, when to start treatment, and how long to treat.
Why give an antiresorptive or bone anabolic drug to a woman at 50 years of age when most fractures in the community occur in women over 65 years of age, and indeed, in the case of hip fractures, when most occur in women older than 75 years? Should we treat all women with osteopenia at 50, knowing that most of the women will not have a fracture for 10-15 years? Should we expose huge numbers of these women to a drug, its costs, inconveniences, side effects when most will not sustain a fracture had no treatment been given? That is, most who take the drug will be exposed to the risk of side effects and costs and receive no benefit at all.
Decisions to treat are based not so much on the risk relative to the neighbor with an average BMD but on absolute risk. For example, say the absolute annual risk for fracture (the thing we want to prevent) is 2 per 1000 women per year and a drug has an efficacy of 50%, ie, halves the risk to 1 per 1000 per year. If we treat 1000 women, we will prevent 1 from sustaining a fracture; 999 would not have fractures this year without treatment, and 1 has a fracture despite treatment. So 999 persons have been exposed to drug and only 1 has benefited.
Now, say we wait until a woman is older, say over 60 years; the annual risk has increased 10-fold, ie, it is 2 per 100 per year. If we treat 100 of these osteopenic women, the risk is reduced from 2 to 1 per 100 per year. We prevented exactly the same number of fractures -- ie, 1, but now we have exposed only 100 women to the drug. The same benefit is achieved by preventing 1 fracture but at much lower cost to the community.
This is the nature of preventive medicine; we have to treat large numbers to avert events in few. This is why the drugs we use must be safe -- because most exposed do not benefit, and even a small number of adverse events can tip the balance of net benefit to net harm.
We might like to believe that we prevent events in every woman that we treat, but this is not so. We reduce the risk. When events are very uncommon, finding the highest-risk individuals is important to ensure that we treat those who will benefit the most.
Therefore, my view is to intervene later rather than sooner. This sounds counterintuitive, but it is the nature-of-event rates and efficacy of treatments that dictate who and when to treat, not just the notions we have of the physiology of the bone loss that continues if we do not intervene. The aim of treatment is not to prevent bone loss or to restore bone mass, it is to prevent fractures and the morbidity and mortality accompanying fractures.
Comments
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Susie, great article.
My mom is 91 years old, lives in a nursing home, and has recently fallen a few times. She finally fractured a wrist. However, I don't know whether or not they have her on a bisphosphonate. And I'm certain she has osteoporosis.
I am 61. I had a bone density done, I believe, in 2002. I had one done right after I started Arimidex, but at a different facility. Since my bone density was "normal" my onc didn't want to do one until two years after taking Arimidex. I wasn't happy with that. Soooo, my pcp ordered one here where I had my first one. From the year 2002 until this year I did have some significant loss. However, I also had gone off estrogen. And the way I read the report from last year (from a different facility) and this year there wasn't much difference. And, at this point I'm still "normal."
I would really put up a fight if offered a bisphosphonate if/when I get osteopenia. I try to be diligent taking my D, mag, and calcium. I so hope I won't lose more bone.
Shirley
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Hi Shirley and thanks for your input here. I've been on Actonel for 3 years for low Osteopenia. After doing much research and further concerns, I'm taking myself off of it. Your article and follow-up research prodded me to do this for my own health, and I appreciate your posting it.
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MusicTeacher, I can recommend that you ALWAYS look for Saluki's (Susie) posts. She is ALWAYS updating us with research. We have other gals here that also help us.
Our "researchers" have made me so aware of some of the do's and don'ts. And they've given me the "tools" to speak with my doctors about some research they have brought to us. For instance, I had my pcp do a vitamin D blood level on me. I am now finding that more doctors are doing this. However, I do not believe my pcp would have ever thought of this. I am seeing him in December and I plan on taking him some "goodies" to read and would also like him to share them with the gals that work in the office.
These women are just so darned smart!
Shirley
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Susie, this is lovely.Really my kind of thing.
BUT.
It begs our question.
We arent NORMAL women of certain ages.We are on aromatase inhibitors which lower our estrogen values to incredible depths.(And estrogen keeps bones strong.)(Which is WHY they put us on fosamax. to begin with.)
This doc is talking about normal women.I'd venture to guess you'd havre to look far and wide to find another 66 year old woman with an estrogen value of....9.
I dont LIKE this.Iwont be fooling myself that having 9 for an estrogen value, I'm not very much at risk of fracture.
I bet many women in their 70s & 80s have more than 9 for an estradiol value.SOME women here at the site are shooting for a value of 0 estrogen!
This scares the hell out of me, personally.Estrogen does SO much more for us than feed bc.
Including helping our bones stay strong.I feel CERTAIN that "NORMAL"women are PERFECTLY well-off taking cal/mag and a lot of vitamin D.
US?Who knows?But doubt we are perfectly well-off.
This may sound strange from me, who refuses to take biophosphates.But I'm just trying to warn you not to buy into this guy's view.It's a good one, but he's not talking about US.
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For sure he is talking about women who have estrogen running around in their bodies. Seemingly, it's not helping them if they already have signs of bone loss. But should they start a drug first or what about counseling them first?
It seems to be so much easier to just hand out a prescription then it is to counsel us first about any needed lifestyle changes, getting exercise and taking the big 3, calcium, mag and D3 before putting us on a drug. The mighty 3 might work to stave off any further loss. Who's to know if a Dr. never mentions it and women don't try it? I got the prescription without so much as a murmer. At least I had a dexa scan first. Dr's. might just be handing these prescriptions out with the AI, trying to be proactive without even knowing if the woman needs to take it.
I'll bet a dollar women aren't even being told about getting a vitamin D test. It could be that a lot of our bone loss has more to do with not absorbing D, then it will be because of reduced estrogen. Who makes money if we start taking our D and that begins to fix the problem because we'll start to absorb calcium and mg better, certainly not big pharma.
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Joan-
I would not given this guy as much credence as I do If I hadn't posted earlier in the year about three of the most foremost experts in the country in the field of oncology taking opposing views on treating bc patients on AI's with prophylactic bisphosphonates. Even with osteopenia the one expert chose to follow his patients with dexascans since osteopenia is not considered a disease.
As a matter of fact this fascinating online conference was brought to my attention by Constantine (Edges) newsletter. Unfortunately, after my posting was lost it with time it was no longer available on his site either.
These guys were so well known in the Breast Cancer field that you would recognize them by name. They were from M.D. Anderson, Dana Farber and Sloane Kettering. At this point I can only remember the researcher Budzar who did the early trials and research for Femara. But I think it was the Oncology Specialist at Sloane Kettering that was questioning the use of Prophylactic Bisphosphonates in early breast cancer treatment with A.I.'s in patients with osteopenia and rather following them with Dexa Scans.
I put the article up there because it pretty much agreed with the stance
of one of the oncologists in the conference and I know that there is now some disagreement in the Oncology community about this in early Breast Cancer.
The main contention that is being brought up even in the BC field in early breast cancer is the same that is being addressed in the "normal" women's health.--from the last paragraph of the article.
(I want to reiterate that the conference I spoke about just addressed this issue in relation to Early Breast Cancer.)
"Therefore, my view is to intervene later rather than sooner. This sounds counterintuitive, but it is the nature-of-event rates and efficacy of treatments that dictate who and when to treat, not just the notions we have of the physiology of the bone loss that continues if we do not intervene. The aim of treatment is not to prevent bone loss or to restore bone mass, it is to prevent fractures and the morbidity and mortality accompanying fractures."
I have tried many hours over the year to find that online conference again because I thought it was so important .
Joan--You would have loved it because Budzar did say that they found the musculoskeletal side effects much worse in those who took AI's compared to Tamoxifen.-----First time I had heard anyone admit that!
Guess I should have made it clear what was going on in my head and how it related to us before I put it up.
There seems to be some rethinking about this stuff for us. I'm going to repeat something I posted under the atrial fibrillation thread that I found even more alarming than the oseonecrosis of the jaw because it potentially affects more of us and really relates to what we are talking about.
Actually of even more concern to me than atrial fibrillation is this regarding the bisphosphonates from a very good article in of all places MORE magazine.
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"Several experts I asked felt it was safe to take a bisphosphonate for 10 years, others suggested a vacation as a good idea after two or three years, and still others felt a break after five years was a better bet. "There's a concern about oversuppression of bone turnover," explains Robert Lindsay, MD, PhD, chief of internal medicine at Helen Hayes Hospital in West Haverstraw, New York. "The drugs incorporate into the bone and, over time, accumulate. That could make the bone rigid and more likely to break, theoretically speaking."
Another consideration in using bisphosphonates: "We don't know what therapy is doing to the underlying physiology and architecture of the bone," Stafford notes. Because bisphosphonates continue to work for as long as two years after they're discontinued, and patients may need to take them for decades, some bone specialists suggest delaying treatment, or taking vacations, as ways to use the drug sparingly. "You've got to think carefully about starting to take drugs, because you may be on them for a long time and we don't know the long-term effects," Lindsay says. "And if you do need treatment, ask your doctor whether or not you should take a holiday after a few years." It's a bit of a trade-off: "If you continue to take these medicines, you'll be on a plateau," Adams says. "You're not losing bone, but you're not building it either."
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For those with mets obviously the benefits outweigh the risks.
But to take a well population and put them on these meds without osteoporosis seems like a giant experiment to me.
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I believe we KNOW that most docs AT THIS TIME do not check or know the value of know what our Vitamin D level is. Nor do they know how important it is to supplement mag with cal. I have tried to tell people, but they don't listen. And thank YOU ladies for educating us about this important issue..especially now that we're on these dang drugs.
I was told by my gyn years ago to take 1200 -1500 cal and 400 IU of D. No one mentioned mag. I do not know what his thinking is now because I have forgotten to go to him since my dx in Dec. 04. LOL I'll be going next month.
So, ladies, are we supposed to try and educate our doctors? Most of them are too busy to read research. Perhaps some of them do not believe these supplements in combination will make that much of a difference. I don't know. It just gets all too crazy. So, I take what I want to take if I think there'll be no problems with Rx. And that's DARN hard! LOL
Shirley
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I am really in a quandry about whether I should or shouldn't take bisphosphonates for osteopenia. I have been taking calcium and vitamin D and exercise daily and have had my vitamin d levels checked and they are normal however my dexa scan after 8 mos on Arimidex showed me to be on the high side of osteopenia. My pcp prescirbed fosamax plus d which I have been taking for several months. My oncologist was OK with me taking the Fosamax. I recently read an article about bone loss possibly being an environment for bone mestastisis which scared me into taking it. I have also read the theory and know of ongoing studies of bisphosphonates possibly prevent mets to bones. I just asked my pcp to prescribe me the weekly Fosamax that includes 5600 IU of D3 which comes to 800 IU since we are approaching the winter months. My multi has 1,000 IU of D3 so my total is now 1800 IU daily. I can't help but think taking care of my bones is the way to go. Hopefully I won't regret taking the Fosamax.
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"I recently read an article about bone loss possibly being an environment for bone mestastisis which scared me into taking it. I have also read the theory and know of ongoing studies of bisphosphonates possibly prevent mets to bones. "
Liz you hit on the very thing that's kept me taking it this long in spite of doubling over in pain the days I took it. Is the evidence enough to warrant the risk of long term bisphosphonates? I wish I had more information with which to make an informed decision.
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Yes, LizM, add me to the chicken little club of those too chicken to stop my AI and, I must admit, my BP (bisphosphonate) due to fear in spite of the horrendous daily impact of the SE's.
From what I recently read, there's even more evidence that the new generation BP's (IV Zometa for one, which may be your needed alteranative due to gut pain, Saluki) 4 mg IV semi annually or perhaps adjuvantly, annually may help in many ways.
Here's a segment from "New developments of aminobisphosphonates: the double face of Janus" by Dr. D. Santini, et al, Rome Italy).
"These compounds have high affinity for calcium ions and therefore target bone mineral, where they are internalized by bone-resorbing osteoclasts and inhibit osteoclast function.
They can be segregated into two distinct pharmacological classes: nitrogen-containing (N-BPs) and
nonnitrogen-containing BPs (non-N-BPs) based on their molecular mechanism of action.
Nitrogen-containing BPs such as zoledronic acid (ZA), pamidronate (PA), alendronate, ibandronate and risedronate act intracellularly by inhibiting farnesyl diphosphate synthase, an enzyme of the mevalonate
pathway.
Nonnitrogen-containing BPs such as clodronate and etidronate do not inhibit protein prenylation and have a different mechanism of action that seems to involve primarily the formation of cytotoxic effects
metabolites in osteoclasts, thereby leading to loss of the mitochondrial membrane potential and to direct induction of apoptosis (cell death).
Growing in vitro and in vivo evidences pointed out that BPs act on cell types different from osteoclasts such as tumor cells (TCs) and endothelial cells (ECs). In fact, extensive in vitro and in vivo preclinical evidences support that N-BPs display an antitumor activity, including direct antitumor
effects (in vitro and animal models) such as inhibition of TC adhesion to mineralized bone, invasion and proliferation and induction of TC apoptosis ; effects on the metastatic process (animal models): inhibition of bone metastasis formation and reduction of skeletal tumor burden [21];
effects on angiogenesis (in vitro, animal models and in humans); stimulation of gamma/delta T lymphocytes (in vitro and in humans): immunomodulation and stimulation of cd T-cell cytotoxicity against TCs. One of the crucial mechanisms responsible for the antitumor activity of BPs is the induction of TC apoptosis."
Tender -
Susie, thank you for clearing that up for me!(And you know I love those docs!)I think it's SUCH a danm shame the way these things are done:Big Pharma invents a drug (in this case invents machines to DX a disease they invented to get us TAKING the drug)and they fill in the need for it.THEN, after they have everyone on it for years, they say "Duhhhhhh.Dis drug might be causing heart problems?" "Oooops! This drug cause osteonecrosis of the jaw in some victoms, uh patients."
And more "We have NO IDEA the consequences of keeping women in estrogen deprivation for long periods of time."
Now you, Susie, have suffered a bad suffering with your tooth extraction.And you're doc still has you off Fosamax.
So how come you're not brokenboned?
Me, I've been on AI 3 & something years.I took Fosamax when my onc prescribed it when I started AI, but hated the whole mystique and jaw necrosis looming.So I quit it after 8 months.And DURING the whole time I've been on AI, my bone density has always been very, very good!
Understanding that AI creates bone loss, or can, I requested Miacalcin from my onc (who really only cares about cancer) , and have been taking it.
And just last August, my DEXA showed good bone EXCEPT in my left hip, which is now.. just osteopenic!!
So how do ya think I made it through (3 and whatever) years of AI??
(And how glad am I to not have been taking fosamax all that time?
I DEFINATELY agree with whichever doc said better treat it later than sooner!
And this buildup of the drug in our bones?Fuggedaboudit!No WAAAAY I get involved with that!!I actually read that this happens to women who just take calcium alone.The bones become brittle and breakable.This caused me to study and perfect my cal/mag -taking.
My onc refused to test my D3.He said insurance wont pay for it.If I pay I could have it done.(This was last year.Maybe they do now.They are always SO behind)).But I just had my internist draw for D3 when I got my flu shot.So now I may know if I need more D3 than I'm taking:800 mgs in calmag suppliments, and 1,000 mg in a D3 suppliment.
Anyway, thanks Susie.Your researching around here is brilliant!We are very lucky you're pretty housebound from femara and so can do this research.You have taught us SO much valuable stuff.
I know I'm reactionary, but I've never been one to unquestioningly take drugs.My onc feels lucky he got chemo into me.(And now I learn it doesnt help es+ women anyway.Grrrrrr!)
And now I feel pretty glad to hear this news.(Except tomorrow I'm sure there will be research telling that miacalcin gives leprosy.)
hugs, j
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Joan, as usual, you can make any bad news, circumstance funny. I just love your humor.
My pcp did my D3, but also wondered how we could get around the insurance thing. I told the gal who drew my blood that I was taking an AI (heck they don't know what that is..have to explain) which can hack away at our bones. LOL So, I don't know if that's a good enough reason for the insurance to pay. It must have paid because I haven't received a bill from them. And you know doctors will send a bill if the insurance doesn't cover the charges.
Hmmm...perhaps going to an endocrinologist would be a good thing. They would get by doing this probably more so than other doctors. Who knows. But who wants ANOTHER doctor!? And besides I'm still concerned about my thyroid function. I've been off the Synthroid for several days. I took one today and wil skip tomorrow. I can't stand feeling the anxieity crap. I don't think it's in my mind because after being off a couple of days I felt so much better. Crazy? I GIVE UP!
Shirley
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In fact, extensive in vitro and in vivo preclinical evidences support that N-BPs display an antitumor activity, including direct antitumor
effectsTender, which of the bisphosphonates is N-BP's? I couldn't tell for sure from the article you posted.
Thanks for the article.
Liz
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Liz
Four of the nitrogen containing bisphosphonates are risedronate (actonel) zoledronate (Zometa) and alendronate sodium (Fosamax). Also , Pamidronate (Aredia) I don't know about the rest.
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Susie,
Which of the bisphosphanates (sp? can't they give it a shorter, easier name?) is Boniva. I think if I have to take one, that is better, since it is only once a month, but I read that it doesn't prevent fractures... why give it to people then....?
I am fighting it tooth & nail... don't want to take something that has such terrible ses. My onc told me that calcium does not help with osteoporosis, only the bps DO... but, he said, he isn't my pcp, so he didn't want to get involved...Thanks
Harley
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Harley, the truth be told, an endocrinologist is probably the best person to handle this.
Shirley
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Harley --Its not in that list so I don't know what kind it is but here is some positive info from Edge's site about Boniva (Ibandronate).
I know what you mean about some information that came out that boniva may not protect as well against hip fractures (was it that?). I brought that up with my oncologist at the time and he kind of poo pooed it as a statistics game.
Here is a very good acticle of how Bisphoshonates exhibit antitumor activity.
http://www.supportiveoncology.net/journal/articles/0203205.pdf
And this from Constantine's site about Boniva
And several studies have evaluated the newly released (March 2005) oral form of ibandronate (Boniva): Lichinitser et al. (28th San Antonio Breast Cancer Symposium (SABCS), December (2005): Non-inferiority of oral ibandronate to intravenous zoledronic acid for reducing markers of bone turnover in metastatic breast cancer patients) in an open-label multicenter, randomized, parallel-group trial found ibandronate (oral administration at 50mg/daily) non-inferior to zoledronic acid (Zometa), IV-administered at 4mg infusion over 15 minutes every 4 weeks, in reducing bone turnover markers, and the same researchers (Bergstrom et al., 28th San Antonio Breast Cancer Symposium (SABCS), December (2005): Intravenous ibandronate 15-minute infusion followed by daily oral ibandronate for metastatic bone disease: bone marker data) found in a phase III trial that rapid 15-minute infusion of intravenous ibandronate (6mg) followed by daily oral ibandronate (50mg) was associated with a marked decrease in bone turnover markers.
Furthermore, in the specific breast cancer context, the Greek research team of Heras et al. (28th San Antonio Breast Cancer Symposium (SABCS), December (2005): Efficacy and safety of intravenous ibandronate 6mg infused over 15 minutes: results from a 2-year study of breast cancer patients with metastatic bone disease) conducted a cohort trial which evaluated the efficacy and safety of an ibandronate infusion over 15 minutes in breast cancer patients with metastatic bone disease, finding that ibandronate reduced the proportion of patients who experienced an skeletal-related events (SREs), and decreased the median time to both first SRE, and the SRE risk, with no evidence of renal toxicity compared with placebo; Breast Cancer Watch notes in this connection that the renal safety of ibandronate has been independently well established (see especially Guarneri et al., cited above, Oncologist (2005): Renal Safety and Efficacy of i.v. Bisphosphonates in Patients with Skeletal Metastases Treated for up to 10 Years), R. von Moos, Oncologist (2005): Bisphosphonate Treatment Recommendations for Oncologists, GH Jackson, Oncologist (2005): Renal Safety of Ibandronate, R Bell, Oncologist (2005): Efficacy of Ibandronate in Metastatic Bone Disease: Review of Clinical Data ).
However, Breast Cancer Watch notes that there is some controversy concerning the relative renal safety of zoledronic acid compared to other bisphosphonates, including ibandronate: see Zohno et al., J Clin Oncol (2005): Zoledronic Acid Significantly Reduces Skeletal Complications Compared With Placebo in Japanese Women With Bone Metastases From Breast Cancer: A Randomized, Placebo-Controlled Trial, and Conte & Guarneri, Oncologist (2005): In Response to Jackson Letter to the Editor Regarding "Safety of Intravenous and Oral Bisphosphonates and Compliance with Dosing Regimens", and BA Chabner, Oncologist (20050: Late Toxicities of Drugs: Bisphosphonates.
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Susie,
So... are they saying that bps prevent bone mets?I am so tired of all these things... I just want my normal life back, the one BEFORE BC, when I didn't have so many problems...
Shirley,
Oh, I have had SO MUCH trouble dealing with endocrinologists about my thryoid problem, I really don't want to get involved with another one...
Harley
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"My onc told me that calcium does not help with osteoporosis, only the bps DO... "
Hmmm, I don't think so:
Can bones be remineralized in old age? The test of this theory is simply to give more calcium, and the vitamin D necessary for its uptake into bone. It has been done, and it works. Over a period of six months, an average of just under 1,200 mg of calcium daily plus vitamin D improved bone density in osteoporotic women over 70 years of age. (Lee, Lawler and Johnson. "Effects of Supplementation of the Diets with Calcium and
Calcium-rich Foods on Bone Density of Elderly Females with Osteoporosis," American Journal of Clinical Nutrition, 34:819-823, May 1981.I'm sure I can find more reports but this is the first one I found.
Dietary Calcium Could Possibly Prevent The Spread Of Breast Cancer To Bone
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Oh dear, the thread cut this post (actually I recall I got kicked off on my wireless, and I think It got swallowed). I'll try to re-write it some. T.
Rosemary, thanks for reminding us to take our calcium and vitamin D for osteoporosis. Such a simple thing to do, yet I am remiss at this at times also. I'm starting to use now my Dad's old larger plastic pill dispenser, you know the kind broken into 4 times a day. Gosh, it's depressing to see me have to do this, but I literally can't remember within minutes if I took a pill like Arimidex, and I've been forgetting too often to take my calcium and multivit. I will by vitamin D after I find the thread.
Harley, it's so rude of me to leave people hangin! I apologize, as I meant to post more of this articles' exciting findings. I'm careful because of copy right yet this is a good cause, and I'm often not thinking clearly as I weed through the article.
So here is some more conclusions, this time addressing your question "so do bp's prevent bone mets?": From "New developments of aminobisphosphonates: the double face of Janus" by Dr. D. Santini, et al, Rome Italy: Annals of Oncology 18 (Supplement 6): vi164–vi167, 2007.
BPs and survival: preliminary clinical data from retrospective trials:
"The first preliminary retrospective analysis (Berenson et al., personal communication data presented at the 2006 American Society of Clinical Oncology) on survival rate has been carried out in patients with multiple myeloma included in a prospective phase III study comparing the effect of ZA
with PA. Patients were stratified by baseline bone alkaline phosphatase (BALP) levels. Among patients with high BALP, ZA improved survival (survival rate 25 months) compared to PA.
Moreover, ZA reduced risk of death by 42% and by 55% among patients with a baseline and high BALP level, respectively. It is interesting to observe that the highest impact on risk of death concerns a subset of patients (high BALP) with worse prognosis. This finding could indicate that tumors characterized by low sensibility to standard therapy are more responsive to ZA therapy. This represents the first evidence in literature demonstrating a positive impact on survival of BP therapy in cancer patients. "
BPs and survival: prospective studies as adjuvant therapy :
"Prospective studies were designed to evaluate the role of ZA as adjuvant therapy in different tumors. Among them, the AZURE study was designed on patients with breast cancer
stage II/III (3300 patients), randomization criteria. "
"The S0307 trial design on breast cancer patients is enrolling stage I, II, IIIa breast cancer patients receiving standard -
Well, I edited this out, because clearly my post is not technically working. Sorry, I'll try again later. T.
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Tender,
Thanks!
I'll be looking for the article, if you can get it to post...
Harley -
Tender,
Your not alone, I tried all different tricks to remember if I took arimidex.. I gave up, I just put it in the Sun-Sat thingy and I can't tell you how many times I look at it during the day to see if I actually took it.
You don't need the D thread, just take 1000 iu of D3, get the blood test done one of these days to be sure your on the right dosage, and that's all there is. D3 should be taken after a meal so you have fats in your system to help it get absorbed.
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