Dr. Keith Roach

Richmond Times-Dispatch - - COMICS, ETC. -

Dear Dr. Roach: I have a rel­a­tive who fits the de­scrip­tion of in­ter­mit­tent ex­plo­sive dis­or­der, which I re­cently read about. Could you please tell me what kind of ther­apy a per­son would need if diagnosed with this prob­lem? — T.M.

Dear T.M.: In­ter­mit­tent ex­plo­sive dis­or­der is an im­pulse con­trol dis­or­der: an in­abil­ity to re­strain be­hav­iors re­lated to emo­tions. As the name sug­gests, peo­ple with in­ter­mit­tent ex­plo­sive dis­or­der have pe­ri­odic bursts of ag­gres­sive be­hav­ior. The out­bursts are im­pul­sive and un­planned, and im­por­tantly, cause dis­tress to the per­son. I sus­pect most read­ers will not find it hard to think of some­one who has had th­ese kinds of out­bursts, but the for­mal di­ag­no­sis re­quires the per­son to meet strict cri­te­ria. The di­ag­no­sis is usu­ally made by a men­tal health pro­fes­sional.

Treat­ment may be with med­i­ca­tion such as the SSRI flu­ox­e­tine (Prozac), with cog­ni­tive be­hav­ioral ther­apy or both. Cog­ni­tive be­hav­ioral ther­apy en­com­passes 12-20 one-hour ses­sions.

Dear Dr. Roach: My doc­tor wants to put me on Pro­lia. I read in a pre­vi­ous col­umn that you didn’t like to pre­scribe this drug. I would like to share your thoughts with my doc­tor, but I can’t re­call your thoughts. Can you share this in­for­ma­tion with me again?  V.F.

Dear V.F.: Deno­sumab (Pro­lia) blocks the for­ma­tion of a cell called the os­teo­clast. Th­ese cells nor­mally break down bone, and are nor­mally bal­anced by the bone build­ing ac­tiv­ity of os­teoblasts. They cre­ate new bone.

In older women and men, the ac­tiv­ity of os­teo­clasts is greater than the ac­tiv­ity of the os­teoblasts. This causes a net loss of bone den­sity and bone strength, lead­ing to frac­ture risk.

Bis­pho­s­pho­nate drugs, such as al­en­dronate (Fosamax), also work by de­creas­ing the ac­tiv­ity of os­teo­clasts. They have much more ro­bust data on ef­fec­tive­ness, so they are the first-line treat­ment for most peo­ple who take med­i­ca­tion for os­teo­poro­sis. How­ever, th­ese drugs have their own is­sues, in­clud­ing ad­her­ing to some very spe­cific re­quire­ments while tak­ing the drug: fast­ing, tak­ing the pills with only wa­ter, re­main­ing up­right for 30 min­utes af­ter tak­ing it, etc. For peo­ple who can’t do this or just don’t want to, deno­sumab is a rea­son­able al­ter­na­tive, even if more ex­pen­sive than generic al­en­dronate.

A pre­vi­ous col­umn cau­tioned against us­ing deno­sumab af­ter a long course of bis­pho­s­pho­nate ther­apy.

This com­bi­na­tion can in­crease the risk of a com­pli­ca­tion, atyp­i­cal fe­mur frac­tures, and I typ­i­cally use a med­i­ca­tion to stim­u­late bone growth, such as teri­paratide.

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