Dr. Keith Roach
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.