Dr. Keith Roach
Dear Dr. Roach: I’m an 85-year-old woman in relatively good health. I was on raloxifene for about 45 years. My doctor at the time said that since I had a hysterectomy, I should have that surgery for the rest of my life to prevent breast cancer and osteoporosis. My bone density is normal.
A few months ago, my doctor refused to renew my prescription because he was not knowledgeable about drugs. We would like to hear your opinion on this decision.
— Hardware
Dear Hardware Person: Raloxifene was approved for use in the United States in 1997 to prevent osteoporosis and in 2007 to reduce the risk of breast cancer. Most experts who prescribe raloxifene believe that the drug must be taken for a long period of time.
One reason many people are concerned about taking osteoporosis drugs is because drugs that slow bone resorption are associated with an increased risk of atypical femoral fractures when taken for long periods of time. Bisphosphonates, such as alendronate and risendronate, belong to this class. RANKL activators like denosumab have also been associated with severe atypical femoral fractures. These drugs are generally reevaluated and usually discontinued after 3 to 5 years.
In contrast, raloxifene, which acts like estrogen to strengthen bones (and an antiestrogen to prevent breast cancer), does not appear to carry a significant risk of developing atypical femoral fractures.
The long-term safety study of raloxifene lasted 8 years, so the published literature has already passed. Still, I don’t think “refusing” to re-prescribe the medication was the best way to handle it. If she felt uncomfortable doing so, it might have been wise to refer you to an osteoporosis specialist.
Dear Dr. Roach: We have lived at 6,000 feet elevation for about 30 years. Over the years, our mean corpuscular volume (MCV) levels slowly increased to 100 fl (normal range is 79 to 97 fl). Our doctor and other doctors have noted that other patients have also seen red blood cells that are larger than normal due to living at high altitude.
My husband and I are in our 80s and 60s, respectively. We were healthy and our blood test results were almost normal. If MCV levels continue to rise, will there ever come a time when we need to worry about MCV levels?
— Scar
Dear SKA: MCV level is the most common way to express the size of red blood cells. Common reasons why red blood cells are larger than normal include low vitamin B12, low folate, low thyroid levels, alcohol use, a few medications, and many blood disorders.
However, doctors are absolutely correct in pointing out that MCV levels are slightly increased among people living at high altitudes. On average, their levels are 6 points higher, so the normal range at high altitude can be 86 to 103 fluid liters.
With this size, there is no risk of the red blood cells becoming too large, so the question is whether there is a cause other than altitude. If your levels continue to rise, your doctor may order laboratory tests or refer you to a hematologist who specializes in blood conditions.
Readers can email questions to [email protected].
