Osteoporosis Drug
Risks
There has been a lot of recent concern recently about
osteoporosis drug risks.
Osteoporosis is a condition of the
bones that increases the risk of fractures.
One in 2 women and one in 4 men
over the age of 50 will break a bone due to osteoporosis.
About 2 million fractures related
to osteoporosis occur each year in the United States.
About 300,000 are hip fractures.
About 300,000 are hip fractures.
Hip, wrist and vertebral (spine)
fractures cause untold suffering and disability.
Guidelines and online calculators and an app for the iphone are available to guide physicians as to who should be treated
with medication. Those persons who have had a so-called fragility fracture are
much more likely to have another fracture.
The most commonly used drugs to
treat or prevent osteoporosis are called bisphosphonates. The four bisphosphonates used
for osteoporosis in the U.S are alendronate, ibandronate, risedronate, and
zoledronic acid.
The brand names for these are
Fosamax, Boniva, Actonel and Reclast.
Reclast is given once a year
intravenously. Boniva is available by mouth given monthly and intravenously once every 3 months . Fosamax and Actonel are given by mouth.
Doctors never want to cause more
harm than good with a medication.
Recently, a possible increased risk
of unusual fracture of the “thigh bone”, the femur, has been seen. This atypical fracture is thought to
be possibly increased in those persons on long-term bisphosphonates.
In this post I will focus on these
so called atypical sub-trochanteric fractures.
Some may be concerned about osteonecrosis of the jaw (abbreviated ONJ)
with bisphosphonates. When bisphosphonates are used for osteoporosis, ONJ appears to be very rare and
not clearly caused by the drug at these doses.
A recent article discusses safety concerns of bisphosphonates.
The American Society of Bone and
Mineral Research has provided a detailed report on atypical
sub-trochanteric fractures. Of all hip and femur fractures, less than 1% are
these atypical sub-trochanteric fractures. These atypical sub-trochanteric fractures
appear more likely, perhaps two and half times more likely, in those who have taken
bisphosphonates for more than 5 years.
That sounds bad but the risk of
such fractures is very low.
Atypical sub-trochanteric fractures
occur at a rate of about 3 in 10,000 women over 1 year who are 65 years or older.
But typical hip fractures overall are 30 times more frequent: 103 in 10,000 women
aged 65 or older over 1 year.
And bisphosphonates have repeatedly been
proven to reduce fractures in those at increased risk for fracture.
Bisphosphonates reduce fractures by 30-70% depending on
the drug studied and the particular fracture.
So what should be done while we
wait to learn more about these atypical sub-trochanteric fractures?
Those who really need
treatment should be treated. FRAX can be very useful. But sound judgement and clinical expertise needs to be coupled with FRAX. I often see patients who probably do not need the medication they are taking for their bones.
We should consider discontinuing treatment in
those who are doing well and who are at lower risk after 5 years of oral bisphosphonates or 2-3 years of intravenous bisphosphonates. Recent data suggest that FRAX may be helpful in deciding when to stop treatment with a bisphosphonate.
At this time, there are no studies on how long treatment might be stopped.
Many people, especially those with more severe disease and history of fractures, will do best by continuing treatment.
Many people, especially those with more severe disease and history of fractures, will do best by continuing treatment.
Keep in mind that we do not have
data on atypical fractures in those treated with Prolia long term.
And Prolia is not a bisphosphonate but it appears to be highly effective.
Discuss matters with your doctor
who should be keeping up to date with developments in this area.
And remember no treatment is without risk.
We should weigh risks versus benefit.
There may be no clear right or wrong answer here.
And if in doubt, patients and or doctors should get another opinion.
In general, endocrinologists and rheumatologists are the specialists with expertise in osteoporosis.
In general, endocrinologists and rheumatologists are the specialists with expertise in osteoporosis.
I hope this helps in thinking about osteoporosis drug risks versus benefits.
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