Osteoporosis treatment is in crisis with lower drug usage
March 14, 2017 12:00 AM
By David Templeton / Pittsburgh Post-Gazette
Available since 1995, bisphosphonate drugs help prevent osteoporosis.
So why does the bone-deteriorating disease continue to wreck the hips and spines of Americans? Medical experts are baffled that many at-risk people are avoiding such medications as Fosamax.
Add to that the growing prevalence of extreme obesity, diabetes, rheumatoid arthritis and chronic obstructive pulmonary disease that also undermine bone health. The result is 8 million women and 2 million men having osteoporosis with another 18 million having low bone mass.
That total of 28 million Americans — 1 in every 9 adults — is comparable to the number of Americans with diabetes.
“The crisis in osteoporosis is an acute one, and in the last several years it has gotten to a crisis level because of the significant decline in treatment. A previous decline in hip-fracture rates now has plateaued, resulting in an increasing number of people at risk for osteoporosis,” said Kenneth G. Saag, a professor of medicine at the University of Alabama Birmingham.
All drugs have side effects, including osteoporosis drugs. But for reasons not fully clear, the use of osteoporosis drugs has declined by 50 percent in recent years, said Dr. Saag, who also serves as president of the National Osteoporosis Foundation’s board of trustees.
The drugs largely were credited with reducing spinal fractures by up to 70 percent and hip fractures by 50 percent from 1995 to 2012. And, yet, only about 20 percent of at-risk patients now are taking the medications, with the percentage dropping.
“Why isn’t this decline in medical use also happening in heart disease and cholesterol with drugs that also have rare side effects?” Dr. Saag said, noting the “massive decline” in the use of osteoporosis prevention drugs.
Despite the drugs’ potential benefits, news and medical journal reports about potential side effects — unusual types of femur fractures and jawbone deterioration — made big headlines nearly a decade ago, leading to lingering fear among those using the drugs.
It may explain a key reason drug usage dropped off, with the steady decline in hip fractures bottoming out from 2012 to 2014, along with concerns they’ll begin climbing with baby boomers now in their senior years.
But Dr. Saag said the unusual femur fractures, side effects of the drugs, occur in only about 1 in 1,000 patients. However, it’s been estimated that for each unusual femur fracture that might occur with these drugs, 100 regular fractures would have been prevented.
Concern may extend beyond the patient, with only 20 percent of people hospitalized with hip fractures being discharged with the preventive drugs. It may show that doctors have become more reluctant to prescribe the drugs.
“If we had 80 percent usage among those patients who had a hip fracture, I’d consider it successful,” said Jane A. Cauley, a University of Pittsburgh Graduate School of Public Health professor. “Sometimes people have a false sense of security by simply taking vitamin D and calcium, or exercising, and thinking they’ll be OK.”
Long-term use of osteoporosis drugs also has been questioned in medical literature, with recommendations that patients on the drugs be re-evaluated every few years. For that reason, she said, the focus should shift from prevention to using the drugs to avoid secondary fractures in those who’ve already had one and prevent disability.
As president of the American Society for Bone and Mineral Research, she said plans are underway for a “Call to Action” to reverse the troublesome trend.
“We have to do better with communication about the risks and benefits on the clinical side,” said Ms. Cauley, who holds a doctoral degree in epidemiology.
Falls and consequences
Healthy bones involve two processes — the breakdown of old bone tissue (osteoclast) and the rebuilding of new bone (osteoblast).
Osteoporosis occurs when bone destruction outpaces reconstruction, usually later in life, leaving bones with ever larger pores, weakening them and making them more brittle and prone to fracturing.
About 90 percent of fractures involve a fall. Patients on anti-anxiety benzo-drugs that cause dizziness and drowsiness face an elevated risk of falling and fracturing their hips, spines, arms and legs, Ms. Cauley said.
Her review of osteoporosis research since 2015, published this month in the journal Rheumatology, raises concern that the burden of osteoporosis will grow with the aging American population. Her review includes the following concerns:
• Falls cause 70 percent of the accidental deaths among the elderly. Those surviving a fall can face serious challenges in regaining an independent lifestyle, which, in turn, can compromise health and longevity.
• High inflammation levels in the blood are linked to increased fracture risk for men and women. Men at the highest inflammatory burden had a two-fold increase risk of hip and a three-fold increased risk of a vertebral fractures.
• Triglyceride levels exceeding 300 milligrams per deciliter were linked with higher fracture risk.
• Fractures were higher among men whose protein consumption was less than 11 percent of total energy intake and women with less than 12 percent.
• Diabetes is an established risk factor for fractures, with one study showing that hip fractures increased as blood sugar levels rose, “emphasizing the need for adequate glucose control” in patients with diabetes.
• The report also says that the “studies are consistent with research linking cardiovascular disease and osteoporosis.”
Beyond the drugs, people can take action, literally, to strengthen bones or at least slow down their deterioration, in conjunction with proper use of medications, the Cauley report stated.
Exercise, especially resistance exercise, can improve bone health, with vitamin D and calcium also showing advantages, including an association between higher vitamin D levels and higher rates of survival following a hip fracture.
There might also be advantages to consuming more vitamin K, with the highest concentrations found in herbs and leafy and green vegetables: “As vitamin K levels drop in the blood, the risk of hip fractures increases,” the report says.
Two recent studies have shown that women with the highest Mediterranean diet score had a 20 percent lower risk of hip fractures. One study showed that people eating no fruits and vegetables actually had an 88 percent higher risk of hip fractures than those consuming five servings daily of fruits and vegetables.
“Taken together, these recent studies showing benefits of the Mediterranean diet, a protein-rich diet and a diet rich in fruits and vegetables highlight modifiable and nonpharmacologic means to improve bone health,” the Cauley report concludes.
David Templeton: firstname.lastname@example.org or 412-263-1578.
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