Wait…is this a piece about how medications prescribed by my know-nothing, lemming-of-a-physician will snap my femur and eat a hole in my jaw? Or is it one of those articles dubiously claiming to carry the torch for science-based medicine? I’m a little confused, because “anti osteoporosis-drug” sounds right up my favorite alley – you know – the one where my preconceived biases and Google-search results are reinforced and confirmed. I’m really, really hoping it’s the former, because everything I’ve read thus far would suggest it has to be…
As is often the case in modern society, your brain stopped processing words on the page as soon as it received the little dopamine hit from the first four. Upon concluding that this would be another scathing indictment of Lamestream Medicine, your brain just dove in, playing right into my trap. In your brain’s defense, however, I deliberately obfuscated my purpose in order to dupe Google into indexing this page right alongside the copious nonsense that has been plastered across the internet about the dangers of osteoporosis medications. Now you’re reading it, and you can’t stop. Your brain wants to see where I’m going with all this, if for no other reason than to report back to your anti-medication, anti-vaccine, climate change-denying brethren that there’s a physician with the audacity to promote an anti-quackery message. It’s okay, it’s okay. I promise you can read this whole piece and still refuse to learn something new. Deal? Good.
Those of you familiar with Hormones Demystified know that I don’t write medical-o-pedia posts; you can get the basics about osteoporosis anywhere. Unfortunately, the number of people getting the basics from sites claiming that the treatment is worse than the disease is staggering – so staggering, in fact, that in 2016 the National Osteoporosis Foundation, American Society for Bone and Mineral Research, and National Bone Health Alliance put out an urgent call to doctors to be more aggressive with diagnosis and treatment, and for patients to be more aware of the need for treatment. Why did they feel compelled to make this statement?
Because they are all paid consultants for Big Pharma, and their BP overlords are freaking out that prescriptions for osteoporosis drugs have been dropping by double-digit percentages over the past decade!
Yes, of course. I’m sure that generic alendronate, which has been available for almost ten years at a patient-cost of maybe $10/month, is the cash cow that drives the unethical edicts issued by these organizations dedicated to helping people live healthier lives. Try again.
Don’t dismiss my argument so fast. There are other osteoporosis drugs that are not available as generics, and they are ridiculously expensive. Those medications generate mad profits for Big Pharma. Of course the NOF, ASBMR, and NBHA will press doctors to diagnose and treat more people, and of course they’ll try to delegitimize our movement in the eyes of patients. But people are too smart to fall for this!
I agree with you that drugs like denosumab and teriparatide are obscenely priced. But let’s not conflate extortionist drug pricing with the drive to reverse what is turning into a public health crisis. What, you think I’m exaggerating? We have several drugs for osteoporosis that, when actually ingested, injected, or infused can reduce the risk of fracture by as much as 70% (for vertebral fractures – nonvertebral fractures are not reduced by as much). In our highest risk patients (people who have already had one osteoporotic fracture), that 70% relative risk reduction translates to a quite respectable absolute risk reduction. As an Endocrinologist who specializes in the treatment of osteoporosis, I assure you: I am happy to use a cost effective medication to prevent the death-spiral that inevitably would occur once grandma suffers a hip fracture. But if grandma can’t tolerate the $10/month drug, I am going to push for the expensive one. Given that I don’t get paid extra to prescribe denosumab or teriparatide – by process of elimination – I guess we have to say that I simply care about saving grandma’s life. I seem to remember swearing an oath that said something about that…I don’t know – it was a long time ago.
Unfortunately, though we have the tools to prevent these devastating fractures, we are either failing to prescribe them or patients are refusing to take them. The authors of a paper in JBMR demonstrated that there was a spike in a series of internet searches for alendronate (Fosamax) between 2006 and 2010 each time the media reported safety concerns – osteonecrosis of the jaw (ONJ) in 2006, atrial fibrillation in 2008, and atypical femoral fracture (AFF) in 2010. Understandable, right? As active consumers, patients want to know if what they’re taking is dangerous. I think we can all agree that is reasonable.
What is not reasonable is the almost deliberately obtuse refusal of the anti-medication crowd to acknowledge that the risks of ONJ, atrial fibrillation, and AFF are so low as to be far outweighed by the benefits of bisphosphonates. Mind you, when we talk about the risk of osteoporotic fracture and its subsequent horrors versus the risk of a serious side effect, we’re generally dealing with differences of several orders of magnitude. Take the example of a woman who fractures a hip. Her risk of being institutionalized is 50% and her risk of dying within the next year is 20%. If she survives, her risk of a second hip fracture in the year after her first fracture is 8%, with a lifetime risk of a second hip fracture approaching 20%. Contrast these substantial risks with her risk of developing an AFF on a bisphosphonate medication: somewhere in the neighborhood of 23 per 100,000 patient-years. For those who are unfamiliar with that type of statistic, it represents the number of atypical femoral fractures x the number of years of bisphosphonate use per patient. Bottom line: dying from complications related to untreated osteoporosis is a very real possibility, while stressing that you might have an AFF is like worrying about your plane crashing.
But the risk of AFF is so much higher in people who have taken drugs like Fosamax, than in people who haven’t taken the drug. Why on earth would you knowingly give a drug to someone when it has the potential to cause a devastating fracture? How is that honoring your Hippocratic Oath?
As is the case with many a histrionic anti-medication enthusiast, you have set up a binary good versus evil debate. But medicine is almost never that simple. Yes, medications like alendronate have the potential to increase the risk of AFF, but we have learned that the risk is higher with prolonged, continuous use of the medication (more than 5-10 years). Because medicine is a constantly evolving field, we take new information and use it to guide to future decisions. That’s part of the scientific method, which differs greatly from your decision-making process: “Drugs…baaaaddddd.” Hence, it is now rare for osteoporosis specialists to recommend taking a bisphosphonate forever. Because of this change in practice, as well as changes in risk assessment and choosing to treat only people at higher risk, the incidence of AFF should be much lower over the next decade.
No, no, no! The incidence of AFF is already decreasing because we are saving women by exposing bisphosphonates as instruments of the devil!
To some extent, that statement is true. The rate of AFF has decreased along with the decrease in bisphosphonate prescriptions and usage. But let’s not forget that the incidence of plain old hip fracture decreased by 26% between 1996 – the year alendronate was approved – and 2006. It decreased by another 14% between 2006 and 2012. With the significant decrease in bisphosphonate use that we’ve seen over the past decade, due to scare tactics, we are poised to see a major increase in hip fracture incidence over the coming decade.
You’ve focused so much on atypical femoral fractures. Is that because you’re trying to draw attention away from osteonecrosis of the jaw? It is, isn’t it? You know that we’ve got you by the short hairs when it comes to ONJ!
Not really. I just figured my argument would be that much more impactful if I replaced your bullets with blanks and let you fire away. The estimated incidence of ONJ with an oral bisphosphonate like alendronate ranges from ZERO to 1 in 100,000 patient-years. Contrast that to the risk of being struck by lightning in your lifetime: 1 in 3,000. Those of you who aren’t summiting mountains in the midst of storms, do you worry about that? Didn’t think so.
I frequently see distortion of evidence when it comes to those who condemn an entire class of medications as evil. ONJ is a terrible condition that is seen at a significantly higher rate in patients with cancer that has spread to bone, when these patients are treated with monthly doses of IV bisphosphonates or monthly subcutaneous injections of denosumab. Why do we give these heroic doses of medication despite the possibility of awful side effects? Because we must balance the risk of ONJ – which is still small – with the risk of a pathologic fracture of a major bone due to a metastasis that is in the process of destabilizing that bone.
In typical postmenopausal osteoporosis, we use much lower doses of these medications at much less frequent intervals. Unless a patient has major dental issues and expects to have them surgically addressed in the near future, there should be almost no concern that treating her osteoporosis will put her at great risk for ONJ. However, there should be tremendous concern that not treating her osteoporosis due to fear of medication side effects will leave her exposed to double-digit risk of having a fragility fracture. Fracturing at an older age is not the same as when you broke your arm as a youngster. All the kids at school clamored to be first to sign your cast, you got lots of attention, and 6-8 weeks later, the cast was sawed off and you went back to normal life. At 60, 70, or 80, chances are you will not be so lucky.
The title of this piece is “The Anti Osteoporosis-Drug Conspiracy.” So what’s the conspiracy? What could the motivation possibly be for people to systematically scare vulnerable patients into not treating an entirely treatable disease? Newsflash: I dissembled. There is no conspiracy. Just as organizations like the National Osteoporosis Foundation are not conspiring with Big Pharma to line their pockets. Just as your doctor is not a clueless pawn of Big Pharma, handing out bone destroying medications willie nilly.
The anti osteoporosis-drug movement is just a bunch of misguided people who don’t understand the nuances of the medical literature on the subject, trying to convert other people to their way of thinking. Should we assume that this is a conspiracy with malicious intent? Of course not. I believe their intentions are good; they probably think that they are helping people by spreading the word. Sure, some of the disreputable sites out there are condemning medications in one breath and promoting their own ten-step program to better bone health or other such nonsense in the next. But I suspect that most of the people demonstrating missionary-like zeal are just passionate about protecting others from what they see as a failure of doctors and the greater medical system. Sadly, it is this “protection” that will propel us into the next era, in which the incidence of treatable diseases will increase, afflicting our friends, our families, and eventually ourselves.
Are you a health care provider who treats osteoporosis? Have you found that patients are more resistant to taking osteoporosis medications? Are they still resistant even after they’ve had a fracture? How do you counsel these patients? Are you a person with low bone density? Have you taken medication? Why or why not? Comment below!
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