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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30 Replies to “The Anti Osteoporosis-Drug Conspiracy”
Hi, I’ll comment since I’m one of those people who’s been advised to take calcium for Osteopenia and I stopped. My Dr. advised me to take the over the counter calcium plus vitamin D and I tried several brands over the next few months. For me the gut pain eventually became unbearable and I had to stop. I was also extruding calcium from several pores in my face. He never suggested an alternative drug, just noted my reaction in the computer.
Since I’m not lactose intolerant I’m now drinking three big glasses of milk a day, eating more yogurt and lots of fresh spinach. That plus my 2.5 mile jog 3 or 4 times a week and I’m trying to jump rope again. At 58 it’s not easy to jump rope, let me tell you. I’m not sure if any of this is working. My Dr. hasn’t suggested I try anything else and so I guess I’ll have to wait and see what the next bone density test shows.
My understanding is that additional calcium does nothing to prevent bone fractures. Personally, I’d be inclined to consult another MD.
Studies on the issue of how well calcium prevents fractures are conflicting. The National Osteoporosis Foundation (NOF) did a meta-analysis showing a 15% reduced risk of total fracture and 30% reduced risk of hip fracture. It is possible that at least some of the failure to demonstrate benefit in studies is due to poor study design and patient noncompliance.
It is the position of American Assn of Clinical Endocrinologists (AACE), NOF, Institute of Medicine (IOM), and Endocrine Society that women aged 51 and over should consume 1200mg of calcium daily (diet + supplements) to reduce the risk of fracture.
Perhaps you could provide links to the studies that support those recommendations.
I’ll link to the AACE guidelines paper, which has all the references (there are way too many to link to individually):
From the Endocrine Society
“In older women in this population with low dietary calcium intake, higher dietary calcium intake was significantly associated with decreased risk of cardiovascular disease, but not significantly associated with risk of stroke and fracture.”
Apparently, the AACE does not consider treatment with calcium and Vit D sufficient in many cases. From your linked paper:
3.Q4. Who Needs Pharmacologic Therapy?
• R20. Strongly recommend pharmacologic therapy for
patients with osteopenia or low bone mass and a history
of fragility fracture of the hip or spine (Grade A; BEL
• R21. Strongly recommend pharmacologic therapy for
patients with a T-score of –2.5 or lower in the spine,
femoral neck, total hip or 33% radius (Grade A; BEL
• R22. Strongly recommend pharmacologic therapy for
patients with a T-score between –1.0 and –2.5 if the
FRAX® 10-year probability for major osteoporotic
fracture is ≥20% or the 10-year probability of hip fracture
is ≥3% in the U.S. or above the country-specific
threshold in other countries or regions (Grade B; BEL
Yes, of course. Calcium and vitamin D alone are not sufficient for people at higher risk of fracture.
I was one of the senior authors of the systematic reviews on which the osteoporosis treatment guidelines are based. Thank you for posting this piece and trying to explain just how overwhelmingly the benefits of these medications outweigh any possible risks. Even as one of the authors who has seen all the data, I’ve had virtually no success convincing skeptical women acquaintences of this important point, and I worry for the ones at high risk of fracture.
Maybe you’ve been unsuccessful convincing your friends because they know your studies were funded by Big Pharma. 😉 #NoKickbacks.
As always, very entertaining and thought provoking piece. I appreciate you pointing out that not all docs are “on the take” from big pharma. At the same time, however, I think it is important to realize that most studies are driven by big pharma money. While this does not invalidate their studies, it makes me wish we had more RANDOMIZED studies on improved lifestyle (ie low carb nutrition, weight bearing and resistance exercise) as well as supplements such as vitamin K2 for prevention. Vitamin K2 has some evidence behind it, yet it is rarely used by primaries or endocrinologists. If we had more studies would that change? I realize I shifted the conversation to prevention rather than treatment, but that’s where my mind automatically goes. What are your thoughts?
I compare it to when I went to my MD with slightly elevated BP. We went over family history, diet, and exercise, with him talking about what was shown to be helpful as well as what was thought to be helpful. He told me to buy a pedometer (I didn’t think to ask if he had stock in the company). Then, and only then, we talked about what if those things didn’t help — how long we would give it, and what meds he would consider.
I think an MD talking to someone at risk for osteoporosis should do exactly the same things … what I didn’t like about Kitty’s story is that her MD apparently did nothing except talk about calcium and Vit D, which may reduce the number of fractures by only some 15% or so. He apparently didn’t ask about family history, talk about weight lifting or other weight-bearing activities like stairs, discuss meds, or look at things for which there is some, though not definitive, evidence … like excess protein in the diet or the other options you mentioned.
I’m enjoying this discussion tremendously. In my Dr.s defense he knows I have been running 2.5 miles/30 minutes a day most days for since my broken leg healed. In the last year I ran 527 miles, there are weeks were I don’t make it out there. My BP was 140/78 and P 79 at my last visit. I’m not overweight and I lift free weights and practice simple yoga at home. My family history is sketchy because I’m adopted, and my birth Mother was a POW in a Japanese camp in WWII and so I’m not sure how much her health is impacted by that. I think I’m an unusual patient for him. And I feel he takes his time and is thoughtful in his approach to my care. I’m not sure what else he could suggest that I’m not trying. But I’m listening here and I will look into the K2 and keep trying to get more calcium in my diet.
Kitty — glad you’re enjoying it. I find this sort of thing interesting myself, obviously. I had the impression that your MD had just talked about calcium and really hadn’t gone much beyond that. I’m glad I was wrong.
As you probably know, those more at risk for osteoporosis are skinny white & Asian women. But in my family, even the men have it or osteopenia. 🙁
From what I’ve read, the running should help a lot, as should the weights. But some of us are just doomed. I’ve lifted weights — heavy ones — for some 35 years, plus paid attention to my calcium and Vit D levels. But I’ve still been diagnosed with osteoporosis, primarily in the forearm (they apparently add in that measurement if there’s variability in the others) and in vertebra L1. At this point, my MD and I are keeping an eye on it and if/when the hip bones are compromised, then I’ll consider medication.
Good luck with all this and if you find the cure, let me know!
Leave it to the preventive cardiologist to go there. 😉 Yes, I agree that prevention is important, though it is uncommon for anyone to seek my advice in the real world for prevention. Anyone who lands in my office is seeing me because they are already in a bad situation with respect to their bones, as I am not consulted for garden-variety osteopenia.
Vitamin K2 – last I checked – sounded intriguing, but had no good hard endpoint data to support its use. Theoretically, vit K2 seems like it would be good for skeletal health; but, it will be tough to get good evidence for something that can’t be monetized up the yin-yang. In that way, I agree that it would be great to have more trials with funding from other sources, other than Big Pharma.
Following hip replacement (surgeon said I had great bones – just lousy cartilage), chemo/radiation for lung cancer and a thyroidectomy for medullary thyroid cancer, all within the last two years, I stay concerned for my bones. Calcium, D3, K, hauling hay bales and water for my horses, trying to minimize my prednisone (necessary for breathing), balancing cardiac damage from radiation. So far so good, Dexa tomorrow. (I’m older than dirt but have good genes.)
This just showed up in my email — https://www.healthnewsreview.org/review/la-times-provides-strong-overview-on-study-showing-vitamin-d-and-calcium-supplements-dont-prevent-fractures/
I saw that article too. I’m sticking with the plan of a multi-vitamin, lots of greens and broccoli, and all the milk I normally drink. Plus exercise of course. Maybe it’s not helping with fractures, but why stop doing something you think makes you feel better? However I have been seriously thinking about joining Planet Fitness for $10 a month and taking advantage of their strength training equipment.
Makes sense to me — I’m convinced that my years of weight lifting has kept my osteoporosis from being much worse than it is.
This link is to a commentary about an article about a study. I think the study to which it is referring is one in which the benefits of calcium and vitamin D for lower risk people was called into question. Those findings are interesting. I would caution against extrapolating the results to women with existing osteoporosis +/- a history of fracture.
“I think the study to which it is referring is one in which the benefits of calcium and vitamin D for lower risk people was called into question.”
I haven’t read the original study, but the LA Times article states:
“Even when the researchers accounted for each study participant’s gender, past history of bone fractures, the amount of calcium they consumed in their diets and the dose of the calcium pills they took (if they did), there was still no sign that supplements were helpful.”
So, this study was a meta-analysis, looking at a bunch of other studies assessing the utility of calcium and vitamin D in reducing fracture. Despite limitations (presence of osteoporosis not accounted for, compliance with supplement use not noted), we can probably say that calcium and vitamin D are not as universally helpful for reducing fracture as we thought. However, I would be hesitant to stop recommending calcium and vitamin D for those with osteoporosis or otherwise high risk of fracture, as I suspect there is still benefit to be had in this population.
Except the LA Times article also noted:
“Upon drilling down to certain subgroups, they found that for people who started out with at least 20 nanograms of vitamin D per milliliter of blood, adding more vitamin D through supplements was associated with a greater risk of hip fractures. The same was true for people who took high doses of vitamin D supplements just once a year.”
Unfortunately, they don’t define “high doses.”
I do take Vit D supplements in the winter, btw, as I live in Minnesota and don’t get very much in my diet. The above quote is making me wonder if it would be worth getting my levels checked again. I attribute my osteoporosis, in part, to having been very low in D in the past — that, plus bad genes and being a skinny, white, old woman.
Great article. As a primary care physician, I spend an inordinate amount of time trying to convince people to treat their osteoporosis.
It’s so hard! And it continually amazes me how I can tell someone that they have a 1 in 100,000 chance of getting ONJ from a bisphosphonate, but a 1 in 20 chance of a hip fracture over the next 10 year, and they STILL refuse the medication.
Humans are terrible at risk perception.
“Humans are terrible at risk perception.”
Flying is just too dangerous, I’d rather drive from Minnesota to Palm Springs.
Flying is actually much safer than driving.
It would be really helpful if the research/medical/pharma community would stop quoting relative risk and start quoting absolute probabilities — maybe then, we patients might be more prone to make more informed decisions. A 33% reduction in risk could mean going from 3 in 10 to 2 in 10 – OR – from 3 in 10,000,000 to 2 in 10,000,000. So relative risk is essentially a marketing tool and pretty useless.
I have to agree with you on this one. When the Women’s Health Initiative study first came out in the early 2000s, the relative risks for things like breast cancer sounded frightening, and that is part of what led to hundreds of thousands – if not millions – of women being abruptly withdrawn from HRT. As the data was dissected in more detail over the ensuing decade, we realized that the absolute risks were really quite small and limited to very specific situations that didn’t apply to many in the demographic that actually uses and benefits from HRT.
I have had to deal with severe bone loss two different times.
The first time was in 2003, when I went to my desevereto get a old filling fixed, and he told me that my jaw x-ray showed severe dangerous bone loss. Further testing showed Osteoporosis.
Now, I had been taking regular calcium supplements, and a multivitamin containing Vitamin D daily since 1973 when I read in the original Rodale Prevention magazine about taking calcium to prevent bone loss. So why in 2003, 30 years later, did I have Osteoporosis? I did some research on-line and found Boron was important to build bone, but my multivitamin contained 3 mg of Boron. Further reading showed people living in Boron-poor areas, eating local foods often needed more than 3 mg of Boron a day. And I had been living in a boron poor soil area of the US, for the previous six years.
So I added an extra 4 mg of Boron, for a total of 7mg of Boron daily, to the calcium and multivitamin plus addied regular, plus 3 times a week weight-lifting. It took almost two years, but my bone density test finally showed Normal Bone Density in all bones tested.
Then in 2016 my endocrinologist told me I had developed Hyperparathyroidism, which he was watching, and so 16 months after a Bone Density test previously showing Normal Bone Density, now I had Severe Osteopenia, only a tiny smidgens of a bone thickness from Osteoporosis again.
This time it required a Parathyroidectomy in December 2016, to stop the bone loss caused by the Parathyroid tumor.
And again I had to increase my calcium, which the surgeon changed to Calcium Citrate as he said it was better absorbed and utilized to build bone, made sure I got the extra Boron, 8 mg daily this time, and added a Vitamin K2 supplement as studies I read on PubMed showed it help escort the calcium to the bones for bone-rebuilding. Plus making sure to do weight-lifting at least twice a week, three times if possible.
So now it is 2020, and my tests show Normal Bone Density once again.
So rebuilding bone without a medication, that prevents the regular breakdown of bone in preparation of replacement with new flexible bone cells, is totally possible.
I have done it twice in the last 17 years.
I don’t think calcium or vitamin d will save you. I think you need a strong metabolism and to eat a lot of food for a long period of time to build everything back up, bones and all other parts of the body. This seems so obvious to me but I think the medical community is just slow af.
Young people – solid metabolism and eat whatever they want whenever they want = great bones.
Adults = more disease and issues you have with your body will probably stop you from eating and including chronic fatigue, so you eat less and less and then your bones are screwed. Taking some calcium or vitamin d isn’t going to revive the whole skeletal structure back to normal, you have to eat a lot over a long period of time and your body has to actually use food properly. Most people in the U.S. look awful so don’t feel so bad about it.