The not-so-scary truth about osteoporosis treatment

Cruising Sanibel Island on a single-speed beach bike, my neighbor Sharon, then 52, did a “Flintstone front brake” (remember how Fred Flintstone stopped his stone car by dragging his heels? Yup, that one) and broke her right foot.

Her doctor frowned. “Something’s off,” he told her. A bone density study later, she was diagnosed with osteoporosis.

Two years ago, an infection caused a dental implant to fall off. Sharon became alarmed when two dentists refused to operate on her because she’d been on “antiresorptive medications” for osteoporosis for 12 years.

Sharon – and four out of 10 white females in the U.S. – will experience a spine, hip or wrist fracture sometime in their lifetimes; the rate is 13 percent for white male per the Centers for Disease Control and Prevention.

Currently we have five classes of drugs to choose from: bisphosphonates, denosumab, parathyroid hormone, raloxifene and estrogens. All except parathyroid hormone are considered antiresorptive; that is, they retard the erosion of the bone matrix. Parathyroid hormone stimulates bone growth.

These drugs, given as a daily pill or yearly injection, are exceptionally accommodating. Doctors recommend starting with a bisphosphonate, like alendronate, a once-weekly pill. For a month supply, generic starts at $6.36 on; brand name starts at $135.50. Low-risk individuals (those without fracture and better bone density scores) can take it for a few years and get off for a few years. The benefits are long-lasting.

Sharon was placed on estrogen, then bisphosphonate, then denosumab (a twice-yearly injection). Easy and getting easier. Her bone density stabilized.

So, what’s the scare?

For Sharon’s dentists – osteonecrosis of the jaw. And there’s the nasty atypical femur fracture.

Osteonecrosis is localized dead bone, usually in the jaw triggered by dental procedures. Most cases are reported in cancer patients who receive high-dose bisphosphonates for bone complications.

Antiresorptive medications have also been associated with an unusual femur (thigh bone) fracture which breaks at the bone shaft, a much worse fracture than the osteoporosis-associated hip fracture.

But in treating osteoporosis, the medications are low dose. Complications are rare. Every year, atypical femur fractures occur in 3 to 50 per 100,000 patients treated. Osteonecrosis of the jaw is even rarer.

The balance sheet: By treating 1,000 women with osteoporosis with antiresorptive agents for three years, doctors can expect one atypical femur fracture while averting 100 osteoporotic fractures.

Sure, targeted treatment for osteoporosis is young and still evolving, but the compliance rate has gone, undeservedly, from bad to swan-dive-into-the-tar-pits worse. A study shows initiation of osteoporosis medications after hip fractures – the group with the most to gain – went from 9.8 percent in 2004 to 3.3 percent in 2015.

Sharon’s third oral surgeon stated correctly, “Things happen ... the risk is minuscule.” He fixed her tooth and allowed her back on her injection. 

At 5 feet 1 inch tall and 110 pounds, Sharon, a-pack-a-day smoker, wasn’t surprised when diagnosed with osteoporosis. Her mother and grandmother had it, too. She sighed. “I have all the risk factors.”

I’m mum. It takes a page to list all the risk factors associated with osteoporosis. She’s cut down smoking significantly. Eh, some fear is healthy.

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Volume 10, Issue 18, Posted 10:13 AM, 09.18.2018