With a new year upon us, I am hoping we get a rest from Sally Field’s perky voice on television. You know, the voice that reminds us there is “something about osteoporosis that you might not know” while selling us on her favorite osteoporosis treatment. You know those ads; they appear almost nightly on our TV screens and in magazines. As a postmenopausal woman at risk for osteoporosis and a practitioner who has cared for elderly women for almost thirty years, I DO care a lot about this disease. But I don’t care for the commercials.
So why am I so annoyed?
Sally Field’s message is confusing and misleading. A few years back when the ads first began, I seem to remember she stated that she had low bone mass or osteopenia. She was taking the drug at that time to improve or strengthen her bones. She is now saying that she has osteoporosis. So if my memory about her initial problem is correct, her bones must have gotten worse over the years! The distinction between osteopenia and osteoporosis may sound subtle but it is important.
Osteopenia simply means lower than average bone mass when compared to a healthy 35 year-old woman. Osteopenia is not a disease that needs to be treated with medication. Knowing I have low bone mass (I confess I have low bone mass on my bone density test) gives me a baseline reference point and a reminder to me that plenty of calcium, vitamin D and physical exercise is in order. It should also remind us to check our medications. Thyroid hormone replacement, steroids (such as prednisone) and seizure medication such as dilantin can all lower our bone mass. Osteopenia is not a reason to take once-monthly medication. There is no doubt that (the type of medication Ms. Field’s is advertising) are beneficial to older women with osteoporosis. They can reduce the risk of potentially painful spine or vertebral fractures by 50% or more and reduce to a lesser degree the risk of a disabling hip and other osteoporosis fractures as well.
Not only can these drugs irritate the esophagus and cause gastrointestinal upset, they can cause mild diffuse aches and pains and other complaints. Rarely one can develop a deterioration or painful breakdown or “necrosis” of the jaw bone (this occurs primarily in women who have had dental surgery or dental trauma). A rare almost spontaneous fracture of the thigh bone of the leg (the femur) or even difficulty in healing a bone after a fracture have also been linked to long term use of these medications. These latter complications are rarely discussed.
Because these spontaneous fractures and difficulty with healing fractures occurs primarily in women who have taken the drug for five years or more, many experts are suggesting that women take a “drug holiday” after five years of use.
A drug holiday means that women stop the drug after five years. They are then advised to resume the drugs only when or if special bone tests suggest they are losing bone rapidly again. Studies have shown that many women maintain their bone density and protection from fractures for at least the first year after they stop the medication. Many women are likely to have continued protection for a very long time. These drugs are absorbed into the bone and can stay there for months to years even after stopping the drugs altogether. So missing a weekly or monthly dose once in a while probably doesn’t make much difference either.
Why do these rare almost spontaneous fractures occur? Although no one knows for certain, here is the leading theory. The main effect of these drugs is to stop bone from breaking down which means to stop bone loss. But they also can impair the mineralization or calcium-fueled build up of bone. For some women the competing effect of preventing bones from mineralizing or strengthening is greater than preventing bone breakdown to the stress or “fragility” fractures that seem almost spontaneous without a preceding fall or trauma.
Ms. Field’s also suggests in the ad that taking a pill once monthly is so much easier than swallowing a pill weekly and therefore is much better. I agree that compliance is always an issue for any medication – and if women will be more compliant taking a monthly pill than a weekly pill then I am all for it. However I know of no good studies comparing both methods. I suspect women are much more likely to not take these pills because of the cost, side effects, or worries about long term risks. If you are committed to the benefits of a medication, taking it only once a week seems pretty easy to me. And as to cost, a once monthly pill can cost four times or more the amount of a once weekly pill so it doesn’t save you any money either.
Better that these nightly ads spend the time to educate us about the disease osteoporosis. They could also teach us how to prevent osteoporosis in the first place. Selling us all on a “one size fits all” medication approach for postmenopausal women (after all, many if not most women will have some bone loss as they age and many will be diagnosed with osteopenia) makes no sense and could be dangerous.
1) Who will benefit most from these drugs? Elderly women with a previous history of an osteoporosis fracture and women on steroids may benefit the most. Women with osteopenia or low bone mass will receive little if any benefit.
5) When should you alert your doctor about possible side effects and any upcoming dental surgery? Perhaps stopping the drug for an extended period of time before elective dental surgery would make sense. Ask your dentist about this.
Two other interesting points I would like to mention. Many people are taking the powerful acid blocking drugs referred to as PPI’s or proton pump inhibitors. These drugs are thought to increase the risk of low bone mass after 2 or more years of use and potentially lead to osteoporosis and bone fractures as well. These drugs are taken by millions of patients and are usually prescribed for the short-term treatment of an ulcer or acid reflux disease. For the patients that require long term treatment with an acid blocking drug for a Barrett’s esophagus or other serious condition, talk to your doctor about the ways you can monitor and avoid low bone mass.
The second point: a recent study found that women on bisphosphonates had a lower risk of breast cancer. This came to me as no surprise as the early Fracture Intervention Trials found that the women with the lowest bone mass density also had the lowest estrogen levels. Estrogen is important in preserving bone mass by preventing bone break down and encouraging bone build up. Women with lower estrogen have the benefit of a reduced risk of the most common estrogen sensitive breast cancers yet unfortunately the added risk of a lower bone density and higher fracture risk. Although more study is needed, I doubt that taking bisphosphonates will lower the risk of breast cancer through some yet to be discovered effect on the breast…but stay tuned. I wouldn’t take these drugs solely to prevent breast cancer.
For now, I am encouraging every women in 2010 to get to know all she can about how best to keep her bones strong and healthy for as long as possible. A disabling hip fracture or painful spinal fracture from osteoporosis can jeopardize a woman’s independence and change her life. I have learned in my practice that a hip fracture is something more dreaded by elderly women than even breast cancer or heart disease. For any woman considering a bisphosphonate, learn all you can about the medication. Review the questions I mention above. Make sure the treatment makes sense for you. And then only stay on it as long as you need to take it – no longer.
How long has Sally Field’s been taking her preferred osteoporosis drug? Maybe five years will soon be up and her doctor will suggest she can stop. A pleasant thought for Ms. Field’s I hope. Will she disappear from our television screens and popular magazines? For all women (and men for that matter), the prevention and best treatment of osteoporosis should remain top of mind.