Medicine For People!

June 2010

Bone Health, the Final Wrap-Up

This is the last of our series of newsletter articles on bone health. Here's what we've covered so far:

Best Bets for Strong Bones

In this final article, I give you my recommendations for maintaining strong bones and avoiding fractures. The most important step toward healthy bones is exercise. Prescription drugs come at the end of the list.

Exercise for Strength and Balance

Force applied to a bone causes microscopic bending, called strain. This produces electrical fields which enhance bone formation.1 Recommended exercises include stair-climbing, jogging, weight lifting, and games which involve jumping and running. Do these three to five days a week, a half-hour per day. As far as we can tell, moderate to vigorous physical activity reduces the risk of fracture by about half,2 which matches the best you can expect from medication. Strain on your bones builds them up a great deal more effectively than a slow, leisurely walk, which seems to have little measurable effect.

You can also benefit from activities which improve your flexibility and balance. Balance exercises include simple standing leg lifts as well as balance poses in Pilates and yoga. When you reinforce your natural ability to maintain equilibrium and balance, the addition of strength and stretch activities will make you less likely to fall less. And if you do fall, you'll fall like a young person, and bounce up again. If you think your bones have lost strength, be sure your home has been "fall-proofed" by removing throw rugs and obstructions, installing any needed hand-rails or grab-bars, and installing good lighting. If you think you are really at risk, you can purchase a hip-protector to help cushion a fall.

Nutrients for Bone Strength

Strontium

Strontium is a naturally occurring mineral. We have no nutritional requirement for strontium, nor is there much of it in food, but it has been apparent for the past century that it strengthens bone. The recent research has all been done on strontium ranelate, but other strontium salts such as strontium citrate should be just as effective. We absorb minerals best when they are combined with an acid to form a salt. Some years ago, pharmaceutical workers combined strontium with ranelic acid to form strontium ranelate which strengthens bones in clinical trials. European physicians prescribe strontium ranelate for osteoporosis, though it is under patent protection and not available in the US. Here, we use strontium citrate since it is available as a supplement.

Is Strontium Safe?

There are no studies on the safety of strontium and some doctors warn that strontium citrate may be dangerous. But over a million of tons of citric acid are consumed annually worldwide, and over a hundred years of experience with strontium have found only minor GI disturbances as adverse effects. Further, the ranelic acid in sodium ranelate appears to have no physiologic effect, being largely excreted unchanged. Strontium ranelate and strontium citrate have similar solubility so should behave similarly in the body According to a manufacturer's safety sheet, a milligram of strontium ranelate dissolves in 3.7 ml of water, so 2000 mg dissolves in 540 ml of water, about two cups. See also

What does strontium ranelate do? It increases the formation of bone and simultaneously reduces its destruction. It reduces fractures, including the hip, in women between the ages of 50 and 80 regardless of DEXA results and other risk factors It has been shown effective for up to five years and, in Europe, is a first line treatment for osteoporosis.3

The recommended dosage of strontium citrate is two capsules at bedtime, 340 mg per capsule, which equals the European recommended dose of strontium ranelate.

Vitamin D

Vitamin D will not prevent fractures in those who already have plenty of vitamin D in their blood, but for those who are low, it will not only prevent fracture but bring many other benefits as well. In people over 65 years of age, those with vitamin D blood levels greater than 24 mg/ml broke bones at just half the rate of those with lower levels4. You can have your vitamin D levels measured and supplement if necessary or work at getting more exposure to the sun. For more information, see the previous newsletters for February and March.

Calcium

Having adequate vitamin D does not decrease our requirement for calcium.5 Optimal calcium intake varies with diet, so see our previous newsletter for a short summary. You can take supplements of calcium citrate and also seek calcium-rich foods such as spinach and beans.

Vitamin K

Vitamin K, like vitamin D, reduces fracture risk only if levels are low, so various studies have shown varying results.6 Vitamin K is required for the function of osteocalcin, an enzyme that lays down calcium in the bone, so loss of bone strength occurs with vitamin K deficiency. Vitamin K also affects energy regulation, though animal and human responses are different, and the processes are still unclear. It may be that vitamin K enhances our ability to exercise. Women taking anti-coagulant medication know not to take vitamin K without medical advice; for others, a daily dose of up 250 to 1000 micrograms is reasonable, because not all of us absorb fat-soluble vitamins, such as vitamin K, adequately. Leafy green vegetables are high in vitamin K.

Prescription Drugs That Strengthen Bones

Bisphosphonates

Bisphosphonates are the most commonly prescribed family of pharmaceuticals for osteoporosis and osteopenia. They include alendronate (Fosamax), ibandronate (Boniva), and risedronate (Actonel). Many studies have been conducted on these medications, especially alendronate, and the results vary and sometimes contradict one another. According to The Cochrane Collaboration7 (a non-profit organization which publishes summaries of the medical literature to make sense of the flood of often contradictory trials of medical treatments), the following results8 are clear:

  1. If a woman has already suffered a vertebral compression fracture or had a DEXA result below 2.5, then alendronate "may" prevent further fractures, but if she does not fall into that category, it probably does not9. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001155/frame.html Alendronate does not significantly reduce fractures in healthy women with low DEXA scores.10
  2. Alendronate has been shown generally safe for up to five years use in many studies. Recent studies have extended that to ten years, with fracture reduction only in women with a DEXA in the osteoporotic range11. Other studies seem to indicate that five years provides optimal benefit12 which wanes over time.13
  3. We have taken pains in previous newsletters to point out that DEXA has faults, and is just one of many risk factors. I mention DEXA here because all studies on treatments for bone strength rely heavily on it.

Treat Many Women – Help Very Few

Medication, such as alendronate, cannot prevent a fracture in all women that take it because not all women are going to get a fracture. In the table below, in the row labeled "Any clinical" (which means any fracture you know about, which excludes many vertebral fractures because often these are silent), you see that you need to treat 13 women who have an existing vertebral fracture to prevent one additional noticeable fracture. Twelve of the women you treat will experience no benefit other than, perhaps, relative peace of mind. And if you treat women without osteoporosis based on DEXA scan scores and without an existing vertebral fracture, you have to treat 66 of them to prevent one hip fracture.

Table from J Clin Endocrinol Metab 85: 4118–4124, 2000) rx risk reduction 4118.pdf

Raloxifene

Raloxifene (Evista) is a prescription pharmaceutical that selectively modulates the estrogen receptor. While FDA approved for fracture prevention, a 2008 study14 concluded "Treatment with raloxifene for 5 yr reduced the risk of clinical vertebral fractures, but not nonvertebral fractures, irrespective of the presence or absence of risk factors for fracture." In other words, it may help prevent spinal fractures but does not reduce hip fracture.

Bottom line –what can you do?

  • First, take some time to get outside and exercise.
  • Next, be sure you have adequate vitamin D. If you haven't had your levels checked, 4000 to 5000 units a day is a ballpark figure for our Northwestern area of the world.
  • Calcium, be sure you get 800 to 1000 milligrams a day supplemental.
  • Eat a variety of fresh fruits, vegetables, and proteins, freshly prepared. A daily multiple vitamin mineral (containing boron, magnesium, vitamin K) will not substitute for healthy foods, but can lessen the hit if good eating isn't part of your life.
  • If you have some of the risk factors we discussed last month, or have had a suspicious fracture already, or a really low DEXA score that you don't think is a mistake, talk to your doctor about the advisability of a weekly dose of alendronate.
  • As you know, many doctors recommend plenty of vodka and cigarettes, but unfortunately, these are not good for your bones. So, ignore those doctors.

Conclusion to series on bone strength

This being the last of our series on bone strength, let's review our main points.

  1. DEXA scans, even at their best, imperfectly predict future fractures15 and are of limited benefit in assessing the efficacy of medication.16
  2. With any preventive treatment, most people tend to lose enthusiasm for buying and taking the treatment as time passes, and fracture prevention is no exception. Indeed, that observation stimulated this series of newsletters, because understanding nourishes adherence to healthful lifestyle. Your physician's job is not just to write a prescription, but to collaborate with you to work out an individual plan that you understand and are comfortable with, including to:
    1. Carefully consider the need for DEXA scans and other measures of bone health, such as urinary tests, specific for your individual situation.17
    2. Consider the chances a prescription may help, and the cost will be over the years.18
    3. Ensure that treatment is simple. For example, non-prescription measures do not require physician visits. Exercise serves purposes other than just bone preservation.
  3. If a doctor in a hurry writes you a prescription for a pharmaceutical based only upon a DEXA scan, remind yourself that if you could magically normalize your bone mass, you would still not eliminate osteoporotic fractures.19 In a population there would be fewer such fractures, but there would still be many. Long life has a price, and fragile bones, for many people, are part of the price. Yet, despite the inexorable toll of time, you control what you put in your mouth and how you spend your hours. With those tools you can maintain good bone health for many decades.

Go now, get out there and put some strain on those bones!

Endnotes

1 Exercise and the preservation of bone health.

Barry DW, Kohrt WM.

J Cardiopulm Rehabil Prev. 2008 May-Jun;28(3):153-62.

Division of General Internal Medicine, Department of Medicine, University of Colorado Denver, Aurora, CO 80045, USA.

Exercise is generally accepted as having favorable effects on bone health and, subsequently, a reduction in fracture risk. In the absence of large randomized controlled trials of the potential benefits of exercise on fracture risk, support for this belief comes from cross-sectional studies and interventional studies using surrogate endpoints such as bone mineral density and falls. In this review, we discuss the characteristics of exercise programs that provide an osteogenic stimulus. The goals and benefits of exercise on bone across the age spectrum are discussed. Where there is a paucity of human data, animal studies examining the roles of variables such as exercise intensity, frequency, duration, and mode in shaping the response of bone to exercise are discussed. The effects of disuse and the limited response of bone to remobilization are described. The rapid and dramatic decrease in bone mineral density observed in the early period after heart or lung transplantation is discussed, as are the available data on the benefits of exercise on bone in this population. For cardiopulmonary rehabilitation programs to improve bone health, they should include not just weight-supported activities (eg, cycling) but also weight-bearing activities (eg, walking, resistance exercise). Although the optimal exercise routine for bone health is unknown, components of an osteogenic program are discussed.

2 The association between physical activity and osteoporotic fractures: a review of the evidence and implications for future research.

Moayyeri A.

Ann Epidemiol. 2008 Nov;18(11):827-35. Epub 2008 Sep 21.

Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, UK. am700@cam.ac.uk

PURPOSE: Physical activity helps maintain mobility, physical functioning, bone mineral density (BMD), muscle strength, balance and, therefore, may help prevent falls and fractures among the elderly. Meanwhile, it is theoretically possible that physical activity increases risk of fractures as it may increase risk of falls and has only a modest effect on BMD. This review aims to assess the potential causal association between physical activity and osteoporotic fractures from an epidemiological viewpoint. METHODS: As the medical literature lacks direct evidence from randomized controlled trials (RCTs) with fracture end points, a meta-analysis of 13 prospective cohort studies with hip fracture end point is presented. The current evidence base regarding the link between exercise and fracture risk determinants (namely, falls, BMD, and bone quality) are also summarized. RESulTS: Moderate-to-vigorous physical activity is associated with a hip fracture risk reduction of 45% (95% CI, 31-56%) and 38% (95% CI, 31-44%), respectively, among men and women. Risk of falling is suggested to be generally reduced among physically active people with a potential increased risk in the most active and inactive people. Positive effects of physical activity on BMD and bone quality are of a questionable magnitude for reduction of fracture risk. CONCLUSION: The complexity of relationship between physical activity and osteoporotic fractures points out to the need for RCTs to be conducted with fractures as the primary end point.

3 Current Osteoporosis Reports 2009, 7:96–102

4 Serum 25-Hydroxyvitamin D and Hip Fracture Risk in Older U.S.

White Adults

Anne C Looker and Michael E Mussolino

ABSTRACT: We used serum 25(OH)D data from NHANES III and incident hip fracture cases identified using linked mortality and Medicare records, and found that serum 25(OH)D was significantly related to reduced hip fracture risk in non-Hispanic white adults 65 yr of age or older.

Introduction: The role of vitamin D status in reducing fracture risk is unclear. We examined the relationship between serum 25 hydroxyvitamin D [25(OH)D] and incident hip fracture risk in older non-Hispanic white adults.

Materials and Methods: The study sample consisted of 1917 white men and women 65 yr of age who were examined in the third National Health and Nutrition Examination Survey (NHANES III, 1988–1994), a nationally representative survey. Incident hip fractures were ascertained using linked mortality and Medicare records that were obtained for NHANES III participants. Serum 25(OH)D values were measured with a radioimmunoassay kit. Cox proportional hazards models were used to estimate the relative risk (RR) of hip fracture by serum 25(OH)D level.

Results: There were 156 incident hip fracture cases in the sample. Cases were older, had lower BMD and body mass index, more prevalent spine or wrist fractures and weight loss before baseline, and ate fewer kilocalories and less calcium than noncases. After adjusting for these differences, serum 25(OH)D values exceeding 60 nM were significantly related to hip fracture risk. For example, the multivariate-adjusted RR was 0.64 (95% CI, 0.46–0.89) among individuals with serum 25(OH)D values 62.5 nM compared with those with values below this level. When grouped into quartiles, the multivariate-adjusted RR for the second, third, and fourth versus the first quartile of serum 25(OH)D were 0.50 (95% CI, 0.25–1.00), 0.41 (95% CI, 0.24–0.70), and 0.50 (95% CI, 0.29–0.86), respectively.

Conclusions: Serum 25(OH)D was related to a significantly lower hip fracture risk in this cohort of older white adults, even after adjusting for several relevant confounding variables. The relationship did not seem to be linear across all values. Our results support other studies suggesting that serum 25(OH)D values exceeding 60 nM are associated with health benefits.

JOURNAL OF BONE AND MINERAL RESEARCH

Volume 23, Number 1, 2008

Published online on October 1, 2007; doi: 10.1359/JBMR.071003

5 Misconceptions –Vitamin D insufficiency causes malabsorption of calcium

Allan G. Need, B.E. Christopher Nordin Bone 42 (2008) 1021–1024

The Division of Clinical Biochemistry, Institute of Medical and Veterinary Science, the Department of Medicine, University of Adelaide and the Hanson Institute,

Adelaide, South Australia 5000, Australia

Received 13 July 2007; revised 16 November 2007; accepted 21 January 2008

Available online 9 February 2008

Abstract

The negative effect of vitamin D insufficiency on bone is commonly attributed to a decrease in calcium absorption although little evidence has

been produced to support this assumption. Using two previously published series of elderly patients we refute this common assumption and

present evidence that low circulating levels of 25 hydroxyvitamin D have a direct and deleterious effect on bone.

Crown Copyright © 2008 Published by Elsevier Inc.

6 Vitamin K to prevent fractures in older women: systematic review and economic evaluation

Health Technol Assess 2009;13(45):1–158

http://www.hta.ac.uk/fullmono/mon1345.pdf

M Stevenson,* M Lloyd-Jones and D Papaioannou

University of Sheffield, School of Health and Related Research (ScHARR), UK

Results mixed, some showed reduction of up to 50%, others no reduction in fracture.

8 Quoting from the Cochrane summary:

"The best estimate of what happens to women that have already been diagnosed with low bone density or have already had a fracture in the bones of their spine:

Fracture of the spine

- 12 out of 100 women had a fracture when taking a placebo

- 6 out of 100 women had a fracture when taking alendronate

Fracture in the hip or wrist

- 2 out of 100 women had a fracture when taking a placebo

- 1 out of 100 women had a fracture when taking alendronate

Fractures in bones other than the spine

- 9 out of 100 women had a fracture when taking a placebo

- 7 out of 100 women had a fracture when taking alendronate

The best estimate of what happens to women whose bone density is closer to normal or who may not yet have had a fracture in the bones of their spine:

Fracture of the spine

- 3 out of 100 women had a fracture when taking a placebo

- 1 out of 100 women had a fracture when taking alendronate

Fractures in bones other than the spine:

- 1 out of 100 women had a hip fracture when taking a placebo

- 1 out of 100 women had a hip fracture when taking alendronate

- 3 out of 100 women had a wrist fracture when taking a placebo

- 4 out of 100 women had a wrist fracture when taking alendronate

- 13 out of 100 women had a fracture somewhere other than the spine when taking a placebo

- 12 out of 100 women had a fracture somewhere other than the spine when taking alendronate"

9 Alendronate for preventing fractures caused by osteoporosis in postmenopausal women

This summary of a Cochrane review presents what we know from research about the effect of alendronate for preventing fractures

(broken bones) caused by osteoporosis.

In women who have already been diagnosed with low bone density, putting them at risk for a fracture, or have already had a

fracture in the bones of their spine, alendronate:

- may prevent fractures in the spine, hip or wrist, or in bones other than the spine.

In women whose bone density is closer to normal, or who may not yet have had a fracture in the bones of their spine, alendronate:

- probably prevents fractures in the spine

- probably leads to no difference in fractures of the hip, wrist or bones other than the spine.

10 JAMA. 1998;280(24):2119-2120

11 Efficacy of continued alendronate for fractures in women with and without prevalent vertebral fracture: The FLEX trial.

Schwartz AV, Bauer DC, Cummings SR, Cauley JA, Ensrud KE, Palermo L, Wallace RB, Hochberg MC, Feldstein AC, Lombardi A, Black DM; for the FLEX Research Group.

J Bone Miner Res. 2010 Jan 8; [Epub ahead of print]

University of California, San Francisco, San Francisco, CA, USA.

In the FIT Long Term Extension (FLEX) trial, 10 years of alendronate (ALN) did not significantly reduce the risk of non-vertebral fractures (NVF), compared with 5 years of ALN. Continuing ALN reduced the risk of clinical, but not morphometric, vertebral fractures, regardless of baseline vertebral fracture status. In previous studies, ALN efficacy for NVF prevention in women without prevalent vertebral fracture was limited to those with femoral neck (FN) T-score </= -2.5. To determine whether the effect of long-term ALN on fracture differs by vertebral fracture status and femoral neck (FN) T-score, we performed a post hoc analysis using FLEX data, a randomized double-blind placebo-controlled trial among 1,099 postmenopausal women originally randomized to ALN in FIT with mean ALN use of 5 years. In FLEX women were randomized to placebo (40%) or ALN 5 (30%) or 10 (30%) mg/d for an additional 5 years. Among women without vertebral fracture at FLEX baseline (N = 720), continuation of ALN reduced NVF in women with FLEX baseline FN T-score </= -2.5 (RR 0.50; 95% CI 0.26-0.96) but not with T-score > -2.5 and </= -2 (RR 0.79; 95% CI 0.37-1.66) or with T-score > -2 (RR 1.41; 95% CI 0.75-2.66) (p for interaction 0.019). Continuing alendronate for 10 years instead of stopping after 5 years reduces non-vertebral fracture risk in women without prevalent vertebral fracture whose FN T-score, achieved after 5 years of ALN, is </= -2.5, but does not reduce risk of NVF in women whose T-score is > -2.

12 The optimal duration of treatment of women with postmenopausal osteoporosis is uncertain. Objective To compare the effects of discontinuing alendronate treatment after 5 years vs continuing for 10 years. Design and Setting Randomized, double-blind trial conducted at 10 US clinical centers that participated in the Fracture Intervention Trial (FIT). Participants One thousand ninety-nine postmenopausal women who had been randomized to alendronate in FIT, with a mean of 5 years of prior alendronate treatment. Intervention Randomization to alendronate, 5 mg/d (n=329) or 10 mg/d (n=333), or placebo (n=437) for 5 years (1998-2003). Main Outcome Measures The primary outcome measure was total hip bone mineral density (BMD); secondary measures wereBMDat other sites and biochemical markers of bone remodeling. An exploratory outcome measure was fracture incidence. Results Compared with continuing alendronate, switching to placebo for 5 years resulted in declines in BMD at the total hip (-2.4%; 95% confidence interval [CI], -2.9% to -1.8%; P .001) and spine (-3.7%; 95% CI, -4.5% to -3.0%; P .001), but mean levels remained at or above pretreatment levels 10 years earlier. Similarly, those discontinuing alendronate had increased serum markers of bone turnover compared with continuing alendronate: 55.6% (P .001) for C-telopeptide of type 1 collagen, 59.5% (P .001) for serum N=propeptide of type 1 collagen, and 28.1% (P .001) for bonespecific alkaline phosphatase, but after 5 years without therapy, bone marker levels remained somewhat below pretreatment levels 10 years earlier. After 5 years, the cumulative risk of nonvertebral fractures (RR, 1.00; 95% CI, 0.76-1.32) was not significantly different between those continuing (19%) and discontinuing (18.9%) alendronate. Among those who continued, there was a significantly lower risk of clinically recognized vertebral fractures (5.3% for placebo and 2.4% for alendronate; RR, 0.45; 95% CI, 0.24-0.85) but no significant reduction in morphometric vertebral fractures (11.3% for placebo and 9.8% for alendronate; RR, 0.86; 95% CI, 0.60-1.22). A small sample of 18 transilial bone biopsies did not show any qualitative abnormalities, with bone turnover (double labeling) seen in all specimens. Conclusions Women who discontinued alendronate after 5 years showed a moderate decline in BMD and a gradual rise in biochemical markers but no higher fracture risk other than for clinical vertebral fractures compared with those who continued alendronate. These results suggest that for many women, discontinuation of alendronate for up to 5 years does not appear to significantly increase fracture risk. However, women at very high risk of clinical vertebral fractures may benefit by continuing beyond 5 years. Trial Registration clinicaltrials.gov Identifier: NCT 00398931 JAMA. 2006;296:2927-2938

13 Bisphos waning effect

J Musculoskel Neuron Interact 2002; 2(3):198-200

Perspective Article

How drugs decrease fracture risk:

Lessons from trials

S.R. Cummings

University of California, San Francisco, California, USA

Abstract

In women with osteoporosis, each 1% improvement in spine BMD (by DXA) is expected to reduce vertebral fracture risk by about 4%. However, randomized trials of antiresorptive agents show that 1 to 6% improvements in spine BMD reduce vertebral fracture risk by 35 to 50%. Less than 20% of the decreased spine fracture risk produced by alendronate or raloxifene be explained by improvement in spine BMD. The discrepancy is even greater during the first year or two of treatment when 1 to 4% improvements in BMD are associated with 65-68% decreases in spine fracture risk. Bisphosphonates continue to increase BMD but the reduction in fracture risk wanes to 20 to 45%. DXA underestimates the change in bone density of spinal trabecular bone and this might explain part of the discrepancy between expected and observed reductions in spine fracture risk. Even more accurate measurement of BMD would not explain the rapid onset and later waning of effect despite gradually increasing BMD. The biomechanical effects inhibiting bone resorption could explain the early onset but not the waning effectiveness. The waning effectiveness of antiresorptives raises concerns that prolonged inhibition of remodeling may weaken bone by allowing microdamage to accumulate.

14 Effects of Raloxifene on Fracture Risk in Postmenopausal Women: The Raloxifene Use for The Heart Trial

Kristine E Ensrud, et al

ABSTRACT: Using data from a randomized placebo-controlled trial of 10,101 postmenopausal women not

selected on the basis of osteoporosis, we examined whether the effect of raloxifene treatment on fractures was

consistent across categories of fracture risk. Treatment with raloxifene for 5 yr reduced the risk of clinical

vertebral fractures, but not nonvertebral fractures, irrespective of the presence or absence of risk factors for

fracture. JOURNAL OF BONE AND MINERAL RESEARCH Volume 23, Number 1, 2008

15 On the basis of all the epidemiological evidence, retrospective and prospective, there is at present no scientific case for screening. This poor performance of measurement of bone density as a screening test does not imply that bone density is unimportant in the aetiology of hip fracture, it simply indicates that most elderly women have lost sufficient bone for the hip to fracture with the impact of an unprotected fall. Differences in bone density between individual women are not great enough to discriminate between who will and who will not later suffer a fracture; this will be determined by chance, by conditions that increase the risk of falling or cause loss of the normal protective reflexes, and by illness and immobility causing bone loss shortly before the fracture. BMJ VOLUME 303, 24 AUGUST 1991 "Strategies for prevention of osteoporosis and hip fracture" M R Law, N J Wald, T W Meade

16 BMJ 2009;338:b2266

17 Repeat measures of bone density are in general a poor predictors of treatment value. DEXA scores often under-estimate the benefits of treatment. Nonetheless, they may help some women decide whether or not to continue treatment.

Measures of bone metabolism, such as osteocalcin and procollagen I N-terminal extension peptide (P1NP) assess bone formation, and type I collagen and Ctelopeptide breakdown products (especially serum CTX) assess bone resorption, These have many of the same limitations as DEXA, and are of no help for women on strontium, but have been shown to help women remain in treatment.

18 European medical authorities seem less influenced by industry that do our American counterparts, and more comfortable making decisions based on economic and practical considerations. Most of our patients are more risk averse than US medical authorities, and most have to think about cost. Here are the European guidelines, from the Scientific Advisory Board of the European Society for Clinical and Economic Evaluation of Osteoporosis and Osteoarthritis (ESCEO), in collaboration with the International Osteoporosis Foundation, "European guidance for the diagnosis and management of osteoporosis in postmenopausal women" Osteoporos Int (2008) 19:399–428

.

These are based on

  • population studies showing that a 60 year old woman with a T-score less than -2.5 has about an 8% risk of fracturing a hip in the next ten years, and will have a 22% ten-year risk when she reaches 75.

  • Population studies showing risks as detailed in our May newsletter. Therefore, any woman who has sustained a low-impact fracture, or has been on steroids, or has achieved the age of 80 years, faces a greater likelihood of another fracture, and probably will benefit from preventive treatment regardless of the results of a DEXA scan (remember, we showed that DEXA fails to predict most fractures.)

NB Here is one study showing otherwise.

  • Overall, the incidence of hip fracture among all the women assigned to risedronate was 2.8 percent, as compared with 3.9 percent among those assigned to placebo (relative risk, 0.7; 95 percent confidence interval, 0.6 to 0.9; P=0.02). In the group of women with osteoporosis (those 70 to 79 years old), the incidence of hip fracture among those assigned to risedronate was 1.9 percent, as compared with 3.2 percent among those assigned to placebo (relative risk, 0.6; 95 percent confidence interval, 0.4 to 0.9; P=0.009). In the group of women selected primarily on the basis of nonskeletal risk factors (those at least 80 years of age), the incidence of hip fracture was 4.2 percent among those assigned to risedronate and 5.1 percent among those assigned to placebo (P=0.35). Conclusions Risedronate significantly reduces the risk of hip fracture among elderly women with confirmed osteoporosis but not among elderly women selected primarily on the basis of risk factors other than low bone mineral density. (N Engl J Med 2001; 344:333-40.)

  • "Vitamin D («500 IU daily) was given if the serum 25-hydroxyvitamin D concentration at the time of screening was below 16 ng per milliliter (40 nmol per liter)"

  • "Risedronate treatment reduces the risk of hip fracture among women with osteoporosis, defined as a low bone mineral density at the femoral neck, but it is not more effective than calcium and vitamin D alone in women identified primarily on the basis of clinical risk factors for hip fracture. Women with the most advanced disease (as evidenced by a low bone mineral density at the femoral neck and a history of vertebral fractures) may benefit the most from risedronate treatment."

Source: N Engl J Med 2001; 344:333-40.)

I point this out just for completeness. Studies conflict, and I want you to know I am not brushing information under the rug.

Again, per European recommendations, the most cost-effective medication to reduce fracture rate is alendronate, currently about $80 per year for a once-weekly tablet. For example, women with a previous low-impact fracture starting alendronate between the ages of 55 and 65 will pay about $25,000 per quality-adjusted year of life [http://en.wikipedia.org/wiki/QALY ] gained, whereas past the age of 70 they will most likely pay less for treatment than they would have without it. Women with a T-score less than -2.9 will save money if they are aged 70 or more and smoke, have a family history of fractures, or have been on steroids. Women with a T-score less than -2.9 will save money if they are aged 80 or more and have rheumatoid arthritis or consume more than 3 alcoholic drinks daily. Women with lesser risk factor profiles will not recover their investment in treatment, but, depending on their risks, may purchase better health for about $25,000 or less per quality-adjusted year gained.

19 Annals of Internal Medicine • Volume 128 • Number 4 pg 313

story: 

Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington.