Osteoporosis and fracture: the myths and facts of prediction and prevention
General Health One in two women over the age of 50 will have an osteoporosis related fracture in their lifetime but the good news is that fracture risk can both be predicted and in many cases safely prevented.
Osteoporosis is one of those conditions which some disreputable or frankly ignorant publishers try to convince their readers is a figment of the imagination of the pharmaceutical companies, invented solely to sell their dangerous products. Try telling that to the lady in her sixties who has lost 4 or 5 inches in height, has developed a severe stoop and has constant back pain! The osteoporosis issue is not that it does not exist but that it is quite simply a risk factor for fractures such as those in the spine or hip that cause so much pain and deformity.
Predicting or detecting those at risk
So how can the fractures be predicted? Clinical risk factors which include, amongst many others, an early menopause (less than the age of 45), a family history of hip fracture and smoking, can be detected by online risk calculators such as the FRAX calculator but often that is not enough to ensure safe use of drugs to prevent fractures. A measurement of bone density (DEXA scan) of the spine and hips at any time after the age of 40 can significantly improve individual risk assessment and allow targeting of treatment advice. A challenge however has been predicting or detecting those at risk of vertebral or spine fractures which are often “silent” in that they occur without pain and do not present until the patient presents with a stoop or loss of height often noted when the individual cannot reach high cupboards in their kitchen! However the best DEXA services now offer a scan from the side which allows the detection of vertebral fractures. A further issue with spine DEXA scans has been that as we get older we often develop wear and tear changes in our back which interfere with the measurement of bone density. A recent add-on tool called Trabecular Bone Score which is available at some NHS DEXA scanning units and at 25 Harley Street can improve the prediction of vertebral fractures and is not influenced to the same extent by those wear and tear changes which we sadly all get in time.
So can treatments in those found to be at significant risk be given safely and effectively? The answer is undoubtedly YES with the benefits of therapy far out-weighing the risks of the drugs used. It would be good if non-drug therapy such as diet and exercise was enough but sadly that is not the case in those at high risk. However for good bone health both men and women should ensure they get enough vitamin D from the sun and supplements combined (at least 400 IU daily as a standard for all adults and 800 IU for those with osteoporosis risk) along with moderate dietary calcium and as much weight bearing exercise as possible.
Drug treatment for prevention and treatment has suffered recently from scare stories which, while they should not be ignored, can be easily minimized with sensible prescribing. It is almost certainly these scare stories which have driven down prescriptions for osteoporosis therapies both in the UK and USA in recent years. A continuation of this trend will lead to increased fracture rates with concomitant suffering in years to come and must be halted.
HRT, which used to be first line therapy in women, has suffered from the “bad press” issue. However many experts would now agree that it can be used safely up until the age of about 60 without significant excess risk of heart attacks, strokes or invasive breast cancer - some specialists would say that some preparations of HRT can be used for a much longer period.
Bisphosphonates are the main group of drugs used in those who do not wish HRT but these, along with another drug which works in a similar way on bone, denosumab, have also suffered from bad press due to 2 issues. One is a rather unpleasant problem with poorly healing mouth ulceration in those having operative dental treatments (osteonecrosis of the jaw or ONJ) and the second very unusual fractures in the thigh below the hip, termed atypical femoral fractures (AFF). However, these rare but real adverse effects need to be considered in perspective. It has been estimated that ONJ occurs in between 1 in 10,000 and 100,000 patients taking bisphosphonates for osteoporosis for up to 5 years and even in those taking it in more than 5 years the likely rate of occurrence is likely to be around 1 in 1000 users. An AFF has been estimated to occur in less than 1 case for every 100 hip fractures prevented by denosumab or the bisphosphonates. A new technique based on DEXA scanning of the long long thigh bone may be able to detect patients at risk of AFF allowing treatment to be stopped before this very rare fracture occurs.
So let’s put the risks of treatment in perspective – they are extremely low compared to the risk of osteoporotic fracture. Therefore the message must be get screened for risk and if the risk is high get treated to prevent the misery and ageing effect of fractures.