Under US guidelines for the prevention of osteoporosis, up to three quarters of white women aged over 65 years have become candidates for drug treatment, says a leading orthopedic specialist – but most hip fractures occur in those without the disease.
Prof. Teppo Järvinen has written an opinion piece with colleagues in The BMJ to say that drug treatment “can achieve at best a marginal reduction in hip fractures at the cost of unnecessary harms and considerable waste of monetary resources.”
The article is part of the journal’s campaign to highlight “the threat to human health and the waste of resources caused by unnecessary care.”
The authors cite a review of the evidence to show that 175 postmenopausal women with bone fragility must be treated for about 3 years to prevent one hip fracture.
The mainstay of drug treatment aimed at preventing osteoporosis is a group of agents known as bisphosphonates sold under the following US brand names: Actonel, Actonel+Ca, Aredia, Boniva, Didronel, Fosamax, Fosamax+D, Reclast, Skelid and Zometa.
The harms to patients of overdiagnosis and overtreatment, says the article, include adverse events associated with drug treatment, “such as gastrointestinal problems, atypical femoral fractures, and osteonecrosis of the jaw” in addition to the “imposed psychological burden” of a raised worry about fracture when the diagnosis of higher risk is made.
The authors choose a damning conclusion: “The dominant approach to hip fracture prevention is neither viable as a public health strategy nor cost-effective.” They add:
“Pharmacotherapy can achieve at best a marginal reduction in hip fractures at the cost of unnecessary psychological harms, serious medical adverse events, and forgone opportunities to have greater impacts on the health of older people.
As such, it is an intellectual fallacy we will live to regret.”
The US guidelines cited by the authors as leading to “overdiagnosis” are produced by the National Osteoporosis Foundation (NOF).
- Postmenopausal women are most likely to get osteoporosis, but it also affects men and younger people.
- Fractures are most likely in the spine, hip and wrists.
- Diagnosis is made directly via a special X-ray-based scan, but sometimes ultrasound.
While these do place importance on diagnosis and on doctors offering “counsel on the risk of osteoporosis and related fractures,” along with pharmacotherapy recommendations, they do also place emphasis on lifestyle and other non-drug measures to reduce risk, including:
- Diet with adequate calcium intake (for men aged 50 to 70 years, 1,000 mg a day, and for women 51 years and older and men 71 and older, 1,200 mg a day)
- Adequate vitamin D intake, including via supplements if needed for men and women aged 50 years and older (800-1,000 IU a day)
- Regular weight-bearing and muscle-strengthening exercise to improve agility, strength, posture and balance
- Giving up smoking and avoiding excessive alcohol intake.
The national recommendations also urge doctors to assess risk factors for falls and instigate “appropriate modifications” where needed – home safety, balance training exercises, review of medications and visual correction are the examples given that may need attention.
On behalf of Prof. Järvinen, of the orthopedics and traumatology department and the Central Hospital at the University of Helsinki in Finland, and his coauthors, The BMJ explains that hip fractures number about 1.5 million worldwide annually and impose an “enormous burden on health care resources.” Their incidence is predicted to rise with growing elderly populations.
Osteoporosis was previously diagnosed only after a bone fracture had occurred, but a new definition was introduced in 1994 based on low bone mineral density – the aim being to identify people at increased fracture risk who were likely to benefit from bone-building drugs.
The authors say that fracture risk calculators now classify 72% of US white women aged over 65 years and 93% of those aged over 75 years as candidates for long-term drug treatment.
Yet most hip fractures, they say, have more to do with falls in frail older people and little to do with osteoporosis. Regardless of access to drugs, rates of hip fracture have also steadily fallen in most western countries.
The opinion article also scrutinizes the practice of using dietary supplements: “Recent evidence also challenges the justification for the general use of calcium and vitamin D supplementation to prevent fractures.”
There is more advice on prevention of osteoporosis and health living from the NOF. The US regulator’s latest drug safety