Osteoporosis: the bare bones of it

In 1996, WDDTY claimed that the so-called cures for osteoporosis may actually cause it (WDDTY, vol 6, no 12). Since then, nothing has changed. In fact, the situation has worsened.

Hormone replacement therapy (HRT) has been a disaster, yet GPs continue to prescribe it, despite all the evidence that suggests it increases the risk of breast and endometrial cancers, and that the longer a woman takes it, the greater the risk becomes.

The gain in bone density that occurs in the first few years of HRT use is lost just as quickly after the drug is discontinued (Lancet, 1979; ii: 33; Lancet, 1981; i: 1192-3). Data from the Heart and Estrogen/Progestin Replacement Study (HERS) also suggest that the protection conferred by HRT against fractures may be less effective than previously thought (J Am Med Assoc, 1998; 280: 605-13).

However, the promise of a potentially lucrative market to supply treatment for men as well as women has tempted manufacturers into developing and producing more antiosteoporosis drugs – such as alendronate (Fosamax) and risedronate (Actonel), members of a family of drugs called bisphosphonates – that supposedly slow the breakdown of bone and increase bone density.

As usual, such drugs are being prescribed despite the fact that they are too new for much to be known about them. However, one recent study showed that alendronate caused severe inflammation of the throat (oesophagitis) and concluded that, even when administered properly, the drug needs to be used with caution (Acta Gastroenterol Latinoam, 2001; 31: 103-5).

Raloxifene (Evista), a SERM (selective oestrogen receptor modulator) type of drug, has been shown to produce blood clots in the leg veins (deep venous thrombosis) or in the lungs (pulmonary embolus) (Lancet, 1997; 349: 1748).

The medical profession has still not learned its lesson – that by throwing drugs at osteoporosis, it is merely trading one set of problems for another. Perhaps part of the reason for this is that GPs aren’t taking the condition seriously enough. A National Osteoporosis Society survey (How Fragile is Her Future, 1999) has revealed that there is a gap between what GPs perceive themselves as doing to prevent osteoporotic fractures and what women actually experience. Indeed, 60 per cent of UK GPs said they routinely assessed postmenopausal women for osteoporosis. Yet, only half the women surveyed felt doctors took osteoporosis seriously, and only 8 per cent said they had discussed long-term risks of the disease with their GP.

So many guidelines for preventing and treating osteoporosis have been issued over the years – from institutions such as the Royal College of Physicians and the US National Institutes of Health (NIH) – that it would be natural to assume that GPs should now be swimming in awareness and best practice, and be taking the condition more seriously. Indeed, the NIH has called for more research into ways to increase peak bone mass during youth as well as an investigation into the effects of a deficiency of calcium and vitamin D, and a study to identify the genetic factors that lead to osteoporosis.

After all, osteoporosis is a thorn in the government’s side, and has been for some time. The condition costs the NHS and government around £1.7 billion each year (Torgerson DJ et al., Key Advances Series, 2000, UCL Press). In the UK, hip fractures account for more than 20 per cent of orthopaedic bed occupancy (Cooney LM, Marottoli RA, Fourth International Symposium on Osteoporosis and Consensus Development Conference Proceedings, 1993), and half of all those who survive hip fracture cannot cope with living independently (National Osteoporosis Society estimated figure).

Now, on the basis of a National Osteoporosis Society strategy for the prevention and treatment of osteoporosis aimed at primary care and local health groups, the government announced a primary care initiative in March which contains a blueprint for doctors to follow. Essentially, it advocates a selective case-finding approach to identify people at risk who can then be investigated and, if necessary, treated. But it also wants to deliver health messages on bone-healthy diets, sun exposure and exercise to patients (or parents) at all ages.

This is finally a first step in the right direction. Current medical thinking should move away from intervention and treatment, and look toward identifying early risk factors and prevention.

In some ways, osteoporosis can be compared with heart disease. Patients don’t just suddenly develop stroke without a previous history of other risk factors. The same type of approach needs to be used when considering how to treat osteoporosis.

Clearly, nutrition must be considered early in life. Make sure there’s optimal calcium and vitamin D intake. Maintain a normal weight since being undernourished is a risk factor, and avoid smoking, alcohol and caffeine.

Above all, there is a need to engage in regular weight-bearing exercise. More than 100 studies confirm that regular exercise strengthens bones and reduces the risk of fracture in pre- and postmenopausal women, and men. The risk of a hip fracture can be reduced by 40 per cent just by walking or other weight-bearing exercise.

Rather than swallowing dangerous drugs, no matter what your age, all you need to do to prevent osteoporosis is to get – and keep on – moving.

Clive Couldwell
Clive Couldwell is a freelance writer specialising in medicine, science and technology.

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Written by What Doctors Don't Tell You

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