The risk of using a medication in patients with milder disease is that the likelihood of harm can start to outweigh the benefits. That’s one of the arguments against aggressive treatment with bisphosphonates.
The debate particularly concerns women with osteopenia.
The problem is that bisphosphonates may increase bone density, but that doesn’t necessarily translate into decreased fracture rates, according to Susan Ott, MD, of the University of Washington. Furthermore, no long-term studies have weighed the benefits against the risks of using bisphosphonates to treat osteopenia.1
“Instead of preventing fractures you might get fractures,” Ott says. “But it doesn’t happen right away. It certainly doesn’t happen in the first 5 years [of treatment].”
Longer-term use of bisphosphonates has been linked to increased risk of atypical fractures of the femur and osteonecrosis of the jaw. Some trials, but not others, have also reported increased rates of atrial fibrillation.
Who needs treatment and for how long?
Research suggests treating osteoporosis can decrease vertebral fractures by 30% to 70%, but Teppo Järvinen, MD, of the University of Helsinki says the evidence is not so clear-cut.2 Evidence that supports the use of bisphosphonates to decrease hip fractures is limited to women aged 65 to 80 who already have osteoporosis. Meager evidence supports the benefit of treating women over age 80 and men of all ages. Furthermore, evidence from clinical trials does not necessarily transfer into real-world situations, according to Järvinen.
1. Spiegel A. How a bone disease grew to fit the prescription. NPR. December 21, 2009.
2. Järvinen TL, Michaëlsson K, Aspenberg P, et al. Osteoporosis: the emperor has no clothes. J Intern Med. 2015;277:662-673. doi: 10.1111/joim.12366.
3. Khosla S, Shane E. A crisis in the treatment of osteoporosis. J Bone Miner Res. 2016;31:1485-1487. doi:10.1002/jbmr.2888
4. Statement from American Society for Bone and Mineral Research, National Osteoporosis Foundation, and National Bone Health Alliance. Nation’s scientific and medical bone health experts call for action on dangers of not treating osteoporosis more aggressively. Accessed March 20, 2018.
5. Solomon DH, Johnston SS, Boytsov NN, et al. Osteoporosis medication use after hip fracture in U.S. patients between 2002 and 2011. J Bone Miner Res. 2014;29:1929-1937. doi: 10.1002/jbmr.2202.
6. Black DM, Rosen CJ. Postmenopausal osteoporosis. N Engl J Med. 2016;374:2096-2097. doi: 10.1056/NEJMc1602599.