Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, M.D.
 8 February 2006

A CAUTION ABOUT OSTEOPOROSIS MEDICATIONS

            The lady was 63 years old and a vigorous exerciser.  She walked every day and would occasionally jog a lap around the track with her grandchildren who were out for track in high school.  She skied with abandon.

            She was very health conscious and acknowledged that she had never been a milk drinker and hadn’t taken a calcium pill.  She had a bone mineral density test done which showed early bone loss in her back and hips.  She had had a hysterectomy at age 32 but had never used hormone replacement therapy.  Thus in spite of her vigorous exercise, her bones had become somewhat weakened.  Her physician suggested that she start on a medication called alendronate (Fosamax).  She took a 70 mg pill once a week and had been doing so for 4 years.  During this time, it was shown that her bone mineral density had improved and she was very pleased with that result.

            The use of Fosamax or Actonel or Boniva which are all very similar products has been associated with a markedly decreased incidence of hip fractures and compression fractures of the spine.  This is a very favorable medication to use with a high benefit to side effect ratio.  The medications are expensive but taken as directed once a week, the side effect profile is not very different than that of a placebo.  But there is a downside to this medication.

            To understand how these osteoporosis medications work, one needs to understand the nature of osteoporosis.  Every day a very small amount of bone is taken up by the body and ideally a similar small amount of bone is laid down new.  This is called bone remodeling and it is like a maintenance and repair system to keep bones strong.  As a person grows older, the lay down of new bone is slowed.  The rate of take up of bone remains about the same or perhaps a little faster and thus bones become demineralized and weakened with time leading to fractures of the back, the wrist, and the hip.

            It just makes sense that there are two ways to treat this problem.  Either slow down the rate at which bone is taken up or speed up the rate at which new bone is laid down.  Unfortunately, there is only one medication available that speeds up the rate at which new bone is laid down.  The cost of this medication at this time is around a $1,000.00 a month, well beyond the means of most people.  However, we know multiple medications that will slow down the rate at which bone mineral is taken up.   One of these medications is called Fosamax (others are Actonel and Boniva).  These medications are deposited in the bone when it is laid down new.  Thus over months of time, these medications become incorporated into the new bone that is laid down.  When the cells that take up bone come back and try to eat this bone with the Fosamax in it, the cells can’t eat up the bone as fast as they could before and the rate of bone take up is slowed down.  Over several years time, the bone lay down cells catch up and the bone mineral density actually increases over several years.  The time to benefit from these drugs is 6 months to a year with improving benefit up to 4 years.

            But note that these medications laid down in bone will remain there for at least 10 years and therein lies a potential problem.  The lady above had an unfortunate situation in which she was struck by a vehicle while crossing the street.  Fosamex may prevent a fracture if a person has an accidental fall but nothing is going to prevent a fracture if the person is hit by a car.  The car fractured the mid portion of the long bone in her right thigh.  She was taken to the hospital and the fracture was stabilized.  Over the next several months, the bones just didn’t seem to heal.  She had continued taking the Fosamax during this time.  After the fracture had not healed at all by 3 months, the doctors began to reconsider the situation and recognized that the basic problem was the Fosamax itself.  It is a wonderful drug to prevent fractures but it is a real bad drug to have on board if a fracture occurs.  Specifically, Fosamax inhibits the healing of a fracture when one occurs.

            These drugs have only been on the market for a little over 5 years.  They would still be highly recommended as one of the best treatments for osteoporosis but the good news is that there now comes a time to stop the medication.  Recommendations at this time indicate that Fosamax should be stopped after 4 or 5 years.  What to do after that is really not clear.  At this point, data does not indicate increased benefit of taking the Fosamax or Actonel or Boniva after 4 years.  Very clearly treating a fracture that has already occurred is impaired by continued use of these drugs.

            Fortunately, there are other steps that one can take to promote healing when a fracture occurs.  But the Fosamax, Actonel, Boniva family of medications should be stopped if a fracture occurs and probably not taken at all after 4 years of use.  Now there is a money saving idea that you can use.  The healthcare professionals at your local clinics are aware of these problems and can help advise an individual on how to best care for their patients that have osteoporosis.  That very expensive $1,000.00 a month medication mentioned above is available on an indigent program and is covered in Medicare Part D.  I’ve said before and repeat, the use of Medicare Part D is an important step in the care of our elderly population.