Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
17 January 2007

SAVING YOUR BONES

            One of the problems getting media attention recently has been the topic of osteoporosis.  Osteoporosis is a bone disease.  Small amounts of bone are “eaten up” each day by special cells as part of natural remodeling.  When a person is young, they lay that “eaten up” bone back down again at a rate equal to the “eating up” process.  But as a person ages, the bone lay down process slows especially in woman.  Postmenopausal the bone lay down process slows dramatically.  As the bone lay down cells fall further and further behind the bones get thinner and weaker causing the disease we call osteoporosis.  This leads to those ugly surprises when a person falls and breaks their hip or fractures a wrist or has one of the terribly painful compression fractures of the spine.  If the spine slowly compresses the person develops a “dowager hump”.

            In the early 1990’s, a product called Fosamax (alendronate) came on the market as a prevention for osteoporotic bone disease.  This product was a salt that was taken on a weekly basis on an empty stomach with only a glass of water.  The person had to remain erect for a half an hour after they had taken this product.  They could take no other food or medication.  Not even coffee.  It was pointed out that some individuals developed esophageal irritation from this product and many individuals stopped it because of that.

            In the recent past, there has been a ten year study published demonstrating the relative safety and effectiveness of this family of medications.  Now there is not only Fosamax but also Actonel(risodronate) which is comparative to Fosamax.  A newer product called Boniva(ibandronate)  has the advantage of being used only once a month.  Safety and effectiveness data for this product lags behind Actonel and Fosamax because of the newness of this product and not as complete “road testing”. 

            The question raised recently is how long a person should use these products.  The column of 8 February 2006 (available on line at www.macpierre.com under South Dakota medical news) indicated that 5 years seemed to be a reasonable length of time to use the product.  After 5 years there seemed to be little usefulness or further effectiveness of the medication except in extreme cases.  An article came out in the Journal of the American Medical Association this past week confirming that recommendation.  Specifically, a large group of patients who had been on Fosamax for 5 years were split into two groups.  One group was continued on Fosamax for an additional 5 years while the other group was not.  At the end of the ten years the question was raised, “Was there a difference in the two groups regarding those that continued the drug and those that did not?”  The answer was that there seemed to be very little difference.  There were no more fractured hips in the group of women who stopped the drug than those who continued it.  This was reassuring regarding the recommendation of stopping the drug after 5 years. 

            The one group of women who did benefit from continuing the drug was those that had compression fractures in their spine and very low bone mineral density values to begin with.  That group did seem to benefit from continued use of the medication.  It would make sense that that might be true since that group of women had the most severe disease. 

            There recently appeared an article in the Journal of the American Medical Association on the 27^th of December 2006, commenting on long term use of “Proton Pump Inhibitors and the Risk of Hip Fracture”.  Proton pump inhibitors are those wonderful medications that treat our heartburn and excess stomach acid.  The common products on the market at this time include Nexium, Prevacid, Protonix, Aciphex, Prilosec, and generic omeprazole.  Each of these products inhibits the stomachs ability to make acid and thereby slightly slows the ability to absorb calcium from the diet.  The study in the Journal of the American Medical Association was done in England and showed that those who used these proton pump inhibitor medications had an increased risk of hip fracture.  Several of the TV networks have picked up on this and advertised that it caused a 50% increase in the likelihood of having a hip fracture.

            Now let’s hear the truth.  This particular study in England considered 13,556 hip fracture cases.  That is a lot of hip fractures.  They then compared people that were taking the proton pump inhibitors as compared to those that were not.  What they found, was that people who did not take the proton pump inhibitors averaged two hip fractures per 1000 people per year.  If the people took a proton pump inhibitor medication, the risk jumped up to 3.2 hip fractures per 1000 persons per year.  So indeed, that is more than a 50% increase in the likelihood of having a hip fracture but the absolute numbers indicate that 1 extra person in 1000 taking the proton pump inhibitor medications will suffer a hip fracture.  The study also showed that the excess hip fractures tended to happen more in men, an unusual finding.

            To put this in perspective, anyone who has ever used one of these proton pump inhibitors most likely found a very favorable response to the medication.  Granted they are expensive but they work marvelously.  Speaking for myself, I will take the one chance in a 1000 of having a hip fracture in order to control my heartburn. 

            It would seem that the lesson from this article is that if you are going to use the proton pump inhibitors, supplementation of calcium and Vitamin D in the diet is probably warranted.  The current recommended dose of calcium for those over age 50 is 1200 mg daily.  The adult minimal daily requirement for Vitamin D is advertised as 400 units per day but in fact those over age 50 really need 800 units of Vitamin D per day.  Supplementation to this level was probably in the interest of those using the proton pump inhibitors and everybody else too.  But I don’t think stopping the proton pump inhibitors to avoid a fractured hip really makes any sense at all. 

            The healthcare providers at your local clinics are aware of the various considerations mentioned above and how to help each individual evaluate their risks and benefits from medications, supplements and general health practices.