As the world’s leading scientific organization for bone health research, the American Society for Bone and Mineral Research (ASBMR) is dedicated to making ground-breaking discoveries, translating these into effective therapies for osteoporosis and other bone diseases, and educating patients and clinicians about appropriate osteoporosis care and treatment. As scientific researchers, physicians and other healthcare practitioners, we are greatly concerned that the recent papers by Järvinen et al. in the British Medical Journal and the Journal of Internal Medicine will confuse and mislead the public and the medical community with inaccurate and harmful conclusions about the treatment of osteoporosis.
We believe that the authors have selectively chosen data to support their conclusions that “The dominant approach to hip fracture prevention is neither viable as a public health strategy nor cost effective” and “the main ways to prevent these fractures have not changed in nearly 25 years: stop smoking, be active and eat well.” Both conclusions are wrong. As scientists and clinicians, we can say without equivocation that for many people with osteoporosis, current drug treatments prevent fractures, which allows them to remain independent and free of suffering. Ultimately, these treatments save lives (20% of elder individuals with femoral neck fractures die within a year). 1
Overwhelming evidence clearly shows that osteoporosis is a significant and costly public health problem that continues to grow with the aging of our population. Contrary to the contention that osteoporosis is overtreated, those that suffer with osteoporosis are vastly undertreated due to lack of awareness and confusion regarding the benefits of, and the need for, treatment, which these articles will increase even further. Even in those who suffer the most devastating of fractures, a hip fracture, only about 20% are treated to reduce the risk of a subsequent fracture.2 Osteoporosis is the underlying cause of millions of wrist, vertebral compression and hip fractures that all too often lead to pain, loss of independence and mortality. Despite this, fewer than 10% of older women with fragility fractures receive any osteoporosis therapy.3
More effectively preventing falls, one of the evidence-based approaches the authors of this study prescribe, is not enough to reduce the risk of fracture because it does not address the underlying bone fragility. Many fracture spontaneously without a fall or precipitating trauma. While adequate intake of calcium and vitamin D, and participation in exercise and fall prevention programs, are important components of treatment, they are insufficient and unable to significantly reduce the risk of fracture and prevent future fractures.4,5
Treating high-risk patients with drug therapy is highly effective in preventing fractures. As little as three years of pharmacotherapy can achieve a 30-50% reduction in fracture incidence6 and reduce mortality in those with hip fracture.7 Current recommendations for osteoporosis drug therapy target high risk individuals who may have already suffered from an osteoporotic fracture and are at great risk of a future fracture. Fracture Liaison Services (FLS), programs to coordinate the diagnosis and treatment of patients over 50 years old suffering fractures, effectively improve treatment rates, save hospital costs by preventing future fractures, and save lives.8
The benefits of osteoporosis drug treatment in high risk individuals are clear; yet, Järvinen et al. have inflated the danger of extremely rare side effects of some osteoporosis therapies. We, as bone experts, are concerned about these rare side effects and are working to understand their causes, but we strive to provide evidence and guidance for clinicians so that high risk individuals are treated for an appropriate interval and low risk individuals are not unnecessarily treated. This summer, the ASBMR Task Force on Long-Term Bisphosphonate Use will release its recommendations offering more specific clinical guidance for practitioners treating patients who are at risk for fractures.
Ongoing research is the best way to improve prevention, detection and treatment of bone diseases like osteoporosis to rein in costs and alleviate suffering. ASBMR urges BJM/JIM to join the experts in the field in accurately informing the public and the medical community with the most comprehensive and current research on the critical need to identify and treat patients at risk for fractures from osteoporosis. To do less than this or worse to do nothing, as these two articles suggest, is irresponsible and a disservice to our patients.
1. Liebson CL, Tosteson AN, Gabriel SE, Ransom JE, Melton LJ. Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study. Journal of the American Geriatric Society 2002; 50(10):1644-50.
2. Solomon DH, Johnson SS, Boytsov NN, McMorrow D, Lane JM, Krohn KD. Osteoporosis medication use after hip fracture in US patients 2002 and 2011. Journal of Bone and Mineral Research 2014; 29(9): 1929-1937.
3. Kanis JA, Svedbom A, Harvey N, McCloskey EV. The Osteoporosis Treatment Gap. Journal of Bone and Mineral Research 2014; 29(9): 1926-1928.
4. Bischoff-Ferarri HA, Dawson-Hughes B, Baron JA et al. Calcium intake and hip fracture risk in men and women: a meta-analysis of prospective cohort studies and randomized controlled trials. Am J Clin Nutr 2007; 86(6): 1780-1790.
5. Tang BM, Eslick GC, Nowson C, Smith C, Bensoussan A. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people 50 years and older: A meta-analysis 2007; Lancet 370 (9588):657-666.
6. Black DM, Delmas PD, Eastell R, Reid IR, Boonen S, Cauley JA, Cosman F, Lakatos P, Leung PC, Man Z, Mautalen C, Mesenbrink P, Hu H, Caminis J, Tong K, Rosario-Jansen T, Krasnow J, Hue TF, Sellmeyer D, Eriksen EF, Cummings SR; HORIZON Pivotal Fracture Trial. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. N Engl J Med. 2007 May 3;356(18):1809-22.
7. Lyles KW, Colon-Emeric CS, Magaziner JS, Adachi JD, Pieper CF, Mautalen C, Hyldstrup L, Recknor C, Nordsletten L, Moore KA, Lavecchia C, Zhang J, Mesenbrink P, Hodgson PK, Abrams K, Orloff JJ, Horowitz Z, Eriksen EF, Boonen S. HORIZON Pivotal Fracture Trial. Zoledronic acid and clinical fracture and mortality after hip fracture. N Engl J Med. 2007; 357(18):1799–809.
8. Eisman JA Bogoch ER, Dell R,Harrington JT, McKinney RE, McLellan A, Mitchell PJ, Silverman S, Singleton R, Siris E. Making the First Fracture the Last Fracture: ASBMR Task Force Report on Secondary Fracture Prevention. For the American Society for Bone and Mineral Research Task Force on Secondary Fracture Prevention. Journal of Bone and Mineral Research 2012; 27(9): 1-8.
Read the full articles here:
British Medical Journal paper published on May 26, 2015
Journal of Internal Medicine paper published online May 25, 2015