Northwest Arkansas Democrat-Gazette
Treating fragile bones
Experts fear a rise in hip fractures as elderly population grows.
A “perfect storm” threatens to derail the progress that has been made in protecting the bone health of Americans.
As the over-50 population swells, fewer adults at risk of advanced bone loss and fractures are undergoing tests for bone density, resulting in a decline in the diagnosis and treatment of osteoporosis, even for people who have already broken bones.
This is a trend, and bone specialists say the result could be devastating, spawning an epidemic of broken bones, hospital and nursing home admissions and even premature deaths. Experts point to the dampening effects of very rare but widely publicized side effects from bone-preserving drugs as discouraging people at risk of a fracture — and often their doctors — from properly weighing the benefits of treating fragile bones.
One serious consequence already seems to have happened: a leveling off and possible reversal in what had been a decade-anda-half decline in hip fractures among postmenopausal women, according to a new study of all women on Medicare who were hospitalized with an osteoporotic hip fracture between 2001 and 2015.
The data revealed a steady decline in hip fractures among women 65 and older on Medicare, to 730 per 100,000 in 2015 from 931 per 100,000 in 2002. But starting in 2012, the rate adjusted for age suddenly leveled off. Had the decline continued, an estimated 11,464 fewer women
would have broken their hips between 2012 and 2015, the researchers reported in December in the journal Osteoporosis International.
“About 80 percent of patients with a hip fracture are never treated” for osteoporosis, said Dr. E. Michael Lewiecki, director of the New Mexico Clinical Research & Osteoporosis Center in Albuquerque and lead author of the study, “although almost all have osteoporosis and are at risk of another hip fracture.”
Although bone-sparing medication has been shown to reduce the risk of a second hip fracture, one study of 22,598 patients found that use of the drugs declined from “an already dismal 15 percent in 2004 to an abysmal 3 percent in the last quarter of 2013,” Dr. Sundeep Khosla, a bone specialist at the Mayo Clinic in Rochester, Minn., wrote in 2016 in the Journal of Bone and Mineral Research.
He likened the situation to not treating patients for high blood pressure or elevated cholesterol following a heart attack.
Calling it “a crisis in the treatment of osteoporosis,” Khosla said, “Despite the development of several effective drugs to prevent fractures, many patients, even those who unequivocally need treatment, are either not being prescribed osteoporosis medication at all, or when prescribed, refuse to take them.”
The problem is hardly trivial — for patients and society at large. Considering hip fractures alone, depending on how they are treated, average direct medical costs for the first six months range from $34,509 to $54,054, most of which is paid for by Medicare, the study authors wrote. Each year more than 300,000 people older than 65, three-quarters of them women, are hospitalized with a fractured hip.
The personal costs are far greater. About 20 percent to 30 percent of patients die within a year after a hip fracture and, the researchers reported, “of those who survive, many do not regain their pre-fracture level of function. About 50 percent of patients with hip fractures will never be able to ambulate without assistance and 25 percent will require long-term care.”
A number of factors may have contributed to the downward trend in hip fractures that ended in 2012, according to Dr. Ethel Siris, a co-author of the new study and director of the Toni Stabile Osteoporosis Center of the Columbia University Medical Center in New York.
“The population may be getting healthier, people are doing more exercise and may be more careful about falling,” she said.
But most likely a leading factor, she and her co-authors believe, was the introduction in 1995 of the drug Fosamax, a bisphosphonate that slows or prevents the loss of bone density, resulting in stronger bones.
BREAKTHROUGH DRUGS
Fosamax is now available generically as alendronate and has been joined by several other medications capable of promoting stable bones. However, Siris said, “There is clearly a treatment gap. Prescriptions have fallen off, and even when people at risk are offered medication, they are refusing to take it.”
Millions of patients who could benefit from bone-preserving drugs are now afraid to take them. Researchers suggest the fear probably has its roots in aggressive marketing and doctors who overprescribed bisphosphonates for every patient in the beginning stages of bone loss, a condition called osteopenia, with treatment continued years longer than now considered appropriate.
Then in the early 2000s, news reports appeared linking extended use of bisphosphonates to two uncommon bone problems: a very rare fracture of the femur and an even rarer condition called osteonecrosis of the jaw.
A fear of these complications resulted in more than a 50 percent decline in bisphosphonate use from 2008 to 2012, Khosla said.
At the same time, Medicare reimbursements for bone density tests were sharply reduced, and doctors who did them in private offices could no longer afford to, which limited patient access and diagnosis and treatment of serious bone loss despite improvements in treatment guidelines.
20 YEARS OF USE
In the more than two decades since bisphosphonates were introduced, “we’ve learned a lot about how to treat and whom to treat,” Khosla said.
No longer is osteopenia a condition that by itself warrants medication unless other factors indicate the patient has a significantly increased risk of breaking a major bone.
Patients should be treated if their bone density measurement indicates osteoporosis in the hip, spine or forearm, the experts said. But even if the test indicates only osteopenia, Siris said, “patients should be considered osteoporotic if they already sustained a nontraumatic fracture in the hip, spine, shoulder, pelvis and sometimes the wrist or if they score high enough on FRAX,” an online fracture risk calculator to estimate one’s risk of breaking a hip or other major bone in the next 10 years.
Her advice is threepronged: “medication when appropriate, an adequate intake of calcium and vitamin D, and don’t fall.”
“Treatment should be individualized,” Khosla said. “Each patient is different, with different family history, risk factors, how fast they’re losing bone and their personal concerns. If the focus is on patients with a high risk of fracture, the evidence is clear that the benefits of drug treatment well outweigh the risks.”