Reader questions fracture diagnosis

Dear Dr. Roach: I am a 79-year-old woman with osteopenia. I had the FRAX assessment and was told my 10-year probability of major osteoporotic fracture percentage is 19.4%, with a hip fracture probability of 5.7%.

Unfortunately, I broke my wrist in a traumatic fall backward last year, landing on a concrete patio. My doctor has said that it is a “fragility fracture,” by which she means I have osteoporosis and that I need alendronate. I feel that the broken wrist is a traumatic injury, rather than a fragility fracture.

Unfortunately, I have a small hiatal hernia. Due to family stress, I have stomach issues. My doctor then said that I should have Reclast infusions rather than alendronate. I have read horror stories from women who have had the infusions. Do you agree that I should have Reclast infusions? Could I try alendronate and see how it goes?

E.R.

Answer: Osteopenia, now more commonly called low bone density, is a precursor to osteoporosis, which is a condition of abnormally weak bones.

Medication treatment is indicated for those at high risk for fracture: low bone density (such as a T score below -2.5); a FRAX score with a 10-year risk of major osteoporotic fracture of greater than 20% or hip fracture greater than 3%; or a history of a fragility fracture. This is defined as a fracture caused by fall from standing height or less. Your doctor is correct based on the definition, even though some people with normal bones might still get a fracture if they hit their bones the wrong way.

A hiatal hernia alone isn’t necessarily a reason not to get an oral bisphosphonate like alendronate (Fosamax), and I don’t have enough information about your stomach problem to say whether oral alendronate is safe for you. But people with difficulty swallowing pills are good candidates for intravenous bisphosphonates like zoledronic acid (Reclast). The IV treatment can cause some flulike symptoms for up to three days. Both oral and IV treatments have the potential for serious side effects, such as osteonecrosis of the jaw.

Your risk of a major fracture is high enough that medication treatment is generally recommended.