Dr. Keith Roach

Richmond Times-Dispatch - - Comics, Etc. -

Dear Dr. Roach: I am in­ter­ested in your opin­ion of the drug Fosamax. I am a 63-year-old fe­male who re­cently had my first bone den­sity scan. The re­sults were se­vere os­teope­nia. On the FRAX tool, I have a 10-year prob­a­bil­ity of a ma­jor os­teo­porotic frac­ture of 10%, with a hip frac­ture risk at 2%. The re­sult, based on the low­est pos­si­ble T-score, was -1.1 to -2.4. I ex­er­cise on a reg­u­lar ba­sis and take a cal­cium sup­ple­ment with vi­ta­min D. The things I have read about Fosamax are con­cern­ing, in­clud­ing a risk of esophageal can­cer. What is your opin­ion on the risk of tak­ing this med­i­ca­tion long term?  R.S.

Dear R.S.: Bis­pho­s­pho­nates such as al­en­dronate (Fosamax) have sig­nif­i­cant risks and should not be used lightly. Rather, they should be used when their ben­e­fits out­weigh their risks. Well-known risks in­clude esophageal re­flux, and in­flam­ma­tion and os­teonecro­sis of the jaw. Th­ese risks are small if the med­i­ca­tion is taken prop­erly.

The stan­dard rec­om­men­da­tion for treat­ment is when the Frac­ture Risk As­sess­ment Tool, or FRAX (www.shef field.ac.uk/FRAX/tool.aspx?), shows a 10-year risk of ma­jor os­teo­porotic frac­ture of 20% or more, or a 10-year risk of hip frac­ture that’s 3% or more. You don’t meet th­ese cri­te­ria.

Be­fore I talk about esophageal can­cer, I want to be sure to ad­dress

“long-term” use of bis­pho­s­pho­nates. They work by de­creas­ing re­sorp­tion of bone, but that can lead to brit­tle bones if used for too long. The risk of frac­tures from brit­tle bone — it’s called atyp­i­cal fe­mur frac­ture — is small when the drugs are used for three to five years, but it in­creases the longer the medicine is taken. I have seen many women (and a few men) with only a very mildly re­duced bone mass and den­sity who do not meet cri­te­ria for treat­ment be­ing treated with bis­pho­s­pho­nates for far longer than rec­om­mended. Peo­ple who have been tak­ing Fosamax, Boniva or Ac­tonel for longer than five years should have a re­assess­ment of the risks and ben­e­fits. The drugs may still be more use­ful than harm­ful, but of­ten it is ap­pro­pri­ate to hold off or stop them.

Esophageal can­cer risk from Fosamax is con­tro­ver­sial. A large co­hort study showed no sig­nif­i­cant in­crease, but a dif­fer­ent type of study (a casec­on­trol study) showed a small in­crease in risk of esophageal can­cer.

I sus­pect al­en­dronate and other sim­i­lar dugs will be proven to have no or min­i­mal ef­fect on esophageal can­cer; how­ever, they should be used only by those who have the most to gain by tak­ing them.

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