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Should I Keep Taking Fosamax for My Osteoporosis?

Carefully weigh the known risks of bisphosphonate drugs against their potential benefits

En español | Q. I'm a 62-year-old woman with osteoporosis (as determined by a -2.87 on my bone density scan). I've been taking Fosamax along with calcium and vitamin D supplements for the past five to six years. In that time I've had three stress fractures of my feet. I'm concerned about my osteoporosis but I'm also worried about Fosamax adding new health issues, especially with more and more evidence suggesting that it can lead to femoral fractures and even cancer. Can you give me some direction?

Fosamax side affects - Are there alternatives for Fosamax?

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Weigh the pros and cons of taking Fosamax to treat osteoporosis.

A. There's no question that osteoporosis — a decrease in bone density that contributes to more than 300,000 hip fractures a year — is a disease that needs to be taken seriously. But are the prescription drugs known as bisphosphonates — such as risedronate (Actonel), ibandronate (Boniva), alendronate (Fosamax) and zoledronic acid (Reclast) — the right approach to treating the disease?

Clinical trials for bisphosphonate drugs have shown that they're only marginally effective at preventing hip fractures — even in high-risk postmenopausal women. For instance, when Merck, the manufacturer of Fosamax, says that the drug can reduce such fractures by more than 50 percent, it's referring to a study published in the Journal of the American Medical Association in 1998 that showed a small reduction in absolute risk among those taking Fosamax.

Of the thousands of women in the study group, 1.0 percent of those taking Fosamax experienced hip fractures, compared with 2.2 percent of those taking placebo (sugar pills). Because 1.0 percent is 44 percent of 2.2 percent, Merck is allowed to say that its drug reduces bone fractures by 56 percent. The same study reported that, among postmenopausal women without osteoporosis, the relative risk of hip fractures actually went up 84 percent with Fosamax treatment.

What's more, a systematic review of 33 studies of bisphosphonate drugs published last year by the highly respected Therapeutics Initiative found "no statistically significant reduction in hip or wrist fracture" in women with no previous fractures or vertebral compression — who make up the majority of women treated with bisphosphonates. In higher-risk women, the review found small reductions in absolute risk — 1 percent for hip fractures and 1.3 percent for wrist fractures, noting that even those statistics are based on "a potentially biased subset" of patients in the studies. Plus, neither the doctors who prescribe bisphosphonate drugs nor the companies that manufacturer them are able to say how long patients should be taking them. As the American College of Physicians puts it, "Evidence is insufficient to determine the appropriate duration of therapy."

Moreover, bisphonate drugs may have adverse side effects, such as:

  • Musculoskeletal pain; gastrointestinal problems: ranging from heartburn, acid reflux and other relatively mild gastrointestinal events to, in rare cases, chronic inflammation and ulcerations.
  • Spontaneous bone fractures; and jawbone deterioration.

I recommend you ask your doctor for a real risk workup. Such a workup — which should take into account your age, weight, previous fracture history, family history and other risk factors — is far more useful from a predictive standpoint than a bone density scan. I'd also ask your doctor to review whether there's something other than age that might be causing the bone loss. Often there is.

Long-term use of many drugs, for example, can cause bone loss, including some that are commonly prescribed to older adults. Among them: steroids, which are used to treat a variety of inflammatory diseases and conditions; short-acting loop diuretics, which are typically prescribed to treat hypertension (high blood pressure) and edema (fluid retention); and proton pump inhibitors, such as esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), and pantoprazole (Protonix), which are typically used to treat the symptoms of gastroesophageal reflux disease (GERD).

I also recommend that you read a report of the Surgeon General of the United States (it's a free download) on the best ways to promote bone health and prevent osteoporosis and fracture, which is the goal that I always focus on with my patients. The main approaches:

Diet. Make sure that you're giving your bones the best chance to stay strong by getting enough calcium (older people should take a calcium citrate — not calcium carbonate — supplement), vitamin D and other bone-building nutrients.

Exercise. Make sure that you're exercising regularly. Weight-bearing exercise — walking, jogging or anything else you can do on your feet — is best. Be sure to consult your doctor before starting a new exercise regimen.

Reduce your risk of falls and fractures. It's important to remember that falls — which play a role in approximately 90 percent of all hip fractures — are what you should really be worrying about.

So I advise my patients to take some simple, common-sense precautions at home to reduce their risk of a bone-fracturing incident: things like getting rid of throw rugs, adding some motion-activated lighting (especially in and around the bathrooms and stairs) and so forth.

I also pay special attention to medications that may adversely affect balance and stability (including benzodiazepines, antihistamines, antidepressants and antipsychotics).

As the old saying goes, an ounce of prevention is worth a pound of cure.

Ask the Pharmacist is written by Armon B. Neel Jr., PharmD, CGP, in collaboration with journalist Bill Hogan. They are coauthors of Are Your Prescriptions Killing You?, which was published in July by Atria Books.

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