Bisphosphonate Drugs May Cause Fractures in Osteopenia Patients

It happens all the time. A woman has a bone-density (DXA) test indicating that she has osteopenia–her bone mineral density levels are below normal, but not low enough to be considered osteoporosis. The fix, her doctor says, is to start taking a bisphosphonate drug. But should these powerful and risky drugs really be the first line of defense for osteopenia?

Bottom Line spoke with Susan Ott, MD, a leading researcher in bone disease and medications that treat it and professor of medicine at the University of Washington in Seattle.

Dr. Ott explains that osteopenia isn’t actually a disease at all, but that it is very common among middle-aged women and that bisphosphonates are not only unnecessary for most of these women but can be quite harmful. Treatments for bone thinning are not keeping up with the research, and she is one of several physicians voicing strong concern about treating such patients with bisphosphonate drugs, including alendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel) and zoledronate (Reclast), meant for the treatment of the far more serious osteoporosis. In addition to recent reports of dangerous side effects from these drugs, research shows that for some women with osteopenia, taking a bisphosphonate drug for too long may ultimately make their condition worse, potentially leading to serious issues including—ironically—an increase in bone fractures.

A History Lesson About Osteopenia

According to Dr. Ott, one of the reasons bisphosphonates are overused is the “arbitrary” way that mild bone thinning has become categorized as problematic. Scientists measured bone density in a group of women in their mid-20s (when bone mass is at its peak) and categorized those in the bottom 16% as having “osteopenia”—but in fact, they were merely at the low end of the healthy scale. It’s true that women with these scores don’t have the enviably strong bones of their peers who are at or above average, but they’re not ill—and the fact is, calling a condition a disease ups the ante for treating it.

Drug marketers saw huge potential in an opportunity to sell bisphosphonates to middle-aged osteopenia patients—but Dr. Ott says that this is harmful for most of them. Bisphosphonates not only don’t help avoid fractures in people with osteopenia, but these powerful drugs have potentially dangerous side effects, including upper gastrointestinal tract irritation and even esophageal ulceration.

People diagnosed with osteoporosis–especially those who have already had a spine or hip fracture–can benefit from the limited use of bisphosphonates. Taking one of these medications for four to five years can cut their risk for a future fracture in half. But even for this group, using these medications for too long can lead to serious problems. It’s unclear why, but many women who have experienced fractures after being on these drugs longer than five years reported that they had begun to experience pain in the area of the bone that broke–weeks or months before the fracture occurred. Another problem: Some incidence of poor healing in the jaw after tooth extraction is also associated with bisphosphonates, although Dr. Ott says that is mostly seen in cancer patients who are treated with much higher dosages to counteract their other medications.

Should Anyone Take Bisphosphonates?

Based on the research currently available, Dr. Ott says she would continue to advise using bisphosphonate drugs only for osteoporosis patients (men and women)…osteopenia patients in whom an X-ray reveals a spinal (vertebral) compression fracture…and osteopenia patients who suffer a fracture anywhere else. Note: Dr. Ott said that generally this last category consists of women with a chronic medical condition such as anorexia (the most common scenario) or a malabsorption problem, such as celiac disease or Crohn’s disease or sometimes kidney or liver disease.

Bone loss is a natural part of aging, but there are a number of ways to improve and protect bone health.

Here is Dr. Ott’s bone-health advice…

  • Avoid being underweight. A body mass index (BMI) of 20 or less (on the edge of underweight) puts women at more than twice the risk for fracture as having a BMI of 25 (normal but toward being overweight). Fat has benefits: A bit of it (not too much, though) protects the bones in a fall…carrying more weight makes the bones stronger…and hormones in fat tissue seem to enhance bone strength.
  • Exercise regularly. It won’t stop or reverse the process, but regular weight-bearing exercise helps slow bone thinning, and people who exercise also tend to fall more gracefully and are thus less likely to fracture their bones.
  • Get sufficient vitamin D and calcium. Dr. Ott says that a vitamin D supplement of 800 IU to 1,000 IU daily is helpful and also advises consuming 1,000 mg of calcium a day through calcium-rich foods such as low-fat dairy, green, leafy vegetables and soybeans.

Women, in particular, need to be conscientious about protecting their bones whatever their age. It is never too early—nor too late—to adopt a bone-healthy lifestyle.