Friday, December 10, 2010

Bisphosphonates vs Atypical Femur Fractures

What's life without controversy?  Are bisphosphonates good for you or not?  Before we answer that question, you need to know that doctors typically try to do their best but are always limited by the current state of science & knowledge (not to mention lack of time!).  And most of us left our crystal balls at the cleaners.  In other words, if we knew something bad was going to happen, if we knew that someone would have a negative side effect from the medication, if we knew that the procedure wouldn't work, if we knew that we couldn't help you live any longer just more miserably, you get the idea, we wouldn't have done what we did at the time.  But we can't practice medicine in hindsight.  Just like we can't drive forward down the road by only looking in the rearview mirror.  Sure we look in the rearview and in our side view mirrors every now & then, but mostly we look forward to see where we're going, trying to guess if that bozo rocking out in the car in front of us, texting, eating, and shaving, is aware of the truck pulling out ahead.  

Ok, enough of my ranting and raving for today.  But my introduction is to discuss the current hot topic of bisphosphonates.  We've known for quite some time that as we get older, our bones become weaker and we have a greater risk of sustaining fractures.  And unfortunately, we typically never recover to our previous baseline function.  So when we discovered bisphosphonates, we all jumped up & down because here was something we could finally offer to our patients to prevent fracture-induced debility.  Little did we know that a decade or more down the road, we'd have to worry about bisphosphonates linkage to osteonecrosis of the jaw, atrial fibrillation, esophageal cancer, and most recently as of this month's study, atypical femoral fractures.

So is it true?  Do bisphosphonates cause atypical femoral fractures?  Well, we're still not absolutely clear.  But the American Society for Bone & Mineral Research (ASBMR) is looking into this as of last month.  An article published in October in JAMA mentioned considering 12 months off after 5 years on treatment to minimize atypical fracture risk.  An earlier analysis published this May in NEJM stated that the risk is small but clearly didn't deny it either.  As far back as June 2008 in my personal archives, researchers were already considering the possibility of atypical skeletal fragility.

So what are we to do as clinicians?  Exactly what was discussed in that USA Today article published 3 days ago:  improve our communication with our patients!  Tell them what we know.  Tell them what we don't know.  And help them decide what's best for our patients as an individuals.

1 comment:

  1. Alvin as a spine surgeon and a CMI doc my recs are far different for fractures and always have been. I have no use for the class of drugs except Forteo in very elderly unstable fractures of the O-c1-c2 complex. I use a paleolithic diet (especially pastured butter and raw milk) to support sex steroid formation and vitamin D substrate. I supplement high dose Vit D3 Vitamin K2 Zn Se Boron and the sex steroids if they need it, bioidentical of course. I have never understood the love affair with this class of drugs that only acts on osteoclasts. When we spoke in Vegas in May of 2010 I told you about resveratrol use in osteopeniain my practice. It too has been shown in humans and mammals to support the formation of rhBMP-2. The synthetic BMP2 is sold by medtronic for 4000 dollars a dose! I think resveratrol is quite a bit cheaper.

    http://www.ncbi.nlm.nih.gov/pubmed/17513867

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