Wednesday, August 31, 2016

A Crisis in the Treatment of Osteoporosis can be Turned Around with a Paradigm Shift

According to an editorial by Drs. Khosla and Shane in the August 2016 Journal of Bone and Mineral Research, there is A Crisis in the Treatment of Osteoporosis.(1) I totally agree...but my call to action is different.

The point of the editorial is that even with all the “remarkable advances in the diagnosis and treatment of osteoporosis…many patients, even those who unequivocally need treatment, are either not being prescribed osteoporosis medications at all, or when prescribed, refuse to take them.” Khosla and Shane point out that this paradox has been brewing for some time, but the issue was brought to a head in a recent article by Gina Kolata in the New York Times titled, Fearing Rare Side Effects, Millions Take Their Chances with Osteoporosis. Coincident with media and public concern about side effects such as osteonecrosis of the jaw (ONJ), atrial fibrillation, and atypical femur fractures from osteoporosis medications, Kolata found bisphosphonate use declined by greater than 50% from 2008 to 2012. The pattern was confirmed by another recent study that used claims data from a U.S. commercial health plan. Those authors found that "among 22,598 patients with hip fractures, use of bisphosphonates decreased from an already dismal 15% in 2004 to an abysmal 3% in the last quarter of 2013." The editorial also notes that the scope of the problem may be worse because the underlying studies did not evaluate patient compliance. “…Most of us in practice have observed that a significant proportion of the patients we see clinically are reluctant to initiate bisphosphonate therapy and many on these drugs want to stop taking them and do so despite our best advice." Khosla and Shane are saddened (and rightly so) because they feel that the medical community has "failed our patients, and that is something we cannot allow to happen." Their call to action is to find ways to ensure that patients who need them are prescribed effective medications and equipped to make informed choices on taking these drugs.

I have dedicated my life to helping others with osteoporosis for the past 15 years and I feel the same sadness. Sad because a diagnosis of osteoporosis just does not have to lead to devastating life-altering consequences of chronic pain, loss of mobility, and the all-to-often "death-spiral" following a hip fracture. It just does not have to be this way.

I am particularly saddened because we (as doctors) have failed our patients by:
  • Pushing medications with potential serious side-effects and not "working with the body" to normalize physiology. We have turned people completely away from approaching osteoporosis treatment in a sane, effective, none-harmful manner. Many of these patients have become afraid of osteoporosis medications. So afraid that they will not use them even as emergency treatment. 
  • Not offering them a "balanced" treatment option. Medications are not inherently "bad" or necessarily harmful...if they are used properly. There are two issues here: (1) the unfortunate practice of prescribing them to patients who don't really need them and/or keeping patients on them for too long; and (2) little or no emphasis on normalizing the bone remodeling process naturally by encouraging a reduction in overly aggressive osteoclastic bone resorption and a boost to osteoblastic bone formation. This, can usually be accomplished through improved diet, exercise, and specific vitamins, herbs and nutritional compounds such as those found in our OsteoNaturals products.
  • Allowing the confusion and fear that media sensationalism causes in our patients to dictate their health care choices. Yes, osteoporosis drugs can cause serious adverse effects and too much supplemental calcium is not good for you but that does NOT mean that a person should never take medications and that does NOT mean that supplemental calcium should not be taken. EVERYONE with osteoporosis NEEDS to take at least 600 mg of calcium/day and there are SOME people that NEED to use osteoporosis medications at least for a short time.

I think the call to action should be to change the medical model for the treatment of osteoporosis. Drugs...and only drugs (ok...also some vitamin D) defines the current model for too many doctors. It is certainly true, osteoporosis medications CAN be helpful, but they should NOT be the primary emphasis of treatment except when the patient is in a situation of impending fracture. Then and only then can we look at medications as the primary short-term EMERGENCY or TRIAGE treatment. But our real effort, even in these situations, is to find a way to slowly change the biochemistry, change the way the patient’s body is functioning, and help promote healthy bone remodeling.

(1)  Khosla, S. and Shane, E. 2016 Editorial: A Crisis in the Treatment of Osteoporosis. Journal of Bone and Mineral Research 31(8):1485-1487.
 
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