Monday, August 14, 2006

Osteopenia-A disease? when do you treat it with medications

Osteoporosis is defined as a decrease in bone mass with pathological changes in the microarchitecture of bone and tendency to fragility fractures. The operational definition is based on the bone mineral density (BMD) measurement and statistical definition is used with osteoporosis said to be present if the BMD is less then 2.5 standard deviations (T score) from the average 25 year old woman's value.For those readings between -1 and -2.5, the term osteopenia is used. By definition 16% of 35 year old women would be osteopenic.

40% of 65 year old women are osteopenic. Of those who should be offered medication? Currently the medications typically used are the bisphosphonates which have largely replaced estrogen which not too long ago was very popular as it was believed to not only mitigate the aging effects of estrogen decline butcould preserve heart health and lessen the risk of dementia.I considered this question because of a quite a number of women who I would see in the office had been placed on bisphosphonate medications by their gynecologist or family doctor or internist seemingly only because of a BMD score in the osteopenic range.

The Osteoporosis Foundation (NOF) and the American Association of Clinical Endocrinology (AACE) have different recommendations regarding the use of medications. NOF seems to recommend medications for those patients with osteopenia with no risk factors if the T score is below -2 and for those patients with T scores of less than -1.5 if they have one or more risk factors which include low body weight ( less than 127),history or family history of fragility fractures,smoking, estrogen lack or excessive alcohol use ,use of certain medications including steroids. AACE would recommends medication if the T score is less than 1.5 IF the patient has had fracture(s) or if the T score is less than -2.5.( This is the WHO definition of osteoporosis so-strictly speaking- AACE is recommending treatment for osteoporosis not osteopenia and recommends treatment for osteopenia only if there is a history of fractures.)

The consensus answer to the introductory questions is no, all persons said to be osteopenic on the basis of a bone density measurement do not need to receive medications. The opposite answer would seem to mean we should be treating those 16% of normal 25 year old women on the basis of their BMD score. Clinical judgment is required to sort out those patients with osteopenia and other risk factors and clinical features would might benefit from prescription medications.Of course with preventive medication use, you never really know if anything is prevented on not in the individual case only in the aggregate. It may make good sense to suggest a bisphosphonate in a 70 year old women who has one fragility fracture already and tends to be a bit unsteady even in the face on a mildly osteopenic BMD while a younger women with the same score who exercises regularly may not be as good a "candidate". As with all preventive treatments-if that is not an oxymoron-the decision should be one reached by the patient after discussion with the physician. and not a unilateral quasi-judicial decision.BMD is one of the factors to consider but not necessarily the determinative one.

A recent article in the Annals of Internal Medicine is referenced as a source for the statement that bisphosphonates are not longer recommended for osteopenic patients. This is misleading.The Annals article was a computer simulation with numerous assumptions (AKA- a cost effectiveness study) which concluded that therapy with bisphosphonates was not cost effective.But it was a close call and with decreases in drug prices the outcome would be turned around and drugs do have a way of becoming generic and cheaper with time.So folks should not take them now but wait until they are cheaper?As is generic with cost effectiveness articles the authors decide what costs too much not the person using the medications ( i.e. the patient).I realize that often the person using the medication is not the person or financial entity paying for the medications, which ,according to my cynical way of thinking,the reason we have cost effectiveness studies in medicine in the first place.In any event, I am not aware that NOF or AACE have made any changes in their recommendations


Anonymous said...

Osteopenia should be treated as soon after it is diagnosed that you can afford to take it.
At least that is "my take" on the long term studies.

The price is the big problem, not the drugs or the conditions. So economic studies show how wretchedly expensive those little tablets are.

(We have known for about 40 years that osteopenia from senile osteoporosis never gets a lot better, just somewhat better. The first drugs to turn this around, the biphosphonates, seem to be safer than I personally expected them to be.)


Anonymous said...

Osteopenia wasn't even considered a problem until Merck, the giant pharmaceutical company found a treatment for Osteoporosis and wasn't selling enough of the drug so they decided to create this as something that needed to be treated.
National Public broadcasting just did a complete story on this. Anyone being treated for this should go on line and listen to this program. 12/21/09