Which is the right osteoporosis treatment for me?
Many people are confused by the options of medication treatment for osteoporosis or treatment to reduce the chance of osteoporotic fractures. In fact, many of my GP colleagues regularly ask me for advice as well. To help you to know more about this important decision, here is a short overview of the most important issues I consider when advising people about these treatments.
1. With all treatments, whether a Bone Physicians recommends a 3-5-year or 10-year course of treatment depends on your specific osteoporosis fracture risk, general health and chance of drug side-effects;
2. The best evidence from research for positive long-term effects is arguably for zoledronate and for Denosumab/Prolia, rather than for alendronate or risedronate; however, the treatments have not been compared head to head over a long-term period
3. Zoledronate has shown to be very effective at preventing osteoporotic fractures (vertebral fracture risk by 70%) with just 3-6 infusion treatments: one given every 12-18 months;
4. You have to take Alendronate/risedronate properly, or it won’t work at all. Seems obvious to say, but I come across many people who miss doses and skimp round the instructions to take it properly and then are surprised when their bone density has actually reduced, or not improved. But it should be remembered that alendronate and risedronate were shown to work in studies where the researchers ensured that every single person in the studies took alendronate every week, and took every tablet correctly;
5. Prolia (Denosumab) can be tricky to use because when / if it is stopped, zoledronate or alendronate or risedronate need to be used seamlessly after it to prevent the rebound negative effects of Prolia withdrawal on the skeleton. These negative effects also might include the risk of something scary such as fractures;
6. All treatments have been shown in robust clinical studies to reduce the risk of osteoporosis related fractures over a 3 to 5y period of continuous treatment;
7. Bone Physicians agree that if fracture risk is high, treatment courses longer than 5 years should be considered. This can mean up to 10 years continuous treatment;
8. Teriparatide is a self-administered subcutaneous injection given daily for 2y. It has bene shown to reduce the risk of vertebral fractures by 70% (about the same as zoledronate)
9. Romosozumab is the newest treatment given by self-administered subcutaneous injections monthly, for a year. It has been shown to reduce vertebral fracture risk by about 70%; similar to teriparatide, denosumab and zoledronate
10. With long-term risks of treatment, we know that the risk of atypical femoral fracture, but not osteonecrosis of the jaw, increases with zoledronate therapy duration, but such events are rare, and their risk is outweighed by the positive effect of vertebral fracture risk reduction in high-risk patients;
11. Zoledronate can cause flu-like symptoms in 1 in 3 to 1 in 4 people after the infusion. For the majority of people who get these side effects they are mild and last, at most, just a few days;
12. Beware of internet chat groups and blogs which promote the idea the treatments are bad, overly risky or poisonous. Think of two things here. Firstly, there is ample, robust, objectively obtained evidence that the chance of side-effects of treatments in large patient group research studies is low – a much better source of information for rationally considering what the risk of medication is in general. Second, it’s worth knowing the Welsh proverb, ‘Bad news goes about in clogs, good news in stockinged feet’ - meaning those who have had side-effects from treatments are more likely to shout about it, than those who have had no side effects.
Links:
Information on treatments: https://drgavinclunie.co.uk/osteoporosis and at: https://theros.org.uk/information-and-support/osteoporosis-treatment/.
More excellent Welsh proverbs at: https://www.bbcamerica.com/anglophenia/2014/10/25-welsh-sayings-to-live-by