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Doctor's corner - bone strengthening drugs and fragility fractures

If you are on bone-strengthening drugs…

I recently attended a meeting in New York City dealing with “fragility fractures.” A fragility fracture, by definition, is a fracture that is sustained in a ground-level fall. These fractures usually involve patients of Medicare age since most young adults, if they lose their balance and fall over, won’t tend to break a bone when they hit the ground. If someone in their 60s or older loses their balance and falls over, they are at risk for breaking their wrists, their shoulders, and their hips depending upon how they hit the ground.

In order to reduce the risk of these so-called “fragility fractures” in older patients, the early part of this millennium saw the introduction of a family of drugs intending to strengthen bones. Some of the more recognizable names are Fosamax, Actonel, and Boniva. There are others, but the point is that these drugs did indeed reduce the risk of fracture in older patients. They strengthen the bone and increase the bone density on x-ray, and they do certainly reduce the risk of fracture—for a time.

It has, however, become apparent in the last year or so that once patients have been on these drugs for about five years, there is an increase in the rate of fractures that occur not only with falls, but sometimes with routine daily activities such as walking for exercise. It seems that while these drugs do strengthen the bone, the new bone does not have the same mechanical properties as young, healthy bone, and in fact, the bone actually behaves in a more brittle fashion. Whether it’s fair to the drug or not, doctors have started to toss around the phrase “Fosamax fracture” when they discuss this situation among themselves. The classic example of such a fracture is the one that occurs in the upper end of the femur or thigh bone. The patient will usually experience a period of activity-related groin and/or thigh aching that gradually worsens and which precedes a complete fracture that can occur spontaneously or with just a trivial injury. Additionally, surgeons have found that when they attempt to fix these fractures, the bone is technically a little bit more difficult to deal with than so-called “normal bone,” and healing times can be unusually prolonged.

I can’t pretend to know what’s right for any particular individual taking these drugs, but if you’ve been on bone-strengthening agents for four to five years, I would encourage you to discuss with your prescribing physician the pros and cons of staying on these drugs indefinitely. Staying on them may be best for you, but a conversation over the wisdom of staying on these drugs beyond 4-5 years is certainly indicated in every case.

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