Osteoporosis

Prescription treatments- How well do they work?

I get asked this question so often I decided to do a post. My thinking may be different than mainstream thought, but that is OK.

One of the differences in thought pertains to Population based risk/benefits vs Individual based risk/benefits. It is good to use and apply both population and individual thought before deciding upon a treatment plan.

However, when an individual asks me what their individual risk/benefit is for a particular intervention/treatment, I need to look at the individual risk/benefit a bit more closely.

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The demographic with the greatest risk of Osteoporosis are Menopausal women so that will be the main focus from here.

Postmenopausal women usually get a bone density screening test known as a DEXAscan to gauge their individual risk of Osteoporosis. The DEXAscan usually comes back as either Osteopenia - low bone mass/density, or Osteoporosis - very low bone mass/density. Every now and then we get surprised with a normal and healthy bone density. I always ask these women what they have done in their lives to keep their bones healthy.

It is always best to learn from those who succeed in remaining healthy!

Interestingly the DEXAscan became very popular when Big Pharma first introduced Osteoporosis drugs. Prior to that I do not believe the DEXAscan was used much other than for research. It’s almost like a new industry was born. But in reality this is a chicken and egg debate as to which came first, the DEXAscan postmenopausal testing protocol or the Big Pharma expensive treatments for Osteoporosis. I’ll let others debate that topic.

Let’s say for a moment the DEXAscan is interpreted as Osteoporosis as this is what is needed to be prescribed Osteoporosis medications.

Mainstream medical care today. Screen with tests so Big Pharma can come to the rescue.

I like to ask if a treatment whether it be prescription, surgical or lifestyle actually fixes and/or reverses the dysfunctional mechanism/process that caused the problem. Surgery to remove an inflamed appendix should solve the problem. If you are in a rowboat that sprung a leak would you rather keep bailing out the water or actually mechanically plug the leak?

But I guess I think too much and ask too many questions because very few people in healthcare want to answer…..

So the question is:

“Should I take the Osteoporosis medications?”

To answer this question I think we should look at some actual research studies and see what we come up with. When I look at studies, the questions I want answered are:

1- Will the treatment reduce my chance of contracting the illness, or reduce its effect on my health AS AN INDIVIDUAL?

2- What are the potential side effects of this treatment on me AS AN INDIVIDUAL?

These questions are much different than how most Big Pharma treatments are advertised and sold to both the FDA and the public. Big Pharma usually has fun with numbers to make their latest treatment appear to work better than they actually do. They employ “fun with numbers” by using relative percentage changes (population based %) which amplify the possible good effects on a population, while using absolute based percentage changes (individual based %) to decrease how the possible side effects look. Aren’t numbers fun???

So make the good look better and the bad, well, let’s minimize how the bad looks.

When I think through to decide on a treatment I prefer to use absolute numbers for both the good and the bad. This allows me to compare apples to apples, or for the fellow carnivores out there, ribeye to ribeye.

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So let’s look at a few of the Osteoporosis drugs. I will be using data collected from www.thennt.com

NNT = Number of people needed to treat to help one person.

The best number would be 1. This would mean for every 1 person treated 1 person would benefit. So it would work 100% of the time.

If by example you get an NNT of 10, then for every 10 people treated, 1 would benefit and 9 would not. So 10% of people would benefit, 90% would not.

If by example you got an NNT of 100, then for every 100 people treated, 1 would benefit and 99 would not. So 1% of people would benefit, 99% would not.

So for NNT, the lower the number and closer it is to 1, the better the treatment.

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Now for some actual NNT numbers as they pertain to Osteoporosis.

You can click on the links for where I pulled the numbers.

Let’s start with the drug class known as bisphosphonates.

Some common bisphosphoantes include:

Reclast, Boniva, Fosamax, Actonel, Zometa, Didronel

The first example is for Postmenopausal women who have already had either a previous postmenopausal fracture or who have very low bone density. So this group is the most at risk for future fractures. Let’s see how they do.

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Bisphosphonates for Fracture Prevention in Post-Menopausal Women With Prior Fractures or With Very Low Bone Density

Benefits in NNT

• 1 in 20 were helped (vertebral fracture prevented) or 5% avoided a vertebral fracture- This means 19 out of 20 or 95% were NOT helped

• 1 in 100 were helped (hip fracture prevented) or 1% avoided a hip fracture- This means 99 out of 100 were NOT helped

• 94% saw no benefit after 3 years of treatment - This means only 6% of people benefitted after 3 years of treatment.

Harms in NNT

• A small number were harmed

So 94% of Postmenopausal women who had prior fractures did NOT benefit from using this treatment.

Is that what you are being told when you are offered this treatment?

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Now let’s look at a lower risk population of Postmenopausal women.

Bisphosphonates for Fracture Prevention in Post-Menopausal Women Without Prior Fractures

Benefits in NNT

• None were helped (fracture prevented after 3 years of medicine) - That’s ZERO

• Benefits in Percentage

  • 100% saw no benefit after 3 years of treatment - That’s another big ZERO

Harms in NNT

• A small number were harmed

• Harms in Percentage

  • A small percentage were harmed

So 0%, yes that means ZERO, none, nada - Postmenopausal women who had no prior fractures had no benefit from this treatment (Bisphosphonates).

Is that what you are being told when you are offered this treatment?

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Monoclonal Antibody treatment for Osteoporosis is different from the bisphosphonates. Let’s see how they did in the study.

Now let’s look at Prolia, otherwise known as Denosumab which is a newer Osteoporosis treatment. This is a type of monoclonal antibody treatment that works to prevent your body from naturally removing calcium from your bones.

That sounds wonderful but what if your body is always removing calcium from your bones and then adding it back later in a more healthy and physiologic method, kind of like taking out a bad warped piece of wood and replacing it with a new and healthier piece?

What if bone remodeling is a natural process that your body is very good at?

Should we be messing with the contractor who is continually renovating your kitchen to keep it running smoothly?

Is putting more pressure on a weak support a good idea?

What did the study tell us?

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Prolia (Denosumab) for Reducing Risk of Fractures in Postmenopausal Women

Benefits in NNT

• 1 in 21 did not have a new vertebral fracture or only 4.8% did not have a new vertebral fracture - This means 20 out of 21 or 95.2% were NOT helped

• 1 in 62 did not have a new clinical vertebral fracture or only 1.6% did not have a new clinical vertebral fracture - This means 61 out of 62 were NOT helped

• 1 in 230 did not have a new hip fracture or only 0.4% did not have a new hip fracture - This means 229 out of 230 were NOT helped.

Harms in NNT

• 1 in 167 developed an infection or only 0.6% developed an infection

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Prolia sounds like another winner, right??

Not to me!

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What else can be done?

How about interventions with low risk of side effects.

Strength and Balance Training Programs for Preventing Falls in the Elderly

In summary, for at-risk elderly community dwellers who used balance and strength training:

Benefits in NNT

• 1 in 11 at-risk elderly were helped (avoid suffering a fall over a one year period)

• Benefits in Percentage

  • 91% saw no benefit

  • 9% were helped by preventing a fall over a 1 year period

Harms in NNT

• None were harmed

• Harms in Percentage

  • 0% were harmed

9% is still not that wonderful. But no one was harmed and there were probably other quality of life issues that improved as exercise improved strength, mobility and independence.

What else can be done for Osteoporosis?

Best treatment is always prevention. Best way to avoid Osteoporosis and it’s cousin sarcopenia (low muscle mass) is to build up strong bones and muscles when you are younger. Remember age is only a number. Good health does not have to be something only for the youngins. If you slowly lose bone and muscle as you age, but you have more to begin with, then your Osteoporosis and sarcopenia risk is greatly diminished.

There are other nutritional and hormonal interventions as well, but that will have to be another future post.

As always comments and civil discussions are welcome.

This substack blog is not meant to be an echochamber but instead a place to have common sense health and wellness discussions.

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