Bone health

Do you really need a drug for your bones?

by Dr. Susan E. Brown, PhD

There are several categories of drugs being prescribed in the name of bone protection. In this article we discuss the latest findings on the group known as bisphosphonates.

If you’ve turned on the TV lately, leafed through a magazine, or surfed the internet, you’ve likely seen an advertisement warning you about bone loss. And the ad most likely recommends a certain medication to prevent it. It’s true that many more people are suffering from osteoporosis today than in the past, but lots of women want to know if they really need to take Fosamax, Actonel, Boniva, or some other prescription medication to strengthen their bones.

Quite simply, my answer is no. In almost all cases, taking a prescription medication is not needed. Women from around the country come to our bone center for a natural approach to strengthening their bones — and it’s been working for more than 25 years. Osteoporosis and osteopenia medications are big business, but despite all the hype and marketing from drug companies, there is a safer, more effective, and natural approach to bone health available to you.

Prescription drugs known as bisphosphonates often do lead to initial increases in bone mineral density in those women taking them, but the osteoporosis story is much more complicated than how dense your bone appears on a bone density scan. In many cases these medications don’t add any benefit in terms of fracture, and as we’ve been seeing lately, they may even hurt bone. Several women have recently reported strange fractures after taking bisphosphonates for five years or more — something I started to see in my practice years ago.

Let’s take a closer look at prescription drugs for bone health, so you can make an informed decision about treatment for osteoporosis and osteopenia.

Effects of bisphosphonates — denser may not mean stronger

Bisphosphonates haven’t been on the market for very long, so we are still learning about their exact effects in the body. But we do know that the molecules in these drugs attach themselves strongly to the mineral surfaces in both cortical (outer compact bone) and trabecular (inner spongy matrix) bone to increase mass.

One way the drugs do this is by preventing trabecular perforations that can weaken bone structure. Another way is by interfering with cells that break down old bone — known as osteoclasts. This means resorption, the natural process of clearing out old bone, is inhibited, so that existing bone stays put for periods much longer than usual. For the first six to 12 months after starting the drugs, bone continues to build and stops being broken down. This initial uncoupling of the natural bone turnover process explains why results on bone density testing appear dramatic in the first year on a bisphosphonate. But after a year, things start to change, and bone volume plateaus.

Bisphosphonates stop bone formation

Like the process of bone resorption, bone formation will eventually stop when on a bisphosphonate. Though the exact mechanism of action isn’t known at this time, we know that osteoblasts (our bone-builder cells) are inhibited by bisphosphonates. Research shows that after the first year, markers for bone turnover — growth and resorption — go down dramatically. So bone is neither building up nor breaking down once you’ve been taking a bisphosphonate for more than a year or so.

The question is: does this make bone stronger? In my opinion, it’s always dangerous to work against nature. And though women who take bisphosphonates may appear to have denser bone initially on a bone scan, it doesn’t mean the bone is actually stronger. In fact, we know that bone naturally becomes less dense as we age, but what protects us from debilitating fracture is our inborn ability to repair, meaning to break down old bone and rebuild new bone naturally.

And because this natural bone repair process is halted by drugs like Fosamax and Actonel, it is very likely that using these drugs over the long haul will weaken, not strengthen, bone.

Dense bones may be brittle

You may have read the recent news about women taking bisphosphonates for more than five years and spontaneously fracturing their femur bones while simply walking or standing. I had a patient who had been on Fosamax for four years, then turned in her bedroom one evening and fell to the floor, breaking her leg in two separate places. Though these “low-trauma” and “nontraumatic” fractures aren’t happening in all women on bisphosphonates, they certainly serve as a warning for those considering prolonged use of these drugs as “preventative medicine.” It also points to the fact that halting bone resorption doesn’t automatically give us stronger bones, and may in fact make them more brittle over time.

Spinning the numbers on fracture prevention

What’s disappointing to me is the way numbers from studies can be manipulated to exaggerate treatment benefits. Allow me to give you an example. When the manufacturers of Fosamax say that the drug can reduce fractures by up to 50% in high-risk women, they are referring to results of a 2004 study showing that out of thousands of high-risk postmenopausal women (those with osteoporotic bone density and a history of previous fracture), about twice as many (2.2%) of the placebo group fractured as those taking the drug (1.1%). Because 1.1% indeed is half of 2.2%, the drug’s manufacturer can advertise that the drug reduces hip fractures by 50% — which is the relative risk reduction (that is, a comparison of the number of people who fractured in both groups).

Relative risk reduction can be a useful tool for researchers. But any good biostatistician will tell you that it does not seem to be as useful a measure for patients or families when choosing a method of treatment. Think of it this way: if you had a 51% chance of developing a migraine and a drug could reduce your risk to 50%, would you consider that drug a smashing success? Probably not. Yet this is the same absolute risk reduction that bisphosphonates provide.

The absolute risk reduction tells us something about the number needed to treat (NNT). This figure gives you a sense of how many women would have to take the medication for one woman to receive a benefit. For example, the study mentioned above tells us that Fosamax reduces fracture risk by about 1% (absolute risk reduction), so 100 women would have to be treated for one to benefit from reduced fracture risk — the NNT is 100. In essence, the NNT is telling us that for every 100 women taking these drugs, 99 are getting no benefit at all!

And let’s not forget that the placebo group in this study was doing nothing to improve their bone health. Had Fosamax been tested against a test group that was exercising, following an alkaline diet, and optimizing their nutrition, I have no doubt that the argument for bisphosphonates would be even less convincing.

What are the side effects of bisphosphonates?

Women need to weigh the purported benefits of bisphosphonates against the potential risks and side effects of these drugs. If women knew the reality of these numbers and the dangerous side effects that come with taking bisphosphonates (see chart at left), I’m sure they would reconsider the merits of taking a prescription for low bone density for the rest of their days.

Another detail we don’t hear from the drug companies is that most of the research on these drugs is for secondary prevention — that is, when bone density is already osteoporotic and/or a fracture has already occurred. There is much less benefit, and likely more risk, in primary prevention, where bone density is not osteoporotic and there have been no previous fractures. In women with osteopenia, some research even suggests increased rates of certain types of fracture with prolonged use! In fact, these drugs are not recommended at all for primary prevention, yet women who are not at elevated risk for fracture are among the largest target audience of direct-to-consumer advertising for bone drugs.

The Surgeon General’s advice — work with nature to protect bone health

In 2004, the Surgeon General studied osteoporosis in the United States and wrote a report over 330 pages long on the best ways to promote bone health and prevent osteoporosis and fracture. His advice, in essence, is to work with nature.

He provides an osteoporosis pyramid for prevention and treatment that starts with nutrition, physical activity, and fall prevention at the base. The second tier involves assessing and treating the underlying causes of compromised bone health. The very tip of the pyramid, and the last resort, is pharmacotherapy. The bottom line is that your bones are meant to last a lifetime. In most cases they don’t need drugs to keep them strong or prevent fracture. There are many, many natural ways to support your bones and prevent osteopenia, osteoporosis, and needless fracture.

Unfortunately, many practitioners have turned this pyramid on its head, and prescribe pharmaceuticals as a first line of defense. It may seem easy to simply pop a pill and forget about it, but prescription medication is rarely easy on your body. And for over 25 years at our bone health center we have helped thousands of women strengthen their bones and prevent fracture — and 96% of them have not needed drugs. Here’s how.

A natural approach to healthy bones

Each of the following suggestions can only help you, and the more you make this program a part of your everyday life, the better for your bones — and your whole body.

I understand that some women may need medication for serious bone disorders. So even if you make the decision to take medication for your bones, please try to incorporate these suggestions along with your prescription.

Look closely at your risk. Have an honest discussion with your healthcare provider about what your risks truly are for fracturing. The World Health Organization has now developed a tool (FRAX) for calculating your risk. It takes into account your age, weight, previous fracture history, family history, and other risk factors to come up with a number that is more accurate than simply looking at a bone density scan. Check out the FRAX tool to get a better sense of your 10-year fracture risk (or take a look at the comprehensive Bone Health Profile tool that we’ve developed).

Nourish your body with basic nutrients. We are living in a time when demineralized soils, overly processed food, low physical activity, and little sun exposure are the norm. We would all increase our life and longevity by providing our bodies with the basic nutrients for our cells to function optimally. Eat fresh fruits and vegetables, and try to avoid processed foods, white flours, and refined sugars. You might also consider a high-quality multivitamin to fill in any gaps.

Provide your body with specific bone-building nutrients. For those women who have a higher risk for bone loss, a quality multivitamin may not be enough. There are many key bone-building nutrients women can supplement with for improved bone health, not the least of which are vitamin D and vitamin K. Appropriate-dose vitamin D, in particular, has been shown to reduce fractures as much or even more than the drug therapies. You might consider a quality bone-building supplement, like the one we offer in the Personal Program for Better Bones. See our article on the 20 key nutrients for more information on specific vitamins and minerals that aid in bone growth.

Eat an alkaline-forming diet. Acid-forming diets are one of the most significant problems in our culture when it comes to osteoporosis. The modern American diet is filled with acid-forming foods, such as large amounts of animal protein, processed foods, low-quality fats, refined sugars and poor-quality salts. This kind of diet can upset the biochemistry of our bodies and leads to a low-grade metabolic acidosis. When this happens, the body turns to your bones to re-establish balance. Bone provides many alkalinizing or “base” minerals to offset the acid load. This is good in the short-term, but detrimental to bone in the long run. By including more fruits, vegetables (especially root crops), nuts, and seeds in your diet you can significantly alkalize your diet.

Generate stronger bone with exercise. Our bones respond to the demands we place on them. Any form of exercise can help halt bone loss through building muscle, and extensive strength training can build bone significantly as it builds muscle. Take more walks, enroll in a yoga class, or meet with a personal trainer at your local gym. There are loads of ways to include more exercise in your life. Remember that our bodies were meant to move, and as we build muscle we build bone!

Prevent falls to live long. Women may live for many decades with osteoporosis, and never know it if they don’t fracture. One natural alternative to drug therapy is simply avoiding fracture by taking steps to prevent falls or diminishing their impact. You can enhance your balance markedly by practicing yoga, t’ai chi, or qi gong. Remove your throw rugs to avoid tripping, or possibly wear hip protection. There are virtually no side effects to these simple measures, and they have helped many avoid the complications associated with fracturing a bone.

Minimize your stress. Chronic stress takes a huge toll on our health. Not just the day-to-day stress of modern life, but issues from the past can also manifest themselves in new places in our lives. Cortisol, our major stress hormone, can be extremely detrimental to bone and other organs in the body if it remains at high levels ‘round-the-clock — more common than most realize! Be good to yourself, and seek help if you need it or simply give yourself more breaks — whether it’s a monthly massage or simply reading alone on the couch for an hour, do whatever you can to lower your cortisol.

You have choices about bone health

There is a lot of fear and anxiety around an osteoporosis or osteopenia diagnosis. Our instinct is to try and “fix” the problem immediately, and many think this means taking a prescription bone drug. Know that your body is capable of building and strengthening bone on its own when given the needed support and time to do so. In the end, the choice is yours. Just remember that you have options when it comes to improving the health of your bones. The prescriptions advertised on television may sound and look enticing, but the benefits are often exaggerated. There is a better way to healthy bones — and we’re here to help you find it.

Related to this article:

References & further reading on drug therapy

 

Original Publication Date: 09/19/2005
Last Modified: 02/16/2010
Principal Author: Dr. Susan E. Brown, PhD