Radical Shift Seen in Osteoporosis Therapy

Sharp surge in doctor visits, prescriptions for new drugs

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HealthDay Reporter

MONDAY, July 26, 2004 (HealthDayNews) -- A new study unearths a seismic shift in osteoporosis treatment in the last decade: More women are getting the newest drugs from their doctors while fewer women are using tried-and-true therapies such as calcium supplementation.

And despite the dramatic surge in both visits to the doctor and prescriptions for the new medications handed out since the 1990s, experts say osteoporosis remains under-diagnosed and under-treated.

"The good news is that we've improved enormously in the likelihood of someone with osteoporosis getting diagnosed and treated. The bad news is there's still a gap," said Dr. Randall S. Stafford, lead author of the study appearing in the July 26 issue of the Archives of Internal Medicine and an assistant professor of medicine at the Stanford Prevention Research Center. "By our calculations, it looks like about 40 percent of the population who may have osteoporosis is actually getting diagnosed and treated in doctors' offices."

Osteoporosis is a disease characterized by low bone mass and fragility, which leads to an increased susceptibility to bone fracture. According to the article, in 2000, about 10 percent of Americans suffered from the condition. It is most common among postmenopausal women, who account for at least 90 percent of the cases.

Using a nationally representative database, the study authors tracked the frequency of osteoporosis visits and drug-prescribing patterns in the United States from 1988 to 2003.

Between 1994 and 2003, the number of doctor visits for osteoporosis increased nearly fivefold, from 1.3 million visits to 6.3 million visits. In 2003, 3.5 million patients visited their doctors for osteoporosis treatment, compared with half a million in 1994. (This takes into account multiple visits.) The proportion of doctor visits for osteoporosis where medications were prescribed jumped from 82 percent in 1988 to 97 percent in 2003.

The sharpest increases were seen in the mid-1990s. This coincided with the availability of new, easier-to-take and more effective drugs for the disease, especially bisphosphonates such as alendronate (Fosamax) and the selective estrogen receptor modulator raloxifene (Evista).

Between 1994 and 2003, the percentage of doctors' visits where bisphosphonates or raloxifene were prescribed increased from 14 percent to 73 percent and from 0 percent to 12 percent, respectively. Prescriptions for older medications declined during the same time period.

Although it's hard to pinpoint exactly why these increases happened, Stafford can think of a number of possibilities. Fosamax was shown to be very effective in helping to reduce fractures and was heavily marketed, having come onto the market after direct-to-consumer advertising was allowed.

This also coincided with improvements in, and the wider availability of, technology for bone mineral density testing. Perhaps as a result, primary-care physicians started taking more responsibility for diagnosing and treating the disease. "[In] the mid-1990s, primary-care physicians as well as the public started to become aware that osteoporosis was something worth worrying about," Stafford said.

Prior to 1996, before these drugs became available, the leading treatments were estrogen and calcium. The decline in estrogen treatment long predated the landmark Women's Health Initiative study, which found in 2002 the therapy was linked to a higher risk of cancer and cardiovascular diseases.

One worrisome and unexpected finding from the study was a decline in the number of osteoporosis patients taking calcium supplements, from 43 percent in 1994 to 24 percent in 2003.

"Calcium is a necessary part of treatment for osteoporosis. Clinical trials require that women take calcium so the trial data basically assumes that these new drugs are effective in women who are taking calcium," Stafford said. "I think physicians and patients are so enamored by the new drugs that they forget osteoporosis treatment should be a package -- and that package should include calcium, vitamin D and some sort of weight-bearing exercise."

These elements also form part of osteoporosis prevention, which should be a priority, the study authors said. "Nature didn't expect us to become osteoporotic," confirmed Dr. Steven R. Goldstein, a professor of obstetrics and gynecology at New York University School of Medicine. "Left to nature's devices, we probably had enough bone mass for the little bit of time after menopause we survived."

All that has changed with soaring life expectancies. "We can encourage women from puberty to be sure that they have enough calcium and vitamin D in their life so that their bone mass peaks at age 35 so that when they get to menopause, they have a better place to start off because that does make a difference," Goldstein said.

After that, "screening for osteoporosis [in postmenopausal women] should be as much on the top shelf of doctors' minds as we have now become ingrained with mammograms," Goldstein said.

More information

For more on osteoporosis, visit the National Osteoporosis Foundation.

SOURCES: Randall S. Stafford, M.D., Ph.D., assistant professor, medicine, Stanford Prevention Research Center, Palo Alto, Calif.; Steven R. Goldstein, M.D., professor, obstetrics and gynecology, New York University School of Medicine School, New York City; July 26, 2004, Archives of Internal Medicine

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