Treating osteoporosis

I read your summary of osteoporosis treatment¹ with a mixture of interest, and of dismay that I still have to treat 99 patients to prevent one serious fracture.

Without an accompanying analysis of serious adverse effects of the drugs, this does not inspire me to treat my patients at all. But there is another factor that has not been analysed – progress in the orthopaedic treatment and aftercare of fractures. Are there any data to suggest that the rationale for osteoporosis treatment – prevention of large bone fracture – is in fact less than it was in the past due to non-pharmacological advances in medicine?

At what point does the number needed to treat cross the line into ineffectiveness, or the line where the cure is worse than the disease?

Tim Metcalf
General practitioner
Bombala, NSW

Lyn March, one of the authors of the article, comments: 

Thank you for your interest in our article. Serious adverse effects from osteoporosis medicines are very uncommon and hence the number needed to harm (approximately 1250 for atypical fractures after two years of treatment) is far greater than the number needed to treat.

The cost of osteoporotic fractures is high in terms of human suffering with pain, loss of mobility, loss of independence and increased risk of dying in the 3–5 years following the fracture, as well as costs to society through healthcare use, direct health costs and productivity loss.

The final decision needs to be made by weighing up potential harms and benefits for the individual patient, taking their preferences into account. The individual fracture risk calculators (e.g. Garvan, FRAX) can help with the decision making.

Unfortunately we do not have any advances in orthopaedic surgery that prevent or reduce the increased risk of subsequent fractures. Nonpharmacological interventions such as nutritional and exercise-based approaches are important components of the overall care. However in the setting of previous fractures, they need to be combined with drugs to reduce the risk of fracture.