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Rapid Responses: Rapid Responses published:
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What about physical activity
- Harriette J Carr (15 August 2003)
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What about physical activity (2)
- douglas salmon (15 August 2003)
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Another great risk factor
- Wladimir K de Paula (15 August 2003)
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Consider other options also
- Jai B Sharma, Monika Malhotra, St Thomas Hospital, London (22 August 2003)
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Bone Densitometry is appropriate to identify Osteoporosis
- A Louise Dolan (28 August 2003)
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Postmenopausal osteoporosis. Is there a place for non-pharmacological options?
- Pablo Alonso-Coello, Merce Marzo (16 September 2003)
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Harriette J Carr, Public Health Specialist Ministry of Health, Wellington, New Zealand
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This editorial on the prevention and treatment of osteoporosis fails to do non-pharmacological options justice. There is no mention of the important role that regular physical activity can play in the prevention and treatment of osteoporosis and reducing risk of hip fractures. Weight bearing activity is important in young people to increase bone mass and strength, and in asymptomatic adults to help preserve bone density. Regular moderate physical activity can reduce risk of hip fracture (1). Regular modified physical activity in those with osteoporosis can improve posture, muscle strength and maintain bone mass. There is more to health care than pharmacology alone. References 1. Hoidrup S, Thorkild IA, Stroger U, Lauritzen JB, Schroll M & Gronbaek. 2001. Leisure time physical activity levels and changes in relation to risk of hip fracture in men and women, American Journal of Epidemiology; 154(1): 60-68. Competing interests: None declared |
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douglas salmon, gp birmingham, b20 3he
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Richard Smith argued previously, in an editorial of an issue of the BMJ in large part devoted to criticising the relationship between Doctors and Pharmaceutical companies, that "journals need systems to prevent advertising influencing editorial content ". Yet this editorial completely ignores non-pharmaceutical approaches to the management of osteoporosis. "Treatment" is implicitly assumed to be drug treatment. Did your systems fail Dr Smith ? Or is a pharmaceutical bias acceptable providing it is general and not specific ? BMJ 2003;326:1155-1156 (31 May) Competing interests: None declared |
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Wladimir K de Paula, MD IPSEMG - Brazil - 30130110
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A great deal of effort is dedicated at achieving optimal drug for treating osteoporosis, but what are our goals here? Does the treatment of osteoporosis leads to a better quality of life? A longer life? We could infer that by diminishing the fracture risk both of the goals could be achieved, but does it is cost effective? Who should be treated and for how long? I think the primary risk of fractures is FALLING. Without falls, osteoporotic fracture would rarely occur. Why we don´t have more systematic views on falls? We even don´t know the primary cause of falls in the elderly. Could it be visual problems? Motor problems? Osteoporosis is indeed a public problem in the elderly people, but it wouldn´t if falls were to be as too much studied. Competing interests: None declared |
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Jai B Sharma, Assistant Professor in Obst & Gynaecology All India Institute of Medical Sciences, New Delhi 110029, Monika Malhotra, St Thomas Hospital, London
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This is a welcome article on an important topic like osteoporosis which is responsible for significant mortality and morbidity in women especially postmenopausal ladies. Although most recent studies including the well known Women's Initiative Study from USA have observed significant adverse effects of estrogen progestogen therapy especially breast cancer and increased chances of ischaemic heart disease. However, estrogens are potent treatment for post-menopausal osteoporosis and may be better than nonhormonal treatments like alendronate, reloxifene, calcitonin and parathyroid hormone. But with decreased use of estrogens due to actual and presumed adverse effects of estrogen therapy such treatments have assumed great significance. However, other treatment options like physical exercise especially Yoga , calcium supplementation and use of phyto- estrogens should also be highlighted as they are useful and effective treatment modalities for menopause. Phyto-estrogens may be effective in ameliorating the physical symptoms of menopause like hot flushes and should be studied in more details considering adverse publicity given to estrogens. The gynaecologists should consider all such treatment options to deal with their menopausal women and should honestly advise them about it. Competing interests: None declared |
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A Louise Dolan, Consultant Rheumatologist Queen Elizabeth Hospital, Woolwich London SE18
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Dear Sir, Prof. Cranney, in her recent editorial on Postmenopausal Osteoporosis (1), suggests that bone mineral density is not a useful tool to identify patients who would merit treatment for osteoporosis. However the arguments used are not valid for GPs and hospital doctors seeking to find at risk patients. It is not appropriate to dismiss the value of scanning on the basis of the fluoride studies (2). This now obsolete drug caused more fractures by producing an unstable bone structure. Likewise the arguments against bone density measurements put forward by Cummings are in the context of repeat scans after treatment, which may not be useful since so many patients respond (3). There is strong evidence that bone mineral density is a marker for future fracture and so is a valid test to identify patients to treat with our efficacious osteoporosis treatments (4). Risk factors are important in identifying whom to assess for osteoporosis but have been shown in a number of studies not to be specific enough to make treatment decisions for a given patient. GPs are inundated with guidelines, yet they are often unheeded. We recently performed a case-controlled study of GP’s prescribing of osteoporosis prophylaxis for steroid treated patients in 10 practices(5). Five were in a Primary Care Trust (PCT) with access to bone densitometry and the other five decided treatment on guidelines alone. Patients aged 35 to 80 years on prednisolone for at least 3 months were identified by a database search. Patients on no previous bone protection other than calcium and vitamin D preparations (Ca/D) were included in the study. Appropriate patients in 5 practices were offered a DEXA scan and treatment review. Patients in the 5 control practices just had their treatment reviewed. We found 0.12% of patients in the practices studied were on prednisolone > 3 months, but on no osteoporosis prophylaxis other than Ca/D. Pre-study use of osteoporosis prophylaxis ranged from 18-36%. Of the 48 patients who received DEXA scans, 43% were abnormal. 47.6% of patients with abnormal scans started a bisphosphonate, compared to only 16% in controls (RR=3, p=0.004). We found there was a three-fold increase in prescription of potent bisphosphonates, if the patient had a bone density scan, compared with patients who’s GPs made a decision on the basis of guidelines alone. Human nature is such that a firm result for a given patient is more likely to result in appropriate prescribing. I would strongly support the need to identify patients with low impact fractures and assess them for treatment. Our unit has an osteoporosis nurse who identifies and assesses patients attending the Fracture Clinic and orthopaedic wards. An audit of 118 women with Colles fracture identified that bone density was low (T<- 2.5 or z< -1) and merited treatment in 40%. However in the elderly, over 75 years, we found that the patients had bone density comparable to their peer group, but 63% were sufficiently frail that they couldn’t get out of a chair without using their arms. In the frail elderly, falls and instability may be the key risks leading to fracture and the National Service Framework for the Elderly Chapter 6 quite rightly suggests the need for a falls assessment in order to prevent further fracture. Bone densitometry and fall assessment must therefore go hand in hand in any strategy to reduce the incidence of fractures in postmenopausal women. A. Louise Dolan MA FRCP
1 Cranney A, Treatment of postmenopausal osteoporosis. BMJ 2003 ;327: 355-6 2 Riggs BL,Hodgson, SF,O Fallon WM, Chao EY, et al. N Eng J Med 1990;322:801-9 3 Cummings SR, Karpf DB, Harris F, Gernant HK,et al. Improvement in spine bone density and reduction in risk of vertebral fracture during treatment with anti-resorptive drugs. Am J Med 2002; 12:281-9 4 Kanis JA, Assessment of bone mass and Osteoporosis. In Osteoporosis.1994 p114-147. Blackwell Science Ltd 5 AL Dolan, E Koshy, M Waker, CM Goble. Access to bone densitometry increases GPs prescribing for osteoporosis in steroid treated patients. Osteoporosis Int.2003; 14: S8 (suppl 4) Competing interests: None declared |
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Pablo Alonso-Coello, research fellow Iberoamerican Cochrane Centre, Barcelona (SPAIN), Merce Marzo
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The editorial by Dr Cranney has thoroughly covered the pharmacological options available for the treatment of postmenopausal osteoporosis (1). There are however several non-pharmacological treatments which should be considered given the uncertainties regarding the evaluation and management of osteoporosis even if the evidence supporting them is weak. Exercise is simple advice that can be given to postmenopausal women with osteoporosis and is beneficial for a whole range of other health issues as well. Several systematic reviews of the effects of exercise on postmenopausal osteoporosis have shown an increase in bone mineral density (2) although there is lack of data regarding the effect of exercise in preventing fractures. Another key issue not mentioned in the editorial is the need to decrease the risk of falling. There are systematic reviews about the effectiveness of measures to prevent falls and there is evidence that some interventions to prevent falls that are likely to be effective are available (muscle strengthening and balance retraining programmes, home hazard assessment and modification, etc.) (3). Some potential interventions are of unknown effectiveness and further research is needed Hip-protectors, assessed in Cranney’s editorial, are still a subject of debate. A recent update of a Cochrane systematic review shows different conclusions from the ones published earlier (4). In this updated review, the initial beneficial effect observed for hip protectors reducing the incidence of hip fracture was not confirmed from studies using individual randomisation within an institution or for those living in their own homes. Another issue is that most trials included people at particularly high risk of hip fracture with a mean age of 80-86 years. Another topic for concern is the absence of long term data about adverse effects of all these still new pharmacological treatments or even their optimal duration. Recent results from the Women’s Health Initiative trial have made clear that we need to be cautious about the long term effects of treatments as sometimes harms might surprisingly outweigh benefits (5). How many years are we going to keep treating patients with these drugs and how many years are they ready to take them properly? Will they improve their quality of life in the long term or will we have to tell them to stop because of new data that alerts us of new unexpected adverse effects? The lack of appropriate research on these non-pharmacological issues is disappointing. More research is needed and head to head comparisons, as mentioned in the article, are required. However, these comparisons are needed not just amongst pharmacological options but between the latter and the non-pharmacological options, and amongst the different non- pharmacological options available. Women who are taking a treatment might change their mind if they knew how little we know about the actual benefit they might obtain from a long-term pharmacological treatment. References 1. Cranney A. Treatment of postmenopausal osteoporosis. BMJ 2003 ; 327: 355-356 2. Bonaiuti D, Shea B, Iovine R, Negrini S, Robinson V, Kemper H, Wells G, Tugwell P, Cranney A. Exercise for preventing and treating osteoporosis in postmenopausal women. [Systematic Review] Cochrane Musculoskeletal Group Cochrane Database of Systematic Reviews. Issue 3, 2002. 3. Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH Interventions for preventing falls in elderly people (Cochrane Review). In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software. 4. Parker MJ, Gillespie LD, Gillespie WJ. Hip protectors for preventing hip fractures in the elderly (Cochrane Review). In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software. 5. Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA 2002; 288:321-333 Competing interests: None declared |
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