Letters Bisphosphonates in osteoporosis

Review overemphasises benefits and downplays serious harms

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e5989 (Published 10 September 2012) Cite this as: BMJ 2012;345:e5989
  1. Vijaya Musini, assistant professor1,
  2. Barbara Mintzes, assistant professor1,
  3. Aaron Tejani, researcher, therapeutics initiative1,
  4. James M Wright, professor1
  1. 1Departments of Anesthesiology, Pharmacology and Therapeutics, and Medicine, University of British Columbia, BC, Vancouver, Canada V6T 1Z3
  1. vijaya{at}ti.ubc.ca

We recently conducted a systematic review of bisphosphonates in postmenopausal women with osteoporosis. Our critical appraisal of evidence from 33 randomised controlled trials (25 375 women) of at least one year’s duration reached different conclusions from those of Poole and Compston.1 2

The goal of treatment is prevention of fragility fractures. Effects on bone mineral density are irrelevant—fluoride increased this measure and fractures concurrently.3

Claimed benefits in vertebral fractures do not necessarily refer to a break in the bone; most fractures are radiographically diagnosed asymptomatic vertebral compression with arbitrary definition in different trials.4

In women without previous fracture, bisphosphonates have no proved benefits. In women with previous fractures, we found an absolute risk reduction of 1% over three years in hip fracture and 1.3% in wrist fracture over 2.9 years.2 However, large proportions of unreported outcomes for hip and wrist fracture rates in 32% and 55% of women enrolled raise doubts about the validity of this effect.

Bisphosphonate associated atypical fractures are described as rare. The absolute risk increase was one in 2000 women per year in a Swedish retrospective cohort analysis; compared with non-users, risk was increased 10 times in women on bisphosphonates for up to two years and 50 times in longer term users.5 Bisphosphonates are associated with osteonecrosis of the jaw, oesophageal injury, and oesophageal cancer.

Poole and Compston’s review overemphasises the benefits and downplays the serious harms. The widespread use of a treatment with modest effectiveness in a subset of users, that causes the effect it aims to prevent, raises questions about whether treatment leads to greater harm than benefit.


Cite this as: BMJ 2012;345:e5989


  • Competing interests: None declared.


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