Drugs for pre-osteoporosis: prevention or disease mongering?

28 February 2008

Dear Sir,

By stating that drug marketing is being directed at women with
osteopenia
and thus at those with only a low risk of fracture, Alonso-Coello and
colleagues are simply misinterpreting the significant advances in the
management of osteoporosis which have occurred over the last few years
(1).
Indeed,

1. At the age of 50, one out of 2 women and one out 5 men are at risk
of
fracture for the rest of their life; thus, osteoporosis cannot be
considered as a
controversial issue (2).

2. Just as stroke can occur in normotensive subjects, inferring
factors other
than blood pressure are involved, fracture is not restricted to DXA-
diagnosed
osteoporosis. Indeed, this technique on which the diagnosis is based does
not capture all determinants of bone fragility. This highlights the need
to
move toward a fracture risk-based intervention threshold, to identify
patients
at increased risk of fracture and to target them for efficacious therapy
(2).

3. Most of the registered treatments are associated with a greater
than 50%
reduction in vertebral fracture risk. Considering this high efficacy of
treatment in patients with increased fracture risk, a cost-effective
management is likely to be achieved due to the low number of patients
needed to be treated to avoid one fracture (3).

4. All drugs have possible side effects. The risk/benefit ratio will
be
determined by the risk of side effects. For instance, with a risk as low
as 1/
100'000 for osteonecrosis of the jaw, the ratio is likely to be favorable
for
bisphosphonates (4).

We disagree with Alonso-Coello and colleagues if they imply that a
disease is
promoted in otherwise healthy subjects. Osteoporosis is a debilitating
disease, associated with significant morbidity and increased mortality.
The
aim of osteoporosis management is thus:

1. to identify patients at increased risk of fracture;

2. to allow them to benefit from efficacious available treatments,
and

3. to thereby decrease the burden of the disease.

By doing so, we are not exposing patients who are at low risk of
fracture to
the possibility of dangerous side effects.

René Rizzoli, MD,
Professor of Medicine,
Head, Division of Bone Diseases,
WHO Collaborating Center for Osteoporosis Prevention,
Chairman, Department of Rehabilitation and Geriatrics,
Geneva University Hospital and Faculty of Medicine,
Geneva, Switzerland,
<Rene.Rizzoli@medecine.unige.ch>

Jean-Yves Reginster, MD,
Professor of Medicine,
President of the European Society for Clinical and Economic Aspects of
Osteoporosis and Osteoarthritis (ESCEO,)
Chairman, School of Public Health Sciences,
University of Liège,
Liège, Belgium

1. Alonso-Coello P, Garcia-Franco AL, Guyatt G, Moynihan R. Drugs for
pre-
osteoporosis: prevention or disease mongering? Bmj 2008;336(7636):126-9.

2. Kanis JA, Burlet N, Cooper C, Delmas PD, Reginster JY, Borgstrom
F, et al.
European guidance for the diagnosis and management of osteoporosis in
postmenopausal women. Osteoporos Int 2008;doi: 10.1007/s00198-008
-0560-z.

3. Delmas PD, Rizzoli R, Cooper C, Reginster JY. Treatment of
patients with
postmenopausal osteoporosis is worthwhile. The position of the
International
Osteoporosis Foundation. Osteoporos Int 2005;16(1):1-5.

4. Rizzoli R, Burlet N, Cahall D, Delmas PD, Fink EF, Felsenberg D,
et al.
Osteonecrosis of the jaw and bisphosphonate treatment for osteoporosis.
Bone 2008;doi:10.1016/j.bone.2008.01.003.

Competing interests:
None declared