Intended for healthcare professionals

Rapid response to:


Drugs for pre-osteoporosis: prevention or disease mongering?

BMJ 2008; 336 doi: (Published 17 January 2008) Cite this as: BMJ 2008;336:126

Rapid Response:

Osteoporosis is not a controversial condition

Contrary to the view expressed by Alonso-Coello et al, osteoporosis
is not
controversial for those who suffer its consequences - fracture. Bone
mineral density (BMD) is a continuous variable (like blood pressure, serum
cholesterol and body weight) that confers a gradient of risk; the lower
the BMD, the higher the risk of fracture (1,2). However, BMD is normally
distributed. There are many more individuals within the 'bell' of the
bell shaped curve of BMD than in the tails of its distribution so, in
numerical terms, most of the population burden of fractures (numbers,
morbidity, mortality cost) arise from the large number of individuals at
modest risk with BMD between - 1 and -2.5 SD (osteopenia) rather than from
the smaller numbers at high risk (osteoporosis).

Reducing this disease burden among the many at moderate risk has been
eloquently written about by Professor G Rose many years ago (3,4). This
is indeed a challenge because of concerns of exposing many individuals to
the uncommon adverse events. However, there is progress. Patients with
osteopenia with a fracture are at higher risk for fracture than patients
with osteoporosis alone (5). Persons with osteopenia coming to sustain
fractures have structural abnormalities that can be detected using high
resolution quantitative computed tomography while those with high bone
remodeling are also at higher risk for fracture. These persons can be
identified (6) and drugs have now been shown to be effective in reducing
fracture risk (5).

No one is suggesting that all women with osteopenia should be
Quite the contrary, efforts by the WHO led by Professor J Kanis to use
absolute risk to target treatment to those who need it while avoiding
needlessly exposing those at low risk is of highest priority.
Alonso-Costello et al trivialize the important public health problem of
fragility fractures in the title of their paper and in almost every
paragraph that follows. Emotive language is not evidence. To suggest that
declaration of potential conflict of interest is evidence of collusion,
“entwined”� collaborations motivated by self serving interests is
demeaning, for the authors they insult, and to themselves. We are all
accountable for words we use, including these authors.

1. Siris ES, Chen YT, Abbott TA, Barrett-Connor E, Miller PD, Wehren
Berger ML 2004 Bone mineral density thresholds for pharmacological
intervention to prevent fractures. Arch Intern Med 164:1108-1112.

2. Sanders K, Nicholson G, Watts J, et al. 2006 Half the Burden of
Fragility Fractures in the Community Occur in Women Without Osteoporosis.
When Is Fracture Prevention Cost Effective? Bone 38:694-700.
Sornay-Rendu E, Munoz F, Garnero P, Duboeuf F, Delmas PD 2005
Identification of Osteopenic Women at High Risk of Fracture: The OFELY
Study. J Bone Miner Res 20:1813-1819.

3. Rose G. Sick individuals and sick populations. Int J Epidemiol

4. Rose G. The strategy of preventative medicine. New York: Oxford Univ.
Press; 1992.

5. Seeman E, Devogelaer J, Lorenc R, Spector T, Brixen K, Balogh A, et al. Strontium ranelate reduces the risk of vertebral fractures in
with osteopenia J Bone Miner Res 2007

Ego Seeman

Professor of Medicine

Past President Australian and New Zealand Bone Mineral Society
Austin Health, University of Melbourne, Melbourne , Australia,

Pierre Delmas

Professor of Medicine

President International Osteoporosis Foundation

Director of INSERM Research Unit 831,
University of Lyon, Lyon, France

Competing interests:
Dr Delmas has received
consultant / speaker fees from
Amgen, GSK, Eli
Lilly, MSD, Novartis, Nycomed,
Procter and Gamble, Roche,
and UCB.

Dr Seeman is medical advisory
committee member with MSD,
Servier, Eli
Lilly, Proctor and Gamble, Sanofi
Aventis, Novaritis. Speaker at
and international meetings with
some of these companies from
time to time.

Competing interests: No competing interests

15 February 2008
Ego Seeman
Professor of Medicine
Pierre Delmas
Austin Health, University of Melbourne, Australia