Intended for healthcare professionals

Rapid response to:

Analysis

Shifting the focus in fracture prevention from osteoporosis to falls

BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39428.470752.AD (Published 17 January 2008) Cite this as: BMJ 2008;336:124

Rapid Response:

Say “No to misleading advertising on osteoporosis"

Editor,

as many clinicians, we highly appreciated this journal’s position on
bone fractures prevention, which recent papers contributed to make
clear.1,2 The loss of bone mineral (BM) itself should be considered a risk
factor rather than a disease. Since clinical studies show that only 18-46%
of women experiencing a fragility fracture have T score <- 2,5 3,4,5,6
bone densitometry should not be longer considered a gold standard in the
evaluation of fracture risk.
Most of all, falls preventive strategies seem far more important than the
administration of antiresorptive drugs, as falls are the direct cause of
most clinical fractures.2

Now this clinically sound message is seriously challenged
by aggressive information campaigns, targeted at citizens. The “Timeless
women campaign”, promoted by the International Osteoporosis Foundation and
sponsored by Novartis, has been launched these days to re-direct attention
on bone testing and drug treatment. Ursula Andress, the unforgettable
interpreter of the 007 movie “Doctor No”, is the testimonial for this
campaign with the slogan “Say: Doctor No to osteoporosis!”. Just in few
days hundreds of reports appeared in the media and many forums collected
thousands of comments.
The actress tells her story: following a former BM test she didn’t take
any drug and in the next examination, T score was lower. Well, nothing
strange in this: aging is always accompanied by BM loss. She says “I don't
want to become a crippled old lady…” leading to the wrong conclusion: bone
loss = invalidity. Now we know that bone microarchitecture is as important
as BM; the majority of elderly women, not experiencing fragility fractures
despite low bone density, witness that fracture risk also depends on other
factors. Another subtle message is that Ursula’s bones became like glass
despite continuous exercise. This may lead to the wrong conclusion that
healthy life habits are useless when, probably, physical exercise
preserved Ursula from bone fractures in spite of her low BM.
Ursula says she’s safe now thanks to a once a year administered drug,
produced by that company who sponsored the campaign. Available evidence
only shows that this treatment could not prevent clinical fractures in all
healthy post-menopausal women, but just in 4 out of 100 of them, mostly
with pre-existing fractures .7

The final misleading message is: “Check your bones year after year,
starting immediately after menopause”. No robust result is available for
implementing such strategy, expecially in those years, when fractures are
very rare and when the effect of drugs has not been adequately evaluated.
The National Screening Committee and the NICE 8 guidance did not recommend
any screening to prevent osteoporotic fracture because of concerns about
the accuracy of BMD assessment for the prediction of fracture and because
there was no evidence indicating that such screening would reduce the
incidence of fractures.

This campaign risks transforming postmenopausal women into sick people and
suggesting that magic bullets rather than avoiding falls and adopting
healthy lifestyles are the keys for healthy bones.

Clinicians do need medical authorities helping them to give
the right information, now women and doctors should say: “No to misleading
direct to consumers advertising”.

1. Alonso Coello P, López García-Franco A, Guyatt G and
Mohinyan R Drugs for pre-osteoporosis: prevention or disease mongering?
BMJ 2008; 336:126-129

2. Järvinen TLN, Sievänen H, Khan KM, Heinonen A, Kannus P
Shifting the focus in fracture prevention from osteoporosis to falls. BMJ
2008; 336:124-126

3. Stone K, Seeley DG, Lui LY, Cauley JA, Ensrud K, Browner
WS, Nevitt MC, Cummings SR BMD at Multiple Sites and Risk of Fracture of
Multiple Types: Long-Term Results From the Study of Osteoporotic
Fractures. J Bone Miner Res 2003;18:1947–1954

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

5. Nguyen ND, Eisman JA, Center JR, Nguyen TV Risk Factors
for Fracture in Nonosteoporotic Men and Women J Clin Endocrinol Metab
1997; 92: 955–962

6. Sornay-Rendu E, Munoz F, Garnero P, Duboeuf F, Delmas PD
Identification of osteopenic women at high risk of fracture: The OFELY
Study J Bone Miner Res 2005; 20:1813–1819

7. Black DM, Delmas PD, Eastell R, Reid IR, Boonen S,
Cauley JA, Cosman F, Lakatos P, Leung PC, Man Z, Mautalen C, Mesenbrink P,
Hu H, Caminis J, Tong K, Rosario-Jansen T, Krasnow J, Hue TF, Sellmeyer D,
Fink Eriksen E, Cummings SR Once-Yearly Zoledronic Acid for Treatment of
Postmenopausal Osteoporosis N Engl J Med 2007; 356: 1809-22.

8. NICE technology appraisal guidance 160: Alendronate,
etidronate, risedronate, raloxifene and strontium ranelate for the primary
prevention of osteoporotic fragility fractures in postmenopausal women;
2008

Competing interests:
None declared

Competing interests: No competing interests

20 November 2008
Emilio Maestri
Consultant endocrinologist
Emilio Maestri, Oreste Capelli, Giulio Formoso, Lucia Magnano, Anna Maria Marata and Nicola Magrini
Unit of Drug Evaluation and Evidence-Based Primary Care (CeVEAS), 41100 Modena, Italy