Intended for healthcare professionals

Letters Vertebral fracture treatment

Clinicians need to treat underlying osteoporosis

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d5040 (Published 10 August 2011) Cite this as: BMJ 2011;343:d5040

Osteoporosis and vertebral fractures: a newly discovered epidemic or just an example of overdiagnosis and disease mongering?

Sir,

We read with interest the recent letter by Wahl et al. entitled:
"Clinicians need to treat underlying osteoporosis" (BMJ 2011;342:d5040),
but respectfully have to disagree with many of their notions. First, the
diagnosis of vertebral fracture is quite arbitrary; depending on the
criteria used for classifying a change in an x-ray as "a fracture", the
prevalence of vertebral fracture can vary as much as 3 - 90% in a given
elderly population. 1

Second, a symptomatic vertebral fracture is rarely "spontaneous" or
purely osteoporotic; at least 50% are trauma-induced, particularly due to
falling on buttocks or lifting an object with straight knees. 2-4 In
fact, seemingly benign activities -- such as bending or lifting light
objects -- produce rather large loads on the spinal column (up to 10 times
higher compared with perfect posture) and are easily capable of fracturing
a vertebra. 4, 5 Thus, prevention of vertebral fractures is not only
treatment of osteoporosis by various bone-acting compounds as proposed by
Wahl et al. (BMJ 2011;342:d5040), but should actually be primarily focused
on prevention of falling and execution of proper lifting ergonomics. 4, 6

Third, only one-third of the x-ray changes termed "vertebral
fractures" are symptomatic, 7 and the occurrence of vertebral fractures
rather poorly predicts either the existence of back pain or functional
status of the spine. 8 Somewhat surprisingly, much of this epidemiological
evidence has been provided by one of the authors of the letter by Wahl et
al. (BMJ 2011;342:d5040), but seems to have escaped their attention.

Fourth, the authors claim that vertebral fractures increase the risk
of death. Almost every illness of older adults, by the very virtue of the
definition of the word "illness" as an indicator of frailty and weakness,
is related to increased morbidity and mortality, but seldom is a truly
independent risk factor or direct cause of death. Accordingly, the more
relevant question here is how much of the increased mortality risk linked
to vertebral fractures can be reduced by pharmacotherapy of osteoporosis?

Regarding this topic, Wahl et al. refer to the results of randomized
clinical trials (so called efficacy trials), which indeed suggest that
treatment of osteoporosis can reduce vertebral fracture rates by 30-70%.
These are the highest relative risk reductions achieved by pharmacotherapy
among the various types of fractures of older adults. But, as we recently
highlighted in the pages of this journal, 9 these efficacy trials and
their carefully selected patient populations poorly represent the real-
life clinical setting. We fear that in clinical practice the results of
osteoporosis treatment are much more modest. This view is supported by the
only existing effectiveness evidence (real-life evidence): In community
living people the risk of fracture among those who had received
bisphosphonates did not differ from those who had not. 10 Also, a recent
population-based study from Canada showed that bone-specific drugs were
rather ineffective in decreasing the fracture risk in real clinical
setting. 11 And for sure, they do not repair an existing vertebral
fracture.

The concept of disease prevention is a difficult one, as highlighted
by Starfield et al. in their paper entitled "The concept of prevention: a
good idea gone astray?". 12 These authors stated: 'Encouraged by interest
vested in selling more medications for "prevention", the pressure for
increasing "prevention" in clinical care directed at individuals is
inexorable - even though it is not well supported by evidence in
populations of patients'. More recently, Ray Moynihan also warned about
overdiagnosis and the dangers of early detection by stating:
'Overdiagnosis is one of medicine's biggest problems, causing millions of
people to become patients unnecessarily, producing untold harm, and
wasting vast amounts of resources'. 13

We have many discouraging examples in which industry - often with the
aid of both paid consultants and disease awareness/advocacy groups - takes the leading
role in "educating" both professionals and the lay public and raises
awareness of "unmet need" in the prevention and treatment of risk factors
portrayed as diseases. 13 A typical example is the widespread promotion
of preventive drugs for high blood pressure, high cholesterol, and high
blood sugar concentrations despite serious doubts about whether this is
money well spent. 9, 14 We feel that these concerns are also pertinent to
pharmacological treatment of osteoporosis and vertebral fractures.

Teppo LN Jarvinen, MD, PhD

Department of Orthopaedic Surgery, University of Tampere, Tampere, Finland

Email: teppo.jarvinen@uta.fi

Pekka Kannus, MD, PhD

Injury and Osteoporosis Research Center, UKK-Institute, Tampere, Finland

References:

1. Melton LJ, 3rd, Wenger DE, Atkinson EJ, Achenbach SJ, Berquist TH,
Riggs BL, et al. Influence of baseline deformity definition on subsequent
vertebral fracture risk in postmenopausal women. Osteoporos Int. 2006;
17(7): 978-85.

2. Cooper C, Atkinson EJ, Kotowicz M, O'Fallon WM, Melton LJ, 3rd.
Secular trends in the incidence of postmenopausal vertebral fractures.
Calcif Tissue Int. 1992; 51(2): 100-4.

3. Cooper C, Atkinson EJ, O'Fallon WM, Melton LJ, 3rd. Incidence of
clinically diagnosed vertebral fractures: a population-based study in
Rochester, Minnesota, 1985-1989. J Bone Miner Res. 1992; 7(2): 221-7.

4. Myers ER, Wilson SE. Biomechanics of osteoporosis and vertebral
fracture. Spine (Phila Pa 1976). 1997; 22(24 Suppl): 25S-31S.

5. Duan Y, Seeman E, Turner CH. The biomechanical basis of vertebral
body fragility in men and women. J Bone Miner Res. 2001; 16(12): 2276-83.

6. Jarvinen TL, Sievanen H, Khan KM, Heinonen A, Kannus P. Shifting
the focus in fracture prevention from osteoporosis to falls. BMJ. 2008;
336(7636): 124-6.

7. Cooper C, O'Neill T, Silman A. The epidemiology of vertebral
fractures. European Vertebral Osteoporosis Study Group. Bone. 1993; 14
Suppl 1: S89-97.

8. O'Neill TW, Cockerill W, Matthis C, Raspe HH, Lunt M, Cooper C, et
al. Back pain, disability, and radiographic vertebral fracture in European
women: a prospective study. Osteoporos Int. 2004; 15(9): 760-5.

9. Jarvinen TL, Sievanen H, Kannus P, Jokihaara J, Khan KM. The true
cost of pharmacological disease prevention. BMJ. 2011; 342: d2175.

10. Feldstein AC, Weycker D, Nichols GA, Oster G, Rosales G, Boardman
DL, et al. Effectiveness of bisphosphonate therapy in a community setting.
Bone. 2009; 44(1): 153-9.

11. Perreault S, Dragomir A, Blais L, Moride Y, Rossignol M, Ste-
Marie LG, et al. Population-based study of the effectiveness of bone-
specific drugs in reducing the risk of osteoporotic fracture.
Pharmacoepidemiology and drug safety. 2008; 17(3): 248-59.

12. Starfield B, Hyde J, Gervas J, Heath I. The concept of
prevention: a good idea gone astray? J Epidemiol Community Health. 2008;
62(7): 580-3.

13. Moynihan R. Reality Check: Overdiagnosis and the dangers of early
detection. BMJ. 2011; 342: doi:10.1136/bmj.d40 (Published 23 February
2011).

14. Moynihan R. Surrogates under scrutiny: fallible correlations,
fatal consequences. BMJ. 2011; 343: d5160.

Competing interests: No competing interests

17 August 2011
Teppo L Jarvinen
Orthopaedic resident
Pekka Kannus
University of Tampere