Many people don’t know that taking osteoporosis medication for a long time can, in some cases, cause fractures

As Don Freeman stepped from the shower, he supported his left thigh with his hand, as usual. The leg had been troubling the 85-year-old man—my father—for several months and was getting worse. His doctor had not yet pinpointed the cause of the pain that ran down the thick of the thigh when he walked.

But on this night last July, as he raised his right leg over the lip of the shower, placing full weight on the left, he fell backward. My mother, unable to help him to his feet, called an ambulance. Then she called me. At the time, we thought he’d simply slipped. When the emergency room doctor revealed he’d broken both his left femur and right hip, we were stunned. He said recovery would be complicated by his age, osteoporosis and the dual break.

While osteoporosis has been on the periphery of my consciousness, I’d not paid it much attention. This ‘silent thief’ can change lives in an instant.

High cost

Canadian statistics on osteoporosis are startling. Fractures related to osteoporosis are more common than incidences of stroke, heart disease and breast cancer combined. At least 1 in 3 women and 1 in 5 men will have one in their lifetime. Of those, a third or more who fracture a hip will die within a year. Many lose their independence and require long-term care. It is a serious, and steadily accelerating, healthcare epidemic that in 2010-2011 cost Canada $4.6 billion dollars. And the emotional and financial cost to patient and families cannot be overstated.

Tracking the cause

Following my father’s five-hour surgery, the orthopedic surgeon who inserted steel rods and screws in femur and hip told us the femur had a pre-existing crack; no doubt the source of the pain. He believed the bone broke, Dad fell, then broke the hip.

My father had been taking medication to strengthen the bones for two years. What caused the crack?

The surgeon told us he’d been seeing more of these kinds of ‘atypical femur fractures’ (AFF)—a thigh fracture that can occur with minimal or no impact—but usually in patients taking osteoporosis medications for prolonged periods of time.

Alarmed that the very medication designed to make his bones stronger had actually made them weaker, I began researching. I discovered Health Canada had issued a 2011 warning identifying this risk with the bisphosphonate medications frequently prescribed to treat osteoporosis.

Although rare, the risk of AFF is real and is being studied. As happened with my father, a hairline crack can take weeks or months to become an actual break. Signs of a potential fracture are dull, aching pain in the thigh, hip or groin area.

If only we’d known.

Naturally, we began the blame game: blame the drugs, the doctor, but mostly ourselves for not paying attention, not taking note of possible risks, not being more proactive. But blame achieves nothing, so I focused on education.

Our bones go through a natural depletion/regeneration cycle that keeps them strong and healthy. Osteoclast cells take away old bone, breaking the calcium down for reabsorption by the body, and osteoblast cells build new, strong bone. As we age, the work of these two kinds of cells often becomes unbalanced and we lose more than we gain. Bisphosphonates impede the action of cells that break down, but this can reduce the body’s access to much-needed calcium, so adequate calcium and vitamin D intake is important.

Dr. Angela M. Cheung is director of the osteoporosis program at the University Health Network, a group of Toronto hospitals. She helped develop the clinical definition of AFF, and has been studying it for a decade.

“We are seeing [AFF] more and I feel the drugs play a part in increasing that number,” she says, “but that number is still small.”

She says there can be various reasons a fracture might occur. Because AFF has existed for many years, and sometimes occurs without bisphosphonate use, she is inclined to think one issue is the interaction of genetics and drugs.

“We are treating osteoporosis as one size fits all,” she says. “As we move more into personalized medicine, we need to broaden that view and to do this better.”

Screening is key

Better screening and monitoring of patients would determine if there are underlying conditions. Although osteoporosis-related fractures create a significant healthcare burden and greatly impact quality of life for many, Canada lags behind in establishing programs to diagnose and treat it.

Dr. Cheung says that men are often forgotten and overlooked.

“People view it as an old lady disease [but] men can have increased risk for fractures,” she says. “There is a huge care gap in osteoporosis care and fractures. People are not being adequately treated and are sustaining fractures.”

While doctors still believe benefits of bisphosphonates and other osteoporotic medications outweigh the risk, it’s important to ask questions and be well-informed. The danger is in thinking a pill relieves us of the need to do anything else.

Dr. Peter Ford is a Moncton-area pharmacist who provides counseling on prescription drugs, and complementary suggestions or alternatives. “We can offer the pros and cons of therapy, as well as discussing with the science about the condition.”

He also supports improved screening of patients before prescribing. He says some medicines work extremely well, such as pain medications and antibiotics; he is always interested in the number of people treated versus those experiencing benefit or harm.

“I think that we have to be much more judicious in the use of our pharmaceuticals. There are really great ones on the market, but there are also several that have the potential to cause significant harm, even though approved by Health Canada.”

He says that minerals, vitamins, diet and exercise play a vital role in maintaining bone strength as we get older. “You need calcium and magnesium to be in balance. About 90-95 per cent of Canadians have a deficiency in magnesium.” A vitamin D supplement is very important. With our limited sun and the use of sunscreens, most Canadians do not get enough.

Road to recovery

My dad is home now after seven months in the hospital. One leg is 2” shorter, and he requires a shoe lift, mobility aids and specialized transportation. He can no longer do the things he loves, but he’s determined to become independent again. He participates in a physio program with weight-bearing and strengthening exercises, has lost weight, adjusted his diet and supplement intake.

We know how lucky we are, but remain concerned about the chance of another fracture. This situation opened my eyes to the complexity of treating osteoporosis, and the many ways this disease impacts quality of life and independence. Most of all, the importance of asking questions, being proactive, and participating in our own healthcare.