To the Editor:
In the November issue (28:1346-1353), Theodorou et al wrote an article on osteoporosis for the orthopedic community. This as a rapidly changing field regarding drug interventions that may be somewhat altered from the article. Would the authors please comment on the following issues?
1. The FDA has removed estrogen as a drug for the treatment of osteoporosis because of increased risk of breast cancer, cardiovascular disease, embolism, pulmonary embolism, and possibly dementia. Advisement of this agent is off label. Why did the authors recommend this drug for osteoporosis?
2. Why did the authors only discuss alendronate sodium when there are two other outstanding bisphosphonates, risedronate sodium and ibandronate sodium?
3. Why did the authors recommend raloxifene hydrochloride and calcitonin when all randomized trials demonstrate no hip fracture prevention?
4. Are bisphosphonates safe in the setting of a new osteoporotic fracture?
5. What should orthopedists do with the report by Odvina et al1 that long-term alendronate sodium is associated with spontaneous femoral fractures?
Joseph Lane, MD
New York, NY
The word advisement mentioned in this letter to the Editor, and the claim that we, as authors, recommend certain drugs for the treatment of osteoporosis is unfounded. Our article does not recommend drugs for the treatment of osteoporosis, but instead reviews what is known on the use of some drugs. It is conceivable that, within a journals space limitations, mention can only be made of the pharmaceutical agents that have been used most commonly in the medical treatment of osteoporosis.
Over the past few years, medical treatment of osteoporosis has entered into a phase of explosive growth while it continues to change and improve. It is well known that there are discrepancies between studies. The balance of risks and benefits for hormone use in healthy postmenopausal women remains uncertain.2 To the date our manuscript was accepted for publication, estrogen-replacement therapy had been shown to be effective in preventing and treating osteoporosis. Recent evidence indicates that estrogen/hormone replacement therapy should be used at the lowest effective dose for increasing bone mass and preventing osteoporosis in women with menopausal symptoms.3 Alternatively, other therapies (ie, biphosphonates, selective estrogen receptor modulators, calcium, and vitamin D) should be considered. The benefits should outweigh the risks in each individual case. Because of space limitations, we confined our biphosphonates review on alendronate sodium, which is the first FDA-approved biphosphonate for the treatment of osteoporosis. Risedronate sodium is mentioned in the beginning of the section on treatment. It is important to understand that our article was never intended to provide the reader with an exhaustive review of all available and rapidly developing osteoporosis pharmaceutical agents. The apparent misunderstanding concerning the efficacy of raloxifene hydrochloride and calcitonin seems to be related to the fact that in our study, we do not comment on the effects of these agents on fracture rates, but rather on their effects on bone mineral density. Several medications and combination therapies for treating osteoporosis are currently under investigation. Which of the emerging therapies will most certainly be on the horizon will be judged by trial and error.
Stavroula J. Theodorou, MD
Daphne J. Theodorou, MD, PhD
David J. Sartoris, MD
- Odvina CV, Zerwekh JE, Rao DS, Maalouf N, Gottschalk FA, Pak CY. Severely suppressed bone turnover: a potential complication of alendronate therapy. J Clin Endocrinol Metab. 2005; 90:1294-1301
- Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Womens Health Initiative randomized controlled trial. JAMA. 2002; 288:321-333.
- Gallagher JC. Effect of estrogen on bone. In: Favus MJ, ed. Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003:327-330.