Dr. Roach: Longtime medication for osteoporosis in need of a change

Keith Roach
To Your Health

Dear Dr. Roach: I have osteoporosis. My mother had it very badly, so I was screened and treated early. I’ve had a five-year-long Reclast prescription, and I worry about my chance of a femur fracture. My T-score for my hip is -3.4 and has worsened despite the Reclast. Prolia scares the heck out of me. I just wonder if you know anything about Evenity. My endocrinologist has only one or two other patients who are on this drug. I’m really struggling with deciding which course of action to take.

— R.C.

Dear R.C.: Osteoporosis is screened for and treated to prevent a fracture, but also when a fracture has already occurred. The T-score is a measure of bone density, with a T-score of 0 meaning normal; a T-score between the -1 to -2.5 range considered low bone mass (osteopenia); and below -2.5 considered osteoporosis. Less than -3 is considered severe osteoporosis.

Dr. Keith Roach

Bone metabolism is characterized by the reabsorption of bone by osteoclast cells and the laying down of new bone by osteoblast cells. When the bone removal exceeds bone growth, the bone loses density and strength. Consequently, treatment of osteoporosis either reduces bone reabsorption or increases bone growth.

Reclast is in the most common class of osteoporosis treatments: the bisphosphonates, which work by slowing down bone reabsorption by the osteoclasts, giving the osteoblasts time to regrow bone. These have been proven to reduce fracture risk in both men and women with osteoporosis. However, they do not work for everybody. Excess use of Reclast can lead to frozen bone, where there is no bone turnover, making the bones brittle and predisposing a person to atypical femur fractures.

Evenity, like teriparatide (Forteo), works by increasing bone growth through stimulating osteoblasts. Many experts prefer this type of agent in someone with severe osteoporosis as the first-line therapy, as well as in your case, when the bisphosphonates have not worked. It would absolutely be an appropriate therapy for you.

Dear Dr Roach: I will be needing a surgery/invasive procedure soon. I have a top-rated physician, but they are at a low-rated facility. I have another top-rated physician who works through a nationally ranked physician and hospital group. Is it reasonable to say that the choice is clear to go with the top-rated physician who works at a top-rated facility?

— H.C.

Dear H.C.: I am very cautious about ratings of individual physicians. These ratings may predict a physician’s likability, but do not correlate well with a physician’s objective abilities and outcomes, nor with peer-reviewed evaluations. There is the potential for conflict of interest: As a physician, imagine that a patient asks you for antibiotics when you know they are not appropriate. Doing the right thing for your patient and your community by not prescribing them would be likely to give you a worse rating.

Ratings for institutions can be much more robust, but may still inadequately account for degrees of complication taken by institutions that accept the most challenging medical and surgical patients. Furthermore, a hospital that is well-rated overall might not be so good at the procedure you are getting. Nevertheless, I would still tend to prefer a more-higher-rated facility than a lower-rated one. The site I use when asked about rating facilities is www.tinyurl.com/AHRQratings, which gives links to ratings by Medicare, the Joint Commission on Hospital Accreditation and other respected rating systems.

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