Osteoporosis

A BMJ Leader (BMJ 2006;333:982-983 (11 November)) brought the apparent link between osteonecrosis of the jaw (ONJ) and bisphosphonate treatment to my attention. Bisphosphonates are widely used in the treatment and prevention of osteoporosis and increasingly are used in patients with metastatic cancer in the bone. I could not recall ever recognising osteonecrosis of the jaw in a patient on bisphosphonate treatment and didn't discuss the potential for this complication with patients initiating onto bisphosphonate treatment - in my practice this is largely with patients known to have or be prone to osteoporosis. What should I do? Fortunately a follow on letter (BMJ 2006;333:1122-1123 (25 November)) came to my rescue. The dose of bisphosphonate used in osteoporosis prevention and treatment is 1/12th that used in oncology. The authors of the letter quote Merck as having received 170 reports of ONJ in alendronate therapy but estimate 20 million patient years of treatment with the drug by 2004 for patients with Pagets disease of the bone and osteoporosis. This puts my concerns into perspective as the majority of patients developing ONJ seem to be those receiving it in high dose and intravenously. Although I need to be aware of this serious side effect, at present I don't think it merits the sort of attention proposed in the original article.
Finally for an up to date clinical review of osteoporosis see BMJ 2006;333:1251-1256 (16 December). One in two women and one in five men over the age of 50 years are affected by fragility fractures. Oral bisphosphonates (alendronate and risedronate) are first line treatments, with strontium ranelate an alternative, especially where bisphosphonates are not well tolerated. Poor compliance and persistence with treatment are common.