Boning Up on Bone Drugs

Can a drug intended to prevent fractures cause them? The scoop on osteoporosis meds.

by Katharine Davis Fishman
Photograph: Photo: Coolife and Carole & Pauline

Late last fall I started walking like a penguin. The array of specialists I waddled in to see—the anesthesiologist, the physiatrist (a doctor who supervises physical therapy and rehabilitation), the rheumatologist, the sports-med doctor and finally the back surgeon—were baffled by my gait and the increasingly intense throbbing in my left buttock. The back doctor called in the hip doctor down the hall to see what he made of it. Nothing. So the back doctor made an appointment for me to see a neurologist.

At 11 o’clock the night of the back- doctor visit, I was heading for the closet to hang up my jacket when I tripped on a rug. As I slid down the wall, my upper thigh shot out to a 45-degree angle, and I felt an excruciating pain. “Joe, call 911!” I shouted to my husband.

My femur, or thigh bone, had fractured. Doctors implanted a titanium rod and two screws, and I spent three weeks, including rehab, at the nearest regional trauma center.

Two months after the accident, when I showed up (still using a walker) for follow-up care at the Hospital for Special Surgery in New York City, I learned that the fracture had probably been caused by bisphosphonates. Those were the what-a-nuisance drugs that had me getting up early, swigging down a little pill with a big mug of water and—forbidden to eat for the next 30 to 60 minutes—enviously watching my husband enjoy his muffin, all in the interest of avoiding . . . hip fractures! After an osteoporosis diagnosis, I’d swallowed Fosamax for nearly 10 years, stopped for a year after I developed an ulcer, then spent three years on Boniva, the Sally Field drug. All this pill taking helped; I moved from osteoporosis to osteopenia, a milder condition. And yet a silly at-home accident had just broken my femur.

It wasn’t as if I’d been using some kind of risky, experimental medication. In 2004 pharmacists filled more than 18 million prescriptions for Fosamax, manufactured by Merck. The first bisphosphonate available, it has been around since 1995 and was the best seller in its class until 2008, when its patent expired and generic equivalents became available. The potential market for Fosamax and its sister drugs—Actonel, Didronel, Boniva, Aredia, Reclast, Zometa and Skelid—is huge: 10 million Americans have osteoporosis, and an additional 34 million are estimated to have its precursor, low bone mass, also called osteopenia.

Bisphosphonates are known to produce side effects, and a few of those listed in the Fosamax package information for patients are “irritation, inflammation or ulcers of the esophagus, which may sometimes bleed. . . . Fosamax may cause jawbone problems in some people [which] may include infection and delayed healing after teeth are pulled. . . . Call your doctor if you develop severe bone, muscle or joint pain. . . . Some patients have experienced fracture in a specific part of the thigh bone. Call your doctor if you develop new or unusual pain in the hip or thigh.” That last warning refers to the kind of bone break I had just experienced: extremely rare (or, more formally, atypical) femur fractures, incurred when the patient is doing nothing very demanding.

So why are these drugs universally recommended (albeit with qualifications) by some of the same doctors who identified the side effects? A few months after I had thrown aside both the walker and the cane that followed it, I put on my rumpled trench coat and set off to seek some answers.
 
Mixed Messages
The first thing I learned was that bisphosphonates are specifically intended to protect against something more serious than what I’d had: hip fractures. My break, on the shaft of the thigh, would eventually heal. But what we commonly call a hip fracture is much worse. It occurs either at the two knobs known as trochanters that sit on the top of each femur or at the neck between them and has dire consequences. Some 24 percent of elderly women and men who fracture their hips die within a year, another quarter end up incapacitated in nursing homes, and most of the rest never walk quite right again.

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