November 2005

Dear friends,

I was fortunate to be in Europe recently, taking in the sights of England and the pastries of Paris with my family. The late summer days were perfect. It was a very special time.

I had made a mental note to look for signs of the osteoporosis epidemic while there, as I haven’t seen much evidence of it in New Zealand. I can now report that over 3 weeks in pretty densely populated areas I saw one woman with an arm fracture, and one elderly bent man. It’s not as though the older citizens are hidden from view – everyone seems to love to promenade in Paris, and the elegant elderly were out in force, walking their dogs and sitting in side-walk cafes in the warm evenings. Not a dowager’s hump to be seen.

I recently asked my friend David Lovell-Smith, a doctor with a busy general practice in Christchurch New Zealand just how many patients he sees annually with an osteoporosis-related fracture. He said that in reality it is hardly ever. On reflection he wrote: Statistically most GP's would be lucky to deal with one new bone fracture per year that you could truly sheet home to osteoporosis. What we do deal with daily is patients who have been led into taking inadequately tested drugs on the pretext that they are being "protected".

This is the major worry. Global sales of the bisphosphonate Fosamax have reached around $ 4 billion this year, making it Merck's second-best-selling drug. Most countries put no restrictions on its availability so it is widely prescribed to well individuals with reduced bone density despite the lack of evidence for benefit and long term safety. Not so in New Zealand. For years we have had reasonably sensible criteria to restrict access. But the NZ government’s drug regulatory agency Pharmac has recently widened access to Fosamax and will now subsidise the expensive drug to the tune of some 17 million dollars of taxpayer’s money every year. Although restrictions still apply, requiring a low BMD reading (-2.5 SDs or less) and a previous low trauma fracture, they are less stringent than previously and make it much easier for enthusiastic doctors to prescribe the drug. It is not clear, for example, just how a fragility fracture is to be determined. Bones are designed to break when struck in a particular way, and how is it decided whether a fracture is linked to fragile bones?

Many women report that any history of fracture in their lifetime seems to be enough for them to qualify for the subsidy. It is estimated that the new criteria will increase the number of users of the drug to about 100,000 – a significant number in a country of just 4 million people.

News of the widened access to Fosamax was broadcast with great fanfare. The nation’s media faithfully published an official press release that exaggerated the drug’s benefits and avoided any reference to the risks, side-effects and considerable unknowns regarding long term use. Hard on the heels of the news, the Dominion Post, the major daily newspaper of the capital city Wellington ran an article titled “How brittle bones can change your life” featuring a 71 year-old woman whose bones are so fragile she is afraid to sneeze lest they break. She was once a champion ballroom dancer and was pictured laying on her sofa unable to enjoy life as once she had. Not until half way through the long article was there a brief mention that the unfortunate woman has asthma and her osteoporosis is caused by long-term steroid use. It is well known that steroids inhibit the formation of new bone and cause bones to fracture easily. The mechanism by which this happens is very different from the mechanism of postmenopausal bone loss. This important clarification was not made. Typical of this type of article, it warned that more than half of all women and a third of men over 60 are ‘affected’ by osteoporosis, and that younger people should not be complacent – “bone loss can begin in women as young as 25”. The subtext of course was to have bones scanned, and if ‘lucky’ enough to qualify, take the subsidised drugs.

I have posted a new article on my website detailing the action of bisphosphonates in the body, the known effects, an explanation of the different types of these drugs on the market and what we currrently know about each of them.

Fortunately, there are new voices questioning the overselling of drugs to the well. A recent article by Susan Kelleher in the Seattle Times chronicles the 1992 redefining of osteoporosis as an arbitrary measurement of bone density; the meteoric rise of the associated calcium/dairy/drug industry; and the way Merck pharmaceuticals cornered the global market on osteoporosis prevention by purchasing and financing bone measuring technology then pressuring doctors to offer tests to their patients – particularly any woman of menopausal age. A low bone density reading called for a Fosamax prescription, and Merck’s cash return was secured.

The article is one of six on the subjects hypertension, obesity, osteoporosis, female sexual dysfunction, and deep vein thrombosis in a Special Report titled ‘Suddenly Sick: The hidden big business behind your doctor's diagnosis’ by Susan Kelleher and Duff Wilson. Definitely recommended reading.

It is difficult to separate hype from fact in the barrage of media coverage about the 'pending' bird flu pandemic. Check out these reassuring facts from a letter in this week’s ‘Listener’ magazine by New Zealand doctor Terry Jones.

Very best wishes,

Gillian