Some older patients may need to take a drug holiday from Fosamax

Published11/10/2008 12:12 AM

Dr. David S. Schneider. D.O., has seen his share of older women with hip fractures.

He knows that 10 million Americans - men and women - either have or are at risk of developing osteoporosis. He's also aware that only 40 percent of hip fracture patients ever regain their independence and nearly 25 percent die within a year.


Is it any wonder that he considers a drug like Fosamax to be a potential lifesaver?

"If I have a patient, a frail elderly woman, living independently in her own home, then yes, I'm going to have her continue with this medication," said Schneider, a physiatrist, board certified in physical medicine and rehabilitation and electrodiagnostic medicine, at Advocate Good Shepherd Hospital in Barrington. "In that case, the benefits far outweigh the risks."

Approved 13 years ago by the FDA, Fosamax was supposed to be every older person's weapon against osteoporosis. But today patients and their doctors are not so sure that long-term use of such drugs is the best option. Some patients, with their doctor's guidance, are taking a drug holiday.

Fosamax belongs to a class of drugs called bisphosphonates. Marketed as Actonel, Aredia, Boniva, Didronel, Fosamax, Reclast, Skelid and Zometa, the drug increases bone mineral density and reduces the risk of spine, hip and wrist fractures in people with osteoporosis and osteopenia - a condition where bones are less dense than normal, but not as severe as in osteoporosis. People with osteopenia are at risk for getting osteoporosis.

Bisphosphonates like Fosamax work by preventing the breakdown of bones and increasing bone density. But some studies have linked Fosamax with osteonecrosis (bone death) of the jaw. Though rare, osteonecrosis is characterized by jaw pain, swelling, loose teeth and exposed jawbone.

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It's not fully known how oral bisphosphonates are associated with osteonecrosis or why it occurs in the jaw. The condition, however, is relatively uncommon and nearly all of the people who have developed the problem have some type of cancer related to the bone and have received Fosamax through a vein. There's also some evidence linking Fosamax with atrial fibrillation, but studies are conflicting.

"Older Americans are more susceptible to heart problems like atrial fibrillation and may be taking drugs to combat osteoporosis," Schneider said. "Is it a correlation or a connection, we don't know."

What is clear is that Fosamax has a long "half-life," meaning that the beneficial effects last for a long time, once it has been taken for at least three years.

"Fosamax and others have been such a great drug treatment, preventing bone loss and helping build bones, said nurse Karen Giammicchio, director of wellness at Alexian Brothers Hospital in Elk Grove Village. "But just because it seems like a good thing - well, too much of a good thing isn't always such a good thing. We need to ask ourselves if we are doing everything we need to do to monitor our patients."


Schneider often recommends patients who have been on the drug for five or more years take a break from the drug, with a physician's approval and guidance.

"Take a drug holiday and then after a few months, have a bone scan," Schneider said. "If the scan shows good results, then you might consider other options for bone health."

Giammicchio, a nurse for 29 years specializing in bone loss and malignancy, says patients taking bisphosphonates should be sure to get their teeth cleaned first. Get plenty of calcium and vitamin D, preferably from food sources. Schneider suggests 800 IU per day of vitamin D and 1200 elemental units of calcium.

"But don't take one vitamin or calcium pill a day. Take one at breakfast, then one in the early evening. If you take too much at one time, it just becomes expensive urine," Giammicchio said.

Limit your coffee, don't smoke and do weight-bearing exercises, such as walking or strength training. You may love swimming, but Giammicchio says that type of exercise won't help your bones.

And, finally, be your own advocate. Educate yourself on risks and benefits of a drug.

"We need to be consumers of our health, just like we're consumers when we walk into the grocery store," Giammicchio said. "It's your body. Take an active, educated role in managing your health."

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