Your doctor breaks the news that you've got osteopenia, an early state of bone loss that is often a precursor to osteoporosis. She's advising osteoporosis drugs. Should you take them?

It's a question that a huge swath of American women may at some point face, since some 40 percent of those who've passed menopause have osteopenia, according to a 2001 study published in the Journal of the American Medical Association. Rheumatologists, endocrinologists, gynecologists, internists, geriatricians, and family practice doctors all diagnose and treat it—and, in the absence of clear guidelines, their approaches vary. Some more aggressive clinicians recommend medications early to head off worsening bone loss; others take a wait-and-see attitude, with suggestions for regular exercise and plenty of calcium through diet and supplements, if needed.

Now, a new analysis by researchers in Spain, Canada, and Australia suggests that more women than really need to may be taking drugs. Noting that most osteopenia studies have focused on preventing a single vertebral fracture—when two thirds of vertebral fractures are asymptomatic, and long-bone and hip fractures are much more of a concern—the researchers raise the
possibility that overzealous drug marketing may result in too much treatment.
 

The medical community doesn't consider osteopenia a disease; rather, it's a marker for risk of fractures. But degree of risk is a tough call in the early stages of bone loss. What's needed, experts say, is advice from the World Health Organization. The group is currently developing guidance to help clinicians advise patients with osteopenia on when drugs may be appropriate. At the moment, "it's entirely possible that we are actually overtreating this condition, but we may also be undertreating it," says Neil Gonter, assistant professor of clinical medicine at Columbia University and a rheumatologist in private practice in New Jersey. Drug options include bisphosphonates such as Fosamax, Boniva, and Actonel; calcitonins such as Fortical and Miacalcin; estrogen and hormone therapy; Forteo (a parathyroid hormone); raloxifene; or combination therapy.

Typically, doctors are apt to look for other risk factors before prescribing drugs, noted lead author Pablo Alonso-Coello, a family practitioner in Spain, in an E-mail interview. These include age, a tendency to fall, poor eyesight, smoking, drinking more than two drinks per day, low body weight, previous fractures, existing spine fracture, and history of parental hip fracture. Some medications, such as corticosteroids and aromatase inhibitors (for breast cancer) may cause bone loss, too. And conditions like rheumatoid arthritis, diabetes, Parkinson's disease, and stroke also heighten the risk. But what remains unclear, according to the analysis, published this month in the journal BMJ, is what level of fracture risk warrants aggressive treatment. Drug marketing since the mid-1990s has urged medication use in younger postmenopausal women at "relatively low risk of fracture," the analysis says. It adds that such messages tied to osteopenia "warrant skepticism."

Bone loss is indeed a serious issue, with aggressive treatment necessary in many cases. But "the big problem is people with true osteoporosis aren't getting treated," says Robert P. Heaney, a Creighton University professor and member of the National Osteoporosis Foundation's Emeritus Board. Someone with osteoporosis can break a bone even without obvious trauma, according to the NOF's treatment guidelines.

Young, healthy women who have been told they have osteopenia should certainly consider possible side effects before turning to drugs. The bisphosphonates can cause gastrointestinal illness, and some women taking raloxifene are at an increased risk of stroke. In Alonso-Coello's opinion, unless you have several risk factors and are older than 65 or 70, the best course of action is a healthy lifestyle that includes exercise, no smoking, and a balanced diet.