@Neo My first line choices are weight bearing exercise with impact, and hormone normalization, appropriate vitamin D/K2. There will be individuals who have severe disease and a decision down this route or monoclonal agents like Prolia (denosumab).
@AnUser You make the points that I was taught in my traditional training. It is important to look at NNT also. This is a fairly balanced article on this topic here.
The real-world benefits of reducing vertebral fracture risk, especially radiographic fractures, remain uncertain. Vertebral fractures are associated with future fracture risk, chronic pain, and functional decline; reducing the risk of these factures is assumed to reduce risk of associated complications. However, the range of clinical trajectories of vertebral fractures is wide: some fractures cause severe pain and disability, others cause no symptoms at all. Some clinical trials distinguished between symptomatic and asymptomatic fractures, but adjudication of symptoms was usually a one-time binary determination without additional data about severity of pain, disability, or need for clinical intervention. In the Fracture Intervention Trial, a randomized placebo-controlled trial of alendronate in postmenopausal women with low bone mass, one arm of the trial examined outcomes among women with new vertebral fractures. The frequency of back pain and back-related disability were not significantly different between women treated with alendronate and placebo.
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Perceptions of the benefits of bisphosphonates depend on how risk reduction is presented. In general, use of relative risk reduction leads to more favorable views of treatment benefits compared with other risk-based statistics like absolute risk reduction. When the baseline risk is low, use of relative risk alone is likely misleading.
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According to the review conducted by the ACP, the relative risk reduction of hip fractures with bisphosphonate treatment for at least 3 years is 36%; however, the absolute risk reduction is only 0.6%. Framed as number needed to treat, 167 patients need to be treated for 3 years to prevent one hip fracture. One study of patients attending an osteoporosis clinic found that presentation of treatment benefits as absolute risk reduction significantly decreased the number of patients who would consider treatment compared with use of relative risk reduction.
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I thought Dr. Greger did a reasonable job discussing this topic here.
Overall, I’ve not come to a firm opinion yet in regard to longevity with these drugs. Clearly osteroporosis, frailty and sarcopenia are predictors of premature death … naturally if you can work on all of these the outcomes would seem better. Some people won’t follow a plan to improve, and you have the options to use these drugs or not, and with various thoughtful reviews not being as glowing, as we need to look at actual quality of life changing fractures. For example, having to treat 170 people for years to have 169 of them not necessarily benefit and 1 benefit - but then there are side effects. That would probably be the harshest review and the benefits are overstated - and possibly the harms/side effects can also be overplayed.
