Public Awareness Fuels Dramatic Rise in Osteoporosis Diagnosis

The number of diagnosed cases of osteoporosis in the US jumped from about half a million in 1994 to more than 3.6 million in 2003, according to a recent study by researchers at Stanford University. The authors attributed the dramatic increase in large part to the development and consumer marketing of new drugs to treat the bone-thinning condition that in turn fueled greater public awareness and an emphasis on prevention.

Osteoporosis is characterized by decrease in bone mass, with low bone density and enlargement of spaces producing porosity and fragility. The condition can devastate the quality of life of older people, resulting in greatly increased likelihood of bone fractures. In the case of hip fractures, death from complications is likely in as many as 20% of victims within a year of the fracture.

"I think the increase is due to the fact that we are looking for osteoporosis and that we can diagnose it," said M. E. Csuka, MD, FACP, Medical College of Wisconsin Associate Professor of Medicine. "I'm not so sure that reports of a sevenfold increase represent an absolute increase. Prior to 1995, when alendronate (sold as Fosamax) became approved, I do not think we were looking for osteoporosis in our patients."

Alendronate, calcitonin, raloxifene, and risedronate are the primary drug treatments for osteoporosis. A new drug, ibandronate sodium, was approved for osteoporosis treatment by the Food and Drug Administration in March 2005 and is expected to enter the market in April. The manufacturers are touting the new drug for both treatment and prevention of postmenopausal osteoporosis and selling the point that it is only taken once a month, unlike others that are taken weekly.

Treatment Options Encourage Diagnosis
"Once you have a treatment, then you start looking," said Dr. Csuka. "When you have a disease but no treatment, you do not always diagnose it until it's really in front of your face because someone fractured a hip.

"When I went to medical school, this was considered 'normal' aging. The line of thought was 'this is osteoporosis, this is what happens when you get old.' It was more or less considered in terms of 'that's the way it is.'"

Estimates of the number of people over age 50 with osteoporosis in the US run as high as 10 million, mostly women, meaning that the vast majority of cases are still not diagnosed and the disease is still undertreated.

"I think that when you start doing epidemiological studies and you start looking at increased incidences, you have to put in the mix that we are much better at diagnosing it now," said Dr. Csuka. "The way we used to diagnose it was when a person presented with a fracture. Now we can diagnose it with bone densitometry before a fracture occurs.

"And you have to do a proportional analysis, too. There are a lot more people making it to old age. People used to die earlier, and now they're living long enough to get this diagnosis. Even with that said, I think it is a significant entity and I do think there are increased numbers. We are still way behind in treating people."

The Role of Marketing
Rules that offer drug manufacturers more leeway in directly marketing drugs to consumers through television, radio and print have been a boon to pharmaceutical companies. The newer osteoporosis drugs sold since the mid-1990s are among those widely advertised.

"People's awareness of osteoporosis has been greatly elevated by direct consumer marketing, but I do not necessarily translate that as a negative," said Dr. Csuka. "This really is a significant epidemic in many ways. It robs people of so much of their quality of life.

"This is an instance where I'm willing to make an exception; a lot of the direct consumer advertising for drugs is just crazy. With osteoporosis, as with the marketing of statin drugs to lower cholesterol, the advertising has done a lot for raising people's awareness and bringing them in for screening and diagnosis.

"I find it much easier when a patient is already interested in osteoporosis than when I bring up one more topic" for discussion, Dr Csuka added.

Universal Screening Recommended
The Stanford study authors supported new guidelines for universal osteoporosis screening of women over age 65 as part of a growing effort to emphasize prevention.

"I agree with that," said Dr. Csuka. "It is important that you do screening to identify the patients at risk. I'm oftentimes amazed at patients who, if I look at just their risk factors - they are on chronic steroids, have low body weight (less than 127 pounds) , and have poor diets - then you do bone densitometry and they're fine. They have very good genes!

"A simple screening test is a good idea; I'd even suggest that we should probably do it around age 60, a little bit earlier than that magical age 65. Because we want to prevent a clinical problem that is going to occur ten or fifteen years down the road. You have to have people's awareness up, including primary care physicians.

"The primary care physician has to be involved. How long did it take cholesterol screening to become routine? It's taken maybe ten to fifteen years. Now, patients want to know their cholesterol level. We do screenings for cholesterol and for colorectal cancer. Recommendations on osteoporosis screening come from the regulatory bodies that tell us what we need to do. Now the physicians and their patients will have to follow through."

Dan Ullrich
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.