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For Treating a Leading Cause of Osteoporosis,
Surgery Is Better Than Usual Medications

While osteoporosis usually results in the process of normal aging, another leading cause of the bone-loss disease is a condition called hyperparathyroidism, in which the parathyroid glands release an excessive amount of a hormone that regulates the body’s calcium levels.

Doctors commonly treat hyperparathyroidism using a class of prescription drugs called bisphosphonates, including alendronate (marketed under the brand name Fosamax) and ibandronate (Boniva), which are supposed to strengthen bones.

A recent study led by scientists at UCLA found that those drugs actually increase the risk of fracture, meaning that taking them is worse than doing nothing at all to treat the condition. The research also revealed that patients who undergo surgery to remove the overactive parathyroid glands have fewer subsequent bone fractures.

The report appears in the April 5 issue of the Annals of Internal Medicine.

About 400,000 people in the United States, or one in 400 women and one in 1,200 men, have hyperparathyroidism. Osteoporotic fractures are a major public health and economic burden, says Michael Yeh, MD, an associate professor of surgery and medicine at the UCLA Medical Center in Santa Monica, California, and the study’s first author.

“Hip fractures in particular are associated with significant rates of mortality, disability, and loss of independence,” says Yeh, who also is chief of endocrine surgery at the UCLA David Geffen School of Medicine. “Before this study, there were no data that compared parathyroid surgery with prescribing medication on the risk for fractures in people with hyperparathyroidism.”

The researchers analyzed data from more than 6,000 people who had been diagnosed with hyperparathyroidism between 1995 and 2010. All had health care coverage through Kaiser Permanente Southern California, and their demographic and socioeconomic profiles mirrored those of the greater Los Angeles population.

The findings, which Yeh described as startling, included the following:

• Among study participants who were not treated for hyperparathyroidism, there were 56 hip fractures per 1,000 people after 10 years.
• Among those who had parathyroid surgery, there were only 20 fractures per 1,000 people.
• For those taking bisphosphonate medications, the rate of hip fractures was 86 per 1,000 patients, which is higher than the combined rate for those who underwent surgery or did nothing at all.

The researchers also reviewed the number of bone fractures of all types (including hip fractures), and the results were similar. For people who did not receive treatment, there were 206 fractures per 1,000; for those who had surgery, there were 157 fractures per 1,000; and for those taking bisphosphonate medications, there were 303 fractures per 1,000.

Yeh says it was also surprising that people taking medications had a higher risk for fractures, even though X-rays showed that they had similar gains in bone density to the people who had undergone surgery.

“The drugs make the bones look dense on scans, but that is deceptive,” Yeh says. “We must presume there is a defect in the quality of the bone. But we don’t know why.”

Researchers found that the risk for fractures among people taking bisphosphonates was higher whether people had osteopenia, or early bone loss, or full-blown osteoporosis, which Yeh says could suggest that either the drugs themselves are harmful or that the people taking them had other risk factors.

“Regardless, we were unable to demonstrate any benefit associated with this class of drugs, which have been around and routinely prescribed for more than 20 years,” he says. “These findings should make bisphosphonates less attractive as an alternative to parathyroid surgery in patients with primary hyperparathyroidism.”

Yeh says more research is needed to determine whether bisphosphonates also increase the risk of fractures for people with underlying causes of osteoporosis other than hyperparathyroidism. Women are more likely to have osteoporosis; other key risk factors are a lack of vitamin D, calcium, or estrogen. Osteoporosis afflicts some 54 million people over the age of 50 in the United States and is responsible for 2 million bone fractures per year.