Revisiting femur fractures and osteoporosis meds

Ask Dr. Keith Roach M.D

Revisiting femur fractures and osteoporosis meds

DR. ROACH WRITES: I have been flooded with letters from women who have suffered atypical femur fractures after having been on bisphosphonates (osteoporosis medicines like Fosamax and Actonel), and wanted to make several points about this condition: –Atypical femur fractures are probably much more common than previously recognized, possibly as high as 1 woman in 500 who has been on bisphosphonates for longer than three to five years.

–Many physicians don't recognize the difference between a typical osteoporotic fracture and an atypical one related to bisphosphonate use. This means that patients continue the drug, putting them at high risk for fracture on the other side and preventing healing. Denosumab (Prolia) also puts people at risk for atypical fractures, so patients should not be switched to this drug after an atypical fracture.

–Some physicians are still, despite abundant warnings, prescribing these medications to women with osteopenia, in whom the absolute risk for fracture is so low that the risk from side effects makes the medications likely to have a net harm. I was shocked to hear from so many women who were prescribed these powerful medicines for osteopenia, which is not a disease but rather low bone mass.

–It is appropriate for all women on these medications for more than three to five years to review with their doctor whether continued use is still appropriate. These medicines last for years in the body, and stopping the medicine may be appropriate for many women.

I appreciate the helpful letters, which caused me to take a more in-depth look at the current research.

DEAR DR. ROACH: Nobody seems to be able to find out why my platelet count has fallen to 50. Two years ago, my count went from 164 to 142, then to 124. I saw a hematologist, but he could not solve the mystery with blood testing. I recently was in the hospital, where they found that I had blood clots in my legs, but still couldn't figure out why my platelet count was so low. — E.B. ANSWER: The most common cause for low platelets is ITP (immune thrombocytopenia, which just means 'low platelets due to the immune system'). There is no specific test that can make this diagnosis; rather, it comes from other causes being excluded. Other causes include over 50 medicines, some foods (including quinine from tonic water) and some supplements. Infections, especially HIV and hepatitis C, also may cause low platelets.

It is surprising that you had blood clots while your platelets were low, since it is platelets that stop bleeding. That makes me concerned about unusual and serious conditions that cause both low platelets and clotting, although it's possible they aren't related.

I think of TTP, thrombotic thrombocytopenic purpura, which is a life-threatening condition, and also disseminated intravascular coagulation, which is associated with cancer or sepsis, a bacterial infection of the bloodstream. These occur in people who are very ill. I doubt that your doctors would have missed these diagnoses.

However, heparin-induced thrombocytopenia is an unusual condition that has a very high risk of blood clotting in the veins or arteries, and can be missed, since heparin often is given by injection in the hospital to prevent blood clots. I would ask your doctors to look very carefully to see if you had any heparin in the hospital. You probably would remember any injection, but heparin can be given as part of a 'flush' of an IV, or may be embedded in catheters. This would be important in the future.

Other causes are antiphospholipid syndrome, often associated with lupus but sometimes with other medical conditions, and a rare disease, paroxysmal nocturnal hemoglobinuria. The hematologist can evaluate you for these. *** Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell. edu or request an order form of available health newsletters at 628 Virginia Dr., Orlando, FL 32803. Health newsletters may be ordered from www.rbmamall. com.