In the May issue, Dr. Bruce Ettinger recommends that we avoid rushing to bone-preserving or enhancing drugs for low-risk women (Update on Menopause: “Curb your enthusiasm—no need to rush bone drugs if risk is low”). He notes that there is an extremely high cost per fracture avoided when treating women in their 50s to prevent osteoporosis. He goes on to recommend that we “give healthy women in their 50s permission not to take drugs if their risk of fracture within the next 5 to 10 years is low.”
I believe the issue here is “beneficence” versus perfection. For example, in the field of obstetrics, we must achieve 100% success with every delivery or risk being sued. While Dr. Ettinger is giving permission to this particular subgroup of women to avoid medical therapy to reduce their fracture risk, I am interested in what their attorneys would have to say if a fracture occurred. Certainly, informed consent is critical here, as are risks and benefits. But we live in a society that expects 100% perfect outcomes all the time.
I think we should be encouraging all patients to be “cost-effective,” but leave the final decision in their hands once we point out the pluses and minuses.
Laurence F. Mack, MD
North Massapequa, NY
Dr. Barbieri Responds:
Dr. Mack highlights an important issue in the management of osteopenia and osteoporosis: the complexity of analyzing the overall clinical effectiveness of an intervention to prevent fractures. As a recent publication noted, the likely cost of alendronate treatment per quality-adjusted life-year in women with a T-score between –1.5 and –2.4 and no additional risk factors ranges from $70,000 to $332,000.1 After weighing the risks and benefits, many women choose to start alendronate when their T-score ranges from –2 to –2.4 because their perception of the serious consequences of a fracture is far more important than the cost of the treatment.
The medical community will probably continue to adjust its recommendations for treating osteopenia and osteoporosis as more data are generated.
- Schousboe JT, Nyman JA, Kane RL, Ensrud KE. Cost-effectiveness of alendronate therapy for osteopenic postmenopausal women. Ann Intern Med. 2005;142:734-741.