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DEAR DR. ROACH: I'm a very healthy and active 74-year-old woman, and I'm also quite proactive with my health. I get bone scans done every two years and have osteopenia in both my hips and spine. But because of a T12 fracture in 2018, which was followed by a kyphoplasty, I was recently recommended to see a specialist for more extensive blood work and scans.
These scans also showed osteopenia, but in my wrists (which were never previously scanned), I have severe osteoporosis. With the severe compression between the T11 and T12 vertebrae, I know I need to do something. The first specialist recommended Forteo for two years. I got a second opinion, not because I didn't believe him but because this is such a big decision. The second physician recommended Prolia instead for five years, which would probably be followed up with a bisphosphonate.
I have two questions: First, from what I've read, it seems that once I'm on these drugs, I'll be taking some of them for the rest of my life. Is this true? Also, I'm very worried about the dangerous side effect of osteonecrosis of the jaw (ONJ). How often does this happen, and since I took Fosamax for five years (a decade ago) and didn't have any problems, is it unlikely that I'd ever develop ONJ?
-- B.J.
ANSWER: I agree that the balance of risks and benefits is strongly in favor of treatment. This is mostly because of your previous compression fracture, which puts you at a high risk for another fracture. The very low bone density in your wrists is less important to me than the vertebral body fracture, but a low bone-density score in the wrists predicts an increased risk of an arm fracture as well.
It sounds like ONJ is a major concern for you. Denosumab (Prolia) does have a higher risk of ONJ than bisphosphonates like alendronate (Fosamax), but the absolute risk is still low -- approximately 5 people for every thousand (0.5%) who take the medicine for 10 years. You need to compare this with a risk of another fracture without treatment, which is 10% to 20% within the first year.
Your first specialist recommended teriparatide (Forteo), which is an excellent idea for you for two reasons: The first is that it very quickly reduces fracture risk, compared to either denosumab or alendronate. The second is that there isn't an increase in the risk of ONJ with teriparatide, since it's a common and effective treatment for ONJ.
Many experts would treat you with teriparatide for 18-24 months, then switch you to a bisphosphonate.
ToYourGoodHealth@med.cornell.edu