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Addressing the Crisis in the Treatment of Osteoporosis: Better Paths Forward

2017; Oxford University Press; Volume: 32; Issue: 6 Linguagem: Inglês

10.1002/jbmr.3145

1523-4681

William V. Stoecker, Aaron Carson, Vu Nguyen, Alex B Willis, Justin G. Cole, Ryan K. Rader,

Optimism, Hope, and Well-being

To the Editor: The report by Khosla and colleagues1 highlights a critical gap in osteoporosis management: Patients who need pharmacological therapy are either not being prescribed these medications or fail to take them, especially bisphosphonates. We suggest three changes to the paths proposed by the authors to further improve osteoporosis treatment: new ways to guide patient decisions, extending new drug development to include therapies from complementary and alternative medicine, and new efforts in osteoporosis research. With enhanced osteoporosis treatment and lifestyle options, we have a better chance to find an approach suitable for each individual. The first path forward offered by the authors is the most critical: patient and physician education to increase therapeutic compliance. Let's pursue that direction further. We would like the authors to respond to this question: Why not use new ways to address patients' false beliefs that osteoporosis treatment risks are likely and that without treatment, a fragility fracture is unlikely? The authors have not adequately addressed the primary problem; in spite of the positive benefits, patients refuse to comply with medication recommendations. New models in disease understanding can guide our counseling efforts; compliance depends on addressing all components of the disease perception model.2, 3 Our goals are 1) increase perceived susceptibility to fragility fractures; 2) increase perceived severity of suffering from a fragility fracture; 3) increase the perceived benefits of medication compliance/adherence; 4) decrease perceived barriers to medication compliance/adherence, such as inflated fear of atypical femoral fractures (AFFs); and 5) continue to monitor health beliefs to promote compliance. In this model, underlying emotional aspects have greater effects on behavior than do cognitive elements;2 narrative (anecdotal) evidence is more effective than statistical evidence.4 A graphic scenario of suffering and incapacitation after a hip fracture will enhance emotional perception of this threat. Although the growing impact of social media on patient decisions can contribute to flawed health beliefs, it also brings an avenue for physicians to participate in social media discussions to align physician and patient viewpoints.5-7 Other avenues for education should be pursued; when a patient enquires about duration of therapy, we can focus on what matters to an individual patient.7, 8 Patients generally prefer weekly therapy over daily therapy—providing a chance to overcome one barrier.9 Newer educational techniques such as gamification bring benefits at any age.10 Gamified learning can be used in clinical waiting areas before the visit to improve flawed decision making. The authors recommended new drug development as a long-term approach; are they taking into account the economic gauntlet of conventional new molecule development? This narrow path should be widened to include potentially osteoprotective substances such as geraniin,11 dalbergin,12 echinocystic acid,13 and Achyranthes japonica extract.14 The National Center for Complementary and Integrative Health (NCCIH) website indicates two herbal medicines that have shown promise in laboratory studies, black cohosh and turmeric extract, the latter study funded by NCCIH.15 In the authors' long-term approach, why did the authors not include research as another avenue to help resolve the crisis? The authors stated, "American Society for Bone and Mineral Research and its members have been very fortunate to have decades of strong support for basic and clinical research efforts by NIH from multiple Institutes." Yet the American Society for Bone and Mineral Research estimates that only 1% of the NIH budget was allotted to bone research;16 osteoporosis research support is even less than this total and has fallen, from $181 million in 2012 to $151 million estimated for 2016,17 less than 0.5% of the NIH budget of $32.3 billion. No ongoing osteoporosis studies are registered at ClinicalTrials.gov as of February 2017. More detailed osteoporosis studies might help to explain intraracial disparities in osteoporosis prevalence.18, 19 Could laboratory-observed osteoprotective effects from dietary components be extended with human studies for promising dietary components, from egg yolks to soy isoflavones?20-27 Osteoporosis may stand alone among major-impact diseases in lacking consensus regarding preventive foods. Data from animal studies showing osteoprotection from specific foods abound, but studies showing improved human outcomes from these dietary components are lacking. Finally, if a 1% reduction in fragility fractures could be achieved with an increase in osteoporosis research funding to 2012 levels, the financial return to the US would be at least sixfold.28, 29 Such an increase must primarily come from investigator-initiated studies, which despite high impact for osteoporosis, must battle for scarce resources. These studies could provide new lifestyle advice and could even provide promising research paths for existing drugs or complementary medicines to counter the epidemic of osteoporosis. All authors state that they have no conflicts of interest.