 Drug therapy for osteoporosis is recommended for those 15-older with a history of past hip or spine fractures, those with hip or spine T-scores of negative 2.5 or less, and postmenopausal women or men 15-older who don't make that cut-off, but have an estimated 20% or higher risk of major osteoporotic fracture of the subsequent decade, or an estimated 3% or greater risk of hip fracture, specifically. A T-score is a measure of how dense your bones are compared to a 30-year-old white woman. Because that's the standard, and we tend to lose bone as we age, you can be labeled as having osteoporosis, even if you have completely normal bone density for your age. Of course, just because your bone density may be normal doesn't mean it's necessarily optimal, which is why the National Osteoporosis Foundation set out these guidelines for drug treatment. Though another reason perhaps is because it gets substantial funding from the drug industry, which reeks in literally billions of dollars in profits from osteoporosis drugs. What does this science say? The primary drug class used to treat osteoporosis is the bisphosphonate, sold as such brands as Fosamax, Actinel, Boniva, and Reclast. They're most effective at reducing vertebral fractures, cutting the risk in postmenopausal women from 2.8% down to 1.4%. That's a relative risk reduction of 50%, but an absolute risk reduction of only 1.4%, meaning you'd have to treat 71 women to prevent just one woman from getting a vertebral fracture. Unfortunately, the diagnosis of vertebral fracture is kind of wishy-washy. Depending on how you define the changes on x-ray, the prevalence of vertebral fractures can vary as much as 3% to 90% in the same elderly population, almost none to almost all. They're also poorly predictive of back pain or disability. Vertebral fractures can certainly lead to back pain, reduced physical function, but only about a third are symptomatic at all. The most harmful fractures are hip fractures. Despite most of the clinical trials for osteoporosis treatment being funded by the drug companies themselves, no primary prevention benefit from bisphosphonates has been found for hip fractures. In other words, taking these drugs has not been convincingly shown to prevent fracturing your hip in the first place. However, having a prior fracture doubles your risk of breaking another bone, so for those at high risk, bisphosphonate drugs may decrease the odds of hip fracture by 25%, though the absolute risk reduction isn't again only about 1%, it may take treating 91 people for 3 years to prevent one hip fracture. In overconfidence in the power of pills and procedures for disease prevention, maybe one of the reasons doctors and patients alike may undervalue diet and lifestyle approaches. In this study, patients were asked to estimate the number of fractures or deaths prevented in a group of 5,000 patients undergoing each drug intervention over a period of 10 years. The vast majority of people tended to wildly overestimate the ability of mammograms and colonoscopies to prevent cancer deaths, the power of drugs like Fosamax to prevent hip fractures, and drugs like Lipitor to prevent fatal heart attacks. No wonder most people continue to rely on drugs to save them. But the dirty little secret is that most people said they wouldn't be willing to take many of these drugs if they knew how little benefit these products actually offered. In a study of those undergoing bone density scans, the average 5-year fracture risk that would motivate most participants to consider preventive medicine was 50% to 60% much higher than their actual risk. Most patients want to be told the truth. They want to be told what the chances are that the drugs will actually benefit them, but there's a tension between the patient's right to know and the likely reduction in their willingness to take the drug if they knew the truth. In the Bone Density Scan Survey, participants greatly overestimate their own personal risk for hip fracture, thinking it was around like 19% over the next five years, which is more than 10 times higher than their actual risk of 1.4%. Rather than disabusing them of this overestimate, some suggest physicians should do the opposite. Stoke fear in patients who refuse to comply with medication recommendations by increasing their perceived susceptibility to fragility fractures, as well as their perceived severity of suffering from a fragility fracture. Since emotion can be more motivating than reason, an anecdotal evidence can be more effective than evidence evidence. A graphic scenario of suffering and incapacitation after hip fracture will enhance emotional perception of this threat. But hip fractures can indeed be devastating and are associated with a significant risk of ensuing death. So what about all the lives these drugs must be saving? Well, only about a quarter of the deaths following fractures may be attributable to the fracture itself. So most of the mortality risk may just be a consequence of the comorbidities, that is, the other diseases and poor health status of people who tend to fracture their hips. So they might have died anyway in that same time frame, even if they hadn't broken any bones. This may help explain why there are no saved lives. Osteoporosis drug treatments, particularly by phosphonates, fail to significantly reduce overall mortality.