Health issues of our parents: Osteoporosis (part 1)

A good friend asked me a few months ago about her mother's osteoporosis, diagnosed in a "government hospital" using "an X-ray". She said that she could take Fosamax 70 mg a week, but was amazed to find out that it cost $270 HK dollars for 4 pills. That comes to almost 10 US dollars per pill... what a sticker shock!

I feel bad because I have not been able to check my e-mails daily, between work, family and public commitments. Her e-mail was not responded to until now, and so I owe her a deep apology.... and probably over 100 dollars too, for the following reason.

Fosamax as a generic form, as she has correctly pointed out, has become available for the past year. It costs only 20% of the brand name drug. Therefore, theoretically, the delay of my advice to her mother has caused the loss of a potential saving of $100 in the last few months. This is a significant amount of money which I would rather that she spent to treat me to a decent meal next time I see her. (Of course, my unintended delay must have annoyed her so much she won't be buying dinner for me anymore... period) Nonetheless, there are finer points to be made which may absolve me from this debt to her.

Well, officially, generic medications and their efficacy should be comparable to the brand name, since the FDA does oversee the process of generic drug approval in manufacturing. In reality, however, the type of clinical trials that are required for brand name drug approval is far more rigorous. While in general, I have seen no significant difference in efficacy between brand name drug and their generic equivalents, there are cases where I was convinced that the substitution of one type for another can be problematic. Unfortunately in this case, I am less certain about the efficacy of alendronate, supposedly an equivalent generic form of Fosamax.

I would deal with this particular friend's situation in 2 separate discussions on this forum. For her mother, both money and health are important issues. Since she is quite healthy, I guess I would talk about money first, leaving discussion of her health (osteoporoses) to the next discussion (i.e. Osteoporosis part 2).

Fosamax has a very low bioavailability. This is a medical jargon for a medicine that is very hard to absorb. It has been said that for the 10 dollars spent on one pill, only dimes were actually absorbed and utilized by the body. The rest simply come out, as you would guess, with your bowel movements. Interestingly, the less food you have in your stomach, and the higher the acidity of the stomach, the better Fosamax can be absorbed. This is why the drug is supposed to be taken on an empty stomach, first thing in the morning, and the patient should not eat within the hour after taking the medication.

The other advice that physicians consistently give to patients who take Fosamax, is to drink a large glass of water. Believe it or not, this is vitally important, because Fosamax is a very irritating medication. If it does not go all the way into the stomach, it will sit in your food pipe (the esophagus), and within a short time, it can burn a hole through the food pipe and cause a lot of trouble. Why doesn't Fosamax do that to my stomach then, you may ask? I can tell you that it may, if you have any open wounds in her stomach, an ulcer for example. Fortunately, our stomach has a fairly strong lining most of the time - strong enough to withstand the acid and digestive juices needed to break up the food, in fact. So usually the Fosamax cannot do any harm to the stomach. Although it is common to feel the irritation, according to patients (including my own mom) who has been taking Fosamax for many years, it is extremely unlikely that it will do damage to the esophagus or stomach if you take Fosamax correctly. 'Twas how I convinced my mom to take it despite the initial discomfort years ago.

To do it correctly, you should also follow your physician's order not to mix Fosamax with other medications. You should avoid a class of medicine called NSAID, which includes a number of pills sold without prescription to treat arthritis. You should also never lie down, say to take a nap, within the first half to one hour of taking Fosamax. Why can't you lie down? You can probably figure it out from what I have just told you. Let's say you swallow the pill, you lie down, and your stomach regurgitates the Fosamax into your esophagus before it is absorbed. You're now taking a nap and you let this irritating pill sit in your esophagus for a while. Again, it may burn a hole through the food pipe. So you can get into trouble you're not careful, as with all medications.

So why am I not sure about substituting Fosamax with alendronate? If a pill like Fosamax is so hard to absorb, any small deviation in the manufacturing process can make it even harder for her body to absorb. If your body cannot use the active ingredient of the medication, it will not help your bones which will continue its relentless decline with age. Unlike other medicines, the impact of Fosamax on bones cannot be determined for at least a year for any given patient. The only way of knowing that it is helping the bone, is to recheck the "bone density" using a technology known as DEXA bone densitometry, and then compare the results with the original DEXA done before starting treatment. One cannot reliably see changes for about 6 months to a year using DEXA. In the United States, most insurances including Medicare would be reluctant to pay if the study is done before the end of 23 months. Would you be comfortable taking a pill the benefit of which will still be uncertain until a year or more has passed? Only you can determine for yourself. For my mom, I would hate to lose a year in her treatment, as long as I can afford to pay.

In the next issue, I would tell you what I know about the DEXA bone densitometry. This is a subject I love, and I continue to attend training and certification programs every 2 years. It is an amazing way to monitor the health of bones, even though it is not the only way. It has really revolutionized the diagnosis and treatment of osteoporoses. In my opinion, it has already delivered on the promise of preventing bone fractures among the elderly. For those of us who are NOT elderly, and that certainly includes ME, it is still very important to know this technology and what osteoporosis means - physicians think they know, but believe me many of them don't. Our parents have probably already needed it. Our age group will likely need it within the next 1,2 or 3 decades. Afterall we cannot stay in the mid-life group forever, right?