Improved management of patients with osteoporosis.
Article Type: Letter to the editor
Subject: Osteoporosis (Diagnosis)
Osteoporosis (Care and treatment)
Diphosphonates (Health aspects)
Fractures (Diagnosis)
Fractures (Care and treatment)
Authors: Hough, Stephen
Brown, Sue
Cassim, Bilkish
Davey, Mike
de Villiers, Tobie
Ellis, Graham
Lipschitz, Stan
Lukhele, Mac
Pettifor, John
Pub Date: 11/01/2012
Publication: Name: South African Medical Journal Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 South African Medical Association ISSN: 0256-9574
Issue: Date: Nov, 2012 Source Volume: 102 Source Issue: 11
Geographic: Geographic Scope: South Africa Geographic Code: 6SOUT South Africa
Accession Number: 308294353
Full Text: To the Editor: We commend Professor Davey's pleas (1) for greater awareness and improved management of patients suffering from osteoporosis or osteopenia and those with fragility fractures, particularly the elderly.

We contend that this disease is not optimally managed locally and is often still regarded as an inevitable part of the ageing process, not amenable to treatment. The facts that 20% of hip fracture victims die within one year of the event and that less than 50% are capable of leading an independent life are often ignored. Moreover, the fact that fracture risk can be halved when lifestyle measures and appropriate bone-active drugs are employed also seems to go unrecognised. The National Osteoporosis Foundation of South Africa (NOFSA) published a guideline on the diagnosis and management of osteoporosis in 2010 that is available in print and also freely available on our website, either as a full guideline or an executive summary. (2)

Unfortunately, osteoporosis medication is still not freely available to sufferers from this common disease, which affects one out of every four postmenopausal women and 20% of elderly men. The essential drugs list (EDL) published in June 2012 (3) suggests that only patients with a bone mineral density (BMD) T-score of -2.5 standard deviation plus a fracture should be considered for treatment with bone-active medication. This is analogous to recommending that you should first have a stroke before your hypertension is eligible for treatment, or have a myocardial infarction before your dyslipidaemia is deserving of a statin! Clearly these EDL recommendations are embarrassingly out of touch with reality. There also appear to be regional differences in the availability of bone-active drugs in the public sector which is particularly problematic in the Western Cape, where NOFSA is frequently approached by patients and doctors unable to obtain justifiable osteoporosis treatment from a clinic or hospital. Moreover, unlike other provinces where access to modern intravenous bisphosphonates, strontium ranelate and even teriparatide can be obtained with or even without motivation, patients in the Western Cape are 'fortunate' when daily generic alendronate is made available--the efficacy and safety of which has been questioned. (4-8)

Access to osteoporosis medication is not only problematic in the public sector, however, and private patients, often the elderly and less wealthy, have similar problems. It is illogical that the test to diagnose the disease (dual-energy X-ray absorptiometry measurement of BMD) and the treatment of its complications (e.g. hip replacement) are readily reimbursed, yet its effective prevention is not. This is reminiscent of HIV/AIDS, the complications of which were treated for many years in this country before effective treatment of the disease itself was finally accepted and implemented. Unless one is on the very top tier of a medical aid scheme, funders do not usually reimburse osteoporosis medication. Since osteoporosis does not feature on the so-called Prescribed Minimum Benefits (PMB) list, medical aid schemes either refuse to pay or draw up their own arbitrary funding criteria and financially cap the reimbursement of osteoporosis treatment. This does not happen with other chronic non-communicable diseases. Patients are requested to make co-payments and the doctor's ability to prescribe a particular drug is often severely limited, regardless of motivation and good scientific evidence of benefit.

Several new osteoporosis drugs, ranging from specific monoclonal antibodies against RANKL (e.g. denosumab, already launched elsewhere) (9) to inhibitors of cathepsin K (e.g. odanacatib) (10) to potent bone formation stimulating agents (e.g. anti-sclerostin antibodies) (11) will hit our markets in the foreseeable future, resulting in what Professor Davey terms '... widening the therapeutic horizons'. Although it might be a while before we have access to these exciting agents, it is NOFSA's firm belief that every effort should be made to provide sufferers from this crippling disease rightful access to available effective therapy, in both the private and the public sectors.

Stephen Hough (Chair), Sue Brown, Bilkish Cassim, Mike Davey, Tobie de Villiers, Graham Ellis, Stan Lipschitz, Mac Lukhele, John Pettifor

for the National Osteoporosis Foundation of South Africa (NOFSA)

PO Box 481

Bellville, 7535

fsh@sun.ac.za

(1.) Davey DA. Osteoporosis, osteopenia and fracture risk: Widening the therapeutic horizons. S Afr Med J 2012;102(5):285-288.

(2.) Hough FS, Ascott-Evans B, Brown SL, Cassim B, de Villiers TJ, Lipschitz S, Pettifor JM, Sonnendecker EWW for the National Osteoporosis foundation of South Africa (NOFSA). NOFSA Guideline for the Diagnosis and Management of Osteoporosis. Journal of Endocrinology Metabolism and Diabetes of South Africa 2010;15(3,suppl 1):1-188. http//www.osteoporosis.org.za (accessed 8 October 2012).

(3.) Standard Treatment Guidelines and Essential Medicines List for South Africa. 3rd ed. 2012. http:// www.kznhealth.gov.za/pharmacy/edladult_2012.pdf (accessed 8 October 2012).

(4.) Hough FS. NOFSA statement on generic bisphosphonates. S Afr Med J 2006;96:758-760.

(5.) Ringe JD, Moller G. Differences in persistence, safety and efficacy of generic and original branded once weekly bisphosphonates in patients with postmenopausal osteoporosis: 1-year results and retrospective patient chart review analysis. Rheumatol Int 2009;30:213-221. [http://dx.doi.org/10.1007/s00296-0090940-5]

(6.) Strom O, Landfeldt E. The association between automatic generic substitution and treatment with oral bisphosphonates. Osteoporos Int 2012;23(8):2201-2209. [http://dx.doi.org/10.1007/s00198-011 1850-4]

(7.) Sheehy O, Kindundu CM, Barbeau M, LeLorier J. Differences in persistence among different weekly oral bisphosphonate medications. Osteoporos Int 2009;20(8):1369-1376. [http://dx.doi.org/10.1007/ s00198-008-0795-8]

(8.) Kanis JA, Reginster JY, Kaufman JM, et al. A reappraisal of generic bisphosphonates in osteoporosis. Osteoporos Int 2012;23(1):213-221. [http://dx.doi.org/10.1007/s00198-011-1796-6]

(9.) Cummings SR, San Martin J, McClung MR et al. for the FREEDOM trial. Denosumab for prevention of fractures in postmenopausal women with osteoporosis. N Engl J Med 2009;361:756-765. [http:// dx.doi.org/10.1056/NEJMoa0809493]

(10.) Boonen S, Rosenberg E, Claessens F, et al. Inhibition of cathepsin K for treatment of osteoporosis. Curr Osteoporosis Rep 2012;10(1):73-79. [http://dx.doi.org/10.1007/s11914-011-0085-9]

(11.) Ke HZ, Richards WG, Ominski MS. Sclerostin and Dickkopf--1 as therapeutic targets in bone disease. Endocr Rev 2012;33(5):747-783. [http://dx.doi.org/10.1210/er.2011-1060]

S Afr Med J 2012;102(11):815. DOI:10.7196/SAMJ.6317
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