Jeffrey Dach Says Bisphosphonate Drugs Are Creating a New Generation of Toulouse Lautrecs

Osteoporotic compression fractures of the spine are the bread and butter of radiology. And for 25 years of viewing these xrays, it was frustrating that many women were obviously not taking their calcium tablets and instead presented with end stage disease. Over the years, we witnessed many fashionable procedures which eventually faded away. One procedure still in vogue is the rather barbaric injection of glue into the osteoporotic compression fracture under x ray control, called vertebroplasty.  

Invented in 1984 by the French and introduced into the US by Mary Jensen MD, the procedure is not for the light hearted. During injection, the acrylic cement may flow into the epidural venous plexus leading to venous thrombosis or pulmonary embolus. The more refined Kyphoplasty version involves inflation of a balloon device to expand the collapsed vertebral body just prior to injection of cement into the cavity. Pain reduction is the goal and is usually achieved.

On the surface, it might appear callous for the medical system to wait years until millions of women develop compression fractures, and then intervene with glue injections. Perhaps some form of prevention would make more sense. While the usual recommendation of calcium tablets didn’t seem to be completely effective, the best preventive plan can be found in Russell Jaffe’s article, Acid-Alkaline Balance and its Effect on Bone Health. Russell Jaffe is a charming and humorous fellow who informed our small group of docs at his course that in the old days he ran a lab at the NIH was actually appointed assistant surgeon general for one day, but quit as it wasn’t his cup of tea. 

According to him, excess acid production from the American diet causes the chronic calcium loss of osteoporosis, because calcium is pulled from the bones and used up to buffer the urinary acids.  With the help of alkaline food charts, and pH test strips along with the usual calcium and vitamin supplements, osteoporosis can be arrested and gradually reversed in a process which may take years. I would add that bio-identical hormonal supplementation is also useful. 

For the impatient ones who wish to see a prompt increase in bone density, the FDA approved the biphosphonate drug Fosamax (alondronate) which was first introduced in 1995. Merck made 3.2 Billion on 22 million Fosamax prescriptions last year.  The major study, (FIT) Fracture Intervention Trial, showed lower fracture rates in the drug group. 

What could alondronate have in common with Toulouse Lautrec, the famous  Impressionist artist? His name came up in conversation at the art studio, and nobody knew the cause of his short stature. It turns out that Toulouse’s parents were first cousins which gave him the autosomal recessive genetic disease called, pycnodysostosis, which means dense bones. I had seen this in radiology board study materials, but never in actual practice. Gelb (link) found this “dense bone disease” to be caused by a genetic defect in cathepsin K, a protease enzyme of the osteoclast cells responsible for removing and remodeling bone. Resultant bone is dense on xrays, yet under the microscopic, there is profound deterioration in trabecular architecture and lamellar arrangement which is presumably the reason for spontaneous fracture and jaw necrosis (link).This osteoclast dysfunction and resulting bone fragility explains why Toulouse had spontaneous fractures of both mid femurs at the age of 12 and 14. The fractures never healed and he attained a height of 4.5 feet (see figure to the right).

Bisphosphonates, like Fosamax and Actonel, are taken up by osteoclasts with resulting loss of osteoclast activity and inhibition of bone resorption, and bone remodeling (link). Although DEXA scanning confirms increased bone density and studies such as the FIT suggest reduced fracture rate, Susan Ott, MD  raises questions about the long term safety of bisphosphonates. Although the  bisphosphonates appear to have short term benefits, she speculates that after 5 years of use, there is severe suppression of bone formation with negative effects such as microdamage and brittleness. 

Jennifer P. Schneider, MD, PhD reports a 59-year old previously healthy woman on long-term alendronate. While on a subway train in New York City one morning, the train jolted, and the woman shifted all her weight to one leg, felt a bone snap, and fell to the floor, suffering a spontaneous mid -femur fracture (see image). In the months following, it became clear that the fracture was not uniting. Schneider speculates that increased bone density from the bisphosphonate drug does not necessarily equate with good bone quality. By decreasing osteoclast activity and bone resorption, and therefore bone formation as well, microdamage, and brittle bone may result in fractures.

Odvina reports on 9 cases of spontanous fracture while on alendonate. Five of the nine cases were spontaneous mid femur fractures. Two had bilateral mid femur fractures same as Toulouse. Six cases had delayed or absent fracture healing. Histomorphometric analysis of the cancellous bone showed markedly suppressed bone formation, and Odvina raised the possibility that severe suppression of  bone turnover could develop during long-term alendronate therapy, resulting in increased susceptibility to, and delayed healing of, nonspinal fractures. 

Dimitrakopoulos reports on 11 patients presenting with necrosis of the jaw, claiming this to be a new complication of bisphosphonate therapy administration, i.e. osteonecrosis of jaws. He advised clinicians to reconsider the merits of the rampant use of bisphosphonates. Osteonecrosis of the jaw is a common finding in pycnodysostosis. The bisphosphonates recreate the same clinical profile of spontaneous mid femur fractures, failure of bone healing and jaw necrosis which tormented Toulouse Lautrec. 

In spite of this well known information, there are four more drugs in clinical trials which are specifically designed to inhibit cathepsin K, the enzyme defect in Lautrec's genetic bone disease. FDA approval for use in osteoporosis treatment is expected. Excuse me here, but perhaps this thinking needs re-evaluation. In essence we are creating a population of women with Toulouse Lautrec’s bone disease. Ironically, women who sustain fractures while on Fosamax are told by their docs that the fractures are due to the underlying osteoporosis, not the drug. For example, recently a friend’s wife sustained a fractured elbow after minor trauma at home in the kitchen. She claims that, if not for the biphosphate drug, her fracture would have been much worse.

Sound familiar?

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Jeffrey Dach M.D. is board certified in interventional radiology and a member of the Board of the American Academy of Anti-Aging Medicine. He retired from radiology two years ago, and is currently in private practice focusing on bio-identical hormone treatment.

Comments

[Steve Keppel-Jones]

Among the numerous nuggets in this article is the following that I think merits a bit more attention.

Dr. Dach mentions that calcium supplementation is not beneficial to bone health, and that excess acid in the North American diet leads to osteoporosis. This is another way of saying that bone health is inversely correlated to animal protein intake, as demonstrated in a study by Dr. Deborah Sellmeyer et al. [1]

Has the dairy industry been up to the same tricks as the pharmaceutical one by promoting milk as a cure, rather than a cause, of osteoporosis?

AZT anyone?

"Sound familiar?"

[1]
Sellmeyer DE, Stone KL, Sebastian A, Cummings SR. A high ratio of dietary animal to vegetable protein increases the rate of bone loss and the risk of fracture in postmenopausal women. Study of Osteoporotic Fractures Research Group. Am J Clin Nutr. 2001 Jan;73(1):118-22.

[Dr. P. S. Duke]

There are dozens of web sites that show the benefits of a pH-balanced diet, which extend far beyond bone strength:
http://www.shrinkyourwaist.com/
http://www.dietobio.com/dossiers/en/pH/index.html

It may seem counter-intuitive, but highly acidic foods such as lemons and limes are actually listed as alkalizing:
http://www.thewolfeclinic.com/acidalkfoods.html

So don't trust your own instincts about what to eat, check the charts first.

[Marcel]

Dr. Dach,

I would very much appreciate hearing your thoughts on a related matter. I have "heard" in various places around the internet that too much Vitamin C causes the body to leach calcium from the bones in order to compensate for the increased acidity in the body.

Since this sounds plausible, I don't immediately dismiss it as I do many of the other bogus anti-Vitamin claims being made by corrupt pharma-flunky scientists in the warmup to the implementation of the WHO/FAO/Codex food regulations*, which, I understand, will become law in most countries by 2009 (this is called "harmonization" of laws), and which outlaw the sale of any vitamin supplements above pitifully low, yet to be announced levels, thus effectively destroying the Natural Health Movement, which was Big Pharma's most detested competitor, and assuring that people will become undernourished and sickly, creating an even vaster market for the Pharma Ghouls than they already have.

So, can you tell us if you think there is any truth to this factoid about vitamin C leaching calcium from the bones?

*For all who want to know more about the coming Codex rules (and EVERYONE should know about them), a visit here and here will be worth your time.

[Jeffrey Dach, MD]

That couldn’t be farther from the truth. Vitamin C is actually required for collagen formation, which is the main organic part of the bone. The inorganic part, calcium, is hydroxyapatite.
I recommend a buffered form of Vitamin C, which actually has mild alkalinzing effect, so there is no net acid production.

An excellent resource on the many health benefits of Vitamin C is Dr . Levy’s book ,

Curing the Incurable: Vitamin C, Infectious Diseases, and Toxins by Thomas E. Levy, MD, JD

[Jeffrey Dach, MD]

The question of animal protein intake and osteoporosis came up on my A4M oral Board Exam last December. Elderly osteoporotic women need adequate protein in their diet to maintain the protein-based collagen matrix of bone, as well as adequate calcium. The better dietary choice is vegetable protein, since it is alkalinizing.

However, animal protein can be OK as long as the remainder of the diet contains enough alkalinizing foods for balance. Using pH strips is one way to find out.

Vitamin D has been implicated as another key for maintaining healthy bones. Vieth reports on the surprising fact that Vitamin D levels in the population should be much higher than we all thought. He feels that optimal serum 25(OH)D is higher than 100 nmol/L. The combined effect of current nutrition guidelines and current sun-avoidance advice usually results in levels lower than 75 nmol/L.

Rucker found a high prevalence of vitamin D insufficiency in Western Canada, defined as a serum level of less than 40 nmol/L, and suggested dietary vitamin D supplementation. Surprisingly, I frequently find low serum Vit D levels even here in sunny Florida, because of sun avoidance.