Sandy’s regular doctor was on maternity leave. The appointment screen told me to call about her recent DEXA scan – a measure of bone density. She was 58, on the young side to be dealing with osteoporosis. Compared with her original DEXA three years earlier, her bone density had significantly increased in her spine. And while the numbers had ticked up only marginally at her hip, the bone there certainly hadn’t thinned any further. Her prescription history showed regular issues of alendronate tablets since 2023 – a bisphosphonate drug that can arrest or reverse osteoporosis.
Sandy sounded delighted with the news. She mentioned how the osteoporosis had come to light – a fall in skiing had fractured an unusual bone, which had prompted her doctor to organise the original DEXA.
“Anyway,” I said, “those figures tell us the alendronate is doing a good job. The vertebrae in your spine are significantly stronger, and while it would have been the icing on the cake to see the same at the hip, the tablets have certainly stopped further loss, so I’d suggest keep going with them for a few years yet.”
“Are there any other things I could be doing that might help?”
I ran through the importance of exercise. “It wants to be something like running that creates weight-bearing impact; swimming or cycling aren’t going to be much help.” And I touched on dietary measures to ensure she was replete with bone-building minerals and vitamins.
“Can I tell you my little secret?” she said in a suddenly conspiratorial tone. “I haven’t taken those tablets for years!”
I will confess to momentary surprise. Right from the first dose, she told me, she’d been plagued by terrible indigestion – their commonest side effect – and she’d managed no more than six weeks before abandoning them for good. “I did a lot of research about exercise and supplements and things instead.” Her joy was unmistakable: those few tablets she’d managed three years ago were irrelevant; this was all her own work.
I felt suddenly conflicted. She evidently didn’t know about zoledronate, an alternative bisphosphonate given by an annual intravenous infusion to people unable to tolerate the tablet form. The osteoporosis guidelines were unequivocal: she should be started on it. But how likely would she be to benefit? Yes, after a few years her bone density might be further enhanced, but only a small minority of patients will see that translate into a concrete clinical outcome: a fracture avoided.
And what of the impressive improvements she’d made with lifestyle modification? I suspect she would be even less likely to get anything out of adding a drug. And the fitness and improved diet would have many knock-on benefits besides bone health – cancer and heart disease protection, frailty and falls and dementia prevention, too. Who’s to say where the balance point lies – quite how much chance of gain she might have from adding pharmaceuticals; quite how much I might risk undermining her health drive by reacting to her “little secret” by suggesting alternative drugs.
It was her call to make, so I talked her through what zoledronate would and would not do. She said she needed no time to consider; she wanted to continue as now. There was something priceless in her voice, a pride at having charted her own course.
Writing up her notes, I marvelled at those three years of alendronate prescriptions. This happens far more often than most doctors imagine. Guidelines, invariably pharmaceutically focused, sway us into becoming precipitous pill-pushers, but many patients are sceptical of our nostrums and want to try to improve their health more naturally. Wary of conflict or causing offence, they will conduct elaborate charades to appear compliant with our recommendations. If entrusted at any point with a “little secret” like Sandy’s, it behoves the physician to handle the disclosure with the utmost care and collaboration.
[Further reading: PCOS to PMOS: can doctors finally understand the syndrome?]