The Emperor’s New Bones

Mrs. Budreau has seen an endocrinologist in the Capitol City for her osteoporosis for over five years now. Her last bone density test shows that she is almost at the point where the average woman her age is.

The specialist has sent me a note outlining how Mrs. Budreau might be a candidate for yearly intravenous infusions. The specialist has pointed out that not much is known about the long-term effects of the medicine Mrs. Budreau is taking, so perhaps it is time to switch over to the newest type of injectable osteoporosis medication instead. The only problem is that I would have to be the one ordering the treatment, since the specialist doesn’t have any affiliation with our local hospital.

I was very honest with the Budreaus when this issue came up. I told them I had never before prescribed the infusions she had been recommended. I told them I needed to do some reading before agreeing to order them.

Her chart spent the next month on the far left corner of my desk. Every so often I would pick it up, read the note from the endocrinologist, and scroll down the drug information page on my computer screen. And every time I felt this was wrong.

Finally, I called Mrs. Budreau up and told her how uncomfortable I still felt with ordering the infusions for her. I told her we don’t have any proof that treatment beyond 5 years with the medication she has been taking is better than stopping and that some researchers have reported increased fracture risk with longer treatment. Thus far I gave her the same advice as the endocrinologist had. But I couldn’t find any evidence to support now giving her another drug with less of a track record. She would be a guinea pig, part of the first large group of people to try the infusions after already treating osteoporosis for five years with the older medication.

I made sure Mrs. Budreau knew that her latest bone density test was much better than her first two, and while she still had osteoporosis, this only means that her bone density is below the normal range for a 17-year old (called T-score). Compared to women her own age (her Z-score) she is in the lower 25%, but not off the chart, which is where she started out five years ago.

I made sure she was aware that with osteoporosis, unlike most other medical conditions, the line between normal and abnormal has been drawn with reference to young people in such a way that even a perfectly average woman over the age of 80 will, by definition, have osteoporosis.

I told her I would be more comfortable if she let the specialist do the infusions at her own hospital, even though this would mean an extra annual trip for the Budreau’s. I just didn’t feel that I should be the one putting my name on her infusion order.

She thanked me for the call and told me she had decided not to go ahead with her infusion anyway.

Sometimes I feel like the little boy watching the Emperor parade down the street in his new, invisible, clothes…

1 Response to “The Emperor’s New Bones”


  1. 1 Wren May 16, 2010 at 5:11 am

    I certainly understand your hesitation to prescribe a new and mostly untested medication, and your advice to stop the one the lady had been taking for years, since it might make her osteoperosis worse.

    But if she’s not taking anything at all, doesn’t that mean that her osteoperosis will start progressing again? I was recently diagnosed with osteopenia and am now taking calcium with Vit. D, hoping to perhaps slow the progression of this disease. So mainly, I’m just curious…

    Thanks, Country Doc. I always enjoy reading your posts. You’re very thoughtful and really do seem to care about your patients.


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