DXA STUDIES FOR OSTEOPOROSIS - Waste of Money to ‘Screen’ Osteoporosis
O P Kapoor
Ex. Hon. Visiting Physician, Jaslok Hospital and Bombay Hospital, Mumbai,
Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.
Dual X-ray absorptiometry machines created a stir in the medical circles when they were brought to India. The medical world was given the impression that these machines could detect what X-rays could not-that was ‘Bone mineral density’ or ‘Bone mass’. This was a fact. Then followed the software with which CT scan could do the same. USG - the cheapest machines were the last to arrive which could do the same screening of the bones.
Any new stunt is tempting. I started sending dozens of patients for DXA studies. Pharmaceutical companies started doing sonography studies of menopausal women ‘free’ to promote their ‘biphosphonates’ in the market. The literature mentioned to repeat DXA studies every year or two in order to treat these patients like an ECG or a TSH test or blood sugar level without which you cannot treat a patient of ischaemic heart, hypothyroidism or diabetes mellitus respectively. Specialists who bought these machines, recovered their money very fast, because doctors were ordering this costly test which is an easy thing to do in the city of Mumbai where patients can be easily lured to spend for costly tests.
Now when I have seen so many patients and think back - what are the facts and conclusions.
As such we have made elderly male patients miserable by giving them a cocktail of drugs to be taken lifetime to prevent myocardial infarction - aspirin (notorious for causing gastritis and iron deficiency anaemia) - statins which would empty the pockets of even moderately rich patients and rarely might cause even pelvic myopathy or abnormality in liver function tests and betablockers or ACE inhibitors (in diabetes or post MI patients) to be taken lifetime - in addition or even after interventional procedures like angioplasty, or a coronary bypass surgery.
Yes-osteoporosis in elderly menopausal females after the age of 80 years is responsible for most hip fractures, from which onwards the dawnfall of the patients health and complications can start. But then if you want to prevent this situation, shall we start screening all Indian menopausal females and make them spend on such costly tests like DXA, when they have to pay from their own pocket (no Government health schemes)?
The fact is that clinical osteoporosis occurs after about twenty years of onset of menopause. There is nothing like a ‘course’ of osteoporosis (like drugs of ischaemic heart disease) and these women have to take very costly biphosphonates lifetime.
What will be the side effects of these drugs after twenty years as compared to the prevention of fractures? HRT treatment is refused even by women in foreign countries because of side effects of vaginal bleeding and perceived risk of breast cancer. And then the ‘cost of biphosphonates’? And no experience of long term treatment? If the woman is around 55, then treatment for five years is irrelevant by the time she reaches 75 or 80, when she is at the greatest risk of fracture. Is that individual therefore committed to treatment which may continue for 30 years or longer?
Even at older age or in women with early menopause or family history of osteoporosis (or on a maintenance dose of long term steroids - nowadays becoming rarer), now ultrasound system can be used which is cheap and as effective as DXA to diagnose menopausal osteoporosis, without exposure to ionising radiation. Finally it is portable and can be carried to the villages (for camps) or could be kept in the dispensaries or the consulting rooms of the specialists.
The fact is, that female patients ever 80, and those with previous fragility fractures, do not require bone density measurement studies and can be treated irrespective of these tests.