Indeed. I hardly every prescribe HRT (or even ERT) in
patients with osteoporosis. However, the assertion that
HRT is bad, and that we can somehow guess something
more about the very long-term risks and benefits of the
alternatives (SERMs, bisphosphonates, PTH ..) is
absurd.
Our whole approach to long-term effectiveness of
risk-prevention medication is intriguing. The recent
story about beneficial effects of statins on bone was
fascinating. Some 15 years after the introduction of
statins an unexpected (possible) beneficial effect of
statins on bone was noted (and this shed new light on
the way in which bisphosphonates work). Wasn't this
fantastic! However, the thought that this unexpected
side effect could have been deleterious rather than
advantageous, and could have entirely undone the
overall risk profile of statins, seems to have been
entirely ignored. Had it been deleterious, would it
have been detected/reported?
Aubrey Blumsohn
WDF> The recent stampede against HRT seems to have
WDF> swept across the UK following the strongly
WDF> negative reaction from the USA. The RCP statement
WDF> and now the CMO statement have a consistent
WDF> message that short term use of HRT is acceptable
WDF> for symptom relief but in the long term HRT is to
WDF> be avoided. This is unfortunate for those women
WDF> who may benefit from long term treatment with HRT
WDF> and ignores all the data supplied (or not
WDF> supplied) in the WHI and Million Women studies. It
WDF> should be noted that the oestrogen only limb of
WDF> the WHI study (a randomised placebo controlled
WDF> study) is still progressing and the independent
WDF> review board did not ask for this limb of the
WDF> study to be stopped. The CMO recommendation on
WDF> oestrogen alone therapy is presumably based on the
WDF> Million Women study which is not randomised
WDF> placebo controlled. The average age of entry into
WDF> the WHI study was well in to the sixties but this
WDF> was not a study looking at patients with proven
WDF> osteoporosis. The significant reduction in hip and
WDF> vertebral fractures is therefore of greater
WDF> significance than may at first be appreciated from
WDF> a glance at the WHI study. Use of HRT in a high
WDF> risk group with reduced bone mass may result in
WDF> greater benefits. The current licensed
WDF> osteoporosis treatments were all tested using
WDF> patients with proven fracture and significant
WDF> reductions in bone mass (a high risk group) which
WDF> may have helped them obtain a beneficial outcome.
WDF> It is interesting that in one study where the BMD
WDF> measurements were re-aligned following the study
WDF> according to NHANES data there was no significant
WDF> difference in fracture efficacy between the
WDF> bisphosphonate (alendronate)and Ca+vit D in
WDF> patients with osteopenia on BMD (a large group in
WDF> the WHI study). I can fully appreciate the
WDF> concerns that the recent studies have raised
WDF> regarding thrombotic events, myocardial infarction
WDF> and breast cancer but the outright condemnation of
WDF> all forms of long term HRT seems misplaced. The MI
WDF> and vascular events in WHI were mainly in the
WDF> early years of the study suggesting a subset of
WDF> women exist who are sensitive to these effects,
WDF> overall mortality was not significantly different
WDF> between the two groups so does HRT actually have a
WDF> cardiovascular benefit in a subset of women? There
WDF> is a lot more that could be discussed and although
WDF> I was never a major advocate for HRT I am
WDF> surprised by the current reaction. The recent data
WDF> should have helped to promote a better
WDF> understanding about HRT and define those who would
WDF> benefit from such treatment and those who should
WDF> avoid this treatment. Alas I very much doubt if
WDF> Ethics Committees will be prepared to condone any
WDF> future research into the value of HRT.
WDF> Bill Fraser
WDF> --On 04 December 2003 15:23 +0000 "Iversen, Andrew (Dr.)"
WDF> <[log in to unmask]> wrote:
>> Is everyone convinced that HRT is such a bad thing? Admittedly the
>> short-term prothrombotic effect in patients with CHD is adverse, but the
>> curves in HERS do tend to converge after a few
>> years. Gallstones are a
>> nuisance. The million women study was not
>> randomised and I'd be surprised
>> if HRT can cause cancer so quickly (i.e. was it
>> there before in a denser
>> breast). The lipid results are still appealing, and the QALY score for
>> some (non-CHD) patients might be quite good.
>> Are the alternatives for
>> osteoporosis as palatable and effective? Or are we now against HRT?
>>
>> Andrew
>> -----Original Message-----
>> From: Mainwaring-Burton Richard (RGZ)
>> [mailto:[log in to unmask]]
>> Sent: 04 December 2003 11:17
>> To: [log in to unmask]
>> Subject: Re: CMO Advice on HRT in the over 50s with osteoporosis
>>
>> It is a bit like the reccomendation "Employ a
>> teenager NOW while he still
>> knows everything"
>>
>> with best wishes
>>
>> Richard
>>
>> Richard Mainwaring-Burton
>> Consultant Biochemist
>> Queen Mary's Hospital
>> Sidcup, Kent
>> DA14 6LT
>> 020-8308-3084
>>
>>
>> -----Original Message-----
>> From: ablumsohn [mailto:[log in to unmask]]
>> Sent: 04 December 2003 08:27
>> To: [log in to unmask]
>> Subject: Re: CMO Advice on HRT in the over 50s with osteoporosis
>>
>>
>> As they say:
>>
>> "Use a new drug while it's still effective"
>>
>> Aubrey
>>
>>
>> GMA> This document became available at 15:00
>> GMA> today relating to the use of HRT in women over 50
>> GMA> years old.
>>
>> GMA> Malcolm Gray
>>
>> ------ACB discussion List Information--------
>> This is an open discussion list for the academic and clinical
>> community working in clinical biochemistry.
>> Please note, archived messages are public and can be viewed
>> via the internet. Views expressed are those of the individual and
>> they are responsible for all message content.
>>
>> ACB Web Site
>> http://www.acb.org.uk
>> List Archives
>> http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html
>> List Instructions (How to leave etc.)
>> http://www.jiscmail.ac.uk/
>>
>> ------ACB discussion List Information--------
>> This is an open discussion list for the academic and clinical
>> community working in clinical biochemistry.
>> Please note, archived messages are public and can be viewed
>> via the internet. Views expressed are those of the individual and
>> they are responsible for all message content.
>>
>> ACB Web Site
>> http://www.acb.org.uk
>> List Archives
>> http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html
>> List Instructions (How to leave etc.)
>> http://www.jiscmail.ac.uk/
>>
>>
>> This message and any attachments to it is
>> intended only for the individual
>> or company to which it is addressed and may
>> contain information which is
>> privileged, confidential or prohibited from
>> disclosure or unauthorised
>> use. If the recipient of this transmission is not the intended
>> recipient, or the employee or agent responsible for delivering such
>> materials to the intended recipient, you are
>> hereby notified that any
>> use, any form of reproduction, dissemination, copying, disclosure,
>> modification, distribution and/or publication of this e-mail message or
>> its attachments other than by its intended recipient is strictly
>> prohibited by the sender. If you have received
>> it in error, please notify
>> us immediately using the address
>> [log in to unmask] and destroy the
>> message and all copies in your possession
>>
>> ------ACB discussion List Information--------
>> This is an open discussion list for the academic and clinical
>> community working in clinical biochemistry.
>> Please note, archived messages are public and can be viewed
>> via the internet. Views expressed are those of the individual and
>> they are responsible for all message content.
>>
>> ACB Web Site
>> http://www.acb.org.uk
>> List Archives
>> http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html
>> List Instructions (How to leave etc.)
>> http://www.jiscmail.ac.uk/
WDF> Professor W D Fraser
WDF> Department of Clinical Chemistry
WDF> The University of Liverpool
WDF> 4th Floor, Duncan Building
WDF> Daulby Street
WDF> Liverpool
WDF> L69 3GA
WDF> Tel: 0151 706 4247/4257
WDF> Fax: 0151 706 5813
WDF> ------ACB discussion List Information--------
WDF> This is an open discussion list for the academic and clinical
WDF> community working in clinical biochemistry.
WDF> Please note, archived messages are public and can be viewed
WDF> via the internet. Views expressed are those of the individual and
WDF> they are responsible for all message content.
WDF> ACB Web Site
WDF> http://www.acb.org.uk
WDF> List Archives
WDF> http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html
WDF> List Instructions (How to leave etc.)
WDF> http://www.jiscmail.ac.uk/
Regards
Aubrey Blumsohn
------ACB discussion List Information--------
This is an open discussion list for the academic and clinical
community working in clinical biochemistry.
Please note, archived messages are public and can be viewed
via the internet. Views expressed are those of the individual and
they are responsible for all message content.
ACB Web Site
http://www.acb.org.uk
List Archives
http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html
List Instructions (How to leave etc.)
http://www.jiscmail.ac.uk/
|
