Reader is in gray area of treatment for osteoporosis

       DEAR DR. ROACH: I took Fosamax for years but stopped five years ago. My bone density score is now -2.5. Should I restart Fosamax? If it creates more mass of brittle bone, then it does not seem advisable. — K.B.
       ANSWER: Fosamax (alendronate) works by preventing absorption of bone by osteoclasts (bone-absorbing cells). When used for three to five years, it improves bone density and reduces the risk of fracture. However, when used for longer periods, it can cause brittle bone, as you have said, and can put people at risk for “atypical” fractures of bone, especially the femur.
       You are in a situation that has no definitive answer. Your bone density is at a level where it might be appropriate to re-treat. However, there is more to fracture risk than just the bone density score, so I would recommend a FRAX test (available at https://www.sheffield.ac.uk/FRAX/tool.aspx?country=9). If your FRAX score indicates a 10-year risk of a hip fracture of 3 percent or greater, or if your 10-year risk of combined major osteoporotic fracture is at least 20 percent, treatment would be recommended.
       Some experts would use a bisphosphonate like Fosamax again, because after five years off treatment, an atypical fracture is not likely. However, others would use a different type of treatment, such as teriparatide, which works by stimulating new bone growth. There are no studies to guide treatment in your situation, so the clinical experience of your treating provider is key. Since you are concerned about brittle bone, I might prefer teriparatide for a person in your situation.
       DEAR DR. ROACH: I sailed for 50 years and now my dermatologist is recommending a treatment to my face (Efudix) that he said will kill sun-damaged cells. However, it also will turn my face beet-red for two months. Needless to say, I am reluctant to submit to such a treatment. Is this treatment worth two months of seclusion and other potential health risks? My problem is periodic (one every year or two) tiny keratosis growths on my nose that he normally burns off with liquid nitrogen. Why can’t I keep getting periodic burn-offs? — K.G.B.
       ANSWER: Actinic keratoses are discrete areas of sun-damaged skin that are prone to develop into squamous cell cancer. They are most common on the face and other sun-exposed areas. They are more common in men, and lighter skin tone is a risk factor. They are uncommon in people with very dark skin.
       Both drug treatment with topical 5-fluorouracil (Efudix) and with treatment of individual lesions (including liquid nitrogen, surgery and phototherapy after a photosensitizing agent) are reasonable treatments for actinic keratoses. The goal of treatment is to prevent cancer.
       Efudix has some advantages over lesion-based therapy. It is effective (50 to 90 percent of people with actinic keratoses will have complete resolution), and it can treat lesions that aren’t yet apparent on exam. This means fewer actinic keratoses requiring treatment in the future. The usual course is redness, blistering, erosion and skin regrowth over the four to six weeks after treatment.
       Since you have few lesions, continuing to get treatment with liquid nitrogen also is reasonable. It should be your choice. If you choose the Efudix, time it keeping in mind when the cosmetic effect is likely to be most noticeable.
       For readers who haven’t yet had 50 years of sailing: Sun protection, such as a broad-spectrum sunscreen, reduces the likelihood of ever getting these precancerous actinic keratoses.
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       Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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