Patients must pay for improved drugs

Priscilla Cole, 74, has given up golf and cross-country skiing. In fact, she can’t vacuum or even lift a bag of milk. Margot Conway, 66, says she can no longer romp with her grandchildren, and trying to put on pantyhose or cut her toenails is torture – because she might fracture a bone.

Both women have osteoporosis, the bone-wasting disease that for its many victims makes a lie of all those articles we read about today’s seniors enjoying vigorous later years.

“As far as quality of life is concerned,” says Cole, who has endured four fractures, one being her hip, “it’s a disaster.”

Doctors frustrated
Incredibly, though, the Ontario Drug Benefit Plan (ODBP) is refusing to pay for new drugs that have a proven record in treating and preventing osteoporosis, leaving many
medical specialists incensed.

“It’s ridiculous, absolutely ridiculous,” says Dr. Rick Adachi, a Hamilton rheumatologist and professor of medicine at McMaster University. He estimates he spends the equivalent of two weeks a year writing letters to the ODBP trying to get emptions for his patients, only to have his judgments questioned by bureaucrats and his requests too often denied.

“It’s really stupid,” charges Dr. Gillian Hawker, an osteoporosis specialist at the Sunnybrook and Women’s College Health Sciences Centre in Toronto. Exemptions, even when granted, can take as long as eight or nine months to be processed. Meanwhile, her patients “are seeing their longevity getting shorter and their quality of life going down, down, down.”

No clout
Since coming to power in 1995, Mike Harris’ Conservative government has approved scores of new drugs for inclusion in the Ontario drug formulary, many of them for heart disease and high cholesterol. Yet not a single one for osteoporosis has made the list. Hawker believes she knows why.

The newly approved drugs, she says, are predominantly for male-oriented diseases.

“Those lobbying for this disease are little old ladies who don’t have the clout of younger, more powerful and wealthy organizations” – organizations which, she says, often advocate on behalf of comparatively rare diseases.

Osteoporosis in Canada
The fact is osteoporosis is a huge and growing concern for a population that’s living longer. According to the Osteoporosis Society of Canada (OSC), the incidence of the disease will more than triple in the next few decades. Today:

  • 1.4 million Canadians have osteoporosis
  • 27,000 a year experience hip fracture.
  • One in four women over 50 has the disease — the cause of which is unknown 
  • One in eight men is also hit.

The prospect of a hip fracture, says OSC president Joyce Gordon, “is very frightening for older people.”

“Osteoporosis,” says Dr. Hawker, “does kill people.” Up to 20 per cent die in the year following a hip fracture – usually from complications, especially pneumonia resulting from immobility – and 50 per cent are disabled.

Limited options
Yet, Ontario doctors find their hands tied when it comes to treating patients who have experienced a fracture or are in danger of fracturing. Only two options for prevention or treatment are available under the ODBP:

  • Hormone therapy (which many women reject because of a slight risk of breast cancer)
  • Etidronate, a first-generation drug in a non-hormone family of pharmaceuticals called bisphosphonates.

Newer bisphosphonates, says Gordon, “show proven and substantive benefits” – but they’re not yet available under the drug plan. But Hawker says government-commissioned best practice guidelines about to be distributed to physicians recommend these medications, presumably at the patient’s cost.

The OSC called off a press conference in April 2000 after senior officials in the premier’s office and the ministry of health agreed to meet society representatives. Since that meeting, says Gordon, there has been “virtual silence.”

Other provinces
Ontario, like the other provinces, has been concerned about the increasing cost of its drug plan for seniors, yet so far there are no (cheaper) generic versions of the three
osteoporosis drugs available.

However, for taxpayers, it’s a case of pay now or pay later:

  • The drugs cost between $700 and $875 a year per patient
  • The treatment cost for a hip fracture averages $30,000.

With the exception of Prince Edward Island, the other nine provinces have all made Fosamax (one of the newest bisphosphonates to hit the market) available, although usually on a limited basis. Quebec, however, has made Fosamax and other bisphosphonate drugs available without restriction.

Fosamax not listed
An Ontario Health Ministry official confirmed that while Fosamax isn’t listed on the Ontario plan, doctors who want to prescribe the drug for particular patients can use the “section eight appeal procedure,” and the osteoporosis drugs fall in an “expedited classification” to avoid delays.

However, says Hawker, the patient must already be on the approved Etidronate and the doctor must prove there’s a side effect or a failure to respond. This involves gathering the evidence, writing several letters… and waiting for a review.

“Meanwhile, during these delays, she has a fracture!” This foolishness doesn’t end there.

“The biggest predictor of who’s going to have a hip fracture,” says Adachi, “is someone who has already had one. Day in, day out, I see patients who have had hip fractures and will continue to get fractures.”

Tough choice
The government, says Hawker, “doesn’t seem to understand long-term prevention. In terms of keeping elderly people out of hospital, they’d do much better by making the new drugs more readily available to those at risk.”

The choice for many Ontario seniors with osteoporosis is a tough one:

  • Find the money for the drugs themselves
  • Accept the added risk of fractures.
“I put myself on Fosamax,” says Margot Conway, of Kitchener-Waterloo. “I’m retired. I can’t afford it. So part of our holidays had to go.”

Says Priscilla Cole, in Toronto: “Two dollars a day (the cost of some of the new drugs) to a senior on $12,000 a year is a problem, especially for older women without pension plans. They don’t eat.” 
Long-term prevention
You’ve no doubt heard it before, but it does no harm to be reminded. Here’s what you can do to help prevent osteoporosis:

  • Keep up your calcium. The Osteoporosis Society of Canada (OSC) recommends 1,000 to 1,500 mg a day for those over 50. Dairy products, leafy green vegetables and canned fish are good sources.
  • Learn the risk factors from the OSC. Call 1-800-463-6842, or visit the website.
  • If you are at risk (female, thin-boned, with a family history of osteoporosis, for instance), talk to your doctor about a bone density test, diet change and/or a calcium supplement.
  • Consider regular weight-bearing exercises.
  • Quit smoking.