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Chapurlat RD. Clinical Pharmacology of Potent New Bisphosphonates for Postmenopausal Osteoporosis. ACTA ACUST UNITED AC 2005; 4:115-25. [PMID: 15783248 DOI: 10.2165/00024677-200504020-00005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Bisphosphonates are potent inhibitors of bone resorption, used in most bone diseases associated with high bone resorption levels. Several bisphosphonates, developed to prevent and treat postmenopausal osteoporosis, increase bone mineral density and decrease biochemical markers of bone turnover, and more importantly, reduce fracture risk. Alendronate and risedronate have proven their efficacy to reduce vertebral and hip fracture risk among postmenopausal osteoporotic women, using daily regimens. Weekly intermittent schedules, however, are now most commonly prescribed, because they have shown pharmacologic equivalence to the daily regimen. Ibandronate has been the first bisphosphonate to demonstrate vertebral fracture risk reduction using an intermittent regimen. Studies using ibandronate as intravenous injections every 3 months are under way. Zoledronic acid may also be an attractive option for the treatment of postmenopausal osteoporosis if a large ongoing trial proves that a single annual injection of this compound allows osteoporotic fracture risk reduction.
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Affiliation(s)
- Roland D Chapurlat
- Department of Rheumatology and Bone Diseases and INSERM U 403, Hôpital E Herriot, Lyon, France.
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Im GI, Qureshi SA, Kenney J, Rubash HE, Shanbhag AS. Osteoblast proliferation and maturation by bisphosphonates. Biomaterials 2004; 25:4105-15. [PMID: 15046901 DOI: 10.1016/j.biomaterials.2003.11.024] [Citation(s) in RCA: 292] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2003] [Accepted: 11/11/2003] [Indexed: 02/07/2023]
Abstract
Aseptic loosening and osteolysis are currently the most common causes of failure of total joint replacements. Osteolysis is initiated by a macrophage response to wear debris, resulting in localized, osteoclastic peri-implant bone loss. We have previously inhibited osteoclast-mediated bone resorption in a canine total hip arthroplasty model using oral bisphosphonate therapy. Based on serendipitous observations from our canine study, we hypothesized that bisphosphonates have an anabolic effect on osteoblasts, in a manner distinct from their inhibitory effect on osteoclastic bone resorption. We studied the anabolic effects of two FDA-approved bisphosphonates (alendronate and risedronate) on two in vitro models: a primary human trabecular bone cell culture and the MG-63 osteoblast-like cell line. Following treatment with bisphosphonates at varying concentrations and time periods, cells were assayed for proliferation effects and results were quantified using the methods of direct cell count, and the colorimetric MTT (3-dimethylthiazol-2,5-diphenyltetrazolium bromide) assay at 24, 48, and 72 h. The effect of bisphosphonates on the maturation of osteoblasts were tested with alkaline phosphatase bioassay and reverse transcription-polymerase chain reaction for markers of osteoblast differentiation. Results from both the primary human trabecular bone cell culture and the MG-63 osteoblast-like cell line showed that both bisphosphonates significantly increased the cell number over controls, attaining peak levels at a concentration of 10(-8)M. Alkaline phosphatase activity was also increased, representing earlier commitment of osteoprogenitor cells towards the osteoblastic phenotype. Bisphosphonates also enhanced gene expression of BMP-2, Type I collagen and osteocalcin. In summary, bisphosphonates, aside from their role as inhibitors of osteoclastic bone resorption, are promoters of osteoblast proliferation and maturation.
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Affiliation(s)
- Gun-Il Im
- Biomaterials Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, GRJ 1115, 55 Fruit Street, Boston, MA 02114, USA
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Mellström DD, Sörensen OH, Goemaere S, Roux C, Johnson TD, Chines AA. Seven years of treatment with risedronate in women with postmenopausal osteoporosis. Calcif Tissue Int 2004; 75:462-8. [PMID: 15455188 DOI: 10.1007/s00223-004-0286-7] [Citation(s) in RCA: 184] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2004] [Accepted: 07/01/2004] [Indexed: 10/26/2022]
Abstract
The effects of 7 years of risedronate treatment were evaluated in a second 2-year extension of a 3-year vertebral fracture study in women with osteoporosis. For the first 5 years of the study, women received risedronate 5 mg/day or placebo according to the original randomization, with maintenance of blinding. All the women who entered into the 6-7 years extension study received risedronate 5 mg/day. Endpoints included vertebral and nonvertebral fracture assessments, changes in biochemical markers of bone turnover, and bone mineral density (BMD) measurements. A total of 164 women (placebo/risedronate group, 81; risedronate group, 83) entered the 6-7 years extension study and 136 (83%) completed the study. Annualized incidence of new vertebral fractures during the 6-7 years was similar between the 2 treatment groups (3.8%). The incidence of vertebral fractures did not change in the 7-year risedronate group during the 6-7 years as compared to 4-5 years, while a significant reduction was observed in the placebo group that switched to risedronate treatment during years 6-7. The incidence of nonvertebral fractures was 7.4% and 6.0% in the placebo/risedronate and risedronate groups, respectively, during years 6-7. Urinary N-telopeptide decreased from baseline by 54% and 63% at 3 months and 7 years, respectively, in the risedronate group. The increases in BMD from baseline after 5 years of risedronate treatment were maintained or increased further during years 6-7; lumbar spine BMD after 5 and 7 years of risedronate treatment increased from baseline by 8.8% and 11.5%, respectively, for this extension study population. Risedronate was well tolerated and the occurrence of upper gastrointestinal adverse events was low. After 7 years of continuous risedronate treatment there were significant increases in BMD and decreases in bone turnover to within premenopausal levels and there was no indication of any loss of anti-fracture efficacy.
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Affiliation(s)
- D D Mellström
- Department of Geriatric Medicine, University of Göteborg, Sweden
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54
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Cauza E, Etemad M, Winkler F, Hanusch-Enserer U, Hanusch-Enserer H, Partsch G, Noske H, Dunky A. Pamidronate increases bone mineral density in women with postmenopausal or steroid-induced osteoporosis. J Clin Pharm Ther 2004; 29:431-6. [PMID: 15482386 DOI: 10.1111/j.1365-2710.2004.00584.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We aimed to determine the efficacy and safety of a cyclic intravenous therapy with pamidronate in patients with postmenopausal or glucocorticoid-induced osteoporosis. METHODS We enrolled 86 Austrian female patients with postmenopausal (n = 69, mean age 68.13 +/- 1.14) or glucocorticoid-induced (n = 17, mean age 66.89 +/- 2.03) osteoporosis defined as a T-score of < -2.5 for bone mineral density (BMD) of the lumbar spine L1-L4. Patients received a single intravenous dose of 30 mg pamidronate at 3 months intervals. The per cent change in BMD was primary, whereas the safety and the biological response were secondary endpoints. RESULTS Seventy-six female patients (88%) completed study. Sixty patients received pamidronate therapy for the treatment of late postmenopausal osteoporosis and 16 patients received the same treatment for glucocorticoid-induced osteoporosis. At the end of the trial, lumbar spine (L1-L4) BMD increased significantly in patients with postmenopausal osteoporosis (P = 0.000067), whereas in patients with glucocorticoid-induced osteoporosis no significant change was observed (P = 0.724). The increase in the Ward's triangle BMD did not reach significance level in postmenopausal women receiving pamidronate (P = 0.0740). However, pamidronate treatment for glucocorticoid-induced osteoporosis resulted in a significant increase in Ward's triangle BMD (P = 0.0029). The efficacy of pamidronate treatment for postmenopausal osteoporosis was also reflected in a decrease in circulating biochemical markers for bone formation, including alkaline phosphatase and osteocalcin. In addition, pamidronate was well tolerated with no incidence of severe gastrointestinal events. CONCLUSION Cyclic intravenous administration of pamidronate is well-tolerated therapy in postmenopausal osteoporosis, and increases spinal BMD. Randomized controlled studies with adequate number of patients are needed to test the efficacy of the compound in the treatment of glucocorticoid-induced osteoporosis.
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Affiliation(s)
- E Cauza
- Department of Internal Medicine V, Wilhelmininspital, Vienna, Austria.
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Vehmanen L, Saarto T, Risteli J, Risteli L, Blomqvist C, Elomaa I. Short-Term Intermittent Intravenous Clodronate in the Prevention of Bone Loss Related to Chemotherapy-Induced Ovarian Failure. Breast Cancer Res Treat 2004; 87:181-8. [PMID: 15377842 DOI: 10.1023/b:brea.0000041624.00665.4e] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Chemotherapy-induced ovarian failure causes rapid bone loss in premenopausal women with early breast cancer. The aim of the present study was to investigate the effect of intravenous intermittent clodronate during adjuvant chemotherapy in prevention of this rapid bone loss. 45 premenopausal women with early stage breast cancer were treated with adjuvant chemotherapy. In addition, all women were randomly allocated to receive either seven cycles of intravenous clodronate infusions (1500 mg each) parallel to the chemotherapy or no further therapy. The mean bone loss in the lumbar spine at 6 months was -0.5% in the clodronate group and -1.4% in the control group (p = 0.22) and, at 12 months, -3.9% and -3.6%, respectively (p = 0.62). Type I collagen metabolite PINP levels at six months were significantly lower in the clodronate group than in the control group: 22.6 microg/l (range 15.7-55.8 microg/l) and 44.0 microg/l (range 12.5-91.9 microg/l), respectively (p = 0.0001). At 12 months, no difference between the PINP levels in clodronate and control groups were seen. In conclusion, in this small study a short-term intermittent intravenous clodronate treatment did not seem to prevent clinically significantly the bone loss related to chemotherapy-induced ovarian failure in premenopausal women with early stage breast cancer, even though a significant reduction of a biochemical marker of bone turnover (PINP) was seen during the therapy.
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Affiliation(s)
- Leena Vehmanen
- Department of Oncology, Helsinki University Central Hospital, Helsinki, Finland
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Yamaguchi K, Masuhara K, Yamasaki S, Fuji T, Seino Y. Effects of discontinuation as well as intervention of cyclic therapy with etidronate on bone remodeling after cementless total hip arthroplasty. Bone 2004; 35:217-23. [PMID: 15207760 DOI: 10.1016/j.bone.2004.03.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2004] [Revised: 03/13/2004] [Accepted: 03/19/2004] [Indexed: 11/25/2022]
Abstract
We previously reported the effects of cyclic therapy with etidronate (CTE) on periprosthetic bone mineral density (BMD) after cementless total hip arthroplasty (THA). This study aimed to evaluate the effects of withdrawal and intervention of CTE after cementless THA. The control group consisted of 24 patients without osteoactive drugs. Sixteen patients continued on CTE (i.e., 400 mg/day oral etidronate for 2 weeks followed by 12 weeks of 500 mg/day calcium lactate, repeated every 14 weeks) for the first 12 months followed by no treatment for 18 months (early-etidronate group). Fifteen patients received no treatment for the first 18 months followed by CTE for 12 months (late-etidronate group). Periprosthetic BMD in seven regions of interest based on the zones of Gruen et al. was measured with dual energy X-ray absorptiometry at 3 weeks, 6, 12, 18, 24, and 30 months postoperatively. At 12 months after operation (off therapy point in the early-etidronate group), postoperative decreases of BMD in the early-etidronate group were significantly smaller than those in the control group in zones 1, 2, 5, 6, and 7 and those in the late-etidronate group in zones 1, 5, 6, and 7 (P < 0.05 for each). In the early-etidronate group, significant decreases in BMD were found during months 12-30 (off therapy period) after withdrawal of CTE in zones 1 and 7 (P < 0.05 for each). In the late-etidronate group, BMD increased significantly in zones 4 and 6 (P < 0.05 for each) during months 18-30 (on therapy period) after intervention trial, while in the controls, BMD decreased significantly in zone 3 (P < 0.05) over this period. At the final follow-up (30 months), BMD loss in zone 7 was significantly less in the early-etidronate group than in the other groups (P < 0.05). BMD changes in the early-etidronate group and late-etidronate group were associated with changes in biochemical bone markers.
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Affiliation(s)
- Katsuyuki Yamaguchi
- Department of Orthopaedic Surgery, Kaizuka City Hospital, Hori, Kaizuka, Osaka 597-0015, Japan.
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Abstract
Postmenopausal osteoporosis (PMO) is a common disease that will become more prevalent in the future, with costly implications for public health. Prevention of the disease and its consequences, namely fractures, is therefore, important for both the individual and society. This review discusses: the goals of PMO prevention; the identification of women at risk, including the use of bone mineral density and bone turnover markers; the relevance in the prevention setting of various current guidelines for PMO management; recent data on therapeutic options for the treatment and prevention of PMO, in particular bisphosphonates, hormone replacement therapy and several other new pharmacological agents. It concludes that it is crucial for PMO prevention to start before disease onset and that, in the light of recent evidence, the existing guidelines need updating if they are to continue to be relevant.
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Affiliation(s)
- J-Y Reginster
- Unit d'Exploration du Metabolisme de l'Os et due Cartilage, CHU Centre Ville, Liége, Belgium.
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58
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Ringa V. Les alternatives au traitement hormonal substitutif de la ménopause : le point épidémiologique. ACTA ACUST UNITED AC 2004; 33:195-209. [PMID: 15170434 DOI: 10.1016/s0368-2315(04)96440-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Recent results put into question the risks/benefits ratio of hormone replacement therapy and emphasize the importance of precise knowledge of the effects of other treatments that exist for postmenopausal symptoms or diseases. Our aim is to analyze their effect. METHODS A review of randomized trials or epidemiological studies was undertaken. RESULTS Bisphophonates, calcitonin, parathormone, strontium ranelate, calcium and vitamin D have specific effects on bone. The efficacy of bisphophonates for prevention and treatment of osteoporosis has been proven and parathormone and strontium ranelate seem promising. These treatments are useful for women at high risk of osteoporosis who do not suffer from menopausal symptoms. Tibolone, SERMs and phytoestrogens exert effects on various tissues. SERMs are very promising, but they do not improve climacteric symptoms and their long term effects are still unknown. Tibolone has beneficial effects on climacteric symptoms and on bone loss, but recent results concerning its effects on the risk of breast cancer call into question its interest. The beneficial effects of phytoestrogens on bone and on vasomotor symptoms need to be confirmed. CONCLUSION At this time, none of the existing treatments for postmenopausal symptoms or diseases is ideal. The existence of several options for treatments of symptoms or diseases of the postmenopause is helpful as it affords several choices for physicians and for women who sometimes need to be treated for many years. However several questions remain unanswered concerning the long term effects of these treatments.
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Affiliation(s)
- V Ringa
- INSERM U 149, Unité de Recherches Epidémiologiques en Santé Périnatale et Santé des Femmes, Hôpital Paul-Brousse, 16 avenue Paul-Vaillant-Couturier, 94807 Villejuif Cedex, France.
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Francis RM, Baillie SP, Chuck AJ, Crook PR, Dunn N, Fordham JN, Kelly C, Rodgers A. Acute and long-term management of patients with vertebral fractures. QJM 2004; 97:63-74. [PMID: 14747620 DOI: 10.1093/qjmed/hch012] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Symptomatic vertebral fractures are associated with significant morbidity, excess mortality and health and social service expenditure. Up to 20% of patients with an incident vertebral fracture experience a further vertebral fracture within one year. It is therefore important that vertebral fractures are detected early, and treatment considered as soon as possible. Only a third of vertebral fractures come to medical attention, where they typically present with acute back pain, but other presentations include loss of height and increasing kyphosis. Spine X-rays should then be performed to confirm the diagnosis and exclude other pathology. Bone density measurements are not essential before starting treatment for osteoporosis in patients with low-trauma vertebral fractures, but may be useful to confirm osteoporosis when there is uncertainty about previous trauma. They may also aid in selecting the most appropriate therapy and monitoring response to treatment. Up to 30% of women and 55% of men with symptomatic vertebral crush fractures have underlying secondary osteoporosis, where treatment may lead to large increases in bone density. These conditions should therefore be sought by medical history, physical examination and appropriate investigations. The management of patients with acute vertebral fractures should include measures to reduce pain and improve mobility, as well as starting treatment for osteoporosis. Treatments have now been shown in randomized controlled trials to improve bone density and reduce the incidence of vertebral and non-vertebral fractures in patients with osteoporosis. Choice of treatment will depend on the underlying causes of bone loss, efficacy in any particular situation, cost, patient preference and the potential non-skeletal advantages and disadvantages.
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Affiliation(s)
- R M Francis
- Department of Medicine (Geriatrics), University of Newcastle upon Tyne, Newcastle upon Tyne, UK.
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Aaseth J, Shimshi M, Gabrilove JL, Birketvedt GS. Fluoride: A toxic or therapeutic agent in the treatment of osteoporosis? ACTA ACUST UNITED AC 2004. [DOI: 10.1002/jtra.10051] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Xenodemetropoulos T, Davison S, Ioannidis G, Adachi JD. The Impact of Fragility Fracture on Health-Related Quality of Life. Drugs Aging 2004; 21:711-30. [PMID: 15323577 DOI: 10.2165/00002512-200421110-00002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Both general and specific health status instruments can be utilised in evaluating health-related quality of life (HR-QOL) deficits resulting from osteoporotic fractures. Osteoporotic hip, vertebral and wrist fractures significantly decrease HR-QOL in most HR-QOL domains investigated. The presence of multiple vertebral fractures leads to larger decrements in HR-QOL. More research needs to be completed with these HR-QOL tools to better assess the true burden of osteoporotic fractures, particularly in the case of hip fractures, as the burden is surely being underestimated without recognition of HR-QOL. Only when the burden of fragility fractures is understood, inclusive of HR-QOL, will the value of proven antifracture prevention and treatment therapies be appreciated. Information collected by HR-QOL instruments may provide new insight as to how to improve quality of life for patients with fractures and how to properly allocate healthcare spending.
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Fadanelli ME, Bone HG. Combining Bisphosphonates with Hormone Therapy for Postmenopausal Osteoporosis. ACTA ACUST UNITED AC 2004; 3:361-9. [PMID: 15511130 DOI: 10.2165/00024677-200403060-00004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Osteoporosis affects many women after menopause. It is a major health problem, as fragility fractures create significant morbidity in this population, especially with advancing age. Available therapies include estrogens, selective estrogen receptor modulators, bisphosphonates, and calcitonin. They all inhibit bone resorption, although through different mechanisms. Several combinations of these agents have been studied in order to determine their effectiveness in comparison with monotherapy. We reviewed eight prospective randomized clinical trials of hormone therapies combined with bisphosphonates (etidronate, alendronate, and risedronate) and one study of a selective estrogen receptor modulator (raloxifene) in combination with a bisphosphonate (alendronate). Bone mineral density change at the lumbar spine was the primary endpoint of all the studies, with one or more measurements of the bone density at the femur as secondary endpoints. None of the studies had the statistical power to determine the relative reduction in fracture risk. All the studies reported greater increases in bone mineral density in patients treated with combination therapies as opposed to single agents. The bone turnover markers were also suppressed to a greater degree in the combination treatment groups, remaining however within normal premenopausal ranges. Four studies reported bone histomorphometry data, indicating no impairment of bone quality by combination therapies. The combination treatments were well tolerated in all the trials and the discontinuation rates did not vary among the groups. However, most patients will not require combination therapy. Combining bisphosphonates with hormone therapy may offer an additional benefit to women who either continue to lose bone mass despite taking estrogen or who need estrogen to control postmenopausal symptoms. The benefit of adding raloxifene to a bisphosphonate is smaller. However, it may be clinically useful if raloxifene reduces the risk of breast cancer.
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Jiang G, Matsumoto H, Yamane J, Kuboyama N, Akimoto Y, Fujii A. Prevention of trabecular bone loss in the mandible of ovariectomized rats. J Oral Sci 2004; 46:75-85. [PMID: 15287540 DOI: 10.2334/josnusd.46.75] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The effect of therapeutic agents on trabecular bone loss in the mandible was investigated in ovariectomized rats. Eighty-seven Wistar SPF female rats were ovariectomized (OVX) or given a sham operation (Sham), and maintained on a diet containing 0.1% calcium. Four weeks later, groups of OVX rats were treated with estriol (E3), calcitonin (CT), etidronate, or 2-carboxyethylgermanium sesquioxide (Ge-132). The Basal group was maintained on a diet containing 1.0% calcium, and the OVX and sham groups on a diet containing 0.1% calcium. The trabecular bone mineral density (BMD) and trabecular bone mineral content (BMC) in 11 mandibular slices from 0.5 mm at the mesial margin of the first molar to 0.5 mm at the distal margin of the third molar, were measured using peripheral Quantitative Computed Tomography (pQCT). The BMD in the OVX group was lower than that in the Sham group, and decreased BMC was observed only in the molar region. BMD and BMC were increased in the etidronate-treated group, but only BMC was increased in the CT group. E3 treatment increased BMD and BMC; significant increases were also observed beneath the molar. Ge-132 treatment increased both BMD and BMC, especially the latter.
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Affiliation(s)
- Guizhen Jiang
- Department of Pharmacology, Nihon University School of Dentistry at Matsudo, Chiba, Japan
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64
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Takaishi Y, Ikeo T, Miki T, Nishizawa Y, Morii H. Suppression of Alveolar Bone Resorption by Etidronate Treatment for Periodontal Disease: 4- to 5-Year Follow-up of Four Patients. J Int Med Res 2003; 31:575-84. [PMID: 14708423 DOI: 10.1177/147323000303100614] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Four women with periodontitis received intermittent cyclical etidronate (etidronate administered orally at a dose of 200 mg/day for 2 weeks, at intervals of 10-12 weeks or 6 months) for 4-5 years in addition to ordinary dental therapy. Alveolar bone density was measured using a new method comparing the percentage increase in density. Mean alveolar bone density increased significantly during intermittent cyclical etidronate treatment. Significant reductions were observed in the mobility of the teeth and the depth of periodontal pockets. There were significant correlations between alveolar bone density and both mobility of the teeth and the depth of the alveolar pockets. It is concluded that increases in alveolar bone density are associated with the clinical benefits of etidronate in the treatment of periodontitis.
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Lippuner K. Medical treatment of vertebral osteoporosis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2003; 12 Suppl 2:S132-41. [PMID: 13680313 PMCID: PMC3591820 DOI: 10.1007/s00586-003-0608-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2003] [Accepted: 07/31/2003] [Indexed: 01/22/2023]
Abstract
Although osteoporosis is a systemic disease, vertebral fractures due to spinal bone loss are a frequent, sometimes early and often neglected complication of the disease, generally associated with considerable disability and pain. As osteoporotic vertebral fractures are an important predictor of future fracture risk, including at the hip, medical management is targeted at reducing fracture risk. A literature search for randomized, double-blind, prospective, controlled clinical studies addressing medical treatment possibilities of vertebral fractures in postmenopausal Caucasian women was performed on the leading medical databases. For each publication, the number of patients with at least one new vertebral fracture and the number of randomized patients by treatment arm was retrieved. The relative risk (RR) and the number needed to treat (NNT, i.e. the number of patients to be treated to avoid one radiological vertebral fracture over the duration of the study), together with the respective 95% confidence intervals (95%CI) were calculated for each study. Treatment of steroid-induced osteoporosis and treatment of osteoporosis in men were reviewed separately, based on the low number of publications available. Forty-five publications matched with the search criteria, allowing for analysis of 15 different substances tested regarding their anti-fracture efficacy at the vertebral level. Bisphosphonates, mainly alendronate and risedronate, were reported to have consistently reduced the risk of a vertebral fracture over up to 50 months of treatment in four (alendronate) and two (risedronate) publications. Raloxifene reduced vertebral fracture risk in one study over 36 months, which was confirmed by 48 months' follow-up data. Parathormone (PTH) showed a drastic reduction in vertebral fracture risk in early studies, while calcitonin may also be a treatment option to reduce fracture risk. For other substances published data are conflicting (calcitriol, fluoride) or insufficient to conclude about efficacy (calcium, clodronate, etidronate, hormone replacement therapy, pamidronate, strontium, tiludronate, vitamin D). The low NNTs for the leading substances (ranges: 15-64 for alendronate, 8-26 for risedronate, 23 for calcitonin and 28-31 for raloxifene) confirm that effective and efficient drug interventions for treatment and prevention of osteoporotic vertebral fractures are available. Bisphosphonates have demonstrated similar efficacy in treatment and prevention of steroid-induced and male osteoporosis as in postmenopausal osteoporosis. The selection of the appropriate drug for treatment of vertebral osteoporosis from among a bisphosphonate (alendronate or risedronate), PTH, calcitonin or raloxifene will mainly depend on the efficacy, tolerability and safety profile, together with the patient's willingness to comply with a long-term treatment. Although reduction of vertebral fracture risk is an important criterion for decision making, drugs with proven additional fracture risk reduction at all clinically relevant sites (especially at the hip) should be the preferred options.
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Affiliation(s)
- K Lippuner
- Osteoporosis Policlinic, University Hospital of Berne, 3010, Berne, Switzerland.
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66
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Santini D, Vespasiani Gentilucci U, Vincenzi B, Picardi A, Vasaturo F, La Cesa A, Onori N, Scarpa S, Tonini G. The antineoplastic role of bisphosphonates: from basic research to clinical evidence. Ann Oncol 2003; 14:1468-76. [PMID: 14504045 DOI: 10.1093/annonc/mdg401] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Bisphosphonates are now well established as successful agents for the prevention and treatment of postmenopausal osteoporosis, corticosteroid-induced bone loss and Paget's disease. Bisphosphonates have also recently become important in the management of cancer-induced bone disease, and they now have a widely recognized role for patients with multiple myeloma and bone metastases secondary to breast cancer and prostate cancer. Recent studies suggest that, besides the strong antiosteoclastic activity, the efficacy of such compounds in the oncological setting could also be due also to direct antitumor effect, exerted at different levels. Here, after a brief analysis of the chemical structure, we will review the antineoplastic and biological properties of bisphosphonates. We will start from well estabilished mechanisms of action and go on to discuss the latest evidence and hypotheses. In particular, we will review the antiresorptive properties in malignant osteolysis and the recent evidence of a direct antitumor effect. Furthermore, this review will analyze the influence of bisphosphonates on cancer growth factor release, their effect on cancer cell adhesion, invasion and viability, the proapoptotic potential on cancer cells, the antiangiogenic effect, and, finally, the immunomodulating properties of bisphosphonates on the gammadelta T cell population.
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Affiliation(s)
- D Santini
- Interdisciplinary Center for Biomedical Research (CIR), Oncology, University Campus Bio-Medico, Rome, Italy.
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67
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Abstract
Osteoporosis is a frequent complication in the course of various gastrointestinal disorders. Since its pathogenesis is complex, and incompletely understood in comparison to the well-known pathomechanism of postmenopausal osteoporosis, adequate management is difficult. We first summarize those therapeutic options which have strong evidence in postmenopausal osteoporosis and, thereafter, we review those in the context of different gastrointestinal diseases. Treatment of the underlying intestinal disorder seems to be most important to normalise altered bone metabolism and to prevent osteoporosis in patients with coeliac disease. In patients with osteoporosis associated with Crohn's disease, various treatment strategies (such as vitamin D, sodium fluoride, bisphosphonates) are discussed. In contrast to postmenopausal osteoporosis, interventional studies in secondary osteoporosis are often limited by the small study population and data about the efficacy of any treatment in prevention of fractures are therefore lacking. Well-conducted, controlled studies with the endpoint of preventing fractures are therefore required to optimise the treatment of osteoporosis in these patients.
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68
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Yamaguchi K, Masuhara K, Yamasaki S, Nakai T, Fuji T. Cyclic therapy with etidronate has a therapeutic effect against local osteoporosis after cementless total hip arthroplasty. Bone 2003; 33:144-9. [PMID: 12919709 DOI: 10.1016/s8756-3282(03)00085-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Proximal bone resorption around the femoral stem is one of the major complications of cementless total hip arthroplasty (THA). The potential complications resulting from proximal bone resorption include femoral fracture and late stem loosening. The purpose of this study was to evaluate the effects of cyclic therapy with etidronate on periprosthetic bone mineral density (BMD) after cementless THA. Fifty-two patients who had undergone cementless THA were randomized for this study. Group A consisted of 30 hips in 29 patients without osteoactive drugs. Group B consisted of 23 hips in 23 patients with cyclic therapy with etidronate (i.e., 400 mg/day of oral etidronate for 2 weeks followed by 12 weeks of 500 mg/day of calcium lactate and repeated every 14 weeks), one of whom was excluded from the study because of side effects attributed to the drug. Periprosthetic BMD in seven regions of interest based on the zones of Gruen et al. (Clin. Orthop. 141 (1979), 17-27) was measured with dual energy X-ray absorptiometry (DXA) at 3 weeks, 6 months, and 12 months postoperatively. The postoperative decreases of BMD in group B were significantly lower than those in group A in zones 1 and 7 (P < 0.05 and P < 0.05, respectively) at 6 months and in zones 1, 2, 6, and 7 (P < 0.05, P < 0.05, P < 0.05, and P < 0.001, respectively) at 12 months. The BMD change appeared to be stabilized at 6 months in all zones in group B, while in group A there was a progressive decrease of average BMD (6.1%) in zone 7 between 6 months and 12 months. These findings suggested that cyclic therapy with etidronate may help to reduce the resorptive changes in the proximal part of the femur after cementless THA. Further follow-up study with larger populations will be required to define the potential efficacy of intermittent cyclic etidronate therapy on postoperative bone loss.
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Affiliation(s)
- Katsuyuki Yamaguchi
- Department of Orthopaedic Surgery, Kaizuka City Hospital, 3-10-20, Hori, Kaizuka, Osaka 597-0015, Japan.
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69
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Tankó LB, Mouritzen U, Lehmann HJ, Warming L, Moelgaard A, Christgau S, Qvist P, Baumann M, Wieczorek L, Hoyle N, Christiansen C. Oral ibandronate: changes in markers of bone turnover during adequately dosed continuous and weekly therapy and during different suboptimally dosed treatment regimens. Bone 2003; 32:687-93. [PMID: 12810176 DOI: 10.1016/s8756-3282(03)00091-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The aims of the present study were to investigate how changes in the cumulative dose and the frequency of dosing influence the short-term antiresorptive efficacy of oral ibandronate treatment and whether serial measurements of bone markers could provide a useful diagnostic tool for the revelation of noncompliance to established treatments with antiresorptive drugs. Study participants were 200 healthy women 50-70 years old (mean 63.1 years) with a lumbar spine BMD t-score of -1 to -5. Women were randomly allocated to receive treatment with oral ibandronate according to one of the following eight dosing regimes: (1) 2.5 mg daily for 84 days; (2) 20 mg weekly for 84 days; (3) 2.5 mg daily for 28 days + no treatment for 56 days; (4) 2.5 mg daily for 28 days + 2.5 mg weekly for 56 days; (5) 2.5 mg daily for 28 days + 2.5 mg three times weekly for 56 days; (6) 2.5 mg daily for 14 days + 2.5 mg three times weekly for 56 days; (7) 2.5 mg three times weekly for 84 days; (8) no treatment for 168 days. Study parameters were the serum concentration of the C-terminal telopeptide of collagen type I (s-CTX, resorption marker) and N-MID osteocalcin (formation marker) measured by enzyme-linked immunosorbent assay. Oral treatment with ibandronate 20 mg weekly (cumulative dose 240 mg) resulted in greater final inhibition in s-CTX and area under the curve (AUC) compared to the 2.5 mg daily treatment (cumulative dose 210 mg), indicating that as long as optimal doses are administered the frequency of dosing has secondary importance for overall efficacy. When the cumulative dose was 130 mg or less, the final degree of inhibition was still the function of the cumulative dose, but the overall efficacy estimated by the AUC was also under the influence of the frequency of dosing. These observations suggest that serial measurements of s-CTX may provide a useful diagnostic tool for the early revelation of suboptimal dosing or noncompliance to already optimized therapies with antiresorptive agents.
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Affiliation(s)
- L B Tankó
- Center for Clinical & Basic Research A/S, Ballerup Byvej 222, 2750 Ballerup, Denmark.
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70
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Abstract
Anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified remain a significant cause of morbidity and mortality in girls and young women. Management of eating disorders typically requires a multidisciplinary team approach, often spear-headed by the clinician initially detecting the illness. This article addresses the definitions and prevalence of eating disorders, tips on recognition and management of medical complications, and reproductive health concerns for these young women. Issues surrounding care of the patient with the female athlete triad, or amenorrhea, osteopenia, and eating disorders, are also discussed.
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Affiliation(s)
- Ellen S Rome
- Section of Adolescent Medicine, The Children's Hospital, Cleveland Clinic Foundation, 9500 Euclid Avenue, A120, Cleveland, OH 44195, USA.
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71
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Masud T, Giannini S. Preventing osteoporotic fractures with bisphosphonates: a review of the efficacy and tolerability. Aging Clin Exp Res 2003; 15:89-98. [PMID: 12889839 DOI: 10.1007/bf03324485] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Although change in bone mineral density was the outcome most commonly measured in early clinical trials of osteoporosis therapies, it is now understood that the most clinically important outcome is reduction in the risk of fractures. Of currently available osteoporosis therapies, the bisphosphonates have been most thoroughly investigated in studies with fracture risk as the primary outcome. The most widely studied bisphosphonates include etidronate, alendronate and risedronate. Alendronate and risedronate have the most compelling evidence for vertebral and non-vertebral fracture reduction. This review provides a comprehensive overview of the anti-fracture efficacy of bisphosphonates at the spine, hip, and non-vertebral sites.
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Affiliation(s)
- Tahir Masud
- Clinical Gerontology Research Unit, Department of Medicine, City Hospital, Nottingham, UK.
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72
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Body JJ. Zoledronic acid: an advance in tumour bone disease therapy and a new hope for osteoporosis. Expert Opin Pharmacother 2003; 4:567-80. [PMID: 12667119 DOI: 10.1517/14656566.4.4.567] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The two main therapeutic applications of bisphosphonates are tumour bone disease and osteoporosis. They constitute the standard treatment for cancer hypercalcaemia, and placebo-controlled trials have shown that the prolonged administration of bisphosphonates, such as pamidronate or clodronate, can reduce the frequency of complications from tumour bone disease due to metastatic breast cancer or myeloma by a quarter to one-half. The results obtained with the intravenous route appear to be more impressive and more rapidly obtained than with oral compounds. Both agents can reduce the risk of vertebral, wrist and hip fractures by 30 - 50%, whereas other antiresorptive agents, such as raloxifene (Eli Lilly & Co.) or calcitonin (Unigene Laboratories Inc.), have only been demonstrated to reduce the incidence of vertebral fractures. The short infusion time (4 mg over 15 min) offers a convenient therapy and constitutes the most evident advantage of zoledronic acid, which will improve patients' quality of life. Zoledronic acid has the potential to change the treatment of osteoporosis dramatically.
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Affiliation(s)
- Jean-Jacques Body
- Supportive Care Clinic, Clinic of Endocrinology and Bone Diseases and Laboratory of Endocrinology and Breast Cancer Research, Dept of Medicine, Institut J Bordet, 1 rue Héger-Bordet, Univ. Libre de Bruxelles, Brussels, Belgium.
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73
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Abstract
Clinical application of bone densitometry has led to increased patient awareness of this increasingly prevalent disease. With bone densitometry, it is possible for clinicians to diagnose osteoporosis before the first fracture has occurred; predict risk for fracture in men, postmenopausal women, and in patients receiving glucocorticoids; and can be used as a surrogate marker to follow the efficacy of therapies and to examine those patients who might be osteoporosis-specific therapeutic non-responders.
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Affiliation(s)
- Paul D Miller
- Colorado Center for Bone Research, 3190 South Wadsworth Boulevard, #250 Lakewood, CO 80227, USA
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74
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Catterall JB, Cawston TE. Drugs in development: bisphosphonates and metalloproteinase inhibitors. Arthritis Res Ther 2003; 5:12-24. [PMID: 12716443 PMCID: PMC154424 DOI: 10.1186/ar604] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2002] [Revised: 09/13/2002] [Accepted: 09/23/2002] [Indexed: 01/23/2023] Open
Abstract
The destruction of bone and cartilage is characteristic of the progression of musculoskeletal diseases. The present review discusses the developments made with two different classes of drugs, the bisphosphonates and matrix metalloproteinase inhibitors. Bisphosphonates have proven to be an effective and safe treatment for the prevention of bone loss, especially in osteoporotic disease, and may have a role in the treatment of arthritic diseases. The development of matrix metalloproteinase inhibitors and their role as potential therapies are also discussed, especially in the light of the disappointing human trials data so far published.
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Affiliation(s)
- Jon B Catterall
- Department of Rheumatology, The Medical School, University of Newcastle upon Tyne, UK
| | - Tim E Cawston
- Department of Rheumatology, The Medical School, University of Newcastle upon Tyne, UK
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75
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Rico Lenza H. La paradójica acción, a nivel óseo, de los bisfosfonatos. Rev Clin Esp 2003. [DOI: 10.1016/s0014-2565(03)71206-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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76
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Theodorou DJ, Theodorou SJ, Sartoris DJ. Treatment of osteoporosis: current status and recent advances. COMPREHENSIVE THERAPY 2002; 28:109-22. [PMID: 12085458 DOI: 10.1007/s12019-002-0048-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
With the advent of new treatment choices, osteoporosis should no longer be considered an inevitable part of aging but rather a disease that can be treated. This article provides an overview of recent advances in treatment of osteoporosis.
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Affiliation(s)
- Daphne J Theodorou
- Department of Radiology, University of California, San Diego Veterans Affairs Medical Center, San Diego, Calif., USA
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77
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Rizzoli R, Greenspan SL, Bone G, Schnitzer TJ, Watts NB, Adami S, Foldes AJ, Roux C, Levine MA, Uebelhart B, Santora AC, Kaur A, Peverly CA, Orloff JJ. Two-year results of once-weekly administration of alendronate 70 mg for the treatment of postmenopausal osteoporosis. J Bone Miner Res 2002; 17:1988-96. [PMID: 12412806 DOI: 10.1359/jbmr.2002.17.11.1988] [Citation(s) in RCA: 139] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this study was to provide confirmation that once-weekly dosing with 70 mg of alendronate (seven times the daily oral dose) and twice-weekly dosing with 35 mg is equivalent to the 10-mg once-daily regimen and to gain more extensive safety experience with this new dosing regimen. Twelve hundred fifty-eight postmenopausal women (aged 42-95 years) with osteoporosis (bone mineral density [BMD] of either lumbar spine or femoral neck at least 2.5 SDs below peak young adult mean or prior vertebral or hip fracture) were assigned to receive oral once-weekly alendronate, 70 mg (n = 519); twice-weekly alendronate, 35 mg (n = 369); or daily alendronate 10 mg (n = 370) for a total of 2 years of double-blind experience. Mean BMD increases from baseline (95% CI) at 24 months in the once-weekly, twice-weekly, and daily treatment groups, respectively, were 6.8% (6.4, 7.3), 7.0% (6.6,7.5), and 7.4% (6.9,7.8) at the lumbar spine and 4.1% (3.8,4.5), 4.3% (3.9,4.7), and 4.3% (3.9,4.7) at the total hip. These increases in BMD as well as the BMD increases at the femoral neck, trochanter, and total body and the reductions of biochemical markers of bone resorption (urinary cross-linked N-telopeptides of type I collagen [NTx]) and bone formation (serum bone-specific alkaline phosphatase [BSAP]) were similar for the three dosing regimens. All treatment regimens were well tolerated with a similar incidence of upper gastrointestinal (GI) adverse experiences. The incidence rates of clinical fractures, captured as adverse experiences, were similar among the groups. The 2-year results confirm the conclusion reached after 1 year that once-weekly alendronate is therapeutically equivalent to daily dosing, providing patients with a more convenient dosing option that may potentially enhance adherence to therapy.
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Affiliation(s)
- R Rizzoli
- Department of Internal Medicine, Hõpital Cantonal, Geneva, Switzerland
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78
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Chilibeck PD, Davison KS, Whiting SJ, Suzuki Y, Janzen CL, Peloso P. The effect of strength training combined with bisphosphonate (etidronate) therapy on bone mineral, lean tissue, and fat mass in postmenopausal women. Can J Physiol Pharmacol 2002; 80:941-50. [PMID: 12450060 DOI: 10.1139/y02-126] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The combined and separate effects of exercise training and bisphosphonate (etidronate) therapy on bone mineral in postmenopausal women were compared. Forty-eight postmenopausal women were randomly assigned (double blind) to groups that took intermittent cyclical etidronate; performed strength training (3 d/week) and received matched placebo; combined strength training with etidronate; or took placebo and served as nonexercising controls. Bone mineral, lean tissue, and fat mass were assessed by dual-energy X-ray absorptiometry before and after 12 months of intervention. After removal of outlier results, changes in bone mineral density (BMD) of the lumbar spine and bone mineral content (BMC) of the whole body were greater in the subjects given etidronate (+2.5 and +1.4%, respectively) compared with placebo (-0.32 and 0%, respectively) (p < 0.05), while exercise had no effect. There was no effect of etidronate or exercise on the proximal femur and there was no interaction between exercise and etidronate at any bone site. Exercise training resulted in significantly greater increases in muscular strength and lean tissue mass and greater loss of fat mass compared with controls. We conclude that etidronate significantly increases lumbar spine BMD and whole-body BMC and that strength training has no additional effect. Strength training favourably affects body composition and muscular strength, which may be important for prevention of falls.
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Affiliation(s)
- P D Chilibeck
- College of Kinesiology, University of Saskatchewan, Saskatoon, SK S7N 5C2, Canada.
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79
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Abstract
OBJECTIVE To review and evaluate the evidence regarding possible associations of bisphosphonate use with upper gastrointestinal (GI) tract adverse events (AEs). METHODS We reviewed and summarized published information and abstracts regarding upper GI tract safety and tolerability of bisphosphonates, including laboratory and animal studies, epidemiological (observational) studies, endoscopy studies, and randomized controlled trials (RCTs). The evidence was summarized by using the principles of evidence-based medicine, giving the greatest credence to high-quality RCTs. RESULTS Clinical reports of esophagitis associated with bisphosphonate use appear to have declined in frequency once the importance of proper administration was explained to physicians after early reports of complications. Conflicting results have been reported in endoscopy studies; some reported no significant increase in upper GI tract lesions, whereas others reported a higher incidence of gastric (but not esophageal) lesions among patients taking oral bisphosphonates. Endoscopy studies that reported differences were of short duration (2 weeks) and were not of double-blind design. Results from large RCTs involving thousands of participants detected no increase in upper GI tract AEs among individuals treated with bisphosphonates. Other studies of patients who discontinued taking bisphosphonates and were randomized to blinded re-treatment with either a bisphosphonate or placebo show that most patients (>85%) were able to continue treatment, with no difference in AEs between the bisphosphonate and placebo groups. CONCLUSIONS The highest level of evidence, RCTs, suggests little or no increase in risk of upper GI tract problems if bisphosphonates are administered properly. Upper GI tract symptoms are common among patients with osteoporosis. The evidence suggests that many upper GI tract AEs reported during therapy with bisphosphonates may reflect a high background incidence of upper GI tract complaints and an increased sensitivity to detection rather than a causal relationship to therapy.
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80
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Parker CR, Blackwell PJ, Fairbairn KJ, Hosking DJ. Alendronate in the treatment of primary hyperparathyroid-related osteoporosis: a 2-year study. J Clin Endocrinol Metab 2002; 87:4482-9. [PMID: 12364423 DOI: 10.1210/jc.2001-010385] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We investigated the effect of alendronate on calcium, PTH, and bone mineral density in 27 female and 5 male patients with primary hyperparathyroidism. The treatment group [n = 14; T score < or = -2.5 SD at the femoral neck (FN) or T < or = -1.0 SD plus previous nonvertebral fracture] was given alendronate 10 mg/d for 24 months. The second group (n = 18; T score > -2.5 SD at the FN) was untreated. Biochemistry was repeated at 1.5, 3, 6, 12, 18, and 24 months, and dual-energy x-ray absorptiometry at 12 and 24 months. There were no significant between-group baseline differences in calcium, creatinine, or PTH. Alendronate-treated patients gained bone at all sites [lumbar spine (LS), 1 yr gain, +7.3 +/- 1.7%; P < 0.001; 2 yr, +7.3 +/- 3.1%; P = 0.04). Untreated patients gained bone at the LS over 2 yr (+4.0 +/- 1.8%; P = 0.03) but lost bone elsewhere. Calcium fell nonsignificantly in the alendronate group between baseline (2.84 +/- 0.12 mmol/liter) and 6 wk (2.76 +/- 0.09 mmol/liter), with a nonsignificant rise in PTH (baseline, 103.5 +/- 14.6 ng/liter; 6 wk, 116.7 +/- 15.6 ng/liter). By 3 months, values had reverted to baseline. In primary hyperparathyroidism, alendronate is well tolerated and significantly improves bone mineral density at the LS (with lesser gains at FN and radius), especially within the first year of treatment. Short-term changes in calcium and PTH resolve by 3 months.
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Affiliation(s)
- C R Parker
- Division of Mineral Metabolism, City Hospital, Nottingham NG5 1PB, United Kingdom.
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81
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82
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Abstract
Osteoporosis is characterised by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and consequent increase in fracture risk. It is a common condition affecting one in three women and one in 12 men, resulting in substantial morbidity, excess mortality, and health and social services expenditure. It is therefore important to develop strategies to prevent and treat osteoporosis in both men and women. This paper reviews the pathogenesis of primary and secondary osteoporosis, as well as diagnosis, investigation, and management. This should include lifestyle changes to reduce bone loss and decrease the risk of falls, the identification and treatment of secondary causes of bone loss, and specific treatment for osteoporosis. Hormone replacement therapy, raloxifene, bisphosphonates, calcium and vitamin D, calcitonin, and parathyroid hormone have all been shown to improve bone density and decrease the risk of fracture in specific situations. It is important that treatment is tailored to the individual patient, to ensure compliance and optimise the potential benefits.
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Affiliation(s)
- S P Tuck
- Musculoskeletal Unit, Freeman Hospital, Newcastle upon Tyne, UK
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83
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Abstract
Although there is a great need for better therapeutic approaches to the patient who presents with a fracture, osteoporotic fractures will remain a condition that is more amenable to prevention than treatment. Hormone replacement therapy (HRT) is still considered by many the mainstay for the prevention and the treatment of posrmenopausal osteoporosis. However, there are several controversies regarding HRT, especially the duration of treatment and the risks/benefits ratio. Recent studies have challenged the assumption that HRT conveys real long-term beneficial effects. Raloxifene or other "selective estrogen receptor modulators" (SERMs) should progressively replace HRT in elderly women. Bisphosphonates have demonstrated a clearcut efficacy in the treatment of osteoporosis. Alendronate and risedronate have been the most extensively studied bisphosphonates under randomized controlled trials conditions. Both agents can reduce the risk of vertebral and hip fractures by one-fourth to one-half. However, oral bisphosphonates are not without gastro-intestinal toxicity and strict adherence to constraining therapeutic schemes is mandatory. Intermittent treatments are already in use. Weekly alendronate is as efficient as daily therapy and improves treatment compliance. Newer more potent bisphosphonates, such as oral ibandronate or intravenous zoledronic acid, will allow much less frequent administration. The anti-fracture efficacy of yearly zoledronic acid infusions is thus currently tested. On the other hand, bone-forming agents, such as daily subcutaneous injections of teriparatide (rhPTH 1-34) offer exciting perspectives for the treatment of severe osteoporosis despite the complexity of such therapy.
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Affiliation(s)
- J J Body
- Clinic of Endocrinology and Bone Diseases, and Supportive Care Clinic, Dept of Medicine, Institut J. Bordet, 1, rue Héger-Bordet Univ. Libre de Bruxelles, Brussels-Belgium.
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84
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Papaioannou A, Watts NB, Kendler DL, Yuen CK, Adachi JD, Ferko N. Diagnosis and management of vertebral fractures in elderly adults. Am J Med 2002; 113:220-8. [PMID: 12208381 DOI: 10.1016/s0002-9343(02)01190-7] [Citation(s) in RCA: 140] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
We reviewed the epidemiology, diagnosis, and treatment of vertebral fractures due to osteoporosis in the elderly. Vertebral fractures are underdiagnosed despite their high prevalence in both men and women. Clinical consequences of vertebral fractures include increased risk of future vertebral and hip fracture, acute and chronic back pain, decreased quality of life, and increased mortality. Patients with vertebral fractures have functional impairment and increased mortality similar to those with hip fractures. Asymptomatic fractures identified on radiograph also affect quality of life and mortality. A vertebral fracture is a clinical marker for a subsequent fracture and should trigger assessment and diagnosis of osteoporosis. The care of patients with vertebral fractures includes pain management, rehabilitation, and prevention of further fractures. There is evidence from randomized controlled trials that pharmacologic therapy can reduce the risk of future fractures by 40% to 50%. Vertebroplasty may be effective in the control of pain and in obtaining stability of the spine.
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Affiliation(s)
- Alexandra Papaioannou
- Department of Medicine, Division of Geriatric Medicine (AP) McMaster University, Hamilton, Ontario, Canada.
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85
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Abstract
The aim of treatment of postmenopausal osteoporosis is to reduce the frequency of vertebral and non-vertebral fractures (especially at the hip), which are responsible for morbidity associated with the disease. Results of large placebo controlled trials have shown that alendronate, raloxifene, risedronate, the 1-34 fragment of parathyroid hormone, and nasal calcitonin, greatly reduce the risk of vertebral fractures. Furthermore, a large reduction of non-vertebral fractures has been shown for alendronate, risedronate, and the 1-34 fragment of parathyroid hormone. Calcium and vitamin D supplementation is not sufficient to treat individuals with osteoporosis but is useful, especially in elderly women in care homes. Hormone replacement therapy remains a valuable option for the prevention of osteoporosis in early postmenopausal women. Choice of treatment depends on age, the presence or absence of prevalent fractures, especially at the spine, and the degree of bone mineral density measured at the spine and hip. Non-pharmacological interventions include adequate calcium intake and diet, selected exercise programmes, reduction of other risk factors for osteoporotic fractures, and reduction of the risk of falls in elderly individuals.
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Affiliation(s)
- Pierre D Delmas
- Claude Bernard University of Lyon and INSERM Research Unit 403, France.
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86
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Abstract
Oral bisphosphonates are effective for osteoporosis and other hyperresorptive bone disorders. Although well-tolerated in efficacy trials, some oral aminobisphosphonates have been associated with upper gastrointestinal intolerance and injury in postmarketing experience. Clinical trials often underestimate the rate of adverse events in clinical practice, and ethics prohibit direct evaluation of toxicity in high-risk patients. Accordingly, animal models and endoscopy studies of oral bisphosphonates provide valuable insight. It is unclear whether variation in ulcerogenic potential reflects differences in dosing, formulation or chemical structure. Furthermore, the clinical relevance of endoscopic lesions is uncertain. Ongoing postmarketing review will determine whether differences in endoscopic damage predict tolerability and safety in clinical practice. However, physicians and patients should consider risk factors for oesophageal injury when initiating therapy.
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Affiliation(s)
- John K Marshall
- Division of Gastroenterology (4W8), Medical Centre, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada.
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87
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Sambrook PN, Seeman E, Phillips SR, Ebeling PR. Preventing osteoporosis: outcomes of the Australian Fracture Prevention Summit. Med J Aust 2002; 176:S1-16. [PMID: 12049064 DOI: 10.5694/j.1326-5377.2002.tb04475.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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88
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Hochberg MC, Greenspan S, Wasnich RD, Miller P, Thompson DE, Ross PD. Changes in bone density and turnover explain the reductions in incidence of nonvertebral fractures that occur during treatment with antiresorptive agents. J Clin Endocrinol Metab 2002; 87:1586-92. [PMID: 11932287 DOI: 10.1210/jcem.87.4.8415] [Citation(s) in RCA: 275] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Some, but not all, antiresorptive agents have been shown to reduce the risk of nonvertebral fractures. Agents that significantly reduced nonvertebral fracture risk also appear to produce larger mean increases in bone mineral density (BMD) and reductions in biochemical markers (BCM) of bone turnover, compared with other agents. To examine the extent to which increases in BMD and reductions in BCM during antiresorptive therapy are associated with reductions in risk of nonvertebral fractures, we performed a meta-analysis of all randomized, placebo-controlled trials of antiresorptive agents conducted in postmenopausal women with osteoporosis (i.e. prior vertebral fracture or low BMD) with available relevant data. A total of 18 such trials with usable data were identified, including a total of 2,415 women with incident nonvertebral fractures over 69,369 women-years of follow-up. Poisson regression was used to estimate the association between changes in BMD or BCM during the first year and overall reductions in risk of nonvertebral fractures (vs. the placebo group) across all trials. Larger increases in BMD and larger reductions in BCM were significantly associated with greater reductions in nonvertebral fracture risk. For example, each 1% increase in spine BMD at 1 yr was associated with an 8% reduction in nonvertebral fracture risk (P = 0.02). Mean BMD changes at the hip were smaller than at the spine, but the predicted net effect on fracture risk was the same; an agent that increases spine BMD by 6% at 1 yr reduces nonvertebral fracture risk by about 39%, and an agent that increases hip BMD by 3% at 1 yr reduces nonvertebral fracture risk by about 46%. The results also predict that a 70% reduction in resorption BCM would reduce risk by 40%, and a 50% reduction in formation BCM would reduce risk by 44%. It appears that either BMD or BCM changes are able to explain the effect of treatment, because a separate variable for treatment was not independently significant in any models. These data demonstrate that larger increases in BMD at both the spine and hip and larger reductions in both formation and resorption BCM are associated with greater reductions in the risk of nonvertebral fractures. Antiresorptive agents that do not produce large increases in BMD or large reductions in BCM do not appear to and would not be expected to decrease the risk of nonvertebral fractures.
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Affiliation(s)
- Marc C Hochberg
- University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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89
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Cummings SR, Karpf DB, Harris F, Genant HK, Ensrud K, LaCroix AZ, Black DM. Improvement in spine bone density and reduction in risk of vertebral fractures during treatment with antiresorptive drugs. Am J Med 2002; 112:281-9. [PMID: 11893367 DOI: 10.1016/s0002-9343(01)01124-x] [Citation(s) in RCA: 487] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To estimate how much the improvement in bone mass accounts for the reduction in risk of vertebral fracture that has been observed in randomized trials of antiresorptive treatments for osteoporosis. METHODS After a systematic search, we conducted a meta-analysis of 12 trials to describe the relation between improvement in spine bone mineral density and reduction in risk of vertebral fracture in postmenopausal women. We also used logistic models to estimate the proportion of the reduction in risk of vertebral fracture observed with alendronate in the Fracture Intervention Trial that was due to improvement in bone mineral density. RESULTS Across the 12 trials, a 1% improvement in spine bone mineral density was associated with a 0.03 decrease (95% confidence interval [CI]: 0.02 to 0.05) in the relative risk (RR) of vertebral fracture. The reductions in risk were greater than predicted from improvement in bone mineral density; for example, the model estimated that treatments predicted to reduce fracture risk by 20% (RR = 0.80), based on improvement in bone mineral density, actually reduce the risk of fracture by about 45% (RR = 0.55). In the Fracture Intervention Trial, improvement in spine bone mineral density explained 16% (95% CI: 11% to 27%) of the reduction in the risk of vertebral fracture with alendronate. CONCLUSION Improvement in spine bone mineral density during treatment with antiresorptive drugs accounts for a predictable but small part of the observed reduction in the risk of vertebral fracture.
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Affiliation(s)
- Steven R Cummings
- Department of Medicine, University of California, San Francisco, California, USA
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90
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Heckman GA, Papaioannou A, Sebaldt RJ, Ioannidis G, Petrie A, Goldsmith C, Adachi JD. Effect of vitamin D on bone mineral density of elderly patients with osteoporosis responding poorly to bisphosphonates. BMC Musculoskelet Disord 2002; 3:6. [PMID: 11860614 PMCID: PMC65678 DOI: 10.1186/1471-2474-3-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2001] [Accepted: 02/08/2002] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bisphosphonates are indicated in the prevention and treatment of osteoporosis. However, bone mineral density (BMD) continues to decline in up to 15% of bisphosphonate users. While randomized trials have evaluated the efficacy of concurrent bisphosphonates and vitamin D, the incremental benefit of vitamin D remains uncertain. METHODS Using data from the Canadian Database of Osteoporosis and Osteopenia (CANDOO), we performed a 2-year observational cohort study. At baseline, all patients were prescribed a bisphosphonate and counseled on vitamin D supplementation. After one year, patients were divided into two groups based on their response to bisphosphonate treatment. Non-responders were prescribed vitamin D 1000 IU daily. Responders continued to receive counseling on vitamin D. RESULTS Of 449 patients identified, 159 were non-responders to bisphosphonates. 94% of patients were women. The mean age of the entire cohort was 74.6 years (standard deviation = 5.6 years). In the cohort of non-responders, BMD at the lumbar spine increased 2.19% (p < 0.001) the year after vitamin D was prescribed compared to a decrease of 0.55% (p = 0.36) the year before. In the cohort of responders, lumbar spine BMD improved 1.45% (p = 0.014) the first year and 1.11% (p = 0.60) the second year. The difference between the two groups was statistically significant the first year (p < 0.001) but not the second (p = 0.60). Similar results were observed at the femoral neck but were not statistically significant. CONCLUSION In elderly patients with osteoporosis not responding to bisphosphonates, vitamin D 1000 IU daily may improve BMD at the lumbar spine.
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Affiliation(s)
- George A Heckman
- Department of Medicine, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - Rolf J Sebaldt
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Centre for Evaluation of Medicines, St. Joseph's Hospital, Hamilton, Ontario, Canada
| | | | - Annie Petrie
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Charlie Goldsmith
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Centre for Evaluation of Medicines, St. Joseph's Hospital, Hamilton, Ontario, Canada
| | - Jonathan D Adachi
- Department of Medicine, St. Joseph's Hospital, McMaster University, Hamilton, Ontario, Canada
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91
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Gehlbach SH, Fournier M, Bigelow C. Recognition of osteoporosis by primary care physicians. Am J Public Health 2002; 92:271-3. [PMID: 11818304 PMCID: PMC1447055 DOI: 10.2105/ajph.92.2.271] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES This study explored the recognition and treatment of osteoporosis and vertebral fracture among older women by primary care physicians. METHODS Data from the National Ambulatory Medical Care Survey from 1993 to 1997 were examined for evidence of diagnosis and treatment of osteoporosis or vertebral fracture during visits by White women 60 years and older to primary care physicians. RESULTS Fewer than 2% of the women received diagnoses of osteoporosis or vertebral fracture, although expected prevalence is 20% to 30%. Appropriate drug treatment, including antiresorptive agents and calcium and vitamin D, was offered to only 36% of the diagnosed patients. CONCLUSIONS Few cases of osteoporosis or vertebral fracture in older women are being diagnosed and treated by primary care physicians.
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Affiliation(s)
- Stephen H Gehlbach
- School of Public Health & Health Sciences, University of Massachusetts, Amherst, 01003, USA.
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92
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Marcus R, Wong M, Heath H, Stock JL. Antiresorptive treatment of postmenopausal osteoporosis: comparison of study designs and outcomes in large clinical trials with fracture as an endpoint. Endocr Rev 2002; 23:16-37. [PMID: 11844743 DOI: 10.1210/edrv.23.1.0453] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Antiresorptive treatments for postmenopausal osteoporosis have been studied extensively, but due to the volume of published data and lack of head-to-head trials, it is difficult to evaluate and compare their fracture reduction efficacy. The objective of this review is to summarize the results from clinical trials that have fracture as an endpoint and to discuss the factors in study design and populations that can affect the interpretation of the results. Although there are numerous observational studies suggesting that estrogen and hormone replacement therapies may reduce the risk of vertebral and nonvertebral fractures, there is no large, prospective, randomized, placebo-controlled, double-blind clinical trial demonstrating fracture efficacy. The effects of raloxifene, alendronate, risedronate, and salmon calcitonin on increasing bone mineral density (BMD) and decreasing fracture risk have been shown in randomized, placebo-controlled, double-blind clinical trials of postmenopausal women with osteoporosis. Although the increases in lumbar spine BMD vary greatly in these trials, the decrease in relative risk of vertebral fractures is similar among therapies. However, nonvertebral fracture efficacy has not been consistently demonstrated. Combined administration of two antiresorptive therapies results in greater BMD increases, but the effects on fracture risk are unknown. Direct comparisons of clinical trial results should be considered carefully, given the differences in study design and populations. Differences in study design that may influence the efficacy of fracture risk reduction include calcium and vitamin D supplementation, primary fracture endpoints, definition of vertebral deformity or fracture, discontinuation rates, and statistical power. Factors in the study population that may influence fracture efficacy include the age of the population and the proportion of subjects with prevalent fractures. The use of surrogate endpoints such as BMD to predict fracture risk should be approached with caution, as the relationship between BMD changes and fracture risk reduction with antiresorptive therapies is uncertain. Consideration of these results from clinical trials can contribute to clinical judgment in selecting the best treatment option for postmenopausal osteoporosis.
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Affiliation(s)
- Robert Marcus
- Department of Medicine, Stanford University School of Medicine, and the Musculoskeletal Research Laboratory, Geriatric Research, Education, and Clinical Center, Veterans' Affairs Medical Center, Palo Alto, California 94304, USA.
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93
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Nozaki M, Koera K, Egami R, Nagata H, Nakano H. Combination of Intermittent Cyclical Etidronate and Hormone Replacement Therapy for Postmenopausal Non-Responders to Estrogen. Clin Drug Investig 2002; 22:111-7. [DOI: 10.2165/00044011-200222020-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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94
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Abstract
Risedronate (Actonel, Procter & Gamble and Aventis) is a novel, orally administered pyridinyl bisphosphonate. Preclinical studies have shown that risedronate is a potent inhibitor of osteoclasts. Risedronate inhibited bone resorption and increased bone density in the spine and hip. Prospective, randomised, placebo-controlled trials (RCTs) in patients with postmenopausal osteoporosis (PMO) have demonstrated that risedronate decreased the risk of vertebral fractures by up to 49% and of non-vertebral fractures by up to 39% over 3 years in postmenopausal women with one or more prevalent vertebral fractures. This reduction of the risk for vertebral fractures was significant from the first year of treatment (risk reduction up to 65%). Risedronate was the first bisphosphonate to be studied in a large RCT with prevention of hip fracture as the primary end point. In this study, risedronate reduced the risk of hip fracture by 40% in elderly women with low hip bone density and one clinical risk factor for hip fracture and by 60% in women with low bone density and a prevalent vertebral fracture at baseline. Risedronate was also effective in the prevention and treatment of bone loss in glucocorticoid-induced osteoporosis (GIO), with a positive effect on vertebral fractures within the first year. Risedronate was well-tolerated with a safety profile comparable to placebo in all clinical studies. Patients with a previous or current history of upper GI illness or who were taking NSAIDs or aspirin were not excluded from these studies. Importantly, the upper GI safety profile of risedronate was shown to be similar to that of placebo in endoscopic studies. There was no evidence of acute-phase reactions or primary mineralisation defects. The most appropriate dose of risedronate was 5 mg/day.
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Affiliation(s)
- P Geusens
- Department of Rheumatology, University Hospital, maastricht, The Netherlands.
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95
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Abstract
The main efficacy criterion for drugs against osteoporosis is protection against fractures. Many resorption-inhibiting agents meet this criterion, including estrogens, alendronate, risedronate, raloxifene, calcitonin, and calcium-vitamin D supplements). Conversely, among anabolic agents, only parathyroid hormone (PTH) is known to reduce the fracture risk, the mechanism being increased bone matrix production by osteoblasts with no alterations in the mechanical properties of bone. Although fluoride salts induce a marked increase in bone mineral density (BMD), there is no evidence that this protects against vertebral or peripheral fractures. Growth hormone, IGF-I, statins, and strontium ranelate are under investigation. A recent controlled clinical trial in 1,637 women with osteoporosis showed that daily subcutaneous injections of PTH (1-34) (20 or 40 microg) for 21 months reduced the fracture risk. With 20 microg/day, the reductions were 65% for vertebral fractures and 57% for extravertebral fractures, 11% of patients had moderate postinjection hypercalcemia, and BMD increased by 9% at both the lumbar spine and the femoral neck. These findings open up the exciting possibility that PTH used alone or in combination with resorption-inhibiting agents may be helpful. To date, PTH is the only anabolic agent that has proved capable of reducing the risk of vertebral and extravertebral fractures in women with established postmenopausal osteoporosis.
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Affiliation(s)
- P J Meunier
- Department of Rheumatology and Bone Diseases, Pavillon F, Hôpital Edouard-Herriot, Lyon, France.
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96
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Vehmanen L, Saarto T, Elomaa I, Mäkelä P, Välimäki M, Blomqvist C. Long-term impact of chemotherapy-induced ovarian failure on bone mineral density (BMD) in premenopausal breast cancer patients. The effect of adjuvant clodronate treatment. Eur J Cancer 2001; 37:2373-8. [PMID: 11720830 DOI: 10.1016/s0959-8049(01)00317-3] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We present the 5-year results of the effect of adjuvant chemotherapy on bone mineral density (BMD) and the efficacy of clodronate in the prevention of bone loss in 73 premenopausal women with primary breast cancer. All patients were treated with cyclophosphamide, methotrexate, 5-fluorouracil (CMF) chemotherapy. The patients were randomised to oral clodronate 1600 mg daily for 3 years or to a control group. At 5 years, patients were divided into those with preserved menstruation and those with amenorrhoea. Changes in BMD correlated significantly with the menstrual function after chemotherapy. The change in the lumbar spine BMD at 3 and 5 years were +0.6 and -1.3% in the menstruating group and -7.5 and -10.4% in the amenorrhoeic group (P=0.0001 and 0.0001, respectively), and in femoral neck +1.7 and -0.3%, and -3.5 and -5.8% (P=0.002 and P=0.001, respectively). Three-year clodronate treatment significantly reduced the bone loss in the lumbar spine -3.0% compared with controls -7.4% at three years (P=0.003), but no significant difference was found in the femoral neck: -1.7% versus -2.8%, respectively (P=0.86). These differences between the study groups were still seen at 5 years: in the lumbar spine -5.8% versus -9.7% (P=0.008) and femoral neck -3.5% versus -5.1% (P=0.91). In conclusion, chemotherapy-induced ovarian failure in premenopausal women caused a temporary accelerated bone loss of the lumbar spine. Adjuvant clodronate treatment significantly reduced this bone loss. Two years after the termination of treatment, the bone loss was still significantly less in the clodronate group compared with the control group.
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Affiliation(s)
- L Vehmanen
- Department of Oncology, Helsinki University Central Hospital, Fin-00290, Huch, Finland
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97
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Abstract
Osteoporosis is a serious, debilitating and potentially fatal chronic disease which places a major burden on both the patient and the NHS. In order to tackle this growing problem successfully, it is essential that it is diagnosed in its early stages so that fractures can be prevented. Nurses in particular can make a big difference, as they are ideally placed to proactively identify those who may be at risk from osteoporosis. This article explains the essential role the nurse can play, highlights the risk factors and symptoms nurses should be looking out for, and provides a brief summary of all the management options available, so that nurses can make informed recommendation on the most appropriate treatment.
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Affiliation(s)
- A Wilson
- Hertfordshire Primary Care Research Network, (HertNet), Letchworth
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98
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Cortet B, Béra-Louville A, Gauthier P, Gauthier A, Marchandise X, Delcambre B. Comparative efficacy and safety study of etidronate and alendronate in postmenopausal osteoporosis. effect of adding hormone replacement therapy. Joint Bone Spine 2001; 68:410-5. [PMID: 11707007 DOI: 10.1016/s1297-319x(01)00297-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To compare the efficacy and safety of etidronate and alendronate in patients with postmenopausal osteoporosis and to assess the efficacy of either bisphosphonate in combination with hormone replacement therapy (HRT). PATIENTS AND METHODS In this pragmatic study, the main efficacy criterion was the mean annual change in bone mineral density (BMD). Patients who had a past or current history of etidronate or alendronate treatment for postmenopausal osteoporosis with at least 18 months follow-up and an evaluation in 1999 were eligible. Recruitment was in an outpatient clinic with a special focus on metabolic bone diseases. Osteoporosis was defined as at least one low-energy fracture or as a lumbar spine or femoral neck BMD decrease to at least 2.5 SD below the mean in young women. HRT was not an exclusion criterion provided treatment duration was longer than 1 year. Etidronate was given cyclically (14-day courses in a dosage of 400 mg/d separated by 76-day intervals with calcium and vitamin D supplementation) and alendronate was given daily in a dosage of 10 mg/d. RESULTS Of the 99 patients who met our inclusion criteria, 53 received etidronate (including 23 on HRT) and 46 alendronate (18 on HRT). Repeat BMD measurements were obtained in 88 patients, including 11 who stopped their bisphosphonate therapy within the first year of use because of adverse events. Lumbar spine BMD (mean +/- SD) increased significantly both in the etidronate group (+2.1% +/- 0.7%/year) and in the alendronate group (+5.3% +/- 0.9%/year). The increase was significantly greater with alendronate (P< 0.01). The lumbar spine BMD increase was largest in the patients on alendronate and HRT (+6.5% +/- 1.4%/year) and was smallest (and nonsignificant) in the patients on etidronate without HRT (+ 1.2% +/- 0.8%). Femoral neck BMD showed no significant changes in any group. In the intention-to-treat analysis, fractures occurred in 12 etidronate patients (22.6%) and six (13.0%) alendronate patients (nonsignificant). Adverse events requiring bisphosphonate discontinuation before the scheduled date of the follow-up BMD measurement occurred in one patient (1.9%) in the etidronate group (generalized osteomalacia) and in ten patients (21.7%) in the alendronate group (upper or lower gastrointestinal tract symptoms in six and four patients, respectively; P < 0.01). CONCLUSION Both etidronate and alendronate significantly increased lumbar BMD, but the effect was significantly more marked with alendronate. Conversely, adverse effects, most notably gastrointestinal symptoms, were more common with alendronate, so that premature treatment discontinuation because of adverse events were more common in the alendronate group. Both differences should be taken into account when selecting the best drug for a patient with postmenopausal osteoporosis.
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Affiliation(s)
- B Cortet
- Rheumatology Department, Hĵpital Roger-Salengro, CHRU Lille, France.
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99
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Shiota E, Tsuchiya K, Yamaoka K, Kawano O. Effect of intermittent cyclical treatment with etidronate disodium (HEBP) and calcium plus alphacalcidol in postmenopausal osteoporosis. J Orthop Sci 2001; 6:133-6. [PMID: 11484098 DOI: 10.1007/s007760100060] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2000] [Accepted: 10/18/2000] [Indexed: 02/09/2023]
Abstract
We evaluated intermittent cyclical treatment with etidronate disodium (HEBP) and calcium plus alphacalcidol in postmenopausal osteoporosis, with special reference to bone mineral density (BMD) and prevention of spinal fracture. The patients were 40 women, over 50 years of age, with lumbo-dorsal pain and low BMD (less than 0.70 g/cm(2)), measured by dual-energy X-ray absorptiometry (DXA). The patients were randomly assigned to two groups. The first group (HEBP) received 200 mg of HEBP per day for 2 weeks, followed by 2 g calcium lactate and 0.5 microg alphacalcidol per day for the next 10 weeks. This 12-week cycle was repeated eight times for 2 years. The second group (Ca. D) received 2 g calcium lactate and 0.5 microg alphacalcidol per day for 2 years. Lumbar BMD was measured before the treatment and every 6 months during the treatment until 24 months, and changes were evaluated. The number of fractured vertebrae was counted on X-ray films before treatment and at the final assessment. After 6 months of treatment, a significant and continuous increase in BMD was observed in the HEBP group. Moreover, the percentage of patients with new vertebral compression fractures in the HEBP group was one-tenth of that in the Ca. D group. These results suggest that intermittent cyclical treatment with HEBP and calcium plus alphacalcidol may be effective for increasing BMD and preventing fractures in postmenopausal osteoporosis.
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Affiliation(s)
- E Shiota
- Department of Orthopaedic Surgery,Chikushi Hospital, Fukuoka University, 377-1 Zokumyoin, Chikushino, Fukuoka 818-8502, Japan
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100
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Mashiba T, Turner CH, Hirano T, Forwood MR, Jacob DS, Johnston CC, Burr DB. Effects of high-dose etidronate treatment on microdamage accumulation and biomechanical properties in beagle bone before occurrence of spontaneous fractures. Bone 2001; 29:271-8. [PMID: 11557372 DOI: 10.1016/s8756-3282(01)00575-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We recently demonstrated that suppressed bone remodeling allows microdamage to accumulate and causes reductions in some mechanical properties. However, in our previous study, 1 year treatment with high-dose etidronate (EHDP) did not increase microdamage accumulation in most skeletal sites of dogs in spite of complete remodeling suppression and the occurrence of spontaneous fractures of ribs and/or thoracic spinous processes. This study evaluates the effects of EHDP on microdamage accumulation and biomechanical properties before fractures occur. Thirty-six female beagles, 1-2 years old, were treated daily for 7 months with subcutaneous injections of saline vehicle (CNT) or EHDP at 0.5 (E-low) or 5 mg/kg per day (E-high). After killing, bone mineral measurement, histomorphometry, microdamage analysis, and biomechanical testing were performed. EHDP treatment suppressed intracortical and trabecular remodeling by 60%-75% at the lower dose, and by 100% at the higher dose. Osteoid accumulation caused by a mineralization deficit occurred only in the E-high group, and this led to a reduction of mineralized bone mass. Microdamage accumulation increased significantly by two- to fivefold in the rib, lumbar vertebra, ilium, and thoracic spinous process in E-low, and by twofold in the lumbar vertebra and ilium in E-high. However, no significant increase in damage accumulation was observed in ribs or thoracic spinous processes in E-high where fractures occur following 12 months of treatment. Mechanical properties of lumbar vertebrae and thoracic spinous processes were reduced significantly in both E-low and E-high. These findings suggest that suppression of bone remodeling by EHDP allows microdamage accumulation, but that osteoid accumulation reduces production of microdamage.
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Affiliation(s)
- T Mashiba
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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