Alendronate with calcium and vitamin D supplementation is safe and effective for the treatment of decreased bone mineral density in HIV

Continuous antiretroviral therapy decreases bone mineral density

OBJECTIVES

To assess the effects of antiretroviral therapy (ART) on bone mineral density (BMD) DESIGN: Randomized comparison of continuous ART (viral suppression group; VS) with intermittent ART (drug conservation group; DC) SETTING: Outpatient clinics in the United States, Australia, and Spain.

PARTICIPANTS

Participants in the Strategies for Management of Antiretroviral Therapy (SMART) Body Composition substudy.

MAIN OUTCOME MEASURES

Annual hip and spine BMD by dual-energy radiographic absorptiometry (DXA) and spine BMD by quantitative computed tomography (qCT).

METHODS

Comparisons were by intention-to-treat analysis, using longitudinal models for change in BMD. Risk factors for BMD loss were evaluated.

RESULTS

The 214 participants (median 44 years, 19% female participants, 73% on ART; median T-scores -0.5 total hip, -0.7 spine DXA, -0.9 spine qCT; 98 randomized to VS and 116 to DC) were followed for a mean 2.4 years. With continuous ART, BMD declined per year by 0.8% (hip), 0.4% (spine DXA), and 2.4% (spine qCT). BMD declined significantly less with intermittent ART. Estimated DC minus VS group differences in mean BMD change through follow-up were 1.4% [hip; 95% confidence interval (CI) 0.6-2.3; P = 0.002], 1.3% (spine DXA; 95% CI 0.1-2.4, P = 0.03), and 3.0% (spine qCT; 95% CI 0.8-5.2, P = 0.007). No consistent drug-specific association with BMD decline was found. In the parent study, 10 of 2753 participants in the VS group and two of 2720 in the DC group reported serious fractures (hazard ratio 4.9; 95% CI 1.1-22.5; P = 0.04).

CONCLUSION

Continuous ART is associated with decline in BMD and possibly more fractures relative to intermittent, CD4 cell count-guided ART.

HIV and the menopause

Dramatic improvement in the survival of the HIV population has occurred with the ascendance of highly active antiretroviral therapy (HAART). In the foreseeable future, HIV-infected women who acquired disease during the peak years of the epidemic are expected to survive to experience menopause and even years beyond. The HIV epidemic may be viewed as 'mature', as its earlier victims become part of the geriatric population. Research about the process of menopause in HIV-infected women and, conversely, about HIV infection in women undergoing menopause is currently limited. Existing research suggests that the process of menopause is affected by HIV infection, inasmuch as infected women appear to experience menopause at an earlier age, with greater symptomatology, and with different reproductive hormone profiles compared with HIV-uninfected women. HIV infection also appears to affect bone mineral density, cardiovascular disease and cognition, with some age-related interactions. Lifestyle and demographic factors have pervasive importance for both HIV infection and the menopause in women. This article reviews the current state of knowledge about the menopausal process in HIV-infected women, and the common conditions in postmenopausal women that are likely to be affected by HIV infection. Clinicians should appreciate the potential role of HIV infection in caring for menopause-aged women.

A double-blinded, randomized controlled trial of zoledronate therapy for HIV-associated osteopenia and osteoporosis

OBJECTIVE

To evaluate the efficacy of a single dose of intravenous zoledronate for the treatment of HIV-associated osteopenia and osteoporosis.

DESIGN

A double-blinded, randomized, placebo-controlled, 12-month trial of 5 mg intravenous zoledronate dose to treat 30 HIV-infected men and women with osteopenia and osteoporosis.

METHODS

Following zoledronate or placebo infusions, participants were followed for 12 months on daily calcium and vitamin D supplements. Lumbar spine and hip bone density was assessed at baseline, 6 and 12 months. Biomarkers of bone metabolism were measured at baseline, 2 weeks, 3, 6, 9, and 12 months. Student's t-test and repeated measure analyses were used to evaluate bone density and bone marker changes over time.

RESULTS

In the 30 HIV-infected individuals [men (27) and women (3)] in the trial, median T-scores at entry were -1.7 for the lumbar spine and -1.4 for the hip. Median CD4 cell count was 461 cells/microl, 93% had HIV-RNA viral loads less than 400 copies/ml, and 97% were taking antiretroviral medications. Bone density measured either absolutely or as sex-adjusted T-scores significantly improved in zoledronate recipients as compared with minimal changes in those receiving placebo. Bone resorption markers significantly decreased over the study period in the zoledronate recipients as compared with placebo controls. No acute infusion reactions were detected, but one patient developed uveitis, a recognized complication of zoledronate, which responded to therapy.

CONCLUSION

In this small study, annual zoledronate appears to be a well tolerated and effective therapy for HIV-associated bone loss.

Bone health in HIV infection

INTRODUCTION

Osteoporosis is among the chronic problems emerging as the human immunodeficiency virus (HIV)-positive population ages.

SOURCES OF DATA

We reviewed the English language bibliography using Pubmed 2.0, Web of Science and Embase for relevant abstracts and articles.

AREAS OF AGREEMENT

The prevalence of low bone mineral density (BMD) and fracture is increased in the HIV-positive population.

AREAS OF CONTROVERSY

The pathogenesis is multifactorial; there is some evidence that HIV infection is an independent risk factor and that highly active antiretroviral therapy has adverse skeletal effects.

GROWING POINTS

Physicians should routinely review the bone health of all HIV patients.

AREAS TIMELY FOR DEVELOPING RESEARCH

More studies of the mechanisms of bone loss, the skeletal effects of antiretroviral therapy and the therapeutic outcome of bone-protective therapy in HIV-positive individuals are needed.

Gynecologic issues in the HIV-infected woman

In this article, gynecologic conditions of increased importance in the HIV-infected woman are discussed. Women living with HIV may have an increase in menstrual disorders, lower genital tract neoplasias, gynecologic surgery, and sexually transmitted infections. The literature relevant to choosing a method of contraception for HIV-positive women is also discussed. With the advent of HAART, seropositive women are now facing issues around longevity, such as menopause and disorders of bone mineral density, as well as those associated with fertility.

The aging of the HIV epidemic

Since the advent of highly active antiretroviral therapy, life expectancies for persons with HIV infection are similar to those for uninfected people. A growing proportion of HIV-infected individuals are now over the age of 50. We are also seeing an increase in the incidence of HIV infection in older adults. To meet the challenges of the ongoing HIV epidemic, prevention efforts should include a focus on older adults. Also, HIV care providers must address the many comorbidities that are common in the aging population. Additional research will clarify how the processes of aging and HIV infection overlap and interact. This review addresses many of these important considerations.

Valid treatment options for osteoporosis and osteopenia in HIV-infected persons

OBJECTIVE

To review clinical data on bone ossification agents that may be considered for use in the treatment of osteoporosis and osteopenia in HIV-infected patients.

DATA SOURCES

A literature search was performed using MEDLINE (1950-January 2008), EMBASE, PubMed, and abstracts from major HIV conferences (February 2001-October 2007). These searches were limited to human data published in English and used the key words bisphosphonates, calcitonin, raloxifene, teriparatide, HAART, osteopenia, osteoporosis, and HIV/AIDS. Additional articles were retrieved from citations of selected references.

STUDY SELECTION AND DATA EXTRACTION

Relevant information on the pharmacology, pharmacokinetics, safety, and efficacy of available treatment with hormonal and nonhormonal agents was selected. Greater emphasis was placed on randomized clinical trials than on retrospective studies.

DATA SYNTHESIS

Osteoporosis in HIV-infected persons is at least as prevalent as in postmenopausal women, yet this population is not listed in primary care guidelines as one that should be considered for screening. In addition to bisphosphonates, calcitonin, raloxifene, and teriparatide are used to treat bone disorders. Three clinical trials to date have evaluated the use of a bisphosphonate in HIV-infected persons. The trials showed a marked increase in bone mineral density in patients taking alendronate versus those in the control groups (with/without calcium, exercise, and/or vitamin D in 1 or both arms). Dosing restrictions complicate the use of these agents; diet, exercise, and calcium supplementation remain the foremost recommended strategies to prevent bone loss. The use of estrogen, testosterone, calcitonin, and teriparatide is less studied in HIV-positive patients, but may be considered in select cases. There are some investigational drugs and agents not available in the US; however, there are not enough data to support their use.

CONCLUSIONS

Alendronate appears to be a promising treatment option for HIV-infected patients with osteoporosis and osteopenia. Further research is required to determine the safety and efficacy of other available drugs. Until additional information is provided, and with available knowledge on the metabolism profiles of antiretroviral and bone ossification agents, alendronate appears to be the preferred agent to use in this population.