Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women

Hop rho iso-alpha acids, berberine, vitamin D3 and vitamin K1 favorably impact biomarkers of bone turnover in postmenopausal women in a 14-week trial

Osteoporosis is a major health issue facing postmenopausal women. Increased production of pro-inflammatory cytokines resulting from declining estrogen leads to increased bone resorption. Nutrition can have a positive impact on osteoporosis prevention and amelioration. The objective of this study was to investigate the impact of targeted phytochemicals and nutrients essential for bone health on bone turnover markers in healthy postmenopausal women. In this 14-week, single-blinded, 2-arm placebo-controlled pilot study, all women were instructed to consume a modified Mediterranean-style low-glycemic-load diet and to engage in limited aerobic exercise; 17 randomized to the placebo and 16 to the treatment arm (receiving 200 mg hop rho iso-alpha acids, 100 mg berberine sulfate trihydrate, 500 IU vitamin D(3) and 500 microg vitamin K(1), twice daily). Thirty-two women completed the study. Baseline nutrient intake did not differ between arms. At 14 weeks, the treatment arm exhibited an estimated 31% mean reduction (P = 0.02) in serum osteocalcin (a marker of bone turnover), whereas the placebo arm exhibited a 19% increase (P = 0.03) compared to baseline. Serum 25-hydroxyvitamin D (25(OH)D) increased by 13% (P = 0.24) in the treatment arm and decreased by 25% (P < 0.01) in the placebo arm. The between-arm differences for OC and 25(OH)D were statistically significant. Serum IGF-I was increased in both arms, but the increase was more significant in the treatment arm at 14 weeks (P < 0.01). Treatment with hop rho iso-alpha acids, berberine sulfate trihydrate, vitamin D(3) and vitamin K(1) produced a more favorable bone biomarker profile that supports a healthy bone metabolism.

Seven years' experience with alendronate in postmenopausal Japanese women with osteoporosis

A retrospective study was performed to evaluate the outcome of alendronate (ALN) treatment for seven years in postmenopausal Japanese women with osteoporosis. Forty-seven postmenopausal women with osteoporosis (mean age at baseline 65.7 years) treated with ALN for over seven years in our outpatient clinic were analyzed. Lumbar spine bone mineral density (BMD) was measured using dual energy X-ray absorptiometry, and urinary levels of cross-linked N-terminal telopeptides of type I collagen (NTX) and serum alkaline phosphatase (ALP) were monitored during the seven-year treatment period. Urinary NTX and serum ALP levels decreased (-48.2% at three months and -15.7% at seven years, respectively) and lumbar spine BMD increased (+12.8% at seven years) compared with baseline values. No serious adverse events were observed, including osteonecrosis of jaw, atypical femoral diaphysis fractures, or atrial fibrillation. To our knowledge, this is the first report of the outcome of ALN treatment for seven years in Japanese patients with osteoporosis. ALN successfully suppressed bone turnover and increased lumbar spine BMD from the baseline value over the course of the seven-year treatment period without causing any severe adverse events.

Gastrointestinal side effects in postmenopausal women using osteoporosis therapy: 1-year findings in the POSSIBLE US study

OBJECTIVE

To characterize gastrointestinal side effects (GI SEs) and its associations with medication discontinuation, health-related quality of life (HRQoL), and treatment) satisfaction in postmenopausal women prescribed osteoporosis (OP) therapies.

METHODS

Prospective Observational Scientific Study Investigating Bone Loss Experience (POSSIBLE US*) participants enrolled October 27, 2004 - January 25, 2007 and complete questionnaires for up to 3 years. GI SEs for women new to or stable on therapy at entry were characterized at 6 and 12 months. Adjusted odds of experiencing GI SEs; mean HRQoL and treatment satisfaction scores; and risk of discontinuing therapy for bisphosphonate (BP) versus non-BP users were compared with logistic and generalized linear models.

RESULTS

About 20% of women reported >or=1 GI SE at entry. GI SEs at month 6 were more common in BP than non-BP users (new: OR = 1.5, 95% CI: 1.2-2.0; stable: OR = 1.7, 95% CI: 1.3-2.1). Women new to OP therapy with GI SEs at month 6 had lower LS Mean HRQoL (OPAQ-SV Emotional Status: 72.3 vs. 78.2, p = 0.005) and treatment satisfaction scores (SEs: 71.4 vs. 82.9;

EFFICACY

58.6 vs. 65.6; Global: 55.0 vs. 64.4; all p <or= 0.02) than those without GI SEs. Women reporting any GI SE had higher therapy discontinuation than those without GI SEs (6-month OR = 1.39, 95% CI: 1.05-1.84; 12-month OR = 1.30, 95% CI: 1.03-1.63; both p <or= 0.03).

CONCLUSION

GI SEs were common among women on OP therapy, were more common in BP than non-BP users, and were associated with increased therapy discontinuation. Lower HRQoL and treatment satisfaction associated with GI SEs may influence medication discontinuation.

Combined vertebral fracture assessment and bone mineral density measurement: a patient-friendly new tool with an important impact on the Canadian Risk Fracture Classification

PURPOSE

Vertebral fractures often go unnoticed, while they constitute a significant risk factor for new fractures, independent of the bone density. Vertebral Fracture Assessment (VFA) is a new feature on DXA bone densitometry equipment. Our purpose was to determine the added value of VFA and its impact on the Canadian fracture risk classification using data from a Dutch academic cohort.

METHODS

All 958 consecutive patients (64% female, mean age 53 [20-94], mean weight 75 kg [32-150]) who underwent BMD measurement at the University Medical Center Groningen, The Netherlands also underwent VFA in the same session.

RESULTS

The prevalence of vertebral fractures was 26%. In 68% of these patients this fracture was unknown. The severity was "mild" (20%-25% height loss) in 43%, "moderate" (25%-35%) in 44% and "severe" (>35% height loss) in 13%. Even after excluding mild fractures, the prevalence of vertebral fractures was 17%. In the 28% with normal BMD the vertebral fracture prevalence was still 18%, in the 43% with osteopenia 23%, and in the 29% with osteoporosis 36%. The Canadian risk classification was "low fracture risk" in 68%, "moderate" in 19%, and "high" in 13%. Adding VFA altered the classification in 20% of the patients, to become 54%, 27%, and 19%, respectively.

CONCLUSIONS

VFA added to BMD is a patient friendly diagnostic tool with a high diagnostic yield, as it detected unknown vertebral fractures and altered diagnostic classification in approximately 1 out of every 5 patients. These results suggest that BMD plus VFA may become the new standard in osteoporosis testing.

A scoping review of strategies for the prevention of hip fracture in elderly nursing home residents

BACKGROUND

Elderly nursing home residents are at increased risk of hip fracture; however, the efficacy of fracture prevention strategies in this population is unclear.

OBJECTIVE

We performed a scoping review of randomized controlled trials of interventions tested in the long-term care (LTC) setting, examining hip fracture outcomes.

METHODS

We searched for citations in 6 respective electronic searches, supplemented by hand searches. Two reviewers independently reviewed all citations and full-text papers; consensus was achieved on final inclusion. Data was abstracted in duplicate.

FINDINGS

We reviewed 22,349 abstracts or citations and 949 full-text papers. Data from 20 trials were included: 7--vitamin D (n = 12,875 participants), 2--sunlight exposure (n = 522), 1--alendronate (n = 327), 1--fluoride (n = 460), 4--exercise or multimodal interventions (n = 8,165), and 5--hip protectors (n = 2,594). Vitamin D, particularly vitamin D(3) > or = 800 IU orally daily, reduced hip fracture risk. Hip protectors reduced hip fractures in included studies, although a recent large study not meeting inclusion criteria was negative. Fluoride and sunlight exposure did not significantly reduce hip fractures. Falls were reduced in three studies of exercise or multimodal interventions, with one study suggesting reduced hip fractures in a secondary analysis. A staff education and risk assessment strategy did not significantly reduce falls or hip fractures. In a study underpowered for fracture outcomes, alendronate did not significantly reduce hip fractures in LTC.

CONCLUSIONS

The intervention with the strongest evidence for reduction of hip fractures in LTC is Vitamin D supplementation; more research on other interventions is needed.

The role of microbial biofilms in osteonecrosis of the jaw associated with bisphosphonate therapy

Microbial biofilms have been observed and described in bone specimens of patients with bisphosphonate (BP)-associated osteonecrosis of the jaw (BONJ) and investigators are more recently suggesting that this condition essentially represents an osteomyelitis of the jaw clinically, with greater susceptibility in some patients on BP therapy. This article explains the role of microbial biofilms in BONJ and also discusses associated factors in the disease pathogenesis, which include BP effects on bone remodeling, anti-angiogenesis, matrix necrosis, microcracks, soft tissue toxicity, and inflammation and wound healing. Recent findings suggest a key role for microbial biofilms in the pathogenesis of BONJ; this has important therapeutic implications because biofilm organisms represent a clinical target for prevention and treatment efforts aimed at reducing the significant morbidity and costs associated with this condition.

Declining incidence of hip fractures and the extent of use of anti-osteoporotic therapy in Denmark 1997-2006

SUMMARY

The incidence of hip fractures in Denmark declined by about 20% from 1997 to 2006 in both men and women aged 60 and over. The decrease in hip fracture rates was much too large to be explained by the extent of anti-osteoporotic medication used in the country.

INTRODUCTION

The purpose of this study is to clarify (1) if hip fracture rates decline in Denmark despite low treatment rates and (2) if changes in age-specific rates could be explained by anti-osteoporotic medications.

METHODS

National registers were used to obtain incidence rates for hip fractures in men and women aged 60+ and aggregated national data on number of users of anti-osteoporotic medications for 1997-2006. The potential contribution of anti-osteoporotic treatment to prevented hip fractures was estimated.

RESULTS

Incidence rates declined by 20% in men and 22% in women. Use of specific anti-osteoporotic medications had increased from 1.8% in 60+-year-old women and 0.2% in 60+-year-old men to 7.3% and 1.3%, respectively. The decrease risk in men was nearly the same as in women, despite a six times lower treatment prevalence. The number of prevented hip fractures that could be attributed to therapy was 1.3% in men and 3.7% in women.

CONCLUSIONS

The decrease in hip fractures is much too large to be explained by the extent of anti-osteoporotic medication. Interestingly, the decrease in fracture rates also applied to men, despite much lower treatment rates. Potential explanations include smoking habits, obesity, national home visit programmes, improved general health and vitamin D supplementation.

Gastric and esophagus events before and during treatment of osteoporosis

Prior studies have indicated an excess risk of gastroduodenal ulcers and esophagus perforations with the use of bisphosphonates. However, little is known about the contribution of comorbid conditions and concomitant drug use on this risk. We studied the risk of esophagus and gastric events in patients on a wide range of drugs against osteoporosis both before and after initiation of these drugs. We studied a nationwide register-based cohort from Denmark with all users of drugs against osteoporosis between 1996 and 2006 (n = 103,562) as cases and three age- and sex-matched controls from the general population (n = 310,683). In a crude analysis, most drugs were already associated with an increased risk of esophagitis, esophageal ulcerations, or esophageal perforations or gastroduodenal ulcers before initiation of the drugs. Upon adjustment, this excess risk disappeared for most drugs except parathyroid hormone and its analogues, etidronate and clodronate. Only for etidronate, alendronate, and raloxifene were sufficient data present for events after initiation of the drugs, and for these, an increased risk was present for all events except gastroduodenal ulcers with raloxifene. Several drugs against osteoporosis are associated with an increased risk of esophagitis, esophageal ulcers, esophageal perforation, and gastroduodenal ulcers. However, the increase was already present before initiation of the drug for several types of drugs against osteoporosis. This points at an effect of the underlying condition being treated or comorbid conditions and drugs being provided in patients with osteoporosis, such as nonsteroidal anti-inflammatory drugs and corticosteroids.

Long-Term Alendronate Use Not without Consequences?

A previously unknown side effect of biphosphonate use is emerging. In a specific patient group on long term biphosphonate therapy stress femur fractures seem to occur. The typical presentation consists of prodromal pain in the affected leg and/or a discrete cortical thickening on the lateral side of the femur in conventional radiological examination or the presentation with a spontaneous transverse subtrochanteric femur with typical features. We present three cases of this stress fracture in patients on bisphosphonate therapy. One of these patients suffered a bilateral femur fracture of the same type. In our opinion, in patients on bisphosphonate therapy who present with a spontaneous femur fracture, seizing therapy is advisable. In bilateral cases preventive nailing should be considered.

Application of the National Osteoporosis Foundation Guidelines to postmenopausal women and men: the Framingham Osteoporosis Study

We applied the 2008 National Osteoporosis Foundation (NOF) Guidelines to Framingham Osteoporosis Study participants and found nearly one half of Caucasian postmenopausal women and one sixth of men aged 50 years and older would be recommended for osteoporosis treatment. Given the high proportion of persons recommended for treatment, NOF Guidelines may need to be re-evaluated with respect to budget impact.

INTRODUCTION

Little is known about the public health impact of the NOF Guidelines. Therefore, we determined the proportion of US Caucasians recommended for treatment of osteoporosis according to NOF Guidelines (2003 and 2008).

METHODS

One thousand nine hundred and forty-six postmenopausal women and 1,681 men aged > or =50 years from the Framingham Study with information on bone mineral density (1987-2001) were included. Information on clinical predictors was used to estimate the 10-year probability of hip and major osteoporotic fracture by FRAX (version 3.0).

RESULTS

Overall proportion of women meeting treatment criterion was less when the 2008 NOF Guidelines were applied (41.1%) compared with 2003 Guidelines (47.8%). The proportion of women aged <65 years meeting treatment criterion was much less when applying 2008 Guidelines (23.1% in 2003, 8.3% in 2008), whereas the proportion of women aged >75 years increased slightly (78.3% in 2003, 86.0% in 2008). Seventeen percent of men aged > or =50 years met treatment criterion (2.5% aged 50-64 years, 49.8% aged >75 years).

CONCLUSIONS

Nearly one half of Caucasian postmenopausal women and one sixth of men aged 50 years and older would be recommended for osteoporosis treatment according to 2008 NOF Guidelines. Given the high proportion of persons recommended for treatment, NOF Guidelines may need to be re-evaluated with respect to budget impact.

Protocol for the Osteoporosis Choice trial. A pilot randomized trial of a decision aid in primary care practice

Background

Bisphosphonates can reduce fracture risk in patients with osteoporosis, but many at-risk patients do not start or adhere to these medications. The aims of this study are to: (1) preliminarily evaluate the effect of an individualized 10-year osteoporotic fracture risk calculator and decision aid (OSTEOPOROSIS CHOICE) for postmenopausal women at risk for osteoporotic fractures; and (2) assess the feasibility and validity (i.e., absence of contamination) of patient-level randomization (vs. cluster randomization) in pilot trials of decision aid efficacy.

Methods/Design

This is a protocol for a parallel, 2-arm, randomized trial to compare an intervention group receiving OSTEOPOROSIS CHOICE to a control group receiving usual primary care. Postmenopausal women with bone mineral density T-scores of <-1.0, not receiving bisphosphonate therapy, and receiving care at participating primary care practices in and around Rochester, Minnesota, USA will be eligible to participate in the trial. We will measure the effect of OSTEOPOROSIS CHOICE on five outcomes: (a) patient knowledge regarding osteoporosis risk factors and treatment; (b) quality of the decision-making process for both the patient and clinician; (c) patient and clinician acceptability and satisfaction with the decision aid; (d) rate of bisphosphonate use and adherence, and (e) trial processes (e.g., ability to recruit participants, collect patient outcomes). To capture these outcomes, we will use patient and clinician surveys following each visit and video recordings of the clinical encounters. These video recordings will also allow us to determine the extent to which clinicians previously exposed to the decision aid were able to recreate elements of the decision aid with control patients (i.e., contamination). Pharmacy prescription profiles and follow-up phone interviews will assess medication start and adherence at 6 months.

Discussion

This pilot trial will provide evidence of feasibility, validity of patient randomization, and preliminary efficacy of a novel approach -- decision aids -- to improving medication adherence for postmenopausal women at risk of osteoporotic fractures. The results will inform the design of a larger trial that could provide more precise estimates of the efficacy of the decision aid.

Trial registration

Clinical Trials.gov Identifier: NCT00578981

Five-year alendronate treatment outcome in older postmenopausal Japanese women with osteoporosis or osteopenia and clinical risk factors for fractures

A retrospective study was conducted to evaluate the outcome of treatment with alendronate (ALN) for 5 years in postmenopausal Japanese women with an increased risk of fractures. Forty postmenopausal Japanese women with osteoporosis or osteopenia and clinical risk factors for fractures (mean age: 75.4 years) were analyzed; 33 patients were treated with alendronate and 7 were treated with alfacalcidol (ALF, controls) in an outpatient clinic run by general practitioners. The metacarpal bone mineral density (BMD) measured using a computed X-ray densitometer, urinary levels of cross-linked N-terminal telopeptides of type I collagen (NTX), and serum levels of alkaline phosphatase (ALP) were monitored during the 5-year treatment period. The urinary NTX and serum ALP levels decreased significantly in the ALN group, compared with the ALF group. The metacarpal BMD was sustained in the ALN group but decreased significantly in the ALF group; the difference between these two groups was also significant. The present study evaluated the outcome of treatment with ALN for 5 years in postmenopausal Japanese women with osteoporosis or osteopenia and clinical risk factors for fractures. ALN successfully suppressed bone turnover and sustained the metacarpal BMD over the 5-year period of treatment in postmenopausal Japanese women with an increased risk of fractures.

Bisphosphonates and atrial fibrillation: Bayesian meta-analyses of randomized controlled trials and observational studies

Background

Occurrence of atrial fibrillation (AF) amongst bisphosphonate users has been increasingly reported but results are conflicting. We performed a Bayesian meta-analysis to address the possible association between the occurrence of AF and bisphosphonate use and estimated the posterior probability of development of AF with bisphosphonate use.

Methods

Randomized controlled trials (RCTs) evaluating the efficacy and safety of bisphosphonates for treating and preventing osteoporosis, and observational studies investigating the incidence of AF amongst bisphosphonate users, were searched in electronic databases. We pooled the effect size with Bayesian meta-analysis for odds ratio (OR) and calculated its posterior probability of development of AF in bisphosphonate users for RCTs and observational studies, reported with the 95% credible interval (CI).

Results

Of 1751 potentially relevant citations initially retrieved, 4 RCTs and 2 reports of RCTs, and 3 observational studies were included for this meta-analysis. On pooling the RCTs, there was a non-significantly higher risk of overall (OR 1.184, 95% CI 0.837-1.656) and serious AF (OR 1.590, 95% CI 0.613-3.751) in bisphosphonate-treated patients. Combining data of observational studies also revealed a non-significantly higher risk of AF in bisphosphonate users (OR 1.251, 95% CI 0.980-1.732). Using Bayesian meta-analysis based on the effect size of observational studies as the prior, the posterior probability of OR>1.2 in the development of AF amongst bisphosphonate users in the RCTs was 0.484. Egger's regression demonstrated no notable publication bias in all the analyses.

Conclusion

The current meta-analysis revealed no evidence of a higher risk of AF associated with bisphosphonate use. Nevertheless, based on Bayesian meta-analysis with the effect size of the observational studies as the prior, the posterior probabilities of development of AF was found to be 0.484 if the risk of AF was estimated to be more than 20%. The results of the current meta-analysis thus offer clinicians the practical probability of development of AF in patients who take bisphosphonates for the treatment of bone loss and corticosteroid induced osteoporosis.

Bisphosphonate use in acute and chronic spinal cord injury: a systematic review

BACKGROUND/OBJECTIVE

Bone density loss occurs rapidly after traumatic spinal cord injury (SCI) and is associated with low-energy fractures below the level of injury, commonly occurring around the knee. Bisphosphonates have been tested as potential agents to prevent bone loss after SCI, but no guidelines exist for clinical use of bisphosphonates in these patients. The objective of this study was to systematically review and evaluate evidence quality in studies of bisphosphonate use in patients with post-treatment follow-up of sublesional bone mineral density.

METHODS

Literature search in MEDLINE/PubMed and ISI database using key words bisphosphonates, spinal cord injury, quadriplegia, paraplegia, and tetraplegia.

RESULTS

The search identified 6 experimental studies and 1 quasi-experimental study of bisphosphonate therapy in patients with acute and chronic SCI. The studies were small and of fair or poor quality, and none included fracture outcomes. Mild attenuation of bone density loss with acute administration of bisphosphonates after SCI was found at some measurement sites but was not always maintained during follow-up.

CONCLUSIONS

Data were insufficient to recommend routine use of bisphosphonates for fracture prevention in these patients. Current studies are limited by heterogeneity of patient populations and outcome measures. Uniform bone density measurement sites with rigorous quality control and compliance monitoring are needed to improve reliability of outcomes. Future studies should address specific populations (acute or chronic SCI) and should assess fracture outcomes.

Once-yearly zoledronic acid in hip fracture prevention

Osteoporosis is an escalating global problem. Hip fractures, the most catastrophic complication of osteoporosis, continue to cause significant mortality and morbidity despite increasing availability of effective preventative agents. Among these agents, oral bisphosphonates have been the first choice for the treatment and prevention of osteoporotic fractures. However, the use of oral bisphosphonates, especially in the older population, has been limited by their side effects and method of administration thus compromising their persistent use. The resultant low adherence by patients has undermined their full potential and has been associated with an increase in the incidence of fragility fractures. Recently, annual intravenous zoledronic acid (ZOL) has been approved for osteoporosis. Randomized controlled trials have demonstrated ZOL to be safe, have good tolerability and produce significant effect on bone mass and microarchitecture. Adherence has also been shown to be better with ZOL. Furthermore two large trials firmly demonstrated significant anti-osteoporotic effect (∼59% relative risk reduction of hip fractures) and mortality benefit (28% reduction in mortality) of ZOL in older persons with recent hip fractures. In this review, we report the current evidence on the use of ZOL for the prevention of hip fractures in the elderly. We also report the pharmacological characteristics and the advantages and disadvantages of ZOL in this particular group.

Management of osteoporosis among home health and long-term care patients with a prior fracture

Osteoporosis is a growing health concern as the number of senior adults continues to increase worldwide. Falls and fractures are very common among frail older adults requiring home health and long-term care. Preventative strategies for reducing falls have been identified and many therapies (both prescription and nonprescription) with proven efficacy for reducing fracture risk are available. However, many practitioners overlook the fact that a fragility fracture is diagnostic for osteoporosis even without knowledge of bone mineral density testing. As a result, osteoporosis is infrequently diagnosed and treated in the elderly after a fracture. Based on existing literature, we have developed an algorithm for the assessment and treatment of osteoporosis among persons with known prior fracture(s) living in long-term care facilities or receiving home health care based on the data available in the literature.

Estimates of the proportion of older white women who would be recommended for pharmacologic treatment by the new U.S. National Osteoporosis Foundation Guidelines

The new U.S. National Osteoporosis Foundation Clinician's Guide to Prevention and Treatment of Osteoporosis includes criteria for recommending pharmacologic treatment based on history of hip or vertebral fracture, femoral neck (FN), or spine BMD T-scores <or=-2.5 and presence of low bone mass at the FN or spine plus a 10-yr risk of hip fracture >or=3% or of major osteoporotic fracture >or=20%. The proportion of women who would be recommended for treatment by these guidelines is not known. We applied the NOF criteria for treatment to women participating in the Study of Osteoporotic Fractures (SOF). To determine how the SOF population differs from the general U.S. population of white women >or=65 yr of age, we compared women in SOF with women who participated in the National Health and Nutrition Examination Survey (NHANES) III on criteria included in the NOF treatment guidelines that were common to both cohorts. Compared with NHANES III, women in SOF had higher FN BMD and were younger. Application of NOF guidelines to SOF data estimated that at least 72% of U.S. white women >or=65 yr of age and 93% of those >or=75 yr of age would be recommended for drug treatment. Application of the new NOF Guidelines would result in recommending a very large proportion of white women in the United States for pharmacologic treatment of osteoporosis.

Nonvertebral fracture risk reduction with nitrogen-containing bisphosphonates

Osteoporosis is a systemic skeletal disorder characterized by low bone mass and microarchitectural deterioration of bone tissue resulting in compromised bone strength and an increased risk of fracture. There are two major fracture types: vertebral and nonvertebral. The latter include fractures involving the upper extremities, lower extremities (including hip), pelvis, and ribs. A recent review comparing the efficacy and safety of drugs approved by the US Food and Drug Administration for treatment of osteoporosis demonstrated that although all of the agents have been shown to reduce the incidence of radiographic vertebral fractures, they do not all reduce the incidence of nonvertebral fractures. This article summarizes the most currently available data relative to nonvertebral and hip fracture risk reduction for the N-containing bisphosphonates alendronate, ibandronate, risedronate, and zoledronic acid, and presents results of an analysis of comparative efficacy of these compounds using the technique of adjusted indirect comparisons.

CLINICAL NEWS

Clinical researchers have clashed over the safety of intensive glucose-lowering regimens designed to reduce cardiovascular risk in people with type 2 diabetes – leading to concerns that some patients might abandon treatment plans already agreed with their physicians.