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Li YY, Gao LJ, Zhang YX, Liu SJ, Cheng S, Liu YP, Jia CX. Bisphosphonates and risk of cancers: a systematic review and meta-analysis. Br J Cancer 2020; 123:1570-1581. [PMID: 32901134 PMCID: PMC7652831 DOI: 10.1038/s41416-020-01043-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 07/28/2020] [Accepted: 08/14/2020] [Indexed: 01/02/2023] Open
Abstract
Background It is unclear whether bisphosphonates are associated with risk of cancers. Therefore, this meta-analysis aimed to evaluate the effect of bisphosphonates on overall cancers. Methods A search in Pubmed, Embase, Cochrane Library and Web of Science databases was conducted, from the inception date of each resource to September 26, 2019. The summarised effect estimates with 95% CIs were calculated using a random-effect model. Heterogeneity and publication bias were explored. Results Thirty-four articles were included in this study (4,508,261 participants; 403,196 cases). The results revealed that bisphosphonates significantly decreased the risk of colorectal cancer (RR = 0.89, 95% CI: 0.81–0.98), breast cancer (RR = 0.87, 95% CI: 0.82–0.93) and endometrial cancer (RR = 0.75, 95% CI: 0.61–0.94), but no significant association was observed in all-cause cancer. Furthermore, nitrogen-containing bisphosphonates only had protective effects both on breast cancer (RR = 0.94, 95% CI: 0.90–0.99) and endometrial cancer (RR = 0.70, 95% CI: 0.54–0.92). Non-nitrogen-containing bisphosphonates tended to increase the risk of liver cancer (RR = 2.14, 95% CI: 1.23–3.72) and pancreas cancer (RR = 1.75, 95% CI: 1.32–2.33). Conclusion Bisphosphonates are significantly associated with risk reduction of colorectal, breast and endometrial cancer, especially nitrogen-containing bisphosphonates. It should be noted that non-nitrogen-containing bisphosphonates might increase the risk of liver and pancreas cancer. Large prospective cohort studies are needed to find the causal association between bisphosphonates and risk of cancers.
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Affiliation(s)
- Yuan-Yuan Li
- Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Li-Jie Gao
- Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yu-Xue Zhang
- Department of Preventive Medicine, Public Health School, Harbin Medical University, Harbin, China
| | - Shu-Juan Liu
- Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Shuo Cheng
- Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yu-Peng Liu
- Department of Preventive Medicine, School of Public Health and Management, Wenzhou Medical University, Wenzhou, China.
| | - Cun-Xian Jia
- Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China.
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Jiang Y, Fu Y, Xing XP, Li M, Wang O, Xia WB, Meng XW. Zoledronic acid-induced hepatotoxicity relieved after subsequent infusions in a Chinese woman with glucocorticoid-induced osteoporosis. Eur J Med Res 2015; 20:68. [PMID: 26297149 PMCID: PMC4546306 DOI: 10.1186/s40001-015-0161-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 08/11/2015] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Zoledronic acid (ZOL) is widely used for treatment of glucocorticoid-induced osteoporosis. The most common adverse effects of ZOL treatment are post-dose symptoms. ZOL-induced hepatotoxicity has very rarely been reported. CASE REPORT Here, we described a 50-year-old Chinese woman who had vertebral fractures and severe back pain after glucocorticoid therapy for Behcet disease for 13 years. Three days after ZOL 5 mg infusion in April 2012, serum alanine aminotransferase (ALT), aspartate aminotransferase (AST) and gamma-glutamyltransferase (GGT) levels increased by 7.7, 4.9 and 3.0 times, respectively, compared with pre-treatment values. Liver protective agents were administered per os. Her hepatic enzyme levels returned to nearly normal range 9 days post-infusion. In the subsequent ZOL infusion with 1 year interval, serum ALT, AST and GGT levels increased slightly after the second infusion and were sustained to be normal after the third infusion. Her post-dose symptoms alleviated in the meantime. CONCLUSIONS Hepatotoxicity due to ZOL therapy is a rare, but possible adverse effect which may be relieved after subsequent infusions.
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Affiliation(s)
- Yan Jiang
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 100730, Beijing, China
| | - Yong Fu
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 100730, Beijing, China
| | - Xiao-ping Xing
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 100730, Beijing, China
| | - Mei Li
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 100730, Beijing, China
| | - Ou Wang
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 100730, Beijing, China
| | - Wei-bo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 100730, Beijing, China.
| | - Xun-wu Meng
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 100730, Beijing, China
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Goossens N, Spahr L, Rubbia-Brandt L. Severe immune-mediated drug-induced liver injury linked to ibandronate: a case report. J Hepatol 2013; 59:1139-42. [PMID: 23770145 DOI: 10.1016/j.jhep.2013.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 06/04/2013] [Accepted: 06/05/2013] [Indexed: 12/19/2022]
Abstract
Ibandronate is a widely used bisphosphonate with no previously well documented hepatotoxicity. We report the first case of ibandronate-related hepatotoxicity and, to our knowledge, the first case of immune-mediated drug-induced liver injury (DILI) related to bisphosphonates.
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Affiliation(s)
- Nicolas Goossens
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland.
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Abstract
Drugs in the bisphosphonate class are the most commonly prescribed therapeutic agents for the treatment of osteoporosis. Prospective, randomized, placebo-controlled clinical trials have demonstrated efficacy in reducing fracture risk, with favourable safety profiles, in women with postmenopausal osteoporosis. However, long-term use in clinical practice has been associated with reports of undesirable events not previously recognized. These have included gastrointestinal intolerance, osteonecrosis of the jaw, atypical femur fractures, oesophageal cancer, atrial fibrillation and chronic musculoskeletal pain. Physicians must be alert to newly recognized safety concerns, understand the level of evidence supporting them and be able to effectively communicate the balance of expected benefit and potential risk to patients. Usually, post-marketing adverse events are first presented as case reports or observational studies with variable levels of supporting evidence for plausibility, pathophysiology and causality. Widespread coverage in the news media, which can be alarming to patients and their physicians, may not present a balanced view of the proven benefits, the uncertain risks of therapy and the relative magnitude of these events. There may be confusion about the risks associated with bisphosphonate use for the treatment of osteoporosis versus treatment of other conditions, such as cancer, which typically involves a very different patient population and different doses or frequency of drug administration. Often reports of possible adverse events do not provide information on the number of patients exposed to the drug in proportion to the reported adverse event, or do not describe the incidence of the adverse event in a comparator population not exposed to the drug. Gastrointestinal intolerance with oral bisphosphonates, and hypocalcaemia, acute phase reactions and renal toxicity with intravenous bisphosphonates are characterized by biological plausibility and demonstration of causality. Safety concerns with uncertain biological plausibility and unproven causality include osteonecrosis of the jaw, atypical femur fractures, oesophageal cancer and ocular inflammation. Suspected concerns that are unlikely to be causally related include atrial fibrillation and hepatotoxicity. When making the decision to use a bisphosphonate for the treatment of osteoporosis, the balance between benefit and potential risks according to clinical circumstances of each patient should be considered.
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Affiliation(s)
- E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, New Mexico 87106, USA.
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5
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Thenappan T, Goel A, Marsboom G, Fang YH, Toth PT, Zhang HJ, Kajimoto H, Hong Z, Paul J, Wietholt C, Pogoriler J, Piao L, Rehman J, Archer SL. A central role for CD68(+) macrophages in hepatopulmonary syndrome. Reversal by macrophage depletion. Am J Respir Crit Care Med 2011; 183:1080-91. [PMID: 21148721 PMCID: PMC3086745 DOI: 10.1164/rccm.201008-1303oc] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 11/21/2010] [Indexed: 12/16/2022] Open
Abstract
RATIONALE The etiology of hepatopulmonary syndrome (HPS), a common complication of cirrhosis, is unknown. Inflammation and macrophage accumulation occur in HPS; however, their importance is unclear. Common bile duct ligation (CBDL) creates an accepted model of HPS, allowing us to investigate the cause of HPS. OBJECTIVES We hypothesized that macrophages are central to HPS and investigated the therapeutic potential of macrophage depletion. METHODS Hemodynamics, alveolar-arterial gradient, vascular reactivity, and histology were assessed in CBDL versus sham rats (n = 21 per group). The effects of plasma on smooth muscle cell proliferation and endothelial tube formation were measured. Macrophage depletion was used to prevent (gadolinium) or regress (clodronate) HPS. CD68(+) macrophages and capillary density were measured in the lungs of patients with cirrhosis versus control patients (n = 10 per group). MEASUREMENTS AND MAIN RESULTS CBDL increased cardiac output and alveolar-arterial gradient by causing capillary dilatation and arteriovenous malformations. Activated CD68(+)macrophages (nuclear factor-κB+) accumulated in HPS pulmonary arteries, drawn by elevated levels of plasma endotoxin and lung monocyte chemoattractant protein-1. These macrophages expressed inducible nitric oxide synthase, vascular endothelial growth factor, and platelet-derived growth factor. HPS plasma increased endothelial tube formation and pulmonary artery smooth muscle cell proliferation. Macrophage depletion prevented and reversed the histological and hemodynamic features of HPS. CBDL lungs demonstrated increased medial thickness and obstruction of small pulmonary arteries. Nitric oxide synthase inhibition unmasked exaggerated pulmonary vasoconstrictor responses in HPS. Patients with cirrhosis had increased pulmonary intravascular macrophage accumulation and capillary density. CONCLUSIONS HPS results from intravascular accumulation of CD68(+)macrophages. An occult proliferative vasculopathy may explain the occasional transition to portopulmonary hypertension. Macrophage depletion may have therapeutic potential in HPS.
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MESH Headings
- Animals
- Antigens, CD/immunology
- Antigens, CD/physiology
- Antigens, Differentiation, Myelomonocytic/immunology
- Antigens, Differentiation, Myelomonocytic/physiology
- Arteriovenous Malformations/etiology
- Arteriovenous Malformations/physiopathology
- Disease Models, Animal
- Extracellular Signal-Regulated MAP Kinases/metabolism
- Hepatopulmonary Syndrome/etiology
- Hepatopulmonary Syndrome/immunology
- Humans
- Lung/blood supply
- Lung/cytology
- Lung/immunology
- Macrophages/immunology
- Macrophages/physiology
- Male
- Muscle, Smooth, Vascular/physiopathology
- Nitric Oxide Synthase Type II/antagonists & inhibitors
- Nitric Oxide Synthase Type II/physiology
- Platelet-Derived Growth Factor/antagonists & inhibitors
- Platelet-Derived Growth Factor/physiology
- Rats
- Rats, Sprague-Dawley
- Signal Transduction/physiology
- Vascular Endothelial Growth Factor A/antagonists & inhibitors
- Vascular Endothelial Growth Factor A/physiology
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Affiliation(s)
- Thenappan Thenappan
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, Illinois; and The Cardiovascular Research Institute, Kurume University, Kurume, Fukuoka, Japan
| | - Ankush Goel
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, Illinois; and The Cardiovascular Research Institute, Kurume University, Kurume, Fukuoka, Japan
| | - Glenn Marsboom
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, Illinois; and The Cardiovascular Research Institute, Kurume University, Kurume, Fukuoka, Japan
| | - Yong-Hu Fang
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, Illinois; and The Cardiovascular Research Institute, Kurume University, Kurume, Fukuoka, Japan
| | - Peter T. Toth
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, Illinois; and The Cardiovascular Research Institute, Kurume University, Kurume, Fukuoka, Japan
| | - Hannah J. Zhang
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, Illinois; and The Cardiovascular Research Institute, Kurume University, Kurume, Fukuoka, Japan
| | - Hidemi Kajimoto
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, Illinois; and The Cardiovascular Research Institute, Kurume University, Kurume, Fukuoka, Japan
| | - Zhigang Hong
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, Illinois; and The Cardiovascular Research Institute, Kurume University, Kurume, Fukuoka, Japan
| | - Jonathan Paul
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, Illinois; and The Cardiovascular Research Institute, Kurume University, Kurume, Fukuoka, Japan
| | - Christian Wietholt
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, Illinois; and The Cardiovascular Research Institute, Kurume University, Kurume, Fukuoka, Japan
| | - Jennifer Pogoriler
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, Illinois; and The Cardiovascular Research Institute, Kurume University, Kurume, Fukuoka, Japan
| | - Lin Piao
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, Illinois; and The Cardiovascular Research Institute, Kurume University, Kurume, Fukuoka, Japan
| | - Jalees Rehman
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, Illinois; and The Cardiovascular Research Institute, Kurume University, Kurume, Fukuoka, Japan
| | - Stephen L. Archer
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, Illinois; and The Cardiovascular Research Institute, Kurume University, Kurume, Fukuoka, Japan
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Polyzos SA, Kountouras J, Anastasilakis AD, Litsas I, Kita M, Arsos G, Moralidis E, Terpos E. Zoledronic acid-induced transient hepatotoxicity in a patient effectively treated for Paget's disease of bone. Osteoporos Int 2011; 22:363-7. [PMID: 20407889 DOI: 10.1007/s00198-010-1230-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Accepted: 03/09/2010] [Indexed: 10/19/2022]
Abstract
Bisphosphonate (BP)-induced hepatotoxicity is very rare. There are only a few reports of liver injury after BP treatment, including aledronate and risedronate in postmenopausal osteoporosis patients. We describe hereby the case of a patient with Paget's disease of bone accompanied by nonalcoholic fatty liver disease (NAFLD) who developed transient hepatotoxicity after zoledronic acid (ZOL) treatment. NAFLD had been diagnosed 1 year before presentation, based on liver ultrasonography (US). One day after infusion, serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma-glutamyltransferase (GGT) were increased by 8.1, 6.7, and 6.7 times, respectively, compared with pretreatment values. Serum bilirubin remained normal. US revealed hepatic mild homogenous brightness without focal lesion of the liver or biliary ducts. Subsequent biochemical and serologic investigation did not reveal a specific liver or systematic disease. The patient remained asymptomatic, and ALT, AST, and GGT were normalized 7 days post-treatment. Although the mechanism by which ZOL may cause liver damage is elusive, physicians should be aware of this possible adverse effect and ZOL cautiously administered in NAFLD patients.
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Affiliation(s)
- S A Polyzos
- Second Medical Clinic, Medical School, Aristotle University of Thessaloniki, Ippokration Hospital, Thessaloniki, Greece.
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7
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Atula S, Powles T, Paterson A, McCloskey E, Nevalainen J, Kanis J. Extended safety profile of oral clodronate after long-term use in primary breast cancer patients. Drug Saf 2003; 26:661-71. [PMID: 12814333 DOI: 10.2165/00002018-200326090-00005] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Long-term safety and tolerance is paramount when treating women who are otherwise healthy after the primary adjuvant therapy of breast cancer. Efficacy and limited safety results of a large-scale clinical trial, using adjuvant oral clodronate to prevent bone metastases in primary breast cancer patients, have been reported previously, demonstrating a reduction in the rate of bone metastases during treatment. Here we present expanded safety and tolerability results for clodronate treatment from this trial (cut-off date extended from June 1997 to June 2000). STUDY DESIGN AND METHODS For this randomised, double-blind, placebocontrolled, multicentre study, patients were enrolled and randomised to receive oral clodronate (Bonefos) 1600 mg/day or placebo for 2 years. The total median treatment period plus follow-up was 5.5 years. Adverse events (AEs) and laboratory parameters were followed up regularly for the total study period. The 95% CIs were estimated for the difference in the rate of AEs between the treatment groups. PATIENTS A total of 1079 women with primary operable breast cancer were enrolled to the study; 538 received clodronate and 541 received placebo. RESULTS Overall incidence of AEs (96.5% of the patients) was the same in both treatment groups, although gastrointestinal disorders were significantly more frequent in the clodronate group during the total study period (66% vs 56.2%; 95% CI 4.0-15.6; p < 0.05). This was mainly due to an increase in non-severe diarrhoea beginning 3-4 months after treatment start. Serious AEs (SAEs) were reported for 39.4% of the patients receiving clodronate and 44.5% of those receiving placebo; no drug-related (clodronate or placebo) SAEs were identified. Clodronate significantly lowered mortality (98 deaths vs 129 deaths; hazard ratio 0.77; 95% CI 0.59-1.00; p = 0.047) reducing the risk of death over the total study period by 23%. AEs caused 58 early discontinuations (five drug-related events) in the clodronate group and 43 discontinuations (three drug-related events) in the placebo group. CONCLUSION These results indicate that in women with early breast cancer receiving adjuvant systemic therapy, oral clodronate for 2 years is generally well tolerated with no serious long-term sequelae, providing a safe, long-term therapy in the adjuvant setting.
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Abstract
The therapy of osteoporosis has made enormous strides in the last decade. There is now a range of interventions, each with its pros and cons. Calcium and vitamin D supplementation remain the foundation and have few safety issues. Bisphosphonates are widely used, though gastrointestinal tolerance is a problem with some oral preparations. Intravenous administration may circumvent this, although this introduces the smaller problem of acute phase reactions. The side effect profile of hormone replacement therapy (HRT) is still being delineated after 40 years of use, with substantial new information expected in the next few years. This will clarify its place in the medical management of the menopause. Raloxifene appears to have a superior safety profile to HRT, though its efficacy on bone may be less. While none of these options is suitable for everyone, the range of available therapies does mean that most patients can find an intervention that is effective and acceptable.
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Affiliation(s)
- Ian R Reid
- Department of Medicine, University of Auckland, Private Bag 92019, Auckland, New Zealand.
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McCloskey EV, Guest JF, Kanis JA. The clinical and cost considerations of bisphosphonates in preventing bone complications in patients with metastatic breast cancer or multiple myeloma. Drugs 2002; 61:1253-74. [PMID: 11511021 DOI: 10.2165/00003495-200161090-00003] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The bisphosphonates are potent inhibitors of osteoclast-mediated bone resorption and are now the treatment of choice for the management of hypercalcaemia of malignancy. The incidences of hypercalcaemia and other skeletal complications (bone pain, pathological fracture) remain high despite apparent responses to systemic therapy, with particularly high event rates in women with advanced skeletal metastases of breast cancer. This review focuses on studies addressing the long-term efficacy of bisphosphonates to reduce skeletal complications in breast cancer (5 studies) and multiple myeloma (4 studies), with particular reference to controlled studies of sufficient magnitude and duration to allow confidence in the estimation of efficacy. Bearing in mind the limitations of differences in trial design and the lack of direct studies comparing drugs, adequate exposure to a bisphosphonate reduces the incidence of skeletal complication by 30 to 40% in both breast cancer and multiple myeloma. Oral clondronate and intravenous pamidronate have similar efficacy in both diseases, but the duration of efficacy may differ between drugs. Both agents have shown intriguing survival benefits in subgroups of patients. The numbers needed to treat (NNT) to prevent a skeletal complication during one year are lowest in metastatic skeletal disease in breast cancer (NNT < 8) but also compare very favourably with other disease for patients with recurrent nonskeletal breast cancer or multiple myeloma (NNTs 7 to 31 depending on the complication to be prevented). Treatment costs of both breast cancer and multiple myloma are driven by inpatient and outpatient hospital visits so that bisphosphonate regimens should be developed that reduce both. Further research is required to determine if subgroups of patients can be better identified that will derive particular benefit, or perhaps no benefit at all, from bisphosphonate therapy. It is not known whether more potent bisphosphonates will deliver greater clinical efficacy in the future.
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Affiliation(s)
- E V McCloskey
- WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School, England.
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Serna Higuera CL, Villoria A, Gómez S, Moreno J, González A, Arribas M. Lesión hepatocelular inducida por alendronato. GASTROENTEROLOGIA Y HEPATOLOGIA 2001. [DOI: 10.1016/s0210-5705(01)70164-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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