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Händel MN, Cardoso I, von Bülow C, Rohde JF, Ussing A, Nielsen SM, Christensen R, Body JJ, Brandi ML, Diez-Perez A, Hadji P, Javaid MK, Lems WF, Nogues X, Roux C, Minisola S, Kurth A, Thomas T, Prieto-Alhambra D, Ferrari SL, Langdahl B, Abrahamsen B. Fracture risk reduction and safety by osteoporosis treatment compared with placebo or active comparator in postmenopausal women: systematic review, network meta-analysis, and meta-regression analysis of randomised clinical trials. BMJ 2023; 381:e068033. [PMID: 37130601 PMCID: PMC10152340 DOI: 10.1136/bmj-2021-068033] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVE To review the comparative effectiveness of osteoporosis treatments, including the bone anabolic agents, abaloparatide and romosozumab, on reducing the risk of fractures in postmenopausal women, and to characterise the effect of antiosteoporosis drug treatments on the risk of fractures according to baseline risk factors. DESIGN Systematic review, network meta-analysis, and meta-regression analysis of randomised clinical trials. DATA SOURCES Medline, Embase, and Cochrane Library to identify randomised controlled trials published between 1 January 1996 and 24 November 2021 that examined the effect of bisphosphonates, denosumab, selective oestrogen receptor modulators, parathyroid hormone receptor agonists, and romosozumab compared with placebo or active comparator. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials that included non-Asian postmenopausal women with no restriction on age, when interventions looked at bone quality in a broad perspective. The primary outcome was clinical fractures. Secondary outcomes were vertebral, non-vertebral, hip, and major osteoporotic fractures, all cause mortality, adverse events, and serious cardiovascular adverse events. RESULTS The results were based on 69 trials (>80 000 patients). For clinical fractures, synthesis of the results showed a protective effect of bisphosphonates, parathyroid hormone receptor agonists, and romosozumab compared with placebo. Compared with parathyroid hormone receptor agonists, bisphosphonates were less effective in reducing clinical fractures (odds ratio 1.49, 95% confidence interval 1.12 to 2.00). Compared with parathyroid hormone receptor agonists and romosozumab, denosumab was less effective in reducing clinical fractures (odds ratio 1.85, 1.18 to 2.92 for denosumab v parathyroid hormone receptor agonists and 1.56, 1.02 to 2.39 for denosumab v romosozumab). An effect of all treatments on vertebral fractures compared with placebo was found. In the active treatment comparisons, denosumab, parathyroid hormone receptor agonists, and romosozumab were more effective than oral bisphosphonates in preventing vertebral fractures. The effect of all treatments was unaffected by baseline risk indicators, except for antiresorptive treatments that showed a greater reduction of clinical fractures compared with placebo with increasing mean age (number of studies=17; β=0.98, 95% confidence interval 0.96 to 0.99). No harm outcomes were seen. The certainty in the effect estimates was moderate to low for all individual outcomes, mainly because of limitations in reporting, nominally indicating a serious risk of bias and imprecision. CONCLUSIONS The evidence indicated a benefit of a range of treatments for osteoporosis in postmenopausal women for clinical and vertebral fractures. Bone anabolic treatments were more effective than bisphosphonates in the prevention of clinical and vertebral fractures, irrespective of baseline risk indicators. Hence this analysis provided no clinical evidence for restricting the use of anabolic treatment to patients with a very high risk of fractures. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019128391.
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Affiliation(s)
- Mina Nicole Händel
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
- Department of Clinical Research, Odense Patient Data Explorative Network, University of Southern Denmark, Odense, Denmark
| | - Isabel Cardoso
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
| | - Cecilie von Bülow
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
- Occupational Science, User Perspectives and Community-Based Interventions, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Jeanett Friis Rohde
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
| | - Anja Ussing
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
| | - Sabrina Mai Nielsen
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Robin Christensen
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Adolfo Diez-Perez
- Department of Internal Medicine, Institut Hospital del Mar of Medical Investigation, Autonomous University of Barcelona and CIBERFES (Frailty and Healthy Aging Research Network), Instituto Carlos III, Barcelona, Spain
| | - Peyman Hadji
- Frankfurt Centre of Bone Health, Frankfurt and Philipps-University of Marburg, Marburg, Germany
| | - Muhammad Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Xavier Nogues
- IMIM (Hospital del Mar Medical Research Institute), Parc de Salut Mar, Pompeu Fabra University, Barcelona, Spain
| | - Christian Roux
- INSERM U 1153, Hospital Paris-Centre, University of Paris, Paris, France
| | - Salvatore Minisola
- Department of Clinical, Internal, Anaesthesiologic, and Cardiovascular Sciences, Rome University, Rome, Italy
| | - Andreas Kurth
- Department of Orthopaedic and Trauma Surgery, Marienhaus Klinikum Mainz, Major Teaching Hospital, University Medicine Mainz, Mainz, Germany
| | - Thierry Thomas
- Université Jean Monnet Saint-Étienne, CHU de Saint-Etienne, Rheumatology Department, INSERM U1059, F-42023, Saint-Etienne, France
| | - Daniel Prieto-Alhambra
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Bente Langdahl
- Departments of Clinical Medicine and of Endocrinology and Internal Medicine, Aarhus University, Aarhus, Denmark
| | - Bo Abrahamsen
- Department of Clinical Research, Odense Patient Data Explorative Network, University of Southern Denmark, Odense, Denmark
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
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Comparative efficacy and safety of pharmacological interventions for osteoporosis in postmenopausal women: a network meta-analysis (Chongqing, China). Menopause 2020; 26:929-939. [PMID: 31021904 DOI: 10.1097/gme.0000000000001321] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to assess the comparative effectiveness and safety of different pharmacological agents, including abaloparatide and romosozumab, for treatment of osteoporosis in postmenopausal women. METHODS We searched PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Google Scholar for relevant randomized controlled trials published up to July 16, 2018. After study selection according to the preplanned criteria, we performed data extraction and quality assessment. With statistical heterogeneity and inconsistency being examined, pairwise and network meta-analyses were conducted to synthesize risk ratio and 95% CI. Finally, we calculated the surface under the cumulative ranking curve to rank the interventions, and carried out three sensitivity analyses to assess the robustness of our main results. RESULTS Our searches yielded 2,584 records in total, of which 21 were finally included in quantitative synthesis and all of them were of high quality. Our 5 outcomes of interest involved a total of 13 interventions and 67,524 participants. For each outcome, the estimated τ values all were less than or equal to 0.0747, and the P values for test of consistency varied from 0.097 to 0.941, respectively, suggesting low heterogeneity and no inconsistency. Abaloparatide and teriparatide, without statistical difference between them, had a statistically lower risk of new vertebral or nonvertebral fractures than placebo, strontium ranelate, risedronate, raloxifene, lasofoxifene (0.25 mg/d), lasofoxifene (0.5 mg/d), denosumab, and alendronate. Zoledronic acid and romosozumab, without statistical difference between them, were significantly more efficacious than placebo, risedronate, and alendronate in preventing clinical fractures. Denosumab was statistically superior to placebo in preventing new vertebral and nonvertebral fractures, and to placebo, risedronate, and alendronate in preventing clinical fractures. For the outcomes of adverse events and serious adverse events, all of treatments were not statistically different from one another, except that zoledronic acid was statistically worse than placebo in terms of adverse events. Based on surface under the cumulative ranking curves, abaloparatide and teriparatide were two of the most effective treatments in preventing new vertebral and nonvertebral fractures; zoledronic acid and romosozumab were two of the most effective treatments in preventing clinical fractures, and denosumab and romosozumab were two of the best interventions for the outcome of adverse events. Three sensitivity analyses revealed the robustness of the main results. CONCLUSIONS Abaloparatide and teriparatide are most efficacious in preventing new vertebral and nonvertebral fractures in postmenopausal women with osteoporosis, whereas zoledronic acid and romosozumab are in preventing clinical fractures. Meanwhile, there is no statistical difference between abaloparatide, teriparatide or romosozumab, and placebo in terms of safety. Furthermore, in terms of adverse events, zoledronic acid is statistically worse than placebo, and two of the best interventions are denosumab and romosozumab, of which denosumab also reduces the risk of different kinds of fractures.
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Ding LL, Wen F, Wang H, Wang DH, Liu Q, Mo YX, Tan X, Qiu M, Hu JX. Osteoporosis drugs for prevention of clinical fracture in white postmenopausal women: a network meta-analysis of survival data. Osteoporos Int 2020; 31:961-971. [PMID: 32002571 DOI: 10.1007/s00198-019-05183-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/27/2019] [Indexed: 01/22/2023]
Abstract
UNLABELLED By Bayesian random effects network meta-analysis stratified by prevalent vertebral fracture (PVF), we conclude that different effective drugs should be used to prevent fragility fractures according to postmenopausal women with or without PVF and that there are two drugs (i.e., parathyroid hormone (1-84) and abaloparatide) less tolerated than placebo. INTRODUCTION No studies have compared various osteoporosis drugs in postmenopausal women (PMW) either with or without prevalent vertebral fracture (PVF). We aimed to compare them in the two different subgroups. METHODS We searched different databases to select relevant studies. We performed Bayesian random effects network meta-analysis to synthesize hazard ratio (HR) and 95% confidence interval (CI) for clinical fracture stratified by PVF and to synthesize risk ratio (RR) for tolerability and vertebral fracture. RESULTS We included 33 trials involving 79,144 PMW. In the PVF ≥ 50% subgroup, teriparatide (HR 0.39, 95% CI 0.28-0.57), romosozumab (HR 0.49, 95% CI 0.29-0.75), risedronate (HR 0.62, 95% CI 0.50-0.79), zoledronate (HR 0.67, 95% CI 0.47-0.96), and alendronate (HR 0.69, 95% CI 0.47-0.97) reduced clinical fracture risk. In the other subgroup, abaloparatide (HR 0.56, 95% CI 0.33-0.92), romosozumab (HR 0.67, 95% CI 0.47-0.95), and denosumab (HR 0.68, 95% CI 0.50-0.85) reduced clinical fracture risk. Five drugs reduced vertebral fracture risk in the PVF ≥ 50% subgroup whereas seven did in the other subgroup. All drugs did not increase withdrawal risk except for parathyroid hormone (1-84) (PTH) (RR 1.9, 95% CI 1.4-2.6) and abaloparatide (RR 1.6, 95% CI 1.2-2.3). CONCLUSION Different effective drugs should be used to prevent fragility fractures according to PMW with or without PVF, and romosozumab is the only one which can reduce clinical and vertebral fractures in both of the two populations. PTH and abaloparatide are less tolerated than placebo whereas the eight other drugs assessed in the study have the same tolerability as placebo.
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Affiliation(s)
- L-L Ding
- Department of Orthopedics, The People's Hospital of Rongchang District, Chongqing, 402460, China
| | - F Wen
- Department of Orthopedics, The People's Hospital of Rongchang District, Chongqing, 402460, China
| | - H Wang
- Department of Orthopedics, The People's Hospital of Rongchang District, Chongqing, 402460, China
| | - D-H Wang
- Department of Orthopedics, The People's Hospital of Rongchang District, Chongqing, 402460, China
| | - Q Liu
- Department of Orthopedics, Yueyang Second People's Hospital, Hunan Normal University, Yueyang, 414000, Hunan, China
| | - Y-X Mo
- Department of Gynecology, The People's Hospital of Rongchang District, Chongqing, 402460, China
| | - X Tan
- Department of Orthopedics, The People's Hospital of Rongchang District, Chongqing, 402460, China
| | - M Qiu
- Department of Gynecology, The People's Hospital of Rongchang District, Chongqing, 402460, China.
| | - J-X Hu
- Department of Orthopedics, Yueyang Second People's Hospital, Hunan Normal University, Yueyang, 414000, Hunan, China.
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Ding L, Hu J, Wang D, Liu Q, Mo Y, Tan X, Wen F. Efficacy and Safety of First- and Second-Line Drugs to Prevent Glucocorticoid-Induced Fractures. J Clin Endocrinol Metab 2020; 105:5568313. [PMID: 31513250 DOI: 10.1210/clinem/dgz023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2019] [Indexed: 12/20/2022]
Abstract
CONTEXT The evidence about benefits and harms of drugs for glucocorticoid (GC)-induced osteoporosis (GIOP) is limited, and the comparative efficacy and safety of first-line and second-line agents to prevent GC-induced (GI) fractures remains unclear. OBJECTIVE To assess the comparative clinical efficacy, safety, and tolerability of first-line and second-line agents in preventing GI fractures. DATA SOURCES We searched 3 different databases through March 5, 2019. STUDY SELECTION We included randomized controlled trials enrolling patients receiving long-term GCs and compared a first-line and second-line agent with one another and with placebo. DATA EXTRACTION Two reviewers independently extracted study and participant characteristics and outcome data. DATA SYNTHESIS We performed multivariate random-effects network meta-analyses including base, 3 subgroups, and 12 sensitivity analyses. We included 22 papers from 19 unique trials involving 4328 patients receiving GCs. Teriparatide (risk ratio [RR] 0.11, 95% confidence interval [CI] 0.03-0.47), denosumab (RR 0.21, 95% CI 0.09-0.49), and risedronate (RR 0.33, 95% CI 0.19-0.58) reduced the risk of GI vertebral fractures, and the former 2 were the most efficacious according to violin plots including the surface under the cumulative ranking curve values calculated by base and sensitivity analyses. Oral alendronate (RR 0.33, 95% CI 0.12-0.93) reduced this risk in patients receiving GCs with at least 7.5 mg/day, while intravenous ibandronate (RR 0.25, 95% CI 0.06-0.99) was efficacious for the primary prevention of GIOP. Six drugs were similar in terms of the 5 other outcomes. CONCLUSIONS In terms of clinical efficacy and safety, second-line teriparatide and denosumab pose a challenge to first-line oral bisphosphonates for prevention of GI fractures.
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Affiliation(s)
- Liangliang Ding
- Department of Orthopedics, The People's Hospital of Rongchang District, Chongqing, China
| | - Jinxi Hu
- Department of Orthopedics, Yueyang Second People's Hospital, Hunan Normal University, Yueyang, Hunan, China
| | - Dehua Wang
- Department of Orthopedics, The People's Hospital of Rongchang District, Chongqing, China
| | - Qi Liu
- Department of Orthopedics, Yueyang Second People's Hospital, Hunan Normal University, Yueyang, Hunan, China
| | - Yuxia Mo
- Department of Gynecology, The People's Hospital of Rongchang District, Chongqing, China
| | - Xiang Tan
- Department of Orthopedics, The People's Hospital of Rongchang District, Chongqing, China
| | - Fei Wen
- Department of Orthopedics, The People's Hospital of Rongchang District, Chongqing, China
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Chandran T, Venkatachalam I. Efficacy and safety of denosumab compared to bisphosphonates in improving bone strength in postmenopausal osteoporosis: a systematic review. Singapore Med J 2019; 60:364-378. [PMID: 30854568 DOI: 10.11622/smedj.2019028] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Osteoporosis is the main cause of fractures among women after menopause. This study aimed to evaluate the efficacy and safety of denosumab compared to bisphosphonates in treating postmenopausal osteoporosis. METHODS Databases including PubMed and the Cochrane Central Register of Controlled Trials were systematically searched for randomised controlled trials (RCTs) that directly compared denosumab and bisphosphonates. RCTs that studied both denosumab and bisphosphonates in postmenopausal women with osteoporosis and had a Jadad score ≥ 3 were included. RESULTS Nine studies were eligible for inclusion. They were further categorised into six cohort groups. All studies had denosumab with oral bisphosphonates as the active comparator. Four out of six cohort studies showed significant improvements in bone strength (p < 0.001) at the distal radius, tibia, total hip, femoral neck, lumbar spine and trochanter at 12 months for patients on denosumab compared to the bisphosphonate group. Serum C-telopeptide of cross-linked collagen, a bone turnover marker, was consistently lower in the denosumab group in all studies. There were no significant differences in hypocalcaemia, atypical fractures, fragility fractures, osteonecrosis of the jaw, all infections (including fever or influenza-like symptoms), gastrointestinal side effects or dermatological conditions in all studies, except for one that did not document side effects. CONCLUSION Denosumab can be used both as a first-line agent and an alternative to bisphosphonate in the treatment of postmenopausal osteoporosis. There is currently insufficient data to show that denosumab is not inferior to bisphosphonates in fracture prevention.
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Iqbal SM, Qamar I, Zhi C, Nida A, Aslam HM. Role of Bisphosphonate Therapy in Patients with Osteopenia: A Systemic Review. Cureus 2019; 11:e4146. [PMID: 31058029 PMCID: PMC6488345 DOI: 10.7759/cureus.4146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
By contrast to clinical trials exploring osteoporosis, clinical trials specifically designed for the osteopenic population are limited. Thus, less clinical data are available regarding treatment benefits and cost-effectiveness of treating a patient population with a bone mass density in the osteopenic range (T-score between -1 and -2.5). In this article, we aimed to highlight this high-risk population with a low bone mass density (BMD) susceptible to high fracture risk by reviewing different national and international guidelines for treating osteopenia. The cost-effectiveness of the therapy for the above-mentioned patient population is also discussed. By reviewing different clinical trials, we have specifically highlighted the role of bisphosphonate therapy for fracture risk reduction and increment in bone mineral density (BMD) in patients with osteopenia.
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Affiliation(s)
- Shumaila M Iqbal
- Internal Medicine, University at Buffalo / Sisters of Charity Hospital, Buffalo, USA
| | - Iqra Qamar
- Internal Medicine, Brigham and Women's Hospital, Boston, USA
| | - Cassandra Zhi
- Internal Medicine, Drexel University College of Medicine, Philadelphia, USA
| | - Anum Nida
- Internal Medicine, University at Buffalo / Sisters of Charity Hospital, Buffalo, USA
| | - Hafiz M Aslam
- Internal Medicine, Hackensack Meridian School of Medicine at Seton Hall University, Trenton, USA
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Farrier AJ, Sanchez Franco LC, Shoaib A, Gulati V, Johnson N, Uzoigwe CE, Choudhury MZ. New anti-resorptives and antibody mediated anti-resorptive therapy. Bone Joint J 2016; 98-B:160-5. [PMID: 26850419 DOI: 10.1302/0301-620x.98b2.36161] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED The ageing population and an increase in both the incidence and prevalence of cancer pose a healthcare challenge, some of which is borne by the orthopaedic community in the form of osteoporotic fractures and metastatic bone disease. In recent years there has been an increasing understanding of the pathways involved in bone metabolism relevant to osteoporosis and metastases in bone. Newer therapies may aid the management of these problems. One group of drugs, the antibody mediated anti-resorptive therapies (AMARTs) use antibodies to block bone resorption pathways. This review seeks to present a synopsis of the guidelines, pharmacology and potential pathophysiology of AMARTs and other new anti-resorptive drugs. We evaluate the literature relating to AMARTs and new anti-resorptives with special attention on those approved for use in clinical practice. Denosumab, a monoclonal antibody against Receptor Activator for Nuclear Factor Kappa-B Ligand. It is the first AMART approved by the National Institute for Health and Clinical Excellence and the US Food and Drug Administration. Other novel anti-resorptives awaiting approval for clinical use include Odanacatib. Denosumab is indicated for the treatment of osteoporosis and prevention of the complications of bone metastases. Recent evidence suggests, however, that denosumab may have an adverse event profile similar to bisphosphonates, including atypical femoral fractures. It is, therefore, essential that orthopaedic surgeons are conversant with these medications and their safe usage. TAKE HOME MESSAGE Denosumab has important orthopaedic indications and has been shown to significantly reduce patient morbidity in osteoporosis and metastatic bone disease.
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Affiliation(s)
| | | | | | - V Gulati
- Chelsea and Westminster Hospital, London, UK
| | - N Johnson
- University Hospitals of Leicester, Leicester, UK
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Umland EM, Karel L, Santoro N. Bazedoxifene and Conjugated Equine Estrogen: A Combination Product for the Management of Vasomotor Symptoms and Osteoporosis Prevention Associated with Menopause. Pharmacotherapy 2016; 36:548-61. [PMID: 27027527 DOI: 10.1002/phar.1749] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Bazedoxifene (BZA), a third-generation selective estrogen receptor modulator (SERM), has been combined with conjugated equine estrogen (CE) to create a tissue selective estrogen complex (TSEC) for the management of vasomotor symptoms (VMS) and the prevention of osteoporosis (OP) associated with menopause. Both of these outcomes of menopause contribute to significant negative effects on quality of life and increases in utilization of health care resources and dollars. Current treatment modalities for VMS and OP include estrogen therapy that requires the use of progestin in women who have a uterus to reduce the risk of endometrial hyperplasia and resultant cancer. However, progestin use results in nuisance bleeding as well as a further increased risk of breast cancer when combined with estrogen. And while SERMs can be used to prevent OP, their use alone has been shown to increase hot flashes. The combination of BZA and CE does not require progestin treatment with CE as the BZA component acts as an antagonist on endometrial tissue. The U.S. Food and Drug Administration approval of BZA/CE in 2013 was based on a series of five phase 3 studies known as the Selective estrogens, Menopause And Response to Therapy (SMART) trials. These trials, in their entirety, evaluated the impact of BZA/CE on VMS frequency and severity, bone mineral density, bone turnover markers, vaginal symptoms, lipid profiles, sleep, quality of life, breast density, and endometrial safety. The approved dose of BZA/CE is 20 mg BZA and 0.45 mg CE. Although this TSEC manages VMS while opposing breast and endometrial proliferation, preventing bone resorption, and improving lipid profiles, long-term experience with BZA/CE is currently lacking.
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Affiliation(s)
- Elena M Umland
- Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Lauren Karel
- Department of Pharmacy, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
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Fadda V, Maratea D, Trippoli S, Messori A. Gastrointestinal and renal side effects of bisphosphonates: differentiating between no proof of difference and proof of no difference. J Endocrinol Invest 2015; 38:189-92. [PMID: 25412945 DOI: 10.1007/s40618-014-0211-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 11/10/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND This study was aimed at comparing the safety of bisphosphonates in women with osteoporosis by application of equivalence testing. METHODS Gastrointestinal and renal side effects were evaluated based on information published in randomized controlled trials. RESULTS The data on gastrointestinal side effects (47 trials) indicated that alendronate, risedronate etidronate, and zolendronate have similar rates of the adverse effects; application of Bayesian network meta-analysis showed that equivalence was demonstrated according to margins around ±10%. The data on renal safety were more sparse and suffered from the use of different outcome measures; hence, a single trial could be evaluated. This trial showed a similar effect of alendronate and risedronate on renal function at 12 months; equivalence was based on differences between the two agents in renal function with margins of less than ±10.4 ml/min. CONCLUSION Our study provided quantitative information to determine to what extent bisphosphonates can be considered equivalent in terms of gastrointestinal and renal side effects.
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Affiliation(s)
- V Fadda
- HTA unit, Area Vasta Centro Toscana, Regional Health System, Via San Salvi 12, 50100, Florence, Italy
| | - D Maratea
- HTA unit, Area Vasta Centro Toscana, Regional Health System, Via San Salvi 12, 50100, Florence, Italy
| | - S Trippoli
- HTA unit, Area Vasta Centro Toscana, Regional Health System, Via San Salvi 12, 50100, Florence, Italy
| | - A Messori
- HTA unit, Area Vasta Centro Toscana, Regional Health System, Via San Salvi 12, 50100, Florence, Italy.
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Messori A, Fadda V, Maratea D, Trippoli S, Gatto R, De Rosa M, Marinai C. Biological drugs for the treatment of rheumatoid arthritis by the subcutaneous route: interpreting efficacy data to assess statistical equivalence. Ther Adv Musculoskelet Dis 2014; 6:207-16. [PMID: 25435923 DOI: 10.1177/1759720x14554792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND No equivalence analysis has yet been conducted on the effectiveness of biologics in rheumatoid arthritis. Equivalence testing has a specific scientific interest, but can also be useful for deciding whether acquisition tenders are feasible for the pharmacological agents being compared. METHODS Our search covered the literature up to August 2014. Our methodology was a combination of standard pairwise meta-analysis, Bayesian network meta-analysis and equivalence testing. The agents examined for their potential equivalence were etanercept, adalimumab, golimumab, certolizumab, and tocilizumab, each in combination with methotrexate (MTX). The reference treatment was MTX monotherapy. The endpoint was ACR50 achievement at 12 months. Odds ratio was the outcome measure. The equivalence margins were established by analyzing the statistical power data of the trials. RESULTS Our search identified seven randomized controlled trials (2846 patients). No study was retrieved for tocilizumab, and so only four biologics were evaluable. The equivalence range was set at odds ratio from 0.56 to 1.78. There were 10 head-to-head comparisons (4 direct, 6 indirect). Bayesian network meta-analysis estimated the odds ratio (with 90% credible intervals) for each of these comparisons. Between-trial heterogeneity was marked. According to our results, all credible intervals of the 10 comparisons were wide and none of them satisfied the equivalence criterion. A superiority finding was confirmed for the treatment with MTX plus adalimumab or certolizumab in comparison with MTX monotherapy, but not for the other two biologics. CONCLUSION Our results indicate that these four biologics improved the rates of ACR50 achievement, but there was an evident between-study heterogeneity. The head-to-head indirect comparisons between individual biologics showed no significant difference, but failed to demonstrate the proof of no difference (i.e. equivalence). This body of evidence presently precludes any option of undertaking competitive tenderings for the procurement of these agents.
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Affiliation(s)
- Andrea Messori
- HTA Unit, Area Vasta Centro Toscana, Regional Health System, Via San Salvi 12, 50100 Firenze, Italy
| | - Valeria Fadda
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
| | - Dario Maratea
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
| | - Sabrina Trippoli
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
| | - Roberta Gatto
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
| | - Mauro De Rosa
- President, SIFACT, Italian Society for Clinical Pharmacy and Therapeutics, Milano, Italy
| | - Claudio Marinai
- Department of Pharmaceutical Logistics, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
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