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Fan Z, Khizar H, Lu J, Wang A, Xun T, Zhang X, Zhao H. From pill to pain: Alendronate-induced esophageal injury-A case report and review. JGH Open 2024; 8:e13080. [PMID: 38832136 PMCID: PMC11144282 DOI: 10.1002/jgh3.13080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 04/14/2024] [Accepted: 04/21/2024] [Indexed: 06/05/2024]
Abstract
Background Alendronate is used to treat Paget's bone disease, glucocorticoid-induced osteoporosis, and postmenopausal osteoporosis because it suppresses osteoclast activity to stop bone resorption. Case report We present an exceptional case of esophagitis caused by alendronate. Blood tests and other data were normal when the patient was taken to the hospital, but an endoscopic examination revealed significant esophageal redness, erosion, and ulceration, along with pseudomembrane. The patient was given medicine after receiving a diagnosis of alendronate pill-induced esophagitis based on the pathological findings. Conclusion This case report is a timely reminder of the importance of thorough pharmacovigilance, patient education, and smart therapeutic decision-making in the context of alendronate use. To properly treat and prevent problems with the esophagus caused by alendronate, additional research is required.
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Affiliation(s)
- Zhen Fan
- Department of GastroenterologyHangzhou First People's HospitalHangzhouChina
| | - Hayat Khizar
- Department of GastroenterologyHangzhou First People's HospitalHangzhouChina
| | - Jinjiao Lu
- The Fourth School of Clinical MedicineZhejiang Chinese Medical UniversityHangzhouChina
| | - Anhua Wang
- Department of GastroenterologyWenling First People's HospitalTaizhouChina
| | - Tong Xun
- Department of PathologyHangzhou First People's HospitalHangzhouChina
| | - Xiao Zhang
- Department of GastroenterologyHangzhou First People's HospitalHangzhouChina
| | - Hongfeng Zhao
- Department of Infection ControlHangzhou First People's HospitalHangzhouChina
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2
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Abstract
BACKGROUND Alendronate-induced esophagitis is a rare form of pill esophagitis. With the wide application of alendronate, the incidence of adverse events affecting the esophagus has increased; however, some endoscopists have a relatively insufficient understanding of the disease and cannot identify the cause in time.
CASE SUMMARY A woman presented with chest pain and she was diagnosed with alendronate-associated pill esophagitis by the medical history and typical endoscopic findings, thus removing the cause and avoiding further esophageal injury.
CONCLUSION Alendronate-associated pill esophagitis relies on prevention and timely diagnosis. A detailed medical history, typical endoscopic manifestations, and pathological features are helpful for early diagnosis.
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Affiliation(s)
- An-Hua Wang
- Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province, China
| | - Tong Xun
- Department of Pathology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Zhen Fan
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
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Choi D, Choi S, Chang J, Park SM. Exposure to oral bisphosphonates and risk of gastrointestinal cancer. Osteoporos Int 2020; 31:775-782. [PMID: 32034451 DOI: 10.1007/s00198-020-05327-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 01/30/2020] [Indexed: 01/09/2023]
Abstract
UNLABELLED Few studies have explored the association of oral bisphosphonate exposure and gastrointestinal cancer within Asian populations. In this study, we investigated 45,397 Korean women from the nationwide population-based cohort from 2002 to 2013. Oral bisphosphonate exposure did not appear to be associated with elevated or reduced risk for gastrointestinal cancer. INTRODUCTION While several studies suggested increased risk in upper gastrointestinal (GI) cancer or reduced risk in colorectal cancer upon bisphosphonate exposure, the association is less explored within Asian populations. We investigated the effect of oral bisphosphonate exposure on the risk of GI cancers within a nationwide population-based cohort. METHODS This study used two separate cohorts. The first cohort included 45,397 women aged 60 years or older from the National Health Insurance Service-Health Screening Cohort during 2002-2013. Participants were classified into bisphosphonate users and non-users based on drug exposure during 2002-2007, and followed-up from the index date of January 1, 2008. The second cohort included 25,665 newly diagnosed osteoporosis patients who started taking oral bisphosphonate during 2003-2008. After 4 years of drug exposure period, patients were separated into quartiles based on cumulative oral bisphosphonate exposure. Participants were followed-up until December 31, 2013 for GI cancer, stomach cancer, and colorectal cancer. Cox proportional hazard regression models were used to assess the hazard ratios (HRs) and 95% confidence intervals (CIs) for the cancer risks. RESULTS Compared to bisphosphonate non-users, no significant risk difference was observed among bisphosphonate users on GI (HR 1.06; 95% CI 0.87-1.28), stomach (HR 1.11; 95% CI 0.85-1.47) and colorectal cancers (HR 1.04; 95% CI 0.79-1.37). Among bisphosphonate users, increasing doses of bisphosphonate exposure was not associated with elevated or reduced risk for GI cancer (p for trend 0.573). CONCLUSION Oral bisphosphonate use did not appear to be associated with elevated or reduced risk for GI cancers.
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Affiliation(s)
- D Choi
- Department of Biomedical Sciences, Seoul National University Graduate School, Seoul, South Korea
- Pyeongchang Health Center and County Hospital, Pyeongchang, South Korea
| | - S Choi
- Department of Biomedical Sciences, Seoul National University Graduate School, Seoul, South Korea
| | - J Chang
- Department of Biomedical Sciences, Seoul National University Graduate School, Seoul, South Korea
| | - S M Park
- Department of Biomedical Sciences, Seoul National University Graduate School, Seoul, South Korea.
- Department of Family Medicine, Seoul National University Hospital, Seoul, South Korea.
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Lee MH, Lubner MG, Peebles JK, Hinshaw MA, Menias CO, Levine MS, Pickhardt PJ. Clinical, Imaging, and Pathologic Features of Conditions with Combined Esophageal and Cutaneous Manifestations. Radiographics 2019; 39:1411-1434. [PMID: 31419189 DOI: 10.1148/rg.2019190052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A variety of clinically significant conditions can affect both the esophagus and the skin. Esophageal and cutaneous manifestations may directly reflect the underlying disease process, as in infections such as herpes simplex virus, bullous diseases such as epidermolysis bullosa and mucous membrane pemphigoid, connective tissue diseases such as systemic sclerosis, and inflammatory diseases such as lichen planus. Alternatively, esophageal and cutaneous findings may result from conditions that are closely associated with and potentially pathognomonic for but distinct from the underlying disease process, as in genetic diseases such as Cowden syndrome or paraneoplastic syndromes such as acrokeratosis paraneoplastica. Other diseases such as Crohn disease may have cutaneous manifestations that directly reflect the same underlying inflammatory process that affects the gastrointestinal tract or cutaneous manifestations that represent reactive or associated conditions distinct from the underlying inflammatory process. The cutaneous manifestations of disease may precede, coincide with, or follow the esophageal manifestations of disease. The authors present the characteristic clinical features and imaging findings associated with common and uncommon conditions that have esophageal and cutaneous manifestations. Each condition is presented with a brief overview, discussion of salient clinical and cutaneous manifestations, and description of the typical esophageal imaging findings, with particular attention to implications for diagnosis, prognosis, and treatment. Recognition of potential associations between cutaneous lesions and esophageal imaging findings is important for establishing a specific diagnosis or generating a meaningful differential diagnosis.
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Affiliation(s)
- Matthew H Lee
- From the Department of Radiology, Naval Medical Center Camp Lejeune, Camp Lejeune, NC (M.H.L.); Departments of Radiology (M.G.L., P.J.P.) and Dermatology (J.K.P., M.A.H.), University of Wisconsin School of Medicine and Public Health, Madison, Wis; Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.); and Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pa (M.S.L.)
| | - Meghan G Lubner
- From the Department of Radiology, Naval Medical Center Camp Lejeune, Camp Lejeune, NC (M.H.L.); Departments of Radiology (M.G.L., P.J.P.) and Dermatology (J.K.P., M.A.H.), University of Wisconsin School of Medicine and Public Health, Madison, Wis; Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.); and Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pa (M.S.L.)
| | - J Klint Peebles
- From the Department of Radiology, Naval Medical Center Camp Lejeune, Camp Lejeune, NC (M.H.L.); Departments of Radiology (M.G.L., P.J.P.) and Dermatology (J.K.P., M.A.H.), University of Wisconsin School of Medicine and Public Health, Madison, Wis; Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.); and Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pa (M.S.L.)
| | - Molly A Hinshaw
- From the Department of Radiology, Naval Medical Center Camp Lejeune, Camp Lejeune, NC (M.H.L.); Departments of Radiology (M.G.L., P.J.P.) and Dermatology (J.K.P., M.A.H.), University of Wisconsin School of Medicine and Public Health, Madison, Wis; Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.); and Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pa (M.S.L.)
| | - Christine O Menias
- From the Department of Radiology, Naval Medical Center Camp Lejeune, Camp Lejeune, NC (M.H.L.); Departments of Radiology (M.G.L., P.J.P.) and Dermatology (J.K.P., M.A.H.), University of Wisconsin School of Medicine and Public Health, Madison, Wis; Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.); and Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pa (M.S.L.)
| | - Marc S Levine
- From the Department of Radiology, Naval Medical Center Camp Lejeune, Camp Lejeune, NC (M.H.L.); Departments of Radiology (M.G.L., P.J.P.) and Dermatology (J.K.P., M.A.H.), University of Wisconsin School of Medicine and Public Health, Madison, Wis; Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.); and Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pa (M.S.L.)
| | - Perry J Pickhardt
- From the Department of Radiology, Naval Medical Center Camp Lejeune, Camp Lejeune, NC (M.H.L.); Departments of Radiology (M.G.L., P.J.P.) and Dermatology (J.K.P., M.A.H.), University of Wisconsin School of Medicine and Public Health, Madison, Wis; Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.); and Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pa (M.S.L.)
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Busby J, Murchie P, Murray L, Iversen L, Lee AJ, Spence A, Watson MC, Cardwell CR. The effect of medications which cause inflammation of the gastro-oesophageal tract on cancer risk: a nested case-control study of routine Scottish data. Int J Cancer 2017; 140:1828-1835. [PMID: 28120338 DOI: 10.1002/ijc.30612] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 12/22/2016] [Accepted: 01/10/2017] [Indexed: 12/14/2022]
Abstract
Bisphosphonate, tetracycline and spironolactone use has been shown to increase gastro-oesophageal inflammation, an accepted risk factor for cancer. However, evidence of the effect of these medications on gastro-oesophageal cancer risk are mixed or missing entirely. Therefore, we conducted a nested case-control study using the Primary Care Clinical Information Unit Research (PCCIUR) database from Scotland. Cases with oesophageal or gastric cancer between 1999 and 2011 were matched to up to five controls based on age, gender, year of diagnosis and general practice. Medication use was ascertained using electronic prescribing records. Conditional logistic regression was used to calculate odds ratios (ORs) for the association between medication use and cancer risk after adjustment for comorbidities and other medication use. A similar proportion of gastro-oesophageal cancer cases received bisphosphonates (3.9% vs. 3.5%), tetracycline (6.0% vs. 6.0%) and spironolactone (1.4% vs. 1.1%) compared with the controls. The adjusted ORs for the association between gastro-oesophageal cancer and bisphosphonates, tetracycline and spironolactone were 1.05 (95% CI: 0.85, 1.31), 0.99 (95% CI: 0.84, 1.17) and 1.04 (95% CI: 0.73, 1.49). Further analysis revealed bisphosphonates were associated with increased oesophageal cancer risk (1.34, 95% CI: 1.03, 1.74) but reduced gastric cancer risk (0.71, 95% CI: 0.49, 1.03), although there was no obvious dose-response relationship. Overall, there is little evidence that the use of bisphosphonate, tetracycline or spironolactone is associated with increased risk of gastro-oesophageal cancer. Our findings should reassure GPs and patients that these widely-used medications are safe with respect to gastro-oesophageal cancer risk.
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Affiliation(s)
- John Busby
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom
| | - Peter Murchie
- Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Liam Murray
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom
| | - Lisa Iversen
- Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Amanda J Lee
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Andrew Spence
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom
| | - Margaret C Watson
- Department of Pharmacy and Pharmacology, University of Bath, United Kingdom
| | - Chris R Cardwell
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom
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6
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Morphology of the Esophagus. Dysphagia 2017. [DOI: 10.1007/174_2017_117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Lee WY, Sun LM, Lin MC, Liang JA, Chang SN, Sung FC, Muo CH, Kao CH. A higher dosage of oral alendronate will increase the subsequent cancer risk of osteoporosis patients in Taiwan: a population-based cohort study. PLoS One 2012; 7:e53032. [PMID: 23300854 PMCID: PMC3534103 DOI: 10.1371/journal.pone.0053032] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 11/22/2012] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Controversy still exists regarding whether alendronate (ALN) use increases the risk of esophageal cancer or breast cancer. METHODS This paper explores the possible association between the use of oral ALN in osteoporosis patients and subsequent cancer risk using the National Health Insurance (NHI) system database of Taiwan with a Cox proportional-hazard regression analysis. The exposure cohort contained 5,624 osteoporosis patients used ALN and randomly frequency-matched by age and gender of 3 osteoporosis patients without any kind of anti-osteoporosis drugs in the same period. RESULTS For a dose ≥ 1.0 g/year, the risk of developing overall cancer was significantly higher (hazard ratio: 1.69, 95% confidence ratio: 1.39-2.04) than in osteoporosis patients without any anti-osteoporosis drugs. The risks for developing liver, lung, and prostate cancers and lymphoma were also significantly higher than in the control group. CONCLUSIONS This population-based retrospective cohort study did not find a relationship between ALN use and either esophageal or breast cancer, but unexpectedly discovered that use of ALN with dose ≥ 1.0 g/year significantly increased risks of overall cancer incidence, as well as liver, lung, and prostate cancers and lymphoma. Further large population-based unbiased studies to enforce our findings are required before any confirmatory conclusion can be made.
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Affiliation(s)
- Wen-Yuan Lee
- China Medical University Hospital Taipei Branch, Taipei, Taiwan
- Graduate Institute of Clinical Medicine Science and School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Li-Min Sun
- Department of Radiation Oncology, Zuoying Armed Forces General Hospital, Kaohsiung, Taiwan
| | - Ming-Chia Lin
- Department of Nuclear Medicine, E-DA Hospital, Kaohsiung, Taiwan
| | - Ji-An Liang
- Graduate Institute of Clinical Medicine Science and School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Radiation Oncology, China Medical University Hospital, Taichung, Taiwan
| | - Shih-Ni Chang
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
- Ph.D. Program for Cancer Biology and Drug Discovery, China Medical University, Taichung, Taiwan
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Fung-Chang Sung
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
- Institute of Environmental Health, College of Public Health, China Medical University, Taichung, Taiwan
| | - Chih-Hsin Muo
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Hung Kao
- Graduate Institute of Clinical Medicine Science and School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan
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9
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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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Affiliation(s)
- Asit K Paul
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
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11
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Morphology of the Esophagus. Dysphagia 2011. [DOI: 10.1007/174_2011_347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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12
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Abstract
CONTEXT Use of oral bisphosphonates has increased dramatically in the United States and elsewhere. Esophagitis is a known adverse effect of bisphosphonate use, and recent reports suggest a link between bisphosphonate use and esophageal cancer, but this has not been robustly investigated. OBJECTIVE To investigate the association between bisphosphonate use and esophageal cancer. DESIGN, SETTING, AND PARTICIPANTS Data were extracted from the UK General Practice Research Database to compare the incidence of esophageal and gastric cancer in a cohort of patients treated with oral bisphosphonates between January 1996 and December 2006 with incidence in a control cohort. Cancers were identified from relevant Read/Oxford Medical Information System codes in the patient's clinical files. Cox proportional hazards modeling was used to calculate hazard ratios and 95% confidence intervals for risk of esophageal and gastric cancer in bisphosphonate users compared with nonusers, with adjustment for potential confounders. MAIN OUTCOME MEASURE Hazard ratio for the risk of esophageal and gastric cancer in the bisphosphonate users compared with the bisphosphonate nonusers. RESULTS Mean follow-up time was 4.5 and 4.4 years in the bisphosphonate and control cohorts, respectively. Excluding patients with less than 6 months' follow-up, there were 41 826 members in each cohort (81% women; mean age, 70.0 (SD, 11.4) years). One hundred sixteen esophageal or gastric cancers (79 esophageal) occurred in the bisphosphonate cohort and 115 (72 esophageal) in the control cohort. The incidence of esophageal and gastric cancer combined was 0.7 per 1000 person-years of risk in both the bisphosphonate and control cohorts; the incidence of esophageal cancer alone in the bisphosphonate and control cohorts was 0.48 and 0.44 per 1000 person-years of risk, respectively. There was no difference in risk of esophageal and gastric cancer combined between the cohorts for any bisphosphonate use (adjusted hazard ratio, 0.96 [95% confidence interval, 0.74-1.25]) or risk of esophageal cancer only (adjusted hazard ratio, 1.07 [95% confidence interval, 0.77-1.49]). There also was no difference in risk of esophageal or gastric cancer by duration of bisphosphonate intake. CONCLUSION Among patients in the UK General Practice Research Database, the use of oral bisphosphonates was not significantly associated with incident esophageal or gastric cancer.
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Affiliation(s)
- Chris R Cardwell
- Centre for Public Health, Queen's University Belfast, Grosvenor Rd, Belfast BT12 6BJ, United Kingdom.
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Lamprecht G. In vitro determination of the release of alendronic acid from alendronate tablets of different brands during deglutition. J Pharm Sci 2010; 98:3575-81. [PMID: 19630066 DOI: 10.1002/jps.21639] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Alendronic acid, a frequently applied compound for the treatment of different forms of diseases of bone metabolism, is a strong acid with a high solubility in water. In connection with the oral administration this exhibits a potential health risk for the upper gastrointestinal tract. The in vitro release of tablets containing alendronic acid of different brands (Stada, ratiopharm, interpharm, Fosamax) was determined by dissolution tests for the time period required for oral intake. The effect of rotation speed, temperature, and solvent volume on the release rate of alendronic acid was determined for the used dissolution apparatus. Analysis of alendronic acid was performed by a validated HPLC method. The highest rate of release was found for the original brand. The dissolution rate of the generic formulations was significantly lower in the early stage of dissolution. Over the complete range of dissolution, more than 85% of the claimed amount was dissolved within 4 min. Dissolution profiles were compared by calculation of the similarity factor f(2) showing equal products with the exception of one generic product, whose dissolution rate was lower.
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Affiliation(s)
- Guenther Lamprecht
- Institute of Analytical Chemistry and Food Chemistry, University of Vienna, Waehringerstrasse 38, A-1090 Vienna, Austria.
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Naniwa T, Maeda T, Mizoshita T, Hayami Y, Watanabe M, Banno S, Ito R. Alendronate-induced esophagitis: possible pathogenic role of hypersensitivity to alendronate. Intern Med 2008; 47:2083-5. [PMID: 19043266 DOI: 10.2169/internalmedicine.47.1457] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Upper gastrointestinal tract mucosal irritations, such as esophagitis, have been reported as rare adverse events due to a variety of aminobisphosphonates, including alendronate sodium, which have been widely used to treat osteoporosis. Although the pathogenesis of aminobisphosphonate-induced esophageal mucosal irritation has not been clearly understood, direct chemical esophageal irritation with prolonged local mucosal exposure to the drug with gastric contents might be the most plausible mechanism according to the previously reported literature. Here we report a young adult man with severe ulcerative esophagitis due to alendronate who demonstrated a strongly positive result on a drug lymphocyte stimulation test against alendronate. This case report provides the new concept that T-cell mediated delayed hypersensitivity to the drug may be involved in the pathogenesis of alendronate-induced esophagitis.
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Affiliation(s)
- Taio Naniwa
- Division of Rheumatology, Nagoya City University Hospital, Nagoya.
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16
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Epstein S, Delmas PD, Emkey R, Wilson KM, Hiltbrunner V, Schimmer RC. Oral ibandronate in the management of postmenopausal osteoporosis: Review of upper gastrointestinal safety. Maturitas 2006; 54:1-10. [PMID: 16522358 DOI: 10.1016/j.maturitas.2006.01.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2005] [Revised: 01/17/2006] [Accepted: 01/26/2006] [Indexed: 11/16/2022]
Abstract
Oral daily bisphosphonates carry a potential for gastrointestinal (GI) adverse events, which has been partly addressed by introducing once-weekly regimens. Nevertheless, the need to follow inconvenient dosing instructions every week could still hinder long-term compliance and therapeutic outcome. In addition, survey data indicates that many patients would prefer a once-monthly rather than once-weekly bisphosphonate dosing regimen. Ibandronate is a potent, nitrogen-containing bisphosphonate specifically developed for less frequent administration. In a pivotal study in postmenopausal osteoporosis, oral ibandronate, administered daily or with a between-dose interval of >2 months, demonstrated robust antifracture efficacy and an overall incidence of upper GI adverse events similar to placebo, even in patients at increased risk of such events. This and other clinical studies conducted in postmenopausal women demonstrate that oral ibandronate has an excellent upper GI safety profile.
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Affiliation(s)
- Sol Epstein
- Mt Sinai Medical Center, NY, USA, and INSERM Research Unit 403 and Claude Bernard University, Lyon, France.
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17
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Abstract
The barium esophagram is a valuable diagnostic test for evaluating structural and functional abnormalities of the esophagus. The study is usually performed as a multiphasic examination that includes upright double-contrast views with a high-density barium suspension, prone single-contrast views with a low-density barium suspension, and, not infrequently, mucosal-relief views with either density of barium suspension. The double-contrast phase optimizes the ability to detect inflammatory or neoplastic diseases, whereas the single-contrast phase optimizes the ability to detect hiatal hernias and lower esophageal rings or strictures. Fluoroscopic examination of the esophagus is also important for assessing motility disorders such as achalasia and diffuse esophageal spasm. This article is a review of gastroesophageal reflux disease, other types of esophagitis, benign and malignant esophageal tumors, varices, lower esophageal rings, diverticula, and esophageal motility disorders, all of which can be diagnosed with the aid of esophagography.
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Affiliation(s)
- Marc S Levine
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
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18
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Abstract
PURPOSE To review and discuss the clinical evaluation and therapeutic options for a postmenopausal woman with osteoporosis. DATA SOURCES Review of scientific literature, practice guidelines, and a case study. CONCLUSIONS To prevent and treat postmenopausal osteoporosis, women should be encouraged to perform weight-bearing exercise, to not smoke, and to optimize calcium and vitamin D intake through diet and supplements. Drug regimens are effective and well tolerated in postmenopausal women with osteoporosis. IMPLICATIONS FOR PRACTICE Drugs currently approved by the U.S. Food and Drug Administration for the treatment of postmenopausal osteoporosis include the bisphosphonates risedronate and alendronate; the selective estrogen receptor modulator, raloxifene; and intranasal calcitonin-salmon spray. Bisphosphonates have demonstrated the most impressive fracture risk reduction in prospective clinical trials of women with postmenopausal osteoporosis. Risedronate has consistently demonstrated significant reductions in vertebral fracture risk at 1 year and in vertebral and nonvertebral fracture risk at 3 years. Alendronate has demonstrated significant reductions in vertebral and nonvertebral fracture risk after 3 years.
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Abstract
The prevalence of osteoporosis in all US postmenopausal women is 17%, and it is as high as 30% in women older than 65. All postmenopausal women should be encouraged to have adequate daily calcium and vitamin D intake, to exercise regularly, and to avoid tobacco and excessive alcohol use. Although the clinical impact and cost-effectiveness of osteoporosis screening tools remain to be established, a rational approach based on current evidence involves using National Osteoporosis Foundation guidelines, Simple Calculated Osteoporosis Risk Estimation, or Osteoporosis Risk Assessment Instrument clinical decision rules to decide when a postmenopausal woman should undergo further evaluation.
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Affiliation(s)
- Gina S Wei
- Department of Medicine, Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
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Luedtke P, Levine MS, Rubesin SE, Weinstein DS, Laufer I. Radiologic diagnosis of benign esophageal strictures: a pattern approach. Radiographics 2003; 23:897-909. [PMID: 12853664 DOI: 10.1148/rg.234025717] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Benign esophageal strictures are a leading cause of dysphagia. Therefore, radiologists have an important role in detecting esophageal strictures and determining their cause. The most common cause of strictures in the distal esophagus is gastroesophageal reflux disease. Reflux-induced ("peptic") strictures may be associated with sacculations, fixed transverse folds, or esophageal intramural pseudodiverticula. In addition, scleroderma, nasogastric intubation, Zollinger-Ellison syndrome, and alkaline reflux esophagitis may be associated with stricture formation in the distal esophagus. Upper and midesophageal strictures may be caused by Barrett esophagus, mediastinal irradiation, ingestion of drugs or caustic substances, congenital esophageal stenosis, skin diseases, or esophageal intramural pseudodiverticulosis. Other unusual causes of esophageal stricture formation include Crohn disease, Candida esophagitis, graft-versus-host disease, eosinophilic esophagitis, Behçet disease, endoscopic sclerotherapy for esophageal varices, and glutaraldehyde contamination at endoscopy. Esophageal strictures are best evaluated with biphasic esophagography that includes both single- and double-contrast spot images. When esophageal strictures are detected at barium examination, the underlying cause can often be determined with a pattern approach that takes into account the clinical history, the appearance and location of the strictures, and the presence of other associated radiographic findings.
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Affiliation(s)
- Pia Luedtke
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA
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21
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Fernandes PA, Pires MS, Gouvêa AP. [Ulcerative esophagitis associated with the use of alendronate sodium: histopathological and endoscopic features]. ARQUIVOS DE GASTROENTEROLOGIA 2002; 39:173-6. [PMID: 12778309 DOI: 10.1590/s0004-28032002000300007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Drug-induced or "pill-induced" esophagitis may be secondary to the prolonged contact of the drug with the esophageal mucosa or secondary to the drug ability to alter the local conditions. The alendronate sodium, a bone resorption inhibitor used in the treatment and prevention of osteoporosis, has been cited, recently, as one of the causes of adverse upper gastrointestinal tract injury. AIM To describe the clinical, endoscopic and histopathological features of patients with ulcerative esophagitis associated with alendronate sodium. PATIENTS Four women and one man with osteoporosis were treated with alendronate sodium and submitted to endoscopy followed esophageal biopsy. RESULTS The age range of the patients was from 64 to 84 years old. The patients showed dyspeptic symptoms after taking alendronate sodium during a period of 2-12 months. At endoscopic evaluation, the mucosa was friable, with erosion and/or ulceration covered by fibrin in the distal esophagus. The pathological examination of the esophageal biopsies revealed ulcerative esophagitis characterized by necrofibrinpurulent material, granulation tissue, and yellow refractile polarizable crystal. The patients' symptoms resolved after stopping alendronate sodium use. CONCLUSIONS The esophagus injuries associated with alendronate sodium are not frequent and seem to be associated with the incorrect use of medication. The endoscopists and pathologists should be alert to the possibility of alendronate sodium therapy in cases of diagnosis of ulcerative esophagitis in ancient patients, particularly in women. The recognition of this condition would improve the patient care.
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22
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Hansten PD. Selecting Appropriate Pharmacotherapy for Patients with Osteoporosis: Holistic Risk—Benefit Analysis. Hosp Pharm 2002. [DOI: 10.1177/001857870203700508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In the US, the major pharmacotherapeutic approaches for the prevention or treatment of osteoporosis in women are estrogen-based hormone replacement therapy, selective estrogen receptor modulators, salmon calcitonin, bisphosphonates, calcium, and vitamin D. All of these treatments are beneficial in increasing bone mineral density and reducing fractures in patients with osteoporosis. However, each of the therapies possesses a unique mechanism of action and other potential benefits and side effects. Estrogen replacement therapy may lower the risk of cardiovascular disease, but it increases the risk of venous thromboembolism (VTE) and may increase the risk of breast cancer. Unopposed estrogen therapy is associated with increased risk for endometrial cancer, but the addition of progestins virtually eliminates this adverse event. The selective estrogen receptor modulator raloxifene is associated with positive cardiovascular effects and demonstrates a protective effect against some types of breast cancer. Like estrogen, raloxifene increases the risk of VTE. Salmon calcitonin has a strong analgesic effect and is not associated with any serious long-term adverse events, but some individuals may not be able to tolerate the nasal formulation. Bisphosphonates are associated with serious upper GI effects. The concomitant administration of calcium and vitamin D in all patients being treated for osteoporosis is generally recommended.Selecting optimal treatment relies on an individualized risk–benefit analysis that takes into account the patient's medical history, concomitant diseases, current medications, general physical and mental well being, and personal feelings about the various therapies. Careful consideration of the various treatment options may lead to improved compliance and more effective management of osteoporosis.
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Affiliation(s)
- Philip D. Hansten
- University of Washington, H-375 Health Sciences Building, Seattle, WA 98195-7630
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23
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Abstract
Oral bisphosphonates are effective for osteoporosis and other hyperresorptive bone disorders. Although well-tolerated in efficacy trials, some oral aminobisphosphonates have been associated with upper gastrointestinal intolerance and injury in postmarketing experience. Clinical trials often underestimate the rate of adverse events in clinical practice, and ethics prohibit direct evaluation of toxicity in high-risk patients. Accordingly, animal models and endoscopy studies of oral bisphosphonates provide valuable insight. It is unclear whether variation in ulcerogenic potential reflects differences in dosing, formulation or chemical structure. Furthermore, the clinical relevance of endoscopic lesions is uncertain. Ongoing postmarketing review will determine whether differences in endoscopic damage predict tolerability and safety in clinical practice. However, physicians and patients should consider risk factors for oesophageal injury when initiating therapy.
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Affiliation(s)
- John K Marshall
- Division of Gastroenterology (4W8), Medical Centre, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada.
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24
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Weitschies W, Siegmund W. [The challenge of patient consultation and pharmaceutical development: bisphosphonate in solid dosage forms]. PHARMAZIE IN UNSERER ZEIT 2002; 30:536-40. [PMID: 11715687 DOI: 10.1002/1615-1003(200111)30:6<536::aid-pauz536>3.0.co;2-h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- W Weitschies
- Institut für Pharmazie Ernst-Moritz-Amdt-Universität Friedrich-Ludwig-John-Strasse 17 D-17487 Greifswald.
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25
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Kleerekoper M, Schein JR. Comparative safety of bone remodeling agents with a focus on osteoporosis therapies. J Clin Pharmacol 2001; 41:239-50. [PMID: 11269564 DOI: 10.1177/00912700122010050] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This article reviews the different treatments currently available for osteoporosis and examines the benefits and adverse events that are associated with each. While emphasizing safety considerations, this review summarizes the following treatments for osteoporosis: calcium supplements, fluoride, hormone replacement therapy, raloxifene, bisphosphonates, salmon calcitonin, and calcitriol. Before prescribing any of these agents, the clinician should review the risk/benefit profile of each drug in the context of the individual patient's history, concomitant diseases, concurrent medications, and general physical condition.
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Affiliation(s)
- M Kleerekoper
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan 48201, USA
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26
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Sewell K, Schein JR. Osteoporosis therapies for rheumatoid arthritis patients: minimizing gastrointestinal side effects. Semin Arthritis Rheum 2001; 30:288-97. [PMID: 11182029 DOI: 10.1053/sarh.2001.16648] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This manuscript identifies characteristics that put people with rheumatoid arthritis (RA) at high risk for osteoporosis or gastrointestinal (GI) disturbances. The manuscript then reviews therapies available for osteoporosis in the United States and makes recommendations about choosing therapies that minimize GI adverse effects in RA patients at high risk for such events. DATA SOURCES References identified through MEDLINE, abstracts, and prescribing information for individual drugs. DATA EXTRACTION Characteristics that predispose patients to osteoporosis and GI problems were identified. Data on individual osteoporosis therapies were assessed by risk-benefit analysis and appropriateness for use in patients at risk for GI disturbances. DATA SYNTHESIS High risk of osteoporosis in people with RA is caused by disease activity, medication effects, physical inactivity, and standard risk factors such as postmenopausal status and increased age. Patients with RA are frequently at high GI risk if they are receiving nonsteroidal anti-inflammatory drugs or corticosteroids. Because of the high potential for erosive esophagitis and other upper GI disorders with alendronate, caution is warranted in prescribing alendronate to RA patients with high GI risk. In such patients, estrogen replacement therapy, selective estrogen receptor modulators, or calcitonin should be considered for treatment, and either estrogen replacement therapy or selective estrogen receptor modulators should be considered for osteoporosis prevention. CONCLUSIONS Assessment of GI risk is important in patients with RA and osteoporosis. Risk factors should be considered when choosing osteoporosis therapies.
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Affiliation(s)
- K Sewell
- Division of Gerontology, Harvard Medical School, Boston, MA, USA
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27
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Cappell MS, Schein JR. Diagnosis and treatment of nonsteroidal anti-inflammatory drug-associated upper gastrointestinal toxicity. Gastroenterol Clin North Am 2000; 29:97-124, vi. [PMID: 10752019 DOI: 10.1016/s0889-8553(05)70109-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed in the United States to treat pain and reduce inflammation from chronic inflammatory disorders such as rheumatoid arthritis and osteoarthritis. Approximately 40% of older Americans take NSAIDs. Chronic NSAID use carries a risk of peptic ulcer and other gastrointestinal disturbances. This article reviews the diagnosis of medication-induced ulcers based on clinical presentation, laboratory tests, and endoscopic findings to assist the clinician in early diagnosis and appropriate therapy. Risk factors for NSAID-induced ulcers include old age, poor medical status, prior ulcer, alcoholism, smoking, high NSAID dosage, prolonged NSAID use, and concomitant use of other drugs that are gastric irritants, such as alendronate, a bone resorption inhibitor prescribed for osteoporosis. Appropriate treatment options for patients with medication-induced ulcers include dosage reduction, medication substitution, medication withdrawal, antiulcer therapy, and discontinuation of other gastrotoxic drugs.
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Affiliation(s)
- M S Cappell
- Division of Gastroenterology, Maimonides Medical Center, Brooklyn, New York, USA
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28
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Walker SJ, Byrne JP, Birbeck N. What's new in the pathology, pathophysiology and management of benign esophageal disorders? Dis Esophagus 2000; 12:219-37. [PMID: 10631918 DOI: 10.1046/j.1442-2050.1999.00056.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- S J Walker
- Department of Surgery, Blackpool Victoria Hospital, Lancs, UK
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29
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30
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Kaplan NM, Palmer BF, Rubin CD. Treatment Considerations in the Management of Age-Related Osteoporosis. Am J Med Sci 1999. [DOI: 10.1016/s0002-9629(15)40608-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Abstract
Nine hundred seventy-nine cases of pill esophagitis due to nearly 100 different medications are reviewed. Pill-induced injuries occur when caustic medicinal pills dissolve in the esophagus rather than passing rapidly into the stomach as intended. Most patients suffer only self-limited pain, but esophageal hemorrhage, stricture, and perforation may occur, and fatal injuries have been reported. The incidence of this iatrogenic injury can be reduced but not eliminated by emphasizing the importance of taking pills while upright and with plenty of fluids.
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Affiliation(s)
- J W Kikendall
- Gastroenterology Service, Walter Reed Army Medical Center, Washington, DC 20307-5001, USA
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32
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Gennari C, Reginster JY. Bisphosphonates and osteoporosis treatment in Italy. AGING (MILAN, ITALY) 1998; 10:284-94. [PMID: 9825019 DOI: 10.1007/bf03339790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A treatment against osteoporosis can be considered efficacious only when its beneficial effects on bone remodeling, bone mass, and osteoporotic fracture incidence are proven. As for any treatment, proven efficacy must be combined with proven safety. This review analyzes published data on efficacy and safety of alendronate, clodronate and etidronate, the bisphosphonates currently marketed in Italy for osteoporosis treatment. Different studies have shown that alendronate, clodronate and etidronate reduce bone turnover, and increase bone mineral density in postmenopausal osteoporotic patients. Prospective, double blind, multicenter studies reported a reduction in osteoporotic fracture incidence for alendronate and etidronate. Fracture incidence reduction by clodronate, on the other hand, was shown only in an open label study. Finally, a reduction in fracture incidence by etidronate was shown in a large retrospective postmarketing study. Postmarketing surveillance evidenced that osteomalacia, a suspected side effect of etidronate treatment, does not occur at the currently used dose regimens. Postmarketing surveillance of alendronate has recently raised some concern regarding possible severe esophageal damage during alendronate treatment, especially when the drug is not taken according to the manufacturer's instructions.
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Affiliation(s)
- C Gennari
- Institute of Medical Pathology, University of Siena, Nuovo Policlinico Le Scotte, Italy
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