Gastrointestinal tolerability and patterns of switching in patients treated for primary osteoporosis: the Swedish Adherence Register Analysis (SARA)

The objective of this study was to describe and analyze the gastrointestinal tolerability and medication switching in patients receiving treatment for primary osteoporosis in Sweden. The study was based on all patients starting therapy with alendronate, risedronate, strontium ranelate, and raloxifene in Sweden between 2005 and 2009. The primary outcome measure was start of treatment with a gastroprotective agent, and the secondary outcome was hospitalization for a gastrointestinal adverse event (GIAE). Switching was analyzed while patients were on treatment. The crude incidence of gastroprotective treatment during the first 6 months after initiation of osteoporosis therapy was 5.14%, 5.93%, 4.25%, and 2.86% for patients prescribed alendronate, risedronate, strontium ranelate, and raloxifene, respectively. Patients prescribed raloxifene had a significantly lower risk of filling a prescription for a gastroprotective agent compared with alendronate. There was no significant difference in the risk of hospitalization for GIAEs. Less than 3% switched therapy while on treatment. Patients prescribed risedronate, strontium ranelate, and raloxifene had a significantly higher risk of switching compared with patients taking alendronate. In conclusion, no significant difference in the incidence of GIAEs was found between patients prescribed alendronate, risedronate, and strontium ranelate. Individuals prescribed raloxifene had a significantly lower risk of GIAEs compared with patients prescribed alendronate. No significant difference was found in the frequency of hospitalization for GIAEs. Switching between osteoporosis medications and drug classes was uncommon. Prescribers should consider the real-world gastrointestinal safety of osteoporosis drugs when choosing between treatment options to potentially improve medication adherence and consequently effectiveness.

Blood pressure effects of the oral contraceptive and postmenopausal hormone therapies

Oral contraceptives and postmenopausal hormone therapy may induce hypertension through multiple mechanisms, including sodium and volume retention. Numerous studies have shown significant increases in blood pressure (BP) with the chronic administration of oral contraceptives as well as reversibility with discontinuation. The effects of different classes of oral contraceptive agents and hormonal replacement therapy on BP and associated effects on other cardiovascular risk factors are covered in this article. Novel hormonal replacement therapy that lowers BP is also discussed.

Stroke in relation to use of raloxifene and other drugs against osteoporosis

Prior studies have associated fatal stroke with raloxifene. In a cohort study, we found no excess risk of stroke with raloxifene; whereas, an excess risk of stroke and fatal stroke was seen with alendronate and etidronate. However, the excess risks were small.

PURPOSE

We aim to study the association between use of raloxifene and other drugs against osteoporosis and risk of stroke.

METHODS

This is a nationwide cohort study from Denmark. All users of bisphosphonates and other drugs against osteoporosis between 1996 and 2006 (n = 103,562) as exposed group and three age- and gender-matched controls from the general population (n = 310,683).

RESULTS

Before the drugs were started, patients later initiating alendronate or raloxifene had fewer strokes than the controls. In contrast, patients who later did start clodronate have more strokes. Among the later users of other bisphosphonates, strontium ranelate or parathyroid hormone, no change in the risk of stroke was present. Patients who started raloxifene neither had an excess risk of strokes nor of fatal strokes. No dose-response relationship was present. Among users of alendronate, a decreasing overall risk of stroke was seen with increasing dose. However, for fatal strokes, the risk increased with increasing dose of alendronate. Among users of etidronate, no trend with dose was present for overall stroke risk; whereas for fatal strokes, an increasing risk was seen with increasing dose of etidronate.

CONCLUSIONS

Raloxifene does not seem associated with an excess risk of strokes. The increase seen for alendronate did not seem to be causal as no classical dose-response relationship was present. The dose-response relationship for fatal strokes with alendronate and etidronate needs further examination. However, the excess risks were small and may be due to the underlying disease.

Efficacy, side effects and route of administration are more important than frequency of dosing of anti-osteoporosis treatments in determining patient adherence: a critical review of published articles from 1970 to 2009

The purposes of the study were to review available published literature on magnitude of non-adherence with osteoporosis regimens and to determine the association between frequency and modality of medication administration with patient preference and adherence. We searched peer-reviewed journal databases--MEDLINE, EMBASE, Biosis and Derwent Drug File for publications (January 1979 to January 2009) including MeSH terms--"patient preference", "adherence" and "compliance" based on "dosing frequency" and "modality". Since adherence was difficult to accurately quantify, preference, compliance and persistence were evaluated. Patients' preference and adherence at 12 months were higher with weekly over daily bisphosphonates (≥ 84% preference for weekly, medication possession ratios (MPR) 60-76% vs 46-64%; persistence 43.6-69.7% vs 31.7-55.7%). MPR reported for oral bisphosphonates were 68-71% at 12 months. At 2 years, only 43% of patients had MPR ≥ 80% for daily and weekly bisphosphonates. Observational studies (6-12 months) reported discontinuation rates of 18-22% for daily and 7% for weekly bisphosphonates. Data on monthly bisphosphonates are conflicting and confounded by cost differences, patient support programmes and definition of persistence. Studies suggest patient preference for annual zoledronic acid infusions over weekly bisphosphonates (66.4-78.8% vs 9.0-19.7%, respectively), but no data on compliance or persistence are available. Drug effectiveness, side effects and route of administration were more important than frequency. Although less frequent dosing is preferred, other factors such as perceived efficacy, side effects, medication cost, availability of patient support programmes and route of delivery are equally important. Adherence is complex and difficult to quantify and may not be exclusively influenced by frequency of medication administration.

Effect of raloxifene on arthritis and bone mineral density in rats with collagen-induced arthritis

We studied the effect of raloxifene (RAL) on arthritis and bone mineral density (BMD) in rats with collagen-induced arthritis (CIA). Seven-month-old female Sprague-Dawley rats were divided into five groups: rats without CIA (CNT), CIA rats that underwent ovariectomy (OVX) and were treated with RAL (CIA + OVX + RAL), CIA rats that underwent OVX and were treated with vehicle (CIA + OVX + Veh), CIA rats that had sham surgery and were treated with RAL (CIA + sham + RAL), and CIA rats that had sham surgery and were treated with vehicle (CIA + sham + Veh). RAL was orally administered at 10 mg/kg every day for 3 weeks, beginning 1 week after initial sensitization until death at 4 weeks. Every week until death, we evaluated hind paw thickness and arthritis score. BMD was measured by peripheral quantitative computed tomography at the distal metaphysis and the diaphysis of the femur; we also performed histomorphometry of the proximal tibia and histological evaluation of arthritis. RAL administration suppressed hind paw thickness and arthritis score and prevented decreases in BMD and cortical thickness. In the histomorphometric analysis, bone-resorption parameters were significantly lower in the RAL groups than in the Veh groups. RAL significantly inhibited synovial proliferation in CIA rats. RAL effects on arthritis and bone were apparent regardless of whether an animal had undergone OVX. RAL could suppress arthritis and bone loss in estrogen-replete or -depleted rats. These findings, using an animal model, indicate the potential usefulness of RAL as an effective treatment for premenopausal RA patients as well as postmenopausal ones.

Sustained vertebral antifracture efficacy of oral anti-osteoporotic therapies in postmenopausal osteoporosis

OBJECTIVE

Vertebral fractures are common in women with postmenopausal osteoporosis, a chronic condition requiring long-term treatment with anti-osteoporotic treatments. Therefore, it is important to assess sustainability of antifracture efficacy.

METHODS

A review of the literature to determine pivotal vertebral fracture studies for oral bisphosphonates (ibandronate, risedronate and alendronate), strontium ranelate, and raloxifene and to evaluate vertebral antifracture efficacy over time.

RESULTS

Data from the BONE trial showed that ibandronate sustained vertebral antifracture efficacy over time (58% vertebral fracture risk reduction in first year p = 0.0561, increased to 62% for years 0-3; p < 0.001). The Vertebral Efficacy with Risedronate Therapy-North America (VERT-NA) and VERT-multi-national (VERT-MN) studies demonstrated that the relative risk reduction (RRR) with risedronate versus placebo decreased over time (VERT-NA: 65% for first year to 41% for years 0-3; VERT-MN: 61% for first year to 49% for years 0-3). Data from the Fracture Intervention Trial (FIT) I trial with alendronate showed that the RRR in the cumulative incidence of new vertebral fractures versus placebo decreased from 62% for years 0-2 to 47% for years 0-3. Similar decreases in RRR over time were reported with strontium ranelate in the Spinal Osteoporosis Therapeutic Intervention study (SOTI; 49% for first year to 33% for years 0-4) and Treatment of Peripheral Osteoporosis Study (TROPOS; 45% for first year to 24% for years 0-5). No clear trend exists for sustained efficacy over time with raloxifene.

CONCLUSIONS

Vertebral fracture protection could be interpreted to decrease over time with alendronate, risedronate and strontium ranelate, and may be due to multiple factors. Ibandronate sustained vertebral antifracture efficacy over time.

Performance of quantitative ultrasound measurements of bone for monitoring raloxifene therapy

Raloxifene increases bone mineral density (BMD) and decreases vertebral fracture risk; the effects on quantitative ultrasound (QUS) variables, however, have been less well studied. We aimed to further evaluate the effectiveness of QUS for monitoring raloxifene treatment and withdrawal effects. Osteopenic, postmenopausal women (age=50-80 yr, n=125), who completed a 96-wk study (phase A) evaluating treatment compliance or monitoring, were invited to participate in a 96-wk raloxifene withdrawal study (phase B). Those originally receiving treatment were then randomized to continue on raloxifene (60 mg/d)+calcium (500 mg/d) (n=23) or to discontinue raloxifene and take placebo+calcium (500 mg/d) (n=23). Previously untreated women remained untreated (n=12). Yearly QUS and BMD measurements were performed. At the end of phase A, lumbar spine BMD (p=0.005), amplitude-dependent speed of sound (Ad-SoS) (p=0.006) and average SoS (p=0.040) decreased in untreated women but remained stable in treated women. Significant changes in Ad-SoS and ultrasonic bone profiler index had occurred in treated women by the end of phase B (p<0.01). All variables, except bone transmission time, were higher for those receiving any raloxifene treatment (p<0.05). Until further knowledge has been acquired, QUS measurement variables should only be used in conjunction with BMD when assessing changes in bone because of raloxifene therapy.

Back pain during different sequential treatment regimens of teriparatide: results from EUROFORS

OBJECTIVE

To investigate changes in back pain in postmenopausal women with severe osteoporosis who received teriparatide for 24 months or switched at 12 months to raloxifene or no active treatment.

STUDY DESIGN AND METHODS

This prospective, controlled, randomised, open-label, 2-year study enrolled 868 postmenopausal women with osteoporosis and a recent fragility fracture. After 12 months of teriparatide (20 microg/day), 507 patients were randomised to further teriparatide (n = 305), raloxifene 60 mg/day (n = 100), or no active treatment (n = 102) for another 12 months (substudy 1); in substudy 2, 199 patients continued teriparatide. All received calcium and vitamin D supplementation. Back pain was self-assessed by patients using a visual analogue scale (0-100 mm). Changes in back pain were analysed using a mixed model for repeated measures.

RESULTS

During year 1, back pain decreased from a mean (SD) of 48.9 mm (24.0) at baseline by 11.5 mm (p < 0.001) in the total study population. In substudy 1, mean change in back pain from month 12 (randomisation) to 24 months was -2.2, -4.4 and +0.7 mm in the teriparatide (p = 0.076), raloxifene (p = 0.041), and no active treatment groups (p = 0.751). There were no between-group differences from randomization to 18 or 24 months. In a sensitivity analysis excluding patients with low baseline back pain (VAS < 30 mm), mean change from randomisation to endpoint was significant for teriparatide (-3.9 mm, p = 0.006) and raloxifene (-6.3 mm, p = 0.018) groups. Subgroup analyses of 503 patients who received teriparatide for up to 2 years showed that patients with a recent vertebral fracture had a greater decrease in back pain than those without (p < 0.05). Those with and without mild back pain (>or=30 mm), and those with and without severe back pain (>or=60 mm) at baseline all had a statistically significant reduction in back pain after 24 months (p < 0.05).

CONCLUSIONS

Teriparatide treatment is associated with significant reductions in back pain regardless of the presence of recent vertebral fracture. These results need to be considered with caution due to the open-label design of the study.

Risk of atrial fibrillation associated with use of bisphosphonates and other drugs against osteoporosis: a cohort study

We studied the association between bisphosphonate use and risk of atrial fibrillation or flutter and the effect of confounders such as heart and lung disease in a nationwide retrospective cohort from Denmark. All users of bisphosphonates and other drugs against osteoporosis between 1996 and 2006 (n = 103,562) were the exposed group and three age- and gender-matched controls from the general population (n = 310,683) were the nonexposed group. The main outcome measure was atrial fibrillation or atrial flutter. Before initiation of treatment against osteoporosis, no excess of atrial fibrillation or flutter was present for any drug except for etidronate (OR = 1.22, 95% CI 1.15-1.29). After initiation of treatment, raloxifene was not associated with any excess risk of atrial fibrillation (OR = 0.98, 95% CI 0.72-1.33). Etidronate (HR = 1.08, 95% CI 1.02-1.14) and alendronate (HR = 1.09, 95% CI 1.00-1.20) were associated with an excess risk of atrial fibrillation after treatment start if statistical adjustments were made for cardiovascular disease. However, this association disappeared upon statistical adjustment for chronic obstructive pulmonary disease (COPD) (etidronate HR = 1.04, 95% CI 0.98-1.10; alendronate HR = 1.05, 95% CI 0.96-1.15). In patients using etidronate (12.5% vs. 3.8%) and alendronate (11.4% vs. 4.6%) major differences were present in prevalence of COPD at start of treatment compared to matched controls. In conclusion, oral bisphosphonates do not seem to be associated with an excess risk of atrial fibrillation. Any excess risk seen in prior studies may be due to confounding from COPD.

[Effects of SERMs on bone health. Combination therapy with raloxifene]

It is generally considered that drugs with different pharmacological actions are prescribed when combination therapy is undertaken. Vitamin D insufficiency or deficiency is prevalent in osteopenic and osteoporotic postmenopausal women. Combination therapy of raloxifene with other agents including vitamin D has been reported and its effect on fracture prevention remains to be elucidated.

The effect of cessation of raloxifene treatment on bone turnover in postmenopausal women

There is evidence to suggest accelerated bone loss following estrogen cessation. The effect of cessation of raloxifene therapy on bone turnover is unknown. Our aim was to determine the effect of cessation of raloxifene treatment on bone turnover and bone mineral density (BMD) in postmenopausal, osteopenic women. Women aged 50 to 80 years received raloxifene for 96 weeks and were then randomized to continue raloxifene (group 1, n=20) or placebo (group 2, n=20) for a further 96 weeks. A third group (group 3, n=14) received no treatment. Bone turnover markers and bone density (BMD) were measured throughout the study. Raloxifene treatment for 96 weeks resulted in a decrease in bone turnover (PINP by 31%) and an increase in spine BMD (by 2%) but no change in hip BMD for groups 1 and 2. Continuation of raloxifene (group 1) maintained these changes. Following cessation of raloxifene (group 2), bone markers returned to baseline levels (by 120 weeks). Hip BMD was decreased by 2% at 192 weeks compared to baseline. Bone markers in the controls (group 3) remained at the upper limit of the reference range throughout, with decreases in BMD of 2.3% (spine) and 2.8% (hip). Bone loss following cessation of raloxifene therapy at 96 weeks was greater than in the control group, suggesting accelerated bone loss. The beneficial effect on bone turnover of 96 weeks of raloxifene was lost 6 months after cessation of treatment.

[Effects of SERMs on bone health. The potential of SERM in the care of chronic kidney disease-mineral bone and disorders]

The umbrella concept chronic kidney disease-mineral bone and disorders (CKD-MBD) has been developed these days, which includes vascular calcification, laboratory abnormalities, and bone abnormalities. Given the high prevalence of CKD stage 3 in the patients with osteoporosis and the high risk of fracture in osteoporosis with CKD, the role of raloxifene, one of SERM, in the care of CKD-MBD should not be overlooked. In the post-hoc analysis of the MORE trial, the effect of raloxifene to reduce vertebral fracture was confirmed as well as a positive effect on bone mineral densities in patients with moderate renal failure and normal parathyroid hormone (PTH). However, there is a possibility of this drug increasing PTH level just like other antiresorbing medications. Therefore, concomitant prescription of active vitamin D might be a good solution. From the viewpoint of pharmacokinetics, it is better to reduce the dose of raloxifene in patients with severe CKD. Moreover, it should be remembered not to prescribe this drug in nephrotic syndrome, which is associated with high risk of thrombosis.

[Effects of SERMs on bone health. Discrimination of SERMs from bisphosphonates in the treatment of postmenopausal osteoporosis]

Since the aim of the treatment of osteoporosis is to prevent fractures, the first-line drugs must be chosen according to their antifracture efficacies. In postmenopausal women with osteoporosis, alendronate, risedronate, minodronate, and raloxifene are effective in preventing vertebral fractures, and alendronate and risedronate significantly prevent hip fractures. Because the antifracture efficacy of raloxifene against vertebral fractures is considered similar to that of bisphosphonates, the discrimination of raloxifene from bisphosphonates depends on the strategy of doctors (internal medicine, gynecology, and orthopaedics) for preventing vertebral fractures according to the possible side effects of drugs including upper gastrointestinal events, hot flash, and deep vein thromboembolism. Recent reports suggest that patients could be identified who are more responsive to raloxifene than bisphosphonates by evaluating collagen cross-links markers such as homocysteine. Because the incidence of vertebral fractures is higher in Japanese patients, raloxifene plays an important role in the prevention of vertebral fractures in postmenopausal Japanese women with osteoporosis.

Raloxifene and body composition and muscle strength in postmenopausal women: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To compare the effects of raloxifene and placebo on body composition and muscle strength.

DESIGN

Randomized, double-blind, placebo-controlled trial involving 198 healthy women aged 70 years or older conducted between July 2003 and January 2008 at the University Medical Centre, Utrecht, The Netherlands.

METHODS

Participants were randomly assigned to receive raloxifene 60 mg or placebo daily for 12 months. Measurements were taken at baseline, 3, 6, and 12 months, and change from baseline was calculated. Main outcome measures were body composition (bioelectrical impedance analysis), muscle strength, and muscle power (maximum voluntary isometric knee extension strength, explosive leg extensor power, and handgrip strength).

RESULTS

At 12 months, the body composition of women taking raloxifene was significantly different from that of women taking placebo: fat-free mass (FFM) had increased by a mean of 0.83 (2.4) kg in the raloxifene group versus 0.03 (1.5) kg in the placebo group (P=0.05), and total body water had increased by a mean of 0.6 (1.8) litres in the raloxifene group versus a decrease of 0.06 (1.1) litres in the placebo group (P=0.02). Muscle strength and power were not significantly different.

CONCLUSION

Raloxifene significantly changed body composition (increased FFM; increased water content) compared with placebo in postmenopausal women.

The effects of long-term raloxifene and estradiol treatments on bone in a patient with congenital aromatase deficiency

INTRODUCTION

In adult aromatase-deficient men, estrogen treatment has always resulted in a rapid skeletal maturation with epiphyseal closure and improved BMD. Raloxifene is a SERM with proven estrogen agonist action on bone that leads to an improvement in BMD and a reduction in bone turnover. The present study reports the effects of raloxifene and transdermal estradiol treatment, respectively, on epiphyseal closure and BMD in an aromatase-deficient man, over a 24-month follow-up, with the aim of obtaining further insight into the role of estrogens in the male skeletal homeostasis.

MATERIALS AND METHODS

A 25-year-old Caucasian man with aromatase deficiency, a bone age of 15.3 years, unfused epiphyses and an impaired BMD was initially administered raloxifene (60 mg/day per os) for 12 months, while transdermal estradiol (25 microg twice weekly) was administered for the subsequent 12 months. During the follow-up, the effects of the two treatments on epiphyseal closure, BMD and bone turnover markers were investigated. An iliac crest bone biopsy was performed only before and after the raloxifene treatment, but it was not repeated after transdermal estradiol treatment.

RESULTS

No changes in bone age were observed after raloxifene therapy, whereas a complete epiphyseal closure was achieved with transdermal estradiol treatment. Compared with baseline values, raloxifene treatment led to improved BMD both at the ultradistal forearm and 33% radius; the transdermal estradiol treatment resulted in a further slight increase in BMD at the 33% radius, but not at the ultradistal forearm. The baseline bone biopsy showed elevated bone remodelling in trabecular bone, while the second biopsy following raloxifene treatment revealed a decrease in remodelling.

DISCUSSION

This study shows that the management of aromatase deficiency in the male cannot consider raloxifene as a first choice treatment, but should be still based on estrogen replacement treatment since in this patient the completion of bone maturation has only been obtained once estradiol substitution was performed. The present case also demonstrates that raloxifene is able to improve BMD in aromatase-deficient men.

Effects of teriparatide in postmenopausal women with osteoporosis on prior alendronate or raloxifene: differences between stopping and continuing the antiresorptive agent

OBJECTIVE

The aim of the study was to assess adding vs. switching to teriparatide 20 microg/d in patients on alendronate or raloxifene.

DESIGN

We conducted a randomized, open-label trial.

PATIENTS AND INTERVENTIONS

Postmenopausal women with osteoporosis on alendronate or raloxifene for at least 18 months added teriparatide (Add groups) or switched to teriparatide (Switch groups) for 18 months.

MAIN OUTCOME MEASURES

We measured bone turnover markers (BTM) and bone mineral density (BMD).

RESULTS

In the alendronate stratum, increases in BTM were smaller in the Add vs. Switch group [6-month PINP (64 vs. 401%); bone ALP (15 vs. 71%); betaCTX (27 vs. 250%); all P < 0.001]. However, at 6 months, total hip BMD increased more in the Add vs. Switch group (1.4 vs. -0.8%; P = 0.002). In the Add vs. Switch group, 18-month BMD increments were higher in lumbar spine (8.4 vs. 4.8%; P = 0.003) and total hip (3.2 vs. 0.9%; P = 0.02), but not in femoral neck (2.7 vs. 2.3%; P = 0.75). In the raloxifene stratum, increases in BTM were also smaller in the Add vs. Switch group [6-month PINP (131 vs. 259%; P < 0.001), bone ALP (31 vs. 44%; P = 0.035), and betaCTX (67 vs. 144%; P = 0.001)]. At 6 months, total hip BMD increase was greater in the Add vs. Switch group (1.8 vs. 0.5%; P = 0.028). At 18 months, increases in lumbar spine (9.2 vs. 8.1%), total hip (2.8 vs. 1.8%), and femoral neck (3.8 vs. 2.2%) were not significantly different between groups.

CONCLUSIONS

In women with osteoporosis treated with antiresorptives, greater bone turnover increases were achieved by switching to teriparatide, whereas greater BMD increases were achieved by adding teriparatide.

Effects of conjugated equine estrogens or raloxifene on lipid profile, coagulation and fibrinolysis factors in postmenopausal women

OBJECTIVES

To compare the effect of conjugated equine estrogens (CEE) and raloxifene on lipid profile and hemostasis.

MATERIALS AND METHODS

A double-blind, randomized and parallel study was performed with 90 healthy postmenopausal women, aged 54 +/- 5 years, divided into three groups and submitted to daily therapy with either CEE 0.625 mg, raloxifene 60 mg or placebo for 4 months. The lipid profile, coagulation and fibrinolytic factors were analyzed.

RESULTS

CEE increased the levels of high density lipoprotein cholesterol (HDL-C) from 49.0 to 56.8 mg/dl (p < 0.001), very low density lipoprotein cholesterol (VLDL-C) from 17.2 to 22.3 mg/dl (p < 0.001), and triglycerides from 86.0 to 111.7 mg/dl (p < 0.001), and decreased the levels of low density lipoprotein cholesterol (LDL-C) from 121.0 to 106.5 mg/dl (p < 0.001). The only significant effect of raloxifene was an increase in the levels of HDL-C from 46.0 to 47.8 mg/dl (p = 0.019). There was no significant reduction in LDL-C, from 115.5 to 110.2 mg/dl (p = 0.06), VLDL-C, from 21.7 to 20.0 mg/dl (p = 0.201), and triglycerides, from 108 to 100 mg/dl (p = 0.201). CEE decreased the levels of fibrinogen, from 370.5 to 326.8 g/l (p = 0.039) and the levels of antithrombin III, from 99.5 to 93.2% (p < 0.001). Raloxifene decreased the levels of fibrinogen, from 354.7 to 302.0 g/l (p = 0.009) and the levels of antithrombin III, from 102.4 to 98.5% (p = 0.039). CEE increased levels of protein C from 103.7 to 115.3 mg/l (p < 0.001) and raloxifene did not change the levels of protein C (107.9 to 105.1 mg/l; p = 0.158). CEE decreased the antigen levels of tissue plasminogen activator (t-PA) from 8.8 to 6.8 U/ml (p < 0.001), and of plasminogen activator inhibitor (PAI-1) from 30.8 to 21.6 U/ml (p < 0.010), whereas raloxifene had no significant effect on either t-PA, from 9.6 to 9.2 U/ml (p = 0.235) or PAI-1 antigen levels, from 32.1 to 30.4 U/ml (p = 0.538). CONCLUSION Both CEE and raloxifene exert significant effects on the lipid and coagulation profile. CEE had a more significant effect on fibrinolysis than raloxifene. These effects may have a significant impact on the cardiovascular risk that needs to be confirmed in larger studies.

The long-term effect of raloxifene on the genitourinary tract

OBJECTIVE

To investigate the effect of long-term treatment with raloxifene on pelvic organ prolapse and urinary incontinence.

METHODS

This was a case-control study in patients attending the Centre for Metabolic Bone Disease. Eighty-two women were included. The average age was 69 years (range 60-85 years). Thirty-nine women had taken raloxifene for an average of 55 +/- 25 months and 43 had taken bisphosphonates for an average of 41.96 +/- 15.93 months. The Prolapse Quality of Life (P-QOL), version 4 and Incontinence Impact questionnaire (IIQ-7) and Urogenital Distress Inventory, short form (UDI-6) were used to evaluate presence of pelvic organ prolapse and urinary incontinence. Women symptomatic with prolapse were offered a pelvic examination to define the type and severity of the prolapse. Women giving a history of urinary incontinence were offered urodynamic evaluation to establish the cause of the incontinence. The main outcome measures were prevalence and severity of pelvic organ prolapse and urinary incontinence and its impact on quality of life.

RESULTS

Over 50% of the women complained of incontinence in both groups, 51% (22) of women taking raloxifene and 53% (28) of the controls. Prolapse was present in two women in the raloxifene group (5%) and six women (11%) in the control group. Urge incontinence was similar in both prevalence (15 vs. 21 women) and severity between cases and controls. Stress incontinence, on the contrary, had a similar prevalence (20 vs. 19 women) but was more severe in the controls (p = 0.004). There was no difference in mean scores of IIQ-7 and P-QOL for quality of life between cases and controls.

CONCLUSIONS

Raloxifene taken long-term does not appear to adversely affect urinary incontinence or prolapse.

Beneficial effects of raloxifene and atorvastatin on serum lipids and HDL phospholipids levels of postmenopausal women

Selective oestrogen receptor modulators (raloxifene) and statins (atorvastatin) have been shown to reduce the risk of cardiovascular disease associated with the postmenopausal status. Their beneficial effects may be mediated partly by favourable changes in serum lipids and particular on HDL phospholipid composition. In the present study, individual administration of either raloxifene (Group A) or atorvastatin (Group B) or both (Group C) was compared for a period of 3 months and their effects on total lipids and HDL phospholipids were evaluated. The combined treatment of raloxifene and atorvastatin resulted in profound changes in the majority of serum lipids, including a significant reduction in total cholesterol and triglycerides (P<0.001), a rise in total phospholipids (P<0.01) and a reduction in LDL-C and Apo B levels (P<0.001). Furthermore, Apo A-I was elevated (P<0.001) whereas total HDL phospholipids were significantly increased (P<0.05). Specifically, HDL phosphatidylcholine levels were markedly increased (P<0.001) and HDL lysophosphatidylcholine, sphingomyelin and phosphatidylinositol levels were reduced (P<0.05). A further attempt to evaluate each treatment group was performed and the significance of these results is discussed.

Comparative analysis of oestrogen and raloxifene effects on the phospholipid composition of high density lipoproteins in healthy postmenopausal women

The beneficial effect of selective oestrogen receptor modulators such as raloxifene in cardiovascular disease may be mediated partly by favourable changes in the phospholipid composition of high density lipoprotein (HDL) subclasses. In Group A (oestrogen alone) HDL2 phosphatidylcholine increased (P<0.001), while there was a decrease in HDL2 phosphatidylinositol (P<0.05) and HDL2 phosphatidylethanolamine (P<0.05) compared to controls (baseline). In the same group, HDL3 phosphatidylcholine increased (P<0.001) and HDL3 phosphatidylethanolamine decreased (P<0.01). In Group B (raloxifene) HDL2 phosphatidylcholine increased (P<0.001) as well as HDL2 diphosphatidylglycerol (P<0.01) while there were decreases in HDL2 sphingomyelin (P<0.01) and HDL2 phosphatidylethanolamine (P<0.05). In the same group, an increase in HDL3 phosphatidylcholine (P<0.001) and a reduction in HDL3 phosphatidylinositol (P<0.05) were observed as well as a decrease in HDL3 phosphatidylethanolamine (P<0.01) and HDL3 diphosphatidylglycerol (P<0.05). The significance of these results is discussed.