Risk of fractures in older adults using antihypertensive medications

Análise dos fatores associados a quedas com fratura de fêmur em idosos: um estudo caso-controle

OBJETIVO: Identificar os principais fatores associados a quedas e fraturas de fêmur em idosos. MÉTODOS: Trata-se de estudo caso-controle (um grupo de casos e dois grupos controle) na proporção de 1:1:1, em que foram estudados 135 indivíduos com idade ≥60 anos, pareados por sexo, no período de 2005 a 2012. Os dados foram coletados por meio de entrevistas nos domicílios dos participantes, e realizou-se levantamento de informações em prontuários. Para análise das diferenças entre proporções e médias entre os grupos, empregaram-se o teste qui-quadrado e o teste t Student, respectivamente. Para o estudo da associação entre variáveis, foram realizadas análises univariadas e multivariadas empregando-se regressão logística. Como medida de efeito, foram empregados odds ratio (OR) e seu intervalo de confiança a 95% (IC95%). Em todas as análises, considerou-se um nível de significância de 5%. RESULTADOS: Após análise multivariada, os fatores de proteção contra fratura de fêmur foram: ouvir bem e possuir corrimão nas escadas de suas residências. Os fatores de risco para fratura de fêmur foram: hipertensão arterial sistêmica, sedentarismo e possuir superfície escorregadia na residência. Os fatores de proteção para queda foram: possuir corrimão nas escadas de suas residências, ser portador de osteoporose e depressão. O fator de risco de queda foi o sedentarismo. CONCLUSÃO: As fraturas de fêmur representam importante fator de morbidade em idosos. Conhecer os fatores de risco para fraturas pós-queda em idosos é essencial para o planejamento de ações individuais e coletivas voltadas à prevenção deste agravo e suas consequências. Atividades físicas, planos terapêuticos mais adequados e correção de inadequações nos domicílios desses indivíduos devem ser orientados e incentivados.

Local renin-angiotensin system is associated with bone mineral density of glucocorticoid-induced osteoporosis patients

The local renin-angiotensin system (RAS) is closely related to bone metabolism. However, it is unknown whether the local RAS is related to bone mineral density (BMD) in glucocorticoid-induced osteoporosis (GIOP). Here, we revealed that the two main characteristics of GIOP might inhibit bone formation and enhance bone resorption.

INTRODUCTION

The aim of this study is to assess the expression of the main RAS components in the trabecular bone of lumbar vertebrae in GIOP and analyze the relationship between the major RAS components and BMD.

METHODS

We collected 96 inpatient cases of lumbar disc herniation from patients who underwent dual-energy X-ray absorptiometry examinations followed by surgical treatment in our hospital. Patients were divided into the GIOP group (n = 48) and control group (n = 48). The circulating and local expression levels of the main RAS components were examined. The correlation between the main RAS components and BMD was then analyzed.

RESULTS

The mRNA expression of local bone angiotensin type 1 and 2 receptors (AT1R and AT2R, respectively) and RANKL was higher in the GIOP group compared with the control group (p < 0.001), but there was no difference in the circulating protein levels between groups (p > 0.05). Multiple logistic regression analysis revealed that AT1R and AT2R expression and the RANKL/OPG ratio in local bone were negatively associated with BMD (p < 0.001, odds ratio (OR) 1.236, 95 % confidence interval (CI) 1.207-1.333; p < 0.001, OR 1.971, 95% CI 1.809-2.233; and p < 0.001, OR 1.676, 95% CI 1.546-1.845, respectively).

CONCLUSION

This study provides evidence that the role of local RAS is related to BMD in GIOP patients, and suggests that local RAS might influence RANKL/OPG signaling to modulate bone metabolism.

Fracture healing: an appraisal of the effects of frequently prescribed medications

BACKGROUND

Recognizing the existence of adverse drug effects of frequently prescribed drugs can empower a clinician with knowledge to avoid dangerous adverse effects that may result in hazardous, negative patient outcomes on either fracture healing or bone health. Pharmacovigilance reports have described the influence of medications, allowing for bone health to be quite unpredictable.

METHODS

First, mechanisms found in the medical literature of potential drug adverse effects regarding fracture healing are presented. Second, the 100 most frequently prescribed medications in 2010 are reviewed regarding adverse effects on fracture healing. These reported adverse effects are evaluated for medical causation. Last, a data table describing the 100 reviewed medications and their reported effects on fracture healing is provided.

RESULTS

The actual number of different medications in the review was 72. Reported drug adverse effects on bone and fracture healing occurred with 59 of the 72 drugs (81.9%). These adverse effects are either described as a definitive statement or represented by postmarketing case reports. Thirteen of the 72 review drugs (18.1%) did not have any description of the possible effects on bone health. A total of 301 cases reports describing delayed union, malunion, and nonunion of fractures represent 31 of the 72 medications reviewed (43.1%).

CONCLUSIONS

This review offers the health-care provider information regarding potential adverse drug effects on bone health. Empowered with this information, clinicians may assist their patients in maximizing pharmacologic outcomes by avoiding these reported harmful adverse effects.

Medication use before and after hip fracture: a population-based cohort and case-control study

BACKGROUND

Osteoporosis, together with age, is the main risk factor for hip fracture, the incidence of which has also been associated with an increased risk of falling or co-morbidities and related pharmacological treatments.

OBJECTIVES

The aim of this study was to investigate changes in concomitant pharmacological treatments prescribed before and after hip fracture in elderly patients compared with treatments prescribed to a matched cohort of subjects without hospitalisation for fractures.

METHODS

Data relating to the study population were extracted from a large population-based administrative database of the Italian National Health Authorities. A retrospective analysis was conducted involving female patients (6,431) aged ≥65 years and hospitalised for a hip fracture. The control group comprised age-matched subjects (38,586) not hospitalised for fracture. Changes in drug prescriptions 1 year before and 1 year after hip fracture and differences versus controls were compared.

RESULTS

Prior to the fracture, patients were taking more anti-Parkinson medications, antidepressants, medications for chronic obstructive pulmonary disease (COPD), bisphosphonates and calcium-vitamin D supplements, although the intake of the routinely monitored drug classes was significantly infrequent. Polypharmacy was less frequent in fractured women before fracture than in controls (22 vs. 25 %, respectively; P < 0.001), but it was more frequent (30 %, P < 0.001) post-fracture. The incidence of fracture was associated with a significant increase in the use of a number of drug classes: insulin, NSAIDs or analgesics, gastroprotectants, loop diuretics, β-blockers, antidepressants, antiparkinson drugs, antiepileptics and drugs for COPD.

CONCLUSION

Our study confirms a strong association between the use of some drugs (antidepressants, antiparkinson drugs, drugs for COPD) and the risk of hip fracture, but drug use is globally less common than in controls. Hip fracture is associated with a significant increase in drug use, suggesting a global deterioration of health conditions.

Association between loop diuretic use and fracture risk

SUMMARY

Loop diuretic use has been shown to be associated with an increased fracture risk, but the findings have been inconsistent. The present meta-analysis suggests that loop diuretics show a significant positive association with the overall risk of total fractures and, specifically, hip fractures.

INTRODUCTION

Despite being widely used, there is limited, prospective randomized trial evidence regarding the skeletal effects of loop diuretics. Previous observational studies have reported conflicting findings regarding the association between loop diuretic use and the risk of fractures.

METHODS

This meta-analysis of observational studies assessed the association between loop diuretic use and the risk of fractures. The PubMed, EMBASE, and OVID databases were searched for prospective cohort and case-control studies. Relative risks (RR) with 95% confidence intervals (CI) were derived using random-effects models throughout the analysis.

RESULTS

Thirteen studies (4 cohort studies and 9 case-control studies) were included, involving 842,644 participants and 108,247 fracture cases. Compared with non-users, people who had taken loop diuretics had an approximately 15% higher risk of total fractures (95% CI, 1.04-1.26; p<0.01), with high heterogeneity between studies (I2=80.5%; p<0.01). The RR was 1.14 (95% CI, 1.08-1.19) for hip fractures and 0.99 (95% CI, 0.93-1.05) for lower arm or wrist fractures. The RR was 1.05 (95% CI, 1.00-1.11) in prospective cohort studies and 1.22 (95% CI, 1.00-1.44) in case-control studies. There was no evidence of publication bias.

CONCLUSION

The results suggest that loop diuretics show a significant positive association with the overall risk of total fractures and hip fractures.

Risk of fractures in subjects with antihypertensive medications: A nationwide claim study

BACKGROUND

The effect of antihypertensives on fracture has important clinical implications, since antihypertensives are frequently prescribed with lifelong exposure. This study aimed to compare risk of fracture between antihypertensive medication classes and non-users among adults.

METHODS

Nationwide claim data from January 1, 2007 to December 31, 2011 were analyzed. Among 8,315,709 subjects with antihypertensive prescriptions in nationwide medical claim database in South Korea, 528,522 subjects, who initiated single-drug antihypertensives or non-users, were analyzed. Subjects were classified as non-user, alpha-blocker (AB), angiotensin-converting-enzyme-inhibitor (ACEI), angiotensin-receptor-blocker (ARB), beta-blocker (BB), calcium-channel-blocker (CCB), and diuretic users. Subjects with combination antihypertensive medications were excluded.

RESULTS

A total of 16,805 fracture outcomes were observed during mean follow-up duration of 1.9 years. Fracture rate per 10,000 person-years varied significantly across type of antihypertensives, with ARB having the lowest rate (152.7, 95% confidence interval (CI) 145.4-160.4), and AB having the highest rate (323.7, 95% CI 237.4-441.4). Non-users had fracture rates (152.2, 95% CI 148.7-155.7) similar to ARB users. In models adjusting for age, gender, comorbidity score, diagnosis of diabetes, diagnosis of osteoporosis, osteoporosis treatment, and osteoporosis related diseases, AB users (adjusted hazard ratio (aHR)=2.26), ACEI users (aHR=1.68), diuretic users (aHR=1.45), CCB users (aHR=1.23), and BB users (aHR=1.15) showed significantly increased risk of fractures compared with non-users (P<0.05). Only the fracture risk of ARB users (aHR=1.00, 95% CI 0.95-1.05) was not significantly different from the non-users.

CONCLUSIONS

The use of antihypertensives except for ARB is associated with increased risk of fracture, with ACEI and AB having higher risk among hypertensive adults.

Adverse skeletal effects of drugs - beyond Glucocorticoids

Osteoporotic fractures are an important public health problem with significant individual and societal costs. In addition to the major risk factors for osteoporotic fracture, low bone mineral density (BMD), age, low body weight and history of fracture or falls, some drugs are now considered to be important secondary risk factor for bone loss and fracture, particularly amongst predisposed individuals. Currently available data are often generated from small observational clinical studies, making risk assessment and development of management guidelines difficult. In many cases, the exposed population has a low baseline risk for fracture and additional assessment and treatment may not be necessary. In this review, we focus on drugs other than glucocorticoids identified as potentially causing adverse skeletal effects, summarizing the existing evidence from preclinical and clinical studies, and suggest recommendations for patient management.

Is use of fall risk-increasing drugs in an elderly population associated with an increased risk of hip fracture, after adjustment for multimorbidity level: a cohort study

Background

Risk factors for hip fracture are well studied because of the negative impact on patients and the community, with mortality in the first year being almost 30% in the elderly. Age, gender and fall risk-increasing drugs, identified by the National Board of Health and Welfare in Sweden, are well known risk factors for hip fracture, but how multimorbidity level affects the risk of hip fracture during use of fall risk-increasing drugs is to our knowledge not as well studied. This study explored the relationship between use of fall risk-increasing drugs in combination with multimorbidity level and risk of hip fracture in an elderly population.

Methods

Data were from Östergötland County, Sweden, and comprised the total population in the county aged 75 years and older during 2006. The odds ratio (OR) for hip fracture during use of fall risk-increasing drugs was calculated by multivariate logistic regression, adjusted for age, gender and individual multimorbidity level. Multimorbidity level was estimated with the Johns Hopkins ACG Case-Mix System and grouped into six Resource Utilization Bands (RUBs 0–5).

Results

2.07% of the study population (N = 38,407) had a hip fracture during 2007. Patients using opioids (OR 1.56, 95% CI 1.34-1.82), dopaminergic agents (OR 1.78, 95% CI 1.24-2.55), anxiolytics (OR 1.31, 95% CI 1.11-1.54), antidepressants (OR 1.66, 95% CI 1.42-1.95) or hypnotics/sedatives (OR 1.31, 95% CI 1.13-1.52) had increased ORs for hip fracture after adjustment for age, gender and multimorbidity level. Vasodilators used in cardiac diseases, antihypertensive agents, diuretics, beta-blocking agents, calcium channel blockers and renin-angiotensin system inhibitors were not associated with an increased OR for hip fracture after adjustment for age, gender and multimorbidity level.

Conclusions

Use of fall risk-increasing drugs such as opioids, dopaminergic agents, anxiolytics, antidepressants and hypnotics/sedatives increases the risk of hip fracture after adjustment for age, gender and multimorbidity level. Fall risk-increasing drugs, high age, female gender and multimorbidity level, can be used to identify high-risk patients who could benefit from a medication review to reduce the risk of hip fracture.

Is use of fall risk-increasing drugs in an elderly population associated with an increased risk of hip fracture, after adjustment for multimorbidity level: a cohort study

BACKGROUND

Risk factors for hip fracture are well studied because of the negative impact on patients and the community, with mortality in the first year being almost 30% in the elderly. Age, gender and fall risk-increasing drugs, identified by the National Board of Health and Welfare in Sweden, are well known risk factors for hip fracture, but how multimorbidity level affects the risk of hip fracture during use of fall risk-increasing drugs is to our knowledge not as well studied. This study explored the relationship between use of fall risk-increasing drugs in combination with multimorbidity level and risk of hip fracture in an elderly population.

METHODS

Data were from Östergötland County, Sweden, and comprised the total population in the county aged 75 years and older during 2006. The odds ratio (OR) for hip fracture during use of fall risk-increasing drugs was calculated by multivariate logistic regression, adjusted for age, gender and individual multimorbidity level. Multimorbidity level was estimated with the Johns Hopkins ACG Case-Mix System and grouped into six Resource Utilization Bands (RUBs 0-5).

RESULTS

2.07% of the study population (N = 38,407) had a hip fracture during 2007. Patients using opioids (OR 1.56, 95% CI 1.34-1.82), dopaminergic agents (OR 1.78, 95% CI 1.24-2.55), anxiolytics (OR 1.31, 95% CI 1.11-1.54), antidepressants (OR 1.66, 95% CI 1.42-1.95) or hypnotics/sedatives (OR 1.31, 95% CI 1.13-1.52) had increased ORs for hip fracture after adjustment for age, gender and multimorbidity level. Vasodilators used in cardiac diseases, antihypertensive agents, diuretics, beta-blocking agents, calcium channel blockers and renin-angiotensin system inhibitors were not associated with an increased OR for hip fracture after adjustment for age, gender and multimorbidity level.

CONCLUSIONS

Use of fall risk-increasing drugs such as opioids, dopaminergic agents, anxiolytics, antidepressants and hypnotics/sedatives increases the risk of hip fracture after adjustment for age, gender and multimorbidity level. Fall risk-increasing drugs, high age, female gender and multimorbidity level, can be used to identify high-risk patients who could benefit from a medication review to reduce the risk of hip fracture.

Intensive blood pressure control, falls, and fractures in patients with type 2 diabetes: the ACCORD trial

BACKGROUND

There are few rigorous studies to confirm or refute the commonly cited concern that control of blood pressure to lower thresholds may result in an increased risk of falls and fractures.

OBJECTIVE

To compare falls and fractures in participants with type 2 diabetes in the intensive (targeting a systolic blood pressure of < 120 mmHg) and standard (targeting a systolic blood pressure of < 140 mmHg) blood pressure control arms of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) randomized trial (N = 4,733).

PARTICIPANTS

A subset of 3,099 participants self-reported annually on the occurrence of falls and non-spine fractures. Fractures were centrally adjudicated.

MAIN MEASURES

The incidence of falls in the two treatment groups was compared using a random-effects negative binomial model, and fracture risk was compared using Cox proportional hazards models.

KEY RESULTS

At enrollment in both groups, the mean age was 62 years, 44% were women, 25% were Black, and mean blood pressure was 138/75 mmHg. During follow-up, all classes of medications, particularly thiazide diuretics, were more commonly prescribed in the intensive group. After 1 year of follow-up, the mean systolic blood pressure was 133 ± 15 mmHg in the standard group and 119 ± 14 mmHg in the intensive group. The adjusted rate of falls did not differ in the intensive and standard groups (62.2/100 person-years vs. 74.1/100 person-years, RR = 0.84, 95% CI 0.54-1.29, p = 0.43). The risk of non-spine fractures was nonsignificantly lower in the intensive than in the standard blood pressure group (HR 0.79, 95% CI 0.62-1.01, p = 0.06).

CONCLUSIONS

We conclude that intensive antihypertensive treatment that lowered mean systolic blood pressure to below 120 mmHg was not associated with an increased risk of falls or non-spine fractures in patients age 40 to 79 years with type 2 diabetes.

Effect of angiotensin II receptor blocker, olmesartan, on turnover of bone metabolism in bedridden elderly hypertensive women with disuse syndrome

AIMS

Although recent studies suggest that several antihypertensive drugs could reduce the risk of bone fracture, it is still unclear how these drugs act on bone remodeling, especially in elderly women with severe osteoporosis with disuse syndrome. In the present study, we investigated the effects of a calcium channel blocker (CCB) and an angiotensin II receptor blocker (ARB) on bone metabolism in elderly bedridden women with hypertension and disuse syndrome.

METHODS

Elderly bedridden women (aged >75 years) receiving antihypertensive therapy treated with CCB were recruited in the present study. The participants were divided into two groups--CCB group and ARB group--and followed up to 12 months.

RESULTS

Markers of bone resorption were markedly increased, suggesting accelerated bone resorption in the participants of the present study. In the follow-up period, the patients treated with a CCB showed a significant decrease in bone mineral density in a time-dependent manner, accompanied by a significant increase in bone resorption markers, whereas treatment with olmesartan inhibited bone loss, associated with attenuation of increased bone resorption markers. Bone mineral density of femoral neck in the CCB group was significantly lower than that in the ARB group at 6 months.

CONCLUSION

The present study showed inhibitory effects of an ARB on bone resorption in hypertensive patients with accelerated bone resorption, such as elderly bedridden women, and indicated an important role of the renin-angiotensin system in bone metabolism. In elderly hypertensive patients, ARB might be expected to have additional beneficial potential to maintain bone health in bedridden patients.

Glucocorticoids activate the local renin-angiotensin system in bone: possible mechanism for glucocorticoid-induced osteoporosis

Bone metabolism disorder has been identified to play a vital role in the pathogenesis of glucocorticoid-induced osteoporosis (GIOP). The local renin-angiotensin system (RAS) in bone is newly defined to be closely related to the bone metabolism. However, it is unknown whether the local RAS is involved in GIOP. Adult male New Zealand white rabbits were treated with saline, dexamethasone (DXM) alone, or DXM combined with perindopril. The expression of main RAS components in trabecular bone was examined at mRNA and/or protein levels. Bone metabolism was analyzed using dual-energy X-ray absorptiometry, histomorphometry, biomechanics, biochemical techniques, and quantitative RT-PCR. The expressions of local bone angiotensin II, angiotensin types 1 and 2 receptors, and angiotensin-converting enzyme at mRNA and/or protein levels increased when DXM-induced osteoporosis was present. Whereas, perindopril significantly blocked the activation of the local RAS and partially reversed GIOP. Mineralizing surface, mineral apposition rate, and bone formation rate were decreased by DXM, along with serum osteocalcin being downregulated. These changes were then reversed by the use of perindopril. Osteoclast number, osteoclast surface, and eroded surface increased after the administration of DXM, and urinary deoxypyridinoline was upregulated. These were also inhibited when perindopril was given. Quantitative RT-PCR using RNA isolated from the lumbar vertebrae revealed an increase in the SOST expression and a decrease in the Runx2 expression, whereas the receptor activator of nuclear factor-κB ligand/osteoprotegerin ratio and the expression of tartrate resistant acid phosphatase were increased, which were all inhibited by perindopril. The results of this study provide evidence for the role of local RAS is involved in GIOP, and GIOP may be ameliorated by blocking the activation of local RAS in the bone.

Risk of Osteoporotic Fractures With Angiotensin II Receptor Blockers Versus Angiotensin-Converting Enzyme Inhibitors in Hypertensive Community-Dwelling Elderly

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are used to treat hypertension; however, in vivo and clinical studies suggest that ARBs and ACE inhibitors may exert different effects on bone. The association between long-term use of ARBs and ACE inhibitors and fracture requiring medical attention is limited. We conducted a population-based, retrospective cohort study with propensity score matching using administrative databases in Ontario, Canada, to examine the risk of osteoporosis-related fractures in hypertensive elderly treated with ARBs versus ACE inhibitors. We identified a cohort of newly treated hypertensive patients aged 66 years and older who initiated an ACE inhibitor from May 1, 2004, to March 31, 2012, and matched them to ARB users on propensity score, sex, and age at drug initiation. The primary outcome was hip fracture, and secondary outcomes were non-hip major osteoporotic fractures (other femoral, clinical vertebral, forearm, wrist, humerus) and other osteoporotic fractures (pelvis, clavicle, patella, shoulder, upper arm, tibia, fibula, ankle, scapula, ribs, sternum, trunk). We calculated hazard ratios (HRs) using Cox proportional hazards model with robust standard errors. Of the 87,635 patients who initiated treatment, 28,819 (32.9%) started ARBs and 58,816 (67.1%) started ACE inhibitors. Among new ARB users, 27,815 (96.5%) were successfully matched to ACE inhibitor users. Without dose adjustment, no significant association was observed for ARBs relative to ACE inhibitor users for hip fractures (HR = 0.88; 95% confidence interval [CI] 0.70-1.11), with a decreased risk of other major osteoporotic fractures (HR = 0.81; CI 0.70-0.93) and no significant association for other osteoporotic fractures (HR = 0.88; CI 0.74-1.05). When adjusted for dosage, there was no significant difference between the effects of ARBs and ACE inhibitors on hip (HR = 0.99; CI 0.78-1.25), other major osteoporotic (HR = 0.87; CI 0.75-1.01), and other osteoporotic fractures (HR = 0.90; CI 0.74-1.08).

Antihypertensive medications, bone mineral density, and fractures: a review of old cardiac drugs that provides new insights into osteoporosis

Osteoporosis is increasing in prevalence and importance as society's age, with the clinical consequence of fractures of the hip, spine, and upper extremity, leading to impaired quality of life, loss of function and independence, and increased morbidity and mortality. A major risk factor for osteoporosis is older age, and cardiovascular diseases also share this risk factor; therefore, osteoporosis and cardiovascular disease often coexist and share risk factors. Medications used for the treatment of cardiovascular diseases, in particular antihypertensive drugs, have been shown in a variety of studies of varying designs to modulate bone health in both a positive or negative manner. In this article, we reviewed the pharmacology, potential mechanisms, and possible effects on bone mineral density and fracture risk of commonly prescribed antihypertensive medications, including thiazide and non-thiazide diuretics, beta-blockers, calcium channel blockers, renin-angiotensin-aldosterone system agents, and nitrates.

Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults

IMPORTANCE The effect of serious injuries, such as hip fracture and head injury, on mortality and function is comparable to that of cardiovascular events. Concerns have been raised about the risk of fall injuries in older adults taking antihypertensive medications. The low risk of fall injuries reported in clinical trials of healthy older adults may not reflect the risk in older adults with multiple chronic conditions. OBJECTIVE To determine whether antihypertensive medication use was associated with experiencing a serious fall injury in a nationally representative sample of older adults. DESIGN, PARTICIPANTS, AND SETTING Competing risk analysis as performed with propensity score adjustment and matching in the nationally representative Medicare Current Beneficiary Survey cohort during a 3-year follow-up through 2009. Participants included 4961 community-living adults older than 70 years with hypertension. EXPOSURES Antihypertensive medication intensity based on the standardized daily dose for each antihypertensive medication class that participants used. MAIN OUTCOMES AND MEASURES Serious fall injuries, including hip and other major fractures, traumatic brain injuries, and joint dislocations, ascertained through Centers for Medicare & Medicaid Services claims. RESULTS Of the 4961 participants, 14.1% received no antihypertensive medications; 54.6% were in the moderate-intensity and 31.3% in the high-intensity antihypertensive groups. During follow-up, 446 participants (9.0%) experienced serious fall injuries, and 837 (16.9%) died. The adjusted hazard ratios for serious fall injury were 1.40 (95% CI, 1.03-1.90) in the moderate-intensity and 1.28 (95% CI, 0.91-1.80) in the high-intensity antihypertensive groups compared with nonusers. Although the difference in adjusted hazard ratios across the groups did not reach statistical significance, results were similar in the propensity score-matched subcohort. Among 503 participants with a previous fall injury, the adjusted hazard ratios were 2.17 (95% CI, 0.98-4.80) for the moderate-intensity and 2.31 (95% CI, 1.01-5.29) for the high-intensity antihypertensive groups. CONCLUSIONS AND RELEVANCE Antihypertensive medications were associated with an increased risk of serious fall injuries, particularly among those with previous fall injuries. The potential harms vs benefits of antihypertensive medications should be weighed in deciding to continue treatment with antihypertensive medications in older adults with multiple chronic conditions.

Long-term effects of antihypertensive medications on bone mineral density in men older than 55 years

Introduction

In this study, we investigated the effects of long-term antihypertensive treatment with calcium channel blockers or beta blockers on the bone mineral density of maxilla, as determined by cone-beam computed tomography (CBCT).

Material and methods

This retrospective study was conducted on CBCT images of men older than 55 years who had received different dental indications. Data were grouped into three categories according to the antihypertensive medication history of the patients: group A included patients who had been taking beta-blocker treatment for more than 5 years, group B included patients who had been taking calcium channel blocker treatment for more than 5 years, and the control group included patients who had never used any hypertensive medications before.

Results

Statistically significant differences were observed between the beta blocker and calcium channel blocker groups.

Conclusion

In hypertension treatment, beta blockers may be preferred to calcium channel blockers in patients at high risk for osteoporosis and bone resorption.

Systemic treatment with telmisartan improves femur fracture healing in mice

Recent clinical studies indicated that angiotensin receptor blockers (ARBs) would decrease the risk of bone fractures in the elderly populations. There is little known about the role of the ARBs in the process of fracture healing. The purpose of the present study was to verify the hypothesis that systemic treatment with telmisartan has the ability to promote fracture healing. In this study, femur fractures were produced in 96 mature male BALB/c mice. Animals were treated with the ARBs telmisartan or vehicle. Fracture healing was analysed after 2, 5 and 10 weeks postoperatively using X-ray, biomechanical testing, histomorphometry, immunohistochemistry and micro-computed tomography (micro-CT). Radiological analysis showed the diameter of the callus in the telmisartan treated animals was significantly increased when compared with that of vehicle treated controls after two weeks of fracture healing. The radiologically observed promotion of callus formation was confirmed by histomorphometric analyses, which revealed a significantly increased amount of bone formation when compared with vehicle-treated controls. Biomechanical testing further showed a significantly greater peak torque at failure, and a higher torsional stiffness in telmisartan-treated animals compared with controls. There was an increased fraction of PCNA-positive cells and VEGF-positive cells in telmisartan-treated group compared with vehicle-treated controls. From the three-dimensional reconstruction of the bony callus, telmisartan-treated group significantly increased the values of BV/TV by 21.7% and CsAr by 26.0% compared to the vehicle-treated controls at 5 weeks post-fracture. In summary, we demonstrate in the current study that telmisartan could promote fracture healing in a mice model via increasing mechanical strength and improving microstructure. The most mechanism is probably by an increase of cell proliferation and neovascularization associated with a decreased VEGF expression in hypertrophic chondrocytes.

Tissue Renin-Angiotensin systems: a unifying hypothesis of metabolic disease

The actions of angiotensin peptides are diverse and locally acting tissue renin-angiotensin systems (RAS) are present in almost all tissues of the body. An activated RAS strongly correlates to metabolic disease (e.g., diabetes) and its complications and blockers of RAS have been demonstrated to prevent diabetes in humans. Hyperglycemia, obesity, hypertension, and cortisol are well-known risk factors of metabolic disease and all stimulate tissue RAS whereas glucagon-like peptide-1, vitamin D, and aerobic exercise are inhibitors of tissue RAS and to some extent can prevent metabolic disease. Furthermore, an activated tissue RAS deteriorates the same risk factors creating a system with several positive feedback pathways. The primary effector hormone of the RAS, angiotensin II, stimulates reactive oxygen species, induces tissue damage, and can be associated to most diabetic complications. Based on these observations, we hypothesize that an activated tissue RAS is the principle cause of metabolic syndrome and type 2 diabetes, and additionally is mediating the majority of the metabolic complications. The involvement of positive feedback pathways may create a self-reinforcing state and explain why metabolic disease initiate and progress. The hypothesis plausibly unifies the major predictors of metabolic disease and places tissue RAS regulation in the center of metabolic control.

β-Adrenergic receptor antagonists and fracture risk: a meta-analysis of selectivity, gender, and site-specific effects

By meta-analysis, the risk of fracture was 15% lower in patients treated with β-adrenergic blockers compared to controls independent of gender, fracture site, and dose. This might be attributable to β1-selective blockers.

INTRODUCTION

The aim of this study is to determine by meta-analysis whether β-adrenergic blockers (BBs) reduce fracture risk and whether the effect, if demonstrable, is dependent upon selectivity, dose, gender, or fracture site.

METHODS

A literature search was performed in electronic databases MEDLINE, EMBASE, and reference sections of relevant articles to identify eligible studies. Adjusted estimates of fracture risk effect size (ES) were pooled across studies using fixed or random-effects (RE) meta-analysis as appropriate. Dose-related effects were evaluated using meta-regression. To explore the relative efficacy of β1-selective blockers in comparison to nonselective BBs, adjusted indirect comparison was performed.

RESULTS

A total of 16 studies (7 cohort and 9 case-control studies), involving 1,644,570 subjects, were identified. The risk of any fracture was found to be significantly reduced in subjects receiving BBs as compared to control subjects (16 studies, RE pooled ES = 0.86, 95% CI 0.78-0.93; I(2) = 87 %). In a sensitivity analysis limited to those studies deemed to be most robust, the BB effect to reduce fracture risk was sustained (four studies, pooled ES = 0.79, 95% CI 0.67-0.94; I(2) = 96%). The risk of a hip fracture was lower in both women and men receiving BBs (women: pooled ES = 0.86, 95% CI 0.80-0.91; I(2) = 1% and men: pooled ES = 0.80, 95% CI 0.71-0.90; I(2) = 0%). Similar risk reductions were found for clinical vertebral and forearm fractures, although statistical significance was not reached. The reduction in risk did not appear to be dose-related (test for a linear trend p value 0.150). Using adjusted indirect comparisons, it was estimated that β1-selective agents were significantly more effective than nonselective BBs in reducing the risk of any fracture (six studies, β1-selective blockers vs. nonselective BBs: RE pooled ES = 0.82, 95% CI = 0.69-0.97).

CONCLUSIONS

The findings suggest that the risk of fracture is approximately 15% lower in patients treated with BBs compared to controls independent of gender, fracture site, and dose. This risk reduction might be associated with the effects of β1-selective blockers.

Antihypertensive drugs and the risk of fall injuries: a systematic review and meta-analysis

OBJECTIVE

A meta-analysis of published studies was performed to determine whether administration of any of five antihypertensive drug classes (thiazide diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers and β-blockers) affected the risk of fall injuries in the elderly (aged ≥60 years).

METHODS

Articles reporting the risk of fall injury in elderly people being treated with the five main classes of antihypertensive drugs were retrieved using MEDLINE®, EMBASE, SCOPUS® and the Cochrane Database. Trial eligibility and methodological quality were assessed before data extraction and analysed using odds ratios with 95% confidence intervals.

RESULTS

Sixty-two articles, included in two meta-analyses, were identified. These meta-analyses drew opposite conclusions about the role of antihypertensive drugs in fall injuries in the elderly. However, the present analysis did not reveal a clear association (or the lack of one) between antihypertensive drugs and risk of fall injuries.

CONCLUSIONS

There is no clear, statistically significant clinical precedent indicating that the use of any of the antihypertensive drugs considered here increases the risk of fall injuries in the elderly. Nonetheless, in following standard clinical guidelines for hypertension management, physicians need to be aware of the impact of drug therapies on fall injuries.

The effects of antihypertensive drugs on bone mineral density in ovariectomized mice

The effects of several antihypertensive drugs on bone mineral density (BMD) and micro-architectural changes in ovariectomized (OVX) mice were investigated. Eight-week-old female C57/BL6 mice were used for this study. Three days after ovariectomy, mice were treated intraperitoneally with nifedipine (15 mg/kg), telmisartan (5 mg/kg), enalapril (20 mg/kg), propranolol (1 mg/kg) or hydrochlorothiazide (12.5 mg/kg) for 35 consecutive days. Uterine atrophy of all mice was confirmed to evaluate estrogen deficiency state. BMD and micro-architectural analyses were performed on tibial proximal ends by micro-computed tomography (micro-CT). When OVX mice with uterine atrophy were compared with mice without atrophy, BMD decreased (P < 0.001). There were significant differences in BMD loss between different antihypertensive drugs (P = 0.005). Enalapril and propranolol increased BMD loss in mice with atrophied uteri compared with control mice. By contrast, thiazide increased BMD in mice with uterine atrophy compared with vehicle-treated mice (P = 0.048). Thiazide (P = 0.032) and telmisartan (P = 0.051) reduced bone loss and bone fraction in mice with uterine atrophy compared with the control. Thiazide affects BMD in OVX mice positively. The reduction in bone loss by thiazide and telmisartan suggest that these drugs may benefit menopausal women with hypertension and osteoporosis.

Diuretic initiation and the acute risk of hip fracture

SUMMARY

We found the risk of hip fracture was transiently elevated around twofold shortly after initiation of a loop or thiazide diuretic drug in a case-crossover and case-control study. No statistical association was found following the initiation of a comparator medication: ACE inhibitors. Awareness of these short-term risks may reduce hip fractures.

INTRODUCTION

Little is known about the acute effects of initiating a diuretic drug on risk of fracture. We evaluated the relationship between initiating a diuretic drug and the occurrence of hip fracture.

METHODS

The study sample included 2,118,793 persons aged ≥50 years enrolled in The Health Improvement Network (THIN) between 1986 and 2010. The effect of a new start of a diuretic drug or comparator medication (ACE inhibitor) on risk of hip fracture was assessed using a case-crossover and case-control study during the 1-7, 8-14, 15-21, and 22-28 days following drug initiation.

RESULTS

Included were 28,703 individuals with an incident hip fracture over a mean of 7.9 years follow-up. In the case-crossover study, the risk of experiencing a hip fracture was increased during the first 7 days following loop diuretic drug initiation (OR = 1.8; 95 % CI, 1.2, 2.7). The elevated risk did not continue during the 8-14, 15-21, or 22-28 days following drug initiation. For thiazide diuretics, the risk of hip fracture was elevated 8-14 days after drug initiation (OR = 2.2; 95 % CI, 1.2, 3.9). No such association was observed in the 1-7, 15-21, or 22-28 days following thiazide drug initiation. ACE inhibitor initiation was not associated with a statistically significant increased risk of hip fracture. Similar results were observed using a case-control study.

CONCLUSIONS

The risk of hip fracture was transiently elevated around twofold shortly after the new start of a loop or thiazide diuretic drug. Awareness of these short-term risks may reduce hip fractures and other injurious falls in vulnerable adults.

Does medication adherence itself confer fracture protection? An investigation of the healthy adherer effect in observational data

OBJECTIVE

Prior observational studies have shown an association between bisphosphonate adherence and fewer fractures. It is unclear if such studies reflect pharmacologic benefits or behavioral attributes, i.e., the healthy adherer effect. Our objective was to examine the association of therapy adherence and fracture risk among patients initiating therapies hypothesized to be favorable, unfavorable, or neutral toward fracture risk, in order to evaluate for a healthy adherer effect.

METHODS

In this observational study, we identified patients within Medicare 2006-2009 data who initiated any of 3 medication groups within 9 months after an osteoporotic fracture as follows: 1) oral bisphosphonates (n = 2,507), 2) selective serotonin reuptake inhibitors (SSRIs; n = 2,420), or 3) angiotensin-converting enzyme (ACE) inhibitor or calcium-channel blocker (CCB; n = 2,178). Cox regression analysis, adjusting for covariates, was used to compare fracture rates at the hip and major osteoporotic fracture sites (including hip, clinical vertebral, humerus, and wrist) during followup, comparing patients with high adherence versus low adherence within each medication group.

RESULTS

There were few baseline differences between those who had high adherence versus lower adherence. High adherence with bisphosphonates decreased fracture risk at both hip (hazard ratio [HR] 0.53, 95% confidence interval [95% CI] 0.32-0.96) and major fracture sites (HR 0.61, 95% CI 0.45-0.80). High adherence with SSRIs suggested increased fracture risk at both hip (HR 1.58, 95% CI 0.97-2.57) and major fracture sites (HR 1.32, 95% CI 0.96-1.83). High adherence with ACE inhibitors/CCBs was neutral toward fracture risk at both hip (HR 1.27, 95% CI 0.67-2.41) and major fracture sites (HR 1.00, 95% CI 0.67-1.49).

CONCLUSION

In this observational cohort of older individuals, the association between medication adherence and fracture risk differed by medication exposure, suggesting a limited role for the healthy adherer effect in observational studies of osteoporosis medications.

Fracture risk is increased by the complication of hypertension and treatment with calcium channel blockers in postmenopausal women with type 2 diabetes

Patients with type 2 diabetes mellitus (T2DM) frequently have other common diseases such as hypertension (HT), dyslipidemia (DL), and cardiovascular disease (CVD). However, it is unknown whether or not the complication of these diseases would affect fracture risk in T2DM patients. We evaluated prevalent morphometric vertebral fractures (VFs) and prior non-VFs in 155 and 195 Japanese T2DM postmenopausal women, respectively, and examined their association with HT, DL, or CVD. VF, non-VF, HT, DL, and CVD were found in 53 (34 %), 30 (15 %), 136 (70 %), 124 (64 %), and 45 (23 %) women, respectively. Multivariate logistic regression analyses adjusted for age, body mass index (BMI), and serum creatinine showed that the presence of HT significantly increased VF risk [odds ratio (OR) 4.05, P = 0.0047], but not non-VF risk. This result was still significant after an additional adjustment for each of blood pressure levels, treatments with anti-hypertensive medications, and a history of falls. In contrast, calcium channel blocker (CCB) treatment significantly increased VF and non-VF risks after adjustments for age, BMI, serum creatinine, and blood pressure levels (OR 2.33, P = 0.0320 and OR 2.95, P = 0.0150, respectively), while these significances disappeared after an additional adjustment for a history of falls. These findings suggest that the presence of HT increases VF risk independent of blood pressure levels, anti-hypertensive medications, or falls, and that CCB treatment increases both VF and non-VF risks possibly via falls in T2DM postmenopausal women.

β1 selectivity of β-blockers and reduced risk of fractures in elderly hypertension patients

INTRODUCTION

Hypertension and osteoporosis are prevalent in the elderly population. Treatments beneficial to both conditions would be helpful. We examined the protective effect of β-blockers (BBs) and their receptor selectivity against fractures compared to other antihypertensives.

MATERIALS AND METHODS

A retrospective cohort was assembled using the Korean Health Insurance Review and Assessment Service database from January 2005 to June 2006. The cohort consisted of 501,924 patients (ages 65 and older) on single-drug therapy for hypertension. Participants were followed to either the date of the first fracture, date of death or end of the study period (30 June 2006), whichever came first. Cox's proportional hazard model was used to calculate the adjusted hazard ratio (aHR) and 95% confidence interval (CI) by sex, adjusting for confounders. Risk of fractures by BBs according to β1 selectivity was compared to non BBs measured in aHR.

RESULTS

Among 501,924 (65% female), the incidence density of fractures in non BB users was 29.3 and 48.2 per 1000 person-years for men and women, respectively, which was higher than in BB users (17.2 for men and 30.5 for women). Compared to BB users, non BB users showed an increased risk of all fracture [aHR 1.56 (95% CI, 1.42-1.72) in men and 1.44 (95% CI, 1.36-1.51) in women] and hip fracture [aHR 2.17 (95% CI 1.45-3.24) in men and 1.61 (95% CI 1.31-1.98) in women] after adjusting for confounding variables. Compared to BBs, the risks of all fractures in α-blockers, calcium channel blockers, diuretics, and renin-angiotensin-aldosterone system blockers were significantly higher (1.72, 1.77, 1.58, 1.29 in men; 2.11, 1.50, 1.46, 1.22 in women, respectively). Compared to non BBs, β1 selective BBs showed a lower risk of fracture (39% for men and 33% for women) after adjusting for confounding factors. On the contrary, non-selective BBs were not protective against fracture.

CONCLUSION

Our results suggested that β1 selective BBs reduce the risk of fractures compared to other classes of antihypertensives in an elderly population, which could have practical applications for strategies to control and prevent adverse outcomes from both hypertension and osteoporosis in this population.

Association between beta-blockers and fracture risk: a Bayesian meta-analysis

BACKGROUND

The association between beta-blockers (BB) and fracture risk is controversial, due largely to conflicting findings from previous studies. The present study sought to evaluate the effect of BB on fracture risk by using a Bayesian meta-analysis approach.

METHODS AND RESULTS

We systematically retrieved 13 observational studies on the association between BB use and fracture risk. This meta-analysis involved more than 907,000 men and women with mean/median age of individual studies ranging from 43 to 81 years. We used a hierarchical Bayesian random effects model to synthesize the results. BB use was associated with an average 17% reduction in the risk of any fracture (risk ratio [RR] 0.83; 95% credible interval [CrI]: 0.71-0.93), hip fracture (RR 0.83; 95% CrI: 0.70-0.92) and vertebral fracture (RR 0.81; 95% CrI: 0.61-0.99). The probability that BB use reduces fracture risk by at least 10% was 0.91.

CONCLUSIONS

Beta-blockers are associated with reduced risk of fracture in older adults, but the effect size is likely to be modest.

Association between cardiovascular diseases and osteoporosis-reappraisal

Positive association between cardiovascular diseases and osteoporosis is important because it concerns two major public health problems. Men and women with cardiovascular diseases (including severe abdominal aortic calcification (AAC) and peripheral arterial disease) tend to have lower areal and volumetric bone mineral density (BMD) as well as faster bone loss, although findings vary according to skeletal site. On one hand, severe forms of cardiovascular diseases (heart failure, myocardial infarction, hypertension, severe AAC) are associated with higher risk of osteoporotic fracture, especially hip fracture. This link was found in the studies based on healthcare databases and the cohort studies. On the other hand, low BMD, history of fragility fracture, vitamin D deficit and increased bone resorption are associated with higher risk of major cardiovascular events (myocardial infraction, stroke, cardiovascular mortality). Moreover, osteocalcin secreted by osteoblasts may be involved in the regulation of energetic and cardiovascular metabolism. The association between both pathologies depends partially on the shared risk factors, and also on the mechanisms that are involved in the regulation of bone and cardiovascular metabolism. Interpretation of the data should take into account methodological limitations: representativeness of the cohorts, quality of the registers and the information obtained from questionnaires, severity of diseases, number of events (statistical power) and their temporal closeness, availability of the information on potential confounders. It seems that patients with severe form of osteoporosis would benefit from assessment of the cardiovascular status and vice versa. However, official guidelines for the clinical practice are still lacking.

Effect of co-morbidities on fracture risk: findings from the Global Longitudinal Study of Osteoporosis in Women (GLOW)

INTRODUCTION

Greater awareness of the relationship between co-morbidities and fracture risk may improve fracture-prediction algorithms such as FRAX.

MATERIALS AND METHODS

We used a large, multinational cohort study (GLOW) to investigate the effect of co-morbidities on fracture risk. Women completed a baseline questionnaire detailing past medical history, including co-morbidity history and fracture. They were re-contacted annually to determine incident clinical fractures. A co-morbidity index, defined as number of baseline co-morbidities, was derived. The effect of adding the co-morbidity index to FRAX risk factors on fracture prevention was examined using chi-squared tests, the May-Hosmer test, c index and comparison of predicted versus observed fracture rates.

RESULTS

Of 52,960 women with follow-up data, enrolled between October 2006 and February 2008, 3224 (6.1%) sustained an incident fracture over 2 years. All recorded co-morbidities were significantly associated with fracture, except for high cholesterol, hypertension, celiac disease, and cancer. The strongest association was seen with Parkinson's disease (age-adjusted hazard ratio [HR]: 2.2; 95% CI: 1.6-3.1; P<0.001). Co-morbidities that contributed most to fracture prediction in a Cox regression model with FRAX risk factors as additional predictors were: Parkinson's disease, multiple sclerosis, chronic obstructive pulmonary disease, osteoarthritis, and heart disease.

CONCLUSION

Co-morbidities, as captured in a co-morbidity index, contributed significantly to fracture risk in this study population. Parkinson's disease carried a particularly high risk of fracture; and increasing co-morbidity index was associated with increasing fracture risk. Addition of co-morbidity index to FRAX risk factors improved fracture prediction.

Heart drugs that affect bone

There have been important developments in our understanding of the mechanisms underlying the development of osteoporosis, and several of these mechanisms also underlie atherosclerosis. Drugs given to treat cardiovascular disease may impact on bone health in either a beneficial or a harmful way. There is evidence that nitrates are beneficial to bone, but evidence for the benefit of statins, thiazide diuretics, and β-blockers is weaker. By contrast, it is likely to be that some drugs such as loop-acting diuretics are harmful to bone, whereas evidence for harm caused by drugs such as warfarin is weaker. These observations point towards opportunities for new drug development for bone diseases, and possibly the development of treatments that will benefit more than one disease.

Genetic polymorphisms of the Wnt receptor LRP5 are differentially associated with trochanteric and cervical hip fractures

Epidemiological studies suggest that cervical and trochanteric hip fractures have different pathogenesis. We tested the hypothesis that genetic factors have different influences on both types of fractures. Ten polymorphisms of genes known to play an important role in skeletal homeostasis [estrogen receptor alpha (ESR1), aromatase (CYP19A1), type I collagen (COL1A1), and lipoprotein receptor-related protein 5 (LRP5)] were analyzed in 471 Spanish patients with fragility hip fractures. Two polymorphisms of the LRP5 gene (rs7116604 and rs3781600) were associated with the type of fracture (P = 0.0085 and 0.0047, respectively). The presence of rare alleles at each locus was associated with trochanteric fractures over cervical fractures (OR = 1.7 in individuals with at least one rare allele at rs7116604 or rs3781600 loci in comparison with the common homozygotes). Considering individuals bearing the four common alleles as reference, the OR for trochanteric fractures was 1.6 in those with one or two rare alleles and 7.5 in those with three or four rare alleles (P for trend = 0.0074), which is consistent with an allele-dosage effect. There were no significant differences in the frequency distributions of the ESR1, CYP19A1, and COL1A1 genotypes between trochanteric and cervical fractures in either the original group or an extended group of 818 patients. These results suggest that LRP5 alleles influence the type of hip fractures. They support the view that different genetic factors are involved in cervical and trochanteric fractures, which should be taken into consideration in future genetic association studies.