A meta-analysis of etidronate for the treatment of postmenopausal osteoporosis

Recommendations for optimal care of the fragility fracture patient to reduce the risk of future fracture

Fragility fractures resulting from low trauma events such as a fall from standing height affect up to one half of women and one third of men after age 50 years. These fractures are frequently associated with osteoporosis. History of a fragility fracture is among the strongest risk factors for future fracture. Therefore, optimal care of the patient with a fragility fracture includes not only treatment of the presenting fracture itself but also evaluation and treatment of the underlying cause or causes to prevent future fractures. However, despite the availability of therapeutic agents that reduce fracture risk among osteoporotic patients who have had a fracture, most patients with fragility fractures are not evaluated for osteoporosis or treated adequately to reduce the risk of future fracture. Orthopaedic surgeons are the first and often the only physicians seen by fracture patients. Thus, they have the unique opportunity to serve as primary advocates to ensure that appropriate action is taken to reduce the risk of future fracture.

Five year study of etidronate and/or calcium as prevention and treatment for osteoporosis and fractures in patients with asthma receiving long term oral and/or inhaled glucocorticoids

BACKGROUND

Glucocorticoids are associated with a reduction in bone density and an increased risk of fracture. Concurrent treatment with bisphosphonates reduces bone loss and may prevent fractures. A randomised study was performed to determine whether treatment with cyclical etidronate and/or calcium for 5 years prevents fractures or reverses/reduces bone loss in patients receiving glucocorticoid treatment for asthma.

METHODS

A multicentre, randomised, parallel group comparison of etidronate alone, calcium alone, etidronate + calcium, and no treatment, with stratification according to level of glucocorticoid exposure was carried out in 39 chest clinics in the UK. Three hundred and forty nine postmenopausal female and male outpatients with asthma aged 50-70 years were randomised. The main outcome measures were fractures and changes in bone mineral density (BMD).

RESULTS

Overall, 8% of the patients experienced symptomatic fractures and 17.5% developed either a symptomatic fracture and/or a semiquantitative vertebral fracture by the end of 5 years There were no significant differences between the four treatment groups. Comparing etidronate with no etidronate, the rates of new fractures were not significantly different for symptomatic fractures (OR 1.07 (95% CI 0.46 to 2.47)) or for any fractures (OR 0.82 (95% CI 0.45 to 1.47)). For the comparison of calcium with no calcium the corresponding ORs were 1.43 (95% CI 0.62 to 3.33) and 0.91 (95% CI 0.50 to 1.63). In post hoc analysis the effect of etidronate was greater in women than in men (interaction p value 0.02) with the fracture incidence roughly halved (OR 0.39, 95% CI 0.14 to 0.99). Etidronate increased BMD at the lumbar spine by 4.1% (p = 0.001) while calcium had no significant effect. At the proximal femur the effects of treatment were not significant (relative increases etidronate 1.6%; calcium 1.1%). The rate of new fractures in patients with fractures at entry (23.7%) was higher than in those without fractures at entry (14.3%): OR 1.87 (95% CI 1.06 to 3.07). No association was found between change in BMD and new fractures.

CONCLUSIONS

In patients receiving glucocorticoids for asthma etidronate significantly increased BMD over 5 years at the lumbar spine but not at the hip and had little if any protective effect against fractures, except possibly in postmenopausal women. The effects of calcium were not significant. Combination treatment had no advantage but increased unwanted effects.

Efficacy of alphacalcidol and calcitriol in primary and corticosteroid-induced osteoporosis: a meta-analysis of their effects on bone mineral density and fracture rate

Vitamin D metabolites alphacalcidol and calcitriol (D-hormones) have been investigated for two decades, but few and conflicting results are available from high-quality randomized controlled trials. Our objectives were to provide an evidence-based update quantitatively summarizing their efficacy on bone mineral density (BMD) and fracture rate. We performed a systematic research of any randomized controlled trial containing relevant data, peer review, data extraction and quality scoring blinded for authors and data sources, and comprehensive meta-analyses of the relevant data. Inclusion criteria were: randomized controlled study, calcitriol or alphacalcidol, BMD or fractures in healthy/osteopenic/osteoporotic patients exposed or not to corticosteroids (CS). Analyses were performed in a conservative fashion using professional dedicated softwares and stratified by outcome, target patients, study quality, and control-group type. Results were expressed as effect size (ES) for bone loss or relative risk (RR) for fracture while allocated to D-hormones vs control. Publication bias and robustness were investigated. Of the trials that were retrieved and subsequently reviewed, 17 papers fitted the inclusion criteria and were assessed. Quality scores ranged from 20 to 100%, the mean (standard deviation) being 72 (22)%. Calcitriol and alphacalcidol were found to have the same efficacy on all outcomes at p>0.13. We globally assessed D-hormones effects in preventing bone loss in patients not exposed to CS, and found positive effect: ES=0.39 ( p<0.001). For lumbar spine, this particular effect was 0.43 ( p<0.001). D-hormones significantly reduced the overall fracture rates: RR=0.52 (0.46; 0.59) and both vertebral and non-vertebral fractures: RR=0.53 (0.47; 0.60) and RR=0.34 (0.16; 0.71), respectively. No statistical difference in response was observed between results from studies on healthy and osteoporotic patients or depending on the fact that controls were allowed to calcium supplementation. Treatment with D-hormones was evaluated for maintaining spinal bone mass in five trials of patients with CS-induced osteoporosis, and provided ES=0.43 at p<0.001. Only two studies specifically addressed the effects of calcitriol on spinal fracture rate. None of them provided significant results, and the global RR did not reach the significance level as well: RR=0.33 (0.07; 1.51). Our data demonstrated efficacy for DH on bone loss and fracture prevention in patients not exposed to CS and on bone loss in patients exposed to CS, in the light of the most reliable scientific evidence. Their efficacy in reducing the number of fractures in patients exposed to CS remains to be determined.

Rational use of oral bisphosphonates for the treatment of osteoporosis

Osteoporosis has become a major public health concern worldwide. Significant morbidity, mortality, and health expenditures are associated with osteoporotic fractures. Evidence from randomized controlled trials and meta- analyses supports the efficacy and safety of oral bisphosphonates as first-line pharmacologic agents for the prevention and treatment of osteoporosis. This article reviews the evidence demonstrating the beneficial effects of etidronate, alendronate, and risedronate on improving bone mass and preventing fractures in individuals with or at risk for osteoporosis. Issues surrounding dosing intervals and optimal duration of therapy are also discussed. We conclude that the nitrogen-containing bisphosphonates alendronate and risedronate are safe and efficacious agents in preventing and treating osteoporosis. They are superior to cyclical etidronate in improving appendicular bone mass, and in reducing future risk for nonvertebral fractures. Once-weekly dosing options with alendronate and risedronate are effective and reduce serious adverse drug effects, and therefore, are welcome additions to our therapeutic armamentarium.

Combining Bisphosphonates with Hormone Therapy for Postmenopausal Osteoporosis

Osteoporosis affects many women after menopause. It is a major health problem, as fragility fractures create significant morbidity in this population, especially with advancing age. Available therapies include estrogens, selective estrogen receptor modulators, bisphosphonates, and calcitonin. They all inhibit bone resorption, although through different mechanisms. Several combinations of these agents have been studied in order to determine their effectiveness in comparison with monotherapy. We reviewed eight prospective randomized clinical trials of hormone therapies combined with bisphosphonates (etidronate, alendronate, and risedronate) and one study of a selective estrogen receptor modulator (raloxifene) in combination with a bisphosphonate (alendronate). Bone mineral density change at the lumbar spine was the primary endpoint of all the studies, with one or more measurements of the bone density at the femur as secondary endpoints. None of the studies had the statistical power to determine the relative reduction in fracture risk. All the studies reported greater increases in bone mineral density in patients treated with combination therapies as opposed to single agents. The bone turnover markers were also suppressed to a greater degree in the combination treatment groups, remaining however within normal premenopausal ranges. Four studies reported bone histomorphometry data, indicating no impairment of bone quality by combination therapies. The combination treatments were well tolerated in all the trials and the discontinuation rates did not vary among the groups. However, most patients will not require combination therapy. Combining bisphosphonates with hormone therapy may offer an additional benefit to women who either continue to lose bone mass despite taking estrogen or who need estrogen to control postmenopausal symptoms. The benefit of adding raloxifene to a bisphosphonate is smaller. However, it may be clinically useful if raloxifene reduces the risk of breast cancer.

Osteoporosis management in the new millennium

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.

Osteoporosis

Osteoporosis is a disease that may have a tremendous impact on the lives of many postmenopausal women. It is encouraging that effective treatments for this disease abound and the challenge is to ensure that those most in need of diagnosis or therapy obtain adequate care. Further research is expected to clarify the role of combination therapy or sequential use of different agents for the maximum benefit in fracture protection. There is an array of efficacious options to consider when diagnosing and treating osteoporosis so that patients and their caregivers can remain optimistic about the management of this chronic disease and prevention of future fractures.

Les grands essais thérapeutiques dans l’ostéoporose

The prevention and treatment of osteoporosis are now a necessary goal because of the aging of the population and the social and economic costs of fracture complications. The publication of guidelines by registration agencies during the last 10 years has provided precise rules for evaluating new drugs designed for the prevention and treatment of postmenopausal osteoporosis. The benefit of combination treatment with calcium and vitamin D in osteoporotic patients has clearly been proven, especially among the oldest patients, but results of prospective studies designed for the prevention of fracture risk are conflicting. In the Fracture Intervention Trial (FIT), treatment with alendronate 10 mg/day reduces the risk of vertebral fracture by 48% and increases bone mineral density (BMD) in patients with vertebral fractures. In the Vertebral Efficacy with Risedronate Therapy Multi-National (VERT-MN) and VERT-NA (North America) studies, treatment with risedronate 5 mg/day reduces the risk of vertebral fracture by 49% and 41%, respectively. Risedronate 5 mg daly for 3 years leads to an increase in BMD. The Prevent Recurrence Of Osteoporotic Fractures (PROOF) study has shown a significant decrease in the risk of vertebral fracture in patients treated with calcitonin 200 IU. However, numerous criticisms of the methodology of this study design have been identified. Selective estrogen receptor modulators could act as agonists or antagonists of estrogens, depending on the target tissue. In the Multiple Outcomes of Raloxifene Evaluation (MORE) study, treatment with raloxifene reduces the risk of vertebral fracture by 50% in patients without prevalent vertebral fracture and by 30% in patients with prevalent vertebral fracture. PTH treatment leads to an increase in BMD and reduces the risk of vertebral fracture by 65%. Strontium ranelate has a novel mechanism of action (stimulation of bone synthesis and decrease in bone resorption), and administration of 2 g daily has a proven positive effect, leading to an increase in bone mass among women with osteoporosis. This effect was especially evident in the Spinal Osteoporosis Therapeutic Intervention phase III (SOTI) study, in which a significant decrease in the incidence of vertebral fracture of 41% over 3 years has been shown. Thus, effective therapeutic strategies now enable improved treatment of postmenopausal osteoporosis. However, this condition is still poorly diagnosed and not all patients are correctly treated. Preventing the occurrence of the first fracture should remain the prime concern.

Bisphosphonates: new indications and methods of administration

In the course of 2002, several new studies were published confirming the efficacy of bisphosphonate drugs in fracture prevention in patients with osteoporosis. Further evidence was provided of their long duration of action, making intermittent administration possible. The potent bisphosphonate zoledronate can be given at intervals of as long as 1 year and produces changes in bone density and in markers of bone turnover comparable with those seen with conventional daily oral dosing with alendronate or risedronate. If such regimens are proven to prevent fractures, their convenience is likely to result in their widespread adoption and potentially an increase in compliance with these medications. Further evidence has been presented documenting the value of bisphosphonates in preventing the skeletal complications of malignancy, and possibly in reducing mortality in patients with breast cancer. The role of bisphosphonates in osteogenesis imperfecta was further confirmed, and novel roles in ankylosing spondylitis, myelofibrosis, and hypertrophic pulmonary osteoarthropathy were suggested.

The menopause and HRT. Prevention and management of osteoporosis

Post-menopausal osteoporosis is characterized by increased fracture risk due to deficiencies in both the quantity and quality of bone. Assessing fracture risk involves combining clinical risk factors, including fall risks, with bone density testing. Treatment strategies are aimed at reducing fracture risk. General nutritional and lifestyle measures are appropriate for all women. Drug treatment is most clearly indicated in post-menopausal women at high current fracture risk. Treatment should also be considered for women at intermediate fracture risk, including those who have both low bone density and other risk factors for fracture. Whether there is practical clinical value in treating low-risk patients is much less clear. Non-pharmacological approaches addressing the consequences of fractures are integral parts of a comprehensive treatment programme. Reducing both the frequency and the effects of falls complements the efforts of treating osteoporosis to reduce the incidence of fractures and their important clinical consequences.

New anabolic therapies in osteoporosis

Anabolic agents represent an important new advance in the therapy of osteoporosis. Their potential might be substantially greater than the anti-resorptives. Because the anti-resorptives and anabolic agents work by completely distinct mechanisms of action, it is possible that the combination of agents could be significantly more potent than either agent alone. Recent evidence suggests that a plateau in BMD might occur after prolonged exposure to PTH. Anti-resorptive therapy during or after anabolic therapy might prevent this skeletal adaptation. Protocols to consider anabolic agents as intermittent recycling therapy would be of interest. Of all the anabolics, PTH is the most promising. However, there are unanswered questions about PTH. More studies are needed to document an anabolic effect on cortical bone. More large-scale studies are needed to further determine the reduction in nonvertebral fractures with PTH, especially at the hip. In the future, PTH is likely to be modified for easier and more targeted delivery. Oral or transdermal delivery systems may become available. Recently, Gowen et al have described an oral calcilytic molecule that antagonizes the parathyroid cell calcium receptor, thus stimulating the endogenous release of PTH. This approach could represent a novel endogenous delivery system for intermittent PTH administration. Rising expectations that anabolic therapies for osteoporosis will soon play a major role in treating this disease are likely to fuel further studies and the development of even more novel approaches to therapy.

Strontium ranelate phase 2 dose-ranging studies: PREVOS and STRATOS studies

The aim of the PREVOS study (PREVention Of early postmenopausal bone loss by Strontium ranelate) and the STRATOS study (STRontium Administration for Treatment of OSteoporosis) was to determine the minimum dose at which strontium ranelate (SR) is effective in, respectively, the prevention of bone loss in early postmenopausal nonosteoporotic women and the treatment of postmenopausal vertebral osteoporosis. Both studies were randomized, double-blind, placebo-controlled, dose-finding studies in parallel groups and lasted 2 years. In the PREVOS study, 160 early postmenopausal women were randomized to receive placebo, SR 125 mg/day, 500 mg/day or 1 g/day. In the STRATOS study, 353 osteoporotic postmenopausal women with at least one previous vertebral fracture and a lumbar T-score <-2.4 were randomized to receive placebo, SR 500 mg/day, 1 g/day or 2 g/day. In both studies, the primary efficacy parameter was lumbar bone mineral density (BMD) measured by dual-energy X-ray absorptiometry. Secondary efficacy criteria included incidence of new vertebral deformities (in the STRATOS study only) and biochemical markers of bone metabolism. In the PREVOS study, the increase in lumbar BMD from baseline in the 1 g/day group (+5.53%) was significantly different from the decrease in the placebo group ( p<0.001). In the STRATOS study, the annual increase in lumbar BMD in the 2 g/day group (+7.3% per year) was significantly higher than in the placebo group ( p<0.001). There was a significant reduction in the number of patients experiencing new vertebral deformities in the second year of treatment in the 2 g/day group (relative risk: 0.56; 95% confidence interval: 0.35, 0.89). In both studies, there was a significant increase in the bone formation marker (bone alkaline phosphatase) in the higher-dose group. Urinary excretion of the marker of bone resorption (cross-linked N-telopeptide) was lower with SR than with placebo in the STRATOS study. SR was very well tolerated in both studies. The minimum dose at which SR is effective in preventing bone loss in early postmenopausal nonosteoporotic women and in the treatment of postmenopausal osteoporosis is 1 g/day and 2 g/day, respectively.

What predicts early fracture or bone loss on bisphosphonate therapy?

Factors predicting early fracture or bone loss on bisphosphonate therapy are not well defined. We studied 1588 patients over the age of 50 yr who were started on cyclic etidronate (1119) or alendronate (469) in the CANDOO (Canadian Database for Osteoporosis and Osteopenia Patients) Study. Incident fracture within 2 yr of starting therapy occurred in 31 patients and was independently predicted by a previous history of nonvertebral fracture (odds ratio [OR], 2.98, 95% confidence interval [CI], 1.30, 6.83, p = 0.010). Two hundred and fifty-seven patients lost >/=3% bone mass at the hip or spine (early bone loss) while on bisphosphonate therapy. Protection from early bone loss was most strongly independently predicted by treatment with alendronate with no previous history of etidronate use (OR, 0.29, CI, 0.13, 0.62, p = 0.002). In conclusion, early fracture on bisphosphonate therapy is most strongly predicted by a previous history of fracture and early bone loss is most strongly predicted by the potency of the prescribed bisphosphonate.

Long-term tolerability of the bisphosphonates in postmenopausal osteoporosis: a comparative review

Osteoporosis in postmenopausal women is a growing health concern for society. Bisphosphonates have become the mainstay of prevention and treatment with the mounting evidence of their efficacy over the past two decades. This review article examines the use of the etidronate, alendronate and risedronate. The pivotal trials are reviewed for long-term tolerability, evidence regarding histological safety and gastrointestinal tolerance. Etidronate, alendronate and risedronate have also been examined in meta-analyses, which reviewed methodologically sound trials. Length of treatment, adverse events and medication discontinuation and patients lost to follow-up were evaluated. Etidronate trials and the recent meta-analysis support the safe clinical use of cyclical etidronate with no signs of osteomalacia or other skeletal pathology over 2 to 3 years. In addition to increased bone mineral density (BMD) and vertebral fracture risk reduction, patients tolerated cyclical etidronate well up to 4 years in randomised studies. Non-randomised data has shown safety up to 7 years with clinical and bone biopsy data. Alendronate studies demonstrated similar overall adverse event rates, study discontinuation rates and loss to follow-up rates between placebo and treatment arms, in addition to consistent improvements in BMD, vertebral and non-vertebral fracture risk reductions over 3 to 4 years. Histological safety has been demonstrated up to 3 years. Longer-term therapy in non-randomised trials up to 7 years showed similar clinical safety between alendronate and placebo. Risedronate trials and the meta-analysis also showed similar adverse event profiles between placebo and treatment arms, as well as improvements in BMD, vertebral and non-vertebral fracture risk reductions up to 3 years. Rates of discontinuation due to gastrointestinal events were similar between groups. Histological safety has also been demonstrated for risedronate up to 3 years. Each of these bisphosphonates have been shown to have comparable safety with placebo up to 3 to 4 years, with the most rigourous trials carried out for alendronate and risedronate. Long-term comparative studies are awaited.

The effect of strength training combined with bisphosphonate (etidronate) therapy on bone mineral, lean tissue, and fat mass in postmenopausal women

The combined and separate effects of exercise training and bisphosphonate (etidronate) therapy on bone mineral in postmenopausal women were compared. Forty-eight postmenopausal women were randomly assigned (double blind) to groups that took intermittent cyclical etidronate; performed strength training (3 d/week) and received matched placebo; combined strength training with etidronate; or took placebo and served as nonexercising controls. Bone mineral, lean tissue, and fat mass were assessed by dual-energy X-ray absorptiometry before and after 12 months of intervention. After removal of outlier results, changes in bone mineral density (BMD) of the lumbar spine and bone mineral content (BMC) of the whole body were greater in the subjects given etidronate (+2.5 and +1.4%, respectively) compared with placebo (-0.32 and 0%, respectively) (p < 0.05), while exercise had no effect. There was no effect of etidronate or exercise on the proximal femur and there was no interaction between exercise and etidronate at any bone site. Exercise training resulted in significantly greater increases in muscular strength and lean tissue mass and greater loss of fat mass compared with controls. We conclude that etidronate significantly increases lumbar spine BMD and whole-body BMC and that strength training has no additional effect. Strength training favourably affects body composition and muscular strength, which may be important for prevention of falls.

Summary of meta-analyses of therapies for postmenopausal osteoporosis and the relationship between bone density and fractures

We review the methodologic quality of the individual randomized trials and summarize the impact of different treatments on the risk of fractures and bone density. We present an estimate of the expected impact of anti-osteoporosis interventions on fracture incidence in prevention and treatment populations using numbers needed to treat. We also examine the relationship between changes in bone density and the relative risk reduction for vertebral and nonvertebral fractures using regression analyses drawn from the results of the systematic reviews. We also outline other important facets of the decision-making process regarding osteoporosis therapy, including attitudes toward uncertainty, circumstances, and patients' and societal preferences.

Meta-analyses of therapies for postmenopausal osteoporosis. IX: Summary of meta-analyses of therapies for postmenopausal osteoporosis

This section summarizes the results of the seven systematic reviews of osteoporosis therapies published in this series [calcium, vitamin D, hormone replacement therapy (HRT), alendronate, risedronate, raloxifene, and calcitonin] and systematic reviews of etidronate and fluoride we have published elsewhere. We highlight the methodological strengths and weaknesses of the individual studies, and summarize the effects of treatments on the risk of vertebral and nonvertebral fractures and on bone density, including effects in different patient subgroups. We provide an estimate of the expected impact of antiosteoporosis interventions in prevention and treatment populations using the number needed to treat (NNT) as a reference. In addition to the evidence, judgements about the relative weight that one places on weaker and stronger evidence, attitudes toward uncertainty, circumstances of patients' and societal values or preferences will, and should, play an important role in decision-making regarding anti-osteoporosis therapy.

Development and pilot testing of a decision aid for postmenopausal women with osteoporosis

This study's aim was to develop and pilot test an evidence-based decision aid for postmenopausal women with osteoporosis who are considering options to prevent fractures. The aid was based on the Ottawa Decision Support Framework, and integrated evidence from our Cochrane systematic reviews. Following development by a panel of experts in osteoporosis and decision making, a user review panel of practitioners and women who had already made their decision about osteoporosis therapy reviewed the decision aid for acceptability. Then the decision aid was pilot tested using a before-after design in women at the point of decision making. Compared to baseline, there were statistically significant improvements in knowledge, realistic expectations and decreased decisional conflict. Our decision aid shows promise in preparing women for counseling about osteoporosis therapies. Long-term adherence to chosen therapy and quality of life will be evaluated in a randomized controlled trial.

Treatment of postmenopausal osteoporosis

The aim of treatment of postmenopausal osteoporosis is to reduce the frequency of vertebral and non-vertebral fractures (especially at the hip), which are responsible for morbidity associated with the disease. Results of large placebo controlled trials have shown that alendronate, raloxifene, risedronate, the 1-34 fragment of parathyroid hormone, and nasal calcitonin, greatly reduce the risk of vertebral fractures. Furthermore, a large reduction of non-vertebral fractures has been shown for alendronate, risedronate, and the 1-34 fragment of parathyroid hormone. Calcium and vitamin D supplementation is not sufficient to treat individuals with osteoporosis but is useful, especially in elderly women in care homes. Hormone replacement therapy remains a valuable option for the prevention of osteoporosis in early postmenopausal women. Choice of treatment depends on age, the presence or absence of prevalent fractures, especially at the spine, and the degree of bone mineral density measured at the spine and hip. Non-pharmacological interventions include adequate calcium intake and diet, selected exercise programmes, reduction of other risk factors for osteoporotic fractures, and reduction of the risk of falls in elderly individuals.

Effect of vitamin D on bone mineral density of elderly patients with osteoporosis responding poorly to bisphosphonates

BACKGROUND

Bisphosphonates are indicated in the prevention and treatment of osteoporosis. However, bone mineral density (BMD) continues to decline in up to 15% of bisphosphonate users. While randomized trials have evaluated the efficacy of concurrent bisphosphonates and vitamin D, the incremental benefit of vitamin D remains uncertain.

METHODS

Using data from the Canadian Database of Osteoporosis and Osteopenia (CANDOO), we performed a 2-year observational cohort study. At baseline, all patients were prescribed a bisphosphonate and counseled on vitamin D supplementation. After one year, patients were divided into two groups based on their response to bisphosphonate treatment. Non-responders were prescribed vitamin D 1000 IU daily. Responders continued to receive counseling on vitamin D.

RESULTS

Of 449 patients identified, 159 were non-responders to bisphosphonates. 94% of patients were women. The mean age of the entire cohort was 74.6 years (standard deviation = 5.6 years). In the cohort of non-responders, BMD at the lumbar spine increased 2.19% (p < 0.001) the year after vitamin D was prescribed compared to a decrease of 0.55% (p = 0.36) the year before. In the cohort of responders, lumbar spine BMD improved 1.45% (p = 0.014) the first year and 1.11% (p = 0.60) the second year. The difference between the two groups was statistically significant the first year (p < 0.001) but not the second (p = 0.60). Similar results were observed at the femoral neck but were not statistically significant.

CONCLUSION

In elderly patients with osteoporosis not responding to bisphosphonates, vitamin D 1000 IU daily may improve BMD at the lumbar spine.