Effect of risedronate on the risk of hip fracture in elderly women. Hip Intervention Program Study Group

Bone density changes with once weekly risedronate in postmenopausal women

Risedronate 5 mg daily is approved by the Food and Drug Administration to treat postmenopausal osteoporosis. Gastrointestinal (GI) symptoms are common with daily bisphosphonates, but recent studies show that once weekly treatment may be better tolerated. Risedronate 30 mg is approved to treat Paget s disease of bone. In this retrospective study, we assessed the GI tolerability of 30 mg of risedronate once weekly and evaluated the effect on bone mineral density (BMD) in a subset of women. Review of patients treated in our osteoporosis clinic identified 150 postmenopausal women with low BMD treated with 30 mg of risedronate once weekly, between February 1998 and March 2001. Baseline GI symptoms or previous intolerance of bisphosphonates was present in 32 patients. An additional antiresorptive treatment was continued with risedronate in 50% of these patients (estrogen, raloxifene, or calcitonin). Risedronate 30 mg was taken once weekly with vitamin D 400 iu daily and 1200 mg of calcium daily. Patient age ranged from 46 to 86 yr. Baseline and followup BMD data were available in 36 patients. Of the 32 patients with baseline GI symptoms or previous intolerance of a bisphosphonate, 1 developed GI symptoms. In those patients with baseline and follow-up BMD results (n = 36), BMD increased 1.9% (p = 0.02) at the trochanter and 2.1% (p = 0.001) at the total hip. In conclusion 30 mg of risedronate once weekly increased BMD at the trochanter and total hip (p < 0.05). This dosage was well tolerated with a low incidence of GI side effects.

Impact of the analysis of a bone density reference range on determination of the T-score

There are uncertainties concerning the optimal threshold value of bone mineral density (BMD) for the diagnosis of osteoporosis using dual-energy X-ray absorptiometry (DXA). The most widely accepted clinical criteria are based on T- and Z-scores, derived statistically from an age-dependent BMD reference range that includes healthy young adults. This study has compared different analyses of BMD data of healthy, nonfractured, adult white females aged 18-90 years, consisting of 953 studied with DXA in the L1-L4 spine and 1018 measured at the hip. Four regression curves were applied to each reference data set; mean peak BMD (PBMD(R)) and the age-independent standard deviation (SD(R)) were calculated. These data, plus derived T-score thresholds, were compared with equivalent values (PBMD(YN), SD(YN)) determined from BMDs of a subgroup of young normals. Choice of regression curve caused a variation of 0.044 g/cm(2) in spinal PBMD(R) and 0.015-0.022 g/cm(2) in the hip. The variation in calculated SD(R) between the regressions was minimal (maximum variation, 0.03 SD unit in the spine). A split-linear model was chosen as the best overall fit for both the spine and the hip on the basis of goodness-of-fit and biological plausibility. PBMD(R) and PBMD(YN) varied by less than 1% at the spine or hip. Although the difference between SD(R) and SD(YN) was < or =7% for the hip sites, SD(R) was 0.022 g/cm(2) > SD(YN) for the spine (17% difference). At each hip site, BMD T-score thresholds, derived from regression analysis of the entire reference range (T(R)) or from young normals only (T(YN)), were not significantly different; however, equivalent spinal values differed by 0.062 g/cm(2) for T = -2.5. The percentage of the Australian female population (AFP) aged 50 yr or older and classified as osteoporotic, using population census data and the split-line-based T-score threshold of T(R) = -2.5, was 23% for spinal BMD and 17% for the total hip. For T(YN) = -2.5, the values were 36% (spine) and 17% (total hip). The hip BMDs of this study were greater than those of NHANES III in the third, seventh and eighth decades by as much as 0.6 SD. This produced a difference of 0.049-0.077 g/cm(2) for T(YN) = -2.5 between the two reference ranges.

The skeletal response to teriparatide is largely independent of age, initial bone mineral density, and prevalent vertebral fractures in postmenopausal women with osteoporosis

In a recent study of women with postmenopausal osteoporosis, treatment with teriparatide for a median of 19 months increased bone mineral density and decreased the risk of vertebral and nonvertebral fractures. Using the same cohort, the current study evaluated the relationship between these therapeutic effects and the patient's baseline age, vertebral bone mineral density, and prevalent vertebral fractures. In women over 65 years of age, treatment resulted in a greater increase in vertebral bone mineral density than in younger women (treatment-by-age interaction, p = 0.037), but baseline age had no effect on the relative risk reduction for vertebral fractures (treatment-by-age interaction, p = 0.558). In women receiving placebo (with calcium and vitamin D), there was an inverse relationship between baseline vertebral bone mineral density and vertebral fracture risk. When compared across bone mineral density tertiles, the effects of teriparatide on the relative risk for developing new vertebral fractures and increase in vertebral bone mineral density did not differ significantly (p = 0.817 and p = 0.615, respectively). Teriparatide treatment significantly decreased vertebral fracture risk in patients with a vertebral bone mineral density T score of less than -33 or a score between -2.1 and -3.3 (p < 0.001 and p = 0.027, respectively) and showed a trend toward reduced fracture risk in the group with a T score greater than -2.1 (p = 0.115). Placebo-treated women with two or more prevalent vertebral fractures had a significantly greater risk of developing new vertebral fractures than women with zero or one prevalent vertebral fracture (p < 0.001). When compared within prevalent vertebral fracture subgroups, the effects of teriparatide on the relative risk for developing new vertebral fractures were similar. The results of this study indicate that teriparatide offers clinical benefit to patients across a broad range of age and disease severity.

Comparison of change in bone resorption and bone mineral density with once-weekly alendronate and daily risedronate: a randomised, placebo-controlled study

OBJECTIVE

To compare the effects of alendronate (ALN) 70 mg once weekly (OW) and risedronate (RIS) 5 mg daily between-meal dosing on biochemical markers of bone turnover and bone mineral density (BMD) in postmenopausal women with osteoporosis.

RESEARCH DESIGN AND METHODS

This was a 3-month, randomised, double-blind, placebo-controlled study with a double-blind extension to 12 months. The study enrolled 549 postmenopausal women (ALN 219, RIS 222 and placebo (PBO) 108) who were > or =60 years of age at outpatient centres.

MAIN OUTCOME MEASURES

The primary endpoint was reduction in urine N-telopeptides of type 1 collagen (NTx) corrected for creatinine level at 3 months. Secondary parameters included change in BMD at the spine and hip at 6 and 12 months, NTx at 1, 6 and 12 months, and serum bone-specific alkaline phosphatase (BSAP) at 1, 3, 6 and 12 months. Adverse experiences (AEs) were recorded throughout the study for an assessment of treatment safety profiles and tolerability.

RESULTS

Over 3 months, ALN produced a significantly greater mean reduction in urine NTx than did RIS (-52% vs -32%, p < 0.001), which was maintained at 12 months. ALN produced a significantly greater mean BMD increase than did RIS at 6 months, and it was maintained at 12 months at the lumbar spine (4.8% vs 2.8%, p < 0.001) and total hip (2.7% vs 0.9%, p < 0.001), as well as at the trochanter and femoral neck. Significant reductions in BSAP with ALN compared to RIS were maintained over the 12 months of treatment. Study size did not allow for meaningful assessment of differences in fracture rates. Tolerability was generally similar between ALN, RIS and PBO, and the incidence of upper GI AEs causing discontinuation and oesophageal AEs was similar in the ALN and RIS groups.

CONCLUSION

In this study, ALN 70 mg OW produced a 50% greater reduction in bone resorption as measured by urine NTx and significantly greater increases in lumbar spine and hip BMD than did RIS 5 mg daily. The treatments had similar safety profiles and were generally well-tolerated. Additional studies are needed comparing OW ALN with OW RIS, which became available after the commencement of the present study.

Effect of daily and intermittent use of ibandronate on bone mass and bone turnover in postmenopausal osteoporosis: a review of three phase II studies

BACKGROUND

Oral bisphosphonates are well established for the treatment and prevention of postmenopausal osteoporosis; however, they are poorly absorbed from the gastrointestinal (GI) tract and have been associated with GI adverse events. Thus, current dosing guidelines recommend that the patient not eat or lie down for at least 30 minutes after taking oral bisphosphonates, a requirement that is inconvenient and may be associated with reduced compliance. The drawbacks of these dosing requirements may be overcome either by reducing dosing frequency or by using alternative routes of administration.

OBJECTIVE

Ibandronate is a potent nitrogen-containing bisphosphonate that can be given orally or IV, daily or intermittently, with a between-dose interval of up to 3 months. This article presents the results of published Phase II trials of the efficacy and safety profile of oral and IV ibandronate administered daily or intermittently to postmenopausal women with low bone mass.

METHODS

MEDLINE was searched through January 2002 to identify all published Phase II clinical studies of oral and IV ibandronate in the treatment of post-menopausal osteoporosis.

RESULTS

In the 3 Phase II studies identified, marked reductions in biochemical markers of bone resorption (50%-70%) and bone formation (40%-50%) were seen to a similar and statistically significant extent with oral ibandronate 2.5 mg/d (P<0.001), oral ibandronate 20 mg QOD given for 12 doses at the start of each 3-monthly period (P<0.001), and injections of ibandronate 2 mg IV given every 3 months (P<0.01). All treatment regimens produced comparable significant increases in bone mineral density at the lumbar spine (P<0.01) and hip (P<0.05). Ibandronate was well tolerated when administered both orally and as an IV injection.

CONCLUSIONS

In these Phase II studies, oral or IV ibandronate, administered continuously or intermittently, reduced markers of bone turnover, significantly increased bone mineral density, and was well tolerated in the treatment of osteoporosis in postmenopausal women. The data from these studies provided the rationale for further investigation of ibandronate in larger longer-term Phase III studies evaluating its potential as an efficacious and flexible alternative to existing bisphosphonate regimens.

Hip fracture patients are not treated for osteoporosis: a call to action

OBJECTIVE

To determine whether hip fracture patients, a group at very high risk for additional fragility fractures, are being evaluated and treated effectively for osteoporosis.

METHODS

Clinical and bone densitometry (dual x-ray absorptiometry [DXA]) records were reviewed in hip fracture patients at 4 Midwestern US health systems to determine the frequency of DXA use, calcium and vitamin D supplementation, and antiresorptive drug treatment.

RESULTS

DXA was performed at the 4 study sites in only 12%, 12%, 13%, and 24% of patients, respectively. Calcium and vitamin D supplements were prescribed in 27%, 1%, 3%, and 25% of the patients at the 4 study sites. Antiresorptive drugs were prescribed in 26%, 12%, 7%, and 37% of the patients with only 2-10% receiving a bisphosphonate.

CONCLUSION

Reducing osteoporotic fractures will require more effective approaches to managing hip fracture patients and other high-risk populations.

Alendronate in the prevention of bone loss after a fracture of the lower leg

Fracture of a leg and the consequent absence from weight-bearing lead to local bone loss. A 1-year, single-center, prospective, randomized, double-blind study was conducted, to determine whether bone loss would occur in the proximal femur and the calcaneus after a fracture of the lower leg and whether this loss could be prevented by the antiresorptive drug bisphosphonate alendronate. Twenty-three men and 18 women with a recent unstable fracture of the lower leg were randomized to receive either 10 mg of alendronate daily or placebo. Bone mineral density (BMD) of both hips and the lumbar spine was measured at baseline and 6 weeks and 3, 6, and 12 months after start of the treatment. Quantitative ultrasound (QUS) measurements of the calcaneus were performed at baseline on the noninjured side and at 6 weeks and 3, 6, and 12 months after start of treatment on both sides. After 1 year, in the placebo group, there was a significant decrease from baseline in BMD of the hip on the side of the fracture. In the alendronate group, there was no significant change from baseline. The differences in BMD between the two treatment groups on the side of the fracture were significant in all sites of the hip: 4.4% (p = 0.016) in the trochanter, 4.6% (p = 0.016) in the femoral neck, and 3.9% (p = 0.009) in the total hip. In the hip on the contralateral side, there were no significant changes from baseline in either treatment group and there was no difference between the two treatment groups. BMD in the lumbar spine increased in the alendronate group, and after 1 year there was a significant difference between the active treatment and placebo group of 3.4% (p = 0.04). One year after fracture, ultrasound parameters of the calcaneus in the placebo group were significantly lower on the fractured side compared with the contralateral side (p < 0.01). In the alendronate group, no significant difference between the two sides was observed. In conclusion, BMD of the proximal femur was still decreased 1 year after a fracture of the lower leg. Alendronate prevented this bone loss.

[Pharmacotherapy of osteoporosis]

Osteoporosis with increased risk of bone fracture is a disabling syndrome that naturally occurs as long as one ages and moves on two legs. Recent progress in bone cell biology has shed light on the mechanisms underlying the anti-osteoporotic properties of drugs that have been in use for a long time, providing a fresh stage for novel pharmacotherapies. In addition, large scale clinical trials developed in the past decade appear not only to rationalize the clinical utilities of these drugs but also to provide new concepts for the development of new therapeutic modalities. Progress in the fields of basic and clinical research field is briefly reviewed herein.

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.

Effects of long-term risedronate on bone quality and bone turnover in women with postmenopausal osteoporosis

The effects of 3 years of oral risedronate treatment on bone quality and remodeling were assessed in women with postmenopausal osteoporosis. Transiliac bone biopsies were obtained at baseline and after treatment with placebo or risedronate 5 mg/day in 55 women (placebo, n = 27; risedronate 5 mg, n = 28); these pairs of samples allowed comparison of treatment effects vs. both baseline values and between treatment groups. A further 15 women (placebo, n = 6; risedronate 5 mg, n = 9) had measurements from a posttreatment biopsy, but not from a baseline biopsy. Samples were examined for qualitative changes (e.g., osteomalacia, peritrabecular fibrosis, and woven bone); no histological abnormalities were found to be associated with treatment. Among women with both baseline and posttreatment biopsies, risedronate-treated women experienced a moderate and expected reduction from baseline in bone turnover, which was reflected in mean decreases in mineralizing surface of 58% and in activation frequency of 47%. Histomorphometrical parameters indicated that bone formation rate decreased significantly from baseline with risedronate treatment, reflecting a decrease in bone turnover; bone mineralization was normal following treatment. Basic multicellular unit (BMU) balance tended to improve in the risedronate-treated women, whereas it tended to worsen in the placebo-treated women, although these changes were not statistically significant. There were no significant changes in structural parameters with treatment. The effects of 3 years of risedronate treatment on bone histology and histomorphometry reflect the antiresorptive mechanism of action, and are consistent with the antifracture efficacy and favorable bone safety profile demonstrated in large clinical trials.

Bone densitometry, steroids and osteoporosis

PURPOSE OF REVIEW

Scans to measure bone mineral density at the spine and hip have an important role in the evaluation of patients at risk of osteoporosis. Oral corticosteroid use is an important risk factor for a fragility fracture and the relative risk is particularly high for vertebral and hip fractures. In Europe and the USA, guidelines have been published for the investigation of patients at risk of corticosteroid-induced osteoporosis, with recommendations on the diagnostic use of bone mineral density scans and the initiation of treatment based on the findings.

RECENT FINDINGS

Large trials of bisphosphonates, selective oestrogen receptor modulators and parathyroid hormone have addressed the issue of fracture prevention in women with postmenopausal osteoporosis and there is a growing consensus that the World Health Organization definition of osteoporosis of a -score=-2.5 is an appropriate threshold for preventive treatment in these patients. For most agents separate studies have been conducted of their use for the prevention and treatment of corticosteroid-induced osteoporosis.

SUMMARY

There is increased awareness of the importance of preventive treatment for osteoporosis in patients taking high doses of oral corticosteroids (daily dose of 7.5 mg prednisolone or greater). In view of evidence that corticosteroid use is an independent risk factor for fracture over and above bone mineral density, guidelines for intervention set a higher threshold than the World Health Organization figure ( -score=-1.5 rather than -2.5) for intervention with bone sparing treatment in these patients.

Oral bisphosphonates and upper gastrointestinal tract problems: what is the evidence?

OBJECTIVE

To review and evaluate the evidence regarding possible associations of bisphosphonate use with upper gastrointestinal (GI) tract adverse events (AEs).

METHODS

We reviewed and summarized published information and abstracts regarding upper GI tract safety and tolerability of bisphosphonates, including laboratory and animal studies, epidemiological (observational) studies, endoscopy studies, and randomized controlled trials (RCTs). The evidence was summarized by using the principles of evidence-based medicine, giving the greatest credence to high-quality RCTs.

RESULTS

Clinical reports of esophagitis associated with bisphosphonate use appear to have declined in frequency once the importance of proper administration was explained to physicians after early reports of complications. Conflicting results have been reported in endoscopy studies; some reported no significant increase in upper GI tract lesions, whereas others reported a higher incidence of gastric (but not esophageal) lesions among patients taking oral bisphosphonates. Endoscopy studies that reported differences were of short duration (2 weeks) and were not of double-blind design. Results from large RCTs involving thousands of participants detected no increase in upper GI tract AEs among individuals treated with bisphosphonates. Other studies of patients who discontinued taking bisphosphonates and were randomized to blinded re-treatment with either a bisphosphonate or placebo show that most patients (>85%) were able to continue treatment, with no difference in AEs between the bisphosphonate and placebo groups.

CONCLUSIONS

The highest level of evidence, RCTs, suggests little or no increase in risk of upper GI tract problems if bisphosphonates are administered properly. Upper GI tract symptoms are common among patients with osteoporosis. The evidence suggests that many upper GI tract AEs reported during therapy with bisphosphonates may reflect a high background incidence of upper GI tract complaints and an increased sensitivity to detection rather than a causal relationship to therapy.

Discoveries, drugs and skeletal disorders

Bone turnover, in which cells of the osteoclast lineage resorb bone and cells of the osteoblast lineage deposit bone, normally occurs in a highly regulated manner throughout life. Perturbations to these processes underlie skeletal disorders, such as osteoporosis, which are common, chronic and disabling, and increase with age. On the basis of empirical observations or on understanding of the endocrinology of the skeleton, excellent bone-resorption inhibitors, but few anabolic agents, have been developed as therapeutics for skeletal disorders. However, powerful new genomic and genetic tools are uncovering new loci that regulate the activity of both osteoclasts and osteoblasts, and these hold great promise for future drug development.

Osteoporosis

Osteoporosis is characterised by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and consequent increase in fracture risk. It is a common condition affecting one in three women and one in 12 men, resulting in substantial morbidity, excess mortality, and health and social services expenditure. It is therefore important to develop strategies to prevent and treat osteoporosis in both men and women. This paper reviews the pathogenesis of primary and secondary osteoporosis, as well as diagnosis, investigation, and management. This should include lifestyle changes to reduce bone loss and decrease the risk of falls, the identification and treatment of secondary causes of bone loss, and specific treatment for osteoporosis. Hormone replacement therapy, raloxifene, bisphosphonates, calcium and vitamin D, calcitonin, and parathyroid hormone have all been shown to improve bone density and decrease the risk of fracture in specific situations. It is important that treatment is tailored to the individual patient, to ensure compliance and optimise the potential benefits.

Bone metabolism and the perimenopause overview, risk factors, screening, and osteoporosis preventive measures

In summary, FDA-approved therapies for prevention and treatment of osteoporosis are all antiresorptive agents. There are no approved therapies at this time that stimulate bone formation, although one such agent (PTH) is awaiting approval. Screening perimenopausal women at risk should identify osteopenic women early in the menopause before the accelerated bone loss of estrogen deficiency causes further irreversible erosion in bone density. The National Osteoporosis Foundation advocates initiating therapy to reduce fracture risk in postmenopausal women with T scores below -2 in the absence or factors and with T scores below -1.5 if other risk factors are present. Estrogen, alendronate, residronate, and raloxifene have all been shown to reduce the incidence of radiographic vertebral fractures in women at risk. Only alendronate and residronate have been shown in large randomized trials to reduce the incidence of nonvertebral fractures including hip fractures in women with postmenopausal osteoporosis. These antiresorptive therapies provide benefits above and beyond those of calcium and vitamin D alone. There is insufficient published evidence from randomized controlled trials convincingly to support a role for soy products, androgens, calcitonin, or fluoride in prevention of postmenopausal osteoporosis or reduction of fracture rates in women at risk.

Management of primary osteoporosis

Although there is a great need for better therapeutic approaches to the patient who presents with a fracture, osteoporotic fractures will remain a condition that is more amenable to prevention than treatment. Hormone replacement therapy (HRT) is still considered by many the mainstay for the prevention and the treatment of posrmenopausal osteoporosis. However, there are several controversies regarding HRT, especially the duration of treatment and the risks/benefits ratio. Recent studies have challenged the assumption that HRT conveys real long-term beneficial effects. Raloxifene or other "selective estrogen receptor modulators" (SERMs) should progressively replace HRT in elderly women. Bisphosphonates have demonstrated a clearcut efficacy in the treatment of osteoporosis. Alendronate and risedronate have been the most extensively studied bisphosphonates under randomized controlled trials conditions. Both agents can reduce the risk of vertebral and hip fractures by one-fourth to one-half. However, oral bisphosphonates are not without gastro-intestinal toxicity and strict adherence to constraining therapeutic schemes is mandatory. Intermittent treatments are already in use. Weekly alendronate is as efficient as daily therapy and improves treatment compliance. Newer more potent bisphosphonates, such as oral ibandronate or intravenous zoledronic acid, will allow much less frequent administration. The anti-fracture efficacy of yearly zoledronic acid infusions is thus currently tested. On the other hand, bone-forming agents, such as daily subcutaneous injections of teriparatide (rhPTH 1-34) offer exciting perspectives for the treatment of severe osteoporosis despite the complexity of such therapy.

American Society of Clinical Oncology clinical practice guidelines: the role of bisphosphonates in multiple myeloma

PURPOSE

To determine clinical practice guidelines for the use of bisphosphonates in the prevention and treatment of lytic bone disease in multiple myeloma and to determine their respective role relative to other conventional therapies for this condition.

METHODS

An expert multidisciplinary Panel reviewed pertinent information from the published literature through January 2002. Values for levels of evidence and grade of recommendation were assigned by expert reviewers and approved by the Panel. Expert consensus was used if there were insufficient published data. The Panel addressed which patients to treat and when to treat them in the course of their disease. Additionally, specific drug delivery issues, duration of therapy, initiation of treatment and management of treatment of lytic bone disease was reviewed and compared with other forms of therapy for lytic bone lesions. Finally, the Panel discussed patient and physician expectations associated with this therapy for bony metastases, as well as public policy implications related to the use of bisphosphonates. The guidelines underwent external review by selected physicians, by the Health Services Research Committee members, and by the ASCO Board of Directors.

RESULTS

The available evidence involving randomized controlled trials is modest but supports that oral clodronate, intravenous pamidronate, and intravenous zoledronic acid are superior to placebo in reducing skeletal complications. A reduction in vertebral fractures has consistently been seen across all studies. No agent has shown a definitive survival benefit. Intravenous zoledronic acid has recently been shown to be as effective as intravenous pamidronate. Because there are no direct comparisons between clodronate and pamidronate or zoledronic acid, the superiority of one agent cannot be definitively established. However, the panel recommends only intravenous pamidronate or zoledronic acid in light of the use of the time to first skeletal event as the primary end point and more complete assessment of bony complications in studies evaluating it. Additionally, clodronate is not available in the United States. The choice between pamidronate and zoledronic acid will depend on choosing between the higher drug cost of zoledronic acid, with its shorter, more convenient infusion time (15 minutes), versus the less expensive drug, pamidronate, with its longer infusion time (2 hours).

CONCLUSION

Bisphosphonates provide a meaningful supportive benefit to multiple myeloma patients with lytic bone disease. However, further research on bisphosphonates is warranted, including the following: (1) when to start and stop therapy, (2) how to integrate their use with other treatments for lytic bone disease, (3) how to evaluate their role in myeloma patients without lytic bone involvement, (4) how to distinguish between symptomatic and asymptomatic bony events, and (5) how to better determine their cost-benefit consequence.

Meta-analyses of therapies for postmenopausal osteoporosis. II. Meta-analysis of alendronate for the treatment of postmenopausal women

OBJECTIVE

To review the effect of alendronate on bone density and fractures in postmenopausal women.

DATA SOURCE

We searched MEDLINE, EMBASE, Current Contents, and the Cochrane Controlled trials registry from 1980 to 1999, and we examined citations of relevant articles and proceedings of international meetings.

STUDY SELECTION

We included 11 trials that randomized women to alendronate or placebo and measured bone density for at least 1 yr.

DATA EXTRACTION

For each trial, three independent reviewers assessed the methodological quality and abstracted data.

DATA SYNTHESIS

The pooled relative risk (RR) for vertebral fractures in patients given 5 mg or more of alendronate was 0.52 [95% confidence interval (CI), 0.43-0.65]. The RR of nonvertebral fractures in patients given 10 mg or more of alendronate was 0.51 (95% CI 0.38-0.69), an appreciably greater effect than for the 5 mg dose. We found a similar reduction in RR across nonvertebral fracture types; in particular, RR reductions for fractures traditionally thought to be "osteoporotic," such as hip and forearm, were very similar to RR reductions for "nonosteoporotic" fractures. Individual studies showed similar results, reflected in the P values of the test of heterogeneity (P = 0.99 for vertebral and 0.88 for nonvertebral fractures). Alendronate produced positive effects on the percentage change in bone density, which increased with both dose and time. After 3 yr of treatment with 10 mg of alendronate or more, the pooled estimate of the difference in percentage change between alendronate and placebo was 7.48% (95% CI 6.12-8.85) for the lumbar spine (2-3 yr), 5.60% (95% CI 4.80-6.39) for the hip (3-4 yr), 2.08% (95% CI 1.53-2.63) for the forearm (2-4 yr), and 2.73% (95% CI 2.27-3.20) for the total body (3 yr). Heterogeneity of the treatment effect of alendronate was not consistently explained by any of our a priori hypotheses; in particular, the effect was very similar in prevention and treatment studies. The pooled RR for discontinuing medication due to adverse effects for 5 mg or greater of alendronate was 1.15 (95% CI 0.93-1.42). The pooled RR for discontinuing medication due to gastro-intestinal (GI) side effects for 5 mg or greater was 1.03 (0.81-1.30, P = 0.83), and the pooled RR for GI adverse effects with continuation of medication was 1.03 (0.98 to 1.07) P = 0.23.

CONCLUSIONS

Alendronate increases bone density in both early postmenopausal women and those with established osteoporosis while reducing the rate of vertebral fracture over 2-3 yr of treatment. Reductions in nonvertebral fractures are evident among postmenopausal women without prevalent fractures and have bone mineral density (BMD) levels below the World Health Organization threshold for osteoporosis. The impact on fractures appears consistent across all fracture types, casting doubt on traditional distinctions between osteoporotic and nonosteoporotic fractures.

Improvement in the undertreatment of osteoporosis following hip fracture

BACKGROUND

Osteoporosis is a common disease characterized by decreased bone mass and increased fracture risk in postmenopausal women and the elderly. Hip fractures are among the most common consequences of osteoporosis and unfortunately usually occur late in the course of the disease. When a patient is admitted to the hospital with a fragility hip fracture, a unique opportunity for diagnosis and treatment presents itself. Fortunately, several medications have proven to be effective in lowering the risk of future fractures. The purposes of the present study were to test the hypothesis that most fragility hip fractures go untreated and to determine whether educational efforts to raise physician awareness have led to an improvement in osteoporosis treatment rates.

METHODS

A retrospective cohort study was performed with use of the patient databases at two university medical centers and one university-affiliated community hospital. The charts of 300 randomly selected patients were sorted with use of ICD-9 (International Classification of Diseases, Ninth Revision) codes for femoral neck fractures. There were 100 patients from each center, with twenty-five patients from each year between 1997 and 2000. The admitting diagnosis, mechanism of injury, admission medications, procedures performed during hospitalization, and discharge medications were then extracted and analyzed. During this period, the National Osteoporosis Foundation established guiding principles for the treatment of fragility fractures.

RESULTS

Of the seventy-five patients from all centers for each year from 1997 to 2000, 11%, 13%, 24%, and 29%, respectively, were discharged with a prescription for some medication targeting osteopenia, either supplemental calcium or an antiosteoporotic medication (estrogen, calcitonin, a bisphosphonate, or raloxifene). A trended chi-square analysis of this increase revealed a p value of <0.001, indicating that this improvement in treatment was unlikely due to chance alone. Fifty-eight (19.3%) of the 300 patients in the study received a prescription at the time of discharge. However, forty of these patients (13.3% of the overall group) received calcium and only eighteen (6.0% of the overall group) received a medication to actively prevent bone resorption and treat osteoporosis. In addition, no patient underwent a bone density scan while in the hospital.

CONCLUSIONS

Elderly patients and postmenopausal women who are admitted to the hospital and diagnosed with a low-energy femoral neck fracture have been undertreated for osteoporosis. However, over the four years of the present study, there was a significant increase in the rate of treatment. It is hoped that treatment rates will continue to increase in the future with continued educational efforts.

Osteoporosis in elderly: prevention and treatment

Osteoporosis is a major clinical problem in older women and men. Almost any bone can fracture as a result of the increased bone fragility of osteoporosis. These fractures are associated with higher health care costs, physical disability, impaired quality of life, and increased mortality. Because the incidence of osteoporotic fracture increases with advancing age, measures to diagnose and prevent osteoporosis and its complications assume a major public health concern. BMD is a valuable tool to identify patients at risk for fracture, to make therapeutic decisions, and to monitor therapy. Several other modifiable and nonmodifiable risk factors for osteoporosis have also been identified. Treatment of potentially modifiable risk factors along with exercise and calcium and vitamin D supplementation forms an important adjunct to pharmacologic management of osteoporosis. Improved household safety can reduce the risk of falls. Hip protectors have been found to be effective in nursing home population. The pharmacologic options include bisphosphonates, HRT, SERMs and calcitonin. PTH had received FDA advisory committee approval. Alendronate has been approved for treatment of osteoporosis in men, and other treatments for men are under evaluation.

The underuse of therapy in the secondary prevention of hip fractures

There is strong evidence to indicate that individuals who sustain a hip fracture are at a greater risk of developing another. The management of such patients should include efforts to prevent future fractures, including prescribing medications that have been shown to lower hip fracture risk. Such therapies that are currently available include calcium and vitamin D supplementation, alendronic acid and risedronic acid. In addition, there is epidemiological evidence to indicate that estrogen may also decrease the risk of hip fracture. Parathyroid hormone is another agent that has shown promise in this regard and is likely to be available for clinical use in the near future. However, the rates of utilisation of these therapies among patients with hip fractures are low. It is important to emphasise that secondary prevention of hip fractures should be an integral part of the management of individuals who sustain hip fractures.

Intervention thresholds for osteoporosis

The aim of this study was to determine the threshold of fracture probability at which interventions become cost-effective. We modeled the effects of a treatment costing $500/year, given for 5 years, that decreased the risk of all osteoporotic fractures by 35%, followed by a waning of effect for 5 years. Sensitivity analyses included a range of effectiveness (10%-50%) and a range of intervention costs (200-500 dollars/year). Data on costs and risks were from Sweden. Costs included direct costs and costs in added years of life, but excluded indirect costs due to morbidity. A threshold for cost-effectiveness of 60,000 dollars per quality-adjusted life-year (QALY) gained was used. Costs of added years were excluded in a sensitivity analysis for which a threshold value of 30,000 dollars per QALY was used. In the base case, intervention was cost-effective when treatment was targeted to women at average risk at age of >or=65 years. Irrespective of the efficacy modeled (10%-50%) or of cost of intervention (200-500 dollars/year) segments of the population at average risk could be targeted cost-effectively: The lower the intervention cost and the higher the effectiveness, the lower the age at which intervention was cost-effective. With the base case (500 dollars/year; 35% efficacy) treatment in women was cost-effective with a 10 year hip fracture probability that ranged from 1.4% at the age of 50 years to 4.4% at the age of 65 years. The exclusion of osteoporotic fractures other than hip fracture would increase the threshold to a 9%-11% 10 year probability because of the substantial morbidity from fractures other than hip fracture, particularly at younger ages. We conclude that the inclusion of all osteoporotic fractures has a marked effect on intervention thresholds, that these vary with age, and that available treatments can be cost-effectively targeted to individuals at moderately increased risk.

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.

Review of raloxifene and its clinical applications in osteoporosis

Raloxifene, a selective oestrogen receptor modulator, is currently utilised for both the prevention and treatment of postmenopausal osteoporosis. Prevention studies with raloxifene have demonstrated preservation of bone density, suppression of markers of bone turnover and maintenance of normal bone histology for up to 4 years in young postmenopausal women. The Multiple Outcomes of Raloxifene Evaluation (MORE) trial, the pivotal treatment trial of raloxifene, demonstrated significant reductions in the risk of vertebral fractures after 1 and 3 years, which is comparable to other currently available agents. Significant reductions in non-vertebral fractures with raloxifene have not been demonstrated yet. In addition to the effects of raloxifene on bone, a number of beneficial non-skeletal effects have been reported on the breast, uterus and cardiovascular system. These latter findings are mainly derived from secondary end points and analyses of the large osteoporosis studies with raloxifene. Two large, prospective, randomised, double-blind studies examining the effects of raloxifene on breast cancer prevention and cardiovascular protection are now underway. Recent information on the effects of raloxifene in postmenopausal osteoporosis, breast cancer prevention and cardiovascular disease in high-risk women and those with uterine disorders is reviewed in this article.

Daily oral pamidronate in women and men with osteoporosis: a 3-year randomized placebo-controlled clinical trial with a 2-year open extension

The efficacy and safety of oral pamidronate was examined in a double-blind, placebo-controlled trial in women and men with established osteoporosis. Seventy-eight postmenopausal women and 23 men with at least one prevalent vertebral fracture were randomized separately to 150 mg/day of pamidronate or placebo for 3 years followed by 150 mg/day of pamidronate for an additional 2 years. In addition, all patients received 400 U/day of cholecalciferol and 500 mg/day of elemental calcium. Pamidronate increased significantly bone mineral density of the lumbar spine (LS-BMD) and of the femoral neck (FN-BMD). The total increase in BMD of the spine after 5 years of treatment was 14.3%. Lateral spine radiographs were obtained at baseline and after 3 years of treatment. Fractures of previously normal vertebrae occurred in 15 of 45 patients treated with placebo (33.3%) and in 5 of 46 patients treated with pamidronate (11%). The relative risk was 0.33 (95% CI, 0.14-0.77). Treatment was well tolerated and there was no difference in gastrointestinal toxicity between pamidronate and placebo-treated patients. One hundred fifty milligrams daily of pamidronate is an effective and safe treatment of women and men with established osteoporosis.

Assessment of mortality in patients enrolled in a risedronate clinical trial program: a retrospective cohort study

Risedronate, a pyridinyl bisphosphonate, has been shown in large clinical trials to be effective in the prevention and treatment of osteoporosis. Analysis of safety data from these trials has shown that risedronate (2.5- and 5-mg doses) has an overall safety profile comparable to placebo during the course of the clinical trials. The clinical trials were powered appropriately to analyze the efficacy endpoints; however, patients were not systematically followed after completion of the clinical trials and therefore vital status for most of the patient cohort after the cessation of the clinical trials was unknown. In order to investigate further the safety profile of risedronate observed in the clinical trials database, we conducted a retrospective cohort mortality study among 7981 patients comprising the intent-to-treat population in three North American risedronate osteoporosis trials. No difference in all cause mortality was observed in patients receiving risedronate treatment compared with patients receiving placebo. There were also no differences between these groups in mortality due to all cancers, lung cancer, and gastrointestinal tract cancer. A trend toward lower cardiovascular mortality was observed in the risedronate groups compared with placebo; this difference was largely due to a significant reduction in stroke mortality in the active treatment groups. Follow-up mortality data in this retrospective cohort study demonstrate that treatment with risedronate has no effect on overall mortality rates.

The gastrointestinal tolerability and safety of oral bisphosphonates

Oral bisphosphonates are effective for osteoporosis and other hyperresorptive bone disorders. Although well-tolerated in efficacy trials, some oral aminobisphosphonates have been associated with upper gastrointestinal intolerance and injury in postmarketing experience. Clinical trials often underestimate the rate of adverse events in clinical practice, and ethics prohibit direct evaluation of toxicity in high-risk patients. Accordingly, animal models and endoscopy studies of oral bisphosphonates provide valuable insight. It is unclear whether variation in ulcerogenic potential reflects differences in dosing, formulation or chemical structure. Furthermore, the clinical relevance of endoscopic lesions is uncertain. Ongoing postmarketing review will determine whether differences in endoscopic damage predict tolerability and safety in clinical practice. However, physicians and patients should consider risk factors for oesophageal injury when initiating therapy.

Pharmacotherapy of osteoporosis in postmenopausal women: focus on safety

The therapy of osteoporosis has made enormous strides in the last decade. There is now a range of interventions, each with its pros and cons. Calcium and vitamin D supplementation remain the foundation and have few safety issues. Bisphosphonates are widely used, though gastrointestinal tolerance is a problem with some oral preparations. Intravenous administration may circumvent this, although this introduces the smaller problem of acute phase reactions. The side effect profile of hormone replacement therapy (HRT) is still being delineated after 40 years of use, with substantial new information expected in the next few years. This will clarify its place in the medical management of the menopause. Raloxifene appears to have a superior safety profile to HRT, though its efficacy on bone may be less. While none of these options is suitable for everyone, the range of available therapies does mean that most patients can find an intervention that is effective and acceptable.

Response of bone mineral density to once-weekly administration of risedronate

OBJECTIVE

To evaluate the changes in bone mineral density (BMD) and the tolerability associated with treatment with risedronate, 30 mg once weekly.

METHODS

Risedronate, 30 mg, was administered once weekly before breakfast to patients with osteoporosis or osteopenia. All patients were also treated with calcium, 1,500 mg daily, and supplemental vitamin D. Patients receiving treatment with other antiresorptive agents were not excluded. BMD was assessed with dual-energy x-ray absorptiometry (DEXA) at baseline and 1 year.

RESULTS

After a mean of 11.6 +/- 0.4 months, mean BMD had increased at the lumbar spine and total hip, respectively, by 5.7% (P<0.001) and 2.9% (P<0.001) among all patients, by 4.8% (P<0.001) and 2.2% (P<0.04) among 23 treated with risedronate alone, and by 6.7% (P<0.003) and 3.6% (P<0.004) among 21 receiving risedronate and other antiresorptive agents. Linear regression analysis of the relationship between baseline T-score and BMD increment at the lumbar spine and femoral neck showed a statistically significant negative correlation, an indication of an enhanced response to treatment in patients with lower baseline T-scores. Adverse events possibly associated with risedronate therapy were recorded in 3 of the 70 enrolled patients (dyspepsia in 2 and urticaria in 1). Of 44 patients with follow-up DEXA scans, 12 (27%) had not tolerated alendronate (10 mg daily) previously, but they tolerated once-weekly risedronate therapy without difficulty.

CONCLUSION

A once-weekly 30-mg regimen of risedronate increases BMD when administered alone or with other antiresorptive agents. Few adverse events possibly associated with risedronate therapy were noted.

Changes in bone density and turnover explain the reductions in incidence of nonvertebral fractures that occur during treatment with antiresorptive agents

Some, but not all, antiresorptive agents have been shown to reduce the risk of nonvertebral fractures. Agents that significantly reduced nonvertebral fracture risk also appear to produce larger mean increases in bone mineral density (BMD) and reductions in biochemical markers (BCM) of bone turnover, compared with other agents. To examine the extent to which increases in BMD and reductions in BCM during antiresorptive therapy are associated with reductions in risk of nonvertebral fractures, we performed a meta-analysis of all randomized, placebo-controlled trials of antiresorptive agents conducted in postmenopausal women with osteoporosis (i.e. prior vertebral fracture or low BMD) with available relevant data. A total of 18 such trials with usable data were identified, including a total of 2,415 women with incident nonvertebral fractures over 69,369 women-years of follow-up. Poisson regression was used to estimate the association between changes in BMD or BCM during the first year and overall reductions in risk of nonvertebral fractures (vs. the placebo group) across all trials. Larger increases in BMD and larger reductions in BCM were significantly associated with greater reductions in nonvertebral fracture risk. For example, each 1% increase in spine BMD at 1 yr was associated with an 8% reduction in nonvertebral fracture risk (P = 0.02). Mean BMD changes at the hip were smaller than at the spine, but the predicted net effect on fracture risk was the same; an agent that increases spine BMD by 6% at 1 yr reduces nonvertebral fracture risk by about 39%, and an agent that increases hip BMD by 3% at 1 yr reduces nonvertebral fracture risk by about 46%. The results also predict that a 70% reduction in resorption BCM would reduce risk by 40%, and a 50% reduction in formation BCM would reduce risk by 44%. It appears that either BMD or BCM changes are able to explain the effect of treatment, because a separate variable for treatment was not independently significant in any models. These data demonstrate that larger increases in BMD at both the spine and hip and larger reductions in both formation and resorption BCM are associated with greater reductions in the risk of nonvertebral fractures. Antiresorptive agents that do not produce large increases in BMD or large reductions in BCM do not appear to and would not be expected to decrease the risk of nonvertebral fractures.

Risedronate for the prevention of fractures in postmenopausal osteoporosis

OBJECTIVE

To evaluate current scientific literature regarding the efficacy of risedronate in the prevention of vertebral and nonvertebral fractures in women with postmenopausal osteoporosis.

DATA SOURCES

Primary research articles were identified by MEDLINE search (1966-May 2001) and through secondary sources. Key search terms were risedronate, postmenopausal osteoporosis, and fractures.

DATA SYNTHESIS

Osteoporosis results in a reduction of bone mineral density, increased bone fragility, and increased risk of fractures. The goal of osteoporosis therapy is not only to increase bone mass, but also to reduce the rate of fractures. Risedronate is the newest bisphosphonate to be approved for the prevention and treatment of osteoporosis. An evaluation of clinical trials using risedronate in the treatment of postmenopausal osteoporosis was performed to determine its efficacy at decreasing fracture rates.

CONCLUSIONS

Risedronate is an effective and safe option for the treatment of postmenopausal osteoporosis. Risedronate significantly decreases the risk of vertebral and nonvertebral fractures in women who have had > or =1 fractures in the past. More studies are warranted to evaluate the efficacy of risedronate in women without preexisting vertebral fractures.

Barriers to osteoporosis identification and treatment among primary care physicians and orthopedic surgeons

OBJECTIVE

To understand better the barriers among orthopedic surgeons and primary care physicians in identifying and treating possible osteoporosis in patients hospitalized with a fragility fracture sustained spontaneously or from a fall no greater than standing height.

METHODS

A 1-page, 7-question survey was sent to 35 admitting orthopedic surgeons and 75 primary care physicians at a midwestern managed care organization in March 2001. Returned surveys were collected until 30 days had passed since the mailing. Primary care physicians were board-certified family practitioners and internal medicine physicians. All orthopedists were admitting surgeons in the hospital system. Responders were anonymous, and posted surveys were returned to the Orthopaedic Collaborative Practice office. The surveys were color-coded to separate responses from orthopedic surgeons and primary care physicians.

RESULTS

Thirty-one surveys were returned: 23 (31%) from primary care physicians and 8 (23%) from orthopedic surgeons. Survey respondents agreed that the responsibility for postfracture attention to nutritional needs, including calcium and vitamin D, rested with the primary care provider. When asked about barriers to recommending bone mineral density testing with dual energy x-ray absorptiometry, 9 primary care physicians (39%) thought this type of testing was unnecessary for treatment, and 4 primary care physicians (17%) thought a barrier was caused by patient frailty. Primary care physicians indicated that potential adverse effects of medication (n=14 [61%]) and cost of therapy (n=13 [57%]) were the main factors limiting treatment. When asked to identify the single most important barrier in treatment, 14 physicians (61%) indicated cost was the greatest deterrent. Twenty-one primary care physicians (91%) reported they would be more likely to treat a patient with osteoporosis if a safe medication with proven fracture risk reduction were available. Primary care physicians indicated they were more likely to treat independently living adults (n=12 [52%]) and women compared with men (n=15 [65%]). All orthopedic surgeons (n=8) were willing for all patients to be evaluated in consultation with a nurse practitioner. Primary care respondents were less apt to agree with a nurse practitioner referral (n=5 [22%]). Both primary care physicians (n=16 [70%]) and orthopedic surgeons (n=4 [50%]) agreed that there is a need for increased primary care education about managing osteoporosis in patients hospitalized with low-impact fracture.

CONCLUSIONS

Orthopedic surgeons were consistent in their opinion that postfracture attention to osteoporosis should rest with the primary care physician. Primary care physicians agree but report that cost and possible adverse effects of medication are major barriers to this care. Despite therapies for high-risk postfracture patients showing relative safety and proven efficacy in reducing future fractures, deterrents to this care are focused on cost and potential adverse effects. Further education is needed to promote a standard of care for the postfracture patient that is directed toward the prevention of a subsequent fracture.

Number of years since menopause: spontaneous bone loss is dependent but response to hormone replacement therapy is independent

In this study we examine the influence of number of years since menopause on spontaneous bone loss and response to hormone replacement therapy (HRT) in 274 women (56.1 +/- 4.2 years) completing two placebo-controlled HRT studies of 2 or 3 year duration. Both cross sectionally and longitudinally, bone loss in untreated women was greatest closest to menopause and declined thereafter (r = 0.34, p < 0.01 for lumbar spine bone loss and r = 0.25, p < 0.05 for femoral neck bone loss when correlated with number of years since menopause), such that the loss was eliminated in the femoral neck and bone mass increased in the spine in women >10 years after menopause. In contrast, bone turnover was consistently elevated throughout postmenopause, both cross-sectionally and longitudinally. The association with number of years since menopause was counteracted by both 1 and 2 mg estradiol combined with gestodene, piperazine, estrone sulfate in combination with norethisterone, and a combination of 2 mg estradiol and 1 mg norethisterone acetate. In addition, the response to various HRT regimens was independent of baseline bone mass. Whereas bone loss was significantly related to number of years since menopause, all HRT regimens applied arrested bone loss in healthy postmenopausal women, regardless of number of years since menopause.

Fractures after stroke: frequency, types, and associations

BACKGROUND AND PURPOSE

Stroke patients may have an increased risk of fractures because of weak bones or an increased risk of falling. Our goal was to estimate the frequency of fracture after stroke and to identify those at greatest risk.

METHODS

This study incorporated 2 complementary strategies: a prospective, single-center, cohort study and an analysis of Scottish routine hospital discharge data.

RESULTS

Eighty-eight fractures (30% hip) occurred in 2696 hospital-referred stroke patients. The proportions sustaining any fracture or hip fracture within 2 years were 4% and 1.1%, respectively, 1.4 (95% CI, 0.92 to 2.07) times the rate of hip fracture in the general population (ie, observed number divided by expected number or standardized morbidity ratio). Female sex, older age, low abbreviated mental test score, and prestroke dependence were associated with an increased hip fracture rate. Routine data identified 129 935 acute stroke patients admitted to Scottish hospitals. During 363 447 patient-years, 4528 patients had hip fractures, 2.0% had fractures by 1 year, and 10.6% had fractures by 10 years. This is 1.7 times the rate of hip fracture in the general population and 2.3 times that in patients with myocardial infarction. Older patients predictably had the highest rate of poststroke hip fractures but a lower standardized morbidity ratio than younger patients.

CONCLUSIONS

Fractures after stroke are probably frequent and serious enough to justify the development of preventive strategies, but the modest event rate would mean that randomized, controlled trials to test these strategies specifically in stroke patients would need to enroll thousands of patients.

Upper gastrointestinal tract safety of risedronate: a pooled analysis of 9 clinical trials

Risedronate sodium is a pyridinyl bisphosphonate effective for treatment and prevention of postmenopausal and glucocorticoid-induced osteoporosis. Some bisphosphonates have been associated with upper gastrointestinal (GI) tract adverse effects. The objective of this study was to determine the frequency of upper GI tract adverse events associated with risedronate, especially among high-risk patients. The GI tract adverse events reported during 9 multicenter, randomized, double-blind, placebo-controlled studies of risedronate conducted from November 1993 to April 1998 were pooled and evaluated. The evaluation included 10,068 men and women who received placebo (n=5048) or 5 mg of risedronate sodium (n=5020) for up to 3 years (intent-to-treat population). Studies incorporated a comprehensive, prospective evaluation of GI tract adverse events. Adverse event information was collected every 3 months. The treatment groups were similar with respect to baseline GI tract disease and use of concomitant treatments during the studies. At study entry, 61.0% of patients had a history of GI tract disease and 38.7% had active GI tract disease; 20.5% used antisecretory drugs during the studies. Sixty-three percent used aspirin and/or nonsteroidal anti-inflammatory drugs (NSAIDs) during the studies. Upper GI tract adverse events were reported by 29.6% of patients in the placebo group compared with 29.8% in the risedronate group. The risk of experiencing such an event in the risedronate group was 1.01 (95% confidence interval, 0.94-1.09) relative to the placebo group (P=.77). The rate of upper GI tract adverse events per 100 patient-years was 19.2 in the placebo group compared with 20.0 in the risedronate group (P=.30). Risedronate-treated patients with active heartburn, esophagitis, other esophageal disorders, or peptic ulcer disease at study entry did not experience worsening of their underlying conditions or an increased frequency of upper GI tract adverse events overall. Concomitant use of NSAIDs, requirement for gastric antisecretory drugs, or the presence of active GI tract disease did not result in a higher frequency of upper GI tract adverse events in the risedronate-treated patients compared with controls. Endoscopy, performed in 349 patients, demonstrated no statistically significant differences across treatment groups. The results of this extensive evaluation indicate that daily treatment with 5 mg of risedronate sodium is not associated with an increased frequency of adverse GI tract effects, even among patients at high risk for these events.