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

Telmisartan alleviates rosiglitazone-induced bone loss in ovariectomized spontaneous hypertensive rats

In the present study, we systematically examined telmisartan, an angiotensin AT(1) receptor antagonist, on rosiglitazone-induced bone loss in ovariectomized spontaneously hypertensive rats. Telmisartan (5 mg/kg/d, 90 days) was found to be able to significantly alleviate rosiglitazone (10 mg/kg/d, 90 days)-induced decrease in BMD of femur and lumbar vertebrae. The BMD changes were associated with positive biomechanical changes of lumbar vertebrae, improvements in microarchitecture of tibial metaphysic and normalized serum osteocalcin (OC) levels and urinary deoxypyridinoline/creatinine (DPD/Cr) ratio. MicroCT analysis of the tibial metaphysis showed that telmisartan significantly prevented the decreases in bone volume/tissue volume (BV/TV), connect density (Conn. D.), trabecular number (Tb. N.) and trabecular thickness (Tb. Th.), and increase in trabecular separation (Tb. Sp.) induced by rosiglitazone. Histomorphometric analysis also showed that telmisartan had protective effects on rosiglitazone-reduced bone formation indices such as histomorphometric bone volume fraction (BV/TV-Histo), mineralizing surface/bone surface (MS/BS), mineral apposition rate (MAR) and bone formation rate (BFR/BS). Our study clearly showed that telmisartan alleviated rosiglitazone-induced bone loss in ovariectomized spontaneous hypertensive rats. The relief of bone loss provides a possible therapeutic application of telmisartan with rosiglitazone for the treatment of elderly women patients afflicted with metabolic syndrome.

The complex relation between bisphosphonate adherence and fracture reduction

CONTEXT

Real-world adherence to bisphosphonate therapy is poor. Consistent data support a relation between medication adherence and fracture reduction, but relatively little attention has been paid to the effect of the method used to measure adherence on this relation or on the relation between adherence and specific fracture types.

OBJECTIVE

Our objective was to assess the relation between bisphosphonate adherence and the risk of hip, vertebral, distal forearm, and any fracture using different measures of adherence.

DESIGN

We conducted a cohort study using administrative claims data. Adherence was assessed in sequential 60-d periods. In models incorporating time-varying measures of adherence, the adjusted relation between adherence and fracture was examined using several methods for calculating the proportion of days covered (PDC).

PATIENTS

Patients included community-dwelling elderly enrolled in a Pennsylvania pharmaceutical assistance program and Medicare initiating an oral bisphosphonate for osteoporosis.

MAIN OUTCOME MEASURES

Risk of hip, vertebral, distal forearm, and any osteoporotic fracture was assessed.

RESULTS

Fractures occurred at a rate of 43 per 1000 person-years among the 19,987 patients meeting study eligibility criteria. There was an inverse relation between adherence and fracture rate for all adherence measures and fracture types, excluding distal forearm fractures. High (80-100%) cumulative PDC was associated with a 22% reduction in overall fracture rate, a 23% reduction in hip fracture rate, and 26% reduction in vertebral fracture rate.

CONCLUSIONS

We found a consistent relation between adherence with osteoporosis treatment and fracture reduction, regardless of method for measuring PDC. The similarity in results across adherence measures is likely due to the high correlation between them.

Estimating the cost effectiveness of alternative drug treatments for postmenopausal osteoporosis

The burden of postmenopausal osteoporosis is substantial and is likely to grow as the baby-boom generation ages. A greater understanding of the costs and clinical benefits of alternative therapies for postmenopausal osteoporosis is needed to develop informed health policies to reduce the future burden of osteoporosis. However, much of the data needed to evaluate the cost effectiveness of alternative therapies for postmenopausal osteoporosis are not available from clinical trials. Thus, cost-effectiveness models must cope with a high degree of uncertainty. This article provides a brief summary of the methodologic issues in cost-effectiveness analyses of current osteoporosis therapies, a review of the findings in published cost-effectiveness studies, and a discussion of challenges likely to be encountered in future economic evaluations of emerging osteoporosis therapies.

Efficacy and safety of bazedoxifene, a novel selective estrogen receptor modulator for the prevention and treatment of postmenopausal osteoporosis

OBJECTIVE

Osteoporosis affects millions of individuals, particularly postmenopausal women, and imposes a severe burden on patients and the healthcare system. Several therapeutic options are commercially available for the prevention and treatment of osteoporosis, including bisphosphonates, hormone therapy, and the selective estrogen receptor modulator (SERM), raloxifene. Because each of these agents has its own individual risk-benefit profile, their use should be tailored to specific patient populations. While many agents are approved for osteoporosis, new therapies are needed that maximize efficacy outcomes and minimize safety concerns. Several new SERMs are being evaluated in an effort to achieve an ideal tissue selectivity profile, with beneficial effects on bone without negative effects on the endometrium and breast. Bazedoxifene is a novel SERM that was recently approved in the European Union and is undergoing regulatory review in the United States for the prevention and treatment of postmenopausal osteoporosis. This article reviews the clinical efficacy and safety data for bazedoxifene in postmenopausal women with or at risk for osteoporosis.

METHODS

The PubMed database and relevant congress abstract databases were searched to identify all pertinent literature on bazedoxifene for the prevention and/or treatment of postmenopausal osteoporosis.

RESULTS

In phase 3 clinical studies, bazedoxifene has demonstrated significant reduction in the risk of new vertebral fracture versus placebo and positive effects on bone mineral density and bone turnover. Moreover, in a subgroup analysis of women at high risk for fracture, bazedoxifene significantly reduced the risk of nonvertebral fracture versus both placebo and raloxifene. Bazedoxifene was generally safe and well-tolerated in women with and at risk for osteoporosis, with no evidence of endometrial or breast stimulation. Data inclusion for this review article was limited by what was available in the public domain.

CONCLUSION

The available clinical data suggest that bazedoxifene may offer a favorable risk-benefit profile for the prevention and treatment of postmenopausal osteoporosis.

The effects of weekly alendronate therapy in Taiwanese males with osteoporosis

The aim of this study was to evaluate the efficacy, safety, and tolerability of weekly alendronate administration on male osteoporosis in Taiwan. This 6-month, randomized, open-label controlled trial enrolled 46 men with osteoporosis who were randomized to either 70 mg alendronate once weekly (n = 23) or control (n = 23). Bone mineral density (BMD) of lumbar spine and hip and biochemical bone turnover markers were measured; adverse events and tolerability were assessed. Subjects treated with alendronate showed a significant increase in BMD of 5.5% (vs. 2% in control group) at the lumbar spine and 2.7% (vs. 0.7%) at the femoral neck (P < 0.05) at 6 months, respectively. There were also significant decreases in serum level of bone formation marker (bone-specific alkaline phosphatase) and urinary excretion of bone resorption marker (deoxypyridinoline) at 3 and 6 months. Thus, alendronate showed anti-osteoporotic effects by increasing BMD and decreasing the concentrations of bone markers. The adverse events were mild and showed no significant difference between the two groups on safety assessments.

Higher doses of bisphosphonates further improve bone mass, architecture, and strength but not the tissue material properties in aged rats

We report the results of a series of experiments designed to determine the effects of ibandronate (Ibn) and risedronate (Ris) on a number of bone quality parameters in aged osteopenic rats to explain how bone material and bone mass may be affected by the dose of bisphosphonates (BP) and contribute to their anti-fracture efficacy. Eighteen-month old female rats underwent either ovariectomy or sham surgery. The ovariectomized (OVX) groups were left untreated for 2 months to develop osteopenia. Treatments started at 20 months of age as follows: sham and OVX control (treated with saline), OVX + risedronate 30 and 90 (30 or 90 microg/kg/dose), and OVX + ibandronate 30 and 90 (30 or 90 microg/kg/dose). The treatments were given monthly for 4 months by subcutaneous injection. At sacrifice at 24 months of age the 4th lumbar vertebra was used for microCT scans (bone mass, architecture, and degree of mineralization of bone, DMB) and histomorphometry, and the 6th lumbar vertebra, tibia, and femur were collected for biomechanical testing to determine bone structural and material strength, cortical fracture toughness, and tissue elastic modulus. The compression testing of the vertebral bodies (LVB6) was simulated using finite-element analysis (FEA) to also estimate the bone structural stiffness. Both Ibn and Ris dose-dependently increased bone mass and improved vertebral bone microarchitecture and mechanical properties compared to OVX control. Estimates of vertebral maximum stress from FEA were correlated with vertebral maximum load (r=0.5, p<0.001) and maximum stress (r=0.4, p<0.005) measured experimentally. Tibial bone bending modulus and cortical strength increased compared to OVX with both BP but no dose-dependent effect was observed. DMB and elastic modulus of trabecular bone were improved with Ibn 30 compared to OVX but were not affected in other BP-treated groups. DMB of tibial cortical bone showed no change with BP treatments. The fracture toughness examined in midshaft femurs did not change with BP even with the higher doses. In summary, the anti-fracture efficacy of BP is largely due to their preservation of bone mass and while the higher doses further improve the bone structural properties do not improve the localized bone material characteristics such as tissue strength, elastic modulus, and cortical toughness.

Effect on bone health of estrogen preparations in premenopausal women with anorexia nervosa: a systematic review and meta-analyses

OBJECTIVE

Because estrogen therapies are widely prescribed for amenorrhea associated with anorexia nervosa (AN), we conducted a systematic review and meta-analyses to estimate the influence of estrogen preparations (EP) on bone mineral density in women with AN.

METHOD

Prospective cohort studies and randomized clinical trials (RCTs) comparing the effect of EP use to no treatment or placebo on bone mineral density and bone fractures were included. Independent reviewers selected studies for inclusion and extracted study characteristics, markers of methodologic quality, and outcomes for the intention-to-treat population.

RESULTS

Using random-effects meta-analyses and inconsistency across trials using the I(2) statistic, data were combined across two eligible prospective cohort studies and four RCTs; none reported effects on bone fractures. Compared with placebo or no treatment, low quality evidence found EPs have a moderate effect on bone mineral density in the lumbar spine [ES (effect size) 0.33, 95% CI (confidence interval) 0.09, 0.56; I(2) = 0%)], but no significant effect on the femoral neck (ES 0.13, 95% CI -0.16, 0.43; I(2) = 0%). There were no significant treatment-subgroup interactions.

DISCUSSION

In general, EPs have uncertain benefit and should be avoided by women with AN in whom the success of weight and nutritional rehabilitation is judged by menses resumption.

Skeletal effects of interventions in mild primary hyperparathyroidism: a meta-analysis

CONTEXT

Uncertainty exists as to the optimal management and monitoring of the skeletal consequences of mild primary hyperparathyroidism (PHPT).

OBJECTIVE

The aim of this study was to determine the effects of surgical treatment, medical treatment and no treatment on bone mineral density (BMD) in mild PHPT.

DATA SOURCES

Our sources were Medline, EMBASE, and Cochrane CENTRAL prior to January 2009, and abstracts from meetings of international bone and mineral societies from 1987-2008.

STUDY SELECTION

Eligible studies were of at least 1-yr duration and included more than 10 participants with mild PHPT (serum calcium < 12 mg/dl) who had BMD measured by dual-energy x-ray absorptiometry while being observed without intervention, or treated with antiresorptive therapy or surgery. Primary analysis was of studies of up to 2-yr duration. Secondary analysis was of studies with follow-up beyond 2 yr.

DATA EXTRACTION

Data were extracted from the text of the retrieved articles or conference abstracts.

DATA SYNTHESIS

Increases in BMD in response to surgical intervention were comparable to those induced by antiresorptive therapies. Significant bone loss was observed in untreated subjects, but the rates of loss ranged from 0.6-1.0%/yr. Analysis of studies reporting data beyond 2 yr of follow-up demonstrated stable increases in BMD after surgery and stable BMD or slow loss (0.1-0.3%/yr) in untreated PHPT.

CONCLUSIONS

Surgical treatment and antiresorptive therapies increase BMD in mild PHPT to a similar degree, and each represents a reasonable option in a patient with mild PHPT and low BMD. Rapid bone loss does not occur in untreated mild PHPT, such that monitoring of BMD less frequently than every 1-2 yr is reasonable in individuals for whom intervention is not immediately required.

Cost-effectiveness of strontium ranelate versus risedronate in the treatment of postmenopausal osteoporotic women aged over 75 years

OBJECTIVE

To estimate the cost-effectiveness of strontium ranelate in the treatment of postmenopausal osteoporotic women aged over 75 years.

MATERIALS AND METHODS

A validated Markov microsimulation model with a Belgian payer's perspective estimated the cost per quality-adjusted life-year (QALY) of a 3-year strontium ranelate treatment compared with no treatment and with the bisphosphonate risedronate. Data on the effect of both treatments on fracture risk were taken from the Cochrane Database of Systematic Reviews. Analyses were performed for postmenopausal women aged 75 and 80 years, either with a diagnosis of osteoporosis (i.e. bone mineral density T-score <or=-2.5 SD) or with prevalent vertebral fractures (PVF). Parameter uncertainty was evaluated using both one-way and probabilistic sensitivity analyses.

RESULTS

Strontium ranelate was dominant (i.e. more effective and less costly) versus risedronate for women with osteoporosis aged over 75 years and for women with PVF aged 80 years. The cost per QALY gained of strontium ranelate compared with risedronate at 75 years of age was euro 11,435 for women with PVF. When compared with no treatment, the costs per QALY gained of strontium ranelate were euro 15,588 and euro 7,708 at 75 and 80 years of age for women with osteoporosis; the equivalent values were euro 16,518 and euro 6,015 for women with PVF. Probabilistic sensitivity analyses showed that strontium ranelate was generally more cost-effective than risedronate, in the range of 60% in all cases.

CONCLUSION

The results of this study suggest that strontium ranelate is a cost-effective strategy, in a Belgian setting, for the treatment of postmenopausal osteoporotic women aged over 75 years.

Mixed treatment comparison analysis provides internally coherent treatment effect estimates based on overviews of reviews and can reveal inconsistency

OBJECTIVES

To propose methods for mixed treatment comparisons (MTC) based on pooled summaries of the type produced in overviews of reviews.

STUDY DESIGN AND SETTING

Overviews of reviews (umbrella reviews) summarize the results of multiple systematic reviews into a single document. They report the summary estimates from the original pairwise meta-analyses and discuss them in narrative form, with the intention of identifying the most effective treatment. We present methods for MTC synthesis, tailored for use with overviews of reviews. These generate a single internally consistent summary of all the relative treatment effects and assessments of whether the summary is consistent with the data. These methods are applied to a published overview of treatments for childhood nocturnal enuresis. We apply the methods to both fixed-effect (FE) and random-effects (RE) meta-analyses of the original trials.

RESULTS

The summary relative risks based on FE meta-analyses, as originally published, were highly inconsistent. Those based on RE meta-analyses were consistent and could, given standard assumptions on comparability of treatment effects in meta-analysis, form a basis for coherent decision making.

CONCLUSION

Along with the summaries from systematic reviews, MTC methods should be used in overviews to provide a single coherent analysis of all treatment comparisons and to check for evidence consistency.

Randomized trial of intensive bisphosphonate treatment versus symptomatic management in Paget's disease of bone

Bisphosphonates are widely regarded as the treatment of choice for Paget's disease of bone (PDB) because of their potent inhibitory effects on bone turnover, but the effects of bisphosphonate therapy on symptoms and complications of PDB have been little studied. Here we report the results of a randomized trial that compared the effects of symptomatic treatment with intensive bisphosphonate therapy in a cohort of 1324 patients with PDB who were followed up for a median of 3 years (range 2 to 5 years). The symptomatic treatment group was treated only if they had pagetic bone pain, for which they were first given analgesics or anti-inflammatory drugs, followed by bisphosphonates if they did not respond. The intensive group received repeat courses of bisphosphonates irrespective of symptoms with the aim of reducing and maintaining serum alkaline phosphatase (ALP) levels within the normal range. The endpoints were fracture, orthopedic surgery, quality of life, bone pain, and hearing thresholds. Serum ALP levels were significantly lower in the intensive treatment group than in with the symptomatic treatment group within 4 months of commencing treatment and remained lower throughout the study (p < .001). There was no difference between the groups in quality of life (as assessed by the SF36 questionnaire), in overall bodily pain, or in pagetic bone pain. Hearing thresholds, as assessed by audiometry did not change significantly and did not differ between the treatment groups. Clinical fractures occurred in 46 of 661 patients (7.0%) in the intensive treatment group compared with 49 of 663 patients (7.4%) in the symptomatic treatment group, and orthopedic surgery was required in 50 of 661 patients (7.3%) in the intensive treatment group and in 55 of 663 patients (8.3%) in the symptomatic treatment group. These differences were not significant. Subgroup analyses of patients with elevated ALP levels at baseline and those who did or did not receive bisphosphonates during the study yielded similar results to those in the study group as a whole. We conclude that striving to maintain normal ALP levels with intensive bisphosphonate therapy confers no clinical advantage over symptom-driven management in patients with established PDB. Neither management strategy had a significant beneficial impact on pain or quality of life (Clinical trial registration number ISRCTN12989577).

A blinded randomized controlled trial of motivational interviewing to improve adherence with osteoporosis medications: design of the OPTIMA trial

We have designed an innovative randomized controlled trial for improving adherence with osteoporosis medications. Recruitment and randomization have been successful. Also, the counseling intervention has been well accepted by subjects randomized to this treatment arm.

INTRODUCTION

While many effective treatments exist for osteoporosis, most people do not adhere to such treatments long term. No proven interventions exist to improve osteoporosis medication adherence. We report here on the design and initial enrollment in an innovative randomized controlled trial aimed at improving adherence to osteoporosis treatments.

METHODS

The trial represents a collaboration between academic researchers and a state-run pharmacy benefits program for low-income older adults. Beneficiaries beginning treatment with a medication for osteoporosis are targeted for recruitment. We randomize consenting individuals to receive 12 months of mailed education (control arm) or an intervention consisting of one-on-one telephone-based counseling and the mailed education. Motivational interviewing forms the basis for the counseling program which is delivered by seven trained and supervised health counselors over ten telephone calls. The counseling sessions include scripted dialog and open-ended questions about medication adherence and its barriers, as well as structured questions. The primary end point of the trial is medication adherence measured over the 12-month intervention period. Secondary end points include fractures, nursing home admissions, health care resource utilization, and mortality.

RESULTS

During the first 7 months of recruitment, we have screened 3,638 potentially eligible subjects. After an initial mailing, 1,115 (30.6%) opted out of telephone recruitment and 1,019 (28.0%) could not be successfully contacted. Of the remaining, 879 (24.2%) consented to participate and were randomized. Women comprise over 90% of all groups; mean ages range from 77 to 80 years old, and the majority in all groups was white. The distribution of osteoporosis medications was comparable across groups and the median number of different prescription drugs used in the prior year was eight to ten.

CONCLUSIONS

We have developed a novel intervention for improving osteoporosis medication adherence. The intervention is currently being tested in a large-scale randomized controlled trial. If successful, the intervention may represent a useful model for improving adherence to other chronic treatments.

Prevalence and trends in low femur bone density among older US adults: NHANES 2005-2006 compared with NHANES III

Hip fracture incidence appears to be declining in the United States, but changes in bone mineral density (BMD) of the population have not been evaluated. We used femur BMD data from the National Health and Nutrition Examination Survey (NHANES) 2005-2006 to estimate the prevalence of low femoral BMD in adults age 50 years and older and compared it with estimates from NHANES III (1988-1994). Dual-energy X-ray absorptiometry systems (pencil-beam geometry in NHANES III, fan-beam geometry in NHANES 2005-2006) were used to measure femur BMD, and World Health Organization (WHO) definitions of low BMD were used to categorize skeletal status. In 2005-2006, 49% of older US women had osteopenia and 10% had osteoporosis at the femur neck. In men, 30% had femur neck osteopenia and 2% had femur neck osteoporosis. An estimated 5.3 million older men and women had osteoporosis at the femur neck, and 34.5 million more had osteopenia in 2005-2006. When compared with NHANES III, the age-adjusted prevalence of femur neck osteoporosis in NHANES 2005-2006 was lower in men (by 3 percentage units) and women (by 7 percentage units) overall and among non-Hispanic whites. Changes in body mass index or osteoporosis medication use between surveys did not fully explain the decline in osteoporosis. Owing to the increase in the number of older adults in the US population, however, more older adults had low femur neck BMD (osteoporosis + osteopenia) in 2005-2006 than in 1988-1994. Thus, despite the decline in prevalence, the estimated number of affected older adults in 2005-2006 remained high.

Comparative effectiveness without head-to-head trials: a method for matching-adjusted indirect comparisons applied to psoriasis treatment with adalimumab or etanercept

The absence of head-to-head trials is a common challenge in comparative effectiveness research and health technology assessment. Indirect cross-trial treatment comparisons are possible, but can be biased by cross-trial differences in patient characteristics. Using only published aggregate data, adjustment for such biases may be impossible. Although individual patient data (IPD) would permit adjustment, they are rarely available for all trials. However, many researchers have the opportunity to access IPD for trials of one treatment, a new drug for example, but only aggregate data for trials of comparator treatments. We propose a method that leverages all available data in this setting by adjusting average patient characteristics in trials with IPD to match those reported for trials without IPD. Treatment outcomes, including continuous, categorical and censored time-to-event outcomes, can then be compared across balanced trial populations. The proposed method is illustrated by a comparison of adalimumab and etanercept for the treatment of psoriasis. IPD from trials of adalimumab versus placebo (n = 1025) were re-weighted to match the average baseline characteristics reported for a trial of etanercept versus placebo (n = 330). Re-weighting was based on the estimated propensity of enrolment in the adalimumab versus etanercept trials. Before matching, patients in the adalimumab trials had lower mean age, greater prevalence of psoriatic arthritis, less prior use of systemic treatment or phototherapy, and a smaller mean percentage of body surface area affected than patients in the etanercept trial. After matching, these and all other available baseline characteristics were well balanced across trials. Symptom improvements of ≥75% and ≥90% (as measured by the Psoriasis Area and Severity Index [PASI] score at week 12) were experienced by an additional 17.2% and 14.8% of adalimumab-treated patients compared with the matched etanercept-treated patients (respectively, both p < 0.001). Mean percentage PASI score improvements from baseline were also greater for adalimumab than for etanercept at weeks 4, 8 and 12 (all p < 0.05). Matching adjustment ensured that this indirect comparison was not biased by differences in mean baseline characteristics across trials, supporting the conclusion that adalimumab was associated with significantly greater symptom reduction than etanercept for the treatment of moderate to severe psoriasis.

Osteoporosis management: a perspective based on bisphosphonate data from randomised clinical trials and observational databases

AIMS

The efficacy of treatments for osteoporosis can be evaluated using a variety of study designs. This article aims to comprehensively review the evidence for bisphosphonate anti-fracture efficacy in postmenopausal women, discussing the strengths and limitations associated with each study method.

METHODS

Literature analysis included English-language publications reporting results of randomised controlled trials (RCTs), post hoc analyses, meta analyses and observational studies evaluating the efficacy of alendronate (ALN), ibandronate (IBN), risedronate (RIS) and zoledronate (ZOL), with an initial sample size > or = 100 patients, and follow-up data for at least 1 year.

RESULTS

Primary and secondary analyses of RCT data suggest differences among bisphosphonates with regard to site-specific anti-fracture efficacy and onset of fracture risk reduction. While some observational studies indicate differences in clinical outcomes among these agents, others report similar effectiveness. ALN and RIS data demonstrate sustained fracture protection for up to 10 and 7 years of treatment respectively. The efficacy of IBN and ZOL has been evaluated for up to 3 and 5 years respectively.

CONCLUSIONS

Understanding of the benefits of bisphosphonate treatment can be maximised by evaluating complementary data from RCTs and observational database studies. Fracture risk reduction with bisphosphonates is shown in RCTs and in real-world clinical settings.

Factors affecting discontinuation of alendronate treatment in postmenopausal Japanese women with osteoporosis

BACKGROUND

The main challenge to the long-term treatment of osteoporosis with bisphosphonates has been patient adherence. The purposes of this cohort study were to investigate the 3-year outcome of alendronate treatment in postmenopausal Japanese women with osteoporosis and to identify factors that contributed to the discontinuation of alendronate treatment.

METHODS

A total of 72 postmenopausal Japanese women with osteoporosis and aged from 58 to 85 years were treated with alendronate in a 3-year trial. Metacarpal bone mineral density, serum alkaline phosphatase, and urinary cross-linked N-terminal telopeptides of type I collagen were monitored, and factors contributing to the discontinuation of alendronate treatment were determined.

RESULTS

Fourteen patients dropped out of the trial. The reasons for dropout were side effects (diarrhea [n = 1], gastric symptoms [n = 9], and inflammation of the mouth [n = 1]) or non-compliance (n = 3). Logistic regression analysis showed that the number of prevalent vertebral fractures was a significant factor affecting the discontinuation of alendronate treatment for the reasons listed above. In 58 patients who continued the 3-year treatment, urinary cross-linked N-terminal telopeptides of type I collagen level was reduced by 44.1% at 3 months and serum alkaline phosphatase level was decreased by 11.6%, 11.8%, and 12.5% at 1, 2, and 3 years, respectively. However, metacarpal bone mineral density did not change significantly.

CONCLUSION

Alendronate treatment decreased urinary cross-linked N-terminal telopeptides of type I collagen and serum alkaline phosphatase levels, and maintained metacarpal bone mineral density in postmenopausal Japanese women with osteoporosis. The patients adhered well to alendronate treatment in our clinic. The number of prevalent vertebral fractures was an important factor affecting the discontinuation of alendronate treatment due to side effects and non-compliance.

Interventions to improve adherence and persistence with osteoporosis medications: a systematic literature review

SUMMARY

Adherence and persistence with osteoporosis medications are poor. We conducted a systematic literature review of interventions to improve adherence and persistence with osteoporosis medications. Seven studies met eligibility requirements and were included in the review. Few interventions were efficacious, and no clear trends regarding successful intervention techniques were identified. However, periodic follow-up interaction between patients and health professionals appeared to be beneficial.

INTRODUCTION

Adherence and persistence with pharmacologic therapy for osteoporosis are suboptimal. Our goal was to examine the design and efficacy of published interventions to improve adherence and persistence.

METHODS

We searched medical literature databases for English-language papers published between January 1990 and July 2008. We selected papers that described interventions and provided results for control and intervention subjects. We assessed the design and methods of each study, including randomization, blinding, and reporting of drop-outs. We summarized the results and calculated effect sizes for each trial.

RESULTS

Seven studies met eligibility requirements and were included in the review. Five of the seven studies provided adherence data. Of those five studies, three showed a statistically significant (p < or = 0.05) improvement in adherence by the intervention group, with effect sizes from 0.17 to 0.58. Five of the seven studies provided persistence data. Of those five, one reported statistically significant improvement in persistence by the intervention group, with an effect size of 0.36.

CONCLUSIONS

Few interventions were efficacious, and no clear trends regarding successful intervention techniques were identified in this small sample of studies. However, periodic follow-up interaction between patients and health professionals appeared to be beneficial.

Medical treatment of osteoporosis in the elderly

Fractures, mostly of the hip and pelvis, wrist, and sometimes of the vertebra, account for nearly half of emergency department treatments for elderly individuals seen because of a fall. Bone density measurements show that more than half of these patients have osteoporosis. The notion that it is too late to start treatment in a late stage of the disease forms a barrier to treatment. The aim of this article is to evaluate the effectiveness of therapeutic options for osteoporosis in the elderly, with a view to reducing the incidence of fractures. Although most studies of fracture reduction with medical treatment were not designed for the "geriatric" population, the average age of participants in most clinical trials was about 70 years. Nowadays, clinicians can choose from several effective treatments for the prevention of osteoporotic fractures in high-risk postmenopausal women. Data on the antifracture potential of calcium/vitamin D, raloxifene, bisphosphonates, strontium ralenate, and parathyroid hormone are now available. In all major studies patients also received calcium and vitamin D supplements. Bisphosphonates and strontium ranelate are good choices for first- or second-line treatment, while for the time being parathyroid hormone should only be used for the second-line treatment of osteoporosis in the elderly. The ease of use of bisphosphonates, with once weekly, once monthly, or intravenous administration, may be advantageous for elderly patients already taking multiple medications.

Osteonecrosis of the Jaw Correlated to Bisphosphonate Therapy in Non-oncologic Patients: Clinicopathological Features of 24 Patients

Objective.

Osteonecrosis of the jaws (ONJ) is a well known side effect of bisphosphonate therapies in patients with multiple myeloma or other malignancies. Its real incidence is still undetermined, and only few cases of ONJ in patients taking bisphosphonates for non-oncologic diseases have been reported. It was postulated that the clinical features, predisposing factors, and treatment outcome of this subset of patients might be different from those of oncologic patients.

Methods.

Over a 4 year period, a total of 102 bisphosphonate-treated patients affected by ONJ were identified. Among these, 24 patients underwent bisphosphonate therapy for non-neoplastic disease and their profile was analyzed.

Results.

In this study cohort, bisphosphonates had been administered mainly for postmenopausal osteoporosis (20/24 patients, 83.3%), the duration of therapy until presentation of ONJ ranging from 11 to 40 months and the most common triggering event being dentoalveolar surgery. All patients were nonsmokers; 6 manifested multiple ONJ lesions and only 3 of them had possible comorbidities. Surgical debridement was performed in 19 patients for a total of 22 lesions, which were individually considered in the followup. The latter showed complete remission of ONJ in 21/22 lesions.

Conclusion.

Although it might be considered a rare condition in non-oncologic patients, ONJ is a harmful side effect of bisphosphonate therapies. Clinicians must be aware of this entity, inform patients of the risks related to dental surgery, and possibly undertake adequate preventive measures.

Enhancement of absolute fracture risk prognosis with genetic marker: the collagen I alpha 1 gene

An important objective of genetic research in osteoporosis is to translate genotype data into the prognosis of fracture. The present study sought to develop a prognostic model for predicting osteoporotic fracture by using information from a genetic marker and clinical risk factors. It was designed as a prospective epidemiological study which involved 894 women of Caucasian background aged 60+ years who had been followed for a median of 9 years (from 1989 and 2008, range 0.2-18 years). During the follow-up period, fragility fracture was ascertained by X-ray reports for all women. Bone mineral density (BMD) at the femoral neck was measured by dual-energy X-ray absorptiometry. Genotypes of the Sp1 binding site in the first intron of the collagen I alpha 1 (COLIA1) gene polymorphism were determined by polymerase chain reaction, digestion with BalI restriction enzyme, and agarose gel electrophoresis. The relationship between COL1A1 genotype and fracture was assessed by the Cox proportional hazards model, from which nomograms were developed for individualizing the risk of fracture. The distribution of COL1A1 genotypes was consistent with the Hardy-Weinberg equilibrium law: GG (63.8%), GT (32.6%), and TT (3.6%). During the follow-up period, there were 322 fractures, including 77 hip and 127 vertebral fractures. There was an overrepresentation of the TT genotype in the fracture group (6.2%) compared with the nonfracture group (2.3%). Compared with carriers of GT and GG, women carrying the TT genotype had increased risk of any fracture (relative risk [RR] = 1.91, 95% CI 1.21-3.00), hip fracture (RR = 3.67, 95% CI 1.69-8.00), and vertebral fracture (RR = 3.36, 95% CI 1.81-6.24). The incorporation of COL1A1 genotypes improved the risk reclassification by 2% for any fragility fracture, 4% for hip fracture, and 5% for vertebral fracture, beyond age, BMD, prior fracture, and fall. Three nomograms were constructed for predicting fracture risk in an individual woman based on age, BMD, and COLIA1 genotypes. These data suggest that the COLIA1 Sp1 polymorphism is associated with the risk of fragility fracture in Caucasian women and that the polymorphism could enhance the predictive accuracy of fracture prognosis. The nonograms presented here can be useful for individualizing the short- and intermediate-term prognosis of fracture risk and help identify high-risk individuals for intervention for appropriate management of osteoporosis.

Acute vertebral fracture

Vertebral fractures resulting from osteoporosis are a significant cause of morbidity and mortality in the aging population and are commonly seen in the hospital setting. Appropriately assessing and treating these conditions continues to be a challenge. This article is an evidence-based clinical update on the evaluation and management options of acute vertebral fractures, ranging from conservative treatment to surgical intervention. Hospitalists can play an influential role in the management of osteoporosis.

Comparison of the effects of alendronate and alfacalcidol on hip bone mineral density and bone turnover in Japanese men having osteoporosis or osteopenia with clinical risk factors for fractures

PURPOSE

The comparative effects of alendronate and alfacalcidol on bone mineral density (BMD) and bone turnover have already been established in postmenopausal women with osteoporosis. An open-labeled prospective study was conducted to compare the treatment effects of alendronate and alfacalcidol on hip BMD and bone turnover in Japanese men with osteoporosis or osteopenia with clinical risk factors for fractures.

MATERIALS AND METHODS

One hundred twelve men with osteoporosis or osteopenia with clinical risk factors for fractures (mean age: 71.4 years) were randomly divided into two groups of 56 patients each: the alendronate (5 mg daily) and alfacalcidol (1 microg daily) groups. The BMD of the total hip, urinary level of cross-linked N-terminal telopeptides of type I collagen (NTX), and serum levels of bone-specific alkaline phosphatase (BSAP) were measured during the 12-month-treatment period.

RESULTS

Forty-five patients in the alendronate group and 42 patients in the alfacalcidol group completed the trial. Alendronate increased BMD (+2.3% at 12 months) following reductions in the urinary level of NTX (-46.4% at 3 months) and serum level of BSAP (-34.1% at 12 months), while alfacalcidol sustained BMD (-1.9% at 12 months) as well as the urinary level of NTX (+13.2% at 3 months) and serum level of BSAP (+1.8% at 12 months).

CONCLUSION

The present study confirmed that alendronate has better efficacy than alfacalcidol (active control) in increasing hip BMD and reducing bone turnover in Japanese men with osteoporosis or osteopenia with clinical risk factors for fractures.

[Current diagnosis and therapy of osteoporosis on the basis of "European guidance 2008"]

Osteoporosis is one of the 10 most important and widespread global diseases. In Germany alone the cost of osteoporosis runs into many billions of Euros. However, it should be noted that in the past 15 years great progress has been made both in diagnosis and in the development of new medications, and this has changed the general perception of and attitude to osteoporosis. It is now taken very seriously and recognised as a national and global disorder which is both preventable and treatable. In spite of this progress, in Europe and especially in Germany, osteoporosis remains an underdiagnosed and undertreated disease. In Germany, only about 10%-15% of patients with manifest osteoporosis are properly treated. However, in addition to national guidelines, there is now a new edition of the "European Position Paper for the Diagnosis and Management of Osteoporosis". This provides physicians treating osteoporosis patients with additional information and therefore more confidence.

Modulation of murine bone marrow-derived CFU-F and CFU-OB by in vivo bisphosphonate and fluoride treatments

OBJECTIVES

Bisphosphonates (BPN) have actions on a variety of cell types including: osteoclasts, osteoblasts, osteocytes, and endothelial cells. The objectives of this report are to review the current state of understanding of the effects of BPNs on orthodontic tooth movement and to provide evidence on BPN's in vivo effects on bone marrow-derived osteoprogenitor cells.

MATERIAL AND METHODS

Mice from the C3H/HeJ (C3H), C57BL/6J (B6), FVB/NJ (FVB), and BALB/cByJ (BALB) strains were treated for 3 weeks with 0, 3, 30, or 150 mcg/kg/week alendronate (ALN) administered subcutaneous alone or in combination with 50 ppm fluoride (F). Bone marrow cells were harvested and subjected to in vitro colony-forming unit fibroblast (CFU-F) and colony-forming unit osteoblasts (CFU-OB) assays.

RESULTS

Baseline differences in CFU-F, CFU-OB/ALP+, and CFU-OB/total were observed among the four strains. Strain-specific responses to ALN and F treatments were observed for CFU-F, CFU-OB/ALP+, and CFU-OB/total. F treatment alone resulted in decreases in CFU-F (p = 0.013), CFU-OB/ALP+ (p = 0.005), and CFU-OB/total (p = 0.003) in the C3H strain. CFU-F (p = 0.036) were decreased by F in the B6 strain. No significant (NS) effects of F were observed for FVB and BALB. ALN treatment resulted in a significant decrease in CFU-F (p = 0.0014) and CFU-OB/total (p = 0.028) in C3H only. ALN treatment had NS effect on CFU-OB/ALP+ in all four strains.

CONCLUSION

Genetic factors appear to play a role in ALN's effects on CFU-F and CFU-OB/total but not on CFU-OB/ALP+.

Trends in hip fracture epidemiology in Australia: possible impact of bisphosphonates and hormone replacement therapy

The purposes of this study were to analyse trends in hip fracture (HF) epidemiology over a 13-year period (1994-2007) in the Australian Capital Territory (ACT), to assess the potential impact of concurrent changes in hormone replacement therapy (HRT) and bisphosphonate use and to present a new prediction of HFs in Australia up to 2021. Annual sex- and age-specific incidence rates (per 100,000 population) were determined and standardized using the Australian 2006 population. The projected number of HFs was estimated by two models applying age- and sex-specific HF rates averaged for 2002-2006 (model 1) or continuously changing as observed in this period (model 2, Poisson regression) to the projected population. In 2006 compared to 2001, the population > or = 60 years in the ACT increased by 19.7%. Over the last 5 years the average annual incidence HF rate compared to the previous 3-year period decreased in females > or = 60 years of age by 28.3%. Between 2001 and 2006 the number of prescriptions for HRT dispensed in the ACT declined by 54.6, while the number of prescriptions for bisphosphonate increased by 245%, accompanied by a decline in standardized incidence of HF rates of 36.4%, mainly in women (42.1%). This represents an annual cost for bisphosphonates per one prevented HF, of $A45,250 or $A576 person/year. Compared to 2006 the total number of HFs in Australia according to model 1 will increase in 2011 by 20.1% and in 2021 by 58.8%, but according to model 2 will decrease by 15.5% in 2011 and 27.5% in 2021. Our data suggest that the previously predicted rising trend in HFs in elderly women reversed, but did not so for men. This was coincident with a significant fall in HRT use and increased prescribing of bisphosphonates, which is cost-effective. However caution should be used in attributing causation as this is an ecological study. If trends in HF observed in 2002-2006 continue, the absolute number of HFs in Australia in 2011-2021 will stabilise or decline (which is more likely), despite the rapid ageing of the population.

Clinical assessment of fracture risk and novel therapeutic strategies to combat osteoporosis

OBJECTIVE

To review the latest tools in the clinical assessment of fracture risk and to review new and emerging options for osteoporosis therapy.

DESIGN

Retrospective analysis of published studies regarding the diagnosis and treatment of osteoporosis.

RESULT(S)

Large-scale epidemiologic data were recently assembled by the World Health Organization to produce a Web-based clinical assessment tool, FRAX, which uses clinical and historical data to provide prompt assessment and quantitation of fracture risk. The FRAX models were developed from studying population-based cohorts in Europe, North America, Asia, and Australia. The FRAX algorithms indicate the 10-year probability of hip fracture and the 10-year probability of a major osteoporotic fracture (at the clinical spine, forearm, hip, or shoulder) on which to base treatment decisions. Recent progress in the study of bone metabolism including anabolic pathways that enhance bone maintenance, is anticipated to improve the ways in which skeletal health can be maintained and osteoporosis can be treated.

CONCLUSION(S)

Using FRAX, fracture risk in now easily assessed in the clinical setting. New and emerging treatment strategies for bone maintenance are reviewed. Improved assessment of fracture risk, combined with tailored therapies for at-risk patients, will increase the number of patients who receive appropriate bone-sparing therapies.

The relation between bisphosphonate use and non-union of fractures of the humerus in older adults

SUMMARY

While nitrogen-containing bisphosphonates have been shown to reduce fracture risk in postmenopausal women and men, their safety in the period after a fracture is unclear. In fully adjusted multivariable regression models, bisphosphonate use in the post-fracture period was associated with an increased probability of non-union [odds ratio (OR) 2.37, 95% confidence interval (CI) 1.13-4.96]. Clinicians might consider waiting for several months before introduction of a bisphosphonate after a fracture.

INTRODUCTION

While nitrogen-containing bisphosphonates have been shown to reduce fracture risk in postmenopausal women and men, their safety in the period after a fracture is unclear. We examined the risk of non-union associated with post-fracture bisphosphonate use among a group of older adults who had experienced a humerus fracture.

METHODS

We conducted a nested case-control study among subjects who had experienced a humerus fracture. From this cohort, cases of non-union were defined as those with an orthopedic procedure related to non-union 91-365 days after the initial humerus fracture. Bisphosphonate exposure was assessed during the 365 days prior to the non-union among cases or the matched date for controls. Multivariable logistic regression models were examined to calculate the OR and 95% CI for the association of post-fracture bisphosphonate use with non-union.

RESULTS

From the cohort of 19,731 patients with humerus fractures, 81 (0.4%) experienced a non-union. Among the 81 cases, 13 (16.0%) were exposed to bisphosphonates post-fracture, while 69 of the 810 controls (8.5%) were exposed in the post-fracture interval. In fully adjusted multivariable regression models, bisphosphonate use in the post-fracture period was associated with an increased odds of non-union (OR 2.37, 95% CI 1.13-4.96). Albeit limited by small sample sizes, the increased risk associated with bisphosphonate use persisted in the subgroup of patients without a history of osteoporosis or prior fractures (OR 1.91, 95% CI 0.75-4.83).

CONCLUSIONS

In this study of older adults, non-union after a humerus fracture was rare. Bisphosphonate use after the fracture was associated with an approximate doubling of the risk of non-union.

Comparing non-vertebral fracture risk reduction with osteoporosis therapies: looking beneath the surface

Data from pivotal trials of pharmacologic agents used to treat osteoporosis differ, suggesting that these agents vary in ability to reduce the risk of non-vertebral fractures (NVFs). However, variability among clinical trials in inclusion criteria, baseline characteristics, and definition of NVFs may account for many of these apparent differences.

INTRODUCTION

Data from pivotal trials of individual pharmacologic agents for osteoporosis differ, and suggest that differences may exist between anti-resorptive agents in their ability to reduce the risk of NVFs. Careful examination of these trials' inclusion criteria and patient characteristics indicates substantial differences between patient populations with respect to the baseline risk of NVFs. When baseline fracture risk is lower, the ability to produce a statistically significant reduction in fracture risk over the course of a clinical trial is reduced.

METHODS

Analysis of clinical trials reveals that the number and type of baseline vertebral fractures and also baseline bone mineral density, all associated with the risk of vertebral fracture, vary.

DISCUSSION AND CONCLUSION

The propensity to fall and patient frailty are additional factors associated with fracture risk that may influence study outcomes. One of the most significant variables, which also often differs considerably between trials, is the definition of an NVF. Variability between clinical trials in inclusion criteria, patients' baseline characteristics, and how NVFs are defined may account for much of the apparent difference between agents in their ability to reduce NVF risk.

Long term hormone therapy for perimenopausal and postmenopausal women

BACKGROUND

Hormone therapy (HT) is widely used for controlling menopausal symptoms and has also been used for the management and prevention of cardiovascular disease, osteoporosis and dementia in older women. This is an updated version of the original Cochrane review first published in 2005.

OBJECTIVES

To assess the effect of long-term HT on mortality, cardiovascular outcomes, cancer, gallbladder disease, cognition, fractures and quality of life.

SEARCH STRATEGY

We searched the following databases to November 2007: Trials Register of the Cochrane Menstrual Disorders and Subfertility Group, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Biological Abstracts. Also relevant non-indexed journals and conference abstracts.

SELECTION CRITERIA

Randomised double-blind trials of HT versus placebo, taken for at least one year by perimenopausal or postmenopausal women. HT included oestrogens, with or without progestogens, via oral, transdermal, subcutaneous or transnasal routes.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

Nineteen trials involving 41,904 women were included. In relatively healthy women, combined continuous HT significantly increased the risk of venous thrombo-embolism or coronary event (after one year's use), stroke (after three years), breast cancer and gallbladder disease. Long-term oestrogen-only HT significantly increased the risk of venous thrombo-embolism, stroke and gallbladder disease (after one to two years, three years and seven years' use respectively), but did not significantly increase the risk of breast cancer. The only statistically significant benefits of HT were a decreased incidence of fractures and (for combined HT) colon cancer, with long-term use. Among women aged over 65 who were relatively healthy (i.e. generally fit, without overt disease) and taking continuous combined HT, there was a statistically significant increase in the incidence of dementia. Among women with cardiovascular disease, long-term use of combined continuous HT significantly increased the risk of venous thrombo-embolism.One trial analysed subgroups of 2839 relatively healthy 50 to 59 year old women taking combined continuous HT and 1637 taking oestrogen-only HT, versus similar-sized placebo groups. The only significantly increased risk reported was for venous thrombo-embolism in women taking combined continuous HT: their absolute risk remained low, at less than 1/500. However, this study was not powered to detect differences between groups of younger women.

AUTHORS' CONCLUSIONS

HT is not indicated for the routine management of chronic disease. We need more evidence on the safety of HT for menopausal symptom control, though short-term use appears to be relatively safe for healthy younger women.

Hormone replacement therapy post Women's Health Initiative study: where do we stand?

PURPOSE OF REVIEW

The aim of this review is to look at all publications from the past 18 months, which deal with the impact of the Women's Health Initiative Trial on hormone replacement therapy.

RECENT FINDINGS

There is a definite decline in the use of hormone replacement therapy among menopausal women.

SUMMARY

More research needs to be done on the long-term effects of hormone replacement therapy, especially with regard to ultra-low dose hormone therapy.

Interventions to improve inpatient osteoporosis management following first osteoporotic fracture: the PREVENT project

OBJECTIVES

To establish a protocol for the treatment of fragility fractures in the hospital setting based on treatment of osteoporosis.

MATERIALS AND METHODS

An intervention protocol was implemented in patients with fragility fractures based on (1) indicating the diagnosis of osteoporotic fracture in the summary of discharge; (2) "lifestyle recommendations"; and (3) therapy for osteoporosis. Thirty-one hospitals were involved and they were informed of the importance of protocol compliance. In the first phase, a retrospective study was conducted to establish the number of low-energy fractures treated and the percentage of them that had complied with the protocol (n = 887). Then, prospectively, the same data were collected for the patients managed for 1 year (n = 6,826) in three sections of 4-month intervals.

RESULTS

The percentage of compliance increased from 8.2 to 57.2% in the first point, from 12.6 to 42.4% in the second, and from 10.3 to 43.2% in the third.

CONCLUSION

The implementation of programs to improve osteoporosis treatment is very useful for ensuring adherence in the management of osteoporosis following admission due to fragility fracture.

New Therapies for Osteoporosis

Osteoporosis is a growing health concern in the United States, with an enormous impact on morbidity and mortality. Despite published guidelines to aid clinicians in its management, several controversies remain. Many trials evaluate surrogate measures of bone strength rather than more clinically relevant outcomes, including fracture. Furthermore, the role of combination and sequential therapy remains unclear. Limited data are available regarding appropriate duration of therapy, management of osteoporosis in men, and treatment of glucocorticoid-induced osteoporosis. The development of unique therapeutic agents could potentially revolutionize the treatment of osteoporosis. Once yearly zoledronic acid may provide advantages over existing therapies. Because of limitations with existing selective estrogen receptor modulators, the search for agents with better efficacy and safety profiles has led to the development of several new medications within this class. Finally, denosumab, a monoclonal antibody to receptor activator for nuclear factor-kappa B ligand, also represents a novel therapeutic option for osteoporosis.

Effectiveness of antiresorptives for the prevention of nonvertebral low-trauma fractures in a population-based cohort of women

Observational studies are needed to quantify real-life effectiveness of antiresorptive therapy in the prevention of clinical fractures. Antiresorptive therapies were associated with an overall 32% reduction in low-trauma nonvertebral fracture risk among women 50 and older. Effectiveness may be lower among older women and those without risk factors.

INTRODUCTION

Randomized controlled trials have shown that antiresorptive therapies reduce the risk of fracture in selected populations, but further study is needed to quantify their real-life effectiveness. The study objective was to determine the association between antiresorptive use and low-trauma nonvertebral fracture in women 50 and older.

METHODS

The design was a retrospective nested case-control study (density-based sampling) within the Canadian Multicentre Osteoporosis Study. There were 5,979 eligible women with 453 cases and 1,304 matched controls.

RESULTS

The current use of antiresorptives was associated with a decreased risk of fracture with OR = 0.68, 95% CI: 0.52-0.91; where OR is the adjusted odds ratio and CI is the confidence interval. Subgroup analysis yielded OR = 0.61, 95% CI: 0.42-0.89 for ages 50-74; OR = 0.76, 95% CI: 0.50-1.17 for ages 75+; OR = 0.58, 95% CI: 0.40-0.83 for those with a major risk factor; and OR = 0.92; 95% CI: 0.59-1.42 for those without a major risk factor. Major risk factors were prevalent low-trauma fracture, vertebral deformity (grade 2+), and BMD T-score < or = -2.5.

CONCLUSIONS

Antiresorptive therapy is associated with a clinically important reduction in low-trauma nonvertebral fracture risk among community-dwelling women aged 50 and older. Antiresorptive therapy may be less effective for women 75 and older and women without major risk factors.

Potential of alfacalcidol for reducing increased risk of falls and fractures

There are no general accepted strategies for combined drug treatments in osteoporosis, while in other important chronic diseases combinations of different medications are used as a rule to improve therapeutic results and reduce the risk of adverse events. It is suggested that the success of combined treatments is related to the different modes of action of the respective single therapies. On the other hand it was shown that a strong antiresorptive bisphosphonate is able to blunt at least in part the effects of anabolic parathyroid hormone peptides Calcitriol, the active vitamin D-hormone and its prodrug alfacalcidol lead to pleiotropic effects on bone remodelling (antiresorptive, anabolic and enhancing mineralization) and in addition to effects on other important target tissues (e.g. gut, parathyroid glands, muscle). With active D-analogs significant improvements in the therapeutic outcome of osteoporosis can be achieved by the resulting improvements of bone quality, calcium absorption and risk reduction of falling. The same beneficial effects cannot be achieved with plain vitamin D due to feedback controlled, limited renal activation or insufficient conversion in the elderly with impairment of renal function. Accordingly alfacalcidol, approved as a treatment for different forms of osteoporosis, is besides adoption as a mono-therapy an interesting candidate for combined therapies. There are interesting preclinical trials and clinical pilote studies in the literature proving that a parallel therapy with selectively anti-osteoclastic bisphophonates and pleiotropically acting D-analogs is able to optimize therapeutic results in osteoporosis. In the AAC-Trial (Alfacalcidol-Alendronate-Combined) we studied 90 patients with established osteoporosis (57 women, 33 men) over two years after alternate allocation to three treatment arms (alfacalcidol plus calcium, alendronate plus plain vitamin D and Ca, and alendronate plus alfacalcidol and Ca). During the 2-year-study we observed the significantly highest lumbar spine and hip BMD increases in the combined treatment group (p < 0.001). The number of patients with new vertebral and non-vertebral fractures after 2 years was 9 with alfacalcidol alone, 10 with alfacalcidol and plain vitamin D and 2 in the group receiving alendronate plus alfacalidol (p < 0.02). Furthermore there was a lower rate of falls and an earlier reduction in back pain in the patients treated with the active combination. This trial confirms the demonstrated highly significant advantages of this combined treatment regimen used in the pilote studies. Especially in patients with severe osteoporosis this interesting combination of two substances with complete different mechanisms of action should be taken into consideration.

The potential effects on fracture outcomes of improvements in persistence and compliance with bisphosphonates

BACKGROUND

Osteoporotic fractures are a substantial public health burden worldwide. Evidence from studies show that treatments, such as bisphosphonates, which reduce the risk of fractures when taken regularly and long term, are being used irregularly and suboptimally. The objective of this study was to quantify the additional number of hip fractures prevented by improving persistence and compliance with bisphosphonates.

METHODS

The study population included patients prescribed alendronate or risedronate in the UK General Practice Research Database. Individualized probabilities of fracture and death during bisphosphonate therapy and of treatment persistence and compliance were estimated by age, gender, dosage, calendar year and clinical risk factors using Cox regression. Persistence was calculated by measuring repeat prescribing and compliance by estimating the medication possession ratio. A unique patient-based decision model was then developed using these probabilities. By varying the persistence and compliance probabilities in the simulation, the fracture outcomes with different scenarios were then evaluated. The outcomes were simulated over a 4-year period (maximum of three years of bisphosphonate use followed by 1 year of offset). It was assumed that the bisphosphonate users had experienced similar fracture reductions as observed in clinical trials.

RESULTS

The study population included 44 531 patients. Modelling showed that improvement of the 3-year persistence by 10% (over current persistence) would prevent an additional 14.4 hip fractures per 10 000 patients with weekly treatment. If weekly was substituted with yearly treatment (refill once a year), an additional 68.4 hip fractures (per 10 000 patients) would be prevented. If 3-year persistence improved by 10% with yearly treatment, an additional 78.5 hip fractures would be prevented compared to monthly bisphosphonates. The effects of this substitution were largest in elderly patients and in women.

CONCLUSION

Improvements in treatment persistence and compliance may improve the impact of bisphosphonates in reducing the risk of fractures. Yearly administration may also improve the impact on fracture risk reduction, unless long-term persistence is substantially reduced.

The efficacy and tolerability of once-weekly alendronate 70 mg on bone mineral density and bone turnover markers in postmenopausal Chinese women with osteoporosis

Osteoporosis has become an important health problem in postmenopausal Chinese women. Bisphosphonates currently are the preferred therapy for treating osteoporosis. However, the use of daily regimen of alendronate in women at risk for osteoporosis has been relatively low in China because of its dosing inconvenience. To determine the efficacy and tolerability of once-weekly alendronate 70 mg in Chinese, a multicenter, randomized, double blind, placebo controlled study was performed in China. Five hundred and sixty postmenopausal women (< or =85 years old) with osteoporosis were randomly assigned to receive either alendronate 70 mg or placebo once-weekly for 12 months. All women received calcium 500 mg daily and vitamin D 200 IU daily. A significant increase in lumbar spine BMD was already evident at 6 months of alendronate treatment (P < 0.001). The alendronate group showed significant increase (P < 0.001) in BMD at 12 months at both the spine and hip when compared with the placebo group (lumbar spine 4.87% vs. 0.4%, femoral neck 2.47% vs. 0.31%, trochanter 3.24% vs. 0.78%, total hip 2.56% vs. 0.28%, respectively). The percentage of women with > or =0% and > or =3% BMD increase in lumbar spine was significantly greater in women with alendronate than placebo (P < 0.001). Significant reduction in urine N-telopeptide (NTx) and serum bone-specific alkaline phosphatase were evident at 6 and 12 months, respectively, with alendronate treatment. No significant differences in the incidence of adverse experiences and upper gastrointestinal adverse experiences were seen. We conclude that once-weekly alendronate 70 mg is an effective and well-tolerated agent for the treatment of postmenopausal osteoporosis in Chinese women.

Effectiveness of bisphosphonate therapy in a community setting

BACKGROUND

Osteoporosis is a major cause of morbidity and mortality. Clinical trials have shown the effectiveness of bisphosphonates, the most commonly prescribed treatments, in reducing fracture risk. The population-based effectiveness of bisphosphonates in clinical practice is uncertain.

METHODS

This retrospective cohort study used a matched design that compared time to clinical fracture in at-risk community women who initiated a bisphosphonate medication between 7/1/1996 and 6/30/2006 to those who did not. The study was conducted in an HMO in Oregon and Washington. Clinical electronic databases provided data. Eligible members were newly treated women aged > or = 55 years with either a BMD T-score of < or = -2.0 or a prior qualifying clinical fracture. They did not have contraindications for bisphosphonate therapy or a diagnosis associated with secondary osteoporosis (n=1829). They were matched to a similar comparison group (n=1829; total N=3658). The primary outcome was the first new incident fracture validated through chart review (closed clinical fracture of any bone except face, skull, finger, or toe or pathological fracture secondary to malignancy) during follow-up. An intention-to-treat analysis used Cox proportional hazards models to estimate the hazard ratio of fracture for treated relative to comparison patients, adjusting for differences in potential confounders.

RESULTS

Treated and comparison patients were similar in mean age (72.0 years) and history of fracture (about 45%). The treated group had more women with T-scores of < or = -2.5 (67.3% vs. 54.7%) and a lower mean weight (146.6 lb vs. 151.8 lb). Only about 45% of treated patients had a bisphosphonate medication possession ratio (MPR) of > or = 0.80. During follow-up, 198 (10.8%) of patients in the treated group had incident fractures, vs. 179 (9.8%) of patients in the comparison group. After adjustments, patients in the treated group were 0.91 (95% CI 0.74-1.13) as likely to have an incident fracture as the comparison patients (p=0.388). The treatment effect remained non-significant after accounting for MPR.

CONCLUSIONS

In this analysis of a community cohort of post-menopausal women at risk, the fracture risk of patients who received bisphosphonates did not differ significantly from those who did not. An enhanced understanding of this lack of treatment effect is urgently needed.

Outcomes after switching from one bisphosphonate to another in 146 patients at a single university hospital

Most patients who switched to a second bisphosphonate continued their treatment long term, although those who stopped their first drug because of adverse events were likely to discontinue the second drug for the same reason. Switching to another bisphosphonate is a reasonable treatment option for some patients with treatment failure.

INTRODUCTION

Patients who experience treatment failure with a bisphosphonate because of adverse events (AEs) or other reasons might receive a second bisphosphonate. However, the frequency and benefits of switching bisphosphonates are unknown.

METHODS

We retrospectively evaluated 197 men and 1110 women newly treated with bisphosphonates between 1 January 2000 and 30 June 2005 at our university hospital.

RESULTS

Among the 497 patients who discontinued bisphosphonate treatment, 146 were switched to a second bisphosphonate. The cumulative probabilities of persistence of treatment after 3 years were 45% with the first bisphosphonate and 65% with the second (P = 0.017). Age >or=65 years, switching bisphosphonates because of AEs, and male gender were associated (P < 0.05) with low persistence of treatment with the second bisphosphonate. Discontinuation of the first drug because of AEs was associated with an increased rate of discontinuation of the second drug because of AEs (hazard ratio, 4.2; 95% confidence interval, 2.1-8.4).

CONCLUSIONS

Patients who switched bisphosphonates had high rates of persistence of therapy. Those who stopped their first bisphosphonate because of AEs were at risk of discontinuing the second drug for the same reason. Switching to another bisphosphonate is a reasonable treatment option for some patients with treatment failure.

A multifaceted intervention to improve treatment of osteoporosis in postmenopausal women with wrist fractures: a cluster randomized trial

In a cluster randomized trial, we evaluated the effect of a multifaceted intervention (directed at both patient and primary care physician) on the rates of testing and treatment of osteoporosis in postmenopausal women within six months of their wrist fracture. Compared to usual care, women in the intervention practices were three times more likely to receive bone mineral density testing and prescribed osteoporosis treatments.

INTRODUCTION

Postmenopausal women with wrist fractures are at increased risk of future fragility fractures, yet they frequently do not receive evaluation and treatment for osteoporosis. We set out to evaluate a multifaceted intervention designed to improve management of osteoporosis in older women with recent wrist fractures.

METHODS

Cluster randomized trial of 270 women cared for in 119 primary care practices. We recruited postmenopausal women with an acute wrist fracture from the emergency departments of hospitals in southeastern Ontario, Canada. Family practices were randomly assigned to either the intervention or usual care. The intervention consisted of a mailed reminder with a summary of treatment guidelines and letter sent to the primary care physician, in addition to an educational package and letter to the women. The primary outcome was the proportion of women prescribed osteoporosis therapy within 6 months of their fracture.

RESULTS

The mean age of women was 69(10.9) years. The intervention increased the proportion of women started on osteoporosis medications (28% vs. 10%) of controls, adjusted OR 3.45, 95% CI, 1.58-7.56, p = 0.002) and the proportion who had a bone mineral density (BMD) test (53.3% vs. 26%) of controls, OR 3.38, 95% CI, 1.83-6.26, p < 0.001). In addition to the intervention, having a female physician was a predictor of increased testing and treatment rates.

CONCLUSION

A multifaceted intervention significantly improved rates of osteoporosis treatment and BMD testing in postmenopausal women with wrist fractures.

The ovariectomized, mature rat model of postmenopausal osteoporosis: an assessment of the bone sparing effects of curcumin

Identification of natural health products that might benefit skeletal health could reduce the negative impact of osteoporotic bone fractures upon society. The objectives of this study were to evaluate an animal model of postmenopausal osteoporosis and to search for evidence that curcumin reduces bone mineral losses in a dose-dependent manner when endogenous estrogen levels are reduced. Bone mineral density was measured at the spine, femur and whole body before and at 2, 4 and 6 months after ovariectomy in each of 40 mature rats. Serum osteocalcin and C-telopeptide were measured as indicators of bone formation and resorption rates. Femoral compressive strength was measured at 6 months. Ovariectomy alone resulted in loss of mineral from the spine (p<0.005) and an increase in osteocalcin levels (p<0.05). At the same time, there was an increase in energy to fracture (p<0.01) due to an increased bone size. When ovariectomized animals were given etidronate there was no loss of mineral from the spine, the size of the femur increased (p<0.005), C-telopeptide levels were reduced (p<0.001) and femoral compressive strength increased (p<0.025). Administration of curcumin to ovariectomized animals resulted in changes that were intermediate between those produced by etidronate and by ovariectomy alone. The increase in femur size produced by the highest dose of curcumin was statistically significant (p< 0.01) and curcumin administration resulted in a significant, dose dependent, increase in energy to fracture. Curcumin produces beneficial changes in bone turnover and increases in bone strength using the ovariectomized mature rat model of postmenopausal osteoporosis.

The effects of strontium ranelate in Asian women with postmenopausal osteoporosis

The aim of this study was to assess the efficacy and safety of strontium ranelate in the treatment of postmenopausal women with osteoporosis in Taiwan. In this 12-month multicenter, randomized, double-blind, placebo-controlled study, 125 women with osteoporosis were randomly given either strontium ranelate 2 g daily or placebo. Lumbar spine, femoral neck, and total-hip bone mineral density (BMD) and biochemical markers of bone turnover were measured; adverse events and tolerability were recorded and assessed. Subjects treated with strontium ranelate showed significant increases in BMD of 5.9% at the lumbar spine, 2.6% at the femoral neck, and 2.7% at the total hip, while the placebo group exhibited no significant change at 12 months. Serum level of a formation marker (bone-specific alkaline phosphatase) was also significantly increased at 6 and 12 months. Thus, although the sample size and the treatment duration of this study could not show its effect of reducing osteoprotic fractures, strontium ranelate showed bone protection effects by increasing BMD and concentrations of a bone formation marker. Safety assessment revealed adverse events were mild and not significantly different from placebo.