Use of bisphosphonate and risk of atrial fibrillation in older women with osteoporosis

Electrocardiogram Changes Following Intravenous Bisphosphonate Infusion: A Systematic Review and Meta-Analysis

Bisphosphonates are first-line treatments for several bone and mineral disorders. Studies have reported an increased incidence of serious atrial fibrillation in patients receiving bisphosphonates; however, uncertainty remains as to whether electrical disturbances are precipitated by bisphosphonates. We aimed to review the literature for studies reporting electrocardiogram (ECG) findings in patients receiving intravenous bisphosphonates for any indication. We searched MEDLINE and EMBASE from inception until January 14, 2023, for studies reporting ECG parameters after intravenous bisphosphonate infusion. We excluded studies that only reported atrial fibrillation. Study quality was assessed using the Newcastle-Ottawa scale. Continuous data were meta-analyzed if reported in at least two studies. Random-effects models were fitted and reported as standardized mean difference (SMD) with 95% confidence intervals (95% CIs). We found 1083 unique records, of which 11 met our inclusion and exclusion criteria. Studies had a low to low/moderate risk of bias. Six prospective cohort studies were included in the meta-analysis. Five studies used zoledronic acid, whereas one study used pamidronate. Most studies (n = 4) were conducted in postmenopausal women with osteoporosis, one study was conducted in patients with bone metastases, and one study in children with osteoporosis secondary to cerebral palsy. Study populations ranged from n = 15 to n = 116. Heart rate-corrected QT (QTc) was significantly longer post-infusion (SMD = 0.46 ms [95% CI 0.80 to 0.11]; n = 67 patients, k = 2 studies, τ2  = 0). There were no differences in heart rate, P wave (maximum), P wave (minimum), P wave dispersion, PR interval, QRS duration, QTc, QTc (maximum), QTc (minimum), and QTc dispersion. The correlation between pre- and post-infusion QTc was not significant (p = 0.93). Overall, there is a weak association between intravenous bisphosphonate infusion and a QTc interval prolongation. However, there is insufficient evidence to support an association between intravenous bisphosphonate and any ECG variable changes, which may precipitate atrial fibrillation. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Effectiveness and Safety of Treatments to Prevent Fractures in People With Low Bone Mass or Primary Osteoporosis: A Living Systematic Review and Network Meta-analysis for the American College of Physicians

BACKGROUND

The prevalence of osteoporosis is increasing in the United States.

PURPOSE

To evaluate low bone mass and osteoporosis treatments to prevent fractures.

DATA SOURCES

Ovid MEDLINE ALL, Ovid Evidence Based Medicine Reviews: Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov from 2014 through February 2022.

STUDY SELECTION

Adults receiving eligible interventions for low bone mass or osteoporosis. Randomized controlled trials (RCTs) for fracture outcomes, and RCTs and large observational studies (n ≥1000) for harms.

DATA EXTRACTION

Abstracted by 1 reviewer and verified by a second. Independent, dual assessments of risk of bias and certainty of evidence (CoE).

DATA SYNTHESIS

We included 34 RCTs (in 100 publications) and 36 observational studies. Bisphosphonates and denosumab reduced hip, clinical and radiographic vertebral, and other clinical fractures in postmenopausal females with osteoporosis (moderate to high CoE). Bisphosphonates for 36 months or more may increase the risk for atypical femoral fractures (AFFs) and osteonecrosis of the jaw (ONJ), but the absolute risks were low. Abaloparatide and teriparatide reduced clinical and radiographic vertebral fractures but increased the risk for withdrawals due to adverse events (WAEs; moderate to high CoE). Raloxifene and bazedoxifene for 36 months or more reduced radiographic vertebral but not clinical fractures (low to moderate CoE). Abaloparatide, teriparatide, and sequential romosozumab, then alendronate, may be more effective than bisphosphonates in reducing clinical fractures for 17 to 24 months in older postmenopausal females at very high fracture risk (low to moderate CoE). Bisphosphonates may reduce clinical fractures in older females with low bone mass (low CoE) and radiographic vertebral fractures in males with osteoporosis (low to moderate CoE).

LIMITATION

Few studies examined participants with low bone mass, males, or Black-identifying persons, sequential therapy, or treatment beyond 3 years.

CONCLUSION

Bisphosphonates, denosumab, abaloparatide, teriparatide, and romosozumab, followed by alendronate, reduce clinical fractures in postmenopausal females with osteoporosis. Abaloparatide and teriparatide increased WAEs; longer duration bisphosphonate use may increase AFF and ONJ risk though these events were rare.

PRIMARY FUNDING SOURCE

American College of Physicians. (PROSPERO: CRD42021236220).

Fucoxanthin: A Promising Phytochemical on Diverse Pharmacological Targets

Fucoxanthin (FX) is a special carotenoid having an allenic bond in its structure. FX is extracted from a variety of algae and edible seaweeds. It has been proved to contain numerous health benefits and preventive effects against diseases like diabetes, obesity, liver cirrhosis, malignant cancer, etc. Thus, FX can be used as a potent source of both pharmacological and nutritional ingredient to prevent infectious diseases. In this review, we gathered the information regarding the current findings on antimicrobial, antioxidant, anti-inflammatory, skin protective, anti-obesity, antidiabetic, hepatoprotective, and other properties of FX including its bioavailability and stability characteristics. This review aims to assist further biochemical studies in order to develop further pharmaceutical assets and nutritional products in combination with FX and its various metabolites.

Cardiovascular Safety and Effectiveness of Bisphosphonates: From Intervention Trials to Real-Life Data

Both osteoporosis with related fragility fractures and cardiovascular diseases are rapidly outspreading worldwide. Since they are often coexistent in elderly patients and may be related to possible common pathogenetic mechanisms, the possible reciprocal effects of drugs employed to treat these diseases have to be considered in clinical practice. Bisphosphonates, the agents most largely employed to decrease bone fragility, have been shown to be overall safe with respect to cardiovascular diseases and even capable of reducing cardiovascular morbidity in some settings, as mainly shown by real life studies. No randomized controlled trials with cardiovascular outcomes as primary endpoints are available. While contradictory results have emerged about a possible BSP-mediated reduction of overall mortality, it is undeniable that these drugs can be employed safely in patients with high fracture risk, since no increased mortality has ever been demonstrated. Although partial reassurance has emerged from meta-analysis assessing the risk of cardiac arrhythmias during bisphosphonates treatment, caution is warranted in administering this class of drugs to patients at risk for atrial fibrillation, possibly preferring other antiresorptives or anabolics, according to osteoporosis guidelines. This paper focuses on the complex relationship between bisphosphonates use and cardiovascular disease and possible co-management issues.

The Association between Treatment with Bisphosphonates and the Risk of Atrial Fibrillation: A Meta-Analysis of Observational Studies

Background: Osteoporosis is one of the most common diseases of the skeletal system, particularly occurring in older adults. Bisphosphonates are frequently used to treat osteoporosis and prevent bone fractures. Studies evaluating the association between treatment with bisphosphonate and the risk of atrial fibrillation have reported conflicting results. This meta-analysis of observational studies was performed to assess this association.Methods: Databases were searched to find relevant observational studies, and the identified articles were selected according to the selection criteria. Sensitivity and subgroup analysis based on various confounding factors were performed. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) for the risk of atrial fibrillation were estimated using a random-effects model.Results: We selected 12 studies, including four case-control and eight cohort studies, for the meta-analysis. Assessment of the estimated effect size yielded an OR of 1.171 (95% CI, 1.011–1.356; P=0.035), with substantial heterogeneity (I 2 =84.74%, P<0.001). When the studies were excluded one-after-another, the pooled OR remained unchanged in only six studies. In addition, subgroup analyses found that treatment with bisphosphonates was positively associated with the risk of atrial fibrillation in studies performed in Western countries (OR, 1.263; 95% CI, 1.092–1.462) and lower-quality studies (OR, 1.214; 95% CI, 1.035–1.423). No publication bias was observed.Conclusion: This meta-analysis showed that treatment with bisphosphonates may be associated with an increased risk of atrial fibrillation. Therefore, bisphosphonates should be carefully prescribed to patients at a high risk of atrial fibrillation.

A Single-Center Prospective Study of 116 Women with Osteoporosis Treated with Zoledronic Acid Monitored by Electrocardiography for the Development of Cardiac Arrhythmia During the Acute Phase in China

Background

Concerns have been raised among clinicians and patients about the cardiovascular risks of bisphosphonates used in the treatment of osteoporosis. The goal of this study was to investigate the acute effect of zoledronic acid (ZA) infusion on arrhythmia development using an electrocardiograph (ECG).

Material/Methods

This prospective study was a self-controlled case series study that recruited 116 female patients with osteoporosis. The patients underwent standard 12-lead electrocardiography before and 1 day after zoledronic acid intravenous infusion to evaluate cardiac adverse effects and the change in ECG parameters after the infusion. Heart rhythm, atrial and ventricular premature contractions, atrial fibrillation, P wave, and QTc parameters were measured using an ECG. A blood biochemical examination was performed for all patients before the ZA infusion. Body temperature was measured twice per day.

Results

Before ZA administration, ECG findings were normal in 47 patients and abnormal in 69 patients. After ZA administration, ECG findings were normal in 35 patients and abnormal in 81 patients. New onsets of premature atrial contractions and atrial fibrillation were observed in 1 patient each, and new onsets of premature ventricular contractions were observed in 2 patients. The heart rate was obviously higher, and the QT interval was obviously shorter after ZA administration, compared with before administration. No significant differences in P wave and QTc parameters were found between the 2 ECG measurements.

Conclusions

During the acute phase, 116 women with osteoporosis who were treated with zoledronic acid infusion did not develop significantly abnormal ECG changes.

Fucoxanthin Suppresses Osteoclastogenesis via Modulation of MAP Kinase and Nrf2 Signaling

Fucoxanthin (FX), a natural carotenoid present in edible brown seaweed, is known for its therapeutic potential in various diseases, including bone disease. However, its underlying regulatory mechanisms in osteoclastogenesis remain unclear. In this study, we investigated the effect of FX on osteoclast differentiation and its regulatory signaling pathway. In vitro studies were performed using osteoclast-like RAW264.7 cells stimulated with the soluble receptor activator of nuclear factor-κB ligand or tumor necrosis factor-alpha/interleukin-6. FX treatment significantly inhibited osteoclast differentiation and bone resorption ability, and downregulated the expression of osteoclast-specific markers such as nuclear factor of activated T cells 1, dendritic cell-specific seven transmembrane protein, and matrix metallopeptidase 9. Intracellular signaling pathway analysis revealed that FX specifically decreased the activation of the extracellular signal-regulated kinase and p38 kinase, and increased the nuclear translocation of phosphonuclear factor erythroid 2-related factor 2 (Nrf2). Our results suggest that FX regulates the expression of mitogen-activated protein kinases and Nrf2. Therefore, FX is a potential therapeutic agent for osteoclast-related skeletal disorders including osteoporosis and rheumatoid arthritis.

Bisphosphonates and atrial fibrillation: revisiting the controversy

Bisphosphonates (BPs) are widely prescribed drugs used to treat osteoporosis, commonly arising in postmenopausal women and in chronic glucocorticoid use. Their mechanism of action is through inhibiting osteoclast-induced bone remodeling, and they also possess calcium sequestering properties. Common side effects involve the gastrointestinal system and rare but serious side effects, including osteonecrosis of the jaw. However, a link between BPs and atrial fibrillation (AF) has been proposed, with early clinical trials, such as the Fracture Intervention Trial and the HORIZON Pivotal Fracture Trial, reporting that BPs are associated with increased risk of AF. Nevertheless, subsequent studies have reported contrasting results, ranging from no effect of BPs to antiarrhythmic effects of BPs. Preclinical and electrophysiological studies on any proarrhythmic effect of BPs are limited in scope and number, but suggest possible mechanisms that include antiangionesis-related myocardial remodeling, calcium handling abnormalities, and inflammatory changes. Contrastingly, some studies indicate that BPs are antiarrhythmic by inhibiting fibrotic myocardial remodeling. In order to continue established clinical prescribing of BPs within absolute margins of safety, it will be necessary to systematically rule in/rule out these mechanisms. Thus, we discuss these studies and examine in detail the potential mechanistic links, with the aim of suggesting further avenues for research.

Epidemiology of atrial fibrillation

BACKGROUND

The most common type of arrhythmia in the USA and in European countries is atrial fibrillation (AF). The prevalence of AF is increasing worldwide with advances in technology, better prediction methods and increased awareness among healthcare professionals and patients.

METHODS

This article summarises the literature on the epidemiology of AF worldwide according to continents, age and ethnicity/race, and also includes the prevalence of AF in stroke patients.

RESULTS

In Australia, Europe and the USA, the current estimated prevalence of AF is about between 1% and 4%, with lower prevalence evident in Asia (0.49%-1.9%). AF prevalence is highest among Whites. In Western Europe, Australia and North America 70% of people with AF are aged >65 years, whereas the average age of AF patients in other geographical regions is often lower.

CONCLUSIONS

Although the prevalence of AF worldwide is increasing steadily, large variation can be seen between studies and countries. Further epidemiological studies should be undertaken globally, especially in Asian and African countries so that a better and more accurate picture of the incidence and prevalence of AF can be captured, to enable stroke prevention strategies to be appropriately implemented to prevent or reduce the risk of stroke, the most severe consequence of AF.

Update on osteoporosis treatment

Treatment of osteoporosis should be directed primarily towards secondary prevention of fractures. The occurrence of drug-related adverse effects for the treatment of osteoporosis has led to a reevaluation of the indications, the duration of treatment and even withdrawal of some drugs from the market. This review has been made from different patient profiles that practitioners will find in usual practice; from patients with hip fracture with cognitive impairment, limitation of their day-to-day living activities and comorbidities, to active patients without any limitations; patients with vertebral fractures and non-vertebral fractures where secondary prevention is highly important. In general, antiresorptive drugs (alendronate and risedronate) will be the first choice. Zoledronate or denosumab will be indicated in cases of digestive intolerance, poor adherence or an increased risk of hip fracture. Teriparatide will be indicated to patients with 2or more previous vertebral fractures or very low bone density.

The Global Burden of Atrial Fibrillation and Stroke: A Systematic Review of the Clinical Epidemiology of Atrial Fibrillation in Asia

BACKGROUND

Our previous review reported great variability in the incidence and prevalence of atrial fibrillation (AF) in non-Western cohorts, especially from Asian countries; in recent years, epidemiologic studies on AF have been increasingly reported from Asia.

METHODS

The goal of this updated systematic review was to present the current knowledge base of AF epidemiology in Asian countries since our previous review. We also explored AF incidence and the risk of stroke in AF by using a meta-analysis, with I² testing the heterogeneity. Third, "real-world" antithrombotic drug use for ischemic stroke (IS) prevention associated with AF was studied.

RESULTS

A total of 58 articles from eight countries in Asia were included in the analysis. The summary annual incidence of AF was 5.38 (95% CI, 4.53-6.24; I² = 99.5%; n = 10) per 1,000 person-years, and the IS annual risk in AF was 3.0% (1.60%-4.95%; I² = 99.8%; n = 8) when meta-analysis was performed on hospital- and community-based studies. Hospital- and community-based AF prevalence ranged from 0.37% to 3.56% and 2.8% to 15.8%, respectively. IS prevalence in AF ranged from 1.9% to 6.0% and 0.36% to 28.3% in community- and hospital-based studies. Warfarin use in Chinese subjects is relatively low (1.0%-4.1%) compared with Japanese subjects (49.1%-70.0%) in community-based studies. The rate of warfarin use was < 50% in hospital-based studies.

CONCLUSIONS

The incidence and prevalence of AF have increased in recent years, although great variability still exists in Asian countries. Variability in annual IS risk in patients with AF was apparent between hospital- and community-based studies. However, the rate of warfarin use was < 50% in hospital studies from Asian countries.

Drug holidays from bisphosphonates and denosumab in postmenopausal osteoporosis: EMAS position statement

BACKGROUND

Bisphosphonates and denosumab are used extensively in the treatment of postmenopausal osteoporosis. Despite their proven efficacy in the reduction of vertebral and non-vertebral fractures, their optimal duration of use has not been determined. The occurrence of adverse effects, such as osteonecrosis of the jaw (ONJ) and atypical femoral fractures (AFF), has raised the issue of bisphosphonate or denosumab discontinuation ("drug holiday") after a certain treatment period.

AIM

To assess the effect of bisphosphonate and denosumab discontinuation on fracture risk, as well as its possible benefits in reducing the risk of adverse effects.

METHODS

Systematic review and consensus of expert opinion.

RESULTS AND CONCLUSIONS

Discontinuation of bisphosphonates should be considered in all patients who have beentreated for more than five years with alendronate, risedronate or zoledronic acid. In view of the limited evidence, no robust recommendations can be made for ibandronate and denosumab. If the patient has not experienced fractures before or during therapy and the fracture risk is low, a "drug holiday" canbe recommended. Although there is no solid evidence, 1-2 years for risedronate, 3-5 years for alendronate and 3-6 years for zoledronic acid are suggested. After this time, the patient should be reassessed. If a new fracture is experienced, or fracture risk has increased or BMD remains low (femoral neck T-score ≤-2.5), anti-osteoporotic treatment should be resumed. In the case of denosumab discontinuation, close monitoring is suggested, due to the possibility of rebound fractures.

Drug-Related Adverse Events of Osteoporosis Therapy

Postmenopausal osteoporosis is associated with microarchitectural deterioration and increased risk of fracture. Osteoporosis therapy effectively reduces the risk of vertebral, nonvertebral, and hip fracture and has been associated with increased survival. Currently approved treatments for osteoporosis include bisphosphonates, denosumab, selective estrogen receptor modulators, and teriparatide. This article reviews the adverse events of therapy associated with these medical interventions. Hormone replacement therapy is not included, because it is no longer indicated for the treatment of osteoporosis in all countries. Calcitonin and strontium ranelate are also not included, because their indication for osteoporosis has recently been limited or withdrawn.

Ginsenoside Re Promotes Osteoblast Differentiation in Mouse Osteoblast Precursor MC3T3-E1 Cells and a Zebrafish Model

Bone homeostasis is tightly regulated to balance bone formation and bone resorption. Many anabolic drugs are used as bone-targeted therapeutic agents for the promotion of osteoblast-mediated bone formation or inhibition of osteoclast-mediated bone resorption. Previous studies showed that ginsenoside Re has the effect of the suppression of osteoclast differentiation in mouse bone-marrow derived macrophages and zebrafish. Herein, we investigated whether ginsenoside Re affects osteoblast differentiation and mineralization in in vitro and in vivo models. Mouse osteoblast precursor MC3T3-E1 cells were used to investigate cell viability, alkaline phosphatase (ALP) activity, and mineralization. In addition, we examined osteoblastic signaling pathways. Ginsenoside Re affected ALP activity without cytotoxicity, and we also observed the stimulation of osteoblast differentiation through the activation of osteoblast markers including runt-related transcription factor 2, type 1 collagen, ALP, and osteocalcin in MC3T3-E1 cells. Moreover, Alizarin red S staining indicated that ginsenoside Re increased osteoblast mineralization in MC3T3-E1 cells and zebrafish scales compared to controls. These results suggest that ginsenoside Re promotes osteoblast differentiation as well as inhibits osteoclast differentiation, and it could be a potential therapeutic agent for bone diseases.

Risk of atrial fibrillation among bisphosphonate users: a multicenter, population-based, Italian study

Bisphosphonate treatment is used to prevent bone fractures. A controversial association of bisphosphonate use and risk of atrial fibrillation has been reported. In our study, current alendronate users were associated with a higher risk of atrial fibrillation as compared with those who had stopped bisphosphonate (BP) therapy for more than 1 year.

INTRODUCTION

Bisphosphonates are widely used to prevent bone fractures. Controversial findings regarding the association between bisphosphonate use and the risk of atrial fibrillation (AF) have been reported. The aim of this study was to evaluate the risk of AF in association with BP exposure.

METHODS

We performed a nested case-control study using the databases of drug-dispensing and hospital discharge diagnoses from five Italian regions. The data cover a period ranging from July 1, 2003 to December 31, 2006. The study population comprised new users of bisphosphonates aged 55 years and older. Patients were followed from the first BP prescription until an occurrence of an AF diagnosis (index date, i.e., ID), cancer, death, or the end of the study period, whichever came first. For the risk estimation, any AF case was matched by age and sex to up to 10 controls from the same source population. A conditional logistic regression was performed to obtain the odds ratio with 95% confidence intervals (CI). The BP exposure was classified into current (<90 days prior to ID), recent (91-180), past (181-364), and distant past (≥365) use, with the latter category being used as a reference point. A subgroup analysis by individual BP was then carried out.

RESULTS

In comparison with distant past users of BP, current users of BP showed an almost twofold increased risk of AF: odds ratio (OR) = 1.78 and 95% CI = 1.46-2.16. Specifically, alendronate users were mostly associated with AF as compared with distant past use of BP (OR, 1.97; 95% CI, 1.59-2.43).

CONCLUSION

In our nested case-control study, current users of BP are associated with a higher risk of atrial fibrillation as compared with those who had stopped BP treatment for more than 1 year.

Long-term risks of bisphosphonate therapy

The objective this study was to summarize long-term risks associated with bisphosphonate therapy. Search of relevant medical publications for data from clinical trials, trial extensions, observational studies and post-marketing reports. Trial extensions and modifications did not reveal significant long-term safety issues. Observational data suggest at least as many benefits as risks. Post-marketing reports of musculoskeletal pain, osteonecrosis of the jaw and atypical femur fractures have been widely circulated in the lay press. Most focus on long-terms risks has been on osteonecrosis of the jaw and atypical femur fractures which occur in patients who have not received bisphosphonate therapy but may be more frequent (though still uncommon) in patients who have been on treatment for 5 years or longer. Lower-risk patients may be able to stop treatment after 3-5 years for a “drug holiday,” which mitigates these long-term risks; for higher risk patients, therapy through 6-10 years appears to be advisable and offers more benefits than risks.

Bisphosphonate drug holiday: choosing appropriate candidates

Osteoporosis related fractures contribute to morbidity and mortality in U.S. patients, placing a heavy financial burden on society. Randomized clinical trials involving over 30,000 subjects have established bisphosphonates' efficacy in reducing the incidence of fragility fractures. However, as bisphosphonates are retained for years in the skeleton, reports of adverse events from prolonged use are surfacing in the literature, namely, esophageal cancer, atrial fibrillation, osteonecrosis of the jaw, and atypical fracture development. The concept of a drug holiday has been proposed to potentially reduce incidence of these adverse events. This review will highlight the benefits and risks of bisphosphonate therapy and discuss the extension data available from the bisphosphonate trials. As randomized clinical trial evidence is not yet available on who may qualify for drug holiday, this review will provide suggestions for clinicians on identification of possible candidates and monitoring during a bisphosphonate drug holiday.

Bisphosphonate treatment and risk of esophageal cancer: a meta-analysis of observational studies

The use of bisphosphonates and the risk of esophageal cancer have recently received increasing concern and related studies have yielded controversial results. The present meta-analysis of observational studies shows that no clear association between bisphosphonate treatment and risk of esophageal cancer was observed.

INTRODUCTION

Epidemiological evidence suggests that bisphosphonate treatment can increase the risk of esophageal cancer. However, data on this issue are unstable and controversial. We conducted a meta-analysis to provide a quantitative assessment of the association between use of bisphosphonates and risk of esophageal cancer.

METHODS

We searched the Medline and Embase databases up to May 2012 to identify studies related to bisphosphonates and esophageal cancer. Summary effect estimates with 95 % confidence intervals (CI) were derived using a fixed or random effects model, depending on the heterogeneity of the included studies.

RESULTS

Seven epidemiologic studies that consisted of four cohort studies and three case-control studies were included in this meta-analysis. In our primary analysis, bisphosphonate treatment was not associated with risk of esophageal cancer in both cohort studies [pooled relative risk (RR) 1.23, 95 % CI 0.79-1.92] and case-control studies [pooled odds ratio (OR) 1.24, 95 % CI 0.98-1.57]. Evidence for the presence of significant heterogeneity was found in cohort studies (p = 0.009, I (2) = 74 %) but not in case-control studies (p = 0.338, I (2) = 7.8 %). In our secondary analysis, no significant increased risk of esophageal cancer was found in alendronate users (pooled RR 1.08, 95 % CI 0.67-1.75 in cohort studies; pooled OR 1.16, 95 % CI 0.82-1.63 in case-control studies).

CONCLUSIONS

Based on current evidences, bisphosphonate treatment was not significantly associated with excess risk of esophageal cancer.

Drug-induced atrial fibrillation

Atrial fibrillation (AF) is a common cardiac arrhythmia that is associated with severe consequences, including symptoms, haemodynamic instability, increased cardiovascular mortality and stroke. While other arrhythmias such as torsades de pointes and sinus bradycardia are more typically thought of as drug induced, AF may also be precipitated by drug therapy, although ascribing causality to drug-associated AF is more difficult than with other drug-induced arrhythmias. Drug-induced AF is more likely to occur in patients with risk factors and co-morbidities that commonly co-exist with AF, such as advanced age, alcohol consumption, family history of AF, hypertension, thyroid dysfunction, sleep apnoea and heart disease. New-onset AF has been associated with cardiovascular drugs such as adenosine, dobutamine and milrinone. In addition, medications such as corticosteroids, ondansetron and antineoplastic agents such as paclitaxel, mitoxantrone and doxorubicin have been reported to induce AF. Whether bisphosphonate drugs are associated with new-onset AF remains controversial and requires further study. The potential contribution of specific drug therapy should be considered when patients present with new-onset AF.

Heart failure as a risk factor for osteoporosis and fractures

Although heart failure (HF) and osteoporosis are common diseases, particularly in elderly populations, patients with HF have an increased risk for osteoporosis. The relationship of HF with osteoporosis is modified by gender and the severity of HF. In addition, shared risk factors, medication use, and common pathogenic mechanisms affect both HF and osteoporosis. Shared risk factors for these 2 conditions include advanced age, hypovitaminosis D, renal disease, and diabetes mellitus. Medications used to treat HF, including spironolactone, thiazide diuretics, nitric oxide donors, and aspirin, may protect against osteoporosis. In contrast, loop diuretics may make osteoporosis worse. HF and osteoporosis appear to share common pathogenic mechanisms, including activation of the renin-angiotensin-aldosterone system, increased parathyroid hormone levels, and/or oxidative/nitrosative stress. HF is a major risk factor for mortality following fractures. Thus, in HF patients, it is important to carefully assess osteoporosis and take measures to reduce the risk of osteoporotic fractures.

Bisphosphonates and glucocorticoid-induced osteoporosis: efficacy and tolerability

In this review, the efficacy concern relating to bisphosphonates therapy for glucocorticoid-induced osteoporosis is considered. Sole the randomised clinical trials that including more than 50 patients in each treatment arm were considered. This review also covered the safety of bisphosphonates in the setting of glucocorticoid-induced osteoporosis with specific focus on atrial fibrillation, osteonecrosis of the jaw, upper gastrointestinal adverse events and esophageal cancer risk, atypical fractures and renal safety. These last adverse events have been selected due to the rationale of a possible additive, pathophysiologic or synergetic, deleterious effect of bisphosphonates and glucocorticoid on these organs. The available evidence for glucocorticoid-induced osteoporosis treatment and management is much less important than for post-menopausal osteoporosis. However, based on randomised clinical trials with lumbar spine BMD as the primary endpoint after one year, bisphosphonates can be considered as efficacious. Alendronate, etidronate, risedronate and zoledronate prevented declines in spine BMD in adults receiving glucocorticoid. Treatment and prevention studies in glucocorticoid-induced osteoporosis have a short duration and have included smaller population than in post-menopausal osteoporosis. However in this setting, the safety profile of bisphosphonates in glucocorticoid-induced osteoporosis was good. Long-term use of bisphosphonates in patients treated with glucocorticoid might be cautiously monitored in order to prevent adverse effects.

Bisphosphonates: focus on inflammation and bone loss

Bisphosphonates are pharmacological compounds that have been used for the prevention and treatment of several pathological conditions including osteoporosis, primary hyperparathyroidism, osteogenesis imperfecta, and other conditions characterized by bone fragility. Many studies have been performed to date to analyze their effects on inflammation and bone remodelling and related pathologies. The aim of this review is, starting from a background on inflammatory processes and bone remodelling, to give an update on the use of bisphosphonates, outlining the possible side effects and proposing new trends for the future. Starting from a brief introduction on inflammation and bone remodelling, we collect and analyze studies involving the use of bisphosphonates for treatment of inflammatory conditions and pathologies characterized by bone loss. Selected articles, including reviews, published between 1976 and 2011, were chosen from Pubmed/Medline on the basis of their content. Bisphosphonates exert a selective activity on inflammation and bone remodelling and related pathologies, which are characterized by an excess in bone resorption. They improve not only skeletal defects, but also general symptoms. Bisphosphonates have found clinical application preventing and treating osteoporosis, osteitis deformans (Paget's disease of bone), bone metastasis (with or without hypercalcaemia), multiple myeloma, primary hyperparathyroidism, osteogenesis imperfecta, and other conditions that feature bone fragility. Further clinical studies involving larger cohorts are needed to optimize the dosage and length of therapy for each of these agents in each clinical field in order to be able to maximize their properties concerning modulation of inflammation and bone remodelling. In the near future, although "old" bisphosphonates will reach the end of their patent life, "new" bisphosphonates will be designed to specifically target a pathological condition.

Bisphosphonates in the treatment of osteoporosis

Bisphosphonates are widely used in the treatment of osteoporosis to reduce fracture risk. Because of their long retention time in bone and uncommon side effects, questions have been raised about the optimal duration of therapy. Potential side effects appear to be rare and may not be causally related. Although there is no strong science to guide "drug holidays," there appears to be some lingering antifracture benefit when treatment is stopped, so some time off treatment should be offered to most patients on long-term bisphosphonate therapy. For most patients with osteoporosis, the benefits of treatment outweigh the risks.

Clinical utility of denosumab for treatment of bone loss in men and women

While most older patients with osteoporosis are treated with antiresorptive bisphosphonates such as alendronate, risedronate, ibandronate, and zoledronic acid, such drugs have side effects, remain in bone for extended periods, and lead to poor adherence to chronic treatment. Denosumab is a humanized monoclonal antibody and antiresorptive agent that works by decreasing the activity of the receptor activator of nuclear factor kappa B ligand. In major trials in postmenopausal women, denosumab increased bone mineral density by dual energy x-ray absorptiometry in the spine, hip, and distal third of the radius and decreased vertebral, nonvertebral, and hip fractures. Denosumab is administered by subcutaneous injection every six months, suggesting that adherence may be improved with such therapy. In addition, pharmacokinetic studies measuring bone turnover markers imply that the antiresorptive effect diminishes more quickly over time. Whether these properties will lead to fewer long-term side effects needs to be proven. Denosumab has also been studied in men with prostate cancer treated with androgen deprivation therapy. These men, at high risk for fracture, also have increases in spine, hip, and forearm dual energy x-ray absorptiometry, as well as fewer morphologic vertebral fractures on x-ray. Denosumab is approved for postmenopausal women with osteoporosis in the US and Europe and for men on androgen deprivation therapy in Europe.