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Lan Z, Lin X, Xue D, Yang Y, Saad M, Jin Q. Can Bisphosphonate Therapy Reduce Overall Mortality in Patients With Osteoporosis? A Meta-analysis of Randomized Controlled Trials. Clin Orthop Relat Res 2024:00003086-990000000-01698. [PMID: 39172899 DOI: 10.1097/corr.0000000000003204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 07/05/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND For patients with osteoporosis, bisphosphonate therapy can reduce the risk of fractures, but its effect on reducing mortality remains unclear. Previous studies on this topic have produced conflicting results and generally have been too small to definitively answer the question of whether bisphosphonate therapy reduces mortality. Therefore, a meta-analysis may help us arrive at a more conclusive answer. QUESTIONS/PURPOSES In a large meta-analysis of placebo-controlled randomized controlled trials (RCTs), we asked: (1) Does bisphosphonate use reduce mortality? (2) Is there a subgroup effect based on whether different bisphosphonate drugs were used (zoledronate, alendronate, risedronate, and ibandronate), different geographic regions where the study took place (Europe, the Americas, and Asia), whether the study was limited to postmenopausal female patients, or whether the trials lasted 3 years or longer? METHODS We conducted a systematic review using multiple databases, including Embase, Web of Science, Medline (via PubMed), Cochrane Library, and ClinicalTrials.gov, with each database searched up to November 20, 2023 (which also was the date of our last search), following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included randomized, placebo-controlled clinical trials with participants diagnosed with osteoporosis and receiving bisphosphonate treatment. We excluded papers posted to preprint servers, other unpublished work, conference abstracts, and papers that were registered on ClinicalTrials.gov but were not yet published. We collected 2263 records. After excluding records due to study type, study content not meeting the inclusion criteria, and duplicates, our meta-analysis included 47 placebo-controlled RCTs involving 59,437 participants. Data extraction, quality assessment, and statistical analyses were performed. The evaluation of randomized trials for potential bias was conducted using the revised Cochrane Risk of Bias tool. This assessment encompassed factors such as sequence generation, allocation concealment, subject blinding, outcome assessor blinding, incomplete outcome data, and reporting bias. Some studies did not provide explicit details regarding random sequence generation, leading to a high risk of selection bias. A few studies, due to their open-label nature, were unable to achieve double-blind conditions for both the subjects and the researchers, resulting in intermediate performance bias. Nevertheless, the overall study quality was high. Due to the low heterogeneity among the studies, as evidenced by the low statistical heterogeneity (that is, a low I2 statistic), we opted for a fixed-effects model, indicating that the effect size is consistent across the studies. In such cases, the fixed-effects model can provide more precise estimates. According to the results of the funnel plot, we did not find evidence of publication bias. RESULTS The use of bisphosphonates did not reduce the overall risk of mortality in patients with osteoporosis (risk ratio 0.95 [95% CI 0.88 to 1.03]). Subgroup analyses involving different bisphosphonate drugs (zoledronate, alendronate, risedronate, and ibandronate), regions (Europe, the Americas, and Asia), diverse populations (postmenopausal female patients and other patients), and trials lasting 3 years or longer revealed no associations with reduced overall mortality. CONCLUSION Based on our comprehensive meta-analysis, there is high-quality evidence suggesting that bisphosphonate therapy for patients with osteoporosis does not reduce the overall risk of mortality despite its effectiveness in reducing the risk of fractures. The primary consideration for prescribing bisphosphonates to individuals with osteoporosis should continue to be centered on reducing fracture risk, aligning with clinical guidelines. Long-term studies are needed to investigate potential effects on mortality during extended treatment periods. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Zhibin Lan
- The Third Ward of Orthopaedic Department, General Hospital of Ningxia Medical University, Yinchuan, PR China
| | - Xue Lin
- The Third Ward of Orthopaedic Department, General Hospital of Ningxia Medical University, Yinchuan, PR China
- Institute of Osteoarthropathy, Ningxia Key Laboratory of Clinical and Pathogenic Microbiology, Institute of Medical Sciences, General Hospital of Ningxia Medical University, Yinchuan, PR China
| | - Di Xue
- The Third Ward of Orthopaedic Department, General Hospital of Ningxia Medical University, Yinchuan, PR China
- Institute of Osteoarthropathy, Ningxia Key Laboratory of Clinical and Pathogenic Microbiology, Institute of Medical Sciences, General Hospital of Ningxia Medical University, Yinchuan, PR China
| | - Yang Yang
- The Third Ward of Orthopaedic Department, General Hospital of Ningxia Medical University, Yinchuan, PR China
| | - Muhammad Saad
- The Third Ward of Orthopaedic Department, General Hospital of Ningxia Medical University, Yinchuan, PR China
| | - Qunhua Jin
- The Third Ward of Orthopaedic Department, General Hospital of Ningxia Medical University, Yinchuan, PR China
- Institute of Osteoarthropathy, Ningxia Key Laboratory of Clinical and Pathogenic Microbiology, Institute of Medical Sciences, General Hospital of Ningxia Medical University, Yinchuan, PR China
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Echevarria-Cruz E, McMillan DW, Reid KF, Valderrábano RJ. Spinal Cord Injury Associated Disease of the Skeleton, an Unresolved Problem with Need for Multimodal Interventions. Adv Biol (Weinh) 2024:e2400213. [PMID: 39074256 DOI: 10.1002/adbi.202400213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 07/11/2024] [Indexed: 07/31/2024]
Abstract
Spinal cord injury is associated with skeletal unloading, sedentary behavior, decreases in skeletal muscle mass, and exercise intolerance, which results in rapid and severe bone loss. To date, monotherapy with physical interventions such as weight-bearing in standing frames, computer-controlled electrically stimulated cycling and ambulation exercise, and low-intensity vibration are unsuccessful in maintaining bone density after SCI. Strategies to maintain bone density with commonly used osteoporosis medications also fail to provide a significant clinical benefit, potentially due to a unique pathology of bone deterioration in SCI. In this review, the available data is discussed on evaluating and monitoring bone loss, fracture, and physical and pharmacological therapeutic approaches to SCI-associated disease of the skeleton. The treatment of SCI-associated disease of the skeleton, the implications for clinical management, and areas of need are considered for future investigation.
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Affiliation(s)
- Evelyn Echevarria-Cruz
- Research Program in Men's Health, Aging and Metabolism, and Boston Claude D. Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave Boston, 5th Floor, Boston, MA, 02115, USA
| | - David W McMillan
- The Miami Project to Cure Paralysis, University of Miami Leonard M. Miller School of Medicine, 1611 NW 12th ave, Office 2.141, Miami, FL, 33136, USA
- Department of Neurological Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, FL, 33136, USA
| | - Kieran F Reid
- Research Program in Men's Health, Aging and Metabolism, and Boston Claude D. Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave Boston, 5th Floor, Boston, MA, 02115, USA
- Laboratory of Exercise Physiology and Physical Performance, Boston Claude D. Pepper Older Americans Independence Center for Function Promoting Therapies, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Rodrigo J Valderrábano
- Research Program in Men's Health, Aging and Metabolism, and Boston Claude D. Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave Boston, 5th Floor, Boston, MA, 02115, USA
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Händel MN, Cardoso I, von Bülow C, Rohde JF, Ussing A, Nielsen SM, Christensen R, Body JJ, Brandi ML, Diez-Perez A, Hadji P, Javaid MK, Lems WF, Nogues X, Roux C, Minisola S, Kurth A, Thomas T, Prieto-Alhambra D, Ferrari SL, Langdahl B, Abrahamsen B. Fracture risk reduction and safety by osteoporosis treatment compared with placebo or active comparator in postmenopausal women: systematic review, network meta-analysis, and meta-regression analysis of randomised clinical trials. BMJ 2023; 381:e068033. [PMID: 37130601 PMCID: PMC10152340 DOI: 10.1136/bmj-2021-068033] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVE To review the comparative effectiveness of osteoporosis treatments, including the bone anabolic agents, abaloparatide and romosozumab, on reducing the risk of fractures in postmenopausal women, and to characterise the effect of antiosteoporosis drug treatments on the risk of fractures according to baseline risk factors. DESIGN Systematic review, network meta-analysis, and meta-regression analysis of randomised clinical trials. DATA SOURCES Medline, Embase, and Cochrane Library to identify randomised controlled trials published between 1 January 1996 and 24 November 2021 that examined the effect of bisphosphonates, denosumab, selective oestrogen receptor modulators, parathyroid hormone receptor agonists, and romosozumab compared with placebo or active comparator. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials that included non-Asian postmenopausal women with no restriction on age, when interventions looked at bone quality in a broad perspective. The primary outcome was clinical fractures. Secondary outcomes were vertebral, non-vertebral, hip, and major osteoporotic fractures, all cause mortality, adverse events, and serious cardiovascular adverse events. RESULTS The results were based on 69 trials (>80 000 patients). For clinical fractures, synthesis of the results showed a protective effect of bisphosphonates, parathyroid hormone receptor agonists, and romosozumab compared with placebo. Compared with parathyroid hormone receptor agonists, bisphosphonates were less effective in reducing clinical fractures (odds ratio 1.49, 95% confidence interval 1.12 to 2.00). Compared with parathyroid hormone receptor agonists and romosozumab, denosumab was less effective in reducing clinical fractures (odds ratio 1.85, 1.18 to 2.92 for denosumab v parathyroid hormone receptor agonists and 1.56, 1.02 to 2.39 for denosumab v romosozumab). An effect of all treatments on vertebral fractures compared with placebo was found. In the active treatment comparisons, denosumab, parathyroid hormone receptor agonists, and romosozumab were more effective than oral bisphosphonates in preventing vertebral fractures. The effect of all treatments was unaffected by baseline risk indicators, except for antiresorptive treatments that showed a greater reduction of clinical fractures compared with placebo with increasing mean age (number of studies=17; β=0.98, 95% confidence interval 0.96 to 0.99). No harm outcomes were seen. The certainty in the effect estimates was moderate to low for all individual outcomes, mainly because of limitations in reporting, nominally indicating a serious risk of bias and imprecision. CONCLUSIONS The evidence indicated a benefit of a range of treatments for osteoporosis in postmenopausal women for clinical and vertebral fractures. Bone anabolic treatments were more effective than bisphosphonates in the prevention of clinical and vertebral fractures, irrespective of baseline risk indicators. Hence this analysis provided no clinical evidence for restricting the use of anabolic treatment to patients with a very high risk of fractures. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019128391.
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Affiliation(s)
- Mina Nicole Händel
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
- Department of Clinical Research, Odense Patient Data Explorative Network, University of Southern Denmark, Odense, Denmark
| | - Isabel Cardoso
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
| | - Cecilie von Bülow
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
- Occupational Science, User Perspectives and Community-Based Interventions, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Jeanett Friis Rohde
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
| | - Anja Ussing
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
| | - Sabrina Mai Nielsen
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Robin Christensen
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Adolfo Diez-Perez
- Department of Internal Medicine, Institut Hospital del Mar of Medical Investigation, Autonomous University of Barcelona and CIBERFES (Frailty and Healthy Aging Research Network), Instituto Carlos III, Barcelona, Spain
| | - Peyman Hadji
- Frankfurt Centre of Bone Health, Frankfurt and Philipps-University of Marburg, Marburg, Germany
| | - Muhammad Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Xavier Nogues
- IMIM (Hospital del Mar Medical Research Institute), Parc de Salut Mar, Pompeu Fabra University, Barcelona, Spain
| | - Christian Roux
- INSERM U 1153, Hospital Paris-Centre, University of Paris, Paris, France
| | - Salvatore Minisola
- Department of Clinical, Internal, Anaesthesiologic, and Cardiovascular Sciences, Rome University, Rome, Italy
| | - Andreas Kurth
- Department of Orthopaedic and Trauma Surgery, Marienhaus Klinikum Mainz, Major Teaching Hospital, University Medicine Mainz, Mainz, Germany
| | - Thierry Thomas
- Université Jean Monnet Saint-Étienne, CHU de Saint-Etienne, Rheumatology Department, INSERM U1059, F-42023, Saint-Etienne, France
| | - Daniel Prieto-Alhambra
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Bente Langdahl
- Departments of Clinical Medicine and of Endocrinology and Internal Medicine, Aarhus University, Aarhus, Denmark
| | - Bo Abrahamsen
- Department of Clinical Research, Odense Patient Data Explorative Network, University of Southern Denmark, Odense, Denmark
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
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Kravvariti E, Kasdagli MI, Diomatari KM, Mouratidou P, Daskalakis K, Mitsikostas DD, Sfikakis PP, Yavropoulou MP. Meta-analysis of placebo-arm dropouts in osteoporosis randomized-controlled trials and implications for nocebo-associated discontinuation of anti-osteoporotic drugs in clinical practice. Osteoporos Int 2023; 34:585-598. [PMID: 36596944 DOI: 10.1007/s00198-022-06658-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/20/2022] [Indexed: 01/05/2023]
Abstract
UNLABELLED Dropout from placebo arms in randomized-controlled trials is a surrogate for nocebo responses, resulting from patients' negative expectations to treatment. Among 16,460 placebo-treated patients in oral anti-osteoporotic drug trials, nocebo dropouts were 8% on average, being higher in older patients. This implies that nocebo may contribute to the osteoporosis treatment gap in clinical practice. PURPOSE Osteoporosis is a common disease requiring long-term treatment. Despite the availability of effective anti-osteoporotic drugs, adherence to treatment is low. Nocebo, a behavior mostly related to the negative expectations to a certain treatment, decreases adherence and negatively affects treatment outcomes and health-related care costs in chronic diseases. Since in double-blind placebo-controlled randomized trials any unfavorable outcome leading to discontinuation in placebo arms is considered as nocebo, we aimed to investigate the size of nocebo response in patients participating in osteoporosis trials. METHODS We searched MEDLINE, EMBASE, SCOPUS, and Cochrane databases for dropouts due to reported adverse events in the placebo arms (nocebo dropouts) in all double-blind trials investigating anti-osteoporotic drugs published between January 1993 and March 2022. Only data on bisphosphonates and selective estrogen receptor modulators (SERMs) were analyzed (Prospero registration number CRD42020212843). RESULTS Data from 44 trials were extracted. In 16,460 placebo-treated patients, the pooled nocebo-dropout was 8% both for bisphosphonates (average: 0.08; range 0.01-0.27; 95%CI 0.06-0.10) and SERMs (average: 0.08; range 0.03-0.15; 95%CI 0.05-0.13). Nocebo-dropouts were higher in bisphosphonate trials enrolling individuals ≥ 65 years (11%) (n = 18) compared to trials enrolling younger individuals (6%) (n = 18) (average: 0.11; 95%CI 0.08-0.13 vs. average: 0.06; 95%CI 0.05-0.08, respectively, p = 0.001). Participants' sex, dosing-intervals, publication year, or severity of osteoporosis had no impact on the nocebo-dropouts. CONCLUSION Almost 1 in 10 osteoporosis patients receiving placebo in trials of bisphosphonates and SERMs experiences AEs leading to dropout, implying that nocebo contributes to treatment-discontinuation in clinical practice. Efforts to identify and minimize nocebo, especially in older patients, are warranted.
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Affiliation(s)
- Evrydiki Kravvariti
- 1st Propaedeutic and Internal Medicine Clinic, Joint Academic Rheumatology Program, Laikon General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527, Athens, Greece.
- Postgraduate Medical Studies in the Physiology of Aging and Geriatric Syndromes, School of Medicine, National and Kapodistrian University of Athens, 11527, Athens, Greece.
| | - Maria-Iosifina Kasdagli
- Department of Hygiene and Epidemiology, School of Medicine, National and Kapodistrian University of Athens, 11527, Athens, Greece
| | - Konstantina Maria Diomatari
- Postgraduate Medical Studies in the Physiology of Aging and Geriatric Syndromes, School of Medicine, National and Kapodistrian University of Athens, 11527, Athens, Greece
| | - Pelagia Mouratidou
- Postgraduate Medical Studies in the Physiology of Aging and Geriatric Syndromes, School of Medicine, National and Kapodistrian University of Athens, 11527, Athens, Greece
| | - Kosmas Daskalakis
- Department of Surgery, Faculty of Medicine and Health, Örebro University, 701 85, Örebro, Sweden
| | - Dimos D Mitsikostas
- 1st Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, 11528, Athens, Greece
| | - Petros P Sfikakis
- 1st Propaedeutic and Internal Medicine Clinic, Joint Academic Rheumatology Program, Laikon General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527, Athens, Greece
- Postgraduate Medical Studies in the Physiology of Aging and Geriatric Syndromes, School of Medicine, National and Kapodistrian University of Athens, 11527, Athens, Greece
| | - Maria P Yavropoulou
- Endocrinology Unit, 1st Department of Propaedeutic and Internal Medicine, School of Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, 11527, Athens, Greece
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Mitsuboshi S, Kotake K. Risks of serious adverse events and kidney injury in patients treated with ibandronate: A systematic review and meta‐analysis. Pharmacotherapy 2022; 42:677-686. [DOI: 10.1002/phar.2713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/25/2022] [Accepted: 05/25/2022] [Indexed: 11/08/2022]
Affiliation(s)
| | - Kazumasa Kotake
- Department of Pharmacy Okayama Saiseikai General Hospital Okayama Japan
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Li J, Sun Y, Chen Z, Xie X, Gu F, Bi S, Yu T. Effects of Bisphosphonates Treatments in Osteopenic Older Women: A Systematic Review and Meta-Analysis. Front Pharmacol 2022; 13:892091. [PMID: 35662708 PMCID: PMC9160388 DOI: 10.3389/fphar.2022.892091] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/05/2022] [Indexed: 11/29/2022] Open
Abstract
Aims: To review the effects of bisphosphonates on bone density, fractures, and bone markers in osteopenic older women. Methods: Relevant articles published before February 2022 were searched in PubMed, EMBASE, and the Cochrane Library. All randomized controlled trials that reported incident fractures, bone mineral density (BMD), bone markers, or adverse events with bisphosphonates in osteopenic older women were included. The quality of included studies was assessed using the Cochrane Risk of Bias tool. The risk ratios (RRs) for fractures, net percent change in bone mineral density and differences in bone markers were calculated using a meta-analysis. Results: A total of 11 studies were included in our meta-analysis. Bisphosphonates significantly increased the percent changes in the lumbar spine BMD (WMD, 5.60; 95% CI, 4.16–7.03; I2 = 93.6%), hip BMD (WMD, 4.80; 95% CI, 2.93 to 6.66; I2 = 97.1%), total body BMD (WMD, 3.24; 95% CI, 2.12–4.35; I2 = 90.9%), femoral neck BMD (WMD, 4.02; 95% CI, 1.70–6.35; I2 = 91.8%) and trochanter BMD (WMD, 5.22; 95% CI, 3.51–6.93; I2 = 83.6%) when compared to placebo. Zoledronate was associated with a great treatment effect on fragility fracture (RR, 0.63; 95% CI, 0.50–0.79), clinical vertebral fracture (RR, 0.41; 95% CI, 0.22–0.76), and radiographic vertebral fracture (RR, 0.60; 95% CI, 0.27–1.35) compared to placebo. Meanwhile, alendronate was also associated with beneficial effects on fragility fracture (RR, 0.40; 95% CI, 0.15–1.07), clinical vertebral fracture (RR, 0.46; 95% CI, 0.17–1.24), and radiographic vertebral fracture (RR, 0.64; 95% CI, 0.38–1.09). In addition, the use of bisphosphonates reduced the concentration of procollagen type I N-terminal propeptide (PINP) and C-terminal telopeptide of type I collagen (CTX) over placebo by 15.79 (95% CI, −18.92 to −12.66; I2 = 28.4%), −0.23 (95% CI, −0.35 to −0.10; I2 = 91.3%), respectively. Although there was insufficient evidence to determine their safety, these bisphosphonates may have an effect on cancer, cardiac events, and mortality in osteopenic older women. Conclusion: All bisphosphonates examined were associated with beneficial effects on fractures, BMD, and bone markers in women with osteopenia. Further randomized controlled trials are necessary to clarify the safety of bisphosphonates in women with osteopenia.
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Affiliation(s)
- Jiangbi Li
- Department of Orthopedics, First Hospital of Jilin University, Changchun, China
| | - Yang Sun
- Department of Orthopedics, First Hospital of Jilin University, Changchun, China
| | - Zhuo Chen
- School of Foreign Language, Northeast Normal University, Changchun, China
| | - Xiaoping Xie
- Department of Orthopedics, First Hospital of Jilin University, Changchun, China
| | - Feng Gu
- Department of Orthopedics, First Hospital of Jilin University, Changchun, China
| | - Songqi Bi
- Department of Orthopedics, First Hospital of Jilin University, Changchun, China
| | - Tiecheng Yu
- Department of Orthopedics, First Hospital of Jilin University, Changchun, China
- *Correspondence: Tiecheng Yu,
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Davis S, Simpson E, Hamilton J, James MMS, Rawdin A, Wong R, Goka E, Gittoes N, Selby P. Denosumab, raloxifene, romosozumab and teriparatide to prevent osteoporotic fragility fractures: a systematic review and economic evaluation. Health Technol Assess 2020; 24:1-314. [PMID: 32588816 PMCID: PMC7357239 DOI: 10.3310/hta24290] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture. OBJECTIVES The objectives were to evaluate the clinical effectiveness, safety and cost-effectiveness of non-bisphosphonates {denosumab [Prolia®; Amgen Inc., Thousand Oaks, CA, USA], raloxifene [Evista®; Daiichi Sankyo Company, Ltd, Tokyo, Japan], romosozumab [Evenity®; Union Chimique Belge (UCB) S.A. (Brussels, Belgium) and Amgen Inc.] and teriparatide [Forsteo®; Eli Lilly and Company, Indianapolis, IN, USA]}, compared with each other, bisphosphonates or no treatment, for the prevention of fragility fracture. DATA SOURCES For the clinical effectiveness review, nine electronic databases (including MEDLINE, EMBASE and the World Health Organization International Clinical Trials Registry Platform) were searched up to July 2018. REVIEW METHODS A systematic review and network meta-analysis of fracture and femoral neck bone mineral density were conducted. A review of published economic analyses was undertaken and a model previously used to evaluate bisphosphonates was adapted. Discrete event simulation was used to estimate lifetime costs and quality-adjusted life-years for a simulated cohort of patients with heterogeneous characteristics. This was done for each non-bisphosphonate treatment, a strategy of no treatment, and the five bisphosphonate treatments previously evaluated. The model was populated with effectiveness evidence from the systematic review and network meta-analysis. All other parameters were estimated from published sources. An NHS and Personal Social Services perspective was taken, and costs and benefits were discounted at 3.5% per annum. Fracture risk was estimated from patient characteristics using the QFracture® (QFracture-2012 open source revision 38, Clinrisk Ltd, Leeds, UK) and FRAX® (web version 3.9, University of Sheffield, Sheffield, UK) tools. The relationship between fracture risk and incremental net monetary benefit was estimated using non-parametric regression. A probabilistic sensitivity analysis and scenario analyses were used to assess uncertainty. RESULTS Fifty-two randomised controlled trials of non-bisphosphonates were included in the clinical effectiveness systematic review and an additional 51 randomised controlled trials of bisphosphonates were included in the network meta-analysis. All treatments had beneficial effects compared with placebo for vertebral, non-vertebral and hip fractures, with hazard ratios varying from 0.23 to 0.94, depending on treatment and fracture type. The effects on vertebral fractures and the percentage change in bone mineral density were statistically significant for all treatments. The rate of serious adverse events varied across trials (0-33%), with most between-group differences not being statistically significant for comparisons with placebo/no active treatment, non-bisphosphonates or bisphosphonates. The incremental cost-effectiveness ratios were > £20,000 per quality-adjusted life-year for all non-bisphosphonate interventions compared with no treatment across the range of QFracture and FRAX scores expected in the population eligible for fracture risk assessment. The incremental cost-effectiveness ratio for denosumab may fall below £30,000 per quality-adjusted life-year at very high levels of risk or for high-risk patients with specific characteristics. Raloxifene was dominated by no treatment (resulted in fewer quality-adjusted life-years) in most risk categories. LIMITATIONS The incremental cost-effectiveness ratios are uncertain for very high-risk patients. CONCLUSIONS Non-bisphosphonates are effective in preventing fragility fractures, but the incremental cost-effectiveness ratios are generally greater than the commonly applied threshold of £20,000-30,000 per quality-adjusted life-year. STUDY REGISTRATION This study is registered as PROSPERO CRD42018107651. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 29. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Sarah Davis
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Simpson
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Marrissa Martyn-St James
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Rawdin
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ruth Wong
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Edward Goka
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Neil Gittoes
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Peter Selby
- School of Medical Sciences, University of Manchester, Manchester, UK
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Cummings SR, Lui LY, Eastell R, Allen IE. Association Between Drug Treatments for Patients With Osteoporosis and Overall Mortality Rates: A Meta-analysis. JAMA Intern Med 2019; 179:1491-1500. [PMID: 31424486 PMCID: PMC6704731 DOI: 10.1001/jamainternmed.2019.2779] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Previous studies have reported that drug treatments, particularly treatment with bisphosphonates, is associated with reduced overall mortality rates in addition to decreased fracture risk. If so, drug treatments should be recommended for this reason alone, regardless of a patient's risk of fracture. OBJECTIVE To assess whether randomized clinical trials demonstrate that treatment with bisphosphonates, particularly zoledronate, is associated with reduced mortality rates. DATA SOURCES Science Direct, MEDLINE, Embase, and the Cochrane Library were searched for randomized placebo-controlled clinical trials of drug treatments for osteoporosis published after 2009 and published or in press before April 19, 2019. Conference abstracts from annual osteoporosis society meetings were also included in the search. STUDY SELECTION Included studies were clinical trials that (1) were randomized and placebo-controlled; (2) studied drug treatments with proven antifracture efficacy; (3) used agents at the approved dose for treatment of osteoporosis; and (4) had a duration of 1 year or more. Abstracts from the literature searches were reviewed for inclusion and exclusion criteria, and mortality rate data were abstracted from the article by 1 researcher and validated by a second. A total of 2045 records were screened; 38 (1.8%) were included in the meta-analyses. DATA EXTRACTION AND SYNTHESIS The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist was followed for abstracting data and assessing data quality and validity. Data were pooled using random-effects models, and between-study variability was assessed using the I2 index. The risk of bias for each study was assessed, and funnel plots and Egger and Begg statistics were used to evaluate publication bias. MAIN OUTCOMES AND MEASURES Associations of all drug treatments, particularly bisphosphonate and zoledronate treatments, with overall mortality. RESULTS Of 38 clinical trials that included 101 642 unique participants, 38 were included in the meta-analyses of all drug treatments (45 594 participants randomized to placebo; 56 048 to treatment); 21 clinical trials, of bisphosphonate treatments (20 244 participants randomized to placebo; 22 623 to treatment); and 6 clinical trials, of zoledronate treatments (6944 participants randomized to placebo; 6926 to treatment). No significant association was found between all drug treatments for osteoporosis and overall mortality rate (risk ratio [RR], 0.98; 95% CI, 0.91-1.05; I2 = 0%). Clinical trials of bisphosphonate treatment (RR, 0.95; 95% CI, 0.86-1.04) showed no significant association with overall mortality. Also, clinical trials of zoledronate treatment (RR, 0.88; 95% CI, 0.68-1.13) showed no association with overall mortality rate; however, evidence existed for heterogeneity of the results (I2 = 48.2%). CONCLUSIONS AND RELEVANCE Results of this meta-analysis suggest that bisphosphonate treatment may not be associated with reduced overall mortality rates in addition to decreased fracture risk and should only be recommended to reduce fracture risk. Additional trials are needed to clarify whether treatment with zoledronate reduces mortality rates.
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Affiliation(s)
- Steven R Cummings
- San Francisco Coordinating Center, San Francisco, California.,California Pacific Medical Center Research Institute, San Francisco.,Department of Medicine, University of California San Francisco, San Francisco.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco
| | - Li-Yung Lui
- San Francisco Coordinating Center, San Francisco, California.,California Pacific Medical Center Research Institute, San Francisco
| | - Richard Eastell
- Sheffield Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Isabel E Allen
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco
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Davis S, Martyn-St James M, Sanderson J, Stevens J, Goka E, Rawdin A, Sadler S, Wong R, Campbell F, Stevenson M, Strong M, Selby P, Gittoes N. A systematic review and economic evaluation of bisphosphonates for the prevention of fragility fractures. Health Technol Assess 2018; 20:1-406. [PMID: 27801641 DOI: 10.3310/hta20780] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture. OBJECTIVES To evaluate the clinical effectiveness and safety of bisphosphonates [alendronic acid (Fosamax® and Fosamax® Once Weekly, Merck Sharp & Dohme Ltd), risedronic acid (Actonel® and Actonel Once a Week®, Warner Chilcott UK Ltd), ibandronic acid (Bonviva®, Roche Products Ltd) and zoledronic acid (Aclasta®, Novartis Pharmaceuticals UK Ltd)] for the prevention of fragility fracture and to assess their cost-effectiveness at varying levels of fracture risk. DATA SOURCES For the clinical effectiveness review, six electronic databases and two trial registries were searched: MEDLINE, EMBASE, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Web of Science and BIOSIS Previews, Clinicaltrials.gov and World Health Organization International Clinical Trials Registry Platform. Searches were limited by date from 2008 until September 2014. REVIEW METHODS A systematic review and network meta-analysis (NMA) of effectiveness studies were conducted. A review of published economic analyses was undertaken and a de novo health economic model was constructed. Discrete event simulation was used to estimate lifetime costs and quality-adjusted life-years (QALYs) for each bisphosphonate treatment strategy and a strategy of no treatment for a simulated cohort of patients with heterogeneous characteristics. The model was populated with effectiveness evidence from the systematic review and NMA. All other parameters were estimated from published sources. A NHS and Personal Social Services perspective was taken, and costs and benefits were discounted at 3.5% per annum. Fracture risk was estimated from patient characteristics using the QFracture® (QFracture-2012 open source revision 38, Clinrisk Ltd, Leeds, UK) and FRAX® (web version 3.9, University of Sheffield, Sheffield, UK) tools. The relationship between fracture risk and incremental net benefit (INB) was estimated using non-parametric regression. Probabilistic sensitivity analysis (PSA) and scenario analyses were used to assess uncertainty. RESULTS Forty-six randomised controlled trials (RCTs) were included in the clinical effectiveness systematic review, with 27 RCTs providing data for the fracture NMA and 35 RCTs providing data for the femoral neck bone mineral density (BMD) NMA. All treatments had beneficial effects on fractures versus placebo, with hazard ratios varying from 0.41 to 0.92 depending on treatment and fracture type. The effects on vertebral fractures and percentage change in BMD were statistically significant for all treatments. There was no evidence of a difference in effect on fractures between bisphosphonates. A statistically significant difference in the incidence of influenza-like symptoms was identified from the RCTs for zoledronic acid compared with placebo. Reviews of observational studies suggest that upper gastrointestinal symptoms are frequently reported in the first month of oral bisphosphonate treatment, but pooled analyses of placebo-controlled trials found no statistically significant difference. A strategy of no treatment was estimated to have the maximum INB for patients with a 10-year QFracture risk under 1.5%, whereas oral bisphosphonates provided maximum INB at higher levels of risk. However, the PSA suggested that there is considerable uncertainty regarding whether or not no treatment is the optimal strategy until the QFracture score is around 5.5%. In the model using FRAX, the mean INBs were positive for all oral bisphosphonate treatments across all risk categories. Intravenous bisphosphonates were estimated to have lower INBs than oral bisphosphonates across all levels of fracture risk when estimated using either QFracture or FRAX. LIMITATIONS We assumed that all treatment strategies are viable alternatives across the whole population. CONCLUSIONS Bisphosphonates are effective in preventing fragility fractures. However, the benefit-to-risk ratio in the lowest-risk patients may be debatable given the low absolute QALY gains and the potential for adverse events. We plan to extend the analysis to include non-bisphosphonate therapies. STUDY REGISTRATION This study is registered as PROSPERO CRD42013006883. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Sarah Davis
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Marrissa Martyn-St James
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Jean Sanderson
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - John Stevens
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Edward Goka
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Andrew Rawdin
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Susi Sadler
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ruth Wong
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Fiona Campbell
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Mark Strong
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Peter Selby
- Department of Medicine, University of Manchester, Manchester Royal Infirmary, Manchester, UK
| | - Neil Gittoes
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University Hospitals Birmingham, Birmingham, UK
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Albert SG, Reddy S. Clinical Evaluation of Cost Efficacy of Drugs for Treatment of Osteoporosis: A Meta-Analysis. Endocr Pract 2017; 23:841-856. [DOI: 10.4158/ep161678.ra] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Sanderson J, Martyn-St James M, Stevens J, Goka E, Wong R, Campbell F, Selby P, Gittoes N, Davis S. Clinical effectiveness of bisphosphonates for the prevention of fragility fractures: A systematic review and network meta-analysis. Bone 2016; 89:52-58. [PMID: 27262775 DOI: 10.1016/j.bone.2016.05.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 05/27/2016] [Accepted: 05/31/2016] [Indexed: 01/18/2023]
Abstract
OBJECTIVES To assess the relative efficacy of bisphosphonates (alendronate, risedronate, ibandronate and zoledronic acid) for the treatment of osteoporosis using network meta-analysis (NMA). METHODS A systematic review of the literature was conducted using PRISMA guidelines. A network meta-analysis was used to determine the relative efficacy of treatments on four fracture outcomes (vertebral, non-vertebral, hip and wrist) and percentage change in femoral neck bone mineral density (BMD). Treatment effects were modelled using an exchangeable treatment effects model. Heterogeneity in treatment effects was explored by considering potential treatment effect modifiers using meta-regression. Where appropriate, inconsistency between direct and indirect evidence was assessed using node-splitting. RESULTS 46 randomised controlled trials (RCTs) were identified. Twenty seven RCTs provided fracture data and 35 RCTs provided BMD data for analysis. Zoledronic acid was associated with the greatest treatment effect on vertebral fractures (HR 0.41, 95% CrI: 0.28, 0.56) and percentage change in BMD (3.21, 95%: CrI 2.52, 3.86) compared to placebo. The greatest treatment effect on non-vertebral and wrist fractures was given by risedronate (HR 0.72, 95%: CrI 0.53, 0.89 and HR 0.77, 95%: CrI 0.44, 1.24, respectively). For hip fractures the greatest treatment effect was given by alendronate (HR 0.78, 95% CrI: 0.44, 1.30). CONCLUSIONS All treatments examined were associated with beneficial effects on fractures and femoral neck BMD relative to placebo. For vertebral fractures and percentage change in femoral neck BMD the treatment effects were statistically significant for all treatments. Pairwise comparisons between treatments indicated that no active treatment was statistically significantly more effective than any other active treatment for fracture outcomes. There was some heterogeneity in treatment effects between studies suggesting differential treatment effects according to study characteristics; however, there was no evidence of differential treatment effects with respect to gender and age.
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Affiliation(s)
- Jean Sanderson
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, United Kingdom.
| | - Marrissa Martyn-St James
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, United Kingdom.
| | - John Stevens
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, United Kingdom.
| | - Edward Goka
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, United Kingdom.
| | - Ruth Wong
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, United Kingdom.
| | - Fiona Campbell
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, United Kingdom.
| | - Peter Selby
- Department of Medicine, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, United Kingdom.
| | - Neil Gittoes
- Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham & University Hospitals Birmingham Health Partners, B15 2TH, United Kingdom.
| | - Sarah Davis
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, United Kingdom.
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Ma Z, Li Y, Zhou M, Huang K, Hu H, Liu X, Xu X. Predictors of Ibandronate Efficacy for the Management of Osteoporosis: A Meta-Regression Analysis. PLoS One 2016; 11:e0150203. [PMID: 26930292 PMCID: PMC4773099 DOI: 10.1371/journal.pone.0150203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 02/10/2016] [Indexed: 11/18/2022] Open
Abstract
Background Aim of the present study was to identify the predictors of ibandronate efficacy in subjects with osteoporosis or decreased bone mineral density (BMD). Method Several electronic databases were searched by using specific keywords for the acquisition of research articles reporting the efficacy of ibandronate in subjects with osteoporosis or decreased BMD. Metaregression analyses were carried out by using changes in the BMD of lumbar spine and total hip following ibandronate treatment as dependent (outcome) variables against several independent (explanatory) variables. Results Data were extracted from 34 studies (11,090 ibandronate treated subjects) which fulfilled eligibility criteria. A history of previous fracture/s was reported by 46% of these subjects. In overall population, longer treatment duration from 1 to 5 years, increasing age, history of previous fractures, lower baseline T score, and higher baseline levels of C-terminal telopeptide of type 1 collagen (CTX) predicted higher ibandronate efficacy in improving BMD of the lumbar spine as well as of the total hip. Lower baseline levels of vitamin D and higher baseline levels of bone specific alkaline phosphatase (BSAP) predicted higher efficacy of ibandronate for lumbar spine only. In postmenopausal women with osteoporosis or decreased BMD, in addition to above-mentioned predictors, better efficacy of ibandronate was also associated with increasing time since menopause for both lumbar spine and total hip and lower body weight for lumbar spine only. Conclusion Longer treatment duration from 1 to 5 years, increasing age, lower baseline T scores, and higher serum CTX levels are identified as the predictors of better efficacy of ibandronate in the study subjects with osteoporosis or decreased BMD.
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Affiliation(s)
- Zeren Ma
- Spinal and Joint Unit, Department of Orthopedics, Nanchang Hongdu Hospital of Traditional Chinese Medicine, Nanchang, Jiangxi 330006, China
- * E-mail:
| | - Yong Li
- Department of Orthopaedics, Shanxi Province People’s Hospital, Xi’an 710068, China
| | - Ming Zhou
- Spinal and Joint Unit, Department of Orthopedics, Nanchang Hongdu Hospital of Traditional Chinese Medicine, Nanchang, Jiangxi 330006, China
| | - Kedi Huang
- Spinal and Joint Unit, Department of Orthopedics, Nanchang Hongdu Hospital of Traditional Chinese Medicine, Nanchang, Jiangxi 330006, China
| | - Hejun Hu
- Spinal and Joint Unit, Department of Orthopedics, Nanchang Hongdu Hospital of Traditional Chinese Medicine, Nanchang, Jiangxi 330006, China
| | - Xiaoping Liu
- Spinal and Joint Unit, Department of Orthopedics, Nanchang Hongdu Hospital of Traditional Chinese Medicine, Nanchang, Jiangxi 330006, China
| | - Xiaosheng Xu
- Spinal and Joint Unit, Department of Orthopedics, Nanchang Hongdu Hospital of Traditional Chinese Medicine, Nanchang, Jiangxi 330006, China
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Hou Y, Gu K, Xu C, Ding H, Liu C, Tuoheti Y. Dose-Effectiveness Relationships Determining the Efficacy of Ibandronate for Management of Osteoporosis: A Meta-Analysis. Medicine (Baltimore) 2015; 94:e1007. [PMID: 26131800 PMCID: PMC4504649 DOI: 10.1097/md.0000000000001007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The purpose of this study was to perform a meta-analysis on the efficacy of ibandronate by evaluating the effect sizes of different dosing regimens.Major electronic databases were searched from 1985 to February 2015. A random effects meta-analysis was performed in STATA.Data from 34 studies (13,639 patients) were included in this meta-analysis. Ibandronate treatment significantly improved lumbar spine bone mineral density (BMD) as shown by the percent change from baseline (4.80%, P < 0.0001, 95% confidence interval [CI] [4.14, 5.45]). The respective effect sizes for oral intake and intravenous (IV) infusion were 4.57% and 5.22% (P < 0.0001, CIs [3.71, 5.42] and [4.37, 6.07]), respectively. All doses led to a significant increase in BMD except 2 oral dose regimens (1 mg/d: 4.65%, P = 0.285, 95% CI [-3.87, 13.18] and 0.5 mg/d: 3.60%, P = 0.38, 95% CI [-4.43, 11.64]. Ibandronate treatment (overall as well as dose wise) also significantly improved the total hip BMD-2.30% overall, 2.13% oral, and 2.63% IV (P < 0.0001, 95% CIs [1.96, 2.64], [1.70, 2.55], and [2.07, 3.20]), respectively. Ibandronate administration significantly decreased serum markers of bone resorption to -46.53% for C-terminal telopeptide of type 1 collagen, -24.03% for bone-specific alkaline phosphatase, and -50.17% for procollagen type I N-terminal propeptide (P < 0.0001, 95% CIs [-53.16, -39.91], [-31.28, -16.77], and [-64.13, -36.20]), respectively. Parathyroid hormone levels remained unaffected by ibandronate treatment (3.03%, P = 0.439, 95% CI [-5.06, 11.66]).There was no significant difference in the efficacy of ibandronate between oral or IV administration. Predominant dose regimens for IV administration were 1 to 3 mg/3 mo and 150 mg/mo oral and 2.5 mg/d for oral ibandronate treatment.
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Affiliation(s)
- Yanjie Hou
- From the Department of Orthopaedics (YH, CX, HD, YT), The Second Affiliated Hospital of Xinjiang Medical University, Urumchi; Department of Pain and Minimally Invasive (KG), The 316th Hospital of People's Liberation Army, Beijing; and Pain Center (CL), The First Affiliated Hospital of Beijing University of Chinese Medicine, Beijing, China
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Brixen K, Chapurlat R, Cheung AM, Keaveny TM, Fuerst T, Engelke K, Recker R, Dardzinski B, Verbruggen N, Ather S, Rosenberg E, de Papp AE. Bone density, turnover, and estimated strength in postmenopausal women treated with odanacatib: a randomized trial. J Clin Endocrinol Metab 2013; 98:571-80. [PMID: 23337728 DOI: 10.1210/jc.2012-2972] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT Odanacatib, a cathepsin K inhibitor, increases spine and hip areal bone mineral density (BMD) in postmenopausal women with low BMD and cortical thickness in ovariectomized monkeys. OBJECTIVE The objective of the study was to examine the impact of odanacatib on the trabecular and cortical bone compartments and estimated strength at the hip and spine. DESIGN This was a randomized, double-blind, 2-year trial. SETTING The study was conducted at a private or institutional practice. PARTICIPANTS PARTICIPANTS included 214 postmenopausal women with low areal BMD. INTERVENTION The intervention included odanacatib 50 mg or placebo weekly. MAIN OUTCOME MEASURES Changes in areal BMD by dual-energy x-ray absorptiometry (primary end point, 1 year areal BMD change at lumbar spine), bone turnover markers, volumetric BMD by quantitative computed tomography (QCT), and bone strength estimated by finite element analysis were measured. RESULTS Year 1 lumbar spine areal BMD percent change from baseline was 3.5% greater with odanacatib than placebo (P < .001). Bone-resorption marker C-telopeptide of type 1 collagen was significantly lower with odanacatib vs placebo at 6 months and 2 years (P < .001). Bone-formation marker procollagen I N-terminal peptide initially decreased with odanacatib but by 2 years did not differ from placebo. After 6 months, odanacatib-treated women had greater increases in trabecular volumetric BMD and estimated compressive strength at the spine and integral and trabecular volumetric BMD and estimated strength at the hip (P < .001). At the cortical envelope of the femoral neck, bone mineral content, thickness, volume, and cross-sectional area also increased from baseline with odanacatib vs placebo (P < .001 at 24 months). Adverse experiences were similar between groups. CONCLUSIONS Over 2 years, odanacatib decreased bone resorption, maintained bone formation, increased areal and volumetric BMD, and increased estimated bone strength at both the hip and spine.
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Affiliation(s)
- Kim Brixen
- Department of Endocrinology, Institute of Clinical Research, University of Southern Denmark, DK-5000 Odense C., Denmark.
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Lee YH, Song GG. Efficacy and safety of monthly 150 mg oral ibandronate in women with postmenopausal osteoporosis: a systematic review and meta-analysis of randomized controlled trials. Korean J Intern Med 2011; 26:340-7. [PMID: 22016595 PMCID: PMC3192207 DOI: 10.3904/kjim.2011.26.3.340] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Revised: 05/06/2011] [Accepted: 06/13/2011] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS The aim of this study was to assess the efficacy and safety of monthly oral 150 mg ibandronate in women with postmenopausal osteoporosis (PMO). METHODS A systematic review and meta-analysis were performed to determine treatment efficacy and safety outcomes between monthly oral 150 mg ibandronate and weekly 70 mg alendronate, daily 2.5 mg ibandronate, and a placebo. RESULTS Eight randomized controlled trials were included in this systematic review and meta-analysis. Once-monthly 150 mg ibandronate therapy was clinically comparable to weekly 70 mg alendronate, showing increased bone mineral density (BMD) in both the lumbar spine and total hip. Pooled data from two cross-over trials showed that significantly more women with PMO preferred once-monthly ibandronate therapy to once-weekly alendronate therapy (relative risk [RR], 2.422; 95% confidence interval [CI], 2.111 to 2.825; p < 1 × 10(-8)) and found the monthly ibandronate regimen more convenient than the weekly alendronate regimen (RR, 3.096; 95% CI, 2.622 to 3.622; p < 1 × 10(-8)). Monthly 150 mg ibandronate therapy resulted in a significantly higher change in BMD of the lumbar spine than with the placebo. A once monthly 150 mg regimen produced greater increases in lumbar spine, total hip, femoral neck, and trochanter BMD than daily treatment, with a similar incidence of adverse events between the groups. CONCLUSIONS Once monthly 150 mg ibandronate therapy was clinically comparable to weekly 70 mg alendronate, and patients strongly preferred the convenience of monthly ibandronate over weekly alendronate. Monthly 150 mg ibandronate was superior to, and as well tolerated as, the daily treatment.
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Affiliation(s)
- Young Ho Lee
- Division of Rheumatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.
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Rizzoli R, Akesson K, Bouxsein M, Kanis JA, Napoli N, Papapoulos S, Reginster JY, Cooper C. Subtrochanteric fractures after long-term treatment with bisphosphonates: a European Society on Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, and International Osteoporosis Foundation Working Group Report. Osteoporos Int 2011; 22:373-90. [PMID: 21085935 PMCID: PMC3020314 DOI: 10.1007/s00198-010-1453-5] [Citation(s) in RCA: 135] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 09/30/2010] [Indexed: 01/17/2023]
Abstract
UNLABELLED This paper reviews the evidence for an association between atypical subtrochanteric fractures and long-term bisphosphonate use. Clinical case reports/reviews and case-control studies report this association, but retrospective phase III trial analyses show no increased risk. Bisphosphonate use may be associated with atypical subtrochanteric fractures, but the case is yet unproven. INTRODUCTION A Working Group of the European Society on Clinical and Economic Aspects of Osteoporosis and Osteoarthritis and the International Osteoporosis Foundation has reviewed the evidence for a causal association between subtrochanteric fractures and long-term treatment with bisphosphonates, with the aim of identifying areas for further research and providing recommendations for physicians. METHODS A PubMed search of literature from 1994 to May 2010 was performed using key search terms, and articles pertinent to subtrochanteric fractures following bisphosphonate use were analysed. RESULTS Several clinical case reports and case reviews report a possible association between atypical fractures at the subtrochanteric region of the femur in bisphosphonate-treated patients. Common features of these 'atypical' fractures include prodromal pain, occurrence with minimal/no trauma, a thickened diaphyseal cortex and transverse fracture pattern. Some small case-control studies report the same association, but a large register-based study and retrospective analyses of phase III trials of bisphosphonates do not show an increased risk of subtrochanteric fractures with bisphosphonate use. The number of atypical subtrochanteric fractures in association with bisphosphonates is an estimated one per 1,000 per year. It is recommended that physicians remain vigilant in assessing their patients treated with bisphosphonates for the treatment or prevention of osteoporosis and advise patients of the potential risks. CONCLUSIONS Bisphosphonate use may be associated with atypical subtrochanteric fractures, but the case is unproven and requires further research. Were the case to be proven, the risk-benefit ratio still remains favourable for use of bisphosphonates to prevent fractures.
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Affiliation(s)
- R Rizzoli
- Division of Bone Diseases, Department of Rehabilitation and Geriatrics, University Hospitals and Faculty of Medicine of Geneva, 1211, Geneva 14, Switzerland.
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Li EK, Zhu TY, Hung VY, Kwok AW, Lee VW, Lee KK, Griffith JF, Li M, Wong KC, Leung PC, Qin L, Tam LS. Ibandronate increases cortical bone density in patients with systemic lupus erythematosus on long-term glucocorticoid. Arthritis Res Ther 2010; 12:R198. [PMID: 20964867 PMCID: PMC2991035 DOI: 10.1186/ar3170] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Revised: 09/10/2010] [Accepted: 10/22/2010] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The purpose of this research is to assess the effects of oral ibandronate on bone microarchitecture by using high-resolution peripheral quantitative computed tomography (HR-pQCT) in patients with systemic lupus erythematosus (SLE) taking a long-term glucocorticoid. METHODS In this double-blind placebo-controlled study, 40 Chinese female SLE patients taking prednisolone were randomly assigned to receive either monthly oral ibandronate (150 mg) or placebo with daily 1-hydroxycholecalciferol (Alfacalcidol; 1 μg) and calcium supplement for 12 months. Assessments of bone microarchitecture by using HR-pQCT and area bone mineral density (aBMD) of the lumbar spine and hip with dual-energy x-ray absorptiometry (DXA) were performed at baseline and 12 months. RESULTS No differences in baseline characteristics were found between the two groups. After 12 months, no statistical differences were noted in any of the bone densities, microarchitectural parameters, or percentage changes of these parameters, as measured with HR-pQCT or DXA between the two groups. However, within the active group, the percentage improvement was significant in cortical bone density (P = 0.023) which was absent in the placebo group. Improvement was also seen in the aBMD of both the lumbar spine (P < 0.0001) and the hip (P < 0.005). In the placebo group, the percentage increase in trabecular separation was significant (P = 0.04), and the percentage improvement in aBMD in the spine also was significant (P = 0.049). CONCLUSIONS Oral ibandronate treatment improves microarchitecture in SLE patients taking long-term glucocorticoid assessed with HR-pQCT, and this new technology may have a role in assessing bony changes in future longitudinal studies in SLE patients. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00668330.
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Affiliation(s)
- Edmund K Li
- Department of Medicine, The Chinese University of Hong Kong, Prince Wales Hospital, 30-32 Ngan Shing Street, Sha Tin, NT, Hong Kong, PR China.
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Patel VC, Lazzarini AM. Bilateral simultaneous femoral diaphyseal fractures in a patient with long-term ibandronate use. Orthopedics 2010; 33:775. [PMID: 20954650 DOI: 10.3928/01477447-20100826-31] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Bisphosphonates are the most common medication used to treat patients with documented osteoporosis. Recently, reports have associated long-term bisphosphonate use with low-energy femur fractures. While no definitive mechanism has been associated, bisphosphonate use has been strongly implicated. This article presents the case of a 65-year-old woman with a 2-year history of ibandronate use presenting with simultaneous low-energy femoral shaft fractures. The patient reported prodromal bilateral thigh pain and was seen by a spine surgeon. A review of the literature implicates long-term ibandronate use in low-energy femur fractures. With most of the basic science studies demonstrating suppressed bone turnover after 5 years of treatment with alendronate, the significance of the present case also lies in the relatively short duration of time the patient was on ibandronate before suffering the bilateral femoral shaft fractures. Possible pathophysiology for the fractures includes suppressed bone turnover that may allow microcracks to propagate in cortical bone, which can weaken the bone and possibly predispose it to fractures. Patients who have been on bisphosphonates long term should be questioned about thigh pain and have radiographs of their femurs obtained if pain exists. Furthermore, if a patient presents with a single subtrochanteric or diaphyseal low-energy femur fracture after long-term bisphosphonate use, a radiograph of the contralateral femur should be obtained to assess for a cortical stress reaction.
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Affiliation(s)
- Vishal C Patel
- Westchester Medical Center, Macy Pavilion 008, 95 Grasslands Dr, Valhalla, NY 10595, USA. vcpatel68@ gmail.com
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Orwoll ES, Binkley NC, Lewiecki EM, Gruntmanis U, Fries MA, Dasic G. Efficacy and safety of monthly ibandronate in men with low bone density. Bone 2010; 46:970-6. [PMID: 20060082 DOI: 10.1016/j.bone.2009.12.034] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Revised: 12/23/2009] [Accepted: 12/28/2009] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Monthly oral ibandronate is indicated for the prevention and treatment of osteoporosis in postmenopausal women. The STudy Researching Osteoporosis iN Guys (STRONG) investigated the efficacy and safety of 150-mg monthly oral ibandronate in men with primary, idiopathic, or hypogonadism-related low bone density. METHODS STRONG was a 1-year, placebo-controlled, randomized (2 ibandronate: 1 placebo), double-blind study that enrolled ambulatory men aged > or =30 years with baseline femoral neck (FN) bone mineral density (BMD) T-scores < or =-2.0 and lumbar spine (LS) BMD T-scores < or =-1.0 or LS BMD T-scores < or =-2.0, FN BMD T-scores < or =-1.0, and BMD T-scores > or =-4.0 at any site assessed by dual-energy X-ray absorptiometry. The primary endpoint was mean percent change from baseline in LS BMD at 1 year (intent-to-treat [ITT] population). Secondary endpoints included mean BMD changes from baseline at the FN, total hip (TH), and trochanter (TR) and changes in bone turnover markers (BTMs), as measured by the bone resorption marker serum C-terminal telopeptide of type 1 collagen (sCTX) and the bone formation marker bone-specific alkaline phosphatase (BSAP). All men received twice daily calcium carbonate (1000 mg/day) and vitamin D (400 IU/day). Changes in BMD for treatment groups were compared using analysis of covariance with treatment, investigative site, and baseline testosterone as factors and baseline BMD as a covariate. RESULTS The ITT population consisted of 132 men; 47 received placebo and 85 received monthly ibandronate. Men who received ibandronate achieved greater increases in LS BMD at 12 months than those who received placebo (3.5% vs. 0.9%, respectively; difference, 2.6; p<0.001). The ibandronate group also achieved greater 12-month BMD increases than the placebo group, respectively, at the TH (1.8% vs. -0.3%; difference, 2.1; p<0.001), FN (1.2% vs. -0.2%; difference, 1.4; p=0.012), and TR (2.2% vs. 0.4%; difference, 1.7; p<0.005). In men who completed the study and adhered to the protocol (per-protocol (PP) population), percent decreases in median sCTX and BSAP levels from baseline were also greater with ibandronate versus placebo (p< or =0.001 for both comparisons). Overall, monthly ibandronate was well tolerated. CONCLUSIONS In men with low BMD, 1 year of treatment with oral once-monthly 150-mg ibandronate significantly increased BMD at the LS and hip (TH, TR, and FN), significantly reduced BTM levels in the PP population, and was generally well tolerated.
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Affiliation(s)
- Eric S Orwoll
- Oregon Health and Science University, Bone and Mineral Unit, Portland, OR 97239, USA
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Boonen S, Kay R, Cooper C, Haentjens P, Vanderschueren D, Callewaert F, Milisen K, Ferrari S. Osteoporosis management: a perspective based on bisphosphonate data from randomised clinical trials and observational databases. Int J Clin Pract 2009; 63:1792-804. [PMID: 19845802 DOI: 10.1111/j.1742-1241.2009.02206.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- S Boonen
- Division of Gerontology and Geriatrics & Center for Musculoskeletal Research, Leuven University Department of Experimental Medicine, Leuven, Belgium.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2009. [DOI: 10.1002/pds.1652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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