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Chartrand NA, Lau CK, Parsons MT, Handlon JJ, Ronquillo YC, Hoopes PC, Moshirfar M. Ocular Side Effects of Bisphosphonates: A Review of Literature. J Ocul Pharmacol Ther 2023; 39:3-16. [PMID: 36409537 DOI: 10.1089/jop.2022.0094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
In rare cases, bisphosphonates are well established to cause ocular inflammation, presenting as uveitis, episcleritis, scleritis, orbital inflammation, and/or conjunctivitis. Some reports of bisphosphonate-associated neuro-ophthalmic complications also exist. We identified 101 reports in the literature relating to bisphosphonate-associated ocular complications. In a great majority of cases, symptoms resolve after discontinuation of the drug and anti-inflammatory treatment. Many cases recur if rechallenged with the same bisphosphonate. First-generation nonamino bisphosphonates, including clodronate and etidronate, are not associated with ocular inflammation. Only 2nd- and 3rd-generation amino bisphosphonates, including pamidronate, alendronate, risedronate, ibandronate, and zoledronate are associated with these complications. The mechanism of bisphosphonate-induced ocular inflammation may be related to activation of γ/δ T cells or M1 macrophages. Intravenous forms, such as pamidronate and zoledronate, tend to have higher rates and faster onset of ocular inflammation, generally presenting within days of infusion. In oral bisphosphonates, such as alendronate and risedronate, these complications present with more sporadic timing. Rates of complications are also higher when bisphosphonates are used for malignancy, as doses tend to be higher compared with doses for osteoporosis.
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Affiliation(s)
| | - Chap-Kay Lau
- College of Medicine Phoenix, University of Arizona, Phoenix, Arizona, USA
| | - Mark T Parsons
- College of Medicine Phoenix, University of Arizona, Phoenix, Arizona, USA
| | | | | | | | - Majid Moshirfar
- Hoopes Vision Research Center, Hoopes Vision, Draper, Utah, USA.,Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Utah Lions Eye Bank, Murray, Utah, USA
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Lee H, Jin Y, Roh M, Tsacogianis TN, Park S, Choi NK, Kim SC. Risk of Cataract Surgery and Age-Related Macular Degeneration After Initiation of Denosumab vs Zoledronic Acid for Osteoporosis: A Multi-Database Cohort Study. Drugs Aging 2020; 37:311-320. [PMID: 32026309 DOI: 10.1007/s40266-020-00745-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVE There is a relative lack of head-to-head comparisons of denosumab against other osteoporosis drugs on safety. We aimed to explore ocular outcomes in patients with osteoporosis initiating denosumab vs zoledronic acid. METHODS We conducted a cohort study using claims data (2010-15) from two large US commercial insurance databases including patients with osteoporosis who were aged 50 years or older and initiators of denosumab or zoledronic acid. The primary outcomes were (1) receipt of cataract surgery and development of (2) wet age-related macular degeneration and (3) dry age-related macular degeneration within 365 days after initiation of denosumab vs zoledronic acid. Propensity score fine stratification and weighting were used to control for potential confounding, and we calculated the incidence rate and hazard ratio for each outcome in the cohorts. The estimates from the two databases were combined with a fixed-effects model meta-analysis. RESULTS The study cohort included 50,821 denosumab and 67,471 zoledronic acid initiators. In the propensity score-weighted analysis, compared to zoledronic acid use, denosumab was associated with a modestly decreased risk of undergoing cataract surgery (hazard ratio 0.91; 95% confidence interval 0.85-0.98) but not with the risk of wet age-related macular degeneration (hazard ratio 1.29; 95% confidence interval 0.99-1.70) or dry age-related macular degeneration (hazard ratio 1.03; 95% confidence interval 0.98-1.09). CONCLUSIONS In this large population-based cohort study of 118,292 patients with osteoporosis, initiation of denosumab was associated with a modestly decreased risk of cataract surgery vs zoledronic acid. The risk of age-related macular degeneration was similar between the two drugs.
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Affiliation(s)
- Hemin Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3-030, Boston, MA, 02120, USA
| | - Yinzhu Jin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3-030, Boston, MA, 02120, USA
| | - Miin Roh
- Beetham Eye Institute, Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA
| | - Theodore N Tsacogianis
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3-030, Boston, MA, 02120, USA
| | - Sangshin Park
- Graduate School of Urban Public Health, University of Seoul, Seoul, Republic of Korea
| | - Nam-Kyong Choi
- Department of Health Convergence, Ewha Women's University, Seoul, Republic of Korea
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3-030, Boston, MA, 02120, USA.
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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Abstract
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.
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Affiliation(s)
- Moin Khan
- McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - Angela M Cheung
- University of Toronto, 200 Elizabeth Street, 7 Eaton North Room 221, Toronto, ON M5G 2C4, Canada
| | - Aliya A Khan
- McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada.
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Acute bilateral uveitis and right macular edema induced by a single infusion of zoledronic acid for the treatment of postmenopausal osteoporosis as a substitution for oral alendronate: a case report. BMC Musculoskelet Disord 2016; 17:72. [PMID: 26867651 PMCID: PMC4751753 DOI: 10.1186/s12891-016-0926-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 02/04/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Zoledronic acid-induced uveitis (ZAIU) is rare but severe, and has been recently considered part of an acute phase reaction. Only 15 cases have been reported since 2005. Here we describe a case with macular edema, which is the first reported case observed after long-term alendronate tolerance. CASE PRESENTATION A 63-year-old Asian woman received her first intravenous zoledronic acid treatment for the management of postmenopausal osteoporosis as a more convenient substitute for oral alendronate. Twenty-four hours later, bilateral eye irritations, periorbital swelling, blurred vision, and diplopia presented. The complete blood count and transaminase levels were normal, but the erythrocytic sedimentation, C-reactive protein, and serum C4 levels were elevated. On detailed ophthalmological examination, a diagnosis of bilateral acute uveitis and macular edema in the right eye was made. The ocular symptoms were not improved until administration of topical and oral steroids. Complete resolution was achieved. There was no rechallenge of bisphosphonates, and no recurrence at 6 months follow-up. Based on an extensive review, abnormal fundus is rarely reported, especially in cases of macular edema. Rechallenge with zoledronic acid in five cases induced no additional uveitis, and changing the medication to pamidronate in another patient was also tolerated. Interestingly, our patient suffered from uveitis soon after intravenous zoledronate exposure after a two-year tolerance to oral alendronate. CONCLUSIONS This is the first report of zoledronic acid induced uveitis with macular edema after long-term alendronate tolerance. Prior oral alendronate may not entirely prevent ZAIU. Steroids are usually necessary in the treatment of ZAIU. Bisphosphonate rechallenge is not fully contraindicated, and prior steroid administration may be a more reasonable treatment choice according to the available evidence.
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Patel DV, Horne A, Mihov B, Stewart A, Reid IR, McGhee CNJ. The Effects of Re-challenge in Patients with a History of Acute Anterior Uveitis Following Intravenous Zoledronate. Calcif Tissue Int 2015; 97:58-61. [PMID: 26001948 DOI: 10.1007/s00223-015-0015-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 05/13/2015] [Indexed: 10/23/2022]
Abstract
To determine the incidence of adverse ocular side effects following re-challenge in patients who previously developed ocular symptoms following intravenous zoledronate. Secondary data analysis of a large, prospective, randomized, double-blind, placebo-controlled clinical trial was performed. Participants consisted of postmenopausal females with osteopenia randomized to placebo (N = 1000) or zoledronate 5 mg (N = 1001) intravenous infusion. Recruitment occurred over a 2-year period, with the first infusion being administered at recruitment, and subsequent infusions every 18 months. Eight participants developed acute anterior uveitis (AAU) (diagnosed by an ophthalmologist) following the first infusion of zoledronate. Following appropriate ophthalmic treatment, no patients had visual loss or other ocular sequelae. One further participant reported "sore red eyes" but did not attend for ophthalmology review. Six participants declined further infusions. The remaining three participants were administered two further zoledronate infusions, 18 months apart, and none developed any ocular symptoms following each infusion. As a precaution, two of these participants were examined by an ophthalmologist 3 days after their second infusion and neither had ocular symptoms or signs of AAU and no subsequent ocular side effects. AAU following zoledronate infusion is likely to be part of the acute phase response. If treated promptly under the care of an ophthalmologist, the visual prognosis is excellent. The results of this study suggest that the development of AAU should not be a contraindication to further infusion. However, in such cases, patients should be warned of the symptoms of AAU (ocular pain, redness, photophobia or blurred vision) and should be promptly referred to an ophthalmologist if symptoms develop.
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Affiliation(s)
- Dipika V Patel
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand,
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Patel DV, Bolland M, Nisa Z, Al-Abuwsi F, Singh M, Horne A, Reid IR, McGhee CNJ. Incidence of ocular side effects with intravenous zoledronate: secondary analysis of a randomized controlled trial. Osteoporos Int 2015; 26:499-503. [PMID: 25187119 DOI: 10.1007/s00198-014-2872-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 08/21/2014] [Indexed: 11/24/2022]
Abstract
SUMMARY This prospective study showed that the incidence of acute anterior uveitis, confirmed by ophthalmic examination, in patients receiving intravenous zoledronate infusions as part of a randomized controlled trial for fracture prevention is 1.1%. INTRODUCTION We prospectively investigated the incidence of ocular side effects after a single intravenous zoledronate infusion. METHODS In a secondary analysis of a double-blind, placebo-controlled trial in which early post-menopausal women (N=1054) with normal bone density or osteopenia were randomized to infusion of zoledronate 5 mg (N=703) or placebo (N=351), we analyzed significant adverse ocular events occurring within 3 months. RESULTS Fourteen participants reported ocular symptoms after the infusion. All were examined by an ophthalmologist and eight were diagnosed with acute anterior uveitis (AAU) and one with sectoral episcleritis. The incidence of AAU and episcleritis was 1.1% (95% CI 0.5-2.1) and 0.1% (95% CI 0.0-0.7), respectively, in the zoledronate group and 0% for both conditions in the placebo group (95% CI 0.0-0.8). The mean time from infusion to symptom onset for AAU was 3 days (range 2-4). Three cases were bilateral. AAU was mild-moderate in seven participants and severe in one. All affected eyes were treated with topical cyclopentolate 1% (to break, or minimize, posterior synechiae), and intensive, potent, topical corticosteroids with a tapering regime based on treatment response. The mean duration of topical corticosteroid was 26±10 days (range 17-44). The mean, best corrected visual acuity was 20/20 (range 20/20-20/40) at presentation, which remained unchanged after AAU resolution. None of the participants lost vision, and no long-term sequelae were reported at last follow-up (range 3-13 months post-infusion). CONCLUSIONS Prescribers should inform patients about the possibility of ocular side effects with zoledronate infusions and refer promptly to an ophthalmologist if symptoms develop.
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Affiliation(s)
- D V Patel
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand,
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Grewal DS, Holland PM, Frankfurt O, Pyatetsky D. Asymmetric anterior uveitis as a delayed complication of treatment with systemic high-dose cytosine-arabinoside: a case report and literature review. Ocul Immunol Inflamm 2014; 22:322-5. [PMID: 24832917 DOI: 10.3109/09273948.2013.801990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Patel DV, Horne A, House M, Reid IR, McGhee CN. The Incidence of Acute Anterior Uveitis after Intravenous Zoledronate. Ophthalmology 2013; 120:773-6. [DOI: 10.1016/j.ophtha.2012.10.028] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 09/17/2012] [Accepted: 09/27/2012] [Indexed: 10/27/2022] Open
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Coleman R, Burkinshaw R, Winter M, Neville-Webbe H, Lester J, Woodward E, Brown J. Zoledronic acid. Expert Opin Drug Saf 2010; 10:133-45. [DOI: 10.1517/14740338.2011.540387] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Procianoy F, Procianoy E. Orbital inflammatory disease secondary to a single-dose administration of zoledronic acid for treatment of postmenopausal osteoporosis. Osteoporos Int 2010; 21:1057-8. [PMID: 19859646 DOI: 10.1007/s00198-009-1048-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Accepted: 07/16/2009] [Indexed: 10/20/2022]
Abstract
A 60-year-old woman received a single 5-mg dose of zoledronic acid (Aclasta) for treatment of postmenopausal osteoporosis. One day after receiving the drug, she acutely developed a painful periorbital swelling, chemosis, and hyperemia in the right eye. The condition worsened despite initial treatment with topical steroids. An orbital CT scan showed right eye proptosis, eyelid edema, and intraorbital fat stranding. A diagnosis of orbital inflammatory disease was made, and the patient was treated with high-dose oral steroids (prednisone 80 mg/day) tapered along 6 weeks. The symptoms and the swelling reduced progressively after initiating oral prednisone, and after 12 days, there was complete resolution of the condition. The patient remained symptom free and had no remission after the treatment interruption.
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Affiliation(s)
- F Procianoy
- Department of Ophthalmology and Otolaringology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
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Colucci A, Modorati G, Miserocchi E, Di Matteo F, Rama P. Anterior Uveitis Complicating Zoledronic Acid Infusion. Ocul Immunol Inflamm 2009; 17:267-8. [DOI: 10.1080/09273940902916111] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Moore MM, Beith JM. Acute unilateral anterior uveitis and scleritis following a single infusion of zoledronate for metastatic breast cancer. Med J Aust 2008; 188:370-1. [DOI: 10.5694/j.1326-5377.2008.tb01658.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2007] [Accepted: 12/11/2007] [Indexed: 11/17/2022]
Affiliation(s)
| | - Jane M Beith
- Medical Oncology, Royal Prince Alfred Hospital, Sydney, NSW
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Campisi G, Di Fede O, Musciotto A, Lo Casto A, Lo Muzio L, Fulfaro F, Badalamenti G, Russo A, Gebbia N. Bisphosphonate-related osteonecrosis of the jaw (BRONJ): run dental management designs and issues in diagnosis. Ann Oncol 2007; 18 Suppl 6:vi168-72. [PMID: 17591816 DOI: 10.1093/annonc/mdm250] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Recently, jawbone osteonecrosis has been largely reported as a potential adverse effect of bisphosphonate (BP) administration. Because of the peculiar pharmacokinetic and pharmacodynamic features of the BF (mainly for i.v. administration), their efficacy and large use, some major issues have to be taken into account extendedly both by oncologists and by dentists: 1) therapeutic dental protocol for patients with diagnosis of bisphosphonate-related osteonecrosis of the jaw (BRONJ); 2) dental strategies for patients in former or current i.v. BF treatment and in absence of BRONJ signs; 3) strategies for patients before i.v. BF treatment. Clinical features and guidelines for the management of this condition have been investigated and reported, sometimes with unclear indications; hence, on the basis of the literature and our clinical experience, major end points of this paper are providing our run protocols for the issues above described and, finally, focusing on a crucial, but not extensively investigated point: the early and correct diagnosis of BRONJ versus metastatic jaw lesions in cancer patients.
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Affiliation(s)
- G Campisi
- Section of Oral Medicine, Department of Oral Sciences, Università di Palermo, Palermo, Italy.
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