Upper gastrointestinal tolerability of once weekly alendronate 70 mg with concomitant non-steroidal anti-inflammatory drug use

Upper gastrointestinal safety of oral bisphosphonate in hospitalized patients

Oral bisphosphonates are effective medications for the prevention of fractures in people suffering from osteoporosis. They are associated with gastrointestinal adverse reactions the most severe being an esophageal ulcer. It is unclear if oral bisphosphonates have a similar gastrointestinal safety profile in the hospital setting as in the community setting because hospitalized patients are often bedridden which may hinder proper drug administration.

INTRODUCTION

To evaluate the incidence of upper gastrointestinal symptoms in hospitalized patients taking oral bisphosphonate.

METHODS

This single-center prospective cohort study included hospitalized adult patients actively taking risedronate or alendronate. Upper gastrointestinal symptoms were actively assessed at the baseline and 1 to 5 h following the administration of the oral bisphosphonate.

RESULTS

A total of 298 patients were included in the study. The mean age was 64 ± 15 years. During the follow-up period, gastric and esophageal symptoms affected 32 patients (10.7%). Epigastric burning, dysphagia, and regurgitation were reported in 4.4% (n = 13), 3% (n = 9), 2.7 (n = 8), and 2.3% (n = 7) patients, respectively. Heartburn, retro-sternal pain, and odynophagia were observed in 1.7% (n = 5), 1.7% (n = 5), and 0.3% (n = 1) patients.

CONCLUSION

The incidence of adverse reaction was similar to that reported in community trials. The administration of oral bisphosphonate in hospitalized patients does not represent an additional risk for upper gastrointestinal adverse events. Treatment should be optimized during the hospital stay to improve the pharmacological management of osteoporosis.

Oral Treatment With Bisphosphonates of Osteoporosis Does Not Increase the Risk of Severe Gastrointestinal Side Effects: A Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

Bisphosphonates (BPs) are first-line therapy for osteoporosis. Adherence is usually low in chronic, asymptomatic diseases, but gastrointestinal (GI) side-effects can also contribute to low adherence in BP therapy and may necessitate a review by a gastroenterologist with or without gastroscopy.

AIMS

Our meta-analysis aims to determine the risk of severe GI adverse events due to oral BP therapy in osteoporotic patients.

METHODS

A systematic search was conducted in three databases up to September 2020 for randomized controlled trials (RCTs) detailing GI adverse events in adults with osteoporosis on BP compared to placebo. Risk ratios (RRs) with 95% confidence intervals (CI) were calculated for non-severe and severe adverse events indicating endoscopic procedure with the random-effects model. Statistical heterogeneity was assessed using chi² and I² statistics.

RESULTS

Forty-two RCTs with 39,047 patients with 9,999 non-severe and 1,503 severe GI adverse events were included. The incidence of non-severe and severe adverse events ranged between 0.3-54.9 and 0-10.3%, respectively. There was no difference between BP and control groups in terms of the risk of non-severe or severe side effects: RR=1.05 (CI: 0.98-1.12), I² = 48.1%, and RR=1.01 (CI: 0.92-1.12), I² = 0.0%, respectively. Subgroup analysis of the most commonly used BP, once-weekly alendronate 70 mg, revealed an association between bisphosphonates and the risk of non-severe GI adverse events, RR=1.16 (CI: 1.00-1.36), I² = 40.7%, while the risk of severe GI side effects was not increased in this subgroup, RR=1.20 (CI: 0.83-1.74), I² = 0.0%.

CONCLUSION

Our results show that bisphosphonates do not increase the risk of severe GI adverse events. However, the marked variability of the screening for side effects in the included studies, and the fact that in most of the studies GI diseases were exclusion criteria limits the strenght of evidence of our results. The conclusions drawn from the meta-analysis are therefore restricted to selected populations, and the results must be interpreted with caution.

2015 Guidelines for Osteoporosis in Saudi Arabia: Recommendations from the Saudi Osteoporosis Society

BACKGROUND AND OBJECTIVES

To provide guidelines for medical professionals in Saudi Arabia regarding osteoporosis.

DESIGN AND SETTINGS

A panel of 14 local experts in osteoporosis assembled to provide consensus based on the strength of evidence and expert opinions on osteoporosis treatment.

PATIENTS AND METHODS

The Saudi Osteoporosis Society (SOS) formed a panel of experts who performed an extensive published studies search to formulate recommendations regarding prevention, diagnosis, and treatment of osteoporosis in Saudi Arabia. Both local and international published studies were utilized whenever available.

RESULTS

Dual x-ray absorptiometry (DXA) scanning is still the golden standard for assessing bone mineral density (BMD). In the absence of local, country-specific fracture risk assessment tool (FRAX), the SOS recommends using the USA (White) version of the FRAX tool. All women above 60 years of age should be evaluated for BMD. This is because the panel recognized that osteoporosis and osteoporotic fractures occur at a younger age in Saudi Arabia. Hormone replacement therapy (HRT) is not recommended for treating postmenopausal women with osteoporosis. BMD evaluation should be performed 1-2 years after initiating intervention, and the assessment of bone turnover biomarkers should be performed whenever available to determine the efficacy of intervention.

CONCLUSION

All Saudi women above the age of 60 years must undergo a BMD assessment using DXA. Therapy decisions should be formulated with the use of the USA (White) version of the FRAX tool.

Extraskeletal benefits and risks of calcium, vitamin D and anti-osteoporosis medications

Drugs used for the prevention and the treatment of osteoporosis exert various favourable and unfavourable extra-skeletal effects whose importance is increasingly recognized notably for treatment selection.

INTRODUCTION

The therapeutic armamentarium for the prevention and the treatment of osteoporosis is increasingly large, and possible extra-skeletal effects of available drugs could influence the choice of a particular compound.

METHODS

The present document is the result of a national consensus, based on a systematic and critical review of the literature.

RESULTS

Observational research has suggested an inverse relationship between calcium intake and cardiovascular diseases, notably through an effect on blood pressure, but recent data suggest a possible deleterious effect of calcium supplements on cardiovascular risk. Many diverse studies have implicated vitamin D in the pathogenesis of clinically important non-skeletal functions or diseases, especially muscle function, cardiovascular disease, autoimmune diseases and common cancers. The possible effects of oral or intravenous bisphosphonates are well-known. They have been associated with an increased risk of oesophageal cancer or atrial fibrillation, but large-scale studies have not found any association with bisphosphonate use. Selective oestrogen receptor modulators have demonstrated favourable or unfavourable extra-skeletal effects that vary between compounds. Strontium ranelate has a limited number of non-skeletal effects. A reported increase in the risk of venous thromboembolism is not found in observational studies, and very rare cases of cutaneous hypersensitivity reactions have been reported. Denosumab has been introduced recently, and its extra-skeletal effects still have to be assessed.

CONCLUSION

Several non-skeletal effects of bone drugs are well demonstrated and influence treatment choices.

Long-term treatment with bisphosphonates and their safety in postmenopausal osteoporosis

Bisphosphonates are the leading drugs for the treatment of osteoporosis. In randomized controlled trials (RCTs), alendronate, risedronate, and zoledronate have shown to reduce the risk of vertebral, nonvertebral, and hip fractures, whereas RCTs with ibandronate show antifracture efficacy at vertebral sites. Bisphosphonates are generally well tolerated and safe. Nevertheless, adverse events have been noted, and it is important to consider the strength of the evidence for causal relationships. Effects on the gastrointestinal tract and kidney function are well recognized, as are transient acute-phase reactions. Atrial fibrillation was first identified as a potential adverse event in a zoledronate trial, but subsequent trials and analyses failed to substantiate an association with bisphosphonates. Case reports have suggested a relationship between oral bisphosphonates and esophageal cancer, but this has not been demonstrated in epidemiologic studies. A possible association between bisphosphonate use and osteonecrosis of the jaw (ONJ) has also been suggested. However, the risk of ONJ in patients with osteoporosis appears to be very low, with no evidence from prospective RCTs of a causal association. There are reports of occasional occurrence of subtrochanteric or diaphyseal fractures in osteoporotic patients, but an association with bisphosphonate therapy is not substantiated by epidemiologic studies or prospective RCTs.

Gastric and esophagus events before and during treatment of osteoporosis

Prior studies have indicated an excess risk of gastroduodenal ulcers and esophagus perforations with the use of bisphosphonates. However, little is known about the contribution of comorbid conditions and concomitant drug use on this risk. We studied the risk of esophagus and gastric events in patients on a wide range of drugs against osteoporosis both before and after initiation of these drugs. We studied a nationwide register-based cohort from Denmark with all users of drugs against osteoporosis between 1996 and 2006 (n = 103,562) as cases and three age- and sex-matched controls from the general population (n = 310,683). In a crude analysis, most drugs were already associated with an increased risk of esophagitis, esophageal ulcerations, or esophageal perforations or gastroduodenal ulcers before initiation of the drugs. Upon adjustment, this excess risk disappeared for most drugs except parathyroid hormone and its analogues, etidronate and clodronate. Only for etidronate, alendronate, and raloxifene were sufficient data present for events after initiation of the drugs, and for these, an increased risk was present for all events except gastroduodenal ulcers with raloxifene. Several drugs against osteoporosis are associated with an increased risk of esophagitis, esophageal ulcers, esophageal perforation, and gastroduodenal ulcers. However, the increase was already present before initiation of the drug for several types of drugs against osteoporosis. This points at an effect of the underlying condition being treated or comorbid conditions and drugs being provided in patients with osteoporosis, such as nonsteroidal anti-inflammatory drugs and corticosteroids.

[Influence of adjuvant pain medication on quality of life in the treatment of postmenopausal osteoporosis]

AIM OF THE STUDY

Chronic pain is the main symptom of postmenopausal osteoporosis. This can decrease mobility and quality of life of the patients. The hypothesis of this study was that administration of an adjuvant pain medication is essential additionally to the basic therapy. The second question was if a recommendation can be formulated whether a peripheral or a central acting pain medication is more effective to prevent osteoporosis induced chronic pain.

METHODS

Three pseudorandomised patient groups were prospectively compared. Group 1 was treated with alendronate, vitamin D, and calcium. Group 2 also received ibuprofen, and group 3 also received tramadol. In 117 women suffering from postmenopausal osteoporosis, quality of life was measured before and 26 weeks after therapy using the International Osteoporosis Foundation Qualeffo-41 score, and pain intensity was measured using a visual analogue scale.

RESULTS

No therapy-associated complications were observed during the study. After 26 weeks, quality of life significantly increased in groups 2 and 3 compared with group 1 (p<0.001). Pain intensity decreased in group 1 by only 6 points, whereas it decreased in group 2 by 31 points and in group 3 by 24 points. Pain relief was significantly different between the treatment groups and the control group and between the treatment groups themselves (p<0.001 and p<0.01).

CONCLUSION

We conclude that pain therapy with an almost peripherally acting drug such as ibuprofen can reduce osteoporosis-associated chronic pain better than a centrally acting pain medication such as tramadol. It therefore can be recommended to prescribe ibuprofen rather than tramadol for treating osteoporosis-associated chronic pain in postmenopausal women if the specific risk for gastrointestinal side effects is considered.

Alendronate for the treatment of osteoporosis in men

BACKGROUND

Men have higher rates of osteoporosis and suffer fragility fractures more often than previously believed. Fracture-related morbidity and mortality in men is substantially higher than in women.

OBJECTIVE

To investigate alendronate for treating osteoporosis in men.

METHODS

Search limited to 'men' and 'English'; keywords were 'osteoporosis' or 'bone density' or 'fracture' and 'alendronate'.

RESULTS/CONCLUSIONS

Alendronate is an amino-bisphosphonate with proved efficacy for increasing bone mineral density in men with idiopathic or secondary osteoporosis and has demonstrated an ability to prevent vertebral fractures in men with low bone mass. There are trends for alendronate to decrease the risk of non-vertebral fracture, but larger trials are needed to conclusively establish this benefit. Alendronate is a well-tolerated and comparatively safe drug with an attractive once-a-week dosing regimen.

Drug injury in the upper gastrointestinal tract: effects of alendronate

Osteoporosis is a disease characterized by an increase in bone resorption and a decline in bone density, which leads to increased susceptibility to bone fractures. Long-term therapy is needed to increase bone mineral density and maintain bone strength. Safe and well-tolerated medical therapies are required for long-term maintenance. Alendronate, an oral bisphosphonate, has been used for treatment of osteoporosis since the mid 1990s; however, recent studies have suggested alendronate can have significant gastrointestinal side effects. Most data suggest that the risk of these effects is low and not significantly higher than with placebo but there are limited reports that suggest otherwise, in both clinical trials and animal studies. Alendronate continues to remain an important mainstay of osteoporosis therapy.

Long-Term Safety of Bisphosphonate Therapy for Osteoporosis

This article reviews the long-term safety profile of bisphosphonates for the treatment and prevention of osteoporosis in postmenopausal women. Bisphosphonates inhibit osteoclastic resorption and reduce the rate of bone turnover, thereby reducing fracture risk. Placebo-controlled trials of oral amino-bisphosphonates of up to 4 years' duration and continuous treatment for up to 10 years in extensions of these trials (without continuous placebo comparison groups) have reported that bone quality remains normal, and suggest that the early reductions in fracture risk may be sustained for as long as treatment continues. Studies in animals using high doses of bisphosphonates have also reported normal quality bone with increased strength. The adverse experience profile (including upper gastrointestinal tolerability) of the oral bisphosphonates alendronic acid and risedronic acid has been similar to placebo in randomised trials with thousands of participants, whereas the incidence of flu-like symptoms was increased with the high doses used in oral monthly and intravenous ibandronic acid. Thus, the existing data are reassuring for long-term continued daily (or its weekly equivalent) administration of alendronic acid and risedronic acid, with no evidence of an adverse effect on bone health. For other dosing regimens, additional data are needed to evaluate their long-term safety.