Fatal esophageal perforation with alendronate

Long-term safety concerns of antiresorptive therapy

Bisphosphonates reduce the risk of major osteoporotic fractures and are the most commonly used medications for the prevention and treatment of osteoporosis. Although these medications are well tolerated and safe during large-scale clinical trials, several rare and serious adverse events are suspected to be associated with long-term bisphosphonate use. These adverse events include osteonecrosis of the jaw, atypical fractures, and esophageal cancer. This review summarizes studies examining the association between bisphosphonate use and these adverse outcomes, with a focus on large case series and controlled epidemiologic studies.

A rare complication with a single dose of alendronate

The authors present a case of an 84-year-old patient who presented to the emergency department with sudden onset abdominal pain radiating to the neck. The patient's medication included warfarin, and alendronate, which was started by the general practitioner 2 days prior to presentation. Initial systemic examination and investigations, including chest x-ray, were unremarkable. Within 24 h of presentation the patient developed bilateral pneumonia with effusions. Due to continued clinical deterioration over the next 48 h, a CT thorax was performed that showed evidence of large oesophageal perforation with mediastinitis and gas in the mediastinum. The patient was treated with an expandable metal stent, bilateral chest drains, broad spectrum antibiotics, antifungals and total parenteral nutrition. Over a period of 8 weeks the patient made an excellent recovery. This rare case illustrates the importance of vigilance for the life-threatening complication of oesophageal perforation with alendronate treatment.

Randomized active and placebo-controlled endoscopy study of a novel protected formulation of oral alendronate

Although generally well tolerated, oral aminobisphosphonates have been associated with sporadic cases of severe esophageal injury attributed to pill contact. A novel protected formulation of oral alendronate uses an inert cylindrical shell to prevent mucosal contact with intact tablets. An active and placebo-controlled endoscopy study was undertaken to assess mucosal injury associated with this protected formulation. Healthy volunteers with normal baseline endoscopy were randomly assigned to receive protected alendronate 70 mg/day, standard alendronate 70 mg/day, or placebo for 14 days. Endoscopy was repeated on days 8 and 15. Of 78 subjects, 30 received protected alendronate, 28 received standard alendronate, and 20 received placebo. Mean gastric injury scores did not differ significantly among treatment groups. However, subjects on standard alendronate were more likely than those on protected alendronate to develop severe gastric injury, defined as Lanza score 3 or 4 (67.9% versus 33.3%, P=.009), and more likely to develop a gastric ulcer (21.4% versus 3.3%, P=.015). No differences in symptoms or adverse events were observed. In conclusion, a novel protected formulation of oral alendronate is less likely than standard alendronate to induce severe mucosal injury to the upper gastrointestinal tract.

Esophageal emergencies: things that will wake you from a sound sleep

Esophageal emergencies are a common problem facing practicing gastroenterologists and it is important to know what therapies are indicated for different situations. Patients ingesting caustic agents should be monitored intensively for signs of perforation and ultimately for signs of stricture development. Foreign bodies impacted in the esophagus should be removed promptly to prevent perforation. Although esophageal perforations are generally managed surgically, conservative management of localized perforations has become more common especially with improved antibiotics and the use of nonsurgical interventional drainage techniques. In either elected course the gastroenterologist should work closely with the surgical team.

Bisphosphonate treatment of osteoporosis

Bisphosphonates represent the agents of choice for most patients with osteoporosis. They are the best studied of all agents for the prevention of bone loss and reduction in fractures. They increase BMD, primarily at the lumbar spine, but also at the proximal femur. In patients who have established osteoporosis, bisphosphonates reduce the risk of vertebral fractures, and are the only agents in prospective trials to reduce the risk of hip fractures and other nonvertebral fractures. Bisphosphonates reduce the risk of fracture quickly. The risk of radiographic vertebral deformities is reduced after 1 year of treatment with risedronate [68]. The risk of clinical vertebral fractures is reduced after 1 year of treatment with alendronate [69] and just 6 months' treatment with risedronate [157]. The antifracture effect of risedronate has been shown to continue through 5 years of treatment [158]. Alendronate and risedronate are approved by the FDA for prevention of bone loss in recently menopausal women, for treatment of postmenopausal osteoporosis, and for prevention (risedronate) and treatment (alendronate and risedronate) of glucocorticoid-induced osteoporosis. Alendronate is also approved for treatment of osteoporosis in men. Other bisphosphonates (etidronate for oral use, pamidronate and zoledronate for intravenous infusion) are also available and can be used off label for patients who cannot tolerate approved agents. Although bisphosphonates combined with estrogen or raloxifene produce greater gains in bone mass compared with single-agent treatment, the use of two antiresorptive agents in combination cannot be recommended because the benefit on fracture risk has not been demonstrated and because of increased cost and side effects.

The gastrointestinal tolerability and safety of oral bisphosphonates

Oral bisphosphonates are effective for osteoporosis and other hyperresorptive bone disorders. Although well-tolerated in efficacy trials, some oral aminobisphosphonates have been associated with upper gastrointestinal intolerance and injury in postmarketing experience. Clinical trials often underestimate the rate of adverse events in clinical practice, and ethics prohibit direct evaluation of toxicity in high-risk patients. Accordingly, animal models and endoscopy studies of oral bisphosphonates provide valuable insight. It is unclear whether variation in ulcerogenic potential reflects differences in dosing, formulation or chemical structure. Furthermore, the clinical relevance of endoscopic lesions is uncertain. Ongoing postmarketing review will determine whether differences in endoscopic damage predict tolerability and safety in clinical practice. However, physicians and patients should consider risk factors for oesophageal injury when initiating therapy.