Anti-fracture efficacy of risedronic acid in men: A meta-analysis of randomized controlled trials

A randomized trial alerting authors, with or without coauthors or editors, that research they cited in systematic reviews and guidelines has been retracted

Retracted clinical trials may be influential in citing systematic reviews and clinical guidelines. We assessed the influence of 27 retracted trials on systematic reviews and clinical guidelines (citing publications), then alerted authors to these retractions. Citing publications were randomized to up to three e-mails to contact author with/without up to two coauthors, with/without the editor. After one year we assessed corrective action. We included 88 citing publications; 51% (45/88) had findings likely to change if retracted trials were removed, 87% (39/45) likely substantially. 51% (44/86) of contacted citing publications replied. Including three authors rather than the contact author alone was more likely to elicit a reply (P = 0.03). Including the editor did not increase replies (P = 0.66). Whether findings were judged likely to change, and size of the likely change, had no effect on response rate or action taken. One year after e-mails were sent only nine publications had published notifications. E-Mail alerts to authors and editors are inadequate to correct the impact of retracted publications in citing systematic reviews and guidelines. Changes to bibliographic and referencing systems, and submission processes are needed. Citing publications with retracted citations should be marked until authors resolve concerns.

Efficacy of anti-osteoporosis treatment for men with osteoporosis: a meta-analysis

INTRODUCTION

Osteoporosis and fracture are important healthcare problems for men worldwide, which are relevant to severe disability and mortality. This meta-analysis aimed to assess the effectiveness of pharmacological therapy in men with osteoporosis, and to provide evidence-based hints for clinical practice.

MATERIALS AND METHODS

PubMed, Embase, Web of Science were searched from inception to July 31, 2022. Pooled standardized mean difference (SMD) and relative risk (RR) were calculated. Heterogeneity between included studies and publication bias were detected.

RESULTS

Twenty clinical studies were enrolled in this meta-analysis. The pooled SMD for mean percentage differences of change from baseline in lumbar spine BMD between the treatment group and the control group was 4.95 (95% CI 2.48, 7.42, I² = 99%, p < 0.0001). For mean percentage differences of change in femoral neck BMD, the overall SMD was 3.08 (95% CI 0.95, 5.20, I² = 99%, p = 0.0045). For a change in total hip BMD, the overall SMD was 1.06 (95% CI 0.50, 1.63, I² = 82%, p = 0.0002). The overall RR for incident vertebral fractures was 0.50 (95% CI 0.37, 0.68, I² = 5%, p = 0.3971). The pooled RR for nonvertebral fractures and clinical fracture were 0.74 (95% CI 0.41, 1.33, I² = 28%, p = 0.3139) and 0.81 (95% CI 0.54, 1.21, I² = 0%, p = 0.2992).

CONCLUSION

Findings in this meta-analysis indicate that pharmacological treatment increases lumbar spine, femoral neck, total hip BMD, and decreases incident vertebral fractures in men with osteoporosis.

Protocol for the models of primary osteoporosis screening in men (MOPS) cluster randomized trial

Current guidelines recommend primary osteoporosis screening for at-risk men to reduce the morbidity, mortality, and cost associated with osteoporotic fractures. However, analyses in a national Veterans Health Administration cohort of over 4,000,000 men demonstrated that primary osteoporosis screening as it is currently operationalized does not benefit most older Veterans due to inefficient targeting and low subsequent treatment and adherence rates. The overall objective of this study is to determine whether a new model of primary osteoporosis screening reduces fracture risk compared to usual care. We are conducting a pragmatic group randomized trial of 38 primary care teams assigned to usual care or a Bone Health Service (BHS) screening model in which screening and adherence activities are managed by a centralized expert team. The study will: 1) compare the impact of the BHS model on patient-level outcomes strongly associated with fracture rates (eligible proportion screened, proportion meeting treatment criteria who receive osteoporosis medications, medication adherence, and femoral neck bone mineral density); 2) quantify the impact on provider and facility-level outcomes including change in DXA volume, change in metabolic bone disease clinic volume, and PACT provider time and satisfaction; and 3) estimate the impact on health system and policy outcomes using Markov models of screening program cost per quality adjusted life year based from health system and societal perspectives.

Consensus document on osteoporosis in males

OBJECTIVE

To provide practical recommendations to assess and treat osteoporosis in males.

PARTICIPANTS

Members of the Bone Metabolism Working Group of the Spanish Society of Endocrinology.

METHODS

Recommendations were formulated using the GRADE system (Grading of Recommendations, Assessment, Development, and Evaluation) to describe both the strength of recommendations and the quality of evidence. A systematic search was made in Medline (PubMed) using the following associated terms: «osteoporosis», «men», «fractures», «bone mineral density», «treatment», «hypogonadism», and «prostate cancer». Papers in English and Spanish with publication date before 30 August 2017 were included. Current evidence for each disease was reviewed by 2group members. Finally, recommendations were discussed in a meeting of the working group.

CONCLUSIONS

The document provides evidence-based practical recommendations for diagnosis, assessment, and management of osteoporosis in men and special situations such as hypogonadism and prostate cancer.

Comparison of screening strategies for prevalent vertebral fractures in South Korea: vertebral fracture assessment vs. spine radiography

BACKGROUND

Vertebral Fracture Assessment (VFA) is a useful tool to detect the vertebral fracture (VF) with low cost and radiation exposure. We aimed to compare screening strategies including VFA and spine radiography (X-ray) for detecting VF in terms of clinical effectiveness, cost and radiation exposure.

METHODS

Three screening strategies: 1) X-ray following VFA, 2) VFA only, and 3) X-ray only were compared using a Markov model based on administrative data from South Korea in a population aged ≥50 years. We compared the incidence of new VFs, cost-effectiveness of reducing new VFs and radiation exposure in each strategy.

RESULTS

The incidence of new VFs was reduced in all screening strategies compared to no screening: 29.4% for women and 12.5% for men in both X-ray following the VFA and VFA only strategies and 35% for women and 17.5% for men in the X-ray only strategy. The X-ray following VFA strategy had the lowest cost, followed by the X-ray only, and VFA only strategies. The radiation doses for X-ray only were 2,647-2,989 μSv and 3,253-3,398 μSv higher than in the X-ray following VFA and VFA only strategies. The new VF prevention effect was greater in women, and more prominent in older people (women ≥ 70, men ≥ 80) than people ≥ 50 years.

CONCLUSIONS

The X-ray following VFA strategy is a cost-effective option for screening prevalent VF to prevent new VF in people aged ≥50 years due to its high effectiveness, lowest cost, and least radiation exposure.

Comparison of fracture risk assessment tools in older men without prior hip or spine fracture: the MrOS study

Femoral neck bone mineral density (BMD), age plus femoral neck BMD T score, and three externally generated fracture risk tools had similar accuracy to identify older men who developed osteoporotic fractures. Risk tools with femoral neck BMD performed better than those without BMD. The externally developed risk tools were poorly calibrated.

INTRODUCTION

We compared the performance of fracture risk assessment tools in older men, accounting for competing risks including mortality.

METHODS

A comparative ROC curve analysis assessed the ability of the QFracture, FRAX® and Garvan fracture risk tools, and femoral neck bone mineral density (BMD) T score with or without age to identify incident fracture in community-dwelling men aged 65 years or older (N = 4994) without hip or clinical vertebral fracture or antifracture treatment at baseline.

RESULTS

Among risk tools calculated with BMD, the discriminative ability to identify men with incident hip fracture was similar for FRAX (AUC 0.77, 95% CI 0.73, 0.81), the Garvan tool (AUC 0.78, 95% CI 0.74, 0.82), age plus femoral neck BMD T score (AUC 0.79, 95% CI 0.75, 0.83), and femoral neck BMD T score alone (AUC 0.76, 95% CI 0.72, 0.81). Among risk tools calculated without BMD, the discriminative ability to identify hip fracture was similar for QFracture (AUC 0.69, 95% CI 0.66, 0.73), FRAX (AUC 0.70, 95% CI 0.66, 0.73), and the Garvan tool (AUC 0.71, 95% CI 0.67, 0.74). Correlated ROC curve analyses revealed better diagnostic accuracy for risk scores calculated with BMD compared with QFracture (P < 0.0001). Calibration was good for the internally generated BMD T score predictor with or without age and poor for the externally developed risk tools.

CONCLUSION

In untreated older men without fragility fractures at baseline, an age plus femoral neck BMD T score classifier identified men with incident hip fracture as accurately as more complicated fracture risk scores.

Time to Osteoporosis and Major Fracture in Older Men: The MrOS Study

INTRODUCTION

For older men who undergo bone mineral density (BMD) testing, the optimal osteoporosis screening schedule is unknown. Time-to-disease estimates are necessary to inform screening intervals.

METHODS

A prospective cohort study of 5,415 community-dwelling men aged ≥65 years without hip or clinical vertebral fracture or antifracture treatment at baseline was conducted. Participants had concurrent BMD and fracture follow-up between 2000 and 2009, and additional fracture follow-up through 2014. Data were analyzed in 2015. Time to incident osteoporosis (lowest T-score ≤ -2.50) for men without baseline osteoporosis, and time to hip or clinical vertebral fracture or major osteoporotic fracture for men without or with baseline osteoporosis, were estimated.

RESULTS

Nine men (0.2%) with BMD T-scores >-1.50 at baseline developed osteoporosis during follow-up. The adjusted estimated time for 10% to develop osteoporosis was 8.5 (95% CI=6.7, 10.9) years for those with moderate osteopenia (lowest T-score, -1.50 to -1.99) and 2.7 (95% CI=2.1, 3.4) years for those with advanced osteopenia (lowest T-score, -2.00 to -2.49) at baseline. The adjusted times for 3% to develop a first hip or clinical vertebral fracture ranged from 7.1 (95% CI=6.0, 8.3) years in men with baseline T-scores > -1.50 to 1.7 (95% CI=1.0, 3.1) years in men with baseline osteoporosis.

CONCLUSIONS

Men aged 65 years and older with femoral neck, total hip, and lumbar spine BMD T-scores >-1.50 on a first BMD test were very unlikely to develop osteoporosis during follow-up. Additional BMD testing may be most informative in older men with T-scores ≤-1.50.

Atypical subtrochanteric femoral shaft fractures: role for mechanics and bone quality

Bisphosphonates are highly effective agents for reducing osteoporotic fractures in women and men, decreasing fracture incidence at the hip and spine up to 50%. In a small subset of patients, however, these agents have recently been associated with 'atypical femoral fractures' (AFFs) in the subtrochanteric region or the diaphysis. These fractures have several atypical characteristics, including occurrence with minimal trauma; younger age than typical osteoporotic fractures; occurrence at cortical, rather than cancellous sites; early radiographic appearance similar to that of a stress fracture; transverse fracture pattern rather than the familiar spiral or transverse-oblique morphologies; initiation on the lateral cortex; and high risk of fracture on the contralateral side, at the same location as the initial fracture. Fracture is a mechanical phenomenon that occurs when the loads applied to a structure such as a long bone exceed its load-bearing capacity, either due to a single catastrophic overload (traumatic failure) or as a result of accumulated damage and crack propagation at sub-failure loads (fatigue failure). The association of AFFs with no or minimal trauma suggests a fatigue-based mechanism that depends on cortical cross-sectional geometry and tissue material properties. In the case of AFFs, bisphosphonate treatment may alter cortical tissue properties, as these agents are known to alter bone remodeling. This review discusses the use of bisphosphonates, their effects on bone remodeling, mechanics and tissue composition, their significance as an effective therapy for osteoporosis, and why these agents may increase fracture risk in a small population of patients.

Therapeutic options for low bone mineral density in HIV-infected subjects

With the advent of effective antiretroviral therapy (ART), the recognition and management of long-term complications of HIV infection and ART are increasingly important for HIV physicians. Low bone mineral density (BMD) is more common in those with HIV infection and this review will outline therapeutic options for the management of low bone mineral density relevant to HIV-infected populations.

Three-year experience with risedronate therapy for patients with an increased fracture risk: assessment of proximal femoral bone density and geometry by DXA

BACKGROUND AND OBJECTIVE

We previously reported that risedronate improved the structural parameters of the proximal femur, as well as lumbar spine and proximal femoral bone mineral density (BMD), after 1 year of therapy by suppressing bone resorption in patients with an increased risk of fracture. Our practice-based observational study was subsequently extended to determine whether these effects were enhanced, maintained or attenuated after 3 years.

METHODS

A total of 174 patients (nine men and 165 postmenopausal women) with a mean age of 67.8 years who had osteoporosis or osteopenia and clinical risk factors for fracture started risedronate therapy. The BMD of the lumbar spine and proximal femur, as well as proximal femoral structural parameters, were evaluated by dual-energy x-ray absorptiometry with advanced hip assessment (AHA) software at baseline and every year for 3 years.

RESULTS

Data were available for 107 patients at 1 year, 80 patients at 2 years and 74 patients at 3 years. Lumbar spine, total hip and femoral neck BMD and the cross-sectional area (CSA) of the proximal femur increased from baseline after 1 year with levels being maintained after 2-3 years. The cross-sectional moment of inertia (CSMI) of the proximal femur increased from baseline after 1 year and the increase was enhanced after 2 years with levels being maintained after 3 years. The femoral strength index (FSI) increased from baseline after 1 and 2 years and the increase was enhanced after 3 years. The increases in proximal femoral CSMI and FSI were greater than those of total hip and femoral neck BMD after 3 years of therapy.

CONCLUSION

The present study showed the effects of risedronate therapy for 3 years on the BMD of the lumbar spine and proximal femur, as well as on proximal femoral structure, in patients with an increased risk for fracture.

Once-yearly zoledronic acid in older men compared with women with recent hip fracture

OBJECTIVES

To assess the efficacy of once-yearly zoledronic acid (ZOL) 5 mg in increasing bone mineral density (BMD) in men with a recent hip fracture participating in the Health Outcomes and Reduced Incidence with Zoledronic Acid Once- Yearly Recurrent Fracture Trial and to compare the efficacy with that in women from the same study.

DESIGN

Randomized, placebo-controlled, double-blind trial.

SETTING

International multicenter.

PARTICIPANTS

Five hundred and eight men and 1,619 women within 90 days of surgical repair of low-trauma hip fracture in the same study (for comparison).

INTERVENTION

Once-yearly intravenous (IV) ZOL 5 mg (n = 248) or placebo (n = 260), loading dose of vitamin D, daily calcium, and vitamin D supplements.

MEASUREMENT

Changes in BMD.

RESULTS

Percentage change from baseline in total hip BMD at Months 12 and 24 was significantly higher with ZOL than with placebo (between-group difference, 2.0%, P = .003, and 3.8%, P = .002, respectively). Percentage change from baseline in femoral neck BMD at Month 24 was significantly higher with ZOL than with placebo (3.8%, P = .003). The BMD benefit was comparable with that observed in women in this study. New clinical fractures occurred in 36 (7.1%) participants (ZOL, n = 16; placebo, n = 20; P = .64). The ZOL safety profile was comparable with that of placebo, with no significant differences in cardiovascular or long-term renal function and a trend toward lower mortality in ZOL-treated men.

CONCLUSION

Once-yearly IV ZOL 5 mg increases bone mass at the hip and femoral neck in men within 90 days of repair of a low-trauma hip fracture. Increases were of a similar magnitude to those observed in women in the same study.

[2011 Up-date of the consensus statement of the Spanish Society of Rheumatology on osteoporosis]

OBJECTIVE

Due to increasing improvement in the diagnosis, evaluation and management of osteoporosis and the development of new tools and drugs, the Spanish Society of Rheumatology (SER) has promoted the development of recommendations based on the best evidence available. These recommendations should be a reference to rheumatologists and other health professionals involved in the treatment of patients with osteoporosis.

METHODS

Recommendations were developed following a nominal group methodology and based on a systematic review. The level of evidence and degree of recommendation were classified according to the model proposed by the Center for Evidence Based Medicine at Oxford. The level of agreement was established through Delphi technique. Evidence from previous consensus and available clinical guidelines was used.

RESULTS

We have produced recommendations on diagnosis, evaluation and management of osteoporosis. These recommendations include the glucocorticoid-induced osteoporosis, premenopausal and male osteoporosis.

CONCLUSIONS

We present the SER recommendations related to the biologic therapy risk management.

[Pharmacologic treatment of osteoporosis--2011]

Osteoporosis affects approximately 9% of the population in Hungary resulting in about 100 000 osteoporotic fractures annually. Thirty-five percent of patients with hip fractures due to osteoporosis will die within 1 year. Direct costs of osteoporosis exceed 25 billion forints per year. Apparently, cost-effective reduction of bone loss and consequent fracture risk will add up to not only financial savings but improvement in quality of life, as well. A number of pharmacological modalities are available for this purpose. The mainstay of the treatment of osteoporosis is the bisphosphonate group that includes effective anti-resorptive compounds mitigating bone loss and fragility. The recently registered denosumab exhibits similar efficacy by neutralizing RANK ligand, however, marked differences can be observed between the two drug classes. Strontium has a unique mechanism of action by rebalancing bone turnover, and thus, providing an efficient treatment option for the not fast bone losers who are at high fracture risk. The purely anabolic teriparatide is available for the extremely severe osteoporotic patients and for those who do not respond to other types of therapy. Older treatment options such as hormone replacement therapy, raloxifene, tibolone or calcitonin may also have a restricted place in the management of osteoporosis.

Heterogeneity of biological bone markers in idiopathic male osteoporosis

In men with idiopathic osteoporosis, histomorphometric studies reported both increased resorption and decreased remodeling. We aimed at examine bone remodeling in these patients by biological marker measurement. We compared pre-treatment carboxy-terminal cross-linking telopeptide of type I collagen (CTX) and bone alkaline phosphatase (bALP) levels in 49 men, mean age 59 ± 14 year, with idiopathic osteoporosis with fractures (40 patients) or osteoporosis diagnosed by densitometry (9 patients) with 50 age-matched controls. The influence of baseline remodeling level on alendronate efficacy was studied. Bone remodeling markers (CTX and bALP) did not significantly differ between patients and controls and were correlated in both groups. There was no correlation between these markers, vitamin D and PTH levels. Twenty-one patients underwent repeat densitometry after 1 year of alendronate (70 mg/week). Mean annual BMD increase, spine +4.1 ± 3.9%, and hip +1.5 ± 1.2% showed no correlation with baseline CTX. Bone remodeling is very heterogeneous and formation and resorption remain biologically coupled in both idiopathic male osteoporosis and controls. Baseline remodeling level does not affect the action of alendronate on BMD.

Risedronate improves proximal femur bone density and geometry in patients with osteoporosis or osteopenia and clinical risk factors of fractures: a practice-based observational study

The purpose of this practice-based observational study was to clarify the acute effect of risedronate on proximal femur bone mineral density (BMD) and structural geometry in patients with an increased risk of fractures. One hundred sixty-four patients (7 men and 157 postmenopausal women; mean age, 69.2 years) with osteoporosis or osteopenia and clinical risk factors of fractures were analyzed. All these patients were treated with risedronate for 1 year. Urinary levels of cross-linked N-terminal telopeptide of type I collagen (NTX) were measured at baseline and 4 months after the start of treatment. BMD of the lumbar spine and proximal femur and structural geometric parameters of the proximal femur were evaluated by dual-energy X-ray absorptiometry with advanced hip assessment (AHA) software at baseline and every 4 months. Urinary NTX levels significantly decreased after 4 months of treatment. BMD of the femoral neck and total hip significantly increased after 4, 8, and 12 months of treatment. Cross-sectional moment of inertia (CSMI) and cross-sectional area significantly increased after 4, 8, and 12 months of treatment. An increase in CSMI was apparently greater than those of proximal femur BMD after 4 months of treatment. These results suggest the acute (4 months) and sustained (12 months) effect of risedronate on proximal femur structural geometry as well as BMD as a result of suppression of bone resorption in patients with an increased risk of fractures.