Updated recommendations for the diagnosis and management of osteoporosis: a local perspective

Prevalence of type 2 diabetes (T2D) in Lebanon: association with inflammatory and infectious clinical markers

BACKGROUND

Diabetes is a growing health concern in the Middle East, particularly in countries with high rates of obesity and unhealthy lifestyles. Therefore, this study aimed to determine the prevalence of type 2 diabetes (T2D) in Lebanon and its association with clinical markers of inflammation and infection.

METHODS

This cross-sectional study examined retrospectively the medical laboratory record of 4093 patients from all Lebanese regions. Prevalence of T2D and its association with age, gender, calcium, vitamin D (VitD), neutrophils-to-lymphocytes ratio (NLR), and C-reactive protein (CRP) were determined. The prevalence of infection in a subpopulation of 712 patients tested from blood, body fluid, sputum, swab, tissue, and urine samples and its etiology was also assessed.

RESULTS

Overall, 17% (n = 690) of our participants had T2D, and the mean HbA1c was 5.9% ± 1.2. Age, gender, triglycerides, NLR, and calcemia were significantly associated with T2D. The prevalence of infections in a subgroup of 712 patients was 11.1% (n = 79). Urinary tract infections (UTIs) caused by Escherichia coli (E. coli) were the most common cause of infection, with the highest prevalence in the pre-diabetic group. Serum CRP level was significantly higher in the diabetic group than the pre-diabetic and control groups. Diabetic patients also presented a significantly higher percentage of NLR > 3 compared to the pre-diabetic and control groups.

CONCLUSION

The prevalence of T2D is increasing in the Lebanese population compared to prior reports. These results should be considered to guide effective public health preventive strategies.

Diagnosis and management of osteoporosis in Saudi Arabia: 2023 key updates from the Saudi Osteoporosis Society

The Saudi Osteoporosis Society (SOS) has updated its guidelines for the diagnosis and management of osteoporosis in Saudi Arabia (SA), with emphasis on postmenopausal women. This document is relevant to all healthcare professionals in SA involved in the care of patients with osteoporosis and osteoporosis-related fractures.

INTRODUCTION

The SOS launched the first national osteoporosis guidelines in 2015 and spearheaded the Gulf Cooperation Council Countries (GCC) osteoporosis consensus report in 2020 which was under the auspices of the European Society for Clinical and Economic Aspects of Osteoporosis (ESCEO). This paper highlights a major update of the guidelines in the SA setting.

METHODS

This guideline is an adaptation of the current guidelines derived from ESCEO, the American Association of Clinical Endocrinologists (AACE), and the GCC osteoporosis consensus report and studies on osteoporosis done in SA. Where accessible, the timeliest systematic review, meta-analysis, and randomized controlled trials were used as evidence.

RESULTS

The present update includes new recommendations for the assessment of osteoporosis taking into consideration the Saudi model of FRAX for fracture probabilities, appropriate doses for the maintenance of vitamin D status and calcium, the use of representative blood analytes for therapy monitoring, the use of romosozumab and sequential therapy in the pharmacological management strategies, and the establishment of fracture liaison services to prevent secondary fractures.

CONCLUSION

This updated guideline is for all healthcare professionals involved in osteoporosis and post-fracture care and management in SA and harmonized the most up-to-date changes in the field based on evidence-based medicine for use in the local setting.

Vitamin D cutoff point in relation to parathyroid hormone: a population based study in Riyadh city, Saudi Arabia

The current recommended cutoff value for low vitamin D may result in overestimation of hypovitaminosis D. Vitamin D levels at 30.0 nmol/L can diagnose the hyperparathyroid cases leading to bone loss, with moderate accuracy, in the Saudi population. The new cutoff may help in identifying true cases that need clinical treatment and can reduce the burden on healthcare system.

PURPOSE

Different regions of the world have reported varying cutoff points as optimal values for vitamin D status to maintain bone health.

METHODS

A cross-sectional study comprising of interviews, anthropometrics, and blood samples was conducted in primary healthcare centers in Riyadh, Saudi Arabia. Standardized serum 25-hydroxyvitamin D [25(OH)D] and parathyroid hormone (PTH) were measured using electrochemiluminescence immunoassays. Independent sample and paired sample t test were conducted to compare the true means. Pearson correlation co-efficient was calculated to measure the association between original and standardized 25(OH)D. Software program, MedCalc, was utilized to measure the receiver operating curve (ROC) for determining the optimal threshold value for vitamin D.

RESULTS

The mean standardized 25(OH)D levels for 846 males and 1285 females were (32.0 ± 14.4 nmol/L vs 31.6 ± 16.7 nmol/L) respectively. Using the gold standard PTH cutoff > 6.9 pmol/L, the ROC had an optimal criterion value for males and females at 30.0 and 24.0 nmol/L, respectively. In the males, the sensitivity and specificity were 72% and 51%, whereas in females, it was 58.2% and 66.7%, respectively. The area under the curve (AUC) was at 0.62 and 0.65 (p < 0.001), respectively.

CONCLUSION

The recommended cutoff value for 25(OH)D for determining bone health in the Saudi population is at 30.0 nmol/L. The comparatively low cutoff point can significantly decrease the number of people diagnosed and treated with low vitamin D, which can also reduce the burden on the health care system.

Vitamin D in the Middle East and North Africa

PURPOSE

The Middle East and North Africa (MENA) region registers some of the lowest serum 25‑hydroxyvitamin D [25(OH)D] concentrations, worldwide. We describe the prevalence and the risk factors for hypovitaminosis D, completed and ongoing clinical trials, and available guidelines for vitamin D supplementation in this region.

METHODS

This review is an update of previous reviews published by our group in 2013 for observational studies, and in 2015 for randomized controlled trials (RCTs) from the region. We conducted a comprehensive search in Medline, PubMed, and Embase, and the Cochrane Library, using MeSH terms and keywords relevant to vitamin D, vitamin D deficiency, and the MENA region, for the period 2012-2017 for observational studies, and 2015-2017 for RCTs. We included large cross-sectional studies with at least 100 subjects/study, and RCTs with at least 50 participants per arm.

RESULTS

We identified 41 observational studies. The prevalence of hypovitaminosis D, defined as a 25‑hydroxyvitamin D [25(OH)D] level below the desirable level of 20 ng/ml, ranged between 12-96% in children and adolescents, and 54-90% in pregnant women. In adults, it ranged between 44 and 96%, and the mean 25(OH)D varied between 11 and 20 ng/ml. In general, significant predictors of low 25(OH)D levels were female gender, increasing age and body mass index, veiling, winter season, use of sun screens, lower socioeconomic status, and higher latitude.We retrieved 14 RCTs comparing supplementation to control or placebo, published during the period 2015-2017: 2 in children, 8 in adults, and 4 in pregnant women. In children and adolescents, a vitamin D dose of 1000-2000 IU/d was needed to maintain serum 25(OH)D level at target. In adults and pregnant women, the increment in 25(OH)D level was inversely proportional to the dose, ranging between 0.9 and 3 ng/ml per 100 IU/d for doses ≤2000 IU/d, and between 0.1 and 0.6 ng/ml per 100 IU/d for doses ≥3000 IU/d. While the effect of vitamin D supplementation on glycemic indices is still controversial in adults, vitamin D supplementation may be protective against gestational diabetes mellitus in pregnant women. In the only identified study in the elderly, there was no significant difference between 600 IU/day and 3750 IU/day doses on bone mineral density. We did not identify any fracture studies.The available vitamin D guidelines in the region are based on expert opinion, with recommended doses between 400 and 2000 IU/d, depending on the age category, and country.

CONCLUSION

Hypovitaminosis D is prevalent in the MENA region, and doses of 1000-2000 IU/d may be necessary to reach a desirable 25(OH)D level of 20 ng/ml. Studies assessing the effect of such doses of vitamin D on major outcomes, and confirming their long term safety, are needed.

Spontaneous osteoclastogenesis: Hypothesis for gender-unrelated osteoporosis screening and diagnosis

Women are at greater risk of developing osteoporosis (OP). However, in the past few years it has become more widely recognized that OP is a significant problem also in men although OP is frequently under-diagnosed and, consequently, under treated in men. Most guidelines, screening and fracture risk evaluation methods as well as pharmacologic agents have been developed for women and then adapted to men. Bone Mineral Density (BMD) measurement by Dual X-ray Absorptiometry (DEXA) is reported as T score and the capability of DEXA to diagnose OP and predict fracture risk is still debated. In addition, the use of female T score references for the diagnosis of OP in men is incorrect for the following reasons: 1) DXA definition was developed just for Caucasian women, 2) men and women display structural differences in terms of bone growth, catabolism and size; 3) aging men have more periosteal apposition, less cortical porosity and endocortical resorption than aging women; and 4) T scores results, both in man and in women, can be affected by the presence of co-morbidities and it is known that in men OP is often secondary. From a biological point of view, OP is mainly due to increased osteoclastic activity leading to an imbalance in bone remodeling that favors resorption. However, some evidence suggests a more complex identity for osteoclasts (OCs) over and above their simple role of 'bone eaters'. In our laboratory, we observed spontaneous OCs formation in vitro in peripheral blood mononuclear cells (PBMC) from OP patients (n.12 female patients and n.6 male patients; DXA T score-2.5 or less). Some researchers demonstrated OCs gender differences in bone resorption activity of female-derived versus male-derived OCs. Indeed, further data from our laboratory also showed gender differences in number of spontaneously differentiated OCs and differentiation time. Therefore, we hypothesized that it would be possible to perform OP screening and diagnosis observing and measuring PBMCs different ability to differentiate spontaneously into OCs in male and female patients. If this hypothesis will be confirmed, it will result in an effective and efficient strategy for OP screening, diagnosis, monitoring and fracture prevention, targeting health service resources on selected patients. However, our hypothesis must be tested in a properly designed clinical trial and several key issues still need to be addressed.

Vitamin D status correction in Saudi Arabia: an experts' consensus under the auspices of the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis, and Musculoskeletal Diseases (ESCEO)

BACKGROUND

Vitamin D deficiency is common in the Middle East and in Saudi Arabia, in particular. While several international recommendations on the management of vitamin D deficiency have been documented and practiced globally, these recommendations should be adapted to the conditions of the Middle Eastern region. To address this challenge, the Prince Mutaib Chair for Biomarkers of Osteoporosis (PMCO) in King Saud University (KSU), Riyadh, KSA, together with local experts and in cooperation with the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO), organized a panel that formulated unified recommendations in the diagnosis and treatment of vitamin D deficiency in the region.

METHODS

The selection of local and international experts commenced during the 2nd International Vitamin D Symposium conducted in Riyadh, Saudi Arabia, last January 20--21, 2016. Reviews of the most recent literature were done, and face-to-face meetings were conducted for revisions and final recommendations.

RESULTS

Vitamin D sufficiency is defined as circulating serum 25(OH)D ≥50 nmol (≥20 ng/ml) for the general population and vitamin D adequacy as serum 25(OH)D >75 nmol/L l (>30 ng/ml) for the frail and osteoporotic elderly. Despite overwhelming prevalence of vitamin D deficiency, universal screening is not recommended. Recommendations for the general population, children, pregnant/lactating women, post-menopausal women, the elderly, and those with subsequent metabolic diseases were provided.

RESULTS

Vitamin D sufficiency is defined as circulating serum 25(OH)D ≥50 nmol (≥20 ng/ml) for the general population and vitamin D adequacy as serum 25(OH)D >75 nmol/L l (>30 ng/ml) for the frail and osteoporotic elderly. Despite overwhelming prevalence of vitamin D deficiency, universal screening is not recommended. Recommendations for the general population, children, pregnant/lactating women, post-menopausal women, the elderly, and those with subsequent metabolic diseases were provided.

CONCLUSION

Vitamin D supplementation/correction is advised in all persons whose serum 25(OH)D falls below 50 nmol/l (20 ng/ml), and achieving a target of 75 nmol/l (30 ng/ml) is particularly suited for frail, osteoporotic, and older patients. Conducting well-designed clinical trials in the region that will address economic implications and investigations on the treatment persistence and compliance to vitamin D treatment in the region are encouraged.

Prevalence of osteoporosis in the Italian population and main risk factors: results of BoneTour Campaign

BACKGROUND

BoneTour is a campaign conducted throughout the Italian territory for the assessment of Italian people bone status and for the prevention of osteoporosis.

METHODS

A total of 7305 sequential subjects of both sexes were screened, collecting clinical data through the FRAX™ questionnaire, and measuring heel bone stiffness by Quantitative Ultrasonography (QUS). The 10-year risk for hip and major osteoporotic fractures was calculated taking into account personal or family history of fragility fracture, smoking, alcohol abuse, rheumatoid arthritis, prolonged steroids assumption. Additional risk factors were evaluated, including early menopause, poor sunlight exposure, low dietary calcium intake, physical inactivity, number of pregnancies, months of lactation, tobacco cigarettes smoked per year, specific causes of secondary osteoporosis. Through a correlation study, the influence of each factor on the development of osteoporosis was analyzed.

RESULTS

As many as 18 % of women suffer from osteoporosis, as defined by QUS T-score. The calculation of FRAX™ confirmed the weight of the already known risk factors. The correlation study revealed the significance of some additional factors, such as hyperthyroidism, nephrolithiasis, Crohn disease, ulcerative colitis, celiac disease, poor sun exposure, and oophorectomy before age 50.

CONCLUSIONS

The high prevalence of secondary osteoporosis in the Italian population clearly indicates the importance of additional risk factors not yet included in the FRAX™ algorithm, for which preventive measures should be considered. Screening campaigns may allow both early diagnosis and access to treatment.

The development, implementation and evaluation of clinical practice guidelines in Gulf Cooperation Council (GCC) countries: a systematic review of literature

RATIONALE, AIMS AND OBJECTIVES

Our aim was to examine and describe the current situation in Gulf Cooperation Council (GCC) member countries regarding the development, implementation and evaluation of clinical practice guidelines (CPG). The objectives were to describe from where the studies originated, what the clinical focus was of each study and examine the methodology and the status of each study (i.e. development, dissemination, implementation and evaluation).

METHODS

Review of literature - two stages: stage 1: screening through an abstract review, followed by independent adjudicator; stage 2: detailed assessment and classification.

RESULTS

Considering the widespread acceptance that CPG's are useful and effective tools for quality improvement in health care, it is worth noting that relatively few studies have been conducted in the GCC region that examine CPG. Furthermore, the reviewers found that the quality of the research methods used could be improved. The majority of the studies that were conducted evaluated the effects of guidelines and focused on the 'lifestyle diseases', in particular diabetes and cardiovascular diseases. It is also worth noting that there has been a steady increase in the number of publications over the 10 years period.

CONCLUSIONS

More attention needs to be given to developing, disseminating, implementing and evaluating CPG's in the GCC region in order to improve the quality and safety of health care.

The Saudi Guidelines for the Diagnosis and Management of COPD

The Saudi Thoracic Society (STS) launched the Saudi Initiative for Chronic Airway Diseases (SICAD) to develop a guideline for the diagnosis and management of chronic obstructive pulmonary disease (COPD). This guideline is primarily aimed for internists and general practitioners. Though there is scanty epidemiological data related to COPD, the SICAD panel believes that COPD prevalence is increasing in Saudi Arabia due to increasing prevalence of tobacco smoking among men and women. To overcome the issue of underutilization of spirometry for diagnosing COPD, handheld spirometry is recommended to screen individuals at risk for COPD. A unique feature about this guideline is the simplified practical approach to classify COPD into three classes based on the symptoms as per COPD Assessment Test (CAT) and the risk of exacerbations and hospitalization. Those patients with low risk of exacerbation (<2 in the past year) can be classified as either Class I when they have less symptoms (CAT < 10) or Class II when they have more symptoms (CAT ≥ 10). High-risk COPD patients, as manifested with ≥2 exacerbation or hospitalization in the past year irrespective of the baseline symptoms, are classified as Class III. Class I and II patients require bronchodilators for symptom relief, while Class III patients are recommended to use medications that reduce the risks of exacerbations. The guideline recommends screening for co-morbidities and suggests a comprehensive management approach including pulmonary rehabilitation for those with a CAT score ≥10. The article also discusses the diagnosis and management of acute exacerbations in COPD.

Prevalence and factors associated with low bone mineral density in Saudi women: a community based survey

Background

Low bone mineral density (BMD) is a public health issue in Saudi Arabia. This study measured the prevalence and factors associated with low BMD in Saudi women in Riyadh, Saudi Arabia.

Methods

A cross sectional study using two stage cluster sampling technique was conducted in Riyadh, 2009. Thirty clusters, each comprising of 300 houses were randomly chosen and from each cluster 38–40 households were selected to identify 1150 women of >40 years. Women were invited to primary health care center for filling of self-administered questionnaire (n = 1069) comprising of sociodemographic, health, diet and physical activity variables. 1008 women underwent screening for low BMD using the quantitative ultrasound technique. 535 (53%) women with positive screening test were referred to King Khalid Hospital for Dual X-ray Energy absorptiometry (DXA).

Results

362 women underwent DXA and 212 (39.6%) were screened low BMD either at lumbar spine or femur neck. Mean age of women was 55.26(±8.84) years. Multivariate logistic analysis found; being aged 61 to 70 years (OR 2.75, 95% CI: 1.32-1.48), no literacy (OR 2.97, 95% CI:1.44 - 6.12) or primary education (OR 4.12, 95% CI:2.05-8.29), history of fractures (OR 2.20, 95% CI:1.03- 4.69) and not drinking laban(diluted yogurt) (OR 2.81, 95% CI:1.47- 5.37) significantly associated with low BMD.

Conclusions

Women with low level of education, who do not drink laban and had history of fractures were at high risk of low BMD.

Alendronate versus Raloxifene for Postmenopausal Women: A Meta-Analysis of Seven Head-to-Head Randomized Controlled Trials

Purpose. The aim of this study was to directly compare the efficacy and the safety of the two agents for postmenopausal women. Methods/Principal Findings. Electronic databases were searched for relevant articles that met our predefined inclusion criteria. Seven randomized controlled trials (RCTs) involving 4054 women were identified and included. Although Aln was more effective than Rlx in increasing bone mineral density (BMD), no statistical differences were observed in reducing the risk of neither vertebral fractures (P = 0.45) nor nonvertebral fractures (P = 0.87) up to two-year followup. Aln reduced the risk of vasomotor (P = 0.006) but increased the risk of diarrhea compared to Rlx (P = 0.01). Our subgroup analysis further indicated the difference between Aln and Rlx in fracture risk and was not materially altered by the administration pattern, the age. The weekly strategy of Aln would further reduce the upper gastrointestinal (GI) disorders and might gain more bone mass increment at lumbar spine compared to its daily treatment. Conclusion. There was no evidence of difference of fracture risk reduction between Aln and Rlx. In addition, age did not obviously influence their relative antifracture efficacy. For Aln the weekly strategy would further reduce the upper GI disorders and gain more bone mass increment compared to the daily treatment. During clinical decision making, the patients' adherence and the related side-effects associated with both drugs should also be taken into account.

Osteoporosis among older Saudis: risk of fractures and unmet needs

Using FRAX®, this study aimed at estimating 10-years probability of osteoporosis (OP)-related fractures and identifies those in need of OP treatment among primary care attendees in Saudi Arabia. Of those aged ≥ 60 years, 14.4 and 18.4 % scored probabilities for major and hip fractures respectively suggesting OP treatment. Predictors for receiving OP screening included the presence of multiple clinical risk factors, occurrence of fragility fractures and physicians recommendation.

PURPOSE

This study aimed at estimating the 10-years probability of osteoporosis (OP)-related fractures and identifying those in need of OP treatment among Saudi adults attending primary care centers (PHCs) in Al Hassa, Saudi Arabia, using FRAX® calculator and to determine factors possibly influence receiving of OP screening among them.

SUBJECTS AND METHODS

A total of 1,251 Saudi aged ≥ 40 years, of both genders, were recruited from four urban and three rural randomly selected PHCs. All were subjected to anthropometric measurements followed by a personal interview with structured questionnaire to asses OP clinical risk factors (CRFs) and possible correlates for receiving OP screening. Ten-year probabilities for major osteoporotic and hip fractures were calculated using the Lebanese version of FRAX® calculator.

RESULTS

Of participants aged ≥ 60 years, 14.4 and 18.4 % were identified with probability scores for major osteoporotic and hip fractures respectively, suggesting OP treatment. Out of sampled population, 16.1 % received OP screening. The presence of ≥two OP CRFs (odds ratio OR = 4.45), being aware of OP (OR = 2.89), physician recommendation of OP screening (OR = 2.01), and history of fragility fracture (OR = 1.92) were all possible positive predictors for receiving OP screening.

CONCLUSION

A sizable portion of the sampled older Saudis especially those aged ≥ 60 years are at high risk for OP-related fractures indicative to receive OP treatment. Occurrence of fragility fractures, multiplicity of CRFs and physician's recommendations are significant positive predictors to receive OP screening among them.

Comparison of estrogenic responses in bone and uterus depending on the parity status in Lewis rats

The reproductive transition of women through peri- to postmenopause is characterized by changes in steroid hormone levels due to the cessation of the ovarian function. Beside several complaints associated with these hormonal changes, the deterioration of the trabecular bone micro-architecture and the loss of skeletal mass can cause osteoporosis. At this life stage, women often have a reproductive history of one to several pregnancies. The ovariectomized skeletally mature rat (>10 months old) is one of the most commonly used animal models for postmenopausal osteoporosis research. Despite the fact that mammals can undergo up to several reproductive cycles (primi-/pluriparous), nulliparous animals are often used and the question whether changes in the hormonal milieu subsequently affect the skeleton and influence the outcome of intervention studies is often neglected in study designs. Therefore, the aim of the present study was to compare the estrogen responsiveness of nulliparous and pluriparous rats. For this purpose, one year old virgin or retired breeder Lewis rats were either sham operated or ovariectomized, whereas half of the ovariectomized animals received subcutaneous 17β-estradiol pellets eight weeks after surgery. After another four weeks, the effects on the uterus were determined by expression analysis of estrogen-dependently regulated steroid receptor genes and well-established marker genes. Moreover, trabecular bone parameters in the tibia were analyzed by micro-computed tomography (μCT). Parity-dependency in estrogen responsiveness was observed with respect to the achieved serum E2 levels in response to similar E2 treatment. This led to differences both on the uterus wet weight and on the expression level of uterine target genes. In addition, a reversal of the ovariectomy-induced changes of the bone architecture after 17β-estradiol substitution was only observed among the nulliparous. In conclusion, the observations of this study support parity-dependent differences in the responses to estrogenic compounds in the uterus and the bone of rats. These results indicate that the parity-status has an impact on the outcome of studies aiming at the investigation of estrogenic effects of compounds potentially used in hormone replacement and thus, this should be taken into consideration for further studies and particularly for the discussion of data obtained with the preclinical ovariectomized rat animal model.

Estimation of an early meaningful time point of bone parameter changes in application to an osteoporotic rat model with in vivo microcomputed tomography measurements

The commonly used preclinical animal model of postmenopausal osteoporosis is the mature ovariectomized rat, whereby cessation of ovarian oestrogen production consequently results in bone volume reduction. The study aim was to precisely define the time course of structural changes resulting from ovariectomy and thereby reduce the time animals have to be treated to judge the effects of osteoporosis treatment. For this purpose, we assessed architectural changes by microcomputed tomography ( μCT) during 10 weeks following ovariectomy or sham surgery at two-week intervals. Moreover, the trabecular microarchitecture of the lumbar vertebrae was assessed after necropsy. Besides this, serum biomarkers of bone turnover were determined. These data were in a new approach additionally correlated to femur mRNA expression profiles. We selected the osteoblast marker genes osteocalcin and type I collagen as well as the two osteoclast marker genes cathepsin k and tartrate-resistant acid phosphatase 5. The gene expression analysis suggested an activation of osteoblasts as well as octeoclasts. The significantly induced serum levels of osteocalcin and collagen degradation fragments also revealed this higher rate of bone turnover. Our results indicate that as soon as four weeks after ovariectomy the bone volume fraction exhibited a decline of 30% and 50% of the connectivity density. In addition, significant decreases of trabecular number and thickness as well as of the bone volume fraction were only observed in vertebrae of ovariectomized animals. Interestingly, changes of trabecular morphology were also found in the sham animals as a consequence of senescence.

Risedronate's Role in Reducing Hip Fracture in Postmenopausal Women with Established Osteoporosis

Osteoporosis is a significant concern for postmenopausal women and is a critical factor in hip fracture. Examining evidence for osteoporosis medications in hip fracture is important for optimizing treatment.

PURPOSE

Review risedronate's role for hip fracture in postmenopausal women.

METHODS

A literature search was conducted using Medline and Web of Science. The search was limited using the terms "risedronate" and "hip fracture," and to studies that included women. Similar articles linked to the search and pertinent articles in bibliographies were also examined.

RESULTS

Risedronate has demonstrated efficacy and cost effectiveness for hip fracture, but may not be beneficial for patients with low fracture risk. Risedronate is generally well tolerated, but may cause side effects in some patient populations.

CONCLUSION

Risedronate has benefit for hip fracture, but patients should be carefully screened to determine the appropriateness of risedronate before starting treatment.