Bisphosphonates for Osteoporosis, A Closer Look at the Data
by Jeffrey Dach MD
Sitting in my office last week, 51 year old Jane Smith told me her story. She had seen a TV commercial which showed the actress, Sally Field, suggesting to everyone to have their bones checked for osteoporosis. This prompted a doctor's visit and a DEXA bone scan which showed a T score of minus 2.3. Even though Janet did not have osteoporosis, and has never had an osteoporotic fracture, she was neverthless prescribed a bisphosphonate drug to "prevent" osteoporosis. The most commonly used drugs in this class Fosamax., Boniva, and Actonel which are all Bisphosphonates. Jane has no risk factors, doesn't smoke or drink, avoids soda pop and caffeine, exercises regularly, eats organic food and takes a handful of vitamins each day. Jane informs me that she did an internet search and found out that Fosamax and Actonel cause necrosis of thejaw, bone pain, and she wanted to know if there was a more natural way to increase bone density without drugs. The following information was shared with Jane.
This article will take a closer look at the data and current recommendations for bisphosphonate drugs for osteoporosis. We will weigh the possible benefits versus the adverse side effects of the bisphosphonate drugs.
Image at left: is a lateral xray of an end stage osteoporotic thoracic spine with multiple compression fractures. Two of the levels have been injected with acrylic cement (white bands), a procedure called kyphoplasty to strengthen the washed out bones.
What is Primary Prevention and Secondary Prevention ?
The main goal of bisphosphonate drug treatment for osteoporosis is the prevention of hip and vertebral fractures, and the major diagnostic tool is the DEXA bone density scan which is reported as the T-score.
The Secondary prevention group is defined as those women who have T scores less than -2.5 along with existing osteoporotic fractures. The Primary prevention group is defined as those women who have T scores greater than -2.5 and do not have osteoporotic fractures. The more severe Osteporosis is defined as a T-score less than -2.5 , and the less severe Osteopenia has a T score of greater than -2.5.
The current NICE guidelines recommend the bisphosphonate drugs for Secondary prevention of osteoporotic fracture in women who already have osteoporosis (T-score less than -2.5), and have a history of osteoporotic fracture. (21) NICE = National Institute for Clinical Excellence.
Bisphosphonates Not Recommended for Primary Prevention
For primary prevention of osteoporotic fracture in women with osteopenia, (T-score greater than -2.5), the use of bisphosphonates is NOT recommended because the Fracture Intervention Trial (FIT) data shows increased fracture rate with bisphosphonates. (15) This is discussed in detail below.
Failure of Treatment
What if the osteoporotic woman continues to fracture while on bisphosphonate drugs? This is called failure of treatment and there are no current guidelines for this scenario.(22). Susan Ott MD, however, would then recommend a trial of intermittent PTH.(30)
FDA Issues Alert About Severe Bone Pain from Bisphosphonates
Two months ago, Jan 7 2008, the FDA issued an alert highlighting “the possibility of severe and sometimes incapacitating bone, joint, and/or muscle (musculoskeletal) pain in patients taking bisphosphonates. “ which may be overlooked, delaying diagnosis, prolonging pain requiring pain medications.(1) Could this pain be caused by microdamage and cracks in the bones?(2)
Adverse Side Effects Posted on Message Message Boards
Here is the link to a Message Board with 613 adverse side effect messages for Fosamax (3) There are also 530 adverse side effect messages posted for Actonel.(3A).
The Adverse Side Effect of Bis- Fossy Jaw (4)
A number of reports have found similarities between bisphosphonate induced avascular necrosis of the jaw and a 19th century occupational disease in workers in match factories from inhalation of white phosphorus. Not only these workers have necrosis of the jaw, they also had systemic weakness of all other bones.
“There is evidence that occupational exposure to white phosphorus affects bones other than those in the jaw; this implies a systemic effect for inhaled white phosphorus. Two middle-aged men occupationally exposed to white phosphorus for 20-30 years had a history of breaking their femurs in accidents not normally expected to result in breakage of bones (Dearden 1899).”(10)(5)-(11)
Avascular Necrosis of the Jaw
Some argue that the adverse side effect of jaw necrosis is seen exclusively in cancer patients receiving intravenous bisphosphonates, rather than in those who take the oral form of the medication. However, there are also cases reported in the medical literature of Jaw Necrosis after dental procedures in patients taking the oral bisphosphonate tablets. For this reason, Bisphosphonates are under litigation for Jaw Necrosis as discussed in my previous article, Protect Your Family from Bad Drugs by Jeffrey Dach MD. (41) The issue raised here is: Why is jaw necrosis happening at all? To me, this raises the serious concern that whole class of bisphosphonate drugs disturb the underlying physiology of bone formation.
Toulouse Lautrec's Disease
My previous article, Fosamax, Actonel, Osteoporosis and Toulouse Lautrec, discussed reports of spontaneous fractures in patients on bisphosphonates and the similarity with pycnodysostosis, a genetic disease of the osteoclast bone cells.(24) These are unusual non-healing fractures of the mid femur indicating weak bone matrix. Toulouse Lautrec suffered this exact type of femur fracture bilaterally at a young age.
Avascular Necrosis of the Femoral Head from Bisphosphonates
Another new report is the revelation of a tripled incidence of avascular necrosis of the femoral head in women taking Fosamax. (13) Again, the issue is why should this adverse event be increased at all? To me it suggested deranged or abnormal bone physiology as a result of drug treatment.
P and G Hiding Data, Again?
According to a correspondence letter by Paul C. Royce, M.D., Ph.D. (31), Proctor and Gamble, the maker of the bisphosphonate Actonel, omitted data in a large clinical trial that they sponsored whose lead author was McClung.
The McClung data included 9,331 elderly women with low bone density. P&G announced that their bisphosphonate risedronate (Actonel) increased bone mineral density by one per cent ( 1%). However, when they conducted their follow-up phase of the trial, the information about the outcome of 3,324 women ( slightly over a third of the trial subjects), was not made available. This data was omitted from publication and peer review in the final article.(32) The whistle blower, Aubrey Blumson has previously documented extensive scientific misconduct by this same company, Proctor and Gamble, the soap company that makes Actonel. (17)
Dr. Cummings did not hide the data in his 1998 JAMA FIT article.
Why Does Fracture Rate Go Up WIth Fosamax in Osteopenia?
Although Fosamax and Actonel reduces fracture rates modestly (1-2% absolute) in elderly women with severe osteoporosis and compression fractures, why does fosamax increase fracture rates in women with osteopenia (T greater than -2.5) ?
Fosamax is supposed to make bones stronger, not weaker. Dr. Cummings' original FIT JAMA article in 1998 did not explain why hip fracture rates went up 84% for fosamax in women with osteopenia (a less severe than osteoporosis with T score greater than -2.5)
In a study published in JAMA in 1998, for example, women with an average age of 68 and a T score of - 2.5 or less who took Fosamax for four years were 56 percent less likely to suffer a hip fracture than women in the control group. This sounds like very good news for women with osteoporosis, but how many hip fractures were really prevented? With no drug therapy at all, women with osteoporosis had a 99.5 percent chance of making it through each year without a hip fracture -- pretty good odds. With drug therapy, their odds improved to 99.8 percent. In other words, taking the drugs decreased their risk of hip fracture from 0.5 percent per year to 0.2 percent per year. This tiny decrease in absolute risk translates into the study's reported 56 percent reduction in relative risk. The bottom line is that 81 women with osteoporosis have to take Fosamax for 4.2 years, at a cost of more than $300,000, to prevent one hip fracture. (This benefit does not include a reduction of less serious fractures, including wrist and vertebral fractures. Most vertebral fractures cause no symptoms.)
What about using these drugs to prevent osteoporosis? The study of Fosamax published in JAMA in 1998 (mentioned earlier) also included women with osteopenia. Did Fosamax reduce their risk of fracture? The results show that the risk of hip fractures actually went up 84 percent with Fosamax treatment.* The risk of wrist fractures increased by about 50 percent.(25)
Effect of Alendronate on Risk of Fracture in Women With Low Bone Density but Without Vertebral Fractures Results From the Fracture Intervention Trial (15)
Steven R. Cummings, MD; Dennis M. Black, PhD; Desmond E. Thompson, PhD; William B. Applegate, MD; Elizabeth Barrett-Connor, MD; Thomas A. Musliner, MD; Lisa Palermo, MA; Ronald Prineas, MD; Susan M. Rubin, MA; Jean C. Scott, PhD; Thomas Vogt, MD, MPH; Robert Wallace, MD; A. John Yates, MD; Andrea Z. LaCroix, PhD; for the Fracture Intervention Trial Research Group , JAMA. 1998;280:2077-2082.
HIP Fractures Reduced for 56% for Osteoporosis,
But Increased 84% in Osteopenia
Alendronate (Fosamax) reduced the risk of hip fractures by 56% among women with a femoral neck T score of -2.5 or less: 18 (2.2%) in the placebo group vs 8 (1.0%) in the alendronate group (RH, 0.44; 95% CI, 0.18-0.97; placebo-treatment difference, 1.2%; NNT, 81).
There was no reduction in risk among those whose femoral neck T scores were more than -2.5: 6 (0.4%) in the placebo group vs 11 (0.8%) in the alendronate group (RH, 1.84; 95% CI, 0.70-5.36).
Fosamax Treatment Increases Wrist Fractures by 53% for T score above -2.5
The effect of alendronate on the risk of wrist fractures also varied by baseline femoral neck BMD. There was no significant reduction among women with a T score of -2.5 or less: 38 (4.7%) in the placebo and 34 (4.2%) in the alendronate group (RH, 0.88; 95% CI, 0.55-1.40).
Similarly, we observed no reduction in risk among women with T scores of -2.0 to -2.5: 20 (2.8%) in the placebo group vs 27 (3.7%) in the alendronate group (RH, 1.33; 95% CI, 0.75-2.4). Among those whose femoral neck T scores were more than -2.0, more fractures occurred in the treatment group (n = 22, 3.3%) than in the placebo group (n = 12, 1.7%; RH, 1.9; 95% CI, 1.0-4.0; placebo-treatment difference, 1.6%).
For T score greater than -2.5 (49 fxs alendronate vs 32 fxs placebo) = RH 1.53
The Osteopenia Group Has No Benefit from the Drug
The FIT data is very clear. For the Osteopenia group, wrist fractures are clearly increased by Fosamax treatment, and there is an increase in Hip fractures in the osteopsenia group. Why should there be increased fractures in any group. This revelation indicates a serious problem which has been ignored, and suggests there is something seriously wrong with the bone physiology of bisphosphonate drug treatment.
Spontaneous Mid Femur Fractures on Bisphosphonates
Reports by Odvina(28) of spontaneous femur fractures and similarities with Pycnodysostosis, Toulous Lautrec's rare genetic bone disease, raises even more questions about the bisphosphonate class of drugs. The report by Odvina of spontaneous mid femur fractures has been duplicated by Goh with his 2007 report of subtrochanteric femur fractures with minimal trauma in women on long term fosamax. (29). A third report of spontaneous fractures in menopausal women on fosamax was just reported in the New England Journal March 20, 2008 by Dr. Joseph M Lane. (42) How many Menopausal women must suffer spontaneous mid femur fractures before we declare enough is enough and ban this entire class of drugs?
Use this link to contact your representative and send an email or letter of concern. (38) https://forms.house.gov/wyr/welcome.shtml
Disease Mongering or Prevention?
A January 2008 BMJ report by Pablo Alonso-Coello makes the case that the drug industry's bisphosphonate marketing programs is actually a form of disease mongering designed to convince osteopenic women to take bisphosphonates even though there is no evidence of benefit for this group.(18)
In order to obtain informed consent, all women offered these drugs must be informed about potential risks and benefits, and then be allowed to make their own decision. I have found that most women with osteopenia who are aware of this information will decline the bisphosphonates.
Aubrey Blumsohn says:
”These are good drugs when used appropriately. However, I'm not sure that the risks and benefits (and possibility of unknown risk) have been appropriately weighed so as to allow correct, cost effective and safe targeting of therapy. We know nothing about the long term (30 year) benefits or risks of bisphosphonates.”(17)
Dr. Blumsohn was the lead researcher in an Actonel study in Sheffield England. The data was blinded, and the paper published by ghost writers hired by P and G without Blumsohn seeing the actual unblinded data. When Blumsohn objected, he was fired from his job at the university. (40)
Susan Ott, MD at the University of Washington Says:
Many physicians do not even consider the possibility that bisphosphonates could have some adverse effects on the bone. The interesting results described in the paper by Odvina et al. along with reports from animal studies and biopsy data from clinical trials, should heighten awareness of the actions of these drugs. The profound suppression of bone formation could have negative effects that occur after long-term accumulation in the skeleton. There is no good surrogate for the passage of time, and it will be at least a decade before we have any data about whether the potential negative effects would ever predominate over the known positive effects. Until then, bisphosphonates should be used carefully. Men and women with established osteoporosis have a high risk of fragility fractures within the 5 yr after diagnosis, and in these cases the proven benefits outweigh the theoretical long-term risks. These benefits, however, are proven only for the first 5 yr. I believe the current evidence suggests that bisphosphonates should be stopped after 5 yr. Those patients who remain at a high risk of fractures or who have had fractures despite bisphosphonate therapy could be considered for treatment with intermittent PTH. (30)
Preventing the Fall is May be More Important Than the Osteoporosis Drug
My grandmother (left image self portrait), who lived to be 100, had severe osteoporosis with many spinal compression fractures and rib deformities, yet she never had a hip fracture because she never sustained a fall. A recent BMJ article has called for a more logical approach, shifting away from osteoporosis drugs to instead, preventing the falls that produce the deadly hip fractures.(23)
For more on the effects of bisphosphonates, and the similarities with Toulouse Lautrec's Disease (pycnodysostosis) see my previous article.(19)
Above image, Eve Garrison Self Portrait, my grandmother the artist, lived to be 100.
Reverse Osteoporosis Naturally WIthout Drugs
Perhaps the most important concept to reverse osteoporosis is acid base balance which is described in this article, Acid-Alkaline Balance and Its Effect on Bone Health by Susan E. Brown, Ph.D., CCN, and Russell Jaffe, MD, Ph.D., CCN, International Journal of Integrative Medicine, Vol. 2, No. 6 Nov/Dec 2000.(39)
Jeffrey Dach MD
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FDA: Alert , Information for Healthcare Professionals
Bisphosphonates (marketed as Actonel, Actonel+Ca, Aredia, Boniva, Didronel, Fosamax, Fosamax+D, Reclast, Skelid, and Zometa)
September 15, 2006 Skeletal Microdamage Stable After First Year, Study Shows
PHILADELPHIA — (Sept. 15, 2006) Skeletal microdamage resulting from bisphosphonate treatment may be maximal during the first year of treatment, and not continue to accumulate with longer periods of treatment, according to new research being presented today at the 28th Annual Meeting of the American Society for Bone and Mineral Research (ASBMR).
Bisphosphonates are the most common class of drugs used for the treatment of osteoporosis because of their demonstrated effect on fracture reduction but the incidence of microcracks - small cracks in the skeleton - has been shown to increase with bisphosphonate treatment. This has led to some concerns regarding the potential long-term adverse effects of these agents. This study shows that the continued use of alendronate (a bisphosphonate) is not associated with continued accumulation of microdamage. Matt R. Allen, Ph.D., assistant research professor, and David B. Burr, Ph.D., chairman, both from the Indiana University School of Medicine Department of Anatomy and Cell Biology, Indianapolis, IN, evaluated the effects of alendronate in one-year-old female beagles.
Message Board adverse side effects of Fosamax (600 messages)
Message Board with 530 messages about adverse effects of Actonel.
Fossy Jaw list of articles
Journal of the New Zealand Medical Association, 01-December-2006, Vol 119 No 1246
Jaw osteonecrosis associated with bisphosphonates
Jodie Battley, Sisira Jayathissa, Eric Seneviratne
Systematic Review: Bisphosphonates and Osteonecrosis of the Jaws
Sook-Bin Woo, DMD; John W. Hellstein, DDS, MS; and John R. Kalmar, DMD, PhD
Bisphosphonates can cause hypocalcemia and vitamin D deficiency.
Berthold HK, Diel IJ, Gouni-Berthold I. Phossy jaw revisited -- do bisphosphonates cause "bisphossy jaws"? Drug Safety. 2004;27:92
Wikipedia Phossy Jaw
There is evidence that occupational exposure to white phosphorus affects bones other than those in the jaw; this implies a systemic effect for inhaled white phosphorus.
Two middle-aged men occupationally exposed to white phosphorus for 20-30 years had a history of breaking their femurs in accidents not normally expected to result in breakage of bones (Dearden 1899).
One man had broken the right and left femurs on two separate occasions by “tripping over a board,” while the other broke the right femur by “stumbling down a single step,” and the left femur in “just as simple a manner.”
Examination of bone from the fingertip of one of the two workers indicated an increased “relative proportion of phosphoric acid to lime” compared to healthy bone by nearly 1%.
Thus, occupational exposure to white phosphorus may change the composition of bone tissue, decreasing the bones ability to resist fracture; however, the information reported in this study is insufficient to definitively attribute the observed effects to occupational exposure to white phosphorus.
Letters, Bisphosphonates and osteonecrosis: analogy to phossy jaw MJA 2005; 183 (3): 163-164
ADRAC Report Bisphosphonates and osteonecrosis of the jaw Patrick M Purcell and Ian W Boyd MJA 2005; 182 (8): 417-418
Use of Oral Bisphosphonates and the Risk of Aseptic Osteonecrosis: A Nested Case-Control Study Oct 2007 MAHYAR ETMINAN, KEVIN AMINZADEH, IAN R. MATTHEW, and JAMES M. BROPHY ABSTRACT.
Objective. To determine whether use of oral bisphosphonates is associated with an increased risk of aseptic osteonecrosis (AON) among a cohort of elderly cardiovascular patients.
Methods. We conducted a nested case-control study within a previously defined cardiovascular cohort of elderly Quebec patients using linked administrative health databases. Cases were defined as those with the diagnosis of hospitalization secondary to AON at a nonspecified site. For each case, 10 controls were randomly selected and matched to the cases by age, calendar time, and length of followup. The main outcome measure was the risk ratio (RR) of AON among ever-users of oral bisphosphonates compared to that among nonusers.
Results. The initial cohort consisted of 87,837 subjects. In the primary analysis, the adjusted RR for AON among bisphosphonate users was 2.87 (95% CI 1.71-5.05). The adjusted RR for alendronate, etidronate, and risedronate were 2.87 (95% CI 1.46-5.67), 2.43 (95% CI 1.05-5.62), and 3.34 (95% CI 1.04-10.67), respectively.
Conclusion. In this cohort of elderly cardiovascular patients, an association was observed between oral bisphosphonate use and aseptic osteonecrosis. Further research into this putative association is required. (J Rheumatol First Release Jan 15 2008)
McClung MR, Geusens P, Miller PD, Zippel H, Bensen WG, Roux C, Adami S, Fogelman I, Diamond T, Eastell R, Meunier PJ, Reginster JY. Effect of risedronate on the risk of hip fracture in elderly women. Hip Intervention Program Study Group. New England Journal of Medicine Feb 1, 2001; 344: 333 - 340. full text of article
Effect of Alendronate on Risk of Fracture in Women With Low Bone Density but Without Vertebral Fractures Results From the Fracture Intervention Trial
Bone Mass, Bone Fragility, and the Decision to Treat Robert P. Heaney, MD JAMA. 1998;280:2119-2120.
Bisphosphonate induced pain in osteoporosis - statistical analysis discovered, Aubrey Blumson
BMJ 2008;336:126-129 (19 January), doi:10.1136/bmj.39435.656250.AD
Drugs for pre-osteoporosis: prevention or disease mongering? Pablo Alonso-Coello, family practitioner1, Alberto López García-Franco, family practitioner2, Gordon Guyatt, professor3, Ray Moynihan, conjoint lecturer
Fosamax, Actonel, Osteoporosis and Toulouse Lautrec by Jeffrey Dach M.D.
http://www.keele.ac.uk/schools/pharm/MTRAC/ProductInfo/verdicts/R/Risedronate%20osteo.pdf MTRAC information on Actonel
NICE guidance recommends bisphosphonates be used as secondary prevention for postmenopausal women who present with osteoporotic fragility fracture
JOHN J. CAREY, MD Department of Rheumatic and Immunologic Diseases, The Cleveland Clinic Foundation What is a ‘failure’ of bisphosphonate therapy for osteoporosis?
BMJ 2002;324:886-891 ( 13 April ) Education and debate,
Selling sickness: the pharmaceutical industry and disease mongering
Commentary: Medicalisation of risk factors, Selling sickness: the pharmaceutical industry and disease mongering
Ray Moynihan, journalist a, Iona Heath, general practitioner b, David Henry, professor of clinical pharmacology c.
Against a background of controversy over disease definition, poor predictive value of bone density measurement, and heavily advertised expensive therapies offering marginal benefits to menopausal women, corporate backed promotional activities are attempting to persuade millions of healthy women worldwide that they are sick.
BMJ 2008;336:124-126 (19 January)
Shifting the focus in fracture prevention from osteoporosis to falls Teppo L N Järvinen, Harri Sievänen, Karim M Khan, Ari Heinonen,Pekka Kannus,
Falling, not osteoporosis, is the strongest single risk factor for fractures in elderly people. Bone mineral density is a poor predictor of an individual’s fracture risk. Drug treatment is expensive and will not prevent most fractures in elderly people.
Randomised controlled trials show that falls in older people can be reduced by up to 50%. General practitioners should shift the focus in fracture prevention by systematically assessing risk of falling and providing appropriate interventions to reduce the risk
Osteoporosis web page on jeffrey dach md Web site
Exerpt from OverDosed America by John Abramson MD
Bisphosphonates will modestly reduce the hip and spinal fracture rate, but the published evidence for this benefit is primarily confined to elderly women with low bone mineral density and at least one other major risk, such as a previous spinal fracture.
An osteoporosis-related hip fracture is rare in women younger than 70 (the average age at which it occurs in women is 79), and only 18% of all white women will ever have a fracture. One reason to reserve treatment for high-risk older women is the lack of long-term information--beyond seven years--about bisphosphonate's safety and continued effectiveness.
The shift in thinking about osteoporosis prevention is reflected in the revised recommendations about when to start bone density testing. Several medical organizations, such as the National Osteoporosis Foundation, now suggest that women not start until age 65, unless they are at extremely high risk. Some osteoporosis researchers have made a case for the quality of bone strength as the more important indicator of a future fracture than bone density. There is no available test for bone strength.
How Good are the Best Drugs?
The bisphosphonates cannot improve bone strength, but they are the only drugs proven to reduce the rate of hip and spinal fractures. Actonel, for example, modestly reduced the fracture rate in a study of 10,000 high-risk elderly women with low bone density or osteoporosis and at least one risk factor for hip fracture, such as an unsteady gait. At three years, there was a 1% lower rate of hip and spinal fractures among the women taking Actonel than those taking the placebo. Interestingly, the three-year fracture rate was low in these supposedly high-risk women, even among those not taking the drug. Overall, the fracture rate was 4% among those taking a placebo versus 3% among those on Actonel (New England Journal of Medicine, 2/1/01).
The fracture prevention value of bisphosphonates in younger women is yet to be demonstrated. In another trial, 1,609 postmenopausal participants, aged 45 to 59 years, were chosen because they did not have osteoporosis. Short-term treatment with Fosamax (5 mg/daily or 2.5 mg/daily) was compared with estrogen plus progestin. The idea was to see whether Fosamax had a sustained effect once the drug was discontinued. The study was paid for in part by a grant from Merck, maker of Fosamax. Some of the women in the Fosamax group took the drug for two years and were than switched to a placebo; others remained on the drug for the four-year duration of the study.
At the end of this study, bone loss had been prevented in those taking Fosamax and in those on estrogen/progestin. Continuous Fosamax treatment, however, was more effective in preventing bone loss than the shorter two-year regimen. The fracture rate is low in this age group, and the study lasted only four years; therefore, this trial could not show that Fosamax reduced fractures (Annals of Internal Medicine, 12/21/99).
gilliansanson.com The Myth of Osteoporosis By Gillian Sanson MCD Century Publications, 2003. In The Myth of Osteoporosis: What Every Women Should Know About Creating Bone Health, Sanson writes about a pervasive set of misperceptions and controversies that surround osteoporosis – from the diagnosis and treatment of the disease to even the definition of the disease itself.
The Journal of Clinical Endocrinology & Metabolism Vol. 90, No. 3 1294-1301, 2005
Severely Suppressed Bone Turnover: A Potential Complication of Alendronate Therapy Clarita V. Odvina, Joseph E. Zerwekh, D. Sudhaker Rao, Naim Maalouf, Frank A. Gottschalk and Charles Y. C. Pak
Journal of Bone and Joint Surgery - British Volume, Vol 89-B, Issue 3, 349-353. 2007 Subtrochanteric insufficiency fractures in patients on alendronate therapy
S.-K. Goh, ; K. Y. Yang, J. S. B. Koh, M. K. Wong, ; S. Y. Chua, ; D. T. C. Chua, FRCS(Orth), and T. S. Howe, FRCS(Orth),
We identified 13 women of whom nine were on long-term alendronate therapy and four were not. The patients treated with alendronate were younger, with a mean age of 66.9 years (55 to 82) vs 80.3 years (64 to 92) and were more socially active.
The fractures sustained by the patients in the alendronate group were mainly at the femoral metaphyseal-diaphyseal junction and many had occurred after minimal trauma. Five of these patients had prodromal pain in the affected hip in the months preceding the fall, and three demonstrated a stress reaction in the cortex in the contralateral femur.
Our study suggests that prolonged suppression of bone remodelling with alendronate may be associated with a new form of insufficiency fracture of the femur. We believe that this finding is important and indicates the need for caution in the long-term use of alendronate in the treatment of osteoporosis.
The Journal of Clinical Endocrinology & Metabolism Vol. 90, No. 3 1897-1899
2005 by The Endocrine Society,
Long-Term Safety of Bisphosphonates,
Susan M. Ott University of Washington Seattle, Washington
Royce PC, Goodman RL, Schott AM, Dargent-Molina P, Meunier PJ, McClung M
New Engl J Med May 31, 2001; 344: 1720 Letter to Editor.
... of such incomplete data. A slight preponderance of fractures among those lost to follow-up in the risedronate group could render the results inconclusive., To the Editor: McClung et al. found that risedronate ...
The Effect of Risedronate on the Risk of Hip Fracture in Elderly Women
To the Editor: The report by McClung et al. (Feb. 1 issue)1 is unconvincing, because information is not presented to show that the women in the treatment and placebo groups had similar clinical risk factors for hip fracture. This information should have been included in the table showing the base-line characteristics of the groups.
To the Editor: McClung et al. state that "complete follow-up data were available for 64 percent of the women." In other words, follow-up data were incomplete for 36 percent, or 3324, of the 9331 . . .
Paul C. Royce, M.D., Ph.D.
9 Prospect Rd.
Atlantic Highlands, NJ 07716
McClung MR, Geusens P, Miller PD, Zippel H, Bensen WG, Roux C, Adami S, Fogelman I, Diamond T, Eastell R, Meunier PJ, Reginster JY. Effect of risedronate on the risk of hip fracture in elderly women. Hip Intervention Program Study Group. New England Journal of Medicine Feb 1, 2001; 344: 333 - 340.
Sally Field, Boniva, and Media Ethics
Sally Field Blog on Osteoporosis and Boniva
video, Sally Field plugs here website for boniva
Boniva Web Site
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Washington, DC 20515
Use this link to Contact Your representative.
Acid-Alkaline Balance and Its Effect on Bone Health by Susan E. Brown, Ph.D., CCN, and Russell Jaffe, MD, Ph.D., CCN, International Journal of Integrative Medicine, Vol. 2, No. 6 Nov/Dec 2000
Rent-a-Researcher Did a British university sell out to Procter & Gamble? By Jennifer Washburn Dec. 22, 2005
Protect Your Family from Bad Drugs, Drugs in Litigation by Jeffrey Dach MD
NEJM Volume 358:1304-1306 March 20, 2008 Number 12
Atypical Fractures of the Femoral Diaphysis in Postmenopausal Women Taking Alendronate Brett A. Lenart, B.S. Dean G. Lorich, M.D. Joseph M. Lane, M.D. Weill Cornell Medical College New York, NY 10021
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