Drawbacks of bisphosphonate holidays, bone benefits of the Mediterranean diet, and a new weapon against glucocorticoid-induced osteoporosis.
References1. Bindon B, Adams W, Balasubramanian N, Sandhu J, Camacho P. Osteoporotic fractures during bisphosphonate drug holiday. Endocr Pract. 2018;24:163-169. doi: 10.4158/EP171975.OR.2. Silva TR, Martins CC, Spritzer PM. Mediterranean dietary pattern is positively associated with bone mineral density and lean mass in postmenopausal women: a cross-sectional study. Presented at: ENDO 2018; March 19, 2018; Chicago, Illinois. Abstract MON-301.3. Saag KG, Wagman RB, Geusens P, et al. Denosumab versus risedronate in glucocorticoid-induced osteoporosis: a multicentre, randomised, double-blind, active-controlled, double-dummy, non-inferiority study. Lancet Diabetes Endocrinol. 2018;6:445-454. doi: 10.1016/S2213-8587(18)30075-5.
Highlights of three studies in osteoporosis include: (1) 15% of patients with osteoporosis who take drug holidays have bone fractures; (2) the heart-healthy Mediterranean diet also appears to improve bone density in older women; and (3) the monoclonal antibody denosumab could be a useful treatment for glucocorticoid-induced osteoporosis.1-3 Scroll through the slides for the latest findings and their clinical implications.
(Spine: ©Lightspring/Shutterstock.com; olive: ©EcoPimStudio/Shutterstock.com; bone: ©Lightspring/Shutterstock.com)
Patients who receive long-term bisphosphonate therapy often temporarily suspend drug use to prevent rare adverse events, such as atypical femoral fractures and osteonecrosis of the jaw. However, drug holidays may increase the risk of bone fractures.
A retrospective chart review of 401 patients with osteopenia or osteoporosis who began a bisphosphonate drug holiday from 2004 to 2013 found 62 patients (15.4%) had a fracture during follow-up.1
Those most likely to experience fractures were older and had lower bone mineral density at the beginning of the study. After the fractures occurred, bisphosphonate therapy was resumed.
Clinical Implications: “Patients who begin drug holidays at high risk for fracture based on bone mineral density, age, or other clinical risk factors warrant close follow-up during the holiday, especially as its duration lengthens. Fracture risk needs to be regularly assessed during the drug holiday and treatment resumed accordingly,” stated the researchers led by senior author Pauline Camacho, MD, Director, Loyola University Osteoporosis and Metabolic Bone Disease Center in Maywood, Illinois.
A Mediterranean diet may be a positive lifestyle factor as well as a nonpharmacologic strategy for primary prevention of osteoporosis and fractures in postmenopausal women.
A study included 103 healthy women (average age, 55 years) who had gone through menopause 5.5 years earlier, on average.2 The women had bone scans to measure their bone mineral density, total body fat, and appendicular lean mass, which was used to estimate skeletal muscle mass. They also completed a food questionnaire about what they had eaten during the past month.
Women with greater adherence to the Mediterranean diet had higher lumbar spine bone mineral density and greater muscle mass, independent of whether they had used hormone therapy previously, their prior smoking behavior, or their current level of physical activity, as measured by wearing a pedometer for 6 days.
For more details about the study, please see Mediterranean Diet Benefits Bone Density and Muscle Mass After Menopause.
Clinical Implications: “We found that the Mediterranean diet could be a useful nonmedical strategy for the prevention of osteoporosis and fractures in postmenopausal women. Postmenopausal women, especially those with low bone mass, should ask their doctor whether they might benefit from consuming this dietary pattern,” said lead author Thais Rasia Silva, PhD, a postdoctoral student at Universidade Federal do Rio Grande do Sul in Brazil.
Denosumab is effective in reducing glucocorticoid-induced bone loss.
A multicenter, randomized, double-blind, non-inferiority study compared denosumab with risedronate in glucocorticoid-induced osteoporosis.3 The study enrolled 795 patients at 79 health care centers in Europe, Latin America, Asia, and North America. Of these, 505 were glucocorticoid-continuing patients who had received glucocorticoids for at least 3 months, and 290 were glucocorticoid-initiating patients who had received glucocorticoids for less than 3 months.
The patients were randomly assigned to subcutaneous denosumab injections every 6 months and a placebo pill (398 patients) or oral risedronate daily and a placebo injection every 6 months (397 patients).
Denosumab was superior to risedronate for bone density measured in the total hip and at the neck of the femur, and led to superior lumbar spine bone density after 12 months. The two treatment groups had similar safety profiles.
Clinical Implications: “To our knowledge, ours is the first large, randomized controlled trial of denosumab in patients with glucocorticoid-induced osteoporosis who were either prevalent glucocorticoid users or newly initiating glucocorticoid therapy. Denosumab could be a useful addition to the treatment armamentarium for glucocorticoid-induced osteoporosis,” stated the researchers led by Kenneth Saag, MD, Professor of Medicine at the University of Alabama at Birmingham.