Two other talks at the meeting presented further data documenting the risks of atypical and typical fractures with bisphosphonate treatment, as follows:
▸ Patients taking a bisphosphonate face a risk of about 1 additional subtrochanteric hip fracture for every 100 typical hip fractures prevented, according to an analysis of national data during 1996-2007. The new data present no direct evidence for a role of bisphosphonate use in causing subtrochanteric hip fractures. But the temporal link between the steady increase in bisphosphonate use in elderly women during 1996-2007 and the concurrent rise in subtrochanteric fractures also in elderly women strongly suggests that a causal link exists, John Wang, Ph.D., a statistician at the National Institute of Arthritis and Musculoskeletal and Skin Diseases, said at the meeting.
His finding was based on an analysis of subtrochanteric fracture rates from the Nationwide Inpatient Sample during 1996-2007, along with data on bisphosphonate use from the Medical Expenditure Panel Survey. The analysis also showed that the start of widespread bisphosphonate use in 1996, quickly followed by even broader use over the following years, had a temporal relationship with subtrochanteric fractures, which began rising in 2000.
▸ Analysis of data collected on residents of Olmsted County, Minn. through the Rochester Epidemiology Project showed that the annual, population-based rate of first, nonhip femoral fractures associated with minimal or moderate trauma was 7 per 100,000 residents during 1984-1995, and 12 per 100,000 residents during 1996-2007, a significant difference. (Routine prescribing of bisphosphonates began in 1996.) This and related findings in the population-based analysis show that “bisphosphonate therapies may have a modest potential impact on nonhip femoral fractures observed across the whole population,” said Dr. Alvin Ng, a physician at the Mayo Clinic in Rochester.
Dr. Wang and Dr. Ng had no disclosures. Dr. Shane has been a consultant to Amgen and has received research support from Merck, Novartis, and Eli Lilly & Co.
'The data argue that if a patient does not have osteoporosis, then bisphosphonates are not the appropriate drug.'
Source DR. OTT
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New Approach to Bisphosphonate Use
DR. EBELING said that he has served as a speaker for Merck & Co., Eli Lilly, Novartis, and Sanofi-Aventis; that he has been on advisory boards for Merck, Amgen, and Novartis; has received educational grants from Amgen, Eli Lilly, and Sanofi-Aventis; and has received research grants from Merck, Novartis, and Amgen.
The task force assembled by the ASBMR recommended several steps for physicians to take when they prescribe a bisphosphonate to reduce atypical fracture risk.
Patients with a low absolute fracture risk should not receive a bisphosphonate, said Dr. Peter R. Ebeling, a task force member, summarizing the group's recommendations at the meeting.
Another step is minimizing the duration of bisphosphonate treatment. This means realizing that patients with secondary causes of rapid bone loss may not need long-term bisphosphonate treatment. Continued use of the drugs beyond 5 years should be evaluated annually, said Dr. Ebeling, professor and chairman of medicine at the University of Melbourne.
Patients without a recent fracture and with a femoral neck T score of more than −2.5 after 5 years of continuous bisphosphonate treatment should receive consideration for a drug holiday. Patients who are taken off bisphosphonate treatment should undergo an annual assessment of their clinical status, markers of bone turnover, bone density, and their fracture risk.
Because most patients who developed an atypical fracture on bisphosphonate treatment had prodromal pain in their thigh or groin, physicians should alert patients to watch for and promptly report such pain. During regular examinations of patients on a bisphosphonate or another potent antiresorptive drug, physicians should ask if prodromal pain exists. When suspicious pain occurs, the patient needs “urgent” radiographic assessment of both femora, Dr. Ebeling said. If the radiographs appear normal, perform a follow-up examination by MRI or radionuclide scintigraphy scanning. Physicians should be aware that bilateral, atypical femur fractures can occur.
If a patient has a fracture while on a bisphosphonate, treatment with the that or any other potent antiresorptive drug should stop. At that time, assess the patient's calcium and vitamin D status and prescribe adequate supplementation if needed. The physician should consider prescribing teriparatide to improve fracture healing, particularly if it appears that the fracture has not healed by 4-6 weeks following surgical repair. In patients who should not receive teriparatide, such as those with a history of breast cancer or skeletal irradiation, consider another option such as treatment with raloxifene.
