Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Risk of Fractures with Long-Term Alendronate Use

BMJ; ePub 2016 Jun 28; Abrahamsen, Eiken, et al

Publish date:

A balance between benefit and risk was observed in patients treated with alendronate in terms of fracture outcomes, even for long-term continuous use of 10 or more years. This according to a cohort and nested study of 61,990 men and women aged 50 to 94 years at the start of treatment who had not previously taken alendronate from 1996 to 2007. Researchers found:

• 1,428 participants sustained a subtrochanteric femur or femoral shaft (ST/FS – also know as atypical femur fractures) and 6,784 sustained a hip fracture.

• Risk of ST/FS was lower with high adherence to treatment with alendronate compared with poor adherence.

• Long-term adherent use of alendronate in excess of 10 dose years was associated with an adjusted 30% lower risk of hip fracture and no increase in the risk of fractures of the ST/FS.

• The risk of fracture was no higher in long-term users (≥10 dose years) or in current users compared with past users.

• Similarly, medication possession ratio (MPR) >80% was associated with a decreased risk of hip fracture was longer term cumulative use for 5 to 10 dose years.

Citation: Abrahamsen B, Eiken P, Prieto-Alhambra D, Eastell R. Risk of hip, subtrochanteric, and femoral shaft fractures among mid and long term users of alendronate: Nationwide cohort and nested case-control study. [Published online ahead of print June 28, 2016]. BMJ. doi:10.1136/bmj.i3365.

Commentary: Concern over atypical femur fractures, which appears to increase in incidence after long-term use of bisphosphonates, has raised questions about the risk vs benefit of bisphosphonates therapy in the treatment of osteoporosis.1 This has in turn led to a 50% decline in prescriptions for bisphosphates in the US.2 Osteoporosis is common and its consequences, both hip fractures and vertebral compression fractures, are severe. The current study raises questions using real world data about the degree to which atypical fractures occur over time. The study makes an important point that the net benefit of bisphosphonates after 10 to 14 years of treatment is that many more fractures are prevented than caused. —Neil Skolnik, MD

1. Järvinen TL, Michaëlsson K, Jokihaara J, et al. Overdiagnosis of bone fragility in the quest to prevent hip fracture. BMJ. 2015;350:h2088. doi:10.1136/bmj.h2088.

2. Jha S, Wang Z, Laucis N, Bhattacharyya T. Trends in media reports, oral bisphosphonate prescriptions, and hip fractures 1996-2012: An ecological analysis. J Bone Miner Res. 2015;30:2179-87. doi:10.1002/jbmr.2565.

This Week's Must Reads

Must Reads in Pain