Comparative effectiveness of pharmacologic treatments to prevent fractures.

[Argirios Argiriou]

October 21, 2014
Pharmacologic Fracture Prevention
Jamaluddin Moloo, MD, MPH reviewing Crandall CJ et al. Ann Intern Med 2014 Sep 9.

Several effective medications are available, but head-to-head comparative data remain sparse.

Much recent research has focused on osteoporosis management. An updated review of 294 articles addresses benefits, harms, and duration of pharmacologic treatments as well as bone-density monitoring.

Compared with placebo, bisphosphonates, denosumab (Prolia), and teriparatide (Forteo) lowered fracture risk in postmenopausal women with osteoporosis (number needed to treat [NNT] to prevent 1 vertebral fracture, 60–89; NNT to prevent 1 hip fracture, 50–60) ( ! )— and, in a trial in men, zoledronic acid (Reclast) was associated with lower clinical fracture rates (1.0% vs. 1.8%; NNT, 125) ( ! ). Limited data suggest that raloxifene only prevents vertebral fractures. Adverse events associated with bisphosphonates, denosumab, and teriparatide include mild upper gastrointestinal symptoms. Raloxifene is associated with hot flashes and thromboembolic events. Long-term bisphosphonate use can raise risk for atypical femoral fractures (however, absolute risk is markedly less than likelihood of hip fracture in untreated high-risk patients). Bisphosphonates also have been associated with osteonecrosis of the jaw, most commonly with intravenous use. Moderate-strength evidence suggests that bone-density monitoring is unnecessary for women with T-scores better than −1.5, because progression to osteoporosis within 15 years is rare. However, monitoring women with vertebral fracture histories and 5 years of alendronate use probably is beneficial. Regarding duration of therapy, continuing beyond 5 years might be minimally beneficial; however, for women with baseline vertebral fractures who receive alendronate, ongoing treatment might be advantageous.
Comment

By condensing a large body of recent literature on pharmacologic treatments and monitoring of patients at risk for fractures, this systematic review provides a good framework for approaches to fracture prevention. Nonetheless, head-to-head efficacy data are sorely needed.

Citation(s):

    Crandall CJ et al. Comparative effectiveness of pharmacologic treatments to prevent fractures: An updated systematic review. Ann Intern Med 2014 Sep 9; [e-pub ahead of print]. (Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος)

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