Pharmacologic Prevention of Osteoporotic Fractures THOMAS M. ZIZIC, M.D., Johns Hopkins University School of Medicine, Baltimore, Maryland

Osteoporosis is characterized by low density and a deterioration in the microarchitecture of bone that increases its susceptibility to fracture. The World Health Organization defines as a bone mineral density that is 2.5 standard deviations or more below the reference mean for healthy, young white women. The prevalence of osteoporosis in black women is one half that in white and Hispanic women. In white women 50 years and older, the risk of osteoporotic fracture is nearly 40 percent over their remaining lifetime. Of the that have been approved for the prevention or treatment of osteoporosis, the bisphosphonates (risedronate and alendronate) are most effective in reducing the risk of vertebral and nonvertebral fractures. Risedronate has been shown to reduce fracture risk within one year in postmenopausal women with osteoporosis and in patients with -induced osteoporosis. Hor- mone therapy reduces fracture risk, but the benefits may not outweigh the reported risks. , a recombinant human parathyroid hormone, reduces the risk of new fractures and is indicated for use in patients with severe osteo- porosis. has been shown to lower the incidence of vertebral fractures in women with osteoporosis. Salmon is reserved for use in patients who cannot tolerate bisphosphonates or hormone therapy. (Am Fam Physician 2004;70:1293-300. Copyright© 2004 American Academy of Family Physicians.) ▲ Editorial: page 1219. steoporosis is a disease that is white women 50 years and older, the lifetime This article exem- characterized by low bone mass risk of osteoporotic fractures approaches plifies the AAFP 2004 and a deterioration in the micro- 40 percent.4 More than 90 percent of hip and Annual Clinical Focus on architecture of bone that increases vertebral fractures in elderly white women caring for America’s aging O its susceptibility to fracture.1 Normal bone are attributed to osteoporosis.5 population. mineral density (BMD) measured using Osteoporosis is responsible for almost See page 1201 for dual x-ray absorptiometry is a T-score that 1 million vertebral and hip fractures annu- definitions of strength-of- 6 recommendation labels. falls within 1 standard deviation (SD) of ally (Figure 1). In 1995, osteoporotic frac- the reference mean for healthy, young white tures resulted in 2.5 million physician visits, women. Based on epidemiologic studies, the 432,000 hospitalizations, and 180,000 nurs- World Health Organization (WHO) defines ing home admissions.7 In the United States osteoporosis as a BMD (hip, spine, or wrist) alone, annual medical expenditures for the that is 2.5 SDs or more below the reference management of osteoporotic fractures may mean for healthy, young white women (cor- be as high as $15 billion.1 responding to a T-score below –2.5) and Vertebral fractures trigger back pain, defines as a BMD that is between limit activity, and confine patients to bed. 1 and 2.5 SDs below the reference mean.2 Multiple vertebral fractures cause kypho- Men generally have 20 percent greater sis and loss of height. Fracture at any site BMD than women. Blacks have 20 percent increases the risk for subsequent fracture8: greater than whites. Therefore, up to 20 percent of women who have an neither men nor blacks are affected with incident vertebral fracture incur another osteoporosis as frequently as white women, fracture within one year.9 One analysis10 although they can develop the disease. Glu- found that postmenopausal women with cocorticoids can induce osteoporosis in any hip or clinical (i.e., symptomatic) vertebral of these groups. fractures had an age-adjusted increased risk of death (greater than sixfold risk [6.68] Impact of Osteoporosis after , greater than eightfold Osteoporosis is twice as common in white risk [8.64] after vertebral fracture) during and Hispanic women as in black women.3 In the next four years.

Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright© 2004 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Risk Factors and Screening sensitivity but low specificity,14 and that the Reported risk factors for osteoporosis include role of clinical risk factors in deciding which a family history of the disease, hormonal patients to treat remains unclear. dysfunction, sedentary lifestyle, low body Low BMD increases the risk of fractures. weight, smoking, alcohol abuse, At the 12-month follow-up in the National and and D Osteoporosis Risk Assessment,16 postmeno- The U.S. Preventive Services deficiencies.11 Glucocorticoid pausal women 50 years and older with no Task Force recommends therapy also leads to fracture in previous diagnosis of osteoporosis but a T- bone mineral density up to 50 percent of patients12; score of �2.5 or lower had an adjusted frac- screening for women 65 bone loss is related to the dos- ture risk that was 2.74 times higher than the years and older without risk age and duration of therapy, and risk in women with a normal BMD. factors. Screening should proceeds rapidly during the first The U.S. Preventive Services Task Force begin at age 60 in women six months of treatment.13 (USPSTF)17 recommends BMD screening who are at increased risk. A recent review14 found that for women 65 years and older without risk the relative risk of osteoporosis factors. Screening should begin at 60 years is highest in women who are in women who are at increased risk for menopausal, undergo oophorectomy before osteoporotic fractures. The USPSTF makes the age of 45, have a grandmother with no recommendation for or against BMD hip fracture, have diabetes mellitus, cur- screening in postmenopausal women who rently smoke, use alcohol heavily, or have are younger than 60 years or women aged decreased weight-bearing activity because of 60 to 64 years who are not at increased risk physical disability. for fractures. Based on research conducted to date, it appears that the short-term risk for osteo- Options for Prevention and Treatment porotic fractures can be estimated by BMD Because complications of osteoporosis prog- testing and identification of risk factors. ress quickly after fracture, rapidly effective Low body weight (less than 70 kg [154 lb]) is therapy is required to reduce fracture risk. the best predictor of low BMD.15 Note, how- A National Osteoporosis Foundation guide ever, that the instruments (e.g., question- offers useful treatment recommendations.18 naires) used to assess clinical risk factors for The U.S. Food and Administration low BMD or fractures have moderate to high (FDA) has approved a number of agents for use in the prevention or treatment of osteo- porosis (Table 1). Head-to-head comparisons of the efficacy of these agents in preventing Osteoporotic Fractures fractures have not been conducted.

750,000 700,000 BISPHOSPHONATES Bisphosphonates suppress -medi- ated . Of the FDA-approved 500,000 agents, bisphosphonates are the most effec- 300,000 tive in reducing the risk of vertebral and 250,000 250,000 nonvertebral fractures.19,20 Calcium (1,000 250,000 to 1,500 mg per day) and (400 to 800 IU per day) typically are administered 1 Annual Number of Fractures 0 along with bisphosphonates. Spine Hip Wrist Other Risedronate (Actonel), alendronate (Fosa- Fracture Site max), and ibandronate (Boniva) are approved for the prevention and treatment of osteo- Figure 1. Estimated incidence of osteoporotic fractures in the United porosis. Only risedronate and alendronate States. currently are available in oral formulations. Information from reference 6. Both of these agents are indicated for the

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prevention or treatment of postmenopausal patients should remain upright for at least osteoporosis and for the treatment of gluco- 30 minutes after dosing. corticoid-induced osteoporosis. Alendronate In randomized clinical trials,19,21-23 risedro- also is approved for the treatment of osteo- nate and alendronate substantially reduced porosis in men. Once-a-week formulations the risk of vertebral fractures. In one pla- of risedronate and alendronate are available cebo-controlled trial,20 risedronate signifi- for use in preventing or treating postmeno- cantly lowered the number of hip and other pausal osteoporosis. nonvertebral fractures in 70- to 79-year-old Because food and certain minerals reduce women who had severe osteoporosis and the absorption of bisphosphonates, risedro- an extremely low BMD. In another trial,23 nate and alendronate should be taken at least alendronate reduced the risk of hip fractures 30 minutes before the first food, drink (other in women with vertebral fractures and a low than water), or of the day. Tablets BMD. should be swallowed with 6 to 8 oz of water. To Administered once a day, risedronate and reduce the risk of gastroesophageal irritation, alendronate were equivalent to placebo in

TABLE 1 Agents Approved in the United States for the Management of Osteoporosis

Agents Dosage FDA-approved indications

Bisphosphonates Risedronate (Actonel) 5 mg orally once a day Prevention or treatment of postmenopausal 35 mg orally once a week osteoporosis 5 mg orally once a day Treatment of glucocorticoid-induced osteoporosis Alendronate (Fosamax) 5 mg orally once a day Prevention of postmenopausal osteoporosis 35 mg orally once a week 10 mg orally once a day Treatment of postmenopausal osteoporosis 70 mg orally once a week 5 mg orally once a day (10 mg orally Treatment of glucocorticoid-induced osteoporosis once a day in postmenopausal women not receiving estrogen) 10 mg orally once a day Treatment of osteoporosis in men 70 mg orally once a week Hormones Conjugated equine estrogen 0.625 mg orally once a day Prevention of postmenopausal osteoporosis Various estrogen preparations Dosage depends on agent. Prevention of postmenopausal osteoporosis Recombinant human parathyroid hormone Teriparatide (Forteo) 20 mcg SC once a day Treatment of postmenopausal osteoporosis Treatment to increase bone mass in men with osteoporosis who are at high risk for fracture Selective estrogen receptor modulator Raloxifene (Evista) 60 mg orally once a day Prevention or treatment of postmenopausal osteoporosis Salmon calcitonin (Miacalcin) 200 IU intranasally once a day Treatment of postmenopausal osteoporosis (alternating nostrils daily) 100 units SC or IM every other day

FDA = U.S. Food and Drug Administration; SC = subcutaneous; IM = intramuscular.

October 1, 2004 ◆ Volume 70, Number 7 www.aafp.org/afp American Family Physician 1295 safety.24,25 However, postmarketing reports was reduced by as much as 20 to 39 percent in showed a high incidence of gastroesophageal the three trials.19-21 In the HIP study,20 rised- irritation and ulceration in patients taking ronate significantly reduced the three-year alendronate.26-28 Although reported adverse risk of hip fractures by 40 percent (P = .009) gastrointestinal events with risedronate were in women aged 70 to 79 years with confirmed low, bisphosphonates have the potential to osteoporosis and by 60 percent (P = .003) in cause gastrointestinal irritation. Studies29,30 women with confirmed osteoporosis and one comparing once-a-day and once-a-week for- vertebral fracture at baseline. The HIP study mulations of either bisphosphonate demon- found no significant reduction in the risk of strated similar efficacy and tolerability. hip fractures in women 80 years or older who Postmenopausal Osteoporosis. Several three- had one or more risk factors but did not have year trials19-21 demonstrated the efficacy of confirmed osteoporosis. risedronate therapy in women with post- Alendronate has been shown to increase menopausal osteoporosis (Table 2).19-23,31 BMD and decrease fracture risk22,23,31 The two Vertebral Efficacy with Risedro- (Table 2).19-23,31 In one study,31 alendronate nate Therapy (VERT) trials19,21 evaluated the was used in postmenopausal women with effectiveness of risedronate, compared with a lumbar-spine T-score of �2.5 or lower. placebo, in reducing the risk of fracture in Patients received alendronate in a dosage of women with postmenopausal osteoporosis. 5 or 10 mg per day for three years, alendro- The North American VERT trial19 included nate in a dosage of 20 mg per day for two patients with two or more vertebral fractures years followed by 5 mg per day for one year, at baseline or one vertebral fracture and a or placebo for three years. Although the low spinal BMD (T-score of �2 or lower), and 10-mg dosage was more effective than the the multinational study21 included patients 5-mg dosage in increasing BMD, it did not with two or more vertebral fractures at base- provide additional fracture protection. The line. The Hip Intervention Program (HIP)20 alendronate regimen of 20 mg per day fol- assessed the efficacy of risedronate in reduc- lowed by 5 mg per day was similar in efficacy ing hip fractures in elderly women. About to the regimen of 10 mg per day in increasing 60 percent of the patients in the HIP study BMD but not in preventing fractures. A sig- were 70 to 79 years of age with established nificant reduction in new vertebral fractures osteoporosis, and about 40 percent were (48 percent, P = 0.03) was observed only when 80 years or older with a low femoral-neck all of the alendronate data were pooled. BMD or one or more clinical risk factors for The Fracture Intervention Trial (FIT)22,23 hip fractures. evaluated the efficacy of alendronate in In the VERT studies,19,21 risedronate reducing the risk of vertebral and nonver- reduced the relative risk of vertebral fractures tebral fractures in postmenopausal women by up to 65 percent after one year, and the with a low femoral-neck BMD. In the three- reduction was sustained for the three years of year arm of the study,23 patients with one or treatment. The risk of nonvertebral fractures more vertebral fractures at baseline received alendronate in a dosage of 5 mg per day for two years followed by 10 mg per day in the The Author third year, or placebo. In the four-year treat- THOMAS M. ZIZIC, M.D., is associate professor of medicine at Johns Hopkins ment arm,22 patients with a T-score of –1.6 University School of Medicine, Baltimore. For the past 24 years, his teaching, or lower but no vertebral fracture at baseline writing, and research have focused primarily on the prevention and treatment of osteoarthritis, osteonecrosis, and osteoporosis. Dr. Zizic founded the United received alendronate in a dosage of 5 mg per States Osteoporosis Network, Inc., in 1996. He has served on the board of day for two years followed by 10 mg per day directors of the Center for Osteonecrosis, the Foundation for Family Health for two years, or placebo. Compared with International, and the National Osteonecrosis Foundation. placebo, alendronate reduced the risk of new Address correspondence to Thomas M. Zizic, M.D., Bionicare Medical Technolo- vertebral fractures by 47 percent (P < .001) gies, Inc., 47R Loveton Circle, Sparks, MD 21152 (e-mail: drzizic@bionicare. in women in the three-year treatment arm com). Reprints are not available from the author. and by 44 percent (P = .001) in the women

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TABLE 2 Summary of Major Clinical Trials of Bisphosphonates (Duration of Three or Four Years) in Women with Postmenopausal Osteoporosis

Relative reduction of fracture risk Absolute reduction of fracture risk Inclusion criteria for active treatment vs. placebo for active treatment (NNT) (number of patients Vertebral Nonvertebral Vertebral Nonvertebral Trial in the trial) Dosage fractures fractures fractures fractures Risedronate (Actonel) VERT19 Two or more 5 mg per day 65% reduction NR 4% reduction NR vertebral after 1 year after 1 year (25) fractures or (P < .001) 39% reduction 5% reduction 3.2% reduction one vertebral 41% reduction after 3 years after 3 years after 3 years fracture and after 3 years (P = .02) (20) (31) a T-score of (P = .003) �2.0 or lower (2,458) VERT21 Two or more 5 mg per day 61% reduction NR 7.4% reduction NR vertebral after 1 year after 1 year (14) fractures (P = .001) 33% reduction 10.9% reduction 5.1% reduction (1,226) 49% reduction after 3 years after 3 years (9) after 3 years after 3 years (P = .06) (20) (P < .001) HIP20 Osteoporosis or 2.5 and 5 mg NR 20% reduction NR 1.8% reduction one or more per day after 3 years after 3 years risk factors for (P = .03) (56) osteoporosis (9,331) Alendronate (Fosamax) FIT22 Low femoral- 5 mg per day 44% reduction 12% reduction 1.7% reduction 1.5% reduction neck BMD for 2 years after 4 years after 4 years after 4 years after 4 years (4,432) followed by (P = .001) (P = .13) (59) (67) 10 mg per day for 2 years FIT23 Low femoral- 5 mg per day 47% reduction 20% reduction 7% reduction 2.8% reduction neck BMD for 2 years after 3 years after 3 years after 3 years after 3 years plus one or followed by (P < .001) (P = .063) (14) (36) more clinical 10 mg per vertebral day for 1 year fractures (2,027) Alendronate Osteoporosis 5 or 10 mg 48% reduction 21% reduction 3% reduction 2.2% reduction Phase III (994) per day for 3 after 3 years, after 3 years after 3 years after 3 years Osteoporosis years based on (P values not (33) (45) Treatment 20 mg per day pooling of all reported; not Study31 for two years data significant) followed by (P = .03) 5 mg per day for 1 year

NNT = number needed to treat to prevent, on average, one fracture; NR = not reported; VERT = Vertebral Efficacy with Risedronate Therapy; HIP = Hip Intervention Program; FIT = Fracture Intervention Trial; BMD = bone mineral density. Information from references 19 through 23, and 31.

October 1, 2004 ◆ Volume 70, Number 7 www.aafp.org/afp American Family Physician 1297 in the four-year treatment arm. dence of coronary heart disease and overall The American College of Reductions in the overall risk of health risks in 16,608 predominantly healthy Rheumatology recom- nonvertebral fractures did not postmenopausal women. A subanalysis of mends that patients who reach statistical significance. WHI data38 indicated that hormone therapy are beginning long-term Prospective one-year data reduced observed clinical vertebral fractures treatment with prednisone on the reduction of vertebral (relative risk [RR], 0.65; 95 percent confi- (three months or longer in fracture risk with alendronate dence interval [CI], 0.46 to 0.92) and hip a dosage of 5 mg per day therapy are not available for fractures (RR, 0.67; 95 percent CI, 0.47 to or higher) or an equivalent individual clinical trial popula- 0.96) by one third compared with placebo. also receive a bisphospho- tions. A pooled subanalysis of However, hormone therapy was associated 32 nate, as well as calcium and the FIT data, which included with increased risks of , heart vitamin D supplementation. only patients with a femoral- attacks, strokes, and clots in the lung; neck T-score of –2.5 or lower but these risks appear to outweigh the benefits of no vertebral fractures or patients hormone therapy for fracture prevention.38 with an existing vertebral fracture, demon- strated a 59 percent reduction (P < .001) in the RECOMBINANT HUMAN PARATHYROID HORMONE risk of vertebral fractures after 12 months of Teriparatide (Forteo), a recombinant human therapy and a 63 percent reduction (P = .014) parathyroid hormone (rhPTH[1-34]), is ap- in the risk of hip fractures after 18 months of proved for the treatment of postmenopausal therapy. The greatest risk reductions occurred osteoporosis. In one placebo-controlled in the patients with the lowest BMD. study,39 daily injections of rhPTH(1-34) Glucocorticoid-Induced Osteoporosis. The reduced the risk of new vertebral fractures by American College of Rheumatology33 recom- 65 percent (20-mcg injections) and 69 percent mends that patients who are beginning long- (40-mcg injections; P ≤ .001), and the risk term treatment with prednisone (three months of new nonvertebral fractures by 35 percent or longer in a dosage of 5 mg per day or higher) (20-mcg injections) and 40 percent (40-mcg or an equivalent also receive a bisphosphonate, injections; P < .05). Because the long-term as well as calcium and vitamin D supplemen- effects of teriparatide are not known, this tation, regardless of their T-score. agent is approved for a maximum of two years In two one-year placebo-controlled clini- of use in patients with severe osteoporosis cal trials, risedronate in a dosage of 5 mg who are at high risk for fractures. per day was effective for the prevention34 and treatment35 of glucocorticoid-induced SELECTIVE ESTROGEN RECEPTOR MODULATORS osteoporosis. An analysis36 of data from the Raloxifene (Evista) is the only selective estro- two trials demonstrated a 70 percent reduc- gen receptor modulator that has been approved tion (P = .01) in the risk of vertebral fractures for the prevention and treatment of postmeno- in the patients treated with risedronate. pausal osteoporosis. In the Multiple Outcomes In a study37 of 477 men and women receiving of Raloxifene Evaluation (MORE) trial40 in glucocorticoid therapy, alendronate in a dosage women with postmenopausal osteoporosis, of 5 or 10 mg per day for 48 weeks increased three years of raloxifene therapy in a dosage BMD but did not significantly reduce the of 60 mg per day reduced the risk of verte- risk of vertebral fractures (morphometrically bral fractures by 30 percent (CI, 0.6 to 0.9) in defined) compared with placebo. The primary patients with vertebral fractures at baseline and outcome was a change in spinal BMD. by 50 percent (CI, 0.4 to 0.8) in patients without vertebral fractures at baseline. The MORE trial HORMONE THERAPY found no significant reduction in the risk of Hormone therapy is approved for the pre- nonvertebral fractures. vention but not the treatment of postmeno- pausal osteoporosis. The Women’s Health SALMON CALCITONIN Initiative (WHI) evaluated the effectiveness Both intranasal and injectable forms of of hormone therapy in reducing the inci- salmon calcitonin (Miacalcin) are approved

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Strength of Recommendations

Key Clinical Recommendations Label References BMD screening is recommended for women 65 years of age and older C 17 without risk factors for osteoporosis. BMD screening should begin at age 60 years in women who are at C 17 increased risk for osteoporotic fractures. The bisphosphonates risedronate (Actonel) and alendronate (Fosamax) A 19, 21-23 are the most effective agents for reducing the risk of vertebral and nonvertebral fractures in women with postmenopausal osteoporosis Patients who are beginning long-term treatment with prednisone (more C 33 than three months in a dosage of 5 mg per day or higher) or an equivalent also should receive a bisphosphonate as well as calcium and vitamin D supplementation, regardless of their T-score. Although hormone therapy reduces fracture risk, the benefits may be A 38 outweighed by the reported risks of treatment.

BMD = bone mineral density.

for the treatment of postmenopausal osteo- 5. Melton LJ 3d, Thamer M, Ray NF, Chan JK, Chesnut CH 3d, Einhorn TA, et al. Fractures attributable to porosis. Calcitonin inhibits bone resorption osteoporosis: report from the National Osteoporosis and is recommended for use in women with Foundation. J Bone Miner Res 1997;12:16-23. osteoporosis who are at least five years past 6. Riggs BL, Melton LJ 3d. The worldwide problem of menopause and cannot take other agents. In osteoporosis: insights afforded by epidemiology. Bone 1995;17(5 suppl):505S-11S. the Prevent Recurrence of Osteoporotic Frac- 7. Ray NF, Chan JK, Thamer M, Melton LJ 3d. Medical expen- 41 tures (PROOF) trial, five years of calcitonin ditures for the treatment of osteoporotic fractures in the therapy in a dosage of 200 IU per day reduced United States in 1995: report from the National Osteopo- the risk of new vertebral fractures by 33 per- rosis Foundation. J Bone Miner Res 1997;12:24-35. 8. Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA 3d, cent (P = .03) in postmenopausal women with Berger M. Patients with prior fractures have an increased established osteoporosis. The PROOF study risk of future fractures: a summary of the literature and found no significant effect for calcitonin on statistical synthesis. J Bone Miner Res 2000;15:721-39. hip BMD or risk of nonvertebral fractures. 9. Lindsay R, Silverman SL, Cooper C, Hanley DA, Barton I, Broy SB, et al. Risk of new vertebral fracture in the year following a fracture. JAMA 2001;285:320-3. The author indicates that he does not have any conflicts 10. Cauley JA, Thompson DE, Ensrud KC, Scott JC, Black D. of interest. Sources of funding: none reported. Risk of mortality following clinical fractures. Osteopo- ros Int 2000;11:556-61. 11. Cummings SR, Nevitt MC, Browner WS, Stone K, Fox REFERENCES KM, Ensrud KE, et al. Risk factors for hip fracture 1. NIH Consensus Development Panel on Osteoporosis in white women. Study of Osteoporotic Fractures Prevention, Diagnosis, and Therapy. Osteoporosis Research Group. N Engl J Med 1995;332:767-73. prevention, diagnosis, and therapy. JAMA 2001;285: 12. Lukert BP, Raisz LG. Glucocorticoid-induced osteopo- 785-95. rosis: pathogenesis and management. Ann Intern Med 2. Assessment of fracture risk and its application to screening 1990;112:352-64. for postmenopausal osteoporosis. Report of a WHO 13. Adachi JD, Papaioannou A. -induced Study Group. World Health Organ Tech Rep Ser osteoporosis: detection and management. Drug Saf 1994;843:1-129. 2001;24:607-24. 3. Hormone replacement therapy and osteoporosis. Sys- 14. Nelson HD, Helfand M, Woolf SH, Allan JD. Screening tematic evidence review no. 12. Rockville, Md.: Agency for postmenopausal osteoporosis: a review of the evi- for Healthcare Research and Quality, September 2002. dence for the U.S. Preventive Services Task Force. Ann Accessed May 29, 2004, at: http://www.ahrq.gov/ Intern Med 2002;137:529-41. clinic/prev/hrtosinv.htm. 15. Michaelsson K, Bergstrom R, Mallmin H, Holmberg 4. Melton LJ 3d, Chrischilles EA, Cooper C, Lane AW, L, Wolk A, Ljunghall S. Screening for osteopenia and Riggs BL. Perspective. How many women have osteo- osteoporosis: selection by body composition. Osteopo- porosis? J Bone Miner Res 1992;7:1005-10. ros Int 1996;6:120-6.

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16. Siris ES, Miller PD, Barrett-Connor E, Faulkner KG, Wehren 30. Brown JP, Kendler DL, McClung MR, Emkey RD, Adachi LE, Abbott TA, et al. Identification and fracture outcomes JD, Bolognese MA, et al. The efficacy and tolerability of of undiagnosed low bone mineral density in postmeno- risedronate once a week for the treatment of postmeno- pausal women: results from the National Osteoporosis pausal osteoporosis. Calcif Tissue Int 2002;71:103-11. Risk Assessment. JAMA 2001;286:2815-22. 31. Liberman UA, Weiss SR, Broll J, Minne HW, Quan H, Bell 17. U.S. Preventive Services Task Force. Screening for osteo- NH, et al. Effect of oral alendronate on bone mineral porosis in postmenopausal women: recommendations density and the incidence of fractures in postmenopausal and rationale. Ann Intern Med 2002;137:526-8. osteoporosis. The Alendronate Phase III Osteoporosis Treat- 18. National Osteoporosis Foundation. Physician’s guide to ment Study Group. N Engl J Med 1995;333:1437-43. prevention and treatment of osteoporosis. Accessed 32. Black DM, Thompson DE, Bauer DC, Ensrud K, Musliner June 21, 2004, at: http://www.nof.org/professionals/ T, Hochberg MC, et al. Fracture risk reduction with clinical/clinical.htm. alendronate in women with osteoporosis: the Fracture 19. Harris ST, Watts NB, Genant HK, McKeever CD, Han- Intervention Trial. FIT Research Group [published correc- gartner T, Keller M, et al. Effects of risedronate treat- tion appears in J Clin Endocrinol Metab 2001;86:938]. J ment on vertebral and nonvertebral fractures in women Clin Endocrinol Metab 2000;85:4118-24. with postmenopausal osteoporosis: a randomized con- 33. Recommendations for the prevention and treatment trolled trial. Vertebral Efficacy with Risedronate Therapy of glucocorticoid-induced osteoporosis: 2001 update. (VERT) Study Group. JAMA 1999;282:1344-52. American College of Rheumatology Ad Hoc Commit- 20. McClung MR, Geusens P, Miller PD, Zippel H, Bensen tee on Glucocorticoid-Induced Osteoporosis. Arthritis WG, Roux C, et al. Effect of risedronate on the risk of Rheum 2001;44:1496-503. hip fracture in elderly women. Hip Intervention Pro- 34. Cohen S, Levy RM, Keller M, Boling E, Emkey RD, Green- gram Study Group. N Engl J Med 2001;344:333-40. wald M, et al. Risedronate therapy prevents corticoste- 21. Reginster J, Minne HW, Sorensen OH, Hooper M, Roux roid-induced bone loss: a twelve-month, multicenter, C, Brandi ML, et al. Randomized trial of the effects of randomized, double-blind, placebo-controlled, parallel- risedronate on vertebral fractures in women with estab- group study. Arthritis Rheum 1999;42:2309-18. lished postmenopausal osteoporosis. Vertebral Efficacy 35. Reid DM, Hughes RA, Laan RF, Sacco-Gibson NA, Wen- with Risedronate Therapy (VERT) Study Group. Osteopo- deroth DH, Adami S, et al. Efficacy and safety of daily ros Int 2000;11:83-91. risedronate in the treatment of corticosteroid-induced 22. Cummings SR, Black DM, Thompson DE, Applegate osteoporosis in men and women: a randomized trial. WB, Barrett-Connor E, Musliner TA, et al. Effect of European Corticosteroid-Induced Osteoporosis Treat- alendronate on risk of fracture in women with low bone ment Study. J Bone Miner Res 2000;15:1006-13. density but without vertebral fractures: results from the 36. Wallach S, Cohen S, Reid DM, Hughes RA, Hosking DJ, Fracture Intervention Trial. JAMA 1998;280:2077-82. Laan RF, et al. Effects of risedronate treatment on bone 23. Black DM, Cummings SR, Karpf DB, Cauley JA, Thomp- density and vertebral fracture in patients on corticoste- son DE, Nevitt MC, et al. Randomised trial of effect of roid therapy. Calcif Tissue Int 2000;67:277-85. alendronate on risk of fracture in women with existing 37. Saag KG, Emkey R, Schnitzer TJ, Brown JP, Hawkins F, vertebral fractures. Fracture Intervention Trial Research Goemaere S, et al. Alendronate for the prevention and Group. Lancet 1996;348:1535-41. treatment of glucocorticoid-induced osteoporosis. Glu- 24. Bauer DC, Black D, Ensrud K, Thompson D, Hochberg cocorticoid-Induced Osteoporosis Intervention Study M, Nevitt M, et al. Upper safety Group. N Engl J Med 1998;339:292-9. profile of alendronate: the Fracture Intervention Trial. 38. Cauley JA, Robbins J, Chen Z, Cummings SR, Jackson Arch Intern Med 2000;160:517-25. RD, LaCroix AZ, et al. Effects of estrogen plus pro- 25. Taggart H, Bolognese MA, Lindsay R, Ettinger MP, gestin on risk of fracture and bone mineral density: Mulder H, Josse RG, et al. Upper gastrointestinal tract the Women’s Health Initiative randomized trial. JAMA safety of risedronate: a pooled analysis of 9 clinical 2003;290:1729-38. trials [published correction appears in Mayo Clin Proc 39. Neer RM, Arnaud CD, Zanchetta JR, Prince R, Gaich 2002;77:601]. Mayo Clin Proc 2002;77:262-70. GA, Reginster JY, et al. Effect of parathyroid hormone 26. De Groen PC, Lubbe DF, Hirsch LJ, Daifotis A, Stephenson (1-34) on fractures and bone mineral density in post- W, Freedholm D, et al. associated with the use menopausal women with osteoporosis. N Engl J Med of alendronate. N Engl J Med 1996;335:1016-21. 2001;344:1434-41. 27. Ettinger B, Pressman A, Schein J, Chan J, Silver P, 40. Ettinger B, Black DM, Mitlak BH, Knickerbocker RK, Connolly N. Alendronate use among 812 women: Nickelsen T, Genant HK, et al. Reduction of vertebral prevalence of gastrointestinal complaints, noncompli- fracture risk in postmenopausal women with osteo- ance with patient instructions, and discontinuation. J porosis treated with raloxifene: results from a 3-year Managed Care Pharm 1998;4:488-92. randomized clinical trial. Multiple Outcomes of Ral- oxifene Evaluation (MORE) Investigators [published 28. Kelly R, Taggart H. Incidence of gastrointestinal side correction appears in JAMA 1999;282:2124]. JAMA effects due to alendronate is high in clinical practice. 1999;282:637-45. BMJ 1997;315:1235. 41. Chesnut CH 3d, Silverman S, Andriano K, Genant H, 29. Rizzoli R, Greenspan SL, Bone G 3d, Schnitzer TJ, Watts Gimona A, Harris S, et al. A randomized trial of nasal NB, Adami S, et al. Two-year results of once-weekly spray salmon calcitonin in postmenopausal women administration of alendronate 70 mg for the treatment with established osteoporosis: the Prevent Recurrence of postmenopausal osteoporosis. J Bone Miner Res of Osteoporotic Fractures Study. PROOF Study Group. 2002;17:1988-96. Am J Med 2000;109:267-76.

1300 American Family Physician www.aafp.org/afp Volume 70, Number 7 ◆ October 1, 2004