Background Glucocorticoid therapy is a major risk factor for osteoporosis related fractures. A previous meta-analysis conducted by Homik et al reported that bisphosphonates therapy increased BMD in glucocorticoid- induced osteoporosis (GIO) when compared to placebo, whereas results for incident vertebral fracture did not reach statistical significance
Objectives To evaluate the efficacy of bisphosphonates in GIO based on randomized controlled trials (RCTs). Both placebo controlled and active comparator trials were analyzed.
Methods Two authors screened citations from the following electronic databases: Medline (1998–2015), EMBASE (1998–2015), Cochrane Library (1998–2015). A manual search was completed for conference proceedings from the ACR (2010–2015), CRA (2009–2015), and ASBMR (2009–2014). We used the study by Homik et al to identify RCTs published prior to 1998. Only RCTs that had a minimum prednisone dosage of 5 mg/day or equivalent and treatment duration of at least 3 months were included. Primary outcomes were changes in BMD and incident fractures. Two authors abstracted data using a standardized data abstraction form. We used the Cochrane Risk of Bias Tool to evaluate the quality of the selected RCTs and devised a quality score ranging from 0 to 6, where 6 represents the highest quality.
Results A total of 466 citations were identified (239 Medline, 217 EMBASE, and 10 Cochrane Library). Fourteen RCTs met the inclusion criteria. An additional two RCTs were identified from conference proceedings. Eleven RCTs compared bisphosphonates to a placebo, three RCTs compared bisphosphonates to a vitamin D derivative, one RCT compared alendronate to teriparatide, and one RCT compared zoledronic acid to risedronate. The RCTs were of reasonably good quality with a mean quality score of 4.
Overall, of the 11 RCTs that compared bisphosphonates to a placebo, all found that the bisphosphonates were superior. Nine RCTs were pooled for mean percentage change in lumbar spine BMD (bisphosphonates n=667, placebo n=654). The pooled mean percentage change was in favor of bisphosphonates compared to placebo [weighted mean difference (WMD) of 4.03%, 95% CI (1.59–6.47), p=0.001]. Six RCTs were pooled for mean percentage change in femoral neck BMD (bisphosphonates n=486, placebo n=481) and the results favored bisphosphonates compared to placebo [WMD of 2.95%, 95% CI (0.09 -5.82), P=0.04]. Seven RCTs were pooled for outcome of incident fractures (bisphosphonates n=613, placebo n=469) and the results favored bisphosphonates compared to placebo [RR of 0.65, 95% CI (0.48–0.88), P=0.006] (Figure 1). Results were pooled using RevMan (version 5.3).
Conclusions Bisphosphonates mitigate adverse changes in BMD and lower fracture risk in patients treated with glucocorticoids.
Homik JE, Cranney A, Shea B, et al. Bisphosphonates for steroid induced osteoporosis. Cochrane Database of Systematic Reviews 1999, Issue 1. Art. No.: CD001347.
Disclosure of Interest None declared
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