Bisphosphonates for treating osteoporosis caused by the use of steroids

Homik J, Cranney A, Shea B, Tugwell P, Wells GA, Adachi J, Suarez-Almazor ME

Published Online:

July 7, 2010

Corticosteroids are widely used to treat inflammation. Bone loss (osteoporosis) is a serious side effect of this therapy. We reviewed a total of 13 trials which included 842 patients. We found that the bone mineral density of the lumbar spine of patients taking bisphosphonate therapy improved 4.3% more than patients who had no treatment. At the femoral neck (top of the thigh bone), the bone mineral density improved 2.1% more in the treatment group. There was no difference in the number of spinal fractures between the the two groups. We found that bisphosphonates are effective at preventing and treating corticosteroid-induced bone loss at the lumbar spine and femoral neck. We do not have enough evidence to say whether or not bisphosphonates prevent fractures.

Abstract (click to read)

Background:

Corticosteroids are widely used in inflammatory conditions as an immunosuppressive agent. Diseases treated with corticosteroids include connective tissue diseases, asthma, inflammatory bowel disease and organ transplantation. Bone loss is a serious side effect of this therapy. Several studies have examined the use of bisphosphonates as a treatment for corticosteroid-induced osteoporosis and have reported varying magnitudes of effect. The best estimate of the magnitude of efficacy regarding bisphosphonate prevention of corticosteroid-induced bone loss is needed, before their use is advocated.

Objectives:

To assess the effects of bisphosphonates for the prevention and treatment of corticosteroid-induced osteoporosis.

Search strategy:

We searched the Cochrane Musculoskeletal Group trials register, MEDLINE up to 1997 and EMBASE 1988-1997), and selected hand searching of reference lists was conducted. Hand searching of scientific abstracts from relevant meetings for the last five years was also done. An electronic search in Current Contents was done for the last six months. The Cochrane Controlled Trials Register (CCTR) will be searched for future updates.

All languages were included in the search. For practical reasons only those in English were included, but all languages will be retrieved and translated for future updates.

Selection criteria:

All controlled clinical trials (CCTs) dealing with prevention or treatment of corticosteroid-induced osteoporosis with bisphosphonates of any type and reporting the outcomes of interest were assessed. Trials had to involve adults only, and subjects had to be taking a mean steroid dose of 7.5 mg/day or more.

Data collection and analysis:

All data extraction was performed by two independent reviewers. Outcomes of interest included change in bone mineral density (BMD) at the lumbar spine and femoral neck at six and 12 months. If present, data on number of new fractures and withdrawals due to adverse effects were also extracted. All data extraction was performed by two independent reviewers.
Both continuous and dichotomous data were analyzed using fixed effects models. When significant heterogeneity was present, a random effects model was used.

Main results:

A total of 13 trials, including 842 patients are included in this meta-analysis. Results are reported as a weighted mean difference of the percent change in BMD between the treatment and placebo groups, with trials being weighted by the inverse of their variance. The 95% confidence intervals (95% CI) are presented. At the lumbar spine, the weighted mean difference of BMD between the treatment and placebo groups was 4.3% (95% CI 2.7, 5.9). At the femoral neck, the weighted mean difference was 2.1% (95%CI 0.01, 3.8). Although there was a 24% reduction in odds of spinal fractures [OR 0.76 (95%CI 0.37, 1.53)], this result was not statistically significant.

Authors' conclusions:

Bisphosphonates are effective at preventing and treating corticosteroid-induced bone loss at the lumbar spine and femoral neck. Efficacy regarding fracture prevention cannot be concluded from this analysis, although bone density changes are correlated with fracture risk.

This record should be cited as:

Homik J, Cranney A, Shea B, Tugwell P, Wells GA, Adachi J, Suarez-Almazor ME. Bisphosphonates for steroid induced osteoporosis. Cochrane Database of Systematic Reviews 1999, Issue 1. Art. No.: CD001347. DOI: 10.1002/14651858.CD001347

Assessed as up to date:

November 17, 1998

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Primary Review Group:

Musculoskeletal Group

Health topics:

Rheumatology > Osteoporosis > Pharmacological therapies

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Bisphosphonates for treating osteoporosis caused by the use of steroids

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