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Bisphosphonate Is Best to Prevent Corticosteroid-Induced Osteoporosis

For patients taking corticosteroids, alendronate is more effective than alfacalcidol at preserving bone mineral density.

Chronic administration of glucocorticoids is a major risk factor for osteoporosis and fractures. This 18-month Dutch trial included 201 patients (mean age, 61 years; 62% women) who had begun glucocorticoid therapy (7.5 mg of prednisone or its equivalent) for the treatment of a rheumatic disease during the prior 3 months. Patients were randomized to the bisphosphonate alendronate (10 mg/day) or the vitamin D₃ analog alfacalcidol (1 µg/day).

Mean BMD of the lumbar spine increased by 2.1% in the alendronate group and decreased by 1.9% in the alfacalcidol group (absolute difference, 4.0%). Similar trends were noted with respect to total hip BMD. In the alendronate group, three participants had radiologic evidence of a new vertebral compression fracture. In contrast, 13 new radiologic vertebral fractures (in eight participants) were noted in the alfacalcidol group. The hazard ratio for radiologic vertebral fractures in the alendronate group compared with the alfacalcidol group was 0.4. Adverse events were generally infrequent in both groups.

Comment: This trial demonstrates that alendronate is more effective than alfacalcidol in preventing loss of BMD in patients receiving chronic corticosteroid therapy. The two bisphosphonates most commonly used in the U.S. (alendronate [Fosamax] and risedronate [Actonel]) are both indicated for the prevention of osteoporosis in individuals taking corticosteroids, are well tolerated, and appear effective when taken as weekly tablets. The findings of this study underscore the recommendations of the American College of Rheumatology that patients taking prednisone for 3 months should also take daily calcium and vitamin D along with weekly alendronate or risedronate. This regimen, along with regular assessment of BMD, is an appropriate strategy to prevent fractures.

— Andrew M. Kaunitz, MD

Published in Journal Watch Women's Health October 5, 2006

Citation(s):

de Nijs RN et al. Alendronate or alfacalcidol in glucocorticoid-induced osteoporosis. N Engl J Med 2006 Aug 17; 355:675-84.

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