Background/Purpose: Glucocorticoids are commonly used in patients with rheumatologic conditions including but not limited to Rheumatoid Arthritis, Polymyalgia Rheumatica, Systemic Lupus Erythematous and so on. There is increased rate of bone resorption after the first few months of initiating glucocorticoid therapy. The risk of bone fractures increase before a decrease in bone mineral density is observed. One of the most common side effects include new fractures and vertebral deformities. Interventions to reduce the risk of fractures involve the use of Alendronate. Alendronate is a bisphosphonate that works by inhibiting the osteoclast mediated bone resorption. It is important to study the benefit of Alendronate on fractures and vertebral deformities in patients who are on long term steroid therapy.

Methods: We conducted a systematic review and meta-analysis of studies that investigated the efficacy of Alendronate for prevention of new fractures and vertebral deformities. We performed a comprehensive search of PubMed/MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from 2006-2016. We considered randomized control trials. We excluded abstracts, animal studies, case reports, reviews, editorials, cohort studies, case-control studies, case series and letters to editors. From each study, we collected the number of patients who received Alendronate and other forms of bone protective measures including vitamin D and calcium. The primary outcome was the rate of new fractures. The secondary outcome was rate of vertebral deformities. The random-effects model was used to calculate the risk ratios (RR), mean differences (MD), and confidence intervals (CI). A p value < 0.05 was considered statistically significant. Heterogeneity was assessed using the Higgins I² index.

Results: Six randomized control involving 898 patients were included in the meta analysis. Five studies showed that there was no significant difference in the rate of new fractures between the Alendronate group in comparison to the control group (5.8% vs. 9.06% ;RR 0.63, 95% CI 0.36-1.11, p=0.11, I² = 0%). Four studies were analyzed to assess for new vertebral deformities in patients receiving Alendronate versus control. There was no significant difference between the rate of vertebral deformities between the two groups (16.5% vs. 1.6%; RR 0.64, 95% CI 0.29-1.39, p=0.26, I² = 70%).

Conclusion: Our meta-analysis demonstrated that the use of Alendronate versus control in patients with rheumatologic conditions on chronic prednisone therapy, did not display any significant reduction in new fractures and vertebral deformities. Further randomized control trials with larger sample sizes are needed to confirm our findings.

Figure 1.1 Forest plot – Rates of fracture when using Alendronate versus Control

Figure 1.2: Forest Plot- Rate of Vertebral Deformities in Patients with Alendronate versus Control

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/efficacy-of-alendronate-for-prevention-of-new-fractures-and-vertebral-deformities-in-patients-with-rheumatologic-disorders-on-chronic-glucocorticoid-therapy-a-systematic-review-and-meta-analysis/