Journals Watch - Osteoporosis, AF and fractures

Too busy to read all the journals? Let Dr Louise Newson keep you up to date with the latest research.

Treatment with denosumab decreased the risk of new hip fractures in patients wiith osteoporosis
Treatment with denosumab decreased the risk of new hip fractures in patients wiith osteoporosis

- A potential new treatment for osteoporosis
- N Engl J Med 2009; 361: 756-65

Denosumab is a human monoclonal antibody to the receptor activator of the nuclear factor-kappa B ligand (RANKL) that blocks its binding to RANK. This action inhibits the development and activity of osteoclasts, decreasing bone resorption, and increasing bone density.

This study involved nearly 8,000 women between 60 and 90 years old who had a bone mineral density T score of less than -2.5 but not less than - 4.0 at the lumbar spine or total hip.

They were then randomly given either 60mg of denosumab or placebo subcutaneously every six months for 36 months. The results were impressive, showing that there was a reduction of from 7.2 to 2.3 per cent in risk of new radiographic vertebral fracture in those treated with denosumab.

Denosumab was also shown to reduce the risk of hip fracture from 1.2 pert cent in the placebo group to 0.7 per cent in the treatment group. Reassuringly, there was no increase in the risk of cancer, infection, cardiovascular disease, delayed fracture healing or osteonecrosis of the jaw. In addition, there were no adverse reactions to this drug. I am sure that many women would opt for a drug given only twice a year compared with taking bisphosphonates.

- Radiofrequency ablation or drugs for AF
- Circ Arrhythm Electrophysiol 2009; 2: 349-61

I am still confused regarding the optimal treatment of AF and also whether controlling the rate or the rhythm is the preferred option. This study involved conducting two separate systematic reviews: one on the use of radiofrequency ablation (RFA) and one on the use of an antiarrhythmic drug, to assess the clinical efficacy and safety of both treatments in the management of AF. A total of 63 RFA and 34 antiarrhythmic drug studies were included in the reviews.

The results showed that those who received RFA had a higher success rate compared with those treated with medication. Also, those who received RFA had a lower rate of complications (5 per cent compared with 30 per cent), although the adverse events following an antiarrhythmic drug were less severe.

Although those patients who received RFA tended to be younger, which may contribute to the greater success, they also had a longer duration of AF and had failed a greater number of prior drug trials compared with those who had taken antiarrhythmic drugs. These results make me think that more patients with AF should be considered for RFA rather than facing lifelong medication.

- Smokeless tobacco use increases risk of fatal MI and stroke
- BMJ 2009; 339: b3,060

Although the use of smokeless tobacco is not widespread in the UK, many people around the world use it as they think it is safer than smoking cigarettes.

Its use has risen, especially in those under 40 years, in the USA and Sweden in recent years. This meta-analysis of 11 studies revealed that users of smokeless tobacco products have a small but significantly increased risk for fatal MI and stroke.

The authors also noted that previous studies of smokeless tobacco have shown a short-term increase in BP; the long-term effect of this is still uncertain. Patients should be informed that smokeless tobacco is not a safer option.

- Protection from cardiovascular disease by healthy living
- Arch Intern Med 2009; 169: 1,355-62

Many of us are keen to learn ways to reduce our future risk of chronic disease as we advance in years. This German study used data from over 23,000 people aged 35-65 years looking at four healthy lifestyle factors - never smoking, having a BMI less than 30, performing at least 3.5 hours of physical activity a week and also having a healthy diet.

The four factors (healthy, 1 point; unhealthy, 0 points) were summed to form an index that ranged from 0 to 4.

Fewer than four per cent of participants had zero healthy factors, most had one to three healthy factors, and nine per cent had four factors.

Over the follow-up period (which averaged 7.8 years) it was demonstrated that those with all four healthy lifestyle factors had a very impressive 78 per cent lower risk of developing a chronic disease when compared with individuals without any healthy lifestyle factors.

- Increased risk of fractures with thiazolidinediones
- Arch Intern Med 2009; 169: 1,395-402

Some GPs have been more cautious in prescribing thiazolidinediones since data was published about their association with heart failure.

Although clinical trials and meta-analyses have found that rosiglitazone increases the risk of fractures in women, the actual association between the use of thiazolidinediones and fractures in men and women is not adequately understood.

This prospective cohort study looked at over 84,000 men and women who had taken thiazolidinediones compared with sulphonylureas.

The results showed that treatment with a thiazolidinedione was associated with a 28 per cent increased risk of peripheral fractures compared with a sulphonylurea in both men and women.

It seems that pioglitazone is more strongly associated with fractures than rosiglitazone. Clearly larger observational studies in this area are needed.

- Dr Newson is a GP in the West Midlands and a member of our team who regularly review the journals

THE QUICK STUDY

- Denosumab appears to be a promising new treatment for osteoporosis in postmenopausal women.

- Radiofrequency ablation may be superior to antiarrhythmic drugs for the management of AF.

- Smokeless tobacco users have a small but significantly increased risk of fatal MI and stroke.

- Preventing chronic diseases can be helped by adhering to four healthy lifestyle measures.

- Pioglitazone and rosiglitazone may be associated with an increased risk of fractures.

 

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