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In reply—Adverse Cardiac Effects of Bisphosphonates

      I appreciate Dr Keller's comments and agree with his call for additional research focusing on the cardiovascular effects of bisphosphonate therapy. A prospective clinical study would be a welcome addition to our knowledge base on this topic. Given the association of oral calcium supplementation with myocardial infarction and other cardiovascular events,
      • Bolland M.J.
      • Avenell A.
      • Baron J.A.
      • et al.
      Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis.
      future studies of bisphosphonates and cardiovascular events should also analyze the effects of oral calcium supplementation. There is a paucity of data on female subjects, and future studies should be designed to include this population.
      Bisphosphonates remain a staple of osteoporosis management and a vital tool for fracture prevention. However, the emerging awareness of the association between cardiovascular events and bisphosphonate therapy prompts clinicians to further personalize osteoporosis management. The World Health Organization Fracture Risk Assessment Tool (FRAX)

      World Health Organization. FRAX: WHO Fracture Risk Assessment Tool. http://www.shef.ac.uk/FRAX/tool.aspx. Accessed April 6, 2014.

      and the National Osteoporosis Foundation's Clinician's Guide to Prevention and Treatment of Osteoporosis,
      National Osteoporosis Foundation
      Clinician's Guide to Prevention and Treatment of Osteoporosis.
      which incorporates the FRAX score, are useful aids. They may assist clinicians to minimize unnecessary bisphosphonate exposure in some patients who have low bone mineral density (BMD) but not osteoporosis. (An important caveat is that FRAX is most useful in patients with a low femoral neck BMD, and it may underestimate fracture risk in patients who have low BMD at the lumbar spine but a relatively normal BMD at the femoral neck.)
      Additionally, health care professionals may submit a MedWatch voluntary report

      US Food and Drug Administration. MedWatch Online Voluntary Reporting Form. https://www.accessdata.fda.gov/scripts/medwatch/. Accessed April 23, 2014.

      when adverse cardiovascular events occur in patients taking bisphosphonates. Such reports may provide a springboard for increased awareness and for future research on this subject.

      References

        • Bolland M.J.
        • Avenell A.
        • Baron J.A.
        • et al.
        Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis.
        BMJ. 2010; 341: c3691
      1. World Health Organization. FRAX: WHO Fracture Risk Assessment Tool. http://www.shef.ac.uk/FRAX/tool.aspx. Accessed April 6, 2014.

        • National Osteoporosis Foundation
        Clinician's Guide to Prevention and Treatment of Osteoporosis.
        National Osteoporosis Foundation, Washington, DC2013
      2. US Food and Drug Administration. MedWatch Online Voluntary Reporting Form. https://www.accessdata.fda.gov/scripts/medwatch/. Accessed April 23, 2014.

      Linked Article

      • Adverse Cardiac Effects of Bisphosphonates
        Mayo Clinic ProceedingsVol. 89Issue 7
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          Pittman et al1 recently reported that bisphosphonate use was associated with an increased risk of incident acute myocardial infarction (AMI) in their observational study of elderly veterans with a history of osteoporotic fractures. Of note, they also reported that “the timing of AMI correlated closely with the timing of bisphosphonate therapy initiation.”
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