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Bisphosphonates and low-impact femoral fractures:

Current evidence on alendronate-fracture risk

Jennifer P. Schneider, MD, PhD

Several recent abstract_cme

medical articles
abstract_cme abstract_cme
fractures of the
have described
of unusual low-impact
stress fractures or completed
femur in patients
abstract_source who have
abstract_source been
A 66-year old, previously healthy woman developed a
spontaneous stress fracture of her right foot, which
eventually healed. Nine months later she took a step
in her bedroom and collapsed to the floor. An x-ray re-
vealed a nontraumatic fracture of her right femur. She
on theabstract_source
for several
abstract_source abstract_source abstract_source italic_ab-
years for osteoporosis or osteopenia. Some
underwent surgery with placement of an intramedullary
stractsource rod. Her physician told her she had most likely had a stress
patients have experienced such fractures in both
bold_abstractkeywords abstract_keywords
femurs. The fractures are often preceded by pain fracture, which became a completed fracture. A bone scan
abstract_keywords abstract_keywords abstract_
in the affected
keywords thigh, may have a typical x-ray
done shortly after her surgery revealed a stress fracture of
appearance, and many have delayed healing. It her left femur. Some months later she underwent prophy-
has been hypothesized that in some patients, lactic rodding of the left femur. The patient had been on
long-term alendronate causes oversuppression alendronate for 7 years.
of bone turnover, resulting in bones that are A 65-year woman visiting Europe stepped off the bottom
brittle despite improved bone density. In patients step of a van and collapsed. An x-ray revealed a nontrau-
with atypical or low-impact fractures of the matic fracture of her left femur. She had been experiencing
femoral shaft, consider the possible connection a dull ache in her left femur for some months. The patient
with alendronate use. Some bone specialists underwent placement of an intramedullary rod. One year
now recommend stopping alendronate in most later she developed a dull ache in her right femur. A bone
patients after 5 years. scan showed a stress fracture in the right femur. A bone
Schneider JP. Bisphosphonates and low-impact femoral frac- specialist recommended prophylactic rodding of the right
tures: Current evidence on alendronate-fracture risk. Geriatrics.
femur, which was done. The patient had been on alendro-
nate for 9 years.
Key words: atypical fracture, femoral shaft, low-
impact fracture, oversuppression, subtrochanteric A 59-year-old-woman took a step, her right leg gave out,
and she fell to the ground as she heard her leg break. Her
Drugs discussed: alendronate, ibandronate, pamidro-
nate, risedronate, teriparatide, zoledronic acid femur was fractured. The orthopedic surgeon on call told
her, “We don’t usually see this type of fracture without
trauma.” For the preceding year she’d experienced pain in
her right thigh, which was severe enough to cause limping.
An x-ray had been negative, and her primary care physician
thought she had fibromyalgia. She had been on alendronate
for more than 5 years.
These unpublished case reports, and several other simi-
lar ones, were sent to the author following publication of
a 2006 report in Geriatrics 1 of a 59-year-old, previously
Dr Schneider practices internal medicine and pain healthy woman who, while riding on a subway train, suf-
management in Tucson, Arizona.
fered a comminuted spiral fracture of the right femur when
Disclosure: As she was the patient in a related 2006
Geriatrics case report, the author discloses that she
the train jolted (see figure, page 20). The patient had been
has a personal interest in understanding the possible experiencing pain in her right thigh for 3 months. A bone
causative role of alendronate and atypical femoral frac- scan a week before the fracture showed a stress fracture of
tures. She states that she has no financial interests in the right femur. The patient had been taking alendronate, 70
any pharmaceutical product used to treat osteoporosis.
mg/week, for approximately 7 years for osteopenia, as well
as calcium plus hormone replacement therapy. Despite pro-

18 Geriatrics January 2009 Volume 64, Number 1 w w w.g e r i . c o m


longed use of an electrical bone stim- Bone turnover is a natural part of pain in the fractured limb, starting 2-
ulator, and cessation of alendronate maintaining bone health. When bone 6 months before the injury; none of
use, the fracture did not unite. After 9 turnover is inhibited by bisphospho- the patients in the non-alendronate
months, the patient had a second surgi- nates, microdamage that occurs regu- group had prodromal symptoms. In
cal procedure to replace the original larly in bone but is normally repaired 6 patients in the alendronate group,
rod with a larger one. After a delay, might accumulate after long-term cortical hypertrophy was identified
the bone finally united. The author use. There have long been concerns on the lateral side of the subtrochan-
suggested a possible causal relation- about the long-term safety of bisphos- teric region of the femur, and 3 of these
ship between long-term alendronate phonates because of their potential to also had cortical hypertrophy on the
and the femoral fracture. cause oversuppression of bone turn- contralateral femur.
Fragility fractures of the proximal over.8-13 The first report
femur are rare. However, in the past 3 suggestive of the clinical
years, multiple additional cases like relevance of these hy- Long-term alendronate
those above have been published and pothetical concerns was
the evidence continues to grow that published in 2005 by Od- therapy may suppress
in a small subpopulation of patients, vina et al, describing 8
long-term alendronate use may be postmenopausal women
bone turnover.
related to low-impact, nontraumatic, and a man who sustained
or “atypical” fractures of the femur, unusual nontraumatic nonspinal frac- The Singapore group recently
often with delayed healing. This paper tures while on alendronate therapy for elaborated on its findings with a ret-
reviews the older evidence for a con- 3-8 years. All 9 continued taking alen- rospective review of postmenopausal
nection between bisphosphonates and dronate after the fracture. Six of the 9 patients with subtrochanteric insuffi-
bone fragility, and summarizes recent patients had delayed or absent fracture ciency fractures admitted to their hos-
reports and recommendations. healing for 3 months to 2 years during pital over a 20-month period.16 They
continued alendronate therapy. All 9 found 17 patients, whose mean age was
Femoral fractures patients underwent iliac crest biopsy 66 years, and all had been taking alen-
and alendronate of trabecular bone. All the specimens dronate, for a mean of 4.4 years (range
Bisphosphonates are considered first- showed markedly suppressed bone for- 2.2-8), except for one patient who
line treatment for postmenopausal mation. The authors concluded that was on risedronate for 6 years after
osteoporosis. They are prescribed for long-term alendronate therapy may 4 years of alendronate. All fractures
millions of geriatric patients. Bisphos- result in severe suppression of bone were low-energy, typically sustained
phonates—alendronate (Fosamax), turnover, with increased susceptibil- after tripping. Seven of the patients re-
risedronate (Actonel), ibandronate ity to nonspinal fractures along with ported experiencing acute pain before
(Boniva), and zoledronic acid (Zo- delayed healing. they fell, suggesting that the fracture
meta, Reclast)—inhibit bone resorp- In 2007 a group from Singapore preceded the fall. Thirteen of the 17
tion by decreasing the activity of published a retrospective review of patients (76%) had experienced pro-
osteoclasts. Extensive studies have patients admitted with a low-energy dromal pain in the affected thigh rang-
shown that therapy with bisphospho- subtrochanteric fracture (defined as ing from 1 week to 2 years before the
nates improves bone density and de- one in the region of the femur that fracture. Often these patients had
creases fracture risk.2-6 When discon- extended from the lesser trochanter been treated for referred pain from a
tinued after 5 years, the physiologic to the junction of the proximal and spinal origin, without improvement.
effect of alendronate continues for at middle third of the femoral shaft.)15 Three patients had sustained prior
least 5 years, with no increase in mor- Of 13 women identified, 9 were on contralateral femoral fractures 2-4
phometric vertebral fracture risk or in long-term alendronate therapy (mean years earlier but had been continued
the risk of nonvertebral fractures com- 4.2 years, range 2.5-5). Their average on their bisphosphonate; the patient
pared with patients who continued to age was 67 years, versus 80 years in who was switched to risedronate was
take alendronate for the full 10 years.7 the non-alendronate group. Four of one of these. Five other patients had
This result is consistent with the fact the 9 patients in the alendronate group stress reactions seen on plain x-rays in
that alendronate is incorporated into reported that the fracture had occurred the contralateral femurs; a bone scan
bone matrix and has a biological half- in the absence of a fall. Five patients of one of these patients showed abnor-
life of more than 10 years. reported experiencing prodromal mal uptake in that femur. Pointing to

w w w.g e r i . c o m January 2009 Volume 64, Number 1 Geriatrics 19


bisphosphonate. Of the 25, 19 (76%)

Jennifer P. Schneider, MD

had a specific pattern to the fracture—

it was transverse, with a one-sided beak
in an area of thickening of the cortex.
This fracture pattern was seen in only
1 patient (2%) of patients not being
treated with alendronate. The odds ra-
tio for this pattern was 139.33 for alen-
dronate users, and was 98% specific
to identifying alendronate users. The
patients with this pattern had been us-
ing alendronate for a mean of 6.9 years.
The authors concluded that although
they have not established a causal re-
lationship, such fractures may result
from propagation of a stress fracture
whose repair is retarded by decreased
osteoclast activity and impaired mi-
X-ray of comminuted spiral fracture involving upper half of right femur. crodamage repair resulting from the
prolonged use of alendronate. Minimal
the incidence of bilateral stress reac- patients with this pattern also had cor- trauma is then required to produce a
tions and fractures in more than half tical thickening of the contralateral completed fracture.
of their patients, the authors conclude femur and 3 had had a prior femoral
that these patients have a systemic fracture; none of the patients had a his- Discussion
disorder reflecting oversuppression of tory of vertebral fractures. The au- Fragility or insufficiency fractures are
bone turnover rather than localized pa- thors conclude that these 10 women a type of stress fracture that occurs in
thology. They advise cautious admin- may represent a subgroup of the popu- osteoporotic bone subjected to normal
istration of alendronate in osteoporosis lation that is more susceptible to the ef- levels of stress. They typically occur
management, and “in situations where fects of prolonged suppression of bone in the vertebrae, hip, distal radius,
the characteristic subtrochanteric frac- turnover. They call for a prospective and the proximal humerus follow-
tures have already developed, physi- study to characterize this subgroup. ing minimal or no trauma, but only
cians should strongly consider discon- rarely in the proximal femur.19 The
tinuing the drug.” A case is made subtrochanteric region of the femur is
In 2008 a group from the Hospital one of the strongest parts of the fe-
for Special Surgery, an orthopedic for discontinuing mur and it is unlikely to fracture in
hospital in New York City, published low low-energy trauma unless ex-
2 reports of patients taking alendro- alendronate. treme osteoporosis is present.15 The
nate who had atypical fractures of reports of multiple cases of low-impact
the femur. One report focused on a The same group also reported on a femoral fractures in patients who were
specific radiographic pattern.17 The retrospective review of patients with taking alendronate for several years, a
authors described 15 postmenopausal femoral shaft fractures (including the previously rare event, have therefore
women who had been receiving alen- 15 in the prior report) admitted between called for further study of the possible
dronate for a mean of 5.4 years and January 2002 and March 2007.18 Sev- connection between alendronate and
who presented with atypical low-en- enty low-energy fractures were identi- such fractures, as has been suggested
ergy fractures, defined as fractures oc- fied, in 59 females and 11 males, with by several authors.
curring in a fall from a standing height an average age of 74.7 years. Osteo- Alendronate is stored in the bone for
or less. Ten of the 15 had a unique ra- porosis was present in 44% of the 70 many years and is reactivated as bone is
diographic pattern, a simple transverse patients. Twenty-five patients (36%), turned over and the drug re-enters the
or oblique fracture with beaking of the all women, were being treated with circulation. Patients on long-term alen-
cortex and diffuse cortical thickening alendronate, 84% for osteoporosis; dronate who experienced completed
of the proximal femoral shaft. All the none of the patients had used any other fractures of the femur with minimal

20 Geriatrics January 2009 Volume 64, Number 1 w w w.g e r i . c o m


trauma continue to be at risk of addi- publications of multiple case reports, been proposed that discontinuation of
tional insufficiency fractures. In those a population-based analysis of IV oral bisphosphonates for a period of
in whom a stress fracture was subse- bisphosphonate therapy concluded 3 months prior to and 3 months fol-
quently diagnosed in the contralateral that the hazard ratio of being diag- lowing elective invasive dental surgery
femur, prophylactic surgical rodding is nosed with inflammatory conditions may lower the risk of bisphosphonate-
typically suggested in order to prevent or osteomyelitis of the jaw was 11.48 related ONJ.”27 There are no actual
a completed fracture. Some bone spe- for recipients of IV bisphosphonates data as yet to help determine the ap-
cialists treat such patients with teripa- as compared with non-recipients.25 propriate length of time the patient
ratide (recombinant human parathy- No randomized, controlled, double- should be off the bisphosphonate, and
roid hormone [Forteo]) in an attempt blind studies have been done regard- this depends on the particular drug.
to reverse their adynamic bone. Unlike ing bisphosphonates and ONJ, and Nonetheless, the dental profession’s
bisphosphonates, which work by de- they are unlikely to be done in the current guidelines are a model for
creasing the activity of osteoclasts that future. Nonetheless, the case reports prudent, patient-centered care in an
break down bone, recombinant PTH and population studies have led to the environment where definitive high-
strengthens bone and improves bone creation of a new syndrome in the den- grade studies are lacking but where
density by increasing the activity of os- tal world, bisphosphonate-associated there are reports of multiple, difficult-
teoblasts that build bone. Teriparatide osteonecrosis of the jaw (BON), and to-treat cases strongly suggestive of
stimulates bone formation, increases position papers on trying to prevent a bisphosphonate cause. There is al-
bone mass, and improves bone micro- this disorder have been published by ready a published case report in the
architecture.20 In patients previously several organizations concerned with dental literature of a refractory case
treated with alendronate or raloxifene, dental surgery. of ONJ that was successfully treated
subsequent treatment with teriparatide with teriparatide.28
significantly increased bone turnover,
although less so in patients formerly on Bisphosphonates, Recommendations
alendronate.21,22 This drug is recom- Citing the 2006 report by Black et al7
mended by Lenart et al of the New York osteonecrosis of about stopping or continuing alen-
City group in a recent published letter23 dronate after 5 years of treatment, the
based on findings of the effects of para-
jaw may be linked. National Osteoporosis Foundation
thyroid hormone and alendronate alone (NOF), in its Clinical Update Online
or in combination in postmenopausal Although most cases of ONJ have of July 2008, said, “Results suggest
osteoporosis.7 Results of treatment occurred in patients treated with IV that for most women, taking a 5-year
with teriparatide in women with alen- bisphosphonates (pamidronate, zole- ‘drug holiday’ after being on alendro-
dronate-related insufficiency fractures dronic acid), the finding of some nate (5-10 mg/day) for 5 years does
will be published in the near future.24 cases related to oral bisphosphonates not increase fracture risk and might
Teriparatide should not be used in pa- resulted in the recent publication by be advantageous. For women at high
tients who are at an increased risk of the American Dental Association risk for vertebral fractures, continuing
developing bone tumors (eg, patients of “Dental management of patients alendronate for a total of 10 years is a
with Paget’s disease, unexplained el- receiving oral bisphosphonate ther- reasonable clinical option.”29
evations of alkaline phosphatase, open apy.”26 This document suggests that In 2008 the NOF published a Clini-
epiphyses, or prior radiation therapy “because there is no validated diag- cian’s Guide to Prevention and Treat-
involving the skeleton). nostic technique currently available to ment of Osteoporosis. This guide in-
determine if patients are at increased troduced a new Fracture Risk Algo-
Osteonecrosis of the jaw risk for developing BON, it may be rithm (FRAX) for calculating which
The evolution of our understanding of prudent to proceed conservatively men and women over 50 require phar-
the relationship between alendronate in some cases.” For example, if full- macologic treatment for osteoporosis.
and femoral fractures parallels the mouth tooth extraction is needed, The report states that FRAX analyses
growing understanding of the relation- begin by extracting one tooth and see generally confirm that it is cost-effec-
ship between use of bisphosphonates if the jaw heals. The Association of tive to treat individuals with a prior hip
and osteonecrosis of the jaw (ONJ), Oral and Maxillofacial Surgeons pub- or vertebral fracture and those with a
which may reflect a similar mecha- lished guidelines in 2006 that state, DEXA femoral neck -T score of -2.5
nism of bone injury. After numerous “If systemic conditions permit, it has or worse.

w w w.g e r i . c o m January 2009 Volume 64, Number 1 Geriatrics 21


The guide does not discuss the rec- have osteopenia, saving these drugs half life might make it more likely
ommended duration of treatment with for those who have osteoporosis. than other bisphosphonates to cause
bisphosphonates. It does discuss the There may be a group of patients problems in susceptible patients. Phy-
usefulness of biochemical markers of with low bone density who should sicians need to be aware that patients
bone metabolism, saying, “Suppres- not be treated with bisphosphonates. on bisphosphonates who experience
sion of biochemical markers of bone At present there is no way of predict- low-impact femoral fractures may re-
turnover after 3-6 month of specific ing who these patients are. There is quire additional evaluation and treat-
antiresorptive osteoporosis therapies, a need for research designed to iden- ment along with surgical fixation.
and biochemical marker increases after tify those patients who are potentially This might include bone scans to de-
1-3 months of specific anabolic thera- at risk for adverse outcomes with tect other stress fractures, stopping
pies, have been predictive of greater bisphosphonates in general, or with alendronate therapy, and referral to
BMD responses in studies evaluating alendronate in particular. These pa- specialists knowledgeable in treating
large groups of patients. Because of tients undoubtedly constitute a small these unusual cases.
the high degree of biological and ana- percentage compared to those who
lytical variability in measurement of benefit from bisphosphonates, but for References
biochemical markers, changes in in- those patients these fractures can be 1. Schneider JP. Should bisphosphonates be
dividuals must be large in order to be devastating events, to be prevented if continued indefinitely? An unusual fracture
in a healthy woman on long-term alendro-
clinically meaningful.”30 at all possible. nate. Geriatrics. 2006;61(1):31-33.
Population research is also 2. Cummings SR, Black DM, Thompson DE
et al. Effect of alendronate on risk of
needed that compares the in-
More study is needed cidence of subtrochanteric
fracture in women with low bone density
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3. Pols HA, Felsenberg D, Hanley DA, et al.

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