How To Use Bisphosphonates Safely And Optimally? . Two

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How to use bisphosphonates safely and optimally?

Two million osteoporosis-related fractures occur annually in the United States alone [1]. Besides the economic burden, these fractures cause significant morbidity, disability and sometimes premature death [2]. The introduction of bisphosphonates (BP) since the 1990s, has led to dramatic improvement in the outcomes of osteoporosis. As bone resorption inhibitors, they are the first-line treatment of osteoporosis with some additional indications of use in Paget’s disease, osteogenesis imperfecta, hypercalcemia of malignancy and bone metastasis. Osteoporosis treatment is offered to patients with either of following conditions: a) osteopenia and history of fragility fracture in hip or spine, b)
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Among patients with osteoporosis, the incidence of ONJ is estimated to be very low at 1 in 100,000 patient-years [3]. In fact, longitudinal clinical studies with more than 60,000 patient-years of exposure to bisphosphonate did not identify a case of ONJ [4]. Low risk of ONJ with BP has also been demonstrated by many systematic reviews. Since the risk factors of development of ONJ are poor dental hygiene, dental procedures, and pathological dental conditions, clinicians must emphasize their patients to maintain good oral hygiene and obtain regular oral exams. Dental issues if present should be addressed prior to initiation of bisphosphonate treatment. Recent guidelines from American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) suggests considering stopping treatment as a precaution, in patients already taking BP and undergoing invasive dental procedures, although strong evidence to suggest that this measure will reduce the risk of ONJ is lacking [5]. Another worrisome adverse effect with the use of BP is atypical femur fracture (AFF). These fractures differ from typical fractures in terms of location in the subtrochanteric region and are often associated with no preceding trauma. Whether or not there is a causal relationship between AFF and BP use is unclear, but there is certainly an association as the risk of AFF increases with duration of treatment. The absolute risk, however still remains very low
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