The use of bisphosphonates in the treatment of osteoporosis

The efficacy of bisphosphonates in the treatment of conditions characterized by increased osteoclastic bone resorption has been established. Recent evidence indicates that these compounds are also effective in the treatment of patients with osteoporosis. Two main protocols have been tried. One is based on the intermittent administration of the bisphosphonate, which is expected to decrease bone resorption, and give a drug-free period during which bone formation may proceed at a normal rate, leading to a positive calcium balance. The other argues that the resetting of the equilibrium in a cyclical process is, as a rule, incomplete and continuous low-grade suppression of resorption will result in a continuing positive bone balance. Intermittent administration of the first generation bisphosphonate, etidronate, for up to three years increases trabecular bone density, stabilizes it after two years, and appears to reduce the rate of new vertebral fractures in women with postmenopausal osteoporosis. Longer follow-up studies are needed before this beneficial effect is unequivocally established. Continuous administration of the second-generation bisphosphonate, pamidronate, increases spinal bone density in patients with osteoporosis linearly for up to four years, and is associated with a low rate of new vertebral fractures. These results need to be confirmed in controlled studies involving more patients. There are indications that pamidronate given continuously can prevent glucocorticoid-induced bone loss. There is no information about the effects of bisphosphonates on non-vertebral fractures. There are limited data about the use of bisphosphonates in the prevention of postmenopausal bone loss. Extensive studies on efficacy and safety are needed before this treatment is offered as an alternative to hormone replacement therapy.