One year of alendronate after one year of parathyroid hormone
N Engl J Med. 2005 Aug 11;353(6):555-65, Black DM and others. PMID: 16093464. This study involves the medications parathyroid hormone (1-84) and alendronate (Fosamax). All patients in the study were women aged 55 to 85 having osteoporosis. Medications given included 100 micrograms parathyroid hormone (1-84) injectable, 10 mg Fosamax daily, 500 mg calcium carbonate, and a multivitamin containing 400 IU vitamin D. Women were randomly assigned to get: 1) Parathyroid hormone (1-84) for the first year followed by one year of Fosamax; 2) Parathyroid hormone (1-84) for year one, followed by placebo in year 2; 3) Parathyroid hormone (1-84) plus Fosamax in year one followed by Fosamax for year 2; 4) Fosamax for two consecutive years. Results were monitored by Hologic QDR 4500A dual-energy X-ray absorptiometry (DXA) at baseline, 12 months, and 24 months. Additionally, volumetric bone density and bone geometry in trabecular and cortical compartments were assessed using quantitative CT at the spine (L1 and L2) and total hip in a subgroup of 204 patients. Biochemical markers of bone formation and resorption were also assayed. Results: 223 (94%) of patients completed the study. Increased bone mineral density (BMD) of the spine: Group 1 - Parathyroid hormone (1-84) followed by Fosamax: 12.1%; Group 2 - Parathyroid hormone (1-84) followed by placebo: 4.1%; Group 3 and 4 showed 8% increases. Of importance is the fact that in the second year, those women taking placebo after having parathyroid hormone (1-84) the first year, had 1.7% decrease in areal BMD of the spine, while those taking Fosamax the second year had 4.9% increase in areal BMD. The authors state: "In summary, increases in bone mineral density during one year of treatment with parathyroid hormone appear to be rapidly lost after therapy is discontinued. Treatment with the bisphosphonate alendronate immediately after discontinuation of parathyroid hormone either maintains or further increases bone mineral density in year 2."
Editor's comments: A previous study has shown that combining Fosamax and Forteo decreases the effectiveness when compared to using Forteo alone. The Black and others study found the same thing. The most effective way to use both Forteo and Fosamax appears to be to use Forteo the first year and alendronate in succeeding years. Men should note that there is a slight concern with Forteo as concerns increased prostate cancer risk, although no direct link has ever been proven. Some non-clinical studies are suggestive, so men should ask their physicians about that if Forteo is recommended to treat their osteoporosis.
Gastric bypass surgery and osteoporosis
Crit Care Nurs Q. 2005 Jul-Sep;28(3):26975, Hogan SL. PMID:16041227. There are several forms of gastric bypass surgery that can be done to treat severe obesity. Particularly the Roux-en-Y procedure, which creates a smaller stomach while bypassing the jejunum in the small intestine, can lead to malabsorption of important nutrients--especially calcium. This can ultimately lead to the unintended development of osteoporosis in these gastric bypass patients. Additionally these people can suffer from other nutritional deficiencies like anemia. Since 30% of patients suffer from nutritional deficiencies after bypass surgery, they need to be aware of these potential problems and ask for routine diagnostic testing to detect them. In cases where osteoporosis might be suspect, that would include DXA perhaps every couple of years. It could also include biochemical markers of bone breakdown. Discuss either or both of these options with your care provider before a problem develops.