It is a journal presentation which was originally published by Ian R. Reid et al, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, NZ on October 1, 2018 at New England Journal of Medicine.

1. Welcome to Journal Club
Presenter
Dr. Mushfiquzzaman
Intern Doctor
Medicine Unit- 3.

2. Fracture Prevention with Zoledronate
in Older Women with Osteopenia

3. • Department of Medicine
Faculty of Medical and Health Sciences
University of Auckland, NZ.
• October 1, 2018 at New England Journal of Medicine
• By Ian R. Reid et al.

4. Introduction
• Bisphosphonates are:
• Principal medications used in postmenopausal osteoporosis.
• Shown to prevent fractures but efficacy in women with osteopenia is
unknown.
• Most fractures in postmenopausal women occur in those with
osteopenia, so therapies that are effective in women with
osteopenia are needed.

5. • Efficacy of Bisphosphonates in osteopenic patients alone is
uncertain.
• Evidence showing fracture prevention with Bisphosphonate in
patients with osteopenia is lacking.

6. • Zoledronate has characteristics that make it attractive for use in patients
with osteopenia.
• Administered by IV injection at intervals of 1 year or longer and preferred
over oral bisphosphonates by a majority of patients with satisfactory safety
profile.
• This trial assesses the effects of Zoledronate on fracture in
postmenopausal women with osteopenia.

7. Methods
• Randomized, double-blind, placebo- controlled trial.
• A total of 2000 women were recruited from Auckland region
• Randomly assigned in a 1:1 ratio
• Received four infusions of either Zoledronate at a dose of 5 mg
or normal saline at 18-month intervals.

8. • Women not taking vitamin D supplements, given a single oral
dose of cholecalciferol (2.5 mg) at least 1 week before their first
infusion and subsequently received at a dose of 1.25 mg/month.
• A dietary calcium intake of 1 g per day was advised.
• Each participant was followed for 6 years.

9. • Ambulatory postmenopausal women ≥65 years of age, with
a T score of −1.0 to −2.5 at either the total hip or any side of
the femoral neck.
• A T score of <−2.5 at one hip site excluded participation in the
trial, as long as another hip site met the criteria.
• The presence of spinal osteoporosis was not an exclusion
criterion as long as the T score was >−3.0.

10. Exclusion criteria
• eGFR less than 30 ml/minute.
• Major systemic disease.
• Cancer in the previous 2 years.
• Metabolic bone disease.
• Regular use of bone-active drugs in the previous year
(bisphosphonates, estrogen, antiestrogens, and prednisone).

11. • Primary end point: Time to first occurrence of a fragility
fracture.
• Secondary end points:
• Occurrence of a symptomatic (clinical) fracture
• Occurrence of a vertebral fracture
• Change in height
• Mortality.

12. • Both the time to the first occurrence of fracture and the
incidence of fracture were assessed for all end points, with the
exception of vertebral fracture.
• Pathological fractures were excluded from all trial end points.

13. • The following adverse events were prespecified for
analysis :
• Death or sudden death
• Myocardial infarction, coronary-artery revascularization or atrial
fibrillation
• Stroke or transient ischemic attack
• Cancer
• Osteonecrosis of the jaw

14. Procedure
• Participants recorded fractures, adverse events, and changes in
medications in a quarterly questionnaire and were also asked to
report fractures immediately.
• Cases in which a participant was hospitalized, an investigator
confirmed diagnoses directly from the participant’s medical
records.

15. • Radiographs of the lateral spine were obtained at baseline, at 3
years and 6 years for vertebral morphometry.
• Height was measured in same interval of time with a
stadiometer and the mean of the three measurements was
used.

16. • All femoral fractures excluding those of the hip were reviewed to
determine whether they met the criteria for “atypical femoral
fractures”.
• Bone mineral density and markers of bone turnover
(carboxy-terminal collagen crosslinks and procollagen type
1 N-propeptide) were assessed.

17. Enrollment, Randomization, and Follow-up of Trial
Participants.

20. • In the placebo group, 825 women received four doses of the
trial regimen,80 received three doses, 53 received two doses,
and 42 received one dose.
• In the Zoledronate group, 806 women received four doses of
the trial regimen, 58 received three doses, 50 received two
doses, and 86 received one dose.

21. Statistical Analysis
• Analyses were based on the intention-to-treat principle, and
missing data were not imputed.
• The prespecified primary analysis was the time to first
occurrence of a fragility fracture, which was modeled with the
use of the Cox proportional-hazards approach.
• For the primary end point, a P value of less than 0.05 was
considered to indicate statistical significance.

22. Results
• Participants were enrolled in the trial from September 2009
through October 2011.
• The last trial visit was in January 2018.
• Final follow-up results (either to trial completion at 6 years or
to death) were available in 97% of the participants in the
placebo group and in 96% of the participants in the
zoledronate group.

23. Fig: First fragility fracture

24. Fig: Nonvertebral fragility fracture

25. Fig: Symptomatic fracture

26. Fig: Change in height

27. Bone Mineral Density and Markers
of Bone Turnover

28. • In the placebo group, serum concentrations of bone turnover markers
did not change significantly during the course of the trial.
• By the end of the trial, the median concentration of procollagen type
1 N-propeptide was 37% lower in the zoledronate group than in the
placebo group, and the median concentration of carboxy-terminal
collagen crosslinks was 50% lower (P<0.001).

29. Adverse Effects
• A total of 1017 serious adverse events were reported in 443
participants in the placebo group, and 820 serious adverse
events were reported in 400 participants in the zoledronate
group (odds ratio with zoledronate, 0.84; 95% CI, 0.70 to 1.00).
• The odds ratio for death was 0.65 (95% CI, 0.40 to 1.05) with
zoledronate, and the odds ratio for cancer was 0.67 (95% CI,
0.50 to 0.89).

30. • Among the 68 deaths that occurred during trial, 41 were from
neoplasms, 8 were from strokes [odds ratio with zoledronate,
0.14; 95% CI, 0.01 to 0.92]), and 7 were from cardiac events.
• No atypical femoral fractures or cases of osteonecrosis of the
jaw were reported in either group.

31. Discussion
• The current trial showed that administration of zoledronate
every 18 months for 6 years reduced the risk of fragility
fractures (both vertebral and nonvertebral) in older women with
hip bone mineral density indicating osteopenia.
• The reduction in the risk of nonvertebral fracture was similar to
that reported previously in patients with osteoporosis who were
treated with zoledronate.

32. • Results depict an important knowledge gap identified in the
recently published American College of Physicians guidelines
on osteoporosis, which stated that “current evidence is limited
for a treatment benefit for women aged 65 years or older with
osteopenia.”

33. • This trial addressed the knowledge gap of National
Osteoporosis Foundation guidelines which stated that there are
relatively few data confirming fracture risk reductions with
pharmacotherapy in older post-menopausal osteopenic group
of patients.

34. • The reduction in the risk of fractures observed in the current trial
suggests that annual administration may be unnecessary for
maximal efficacy in the prevention of fractures and that even
longer intervals between doses should be considered.
• The adverse-event data from the current trial are not completely
consistent with data from other trials, and confirmation of the
results is warranted.

35. • The possible vascular and cancer benefits in the current trial
justify additional trials of zoledronate in which these conditions
are the primary end points.

36. Strength of the Trial
• The trial was well powered for the primary end point.
• It was of long duration.
• The rate of participant retention was high.

37. Weakness of the Trial
• As the trial was intention to treat (ITT) analysis based so there
was issues like: Missing Data and Poor Adherence to
Treatment Protocol.
• Findings of this trial are not applicable to younger women,
men, or persons who have normal bone mineral density.

38. Funding
• Funding for the trial was provided by the Health Research
Council of New Zealand
• The trial medication was supplied by Novartis.

39. Take Home Message
Treatment with zoledronate every 18 months, with minimal use of
calcium supplements will reduce the risk of fragility fractures
(vertebral and nonvertebral) in older women with osteopenia.