The objectives of this randomized double-blinded trial «Golden NH, Iglesias EA, Jacobson MS, ym. Alendrona...»1 was to compare alendronate (10 mg daily) with placebo. The patients were 32 adolescents with anorexia nervosa (mean age, 16.9 ± 1.9 yr, range 13-21 yr). Eligible subjects had either primary amenorrhea or secondary amenorrhea of greater than 6-months duration and had a lumbar vertebral spine BMD more than 1 SD below the age-matched mean (z-score, <-1.0). All subjects received 1 200 mg elemental calcium and 400 IU vitamin D daily and received the same multidisciplinary treatment for their eating disorder. Bone mineral densities (BMDs) of the lumbar spine and femoral neck were measured by dual energy x-ray absorptiometry at baseline and after 1 yr of treatment. Twenty-nine subjects completed the study. Femoral neck and lumbar spine BMDs increased 4.4 +/- 6.4 % and 3.5 +/- 4.6 % in the alendronate group compared with increases of 2.3 +/- 6.9 % and 2.2 +/- 6.1 % in the control group (P = 0.41, femoral neck; P = 0.53, lumbar spine). From baseline to follow-up, BMD increased significantly at the femoral neck (P = 0.02) and lumbar spine (P = 0.02) in those receiving alendronate, but did not increase in those assigned placebo (P = 0.22, femoral neck; P = 0.18, lumbar spine). However, there was no statistically significant difference between the groups in the percent increase in BMD of the femoral neck (P = 0.41) or lumbar spine (p = 0.53) over the study period, which was the primary outcome measure. In addition, at follow-up, body weight was the most important determinant of BMD. BMD was significantly higher in subjects who were weight-restored compared with those who remained at low weight (P = 0.002, femoral neck; P = 0.04, lumbar spine). After controlling for body weight, treatment group assignment still had an independent effect at the femoral neck. The authors conclude that in adolescents with anorexia nervosa, weight restoration is the most important determinant of BMD, but treatment with alendronate did increase the BMD of the lumbar spine and femoral neck within the group receiving alendronate, but not compared with placebo in the primary analysis. Until additional studies have demonstrated efficacy and long-term safety, the use of alendronate in this population should be confined to controlled clinical trials.
This randomized placebo-controlled study «Nakahara T, Nagai N, Tanaka M, ym. The effects of ...»2 on the effects of etidronate and calcium (600 mg/d) and alfacalcidol (1 µg/d) on bone loss was conducted in 41 outpatients with the restricting type of anorexia nervosa. The mean patient age was 26.2 ± 8.5 years and all had secondary amenorrhea for at least 3 months before the study. BMI and body fat mass increased in all three groups similarly during the study. Bone mass was evaluated by the tibial speed of sound (SOS) and measured before and after 3 months of treatment. The tibial SOS change in both the etidronate group (n = 14) and the calcium and alfacalcidol group (n = 15) was significantly greater (p < 0.001) than in the control placebo group (n = 12). However, the etidronate group and calcium and alfacalcidol group did not differ in the tibial SOS change.
This 12-month, randomized, placebo-controlled study «Miller KK, Meenaghan E, Lawson EA, ym. Effects of ...»3 investigated the effect of risedronate alone or its combination with low-dose transdermal testosterone on bone density in adult women with AN and BMD Z-scores below 1.0 in at least one skeletal site. BMD at the spine (primary endpoint), hip, and radius and body composition were measured by dual-energy x-ray absorptiometry. After baseline evaluation, 77 women with AN were randomized to receive 1) risedronate 35 mg weekly plus a placebo patch (n = 20), 2) testosterone 150 μg daily patch plus a weekly placebo pill (n = 19), 3) risedronate 35 mg weekly plus testosterone 150 μg daily (n = 20), or 4) double placebo (n = 18) for 12 months. Follow-up visits were performed at 1, 3, 6, 9, and 12 months after the baseline evaluation. BMD and body composition were assessed at 6, 9, and 12 months after randomization. Markers of bone metabolism, total testosterone, free testosterone, and ALT were measured, and hirsutism (by the Lorenzo Hirsutism Scoring System) and acne were assessed 1, 3, 6, 9, and 12 months after randomization.
Risedronate increased posteroanterior spine BMD 3 % (95 % CI 1.8–4.6 %) compared with placebo (p < 0.0001), lateral spine BMD 4 % (95 % CI 1.9–5.6 %) compared with placebo (p = 0.0002), and hip BMD 2 % (95 % CI 0.4–3.4 %) compared with placebo (p = 0.013) in women with AN over the 12-month clinical trial. Testosterone administration did not improve BMD but increased lean body mass 1.9 % (95 % CI 0.2–3.6 %) compared with placebo (p = 0.037) and acutely stimulated bone formation, but had no significant effect on total body water or fat mass. There was no significant difference in the response of BMD to risedronate between the patients receiving testosterone coadministration and those receiving placebo patches. There were few side effects associated with either therapy.
The objective of this 12-month, randomized, placebo-controlled study «Haines MS, Kimball A, Meenaghan E, ym. Sequential ...»4 was to determine whether bone anabolic therapy with recombinant human (rh) IGF-1 used off-label followed by antiresorptive therapy with risedronate would increase BMD more than risedronate or placebo in women with anorexia nervosa (and atypical AN, DSM-V). 90 ambulatory women (age 18-45 yr) with anorexia nervosa and low areal BMD (aBMD, defined as at least one aBMD Z-score or T-score < -1.0 at the lumbar spine, hip, or radius measured within 6 months of the screening visit) were randomized to three groups: 6 months of rhIGF-1 followed by 6 months of risedronate ("rhIGF-1/Risedronate") (n = 33), 12 months of risedronate ("Risedronate") (n = 33), or double placebo ("Placebo") (n = 16). Outcome measures were lumbar spine (primary endpoint: postero-anterior [PA] spine), hip, and radius aBMD by dual-energy X-ray absorptiometry (DXA), and vertebral, tibial, and radial volumetric BMD (vBMD) and estimated strength by high-resolution peripheral quantitative computed tomography (HR-pCT) (for extremity measurements) and multi-detector computed tomography (for vertebral measurements).
61 patients completed the study. At baseline, mean age, body mass index (BMI), aBMD, and vBMD were similar among groups. At 12 months, mean PA lumbar spine aBMD was higher in the rhIGF-1/Risedronate group than placebo group (0.89 +/-0.01 g/cm2 vs 0.87+/-0.02 g/cm2, p = 0.03) but similar as in the Risedronate group (0.89+/-0.01 g/cm2, p = 0.61). There was no statistically significant difference between the placebo group and the Risedronate group (p = 0.08).
Mean lateral lumbar spine aBMD was higher, in the rhIGF-1/Risedronate than the Risedronate or Placebo groups (p < 0.05). Vertebral vBMD was higher, and estimated strength trended toward being higher, in the rhIGF-1/Risedronate than Placebo group (p < 0.05). Neither hip or radial aBMD or vBMD, nor radial or tibial estimated strength, differed among groups. rhIGF-1 was well tolerated. Therefore, sequential therapy with rhIGF-1 followed by risedronate increased lateral lumbar spine aBMD more than risedronate alone or placebo.
The authors state that the results are not generalizable to adolescents with anorexia nervosa, as adolescence is normally a state of high bone turnover and rapid bone accrual, and bone metabolism in adolescents with the disease is characterized by both low bone formation and resorption.
General comment:
The treatment durations were short (up to 1 year at most) and the patient numbers were small. Bisphosphonates further reduce bone turnover in AN-patients, and they have a long half-life. Osteonecrosis of the jaw and atypical femoral fractures are rare adverse events associated with treatment. Studies on the long-term effects of bisphosphonates, especially their potential teratogenic effects during pregnancy, are limited (adverse effects have been observed in animals). Since bisphosphonates cross the placenta, their use cannot be recommended for fertile-aged patients with anorexia nervosa. Furthermore, there are no studies on the efficacy of bisphosphonates in fracture prevention in this patient group. Studies on bisphosphonate treatment in boys or men with anorexia nervosa have not been conducted.