Bisphosphonates Reduce Fracture Risk in Polymyalgia Rheumatica Patients on Steroids

For individuals managing polymyalgia rheumatica (PMR) with steroid treatment, a new understanding of preventative medications is emerging. Research indicates that bisphosphonates, drugs commonly used to strengthen bones, are associated with a reduced risk of fractures. However, medications intended to protect the stomach do not appear to offer the same benefit. This finding refines the approach to managing potential side effects of long-term steroid apply in PMR patients.

Understanding Polymyalgia Rheumatica and Steroid Treatment

Polymyalgia rheumatica is an inflammatory disorder causing muscle pain and stiffness, particularly in the shoulders and hips. It typically affects people over 50. Glucocorticoids, commonly known as steroids, are frequently prescribed to quickly reduce inflammation and relieve symptoms. While effective, long-term steroid use carries risks, including osteoporosis (weakening of the bones) and gastrointestinal issues like ulcers or bleeding. A recent study highlights the importance of mitigating these risks.

Bisphosphonates and Fracture Risk Reduction

The study, published in the Journal of Rheumatology and analyzed data from over 40,000 individuals diagnosed with PMR between January 2010 and March 2022, found a statistically significant reduction in fracture risk among those prescribed bisphosphonates alongside glucocorticoids. Specifically, 1.40% of patients taking bisphosphonates for 12 months experienced a fracture, compared to 2.32% of those who weren’t. This translates to a risk difference of 0.92% (95% confidence interval 0.56%-1.27%), meaning approximately 109 patients would need to be treated with bisphosphonates to prevent one fracture.

Bisphosphonates work by slowing bone loss, increasing bone density, and reducing the risk of fractures. They are often used to treat osteoporosis in individuals not specifically diagnosed with PMR. Researchers also note that amino bisphosphonates may have immunomodulatory properties, potentially offering benefits beyond bone protection, though this aspect requires further investigation.

Gastroprotective Medications: No Clear Benefit

In contrast to bisphosphonates, the study found no association between the use of gastroprotective medications – proton-pump inhibitors (PPIs) and H2 receptor antagonists – and a reduction in gastrointestinal ulceration or bleeding among PMR patients on steroids. Approximately 78.6% of participants were prescribed these medications, yet the study did not demonstrate a corresponding decrease in GI events. This suggests that routine use of these drugs for PMR patients on steroids may not be necessary, although clinical judgment should always prevail based on individual patient risk factors.

Who is Affected and Why This Matters

This research directly impacts the approximately 1 in 1,000 adults over the age of 50 who are affected by PMR. The findings are particularly relevant for those requiring long-term steroid treatment, as the risk of osteoporosis increases with prolonged use. The study’s large sample size strengthens the reliability of its conclusions, offering more robust evidence than previously available. However, it’s important to note that the data comes from the Clinical Practice Research Datalink Aurum, a UK database, and may not be fully generalizable to populations outside of the UK.

Study Limitations and Considerations

The study utilized a “target trial approach,” which involves analyzing existing data to simulate a randomized controlled trial. While this method is valuable when conducting traditional trials is impractical, it’s crucial to acknowledge its limitations. Observational studies, like this one, can demonstrate associations but cannot definitively prove causation. There may be unmeasured confounding factors influencing the results. For example, patients prescribed bisphosphonates might also have engaged in other health-promoting behaviors, such as increased calcium and vitamin D intake or regular exercise, which could contribute to fracture prevention.

the study focused on prescriptions for bisphosphonates and gastroprotective medications. It did not assess adherence to these medications, meaning it’s unclear how many patients actually took the prescribed drugs as directed.

Prescribing Patterns and Disparities

The research also revealed disparities in prescribing patterns. Men and individuals from more deprived areas were less likely to receive bisphosphonates. This highlights the need to address potential inequities in healthcare access and ensure that all eligible patients receive appropriate preventative treatment. Understanding the reasons behind these disparities is crucial for improving patient outcomes.

What Comes Next: Refining Guidance and Future Research

The findings from this study are likely to inform future clinical guidelines for managing PMR. While current recommendations already suggest bone protection for patients on long-term steroids, this research provides stronger evidence supporting the use of bisphosphonates. Medscape reports that these findings could lead to more targeted prescribing practices, focusing on bisphosphonates for bone health while reassessing the routine use of gastroprotective medications.

Further research is needed to investigate the potential immunomodulatory effects of bisphosphonates in PMR and to determine the optimal duration of treatment. Studies are needed to understand the reasons for prescribing disparities and to develop strategies to ensure equitable access to preventative care. Ongoing surveillance of fracture and gastrointestinal event rates in PMR patients will be essential for monitoring the impact of these findings and refining clinical practice.