Traumatology and Orthopedics of RussiaTraumatology and Orthopedics of RussiaТравматология и ортопедия России2311-29052542-0933Vreden National Medical Research Center of Traumatology and Orthopedics32010.21823/2311-2905-2013--1-113-123DiscussionsДискуссииDiscussionsATYPICAL FRACTURES DUE TO LONG TREATMENT WITH BISPHOSPHONATES (CRITICAL REVIEW)АТИПИЧНЫЕ ПЕРЕЛОМЫ БЕДРА ПРИ ДЛИТЕЛЬНОМ ЛЕЧЕНИИ БИСФОСФОНАТАМИ (КРИТИЧЕСКИЙ ОБЗОР ЛИТЕРАТУРЫ)GolubevG. S.ГолубевГ. Ш.
Russian Federation
ortho-rostgmu@yandex.ruRostov State Medical UniversityГБОУ ВПО «Ростовский государственный медицинский университет» Минздрава России3003201319111312301112016https://journal.rniito.org/jour/article/view/320

This paper reviews the evidence for an association between atypical subtrochanteric fractures and long-term bisphosphonate use. A PubMed search of literature was performed. Estimation of scientific level of evidences, extraction of quantitative data about atypical fractures from publication were performed. Common clinical and X-ray features of ‘atypical’ fractures are described. Level IV publications contain assumptions of relationship between long term (more than 5 years) bisphosphonates’ (alendronate, ibandronate) treatment and atypical fractures. No data found about connection between zoledronic acid and atypical fractures. Data about relative risk of atypical fractures which is retrieved from meta-analysis’s and post-hock analysis’s of randomized clinical investigations is discrepant. No meta-analysis’s and randomized clinical investigations with statistically valid evidence of correlation between atypical fractures and long term bisphosphonates treatment have been found. Despite the relative rarity of atypical femoral fractures and doubtful evidences of their connection to bisphosphonates therapy, physicians and patients should be made aware of the possibility of such phenomenon. Principles of rational bisphosphonates therapy are being discussing. Because bisphosphonates accumulate in bone, they create a reservoir leading to continued release from bone for months or years after treatment is stopped. The feature described above is the base to recommendation for a drug holiday after 5-10 yr of bisphosphonate treatment. Clinical recommendations to reduce risks, rational diagnostic and surgical algorithm to treat atypical fractures are proposed for physicians dealing with osteoporosis, osteoporotic fractures and their consequences. Researches should be undertaken to get additional epidemiologic and clinical data to establish the true relationship between atypical fractures and long term bisphosphonates using. Bisphosphonates are effective and relatively safe remedies which reduce risk of osteoporotic fractures of any part of skeleton. Clinical advantages of bisphosphonates using exceed the doubtful and unproved risk of atypical fractures.

Анализируются доказательства связи длительной терапии остеопороза бисфосфонатами с атипичным переломам бедра. Ссылки на публикации отобраны из базы PubMed. Проведены оценка уровня доказательности статей, извлечение количественной информации об атипичных переломах. Описаны клинические и рентгенологические характеристики атипичных переломов. В публикациях 4-го уровня высказываются предположения о связи атипичных переломов с многолетним (более 5 лет) лечением бисфосфонатами (алендронат, ибандронат). Атипичных переломов, связанных с лечением остеопороза золедроновой кислотой, не описано. Данные мета-анализов, post-hoc анализов клинических испытаний бисфосфонатов в отношении атипичных переломов противоречивы. Не найдено мета-анализов и рандомизированных клинических испытаний, статистически достоверно доказывающих связь «атипичных переломов» с длительным лечением остеопороза бисфосфонатами. Несмотря на редкость атипичных переломов и сомнительные доказательства их связи с терапией бисфосфонатами, врачи и пациенты должны быть информированы о такой возможности. Обсуждаются принципы рационального планирования терапии бисфосфонатами. Рекомендуется использование практики «отдыха от лекарств», основанной на сохранении терапевтического эффекта бисфосфонатов в течение длительного периода (годы) после их отмены. Предложены клинические рекомендации по снижению риска осложнений терапии бисфосфонатами, диагностике и лечению атипичных переломов для специалистов, занимающихся лечением остеопороза, переломов и их последствий. Для доказательства достоверной связи атипичных переломов бедра с длительным лечением остеопороза бисфосфонатами необходимы дополнительные эпидемиологические и клинические исследования. Бисфосфонаты являются эффективными и достаточно безопасными препаратами, снижающими риск переломов любых локализаций при остеопорозе. Клинические преимущества их использования несопоставимы с сомнительным риском атипичных переломов.

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