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Clinical Review State of the Art Review

Bisphosphonates for the prevention and treatment of osteoporosis

BMJ 2015; 351 doi: (Published 02 September 2015) Cite this as: BMJ 2015;351:h3783
Treating osteoporosis with bisphophonates infographic
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MINISOLA Salvatore, CIPRIANI Cristiana, SCILLITANI Alfredo1, PEPE Jessica
Department of Internal Medicine and Medical Disciplines “Sapienza”, Rome University, Rome, Italy; 1Unit of Endocrinology, "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo (FG), Italy.

We read with interest the review of Maraka and Kennel, concerning the use of bisphosphonates for the prevention and treatment of osteoporosis. 1 However, we believe that more information could be important for both doctors and patients.
A soluble formulation of alendronate is commercialized; this overcomes some of the gastrointestinal side effects often complained by the patients with the ingestion of pills.
With reference to the acute phase response, an inverse association has been demonstrated between first dose of intravenous nitrogen-containing bisphosphonates and serum 25(OH)D. 2 As a practical consequence, a state of vitamin D sufficiency should be reached before the infusion of the drug.
An important disease determining reduced bone strength, not mentioned in table 1, is monoclonal gammopathy of undetermined significance. 3 It is more prevalent than multiple myeloma, almost always preceding it. Indeed, to more accurately reflect the enhanced skeletal risk inherent in this haematological disease, the term of “monoclonal gammopathy of skeletal significance ”has been proposed. 4 Alendronate has been shown to be effective in preventing further bone loss in this condition. 5
Finally, concerning the duration of treatment, the problem doctors must face in their daily practice is the management of patients with two or more vertebral or peripheral fractures already on long-term treatment with bisphosphonates. Indeed, it is well known that fractures “per se” are an important risk factors for further fractures, independently of bone mineral density values achieved.
1. Maraka S, Kennel KA. Bisphosphonates for the prevention and treatment of osteoporosis. BMJ 2015;351:h3783
2. Bertoldo F, Pancheri S, Zenari S,et al. Serum 25-hydroxyvitamin D levels modulate the acute-phase response associated with the first nitrogen-containing bisphosphonate Infusion. J Bone Miner Res 2010;25:447–54
3. Pepe J, Petrucci MT, Nofroni I, et al. Lumbar bone mineral density as the major factor determining increased prevalence of vertebral fractures in monoclonal gammopathy of undetermined significance. Br J Haematol 2006;134:485-90
4. Drake MT. Unveiling skeletal fragility in patients diagnosed with MGUS: no longer a condition of undetermined significance? J Bone Miner Res 2014;29:2529-33

5. Pepe J, Petrucci MT, Mascia ML, et al. The effects of alendronate treatment in osteoporotic patients affected by monoclonal gammopathy of undetermined significance. Calcif Tissue Int 2008;82:418-26

Competing interests: No competing interests

13 September 2015
Salvatore MINISOLA
Full Professor of Internal Medicine
"Sapienza" Rome University
Department of Internal Medicine and Medical Disciplines, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy