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Clinical Review State of the Art Review

Bisphosphonates for the prevention and treatment of osteoporosis

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h3783 (Published 02 September 2015) Cite this as: BMJ 2015;351:h3783
Treating osteoporosis with bisphophonates infographic
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Author's Reply

We acknowledge with appreciation the response from Dr. Kausar which serves to maintain the currentness of this review. In our discussion, we focused on the initial conclusions reached regarding the association of atrial fibrillation (AF) and bisphosphonates based primarily on analysis of pivotal prospective bisphosphonate clinical trials. The meta-analysis performed by Sharma et al.1 includes additional data from an extension trial as well as more recent observational studies and adds to our understanding of this important issue. However, confidence in the clinical importance of this issue remains variable given that vast majority of the data analyzed is obtained from studies that were not designed to determine the rate of atrial fibrillation following bisphosphonate administration.

We agree with Sharma et al. that possible confounders and missing or misclassified data influencing the results would be ideally addressed by prospective randomized data to further evaluate the risk of AF with bisphosphonate therapy. In the meantime, we concur with Dr. Kausar’s assertion that, while such uncertainty remains, reporting of adverse events associated with bisphosphonate therapy to regulatory agencies remains important to refining our understanding of the risks associated with bisphosphonate therapy. Most importantly, Dr. Kausar astutely reminds us that justifying even a potential risk of treatment begins with selecting patients most likely to benefit from bisphosphonate therapy.

1. Sharma A, Einstein AJ et al. Risk of atrial fibrillation with use of oral and intravenous bisphosphonates. Am J Cardiol 2014; 113(11): 1815-21.

Competing interests: No competing interests

19 October 2015
Kurt A. Kennel
Consulting Endocrinologist
Spyridoula Maraka
Mayo Clinic
Rochester, MN, USA