Changes in bone density and turnover after alendronate or estrogen withdrawal
In Brief Objective: To compare bone mineral density (BMD) and bone turnover changes after therapy withdrawal in postmenopausal women treated with alendronate or estrogen-progestin. Design: In this randomized, blinded, multinational, placebo-controlled trial, 1,609 healthy postmenopausal women ages 45 to 59 years were assigned to receive alendronate, placebo, or open-label estrogen-progestin (conjugated equine estrogens plus medroxyprogesterone acetate or a cyclic regimen of 17β-estradiol, norethisterone acetate and estradiol). Of the original women, one third after year 2 and one third after year 4 were switched from alendronate to placebo, while remaining blinded to treatment assignment. The women taking estrogen-progestin in years 1 to 4 were followed off therapy in years 5 and 6. BMD at the lumbar spine and hip and biochemical markers of bone turnover were measured. Results: The treatment groups described in the current report represent 860 women at baseline; 481 women entered year 5, and 430 completed 6 years. BMD steadily decreased in the placebo group during all 6 years. In contrast, spine and hip BMD increased during the first 4 years in the groups receiving daily continuous alendronate 5 mg and estrogen-progestin. During years 5 and 6, BMD decreased at the lumbar spine -2.42% (95% CI = −4.10, −0.74) and total hip −1.09% (−2.60, 0.41) in the group previously treated with alendronate 5 mg for 4 years. In comparison, large BMD decreases were observed at the spine [−7.69% (−8.96, −6.41)] and total hip [−5.16% (−6.30, −4.01)] among women who had received estrogen-progestin for 4 years. Conclusion: Alendronate produces greater residual skeletal effects than estrogen-progestin after therapy discontinuation. Early postmenopausal women (N = 860) were randomized to placebo, alendronate, or estrogen-progestin for 4 years followed by 2 years on placebo, with 430 women completing all 6 years of the trial in these treatment subgroups. Bone density increased during the first 4 years of treatment with alendronate or estrogen-progestin, but decreases in bone density and increases in bone turnover during the subsequent 2 years were much larger after stopping estrogen-progestin than after stopping alendronate.