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Association of bisphosphonate therapy with incident lower extremity fractures in persons with spinal cord injuries/disorders

Carbone LD1, Gonzalez B2, Miskevics S3, Ray C3, Etingen B3, Guihan M4, Craven BC5, George V6, Weaver FM7.

Arch Phys Med Rehabil. 2020 Jan 17. pii: S0003-9993(20)30005-8. doi: 10.1016/j.apmr.2019.12.010. [Epub ahead of print]

Abstract
OBJECTIVE:
To investigate the association between prescriptions for bisphosphonates, calcium/Vitamin D supplements, and receipt of DXA screening, and incident fracture risk in men and women with a spinal cord injury/disorder (SCI/D).

DESIGN:
Propensity matched case control analyses.

SETTING:
U.S. Veterans Affairs facilities.

PARTICIPANTS:
7,989 men and 849 women with a SCI/D included in VA administrative databases between October 1, 2005 and October 1, 2015 were identified. Cases included 267 men and 59 women with a bisphosphonate prescription propensity matched with up to four controls.

INTERVENTIONS:
Not applicable.

MAIN OUTCOME MEASURES:
Incident lower extremity fractures.

RESULTS:
There was no significant association between prescriptions for bisphosphonates and incident lower extremity fractures in men (OR 1.04, 95% CI: 0.62-1.77) or women (OR 1.02, 95% CI 0.28-3.75). In men, similar null associations were seen among those who were adherent to bisphosphonate therapy (OR 1.25, 95% CI: 0.73-2.16), were concomitant users of Vitamin D/calcium and a bisphosphonate (OR 1.05 95% CI: 0.57-1.96), had more than one fracture on different dates during the study period (OR 0.13, 95% CI: 0.02-1.16) and in those who had undergone dual-energy x-ray absorptiometry (DXA) testing prior to the date of the bisphosphonate prescription and incident fracture (OR 1.26, 95% CI: 0.69-2.32).

CONCLUSIONS:
In men with a traumatic SCI and women with a traumatic SCI or disorder, bisphosphonate therapies for osteoporosis do not appear to significantly impact fracture risk. Adequately powered randomized clinical trials are needed to definitively demonstrate efficacy of bisphosphonates for fracture prevention in this population. There is a compelling need to identify new medications to prevent fractures in this high-risk population.