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THERAPEUTIC CONTROVERSIES

Valid Treatment Options for Osteoporosis and Osteopenia in HIV-Infected Persons

Associate Professor of Medicine and Director, Dybedal Center for Clinical Research, Kansas City University of Medicine and Biosciences; Adjunct Associate Professor, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO

Laura E Voss, BS

at time of writing, PharmD Student, School of Pharmacy, University of Missouri-Kansas City

Charlott Williams, RN CCRC

Nurse Manager, Dybedal Center for Clinical Research, Kansas City University of Medicine and Biosciences

Eric C Daume

at time of writing, PharmD Student, School of Pharmacy, University of Missouri-Kansas City

Reprints: Dr. Clay, Dybedal Center for Clinical Research, 1750 Independence Ave., DYB 151, Kansas City, MO 64106, fax 816/283-2376, crc{at}kcumb.edu

OBJECTIVE: To review clinical data on bone ossification agents that may be considered for use in the treatment of osteoporosis and osteopenia in HIV-infected patients.

DATA SOURCES: A literature search was performed using MEDLINE (1950-January 2008), EMBASE, PubMed, and abstracts from major HIV conferences (February 2001-October 2007). These searches were limited to human data published in English and used the key words bisphosphonates, calcitonin, raloxifene, teriparatide, HAART, osteopenia, osteoporosis, and HIV/AIDS. Additional articles were retrieved from citations of selected references.

STUDY SELECTION AND DATA EXTRACTION: Relevant information on the pharmacology, pharmacokinetics, safety, and efficacy of available treatment with hormonal and nonhormonal agents was selected. Greater emphasis was placed on randomized clinical trials than on retrospective studies.

DATA SYNTHESIS: Osteoporosis in HIV-infected persons is at least as prevalent as in postmenopausal women, yet this population is not listed in primary care guidelines as one that should be considered for screening. In addition to bisphosphonates, calcitonin, raloxifene, and teriparatide are used to treat bone disorders. Three clinical trials to date have evaluated the use of a bisphosphonate in HIV-infected persons. The trials showed a marked increase in bone mineral density in patients taking alendronate versus those in the control groups (with/without calcium, exercise, and/or vitamin D in 1 or both arms). Dosing restrictions complicate the use of these agents; diet, exercise, and calcium supplementation remain the foremost recommended strategies to prevent bone loss. The use of estrogen, testosterone, calcitonin, and teriparatide is less studied in HIV-positive patients, but may be considered in select cases. There are some investigational drugs and agents not available in the US; however, there are not enough data to support their use.

CONCLUSIONS: Alendronate appears to be a promising treatment option for HIV-infected patients with osteoporosis and osteopenia. Further research is required to determine the safety and efficacy of other available drugs. Until additional information is provided, and with available knowledge on the metabolism profiles of antiretroviral and bone ossification agents, alendronate appears to be the preferred agent to use in this population.

Key Words: antiretrovirals, bisphosphonates, HIV/AIDS, osteopenia, osteoporosis

Published Online, April 15, 2008. www.theannals.com, DOI 10.1345/aph.1K465