Home > Bisphosphonates and low-impact femoral fractures: Current evidence on alendronate-fracture risk

Bisphosphonates and low-impact femoral fractures: Current evidence on alendronate-fracture risk

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Bisphosphonates and low-impact femoral fractures: Current evidence on alendronate-fracture risk
Jennifer P. Schneider, MD, PhD
Dr Schneider practices internal medicine and pain
management in Tucson, Arizona. Disclosure: As she was the patient in a related 2006 Geriatrics case report, the author discloses that she has a personal interest in understanding the possible causative role of alendronate and atypical femoral frac- tures. She states that she has no financial interests in any pharmaceutical product used to treat osteoporosis.
A 66-year old, previously healthy woman developed a
spontaneous stress fracture of her right foot, which eventually healed. Nine months later she took a step in her bedroom and collapsed to the floor. An x-ray re- vealed a nontraumatic fracture of her right femur. She underwent surgery with placement of an intramedullary rod. Her physician told her she had most likely had a stress fracture, which became a completed fracture. A bone scan done shortly after her surgery revealed a stress fracture of her left femur. Some months later she underwent prophy- lactic rodding of the left femur. The patient had been on alendronate for 7 years. A 65-year woman visiting Europe stepped off the bottom step of a van and collapsed. An x-ray revealed a nontrau- matic fracture of her left femur. She had been experiencing a dull ache in her left femur for some months. The patient underwent placement of an intramedullary rod. One year later she developed a dull ache in her right femur. A bone scan showed a stress fracture in the right femur. A bone specialist recommended prophylactic rodding of the right femur, which was done. The patient had been on alendro- nate for 9 years. A 59-year-old-woman took a step, her right leg gave out, and she fell to the ground as she heard her leg break. Her femur was fractured. The orthopedic surgeon on call told her, ��We don��t usually see this type of fracture without trauma.�� For the preceding year she��d experienced pain in her right thigh, which was severe enough to cause limping. An x-ray had been negative, and her primary care physician thought she had fibromyalgia. She had been on alendronate for more than 5 years. These unpublished case reports, and several other simi- lar ones, were sent to the author following publication of a 2006 report in Geriatrics 1 of a 59-year-old, previously healthy woman who, while riding on a subway train, suf- fered a comminuted spiral fracture of the right femur when the train jolted (see figure, page 20). The patient had been experiencing pain in her right thigh for 3 months. A bone scan a week before the fracture showed a stress fracture of the right femur. The patient had been taking alendronate, 70 mg/week, for approximately 7 years for osteopenia, as well as calcium plus hormone replacement therapy. Despite pro-
Several recent medical articles have described multiple cases of unusual low-impact subtrochanteric stress fractures or completed fractures of the femur in patients who have been on the bisphosphonate alendronate for several years for osteoporosis or osteopenia. Some patients have experienced such fractures in both femurs. The fractures are often preceded by pain in the affected thigh, may have a typical x-ray appearance, and many have delayed healing. It has been hypothesized that in some patients, long-term alendronate causes oversuppression of bone turnover, resulting in bones that are brittle despite improved bone density. In patients with atypical or low-impact fractures of the femoral shaft, consider the possible connection with alendronate use. Some bone specialists now recommend stopping alendronate in most patients after 5 years.
Schneider JP. Bisphosphonates and low-impact femoral frac- tures: Current evidence on alendronate-fracture risk. Geriatrics. 2009;64(1):18-23.
Key words: atypical fracture, femoral shaft, low-
impact fracture, oversuppression, subtrochanteric
Drugs discussed: alendronate, ibandronate, pamidro-
nate, risedronate, teriparatide, zoledronic acid 18
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longed use of an electrical bone stim- ulator, and cessation of alendronate use, the fracture did not unite. After 9 months, the patient had a second surgi- cal procedure to replace the original rod with a larger one. After a delay, the bone finally united. The author suggested a possible causal relation- ship between long-term alendronate and the femoral fracture. Fragility fractures of the proximal femur are rare. However, in the past 3 years, multiple additional cases like those above have been published and the evidence continues to grow that in a small subpopulation of patients, long-term alendronate use may be related to low-impact, nontraumatic, or ��atypical�� fractures of the femur, often with delayed healing. This paper reviews the older evidence for a con- nection between bisphosphonates and bone fragility, and summarizes recent reports and recommendations. Femoral fractures and alendronate Bisphosphonates are considered first- line treatment for postmenopausal osteoporosis. They are prescribed for millions of geriatric patients. Bisphos- phonates—alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), and zoledronic acid (Zo- meta, Reclast)—inhibit bone resorp- tion by decreasing the activity of osteoclasts. Extensive studies have shown that therapy with bisphospho- nates improves bone density and de- creases fracture risk.2-6 When discon- tinued after 5 years, the physiologic effect of alendronate continues for at least 5 years, with no increase in mor- phometric vertebral fracture risk or in the risk of nonvertebral fractures com- pared with patients who continued to take alendronate for the full 10 years.7 This result is consistent with the fact that alendronate is incorporated into bone matrix and has a biological half- life of more than 10 years. Bone turnover is a natural part of maintaining bone health. When bone turnover is inhibited by bisphospho- nates, microdamage that occurs regu- larly in bone but is normally repaired might accumulate after long-term use. There have long been concerns about the long-term safety of bisphos- phonates because of their potential to cause oversuppression of bone turn- over.8-13 The first report suggestive of the clinical relevance of these hy- pothetical concerns was published in 2005 by Od- vina et al,14 describing 8 postmenopausal women and a man who sustained unusual nontraumatic nonspinal frac- tures while on alendronate therapy for 3-8 years. All 9 continued taking alen- dronate after the fracture. Six of the 9 patients had delayed or absent fracture healing for 3 months to 2 years during continued alendronate therapy. All 9 patients underwent iliac crest biopsy of trabecular bone. All the specimens showed markedly suppressed bone for- mation. The authors concluded that long-term alendronate therapy may result in severe suppression of bone turnover, with increased susceptibil- ity to nonspinal fractures along with delayed healing. In 2007 a group from Singapore published a retrospective review of patients admitted with a low-energy subtrochanteric fracture (defined as one in the region of the femur that extended from the lesser trochanter to the junction of the proximal and middle third of the femoral shaft.)15 Of 13 women identified, 9 were on long-term alendronate therapy (mean 4.2 years, range 2.5-5). Their average age was 67 years, versus 80 years in the non-alendronate group. Four of the 9 patients in the alendronate group reported that the fracture had occurred in the absence of a fall. Five patients reported experiencing prodromal pain in the fractured limb, starting 2- 6 months before the injury; none of the patients in the non-alendronate group had prodromal symptoms. In 6 patients in the alendronate group, cortical hypertrophy was identified on the lateral side of the subtrochan- teric region of the femur, and 3 of these also had cortical hypertrophy on the contralateral femur. The Singapore group recently elaborated on its findings with a ret- rospective review of postmenopausal patients with subtrochanteric insuffi- ciency fractures admitted to their hos- pital over a 20-month period.16 They found 17 patients, whose mean age was 66 years, and all had been taking alen- dronate, for a mean of 4.4 years (range 2.2-8), except for one patient who was on risedronate for 6 years after 4 years of alendronate. All fractures were low-energy, typically sustained after tripping. Seven of the patients re- ported experiencing acute pain before they fell, suggesting that the fracture preceded the fall. Thirteen of the 17 patients (76%) had experienced pro- dromal pain in the affected thigh rang- ing from 1 week to 2 years before the fracture. Often these patients had been treated for referred pain from a spinal origin, without improvement. Three patients had sustained prior contralateral femoral fractures 2-4 years earlier but had been continued on their bisphosphonate; the patient who was switched to risedronate was one of these. Five other patients had stress reactions seen on plain x-rays in the contralateral femurs; a bone scan of one of these patients showed abnor- mal uptake in that femur. Pointing to
Long-term alendronate therapy may suppress bone turnover.
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the incidence of bilateral stress reac- tions and fractures in more than half of their patients, the authors conclude that these patients have a systemic disorder reflecting oversuppression of bone turnover rather than localized pa- thology. They advise cautious admin- istration of alendronate in osteoporosis management, and ��in situations where the characteristic subtrochanteric frac- tures have already developed, physi- cians should strongly consider discon- tinuing the drug.�� In 2008 a group from the Hospital for Special Surgery, an orthopedic hospital in New York City, published 2 reports of patients taking alendro- nate who had atypical fractures of the femur. One report focused on a specific radiographic pattern.17 The authors described 15 postmenopausal women who had been receiving alen- dronate for a mean of 5.4 years and who presented with atypical low-en- ergy fractures, defined as fractures oc- curring in a fall from a standing height or less. Ten of the 15 had a unique ra- diographic pattern, a simple transverse or oblique fracture with beaking of the cortex and diffuse cortical thickening of the proximal femoral shaft. All the patients with this pattern also had cor- tical thickening of the contralateral femur and 3 had had a prior femoral fracture; none of the patients had a his- tory of vertebral fractures. The au- thors conclude that these 10 women may represent a subgroup of the popu- lation that is more susceptible to the ef- fects of prolonged suppression of bone turnover. They call for a prospective study to characterize this subgroup. The same group also reported on a retrospective review of patients with femoral shaft fractures (including the 15 in the prior report) admitted between January 2002 and March 2007.18 Sev- enty low-energy fractures were identi- fied, in 59 females and 11 males, with an average age of 74.7 years. Osteo- porosis was present in 44% of the 70 patients. Twenty-five patients (36%), all women, were being treated with alendronate, 84% for osteoporosis; none of the patients had used any other bisphosphonate. Of the 25, 19 (76%) had a specific pattern to the fracture— it was transverse, with a one-sided beak in an area of thickening of the cortex. This fracture pattern was seen in only 1 patient (2%) of patients not being treated with alendronate. The odds ra- tio for this pattern was 139.33 for alen- dronate users, and was 98% specific to identifying alendronate users. The patients with this pattern had been us- ing alendronate for a mean of 6.9 years. The authors concluded that although they have not established a causal re- lationship, such fractures may result from propagation of a stress fracture whose repair is retarded by decreased osteoclast activity and impaired mi- crodamage repair resulting from the prolonged use of alendronate. Minimal trauma is then required to produce a completed fracture. Discussion Fragility or insufficiency fractures are a type of stress fracture that occurs in osteoporotic bone subjected to normal levels of stress. They typically occur in the vertebrae, hip, distal radius, and the proximal humerus follow- ing minimal or no trauma, but only rarely in the proximal femur.19 The subtrochanteric region of the femur is one of the strongest parts of the fe- mur and it is unlikely to fracture in low low-energy trauma unless ex- treme osteoporosis is present.15 The reports of multiple cases of low-impact femoral fractures in patients who were taking alendronate for several years, a previously rare event, have therefore called for further study of the possible connection between alendronate and such fractures, as has been suggested by several authors. Alendronate is stored in the bone for many years and is reactivated as bone is turned over and the drug re-enters the circulation. Patients on long-term alen- dronate who experienced completed fractures of the femur with minimal
A case is made for discontinuing alendronate.
J e n n ife r P . S c h n e id e r, M D
X-ray of comminuted spiral fracture involving upper half of right femur.
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trauma continue to be at risk of addi- tional insufficiency fractures. In those in whom a stress fracture was subse- quently diagnosed in the contralateral femur, prophylactic surgical rodding is typically suggested in order to prevent a completed fracture. Some bone spe- cialists treat such patients with teripa- ratide (recombinant human parathy- roid hormone [Forteo]) in an attempt to reverse their adynamic bone. Unlike bisphosphonates, which work by de- creasing the activity of osteoclasts that break down bone, recombinant PTH strengthens bone and improves bone density by increasing the activity of os- teoblasts that build bone. Teriparatide stimulates bone formation, increases bone mass, and improves bone micro- architecture.20 In patients previously treated with alendronate or raloxifene, subsequent treatment with teriparatide significantly increased bone turnover, although less so in patients formerly on alendronate.21,22 This drug is recom- mended by Lenart et al of the New York City group in a recent published letter23 based on findings of the effects of para- thyroid hormone and alendronate alone or in combination in postmenopausal osteoporosis.7 Results of treatment with teriparatide in women with alen- dronate-related insufficiency fractures will be published in the near future.24 Teriparatide should not be used in pa- tients who are at an increased risk of developing bone tumors (eg, patients with Paget��s disease, unexplained el- evations of alkaline phosphatase, open epiphyses, or prior radiation therapy involving the skeleton). Osteonecrosis of the jaw The evolution of our understanding of the relationship between alendronate and femoral fractures parallels the growing understanding of the relation- ship between use of bisphosphonates and osteonecrosis of the jaw (ONJ), which may reflect a similar mecha- nism of bone injury. After numerous publications of multiple case reports, a population-based analysis of IV bisphosphonate therapy concluded that the hazard ratio of being diag- nosed with inflammatory conditions or osteomyelitis of the jaw was 11.48 for recipients of IV bisphosphonates as compared with non-recipients.25 No randomized, controlled, double- blind studies have been done regard- ing bisphosphonates and ONJ, and they are unlikely to be done in the future. Nonetheless, the case reports and population studies have led to the creation of a new syndrome in the den- tal world, bisphosphonate-associated osteonecrosis of the jaw (BON), and position papers on trying to prevent this disorder have been published by several organizations concerned with dental surgery. Although most cases of ONJ have occurred in patients treated with IV bisphosphonates (pamidronate, zole- dronic acid), the finding of some cases related to oral bisphosphonates resulted in the recent publication by the American Dental Association of ��Dental management of patients receiving oral bisphosphonate ther- apy.��26 This document suggests that ��because there is no validated diag- nostic technique currently available to determine if patients are at increased risk for developing BON, it may be prudent to proceed conservatively in some cases.�� For example, if full- mouth tooth extraction is needed, begin by extracting one tooth and see if the jaw heals. The Association of Oral and Maxillofacial Surgeons pub- lished guidelines in 2006 that state, ��If systemic conditions permit, it has been proposed that discontinuation of oral bisphosphonates for a period of 3 months prior to and 3 months fol- lowing elective invasive dental surgery may lower the risk of bisphosphonate- related ONJ.��27 There are no actual data as yet to help determine the ap- propriate length of time the patient should be off the bisphosphonate, and this depends on the particular drug. Nonetheless, the dental profession��s current guidelines are a model for prudent, patient-centered care in an environment where definitive high- grade studies are lacking but where there are reports of multiple, difficult- to-treat cases strongly suggestive of a bisphosphonate cause. There is al- ready a published case report in the dental literature of a refractory case of ONJ that was successfully treated with teriparatide.28 Recommendations Citing the 2006 report by Black et al7 about stopping or continuing alen- dronate after 5 years of treatment, the National Osteoporosis Foundation (NOF), in its Clinical Update Online of July 2008, said, ��Results suggest that for most women, taking a 5-year ��drug holiday�� after being on alendro- nate (5-10 mg/day) for 5 years does not increase fracture risk and might be advantageous. For women at high risk for vertebral fractures, continuing alendronate for a total of 10 years is a reasonable clinical option.��29 In 2008 the NOF published a Clini- cian��s Guide to Prevention and Treat- ment of Osteoporosis. This guide in- troduced a new Fracture Risk Algo- rithm (FRAX) for calculating which men and women over 50 require phar- macologic treatment for osteoporosis. The report states that FRAX analyses generally confirm that it is cost-effec- tive to treat individuals with a prior hip or vertebral fracture and those with a DEXA femoral neck -T score of -2.5 or worse.
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The guide does not discuss the rec- ommended duration of treatment with bisphosphonates. It does discuss the usefulness of biochemical markers of bone metabolism, saying, ��Suppres- sion of biochemical markers of bone turnover after 3-6 month of specific antiresorptive osteoporosis therapies, and biochemical marker increases after 1-3 months of specific anabolic thera- pies, have been predictive of greater BMD responses in studies evaluating large groups of patients. Because of the high degree of biological and ana- lytical variability in measurement of biochemical markers, changes in in- dividuals must be large in order to be clinically meaningful.��30 The North American Menopause Society (NAMS), in its 2006 position statement on management of osteopo- rosis in post-menopausal women, says, ��Current evidence does not support rec- ommendations regarding the optimal duration of bisphosphonate therapy.��31 In the absence of definite guidelines from NOF or NAMS, some bone me- tabolism specialists are increasingly suggesting that alendronate use be stopped in most cases after 5 years, despite the absence of randomized prospective studies.14 Patients should continue weight-bearing activities, calcium and Vitamin D, and undergo periodic DEXA scanning. Those with a high fracture risk might best be served by continuing treatment with a bisphsphonate or treatment with an al- ternative agent, such as teriparatide. As implied by the recent NOF guidelines, it might be prudent to withhold initiating bisphosphonates in otherwise healthy postmenopausal women who merely have osteopenia, saving these drugs for those who have osteoporosis. There may be a group of patients with low bone density who should not be treated with bisphosphonates. At present there is no way of predict- ing who these patients are. There is a need for research designed to iden- tify those patients who are potentially at risk for adverse outcomes with bisphosphonates in general, or with alendronate in particular. These pa- tients undoubtedly constitute a small percentage compared to those who benefit from bisphosphonates, but for those patients these fractures can be devastating events, to be prevented if at all possible. Population research is also needed that compares the in- cidence of subtrochanteric fractures among people be- ing treated with alendronate with the incidence among a group with comparable bone density who have not been treated with alendronate. This re- mains to be done. In September 2008 at a bone research meeting, research- ers reported a large Danish registry co- hort analysis showing that alendronate use was indeed significantly associ- ated with an increased risk of atypi- cal subtrochanteric fractures.32 The alendronate group had an incidence of subtrochanteric fractures of 2.9/1,000 patient years, compared with only 1.6 among the controls. However, regular hip fractures were also significantly more common among the alendronate group, suggesting that that the alen- dronate-treated group had weaker bones than controls in the first place. Clearly, additional population studies are needed. It is uncertain whether all bisphos- phonates have the potential risk of suppressing bone repair, or only alen- dronate. Alendronate was the first bisphosphonate available and still the most widely used. Its long biological half life might make it more likely than other bisphosphonates to cause problems in susceptible patients. Phy- sicians need to be aware that patients on bisphosphonates who experience low-impact femoral fractures may re- quire additional evaluation and treat- ment along with surgical fixation. This might include bone scans to de- tect other stress fractures, stopping alendronate therapy, and referral to specialists knowledgeable in treating these unusual cases.
References
1. Schneider JP. Should bisphosphonates be continued indefinitely? An unusual fracture in a healthy woman on long-term alendro- nate. Geriatrics. 2006;61(1):31-33. 2. Cummings SR, Black DM, Thompson DE et al. Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: Results from the Fracture Intervention Trial. JAMA. 1998;280(24):2077-2082. 3. Pols HA, Felsenberg D, Hanley DA, et al. Multinational, placebo-controlled, random- ized trial of the effects of alendronate on bone density and fracture risk in post- menopausal women with low bone mass: Results of the FOSIT study. Osteoporos Int. 1999;9(5):461-468. 4. Tonino RP, Meunier PJ, Emkey R, et al. Skeletal benefits of alendronate: 7-year treatment of postmenopausal osteopo- rotic women. J. Clin Endoc Metab. 2000; 85(9):3109-3115. 5. Black DM, Thompson DE, Bauer DC, et al. Fracture risk reduction with alendronate in women with osteoporosis: The Fracture Intervention Trial FIT Research Group. J Clin Endocrinol Metab. 2000:85(11):4118- 4124. Erratum in: J Clin Endocrinol Metab. 2001;86(2):938. 6. Orwoll E, Ettinger M, Weiss S, et al. Alendronate for the treatment of osteoporo- sis in men. N Eng J Med. 2000;343(9):604- 610. 7. Black DM, Schwartz AV, Ensrud KE, et al. Effects of continuing or stopping alen- dronate after 5 years of treatment: The Fracture Intervention Long-term exten- sion (FLEX): A randomized trial. JAMA. 2006;296:2927-2938. 8. Mashiba T, Turner CH, Hirano T, et al. Effects of suppressed bone turnover by bisphos- phonates on microdamage accumulation and biomechanical properties in clinically relevant skeletal sites in beagles. Bone. 2001;28(5)524-531. 9. Hirano T, Turner CH, Forwood MR, et al. Does suppression of bone turnover impair mechanical properties by allow- ing microdamage accumulation? Bone. 2000:227(1)13-20. 10. Boivin G, Meunier PJ. Changes in bone remodeling rate influence the degree of
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mineralization of bone. Connect Tiss Res. 2002;43(2-3):535-537. 11. Akkus O, Polyakova-Akkus, Adar F, Schaffler MB. Aging of micro- structural compartments in human compact bone. J Bone Miner Res. 2003;18(6):1012-1019. 12. Ciarelli TE, Fyhrie DP, Parfitt AM. Effects of vertebral bone fragil- ity and bone formation on the mineralization levels of cancellous bone from white females. Bone. 2003;32(3):311-315. 13. O��Brien FJ, Brennan O, Kennedy OD, Lee TC. Microcracks in corti- cal bone: How do they affect bone biology? Curr Osteoporos Rep. 2005 Jun;3(2):39-45. 14. Odvina CV, Zerwekh JE, Rao DS, et al. Severely suppressed bone turnover: A potential complication of alendronate therapy. J Clin Endocrinol Metab. 2005;90(3):1897-1899. 15. Goh SK, Yang KY, Koh JS, et al. Subtrochanteric insufficiency fractures in patients on alendronate therapy: A caution. J Bone Joint Surg Br. 2007;89:349-353. 16. Kwek EB, Goh SK, Koh JS, et al. An emerging pattern of subtro- chanteric stress fractures: A long-term complication of alendro- nate therapy? Injury. 2008;39(2):224-231. 17. Lenart BQ, Lorich CG, Lane JM. Atypical fractures of the femoral diaphysis in postmenopausal women taking alendronate. N Engl J Med. 2008;358(12):1304-1306. 18. Neviaser AS, Lane JM, Lenart BA, et al. Low-energy femoral shaft fractures associated with alendronate use. J Orthop Trauma. 2008;22(5):346-350. 19. Gibson MV. Evaluation and treatment of bone disease after fragil- ity fracture. Geriatrics. 2008;63(7):21-30. 20. McClung M, San Martin J, Miller PD, Civiteli R, et al. Opposite bone remodeling effects of teriparatide and alendronate in increasing bone mass. Arch Int Med. 2005;1762-1768. 21. Ettinger B, San Martin J, Crans G, Pavo I. Differential effects of teriparatide on BMD after treatment with raloxifene or alendro- nate. J Bone Miner Res. 2004;19:745-751. 22. Miller PD, Delmas PD, Lindsay R, Watts NB, et al. Early respon- siveness of women with osteoporosis to teriparatide after thera- py with alendronate or risedronate. J Clin Endocrinol Metab. 2008 Oct;93(10):3785-93. 23. Lenart BA, Lorich DG, Lane JM. More on atypical fractures of the femoral diaphysis. Letter. N Engl J Med. 2008;359(3):317-318. 24. Miller P. Personal communication. July 2008. 25. Wilkinson GS, Kuo Y-F, Freeman JL, Goodman JS. Intravenous bisphosphonate therapy and inflammatory conditions or sur- gery of the jaw: A population-based analysis. J Nat Cancer Inst. 2007;99:1016-24. 26. Dental management of patients receiving oral bisphosphonate therapy: Report of the Council on Scientific Affairs. 1 July 1998. American Dental Association web site. http://www.ada.org/prof/ resources/topics/topics_osteonecrosis_bisphosphonate_report. pdf. Accessed September 6, 2008. 27. Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaw. 2006. American Association of Oral and Maxillofacial Surgeons web site. http://www.aaoms.org/docs/position_ papers/osteonecrosis.pdf. Accessed September 12, 2008. 28. Harper RP. Resolution of bisophosphonate-associated osteone- crosis of the mandible: Possible application for intermittent low- dose parathyroid hormone [rhPTH(1-34)]. J Oral Maxillofac Surg. 2007;65:573-580. 29. Update on Bisphosphonates FDA-Approved for Prevention and Treatment of Osteoporosis. July 2008. National Osteoporosis Foundation web site. http://www.nof.org. CUOnline-July08-forweb. pdf. Accessed January 2, 2009. 30. Clinician��s Guide to Prevention and Treatment of Osteoporosis. National Osteoporosis Foundation web site. http://www.nof.org/ professionals/cliniciansguide_form.asp. Accessed January 2, 2009. 31. North American Menopause Society Position Statement: Management of osteoporisis in postmenopausal women, 2006. The Journal of the North American Menopause Society. 13(3):340-367. 32. ASBMR: Alendronate Exonerated in ��Atypical�� Femoral Fractures. September 15, 2008. MedPage Today web site. http://www. medpagetoday.com/MeetingCoverage/ASBMR/10904. Accessed September 22, 2008.
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