Drug treatment strategies for osteoporosis in stroke patients

ABSTRACT

Introduction

Osteoporosis and subsequent fractures are well-recognized complications of stroke. However, drug treatment strategies for osteoporosis after stroke have been rarely discussed in the current guidelines for the management of stroke or osteoporosis.

Areas covered

The authors review the epidemiology, characteristics, pathophysiology, and risk prediction of post-stroke osteoporosis and fractures. Then they provide an overview of existing evidence regarding drug treatment strategies for osteoporosis in stroke patients. They also review the effects on bone mineral density (BMD) and fractures for those drugs commonly used in stroke patients.

Expert opinion

Currently, there is scarce evidence. A small randomized control trial suggested that a single use of 4 mg of intravenous zoledronate within 5 weeks of stroke onset was beneficial for preserving BMD, while simultaneous use of calcium and vitamin D supplements may be effective in preventing hypocalcemia. Further studies are needed to address several important issues of post-stroke osteoporosis, including who (the eligibility for treatment), when (the best timing of treatment), what (which drug), and how long (the best duration of treatment). On the other hand, physicians should bear in mind that drugs commonly used for stroke, such as statins or warfarin, may have beneficial or adverse effects on BMD and fracture risks.

KEYWORDS:

• Osteoporosis
• fracture
• stroke
• antiresorptive medications
• osteoanabolic agents

Article highlights

• Stroke survivors have an up to 7-fold increased risk of fracture, compared to the age- and sex-matched general population. It is likely due to increased risks of falls and post-stroke osteoporosis.

• Bone mineral density markedly declines within the first six months after stroke, followed by a slower rate of reduction thereafter. It is caused by a complex interaction of decreased mobility, reduced bone load, and a variety of endocrinological, nutritional, and pharmacological factors.

• Although osteoporosis is a well-recognized complication of stroke, drug treatment strategy has rarely been mentioned in clinical practice guidelines. Only 15.5% of stroke patients were prescribed medications for prevention of osteoporosis and fracture.

• Adequate calcium and vitamin D supplements are essential for stroke patients, especially when other anti-osteoporosis medications, such as bisphosphonates, are given.

• There were few clinical trials evaluating drug treatment for post-stroke osteoporosis. Based on the existing evidence, one option would be to administer intravenous zoledronate in high-risk patients during the initial hospitalization for stroke. Nevertheless, more studies are needed to determine the efficacy and safety of other drug treatment strategies.

• Medications commonly used in patients with stroke, such as warfarin, may have adverse effects on bone mineral density and fracture risks.

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Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.