Abstract
Summary
Prior studies have associated fatal stroke with raloxifene. In a cohort study, we found no excess risk of stroke with raloxifene; whereas, an excess risk of stroke and fatal stroke was seen with alendronate and etidronate. However, the excess risks were small.
Purpose
We aim to study the association between use of raloxifene and other drugs against osteoporosis and risk of stroke.
Methods
This is a nationwide cohort study from Denmark. All users of bisphosphonates and other drugs against osteoporosis between 1996 and 2006 (n = 103,562) as exposed group and three age- and gender-matched controls from the general population (n = 310,683).
Results
Before the drugs were started, patients later initiating alendronate or raloxifene had fewer strokes than the controls. In contrast, patients who later did start clodronate have more strokes. Among the later users of other bisphosphonates, strontium ranelate or parathyroid hormone, no change in the risk of stroke was present. Patients who started raloxifene neither had an excess risk of strokes nor of fatal strokes. No dose–response relationship was present. Among users of alendronate, a decreasing overall risk of stroke was seen with increasing dose. However, for fatal strokes, the risk increased with increasing dose of alendronate. Among users of etidronate, no trend with dose was present for overall stroke risk; whereas for fatal strokes, an increasing risk was seen with increasing dose of etidronate.
Conclusions
Raloxifene does not seem associated with an excess risk of strokes. The increase seen for alendronate did not seem to be causal as no classical dose–response relationship was present. The dose–response relationship for fatal strokes with alendronate and etidronate needs further examination. However, the excess risks were small and may be due to the underlying disease.
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References
Barrett-Connor E, Mosca L, Collins P, Geiger M, Grady D, Kornitzer M, McNabb M, Wenger N (2006) Effects of raloxifene on cardiovascular events and breast cancer in postmenopausal women. N Engl J Med 355:125–137
Urushihara H, Kikuchi N, Yamada M, Yoshiki F, Miyauchi A (2009) Raloxifene and stroke risks in Japanese postmenopausal women with osteoporosis on postmarketing surveillance. Menopause 16:971–977
Barrett-Connor E, Grady D, Sashegyi A, Anderson P, Cox D, Hoszowski K, Rautaharju P, Harper K (2002) Raloxifene and cardiovascular events in osteoporotic postmenopausal women: four-year results from the MORE (Multiple Outcomes of Raloxifene Evaluation) randomized trial. JAMA 287:847–857
Delmas P, Ensrud K, Adachi J, Harper K, Sarkar S, Gennari C, Reginster J, Pols H, Recker R, Harris S, Wu W, Genant H, Black D, Eastell R (2002) Efficacy of raloxifene on vertebral fracture risk reduction in postmenopausal women with osteoporosis: four-year results from a randomized clinical trial. J Clin Endocrinol Metab 87:3609–3617
Mosca L, Grady D, Barrett-Connor E, Collins P, Wenger N, Abramson BL, Paganini-Hill A, Geiger MJ, Dowsett SA, Amewou-Atisso M, Kornitzer M (2009) Effect of raloxifene on stroke and venous thromboembolism according to subgroups in postmenopausal women at increased risk of coronary heart disease. Stroke 40:147–155
Barrett-Connor E, Cox DA, Song J, Mitlak B, Mosca L, Grady D (2009) Raloxifene and risk for stroke based on the framingham stroke risk score. Am J Med 122:754–761
Andersen T, Madsen M, Jørgensen J, Mellemkjær L, Olsen J (1999) The Danish National Hospital Register. Dan Med Bull 46:263–268
Mosbech J, Jørgensen J, Madsen M, Rostgaard K, Thornberg K, Poulsen T (1995) The Danish National Patient Register: evaluation of data quality. Ugeskr Laeger 157:3741–3745
Johnsen SP, Overvad K, Sørensen HT, Tjønneland A, Husted SE (2002) Predictive value of stroke and transient ischemic attack discharge diagnoses in The Danish National Registry of Patients. J Clin Epidemiol 55:602–607
Krarup L, Boysen G, Janjua H, Prescott E, Truelsen T (2007) Validity of stroke diagnoses in a National Register of Patients. Neuroepidemiology 28:150–154
Lévesque LE, Hanley JA, Kezouh A, Suissa S (2010) Problem of immortal time bias in cohort studies: example using statins for preventing progression of diabetes. BMJ 340:b5087
Fleisch H (1995) Bisphosphonates in bone disease: from the laboratory to the patient. Fleisch H (Ed.). Parthenon Pub Group, pp 38–56
Deckers MML, Van Beek ER, Van Der Pluijm G, Wetterwald A, Van Der Wee-Pals L, Cecchini MG, Papapoulos SE, Löwik CWGM (2002) Dissociation of angiogenesis and osteoclastogenesis during endochondral bone formation in neonatal mice. J Bone Miner Res 17:998–1007
Browner W, Pressman A, Nevitt M, Cauley J, Cummings S (1993) Association between low bone density and stroke in elderly women. The study of osteoporotic fractures. Stroke 24:940–946
Nordström A, Eriksson M, Stegmayr B, Gustafson Y, Nordström P (2010) Low bone mineral density is an independent risk factor for stroke and death. Cerebrovasc Dis 29:130–136
Tanko LB, Bagger YZ, Christiansen C (2003) Low bone mineral density in the hip as a marker of advanced atherosclerosis in elderly women. Calcif Tissue Int 73:15–20
Melton L III, Brown R Jr, Achenbach S, O'Fallon W, Whisnant J (2001) Long-term fracture risk following ischemic stroke: a population-based study. Osteoporos Int 19:980–986
Hamdy R, Moore S, Cancellaro V, Harvill L (1995) Long-term effects of strokes on bone mass. Am J Phys Med Rehabil 74:351–356
Jorgensen L, Jacobsen B, Wilsgaard T, Magnus J (2000) Walking after stroke: does it matter? Changes in bone mineral density within the first 12 months after stroke. A longitudinal study Osteoporosis Int 11:381–387
Bolland MJ, Barber PA, Doughty RN, Mason B, Horne A, Ames R, Gamble GD, Grey A, Reid IR (2008) Vascular events in healthy older women receiving calcium supplementation: randomised controlled trial. BMJ 336:262–266
Loke Y, Jeevanantham V, Singh S (2009) Bisphosphonates and atrial fibrillation: systematic review and meta-analysis. Drug Saf 32:219–228
Sorensen H, Christensen S, Mehnert F, Pedersen L, Chapurlat R, Cummings S et al (2008) Use of bisphosphonates among women and risk of atrial fibrillation and flutter: population based case-control study. BMJ 336:813–816
Abrahamsen B, Eiken P, Brixen K (2009) Atrial fibrillation in fracture patients treated with oral bisphosphonates. J Intern Med 265:581–592
Frost L, Vestergaard P (2004) Alcohol and risk of atrial fibrillation or flutter: a cohort study. Arch Intern Med 164:1993–1998
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This study was supported by an unrestricted grant from the Dandy Foundation and Servier Denmark.
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Vestergaard, P., Schwartz, K., Pinholt, E.M. et al. Stroke in relation to use of raloxifene and other drugs against osteoporosis. Osteoporos Int 22, 1037–1045 (2011). https://doi.org/10.1007/s00198-010-1276-4
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DOI: https://doi.org/10.1007/s00198-010-1276-4