title: Management of aromatase inhibitor-associated bone loss in postmenopausal women with breast cancer: practical guidance for prevention and treatment.
abstract: BACKGROUND
  Bone mineral density (BMD)-based guidelines for bone-directed therapy in women with early breast cancer (EBC) appear inadequate for averting fractures, particularly during aromatase inhibitor (AI) therapy. Therefore, an algorithm was developed to better assess risk and direct treatment (Hadji P, Body JJ, Aapro MS et al. Practical guidance for the management of aromatase inhibitor-associated bone loss. Ann Oncol 2008; 19: 1407-1416). Here, we provide updated guidance on pharmacologic interventions to prevent/treat aromatase inhibitor-associated bone loss (AIBL).
  
  
  METHODS
  Systematic literature review identified recent advances in preventing/treating AIBL. Individual agents were assessed based on trial size, design, follow-up, and safety.
  
  
  RESULTS
  Fracture risk factors in patients with EBC remain unchanged (Hadji P, Body JJ, Aapro MS et al. Practical guidance for the management of aromatase inhibitor-associated bone loss. Ann Oncol 2008; 19: 1407-1416). The World Health Organization Fracture Risk Assessment Tool algorithm includes fracture risk factors plus BMD but does not adequately address AIBL effects. Several antiresorptives can prevent/treat AIBL. However, concerns regarding compliance and long-term efficacy/safety remain. Overall, evidence is strongest for twice-yearly zoledronic acid (ZOL), and recent advances support additional anticancer benefits from ZOL.
  
  
  CONCLUSIONS
  All patients initiating AIs need advice regarding exercise, calcium/vitamin D supplements, baseline BMD monitoring (when available), and bone-directed therapy if T-score <-2.0 or at least two fracture risk factors were observed. Patients with T-score > -2.0 and no risk factors should be managed based on BMD loss during years 1-2. Unsatisfactory compliance/decreasing BMD after 12-24 months on oral bisphosphonates should trigger a switch to i.v. bisphosphonate.
authors.affiliation: Department of Endocrinology, Philipps-University of Marburg, Marburg, Germany. Electronic address: hadji@med.uni-marburg.de.
authors.forename: P
authors.initials: P
authors.lastname: Hadji
authors.affiliation: Institut Multidisciplinaire d'Oncologie, Clinique de Genolier, Genolier, Switzerland.
authors.forename: M S
authors.initials: MS
authors.lastname: Aapro
authors.affiliation: Department of Medicine, Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, Brussels, Belgium.
authors.forename: J J
authors.initials: JJ
authors.lastname: Body
authors.affiliation: Department of Academic Surgery, South Manchester University Hospital, Manchester, UK.
authors.forename: N J
authors.initials: NJ
authors.lastname: Bundred
authors.affiliation: Division of Medicine, University of Pittsburgh Cancer Institute, Pittsburgh, USA.
authors.forename: A
authors.initials: A
authors.lastname: Brufsky
authors.affiliation: Department of Oncology, Cancer Research Centre, University of Sheffield, Weston Park Hospital, Sheffield, UK.
authors.forename: R E
authors.initials: RE
authors.lastname: Coleman
authors.affiliation: Department of Surgery, Medical University of Vienna, Vienna, Austria.
authors.forename: M
authors.initials: M
authors.lastname: Gnant
authors.affiliation: Department of Medicine, Indiana University School of Medicine, Indianapolis.
authors.forename: T
authors.initials: T
authors.lastname: Guise
authors.affiliation: Departments of Medicine and Microbiology, Milton S. Hershey Medical Center, Pennsylvania State University, Hershey, USA.
authors.forename: A
authors.initials: A
authors.lastname: Lipton
mesh_terms: D000970:Antineoplastic Agents / Q000009:adverse effects* / Q000627:therapeutic use; D047072:Aromatase Inhibitors / Q000009:adverse effects* / Q000627:therapeutic use; D050071:Bone Density Conservation Agents / Q000627:therapeutic use*; D001943:Breast Neoplasms / Q000188:drug therapy*; D004164:Diphosphonates / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D007093:Imidazoles; D015663:Osteoporosis, Postmenopausal / Q000139:chemically induced* / Q000517:prevention & control; D017410:Practice Guidelines as Topic; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors; D000077211:Zoledronic Acid
chemical_list: D000970:Antineoplastic Agents; D047072:Aromatase Inhibitors; D050071:Bone Density Conservation Agents; D004164:Diphosphonates; D007093:Imidazoles; D000077211:Zoledronic Acid