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Context: Recent studies have reported low bone mineral density Measurements: BMD at the lumbar spine, total hip and total body,
(BMD) in HIV-infected patients. Annual iv administration of 4 mg and bone turnover markers were measured.
zoledronate has been shown to increase BMD and suppress bone
turnover in postmenopausal women. Results: At the lumbar spine, BMD increased by 8.9% over 2 yr in the
zoledronate group compared with an increase of 2.6% in the control
Objective: The objective of the study was to determine whether group (P ⬍ 0.001). At the total hip, BMD increased by 3.8% over 2 yr
annual administration of 4 mg zoledronate will increase BMD in in the zoledronate group compared with a decrease of 0.8% in the
HIV-infected men receiving highly active antiretroviral therapy. control group (P ⬍ 0.001). At the total body, BMD increased by 2.3%
over 2 yr compared with a decrease of 0.5% in the control group (P ⬍
Design and Setting: A 2-yr randomized placebo-controlled trial was 0.001). Urine N-telopeptide decreased by 60% at 3 months in the
conducted in a clinical research center. zoledronate group and thereafter remained stable.
Participants: A total of 43 HIV-infected men were treated with Conclusions: Annual administration of zoledronate is a potent and
highly active antiretroviral therapy for at least 3 months, with BMD effective therapy for the prevention or treatment of bone loss in HIV-
T score less than ⫺0.5. infected men. The current data provide the first trial evidence of the
BMD effects of annual zoledronate beyond 1 yr in any population, as
Intervention: Participants received annual iv administration of 4 well as being the first reported trial in men. (J Clin Endocrinol
mg zoledronate or placebo. All participants took 400 mg/d calcium and Metab 92: 1283–1288, 2007)
1.25 mg/month vitamin D.
1283
1284 J Clin Endocrinol Metab, April 2007, 92(4):1283–1288 Bolland et al. • HIV and Zoledronate in Men
if they had been treated with HAART for at least 3 months and had a Measurements
BMD T score of less than ⫺0.5 at the lumbar spine or total hip. HAART
was defined as an HIV treatment regimen containing at least three BMD and body composition were measured every 6 months at the
antiretroviral agents. We excluded men with: significant renal, hepatic, lumbar spine, proximal femur, and total body using a Lunar Expert
or thyroid dysfunction; concurrent major systemic illness, including dual-energy x-ray absorptiometer (GE Lunar, Madison, WI). BMD T and
malignancy; metabolic bone disease; or current use of a bisphosphonate Z scores were calculated using the manufacturer-supplied Lunar US/
or systemic glucocorticoids. Approximately 220 men were approached, Northern Europe database for men. At baseline and 2 yr, vertebral
and 72 agreed to have a screening bone density scan. A total of 45 men morphometry was also performed. Daily calcium intake was assessed at
had a BMD T score below ⫺0.5 at the lumbar spine or total hip. One man baseline using a validated questionnaire (10). At baseline, and 3, 12, and
was excluded because of liver cirrhosis, and one because of newly 24 months, fasting blood and second-voided morning urine samples
diagnosed primary hypogonadism. Thus, 43 men were enrolled in the were collected. The following assays were used: serum 25-hydroxyvi-
2-yr study. tamin D was measured by RIA (DiaSorin, Stillwater, MN); serum PTH
Figure 1 shows the flow of participants through the trial. One man and serum testosterone by electrochemiluminescence immunoassays
withdrew from the study for personal reasons after randomization but (E170; Roche Diagnostics, Indianapolis, IN); and urine N-telopeptide of
before administration of study medication, one died of unknown causes, type 1 collagen (NTx) by ELISA (Ostex International Inc., Seattle, WA).
and four emigrated during the study. Thus, 37 men completed 2 yr of At baseline, measurements of biochemistry, calcium metabolism, tes-
follow-up. Two men (both received zoledronate) stopped iv study med- tosterone, HIV parameters (CD4 count, viral load), and bone turnover
ication because of influenza-like illnesses after the first administration were performed. Measurements of bone turnover were repeated at 3, 12,
of study drug but remained in the study. However, after the intention to and 24 months, and HIV parameters at 24 months.
treat principle, all 43 men enrolled in the trial were included in the analyses.
One man in the zoledronate group was taking testosterone supplementa- Statistics
tion at baseline but emigrated 2 months into the study and, so, was not
The primary endpoint was the difference between groups in the
included in any of the outcome data. Another man in the zoledronate group
change in BMD at the spine over 2 yr. This study had a power of at least
took testosterone supplementation for 5 months during the study. No
80% to detect a between-group difference in percent change from base-
subjects took GH, anabolic steroids, or other agents that might impact upon
line BMD of the lumbar spine of 4% (␣ ⫽ 0.05). Differences between
BMD during the study. The study received ethical approval from the
groups for continuous variables were assessed using Student’s t test and
Auckland Ethics Committee and was registered with the Australian Clin-
for categorical groups using the 2 test. Pearson correlation analysis was
ical Trials Registry (ACTRN012605000208606). All participants gave writ-
used to test for significant linear correlations between variables. BMD
ten informed consent.
data were analyzed as absolute changes from baseline values, although
results are presented as percentage change from baseline for ease of
Protocol interpretation. A mixed models approach to repeated measures (analysis
of covariance) was used to examine the time course of response in
Participants were randomly allocated to receive an annual adminis- treatment and control arms for BMD measurements, bone turnover
tration of either zoledronate 4 mg, given as a 15-min iv infusion in 100 markers, and measurements of body composition. Changes in variables
ml 0.9% NaCl, or placebo for 2 yr. Randomization was performed in between time points were furthered explored using the method of
blocks of variable size, using computer-generated random numbers Tukey. Inspection of plots for urine NTx showed that data were not
(Excel 2000; Microsoft Corp., Redmond, WA). Subject numbers were normally distributed. Therefore, these data were ranked, and the ranked
allocated and medication dispensed by staff that had no direct contact values were analyzed using a nonparametric mixed models approach,
with the participants. All study staff and participants remained blinded although data are presented using medians and confidence intervals
to treatment allocation throughout. In addition, all participants received (binomial method: Confidence Interval Analysis, version 2.1.1) for ease
a supplement of 400 mg/d elemental calcium and 1.25 mg/month vi- of interpretation. All tests were two-tailed, and statistical significance
tamin D (cholecalciferol). Participants were seen every 6 months during was set at P ⬍ 0.05. All statistical analyses were performed using the SAS
the study period. software package (version 9.1; SAS Institute, Cary, NC).
men, in HIV-infected subjects, or with drug administration ter, total hip, or total body. Bone turnover markers decreased
beyond 12 months. These results are consistent with those of in both groups, but the between-group difference was only
Reid et al. (9) who reported an increase in BMD at the lumbar statistically significant for bone-specific ALP. Negredo et al.
spine of 5% and at the femoral neck of 2.5%, and a reduction (6) reported a 96-wk trial of alendronate with dietary coun-
in bone resorption markers of 50 – 60% in postmenopausal seling to ensure a daily calcium intake of more than 1200 mg
women at 12 months after a single administration of 4 mg of compared with dietary counseling alone in 25 HIV-infected
iv zoledronate. Thus, our findings extend the beneficial ac- patients taking HAART with T score less than ⫺2.5. There
tions of zoledronate on BMD to men, and HIV-infected sub- were increases in BMD at the spine and hip in the alendro-
jects, and suggest that there are ongoing benefits from annual nate group, whereas BMD tended to decrease in the control
administration of zoledronate for at least 24 months. The group. The between-group differences in BMD were only
annual administration of this agent is an additional benefit statistically significant at the trochanter. The conflicting re-
in HIV-infected patients because many HAART regimens sults between these studies may be due to the small size of
involve a complicated daily schedule of ingestion of several the studies or the differences in study design and duration
different medications, which is likely to impact adversely on of follow-up. Our study provides rigorous evidence that
compliance with other treatments. bisphosphonate therapy improves BMD in HIV-infected
There are few published studies on the use of bisphos- subjects.
phonates in men. Two studies have reported on the effect of Although we have shown that annual administration of
daily 10 mg alendronate on men with primary osteoporosis zoledronate causes significant increases in BMD in men in-
(12, 13). Both studies reported significant increases in BMD fected with HIV, it remains uncertain what proportion of
from baseline over 2 yr of treatment with increases of 7.1– HIV-infected patients are likely to require treatment with
10.1% at the lumbar spine and 3.5–5.2% at the femoral neck. bisphosphonates. The stability of BMD in the placebo group
These increases in BMD were associated with a 7% reduction in this study is consistent with other recent studies that also
in vertebral fractures compared with placebo (12) and an 11% report stable BMD in HIV-infected patients taking HAART
reduction compared with alfacalcidol (13). We observed sim- (17–19). Therefore, in the absence of definitive evidence of
ilar changes in BMD to these two studies suggesting that increased skeletal morbidity in HIV-infected subjects, it
annual administration of zoledronate may have similar ef- seems reasonable to apply standard guidelines for the treat-
ficacy to daily treatment with alendronate. ment of patients with osteoporosis to HIV-infected subjects
An important finding of the current study is that suppres- (20, 21). The present study provides evidence for efficacy,
sion of bone resorption remains stable and does not pro- tolerability, and convenience of annual zoledronate therapy
gressively decline during the second year of zoledronate for those HIV-infected patients who require treatment for
therapy. Recently, concerns have been raised about potential osteoporosis.
over-suppression of bone turnover during long-term
bisphosphonate therapy. Such over-suppression could in- Conclusions
crease susceptibility to fractures that fail to heal or heal The annual administration of 4 mg zoledronate is a potent
poorly (14, 15). We found that annual administration of and effective treatment for bone loss in men infected with
zoledronate led to a rapid 60% decrease in urine NTx levels HIV. It produces substantial increases in BMD and suppres-
after the first dose, but thereafter, median levels of urine NTx sion of bone turnover that persist for at least 2 yr. The only
remained stable, within the lower part of the normal range, previous report of annual zoledronate treatment showed
between 3 and 24 months. Epidemiological evidence sug- benefits for postmenopausal women with low BMD over 12
gests that suppression of bone resorption into this range is months of follow-up. Our findings extend the potential ben-
associated with optimal antifracture efficacy conferred by efits of annual treatment with zoledronate to include men,
antiresorptive therapy (16). and low BMD in association with HIV infection, and show
There are three previous studies of bisphosphonate treat- that benefits persist for at least 2 yr. Annual administration
ment in patients infected with HIV. All were randomized, of zoledronate is a convenient and effective option for the
open-label trials of alendronate 70 mg weekly, and produced treatment or prevention of bone loss for HIV-infected men
conflicting results. Guaraldi et al. (8) reported a 52-wk trial with low BMD.
of alendronate compared with placebo in 41 HIV-infected
patients who had been taking HAART for at least 6 months Acknowledgments
and had a BMD T score below ⫺1. All participants took The authors thank Karen Callon, who performed the urine NTx
calcium carbonate 1000 mg daily and vitamin D 500 IU daily. assays.
There were no statistically significant between-group differ-
ences in bone turnover markers or BMD at the spine or Received October 11, 2006. Accepted January 8, 2007.
Address all correspondence and requests for reprints to: Mark J.
femoral neck. Mondy et al. (7) reported a 48-wk trial of
Bolland, MBChB, Osteoporosis Research Group, Department of Medi-
alendronate compared with placebo in 31 HIV-infected pa- cine, University of Auckland, Private Bag 92 019, Auckland 1020, New
tients treated with HAART for at least 6 months who had a Zealand. E-mail: m.bolland@auckland.ac.nz.
lumbar spine T score below ⫺1. All participants received This work was supported by the Health Research Council of New
1000 mg calcium and 400 IU vitamin D daily. BMD at the Zealand. M.J.B. is the recipient of an Australian and New Zealand Bone
and Mineral Society (ANZBMS) Postgraduate Research Scholarship.
spine increased by 5.2% in the alendronate group compared Disclosure Statement: M.J.B., A.B.G., A.M.H., S.E.B., M.G.T., R.B.E.-P.,
with 1.3% in the control group (P ⬍ 0.05), whereas there were A.F.W., and G.D.G. have nothing to declare. I.R.R. has received lecture
no between-group differences at the femoral neck, trochan- and consultancy fees from Novartis.
1288 J Clin Endocrinol Metab, April 2007, 92(4):1283–1288 Bolland et al. • HIV and Zoledronate in Men
JCEM is published monthly by The Endocrine Society (http://www.endo-society.org), the foremost professional society serving the
endocrine community.