Cyclical etidronate in the treatment of postmenopausal osteoporosis: efficacy and safety after seven years of treatment

PURPOSE: To determine the efficacy and safety of cyclical etidronate for up to 7 years in the treatment of postmenopausal osteoporosis and to examine the effects of discontinuing treatment after 2 or 5 years of therapy. PATIENTS AND METHODS: Patients were randomized at entry into the original study in 1986 to blinded treatment for 2 years with either a calcium (placebo) or an intermittent cyclical etidronate regimen, which most patients continued for a third year. Following this phase of the study, patients were enrolled into an open-label, follow-up study (years 4 and 5), during which all patients received cyclical etidronate treatment. In the present double-blind study (years 6 and 7), patients were rerandomized to receive intermittent cyclical therapy with either etidronate or placebo; all patients received calcium. The treatment regimen consisted of 400 mg/day etidronate or placebo for 14 days, followed by 76 days of elemental calcium (500 mg/day); this cycle was repeated approximately 4 times in each year. Of the 193 patients who continued in years 6 and 7 of the study, 93 were randomized to receive cyclical etidronate and 100 were randomized to receive calcium only. For purposes of efficacy analyses, patients were categorized by their total years of cumulative etidronate treatment (7, 5, 4, or 2 years). There were 51, 46, 42, and 54 patients in the 7-, 5-, 4-, and 2-year groups, respectively. Annual assessments included lumbar spine bone mineral density (BMD), as measured by densitometry, and vertebral radiographs. RESULTS: The groups receiving cyclical etidronate during this 2-year study period (7- and 4-year groups) had statistically significant mean percent increases in spinal BMD of 1.8% and 2.2%, respectively (P < 0.05) at the week 104 observation time. The 5- and 2-year groups, which did not receive etidronate during this period, had mean values of 1.4% and 0.2%, respectively (not significant) at week 104. In the 7-, 5-, 4-, and 2-year groups, the increases in spinal BMD at the end of 7 years were 7.6%, 8.6%, 8.1%, and 3.9%, respectively; these values were statistically significant for all groups compared with original baseline (year 0) (P < 0.05). BMD of the femur and wrist was maintained throughout the 7-year period. The incidence and rate of vertebral fractures were lowest in patients with the longest exposure to etidronate. Etidronate was well tolerated during the study, with low incidences of gastrointestinal side effects and nonvertebral fractures. CONCLUSIONS: Long-term cyclical etidronate is a safe, effective, and well-tolerated treatment for postmenopausal osteoporosis. Bone mass is maintained for at least 2 years after treatment with etidronate is stopped; however, further gains in spinal bone mass are seen in patients who continue therapy.     

The central nucleus of the amygdala contributes to the production of morphine antinociception in the formalin test

The rat paw formalin test is a model of prolonged pain due to mild tissue injury. There is some evidence suggesting that morphine does not produce antinociception in the formalin test via the brain-stem and spinal cord circuitry normally associated with antinociception. Furthermore, morphine appears to require an intact forebrain in order to function as an analgesic for formalin pain. In the 2 experiments reported here, we investigated the possibility that the central nucleus of the amygdala (Ce) contributes to the production of morphine antinociception (MA) in the formalin test. Nociception in this test occurs in 2 phases, with the 1st phase occurring 0-5 min after formalin injection and the 2nd phase beginning 10-15 min after injection and continuing for approximately 1 h. In Exp. 1, bilateral neurotoxic lesions of the Ce, but not lesions of the adjacent basolateral nucleus (BL), reliably attenuated MA (7 mg/kg morphine sulfate) during the 2nd phase of the formalin test without affecting baseline nociception. These results were obtained regardless of whether the rating scale method or flinch-frequency method of nociceptive scoring was used. During the 1st phase, Ce lesions reliably attenuated MA as measured by the flinch-frequency method, but not as measured by the rating scale method. In Exp. 2, Ce lesions also reliably attenuated the antinociception produced by 12 mg/kg morphine sulfate during the 2nd phase of the formalin test. Antinociception appeared to be almost completely re-instated, however, if the dose of morphine was raised to 20 mg/kg. The results indicate that neurons originating from the Ce contribute to the production of MA during the 2nd phase, and possibly the 1st phase, of the formalin test, especially at relatively lower doses of morphine. This suggests that in addition to coordinating conditioned antinociceptive responses, the amygdala may be a component of endogenous antinociceptive circuitry. These and other issues are discussed with reference to the spino-ponto-amygdaloid nociceptive pathway, and the proposed role of the amygdala in the mediation of defense reactions.     

Inhibition of aldose reductase: 13C NMR studies in isolated peripheral nerve

We report 13C NMR measurements of the flux through aldose reductase in isolated rat sciatic nerve, and its inhibition by an aldose reductase inhibitor of the sulphonylnitromethane class. [1-13C] galactose was used as substrate, and the rate of production of [1-13C] dulcitol was measured. Quantitation required the use both of internal extracellular, and external, standards. The mean net forward flux (+/- SD) was 20 +/- 11 nmol/(mL nerve water)/min (n = 10). In the presence of the inhibitor, flux was reduced significantly (p < 0.001) to 13% of control. Since dulcitol is symmetrical, an estimate of the backward flux, to [6-13C] galactose, is also possible; under our conditions, this was negligible.     

Reversible acute renal failure induced by losartan in a renal transplant recipient

A 56-year-old man who received a live-related renal transplant in 1988 was started in 1995 on the selective angiotensin II antagonist losartan (Dupont-Merke) to treat worsening hypertension. Two months later because of pulmonary oedema, loop diuretics were started. Within two weeks, serum creatinine had increased from 245 to 571 mumol/l, and the patient became oliguric. A systolic bruit was noted over the graft. Renal angiography showed a 90% stenosis of the transplant renal artery. Losartan was withdrawn, with prompt improvement in renal function. A successful percutaneous transluminal angioplasty performed a few days later resulted in further improvement in renal function accompanied by a significant diuresis.