Strategy of Aggressive Steroid Weaning and Routine Alendronate Therapy to Reduce Bone Loss After Cardiac Transplantation

Abstract

Objective Osteoporosis is common after cardiac transplantation. The routine use of prednisolone posttransplantation is a major contributor to bone mineral loss. We sought to study the effectiveness of a strategy combining aggressive steroid weaning and routine prophylaxis with alendronate to reduce bone loss without adversely affecting posttransplantation survival. Patients and Methods This retrospective clinical study compared 2 cohorts of patients. Group A included 28 patients who had undergone transplantation since June 1999, all of whom were prescribed alendronate (10 mg daily or 70 mg weekly). All were aggressively weaned off prednisolone with the aim of being steroid-free by 9 months posttransplantation. Only 10 of the 28 patients were on prednisolone at the time of the study. Group B was an historical control cohort of 28 posttransplant patients reviewed in a cross-sectional study in 1995. Only 2 patients were on osteoporosis prophylaxis with estrogen or vitamin D; 26 patients were on prednisolone at the time of the study. The groups were compared by dual-energy X-ray absorptiometry (DEXA) bone mineral densitometry at the femoral neck and lumbar spine at a mean of 3 years after transplantation. We compared the cumulative survival of the 2 groups. Results Cumulative survival posttransplantation was similar in both groups. Compared with group B, group A showed a significantly higher mean femoral Z-score (+0.3 vs −0.5, P = .01) and lumbar spine Z-score (0.0 vs −0.9, P < .02). The incidence of osteoporosis (defined by WHO criteria as T-score ≤ −2.5) was lower in group A compared with group B (18% vs 29%, P = NS). Conclusions A strategy of aggressive weaning of prednisolone postcardiac transplantation coupled with routine osteoporosis prophylaxis using alendronate was associated with significantly higher bone mass and a trend toward a reduced incidence of osteoporosis. This strategy was successful to reduce the use of steroid without any adverse effect on cumulative survival posttransplantation.