A pilot trial of the effect of bone antiresorptive agents on bone turnover markers in critically ill women

Abstract Rationale: Critical illness is associated with increased bone turnover, loss of bone density, and increased risk of fragility fractures. The impact of bone antiresorptive agents in this population is not established. Objectives: Examine the efficacy, feasibility, and safety of antiresorptive agents administered to critically ill women aged fifty years or greater. Methods: Women aged 50 years or greater admitted to an intensive care unit for at least 24 hours were randomised to receive an antiresorptive agent (zoledronic acid or denosumab) or placebo, during critical illness and six months later (denosumab only). Bone turnover markers and bone mineral density (BMD) were monitored for one year. Measurements and Main Results: We studied 18 patients over 35 months before stopping the study due to the COVID-19 pandemic. Antiresorptive medications decreased the bone turnover marker type 1 cross-linked c-telopeptide (CTX) from day 0 to 28 by 43% ( + 40%), compared to an increase of 26% ( + 55%) observed with placebo (absolute difference -69%, 95% CI -127% to -11%), p=0.03). Mixed linear modelling revealed differences in the month after trial drug administration between the groups in serum CTX, alkaline phosphatase, parathyroid hormone, and phosphate. Change in BMD between antiresorptive and placebo groups was not statistically analysed due to small numbers. No serious adverse events were recorded. Conclusions: In critically ill women aged 50-years and over, antiresorptive agents suppressed bone resorption markers without serious adverse events. However, recruitment was slow. Further phase 2 trials examining the efficacy of these agents are warranted and should address barriers to enrolment. Trial registration: ACTRN12617000545369, registered 18 th April 2017