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Original Article

Denosumab for Prevention of Fractures in Postmenopausal Women with Osteoporosis

Steven R. Cummings, M.D., Javier San Martin, M.D., Michael R. McClung, M.D., Ethel S. Siris, M.D., Richard Eastell, M.D., Ian R. Reid, M.D., Pierre Delmas, M.D., Ph.D., Holly B. Zoog, Ph.D., Matt Austin, M.S., Andrea Wang, M.A., Stepan Kutilek, M.D., Silvano Adami, M.D., Ph.D., Jose Zanchetta, M.D., Cesar Libanati, M.D., Suresh Siddhanti, Ph.D., and Claus Christiansen, M.D. for the FREEDOM Trial

N Engl J Med 2009; 361:756-765August 20, 2009

Abstract

Background

Denosumab is a fully human monoclonal antibody to the receptor activator of nuclear factor-κB ligand (RANKL) that blocks its binding to RANK, inhibiting the development and activity of osteoclasts, decreasing bone resorption, and increasing bone density. Given its unique actions, denosumab may be useful in the treatment of osteoporosis.

Methods

We enrolled 7868 women between the ages of 60 and 90 years who had a bone mineral density T score of less than −2.5 but not less than −4.0 at the lumbar spine or total hip. Subjects were randomly assigned to receive either 60 mg of denosumab or placebo subcutaneously every 6 months for 36 months. The primary end point was new vertebral fracture. Secondary end points included nonvertebral and hip fractures.

Results

As compared with placebo, denosumab reduced the risk of new radiographic vertebral fracture, with a cumulative incidence of 2.3% in the denosumab group, versus 7.2% in the placebo group (risk ratio, 0.32; 95% confidence interval [CI], 0.26 to 0.41; P<0.001) — a relative decrease of 68%. Denosumab reduced the risk of hip fracture, with a cumulative incidence of 0.7% in the denosumab group, versus 1.2% in the placebo group (hazard ratio, 0.60; 95% CI, 0.37 to 0.97; P=0.04) — a relative decrease of 40%. Denosumab also reduced the risk of nonvertebral fracture, with a cumulative incidence of 6.5% in the denosumab group, versus 8.0% in the placebo group (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) — a relative decrease of 20%. There was no increase in the risk of cancer, infection, cardiovascular disease, delayed fracture healing, or hypocalcemia, and there were no cases of osteonecrosis of the jaw and no adverse reactions to the injection of denosumab.

Conclusions

Denosumab given subcutaneously twice yearly for 36 months was associated with a reduction in the risk of vertebral, nonvertebral, and hip fractures in women with osteoporosis. (ClinicalTrials.gov number, NCT00089791.)

Media in This Article

Figure 1Incidence of New Vertebral, Nonvertebral, and Hip Fractures.
Figure 2Percent Changes in Bone Mineral Density and Biochemical Markers of Bone Turnover.
Article

Fractures are a major cause of disability and health care costs.1,2 The use of denosumab is a novel approach to fracture prevention. It is a fully human monoclonal antibody against the receptor activator of nuclear factor-κB ligand (RANKL), a cytokine that is essential for the formation, function, and survival of osteoclasts.3 By binding RANKL, denosumab prevents the interaction of RANKL with its receptor, RANK, on osteoclasts and osteoclast precursors and reversibly inhibits osteoclast-mediated bone resorption. 4

In previous trials, the subcutaneous administration of 60 mg of denosumab every 6 months reduced bone turnover and increased bone mineral density. 5-8 We tested the effect of denosumab on the risk of fracture in postmenopausal women with osteoporosis.

Methods

Study Design

Our study, called Fracture Reduction Evaluation of Denosumab in Osteoporosis Every 6 Months (FREEDOM), was an international, randomized, placebo-controlled trial. Subjects were randomly assigned to receive subcutaneous injections of either 60 mg of denosumab or placebo at study sites every 6 months for 36 months. Randomization was stratified according to 5-year age groups.

Subjects

Women between the ages of 60 and 90 years with a bone mineral density T score of less than −2.5 at the lumbar spine or total hip were eligible for inclusion. Women were excluded if they had conditions that influence bone metabolism or had taken oral bisphosphonates for more than 3 years. If they had taken bisphosphonates for less than 3 years, they were eligible after 12 months without treatment. Women were also excluded if they had used intravenous bisphosphonates, fluoride, or strontium for osteoporosis within the past 5 years; or parathyroid hormone or its derivatives, corticosteroids, systemic hormone-replacement therapy, selective estrogen-receptor modulators, or tibolone, calcitonin, or calcitriol within 6 weeks before study enrollment.

Although consensus conferences have not specified a permissible risk of fracture for placebo-controlled trials,9,10 women were excluded if they had a bone mineral density T score of less than −4.0 at the lumbar spine or total hip or any severe (or more than two moderate) prevalent vertebral fractures. As part of the consent process, potential subjects were informed about alternative treatments for osteoporosis. All women received daily supplements containing at least 1000 mg of calcium. Women were excluded if they had a serum 25-hydroxyvitamin D level of less than 12 ng per milliliter. Subjects with a baseline 25-hydroxyvitamin D level of 12 to 20 ng per milliliter were given at least 800 IU of vitamin D daily, and those with a baseline level above 20 ng per milliliter were given at least 400 IU daily. If total hip bone mineral density decreased by more than 7% during a 12-month period or by 10% or more during the study or if the T score dropped below −4.0, the subject was again counseled by the local study clinician about using alternative treatments in lieu of continuing to participate in the study. The trial and consent process were approved by the institutional review boards and ethics committees overseeing the study sites in the United States and other countries; 139 of 142 boards that reviewed the protocol approved it.

Assessments of Efficacy

Lateral spine radiographs were taken annually and assessed for new vertebral fractures by a semiquantitative grading scale11 at the central imaging center (Synarc). A prevalent fracture was defined as a vertebral body with a semiquantitative grade of 1 or more. A new vertebral fracture was defined as an increase of at least 1 grade in a vertebral body that was normal at baseline. Secondary end points were the time to the first nonvertebral fracture and the time to the first hip fracture. Fractures of the skull, face, mandible, metacarpals, fingers, or toes were excluded because they are not associated with decreased bone mineral density; pathologic fractures and those that were associated with severe trauma (defined as a fall from a height higher than a stool, chair, or first rung of a ladder or severe trauma other than a fall) were also excluded.12 Clinical fractures were confirmed by diagnostic imaging or a radiologist's report.

Bone mineral density as evaluated on dual-energy x-ray absorptiometry was measured at baseline and then annually at the hip and after 36 months at the lumbar spine. Bone mineral density of both sites was measured at baseline and at 1, 6, 12, 24, and 36 months in 441 subjects. Concentrations of two markers of bone turnover were measured in 160 subjects from fasting serum samples collected before the injection on day 1, at 1 month after the baseline injection, and before injections at 6, 12, 24, and 36 months. Bone-turnover marker serum C-telopeptide of type I collagen was evaluated with the use of enzyme-linked immunosorbent assay (ELISA) (Nordic Bioscience Diagnostics A/S), and intact serum procollagen type I N-terminal propeptide (PINP) was evaluated with the use of radioimmunoassay (Orion Diagnostica Oy).

Adverse Events

Physicians at study sites reported adverse events that were coded as preferred terms in the Medical Dictionary for Regulatory Activities (MedDRA) system. All deaths and serious adverse events that were possibly related to cardiovascular disease were adjudicated by a committee of cardiologists using predefined criteria. A committee of experts reviewed reported events that met a broad range of MedDRA terms that might represent osteonecrosis of the jaw, defined as an area of exposed bone in the maxillofacial region that does not heal within 8 weeks after diagnosis.13 Study investigators clinically assessed the healing of nonvertebral fractures within 6 months after their occurrence. A positive result on hypocalcemia testing was defined as an albumin-adjusted calcium level of less than 8.0 mg per deciliter (2.0 mmol per liter) in fasting specimens drawn just before injection of the study drug. Denosumab-specific antibodies were also assessed in those samples.

Study Oversight

A steering committee, consisting of a majority of investigators who were not employed by study sponsor Amgen, planned the analyses for the manuscript before the unblinding of data, and one member wrote the first draft of the manuscript. The committee members approved the manuscript for publication and vouch for the completeness and accuracy of the data. Analyses were performed by the sponsor and confirmed by an analyst at the San Francisco Coordinating Center. The authors received all analyses that they requested. The sponsor designed the protocol with advice from external investigators and was responsible for the management and quality control of data collected by the clinical sites. A data and safety monitoring committee reviewed unblinded data at least twice yearly.

Statistical Analysis

The study had a power of more than 99% to detect a 45% reduction in the incidence of new vertebral fractures and to detect a 40% reduction in the risk of any nonvertebral fracture and a power of 91% to detect a 40% reduction in the risk of hip fracture. These estimates were based on the assumption that the annual fracture rate in the placebo group over a 36-month period would be 4.0% for vertebral fractures, 3.3% for nonvertebral fractures, and 1.0% for hip fractures.

Analyses of efficacy were based on the intention-to-treat principle. To adjust for multiplicity and maintain the overall significance level at 0.05, the primary end point of new vertebral fracture was required to achieve significance before the next end points in the sequence (nonvertebral fracture and hip fracture) could be tested. Analyses regarding vertebral fractures included all subjects who had at least one follow-up radiograph.

The effect of treatment on the risk of new vertebral fracture was analyzed with the use of a logistic-regression model with adjustment for age strata. An age-stratified Cox proportional-hazards model was used to compare the two study groups for the secondary end points. Score tests were used to calculate P values in each model.14,15 Subjects who were lost to follow-up or withdrew before having a fracture event had their last known fracture status carried forward. Radiographically defined vertebral fractures were analyzed by cumulative incidence and secondary end points by time-to-event analysis with the use of Kaplan–Meier methods. The absolute risk reduction between study groups was computed as the difference in incidence at 36 months for the primary end point and the difference in the Kaplan–Meier estimates at 36 months for the secondary end points with the use of a weighted average across the age strata. Analyses of changes in bone mineral density included all subjects who had at least one follow-up measurement at or before the time point under consideration. Missing values were imputed by carrying forward the last observation.

Safety analyses included all subjects who received at least one dose of a study drug. Analyses of adverse and serious adverse events of cancer, infection, specific cardiovascular events, and potential adverse effects of potent antiresorptive therapies (including osteonecrosis of the jaw, delayed fracture healing, femoral-shaft fracture, hypocalcemia, and atrial fibrillation) were specified in advance. Preferred terms similar to eczema were combined as eczema, and erysipelas was included with cellulitis. To adjust for multiple comparisons for numerous reports of adverse events, we specified in advance to report MedDRA preferred terms of adverse events that occurred in at least 2% of subjects in either study group with a P value of 0.05 or less and serious adverse events that occurred in at least 0.1% of subjects in either group with a P value of 0.01 or less.

Results

Subjects

A total of 7868 women were enrolled in the study, 3933 in the denosumab group and 3935 in the placebo group. Of these subjects, 60 (31 in the denosumab group and 29 in the placebo group) were excluded from all analyses because the participation of their study center was halted owing to issues related to study procedures and the reliability of data. Baseline characteristics were similar between the two study groups (Table 1Table 1Baseline Characteristics of the Subjects.). The mean bone mineral density T scores were −2.8 at the lumbar spine, −1.9 at the total hip, and −2.2 at the femoral neck. About 24% of women had a vertebral fracture at baseline. Of 7868 subjects, 6478 (82%) completed 36 months of study and 5979 (76%) received all injections.

Fractures, Bone Density, and Markers of Bone Turnover

The calculations of percentages of new and multiple new vertebral fractures were based on the number of subjects who underwent spinal radiography at baseline and during at least one visit after baseline. The 36-month incidence of new radiographic vertebral fracture was 2.3% (86 of 3702 subjects) in the denosumab group and 7.2% (264 of 3691 subjects) in the placebo group, representing a 68% reduction in relative risk (P<0.001) (Table 2Table 2Effect of Denosumab on the Risk of Fracture at 36 Months.). The reduction in risk was similar during each year of the trial (Figure 1AFigure 1Incidence of New Vertebral, Nonvertebral, and Hip Fractures.). There were similar reductions in clinically diagnosed vertebral fractures (69%) and multiple new vertebral fractures (61%, P<0.001 for both comparisons) (Table 2).

The calculations of cumulative incidences of nonvertebral, hip, and new clinical vertebral fractures were based on Kaplan–Meier estimates of a 36-month cumulative incidence in 3902 subjects in the denosumab group and 3906 in the placebo group. Denosumab reduced the risk of nonvertebral fracture, with a cumulative incidence of 6.5% in the denosumab group, as compared with 8.0% in the placebo group (hazard ratio, 0.80; 95% confidence interval [CI], 0.67 to 0.95; P=0.01) — a 20% relative reduction (Table 2 and Figure 1B). Denosumab also decreased the risk of hip fracture, with a cumulative incidence of 0.7% in the denosumab group, versus 1.2% in the placebo group (hazard ratio, 0.60; 95% CI, 0.37 to 0.97; P=0.04) — a 40% relative reduction (Table 2 and Figure 1C).

After 36 months, denosumab was associated with a relative increase in bone mineral density of 9.2% (95% CI, 8.2 to 10.1) at the lumbar spine and 6.0% (95% CI, 5.2 to 6.7) at the total hip, as compared with placebo (Figure 2Figure 2Percent Changes in Bone Mineral Density and Biochemical Markers of Bone Turnover.). As compared with placebo, denosumab decreased serum C-telopeptide levels by 86% at 1 month, by 72% before treatment was administered at 6 months, and by 72% at 36 months. Levels of PINP, a marker of bone formation, were 18%, 50%, and 76% below those in the placebo group at the same time points.

Adverse Events

There were no significant differences between subjects who received denosumab and those who received placebo in the total incidence of adverse events, serious adverse events, or discontinuation of study treatment because of adverse events (Table 3Table 3Adverse Events.). Similarly, there were no significant differences in the overall incidence of cancer, cardiovascular events, or either adverse or serious adverse events of infection. Four cases of opportunistic infections were reported in the denosumab group and three in the placebo group. Seventy subjects (1.8%) died in the denosumab group and 90 (2.3%) in the placebo group (P=0.08).

No cases of osteonecrosis of the jaw occurred in either group. Delayed fracture healing was reported for two subjects in the denosumab group and four subjects in the placebo group, and one case of nonunion of a humerus fracture was reported in the placebo group. There were no fractures of the femoral shaft in the denosumab group and three such fractures in the placebo group (0.1%). There were no reports of hypocalcemia in the denosumab group and three events (0.1%) in the placebo group. Decreases in serum calcium to levels below 8.0 mg per deciliter occurred in four subjects in the denosumab group and five in the placebo group. Local reactions after injection of a study drug occurred in 33 subjects (0.8%) in the denosumab group and 26 subjects (0.7%) in the placebo group. Neutralizing antibodies to denosumab did not develop in any of the subjects.

Eczema was reported in 3.0% of subjects in the denosumab group and 1.7% in the placebo group (P<0.001). Falls that were not associated with a fracture were reported in 4.5% of subjects in the denosumab group and 5.7% in the placebo group (P=0.02). Flatulence was reported more frequently in the denosumab group (2.2%) than in the placebo group (1.4%, P=0.008). Twelve subjects (0.3%) in the denosumab group reported serious adverse events of cellulitis, as compared with one subject (<0.1%) in the placebo group (P=0.002). There were no significant differences in the overall incidence of adverse events of cellulitis, with 47 (1.2%) in the denosumab group and 36 (0.9%) in the placebo group.

Discussion

In postmenopausal women with osteoporosis, the subcutaneous administration of 60 mg of denosumab every 6 months for 36 months significantly reduced the risk of vertebral and nonvertebral fractures and the risk of hip fracture. The reduction in the risk of vertebral fracture was similar in the first and subsequent years and for both clinically diagnosed and multiple vertebral fractures.

Denosumab prevents the interaction of RANKL with RANK, its receptor, on osteoclasts and their precursors, thereby blocking the formation, function, and survival of osteoclasts.3 In contrast, bisphosphonates chemically bind to calcium hydroxyapatite in bone; they decrease bone resorption by blocking the function and survival, but not the formation, of osteoclasts.16

The magnitude of the risk reduction of vertebral fracture with denosumab was similar to that reported for intravenously administered zoledronic acid and appears to be greater than reductions reported for oral osteoporosis agents.17-20 For nonvertebral fractures, the risk reduction with denosumab was similar to those reported for alendronate, risedronate, and zoledronic acid.17,20,21 However, comparisons of efficacy are limited because there has been no head-to-head trial comparing rates of fracture reduction associated with denosumab and bisphosphonates. In addition, trials have included various subgroups of nonvertebral fractures,22-24 and study populations have varied. At least 50% of patients stop bisphosphonate treatment within 1 year after receiving a prescription for an oral agent.25 Twice-yearly subcutaneous injections might improve adherence.

During 36 months of treatment, denosumab increased bone mineral density at the lumbar spine by about 9% and at the total hip by about 6%. A separate 12-month trial showed that denosumab increased bone mineral density significantly more than alendronate at the total hip and spine.26

Denosumab reduced bone resorption by a median of 86% at 1 month, which is greater than the reductions seen with other antiresorptive drugs.21,27 In retrospective analyses from trials of antiresorptive drugs, the magnitude of the decrease in bone-turnover markers was shown to be associated with the reduction in fracture risk.28 Whether this finding also applies to denosumab requires further study. Impaired fracture healing and osteonecrosis of the jaw have been reported with bisphosphonate therapy in postmarketing case reports, raising concern that these conditions may be caused by decreased bone resorption. No significant adverse effects on fracture healing and no cases of osteonecrosis of the jaw occurred in our study. There have also been reports of cases of unusual fractures of the femoral shaft associated with long-term administration of alendronate. No fractures of the femoral shaft occurred in the denosumab group during 36 months of study. Patients in the trial are continuing to receive denosumab, to assess the potential effects of long-term treatment, including fractures, fracture healing, infections, and cancer.

RANKL and RANK are members of the tumor necrosis factor superfamily that are expressed by a variety of lymphoid cells.29 It has been theorized that the inhibition of RANKL might increase the risk of cancer or infection.30 In this trial, there was no significant difference in the incidence of cancer or in the overall incidence of infection, serious adverse events of infection, or opportunistic infection during 36 months of treatment; longer follow-up is under way. An increased incidence of hospitalization for cellulitis was observed in subjects who were treated with denosumab; however, there was no significant difference in the overall incidence of cellulitis between the two groups.

Before a new treatment for osteoporosis can be approved, the Food and Drug Administration and the European Committee for Medicinal Products for Human Use have required that placebo-controlled trials be conducted for 3 years in subjects with osteoporosis. Some observers have raised concern about the enrollment of subjects with osteoporosis in placebo-controlled trials, although there is no consensus about an allowable risk for inclusion.9,10 To reduce the risk for control subjects, trials involving subjects at reduced risk for osteoporosis might be considered. However, the effects of treatment on the risk of nonvertebral fracture in women with a bone mineral density T score above −2.5 may be weaker and not applicable to women with osteoporosis.18,19,31 In addition, although shorter trials have been considered,10 the results may be misleading because treatments may have greater efficacy for vertebral fracture in the first year than in subsequent years.32-35

In conclusion, denosumab offers an alternative approach to the treatment of osteoporosis by decreasing bone resorption and increasing bone mineral density through the inhibition of RANKL. Denosumab was associated with a significant reduction in the risk of vertebral, hip, and nonvertebral fractures in postmenopausal women with osteoporosis.

Supported by Amgen.

Dr. Cummings reports receiving consulting fees from Amgen, Eli Lilly, GlaxoSmithKline, Organon, and Pfizer, lecture fees from Novartis and Eli Lilly, and grant support from Amgen and Eli Lilly; Dr. McClung, receiving consulting fees or participating on paid advisory boards for Amgen, Eli Lilly, Merck, and Novartis and receiving lecture fees from Eli Lilly, Novartis, Merck, and Sanofi-Aventis and grant support from Amgen, GlaxoSmithKline, Eli Lilly, Merck, Novartis, Procter & Gamble, Roche, AstraZeneca, Nordic Bioscience, Radius, and Sanofi-Aventis; Dr. Siris, receiving consulting fees from the Alliance for Better Bone Health and lecture fees from Eli Lilly, Novartis, and the Alliance for Better Bone Health, participating on paid advisory boards for Eli Lilly, Novartis, and Amgen, and being the immediate past president of the National Osteoporosis Foundation; Dr. Eastell, receiving consulting fees from or participating on paid advisory boards for Amgen, Novartis, Procter & Gamble, Servier, Ono, and GlaxoSmithKline and receiving lecture fees from Eli Lilly and grant support from AstraZeneca, Procter & Gamble, and Novartis; Dr. Reid, receiving consulting fees from or participating on paid advisory boards for Amgen, Merck, and Novartis and receiving lecture fees from Novartis, Merck, and Amgen and grant support from Amgen, Novartis, Merck, and Procter & Gamble; Dr. Kutilek, receiving consulting fees from or participating on paid advisory boards for Amgen and Zentiva, receiving lecture fees from and providing expert opinions and consultations for Zentiva, Servier, and Amgen, and participating as a clinical trial investigator for Amgen, Servier, and Novartis; Dr. Adami, receiving consulting fees from or participating on paid advisory boards for Servier, Novartis, Amgen, Roche, and Eli Lilly and receiving lecture fees from Novartis, Amgen, Roche, and Servier; Dr. Zanchetta, receiving consulting fees from and participating on paid advisory boards for Eli Lilly, Pfizer, Amgen and Servier; and Dr. Christiansen, receiving consulting fees from Amgen. Dr. San Martin, Dr. Zoog, Mr. Austin, Ms. Wang, Dr. Libanati, and Dr. Siddhanti report being employed by and having an equity interest in Amgen. No other potential conflict of interest relevant to the article was reported.

This article (10.1056/NEJMoa0809493) was published on August 11, 2009, and was updated on November 4, 2009, at NEJM.org.

This article (10.1056/NEJMoa0809493) was published on August 11, 2009, at NEJM.org.

We thank Lisa Palermo of the San Francisco Coordinating Center for reanalysis of the data presented in the manuscript.

Source Information

From the San Francisco Coordinating Center, California Pacific Medical Center Research Institute and University of California, San Francisco, San Francisco (S.R.C.); Amgen, Thousand Oaks, CA (J.S.M., H.B.Z., M.A., A.W., C.L., S.S.); Oregon Osteoporosis Center, Portland (M.R.M.); Columbia University Medical Center, New York (E.S.S.); University of Sheffield, Sheffield, United Kingdom (R.E.); University of Auckland, Auckland, New Zealand (I.R.R.); Université de Lyon and INSERM Research Unit 831, Lyon, France (P.D.); the Center for Clinical and Basic Research, Pardubice, Czech Republic (S.K.); University of Verona, Verona, Italy (S.A.); Instituto de Investigaciones Metabolicas and University of Salvador, Buenos Aires, Argentina (J.Z.); and the Center for Clinical and Basic Research, Ballerup, Denmark (C.C.).

Address reprint requests to Dr. Cummings at 185 Berry St. Lobby 4, Suite 5700, San Francisco, CA 94107, or at .

Investigators for the Fracture Reduction Evaluation of Denosumab in Osteoporosis Every 6 Months (FREEDOM) trial are listed in the Appendix.

Appendix

Investigators for the FREEDOM trial are as follows. Steering Committee: S. Cummings (chair), C. Christiansen, P. Delmas, R. Eastell, M. McClung, I. Reid, E. Siris. Study Investigators: United States: K. Aqua, E. Lee, E. Boling, M. Bolognese, F. Burch, S. Cohen, D. Fiske, C. Petit, M. Pierson, K. Garrison, E. Gallup, H. Geisberg, D. Hassman, D. Helfrich, K. Krohn, E. Cuevas, W. Larson, J. Seiler, S. Lederman, M. Lewiecki, D. MacCarter, M. McClung, P. Miller, A. Moffett, Jr., C. Recknor, J. Simon, R. Trapp, G. Woodson III, H. Bone, T. Murtaugh, J. Ruckle, R. Wasnich, C. Gallagher, G. Dhillon, R. Feldman, G. Pennington, P. Saxe, C. Goldberg, K. Rogers, M. Keller, M. Swor, A. Rosen, M. Stjernholm; Canada: J. Adachi, J. Brown, R. Faraawi, D. Kendler, R. Kremer, W. Olszynski, C.K. Yuen, R. McKendry, J. Boudreau; Argentina: Z. Man, J. Zanchetta, C. Mautalen; Brazil: L. de Gregorio, S. Eis, S. Radominski, N. da Silva, L. Griz, J. Provenza, C. Zerbini; Mexico: P. García-Hernández, M. Araujo-Arias, E. Rios Rodriguez Bueno, A. Fuentes-Cantu, E. Cortes Perez, J. Balderas-Acata, H. Avila-Armengol, M. de la Peña-Rodríguez; Australia: G. Nicholson, P. Ebeling, P. Sambrook, M. Hooper, J. Prins, A. Russell; New Zealand: I. Reid, N. Gilchrist; Austria: E. Preisinger, H. Resch, A. Fahrleitner-Pammer, J. Huber, S. Kudlacek; Belgium: J.-Y. Reginster, J.-M. Kaufman, S. Boonen, J.-J. Body, J.-P. Devogelaer; Denmark: C. Stubbe Teglbjærg, R. Bente Juel, P. Alexandersen, H.C. Hoeck, J.-E. Beck Jensen; Finland: M. Välimäki, J. Salmi; France: P. Delmas, P. Fardellone, G. Weryha, C.-L. Benhamou, Y. Maugars, C. Roux; Germany: H.-D. Stahl, U. Blome-Henning, B. Lochman, U. Kopsch, A. Roitenberg; Italy: S. Adami, M. Brandi, S. Minisola, G. Bianchi, L. Sinigaglia, B. Frediani, R. Marcolongo, C. Fiore, R. Nuti, G. Realdi; the Netherlands: B. Dijkmans, R. Laan, G. Bruyn, A. Deijl, E. Meesters, W. Lems, A. Verhage, V. van de Walle; Norway: J. Halse, A. Hoiseth, U. Syversen, J. Stakkestad; Spain: J. Farrerons Minguella, E. Martín Mola, M. Muñoz Torres, J. Quesada Gómez, F. Hawkins, J. Román, J. Álvaro-Gracia, J. Del Pino, S. Palacios; Sweden: Ö. Ljunggren, G. Toss, G. Samsioe, D. Mellström, J. Löfgren, O. Törring; Switzerland: K. Lippuner, M.-A. Krieg, D. Uebelhart; United Kingdom: R. Eastell, H. Thomas, H. Shaw, H. Donnachie, I. Pavel-Knox, J. Robinson, N. Kola, R. Sarmiento, R. Pawa, N. Savani; Czech Republic: I. Kucerova, V. Kuba, V. Vyskocil, S. Kutilek, P. Novosad, J. Slesinger, E. Dokoupilova, J. Doubravsky, J. Gorgol, K. Pavelka; Estonia: I. Valter, K. Maasalu, I. Kull; Greece: C. Phenekos, G. Lyritis, A. Dimitriadis; Hungary: B. Spengler, A. Insperger, T. Balázs, P. Lakatos, K. Takács, I. Szombati, K. Tarján, Z. Valkusz, O. Torma, K. Seregely; Latvia: I. Kaze, A. Lejnieks, A. Medne; Lithuania: M. Tamulaitiene, D. Velickiene, S. Stonkus; Malta: M. Brincat; Poland: J. Walecki, M. Bykowska, A. Sidorowicz-Bialynicka, J. Szechinski, M. Korkosz, J. Supronik, M. Koziara, E. Czerwinski, A. Milewicz, S. Jeka, G. Kania, P. Gidzinski, A. Sawicki, W. Tlustochowicz, E. Franek, K. Hoszowski, W. Pluskiewicz, W. Porawska, W. Zgliczynski; Slovak Republic: Z. Killinger, P. Masaryk, Z. Kmecova, S. Tomkova, V. Spustova, B. Steno; Romania: E. Zbranca, C. Codreanu; Bulgaria: V. Hristov, T. Russev, A.-M. Ivanova, R. Velev, M. Mitkov, D. Troev; Serbia: S. Brankovic, A. Dimic, N. Pilipovic. Cardiovascular End-Points Adjudication Committee: M. Hlatky, N. Goldschlager, D. Herrington, C. Ryan. Osteonecrosis of the Jaw Adjudication Committee: C. Migliorati, S. Ruggiero, M. Schubert.

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