Management of arthralgias associated with aromatase inhibitor therapy

Abstract

For the upfront adjuvant therapy of postmenopausal estrogen receptor–positive breast cancer, the third-generation aromatase inhibitors (AIs) have shown a more favourable overall risk–benefit profile than has tamoxifen. Benefits of the AIs include less frequent gynecologic, cerebrovascular, and thromboembolic adverse events; greater disease-free survival; and lower tumour recurrence. Although approximately 25% of postmeno-pausal women with early breast cancer report experiencing symptoms of arthralgia with AI therapy, 68-month data from the Arimidex, Tamoxifen, Alone or in Combination trial showed that, compared with tamoxifen, anastrozole treatment was associated with only a modest increase in the incidence of joint symptoms. The events, which were mostly mild-to-moderate in intensity, led to treatment withdrawal in 2% of patients on anastrozole as compared with 1% in the tamoxifen arm. The symptoms and changes correlate with clinical, biochemical, and radiologic findings in symptomatic women. To determine appropriate intervention, it is therefore essential to perform a comprehensive evaluation of musculoskeletal complaints to distinguish natural menopause-related degenerative disease from AI-related effects. The present review explores the advantages of differential diagnosis with an emphasis on history and physical and musculo-skeletal examination; laboratory investigations are used to corroborate or rule out clinical impressions. The transient symptoms associated with the AIs are manageable with an appropriate combination of lifestyle changes, including exercise and joint protection in conjunction with pharmacologic approaches.