Osteoporosis International

, Volume 30, Issue 10, pp 2039–2056 | Cite as

The renin-angiotensin aldosterone system and osteoporosis: findings from the Women’s Health Initiative

  • L.D. CarboneEmail author
  • S. Vasan
  • R.L. Prentice
  • G. Harshfield
  • B. Haring
  • J.A. Cauley
  • K.C. Johnson
Original Article



New users of RAAS inhibitors, including ACE inhibitors and ARBs, have a small increased risk for fracture in the first 3 years of use, with a reduced risk of fracture with longer duration of use.


Pharmacological inhibitors of the renin-angiotensin aldosterone system (RAAS) are used to treat hypertension. However, the relationship of these medications to osteoporosis is inconsistent, and no study has included simultaneous measurements of both incident fractures and bone mineral density (BMD).


The association of RAAS inhibitor use (n = 131,793) with incident fractures in new users of these medications in women in the Women’s Health Initiative over a minimum median follow-up of 6.5 years was assessed by Cox proportional hazard models. The association of incident fractures by a cumulative duration of use of these medications (< 3 years.) and (> 3 years.) was also estimated. Subgroup analysis of fracture risk by RAAS inhibitor use confined to women with hypertension was also performed (n = 33,820). The association of RAAS inhibitor use with changes in BMD of the hip was estimated by linear regression in 8940 women with dual energy X-ray absorptiometry measurements.


There was no significant association between RAAS inhibitor use and all fractures in the final adjusted multivariable models including hip BMD (HR 0.86 (0.59, 1.24)). However, among users of RAAS inhibitors, including ACE inhibitors and angiotensin receptor blockers (ARBs), hazard ratios for all incident fracture sites in final multivariable models including hip BMD showed dramatic differences by duration of use, with short duration of use (3 years or less) associated with a marked increased risk for fracture (HR 3.28 (1.66, 6.48)) to (HR 6.23 (3.11, 12.46)) and use for more than 3 years associated with a reduced fracture risk (HR 0.40 (0.24, 0.68) to (HR 0.44 (0.20, 0.97)) . Findings were similar in the subgroup of women with a history of hypertension. There was no significant change in BMD of the hip by RAAS inhibitor use.


In postmenopausal women, use of RAAS inhibitors, including ACE inhibitors and ARBs, is associated with an increased risk for fracture among new users of these medications in the first 3 years of use. However, long-term use (> 3 years) is associated with a reduced risk. Consideration for fracture risk may be part of the decision-making process for initiation of these medications for other disease states.


Aging Fracture Medication Postmenopausal 



Drs. Carbone, Vasan, Prentice, Harshfield, Bernard, Johnson, and Cauley participated in the analysis/interpretation of the data, drafting, and/or critical analysis of the manuscript and approved the final version of the submitted manuscript. Drs. Carbone, Prentice, and Vasan accept responsibility for the integrity of the data analysis.

Additional information

A full list of all the investigators who have contributed to Women’s Health Initiative science appears at

The contents do not represent the views of the Department of Veterans Affairs or the United States Government. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Funding information

The WHI program is funded by the National Heart, Lung, and Blood Institute, National Institutes of Health, U.S. Department of Health and Human Services through contracts HHSN268201100046C, HHSN268201100001C, HHSN268201100002C, HHSN268201100003C, HHSN268201100004C, and HHSN271201100004C.

Compliance with ethical standards

Conflicts of interest



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Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2019

Authors and Affiliations

  1. 1.Department of Medicine, Division of Rheumatology, J. Harold Harrison MD, Distinguished University Chair in RheumatologyMedical College of Georgia at Augusta UniversityAugustaUSA
  2. 2.Charlie Norwood Veterans Affairs Medical CenterAugustaUSA
  3. 3.Fred Hutchinson Cancer Research CenterSeattleUSA
  4. 4.Georgia Prevention InstituteMedical College of Georgia at Augusta UniversityAugustaUSA
  5. 5.Department of Medicine, Comprehensive Heart Failure CenterUniversity of WürzburgWürzburgGermany
  6. 6.Department of Epidemiology, Graduate School of Public HealthUniversity of PittsburghPittsburghUSA
  7. 7.Department of Preventive MedicineUniversity of Tennessee Health Science CenterMemphisUSA

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