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Affiliation(s)
- Kristine E Ensrud
- Division of Epidemiology & Community Health, Department of Medicine, University of Minnesota, Minneapolis
- Center for Care Delivery and Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Carolyn J Crandall
- Department of Medicine, University of California, Los Angeles
- Associate Editor, JAMA
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52
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Shapiro CL, Van Poznak C, Lacchetti C, Kirshner J, Eastell R, Gagel R, Smith S, Edwards BJ, Frank E, Lyman GH, Smith MR, Mhaskar R, Henderson T, Neuner J. Management of Osteoporosis in Survivors of Adult Cancers With Nonmetastatic Disease: ASCO Clinical Practice Guideline. J Clin Oncol 2019; 37:2916-2946. [DOI: 10.1200/jco.19.01696] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE The aim of this work is to provide evidence-based guidance on the management of osteoporosis in survivors of adult cancer. METHODS ASCO convened a multidisciplinary Expert Panel to develop guideline recommendations based on a systematic review of the literature. RESULTS The literature search of the 2018 systematic review by the US Preventive Services Task Force in the noncancer population was used as the evidentiary base upon which the Expert Panel based many of its recommendations. A total of 61 additional studies on topics and populations not covered in the US Preventive Services Task Force review were also included. Patients with cancer with metastatic disease and cancer survival outcomes related to bone-modifying agents are not included in this guideline. RECOMMENDATIONS Patients with nonmetastatic cancer may be at risk for osteoporotic fractures due to baseline risks or due to the added risks that are associated with their cancer therapy. Clinicians are advised to assess fracture risk using established tools. For those patients with substantial risk of osteoporotic fracture, the clinician should obtain a bone mineral density test. The bone health of all patients may benefit from optimizing nutrition, exercise, and lifestyle. When a pharmacologic agent is indicated, bisphosphonates or denosumab at osteoporosis-indicated dosages are the preferred interventions.
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Affiliation(s)
| | | | | | - Jeffrey Kirshner
- Hematology-Oncology Associates of Central New York, Syracuse, NY
| | | | | | | | - Beatrice J. Edwards
- University of Texas Dell Med School and Central Texas Veterans Healthcare System, Austin, TX
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53
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Lu L, Lu L, Zhang J, Li J. Potential risks of rare serious adverse effects related to long-term use of bisphosphonates: An overview of systematic reviews. J Clin Pharm Ther 2019; 45:45-51. [PMID: 31608489 DOI: 10.1111/jcpt.13056] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 07/19/2019] [Accepted: 08/20/2019] [Indexed: 12/22/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE There have been concerns about a potential link between long-term use of bisphosphonates (BPs) for the treatment of osteoporosis and rare serious adverse effects, such as atypical femoral fractures. However, many reviews exist with conflicting conclusions about this issue. The aim of this overview of reviews was to systematically evaluate the risk of rare serious adverse effects of long-term use of BPs for the treatment of osteoporosis. METHODS We identified systematic reviews with meta-analyses of randomized controlled trials (RCTs) and (or) observational studies published in English or Chinese that evaluated the safety of BPs through to December 2018. The Cochrane library, PubMed, Web of Science and hand-searching of reference lists and clinical practice guidelines were electronically searched for data sources. Carcinogenicity, atypical fracture, osteonecrosis of jaw (ONJ) and fracture union time were specified as the primary outcomes. The methodological quality of each systematic review was assessed by two reviewers using the Assessment of Multiple Systematic Reviews (AMSTAR) tool, and the quality of evidence for key outcomes was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. RESULTS AND DISCUSSION In total, 1376 potentially relevant citations were identified, of which only 8 systematic reviews with meta-analyses met the eligibility criteria. All the included reviews were published between 2012 and 2015 and documented the pooled estimates of effect size (relative risk [RR], odds ratio [OR] or hazard ratio [HR] and their 95% confidence intervals [95% CI]) for the incidence of adverse events. All included systematic reviews were of moderate or high quality. The median AMSTAR score was 7.5 (interquartile range, 5-10). However, evidence of the key outcomes was mainly of very low or moderate quality. BP treatment only increased the risk of atypical fracture and ONJ, and prolonged union time compared with placebo or other anti-osteoporosis drugs (P < .05). WHAT IS NEW AND CONCLUSION This study indicated that long-term use of BPs could increase the risk of rare serious adverse effects, but the relationship between long-term use of BPs and carcinogenicity was often uncertain. Therefore, high-quality research and more complete inclusion criteria are needed.
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Affiliation(s)
- Liqing Lu
- General Hospital of Southern Theatre of PLA, Guangzhou, China
| | - Lifen Lu
- Guangxi Medical University, Nanning, Guangxi, China
| | | | - Jian Li
- General Hospital of Southern Theatre of PLA, Guangzhou, China
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54
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Tan J, Sano H, Poole K. Antiresorptive-associated spontaneous fractures of both tibiae, followed by an atypical femur fracture during the sequential treatment with alendronate, denosumab then teriparatide. BMJ Case Rep 2019; 12:12/7/e229366. [PMID: 31340943 PMCID: PMC6663157 DOI: 10.1136/bcr-2019-229366] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
A 35-year-old man with juvenile idiopathic arthritis since childhood presented with bilateral atypical tibial fractures, followed by a later, single atypical fracture of the femur. The fractures were associated with 6 years of oral alendronate treatment immediately followed by subcutaneous denosumab therapy and later teriparatide therapy for osteoporosis. Atypical fractures are known to occur in the femur following bisphosphonate therapy; however, there are only a few documented cases of atypical fractures in the tibia. Our case highlights a rare but serious complication of a commonly prescribed antiresorptive agent. It also shows that teriparatide, while helpful in increasing bone mass, does not fully prevent the development of atypical fractures. Careful investigation should be considered in patients on long-term antiresorptive therapy presenting with bony tenderness to exclude an atypical fracture.
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Affiliation(s)
- Juan Tan
- Department of Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Hiroshige Sano
- Department of Medicine, Cambridge University, Cambridge, UK
| | - Kenneth Poole
- Metabolic Bone Disease Unit, Addenbrooke's Hospital, Cambridge, UK
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55
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Van Baarsel ED, Patel V, Kesbeh Y, Kahf H, Alonzo N. Atypical femoral fracture in the setting of alendronate treatment for osteoporosis: a case report and literature review. J Community Hosp Intern Med Perspect 2019; 9:340-343. [PMID: 31528285 PMCID: PMC6735290 DOI: 10.1080/20009666.2019.1644894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 07/11/2019] [Indexed: 11/15/2022] Open
Abstract
Osteoporosis leads to reduced bone mass and disrupted bone architecture. Bisphosphonates are used to treat osteoporosis by inhibiting bone resorption. Chronic bisphosphonate use has been associated with adverse effects including atypical femoral fractures (AFF). We report the case of a 63-year-old woman with a history of osteoporosis treated with alendronate, who presented with bilateral hip and groin pain. Radiography detected a chronic-appearing callus in the left hip concerning for a chronic stress fracture versus malignancy. Initial imaging could not rule out malignancy, prompting positron emission tomography (PET) and bone biopsy. PET scan was negative for malignancy and biopsy found changes consistent with chronic bisphosphonate use. This prompted prophylactic intramedullary nailing of the femur. This case highlights the importance of considering AFF in patients with a history of hip pain in the setting of chronic BPs use and reviews criteria within the literature to manage patients with AFFs.
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Affiliation(s)
| | - Vandan Patel
- School of Medicine, University of California, Riverside, CA, USA
| | - Yazeed Kesbeh
- School of Medicine, University of California, Riverside, CA, USA
| | - Huthayfa Kahf
- School of Medicine, University of California, Riverside, CA, USA
| | - Nicholas Alonzo
- School of Medicine, University of California, Riverside, CA, USA
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56
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Naranjo Hernández A, Díaz del Campo Fontecha P, Aguado Acín MP, Arboleya Rodríguez L, Casado Burgos E, Castañeda S, Fiter Aresté J, Gifre L, Gómez Vaquero C, Candelas Rodríguez G, Francisco Hernández FM, Guañabens Gay N. Recomendaciones de la Sociedad Española de Reumatología sobre osteoporosis. ACTA ACUST UNITED AC 2019; 15:188-210. [DOI: 10.1016/j.reuma.2018.09.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/17/2018] [Accepted: 09/19/2018] [Indexed: 01/09/2023]
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57
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Affiliation(s)
- Agostino Gaudio
- Department of Clinical and Experimental Medicine, University of Catania, Italy.
| | | | - Pietro Castellino
- Department of Clinical and Experimental Medicine, University of Catania, Italy
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58
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Rajput IM, Kumar J, Siddiqui AA, Jamil M, Soughat M, Ahmed MW. Surgical Fixation of Atypical Femur Fractures in Bisphosphonate-treated Patients. Cureus 2019; 11:e4690. [PMID: 31333916 PMCID: PMC6636699 DOI: 10.7759/cureus.4690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objective To evaluate the outcomes of the surgical fixation of atypical femoral fractures in bisphosphonate-treated patients with an intramedullary device. Materials and methods This multicentric study was carried out at the department of orthopedics, Dr. Ruth Phau Civil Hospital and Medicare Hospital, Karachi, Pakistan, between 2013 and 2018. In this retrospective observational study, we reviewed 10 bisphosphonate-treated patients, fixed surgically with an intramedullary nail after presenting with radiologically characteristic atypical femur fractures identified according to the American Society for Bone and Mineral Research criteria. We excluded patients with fractures sustained by high-energy trauma, road traffic accidents, fall from a height, and those associated with underlying malignancy. Results A total of 11 atypical femoral fractures in 10 patients were included, all of whom were females with a mean age of 68.6 (range 57-82) years. Out of 11 fractures, 81.8% (n=9) were located in the subtrochanteric region and two were located in the femoral shaft. The mean bisphosphonate use was 58.3 months. All patients were treated with intramedullary devices; an intramedullary interlocking nail in two cases and proximal femoral nail antirotation in nine cases. The mean follow-up duration was 12 months. All fractures were united in an average time of 9.9 months (range 6 - 16 months). Implant failure and/or nonunion were not observed, whereas delayed union was noted in five patients. Conclusion Intramedullary fixation is a reliable method for the treatment of atypical femur fractures in bisphosphonate-treated patients owing to its intramedullary placement. These devices act as an internal splint and can provide much more axial stability, reducing the risk of implant fatigue failure due to a delay in fracture healing from prolonged bisphosphonate use.
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Affiliation(s)
| | - Jagdesh Kumar
- Orthopaedic Surgery, Dow University of Health Sciences, Karachi, PAK
| | - Adeel A Siddiqui
- Orthopaedic Surgery, Dow University of Health Sciences, Karachi, PAK
| | - Muhammad Jamil
- Orthopaedics, Dow University of Health Sciences, Karachi, PAK
| | | | - Malik W Ahmed
- Orthopaedic Surgery, Dow Medical College Karachi, Karachi, PAK
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59
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Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society* Clinical Practice Guideline. J Clin Endocrinol Metab 2019; 104:1595-1622. [PMID: 30907953 DOI: 10.1210/jc.2019-00221] [Citation(s) in RCA: 405] [Impact Index Per Article: 81.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 01/28/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective is to formulate clinical practice guidelines for the pharmacological management of osteoporosis in postmenopausal women. CONCLUSIONS Evidence from clinical trials and insights from clinical experience with pharmacologic therapies for osteoporosis were critically evaluated in formulating this guideline for the management of postmenopausal osteoporosis. Patient preferences, data on adherence and persistence, and risks and benefits from the patient and provider perspectives were also considered in writing committee deliberations. A consensus by the Writing Committee members was achieved for four management principles: (i) The risk of future fractures in postmenopausal women should be determined using country-specific assessment tools to guide decision-making. (ii) Patient preferences should be incorporated into treatment planning. (iii) Nutritional and lifestyle interventions and fall prevention should accompany all pharmacologic regimens to reduce fracture risk. (iv) Multiple pharmacologic therapies are capable of reducing fracture rates in postmenopausal women at risk with acceptable risk-benefit and safety profiles.
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Affiliation(s)
| | | | - Dennis M Black
- University of California San Francisco, San Francisco, California
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minnesota
| | - Dolores Shoback
- Endocrine Research Unit, San Francisco Veterans Affairs Medical Center, San Francisco, California
- Department of Medicine, University of California San Francisco, San Francisco, California
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60
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Ensrud KE, Crandall CJ. In older postmenopausal women with osteopenia, zoledronate reduced fragility fractures at 6 years. Ann Intern Med 2019; 170:JC42. [PMID: 30986832 DOI: 10.7326/acpj201904160-042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Kristine E. Ensrud
- University of Minnesota andMinneapolis Veterans Affairs Health Care SystemMinneapolis, Minnesota, USA
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61
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Black DM, Abrahamsen B, Bouxsein ML, Einhorn T, Napoli N. Atypical Femur Fractures: Review of Epidemiology, Relationship to Bisphosphonates, Prevention, and Clinical Management. Endocr Rev 2019; 40:333-368. [PMID: 30169557 DOI: 10.1210/er.2018-00001] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 05/08/2018] [Indexed: 12/18/2022]
Abstract
Bisphosphonates (BPs) are highly effective in treating osteoporosis and reducing hip, vertebral, and other fractures by as much as 50% to 70%. However, since 2006, atypical femur fractures (AFFs) emerged as potential side effects of BPs and other treatments. These fractures have unusual radiologic features and occur with little trauma. Public concern has led to a >50% decrease in BP usage. AFFs are rare: for each AFF, >1200 fractures, including 135 hip fractures, are prevented. Case definition criteria were updated by the American Society of Bone and Mineral Research in 2014. Many epidemiologic studies have been reported, and although methodologically challenging, generally support a BP-AFF association. However, the magnitude of the association between BPs and AFFs is uncertain: estimates of relative risk for AFFs among BP users vs nonusers range from 1 to 65 with a meta-analysis estimate of 1.7. Although mechanistic studies have proposed several hypotheses explaining how BPs might decrease bone strength, AFF pathogenesis remains uncertain and cannot explain the paradox of efficacy of reduction of common fractures while increasing risk for rare fractures at one site. There are several consistent risk factors, including Asian race (in North America), femoral bowing, and glucocorticoid use, whereas others remain unclear. Consensus is emerging about strategies to prevent AFFs in BP users (including drug holidays after 5 years' use in some patients). In conclusion, AFFs can be devastating, but even under the most pessimistic assumptions, the benefit/risk ratio is highly positive for BPs, particularly during 3 to 5 years of use. As understanding of AFFs increases, it is becoming increasingly possible to maximize BP benefits while minimizing AFF risk.
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Affiliation(s)
- Dennis M Black
- University of California, San Francisco, San Francisco, California
| | | | | | | | - Nicola Napoli
- Università Campus Bio-Medico di Roma, Rome, Italy.,IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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62
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Abstract
Antiresorptive drugs, such as the bisphosphonates and the RANKL inhibitor denosumab, are currently the most widely used osteoporosis medications. These drugs increase bone mineral density (BMD) and reduce the risk of vertebral (by 40-70%), nonvertebral (by 25-40%) and hip fractures (by 40-53%) in postmenopausal women with osteoporosis. Due to the risk of rare side-effects, the use of bisphosphonates has been limited to up to 10 years with oral bisphosphonates and 6 years with intravenous zoledronic acid. Despite their well-proven efficacy and safety, few women at high risk of fracture are started on treatment. Case finding strategies, such as fracture risk-based screening in primary care using the fracture risk assessment tool (FRAX) and Fracture Liaison Services, have proved effective in increasing treatment rates and reducing fracture rates. Recently, anabolic therapy with teriparatide was demonstrated to be superior to the bisphosphonate risedronate in preventing vertebral and clinical fractures in postmenopausal women with vertebral fracture. Treatment with the sclerostin antibody romosozumab increases BMD more profoundly and rapidly than alendronate and is also superior to alendronate in reducing the risk of vertebral and nonvertebral fracture in postmenopausal women with osteoporosis. For patients with severe osteoporosis and high fracture risk, bisphosphonates alone are unlikely to be able to provide long-term protection against fracture and restore BMD. For those patients, sequential treatment, starting with a bone-building drug (e.g. teriparatide), followed by an antiresorptive, will likely provide better long-term fracture prevention and should be the golden standard of future osteoporosis treatment.
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Affiliation(s)
- Mattias Lorentzon
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.,Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
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63
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Buitendijk SKC, van de Laarschot DM, Smits AAA, Koromani F, Rivadeneira F, Beck TJ, Zillikens MC. Trabecular Bone Score and Hip Structural Analysis in Patients With Atypical Femur Fractures. J Clin Densitom 2019; 22:257-265. [PMID: 29661684 DOI: 10.1016/j.jocd.2018.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 03/13/2018] [Indexed: 01/03/2023]
Abstract
Bisphosphonate use has declined dramatically in recent years, partly because of fear of rare side effects like atypical femur fractures (AFFs). It is therefore desirable to have a diagnostic method to identify those at risk of AFF to prevent this serious complication. We compared trabecular microarchitecture and hip geometry between 30 patients with AFF and 141 controls of similar age and sex, using bisphosphonates. Trabecular bone score (TBS) and hip structural analysis (HSA) were used to assess trabecular microarchitecture and macroscopic hip geometry from dual-energy X-ray absorptiometry images of the lumbar spine and hip, respectively. General characteristics, TBS, and HSA were compared between patients with AFF and controls using Student's t tests and chi-square statistics. Associations between AFF and TBS and femur geometric characteristics by HSA were adjusted for sex, age, height, weight, ethnicity, duration of bisphosphonate use, and glucocorticoid use. Additionally, the analysis of TBS was adjusted for lumbar spine bone mineral density and the time difference between dual-energy X-ray absorptiometry scanning and the diagnosis of AFF. Patients with AFF had significantly higher body mass index than controls, had used bisphosphonates longer, and glucocorticoids and proton pump inhibitors more frequently. Sex-specific T-score was significantly higher in patients with AFF at the lumbar spine (p = 0.004), but not at the femoral neck (p = 0.190) after adjustment for age, height, and weight. TBS did not differ significantly between patients with AFF and controls. Neither neck shaft angle nor any geometric variables at the femoral shaft measured by HSA differed between patients with AFF and controls. At the narrow neck, patients with AFF had lower buckling ratio and higher centroid position, consistent with a lower risk of classical fragility hip fractures. The findings at narrow neck and higher bone mineral density might be explained by the fact that the majority of patients with AFF used bisphosphonates to prevent glucocorticoid-induced osteoporosis. Based on our results, TBS and HSA do not appear to have value in detecting patients at risk of AFF.
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Affiliation(s)
- Sanne K C Buitendijk
- Bone Center, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | | | - Alexandra A A Smits
- Bone Center, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Fjorda Koromani
- Bone Center, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands; Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Fernando Rivadeneira
- Bone Center, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands; Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | | | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands.
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64
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Anthamatten A, Parish A. Clinical Update on Osteoporosis. J Midwifery Womens Health 2019; 64:265-275. [PMID: 30869832 DOI: 10.1111/jmwh.12954] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 12/11/2018] [Accepted: 12/19/2018] [Indexed: 01/15/2023]
Abstract
Osteoporosis is described as a silent disease prior to fracture, and the sequelae of an osteoporotic fracture can be devastating. Primary care providers should routinely assess and remediate bone health during wellness visits for women aged at least 50 years. Assessment includes review of a variety of risk factors, bone density testing, and an online fracture risk assessment tool calculation. Diagnosis is based on bone density score and clinical risk factors. Evidence-based nonpharmacologic therapies are important adjuncts of care, and pharmacologic intervention may also be recommended. A variety of pharmacologic options are available for women with postmenopausal osteoporosis, and it is important to weigh benefits and risks. Pharmacologic indications, therapeutic variations among products, adverse effect profiles, administration considerations, and cost are addressed. Once pharmacotherapy is initiated, duration and drug holidays should also be considered. In general, medication benefits fade when treatment stops, so health care providers should be prepared to routinely revisit therapy indicators that will help define risk and guide treatment decisions. A comprehensive approach to bone health can make a valuable difference in the health of women.
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Affiliation(s)
| | - Abby Parish
- Vanderbilt University School of Nursing, Nashville, TN
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65
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Mailoo VJ, Srinivas V, Turner J, Fraser WD. Beware of bone pain with bisphosphonates. BMJ Case Rep 2019; 12:12/3/e225385. [PMID: 30872334 DOI: 10.1136/bcr-2018-225385] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 71-year-old woman who had been taking ibandronate for 10 years presented to an Endocrinology Department with persistent mid-thigh pain. Pelvic X-ray showed bilateral femoral cortical expansion, indicating impending atypical femoral fractures (AFFs). AFFs have been linked to long-term bisphosphonate therapy and have morbidity and mortality similar to that of hip fractures. Such fractures can be averted by regular reviews of bisphosphonate therapy and vigilance for prodromal symptoms. This patient's bisphosphonate therapy was stopped, and fractures were avoided by treatment with vitamin D and parathyroid hormone.
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Affiliation(s)
| | - Vidya Srinivas
- Diabetes and Endocrinology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Jeremy Turner
- Diabetes and Endocrinology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - William Duncan Fraser
- Diabetes and Endocrinology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Medical School, Norwich Research Park, University of East Anglia, Norwich, UK
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Abstract
Bone is the most common site of metastasis for breast cancer. Bone metastasis significantly affects both quality of life and survival of the breast cancer patient. Clinically, complications secondary to bone metastasis include pain, pathologic fractures, spinal cord compression, and hypercalcemia of malignancy. Because bone metastasis is extremely common in patients with metastatic breast cancer, clinical management of bone metastases is an important and challenging aspect of treatment in the metastatic setting.The skeleton is a metabolically active organ system that undergoes continuous remodeling throughout life. A delicate balance of the bone-forming osteoblasts and bone-resorbing osteoclasts in the dynamic microenvironment of the skeleton maintains normal bone remodeling and integrity. The presence of metastatic lesions in bone disrupts the normal bone microenvironment and upsets the fine balance between the key components. The changes in the bone microenvironment then create a vicious cycle that further promotes bone destruction and tumor progression.Various therapeutic options are available for bone metastases of breast cancer. Treatment can be tailored for each patient and, often requires multiple therapeutic interventions. Commonly used modalities include local therapies such as surgery, radiation therapy and radiofrequency ablation (RFA) together with systemic therapies such as endocrine therapy, chemotherapy, monoclonal antibody-based therapy, bone-enhancing therapy and radioisotope therapy. Despite the use of various therapeutic modalities, bone metastases eventually become resistant to therapy, and disease progresses.In this chapter, we describe the clinical picture and biological mechanism of bone metastases in breast cancer. We also discuss known risk factors as well as detection and assessment of bone metastases. We present therapeutic options for bone metastasis using a multidisciplinary approach. Further, we describe future directions for bone metastasis management, focusing on novel bone-specific targeted therapies.
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67
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White KA, Olabisi RM. Spatiotemporal Control Strategies for Bone Formation through Tissue Engineering and Regenerative Medicine Approaches. Adv Healthc Mater 2019; 8:e1801044. [PMID: 30556328 DOI: 10.1002/adhm.201801044] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/06/2018] [Indexed: 02/06/2023]
Abstract
Global increases in life expectancy drive increasing demands for bone regeneration. The gold standard for surgical bone repair is autografting, which enjoys excellent clinical outcomes; however, it possesses significant drawbacks including donor site morbidity and limited availability. Although collagen sponges delivered with bone morphogenetic protein, type 2 (BMP2) are a common alternative or supplement, they do not efficiently retain BMP2, necessitating extremely high doses to elicit bone formation. Hence, reports of BMP2 complications are rising, including cancer promotion and ectopic bone formation, the latter inducing complications such as breathing difficulties and neurologic impairments. Thus, efforts to exert spatial control over bone formation are increasing. Several tissue engineering approaches have demonstrated the potential for targeted and controlled bone formation. These approaches include biomaterial scaffolds derived from synthetic sources, e.g., calcium phosphates or polymers; natural sources, e.g., bone or seashell; and immobilized biofactors, e.g., BMP2. Although BMP2 is the only protein clinically approved for use in a surgical device, there are several proteins, small molecules, and growth factors that show promise in tissue engineering applications. This review profiles the tissue engineering advances in achieving control over the location and onset of bone formation (spatiotemporal control) toward avoiding the complications associated with BMP2.
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Affiliation(s)
- Kristopher A. White
- Department of Chemical and Biochemical Engineering; Rutgers University; 98 Brett Road Piscataway NJ 08854 USA
| | - Ronke M. Olabisi
- Department of Biomedical Engineering; Rutgers University; 599 Taylor Road Piscataway NJ 08854 USA
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68
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Leclerc JT, Michou L, Vaillancourt F, Pelet S, Simonyan D, Belzile EL. Prevalence and Characteristics of Atypical Periprosthetic Femoral Fractures. J Bone Miner Res 2019; 34:83-92. [PMID: 30280425 DOI: 10.1002/jbmr.3584] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/14/2018] [Accepted: 08/26/2018] [Indexed: 12/12/2022]
Abstract
Bisphosphonate use has been associated with atypical femoral fractures (AFFs), defined by the American Society of Bone and Mineral Research (ASBMR) Task Force criteria, which currently exclude periprosthetic fractures. The objectives of this study were to establish the prevalence of atypical periprosthetic femoral fractures (APFFs) in patients with hip and knee arthroplasties and to determine the clinical and radiological risk factors associated with these fractures. We performed a retrospective radiological review of all femoral fractures between January 1, 2006, and March 31, 2015, in Quebec City, Canada. Patients who sustained a periprosthetic femoral fracture (PFF) were identified and included in this study. We used the ASBMR Task Force criteria to identify atypical fractures and establish their prevalence. Data from medical records and radiological assessments of the femoral anatomy, the characteristics of the fracture, and the positioning of the prosthesis were collected. The prevalence of APFFs among PFFs was 8.3% (11/133). A strong association with bisphosphonates (p = 0.007) was observed, as well as an increased risk of APFFs among alendronate users compared to risedronate users (p = 0.04). A transverse fracture (p < 0.0001), a periosteal thickening of the lateral cortex at the fracture (p < 0.0001), a unicortical fracture (p = 0.02), and prodromal symptoms (p = 0.03) were associated with APFFs. The type of implant, its positioning, and the femoral geometry did not appear to be risk factors for APFFs compared to PFFs. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Jean-Thomas Leclerc
- Department of Orthopedic Surgery, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Quebec, QC, Canada
| | - Laëtitia Michou
- Division of Rheumatology, Department of Medicine, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Quebec, QC, Canada.,Centre de recherche Fonds de la recherche du Québec en santé (FRQS) du Centre Hospitalier Universitaire (CHU) de Québec, Quebec, QC, Canada
| | | | - Stéphane Pelet
- Department of Orthopedic Surgery, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Quebec, QC, Canada.,Centre de recherche Fonds de la recherche du Québec en santé (FRQS) du Centre Hospitalier Universitaire (CHU) de Québec, Quebec, QC, Canada
| | - David Simonyan
- Clinical and Evaluative Research Platform, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval Research Centre, Quebec, QC, Canada
| | - Etienne L Belzile
- Department of Orthopedic Surgery, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Quebec, QC, Canada.,Centre de recherche Fonds de la recherche du Québec en santé (FRQS) du Centre Hospitalier Universitaire (CHU) de Québec, Quebec, QC, Canada
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69
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Giannasi C, Niada S, Farronato D, Lombardi G, Manfredi B, Farronato G, Brini AT. Nitrogen Containing Bisphosphonates Impair the Release of Bone Homeostasis Mediators and Matrix Production by Human Primary Pre-Osteoblasts. Int J Med Sci 2019; 16:23-32. [PMID: 30662325 PMCID: PMC6332484 DOI: 10.7150/ijms.27470] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 10/11/2018] [Indexed: 12/22/2022] Open
Abstract
Bisphosphonates (BPs) represent the first-line treatment for a wide array of bone disorders. Despite their well-known action on osteoclasts, the effects they induce on osteoblasts are still unclear. In order to shed light on this aspect we evaluated the impact of two nitrogen containing bisphosphonates, Alendronate (ALN) and Zoledronate (ZOL), on human primary pre-osteoblasts. At first, we showed an inhibitory effect on cell viability and alkaline phosphatase activity starting from µM concentrations of both drugs. In addition, an inhibitory trend on mineralized nodules deposition was observed. Then low doses of both ALN and ZOL rapidly increased the release of the pro-inflammatory mediators TNFα and IL-1β, while increased DKK-1 and Sclerostin, both inhibitors of osteoblastogenesis. Finally, ALN and 10-7M ZOL decreased the expression of type I Collagen and Osteopontin, while both drugs slightly stimulated SPARC production. With these results, we would like to suggest a direct inhibitory action on bone-forming cells by nitrogen containing bisphosphonates.
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Affiliation(s)
- Chiara Giannasi
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy.,IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | | | - Davide Farronato
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | | | - Barbara Manfredi
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Giampietro Farronato
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy.,IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Teresa Brini
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy.,IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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70
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Zanker J, Duque G. Osteoporosis in Older Persons: Old and New Players. J Am Geriatr Soc 2018; 67:831-840. [PMID: 30570741 DOI: 10.1111/jgs.15716] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 11/06/2018] [Accepted: 11/07/2018] [Indexed: 12/24/2022]
Abstract
Osteoporosis is the most common bone disease in humans. Older persons are at higher risk of osteoporotic fractures that also result in poor quality of life, disability, loss of independence, institutionalization, and higher mortality. Osteoporosis shares a distinct pathophysiologic relationship with sarcopenia, an age-related disease comprising declines in muscle mass, strength, or function. The combination of these two diseases is known as osteosarcopenia. Understanding the pathophysiology of osteosarcopenia, in addition to its diagnostic and therapeutic approaches, is key in providing older adults with the best falls and fractures prevention strategies. This review provides updated information on new discoveries on the combined pathophysiology of osteoporosis and sarcopenia that have led to the development of novel therapeutic approaches. New recommendations for the use of risk calculators and densitometry are also presented in this review as well as evidence on current and upcoming pharmacologic treatments to prevent falls and fractures in older persons. J Am Geriatr Soc 67:831-840, 2019.
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Affiliation(s)
- Jesse Zanker
- Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Western Health, St. Albans, Victoria, Australia.,Department of Medicine, Melbourne Medical School, The University of Melbourne - Western Health, St. Albans, Victoria, Australia
| | - Gustavo Duque
- Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Western Health, St. Albans, Victoria, Australia.,Department of Medicine, Melbourne Medical School, The University of Melbourne - Western Health, St. Albans, Victoria, Australia
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71
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Rocos B, Fleming T, Harding K, Acharya M, Riddick A, Kelly M. A Case Series and Discussion on Surgical Treatment Strategy for Atypical Proximal Femoral Fractures Associated with Bisphosphonate Use. Cureus 2018; 10:e3670. [PMID: 30761223 PMCID: PMC6364955 DOI: 10.7759/cureus.3670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
The aim of this study was to determine the incidence of atypical femoral fractures in our local population, study their current outcomes and present a novel surgical strategy based on these data. Patients who received surgical fixation of an atypical pattern proximal femoral fracture over a four-year period were identified and followed up in the clinic until union, revision surgery or death. The local incidence of atypical femoral fractures is 1.1 per 1000 per annum amongst patients receiving bisphosphonates. Twelve fixation procedures were carried out in 10 patients. Intra-operative reduction and nailing led to an average deformity of 8.5° varus and 13° apex anterior. Five cases required revision surgery. Fifty percent of primary procedures resulted in radiographic union within two years. We suggest that the lateral side of the fracture should be considered a primary nonunion. We advocate undertaking a wedge excision to correct the bone to a valgus morphology and stabilising with an intramedullary nail and a lateral tension plate. Multicentre studies are needed to demonstrate the efficacy of any particular approach.
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Affiliation(s)
- Brett Rocos
- Orthopaedics, North Bristol National Health Service Trust, Bristol, GBR
| | - Thomas Fleming
- Orthopaedics, North Bristol National Health Service Trust, Bristol, GBR
| | - Karen Harding
- Orthopaedic Surgery, North Bristol National Health Service Trust, Bristol, GBR
| | - Mehool Acharya
- Orthopaedic Surgery, North Bristol National Health Service Trust, Bristol, GBR
| | - Andrew Riddick
- Orthopaedic Surgery, North Bristol National Health Service Trust, Bristol, GBR
| | - Mike Kelly
- Orthopaedic Surgery, North Bristol National Health Service Trust, Bristol, GBR
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72
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Briot K, Roux C, Thomas T, Blain H, Buchon D, Chapurlat R, Debiais F, Feron JM, Gauvain JB, Guggenbuhl P, Legrand E, Lehr-Drylewicz AM, Lespessailles E, Tremollieres F, Weryha G, Cortet B. Actualisation 2018 des recommandations françaises du traitement de l’ostéoporose post-ménopausique. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.rhum.2018.02.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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73
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Zandi M, Shokri A, Mousavi M, Rajaei S, Mohammad Gholi Mezerji N. Does zoledronate therapy make mandibular bone susceptible to fracture? A radiographical and biomechanical study in rats. Injury 2018; 49:1746-1749. [PMID: 30007517 DOI: 10.1016/j.injury.2018.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 07/04/2018] [Accepted: 07/05/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The aim of this study was to evaluate the effect of zoledronate therapy on susceptibility of mandibular bone to fracture in rats. METHODS Fifty rats were randomly allocated to two groups of 25 animals. The rats in group Z received monthly intravenous infusion of 0.06 mg/kg zoledronate for 6 months. The rats in the group C were injected with an equal volume of saline in the same manner. A month after the last zoledronate/saline administration, all 50 rats were euthanized. Using a cone beam computed tomography, the cortical thickness of inferior border of mandible and the mandibular bone mineral density were calculated, and using a three-point bending test, the peak load failure and the ultimate stress of mandibular bone were determined. RESULTS The mean mandibular inferior cortical bone thickness and the mean bone mineral density were significantly larger in zoledronate-treated rats (0.30 ± 0.02 mm and 1045.00 ± 185.79, respectively) compared to control rats (0.21 ± 0.01 mm and 878.66 ± 166.53, respectively). The peak load and the ultimate stress were lower in the zoledronate-treated hemimandibles (84.61 ± 33.62 N and 1.76 ± 0.72 MPa, respectively) compared to the control hemimandibles (98.36 ± 16.5 9 N and 2.03 ± 0.44 MPa, respectively). CONCLUSION Zoledronate therapy reduced the mechanical strength of the mandibles, implying an increased risk of mandibular fracture in rats.
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Affiliation(s)
- Mohammad Zandi
- Department of Oral and Maxillofacial Surgery, Hamadan University of Medical Sciences, Hamadan, Iran; Dental Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Abbas Shokri
- Department of Oral and Maxillofacial Radiology, Hamadan University of Medical Sciences, Hamadan, Iran.
| | - Maryam Mousavi
- Faculty of Dentistry, Hamadan University of Medical sciences, Hamadan, Iran
| | - Sanaz Rajaei
- Faculty of Dentistry, Hamadan University of Medical sciences, Hamadan, Iran
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74
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Gourlay ML. Osteoporosis Screening-2 Steps May Be Too Much for Women Younger Than 65 Years. JAMA Intern Med 2018; 178:1159-1160. [PMID: 29946684 DOI: 10.1001/jamainternmed.2018.2776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Margaret L Gourlay
- Department of Family Medicine, University of North Carolina at Chapel Hill
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75
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Demirtas A, Ural A. Interaction of Microcracks and Tissue Compositional Heterogeneity in Determining Fracture Resistance of Human Cortical Bone. J Biomech Eng 2018; 140:2680999. [PMID: 29801171 DOI: 10.1115/1.4040123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Indexed: 11/08/2022]
Abstract
Recent studies demonstrated an association between atypical femoral fracture (AFF) and long-term bisphosphonate (BP) use for osteoporosis treatment. Due to BP treatment, bone undergoes alterations including increased microcrack density and reduced tissue compositional heterogeneity. However, the effect of these changes on the fracture response of bone is not well understood. As a result, the goal of the current study is to evaluate the individual and combined effects of microcracks and tissue compositional heterogeneity on fracture resistance of cortical bone using finite element modeling (FEM) of compact tension (CT) specimen tests with varying microcrack density, location, and clustering, and material heterogeneity in three different bone samples. The simulation results showed that an increase in microcrack density improved the fracture resistance irrespective of the local material property heterogeneity and microcrack distribution. A reduction in material property heterogeneity adversely affected the fracture resistance in models both with and without microcracks. When the combined changes in microcrack density and tissue material property heterogeneity representing BP treatment were evaluated, the models corresponding to BP-treated bone demonstrated reduced fracture resistance. The simulation results also showed that although microcrack location and clustering, and microstructure significantly influenced fracture resistance, the trends observed on the effect of microcrack density and tissue material property heterogeneity did not change. In summary, these results provide new information on the interaction of microcracks, tissue material property heterogeneity, and fracture resistance and may improve the understanding of the influence of mechanical changes due to prolonged BP use on the fracture behavior of cortical bone.
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Affiliation(s)
- Ahmet Demirtas
- Department of Mechanical Engineering, Villanova University, 800 Lancaster Avenue, Villanova, PA 19085 e-mail:
| | - Ani Ural
- Department of Mechanical Engineering, Villanova University, , Villanova, PA 19085 e-mail:
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76
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Zura R, Kaste SC, Heffernan MJ, Accousti WK, Gargiulo D, Wang Z, Steen RG. Risk factors for nonunion of bone fracture in pediatric patients: An inception cohort study of 237,033 fractures. Medicine (Baltimore) 2018; 97:e11691. [PMID: 30075567 PMCID: PMC6081185 DOI: 10.1097/md.0000000000011691] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
UNLABELLED Adult fracture nonunion risk is related to injury severity and surgical technique, yet nonunion is not fully explained by these risk factors alone; biological risk factors are also important. We test a hypothesis that risk factors associated with pediatric fracture nonunion are similar to adult nonunion risk factors.Inception cohort study in a large payer database of pediatric fracture patients (0-17 years) in the United States in calendar year 2011. Continuous enrollment in the database was required for 12 months, to allow time to capture a nonunion diagnosis. The final database collated demographic descriptors, treatment procedures as per Current Procedural Terminology (CPT) codes, comorbidities as per International Statistical Classification of Diseases and Related Health Problems (ICD-9) codes, and drug prescriptions as per National Drug Code Directory (Red Book) codes. Logistic regression was used to calculate odds ratios (ORs) for variables associated with nonunion.Among 237,033 pediatric fractures in 18 bones, the nonunion rate was 0.85%. Increased nonunion risk was associated with increasing age, male gender, high body-mass index, severe fracture (e.g., open fracture, multiple fractures), and tobacco smoking (all, P < .0001). Nonunion rate varied with fracture location; scaphoid, neck of femur, and tibia/fibula were most likely to go to nonunion. Nonunion ORs were significantly increased for risk factors including; surgical procedure, cardiovascular disease, Vitamin D deficiency, osteoarthritis, osteoporosis, and opioid prescription (all, multivariable P < .001).Nonunion is rare in pediatric patients, but nonunion risk increases with increasing age. We confirm a hypothesis that risk factors for pediatric nonunion are similar to adult nonunion risk factors. Scaphoid fractures in adolescents have nearly the same risk of nonunion as in adults. Opioids should be used cautiously in pediatric patients, as they are associated with a significant and substantial elevation of nonunion risk. LEVEL OF EVIDENCE Prognostic study, Retrospective, Level II.
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Affiliation(s)
- Robert Zura
- Department of Orthopedic Surgery, Louisiana State University Health Science Center, New Orleans
| | - Sue C. Kaste
- Departments of Radiology and Oncology, St. Jude Children's Research Hospital
- Department of Radiology, University of Tennessee School of Health Sciences, Memphis, Tennessee
| | - Michael J. Heffernan
- Department of Orthopedic Surgery, Louisiana State University Health Science Center, New Orleans
| | - William K. Accousti
- Department of Orthopedic Surgery, Louisiana State University Health Science Center, New Orleans
- Department Orthopedic Surgery, Children's Hospital, New Orleans, Louisiana
| | - Dominic Gargiulo
- Department of Orthopedic Surgery, Louisiana State University Health Science Center, New Orleans
- Department Orthopedic Surgery, Children's Hospital, New Orleans, Louisiana
| | - Zhe Wang
- Department of Statistics, North Carolina State University, Raleigh, North Carolina
| | - R. Grant Steen
- Department of Orthopedic Surgery, Louisiana State University Health Science Center, New Orleans
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77
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Genest F, Seefried L. Subtrochanteric and diaphyseal femoral fractures in hypophosphatasia-not atypical at all. Osteoporos Int 2018; 29:1815-1825. [PMID: 29774402 DOI: 10.1007/s00198-018-4552-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 04/25/2018] [Indexed: 12/18/2022]
Abstract
UNLABELLED Risk for subtrochanteric and diaphyseal femoral fractures is considered increased in patients with hypophosphatasia (HPP). Evaluating a large cohort of HPP patients, we could for the first time quantify the prevalcence and identify both morphometric features as well as predisposing factors for this complication of severe HPP. INTRODUCTION Subtrochanteric and diaphyseal femoral fractures have been associated with both, long-term antiresorptive treatment and metabolic bone disorders, specifically Hypophosphatasia (HPP). Building on a cross-sectional evaluation of real-world data, this study reports risk factors, prevalence, treatment outcome and morphometric particularities for such fractures in HPP as compared to Atypical Femoral Fractures (AFF) in long-term antiresorptive treatment. METHODS For 15 out of 150 HPP patients identified with having experienced at least one such fracture, medical records were reviewed in detail, extracting medical history, genotype, lab assessments, bone mineral density (DXA), radiographic data on femoral geometry and clinical aspects of fracture etiology and healing. RESULTS Bilateral fractures were documented in 10 of these 15 patients, yielding a total of 25 fractures for evaluation. Disease-inherent risk factors included autosomal-recessive, childhood onset HPP, apparently low alkaline phosphatase (ALP) ≤ 20 U/l and substantially elevated pyridoxal 5'-phosphate (PLP) > 3 times upper limit of normal as well as high lumbar spine BMD. Fracture morphology met definition criteria for AFF in 88% of cases. Femoral geometry revealed additional risk factors previously described for AFF, including decreased femoral neck-shaft angle and increased femoral offset. Extrinsic risk factors include Hypovitaminosis D (80%) and pre-treatment with bisphosphonates (46,7%) and Proton-Pump Inhibitors (40%). CONCLUSIONS Increased risk for subtrochanteric and diaphyseal femoral fractures in HPP appears to result from both compromised bone metabolism as well as disease-associated bone deformities. In severe HPP, generous screening for such fractures seems advisable. Bisphosphonates and Hypovitaminosis D should be avoided. Healing is compromised and requires mindful consideration of both pharmacological and surgical options.
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Affiliation(s)
- F Genest
- Clinical Trial Unit, Orthopedic Department, University of Wuerzburg, Brettreichstrasse 11, 97074, Wuerzburg, Germany
| | - L Seefried
- Clinical Trial Unit, Orthopedic Department, University of Wuerzburg, Brettreichstrasse 11, 97074, Wuerzburg, Germany.
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78
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Cho YJ, Kang KC, Chun YS, Rhyu KH, Kim SJ, Jang TS. Critical differences between subtrochanteric and diaphyseal atypical femoral fractures: analyses of 51 cases at a single institution in Korean population. Arch Osteoporos 2018; 13:53. [PMID: 29725835 DOI: 10.1007/s11657-018-0457-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 04/02/2018] [Indexed: 02/03/2023]
Abstract
UNLABELLED There still remains controversy on the pathomechanism of atypical femoral fracture (AFF). The angle of lateral bowing and bone mineral density showed significant differences between subtrochanteric and diaphyseal atypical fracture groups. In addition to the use of bisphosphonate, mechanical factors might play important roles in the occurrence of AFFs. INTRODUCTION Although AFF could be divided into subtrochanteric and diaphyseal fracture according to the location of fractures, there is a lack of evidence regarding differences between two fractures and etiology of the occurrence. The aim of study is to determine differences between atypical subtrochanteric and diaphyseal fracture in Korean population. METHODS Between February 2010 and March 2015, 51 AFFs in 40 patients were included in this study. Their medical records were retrospectively reviewed. The AFF patients satisfied all the diagnostic criteria of the 2014 revised edition of the ASMBR. To analyze the differences according to the location of fracture, the AFFs were divided into subtrochanteric (n = 16) and diaphyseal (n = 35) fracture groups. The following factors were compared between two groups: patients' demographics, underlying diseases, laboratory findings (serum-25(OH) VitD3, osteocalcin, c-telopeptide, ALP, Ca, and P), bone mineral density (BMD), duration of bisphosphonate (BP) usage, and lateral bowing of the femur at time of the fracture. RESULTS All AFFs happened in female patients (mean age, 73.8 years) who have received bisphosphonate treatments except three patients. The mean duration of bisphosphonate usage was 95.3 months. Between the two groups, demographic data (age, height, weight, and BMI), underlying diseases, laboratory findings, hip BMD, and duration of BP treatment were comparable to each other (p > 0.05). However, the subtrochanteric fracture group showed higher FNSBA (femoral neck shaft bowing angle, p < 0.001) and spine BMD (p = 0.014) compared to the diaphyseal fracture group. CONCLUSIONS Angle of lateral bowing (FNSBA) and spine BMD showed significant differences between subtrochanteric and diaphyseal atypical fracture groups. According to our results, femoral bowing and spine BMD may play important roles in the AFF locations.
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Affiliation(s)
- Yoon-Je Cho
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23 Kyungheedaero, Dongdaemun-gu, Seoul, 02447, Republic of Korea
- College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Kyung-Chung Kang
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23 Kyungheedaero, Dongdaemun-gu, Seoul, 02447, Republic of Korea.
- College of Medicine, Kyung Hee University, Seoul, Republic of Korea.
| | - Young-Soo Chun
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Dongnamro, Gangdong-gu, 05278, Seoul, Republic of Korea
- College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Kee Hyung Rhyu
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23 Kyungheedaero, Dongdaemun-gu, Seoul, 02447, Republic of Korea
- College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Sang-Jun Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23 Kyungheedaero, Dongdaemun-gu, Seoul, 02447, Republic of Korea
- College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Tae-Su Jang
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23 Kyungheedaero, Dongdaemun-gu, Seoul, 02447, Republic of Korea
- College of Medicine, Kyung Hee University, Seoul, Republic of Korea
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79
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Lee OL, Horvath N, Lee C, Joshua D, Ho J, Szer J, Quach H, Spencer A, Harrison S, Mollee P, Roberts AW, Talaulikar D, Brown R, Augustson B, Ling S, Jaksic W, Gibson J, Kalff A, Johnston A, Kalro A, Ward C, Prince HM, Zannettino A. Bisphosphonate guidelines for treatment and prevention of myeloma bone disease. Intern Med J 2018; 47:938-951. [PMID: 28782211 DOI: 10.1111/imj.13502] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/26/2017] [Accepted: 05/15/2017] [Indexed: 01/10/2023]
Abstract
Multiple myeloma (MM) is a haematological malignancy characterised by the clonal proliferation of plasma cells in the bone marrow. More than 80% of patients with MM display evidence of myeloma bone disease (MBD), characterised by the formation of osteolytic lesions throughout the axial and appendicular skeleton. MBD significantly increases the risk of skeletal-related events such as pathologic fracture, spinal cord compression and hypercalcaemia. MBD is the result of MM plasma cells-mediated activation of osteoclast activity and suppression of osteoblast activity. Bisphosphonates (BP), pyrophosphate analogues with high bone affinity, are the only pharmacological agents currently recommended for the treatment and prevention of MBD and remain the standard of care. Pamidronate and zoledronic acid are the most commonly used BP to treat MBD. Although generally safe, frequent high doses of BP are associated with adverse events such as renal toxicity and osteonecrosis of the jaw. As such, optimal duration and dosing of BP therapy is required in order to minimise BP-associated adverse events. The following guidelines provide currently available evidence for the adoption of a tailored approach when using BP for the management of MBD.
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Affiliation(s)
- Oi Lin Lee
- Department of Haematology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Noemi Horvath
- Department of Haematology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia
| | - Cindy Lee
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Doug Joshua
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Cancer and Haematology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Joy Ho
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Cancer and Haematology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Jeff Szer
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Clinical Haematology and BMT, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Hang Quach
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Haematology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Andrew Spencer
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Haematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Simon Harrison
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Peter Mollee
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Andrew W Roberts
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Clinical Haematology and BMT, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
| | - Dipti Talaulikar
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Canberra Hospital, Canberra, Australian Capital Territory, Australia.,College of Medicine, Biology and Environment, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Ross Brown
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Bradley Augustson
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Silvia Ling
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Wilfrid Jaksic
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - John Gibson
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Cancer and Haematology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Anna Kalff
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Anna Johnston
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Royal Hobart Hospital, Hobart, Tasmania, Australia.,Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - Akash Kalro
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Chris Ward
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Cancer and Haematology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - H Miles Prince
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Andrew Zannettino
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Cancer Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
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80
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Briot K, Roux C, Thomas T, Blain H, Buchon D, Chapurlat R, Debiais F, Feron JM, Gauvain JB, Guggenbuhl P, Legrand E, Lehr-Drylewicz AM, Lespessailles E, Tremollieres F, Weryha G, Cortet B. 2018 update of French recommendations on the management of postmenopausal osteoporosis. Joint Bone Spine 2018; 85:519-530. [PMID: 29654947 DOI: 10.1016/j.jbspin.2018.02.009] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To update the 2012 recommendations on pharmacotherapy for postmenopausal osteoporosis, under the aegis of the Bone Task Force of the French Society for Rheumatology (SFR) and of the Osteoporosis Research and Information Group (GRIO), in collaboration with scientific societies (Collège national des généralistes enseignants, Collège national des gynécologues et obstétriciens français, Fédération nationale des collèges de gynécologie médicale, Groupe d'étude de la ménopause et du vieillissement hormonal, Société française de chirurgie orthopédique, Société française d'endocrinologie, and Société française de gériatrie et de gérontologie). METHODS Updated recommendations were developed by a task force whose members represented the medical specialties involved in the management of postmenopausal osteoporosis. The update was based on a literature review and developed using the method advocated by the French National Authority for Health (HAS). DISCUSSION AND CONCLUSION The updated recommendations place strong emphasis on the treatment of women with severe fractures, in whom the use of osteoporosis medications is recommended. All the available osteoporosis medications are suitable in patients with severe fractures; zoledronic acid deserves preference as the fist-line drug after a hip fracture. In patients with or without non-severe fractures, the decision to use osteoporosis medications is based on bone mineral density values and in challenging cases, on probabilities supplied by prediction tools such as FRAX®. All osteoporosis medications are suitable; raloxifene should be reserved for patients at low risk for peripheral fractures. The fracture risk should be reevaluated every 2 to 3 years to decide on the best follow-up treatment. These updated recommendations discuss the selection of first-line osteoporosis medications and treatment sequences.
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Affiliation(s)
- Karine Briot
- Service de rhumatologie, hôpital Cochin, 27, rue de Faubourg Saint-Jacques, 75014 Paris, France.
| | - Christian Roux
- Service de rhumatologie, hôpital Cochin, 27, rue de Faubourg Saint-Jacques, 75014 Paris, France
| | - Thierry Thomas
- Inserm U1059, service de rhumatologie, CHU de Saint-Etienne, 42100 Saint-Etienne, France
| | - Hubert Blain
- Unité de soins aigus gériatriques, centre Antonin-Balmes, CHU de Montpellier, université Montpellier 1, 34090 Montpellier, France
| | | | - Roland Chapurlat
- Inserm U1033, service de rhumatologie, université de Lyon, hôpital Edouard-Herriot, 5, place d'Arsonval, 69437 Lyon, France
| | | | - Jean Marc Feron
- Service de chirurgie orthopédique de l'hôpital Saint-Antoine, hôpitaux universitaires Est-Parisiens, 75012 Paris, France
| | | | - Pascal Guggenbuhl
- Inserm U1241, Inra U1341, institut NUMECAN, 35000 Rennes, France; Service de rhumatologie, CHU, hôpital Sud, 35000 Rennes, France; Université de Rennes 1, 35000 Rennes, France
| | - Eric Legrand
- Service de rhumatologie, CHU de Angers, 49000 Angers, France
| | | | | | | | - Georges Weryha
- Service d'endocrinologie, CHU de Nancy, 54000 Nancy, France
| | - Bernard Cortet
- EA 4490, service de rhumatologie, CHU de Lille, 59000 Lille, France
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81
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Abstract
The bone remodelling cycle replaces old and damaged bone and is a highly regulated, lifelong process essential for preserving bone integrity and maintaining mineral homeostasis. During the bone remodelling cycle, osteoclastic resorption is tightly coupled to osteoblastic bone formation. The remodelling cycle occurs within the basic multicellular unit and comprises five co-ordinated steps; activation, resorption, reversal, formation and termination. These steps occur simultaneously but asynchronously at multiple different locations within the skeleton. Study of rare human bone disease and animal models have helped to elucidate the cellular and molecular mechanisms that regulate the bone remodelling cycle. The key signalling pathways controlling osteoclastic bone resorption and osteoblastic bone formation are receptor activator of nuclear factor-κB (RANK)/RANK ligand/osteoprotegerin and canonical Wnt signalling. Cytokines, growth factors and prostaglandins act as paracrine regulators of the cycle, whereas endocrine regulators include parathyroid hormone, vitamin D, calcitonin, growth hormone, glucocorticoids, sex hormones, and thyroid hormone. Disruption of the bone remodelling cycle and any resulting imbalance between bone resorption and formation leads to metabolic bone disease, most commonly osteoporosis. The advances in understanding the cellular and molecular mechanisms underlying bone remodelling have also provided targets for pharmacological interventions which include antiresorptive and anabolic therapies. This review will describe the remodelling process and its regulation, discuss osteoporosis and summarize the commonest pharmacological interventions used in its management.
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Affiliation(s)
- J S Kenkre
- 1 Section of Investigative Medicine, Imperial College London, London, UK
| | - Jhd Bassett
- 2 Molecular Endocrinology Laboratory, Department of Medicine, Imperial College London, London, UK
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82
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Wodkowski M, Boily M, Morin S. Atypical femur fracture in a patient with indolent mastocytosis: A case report. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY CASE REPORTS 2018. [DOI: 10.1016/j.jecr.2017.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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83
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Adler RA. MANAGEMENT OF ENDOCRINE DISEASE: Atypical femoral fractures: risks and benefits of long-term treatment of osteoporosis with anti-resorptive therapy. Eur J Endocrinol 2018; 178:R81-R87. [PMID: 29339529 DOI: 10.1530/eje-17-1002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 01/16/2018] [Indexed: 01/04/2023]
Abstract
Modern osteoporosis treatment began in the mid-1990s with the approval of amino-bisphosphonates, anti-resorptive agents that have been shown to decrease osteoporotic fracture risk by about half. In 2005, the first cases of atypical femoral fractures (AFF), occurring in the shaft of the femur, were reported. Since then, more cases have been found, leading to great concern among patients and a dramatic decrease in bisphosphonate prescribing. The pathogenesis and incidence of AFF are reviewed herein. Management and an approach to prevention or early detection of AFF are also provided. Denosumab, a more recently approved anti-resorptive medication has also been associated with AFF. Long-term management of osteoporosis and prevention of fracture are challenging in light of this serious but uncommon side effect, yet with an aging population osteoporotic fracture is destined to increase in frequency.
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Affiliation(s)
- Robert A Adler
- Endocrinology and Metabolism Section, McGuire Veterans Affairs Medical Center, Division of Endocrinology,Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
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84
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Abstract
Atypical Femoral Fractures (AFF) represent fractures located between the lesser trochanter and the supracondylar flare of a femur. An increasing pool of evidence supports their association with the prolonged use of bisphosphonates, even though a direct correlation is yet to be proved. The purpose of this review is to encapsulate the current evidence associating bisphosphonate use and the development of AFFs, the clinical features related to their presentation, as well as to report the armamentarium of strategies available in the prevention and treatment of AFFs. Based on these evidence, we propose a management algorithm for AFFs, that can serve as a guide for patients presenting with this condition.
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85
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Davis S, Martyn-St James M, Sanderson J, Stevens J, Goka E, Rawdin A, Sadler S, Wong R, Campbell F, Stevenson M, Strong M, Selby P, Gittoes N. A systematic review and economic evaluation of bisphosphonates for the prevention of fragility fractures. Health Technol Assess 2018; 20:1-406. [PMID: 27801641 DOI: 10.3310/hta20780] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture. OBJECTIVES To evaluate the clinical effectiveness and safety of bisphosphonates [alendronic acid (Fosamax® and Fosamax® Once Weekly, Merck Sharp & Dohme Ltd), risedronic acid (Actonel® and Actonel Once a Week®, Warner Chilcott UK Ltd), ibandronic acid (Bonviva®, Roche Products Ltd) and zoledronic acid (Aclasta®, Novartis Pharmaceuticals UK Ltd)] for the prevention of fragility fracture and to assess their cost-effectiveness at varying levels of fracture risk. DATA SOURCES For the clinical effectiveness review, six electronic databases and two trial registries were searched: MEDLINE, EMBASE, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Web of Science and BIOSIS Previews, Clinicaltrials.gov and World Health Organization International Clinical Trials Registry Platform. Searches were limited by date from 2008 until September 2014. REVIEW METHODS A systematic review and network meta-analysis (NMA) of effectiveness studies were conducted. A review of published economic analyses was undertaken and a de novo health economic model was constructed. Discrete event simulation was used to estimate lifetime costs and quality-adjusted life-years (QALYs) for each bisphosphonate treatment strategy and a strategy of no treatment for a simulated cohort of patients with heterogeneous characteristics. The model was populated with effectiveness evidence from the systematic review and NMA. All other parameters were estimated from published sources. A NHS and Personal Social Services perspective was taken, and costs and benefits were discounted at 3.5% per annum. Fracture risk was estimated from patient characteristics using the QFracture® (QFracture-2012 open source revision 38, Clinrisk Ltd, Leeds, UK) and FRAX® (web version 3.9, University of Sheffield, Sheffield, UK) tools. The relationship between fracture risk and incremental net benefit (INB) was estimated using non-parametric regression. Probabilistic sensitivity analysis (PSA) and scenario analyses were used to assess uncertainty. RESULTS Forty-six randomised controlled trials (RCTs) were included in the clinical effectiveness systematic review, with 27 RCTs providing data for the fracture NMA and 35 RCTs providing data for the femoral neck bone mineral density (BMD) NMA. All treatments had beneficial effects on fractures versus placebo, with hazard ratios varying from 0.41 to 0.92 depending on treatment and fracture type. The effects on vertebral fractures and percentage change in BMD were statistically significant for all treatments. There was no evidence of a difference in effect on fractures between bisphosphonates. A statistically significant difference in the incidence of influenza-like symptoms was identified from the RCTs for zoledronic acid compared with placebo. Reviews of observational studies suggest that upper gastrointestinal symptoms are frequently reported in the first month of oral bisphosphonate treatment, but pooled analyses of placebo-controlled trials found no statistically significant difference. A strategy of no treatment was estimated to have the maximum INB for patients with a 10-year QFracture risk under 1.5%, whereas oral bisphosphonates provided maximum INB at higher levels of risk. However, the PSA suggested that there is considerable uncertainty regarding whether or not no treatment is the optimal strategy until the QFracture score is around 5.5%. In the model using FRAX, the mean INBs were positive for all oral bisphosphonate treatments across all risk categories. Intravenous bisphosphonates were estimated to have lower INBs than oral bisphosphonates across all levels of fracture risk when estimated using either QFracture or FRAX. LIMITATIONS We assumed that all treatment strategies are viable alternatives across the whole population. CONCLUSIONS Bisphosphonates are effective in preventing fragility fractures. However, the benefit-to-risk ratio in the lowest-risk patients may be debatable given the low absolute QALY gains and the potential for adverse events. We plan to extend the analysis to include non-bisphosphonate therapies. STUDY REGISTRATION This study is registered as PROSPERO CRD42013006883. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Sarah Davis
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Marrissa Martyn-St James
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Jean Sanderson
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - John Stevens
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Edward Goka
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Andrew Rawdin
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Susi Sadler
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ruth Wong
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Fiona Campbell
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Mark Strong
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Peter Selby
- Department of Medicine, University of Manchester, Manchester Royal Infirmary, Manchester, UK
| | - Neil Gittoes
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University Hospitals Birmingham, Birmingham, UK
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86
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Abstract
Osteoporosis in the elderly population is common. It results in more than 1.5 million fractures per year in the United States. The goal of managing osteoporosis is to prevent fractures. In men, osteoporosis is underrecognized and undertreated. More men than women die every year as a consequence of hip fractures. A review of diagnosis and treatment of osteoporosis is described in this article. Bisphosphonates are the first-line treatment for men and women. In the past several years, advances in bone biology have resulted in major therapeutic advances.
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Affiliation(s)
- Paloma Alejandro
- Division of Rheumatology, MedStar Washington Hospital Center, Georgetown University Medical Center, 110 Irving Street Northwest 2A-66, Washington, DC 20010, USA.
| | - Florina Constantinescu
- Division of Rheumatology, MedStar Washington Hospital Center, Georgetown University Medical Center, 110 Irving Street Northwest 2A-66, Washington, DC 20010, USA
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87
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Lagari V, Gavcovich T, Levis S. The Good and the Bad About the 2017 American College of Physicians Osteoporosis Guidelines. Clin Ther 2018; 40:168-176. [DOI: 10.1016/j.clinthera.2017.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 11/14/2017] [Accepted: 11/14/2017] [Indexed: 01/06/2023]
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88
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Yeh WL, Su CY, Chang CW, Chen CH, Fu TS, Chen LH, Lin TY. Surgical outcome of atypical subtrochanteric and femoral fracture related to bisphosphonates use in osteoporotic patients with or without teriparatide treatment. BMC Musculoskelet Disord 2017; 18:527. [PMID: 29237448 PMCID: PMC5729282 DOI: 10.1186/s12891-017-1878-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 11/28/2017] [Indexed: 11/19/2022] Open
Abstract
Background Atypical subtrochanteric fracture and femoral fracture have been considered to be rare complications related to long-term bisphosphonates use. A reduced bone turnover rate may lead to delayed bone healing. Limited data have revealed that teriparatide treatment may reverse the effect of bisphosphonates and be effective in bone healing. Methods We reviewed patients with atypical subtrochanteric and femoral fracture related to bisphosphonates use between January 2008 and December 2014. Thirteen female patients were enrolled. Radiographic findings were compatible with the characteristics of atypical fracture. Surgical intervention was performed for all, and teriparatide use was advised postoperatively. Outcome measures included perioperative results, and clinical and radiographic outcome. Results Of the 13 female patients enrolled, 10 had subtrochanteric and 6 had proximal femoral fracture; 3 had bilateral fractures. The mean age of the patients at surgery was 70.15±6.36 years. Most fractures (68.8%) presented prodromal thigh pain. All patients were treated with an intramedullary fixation system without severe complications. The patients were divided into 2 groups based on whether they had received treatment with teriparatide or not. The mean time to bone union was 4.4 months in the teriparatide-treated group, and 6.2 months in the non-teriparatide-treated group (p=0.116). Six patients (75%) in the teriparatide-treated group and 4 (50%) in the non-teriparatide-treated group (p= 0.3) achieved bone union within 6 months. The means of the modified Harris Hip Score and Numerical Rating Scale were significantly better in the teriparatide-treated group at postoperative 6 months. Seven patients had the same ability to walk at the 1-year follow-up as they did before the atypical fracture. Conclusions Teriparatide treatment in patients with atypical fracture may help in fracture healing, hip function recovery, and pain relief in this reduced bone turnover patient group.
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Affiliation(s)
| | | | - Chia-Wei Chang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Bone and Joint Research Center, and Chang Gung University,, Taiwan, F7, No 222 Mai-King Road, Keelung, Taiwan
| | - Chien-Hao Chen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Bone and Joint Research Center, and Chang Gung University,, Taiwan, F7, No 222 Mai-King Road, Keelung, Taiwan
| | - Tsai-Sheng Fu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Bone and Joint Research Center, and Chang Gung University,, Taiwan, F7, No 222 Mai-King Road, Keelung, Taiwan
| | - Lih-Huei Chen
- Department of Orthopedic Surgery, Division of Trauma, Chang Gung Memorial Hospital, Linkou branch, Bone and Joint Research Center and Chang Gung University, Taoyuan, Taiwan
| | - Tung-Yi Lin
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Bone and Joint Research Center, and Chang Gung University,, Taiwan, F7, No 222 Mai-King Road, Keelung, Taiwan.
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89
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Low prevalence of osteoporosis treatment in patients with recurrent major osteoporotic fracture. Arch Osteoporos 2017; 12:24. [PMID: 28251468 DOI: 10.1007/s11657-017-0317-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 02/13/2017] [Indexed: 02/03/2023]
Abstract
UNLABELLED The majority of patients do not receive anti-osteoporotic treatment following a major osteoporotic fracture, despite the guidelines and the availability of effective anti-osteoporotic treatments. The fight against factors limiting the diagnosis and treatment of osteoporosis should become a priority to improve secondary prevention after an initial osteoporotic fracture. PURPOSE Despite the availability of effective anti-osteoporotic treatments, osteoporosis management is currently insufficient. The main objective of this study was to assess the prevalence of anti-osteoporotic treatments introduced after an initial prior major osteoporotic fracture during hospitalization for recurring fractures. METHODS We conducted an observational, cross-sectional, bicentric study that included all patients aged over 50 years who were hospitalized or seen in consultation for major osteoporotic fracture. RESULTS One hundred twenty-eight out of two hundred four (62.7%) patients had a past history of major osteoporotic fracture and therefore had an indication of treatment based on guidelines. Among these patients, only 43/128 (33.5%) had received anti-osteoporotic treatment as secondary prevention after the initial fracture. The main causes of non-prescription identified were the attending physicians' ignorance of the indication of treatment (n = 30; 35.3%), ignorance of the fracture (n = 17; 20%), and comorbidities (n = 12; 14.1%). The failure to introduce treatment was associated with the presence of comorbidities with a Charlson Comorbidity Index ≥6 (OR = 0.34 [0.16-0.73], p < 0.05), dementia (OR = 0.23 [0.08-0.72], p < 0.05), and past history of proximal femur fracture (OR = 0.20 [0.04-0.91], p < 0.05). CONCLUSIONS Two thirds of patients with a past history of major osteoporotic fracture presenting with a new fracture were not treated. The main reason for lack of treatment seems to stem from the incorrect assessment of the patient's fracture risk. Although major osteoporotic fracture leads to an increased risk of mortality and requires treatment, the significance of patient comorbidities was an independent risk factor leading to non-treatment.
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90
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Compston J, Cooper A, Cooper C, Gittoes N, Gregson C, Harvey N, Hope S, Kanis JA, McCloskey EV, Poole KES, Reid DM, Selby P, Thompson F, Thurston A, Vine N. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos 2017; 12:43. [PMID: 28425085 PMCID: PMC5397452 DOI: 10.1007/s11657-017-0324-5] [Citation(s) in RCA: 517] [Impact Index Per Article: 73.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 03/07/2017] [Indexed: 02/03/2023]
Abstract
INTRODUCTION In 2008, the UK National Osteoporosis Guideline Group (NOGG) produced a guideline on the prevention and treatment of osteoporosis, with an update in 2013. This paper presents a major update of the guideline, the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women and men age 50 years or over. METHODS Where available, systematic reviews, meta-analyses and randomised controlled trials were used to provide the evidence base. Conclusions and recommendations were systematically graded according to the strength of the available evidence. RESULTS Review of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment, lifestyle measures and pharmacological interventions, duration and monitoring of bisphosphonate therapy, glucocorticoid-induced osteoporosis, osteoporosis in men, postfracture care and intervention thresholds. CONCLUSION The guideline, which has received accreditation from the National Institute of Health and Care Excellence (NICE), provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals who are involved in its management.
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Affiliation(s)
- J. Compston
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - A. Cooper
- Crawley Fracture Liaison Service, Crawley, Sussex, UK
| | - C. Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - N. Gittoes
- University Hospitals Birmingham NHS Foundation Trust, Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham & Birmingham Health Partners, Birmingham, UK
| | - C. Gregson
- Musculoskeletal Research Unit, University of Bristol and Royal United Hospital NHS Foundation Trust, Bath, UK
| | - N. Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - S. Hope
- Metabolic Bone, Nuffield Orthopaedic Hospital, Oxford, UK
| | - J. A. Kanis
- Centre for Metabolic Diseases, University of Sheffield Medical School, Sheffield, UK
| | | | - K. E. S. Poole
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - D. M. Reid
- Emeritus Professor of Rheumatology, University of Aberdeen, Aberdeen, UK
| | - P. Selby
- Metabolic Bone Disease, University of Manchester, Manchester, UK
| | | | | | - N. Vine
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - The National Osteoporosis Guideline Group (NOGG)
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
- Crawley Fracture Liaison Service, Crawley, Sussex, UK
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- University Hospitals Birmingham NHS Foundation Trust, Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham & Birmingham Health Partners, Birmingham, UK
- Musculoskeletal Research Unit, University of Bristol and Royal United Hospital NHS Foundation Trust, Bath, UK
- Metabolic Bone, Nuffield Orthopaedic Hospital, Oxford, UK
- Centre for Metabolic Diseases, University of Sheffield Medical School, Sheffield, UK
- Metabolic Bone, University of Sheffield, Sheffield, UK
- Emeritus Professor of Rheumatology, University of Aberdeen, Aberdeen, UK
- Metabolic Bone Disease, University of Manchester, Manchester, UK
- National Osteoporosis Society, Camerton, UK
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91
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Mignot MA, Taisne N, Legroux I, Cortet B, Paccou J. Bisphosphonate drug holidays in postmenopausal osteoporosis: effect on clinical fracture risk. Osteoporos Int 2017; 28:3431-3438. [PMID: 28875236 DOI: 10.1007/s00198-017-4215-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 08/29/2017] [Indexed: 01/08/2023]
Abstract
UNLABELLED A cohort of 183 postmenopausal women, who had either discontinued or continued bisphosphonates (BPs) after first-line therapy, was used to investigate the relationships between "drug holiday" and clinical fracture. The risk of new clinical fractures was found to be 40% higher in women who had taken a BP "drug holiday." INTRODUCTION BPs are the most widely used treatment for postmenopausal osteoporosis. The optimal treatment duration, however, remains unclear. The purpose of this study was to evaluate the fracture risk in postmenopausal women with osteoporosis after discontinuing BP treatment (BP "drug holiday"). METHODS A retrospective analysis was performed at Lille University Hospital (LUH) on postmenopausal women with osteoporosis who had taken a "drug holiday" or continued treatment after first-line BP therapy (3 to 5 years). The occurrence of new clinical fractures during follow-up was also explored. Cox proportional hazards models were used to investigate the relationships between BP "drug holiday" and the occurrence of clinical fractures, while controlling for confounding factors. Survival without new clinical fractures was analyzed using Kaplan-Meier curves and log-rank tests. RESULTS One hundred eighty-three women (mean age: 61.8 years; SD: 8.7) who had previously undergone BP treatment for 3 to 5 years were enrolled in our study. The patients had received alendronate (n = 81), risedronate (n = 73), zoledronic acid (n = 20), and ibandronate (n = 9). In 166 patients ("drug holiday" group: n = 31; continuous-treatment group: n = 135), follow-up ranged from 6 to 36 months (mean duration: 31.8 months; SD: 8.2). The incidences of new clinical fractures during follow-up were 16.1% (5/31) and 11.9% (16/135). After full adjustment, the hazard ratio of new clinical fractures among "drug holiday" patients was 1.40 (95% CI: 1.12-1.60; p = 0.0095). CONCLUSIONS After first-line BP therapy in postmenopausal women with osteoporosis, the risk of new clinical fractures was 40% higher in subjects who took a bisphosphonate drug holiday.
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Affiliation(s)
- M A Mignot
- Department of Rheumatology, Lille University Hospital, Rue Emile Laine, 59037, Lille, France
| | - N Taisne
- Department of Rheumatology, Lille University Hospital, Rue Emile Laine, 59037, Lille, France
| | - I Legroux
- Department of Rheumatology, Lille University Hospital, Rue Emile Laine, 59037, Lille, France
- Lille University - ULCO, PMOI, EA 4490, 59000, Lille, France
| | - B Cortet
- Department of Rheumatology, Lille University Hospital, Rue Emile Laine, 59037, Lille, France
- Lille University - ULCO, PMOI, EA 4490, 59000, Lille, France
| | - J Paccou
- Department of Rheumatology, Lille University Hospital, Rue Emile Laine, 59037, Lille, France.
- Lille University - ULCO, PMOI, EA 4490, 59000, Lille, France.
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92
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Eastell R, Szulc P. Use of bone turnover markers in postmenopausal osteoporosis. Lancet Diabetes Endocrinol 2017; 5:908-923. [PMID: 28689768 DOI: 10.1016/s2213-8587(17)30184-5] [Citation(s) in RCA: 297] [Impact Index Per Article: 42.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 05/07/2017] [Accepted: 05/08/2017] [Indexed: 12/30/2022]
Abstract
Bone turnover comprises two processes: the removal of old bone (resorption) and the laying down of new bone (formation). N-terminal propeptide of type I procollagen (PINP) and C-telopeptide of type I collagen (CTX-I) are markers of bone formation and resorption, respectively, that are recommended for clinical use. Bone turnover markers can be measured on several occasions in one individual with good precision. However, these markers are subject to several sources of variability, including feeding (resorption decreases) and recent fracture (all markers increase for several months). Bone turnover markers are not used for diagnosis of osteoporosis and do not improve prediction of bone loss or fracture within an individual. In untreated women, very high bone turnover marker concentrations suggest secondary causes of high bone turnover (eg, bone metastases or multiple myeloma). In people with osteoporosis, bone turnover markers might be useful to assess the response to anabolic and antiresorptive therapies, to assess compliance to therapy, or to indicate possible secondary osteoporosis. Much remains to be learnt about how bone turnover markers can be used to monitor the effect of stopping bisphosphonate therapy (eg, to identify a threshold above which restarting therapy should be considered). More studies are needed to investigate the use of bone turnover markers for assessment of the bone safety of new medications.
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Affiliation(s)
- Richard Eastell
- Academic Unit of Bone Metabolism, University of Sheffield, Sheffield, UK.
| | - Pawel Szulc
- INSERM UMR 1033, University of Lyon, Hôpital Edouard Herriot, Lyon, France
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93
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LeBlanc ES, Rosales AG, Black DM, Genant HK, Dell RM, Friess DM, Boardman DL, Bauer DC, de Papp A, Santora AC, Orwoll ES. Evaluating Atypical Features of Femur Fractures: How Change in Radiological Criteria Influenced Incidence and Demography of Atypical Femur Fractures in a Community Setting. J Bone Miner Res 2017; 32:2304-2314. [PMID: 28731209 DOI: 10.1002/jbmr.3221] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 07/11/2017] [Accepted: 07/13/2017] [Indexed: 11/11/2022]
Abstract
Identification of atypical femoral fractures (AFFs) can be challenging. To assist in the radiological assessment, an American Society for Bone and Mineral Research (ASBMR) Task Force developed a case definition for AFFs in 2010, revising it in 2013. How the revised definition performs in a community setting compared with the 2010 definition is unknown. We applied the 2013 criteria to 372 femoral fractures that occurred between January 1, 1996, and June 30, 2009, employing two independent expert physician reviewers. We used radiographs that had been categorized in a previous study on the incidence of atypical fractures using 2010 ASMBR criteria (BEAK1). In this follow-up study (BEAK2), the same reviewers reviewed all previously identified femoral shaft fractures (FSFs) (n = 197) and distal femur fractures (n = 131) plus a 15% random sample of intertrochanteric fractures (n = 49). After initial review, agreement between the two reviewers ranged from 63% to 100% for specific features, and 84% of radiographs received the same overall classification. Fewer fractures met the 2013 compared with 2010 ASMBR case definition of AFFs (37 per 2013 criteria versus 74 per 2010 criteria). Forty-three radiographs (58%) categorized as AFFs according to 2010 criteria were no longer AFFs when 2013 criteria were applied, and an additional 12 non-atypical FSFs according to 2010 criteria were reclassified as AFFs according to 2013 criteria. The major cause of AFF reclassification was the change in the definition of transverse configuration. The modification of the comminution, non-traumatic, and periosteal/endosteal thickness criteria resulted in the reclassification of non-atypical FSFs to AFFs. Incidence rate of AFFs according to 2013 ASBMR criteria was lower overall during the 13 years of observation than when the 2010 ASBMR criteria were applied, although we saw a slight increase starting in 2000. As in BEAK1, we found that those with AFFs were younger, more often female, and had a higher exposure rate to bisphosphonates than those with non-atypical FSFs. As we continue to unravel the demographics of those who suffer from AFFs, our study adds information about how the change in criteria influences epidemiological work. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
- Erin S LeBlanc
- Kaiser Permanente Center for Health Research, Portland, OR, USA
| | | | - Dennis M Black
- University of California San Francisco (UCSF), San Francisco, CA, USA
| | - Harry K Genant
- University of California San Francisco (UCSF), San Francisco, CA, USA
| | | | - Darin M Friess
- Oregon Health & Science University (OHSU), Portland, OR, USA
| | | | - Douglas C Bauer
- University of California San Francisco (UCSF), San Francisco, CA, USA
| | | | | | - Eric S Orwoll
- Oregon Health & Science University (OHSU), Portland, OR, USA
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94
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Bhat SB, Ilyas AM. Economic Analysis of Bisphosphonate Use after Distal Radius Fracture for Prevention of Hip Fracture. THE ARCHIVES OF BONE AND JOINT SURGERY 2017; 5:380-383. [PMID: 29299492 PMCID: PMC5736886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 04/13/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Osteoporosis is a common condition among the elderly population, and is associated with an increased risk of fracture. One of the most common fragility fractures involve the distal radius, and are associated with risk of subsequent fragility fracture. Early treatment with bisphosphonates has been suggested to decrease the population hip fracture burden. However, there have been no prior economic evaluations of the routine treatment of distal radius fracture patients with bisphosphonates, or the implications on hip fracture rate reduction. METHODS Age specific distal radius fracture incidence, age specific hip fracture rates after distal radius fracture with and without risendronate treatment, cost of risendronate treatment, risk of atypical femur fracture with bisphosphonate treatment, and cost of hip fracture treatment were obtained from the literature. A unique stochastic Markov chain decision tree model was constructed from derived estimates. The results were evaluated with comparative statistics, and a one-way threshold analysis performed to identify the break-even cost of bisphosphonate treatment. RESULTS Routine treatment of the current population of all women over the age of 65 suffering a distal radius fracture with bisphosphonates would avoid 94,888 lifetime hip fractures at the cost of 19,464 atypical femur fractures and $19,502,834,240, or on average $2,186,617,527 annually, which translates to costs of $205,534 per hip fracture avoided. The breakeven price point of annual bisphosphonate therapy after distal radius fracture for prevention of hip fractures would be approximately $70 for therapy annually. CONCLUSION Routine treatment of all women over 65 suffering distal radius fracture with bisphosphonates would result in a significant reduction in the overall hip fracture burden, however at a substantial cost of over a $2 billion dollars annually. To optimize efficiency of treatment either patients may be selectively treated, or the cost of annual bisphosphonate treatment should be reduced to cost-effective margins.
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Affiliation(s)
- Suneel B Bhat
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Asif M Ilyas
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
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95
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Nakata E, Sugihara S, Yamashita N, Osumi S. The incidence of atypical femoral fractures in breast cancer patients with bone metastases who received bisphosphonate treatment. J Orthop Sci 2017; 22:946-950. [PMID: 28549530 DOI: 10.1016/j.jos.2017.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/26/2017] [Accepted: 04/30/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Atypical femoral fractures (AFFs) have been reported to occur in patients with bone metastases who received long-term bisphosphonate treatment. However, the incidence of AFFs in breast cancer patients with bone metastases who received intravenous bisphosphonate is unclear. The purpose of this study is to examine the incidence of AFFs in breast cancer patients with bone metastases who received intravenous bisphosphonate. In addition, we estimated the number of dose and duration of intravenous bisphosphonate at the time of occurrence of AFFs. METHODS We identified 356 female breast cancer patients with bone metastases who received intravenous bisphosphonate between November 2004 and October 2013 in our institution. The median number of doses of intravenous bisphosphonate was 18 (range, 1-103). The median duration of intravenous bisphosphonate treatment was 16 months (range, 1-102 months). We estimated the incidence of AFFs in patients who received intravenous bisphosphonate and used Poisson regression model to obtain the incidence rates of AFFs. RESULTS Three AFFs in two patients were identified and the estimated incidence of AFFs was 2.99 per 1000 person-years. At the time of occurrence of AFFs, the patients had received 41 and 83 doses of intravenous bisphosphonate, for 37 and 79 months, respectively. The patients underwent open reduction and internal fixation with intramedullary nail. The frequency and incidence of AFFs in patients who received intravenous bisphosphonate for at least 41 or 83 doses or for more than 37 or 79 months were 2/60 (3.3%), 1/7 (14.3%), 2/70 (2.9%), and 1/9 (11.1%), respectively. CONCLUSIONS The incidence of AFFs is low in breast cancer patients with bone metastases who received intravenous bisphosphonate. Careful observation is warranted and radiography should be performed to investigate AFFs when clinical signs such as thigh pain appear. STUDY DESIGN Clinical study.
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Affiliation(s)
- Eiji Nakata
- Department of Orthopedic Surgery, Shikoku Cancer Center, Ko-160, Minamiumemoto-cho, Matsuyama City, 791-0280, Ehime, Japan.
| | - Shinsuke Sugihara
- Department of Orthopedic Surgery, Shikoku Cancer Center, Ko-160, Minamiumemoto-cho, Matsuyama City, 791-0280, Ehime, Japan.
| | | | - Shozo Osumi
- Department of Breast Oncology, Shikoku Cancer Center, Japan.
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96
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Lateral Cortical Thickening and Bone Heterogeneity of the Subtrochanteric Femur Measured With Quantitative CT as Indicators for Early Detection of Atypical Femoral Fractures in Long-Term Bisphosphonate Users. AJR Am J Roentgenol 2017; 209:867-873. [PMID: 28796551 DOI: 10.2214/ajr.17.17938] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of our study was to compare subtrochanteric femur bone mineral density (BMD) and bone quality of long-term bisphosphonate (BP) users who sustained an atypical femoral fracture (AFF) with BP users who did not sustain a femoral fracture and BP-naïve patients with no history of femoral fracture using quantitative CT (QCT). MATERIALS AND METHODS Fourteen female BP users with an AFF (mean age, 72.6 years; mean duration of BP use, 6.2 years; mean body mass index, 21.9) who had undergone QCT before fracture events were sex-, age-, BP use duration-, and body mass index-matched to 14 BP users who did not sustain a fracture and 14 BP-naïve patients. The lateral cortical thickness index (CTI) and the mean BMD (BMDmean) and SD of the BMD (BMDSD) within the lateral cortex and within the entire cross-sectional area of the subtrochanteric femur were measured on axial QCT. Femoral neck-shaft angles were measured on the QCT scout image. Parameters were analyzed using the Kruskal-Wallis test. RESULTS Lateral CTIs were greater in the BP users with an AFF (median, 0.28) than in the BP users without a femoral fracture (median, 0.21) (p = 0.038) and the BP-naïve group (median, 0.21) (p = 0.009). The lateral cortex BMDSD was significantly higher in the BP users with an AFF (median, 59.59 mg/cm3) than the BP users without a femoral fracture (median, 39.27 mg/cm3; p = 0.049) and the BP-naïve group (median, 31.02 mg/cm3; p = 0.037). There was no significant difference among groups in lateral cortex BMDmean, BMDmean and BMDSD of the entire cross-sectional area, and femoral neck-shaft angle. CONCLUSION Long-term BP users with a subsequent AFF had a thicker lateral cortex and higher lateral cortex BMDSD at the subtrochanteric area before the fracture on QCT than BP users who did not sustain a femoral fracture and BP-naïve patients.
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97
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Shin MS, Cho EH, Kim HY. Longitudinal Change in Trabecular Bone Score during and after Treatment of Osteoporosis in Postmenopausal Korean Women. J Bone Metab 2017; 24:117-124. [PMID: 28642856 PMCID: PMC5472798 DOI: 10.11005/jbm.2017.24.2.117] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 05/24/2017] [Accepted: 05/24/2017] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The aim of this study was to evaluate the longitudinal changes of trabecular bone score (TBS) during and after bisphosphonate (BP) treatment in postmenopausal Korean women with osteoporosis. METHODS We analyzed 191 patients who took BP and underwent bone mineral density (BMD) test for the period from January 2010 to December 2015. The mean follow up period during treatment and after treatment was 22.8 months and 18 months, respectively. The TBS and BMD values were evaluated by the percent changes relative to the baseline. RESULTS In 191 patients, who treated with BPs, L-spine BMD increased 3.65±0.5% and TBS increased 0.26±0.4% from baseline during first 1 year. At 2 to 4 years, the changes of BMD and TBS from baseline gradually increased up to 9.3±3.25% and 2.69±0.98% and both results showed statistically significant correlation. In 86 patients who stopped BPs, L-spine BMD decreased -0.54±1.07% and TBS increased 0.33±1.96% from baseline during 3 years follow up period. CONCLUSIONS Lumbar spine TBS increase over time with BPs treatment although the changes were less than that of BMD. Also, it preserve for years after stopping treatment, as the changes of lumbar spine BMD. The results of BMD and TBS showed significant correlation during treatment but not during drug withdrawal.
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Affiliation(s)
- Mi-Seon Shin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Hanil General Hospital, Seoul, Korea
| | - Eun-Hee Cho
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon, Korea
| | - Ha Young Kim
- Department of Internal Medicine, Wonkwang University Sanbon Hospital, Gunpo, Korea
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98
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Anagnostis P, Paschou SA, Mintziori G, Ceausu I, Depypere H, Lambrinoudaki I, Mueck A, Pérez-López FR, Rees M, Senturk LM, Simoncini T, Stevenson JC, Stute P, Trémollieres FA, Goulis DG. Drug holidays from bisphosphonates and denosumab in postmenopausal osteoporosis: EMAS position statement. Maturitas 2017; 101:23-30. [PMID: 28539165 DOI: 10.1016/j.maturitas.2017.04.008] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Bisphosphonates and denosumab are used extensively in the treatment of postmenopausal osteoporosis. Despite their proven efficacy in the reduction of vertebral and non-vertebral fractures, their optimal duration of use has not been determined. The occurrence of adverse effects, such as osteonecrosis of the jaw (ONJ) and atypical femoral fractures (AFF), has raised the issue of bisphosphonate or denosumab discontinuation ("drug holiday") after a certain treatment period. AIM To assess the effect of bisphosphonate and denosumab discontinuation on fracture risk, as well as its possible benefits in reducing the risk of adverse effects. METHODS Systematic review and consensus of expert opinion. RESULTS AND CONCLUSIONS Discontinuation of bisphosphonates should be considered in all patients who have beentreated for more than five years with alendronate, risedronate or zoledronic acid. In view of the limited evidence, no robust recommendations can be made for ibandronate and denosumab. If the patient has not experienced fractures before or during therapy and the fracture risk is low, a "drug holiday" canbe recommended. Although there is no solid evidence, 1-2 years for risedronate, 3-5 years for alendronate and 3-6 years for zoledronic acid are suggested. After this time, the patient should be reassessed. If a new fracture is experienced, or fracture risk has increased or BMD remains low (femoral neck T-score ≤-2.5), anti-osteoporotic treatment should be resumed. In the case of denosumab discontinuation, close monitoring is suggested, due to the possibility of rebound fractures.
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Affiliation(s)
- Panagiotis Anagnostis
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Greece.
| | - Stavroula A Paschou
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Greece
| | - Gesthimani Mintziori
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Greece
| | - Iuliana Ceausu
- Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, and Department of Obstetrics and Gynecology, 'Dr. I. Cantacuzino' Hospital, Bucharest, Romania
| | - Herman Depypere
- Breast Clinic and Menopause Clinic, University Hospital, De Pintelaan 185, 9000 Gent, Belgium
| | - Irene Lambrinoudaki
- Second Department of Obstetrics and Gynecology, National and Kapodestrian University of Athens, Greece
| | - Alfred Mueck
- University Women's Hospital of Tuebingen,Calwer Street 7, 72076 Tuebingen, Germany
| | - Faustino R Pérez-López
- Department of Obstetrics and Gynecology, Zaragoza University Faculty of Medicine, Lozano-Blesa University Hospital, Zaragoza 50009, Spain
| | - Margaret Rees
- Women's Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Levent M Senturk
- Istanbul University Cerrahpasa School of Medicine, Dept. of Obstetrics and Gynecology, Division of Reproductive Endocrinology, IVF Unit, Istanbul, Turkey
| | - Tommaso Simoncini
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56100, Pisa, Italy
| | - John C Stevenson
- National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, London SW3 6NP, UK
| | - Petra Stute
- Department of Obstetrics and Gynecology, University Women's Hospital, Bern, Switzerland
| | - Florence A Trémollieres
- Menopause and Metabolic Bone Disease Unit, Hôpital Paule de Viguier, CHU Toulouse, Toulouse, France
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Greece
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99
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Abstract
PURPOSE OF THE REVIEW The purposes of this study are to examine the literature within the past 5 years regarding osteoporosis and offer a discussion on new topics and controversies. RECENT FINDINGS Patient compliance with therapy remains an issue. The effectiveness of Vitamin D and calcium are being called into question Atypical femur fractures have been associated with bisphosphonate and denosumab use. Treatment is both surgical and pharmaceutical. A multidisciplinary approach to osteoporotic fractures is important and having some form of fracture liaison service (FLS) improves the efficacy of osteoporotic care and decreases secondary fractures. Screening for osteoporosis remains low. Ultrasound may be cost-effective for diagnosis. Understanding of osteoporosis has come a long way in the medical community, but the translation to the lay community has lagged behind. Patients often take a laissez-faire attitude toward osteoporosis that can affect compliance. Information read by patients often focuses on complications, such as atypical femur fractures and myocardial infarctions. It is essential for providers to be able to discuss these issues with patients. Newer medications and more cost-effective diagnostic tests exist, but availability may be limited. FLS are effective, but the most cost-effective model for therapy still eludes us. Areas for further investigation include FLS models, the effectiveness of vitamin supplementation, and more ubiquitous and cost-effective diagnostic tools.
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Affiliation(s)
- Kyle M Schweser
- Department of Orthopaedic Surgery, University of Missouri, N116, One Hospital Dr, Columbia, MO, 65212, USA
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, N116, One Hospital Dr, Columbia, MO, 65212, USA.
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Vuorimies I, Mäyränpää MK, Valta H, Kröger H, Toiviainen-Salo S, Mäkitie O. Bisphosphonate Treatment and the Characteristics of Femoral Fractures in Children With Osteogenesis Imperfecta. J Clin Endocrinol Metab 2017; 102:1333-1339. [PMID: 28323993 DOI: 10.1210/jc.2016-3745] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 01/12/2017] [Indexed: 01/08/2023]
Abstract
CONTEXT The short-term benefits of bisphosphonates (BPs) are evident in the treatment of children with osteogenesis imperfecta (OI), but some concerns related to long-term effects remain. OBJECTIVE To elucidate the effect of BPs on characteristics of femoral fractures in children with OI. DESIGN AND SETTING Retrospective cohort study at a university hospital. PATIENTS AND MAIN OUTCOME MEASURE The study included 93 patients with OI. We recorded fracture histories and analyzed all femoral fractures for location and fracture type using radiographs obtained at fracture diagnosis. Effects of BPs were evaluated by comparing fracture characteristics in three groups: patients (1) naive to BPs, (2) receiving ongoing BP treatment, and (3) whose treatment was discontinued. RESULTS In total, 127 femoral fractures occurred in 24 patients. Of the fractures, 63 (50%) occurred in patients naive to BPs, 44 (35%) during BP treatment, and 20 (16%) after treatment discontinuation. Mid or distal shaft fractures were most common (41%), followed by subtrochanteric (33%) and distal (20%) fractures. Almost all fractures were transverse (65%) or oblique (28%). The pattern of femoral fractures was similar in all three BP treatment groups (P = 0.78 for location; P = 0.35 for fracture type) and was not related to cumulative BP dose. Instead, OI type correlated with fracture characteristics, and distal location and transverse configuration were more common in the more severe types III and IV compared with type I OI. CONCLUSION Characteristics of femoral fractures in children with OI are affected by OI type but not by BP exposure.
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Affiliation(s)
- Ilkka Vuorimies
- Children's Hospital and
- Folkhälsan Institute of Genetics, 00029 Helsinki, Finland
| | - Mervi K Mäyränpää
- Department of Pediatric Radiology, Helsinki Medical Imaging Center, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
| | | | - Heikki Kröger
- Bone and Cartilage Research Unit, University of Eastern Finland and Kuopio University Hospital, 70029 Kuopio, Finland
| | - Sanna Toiviainen-Salo
- Department of Pediatric Radiology, Helsinki Medical Imaging Center, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
| | - Outi Mäkitie
- Children's Hospital and
- Folkhälsan Institute of Genetics, 00029 Helsinki, Finland
- Center for Molecular Medicine, Karolinska Institutet, and Clinical Genetics, Karolinska University Hospital, 17176 Stockholm, Sweden
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