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Messina OD, Vidal LF, Wilman MV, Bultink IEM, Raterman HG, Lems W. Management of glucocorticoid-induced osteoporosis. Aging Clin Exp Res 2021; 33:793-804. [PMID: 33751462 DOI: 10.1007/s40520-021-01823-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 02/19/2021] [Indexed: 12/19/2022]
Abstract
Long-term glucocorticoid (GC) therapy is frequently indicated to treat autoimmune and chronic inflammatory diseases in daily clinical practice. Two of the most devastating untoward effects are bone loss and fractures. Doses as low as 2.5 mg of prednisone for more than 3 months can impair bone integrity. Population at risk is defined based on the dose and duration of GC therapy and should be stratified according to FRAX (Fracture Risk Assessment Tool), major osteoporotic fracture, prior fractures, and bone mineral density values (BMD). General measures include to prescribe the lowest dose of GC to control the underlying disease for the shortest possible time, maintain adequate vitamin D levels and calcium intake, maintain mobility, and prescribe a bone acting agent in patients at high risk of fracture. These agents include oral and intravenous bisphosphonates, denosumab, and teriparatide.
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Fiani B, Newhouse A, Sarhadi KJ, Arshad M, Soula M, Cathel A. Special Considerations to Improve Clinical Outcomes in Patients with Osteoporosis Undergoing Spine Surgery. Int J Spine Surg 2021; 15:386-401. [PMID: 33900998 PMCID: PMC8059385 DOI: 10.14444/8050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Osteoporosis is a condition that is commonly encountered, with increasing diagnosis by the medical community with the aging population. Osteoporosis leaves patients susceptible to fragility fractures in the vertebrae and is also associated with degenerative changes, both of which may require intervention from a spine surgeon. The goal of this review is to concisely outline special nonoperative adjuncts, as well as preoperative, intraoperative, and postoperative considerations of osteoporotic patients undergoing spine intervention. METHODS A literature analysis was completed for this narrative review. A database search of PubMed and Google Scholar was conducted using "osteoporosis" combined with "spine," "spine surgery," and "spinal fusion" without exclusion based on publication date. Articles were screened to exclude duplicate articles and screened for their full text and English language availability. RESULTS The database search yielded recent publications from which the narrative review was completed. CONCLUSIONS Preoperatively, screening is traditionally completed with dual-energy x-ray absorptiometry (DEXA). Pharmacological therapy modalities currently include teriparatide, raloxifene, denosumab, bisphosphonates, and calcitonin. In order to prevent operative complications associated with osteoporosis, surgeons have found success in increasing the diameter and the length of pedicle screws, limiting pedicle tapping, achieving bicortical or even tricortical purchase, augmenting with polymethyl methacrylate, using iliosacral stabilization, preventing positive sagittal balance, and using adequate fusion products when necessary. Postoperatively, it is important to implant a care plan that includes adequate pain control and necessary care, and to understand risks associated with falls may increase risk of postoperative fragility fractures as well as instrumentation displacement. At this time there are no recommendations in regard to bracing in the postoperative setting. CLINICAL RELEVANCE This review article outlines the most current evidence-based medicine with regard to considerations in spine surgery of the osteoporotic patient, and aims to bring about new questions to be investigated in that paradigm.
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Affiliation(s)
- Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California
| | - Alexander Newhouse
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | | | - Mohammad Arshad
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California
| | - Marisol Soula
- New York University School of Medicine, New York University, New York, New York
| | - Alessandra Cathel
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California
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Belaya ZE, Rozhinskaya LY, Grebennikova TA, Kanis JA, Pigarova EA, Rodionova SS, Toroptsova NV, Nikitinskaya OA, Skripnikova IA, Drapkina OМ, Ershova OV, Biryukova EV, Lesnyak OМ, Tsoriev TТ, Belova KY, Marchenkova LА, Dzeranova LK, Dreval’ AV, Mamedova EO, Tkacheva ON, Dudinskaya EN, Nikankina LV, Farba LY, Chernova TO, Yureneva SV, Yakushevskaya OV, Ilyukhina OB, Kryukova IV, Tarbaeva NV, Petryaykin AV, Zagorodniy NV, Mel’nichenko GА, Dedov II. Summary of the draft federal clinical guidelines for osteoporosis. ACTA ACUST UNITED AC 2021. [DOI: 10.14341/osteo12710] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A summary of the draft federal clinical guidelines on osteoporosis developed by members of the Russian Association of Endocrinologists, the Russian Association for Osteoporosis, the Association of Rheumatologists of Russia, the Association of Traumatologists and Orthopedists of Russia, the Russian Association for Menopause and the Russian Association of Gerontologists and Geriatrics is presented. The recommendations were developed from the perspective of evidence-based medicine, in accordance with the requirements for compiling clinical recommendations of the Ministry of Health of Russia published in 2019. A significant place is given to screening of primary osteoporosis in adults, differential diagnosis with other metabolic diseases of the skeleton, modern methods of diagnosing osteoporosis, principles of prescribing pathogenetic treatment, features of sequential and combination therapy, disease prevention and rehabilitation. Clinical recommendations will be useful both to general practitioners and physicians, as well as to narrow specialists, primarily endocrinologists, rheumatologists, orthopedic traumatologists, nephrologists, obstetrician-gynecologists and neurologists, since osteoporosis is a multifactorial and multidisciplinary disease.
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Affiliation(s)
| | | | | | - John A. Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield; Catholic University of Australia, Melbourne
| | | | | | | | | | | | | | | | - Elena V. Biryukova
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov
| | - Olga М. Lesnyak
- North-Western State Medical University named after I.I. Mechnikov
| | | | - Kseniya Y. Belova
- Yaroslavl State Medical University; Clinical emergency hospital named. N. V. Soloviev
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Alexey V. Petryaykin
- Scientific and Practical Clinical Center for Diagnostics and Telemedicine Technologies of the Moscow Department of Health
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Hayes KN, Baschant U, Hauser B, Burden AM, Winter EM. When to Start and Stop Bone-Protecting Medication for Preventing Glucocorticoid-Induced Osteoporosis. Front Endocrinol (Lausanne) 2021; 12:782118. [PMID: 34975756 PMCID: PMC8715727 DOI: 10.3389/fendo.2021.782118] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/19/2021] [Indexed: 01/28/2023] Open
Abstract
Glucocorticoid-induced osteoporosis (GIOP) leads to fractures in up to 40% of patients with chronic glucocorticoid (GC) therapy when left untreated. GCs rapidly increase fracture risk, and thus many patients with anticipated chronic GC exposures should start anti-osteoporosis pharmacotherapy to prevent fractures. In addition to low awareness of the need for anti-osteoporosis therapy among clinicians treating patients with GCs, a major barrier to prevention of fractures from GIOP is a lack of clear guideline recommendations on when to start and stop anti-osteoporosis treatment in patients with GC use. The aim of this narrative review is to summarize current evidence and provide considerations for the duration of anti-osteoporosis treatment in patients taking GCs based on pre-clinical, clinical, epidemiologic, and pharmacologic evidence. We review the pathophysiology of GIOP, outline current guideline recommendations on initiating and stopping anti-osteoporosis therapy for GIOP, and present considerations for the duration of anti-osteoporosis treatment based on existing evidence. In each section, we illustrate major points through a patient case example. Finally, we conclude with proposed areas for future research and emerging areas of interest related to GIOP clinical management.
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Affiliation(s)
- Kaleen N. Hayes
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States
| | - Ulrike Baschant
- Division of Endocrinology, Diabetes and Bone Diseases, Department of Medicine III and Center for Healthy Aging, Technische Universität Dresden, Dresden, Germany
- *Correspondence: Ulrike Baschant,
| | - Barbara Hauser
- Rheumatic Disease Unit, Western General Hospital, National Health Service (NHS) Lothian, Edinburgh, United Kingdom
- Rheumatology and Bone Disease Unit, Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Andrea M. Burden
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, Swiss Federal Institute of Technology [Eidgenössische Technische Hochschule (ETH)] Zurich, Zurich, Switzerland
| | - Elizabeth M. Winter
- Center for Bone Quality, Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, Netherlands
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Lee TH, Song YJ, Kim H, Sung YK, Cho SK. Intervention Thresholds for Treatment in Patients with Glucocorticoid-Induced Osteoporosis: Systematic Review of Guidelines. J Bone Metab 2020; 27:247-259. [PMID: 33317228 PMCID: PMC7746480 DOI: 10.11005/jbm.2020.27.4.247] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/26/2020] [Indexed: 01/27/2023] Open
Abstract
Background In this study, we aimed to evaluate and compare the treatment indication for patients with glucocorticoid-induced osteoporosis (GIOP) in various clinical practice guidelines. Methods We searched for potentially relevant studies conducted from January 2000 to March 2020 using online databases, including PubMed, Ovid-EMBASE, Guidelines International Network, National Institute for Health and Clinical Excellence, KoreaMed, KMbase, and KoMGI. We reviewed and analyzed the guidelines that included recommendations on GIOP and fulfilled the inclusion criteria. Results A total of 94 articles were selected based on review of the title and abstract; 14 guidelines were assessed upon reviewing the full text. The bone mineral density score for therapeutic intervention of GIOP in postmenopausal women was presented in 7 guidelines, among which 3 guidelines set a T-score of −2.5 or lower and the other 4 guidelines proposed a less stringent cut-off point of −1.5 or lower. Among the 10 guidelines published since 2012 after the emergence of the fracture risk assessment tool (FRAX), 6 guidelines included FRAX in their criteria for defining intervention thresholds. However, they were further divided into fixed-probability (n=3) and age-dependent (n=3) thresholds based on the country. Conclusions Recently developed guidelines use FRAX as the criterion for establishing the treatment of patients with GIOP. However, these intervention thresholds need to be adapted for each country.
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Affiliation(s)
- Tae-Han Lee
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Yeo-Jin Song
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Hyoungyoung Kim
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Yoon-Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Soo-Kyung Cho
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
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Xia J, Xie SY, Liu KQ, Xu L, Zhao PP, Gai SR, Guan PL, Zhao JQ, Zhu YP, Tsoi LC, Stuart PE, Nair RP, Yang HQ, Liao YT, Mao K, Qiu MC, Ying ZM, Hu B, Yang ZH, Bai WY, Zhu XW, Cong PK, Elder JT, Ye ZM, Wang B, Zheng HF. Systemic evaluation of the relationship between psoriasis, psoriatic arthritis and osteoporosis: observational and Mendelian randomisation study. Ann Rheum Dis 2020; 79:1460-1467. [PMID: 32737104 PMCID: PMC7970448 DOI: 10.1136/annrheumdis-2020-217892] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/28/2020] [Accepted: 06/29/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVES AND METHODS With 432 513 samples from UK Biobank dataset, multivariable linear/logistic regression were used to estimate the relationship between psoriasis/psoriatic arthritis (PsA) and estimated bone mineral density (eBMD)/osteoporosis, controlling for potential confounders. Here, confounders were set in three ways: model0 (including age, height, weight, smoking and drinking), model1 (model0 +regular physical activity) and model2 (model1 +medication treatments). The eBMD was derived from heel ultrasound measurement. And 4904 patients with psoriasis and 847 patients with PsA were included in final analysis. Mendelian randomisation (MR) approach was used to evaluate the causal effect between them. RESULTS Lower eBMD were observed in patients with PsA than in controls in both model0 (β-coefficient=-0.014, p=0.0006) and model1 (β-coefficient=-0.013, p=0.002); however, the association disappeared when conditioning on treatment with methotrexate or ciclosporin (model2) (β-coefficient=-0.005, p=0.28), mediation analysis showed that 63% of the intermediary effect on eBMD was mediated by medication treatment (p<2E-16). Patients with psoriasis without arthritis showed no difference of eBMD compared with controls. Similarly, the significance of higher risk of osteopenia in patients with PsA (OR=1.27, p=0.002 in model0) could be eliminated by conditioning on medication treatment (p=0.244 in model2). Psoriasis without arthritis was not related to osteopenia and osteoporosis. The weighted Genetic Risk Score analysis found that genetically determined psoriasis/PsA were not associated with eBMD (p=0.24 and p=0.88). Finally, MR analysis showed that psoriasis/PsA had no causal effect on eBMD, osteoporosis and fracture. CONCLUSIONS The effect of PsA on osteoporosis was secondary (eg, medication) but not causal. Under this hypothesis, psoriasis without arthritis was not a risk factor for osteoporosis.
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Affiliation(s)
- Jiangwei Xia
- Diseases & Population (DaP) Geninfo Lab, School of Life Sciences, Westlake University, 18 Shilongshan Road, Hangzhou, Zhejiang, 310024, China,Instituteof Basic Medical Sciences, Westlake Institute for Advanced Study, 18 Shilongshan Road, Hangzhou, Zhejiang, 310024, China
| | - Shu-Yang Xie
- Binzhou Medical University, Yantai, Shandong, 264003, China
| | - Ke-Qi Liu
- Jiangxi Medical College, Shangrao, Jiangxi, China
| | - Lin Xu
- Binzhou Medical University, Yantai, Shandong, 264003, China
| | - Pian-Pian Zhao
- Diseases & Population (DaP) Geninfo Lab, School of Life Sciences, Westlake University, 18 Shilongshan Road, Hangzhou, Zhejiang, 310024, China,Instituteof Basic Medical Sciences, Westlake Institute for Advanced Study, 18 Shilongshan Road, Hangzhou, Zhejiang, 310024, China
| | - Si-Rui Gai
- Diseases & Population (DaP) Geninfo Lab, School of Life Sciences, Westlake University, 18 Shilongshan Road, Hangzhou, Zhejiang, 310024, China,Instituteof Basic Medical Sciences, Westlake Institute for Advanced Study, 18 Shilongshan Road, Hangzhou, Zhejiang, 310024, China
| | - Peng-Lin Guan
- Diseases & Population (DaP) Geninfo Lab, School of Life Sciences, Westlake University, 18 Shilongshan Road, Hangzhou, Zhejiang, 310024, China,Instituteof Basic Medical Sciences, Westlake Institute for Advanced Study, 18 Shilongshan Road, Hangzhou, Zhejiang, 310024, China
| | - Jin-Qiu Zhao
- The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yan-Ping Zhu
- Binzhou Medical University, Yantai, Shandong, 264003, China
| | - Lam C. Tsoi
- Department of Dermatology, University of Michigan, Ann Arbor, Michigan, United States,Department of Biostatistics, Center for Statistical Genetics, University of Michigan, Ann Arbor, Michigan, United States
| | - Philip E. Stuart
- Department of Dermatology, University of Michigan, Ann Arbor, Michigan, United States,Department of Biostatistics, Center for Statistical Genetics, University of Michigan, Ann Arbor, Michigan, United States
| | - Rajan P. Nair
- Department of Dermatology, University of Michigan, Ann Arbor, Michigan, United States,Department of Biostatistics, Center for Statistical Genetics, University of Michigan, Ann Arbor, Michigan, United States
| | - Han-Qi Yang
- School of Public Health, Boston University, Boston, Massachusetts, 02118, United States
| | - Yu-Ting Liao
- School of Public Health and Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Kaijing Mao
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Mo-Chang Qiu
- Jiangxi Medical College, Shangrao, Jiangxi, China
| | - Zhi-Min Ying
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
| | - Bin Hu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
| | - Zhi-Hua Yang
- Department of Orthopedic Surgery, Zhejiang Xiaoshan hospital, Hangzhou, Zhejiang, China
| | - Wei-Yang Bai
- Diseases & Population (DaP) Geninfo Lab, School of Life Sciences, Westlake University, 18 Shilongshan Road, Hangzhou, Zhejiang, 310024, China,Instituteof Basic Medical Sciences, Westlake Institute for Advanced Study, 18 Shilongshan Road, Hangzhou, Zhejiang, 310024, China
| | - Xiao-Wei Zhu
- Diseases & Population (DaP) Geninfo Lab, School of Life Sciences, Westlake University, 18 Shilongshan Road, Hangzhou, Zhejiang, 310024, China,Instituteof Basic Medical Sciences, Westlake Institute for Advanced Study, 18 Shilongshan Road, Hangzhou, Zhejiang, 310024, China
| | - Pei-Kuan Cong
- Diseases & Population (DaP) Geninfo Lab, School of Life Sciences, Westlake University, 18 Shilongshan Road, Hangzhou, Zhejiang, 310024, China,Instituteof Basic Medical Sciences, Westlake Institute for Advanced Study, 18 Shilongshan Road, Hangzhou, Zhejiang, 310024, China
| | - James T. Elder
- Department of Dermatology, University of Michigan, Ann Arbor, Michigan, United States,Ann Arbor Veterans Affairs Hospital, Ann Arbor, Michigan, United States
| | - Zhao-Ming Ye
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
| | - Bin Wang
- Binzhou Medical University, Yantai, Shandong, 264003, China
| | - Hou-Feng Zheng
- Diseases & Population (DaP) Geninfo Lab, School of Life Sciences, Westlake University, 18 Shilongshan Road, Hangzhou, Zhejiang, 310024, China,Instituteof Basic Medical Sciences, Westlake Institute for Advanced Study, 18 Shilongshan Road, Hangzhou, Zhejiang, 310024, China
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Osteoporosis: A Long-Term and Late-Effect of Breast Cancer Treatments. Cancers (Basel) 2020; 12:cancers12113094. [PMID: 33114141 PMCID: PMC7690788 DOI: 10.3390/cancers12113094] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/07/2020] [Accepted: 10/19/2020] [Indexed: 12/17/2022] Open
Abstract
Simple Summary Osteoporosis is a prevalent condition affecting 200 million individuals world-wide. Estimates are about one in three women will experience a fragility fracture of hip, spine or wrist. Common breast cancer treatments, such as aromatase inhibitors in postmenopausal women and chemotherapy-induced ovarian failure in premenopausal women, cause bone loss that in some women will lead to osteoporosis and fragility fractures. Fragility fractures cause morbidity and mortality and are entirely preventable. Prevention or treatment of osteoporosis includes lifestyle modifications (e.g., reducing smoking and excessive alcohol consumption, and increasing physical activity), taking calcium and vitamin D3, screening for osteoporosis with dual-energy absorptiometry, and treatment, if clinically indicated, with ether oral bisphosphonates, intravenous zoledronic acid, or subcutaneous denosumab. This chapter reviews the pathogenesis of osteoporosis, the magnitude of bone loss related to common breast cancer treatments, osteoporosis risk factor assessment and screening, and the specific drugs to treat or prevent osteoporosis. Abstract Osteoporosis is both a long-term effect (occurs during treatment and extends after treatment) and a late-effect (occurs after treatment ends) of breast cancer treatments. The worldwide prevalence of osteoporosis is estimated to be some 200 million patients. About one in three postmenopausal women will experience an osteoporotic (or fragility) fracture of the hip, spine, or wrist. breast cancer treatments, including gonadotropin-releasing hormone (GnRH) agonists, chemotherapy-induced ovarian failure (CIOF), and aromatase inhibitors (AIs), cause bone loss and increase the risks of osteoporosis. Also, breast cancer is a disease of aging, and most of the “one in eight” lifetime risks of breast cancer are in women in their sixth, seventh, and eighth decades. The majority of women diagnosed with breast cancers today will be long-term survivors and experience personal cures. It is the coalescence of osteoporosis with breast cancer, two common and age-related conditions that make osteoporosis relevant in women with breast cancer throughout the continuum from diagnosis, treatment, and survivorship. It is critical to remember that women (and men) will lose bone after age thirty years. However, only certain women will lose bone of sufficient magnitude to merit treatment with anti-osteoporosis drugs. The narrative review is intended for medical, surgical, radiation oncologists, and other mid-level providers, and provides an overview of bone loss and the prevention and treatment of osteoporosis.
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Mettawi AS, Soliman SS, Taha ME. Clinician's guide for the management and research of osteoporosis in North African men: a guidelines comparison, a cost-effectiveness analysis, and a local algorithm. Arch Osteoporos 2020; 15:159. [PMID: 33037516 DOI: 10.1007/s11657-020-00830-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 09/28/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED A local management algorithm and practice recommendations for the management of osteoporosis in Egyptian males were developed after assessing the applicability of current international recommendations and the cost effectiveness of local drugs. A systematic review and sensitivity analyses augmented the quality of the research efforts. PURPOSE Osteoporosis affects both men and women; however, no local recommendations for the condition are available for the male population. Therefore, this study was undertaken to produce recommendations for men based on the applicability of current international recommendations and the cost effectiveness of local drugs. METHODS The International Osteoporosis Foundation website, EMBASE, and SUMSEARCH-2 databases were searched to identify all guidelines that included recommendations for males. Regional and international guidelines were then appraised using the Advancing Guideline Development, Reporting, and Evaluation in Healthcare-II tool. A cost-effectiveness analysis was conducted using the perspective of an uninsured patient, international outcomes, and local costs. Recommendations were then formulated using the Grading of Recommendations Assessment, Development and Evaluation guidelines, and symbolic representations. RESULTS Twenty-six guidelines were found. Only one of the guidelines focused entirely on males, with the remainder making inferences based on recommendations for females. Six regional guidelines were mainly of low quality. Alendronate was considered to be the most cost-effective drug, while teriparatide was found to be unaffordable. CONCLUSION Recommendations for men with osteoporosis are based on that of women, and the topic lacks exploration in the Middle East. International recommendations and other guidelines were evaluated and adopted to create guidance for the management of osteoporosis in men for application in Egypt.
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Affiliation(s)
- Ahmed S Mettawi
- Faculty of life sciences and education (FLSE), University of South Wales (USW), Llantwit Rd, Pontypridd, CF37 1DL, UK.
| | - Saeed S Soliman
- Department of Family Medicine, Kasralainy School of Medicine, Cairo University, Cairo, Egypt
| | - Mohy E Taha
- Department of Orthopaedics and Trauma Surgery, Basel University Hospital, Basel, Switzerland
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Lespessailles E, Chapurlat R. High fracture risk patients with glucocorticoid-induced osteoporosis should get an anabolic treatment first. Osteoporos Int 2020; 31:1829-1834. [PMID: 32780152 DOI: 10.1007/s00198-020-05568-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 07/23/2020] [Indexed: 12/29/2022]
Abstract
Long-term glucocorticoid (GC) therapy induces glucocorticoid-induced osteoporosis (GIOP) and its associated fractures. Most specialty organizations recommend bisphosphonates as first-line therapies based only on bone mineral density efficacy data. Effective treatment of GIOP based on head-to-head trials with fracture endpoint has not yet been established. The pathophysiologic mechanisms of GIOP that lead to the detrimental effects on bone are not yet fully elucidated. Although GCs in an early and transitory period promote osteoclastic activity, in the current paper, we outline why GIOP is in fact a disease of the bone formation and then provide the rationale for the use of bone-forming agents as first-line therapy for patients with high fracture risk in GIOP.
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Affiliation(s)
- E Lespessailles
- EA 4708 - I3MTO Laboratory, University of Orleans, 45067, Orleans, France.
- Department of Rheumatology, Translational Medicine Research Platform, Regional Hospital of Orleans, 14 avenue de l'hopital, 45067, Orleans Cedex 2, France.
| | - R Chapurlat
- INSERM UMR 1033, University of Lyon, Hôpital E Herriot, Lyon, France
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Pepe J, Body JJ, Hadji P, McCloskey E, Meier C, Obermayer-Pietsch B, Palermo A, Tsourdi E, Zillikens MC, Langdahl B, Ferrari S. Osteoporosis in Premenopausal Women: A Clinical Narrative Review by the ECTS and the IOF. J Clin Endocrinol Metab 2020; 105:5846185. [PMID: 32453819 DOI: 10.1210/clinem/dgaa306] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/20/2020] [Indexed: 02/07/2023]
Abstract
CONTEXT Consensus regarding diagnosis and management of osteoporosis in premenopausal women (PW) is still lacking due to few studies carried out in this population. DESIGN The European Calcified Tissue Society and the International Osteoporosis Foundation convened a working group to produce an updated review of literature published after 2017 on this topic. RESULTS Fragility fractures in PW are rare and mostly due to secondary osteoporosis (ie, in presence of an underlying disease such as hormonal, inflammatory, or digestive disorders). In absence of another disorder, low bone mineral density (BMD) together with fragility fractures qualifies as idiopathic osteoporosis. In contrast, low BMD alone does not necessarily represent osteoporosis in absence of bone microarchitectural abnormalities. BMD increases in PW with osteoporosis when the underlying disease is treated. For example, in celiac disease, an increase of 9% in radius trabecular volumetric density was achieved after 1 year of gluten-free diet, while anti-tumor necrosis factor alpha improved BMD in PW with inflammatory bowel diseases. In amenorrhea, including anorexia nervosa, appropriately delivered estrogen replacement therapy can also improve BMD. Alternatively, antiresorptive or anabolic therapy has been shown to improve BMD in a variety of conditions, the range of improvement (3%-16%) depending on skeletal site and the nature of the secondary cause. No studies were powered to demonstrate fracture reduction. The effects of bisphosphonates in childbearing women have been scantly studied and caution is needed. CONCLUSION The majority of PW with osteoporosis have an underlying disease. Specific therapy of these diseases, as well as antiresorptive and anabolic drugs, improve BMD, but without evidence of fracture reduction.
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Affiliation(s)
- Jessica Pepe
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, "Sapienza" University of Rome, Italy
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Peyman Hadji
- Frankfurt Center of Bone Health, Frankfurt, Germany and Philipps-University of Marburg, Marburg, Germany
| | - Eugene McCloskey
- Centre for Integrated Research in Musculoskleetal Ageing, Mellanby Centre for Bone Research, Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Christian Meier
- Division of Endocrinology, Diabetology and Metabolism, University Hospital and University of Basel, Basel, Switzerland
| | - Barbara Obermayer-Pietsch
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Andrea Palermo
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University, Rome, Italy
| | - Elena Tsourdi
- Department of Medicine III, Technische Universität Dresden Medical Center, Dresden, Germany
- Center for Healthy Aging, Technische Universität Dresden Medical Center, Dresden, Germany
| | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Bente Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Serge Ferrari
- Service of Bone Diseases, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
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Wang Y, Zhao R, Gu Z, Dong C, Guo G, Li L. Effects of glucocorticoids on osteoporosis in rheumatoid arthritis: a systematic review and meta-analysis. Osteoporos Int 2020; 31:1401-1409. [PMID: 32291467 DOI: 10.1007/s00198-020-05360-w] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 02/19/2020] [Indexed: 12/19/2022]
Abstract
We evaluated the effects of glucocorticoids on bone mineral density (BMD), and prevalence of osteoporosis and fracture in rheumatoid arthritis (RA) by meta-analysis. Until June 26, 2019, we conducted a systematic literature search in EMBASE, Web of science, PubMed, and Cochrane Library to obtain BMD and the prevalence of osteoporosis and fracture in glucocorticoid-treated subjects with RA. The BMD of the treatment and control groups were analyzed by meta-analysis (Stata. version 15), and the 95% confidence interval (CI) was calculated. We identified 15 observational studies, including 46,711 RA subjects and 857 healthy controls. The BMD of the lumbar spine (- 0.038 g/cm2; CI, - 0.052, - 0.024) and femoral neck (- 0.017 g/cm2; - 0.030, - 0.003) in RA treated with glucocorticoids were significantly lower than those in RA controls. Compared with healthy control group, the BMD of the lumbar spine (- 0.094 g/cm2; - 0.126, - 0.061) and femoral neck (- 0.097 g/cm2, - 0.109, - 0.085) of RA treated with glucocorticoids decreased more significantly. The prevalence of osteoporosis in whole body, spine, and femur was 38.6% (0.305, 0.466), 32.9% (0.277, 0.381), and 21.7% (0.106, 0.328), respectively. And the prevalence of vertebral fracture was 13.0% (0.058, 0.203). Glucocorticoids may lead to a decline in skeletal health in subjects with RA, especially in vertebral and femoral BMD, compared with normal people or RA without glucocorticoid therapy. Meanwhile, osteoporosis and fractures were also common. Therapeutic measures should be targeted at individuals, which needs further study. Through meta-analysis, we found that glucocorticoids have some negative effects on the bone health of subjects with rheumatoid arthritis. Therefore, when using glucocorticoids to treat rheumatoid arthritis, we should take strategic measures to prevent the decline of bone quality.
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Affiliation(s)
- Y Wang
- Research Center of Clinical Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Department of Nursing, Affiliated Hospital of Nantong University, Nantong, China
| | - R Zhao
- Research Center of Clinical Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Department of Nursing, Affiliated Hospital of Nantong University, Nantong, China
| | - Z Gu
- Research Center of Gerontology and Longevity, Affiliated Hospital of Nantong University, Nantong, China
- Department of Rheumatology, Affiliated Hospital of Nantong University, 20th Xisi Road, Nantong, 226001, Jiangsu Province, People's Republic of China
| | - C Dong
- Research Center of Clinical Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Research Center of Gerontology and Longevity, Affiliated Hospital of Nantong University, Nantong, China
| | - G Guo
- Department of Rheumatology, Affiliated Hospital of Nantong University, 20th Xisi Road, Nantong, 226001, Jiangsu Province, People's Republic of China.
| | - L Li
- Department of Gastroenterology, Affiliated Hospital of Nantong University, 20th Xisi Road, Nantong, 226001, Jiangsu Province, People's Republic of China.
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Chotiyarnwong P, McCloskey EV. Pathogenesis of glucocorticoid-induced osteoporosis and options for treatment. Nat Rev Endocrinol 2020; 16:437-447. [PMID: 32286516 DOI: 10.1038/s41574-020-0341-0] [Citation(s) in RCA: 209] [Impact Index Per Article: 52.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2020] [Indexed: 12/31/2022]
Abstract
Glucocorticoids are widely used to suppress inflammation or the immune system. High doses and long-term use of glucocorticoids lead to an important and common iatrogenic complication, glucocorticoid-induced osteoporosis, in a substantial proportion of patients. Glucocorticoids mainly increase bone resorption during the initial phase (the first year of treatment) by enhancing the differentiation and maturation of osteoclasts. Glucocorticoids also inhibit osteoblastogenesis and promote apoptosis of osteoblasts and osteocytes, resulting in decreased bone formation during long-term use. Several indirect effects of glucocorticoids on bone metabolism, such as suppression of production of insulin-like growth factor 1 or growth hormone, are involved in the pathogenesis of glucocorticoid-induced osteoporosis. Fracture risk assessment for all patients with long-term use of oral glucocorticoids is required. Non-pharmacological interventions to manage the risk of fracture should be prescribed to all patients, while pharmacological management is reserved for patients who have increased fracture risk. Various treatment options can be used, ranging from bisphosphonates to denosumab, as well as teriparatide. Finally, appropriate monitoring during treatment is also important.
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Affiliation(s)
- Pojchong Chotiyarnwong
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Academic Unit of Bone Metabolism, Department of Oncology and Metabolism, The Mellanby Centre For Bone Research, University of Sheffield, Sheffield, UK
| | - Eugene V McCloskey
- Academic Unit of Bone Metabolism, Department of Oncology and Metabolism, The Mellanby Centre For Bone Research, University of Sheffield, Sheffield, UK.
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, UK.
- Centre for Integrated Research into Musculoskeletal Ageing, University of Sheffield Medical School, Sheffield, UK.
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Mori Y, Izumiyama T, Baba K, Mori N, Fujii H, Ishii T, Itoi E. Evaluation of risk factors of vertebral fracture in Japanese female patients with glucocorticoid-induced osteoporosis. J Orthop Surg Res 2020; 15:290. [PMID: 32727595 PMCID: PMC7391489 DOI: 10.1186/s13018-020-01813-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/22/2020] [Indexed: 01/23/2023] Open
Abstract
Background Glucocorticoid-induced osteoporosis and vertebral fracture are common complications in patients on glucocorticoid treatment for rheumatological diseases. The present study aimed to identify the risk factors of vertebral fracture in Japanese female patients with glucocorticoid-induced osteoporosis. Methods This study included 225 Japanese women with glucocorticoid-induced osteoporosis and 72 patients with postmenopausal osteoporosis. All participants were treated with bisphosphonate or denosumab for osteoporosis with active form of vitamin D for at least 3 years. The differences of clinical parameters, including age, disease duration, body mass index (BMI), bone mineral density (BMD), and the dose and treatment duration of glucocorticoid were assessed between patients with and without vertebral fracture. Multivariate logistic regression analysis was also performed to evaluate the association of vertebral fracture with clinical parameters. Results The significant differences related to age, BMD of the hip, disease duration, glucocorticoid treatment duration between patients with and without vertebral fractures were demonstrated. The present study indicated that disease duration, BMI, and the total hip BMD were independent risk factors for vertebral fractures in patients with glucocorticoid-induced osteoporosis. Conclusions Prolonged disease duration, low BMI, and low total hip BMD could be risk factors of vertebral fracture in patients on glucocorticoid treatment for rheumatological diseases.
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Affiliation(s)
- Yu Mori
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo machi, Aobaku, Sendai, Miyagi, 980-8574, Japan.
| | - Takuya Izumiyama
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo machi, Aobaku, Sendai, Miyagi, 980-8574, Japan
| | - Kazuyoshi Baba
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo machi, Aobaku, Sendai, Miyagi, 980-8574, Japan
| | - Naoko Mori
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, 1-1 Seiryo machi, Aobaku, Sendai, Miyagi, 980-8574, Japan
| | - Hiroshi Fujii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, 1-1 Seiryo machi, Aobaku, Sendai, Miyagi, 980-8574, Japan
| | - Tomonori Ishii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, 1-1 Seiryo machi, Aobaku, Sendai, Miyagi, 980-8574, Japan
| | - Eiji Itoi
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo machi, Aobaku, Sendai, Miyagi, 980-8574, Japan
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Gupta A, Jayes LR, Holmes S, Sahota O, Canavan M, Elkin SL, Lim K, Murphy AC, Singh S, Towlson EA, Ward H, Scullion J, McKeever TM, Bolton CE. Management of Fracture Risk in Patients with Chronic Obstructive Pulmonary Disease (COPD): Building a UK Consensus Through Healthcare Professional and Patient Engagement. Int J Chron Obstruct Pulmon Dis 2020; 15:1377-1390. [PMID: 32606647 PMCID: PMC7311204 DOI: 10.2147/copd.s233398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 03/23/2020] [Indexed: 12/21/2022] Open
Abstract
Introduction Osteoporosis and bone fractures are common in chronic obstructive pulmonary disease (COPD) and contribute significantly to morbidity and mortality. Current national guidance on COPD management recommends addressing bone health in patients, however, does not detail how. This consensus outlines key elements of a structured approach to managing bone health and fracture risk in patients with COPD. Methods A systematic approach incorporating multifaceted methodologies included detailed patient and healthcare professional (HCP) surveys followed by a roundtable meeting to reach a consensus on what a pathway would look like. Results The surveys revealed that fracture risk was not always assessed despite being recognised as an important aspect of COPD management by HCPs. The majority of the patients also stated they would be receptive to discussing treatment options if found to be at risk of osteoporotic fractures. Limited time and resource allocation were identified as barriers to addressing bone health during consultations. The consensus from the roundtable meeting was that a proactive systematic approach to assessing bone health should be adopted. This should involve using fracture risk assessment tools to identify individuals at risk, investigating secondary causes of osteoporosis if a diagnosis is made and reinforcing non-pharmacological and preventative measures such as smoking cessation, keeping active and pharmacological management of osteoporosis and medicines management of corticosteroid use. Practically, prioritising patients with important additional risk factors, such as previous fragility fractures, older age and long-term oral corticosteroid use for an assessment, was felt required. Conclusion There is a need for integrating fracture risk assessment into the COPD pathway. Developing a systematic and holistic approach to addressing bone health is key to achieving this. In tandem, opportunities to disseminate the information and educational resources are also required.
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Affiliation(s)
- Ayushman Gupta
- NIHR Nottingham BRC Respiratory Theme, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
| | - Leah R Jayes
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
| | - Steve Holmes
- General Practitioner, Park Medical Partnership, Shepton Mallet, UK
| | - Opinder Sahota
- Department of Geriatric Medicine, Nottingham University Hospitals Trust, Nottingham, UK
| | - Melissa Canavan
- Department of Respiratory, Respiratory Care Solutions, Leeds, UK
| | - Sarah L Elkin
- Department of Respiratory Medicine, Imperial College Healthcare Trust, London W2 1NY, UK; Airways Section, National Heart and Lung Institute, Imperial College, London, UK
| | - Kelvin Lim
- Eastwood Primary Care Centre, Eastwood, Nottingham, UK
| | - Anna C Murphy
- Department of Pharmacy, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sally Singh
- Department of Respiratory Science, University Hospitals of Leicester NHS Trust, Leicester, UK.,Department of Respiratory Science, University of Leicester, Leicester, UK
| | | | - Helen Ward
- Faculty of Medicine, The Royal Wolverhampton NHS Trust, West Midlands, UK
| | - Jane Scullion
- Department of Respiratory Science, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Tricia M McKeever
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
| | - Charlotte E Bolton
- NIHR Nottingham BRC Respiratory Theme, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
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Chiodini I, Falchetti A, Merlotti D, Eller Vainicher C, Gennari L. Updates in epidemiology, pathophysiology and management strategies of glucocorticoid-induced osteoporosis. Expert Rev Endocrinol Metab 2020; 15:283-298. [PMID: 32584619 DOI: 10.1080/17446651.2020.1772051] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Endogenous or exogenous (corticosteroid-induced) glucocorticoids (GCs) excess represents, together with diabetes, the most common cause of secondary osteoporosis. AREAS COVERED We present a comprehensive overview about the pathophysiology, clinical management and treatment of GCs induced osteoporosis (GIOP). According to PRISMA guidelines, a literature search identifying articles about bone and GCs was done. EXPERT OPINION Despite the progress over the years and the increase in therapeutic options, there still are controversial issues about the management of GIOP. These mainly include the failure of BMD or FRAX to completely account for the rapid increase in fracture risk of most GC-treated patients, the understanding about the independent contribution on bone fragility of the underlying disease requiring GCs therapy, and the necessity of clearer information about the anti-fracture efficacy and long term-safety of most therapeutic options. Moreover, there are no specific indications for the management of bone fragility in endogenous hypercortisolism. Notwithstanding the above limitations there is a general consensus to recommend an assessment of fracture risk in all individuals >40 years committed to receive (or continuing) high dose (>7.5 mg of prednisone equivalent) GCs for ≥3 months and in all patients with fragility fracture history.
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Affiliation(s)
- Iacopo Chiodini
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Milan , Italy
| | - Alberto Falchetti
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Milan , Italy
| | - Daniela Merlotti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena , Italy
| | - Cristina Eller Vainicher
- Endocrinology and Diabetology Units, Department of Medical Sciences and Community, Fondazione Ca'Granda Ospedale Maggiore Policlinico IRCCS , Milan, Italy
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena , Italy
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Schepper JD, Collins F, Rios-Arce ND, Kang HJ, Schaefer L, Gardinier JD, Raghuvanshi R, Quinn RA, Britton R, Parameswaran N, McCabe LR. Involvement of the Gut Microbiota and Barrier Function in Glucocorticoid-Induced Osteoporosis. J Bone Miner Res 2020; 35:801-820. [PMID: 31886921 DOI: 10.1002/jbmr.3947] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/05/2019] [Accepted: 12/14/2019] [Indexed: 12/14/2022]
Abstract
Glucocorticoids (GCs) are potent immune-modulating drugs with significant side effects, including glucocorticoid-induced osteoporosis (GIO). GCs directly induce osteoblast and osteocyte apoptosis but also alter intestinal microbiota composition. Although the gut microbiota is known to contribute to the regulation of bone density, its role in GIO has never been examined. To test this, male C57/Bl6J mice were treated for 8 weeks with GC (prednisolone, GC-Tx) in the presence or absence of broad-spectrum antibiotic treatment (ABX) to deplete the microbiota. Long-term ABX prevented GC-Tx-induced trabecular bone loss, showing the requirement of gut microbiota for GIO. Treatment of GC-Tx mice with a probiotic (Lactobacillus reuteri [LR]) prevented trabecular bone loss. Microbiota analyses indicated that GC-Tx changed the abundance of Verrucomicobiales and Bacteriodales phyla and random forest analyses indicated significant differences in abundance of Porphyromonadaceae and Clostridiales operational taxonomic units (OTUs) between groups. Furthermore, transplantation of GC-Tx mouse fecal material into recipient naïve, untreated WT mice caused bone loss, supporting a functional role for microbiota in GIO. We also report that GC caused intestinal barrier breaks, as evidenced by increased serum endotoxin level (2.4-fold), that were prevented by LR and ABX treatments. Enhancement of barrier function with a mucus supplement prevented both GC-Tx-induced barrier leakage and trabecular GIO. In bone, treatment with ABX, LR or a mucus supplement reduced GC-Tx-induced osteoblast and osteocyte apoptosis. GC-Tx suppression of Wnt10b in bone was restored by the LR and high-molecular-weight polymer (MDY) treatments as well as microbiota depletion. Finally, we identified that bone-specific Wnt10b overexpression prevented GIO. Taken together, our data highlight the previously unappreciated involvement of the gut microbiota and intestinal barrier function in trabecular GIO pathogenesis (including Wnt10b suppression and osteoblast and osteocyte apoptosis) and identify the gut as a novel therapeutic target for preventing GIO. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
| | - Fraser Collins
- Department of Physiology, Michigan State University, East Lansing, MI, USA
| | - Naiomy Deliz Rios-Arce
- Department of Physiology, Michigan State University, East Lansing, MI, USA.,Comparative Medicine and Integrative Biology Program, Michigan State University, East Lansing, MI, USA
| | - Ho Jun Kang
- Department of Physiology, Michigan State University, East Lansing, MI, USA
| | - Laura Schaefer
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, USA
| | | | - Ruma Raghuvanshi
- Department of Biochemistry and Molecular Biology, Michigan State University, East Lansing, MI, USA
| | - Robert A Quinn
- Department of Biochemistry and Molecular Biology, Michigan State University, East Lansing, MI, USA
| | - Robert Britton
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, USA
| | | | - Laura R McCabe
- Department of Physiology, Michigan State University, East Lansing, MI, USA
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Bahat G, Ilhan B, Karan MA. Comment on: "Pharmacological Management of Osteoporosis in Rheumatoid Arthritis Patients: A Review of the Literature and Practical Guide". Drugs Aging 2020; 37:237-238. [PMID: 32048236 DOI: 10.1007/s40266-020-00752-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Gulistan Bahat
- Division of Geriatrics, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey.
| | - Birkan Ilhan
- Division of Geriatrics, Department of Internal Medicine, Şişli Hamidiye Etfal Training and Research Hospital, University of Medical Sciences, Istanbul, Turkey
| | - Mehmet Akif Karan
- Division of Geriatrics, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey
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Wong SPY, Mok CC. Management of glucocorticoid-related osteoporotic vertebral fracture. Osteoporos Sarcopenia 2020; 6:1-7. [PMID: 32226826 PMCID: PMC7093682 DOI: 10.1016/j.afos.2020.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/15/2019] [Accepted: 02/08/2020] [Indexed: 12/11/2022] Open
Abstract
The vertebral column is the most common site of osteoporotic fractures in long-term users of glucocorticoids. Vertebral fracture leads to significant morbidities such as unrelenting pain, spinal deformities and reduced mobility, leading to diminished quality of life. Epidemiological data on the prevalence of glucocorticoid-induced vertebral fractures are limited. As vertebral fracture is a strong risk factor for further fragility fractures and mortality, it should be treated appropriately. This article reviews recent data on the prevalence of vertebral fractures in glucocorticoid users, fracture risk stratification, and evidence-based treatment options. The risk of osteoporotic fractures estimated by FRAX should be adjusted for glucocorticoid users. The first-line treatment of glucocorticoid-induced osteoporosis remains the bisphosphonates. Teriparatide and denosumab are alternative options. Percutaneous vertebroplasty and kyphoplasty may be considered for symptomatic control of acute vertebral fracture-related pain when conservative measures fail.
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Affiliation(s)
| | - Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong, China
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69
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Wang Y, Yu S, Hsu C, Tsai C, Cheng T. Underestimated fracture risk in postmenopausal women-application of the hybrid intervention threshold. Osteoporos Int 2020; 31:475-483. [PMID: 31696272 DOI: 10.1007/s00198-019-05201-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 10/16/2019] [Indexed: 01/07/2023]
Abstract
UNLABELLED This study evaluated the fragility fracture risk of Taiwanese postmenopausal women with osteopenia. With the incorporation of FRAX and hybrid intervention threshold (HIT), 25% of the participants had high fracture risk. We suggest intervention for fragility fracture for postmenopausal women should be guided by FRAX and HIT instead of bone mineral density alone. INTRODUCTION To explore the risk of fragility fracture in Taiwanese postmenopausal women with osteopenia using the hybrid intervention threshold (HIT) and Fracture Risk Assessment tool (FRAX). METHODS The Taiwan Osteoporosis Association (TOA) conducted a nationwide bone mineral density (BMD) survey between 2008 and 2011 using a bus equipped with a dual-energy X-ray absorptiometry (DXA) machine. All participants completed a structured questionnaire, which included the elements in the FRAX. Based on the results, the group made up of postmenopausal women with osteopenia was identified. In order to explore the risk of fragility fracture by HIT and FRAX among Taiwan postmenopausal women with osteopenia, the 10-year probability of fracture (FRAX score) and individual intervention threshold (IIT) in this group were calculated. If the FRAX score of a participant was higher than or equal to the IIT or fixed intervention threshold (FIT), the participant was considered as above the HIT (HIT could be reached by being over a threshold at either major osteoporotic fracture or hip fracture) and categorized as having a high FRAX fracture risk. RESULTS A total of 13,068 postmenopausal women were enrolled in the program. A total of 5743 (43.9%) participants had osteopenia, of which 1434 (25.0%) had high FRAX fracture risk. CONCLUSIONS One quarter of Taiwanese postmenopausal women with osteopenia had high fragility fracture risk evaluated by FRAX and HIT. Due to the poor sensitivity of BMD for fragility fracture, we suggest that intervention for fragility fracture for postmenopausal women should also be guided by FRAX and HIT instead of BMD alone.
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Affiliation(s)
- Y Wang
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosung District, 83301, Kaohsiung City, Taiwan
| | - S Yu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosung District, 83301, Kaohsiung City, Taiwan
| | - C Hsu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosung District, 83301, Kaohsiung City, Taiwan
| | - C Tsai
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosung District, 83301, Kaohsiung City, Taiwan.
| | - T Cheng
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosung District, 83301, Kaohsiung City, Taiwan.
- College of Medicine, Chang Gung University, No. 123, Dapi Road, Niaosung District, 83301, Kaohsiung City, Taiwan.
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Hsu CY, Wu CH, Yu SF, Su YJ, Chiu WC, Chen YC, Lai HM, Chen JF, Ko CH, Chen JF, Cheng TT. Novel algorithm generating strategy to identify high fracture risk population using a hybrid intervention threshold. J Bone Miner Metab 2020; 38:213-221. [PMID: 31583541 DOI: 10.1007/s00774-019-01046-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/02/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The aim of this study was to develop an algorithm to identify high-risk populations of fragility fractures in Taiwan. MATERIALS AND METHODS A total of 16,539 postmenopausal women and men (age ≥ 50 years) were identified from the Taiwan Osteoporosis Survey database. Using the Taiwan FRAX® tool, the 10-year probability of major osteoporotic fracture (MOF) and hip fracture (HF) and the individual intervention threshold (IIT) of each participant were calculated. Subjects with either a probability above the IIT or those with MOF ≥ 20% or HF ≥ 9% were included as group A. Subjects with a bone mineral density (BMD) T-score at femoral neck based on healthy subjects of ≤ - 2.5 were included in group B. We tested several cutoff points for MOF and HF so that the number of patients in group A and group B were similar. A novel country-specific hybrid intervention threshold along with an algorithm was generated to identify high fracture risk individuals. RESULTS 3173 (19.2%) and 3129 (18.9%) participants were categorized to groups A and B, respectively. Participants in group B had a significantly lower BMD (p < 0.001), but clinical characteristics, especially the 10-year probability of MOF (p < 0.001) or HF (p < 0.001), were significantly worse in group A. We found the algorithm generated from the hybrid intervention threshold is practical. CONCLUSION The strategy of generating an algorithm for fracture prevention by novel hybrid intervention threshold is more efficient as it identifies patients with a higher risk of fragility fracture and could be a template for other country-specific policies.
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Affiliation(s)
- Chung-Yuan Hsu
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Chih-Hsing Wu
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shan-Fu Yu
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Yu-Jih Su
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Wen-Chan Chiu
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Ying-Chou Chen
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Han-Ming Lai
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Jia-Feng Chen
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Chi-Hua Ko
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Jung-Fu Chen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tien-Tsai Cheng
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan.
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Compston J. Management of glucocorticoid-induced osteoporosis: What is new? Int J Rheum Dis 2020; 22:1595-1597. [PMID: 31478605 DOI: 10.1111/1756-185x.13680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 07/24/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Juliet Compston
- Emeritus of Bone Medicine, Cambridge Biomedical Campus, Cambridge, UK
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A decade of FRAX: how has it changed the management of osteoporosis? Aging Clin Exp Res 2020; 32:187-196. [PMID: 32043227 DOI: 10.1007/s40520-019-01432-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 11/21/2019] [Indexed: 01/14/2023]
Abstract
The fracture risk assessment tool, FRAX®, was released in 2008 and provides country-specific algorithms for estimating individualized 10-year probability of hip and major osteoporotic fracture (hip, clinical spine, distal forearm, and proximal humerus). Since its release, 71 models have been made available for 66 countries covering more than 80% of the world population. The website receives approximately 3 million visits annually. Following independent validation, FRAX has been incorporated into more than 80 guidelines worldwide. The application of FRAX in assessment guidelines has been heterogeneous with the adoption of several different approaches in setting intervention thresholds. Whereas most guidelines adopt a case-finding strategy, the case for FRAX-based community screening in the elderly is increasing. The relationship between FRAX and efficacy of intervention has been explored and is expected to influence treatment guidelines in the future.
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Curtis EM, Woolford S, Holmes C, Cooper C, Harvey NC. General and Specific Considerations as to why Osteoporosis-Related Care Is Often Suboptimal. Curr Osteoporos Rep 2020; 18:38-46. [PMID: 32103393 PMCID: PMC7067731 DOI: 10.1007/s11914-020-00566-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW The assessment of fracture risk and use of antiosteoporosis medications have increased greatly over the last 20-30 years. However, despite this, osteoporosis care remains suboptimal worldwide. Even in patients who have sustained a fragility fracture, fewer than 20% actually receive appropriate antiosteoporosis therapy in the year following the fracture. There is also evidence that treatment rates have declined substantially in the last 5-10 years, in many countries. The goal of this article is to consider the causes for this decline and consider how this situation could be remedied. RECENT FINDINGS A number of possible reasons, including the lack of prioritisation of osteoporosis therapy in ageing populations with multimorbidity, disproportionate concerns regarding the rare side effects of anti-resorptives and adverse changes in reimbursement in the USA, have been identified as contributing factors in poor osteoporosis care. Improved secondary prevention strategies; screening measures (primary prevention) and appropriate, cost-effective guideline and treatment threshold development could support the optimisation of osteoporosis care and prevention of future fractures.
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Affiliation(s)
- Elizabeth M Curtis
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, UK.
| | - Stephen Woolford
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, UK
| | - Claire Holmes
- Rheumatology Department, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, UK
- NIHR Oxford Biomedical Research Unit, University of Oxford, Oxford, UK
- NIHR Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, University of Southampton, Southampton, UK
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, University of Southampton, Southampton, UK
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Chiodini I, Merlotti D, Falchetti A, Gennari L. Treatment options for glucocorticoid-induced osteoporosis. Expert Opin Pharmacother 2020; 21:721-732. [PMID: 32004105 DOI: 10.1080/14656566.2020.1721467] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Glucocorticoid (GC) induced osteoporosis (GIOP) is the most common form of secondary osteoporosis. It develops in a dose and time dependent manner, due to a rapid and transient increase in bone resorption, followed by the inhibition of bone formation. AREAS COVERED In this review, the authors summarize the pathophysiology of GIOP and give discussion to the clinical management of patients taking GCs, focusing on the currently available drugs that have antiresorptive or anabolic activity on bone. EXPERT OPINION Despite the widespread use of GCs and their well-established detrimental skeletal effects, GIOP remains an under-diagnosed and under-treated condition. Indeed, the clinical management of GIOP is still debated, so that the recent guidelines differ in their indications for pharmacological intervention. Either bone mineral density (BMD) or algorithms such as FRAX do not completely account for the remarkable and rapid increase in fracture risk of most GC-treated patients. Moreover, while oral bisphosphonates remain the most used and cost-effective option, the potential increased benefits of more potent antiresorptive agents (e.g. denosumab and zoledronate) or anabolic compounds (e.g. teriparatide) warrant further investigation. Despite the above limitations, the assessment of fracture risk is recommended for all individuals committed to receiving oral GCs for 3 months or longer.
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Affiliation(s)
- Iacopo Chiodini
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research , Milan, Italy
| | - Daniela Merlotti
- Department of Medicine, Surgery and Neurosciences, University of Siena , Italy
| | - Alberto Falchetti
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research , Milan, Italy
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena , Italy
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Kanis JA, Harvey NC, McCloskey E, Bruyère O, Veronese N, Lorentzon M, Cooper C, Rizzoli R, Adib G, Al-Daghri N, Campusano C, Chandran M, Dawson-Hughes B, Javaid K, Jiwa F, Johansson H, Lee JK, Liu E, Messina D, Mkinsi O, Pinto D, Prieto-Alhambra D, Saag K, Xia W, Zakraoui L, Reginster JY. Algorithm for the management of patients at low, high and very high risk of osteoporotic fractures. Osteoporos Int 2020; 31:1-12. [PMID: 31720707 PMCID: PMC7018677 DOI: 10.1007/s00198-019-05176-3] [Citation(s) in RCA: 180] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/18/2019] [Indexed: 01/26/2023]
Abstract
Guidance is provided in an international setting on the assessment and specific treatment of postmenopausal women at low, high and very high risk of fragility fractures. INTRODUCTION The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2019. This manuscript seeks to apply this in an international setting, taking additional account of further categorisation of increased risk of fracture, which may inform choice of therapeutic approach. METHODS Clinical perspective and updated literature search. RESULTS The following areas are reviewed: categorisation of fracture risk and general pharmacological management of osteoporosis. CONCLUSIONS A platform is provided on which specific guidelines can be developed for national use to characterise fracture risk and direct interventions.
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Affiliation(s)
- J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, S10 2RX, Sheffield, UK.
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia.
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - E McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, S10 2RX, Sheffield, UK
- MRC and Arthritis Research UK Centre for Integrated Research in Musculoskeletal Ageing Mellanby, Sheffield, UK
| | - O Bruyère
- World Health Organization Collaborating Center for the Public Health Aspects of Musculoskeletal Health and Aging, Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - N Veronese
- National Research Council, Neuroscience Institute, Aging Branch, Via Giustiniani, 2, 35128, Padova, Italy
| | - M Lorentzon
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Geriatric Medicine Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - R Rizzoli
- Service of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - G Adib
- Syrian National Osteoporosis Society, Damascus, Syria
| | - N Al-Daghri
- Chair for Biomarkers of Chronic Diseases, Biochemistry Dept., College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - C Campusano
- Clinica Universidad de los Andes and Faculty of Medicine, Universidad de los Andes, Santiago, Chile
| | - M Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, ACADEMIA, 20, College Road, Singapore, 169856, Singapore
| | - B Dawson-Hughes
- Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA, USA
| | - K Javaid
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - F Jiwa
- Chair of the Committee of Patients Societies at the International Osteoporosis Foundation, Osteoporosis Canada, Toronto, Canada
| | - H Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, S10 2RX, Sheffield, UK
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
| | - J K Lee
- Beacon International Specialist Centre, Petaling Jaya, Malaysia
| | - E Liu
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
| | - D Messina
- IRO Medical Research Center, Buenos Aires and Rheumatology section, Cosme Argerich, Buenos Aires, Argentina
| | - O Mkinsi
- Department of Rheumatology, Ibn Rochd University Hospital, Casablanca, Morocco
| | - D Pinto
- Department of Physical Therapy, Marquette University, Milwaukee, WI, USA
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - D Prieto-Alhambra
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
- GREMPAL Research Group, CIBERFes and Idiap Jordi Gol, Instituto de Salud Carlos III and Universitat Autonoma de Barcelona, Barcelona, Spain
| | - K Saag
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - W Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuaifuyuan No. 1, Wangfujing, Dongcheng District, Beijing, 100730, China
| | - L Zakraoui
- Service de Rhumatologie, University Tunis Manar and Hôpital Mongi-Slim, la Marsa, Tunisia
| | - J -Y Reginster
- Chair for Biomarkers of Chronic Diseases, Biochemistry Dept., College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
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Kanis JA, Chandran M, Chionh SB, Ganeson G, Harvey NC, Koh WP, Kwok T, Lau TC, Liu E, Lorentzon M, McCloskey EV, Tan KB, Vandenput L, Johansson H. Use of age-dependent FRAX-based intervention thresholds for Singapore. Arch Osteoporos 2020; 15:104. [PMID: 32700118 PMCID: PMC7376084 DOI: 10.1007/s11657-020-00782-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/30/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED Assessment and treatment pathways based on age-specific intervention thresholds in Singapore using FRAX paths can be used to identify patients at high risk of fracture and avoid unnecessary treatment in those at low risk. PURPOSE Intervention thresholds for the treatment of osteoporosis have been based historically on the measurement of bone mineral density. The development of FRAX® has permitted a more accurate assessment of fracture risk. The aim of the present study was to explore treatment paths and characteristics of women selected for treatment in Singapore based on FRAX. METHODS The approach to the setting of intervention and assessment thresholds used the methodology adopted by the National Osteoporosis Guideline Group for FRAX-based guidelines in the UK but based on the epidemiology of fracture and death in Singapore. The methodology was applied to women age 50 years or more drawn from the population-based Singapore Chinese Health Study (SCHS) cohort. Missing data for the calculation of FRAX was simulated using data from Chinese cohorts from Hong Kong. RESULTS Intervention thresholds expressed as a 10-year probability of a major osteoporotic fracture ranged from 2.9% at the age of 50 years increasing to 32% at the age of 90 years. A total of 1927 of 29,323 women (7%) had a prior fragility fracture and would be eligible for treatment for this reason. An additional 3019 women (10.3%) would be eligible for treatment on the basis of age-dependent thresholds. The mean BMD T-score of women so selected was -2.94. CONCLUSION Probability-based assessment of fracture risk using age-specific intervention thresholds was developed for Singapore to help guide decisions about treatment.
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Affiliation(s)
- John A. Kanis
- grid.11835.3e0000 0004 1936 9262Centre for Metabolic Bone Diseases, University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK ,grid.411958.00000 0001 2194 1270Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Manju Chandran
- grid.163555.10000 0000 9486 5048Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore, Singapore
| | - Siok Bee Chionh
- grid.4280.e0000 0001 2180 6431Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ganga Ganeson
- grid.415698.70000 0004 0622 8735Division of Policy, Research and Evaluation, Ministry of Health, Singapore, Singapore
| | - Nicholas C Harvey
- grid.5491.90000 0004 1936 9297MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Woon-Puay Koh
- grid.428397.30000 0004 0385 0924Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore ,grid.4280.e0000 0001 2180 6431Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, Singapore, 117549 Singapore
| | - Timothy Kwok
- grid.415197.f0000 0004 1764 7206Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China ,grid.10784.3a0000 0004 1937 0482Jockey Club Centre for Osteoporosis Care and Control, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Tang Ching Lau
- grid.4280.e0000 0001 2180 6431Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Enwu Liu
- grid.411958.00000 0001 2194 1270Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Mattias Lorentzon
- grid.411958.00000 0001 2194 1270Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia ,grid.8761.80000 0000 9919 9582Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eugene V McCloskey
- grid.11835.3e0000 0004 1936 9262Centre for Metabolic Bone Diseases, University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK ,grid.11835.3e0000 0004 1936 9262MRC and Arthritis Research UK Centre for Integrated Research in Musculoskeletal Ageing, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - Kelvin Bryan Tan
- grid.415698.70000 0004 0622 8735Ministry of Health Singapore, Singapore, Singapore
| | - Liesbeth Vandenput
- grid.411958.00000 0001 2194 1270Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia ,grid.8761.80000 0000 9919 9582Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helena Johansson
- grid.11835.3e0000 0004 1936 9262Centre for Metabolic Bone Diseases, University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK ,grid.411958.00000 0001 2194 1270Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
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Diagnosis and treatment of autoimmune hemolytic anemia in adults: Recommendations from the First International Consensus Meeting. Blood Rev 2019; 41:100648. [PMID: 31839434 DOI: 10.1016/j.blre.2019.100648] [Citation(s) in RCA: 236] [Impact Index Per Article: 47.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 11/21/2019] [Accepted: 11/25/2019] [Indexed: 12/15/2022]
Abstract
Autoimmune hemolytic anemias (AIHAs) are rare and heterogeneous disorders characterized by the destruction of red blood cells through warm or cold antibodies. There is currently no licensed treatment for AIHA. Due to the paucity of clinical trials, recommendations on diagnosis and therapy have often been based on expert opinions and some national guidelines. Here we report the recommendations of the First International Consensus Group, who met with the aim to review currently available data and to provide standardized diagnostic criteria and therapeutic approaches as well as an overview of novel therapies. Exact diagnostic workup is important because symptoms, course of disease, and therapeutic management relate to the type of antibody involved. Monospecific direct antiglobulin test is considered mandatory in the diagnostic workup, and any causes of secondary AIHA have to be diagnosed. Corticosteroids remain first-line therapy for warm-AIHA, while the addition of rituximab should be considered early in severe cases and if no prompt response to steroids is achieved. Rituximab with or without bendamustine should be used in the first line for patients with cold agglutinin disease requiring therapy. We identified a need to establish an international AIHA network. Future recommendations should be based on prospective clinical trials whenever possible.
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78
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Liu J, Curtis EM, Cooper C, Harvey NC. State of the art in osteoporosis risk assessment and treatment. J Endocrinol Invest 2019; 42:1149-1164. [PMID: 30980341 PMCID: PMC6751157 DOI: 10.1007/s40618-019-01041-6] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 03/22/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Osteoporosis constitutes a major public health problem, through its association with age-related fractures, particularly of the hip, vertebrae, distal forearm, and humerus. Over recent decades, it has evolved from being viewed as an inevitable consequence of ageing, to being recognised as a serious and eminently treatable disease. MATERIALS AND METHODS In this article, we review the literature pertaining to the epidemiology of osteoporosis, associated health burden, approaches to risk assessment and treatment. RESULTS Although there is some evidence that fracture incidence has reached a plateau, or even started to decline, in the developed world, an ageing population and adoption of westernised lifestyles in transitioning populations is leading to an increasing burden of osteoporosis across the world. Whilst the clinical definition of osteoporosis has been based solely on bone mineral density, the prediction of fracture at the individual level has been improved by consideration of clinical risk factors in tools such as FRAX®, derived from a greater understanding of the epidemiology of osteoporosis. Such advances in approaches to primary and secondary prevention of fractures, coupled with elucidation of the underlying biology, and the development of a range of highly effective antiosteoporosis medications, have enabled a step change in our ability to prevent osteoporosis-related fractures. However, there remains a substantial disparity between the number of individuals at high fracture risk and number treated globally. CONCLUSION Urgent work is needed at the level of health care systems, national and international policy, and in communication with patients and public, to ensure that all patients who should receive treatment for osteoporosis actually do so.
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Affiliation(s)
- J Liu
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK
| | - E M Curtis
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK
- NIHR Southampton Nutrition Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK.
- NIHR Southampton Nutrition Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK.
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Zhao J, Li Y, Zhang H, Shi D, Li Q, Meng Y, Zuo L. Preventative effects of metformin on glucocorticoid-induced osteoporosis in rats. J Bone Miner Metab 2019; 37:805-814. [PMID: 30706148 DOI: 10.1007/s00774-019-00989-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 01/19/2019] [Indexed: 02/05/2023]
Abstract
This study evaluated the preventative effects of metformin (Met) on glucocorticoid (GC)-induced osteoporosis in a rat model, compared with alendronate (Aln). Twenty-eight 3-month-old female Sprague-Dawley rats were randomly assigned into four groups: normal control (Ctr), methylprednisolone (MP, 13 mg/kg/day, sc, 5 days per week), MP plus Aln orally (1 mg/kg/day), and MP plus Met orally (200 mg/kg/day). After 9 weeks, serum bone metabolic biochemistry, bone densitometry and histomorphometry were performed. The GC-induced osteoporosis model was characterized by decreased osteocalcin, increased tartrate-resistant acid phosphatase-5b (TRAP-5b), and decreased bone mineral density (BMD) in the femur and fifth lumbar vertebra (L5). Histomorphometrically, MP significantly decreased trabecular bone volume, decreased bone formation and increased bone resorption in proximal metaphysis, compared with the controls. Aln and Met increased the BMDs of femur (0.305 ± 0.011 vs. 0.280 ± 0.012, P < 0.05; 0.304 ± 0.019 vs. 0.280 ± 0.012, P < 0.05) and L5 (0.399 ± 0.029 vs. 0.358 ± 0.022, P < 0.05; 0.397 ± 0.022 vs. 0.358 ± 0.022, P < 0.05), compared with the model group. Met increased osteocalcin and decreased TRAP-5b, but Aln only decreased TRAP-5b, compared with model group. In histomorphometry of tibial proximal metaphysis, Aln and Met increased trabecular bone volume (39.21 ± 2.46 vs. 30.98 ± 5.83, P < 0.05; 38.97 ± 5.56 vs. 30.98 ± 5.83, P < 0.05), while Met increased the bone formation dynamic parameters and decreased bone resorption dynamic parameters, but Aln just decreased bone resorption dynamic parameters, compared with model group significantly. These findings suggest that metformin prevents GC-induced bone loss by suppressing bone resorption and stimulating bone formation in trabecular bone. The action mode of metformin was different from alendronate, which only suppressed bone resorption.
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Affiliation(s)
- Jianrong Zhao
- Department of Nephrology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, 010050, Inner Mongolia, People's Republic of China
| | - Yingbin Li
- Guangdong Legend Pharmaceutical Technology Co., Ltd., Jiangmen, People's Republic of China
| | - Hao Zhang
- School of Dentistry, Hubei University of Medicine, Shiyan, People's Republic of China
| | - Dongying Shi
- Department of Nephrology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, 010050, Inner Mongolia, People's Republic of China
| | - Qingnan Li
- Guangdong Laboratory Animals Monitoring Institute and Key Laboratory of Guangdong Laboratory Animals, Guangzhou, People's Republic of China
- The Center for New Drug Function Research, School of Life Science and Biopharmaceutics, Guangdong Pharmaceutical University, Guangzhou, People's Republic of China
| | - Yan Meng
- Department of Nephrology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, 010050, Inner Mongolia, People's Republic of China.
| | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China.
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Taylor AD, Saag KG. Anabolics in the management of glucocorticoid-induced osteoporosis: an evidence-based review of long-term safety, efficacy and place in therapy. CORE EVIDENCE 2019; 14:41-50. [PMID: 31692480 PMCID: PMC6711555 DOI: 10.2147/ce.s172820] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 07/17/2019] [Indexed: 12/30/2022]
Abstract
Introduction Glucocorticoid-induced osteoporosis is an underrecognized complication of chronic glucocorticoid therapy characterized by a decrease in new bone formation. Anabolic therapies, such as teriparatide, a recombinant human parathyroid hormone, combat the disease by promoting new bone growth. Aims This article outlines the pathophysiology of glucocorticoid-induced osteoporosis and details the evidence of efficacy, safety, and patterns of use of teriparatide and other future anabolic therapies. Evidence review In multiple clinical trials, teriparatide has been shown to significantly increase lumbar spine bone mineral density (BMD) in patients with glucocorticoid-induced osteoporosis when compared with placebo, alendronate, and risedronate. When compared with alendronate, significantly fewer vertebral fractures were noted in the teriparatide group. Adverse effects noted in clinical trials include nausea, insomnia, flushing, myalgias, and mild hypercalcemia/hyperuricemia. Early studies in rats noted an increased incidence of osteosarcoma; however, an increased rate beyond levels seen in general populations has not been noted in human studies or with long-term pharmacovigilance. Abaloparatide and romosozumab are newer anabolic therapies that have shown some benefit in postmenopausal osteoporosis but have not yet been studied in the chronic glucocorticoid population. Place in therapy Major specialty organizations continue to recommend bisphosphonates as first-line therapy in glucocorticoid-induced osteoporosis due to the proven benefit and relative affordability. However, the use of anabolics shows promise to improve outcomes by increasing BMD and reducing fracture-associated morbidity and mortality and has a role for selected populations at high fracture risk.
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Affiliation(s)
- Adam D Taylor
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kenneth G Saag
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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81
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Assessing the risk of osteoporotic fractures: the Ecuadorian FRAX model. Arch Osteoporos 2019; 14:93. [PMID: 31440846 DOI: 10.1007/s11657-019-0644-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/12/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED The FRAX tool incorporates data on the incidence of fractures and mortality in each country. The epidemiology of fractures changes over time, this makes it necessary to update the specific FRAX model of each population. It is shown that there are differences between old and new FRAX models in older individuals. PURPOSE A new FRAX® model for Ecuador was released online in April 2019. This paper describes the data used to build the revised model, its characteristics, and how intervention and assessment thresholds were constructed. METHODS The national rates of hip fracture incidence standardized by age and sex from the age of 40 years for 2016 were used to synthesize a FRAX model for Ecuador. For other major fractures, Ecuadorian incidence rates were calculated using ratios obtained in Malmö, Sweden, for other major osteoporotic fractures. The new FRAX model was compared with the previous model released in 2012. Assessment and intervention thresholds were based on age-specific probabilities of a major osteoporotic fracture equivalent to women with a previous fracture. RESULTS Fracture incidence rates increase with age. The probability of hip or major fractures at 10 years increased in patients with a clinical risk factor, lower BMI, female sex, a higher age, and a lower BMD T-score. Compared to the previous model, the new FRAX model gave similar 10-year fracture probabilities in men and women age less than70 years but substantially higher above this age. Notwithstanding, there were very close correlations in fracture probabilities between the two models (> 0.99) so that the revision had little impact on the rank order of risk. CONCLUSIONS The FRAX tool provides a country-specific fracture prediction model for Ecuador. This update of the model is based on the original FRAX methodology, which has been validated externally in several independent cohorts. The FRAX model is an evolving tool that is being continuously refined, as the databases of each country are updated with more epidemiological information.
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The glucocorticoid receptor agonistic modulators CpdX and CpdX-D3 do not generate the debilitating effects of synthetic glucocorticoids. Proc Natl Acad Sci U S A 2019; 116:14200-14209. [PMID: 31221758 DOI: 10.1073/pnas.1908264116] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Seventy years after the discovery of their anti-inflammatory properties, glucocorticoids (GCs) remain the mainstay treatment for major allergic and inflammatory disorders, such as atopic dermatitis, asthma, rheumatoid arthritis, colitis, and conjunctivitis, among others. However, their long-term therapeutical administration is limited by major debilitating side effects, e.g., skin atrophy, osteoporosis, Addison-like adrenal insufficiency, fatty liver, and type 2 diabetes syndrome, as well as growth inhibition in children. These undesirable side effects are mostly related to GC-induced activation of both the direct transactivation and the direct transrepression functions of the GC receptor (GR), whereas the activation of its GC-induced indirect tethered transrepression function results in beneficial anti-inflammatory effects. We have reported in the accompanying paper that the nonsteroidal compound CpdX as well as its deuterated form CpdX-D3 selectively activate the GR indirect transrepression function and are as effective as synthetic GCs at repressing inflammations generated in several mouse models of major pathologies. We now demonstrate that these CpdX compounds are bona fide selective GC receptor agonistic modulators (SEGRAMs) as none of the known GC-induced debilitating side effects were observed in the mouse upon 3-mo CpdX treatments. We notably report that, unlike that of GCs, the administration of CpdX to ovariectomized (OVX) mice does not induce a fatty liver nor type 2 diabetes, which indicates that CpdX could be used in postmenopausal women as an efficient "harmless" GC substitute.
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83
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Current Treatments and New Developments in the Management of Glucocorticoid-induced Osteoporosis. Drugs 2019; 79:1065-1087. [DOI: 10.1007/s40265-019-01145-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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84
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Araujo-Castro M, Sampedro Núñez MA, Marazuela M. Autonomous cortisol secretion in adrenal incidentalomas. Endocrine 2019; 64:1-13. [PMID: 30847651 DOI: 10.1007/s12020-019-01888-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 02/28/2019] [Indexed: 02/06/2023]
Abstract
Adrenal incidentalomas (AI) are one of the most frequent reasons for consultation in Endocrinology, as they are present in 3-10% of the general population. Up to 20% of them may have autonomous cortisol secretion (ACS), a term that refers to AI carriers with biochemical evidence of excess cortisol, but without the "specific" clinical signs of Cushing's syndrome. As ACS is associated with an increased risk of diabetes, obesity, high blood pressure (HBP), osteoporosis, cardiovascular events, and global mortality; its correct identification is of great importance. There are different laboratory assays to detect ACS, but all of them have some limitations. The dexamethasone suppression test is the most accepted for screening. However, there is no consensus on the cutoff point that should be used. Low levels of ACTH and DHEA-S and high urinary free cortisol are also associated with ACS, but in isolation they are of little value to establish the diagnosis. Considering its clinical implications and the lack of consensus in the diagnosis and in which is the most appropriate management of these patients, this review offers a quick reference guide of ACS, presenting an exhaustive review of the topic: its definition, epidemiology, diagnosis, clinical implications, treatment, and follow-up.
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Affiliation(s)
- Marta Araujo-Castro
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Madrid, Spain.
| | - Miguel Antonio Sampedro Núñez
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Madrid, Spain.
| | - Mónica Marazuela
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Madrid, Spain.
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85
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Koller G, Katz S, Charrois TL, Ye C. Glucocorticoid-induced osteoporosis preventive care in rheumatology patients. Arch Osteoporos 2019; 14:16. [PMID: 30723883 DOI: 10.1007/s11657-019-0570-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 01/27/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED Glucocorticoid-induced osteoporosis (GIOP) is common in patients prescribed with long-term glucocorticoids. Guidelines suggest patients receiving moderate-dose glucocorticoid therapy receive GIOP preventive care. Previous studies have shown preventive care rates are not optimal. We look at GIOP preventive care rates in rheumatology patients and predictors of various components of care. PURPOSE Glucocorticoid-induced osteoporosis (GIOP) is a common concern in patients prescribed with long-term glucocorticoids. Studies have shown GIOP preventive care is not provided optimally in the general population; however, little is published on GIOP preventive care among patients with rheumatic disease. The objective of this study is to determine the proportion of rheumatology patients who received GIOP preventive care. METHODS A population-based retrospective quality assurance study of adults seen at the University of Alberta Rheumatology Clinic was performed using the electronic outpatient medical record. Records of adult patients prescribed with prednisone from January 1st to December 31st, 2016 by a rheumatologist were initially included for review. Those who had been prescribed ≥ 7.5 mg/day for ≥ 3 months were assessed for concurrent GIOP preventive care. RESULTS A total of 745 discreet courses of prednisone were prescribed in 433 patients with 113 meeting the above inclusion criteria. Following the prednisone prescription, 79% were taking vitamin D, 86% were taking calcium, and 50% were prescribed with osteoporosis pharmacotherapy. Twenty-five percent of patients had DXA imaging ordered by the rheumatologist within the first 6 months; of these, 86% of patients completed the DXA. CONCLUSIONS Overall, our study shows that patients under the care of rheumatologists receive better GIOP preventative care than previously reported care in the general population. However, there is still room for improvement. In particular, men, younger patients, and rural patients seem to be at the most at risk of not receiving optimal GIOP prevention.
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Affiliation(s)
- G Koller
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - S Katz
- Department of Medicine, Division of Rheumatology, University of Alberta, 8-130 Clinical Sciences Building, 11350 83rd Avenue NW, Edmonton, AB, T6G 2G3, Canada
| | - T L Charrois
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - C Ye
- Department of Medicine, Division of Rheumatology, University of Alberta, 8-130 Clinical Sciences Building, 11350 83rd Avenue NW, Edmonton, AB, T6G 2G3, Canada.
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86
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Hayashi M, Morimoto Y, Iida T, Tanaka Y, Sugiyama S. Risk of Delayed Healing of Tooth Extraction Wounds and Osteonecrosis of the Jaw among Patients Treated with Potential Immunosuppressive Drugs: A Retrospective Cohort Study. TOHOKU J EXP MED 2019; 246:257-264. [PMID: 30568073 DOI: 10.1620/tjem.246.257] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Bone-modifying or antiresorptive agents that target osteoclasts, such as bisphosphonates, are known to cause delayed wound healing and osteonecrosis of the jaw (ONJ) following tooth extraction. However, there are no data on whether such adverse events are also caused by drugs that may suppress the immune system, including corticosteroids, immunosuppressants, biological agents, and disease-modifying anti-rheumatic drugs (DMARDs). The aim of this retrospective study was to examine the incidence of delayed post-extraction wound healing and identify risk factors among patients treated with potential immunosuppressive drugs undergoing tooth extraction. We performed a retrospective cohort study involving 101 patients by reviewing their medical records. The underlying diseases of the enrolled patients included dilated cardiomyopathy, hematological malignancy, sarcoidosis, rheumatoid arthritis, and systemic lupus erythematosus. The sample comprised 131 cases of tooth extraction among the 101 patients; delayed post-extraction wound healing occurred in 10 patients (12 cases, 9.2%), including ONJ in three patients (3 cases, 2.3%). The surgical tooth extraction performed for impacted teeth or a residual root (P = 0.009), the number of surgical tooth extraction (P = 0.012), decreased lymphocyte counts (P = 0.008), and decreased eosinophil counts (P = 0.009) were significantly related to delayed wound healing. Thus, among patients taking corticosteroids, immunosuppressants, biological agents, and/or DMARDs, there is a risk of delayed wound healing and ONJ. Moreover, the significant risk factors are low lymphocyte counts, low eosinophil counts, and surgical extraction. It is of particular importance to prevent surgical site infection, when the high-risk patients undergo tooth extraction.
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Affiliation(s)
- Megumi Hayashi
- Department of Critical Care Medicine and Dentistry, Graduate School of Dentistry, Kanagawa Dental University.,Special Patient Oral Care Unit, Kyushu University Hospital
| | - Yoshinari Morimoto
- Department of Critical Care Medicine and Dentistry, Graduate School of Dentistry, Kanagawa Dental University.,Special Patient Oral Care Unit, Kyushu University Hospital.,Department of Dentistry, National Cerebral and Cardiovascular Center
| | - Takatoshi Iida
- Department of Critical Care Medicine and Dentistry, Graduate School of Dentistry, Kanagawa Dental University
| | - Yohei Tanaka
- Department of Critical Care Medicine and Dentistry, Graduate School of Dentistry, Kanagawa Dental University
| | - Shuntaro Sugiyama
- Department of Critical Care Medicine and Dentistry, Graduate School of Dentistry, Kanagawa Dental University
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87
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Hill QA, Grainger JD, Thachil J, Provan D, Evans G, Garg M, Bradbury C, Bagot C, Kanis JA, Compston JE. The prevention of glucocorticoid‐induced osteoporosis in patients with immune thrombocytopenia receiving steroids: a British Society for Haematology Good Practice Paper. Br J Haematol 2019; 185:410-417. [DOI: 10.1111/bjh.15735] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
| | - John D. Grainger
- Royal Manchester Children's Hospital Manchester University Hospitals NHS Foundation Trust Manchester Academic Health Science Centre Manchester UK
- Faculty of Medical & Human Sciences University of Manchester Manchester UK
| | - Jecko Thachil
- Department of Haematology Manchester Royal Infirmary Manchester UK
| | - Drew Provan
- Department of Haematology Barts& The London School of Medicine & Dentistry London UK
| | - Gillian Evans
- Department of Haematology Kent and Canterbury Hospital Canterbury UK
| | - Mamta Garg
- Department of Haematology Leicester Royal Infirmary Leicester UK
| | - Charlotte Bradbury
- University Hospitals Bristol NHS Foundation Trust Bristol UK
- Department of Cellular and Molecular Medicine University of Bristol Bristol UK
| | - Catherine Bagot
- Department of Haematology Glasgow Royal Infirmary Glasgow UK
| | - John A. Kanis
- Centre for Metabolic Bone Diseases University of Sheffield Medical School Sheffield UK
- Institute for Health and Ageing Australian Catholic University Melbourne Australia
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88
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Suh CH. Korean Guideline of Glucocorticoid-induced Osteoporosis; Time to Prevent Fracture! JOURNAL OF RHEUMATIC DISEASES 2019. [DOI: 10.4078/jrd.2019.26.2.87] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Chang-Hee Suh
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
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89
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Kanis JA, Cooper C, Rizzoli R, Reginster JY. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 2019; 30:3-44. [PMID: 30324412 PMCID: PMC7026233 DOI: 10.1007/s00198-018-4704-5] [Citation(s) in RCA: 858] [Impact Index Per Article: 171.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 09/12/2018] [Indexed: 12/25/2022]
Abstract
Guidance is provided in a European setting on the assessment and treatment of postmenopausal women at risk from fractures due to osteoporosis. INTRODUCTION The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2013. This manuscript updates these in a European setting. METHODS Systematic reviews were updated. RESULTS The following areas are reviewed: the role of bone mineral density measurement for the diagnosis of osteoporosis and assessment of fracture risk; general and pharmacological management of osteoporosis; monitoring of treatment; assessment of fracture risk; case-finding strategies; investigation of patients; health economics of treatment. The update includes new information on the evaluation of bone microstructure evaluation in facture risk assessment, the role of FRAX® and Fracture Liaison Services in secondary fracture prevention, long-term effects on fracture risk of dietary intakes, and increased fracture risk on stopping drug treatment. CONCLUSIONS A platform is provided on which specific guidelines can be developed for national use.
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Affiliation(s)
- J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia.
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - R Rizzoli
- University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
| | - J-Y Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- Prince Mutaib Chair for Biomarkers of Osteoporosis, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
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90
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Abstract
Osteoporosis is a "skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture" which, in light of demographic change, is becoming an increasing burden on health care worldwide. Increasing age and female gender are associated with the condition, although a wider range of clinical risk factors are being used increasingly to identify those at risk of osteoporosis and its most important sequelae, fracture.While osteoporosis and fracture have long been associated with women in the post-menopausal age, fracture incidence increases because of the ageing of our population. Interventions to abate the progression of osteoporosis and to prevent fractures must focus on the old and the very old. Evidence associating nutritional factors, particularly calcium and vitamin D are reviewed as are the association of falls risk with fracture and the potential for interventions to prevent falls. Finally, the assessment of frailty in the oldest old, associated sarcopenia and multi-morbidity are considered in the evaluation of fall and fracture risk and the management of osteoporosis in the ninth decade of life and beyond.
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Affiliation(s)
- Terry J Aspray
- NIHR Biomedical Research Centre, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, UK. .,Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK. .,Institute of Ageing, Newcastle University, Newcastle-Upon-Tyne, UK.
| | - Tom R Hill
- Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK.,Institute of Ageing, Newcastle University, Newcastle-Upon-Tyne, UK.,Human Nutrition Research Centre, Newcastle University, Newcastle-Upon-Tyne, UK
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91
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Adler RA. Glucocorticoid-Induced Osteoporosis: Management Challenges in Older Patients. J Clin Densitom 2019; 22:20-24. [PMID: 29941355 DOI: 10.1016/j.jocd.2018.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 03/07/2018] [Indexed: 12/11/2022]
Abstract
Glucocorticoid-induced osteoporosis remains the most common type of secondary osteoporosis, mostly due to use of oral glucocorticoids rather than due to endogenous overproduction of cortisol. Partly because glucocorticoids are prescribed by a wide variety of clinicians for many different inflammatory disorders, only a minority of older individuals have adequate and timely assessment of their enhanced fracture risk, and fewer are offered treatment. Assessment should include bone density, the FRAX calculation, and, in many cases, images of the spine. Glucocorticoids decrease osteoblast function and increase apoptosis of osteoblasts and osteocytes, leading to increased fracture risk soon after starting glucocorticoids. Guidelines provide evidence-based recommendations for evaluation and treatment, but there are differences in extant guidelines, and methods to improve adherence to the guidelines have mostly failed. A strong case can be made to use anabolic drugs first in high-risk patients based on pathophysiology and head-to-head clinical trials.
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Affiliation(s)
- Robert A Adler
- Endocrinology and Metabolism (111P), McGuire Veterans Affairs Medical Center, Richmond, VA, USA; Endocrine Division, Virginia Commonwealth University School of Medicine, Richmond, VA, USA.
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92
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Affiliation(s)
- Lenore Buckley
- From the Yale School of Medicine, New Haven, CT (L.B.); and the University of Oklahoma Health Sciences Center, Oklahoma City (M.B.H.)
| | - Mary B Humphrey
- From the Yale School of Medicine, New Haven, CT (L.B.); and the University of Oklahoma Health Sciences Center, Oklahoma City (M.B.H.)
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93
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Vidal M, Thibodaux RJ, Neira LFV, Messina OD. Osteoporosis: a clinical and pharmacological update. Clin Rheumatol 2018; 38:385-395. [PMID: 30542797 DOI: 10.1007/s10067-018-4370-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 11/12/2018] [Indexed: 12/19/2022]
Abstract
Osteoporosis is characterized by the loss of bone mass, deterioration of the bone microarchitecture, and an increased risk of fractures; these later complications are associated with significant morbidity and mortality. The asymptomatic and progressive nature of osteoporosis underscores the importance of identifying this entity in early stages. Despite the various treatments available, the prevention of the disease represents the most important aspect of management. An adequate intake of calcium and vitamin D as well as a healthy lifestyle is the basis for maintaining bone health. When osteoporosis is diagnosed, the choice of medications must be individualized considering characteristics of the patient and the risk of fractures. In this article, we review the main causes of osteoporosis, when and how to start treatment, and appropriate therapy and monitoring.
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Affiliation(s)
- Maritza Vidal
- Centro de Diagnóstico de Osteoporosis y Enfermedades Reumáticas (CEDOR), Lima, Peru.
| | - Ross J Thibodaux
- Division of Rheumatology, LSU Health Sciences Center - New Orleans, New Orleans, LA, USA
| | - Luis Fernando Vidal Neira
- Centro de Diagnóstico de Osteoporosis y Enfermedades Reumáticas (CEDOR), Lima, Peru.,Hospital María Auxiliadora, Lima, Peru.,International Osteoporosis Foundation (IOF), Nyon, Switzerland
| | - Osvaldo Daniel Messina
- Hospital Cosme Argerich, Buenos Aires, Argentina.,International Osteoporosis Foundation (IOF), Buenos Aires, Argentina
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94
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Kendler DL, Body JJ, Brandi ML, Broady R, Cannata-Andia J, Cannata-Ortiz MJ, El Maghraoui A, Guglielmi G, Hadji P, Pierroz DD, de Villiers TJ, Rizzoli R, Ebeling PR. Bone management in hematologic stem cell transplant recipients. Osteoporos Int 2018; 29:2597-2610. [PMID: 30178158 DOI: 10.1007/s00198-018-4669-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 08/13/2018] [Indexed: 12/13/2022]
Abstract
Autologous and allogeneic hematopoietic stem cell transplantation (HSCT) is the treatment of choice for patients with some malignant and non-malignant hematological diseases. Advances in transplantation techniques and supportive care measures have substantially increased the number of long-term HSCT survivors. This has led to an increasing patient population suffering from the late effects of HSCT, of which, bone loss and its consequent fragility fractures lead to substantial morbidity. Altered bone health, with consequent fragility fractures, and chronic graft-versus-host disease (GVHD) are factors affecting long-term quality of life after HSCT. Hypogonadism, HSCT preparative regimens, nutritional factors, and glucocorticoids all contribute to accelerated bone loss and increased fracture risk. Management strategies should include bone mineral density examination, evaluation of clinical risk factors, and general dietary and physical activity measures. Evidence has accumulated permitting recommendations for more attentiveness to evaluation and monitoring of bone health, with appropriate application of osteoporosis pharmacotherapies to patients at increased risk of bone loss and fracture.
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Affiliation(s)
- D L Kendler
- Department of Medicine, Division of Endocrinology, University of British Columbia, 150 - 943 W. Broadway, Vancouver, V5Z 4E1, Canada.
| | - J J Body
- CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - M L Brandi
- Mineral and Bone Metabolic Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - R Broady
- Department of Medicine, Division of Hematology, University of British Columbia, Vancouver, Canada
| | - J Cannata-Andia
- Servicio de Metabolismo Óseo y Mineral, Hospital Universitario Central de Asturias, Universidad de Oviedo, Oviedo, Spain
| | - M J Cannata-Ortiz
- Haematology Department, IIS Princesa, Hospital de la Princesa, Madrid, Spain
| | - A El Maghraoui
- Rheumatology Department, Military Hospital Mohammed V, Mohammed V-Souissi University, Rabat, Morocco
| | - G Guglielmi
- Department of Radiology, University of Foggia, Foggia, Italy
| | - P Hadji
- Department of Bone Oncology, Endocrinology and Reproductive Medicine, Nord West Hospital, Frankfurt, Germany
| | - D D Pierroz
- International Osteoporosis Foundation (IOF), Nyon, Switzerland
| | - T J de Villiers
- Department of Gynaecology, Faculty of Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Mediclinic Panorama, Cape Town, South Africa
| | - R Rizzoli
- Division of Bone Diseases, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - P R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Australia
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95
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Park SY, Gong HS, Kim KM, Kim D, Kim HY, Jeon CH, Ju JH, Lee SS, Park DA, Sung YK, Kim SW. Korean Guideline for the Prevention and Treatment of Glucocorticoid-induced Osteoporosis. J Bone Metab 2018; 25:195-211. [PMID: 30574464 PMCID: PMC6288607 DOI: 10.11005/jbm.2018.25.4.195] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/06/2018] [Accepted: 08/10/2018] [Indexed: 12/15/2022] Open
Abstract
Background To develop guidelines and recommendations to prevent and treat glucocorticoid (GC)-induced osteoporosis (GIOP) in Korea. Methods The Korean Society for Bone and Mineral Research and the Korean College of Rheumatology have developed this guideline based on Guidance for the Development of Clinical Practice Guidelines ver. 1.0 established by the National Evidence-Based Healthcare Collaborating Agency. This guideline was developed by adapting previously published guidelines, and a systematic review and quality assessment were performed. Results This guideline applies to adults aged ≥19 years who are using or plan to use GCs. It does not include children and adolescents. An initial assessment of fracture risk should be performed within 6 months of initial GC use. Fracture risk should be estimated using the fracture-risk assessment tool (FRAX) after adjustments for GC dose, history of osteoporotic fractures, and bone mineral density (BMD) results. All patients administered with prednisolone or an equivalent medication at a dose ≥2.5 mg/day for ≥3 months are recommended to use adequate calcium and vitamin D during treatment. Patients showing a moderate-to-high fracture risk should be treated with additional medication for osteoporosis. All patients continuing GC therapy should undergo annual BMD testing, vertebral X-ray, and fracture risk assessment using FRAX. When treatment failure is suspected, switching to another drug should be considered. Conclusions This guideline is intended to guide clinicians in the prevention and treatment of GIOP.
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Affiliation(s)
- So Young Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Hyun Sik Gong
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Kyoung Min Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Dam Kim
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Young Kim
- Division of Endocrinology, Department of Internal Medicine, Wonkwang University Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, Korea
| | - Chan Hong Jeon
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University Hospital, Bucheon, Korea
| | - Ji Hyeon Ju
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Shin-Seok Lee
- Department of Rheumatology, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Dong-Ah Park
- Division of Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Yoon-Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Sang Wan Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University College of Medicine, Boramae Medical Center, Seoul, Korea
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96
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Balasubramanian A, Wade SW, Adler RA, Saag K, Pannacciulli N, Curtis JR. Glucocorticoid Exposure and Fracture Risk in a Cohort of US Patients With Selected Conditions. J Bone Miner Res 2018; 33:1881-1888. [PMID: 29924418 DOI: 10.1002/jbmr.3523] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 06/05/2018] [Accepted: 06/07/2018] [Indexed: 11/07/2022]
Abstract
The purpose of this work was to evaluate systemic glucocorticoid exposure and fracture among patients with newly-diagnosed inflammatory and immune-modulated conditions. Using administrative data, inception cohorts of rheumatoid arthritis (RA), asthma/chronic obstructive pulmonary disease (COPD), inflammatory bowel disease (IBD), multiple sclerosis (MS), lupus, and sarcoidosis patients age 18 to 64 years with benefits coverage ≥12 months before diagnosis (January 1, 2005 to December 31, 2012) were followed to clinical fracture, cancer diagnosis, or December 31, 2012. Glucocorticoid users were new to therapy. Fracture incidence rates (IRs) per 1000 person-years were stratified by prednisone equivalent doses. Cox's proportional hazards models assessed risk by daily and cumulative dose, and by time since discontinuation, adjusted for baseline characteristics. Most patients (72% of 403,337) had glucocorticoid exposure; 52% were under age 50. IR (95% confidence interval [CI]) of any osteoporotic fracture was elevated at doses <5 mg/day (IR 9.33; 95% CI, 7.29 to 11.77) versus 0 mg/day (IR 4.87 (95% CI, 4.72 to 5.02). Fracture rates were elevated at doses <5 mg/day in patients <50 years and those ≥50 years. In both age groups, fracture risk increased with increasing cumulative exposure, being approximately 2.5-fold higher at cumulative dose ≥5400 mg compared to <675 mg. At ≥5400 mg, IR values were 5.69 (95% CI, 4.32 to 7.35) in patients <50 years and 17.10 (95% CI, 14.97 to 19.46) in older patients. Fracture risk decreased significantly within months following glucocorticoid discontinuation. In patients with a variety of inflammatory conditions, fracture risk increased at doses as low as <5 mg/day. Risk increased with increasing cumulative exposure and decreased soon following glucocorticoid discontinuation. Trends were similar between patients older and younger than 50 years. © 2018 The Authors. Journal of Bone and Mineral Research Published by Wiley Periodicals, Inc.
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Affiliation(s)
| | - Sally W Wade
- Wade Outcomes Research and Consulting, Salt Lake City, UT, USA
| | - Robert A Adler
- McGuire Veterans Affairs Medical Center and Virginia Commonwealth University, Richmond, VA, USA
| | - Kenneth Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
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97
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Hardy RS, Zhou H, Seibel MJ, Cooper MS. Glucocorticoids and Bone: Consequences of Endogenous and Exogenous Excess and Replacement Therapy. Endocr Rev 2018; 39:519-548. [PMID: 29905835 DOI: 10.1210/er.2018-00097] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/08/2018] [Indexed: 02/02/2023]
Abstract
Osteoporosis associated with long-term glucocorticoid therapy remains a common and serious bone disease. Additionally, in recent years it has become clear that more subtle states of endogenous glucocorticoid excess may have a major impact on bone health. Adverse effects can be seen with mild systemic glucocorticoid excess, but there is also evidence of tissue-specific regulation of glucocorticoid action within bone as a mechanism of disease. This review article examines (1) the role of endogenous glucocorticoids in normal bone physiology, (2) the skeletal effects of endogenous glucocorticoid excess in the context of endocrine conditions such as Cushing disease/syndrome and autonomous cortisol secretion (subclinical Cushing syndrome), and (3) the actions of therapeutic (exogenous) glucocorticoids on bone. We review the extent to which the effect of glucocorticoids on bone is influenced by variations in tissue metabolizing enzymes and glucocorticoid receptor expression and sensitivity. We consider how the effects of therapeutic glucocorticoids on bone are complicated by the effects of the underlying inflammatory disease being treated. We also examine the impact that glucocorticoid replacement regimens have on bone in the context of primary and secondary adrenal insufficiency. We conclude that even subtle excess of endogenous or moderate doses of therapeutic glucocorticoids are detrimental to bone. However, in patients with inflammatory disorders there is a complex interplay between glucocorticoid treatment and underlying inflammation, with the underlying condition frequently representing the major component underpinning bone damage.
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Affiliation(s)
- Rowan S Hardy
- University of Birmingham, Birmingham, United Kingdom
| | - Hong Zhou
- Bone Research Program, ANZAC Research Institute, Sydney, New South Wales, Australia
| | - Markus J Seibel
- Bone Research Program, ANZAC Research Institute, Sydney, New South Wales, Australia.,Department of Endocrinology and Metabolism, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Concord Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mark S Cooper
- Department of Endocrinology and Metabolism, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Concord Clinical School, University of Sydney, Sydney, New South Wales, Australia.,Adrenal Steroid Laboratory, ANZAC Research Institute, Sydney, New South Wales, Australia
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98
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Campbell EJ, Clarke AE, Ramsey-Goldman R. Systemic lupus erythematosus: a case-based presentation of renal, neurologic, and hematologic emergencies. Expert Rev Clin Immunol 2018; 14:803-816. [PMID: 30173578 DOI: 10.1080/1744666x.2018.1518132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder with systemic manifestations and multiorgan involvement. Although primarily diagnosed, and managed in the outpatient setting, it can occasionally present with life-threatening complications that require rapid assessment and urgent aggressive therapy. Areas covered: In our review, we explore three organ systems that are often affected in SLE, but have the potential to present as medical emergencies; these are the kidney, the central nervous system, and the hematologic system. We take a case-based approach to each clinical scenario, with information given sequentially in order to reflect "real-life" situations where management decisions need to be made with limited information. We review the acute management, pathophysiology, diagnostic approach, and treatment along with a review of the literature, for lupus nephritis presenting as rapidly progressive glomerulonephritis, acute lupus transverse myelitis, and refractory antiphospholipid syndrome. Expert commentary: At the conclusion of each section, we provide an expert commentary regarding each issue, relating to diagnosis, early management, and current evidence behind treatment recommendations.
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Affiliation(s)
- Eric J Campbell
- a Internal Medicine Resident, Department of Medicine, Cumming School of Medicine , University of Calgary , Calgary , Alberta , Canada
| | - Ann E Clarke
- b Professor of Medicine, Division of Rheumatology, The Arthritis Society Chair in Rheumatic Diseases, Cumming School of Medicine , University of Calgary , Calgary , Alberta , Canada
| | - Rosalind Ramsey-Goldman
- c Solovy Arthritis Research Society Professor of Medicine, Department of Medicine/Rheumatology , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
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99
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Shen G, Ren H, Shang Q, Qiu T, Yu X, Zhang Z, Huang J, Zhao W, Zhang Y, Liang D, Jiang X. Autophagy as a target for glucocorticoid-induced osteoporosis therapy. Cell Mol Life Sci 2018; 75:2683-2693. [PMID: 29427075 PMCID: PMC11105583 DOI: 10.1007/s00018-018-2776-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 01/25/2018] [Accepted: 02/06/2018] [Indexed: 02/07/2023]
Abstract
Autophagy takes part in regulating the eukaryotic cells function and the progression of numerous diseases, but its clinical utility has not been fully developed yet. Recently, mounting evidences highlight an important correlation between autophagy and bone homeostasis, mediated by osteoclasts, osteocytes, bone marrow mesenchymal stem cells, and osteoblasts, and autophagy plays a vital role in the pathogenesis of glucocorticoid-induced osteoporosis (GIOP). The combinations of autophagy activators/inhibitors with anti-GIOP first-line drugs or some new autophagy-based manipulators, such as regulation of B cell lymphoma 2 family proteins and caspase-dependent clearance of autophagy-related gene proteins, are likely to be the promising approaches for GIOP clinical treatments. In view of the important role of autophagy in the pathogenesis of GIOP, here we review the potential mechanisms about the impacts of autophagy in GIOP and its association with GIOP therapy.
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Affiliation(s)
- Gengyang Shen
- Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Hui Ren
- Department of Spinal Surgery, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Qi Shang
- Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Ting Qiu
- Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Xiang Yu
- Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Zhida Zhang
- Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Jinjing Huang
- Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Wenhua Zhao
- Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Yuzhuo Zhang
- Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - De Liang
- Department of Spinal Surgery, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Xiaobing Jiang
- Department of Spinal Surgery, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
- Laboratory Affiliated to National Key Discipline of Orthopaedic and Traumatology of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
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100
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Kanis JA, Cooper C, Rizzoli R, Reginster JY. Review of the guideline of the American College of Physicians on the treatment of osteoporosis. Osteoporos Int 2018; 29:1505-1510. [PMID: 29869039 PMCID: PMC6037298 DOI: 10.1007/s00198-018-4504-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 01/11/2018] [Indexed: 10/14/2022]
Abstract
This review, endorsed by the International Osteoporosis Foundation and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases, summarizes several failings of the recent guidelines of the American College of Physicians (ACP) on the treatment of low bone density or osteoporosis to prevent fractures. INTRODUCTION The ACP recently issued guidelines for the treatment of low bone density or osteoporosis to prevent fractures. METHODS Literature review and critical review of the ACP guidelines. RESULTS The guideline is lacking in scope due to the endorsement of treatment based on T-scores rather than fracture risk assessment and in failure to adequately consider anabolic therapies. CONCLUSIONS The ACP guideline appears outdated.
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Affiliation(s)
- J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia.
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - R Rizzoli
- Service of Bone Diseases, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - J-Y Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- WHO Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, Liège, Belgium
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