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Amiche MA, Abtahi S, Driessen JHM, Vestergaard P, de Vries F, Cadarette SM, Burden AM. Impact of cumulative exposure to high-dose oral glucocorticoids on fracture risk in Denmark: a population-based case-control study. Arch Osteoporos 2018; 13:30. [PMID: 29552730 PMCID: PMC5857556 DOI: 10.1007/s11657-018-0424-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 01/03/2018] [Indexed: 02/03/2023]
Abstract
UNLABELLED We examined the effect of cumulative exposure to high doses of oral glucocorticoids on fracture risk. Compared to short-course users (daily dose ≥ 15 mg + cumulative < 1 g), heavy users (daily dose ≥ 15 mg + cumulative dose ≥ 1 g) had the highest risk of fracture. These patients should be monitored for fracture management strategies. PURPOSE The effect of cumulative exposure to high daily doses of oral glucocorticoids on fracture risk remains debated. We therefore aimed to examine the hip fracture risk associated with short courses and heavy use of high-dosed oral glucocorticoids. METHODS We conducted a population-based case-control study using the Danish National Health Service data, 1996-2011. Cases were those aged ≥ 18 years who sustained a hip (primary outcome) fracture (n = 81,342). Vertebral and forearm fractures were considered in secondary analyses. Controls (matched 1:1) were those without a fracture. Average daily dose (DD) and total cumulative dose (CD) were calculated among current oral glucocorticoid users. Among patients with a high daily dose (DD ≥ 15 mg), we identified short-course users as those with a CD < 1 g and heavy users as those with a CD ≥ 1 g. We estimated adjusted odds ratio (adj.OR) of fracture with current glucocorticoid use compared to never-use, using conditional logistic regression. RESULTS A high DD (≥ 15 mg) and high CD (≥ 1 g) were independently associated with an increased hip fracture risk (adj.OR 2.5; 95% CI 2.2-2.9; adj.OR 1.6; 95% CI 1.5-1.8, respectively). However, the risk was substantially increased among heavy users (DD ≥ 15 mg and CD ≥ 1 g: adj.OR 2.9; 95% CI 2.5-3.4) as compared to short-course users (DD ≥ 15 mg and CD < 1 g: adj.OR 1.4; 95% CI 1.1-1.9). Associations were stronger for vertebral fractures, yet little association was identified for forearm fractures. CONCLUSION Among patients receiving a high DD (≥ 15 mg), heavy users (≥ 1 g CD) showed the most substantial increase in hip fracture risk. Among those receiving high DD, a threshold of 1 g CD may identify heavy users that are candidates for focused fracture management services.
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Affiliation(s)
- M. Amine Amiche
- 0000 0001 2157 2938grid.17063.33Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada
| | - Shahab Abtahi
- 0000 0004 0480 1382grid.412966.eDepartment of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands ,0000 0001 0481 6099grid.5012.6Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands
| | - Johanna H. M. Driessen
- 0000 0004 0480 1382grid.412966.eDepartment of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands ,0000 0001 0481 6099grid.5012.6Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands ,0000000120346234grid.5477.1Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands ,0000 0001 0481 6099grid.5012.6NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Peter Vestergaard
- 0000 0001 0742 471Xgrid.5117.2Department of Clinical Medicine, Aalborg University, Aalborg, Denmark ,0000 0004 0646 7349grid.27530.33Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Frank de Vries
- 0000 0004 0480 1382grid.412966.eDepartment of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands ,0000 0001 0481 6099grid.5012.6Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands ,0000000120346234grid.5477.1Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Suzanne M. Cadarette
- 0000 0001 2157 2938grid.17063.33Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada
| | - Andrea M. Burden
- 0000 0004 0480 1382grid.412966.eDepartment of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands ,0000 0001 0481 6099grid.5012.6Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands ,0000000120346234grid.5477.1Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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Paskins Z, Jinks C, Mahmood W, Jayakumar P, Sangan CB, Belcher J, Gwilym S. Public priorities for osteoporosis and fracture research: results from a general population survey. Arch Osteoporos 2017; 12:45. [PMID: 28455735 PMCID: PMC5409917 DOI: 10.1007/s11657-017-0340-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 04/18/2017] [Indexed: 02/03/2023]
Abstract
This is the first national study of public and patient research priorities in osteoporosis and fracture. We have identified new research areas of importance to members of the public, particularly 'access to information from health professionals'. The findings are being incorporated into the research strategy of the National Osteoporosis Society. PURPOSE This study aimed to prioritise, with patients and public members, research topics for the osteoporosis research agenda. METHODS An e-survey to identify topics for research was co-designed with patient representatives. A link to the e-survey was disseminated to supporters of the UK National Osteoporosis Society (NOS) in a monthly e-newsletter. Responders were asked to indicate their top priority for research across four topics (understanding and preventing osteoporosis, living with osteoporosis, treating osteoporosis and treating fractures) and their top three items within each topic. Descriptive statistics were used to describe demographics and item ranking. A latent class analysis was applied to identify a substantive number of clusters with different combinations of binary responses. RESULTS One thousand one hundred eighty-eight (7.4%) respondents completed the e-survey. The top three items overall were 'Having easy access to advice and information from health professionals' (63.8%), 'Understanding further the safety and benefit of osteoporosis drug treatments' (49.9%) and 'Identifying the condition early by screening' (49.2%). Latent class analysis revealed distinct clusters of responses within each topic including primary care management and self-management. Those without a history of prior fracture or aged under 70 were more likely to rate items within the cluster of self-management as important (21.0 vs 12.9 and 19.8 vs 13.3%, respectively). CONCLUSION This is the first study of public research priorities in osteoporosis and has identified new research areas of importance to members of the public including access to information. The findings are being incorporated into the research strategy of the National Osteoporosis Society.
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Affiliation(s)
- Zoe Paskins
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK.
- Haywood Academic Rheumatology Centre, Staffordshire and Stoke-on-Trent Partnership Trust, Stoke-on-Trent, ST6 7AG, UK.
| | - Clare Jinks
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Waheed Mahmood
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Prakash Jayakumar
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - John Belcher
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Stephen Gwilym
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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103
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Prevalence and risk factors associated with glucocorticoid-induced osteoporosis in Chinese patients with rheumatoid arthritis. Arch Osteoporos 2017; 12:33. [PMID: 28374332 DOI: 10.1007/s11657-017-0329-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 03/27/2017] [Indexed: 02/03/2023]
Abstract
UNLABELLED Usage of glucocorticoid (GC) is a strong risk factor of osteoporosis (OP) and osteoporotic fracture (OPF) in Chinese patients with rheumatoid arthritis (RA). Controlling GC daily dosage and shortening GC course are helpful in preventing glucocorticoid-induced osteoporosis (GIOP) and OPF for Chinese patients with RA. INTRODUCTION This study aims to investigate the prevalence and risk factors of GIOP, and also identify influences of GC daily dosage and GC treatment course for GIOP in Chinese patients with RA. METHODS Seven hundred and ninety patients with RA and 158 normal subjects were enrolled in the study. Clinical and laboratory features and medications of GC were recorded in detail. Bone mineral density (BMD) was measured by dual energy X-ray absorptiometry in all subjects. RESULTS BMD at all measured sites in RA was significantly lower than that in control group. Prevalence of OP was obviously higher in RA with GC group (41.6%), compared with RA without GC group (29.4%). Prevalence of OPF in group of RA with GC (21.0%) was higher than that in group of RA without GC (13.3%). Usage of GC, female, and age were risk factors for the occurrence of OP and OPF in RA, while body mass index (BMI) was the protective factor of OP. Prevalence of GIOP and OPF had statistical significance among groups of different treatment courses with GC, whereas no statistical difference was found among groups with different daily dosages of GC. CONCLUSIONS GIOP exists generally in Chinese patients with RA, which relates to treatment course not daily dosage of GC. Usage of GC is also the risk factor for the happening of OPF in Chinese patients with RA.
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Compston J, Cooper A, Cooper C, Gittoes N, Gregson C, Harvey N, Hope S, Kanis JA, McCloskey EV, Poole KES, Reid DM, Selby P, Thompson F, Thurston A, Vine N. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos 2017; 12:43. [PMID: 28425085 PMCID: PMC5397452 DOI: 10.1007/s11657-017-0324-5] [Citation(s) in RCA: 500] [Impact Index Per Article: 71.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 03/07/2017] [Indexed: 02/03/2023]
Abstract
INTRODUCTION In 2008, the UK National Osteoporosis Guideline Group (NOGG) produced a guideline on the prevention and treatment of osteoporosis, with an update in 2013. This paper presents a major update of the guideline, the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women and men age 50 years or over. METHODS Where available, systematic reviews, meta-analyses and randomised controlled trials were used to provide the evidence base. Conclusions and recommendations were systematically graded according to the strength of the available evidence. RESULTS Review of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment, lifestyle measures and pharmacological interventions, duration and monitoring of bisphosphonate therapy, glucocorticoid-induced osteoporosis, osteoporosis in men, postfracture care and intervention thresholds. CONCLUSION The guideline, which has received accreditation from the National Institute of Health and Care Excellence (NICE), provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals who are involved in its management.
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Affiliation(s)
- J. Compston
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - A. Cooper
- Crawley Fracture Liaison Service, Crawley, Sussex, UK
| | - C. Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - N. Gittoes
- University Hospitals Birmingham NHS Foundation Trust, Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham & Birmingham Health Partners, Birmingham, UK
| | - C. Gregson
- Musculoskeletal Research Unit, University of Bristol and Royal United Hospital NHS Foundation Trust, Bath, UK
| | - N. Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - S. Hope
- Metabolic Bone, Nuffield Orthopaedic Hospital, Oxford, UK
| | - J. A. Kanis
- Centre for Metabolic Diseases, University of Sheffield Medical School, Sheffield, UK
| | | | - K. E. S. Poole
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - D. M. Reid
- Emeritus Professor of Rheumatology, University of Aberdeen, Aberdeen, UK
| | - P. Selby
- Metabolic Bone Disease, University of Manchester, Manchester, UK
| | | | | | - N. Vine
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - The National Osteoporosis Guideline Group (NOGG)
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
- Crawley Fracture Liaison Service, Crawley, Sussex, UK
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- University Hospitals Birmingham NHS Foundation Trust, Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham & Birmingham Health Partners, Birmingham, UK
- Musculoskeletal Research Unit, University of Bristol and Royal United Hospital NHS Foundation Trust, Bath, UK
- Metabolic Bone, Nuffield Orthopaedic Hospital, Oxford, UK
- Centre for Metabolic Diseases, University of Sheffield Medical School, Sheffield, UK
- Metabolic Bone, University of Sheffield, Sheffield, UK
- Emeritus Professor of Rheumatology, University of Aberdeen, Aberdeen, UK
- Metabolic Bone Disease, University of Manchester, Manchester, UK
- National Osteoporosis Society, Camerton, UK
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Arnold J, Mytton J, Evison F, Gill PS, Cockwell P, Sharif A, Ferro CJ. Fractures in Kidney Transplant Recipients: A Comparative Study Between England and New York State. EXP CLIN TRANSPLANT 2017; 16:410-418. [PMID: 29137594 DOI: 10.6002/ect.2017.0016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Fractures are associated with high morbidity and are a major concern for kidney transplant recipients. No comparative analysis has yet been conducted between countries in the contemporary era to inform future international prevention trials. MATERIALS AND METHODS Data were obtained from the Hospital Episode Statistics and the Statewide Planning and Research Cooperative databases on all adult kidney transplants performed in England and New York State from 2003 to 2013, respectively, and on posttransplant fracture-related hospitalization from 2003 to 2014. RESULTS Our analysis included 18 493 English and 11 602 New York State kidney transplant recipients. Overall, 637 English recipients (3.4%) and 398 New York State recipients (3.4%) sustained a fracture, giving an unadjusted event rate of 7.0 and 5.9 per 1000 years, respectively (P = .948). Of these, 147 English (0.8%) and 101 New York State recipients (0.9%) sustained a hip fracture, giving an unadjusted event rate of 1.6 and 1.5 per 1000 years, respectively (P = .480). There were no differences in the cumulative incidence of all fractures or hip fractures. One-year mortality rates after any fracture (9% and 11%) or after a hip fracture (15% and 17%) were not different between cohorts. CONCLUSIONS Contemporaneous English and New York State kidney transplant recipients have similar fracture rates and mortality rates postfracture.
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Affiliation(s)
- Julia Arnold
- From the Department of Nephrology, University Hospitals Birmingham NHS Foundation Trust and Department of Renal Medicine, University of Birmingham, United Kingdom
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106
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Kawano T, Miyakoshi N, Kasukawa Y, Hongo M, Tsuchie H, Sato C, Fujii M, Suzuki M, Akagawa M, Ono Y, Yuasa Y, Nagahata I, Shimada Y. Effects of combined therapy of alendronate and low-intensity pulsed ultrasound on metaphyseal bone repair after osteotomy in the proximal tibia of glucocorticoid-induced osteopenia rats. Osteoporos Sarcopenia 2017; 3:185-191. [PMID: 30775528 PMCID: PMC6372826 DOI: 10.1016/j.afos.2017.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 10/15/2017] [Accepted: 11/05/2017] [Indexed: 01/30/2023] Open
Abstract
Objectives Glucocorticoid (GC) treatment inhibits activation of runt-related transcription factor 2 (Runx2), which is essential for osteoblast differentiation from stem cells. As a result, GC treatment results in bone loss, GC-induced osteoporosis (GIO), elevated fracture risk, and delayed bone healing. Bisphosphonates such as alendronate (ALN) are recommended for treating or preventing GIO, and low-intensity pulsed ultrasound (LIPUS) facilitates fracture healing and maturation of regenerated bone. Combined therapy with ALN and LIPUS may stimulate cancellous bone healing in GIO rats. Here, we examined the effect of ALN and LIPUS on cancellous bone osteotomy repair in the proximal tibia of GIO rats. Methods Prednisolone (10 mg/kg body weight/day) was administered for 4 weeks to induce GIO in 6-month-old female Sprague-Dawley rats. Tibial osteotomy was then performed and daily subcutaneous injection of ALN (1-μg/kg body weight) was subsequently administered alone or in combination with LIPUS (20 min/day) for 2 or 4 weeks. Results ALN significantly increased bone mineral density (BMD) at 2 and 4 weeks, and ALN + LIPUS significantly increased BMD at 4 weeks. Bone union rates were significantly increased after 2 and 4 weeks ALN and ALN + LIPUS treatment. Lastly, ALN and ALN + LIPUS significantly increased the proportion of Runx2 positive cells at 4 weeks. Conclusions ALN monotherapy and combined ALN and LUPUS treatment augmented BMD and stimulated cancellous bone repair with increased Runx2 expression at the osteotomy site in GIO rats. However, the combined treatment had no additional effect on cancellous bone healing compared to ALN monotherapy.
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Affiliation(s)
- Tetsuya Kawano
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Naohisa Miyakoshi
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Yuji Kasukawa
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Michio Hongo
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Hiroyuki Tsuchie
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Chie Sato
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Masashi Fujii
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Masazumi Suzuki
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Manabu Akagawa
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Yuichi Ono
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Yusuke Yuasa
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Itsuki Nagahata
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Yoichi Shimada
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
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Koh JH, Myong JP, Yoo J, Lim YW, Lee J, Kwok SK, Park SH, Ju JH. Predisposing factors associated with atypical femur fracture among postmenopausal Korean women receiving bisphosphonate therapy: 8 years' experience in a single center. Osteoporos Int 2017; 28:3251-3259. [PMID: 28748389 DOI: 10.1007/s00198-017-4169-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 07/18/2017] [Indexed: 01/27/2023]
Abstract
UNLABELLED The risk factors for atypical femur fracture in patients exposed to bisphosphonates for at least 1 year were examined. Prolonged and continuous use of bisphosphonates, long-term use of glucocorticoids, and a higher body mass index were associated with increased risk of atypical femur fracture. INTRODUCTION The purpose of the present study is to determine whether rheumatoid arthritis (RA) and other clinical factors are associated with an increased risk of bisphosphonate (BP)-related atypical femur fracture (AFF). METHODS A retrospective nested case-control study of patients who had taken BPs for at least 1 year was conducted. Patients with AFF were identified by reviewing surgical and radiographic records. Three controls with no history of AFFs were randomly selected and age- and sex-matched to each patient with AFFs. Cox proportional hazard models were used to analyze the independent contribution of risk factors to BP-related AFF. RESULTS Among the 35,104 patients prescribed BPs for at least 1 year, 43 females (mean age, 68 years) suffered AFFs (0.12%). Patients with AFFs were exposed to BPs for a mean of 7.3 years. Patients with AFFs were exposed to BPs for longer than those without AFFs and continued treatment without a drug holiday. More patients with AFF than controls had taken glucocorticoids and disease-modifying anti-rheumatic drugs. Multivariate Cox regression analyses estimated that long-term use of glucocorticoids, prolonged exposure to BP without cessation, and every 1 kg/m2 increase in the body mass index (BMI) increased the hazard ratio for AFFs by 3.0, 5.2, and 1.2, respectively. CONCLUSIONS Prolonged and continuous use of BPs, long-term use of glucocorticoids, and a higher BMI increase the risk of AFFs. Switching long-term BP and glucocorticoid users to other bone-protective agents should be considered.
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Affiliation(s)
- J H Koh
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-040, South Korea
| | - J P Myong
- Department of Occupational & Environmental Medicine, Center for Occupational & Environmental Medicine (WHO Collaboratory Center), Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - J Yoo
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-040, South Korea
| | - Y-W Lim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - J Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-040, South Korea
| | - S-K Kwok
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-040, South Korea
| | - S-H Park
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-040, South Korea
| | - J H Ju
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-040, South Korea.
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Review of Routine Laboratory Monitoring for Patients with Rheumatoid Arthritis Receiving Biologic or Nonbiologic DMARDs. Int J Rheumatol 2017; 2017:9614241. [PMID: 29225625 PMCID: PMC5684575 DOI: 10.1155/2017/9614241] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 08/15/2017] [Indexed: 12/21/2022] Open
Abstract
Safety concerns associated with many drugs indicated for the treatment of rheumatoid arthritis (RA) can be attenuated by the early identification of toxicity through routine laboratory monitoring; however, a comprehensive review of the recommended monitoring guidelines for the different available RA therapies is currently unavailable. The aim of this review is to summarize the current guidelines for laboratory monitoring in patients with RA and to provide an overview of the laboratory abnormality profiles associated with each drug indicated for RA. Recommendations for the frequency of laboratory monitoring of serum lipids, liver transaminases, serum creatinine, neutrophil counts, and platelet counts in patients with RA were compiled from a literature search for published recommendations and guidelines as well as the prescribing information for each drug. Laboratory abnormality profiles for each drug were compiled from the prescribing information for each drug and a literature search including meta-analyses and primary clinical trials data.
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109
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Rodrigues JC, Walsh M. Risks and Benefits of Glucocorticoids in ANCA-Associated Vasculitis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017. [DOI: 10.1007/s40674-017-0081-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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110
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González-Gay MA, Matteson EL, Castañeda S. Polymyalgia rheumatica. Lancet 2017; 390:1700-1712. [PMID: 28774422 DOI: 10.1016/s0140-6736(17)31825-1] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/09/2017] [Accepted: 06/19/2017] [Indexed: 12/12/2022]
Abstract
Polymyalgia rheumatica is an inflammatory disease that affects the shoulder, the pelvic girdles, and the neck, usually in individuals older than 50 years. Increases in acute phase reactants are typical of polymyalgia rheumatica. The disorder might present as an isolated condition or in association with giant cell arteritis. Several diseases, including inflammatory rheumatic and autoimmune diseases, infections, and malignancies can mimic polymyalgia rheumatica. Imaging techniques have identified the presence of bursitis in more than half of patients with active disease. Vascular uptake on PET scans is seen in some patients. A dose of 12·5-25·0 mg prednisolone daily or equivalent leads to rapid improvement of symptoms in most patients with isolated disease. However, relapses are common when prednisolone is tapered. Methotrexate might be used in patients who relapse. The effectiveness of biological therapies, such as anti-interleukin 6, in patients with polymyalgia rheumatica that is refractory to glucocorticoids requires further investigation. Most population-based studies indicate that mortality is not increased in patients with isolated disease.
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Affiliation(s)
- Miguel A González-Gay
- Division of Rheumatology and Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla, University of Cantabria, Santander, Spain; Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Eric L Matteson
- Division of Rheumatology and Division of Epidemiology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Santos Castañeda
- Rheumatology Division, Hospital de La Princesa, Instituto de Investigación Sanitaria-Princesa, Universidad Autónoma de Madrid, Madrid, Spain
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111
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Watts NB. Adverse bone effects of medications used to treat non-skeletal disorders. Osteoporos Int 2017; 28:2741-2746. [PMID: 28752332 DOI: 10.1007/s00198-017-4171-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 07/20/2017] [Indexed: 12/11/2022]
Abstract
There is a growing list of medications used to treat non-skeletal disorders that cause bone loss and/or increase fracture risk. This review discusses glucocorticoids, drugs that reduce sex steroids, antidiabetic agents, acid-reducing drugs, selective serotonin reuptake inhibitors, and heparin. A number of drugs are known to cause bone loss, increase fracture risk, or both. These drugs should be used in the lowest dose necessary to achieve the desired benefit and for the shortest time necessary, but in many cases, long-term treatment is required. Effective countermeasures are available for some.
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Affiliation(s)
- N B Watts
- Mercy Health Osteoporosis and Bone Health Services, 4760 E. Galbraith Rd., Suite 212, Cincinnati, OH, 45236, USA.
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112
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Affiliation(s)
- Kripa Elizabeth Cherian
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
| | - Nitin Kapoor
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
| | - Thomas Vizhalil Paul
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
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Muto M, Giurazza F, Frauenfelder G, Marcia S, Masala S, Guarnieri G. Interventions and Therapy in Rheumatology. Radiol Clin North Am 2017; 55:1103-1110. [DOI: 10.1016/j.rcl.2017.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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114
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Rizzoli R. Towards a better management of glucocorticoid-induced osteoporosis? Nat Rev Rheumatol 2017; 13:635-636. [DOI: 10.1038/nrrheum.2017.141] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Chen J, Yu L, Chen L, Wu X, Tang P, Yin J, Jiang T, Yin G, Fan J. Surgical trauma and low-dose methylprednisolone modulate the severity of the acute-phase response induced by zoledronic acid infusion. Exp Ther Med 2017; 14:1802-1808. [PMID: 28810653 DOI: 10.3892/etm.2017.4646] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 03/23/2017] [Indexed: 12/18/2022] Open
Abstract
The aim of the present study was to investigate risk factors for the development of an acute-phase response (APR) associated with the initial zoledronic acid (ZA) infusion in patients undergoing surgery, and to assess whether its onset may be reduced by post-dose administration of low-dose methylprednisolone (MP) or acetaminophen. A retrospective study of patients with osteoporosis who attended the departments of orthopedics and endocrinology of a single hospital and received 5 mg ZA was conducted; the patients included surgical and non-surgical cases. A total of 450 ZA-naïve patients who were treated with acetaminophen following ZA infusion were stratified based on whether they suffered APR (APR+) or not (APR-). In addition, 155 of the aforementioned acetaminophen-treated patients (acetaminophen group) were compared with another 32 patients from the orthopedic department who were treated with MP immediately following ZA infusion (MP group). Inflammatory marker levels were significantly higher in APR+ patients than in APR- patients, and the odds ratios of experiencing APR following minimally invasive or open surgery were found to be 3.54 (P<0.001) and 5.71 (P<0.001), respectively, compared with non-surgical intervention after multiple adjustments. C-reactive protein levels prior to dosing were positively correlated with body temperature (r=0.023; P<0.001). The severity of APR also exhibited a negative correlation with 23-hydroxyvitamin D3 levels (r=-0.006; P<0.05). Patients treated with MP following surgery and ZA infusion had a significantly lower incidence of APR compared with those treated with acetaminophen (6.3 vs. 62.6%; P<0.05). However, no significant differences were observed in bone mineral density between the MP and acetaminophen groups at 12 months post-surgery. The results of the present study suggest that surgical trauma serves a key role in ZA-associated APR, and low-dose MP may a suitable post-dose treatment to manage the symptoms of APR in patients undergoing surgery.
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Affiliation(s)
- Jian Chen
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210000, P.R. China
| | - Lipeng Yu
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210000, P.R. China
| | - Lixin Chen
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210000, P.R. China
| | - Xuan Wu
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210000, P.R. China.,Department of Orthopedics, Nanjing Jiangbei People's Hospital, Nanjing, Jiangsu 210000, P.R. China
| | - Pengyu Tang
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210000, P.R. China
| | - Jian Yin
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210000, P.R. China
| | - Tao Jiang
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210000, P.R. China
| | - Guoyong Yin
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210000, P.R. China
| | - Jin Fan
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210000, P.R. China
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Giant Cell Arteritis: Current and Future Treatment Options. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017. [DOI: 10.1007/s40674-017-0071-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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118
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Lupi I, Cosottini M, Caturegli P, Manetti L, Urbani C, Cappellani D, Scattina I, Martino E, Marcocci C, Bogazzi F. Diabetes insipidus is an unfavorable prognostic factor for response to glucocorticoids in patients with autoimmune hypophysitis. Eur J Endocrinol 2017. [PMID: 28626085 DOI: 10.1530/eje-17-0123] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Autoimmune hypophysitis (AH) has a variable clinical presentation and natural history; likewise, its response to glucocorticoid therapy is often unpredictable. OBJECTIVE To identify clinical and radiological findings associated with response to glucocorticoids. DESIGN AND METHODS 12 consecutive patients with AH, evaluated from 2008 to 2016. AH was the exclusion diagnosis after ruling out other pituitary masses and secondary causes of hypophysitis. Mean follow-up time was 30 ± 27 months (range 12-96 months). RESULTS MRI identified two main patterns of presentation: global enlargement of the pituitary gland or panhypophysitis (n = 4, PH), and pituitary stalk abnormality only, or infundibulo-neuro-hypophysitis (n = 8, INH). Multiple tropin defects were more common in PH (100%) than those in INH (28% P = 0.014), whereas diabetes insipidus was more common in INH (100%) than that in PH (50%; P = 0.028). All 4 PH and 4 out of 8 INH were treated with glucocorticoids. Pituitary volume significantly reduced in all PH patients (P = 0.012), defective anterior pituitary function recovered only in the two patients without diabetes insipidus (50%) and panhypopituitarism persisted, along with diabetes insipidus, in the remaining 2 (50%). In all INH patients, either treated or untreated, pituitary stalk diameter reduced (P = 0.008) but diabetes insipidus persisted in all. CONCLUSIONS Glucocorticoid therapy may improve anterior pituitary function in a subset of patients but has no effect on restoring posterior pituitary function. Diabetes insipidus appears as a negative prognostic factor for response to glucocorticoids.
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Affiliation(s)
- Isabella Lupi
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Pisa, Italy
| | - Mirco Cosottini
- Department of Translational Research and New Surgical and Medical Technologies, University of Pisa, Pisa, Italy
| | - Patrizio Caturegli
- Division of Immunology, Department of Pathology, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Luca Manetti
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Pisa, Italy
| | - Claudio Urbani
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Pisa, Italy
| | - Daniele Cappellani
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Pisa, Italy
| | - Ilaria Scattina
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Pisa, Italy
| | - Enio Martino
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Pisa, Italy
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Pisa, Italy
| | - Fausto Bogazzi
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Pisa, Italy
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Adler RA. Glucocorticoid-Induced Osteoporosis and the New ACR Guideline. Clin Rev Bone Miner Metab 2017. [DOI: 10.1007/s12018-017-9234-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Bénard-Laribière A, Pariente A, Pambrun E, Bégaud B, Fardet L, Noize P. Prevalence and prescription patterns of oral glucocorticoids in adults: a retrospective cross-sectional and cohort analysis in France. BMJ Open 2017; 7:e015905. [PMID: 28760791 PMCID: PMC5642779 DOI: 10.1136/bmjopen-2017-015905] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To study trends in use of oral glucocorticoids (GCs) among adults, characteristics of oral GC initiators and prescriptions for the prevention of potential adverse effects associated with GC therapy. DESIGN First, a cross-sectional study repeated yearly was performed from 2007 to 2014 in a nationwide representative sample. Second, characteristics of initiators and patterns of GC therapy during the year following treatment initiation were described in a cohort of patients who began GC between 2007 and 2013. SETTING Population-based study using data from the French reimbursement healthcare system (covering approximately 90% of the population) in patients aged ≥18 years. RESULTS Over the study period, the prevalence of oral GC use ranged from 14.7% to 17.1% (95% CI 17.0%-17.2%) with a significant increase of 14.1% (95% CI +13.5% to +14.8%). The 2007-2013 cohort of oral GC initiators comprised 206 759 individuals. Oral GC use was mostly short-term (68% of unique reimbursement) and more than half of short-term users took concurrent antibiotics or respiratory/otological drugs. Chronic users (≥6 reimbursements/year) represented 1.8% (n=3789) of the cohort. The proportion of chronic users with comorbidities likely to be worsened by GC use (diabetes, psychotic disorders, osteoporosis) was 25%. Among patients at increased risk of osteoporosis, 62% received specific prevention/monitoring measures and only 27% had a bisphosphonate. Half of chronic oral GC users had a concurrent reimbursement of a proton pump inhibitor in the absence of non-steroidal anti-inflammatory drug use. CONCLUSIONS Oral GC use was highly widespread and increased among adults from 2007 to 2014. The overwhelming short-term use could mainly concern a growing use of unjustified prescriptions rather than situations with a favourable benefit/risk ratio. For chronic users, our findings plead for the development of interventions designed to improve monitoring with regard to the frequent comorbidities at risk and inappropriate prescribing of preventive therapeutic measures.
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Affiliation(s)
- Anne Bénard-Laribière
- University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Pharmacoepidemiology Team, Bordeaux, France
| | - Antoine Pariente
- University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Pharmacoepidemiology Team, Bordeaux, France
- CHU Bordeaux, Service de Pharmacologie Médicale, Bordeaux, France
| | - Elodie Pambrun
- University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Pharmacoepidemiology Team, Bordeaux, France
| | - Bernard Bégaud
- University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Pharmacoepidemiology Team, Bordeaux, France
- CHU Bordeaux, Service de Pharmacologie Médicale, Bordeaux, France
| | - Laurence Fardet
- Université Paris Est Créteil (UPEC), Créteil, France
- CHU Henri Mondor, Service de Dermatologie, Créteil, France
| | - Pernelle Noize
- University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Pharmacoepidemiology Team, Bordeaux, France
- CHU Bordeaux, Service de Pharmacologie Médicale, Bordeaux, France
- CIC Bordeaux CIC1401, Bordeaux, France
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Axelsson KF, Nilsson AG, Wedel H, Lundh D, Lorentzon M. Association Between Alendronate Use and Hip Fracture Risk in Older Patients Using Oral Prednisolone. JAMA 2017; 318:146-155. [PMID: 28697254 PMCID: PMC5817469 DOI: 10.1001/jama.2017.8040] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE Oral glucocorticoid treatment increases fracture risk, and evidence is lacking regarding the efficacy of alendronate to protect against hip fracture in older patients using glucocorticoids. OBJECTIVE To investigate whether alendronate treatment in older patients using oral prednisolone is associated with decreased hip fracture risk and adverse effects. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study using a national database (N = 433 195) of patients aged 65 years or older undergoing a health evaluation (baseline) at Swedish health care facilities; 1802 patients who were prescribed alendronate after at least 3 months of oral prednisolone treatment (≥5 mg/d) were identified. Propensity score matching was used to select 1802 patients without alendronate use from 6076 patients taking prednisolone with the same dose and treatment time criteria. Follow-up occurred between January 2008 and December 2014. EXPOSURES Alendronate vs no alendronate use; no patients had previously taken alendronate at the time of prednisolone initiation. MAIN OUTCOMES AND MEASURES The primary outcome was incident hip fracture. RESULTS Of the 3604 included patients, the mean age was 79.9 (SD, 7.5) years, and 2524 (70%) were women. After a median follow-up of 1.32 years (interquartile range, 0.57-2.34 years), there were 27 hip fractures in the alendronate group and 73 in the no-alendronate group, corresponding to incidence rates of 9.5 (95% CI, 6.5-13.9) and 27.2 (95% CI, 21.6-34.2) fractures per 1000 person-years, with an absolute rate difference of -17.6 (95% CI, -24.8 to -10.4). The use of alendronate was associated with a lower risk of hip fracture in a multivariable-adjusted Cox model (hazard ratio, 0.35; 95% CI, 0.22-0.54). Alendronate treatment was not associated with increased risk of mild upper gastrointestinal tract symptoms (alendronate vs no alendronate, 15.6 [95% CI, 11.6-21.0] vs 12.9 [95% CI, 9.3-18.0] per 1000 person-years; P = .40) or peptic ulcers (10.9 [95% CI, 7.7-15.5] vs 11.4 [95% CI, 8.0-16.2] per 1000 person-years; P = .86). There were no cases of incident drug-induced osteonecrosis and only 1 case of femoral shaft fracture in each group. CONCLUSIONS AND RELEVANCE Among older patients using medium to high doses of prednisolone, alendronate treatment was associated with a significantly lower risk of hip fracture over a median of 1.32 years. Although the findings are limited by the observational study design and the small number of events, these results support the use of alendronate in this patient group.
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Affiliation(s)
- Kristian F. Axelsson
- Department of Orthopaedic Surgery, Skaraborg Hospital, Skövde, Sweden
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Anna G. Nilsson
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hans Wedel
- Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Dan Lundh
- School of Bioscience, University of Skövde, Skövde, Sweden
| | - Mattias Lorentzon
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
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Saag KG, Agnusdei D, Hans D, Kohlmeier LA, Krohn KD, Leib ES, MacLaughlin EJ, Alam J, Simonelli C, Taylor KA, Marcus R. Trabecular Bone Score in Patients With Chronic Glucocorticoid Therapy-Induced Osteoporosis Treated With Alendronate or Teriparatide. Arthritis Rheumatol 2017; 68:2122-8. [PMID: 27111239 DOI: 10.1002/art.39726] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 04/14/2016] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To determine the effect of alendronate (ALN) and teriparatide on trabecular bone score (TBS) in patients with glucocorticoid-induced osteoporosis. METHODS Patients with chronic glucocorticoid therapy-induced osteoporosis (median 7.5 mg/day prednisone equivalent for ≥90 days) were randomized to receive oral ALN 10 mg/day (n = 214) or subcutaneous teriparatide 20 μg/day (n = 214) for 36 months; 118 patients in the ALN group and 123 patients in the teriparatide group completed treatment. Dual x-ray absorptiometry (DXA) results for 53 patients receiving ALN and 56 patients receiving teriparatide who had DXA scans with adequate resolution to perform TBS analysis and completed 36 months of therapy were blindly analyzed for TBS at baseline and 3, 6, 12, 18, 24, and 36 months. RESULTS In teriparatide-treated patients, TBS was significantly increased at 18 months compared to baseline, and by 36 months had increased 3.7% (P < 0.05). In ALN-treated patients, there was not a significant change in TBS compared to baseline at any time point. Changes in lumbar spine bone mineral density (BMD) measured by DXA in the subgroup with TBS data were similar to BMD results in the overall study population. At 36 months, increases in lumbar spine BMD were 5.5% and 10.3% in patients treated with ALN and teriparatide, respectively. CONCLUSION In patients with glucocorticoid-induced osteoporosis, both ALN and teriparatide increased lumbar spine BMD. However, trabecular bone score significantly increased with teriparatide but did not significantly change with ALN. The pathogenesis of glucocorticoid-induced osteoporosis is predominantly reduced bone formation. TBS may represent a sensitive measure to discriminate treatment effects of an anabolic versus an antiresorptive drug in glucocorticoid-induced osteoporosis.
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Affiliation(s)
| | | | - Didier Hans
- Lausanne University Hospital, Lausanne, Switzerland
| | | | | | - Edward S Leib
- University of Vermont College of Medicine, Burlington
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Thong B, Olsen NJ. Systemic lupus erythematosus diagnosis and management. Rheumatology (Oxford) 2017; 56:i3-i13. [PMID: 28013206 DOI: 10.1093/rheumatology/kew401] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Indexed: 01/07/2023] Open
Abstract
SLE presents many challenges for clinicians. The onset of disease may be insidious, with many different symptoms and signs, making early and accurate diagnosis challenging. Tests for SLE in the early stages lack specificity; those that are useful later often appear only after organ damage is manifest. Disease patterns are highly variable; flares are not predictable and not always associated with biomarkers. Children with SLE may have severe disease and present special management issues. Older SLE patients have complicating co-morbid conditions. Therapeutic interventions have improved over recent decades, but available drugs do not adequately control disease in many patients, and successful outcomes are limited by off-target effects; some of these become manifest with longer duration of treatment, now in part revealed by improved rates of survival. Despite all of these challenges, advances in understanding the biological basis of SLE have translated into more effective approaches to patient care. This review considers the current state of SLE diagnosis and management, with a focus on new approaches and anticipated advances.
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Affiliation(s)
- Bernard Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore, Republic of Singapore
| | - Nancy J Olsen
- Division of Rheumatology, Department of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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Buckley L, Guyatt G, Fink HA, Cannon M, Grossman J, Hansen KE, Humphrey MB, Lane NE, Magrey M, Miller M, Morrison L, Rao M, Byun Robinson A, Saha S, Wolver S, Bannuru RR, Vaysbrot E, Osani M, Turgunbaev M, Miller AS, McAlindon T. 2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid‐Induced Osteoporosis. Arthritis Care Res (Hoboken) 2017; 69:1095-1110. [DOI: 10.1002/acr.23279] [Citation(s) in RCA: 167] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 04/20/2017] [Indexed: 01/29/2023]
Affiliation(s)
| | | | - Howard A. Fink
- Geriatric Research Education and Clinical Center, VA Health Care SystemMinneapolis Minnesota
| | - Michael Cannon
- Arthritis Consultants of TidewaterVirginia Beach Virginia
| | | | | | | | | | - Marina Magrey
- Case Western Reserve University, MetroHealth SystemCleveland Ohio
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125
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Buckley L, Guyatt G, Fink HA, Cannon M, Grossman J, Hansen KE, Humphrey MB, Lane NE, Magrey M, Miller M, Morrison L, Rao M, Robinson AB, Saha S, Wolver S, Bannuru RR, Vaysbrot E, Osani M, Turgunbaev M, Miller AS, McAlindon T. 2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Rheumatol 2017; 69:1521-1537. [DOI: 10.1002/art.40137] [Citation(s) in RCA: 303] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 04/20/2017] [Indexed: 12/18/2022]
Affiliation(s)
| | | | - Howard A. Fink
- Geriatric Research Education and Clinical Center, VA Health Care System; Minneapolis Minnesota
| | - Michael Cannon
- Arthritis Consultants of Tidewater; Virginia Beach Virginia
| | | | | | | | | | - Marina Magrey
- Case Western Reserve University, MetroHealth System; Cleveland Ohio
| | | | - Lake Morrison
- Duke University Medical Center; Durham North Carolina
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Schüle S, Rossel JB, Frey D, Biedermann L, Scharl M, Zeitz J, Freitas-Queiroz N, Kuntzen T, Greuter T, Vavricka SR, Rogler G, Misselwitz B. Widely differing screening and treatment practice for osteoporosis in patients with inflammatory bowel diseases in the Swiss IBD cohort study. Medicine (Baltimore) 2017; 96:e6788. [PMID: 28562531 PMCID: PMC5459696 DOI: 10.1097/md.0000000000006788] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 04/06/2017] [Accepted: 04/09/2017] [Indexed: 02/06/2023] Open
Abstract
Low bone mineral density (BMD) and osteoporosis remain frequent problems in patients with inflammatory bowel diseases (IBDs). Several guidelines with nonidentical recommendations exist and there is no general agreement regarding the optimal approach for osteoporosis screening in IBD patients. Clinical practice of osteoporosis screening and treatment remains insufficiently investigated.In the year 2014, a chart review of 877 patients included in the Swiss IBD Cohort study was performed to assess details of osteoporosis diagnostics and treatment. BMD measurements, osteoporosis treatment, and IBD medication were recorded.Our chart review revealed 253 dual-energy x-ray absorptiometry (DXA) scans in 877 IBD patients; osteoporosis was prevalent in 20% of tested patients. We identified widely differing osteoporosis screening rates among centers (11%-62%). A multivariate logistic regression analysis identified predictive factors for screening including steroid usage, long disease duration, and perianal disease; even after correction for all risk factors, the study center remained a strong independent predictor (odds ratio 2.3-21 compared to the center with the lowest screening rate). Treatment rates for patients with osteoporosis were suboptimal (55% for calcium, 65% for vitamin D) at the time of chart review. Similarly, a significant fraction of patients with current steroid medication were not treated with vitamin D or calcium (treatment rates 53% for calcium, 58% for vitamin D). For only 29% of patients with osteoporosis bisphosphonate treatment was started. Treatment rates also differed among centers, generally following screening rates. In patients with longitudinal DXA scans, calcium and vitamin D usage was significantly associated with improvement of BMD over time.Our analysis identified inconsistent usage of osteoporosis screening and underuse of osteoporosis treatment in IBD patients. Increasing awareness of osteoporosis as a significant clinical problem in IBD patients might improve patient care.
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Affiliation(s)
- Solvey Schüle
- Division of Gastroenterology and Hepatology, University Hospital Zurich and University of Zurich, Zurich
| | - Jean-Benoît Rossel
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne
| | - Diana Frey
- Division of Rheumatology, University Hospital Zurich and University of Zurich
| | - Luc Biedermann
- Division of Gastroenterology and Hepatology, University Hospital Zurich and University of Zurich, Zurich
| | - Michael Scharl
- Division of Gastroenterology and Hepatology, University Hospital Zurich and University of Zurich, Zurich
| | - Jonas Zeitz
- Division of Gastroenterology and Hepatology, University Hospital Zurich and University of Zurich, Zurich
| | - Natália Freitas-Queiroz
- Division of Gastroenterology and Hepatology, University Hospital Zurich and University of Zurich, Zurich
| | - Thomas Kuntzen
- Division of Gastroenterology and Hepatology, University Hospital Zurich and University of Zurich, Zurich
| | - Thomas Greuter
- Division of Gastroenterology and Hepatology, University Hospital Zurich and University of Zurich, Zurich
| | - Stephan R. Vavricka
- Division of Gastroenterology and Hepatology, University Hospital Zurich and University of Zurich, Zurich
- Department of Medicine, Division of Gastroenterology, Triemli Hospital, Zurich, Switzerland
| | - Gerhard Rogler
- Division of Gastroenterology and Hepatology, University Hospital Zurich and University of Zurich, Zurich
| | - Benjamin Misselwitz
- Division of Gastroenterology and Hepatology, University Hospital Zurich and University of Zurich, Zurich
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Franco AS, Freitas TQ, Bernardo WM, Pereira RMR. Vitamin D supplementation and disease activity in patients with immune-mediated rheumatic diseases: A systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e7024. [PMID: 28591033 PMCID: PMC5466211 DOI: 10.1097/md.0000000000007024] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Vitamin D serum levels and the presence and activity of rheumatic conditions have been associated. However, many studies are merely observational, and the existent randomized clinical trials were never systematically analyzed. Therefore, this study aims to provide a systematic review and meta-analysis of such a topic. METHODS MEDLINE, EMBASE, LILACS, COCHRANE, and CINAHL were explored to identify randomized trials that investigated clinical repercussions of vitamin D (or analogs) supplementation for at least 3 months in rheumatic diseases. Standardized clinical and/or laboratorial outcomes related to disease activity were analyzed according to each disease before and after supplementation. RESULTS Database searches rendered 668 results; 9 were included-5 on rheumatoid arthritis, 3 on systemic lupus erythematosus, and 1 on systemic sclerosis. Seven of the studies were meta-analyzed. After vitamin D supplementation, rheumatoid arthritis recurrence decreased; however, not significantly (risk difference = -0.10, 95% CI = -0.21, 0.00, P = .05). No statistical significance was observed regarding visual analog scale (mean difference = 2.79, 95% CI = -1.87, 7.44, P = .24) and disease activity score28 (mean difference = -0.31, 95% CI = -0.86, 0.25, P = .28). Regarding systemic lupus erythematosus, anti-dsDNA positivity was significantly reduced (risk difference = -0.10, 95% CI = -0.18, -0.03; P = .005). CONCLUSION Vitamin D supplementation reduced anti-dsDNA positivity on systemic lupus erythematosus and could possibly reduce rheumatoid arthritis recurrence, although novel randomized clinical trials are needed to confirm and extend the benefits of this hormone in immune-mediated rheumatic diseases.
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Affiliation(s)
- André Silva Franco
- Bone Metabolism Laboratory, Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo
| | - Thiago Quadrante Freitas
- Bone Metabolism Laboratory, Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo
| | - Wanderley M. Bernardo
- Evidence-based Guidelines Developing—Brazilian Medical Association—Sao Paulo, Sao Paulo, Brazil
| | - Rosa Maria R. Pereira
- Bone Metabolism Laboratory, Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo
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Kageyama G, Okano T, Yamamoto Y, Nishimura K, Sugiyama D, Saegusa J, Tsuji G, Kumagai S, Morinobu A. Very high frequency of fragility fractures associated with high-dose glucocorticoids in postmenopausal women: A retrospective study. Bone Rep 2017; 6:3-8. [PMID: 28377975 PMCID: PMC5365272 DOI: 10.1016/j.bonr.2016.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 11/10/2016] [Accepted: 11/16/2016] [Indexed: 01/22/2023] Open
Abstract
Purpose To evaluate the incidence of fragility fractures associated with high-dose glucocorticoid therapy in patients with systemic rheumatic disease. METHODS A retrospective study of patients who were treated with high-dose prednisolone (> 0.8 mg/kg) for systemic rheumatic disease at Kobe University Hospital from April 1988 to March 2012. The primary outcome was a major osteoporotic fracture (defined as a clinical vertebral, hip, forearm, or proximal humerus fracture) after high-dose glucocorticoid therapy. For postmenopausal women and men over 40 of age, the patient's fracture risk at the beginning of high-dose glucocorticoid therapy was assessed by the World Health Organization's Fracture Risk Assessment Tool (FRAX®). Results Of 229 patients (median age: 49 years), 57 suffered a fragility fracture during the observation period (median observation period: 1558 days). Of 84 premenopausal patients, 5 suffered a fracture. In contrast, of 86 postmenopausal female, 36 suffered a fracture. Fragility fractures were far more frequent than predicted by the FRAX® score. Patients with FRAX® scores over 8.3% had a particularly high risk of fracture. Conclusions Fragility fractures associated with high-dose glucocorticoid therapy are common among postmenopausal women. Extreme care should be taken especially for postmenopausal women when high-dose glucocorticoid therapy is required.
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Affiliation(s)
- Goichi Kageyama
- Department of Rheumatology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
- Department of Rheumatology, Kobe University Hospital, Kobe, Japan
| | - Takaichi Okano
- Department of Rheumatology, Kobe University Hospital, Kobe, Japan
| | - Yuzuru Yamamoto
- Department of Rheumatology, Kobe University Hospital, Kobe, Japan
| | | | - Daisuke Sugiyama
- Department of Preventive Medicine and Public Health, Keio University, Tokyo, Japan
| | - Jun Saegusa
- Department of Rheumatology, Kobe University Hospital, Kobe, Japan
| | - Goh Tsuji
- Department of Rheumatology, Shinko Hospital, Kobe, Japan
| | | | - Akio Morinobu
- Department of Rheumatology, Kobe University Hospital, Kobe, Japan
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129
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Affiliation(s)
- Luis Alonso González
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Medellín, Colombia
| | - Graciela S. Alarcón
- Department of Medicine, Division of Clinical Immunology and Rheumatology, School of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
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130
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Negative impact of high cumulative glucocorticoid dose on bone metabolism of patients with myasthenia gravis. Neurol Sci 2017; 38:1405-1413. [PMID: 28488158 DOI: 10.1007/s10072-017-2964-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 04/12/2017] [Indexed: 01/29/2023]
Abstract
This current study aimed to evaluate the frequency of low bone mass, osteopenia, and osteoporosis in patients with myasthenia gravis (MG) and to investigate the possible association between bone mineral density (BMD) and plasma levels of bone metabolism markers. Eighty patients with MG and 62 controls BMD were measured in the right femoral neck and lumbar spine by dual-energy X-ray absorptiometry. Plasma concentrations of osteocalcin, osteopontin, osteoprotegerin, tumor necrosis factor (TNF-α), interleukin (IL)-1β, IL-6, dickkopf (DKK-1), sclerostin, insulin, leptin, adrenocorticotropic hormone, parathyroid hormone, and fibroblast growth factor (FGF-23) were analyzed by Luminex®. The mean age of patients was 41.9 years, with 13.5 years of length of illness, and a mean cumulative dose of glucocorticoids 38,123 mg. Patients had significant reduction in BMD of the lumbar, the femoral neck, and in the whole body when compared with controls. Fourteen percent MG patients had osteoporosis at the lumbar spine and 2.5% at the femoral neck. In comparison with controls, patients with MG presented lower levels of osteocalcin, adrenocorticotropic hormone, parathyroid hormone, sclerostin, TNF-α, and DKK-1 and higher levels of FGF-23, leptin, and IL-6. There was a significant negative correlation between cumulative glucocorticoid dose and serum calcium, lumbar spine T-score, femoral neck BMD, T-score, and Z-score. After multivariate analysis, higher TNF-α levels increased the likelihood of presenting low bone mass by 2.62. MG patients under corticotherapy presented low BMD and altered levels of bone markers.
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131
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Available and incoming therapies for idiopathic focal and segmental glomerulosclerosis in adults. J Nephrol 2017; 31:37-45. [DOI: 10.1007/s40620-017-0402-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 04/10/2017] [Indexed: 01/30/2023]
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Chowdhary VR. Broad Concepts in Management of Systemic Lupus Erythematosus. Mayo Clin Proc 2017; 92:744-761. [PMID: 28473038 DOI: 10.1016/j.mayocp.2017.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 01/18/2017] [Accepted: 02/16/2017] [Indexed: 12/14/2022]
Abstract
Systemic lupus erythematosus is a multisystem autoimmune disease with protean manifestation. Although commonly seen in young women, it can affect men as well as elderly patients. Approach to treatment is multidisciplinary, involves defining the extent of organ involvement, and distinguishing between active manifestations and damage. The mainstay of therapy is judicious use of immunosuppressive medications. Long-term follow-up to address morbidity arising from treatment complications, disease damage, and increased cardiovascular risk is essential.
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Affiliation(s)
- Vaidehi R Chowdhary
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester MN.
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133
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Caplan A, Fett N, Rosenbach M, Werth VP, Micheletti RG. Prevention and management of glucocorticoid-induced side effects: A comprehensive review: A review of glucocorticoid pharmacology and bone health. J Am Acad Dermatol 2017; 76:1-9. [PMID: 27986132 DOI: 10.1016/j.jaad.2016.01.062] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 01/28/2016] [Accepted: 01/29/2016] [Indexed: 01/29/2023]
Abstract
Systemic glucocorticoids are an essential therapy for a range of conditions, but their multiple side effects can produce significant morbidity for patients. The objective of this review is to discuss these side effects while addressing 3 questions: 1) What dose and duration of glucocorticoid therapy should prompt concern for individual side effects?; 2) How should clinicians counsel patients about these complications?; and 3) How can these problems be prevented or managed? To accomplish these objectives, we have created a series of tables and algorithms based on a review of relevant data to guide counseling, prophylaxis, and management of 11 glucocorticoid side effects. The first article in this 4-part continuing medical education series begins with a review of glucocorticoid pharmacology followed by a discussion of bone health (ie, osteoporosis and osteonecrosis).
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Affiliation(s)
- Avrom Caplan
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicole Fett
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | - Misha Rosenbach
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Victoria P Werth
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert G Micheletti
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania.
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Predictive Risk Factors of Cervical Spine Instabilities in Rheumatoid Arthritis: A Prospective Multicenter Over 10-Year Cohort Study. Spine (Phila Pa 1976) 2017; 42:556-564. [PMID: 27525538 DOI: 10.1097/brs.0000000000001853] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective multicenter cohort study for more than 10 years of outpatients with rheumatoid arthritis (RA). OBJECTIVE To identify predictive risk factors of cervical spine instabilities, which may induce compression myelopathy in patients with RA. SUMMARY OF BACKGROUND DATA Many reports described the natural course of cervical spine involvement in RA. Only a few studies, however, conducted comprehensive evaluation of its prognostic factors. METHODS Cervical spine instability was radiographically defined as atlantoaxial subluxation with the atlantodental interval greater than 3 mm, vertical subluxation (VS) with the Ranawat value less than 13 mm, and subaxial subluxation with irreducible translation of 2 mm or higher. The "severe" category of instability was defined as atlantoaxial subluxation with the atlantodental interval of 10 mm or lower, vertical subluxation with the Ranawat value of 10 mm or higher, and subaxial subluxation with translation of 4 mm or higher or at multiple levels. Of 503 "definite" or "classical" patients with RA without baseline "severe" instability, 143 were prospectively followed throughout for more than 10 years. The Cox proportional hazards regression analysis was performed to determine predictors for the development of "severe" instabilities. To exclude biases from the low follow-up rate, similar assessments were performed in 223 patients followed for more than 5 years from baseline. RESULTS The incidence of cervical spine instabilities and "severe" instabilities significantly increased during more than 10 years in both 143 and 223 cohorts (all P < 0.01). Multivariable Cox proportional hazards models found that baseline mutilating changes (hazard ratio [HR]=19.15, 95% confidence interval [95% CI] = 3.96-92.58, P < 0.01), corticosteroid administration (HR = 4.00, 95% CI = 1.76-9.11, P < 0.01), and previous joint surgery (HR = 1.99, 95% CI = 1.01-3.93, P = 0.048) correlated with the progression to "severe" instability in 143 cases and also in 223 cases (HR = 8.12, 95% CI = 2.22-29.64, P < 0.01; HR = 3.31, 95% CI = 1.68-6.53, P < 0.01; and HR = 2.07, 95% CI = 1.16-3.69, P = 0.014, respectively). CONCLUSION Established mutilating changes, concomitant corticosteroid treatment, and previous joint surgery are relatively robust indicators for a poor prognosis of the cervical spine in patients with RA, based on the consistency in more than 10-year analysis of two different settings. LEVEL OF EVIDENCE 3.
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Waljee AK, Rogers MAM, Lin P, Singal AG, Stein JD, Marks RM, Ayanian JZ, Nallamothu BK. Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ 2017; 357:j1415. [PMID: 28404617 PMCID: PMC6284230 DOI: 10.1136/bmj.j1415] [Citation(s) in RCA: 449] [Impact Index Per Article: 64.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objective To determine the frequency of prescriptions for short term use of oral corticosteroids, and adverse events (sepsis, venous thromboembolism, fractures) associated with their use.Design Retrospective cohort study and self controlled case series.Setting Nationwide dataset of private insurance claims.Participants Adults aged 18 to 64 years who were continuously enrolled from 2012 to 2014.Main outcome measures Rates of short term use of oral corticosteroids defined as less than 30 days duration. Incidence rates of adverse events in corticosteroid users and non-users. Incidence rate ratios for adverse events within 30 day and 31-90 day risk periods after drug initiation.Results Of 1 548 945 adults, 327 452 (21.1%) received at least one outpatient prescription for short term use of oral corticosteroids over the three year period. Use was more frequent among older patients, women, and white adults, with significant regional variation (all P<0.001). The most common indications for use were upper respiratory tract infections, spinal conditions, and allergies. Prescriptions were provided by a diverse range of specialties. Within 30 days of drug initiation, there was an increase in rates of sepsis (incidence rate ratio 5.30, 95% confidence interval 3.80 to 7.41), venous thromboembolism (3.33, 2.78 to 3.99), and fracture (1.87, 1.69 to 2.07), which diminished over the subsequent 31-90 days. The increased risk persisted at prednisone equivalent doses of less than 20 mg/day (incidence rate ratio 4.02 for sepsis, 3.61 for venous thromboembolism, and 1.83 for fracture; all P<0.001).Conclusion One in five American adults in a commercially insured plan were given prescriptions for short term use of oral corticosteroids during a three year period, with an associated increased risk of adverse events.
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Affiliation(s)
- Akbar K Waljee
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
- University of Michigan Medical School, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- University of Michigan Medical School, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Ann Arbor, MI, USA
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, MI, USA
| | - Mary A M Rogers
- University of Michigan Medical School, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, MI, USA
- University of Michigan Medical School, Department of Internal Medicine, Division of General Medicine, Ann Arbor, MI, USA
| | - Paul Lin
- University of Michigan Medical School, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Amit G Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Joshua D Stein
- University of Michigan Medical School, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- University of Michigan Medical School, Department of Ophthalmology and Visual Science, Ann Arbor, MI, USA
- University of Michigan School of Public Health, Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Rory M Marks
- University of Michigan Medical School, Department of Internal Medicine, Division of Rheumatology, Ann Arbor, MI, USA
| | - John Z Ayanian
- University of Michigan Medical School, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- University of Michigan Medical School, Department of Internal Medicine, Division of General Medicine, Ann Arbor, MI, USA
- University of Michigan School of Public Health, Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Brahmajee K Nallamothu
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
- University of Michigan Medical School, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, MI, USA
- University of Michigan Medical School, Department of Internal Medicine, Division of Cardiovascular Medicine, Ann Arbor, MI, USA
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Torre-Alonso JC, Carmona L, Moreno M, Galíndez E, Babío J, Zarco P, Linares L, Collantes-Estevez E, Barrial MF, Hermosa JC, Coto P, Suárez C, Almodóvar R, Luelmo J, Castañeda S, Gratacós J. Identification and management of comorbidity in psoriatic arthritis: evidence- and expert-based recommendations from a multidisciplinary panel from Spain. Rheumatol Int 2017; 37:1239-1248. [DOI: 10.1007/s00296-017-3702-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 03/14/2017] [Indexed: 02/08/2023]
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137
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Yang Y, Nian H, Tang X, Wang X, Liu R. Effects of the combined Herba Epimedii and Fructus Ligustri Lucidi on bone turnover and TGF-β1/Smads pathway in GIOP rats. JOURNAL OF ETHNOPHARMACOLOGY 2017; 201:91-99. [PMID: 28254481 DOI: 10.1016/j.jep.2017.02.033] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 02/06/2017] [Accepted: 02/13/2017] [Indexed: 06/06/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Kidney deficiency is the main pathogenesis of osteoporosis based on the theory of "kidney governing bones" in traditional Chinese medicine (TCM). Combined Herba Epimedii and Fructus Ligustri Lucidi, based on traditional Chinese formula Er-Zhi pills, were frequently used in TCM formulas that were prescribed for kidney tonifying and bone strengthening. However, it is unclear whether the combination of the two herbs may have a protective influence on glucocorticoid-induced osteoporosis (GIOP). The objective of this study was to evaluate the therapeutic effects and the underlying molecular mechanism of the decoction and the active fractions of the combined herbs in GIOP rats. MATERIALS AND METHODS Male Sprague-Dawley rats were divided into seven groups, including the normal control (NC), GIOP model (MO), active fractions low (100mg/kg, LAF), active fractions high (200mg/kg, HAF), decoction low (3.5g/kg, LD), decoction high (7g/kg, HD) and Calcium with Vitamin D3 (0.2773g/kg, CaD)-treated group. The GIOP model was established by intramuscular injection of dexamethasone (1mg/kg) twice a week for 8 weeks. Different kinds of indicators were measured, including bone mineral density (BMD), bone biomechanical properties, serum bone alkaline phosphatase (b-ALP), serum bone γ-carboxyglutamic acid-containing protein (BGP), serum bone morphogenetic protein-2 (BMP-2), serum tartrate-resistant acid phosphatase (TRACP) and serum carboxy terminal cross linked telopeptide of typeⅠcollagen (ICTP), bone mineral content (BMC) and bone structured histomorphometry. The protein and mRNA expression of TGF-β1, Smad2, Smad3, Smad4 and Smad7 were detected by Western blotting (WB) and quantitative real time polymerase chain reaction (qRT-PCR), respectively. RESULTS Administration of combined Herba Epimedii and Fructus Ligustri Lucidi decoction and combined active fractions could significantly prevent GC-induced bone loss by increasing the contents of serum b-ALP, BGP and BMP-2 as the markers of bone formation, reducing the serum TRACP and ICTP contents to inhibit bone resorption and enhancing BMC. They could also attenuate biomechanical properties and BMD reduction, deterioration of trabecular architecture in MO rats. The mRNA and protein expressions of TGF-β1, smad2, smad3 and smad4 were up-regulated, and the mRNA and protein expression of Smad7 was down-regulated following combined Herba Epimedii and Fructus Ligustri Lucidi treatment. CONCLUSION Combination of Herba Epimedii and Fructus Ligustri Lucidi exhibited protective effects on promoting bone formation and precluding bone resorption. The underlying mechanism may be attributed to its regulations on TGF-β1/Smads pathway. The substance bases of the combined herbs on anti-osteoporosis were total flavonoids of Herba Epimedii, total iridoids and flavonoids of Fructus Ligustri Lucidi.
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Affiliation(s)
- Yan Yang
- Beijing Key Lab of TCM Collateral Disease Theory Research, School of Traditional Chinese Medicine, Capital Medical University, No.10 Xitoutiao, Youanmenwai, Fengtai District, Beijing 100069, China
| | - Honglei Nian
- Beijing Key Lab of TCM Collateral Disease Theory Research, School of Traditional Chinese Medicine, Capital Medical University, No.10 Xitoutiao, Youanmenwai, Fengtai District, Beijing 100069, China
| | - Xiufeng Tang
- Beijing Key Lab of TCM Collateral Disease Theory Research, School of Traditional Chinese Medicine, Capital Medical University, No.10 Xitoutiao, Youanmenwai, Fengtai District, Beijing 100069, China
| | - Xiujuan Wang
- Beijing Key Lab of TCM Collateral Disease Theory Research, School of Traditional Chinese Medicine, Capital Medical University, No.10 Xitoutiao, Youanmenwai, Fengtai District, Beijing 100069, China.
| | - Renhui Liu
- Beijing Key Lab of TCM Collateral Disease Theory Research, School of Traditional Chinese Medicine, Capital Medical University, No.10 Xitoutiao, Youanmenwai, Fengtai District, Beijing 100069, China.
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138
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Jain RK, Bennet B, Vokes T. Ethnic Differences in Osteoporosis After Cardiac Transplantation. J Clin Densitom 2017; 20:164-171. [PMID: 27595486 DOI: 10.1016/j.jocd.2016.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 08/10/2016] [Indexed: 01/30/2023]
Abstract
Cardiac transplantation is associated with a high risk of fracture. African Americans (AAs) are believed to have a lower risk of osteoporosis than Caucasians, but it is not clear whether they are also protected from osteoporosis resulting from the use of glucocorticoids and/or organ transplantation. We examined possible ethnic differences in 33 cardiac transplant recipients (16 AAs) in a cross-sectional analysis. In addition to bone mineral density and vertebral fracture assessment, we also compared biochemical variables, trabecular bone score, total body dual-energy X-ray absorptiometry, and disability. Overall fracture rates were low in both groups, with only 6 total subjects with fractures on vertebral fracture assessment or history of fracture. While T-scores were similar between groups, Z-scores were lower in AA with the difference reaching statistical significance when controlling for important covariates. The trabecular bone score was also lower in AAs than in Caucasians even when adjusting for age and tissue thickness (1.198 ± 0.140 vs 1.312 ± 0.140, p = 0.03). While AAs are generally thought to be protected from osteoporosis, our study instead suggests that AAs may be at higher risk of bone deterioration after cardiac transplantation and may need to be managed more aggressively than suggested by current guidelines.
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Affiliation(s)
- Rajesh K Jain
- Department of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL, USA.
| | - Betsy Bennet
- Department of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL, USA
| | - Tamara Vokes
- Department of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL, USA
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139
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Westaway K, Frank O, Husband A, McClure A, Shute R, Curtis J. Minimising fracture risk in older people taking long-term oral corticosteroids. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2017. [DOI: 10.1002/jppr.1321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Kerrie Westaway
- Veterans’ MATES Program; Quality Use of Medicines and Pharmacy Research Centre; Sansom Institute; School of Pharmacy and Medical Sciences; University of South Australia; Adelaide Australia
| | - Oliver Frank
- Oakden Medical Centre; Adelaide Australia
- Discipline of General Practice; University of Adelaide; Adelaide Australia
| | - Alan Husband
- Medicines Information NPS MedicineWise; Surry Hills Australia
| | - Anna McClure
- Royal Adelaide Hospital and Glenside Campus; Adelaide Australia
| | - Russell Shute
- Crafter Medical Centre; Hawthorn Australia
- Department of Veterans’ Affairs; Veterans’ Medicines Advice and Therapeutics Education Services (Veterans’ MATES) Clinical Reference Group; Adelaide Australia
| | - Jane Curtis
- Australian Medicines Handbook Pty Ltd; Adelaide Australia
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140
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Abstract
Most premenopausal women with low trauma fracture(s) or low bone mineral density have a secondary cause of osteoporosis or bone loss. Where possible, treatment of the underlying cause should be the focus of management. Premenopausal women with an ongoing cause of bone loss and those who have had, or continue to have, low trauma fractures may require pharmacologic intervention. Clinical trials provide evidence of benefits of bisphosphonates and teriparatide for bone mineral density in several types of premenopausal osteoporosis, but studies are small and do not provide evidence regarding fracture risk reduction.
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Affiliation(s)
- Adi Cohen
- Division of Endocrinology, Department of Medicine, Columbia University Medical Center, Columbia University, College of Physicians & Surgeons, PH8-864, 630 West 168th Street, New York, NY 10032, USA.
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141
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Jassim NA, Adib G, Abdul Rahman YA, Gorial FI, Maghraoui A, Al Suhaili AR, Murtaji A, Otom A, Masri B, Saba E, Badran F, Maalouf G, Saleh J, El Muntaser K, Zakraoui L, Al Izzi M, Al Ali N, Sulaimani R, Abdul Majeed S, Al Emadi S. Pan Arab Osteoporosis Society Guidelines for Osteoporosis Management. Mediterr J Rheumatol 2017; 28:27-32. [PMID: 32185251 PMCID: PMC7045926 DOI: 10.31138/mjr.28.1.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 02/03/2017] [Accepted: 02/15/2017] [Indexed: 12/28/2022] Open
Abstract
Osteoporosis is the most common bone disease in humans. With its related fragility fracture, it represents a major public health problem in our region, with a significant medical and socio-economic burden. The high prevalence rate of vitamin D deficiency, the increase in life expectancy, the low socioeconomic level and the significant restriction to access to health care in some countries represent the major causes for the increasing prevalence of osteoporosis and incidence of fragility fractures in the Arabic countries. Bone mineral density (BMD) assessment is the gold standard to diagnose osteoporosis. However, a clinical diagnosis of osteoporosis may be made in the presence of a fragility fracture, without BMD measurement. Dual energy x-ray absorptiometry (DXA) is the preferred method for screening bone mineral density. For screening site of measurement, DXA of hip and spine is suggested. BMD assessment is recommended in all women 65 years of age and older and men 70 and older regardless of risk factors. Younger subjects with clinical risk factors and persons with clinical evidence of osteoporosis or diseases leading to osteoporosis should also be screened. These guidelines are aimed to provide to health care professionals in the region of an updated process for the diagnosis and treatment of osteoporosis. It includes risk factors for osteoporosis and the indications for screening, diagnosis of osteoporosis, treatment of osteoporosis in postmenopausal and premenopausal women, and men; in addition to prevention and treatment of glucocorticoid-induced osteoporosis.
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Affiliation(s)
| | | | | | | | | | | | | | - Ali Otom
- Jordanian Physicians Osteoporosis Society
| | | | - Elias Saba
- Palestinian Osteoporosis Prevention Society
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Monthly Oral Ibandronate Reduces Bone Loss in Korean Women With Rheumatoid Arthritis and Osteopenia Receiving Long-term Glucocorticoids: A 48-week Double-blinded Randomized Placebo-controlled Investigator-initiated Trial. Clin Ther 2017; 39:268-278.e2. [DOI: 10.1016/j.clinthera.2017.01.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 12/17/2016] [Accepted: 01/08/2017] [Indexed: 01/25/2023]
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143
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Zerbini CAF, Clark P, Mendez-Sanchez L, Pereira RMR, Messina OD, Uña CR, Adachi JD, Lems WF, Cooper C, Lane NE. Biologic therapies and bone loss in rheumatoid arthritis. Osteoporos Int 2017; 28:429-446. [PMID: 27796445 DOI: 10.1007/s00198-016-3769-2] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 09/07/2016] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) is a common systemic autoimmune disease of unknown cause, characterized by a chronic, symmetric, and progressive inflammatory polyarthritis. One of the most deleterious effects induced by the chronic inflammation of RA is bone loss. During the last 15 years, the better knowledge of the cytokine network involved in RA allowed the development of potent inhibitors of the inflammatory process classified as biological DMARDs. These new drugs are very effective in the inhibition of inflammation, but there are only few studies regarding their role in bone protection. The principal aim of this review was to show the evidence of the principal biologic therapies and bone loss in RA, focusing on their effects on bone mineral density, bone turnover markers, and fragility fractures. METHODS Using the PICOST methodology, two coauthors (PC, LM-S) conducted the search using the following MESH terms: rheumatoid arthritis, osteoporosis, clinical trials, TNF- antagonists, infliximab, adalimumab, etanercept, certolizumab, golimumab, IL-6 antagonists, IL-1 antagonists, abatacept, tocilizumab, rituximab, bone mineral density, bone markers, and fractures. The search was conducted electronically and manually from the following databases: Medline and Science Direct. The search period included articles from 2003 to 2015. The selection included only original adult human research written in English. Titles were retrieved and the same two authors independently selected the relevant studies for a full text. The retrieved selected studies were also reviewed completing the search for relevant articles. The first search included 904 titles from which 253 titles were selected. The agreement on the selection among researchers resulted in a Kappa statistic of 0.95 (p < 0.000). Only 248 abstracts evaluated were included in the acronym PICOST. The final selection included only 28 studies, derived from the systematic search. Additionally, a manual search in the bibliography of the selected articles was made and included into the text and into the section of "small molecules of new agents." CONCLUSION Treatment with biologic drugs is associated with the decrease in bone loss. Studies with anti-TNF blocking agents show preservation or increase in spine and hip BMD and also a better profile of bone markers. Most of these studies were performed with infliximab. Only three epidemiological studies analyzed the effect on fractures after anti-TNF blocking agent's treatment. IL-6 blocking agents also showed improvement in localized bone loss not seen with anti-TNF agents. There are a few studies with rituximab and abatacept. Although several studies reported favorable actions of biologic therapies on bone protection, there are still unmet needs for studies regarding their actions on the risk of bone fractures.
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Affiliation(s)
- C A F Zerbini
- Centro Paulista de Investigação Clínica, Rua Moreira e Costa, 342-Ipiranga, São Paulo, SP, 04266-010, Brazil.
| | - P Clark
- Hospital Infantil Federico Gómez-Faculty of Medicine UNAM, Ciudad de México D.F, Mexico
| | - L Mendez-Sanchez
- Hospital Infantil Federico Gómez-Faculty of Medicine UNAM, Ciudad de México D.F, Mexico
| | - R M R Pereira
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - O D Messina
- IRO Clinical Research Center Buenos Aires, Buenos Aires, Argentina
| | - C R Uña
- IRO Clinical Research Center Buenos Aires, Buenos Aires, Argentina
| | - J D Adachi
- Actavis Chair for Better Bone Health in Rheumatology, Hamilton, ON, Canada
| | - W F Lems
- Amsterdam Rheumatology and Immunology Centre, VU University Medical Centre, Amsterdam, The Netherlands
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, Southampton, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
- University of Oxford, Oxford, UK
| | - N E Lane
- Center for Musculoskeletal Health, Sacramento, CA, USA
- UC Davis Health System, University of California, Sacramento, CA, USA
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144
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Yu SF, Chen JF, Chen YC, Lai HM, Ko CH, Chiu WC, Su FM, Hsu CY, Su BYJ, Wu CH, Cheng TT. Beyond bone mineral density, FRAX-based tailor-made intervention thresholds for therapeutic decision in subjects on glucocorticoid: A nationwide osteoporosis survey. Medicine (Baltimore) 2017; 96:e5959. [PMID: 28151883 PMCID: PMC5293446 DOI: 10.1097/md.0000000000005959] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Glucocorticoid-induced osteoporosis (GIOP) is the most common cause of secondary osteoporosis and confers a substantial risk for future fractures. Several recent guidelines for GIOP management have recommended the use of intervention thresholds to direct pharmacological therapy in those at high risk of fracture. The aim of this study was to analyze the characteristics of subjects on a glucocorticoid (GC) and to implement the Fracture Risk Assessment Tool (FRAX)-based intervention threshold for therapeutic decision-making.This was a cohort substudy of a nationwide osteoporosis screening program conducted in Taiwan from 2008 to 2011. All participants were requested to complete a questionnaire including FRAX elements, and antiosteoporosis medication (AOM) history was assessed before bone mineral density (BMD) measurement. GC users were recruited as the study group. Controls comprised randomly selected age- and sex-matched non-GC users. Individual intervention threshold (IIT) was set at individual-specific FRAX probability of a major osteoporotic fracture, relative to subjects with prior fractures. The characteristics and calculated IIT of all participants were analyzed.A total of 8704 participants were enrolled, including GC users (n = 807) and controls (n = 7897). There was no significant difference in BMD between GC users and controls. Clinical fracture risks, including previous fracture, parental hip fracture, rheumatoid arthritis, and secondary osteoporosis were higher in GC users than in controls. GC users had a higher 10-year probability of either major or hip fracture than controls. The proportion of GC users with a 10-year probability of major osteoporotic fracture above IIT was higher than in controls (75.0% vs 10.6%; P < 0.001). Only 20.3% of GC users and 30.5% of controls whose fracture risk was above IIT reported taking AOM.These findings suggest that more GC users should receive active intervention based on IIT, regardless of BMD. However, less than one-fourth of GC users whose fracture risk was above IIT received AOM, indicating that GIOP is markedly undertreated. We recommend commencing AOM for GIOP according to IIT, instead of BMD alone.
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Affiliation(s)
- Shan-Fu Yu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital
- Chang Gung University College of Medicine, Kaohsiung
| | - Jia-Feng Chen
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital
- Chang Gung University College of Medicine, Kaohsiung
| | - Yin-Chou Chen
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital
- Chang Gung University College of Medicine, Kaohsiung
| | - Han-Ming Lai
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital
- Chang Gung University College of Medicine, Kaohsiung
| | - Chi-Hua Ko
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital
- Chang Gung University College of Medicine, Kaohsiung
| | - Wen-Chan Chiu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital
- Chang Gung University College of Medicine, Kaohsiung
| | - Fu-Mei Su
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital
- Chang Gung University College of Medicine, Kaohsiung
| | - Chung-Yuan Hsu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital
- Chang Gung University College of Medicine, Kaohsiung
| | - Ben Yu-Jih Su
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital
- Chang Gung University College of Medicine, Kaohsiung
| | - Chih-Hsing Wu
- Department of Family Medicine, National Cheng Kung University Hospital, Tainan, 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, Kaohsiung
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145
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Provan SA, Olsen IC, Austad C, Haugeberg G, Kvien TK, Uhlig T. Calcium supplementation and inflammation increase mortality in rheumatoid arthritis: A 15-year cohort study in 609 patients from the Oslo Rheumatoid Arthritis Register. Semin Arthritis Rheum 2017; 46:411-417. [DOI: 10.1016/j.semarthrit.2016.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 07/07/2016] [Accepted: 07/22/2016] [Indexed: 01/24/2023]
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146
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Ye X, Bo X, Hu X, Cui H, Lu B, Shao J, Wang J. Efficacy and safety of mycophenolate mofetil in patients with active moderate-to-severe Graves' orbitopathy. Clin Endocrinol (Oxf) 2017; 86:247-255. [PMID: 27484048 DOI: 10.1111/cen.13170] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 06/14/2016] [Accepted: 07/09/2016] [Indexed: 01/16/2023]
Abstract
CONTEXT Graves' orbitopathy (GO) is a potentially sight-threatening disease for which currently available medical therapy is not reliably successful. Mycophenolate mofetil (MMF) is a selective immunosuppressant used widely in many autoimmune diseases. Preliminary studies have shown that MMF is effective in the treatment of active GO. OBJECTIVE To evaluate the efficacy and safety of MMF in patients with active moderate-to-severe GO. PATIENTS One hundred and 74 patients with active moderate-to-severe GO were randomized to receive either MMF or glucocorticoids (GC). MAIN OUTCOME MEASURES The primary outcome was overall response at the 12th and 24th weeks; the outcome assessments included clinical activity score (CAS), soft tissue involvement, pain, visual acuity, proptosis, diplopia and reduction in eye movements. The secondary outcome was changes in those individual parameters. Adverse effects were recorded at each visit. RESULTS A greater overall response rate was found in the MMF group compared with the GC group at the 24th week (91·3% vs 67·9%, P = 0·000). MMF therapy showed a better CAS response than GC (92·5% vs 70·5% improved, P < 0·05). Patients treated with MMF showed a significantly improved rate of diplopia and proptosis than patients treated with GC at the 24th week (90·4% and 68·8% improved, respectively). Disease reactivation was not observed in the patients treated with MMF but was observed in five patients after GC therapy. Adverse events occurred in 4 of 80 patients treated with MMF (5%), all of which were mild to moderate. A severe adverse event was only observed in one patient treated with GC but not at all in patients treated with MMF. CONCLUSION Compared with GC treatment, MMF therapy is more effective and safer for patients with active moderate-to-severe GO.
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Affiliation(s)
- Xiaozhen Ye
- Department of Endocrinology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Xiaoyong Bo
- Department of Endocrinology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Xiaohao Hu
- Department of Endocrinology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Huanhuan Cui
- Department of Endocrinology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Bin Lu
- Department of Endocrinology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Jiaqing Shao
- Department of Endocrinology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Jian Wang
- Department of Endocrinology, Jinling Hospital, Southern Medical University, Nanjing, China
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147
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Wakefield D, McCluskey P, Wildner G, Thurau S, Carr G, Chee SP, Forrester J, Dick A, Hudson B, Lightman S, Smith J, Tugal-Tutkun I. Inflammatory eye disease: Pre-treatment assessment of patients prior to commencing immunosuppressive and biologic therapy: Recommendations from an expert committee. Autoimmun Rev 2017; 16:213-222. [PMID: 28137477 DOI: 10.1016/j.autrev.2017.01.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 10/25/2016] [Indexed: 12/14/2022]
Abstract
AIM To outline recommendations from an expert committee on the assessment and investigation of patients with severe inflammatory eye disease commencing immunosuppressive and/or biologic therapy. METHOD The approach to assessment is based on the clinical experience of an expert committee and a review of the literature with regard to corticosteroids, immunosuppressive drug and biologic therapy and other adjunct therapy in the management of patients with severe sight-threatening inflammatory eye disease. CONCLUSION We recommend a careful assessment and consultative approach by ophthalmologists or physicians experienced in the use of immunosuppressive agents for all patients commencing immunosuppressive and/or biologic therapy for sight threatening inflammatory eye disease with the aim of preventing infection, cardiovascular, metabolic and bone disease and reducing iatrogenic side effects.
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Affiliation(s)
- Denis Wakefield
- University of New South Wales, Faculty of Medicine, Kensington, Australia.
| | - Peter McCluskey
- Save Sight Institute, Sydney Eye Hospital, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Gerhild Wildner
- Section of Immunobiology, Department of Ophthalmology, Clinic of the University of Munich, Munich, Germany
| | - Stephan Thurau
- Section of Immunobiology, Department of Ophthalmology, Clinic of the University of Munich, Munich, Germany
| | - Gregory Carr
- Manly Hospital, North Shore Private Hospital, St Leonards, NSW, Australia
| | - Soon-Phaik Chee
- Ocular Inflammation and Immunology Service, Singapore National Eye Centre, Singapore; Singapore Eye Research Institute, Department of Ophthalmology, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Duke-NUS Graduate Medical School, Singapore National Eye Centre, Ocular Inflammation and Immunology Department, Singapore
| | - John Forrester
- The Institute of Medical Sciences, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Andrew Dick
- UCL-Institute of Ophthalmology, London, UK; School of Clinical Science, University of Bristol, UK; National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital, London, UK
| | - Bernard Hudson
- Department of Microbiology & Infectious Diseases, Royal North Shore Hospital, St Leonards, Sydney 2065, Australia
| | - Susan Lightman
- UCL/Institute of Ophthalmology, Moorfields Eye Hospital, London EC1V 2PD, UK
| | - Justine Smith
- Eye & Vision Health, Flinders University School of Medicine, Adelaide, Australia
| | - Ilknur Tugal-Tutkun
- Department of Ophthalmology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
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Yeap SS, Hew FL, Damodaran P, Chee W, Lee JK, Goh EML, Chan SP. An update of the Malaysian Clinical Guidance on the management of glucocorticoid-induced osteoporosis, 2015. Osteoporos Sarcopenia 2017; 3:1-7. [PMID: 30775497 PMCID: PMC6372780 DOI: 10.1016/j.afos.2017.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 01/02/2017] [Accepted: 01/03/2017] [Indexed: 01/29/2023] Open
Abstract
Objectives This Clinical Guidance is aimed to help practitioners assess, diagnose and manage their patients with glucocorticoid-induced osteoporosis (GIO), using the best available evidence. Methods A literature search using PubMed (MEDLINE) and The Cochrane Library identified all relevant articles on GIO and its assessment, diagnosis and treatment, from 2011, to update from the 2012 edition. The studies were assessed and the level of evidence assigned. For each statement, studies with the highest level of evidence were used to frame the recommendation. Results Consider treatment early in all patients on glucocorticoids (GC) as fracture risk increases within 3–6 months of starting GC. The decision to start treatment for GIO depends on the presence of prior fracture, category of risk (as calculated using Fracture Risk Assessment Tool), daily dose and duration of GC treatment, age, and menopausal status. General measures include adequate calcium and vitamin D intake and reducing the dose of GC to the minimum required to achieve disease control. In patients on GC with osteoporotic fractures or confirmed osteoporosis on dual-energy X-ray absorptiometry, bisphosphonates are the first-line treatment. Treatment should be continued as long as patients remain on GC. Algorithms for the management of GIO in both pre- and post-menopausal women and men have been updated. Conclusions In post-menopausal women and men above 50 years, bisphosphonates remain the mainstay of treatment in GIO. In pre-menopausal women and men below 50 years, bisphosphonates are recommended for those with a prevalent fracture or at very high risk only.
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Affiliation(s)
- Swan Sim Yeap
- Subang Jaya Medical Centre, Subang Jaya, Selangor, Malaysia
| | - Fen Lee Hew
- Subang Jaya Medical Centre, Subang Jaya, Selangor, Malaysia
| | | | - Winnie Chee
- International Medical University, Seremban, Negeri Sembilan, Malaysia
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149
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Watelet B, Samson M, de Boysson H, Bienvenu B. Treatment of giant-cell arteritis, a literature review. Mod Rheumatol 2017; 27:747-754. [PMID: 27919193 DOI: 10.1080/14397595.2016.1266070] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Giant-cell arteritis (GCA) is the most common vasculitis in people aged more than 50 years. Despite the frequency of this disease, there is currently no international consensus on its therapeutic modalities. The aim of this study was to conduct a review on an international literature about the treatment of GCA, whatever the clinical pattern might be. Oral corticosteroids remain the cornerstone treatment, possibly preceded by intravenous bolus in complicated forms. In cases of glucocorticoid (GC) dependence or GC-related side effects, a GC-sparing agent may be necessary. Methotrexate is one of the most used treatments despite its low level of evidence and mild efficacy. Cyclophosphamide and tocilizumab look promising but require validation in further studies. The results for TNF-α blockers and azathioprine are disappointing. Preventing complications of prolonged corticosteroid therapy is a world challenge and the management of GC-induced osteoporosis is not the same from one country to another. There is a significant risk of arterial thrombosis, mainly at treatment onset, which may encourage to associate an antiplatelet therapy, especially in patients with other cardiovascular risk factors. Place of statins in the treatment of the disease is uncertain.
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Affiliation(s)
- Bénédicte Watelet
- a Department of Vascular Medicine , Centre Hospitalier Universitaire de Caen , Caen , Basse Normandie , France
| | - Maxime Samson
- b Department of Internal Medicine and Clinical Immunology , Hôpital François Mitterrand, CHU de Dijon; INSERM UMR1098, University of Bourgogne Franche-Comté, FHU INCREASE , Dijon , France , and
| | - Hubert de Boysson
- c Department of Internal Medicine , Centre Hospitalier Universitaire de Caen , Caen , Basse Normandie , France
| | - Boris Bienvenu
- c Department of Internal Medicine , Centre Hospitalier Universitaire de Caen , Caen , Basse Normandie , France
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150
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Babigumira JB, Li M, Boudreau DM, Best JH, Garrison LP. Estimating the Cost of Illness of Giant Cell Arteritis in the United States. Rheumatol Ther 2017; 4:111-119. [PMID: 28084585 PMCID: PMC5443721 DOI: 10.1007/s40744-017-0052-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Indexed: 01/30/2023] Open
Abstract
Introduction Giant cell arteritis (GCA) is a chronic vasculitis affecting approximately 230,000 Americans. Limited data exist on the healthcare resource utilization and costs attributable to GCA. The objective of this study was to estimate the cost of illness in patients with GCA in the US. Methods A cohort of patients with a new GCA diagnosis was identified from a large US claims database between 1 January 2008 and 31 December 2012. Newly diagnosed GCA patients were defined by two claims with GCA (ICD-9 446.5) as one of the listed diagnoses during the study period and no GCA diagnosis in the 12 months prior. Subjects without a GCA diagnosis were matched 5:1 to cases. One-year healthcare costs were compared among cases and controls, adjusting for covariates using generalized linear models. Results A cohort of 1293 GCA patients and 6465 controls was identified. The mean age was 73 years, and 69% were females. Mean Charlson Comorbidity Index was 1.9 for GCA patients and 1.0 for controls. Mean 1-year cost for GCA patients was $34,065 [standard deviation (SD) $52,411], and mean 1-year cost for controls was $12,890 (SD $37,345). After multivariate adjustment, the difference in 1-year cost between GCA patients and controls was $16,431 (95% CI $13,821–$19,041). Conclusions Patients with GCA experience substantially higher healthcare costs in the first year following diagnosis compared to patients without GCA. These results add to the limited evidence available to inform researchers, clinicians, and policymakers on the cost burden of GCA in the US. Funding Genentech Inc.
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Affiliation(s)
- Joseph B Babigumira
- Global Medicines Program, Department of Global Health, University of Washington, Seattle, WA, USA. .,Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington, Seattle, WA, USA.
| | - Meng Li
- Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Denise M Boudreau
- Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington, Seattle, WA, USA
| | | | - Louis P Garrison
- Global Medicines Program, Department of Global Health, University of Washington, Seattle, WA, USA.,Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington, Seattle, WA, USA
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