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Bandeira F, Dantas W, Bilezikian JP. Controversies in the treatment of postmenopausal osteoporosis: How long to treat with bisphosphonates? ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2020; 64:331-336. [PMID: 32725062 PMCID: PMC10522084 DOI: 10.20945/2359-3997000000275] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/17/2020] [Indexed: 11/23/2022]
Abstract
Osteoporosis is a systemic skeletal disease characterized by reduced bone mass and deterioration of bone tissue microarchitecture leading to an increased risk of fractures. Fragility fractures, especially hip fractures, are associated with a significant reduction in the physical function and quality of life of affected patients, as well as increased mortality, leading to a major financial impact on health care. Many drugs have been registered for the treatment of osteoporosis and very recently, a new anabolic agent, romosozumab, has been approved in some countries. Despite the expansion of efficacious antiresorptive and anabolic therapies in recent years, a concomitant increase in concerns have been raised by physicians, patients and the lay press about the potential for adverse events, especially atypical femoral fractures (AFF) following prolonged use of bisphosphonates. Whatever the mechanism(s) may be, direct or indirect, linking prolonged bisphosphonate use to atypical femoral fractures, this adverse event is very rare in comparison to the magnitude of risk reduction of typical osteoporotic fractures. An estimated 162 osteoporosis-related fractures are prevented for each atypical femoral fracture associated with an anti-resorptive medication. Until a risk calculator for predicting risk of atypical fractures, becomes available in clinical practice, and we view this as an unlikely scenario, it is up to the physician to consider continuing or discontinuing bisphosphonate use after the critical 3-5 year period of treatment with zoledronic acid or alendronate, but close monitoring for the residual bone effects overtime should be planned. For other bisphosphonates, in which no residual effects are expected, drug holiday is usually not applied.
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Affiliation(s)
- Francisco Bandeira
- Hospital Agamenon MagalhãesFaculdade de Ciências MédicasUniversidade de PernambucoRecifePEBrasil Divisão de Endocrinologia e Diabetes do Hospital Agamenon Magalhães. Faculdade de Ciências Médicas da Universidade de Pernambuco, Recife, PE, Brasil
| | - Wesdrey Dantas
- Hospital Agamenon MagalhãesFaculdade de Ciências MédicasUniversidade de PernambucoRecifePEBrasil Divisão de Endocrinologia e Diabetes do Hospital Agamenon Magalhães. Faculdade de Ciências Médicas da Universidade de Pernambuco, Recife, PE, Brasil
| | - John P. Bilezikian
- Division of EndocrinologyCollege of Physicians and SurgeonsColumbia UniversityNew YorkNYUSADivision of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Black DM, Bauer DC, Vittinghoff E, Lui LY, Grauer A, Marin F, Khosla S, de Papp A, Mitlak B, Cauley JA, McCulloch CE, Eastell R, Bouxsein ML. Treatment-related changes in bone mineral density as a surrogate biomarker for fracture risk reduction: meta-regression analyses of individual patient data from multiple randomised controlled trials. Lancet Diabetes Endocrinol 2020; 8:672-682. [PMID: 32707115 DOI: 10.1016/s2213-8587(20)30159-5] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND The validation of bone mineral density (BMD) as a surrogate outcome for fracture would allow the size of future randomised controlled osteoporosis registration trials to be reduced. We aimed to determine the association between treatment-related changes in BMD, assessed by dual-energy x-ray absorptiometry, and fracture outcomes, including the proportion of treatment effect explained by BMD changes. METHODS We did a pooled analysis of individual patient data from multiple randomised placebo-controlled clinical trials. We included data from multicentre, randomised, placebo-controlled, double-blind trials of osteoporosis medications that included women and men at increased osteoporotic fracture risk. Using individual patient data for each trial we calculated mean 24-month BMD percent change together with fracture reductions and did a meta-regression of the association between treatment-related differences in BMD changes (percentage difference, active minus placebo) and fracture risk reduction. We also used individual patient data to determine the proportion of anti-fracture treatment effect explained by BMD changes and the BMD change needed in future trials to ensure fracture reduction efficacy. FINDINGS Individual patient data from 91 779 participants of 23 randomised, placebo-controlled trials were included. The trials had 1-9 years of follow-up and included 12 trials of bisphosphonate, one of odanacatib, two of hormone therapy (one of conjugated equine oestrogen and one of conjugated equine oestrogen plus medroxyprogesterone acetate), three of PTH receptor agonists, one of denosumab, and four of selective oestrogen receptor modulator trials. The meta-regression revealed significant associations between treatment-related changes in hip, femoral neck, and spine BMD and reductions in vertebral (r2 0·73, p<0·0001; 0·59, p=0·0005; 0·61, p=0·0003), hip (0·41, p=0·014; 0·41, p=0·0074; 0·34, p=0·023) and non-vertebral fractures (0·53, p=0·0021; 0·65, p<0·0001; 0·51, p=0·0019). Minimum 24-month percentage changes in total hip BMD providing almost certain fracture reductions in future trials ranged from 1·42% to 3·18%, depending on fracture site. Hip BMD changes explained substantial proportions (44-67%) of treatment-related fracture risk reduction. INTERPRETATION Treatment-related BMD changes are strongly associated with fracture reductions across randomised trials of osteoporosis therapies with differing mechanisms of action. These analyses support BMD as a surrogate outcome for fracture outcomes in future randomised trials of new osteoporosis therapies and provide an important demonstration of the value of public access to individual patient data from multiple trials. FUNDING Foundation for National Institutes of Health.
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Affiliation(s)
- Dennis M Black
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA, USA.
| | - Douglas C Bauer
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Eric Vittinghoff
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Li-Yung Lui
- California Pacific Medical Center, San Francisco, CA, USA
| | - Andreas Grauer
- Amgen, Thousand Oaks, CA, USA; Corcept Therapeutics, Menlo Park, CA, USA
| | - Fernando Marin
- Eli Lilly and Company, Lilly Research Centre, Windlesham, UK
| | | | | | | | - Jane A Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Charles E McCulloch
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Richard Eastell
- Academic Unit of Bone Metabolism, University of Sheffield, Sheffield, UK
| | - Mary L Bouxsein
- Center for Advanced Orthopedic Studies, Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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103
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Comparative efficacy and safety of pharmacological interventions for osteoporosis in postmenopausal women: a network meta-analysis (Chongqing, China). Menopause 2020; 26:929-939. [PMID: 31021904 DOI: 10.1097/gme.0000000000001321] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to assess the comparative effectiveness and safety of different pharmacological agents, including abaloparatide and romosozumab, for treatment of osteoporosis in postmenopausal women. METHODS We searched PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Google Scholar for relevant randomized controlled trials published up to July 16, 2018. After study selection according to the preplanned criteria, we performed data extraction and quality assessment. With statistical heterogeneity and inconsistency being examined, pairwise and network meta-analyses were conducted to synthesize risk ratio and 95% CI. Finally, we calculated the surface under the cumulative ranking curve to rank the interventions, and carried out three sensitivity analyses to assess the robustness of our main results. RESULTS Our searches yielded 2,584 records in total, of which 21 were finally included in quantitative synthesis and all of them were of high quality. Our 5 outcomes of interest involved a total of 13 interventions and 67,524 participants. For each outcome, the estimated τ values all were less than or equal to 0.0747, and the P values for test of consistency varied from 0.097 to 0.941, respectively, suggesting low heterogeneity and no inconsistency. Abaloparatide and teriparatide, without statistical difference between them, had a statistically lower risk of new vertebral or nonvertebral fractures than placebo, strontium ranelate, risedronate, raloxifene, lasofoxifene (0.25 mg/d), lasofoxifene (0.5 mg/d), denosumab, and alendronate. Zoledronic acid and romosozumab, without statistical difference between them, were significantly more efficacious than placebo, risedronate, and alendronate in preventing clinical fractures. Denosumab was statistically superior to placebo in preventing new vertebral and nonvertebral fractures, and to placebo, risedronate, and alendronate in preventing clinical fractures. For the outcomes of adverse events and serious adverse events, all of treatments were not statistically different from one another, except that zoledronic acid was statistically worse than placebo in terms of adverse events. Based on surface under the cumulative ranking curves, abaloparatide and teriparatide were two of the most effective treatments in preventing new vertebral and nonvertebral fractures; zoledronic acid and romosozumab were two of the most effective treatments in preventing clinical fractures, and denosumab and romosozumab were two of the best interventions for the outcome of adverse events. Three sensitivity analyses revealed the robustness of the main results. CONCLUSIONS Abaloparatide and teriparatide are most efficacious in preventing new vertebral and nonvertebral fractures in postmenopausal women with osteoporosis, whereas zoledronic acid and romosozumab are in preventing clinical fractures. Meanwhile, there is no statistical difference between abaloparatide, teriparatide or romosozumab, and placebo in terms of safety. Furthermore, in terms of adverse events, zoledronic acid is statistically worse than placebo, and two of the best interventions are denosumab and romosozumab, of which denosumab also reduces the risk of different kinds of fractures.
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Camacho PM, Petak SM, Binkley N, Diab DL, Eldeiry LS, Farooki A, Harris ST, Hurley DL, Kelly J, Lewiecki EM, Pessah-Pollack R, McClung M, Wimalawansa SJ, Watts NB. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS/AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS-2020 UPDATE. Endocr Pract 2020; 26:1-46. [PMID: 32427503 DOI: 10.4158/gl-2020-0524suppl] [Citation(s) in RCA: 430] [Impact Index Per Article: 107.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Objective: The development of these guidelines is sponsored by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs). Methods: Recommendations are based on diligent reviews of the clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols. Results: The Executive Summary of this 2020 updated guideline contains 52 recommendations: 21 Grade A (40%), 24 Grade B (46%), 7 Grade C (14%), and no Grade D (0%). These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world care of patients. The evidence base presented in the subsequent Appendix provides relevant supporting information for the Executive Summary recommendations. This update contains 368 citations: 123 (33.5%) evidence level (EL) 1 (highest), 132 (36%) EL 2 (intermediate), 20 (5.5%) EL 3 (weak), and 93 (25%) EL 4 (lowest). New or updated topics in this CPG include: clarification of the diagnosis of osteoporosis, stratification of the patient according to high-risk and very-high-risk features, a new dual-action therapy option, and transitions from therapeutic options. Conclusion: This guideline is a practical tool for endocrinologists, physicians in general, regulatory bodies, health-related organizations, and interested laypersons regarding the diagnosis, evaluation, and treatment of post-menopausal osteoporosis. Abbreviations: 25(OH)D = 25-hydroxyvitamin D; AACE = American Association of Clinical Endocrinologists; ACE = American College of Endocrinology; AFF = atypical femoral fracture; ASBMR = American Society for Bone and Mineral Research; BEL = best evidence level; BMD = bone mineral density; BTM = bone turnover marker; CI = confidence interval; CPG = clinical practice guideline; CTX = C-terminal telopeptide type-I collagen; DXA = dual-energy X-ray absorptiometry; EL = evidence level; FDA = U.S. Food and Drug Administration; FRAX® = Fracture Risk Assessment Tool; GI = gastrointestinal; HORIZON = Health Outcomes and Reduced Incidence with Zoledronic acid ONce yearly Pivotal Fracture Trial (zoledronic acid and zoledronate are equivalent terms); ISCD = International Society for Clinical Densitometry; IU = international units; IV = intravenous; LSC = least significant change; NOF = National Osteoporosis Foundation; ONJ = osteonecrosis of the jaw; PINP = serum amino-terminal propeptide of type-I collagen; PTH = parathyroid hormone; R = recommendation; ROI = region of interest; RR = relative risk; SD = standard deviation; TBS = trabecular bone score; VFA = vertebral fracture assessment; WHO = World Health Organization.
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Ishida H, Komaba H, Hamano N, Yamato H, Sawada K, Wada T, Nakamura M, Fukagawa M. Skeletal and mineral metabolic effects of risedronate in a rat model of high-turnover renal osteodystrophy. J Bone Miner Metab 2020; 38:501-510. [PMID: 32140785 DOI: 10.1007/s00774-020-01095-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/24/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION High-turnover bone disease is a major consequence of SHPT and may explain the high risk for fracture in patients with advanced chronic kidney disease (CKD). Bisphosphonates suppress bone turnover and improve bone strength, but their effects have not been fully characterized in advanced CKD with severe SHPT. Bisphosphonates also increase 1,25-dihydroxyvitamin D levels in normal and uremic rats, but the underlying mechanism remains to be determined. MATERIALS AND METHODS We investigated the skeletal and mineral metabolic effects of RIS, a pyridinyl bisphosphonate, in rats with severe SHPT induced by 5/6 nephrectomy plus a high phosphate diet. RESULTS Nephrectomized rats developed severe SHPT, along with hyperphosphatemia, low 1,25-dihydroxyvitamin D, and markedly increased FGF23. Moreover, these rats exhibited characteristic features of high-turnover renal osteodystrophy, including increased indices of trabecular bone turnover, decreased cortical bone thickness, inferior cortical biomechanical properties, and a prominent increase in peritrabecular fibrosis. RIS treatment increased bone volume and partially attenuated trabecular bone remodeling, cortical bone loss, and mechanical properties, whereas it produced a marked improvement in peritrabecular fibrosis along with a corresponding decrease in osteogenic gene markers. RIS treatment also suppressed the elevation of FGF23, which was associated with increased 1,25-dihydroxyvitamin D. CONCLUSIONS In a rat model of severe SHPT, treatment with RIS partially attenuated histological manifestations of high-turnover bone disease. RIS treatment also suppressed the elevation of FGF23, which may explain the increased 1,25-dihydroxyvitamin D production during the treatment.
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Affiliation(s)
- Hiroaki Ishida
- Department of Transplant Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Hirotaka Komaba
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan.
- Interactive Translational Research Center for Kidney Diseases, Tokai University School of Medicine, Isehara, Japan.
- The Institute of Medical Sciences, Tokai University, Isehara, Japan.
| | - Naoto Hamano
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan
| | - Hideyuki Yamato
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan
| | - Kaichiro Sawada
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan
| | - Takehiko Wada
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan
| | - Michio Nakamura
- Department of Transplant Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan
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106
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Compston J. Practical guidance for the use of bisphosphonates in osteoporosis. Bone 2020; 136:115330. [PMID: 32222607 DOI: 10.1016/j.bone.2020.115330] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/12/2020] [Accepted: 03/22/2020] [Indexed: 12/23/2022]
Abstract
Bisphosphonates are widely used in the treatment of osteoporosis in postmenopausal women and older men. In clinical trials they have been shown to reduce fractures in women with osteoporosis and there is increasing evidence that they are also effective in women with osteopenia, in whom the majority of fractures occur. In addition to their role as initial therapy in individuals at increased risk of fracture, bisphosphonates are used as sequential therapy after treatment with anabolic drugs. There are no head-to head studies to compare the anti-fracture efficacy of different bisphosphonates, but there is limited evidence that zoledronate treatment results in greater increases in BMD than risedronate or alendronate. This, together with the need for less frequent administration of zoledronate, supports its wider use in clinical practice, particularly if longer dosing intervals than those currently recommended are shown to be effective.
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107
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Kristensen PK, Perez-Vicente R, Leckie G, Johnsen SP, Merlo J. Disentangling the contribution of hospitals and municipalities for understanding patient level differences in one-year mortality risk after hip-fracture: A cross-classified multilevel analysis in Sweden. PLoS One 2020; 15:e0234041. [PMID: 32492053 PMCID: PMC7269247 DOI: 10.1371/journal.pone.0234041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/18/2020] [Indexed: 12/18/2022] Open
Abstract
Background One-year mortality after hip-fracture is a widely used outcome measure when comparing hospital care performance. However, traditional analyses do not explicitly consider the referral of patients to municipality care after just a few days of hospitalization. Furthermore, traditional analyses investigates hospital (or municipality) variation in patient outcomes in isolation rather than as a component of the underlying patient variation. We therefore aimed to extend the traditional approach to simultaneously estimate both case-mix adjusted hospital and municipality comparisons in order to disentangle the amount of the total patient variation in clinical outcomes that was attributable to the hospital and municipality level, respectively. Methods We determined 1-year mortality risk in patients aged 65 or above with hip fractures registered in Sweden between 2011 and 2014. We performed cross-classified multilevel analysis with 54,999 patients nested within 54 hospitals and 290 municipalities. We adjusted for individual demographic, socioeconomic and clinical characteristics. To quantify the size of the hospital and municipality variation we calculated the variance partition coefficient (VPC) and the area under the receiver operator characteristic curve (AUC). Results The overall 1-year mortality rate was 25.1%. The case-mix adjusted rates varied from 21.7% to 26.5% for the 54 hospitals, and from 18.9% to 29.5% for the 290 municipalities. The VPC was just 0.2% for the hospital and just 0.1% for the municipality level. Patient sociodemographic and clinical characteristics were strong predictors of 1-year mortality (AUC = 0.716), but adding the hospital and municipality levels in the cross-classified model had a minor influence (AUC = 0.718). Conclusions Overall in Sweden, one-year mortality after hip-fracture is rather high. However, only a minor part of the patient variation is explained by the hospital and municipality levels. Therefore, a possible intervention should be nation-wide rather than directed to specific hospitals or municipalities.
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Affiliation(s)
- Pia Kjær Kristensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Orthopedic Surgery, Regional Hospital Horsens, Horsens, Denmark
- * E-mail:
| | - Raquel Perez-Vicente
- Research Unit of Social Epidemiology, Clinical Research Centre, Faculty of Medicine, Lund University, Malmö, Sweden
| | - George Leckie
- Centre for Multilevel Modelling, School of Education, University of Bristol, United Kingdom
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Juan Merlo
- Research Unit of Social Epidemiology, Clinical Research Centre, Faculty of Medicine, Lund University, Malmö, Sweden
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Cho YH, Bae KH, Lee DR, Lee J. Anti-fracture Efficacy of Monthly Risedronate Compared with That of Weekly Risedronate in Postmenopausal Korean Women with Osteoporosis: A Nationwide Cohort Study. Korean J Fam Med 2020; 41:339-345. [PMID: 32447881 PMCID: PMC7509122 DOI: 10.4082/kjfm.19.0110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 12/05/2019] [Indexed: 12/04/2022] Open
Abstract
Background Intermittent dosing regimens for oral risedronate (once-monthly and once-weekly) were developed for patient convenience. While several studies have reported the anti-fracture efficacy of weekly dosing, few have assessed monthly dosing. The lower efficacy of monthly dosing has been previously suggested. The aim of this study was to compare the anti-fracture efficacy of monthly and weekly dosing. Methods We obtained information from the Korea National Health Insurance Service database from 2012 to 2017 of Korean women of ≥50 years of age who used weekly or monthly risedronate. We compared the time of occurrence of the first osteoporotic fracture after the first prescription of risedronate. Using a Cox proportional model, we assessed incidence rate ratios (IRRs) with 95% confidence intervals (CIs) for fractures at any site, and the hip, vertebral, and non-vertebral sites between both regimens. Propensity score weighting was used to balance the treatment groups. Results The study populations were distributed according to dosing frequency (monthly, 27,329; weekly, 47,652). There was no significant difference in the incidence rate of new fractures in any site (IRR, 1.008; 95% CI,0.963–1.055; P=0.737), hip (IRR, 0.999; 95% CI, 0.769–1.298; P=0.996), vertebral (IRR, 0.962; 95% CI, 0.890–1.040; P=0.330), or non-vertebral (1.022; 95% CI, 0.968–1.078; P=0.439) sites between monthly and weekly risedronate. Conclusion The anti-fracture efficacy at any site and the examined individual sites was similar for the monthly and weekly risedronate regimens. Large-scale randomized controlled trials are required for confirmation.
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Affiliation(s)
- Yong Ho Cho
- Department of Family Medicine, Wonkwang University Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, Korea
| | - Kyung Hyun Bae
- Department of Family Medicine, Wonkwang University Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, Korea
| | - Dong Ryul Lee
- Department of Family Medicine, Wonkwang University Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, Korea
| | - Jungun Lee
- Department of Family Medicine, Wonkwang University Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, Korea
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Primary osteoporosis in men: an unmet medical need. Fertil Steril 2020; 112:791-798. [PMID: 31731933 DOI: 10.1016/j.fertnstert.2019.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/01/2019] [Indexed: 12/27/2022]
Abstract
Osteoporosis is a skeletal disease characterized by loss of bone strength and increased risk of fractures. Even though fracture prevalence is higher in women, fractures also constitute a significant public health issue in older men. Men are screened less and more frequently undertreated than female patients. It is the goal of this review, to summarize updated information about the current understanding of pathophysiology and clinical aspects of diagnosis and treatment of osteoporosis in men.
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110
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Clynes MA, Harvey NC, Curtis EM, Fuggle NR, Dennison EM, Cooper C. The epidemiology of osteoporosis. Br Med Bull 2020; 133:105-117. [PMID: 32282039 PMCID: PMC7115830 DOI: 10.1093/bmb/ldaa005] [Citation(s) in RCA: 201] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/24/2020] [Accepted: 02/28/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION With a worldwide ageing population, the importance of the prevention and management of osteoporotic fragility fractures is increasing over time. In this review, we discuss in detail the epidemiology of fragility fractures, how this is shaped by pharmacological interventions and how novel screening programmes can reduce the clinical and economic burden of osteoporotic fractures. SOURCES OF DATA PubMed and Google Scholar were searched using various combinations of the keywords 'osteoporosis', 'epidemiology', 'fracture', 'screening', `FRAX' and 'SCOOP'. AREAS OF AGREEMENT The economic burden of osteoporosis-related fracture is significant, costing approximately $17.9 and £4 billion per annum in the USA and UK. AREAS OF CONTROVERSY Risk calculators such as the web-based FRAX® algorithm have enabled assessment of an individual's fracture risk using clinical risk factors, with only partial consideration of bone mineral density (BMD). GROWING POINTS As with all new interventions, we await the results of long-term use of osteoporosis screening algorithms and how these can be refined and incorporated into clinical practice. AREAS TIMELY FOR DEVELOPING RESEARCH Despite advances in osteoporosis screening, a minority of men and women at high fracture risk worldwide receive treatment. The economic and societal burden caused by osteoporosis is a clear motivation for improving the screening and management of osteoporosis worldwide.
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Affiliation(s)
- Michael A Clynes
- The MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
| | - Nicholas C Harvey
- The MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
| | - Elizabeth M Curtis
- The MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
| | - Nicholas R Fuggle
- The MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
| | - Elaine M Dennison
- The MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
| | - Cyrus Cooper
- The MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
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111
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Friesen KJ, Bugden S, Falk J. Time to benefit and the long-term persistence of new users of oral bisphosphonates. J Bone Miner Metab 2020; 38:371-377. [PMID: 31894490 DOI: 10.1007/s00774-019-01069-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/08/2019] [Indexed: 01/02/2023]
Abstract
INTRODUCTION This study aimed to examine long-term persistence in new users of oral bisphosphonates in a population-wide cohort in Manitoba, Canada. MATERIALS AND METHODS A longitudinal observational study was conducted using administrative health data characterizing long-term bisphosphonate persistence in those who started treatment between 1997 and 2018. Treatment discontinuation was evaluated using Kaplan-Meier methods. Cox regression was used to examine associations between discontinuation and osteoporosis diagnosis, previous fractures, and age. A sub-analysis of users with FRAX scores examined the relationship between 10-year fracture risk estimations and discontinuation. RESULTS Of 42,249 new bisphosphonate users, median age was 71 years, with 88.6% being female. Median duration of bisphosphonate use was 0.95 years (IQR 0.25, 3.9 years). Overall, 47.9% of incident users persisted up to 1 year, 25.0% persisted up to 3 years, and 14.1% up to 5 years. Presence of an indication for bisphosphonate use was associated with decreased discontinuation risk. Persistence generally increased with age. Having a BMD test performed was a predictor of lower discontinuation. The strongest predictor was having an osteoporosis diagnosis [HR for discontinuation = 0.68 (95% CI 0.66, 0.70)]. In users with FRAX scores (n = 14,114), moderate-risk [HR = 0.86 (95% CI 0.77, 0.96)] and high-risk users [HR = 0.77 (95% CI 0.69, 0.85)] were less likely to discontinue compared to lower-risk users. CONCLUSIONS A rapid decline in bisphosphonate persistence was shown. Almost half of users would not be expected to achieve clinically relevant benefits with a persistence of less than 1 year. Allowing informed choice in high-risk patients may be the best way to focus on those likely to benefit and persist with treatment.
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Affiliation(s)
- Kevin J Friesen
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Apotex Centre, 750 McDermot Avenue, Winnipeg, MB, R3E 0T5, Canada
| | - Shawn Bugden
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Apotex Centre, 750 McDermot Avenue, Winnipeg, MB, R3E 0T5, Canada
- School of Pharmacy, Memorial University, St. John's, NL, Canada
| | - Jamie Falk
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Apotex Centre, 750 McDermot Avenue, Winnipeg, MB, R3E 0T5, Canada.
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112
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Howe JG, Hill RS, Stroncek JD, Shaul JL, Favell D, Cheng RR, Engelke K, Genant HK, Lee DC, Keaveny TM, Bouxsein ML, Huber B. Treatment of bone loss in proximal femurs of postmenopausal osteoporotic women with AGN1 local osteo-enhancement procedure (LOEP) increases hip bone mineral density and hip strength: a long-term prospective cohort study. Osteoporos Int 2020; 31:921-929. [PMID: 31802158 PMCID: PMC7170985 DOI: 10.1007/s00198-019-05230-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 11/07/2019] [Indexed: 12/14/2022]
Abstract
UNLABELLED This first-in-human study of AGN1 LOEP demonstrated that this minimally-invasive treatment durably increased aBMD in femurs of osteoporotic postmenopausal women. AGN1 resorption was coupled with new bone formation by 12 weeks and that new bone was maintained for at least 5-7 years resulting in substantially increased FEA-estimated femoral strength. INTRODUCTION This first-in-human study evaluated feasibility, safety, and in vivo response to treating proximal femurs of postmenopausal osteoporotic women with a minimally-invasive local osteo-enhancement procedure (LOEP) to inject a resorbable triphasic osteoconductive implant material (AGN1). METHODS This prospective cohort study enrolled 12 postmenopausal osteoporotic (femoral neck T-score ≤ - 2.5) women aged 56 to 89 years. AGN1 LOEP was performed on left femurs; right femurs were untreated controls. Subjects were followed-up for 5-7 years. Outcomes included adverse events, proximal femur areal bone mineral density (aBMD), AGN1 resorption, and replacement with bone by X-ray and CT, and finite element analysis (FEA) estimated hip strength. RESULTS Baseline treated and control femoral neck aBMD was equivalent. Treated femoral neck aBMD increased by 68 ± 22%, 59 ± 24%, and 58 ± 27% over control at 12 and 24 weeks and 5-7 years, respectively (p < 0.001, all time points). Using conservative assumptions, FEA-estimated femoral strength increased by 41%, 37%, and 22% at 12 and 24 weeks and 5-7 years, respectively (p < 0.01, all time points). Qualitative analysis of X-ray and CT scans demonstrated that AGN1 resorption and replacement with bone was nearly complete by 24 weeks. By 5-7 years, AGN1 appeared to be fully resorbed and replaced with bone integrated with surrounding trabecular and cortical bone. No procedure- or device-related serious adverse events (SAEs) occurred. CONCLUSIONS Treating femurs of postmenopausal osteoporotic women with AGN1 LOEP results in a rapid, durable increase in aBMD and femoral strength. These results support the use and further clinical study of this approach in osteoporotic patients at high risk of hip fracture.
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Affiliation(s)
- J G Howe
- AgNovos Healthcare LLC, Rockville, MD, USA
| | - R S Hill
- AgNovos Healthcare LLC, Rockville, MD, USA.
| | | | - J L Shaul
- AgNovos Healthcare LLC, Rockville, MD, USA
| | - D Favell
- AgNovos Healthcare LLC, Rockville, MD, USA
| | - R R Cheng
- AgNovos Healthcare LLC, Rockville, MD, USA
| | - K Engelke
- Bioclinica-Synarc, Inc., Hamburg, Germany
- FAU University Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - H K Genant
- University of California San Francisco, San Francisco, CA, USA
- Bioclinica-Synarc, Inc., Newark, CA, USA
| | - D C Lee
- O.N. Diagnostics, Berkeley, CA, USA
| | - T M Keaveny
- University of California Berkeley, Berkley, CA, USA
| | - M L Bouxsein
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - B Huber
- Mansfield Orthopedics, Morrisville, VT, USA
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113
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Talla MR, Gallacher SJ. Osteoporosis: to treat or not to treat? Age Ageing 2020; 49:327-328. [PMID: 32343790 DOI: 10.1093/ageing/afaa026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 09/20/2019] [Accepted: 12/17/2019] [Indexed: 11/14/2022] Open
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114
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Koo YA, Son KA, Choi SJ, Yoon BK. Effects of Adding Intravenous Pamidronate to Ongoing Menopausal Hormone Therapy in Postmenopausal Korean Women with Low Bone Mineral Density. J Menopausal Med 2020; 25:117-122. [PMID: 32307936 PMCID: PMC6952709 DOI: 10.6118/jmm.19198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 08/02/2019] [Accepted: 10/13/2019] [Indexed: 11/05/2022] Open
Abstract
Objectives We evaluated the effects of adding intravenous pamidronate to ongoing menopausal hormone therapy (MHT) on bone mineral density (BMD) in postmenopausal Korean women with low BMD. Methods This retrospective cohort study included 74 postmenopausal women who received MHT for at least 1 year and had a BMD T-score of less than −2.0. Maintaining the same MHT regimen, these women were divided into two groups: oral placebo group (n = 44) and a pamidronate group of patients with gastrointestinal discomfort (n = 30) who received 15–30 mg pamidronate intravenously every 3–12 months. BMD was reviewed at 12-month follow-up. Bone resorption markers in both groups, urinary deoxypyridinoline levels in the placebo group, and serum N-telopeptide of type I collagen in the pamidronate group were assessed at 6 and 12 months. Results At baseline, the body mass index (BMI), duration of previous MHT, and femur neck (FN) BMD differed between the groups. Within-group analysis revealed that BMD of the lumbar spine (LS) and total hip (TH) significantly increased in the placebo group, whereas those of the LS, FN, and TH increased in the pamidronate group. The increase in BMD of LS was significantly greater in the pamidronate group, after adjusting for BMI and duration of previous MHT (mean change: 3.7% vs. 6.2%; P < 0.001). There were no changes in bone resorption markers in either group. Conclusions Adding intravenous pamidronate to ongoing MHT for 12 months might increase LS BMD in postmenopausal Korean women with low BMD.
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Affiliation(s)
- Young Ah Koo
- Department of Obstetrics, Gynecology and Women's Health, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung A Son
- Department of Obstetrics, Gynecology and Women's Health, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Suk Joo Choi
- Department of Obstetrics, Gynecology and Women's Health, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung Koo Yoon
- Department of Obstetrics, Gynecology and Women's Health, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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115
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Rothe R, Schulze S, Neuber C, Hauser S, Rammelt S, Pietzsch J. Adjuvant drug-assisted bone healing: Part III - Further strategies for local and systemic modulation. Clin Hemorheol Microcirc 2020; 73:439-488. [PMID: 31177207 DOI: 10.3233/ch-199104] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In this third in a series of reviews on adjuvant drug-assisted bone healing, further approaches aiming at influencing the healing process are discussed. Local and systemic modulation of bone metabolism is pursued with use of a number of drugs with completely different indications, which are characterized by a pleiotropic spectrum of action. These include drugs used to treat lipid disorders (HMG-CoA reductase inhibitors), hypertension (ACE inhibitors), osteoporosis (bisphosphonates), cancer (proteasome inhibitors) and others. Potential applications to enhance bone healing are discussed.
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Affiliation(s)
- Rebecca Rothe
- Department of Radiopharmaceutical and Chemical Biology, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - Sabine Schulze
- University Center of Orthopaedics and Traumatology (OUC), University Hospital Carl Gustav Carus, Dresden, Germany.,Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus and Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Christin Neuber
- Department of Radiopharmaceutical and Chemical Biology, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - Sandra Hauser
- Department of Radiopharmaceutical and Chemical Biology, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - Stefan Rammelt
- University Center of Orthopaedics and Traumatology (OUC), University Hospital Carl Gustav Carus, Dresden, Germany.,Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus and Faculty of Medicine, Technische Universität Dresden, Dresden, Germany.,Center for Regenerative Therapies Dresden (CRTD), Tatzberg 4, Dresden
| | - Jens Pietzsch
- Department of Radiopharmaceutical and Chemical Biology, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Institute of Radiopharmaceutical Cancer Research, Dresden, Germany.,Technische Universität Dresden, School of Science, Faculty of Chemistry and Food Chemistry, Dresden, Germany
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116
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Langdahl BL. Overview of treatment approaches to osteoporosis. Br J Pharmacol 2020; 178:1891-1906. [PMID: 32060897 DOI: 10.1111/bph.15024] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 01/16/2020] [Accepted: 01/31/2020] [Indexed: 12/28/2022] Open
Abstract
Efficient therapies are available for the treatment of osteoporosis. Anti-resorptive therapies, including bisphosphonates and denosumab, increase bone mineral density (BMD) and reduce the risk of fractures by 20-70%. Bone-forming or dual-action treatments stimulate bone formation and increase BMD more than the anti-resorptive therapies. Two studies have demonstrated that these treatments are superior to anti-resorptives in preventing fractures in patients with severe osteoporosis. Bone-forming or dual-action treatments should be followed by anti-resorptive treatment to maintain the fracture risk reduction. The BMD gains seen with bone-forming and dual-action treatments are greater in treatment-naïve patients compared to patients pretreated with anti-resorptive treatments. However, the antifracture efficacy seems to be preserved. Treatment failure will often lead to switch of treatment from orally to parentally administrated anti-resorptives treatment or from anti-resorptive to bone-forming or dual-action treatment. Osteoporosis is a chronic condition and therefore needs a long-term management plan with a personalized approach to treatment. LINKED ARTICLES: This article is part of a themed issue on The molecular pharmacology of bone and cancer-related bone diseases. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v178.9/issuetoc.
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Affiliation(s)
- Bente L Langdahl
- Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
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117
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Condurache CI, Chiu S, Chotiyarnwong P, Johansson H, Shepstone L, Lenaghan E, Cooper C, Clarke S, Khioe RFS, Fordham R, Gittoes N, Harvey I, Harvey NC, Heawood A, Holland R, Howe A, Kanis JA, Marshall T, O'Neill TW, Peters TJ, Redmond NM, Torgerson D, Turner D, McCloskey E. Screening for high hip fracture risk does not impact on falls risk: a post hoc analysis from the SCOOP study. Osteoporos Int 2020; 31:457-464. [PMID: 31960099 DOI: 10.1007/s00198-019-05270-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 12/17/2019] [Indexed: 12/30/2022]
Abstract
UNLABELLED A reduction in hip fracture incidence following population screening might reflect the effectiveness of anti-osteoporosis therapy, behaviour change to reduce falls, or both. This post hoc analysis demonstrates that identifying high hip fracture risk by FRAX was not associated with any alteration in falls risk. INTRODUCTION To investigate whether effectiveness of an osteoporosis screening programme to reduce hip fractures was mediated by modification of falls risk in the screening arm. METHODS The SCOOP study recruited 12,483 women aged 70-85 years, individually randomised to a control (n = 6250) or screening (n = 6233) arm; in the latter, osteoporosis treatment was recommended to women at high risk of hip fracture, while the control arm received usual care. Falls were captured by self-reported questionnaire. We determined the influence of baseline risk factors on future falls, and then examined for differences in falls risk between the randomisation groups, particularly in those at high fracture risk. RESULTS Women sustaining one or more falls were slightly older at baseline than those remaining falls free during follow-up (mean difference 0.70 years, 95%CI 0.55-0.85, p < 0.001). A higher FRAX 10-year probability of hip fracture was associated with increased likelihood of falling, with fall risk increasing by 1-2% for every 1% increase in hip fracture probability. However, falls risk factors were well balanced between the study arms and, importantly, there was no evidence of a difference in falls occurrence. In particular, there was no evidence of interaction (p = 0.18) between baseline FRAX hip fracture probabilities and falls risk in the two arms, consistent with no impact of screening on falls in women informed to be at high risk of hip fracture. CONCLUSION Effectiveness of screening for high FRAX hip fracture probability to reduce hip fracture risk was not mediated by a reduction in falls.
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Affiliation(s)
- C I Condurache
- Centre for Integrated Research in Musculoskeletal Aging, University of Sheffield Medical School, Sheffield, UK
- Department of Oncology and Metabolism, Academic Unit of Bone Metabolism, The Mellanby Centre For Bone Research, University of Sheffield, Sheffield, UK
| | - S Chiu
- Centre for Integrated Research in Musculoskeletal Aging, University of Sheffield Medical School, Sheffield, UK
- Department of Oncology and Metabolism, Academic Unit of Bone Metabolism, The Mellanby Centre For Bone Research, University of Sheffield, Sheffield, UK
| | - P Chotiyarnwong
- Department of Oncology and Metabolism, Academic Unit of Bone Metabolism, The Mellanby Centre For Bone Research, University of Sheffield, Sheffield, UK
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - H Johansson
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
- Centre for Bone and Arthritis Research (CBAR), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - L Shepstone
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - E Lenaghan
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Oxford Biomedical Research Unit, University of Oxford, Oxford, UK
| | - S Clarke
- Department of Rheumatology, University Hospitals Bristol, Bristol, UK
| | - R F S Khioe
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - R Fordham
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - N Gittoes
- Centre for Endocrinology, Diabetes and Metabolism, Queen Elizabeth Hospital, Birmingham, UK
| | - I Harvey
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - A Heawood
- Bristol Medical School, University of Bristol, Bristol, UK
| | - R Holland
- Leicester Medical School, Centre for Medicine, University of Leicester, Leicester, UK
| | - A Howe
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - J A Kanis
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - T Marshall
- Norfolk and Norwich University Hospital, Norwich, UK
| | - T W O'Neill
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK
| | - T J Peters
- Bristol Medical School, University of Bristol, Bristol, UK
| | - N M Redmond
- Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Collaborations for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), University Hospitals Bristol NHS Foundation, Bristol, UK
| | - D Torgerson
- Department of Health Sciences, University of York, York, UK
| | - D Turner
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - E McCloskey
- Centre for Integrated Research in Musculoskeletal Aging, University of Sheffield Medical School, Sheffield, UK.
- Department of Oncology and Metabolism, Academic Unit of Bone Metabolism, The Mellanby Centre For Bone Research, University of Sheffield, Sheffield, UK.
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
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Hodsman AB. Fragility Fractures in Dialysis and Transplant Patients. Is it Osteoporosis, and how should it be Treated? Perit Dial Int 2020. [DOI: 10.1177/089686080102103s44] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Anthony B. Hodsman
- University of Western Ontario and Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada
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119
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Yang C, Le G, Lu C, Wei R, Lan W, Tang J, Zhan X. Effects of teriparatide compared with risedronate in the treatment of osteoporosis: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2020; 99:e19042. [PMID: 32049802 PMCID: PMC7035098 DOI: 10.1097/md.0000000000019042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This meta-analysis was conducted to compare the effects and safety of teriparatide with risedronate in the treatment of osteoporosis. MATERIAL AND METHODS PubMed, Embase, Web of Science and Cochrane library database were systematically reviewed for studies published up to February 24, 2019. Eligible studies that compared the effects of teriparatide with risedronate in osteoporosis were included in this meta-analysis. The outcomes included percentage change in bone mineral density (BMD) of lumbar spine, femoral neck, and total hip, the incidence of clinical fractures, serum bone markers, and adverse events. A random-effects or fixed-effects model was used to pool the estimate, according to the heterogeneity among the included studies. RESULTS Seven studies were included in this meta-analysis. Compared with risedronate, teriparatide was associated with a significant increase in lumbar spine BMD [weight mean difference (WMD)=4.24, 95%CI: 3.11, 5.36; P < .001], femoral neck BMD (WMD=2.28, 95%CI: 1.39, 3.18; P < .001), and total hip BMD (WMD = 1.19, 95%CI: 0.47, 1.91; P = .001). Moreover, patients in teriparatide group had significantly lower incidences of clinical fracture (risk ratio [RR] = 0.48, 95%CI: 0.32, 0.72; P < .001), new vertebral fracture (RR = 0.45, 95%CI: 0.32, 0.63; P < .001), and non-vertebral fracture (RR = 0.63, 95%CI: 0.40, 0.98; P = .042) than those in risedronate group. There were significant differences between the 2 groups in serum change, including P1NP (WMD = 122.34, 95%CI: 68.89, 175.99; P < .001), CTx (WMD = 0.62, 95%CI: 0.29, 0.96; P < .001), and iPTH (WMD = -13.18, 95%CI: -15.04, -11.33; P < .001). The incidence of adverse events was similar between the 2 groups (RR = 0.93, 95%CI: 0.69, 1.25; P = .610). CONCLUSION This study suggested that teriparatide was more effective than risedronate for increasing the BMD in lumbar spine, femoral neck, and total hip, as well as reducing the incidences of clinical fracture, new vertebral fracture and non-vertebral fracture. There was no significant difference in incidence of adverse events between the 2 drugs. Considering the potential limitations in the present study, further large-scale, well-performed randomized trials are needed to verify our findings.
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Affiliation(s)
- Chengzhi Yang
- Department of spine osteopathic surgery, the first affiliated hospital of Guangxi medical University
- Trauma centers
| | - Guoping Le
- Department of arthropathy, the fourth affiliated hospital of Guangxi medical University
- Department of arthropathy, Guangxi liuzhou workers hospital
| | | | - Renjie Wei
- Department of orthopedic trauma, People's hospital of Hechi, Guangxi province, China
| | - Wanjie Lan
- Department of orthopedic trauma, People's hospital of Hechi, Guangxi province, China
| | | | - Xinli Zhan
- Department of spine osteopathic surgery, the first affiliated hospital of Guangxi medical University
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120
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Abstract
Since its development in 2008, FRAX has booked its place in the standard day to day management of osteoporosis. The FRAX tool has been appreciated for its simplicity and applicability for use in primary care, but criticised for the same reason, as it does not take into account exposure response. To address some of these limitations, relatively simple arithmetic procedures have been proposed to be applied to the conventional FRAX estimates of hip and major fracture probabilities aiming at adjustment of the probability assessment. However, as the list of these adjustments got longer, this has reflected on its implementation in the standard practice and gave FRAX a patchy look. Consequently, raises the need to re-think of the current FRAX and whether a second generation of the tool is required to address the perceived limitations of the original FRAX. This article will discuss both point of views of re-adjustment and re-thinking.
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Affiliation(s)
- Yasser El Miedany
- grid.13097.3c0000 0001 2322 6764King’s College London, London, England
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121
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Ali MS, Ernst M, Robinson DE, Caskey F, Arden NK, Ben-Shlomo Y, Nybo M, Rubin KH, Judge A, Cooper C, Javaid MK, Hermann AP, Prieto-Alhambra D. Alendronate use and bone mineral density gains in women with moderate-severe (stages 3B-5) chronic kidney disease: an open cohort multivariable and propensity score analysis from Funen, Denmark. Arch Osteoporos 2020; 15:81. [PMID: 32483674 PMCID: PMC8448716 DOI: 10.1007/s11657-020-00746-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 04/30/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED Bisphosphonates are contraindicated in moderate-to-severe chronic kidney disease patients. However, they are used to prevent fragility fractures in patients with impaired kidney function, despite a lack of evidence on their effects on bone density in these patients. We demonstrated that Alendronate had a positive effect on bone in these patients. PURPOSE This study aimed to assess the association between alendronate use and bone mineral density (BMD) change in subjects with moderate-severe chronic kidney disease (CKD). METHODS We created a cohort of CKD stage 3B-5 patients by linking all DXA-based measurements in the Funen area, Denmark, to biochemistry, national health registries and filled prescriptions. Exposure was dispensation of alendronate and the outcome was annualized percentage change in BMD at the femoral neck, total hip and lumbar spine. Individuals were followed from first BMD to the latest of subsequent DXA measurements. Alendronate non-users were identified using incidence density sampling and matched groups were created using propensity scores. Linear regression was used to estimate average differences in the annualized BMD. RESULTS Use of alendronate was rare in this group of patients: propensity score matching (PSM) resulted in 71 alendronate users and 142 non-users with stage 3B-5 CKD (as in the 1 year before DXA). Whilst alendronate users gained an average 1.07% femoral neck BMD per year, non-users lost an average of 1.59% per annum. The PSM mean differences in annualized BMD were + 2.65% (1.32%, 3.99%), + 3.01% (1.74%, 4.28%) and + 2.12% (0.98%, 3.25%) at the femoral neck, total hip and spine BMD, respectively, all in favour of alendronate users. CONCLUSION In a real-world cohort of women with stage 3B-5 CKD, use of alendronate appears associated with a significant improvement of 2-3% per year in the femoral neck, total hip and spine BMD. More data are needed on the anti-fracture effectiveness and safety of bisphosphonate therapy in moderate-severe CKD.
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Affiliation(s)
- M Sanni Ali
- Faculty of Epidemiology and Population Health, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Center for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Public Health, Saint Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Martin Ernst
- OPEN, Department of Health, University of Southern Denmark, Odense, Denmark
- Department of Public Health, Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark
| | - Danielle E Robinson
- Center for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Fergus Caskey
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nigel K Arden
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- MRC Lifecourse Epidemiology Unit, Southampton, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mads Nybo
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Katrine H Rubin
- OPEN, Department of Health, University of Southern Denmark, Odense, Denmark
| | - Andrew Judge
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- MRC Lifecourse Epidemiology Unit, Southampton, UK
| | - Cyrus Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- MRC Lifecourse Epidemiology Unit, Southampton, UK
| | - M K Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- MRC Lifecourse Epidemiology Unit, Southampton, UK
| | - Anne P Hermann
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Daniel Prieto-Alhambra
- Center for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
- MRC Lifecourse Epidemiology Unit, Southampton, UK.
- GREMPAL Research Group (Idiap Jordi Gol Primary Care Research Institute) and CIBERFes, Universitat Autonoma de Barcelona, Barcelona, Spain.
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Dömötör ZR, Vörhendi N, Hanák L, Hegyi P, Kiss S, Csiki E, Szakó L, Párniczky A, Erőss B. Oral Treatment With Bisphosphonates of Osteoporosis Does Not Increase the Risk of Severe Gastrointestinal Side Effects: A Meta-Analysis of Randomized Controlled Trials. Front Endocrinol (Lausanne) 2020; 11:573976. [PMID: 33240217 PMCID: PMC7683730 DOI: 10.3389/fendo.2020.573976] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/14/2020] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Bisphosphonates (BPs) are first-line therapy for osteoporosis. Adherence is usually low in chronic, asymptomatic diseases, but gastrointestinal (GI) side-effects can also contribute to low adherence in BP therapy and may necessitate a review by a gastroenterologist with or without gastroscopy. AIMS Our meta-analysis aims to determine the risk of severe GI adverse events due to oral BP therapy in osteoporotic patients. METHODS A systematic search was conducted in three databases up to September 2020 for randomized controlled trials (RCTs) detailing GI adverse events in adults with osteoporosis on BP compared to placebo. Risk ratios (RRs) with 95% confidence intervals (CI) were calculated for non-severe and severe adverse events indicating endoscopic procedure with the random-effects model. Statistical heterogeneity was assessed using chi2 and I2 statistics. RESULTS Forty-two RCTs with 39,047 patients with 9,999 non-severe and 1,503 severe GI adverse events were included. The incidence of non-severe and severe adverse events ranged between 0.3-54.9 and 0-10.3%, respectively. There was no difference between BP and control groups in terms of the risk of non-severe or severe side effects: RR=1.05 (CI: 0.98-1.12), I2 = 48.1%, and RR=1.01 (CI: 0.92-1.12), I2 = 0.0%, respectively. Subgroup analysis of the most commonly used BP, once-weekly alendronate 70 mg, revealed an association between bisphosphonates and the risk of non-severe GI adverse events, RR=1.16 (CI: 1.00-1.36), I2 = 40.7%, while the risk of severe GI side effects was not increased in this subgroup, RR=1.20 (CI: 0.83-1.74), I2 = 0.0%. CONCLUSION Our results show that bisphosphonates do not increase the risk of severe GI adverse events. However, the marked variability of the screening for side effects in the included studies, and the fact that in most of the studies GI diseases were exclusion criteria limits the strenght of evidence of our results. The conclusions drawn from the meta-analysis are therefore restricted to selected populations, and the results must be interpreted with caution.
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Affiliation(s)
- Zsuzsa Réka Dömötör
- Faculty of Medicine, University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, Romania
- Institute for Translational Medicine, University of Pécs, Medical School, Pécs, Hungary
| | - Nóra Vörhendi
- Institute for Translational Medicine, University of Pécs, Medical School, Pécs, Hungary
| | - Lilla Hanák
- Institute for Translational Medicine, University of Pécs, Medical School, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, University of Pécs, Medical School, Pécs, Hungary
| | - Szabolcs Kiss
- Institute for Translational Medicine, University of Pécs, Medical School, Pécs, Hungary
- Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Endre Csiki
- Institute for Translational Medicine, University of Pécs, Medical School, Pécs, Hungary
| | - Lajos Szakó
- Institute for Translational Medicine, University of Pécs, Medical School, Pécs, Hungary
| | - Andrea Párniczky
- Institute for Translational Medicine, University of Pécs, Medical School, Pécs, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, University of Pécs, Medical School, Pécs, Hungary
- *Correspondence: Bálint Erőss,
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123
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Efficacy of risedronate with cholecalciferol on bone mineral density in Korean patients with osteoporosis. Arch Osteoporos 2019; 15:3. [PMID: 31820121 DOI: 10.1007/s11657-019-0663-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 10/23/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED The efficacy of once-weekly risedronate with and without cholecalciferol in bone mineral density (BMD) in Korean patients with osteoporosis was compared. After 12 months, both spine and hip BMD increased significantly in both groups, but there was no significant difference between two groups. INTRODUCTION This study investigated the efficacy and safety of once-weekly risedronate with and without cholecalciferol in BMD in Korean patients with osteoporosis. METHODS This was a prospective, 12-month, randomized, open-labeled, actively controlled trial involving 41 hospitals. A total of 841 subjects with osteoporosis were randomized to once-weekly risedronate (35 mg) and cholecalciferol (5600 IU) in a single pill (RSD+, n = 642) or once-weekly risedronate (35 mg) alone (RSD, n = 199). BMD was measured via dual-energy X-ray absorptiometry at the lumbar spine and hip, and the serum levels of 25-hydroxy vitamin D (25(OH) D), parathyroid hormone (PTH), and alkaline phosphatase (ALP) were assayed at baseline and after 12 months of treatment. RESULTS After 12 months, the lumbar spine, femoral neck, and total hip BMD increased significantly in both groups; there was no significant difference between two groups. Women in the RSD+ group exhibited significantly increased lumbar spine BMD, and subjects with previous fracture history in the RSD+ group had significantly increased total hip BMD compared with the RSD group. The serum 25(OH) D level increased significantly in the RSD+ group. The serum PTH level decreased in the RSD+ group but increased in the RSD group. The serum ALP level significantly decreased in both groups; there was no significant difference between two groups. CONCLUSIONS A once-weekly pill containing risedronate and cholecalciferol had the equivalent antiresorptive efficacy on BMD compared with risedronate alone and improved 25(OH) D serum levels after 12 months of treatment without significant adverse events in Korean patients with osteoporosis.
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Cummings SR, Lui LY, Eastell R, Allen IE. Association Between Drug Treatments for Patients With Osteoporosis and Overall Mortality Rates: A Meta-analysis. JAMA Intern Med 2019; 179:1491-1500. [PMID: 31424486 PMCID: PMC6704731 DOI: 10.1001/jamainternmed.2019.2779] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Previous studies have reported that drug treatments, particularly treatment with bisphosphonates, is associated with reduced overall mortality rates in addition to decreased fracture risk. If so, drug treatments should be recommended for this reason alone, regardless of a patient's risk of fracture. OBJECTIVE To assess whether randomized clinical trials demonstrate that treatment with bisphosphonates, particularly zoledronate, is associated with reduced mortality rates. DATA SOURCES Science Direct, MEDLINE, Embase, and the Cochrane Library were searched for randomized placebo-controlled clinical trials of drug treatments for osteoporosis published after 2009 and published or in press before April 19, 2019. Conference abstracts from annual osteoporosis society meetings were also included in the search. STUDY SELECTION Included studies were clinical trials that (1) were randomized and placebo-controlled; (2) studied drug treatments with proven antifracture efficacy; (3) used agents at the approved dose for treatment of osteoporosis; and (4) had a duration of 1 year or more. Abstracts from the literature searches were reviewed for inclusion and exclusion criteria, and mortality rate data were abstracted from the article by 1 researcher and validated by a second. A total of 2045 records were screened; 38 (1.8%) were included in the meta-analyses. DATA EXTRACTION AND SYNTHESIS The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist was followed for abstracting data and assessing data quality and validity. Data were pooled using random-effects models, and between-study variability was assessed using the I2 index. The risk of bias for each study was assessed, and funnel plots and Egger and Begg statistics were used to evaluate publication bias. MAIN OUTCOMES AND MEASURES Associations of all drug treatments, particularly bisphosphonate and zoledronate treatments, with overall mortality. RESULTS Of 38 clinical trials that included 101 642 unique participants, 38 were included in the meta-analyses of all drug treatments (45 594 participants randomized to placebo; 56 048 to treatment); 21 clinical trials, of bisphosphonate treatments (20 244 participants randomized to placebo; 22 623 to treatment); and 6 clinical trials, of zoledronate treatments (6944 participants randomized to placebo; 6926 to treatment). No significant association was found between all drug treatments for osteoporosis and overall mortality rate (risk ratio [RR], 0.98; 95% CI, 0.91-1.05; I2 = 0%). Clinical trials of bisphosphonate treatment (RR, 0.95; 95% CI, 0.86-1.04) showed no significant association with overall mortality. Also, clinical trials of zoledronate treatment (RR, 0.88; 95% CI, 0.68-1.13) showed no association with overall mortality rate; however, evidence existed for heterogeneity of the results (I2 = 48.2%). CONCLUSIONS AND RELEVANCE Results of this meta-analysis suggest that bisphosphonate treatment may not be associated with reduced overall mortality rates in addition to decreased fracture risk and should only be recommended to reduce fracture risk. Additional trials are needed to clarify whether treatment with zoledronate reduces mortality rates.
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Affiliation(s)
- Steven R Cummings
- San Francisco Coordinating Center, San Francisco, California.,California Pacific Medical Center Research Institute, San Francisco.,Department of Medicine, University of California San Francisco, San Francisco.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco
| | - Li-Yung Lui
- San Francisco Coordinating Center, San Francisco, California.,California Pacific Medical Center Research Institute, San Francisco
| | - Richard Eastell
- Sheffield Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Isabel E Allen
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco
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Effects of abaloparatide on bone mineral density and risk of fracture in postmenopausal women aged 80 years or older with osteoporosis. Menopause 2019; 25:767-771. [PMID: 29462094 DOI: 10.1097/gme.0000000000001080] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Advanced age is an important risk factor for fracture. The Abaloparatide Comparator Trial In Vertebral Endpoints (ACTIVE) trial showed that subcutaneous abaloparatide increased bone mineral density (BMD) and reduced the risk of vertebral and nonvertebral fractures in postmenopausal women with osteoporosis. This study describes the effects of abaloparatide in the subgroup of women aged 80 or more years in ACTIVE. METHODS Post hoc analyses of BMD and fracture incidence in this subgroup of women who received abaloparatide or placebo in the 18-month, phase 3, double-blind, randomized controlled ACTIVE trial. RESULTS The mean ages of the women ≥80 years were 81.9 and 81.7 years in the placebo (n = 43) and abaloparatide (n = 51) groups, respectively. The increases in BMD from baseline to 18 months with abaloparatide treatment were 3.9% at the total hip (P < 0.001), 3.6% at the femoral neck (P < 0.01), and 12.1% at the lumbar spine (P < 0.001), and were similar to those observed in the overall population. Abaloparatide therapy was associated with numerical, but not statistically significant, reductions in the risk of vertebral and nonvertebral fractures in this subpopulation, compared with placebo. The proportion of participants reporting adverse events was similar between treatment groups and between the older subgroup and the overall population. CONCLUSION Abaloparatide was effective in increasing BMD in the very elderly subgroup of ACTIVE, with a safety profile similar to that of the overall study population.
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Fuggle NR, Curtis EM, Ward KA, Harvey NC, Dennison EM, Cooper C. Fracture prediction, imaging and screening in osteoporosis. Nat Rev Endocrinol 2019; 15:535-547. [PMID: 31189982 DOI: 10.1038/s41574-019-0220-8] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Osteoporosis is associated with increased fragility of bone and a subsequent increased risk of fracture. The diagnosis of osteoporosis is intimately linked with the imaging and quantification of bone and BMD. Scanning modalities, such as dual-energy X-ray absorptiometry or quantitative CT, have been developed and honed over the past half century to provide measures of BMD and bone microarchitecture for the purposes of clinical practice and research. Combined with fracture prediction tools such as Fracture Risk Assessment Tool (FRAX) (which use a combination of clinical risk factors for fracture to provide a measure of risk), these elements have led to a paradigm shift in the ability to diagnose osteoporosis and predict individuals who are at risk of fragility fracture. Despite these developments, a treatment gap exists between individuals who are at risk of osteoporotic fracture and those who are receiving therapy. In this Review, we summarize the epidemiology of osteoporosis, the history of scanning modalities, fracture prediction tools and future directions, including the most recent developments in prediction of fractures.
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Affiliation(s)
- Nicholas R Fuggle
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Elizabeth M Curtis
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Kate A Ward
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- MRC Nutrition and Bone Health Research Group, Cambridge, UK
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Elaine M Dennison
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- Victoria University of Wellington, Wellington, New Zealand
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK.
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK.
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.
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Ensrud KE, Kats AM, Boyd CM, Diem SJ, Schousboe JT, Taylor BC, Bauer DC, Stone KL, Langsetmo L. Association of Disease Definition, Comorbidity Burden, and Prognosis With Hip Fracture Probability Among Late-Life Women. JAMA Intern Med 2019; 179:1095-1103. [PMID: 31206140 PMCID: PMC6580441 DOI: 10.1001/jamainternmed.2019.0682] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 02/19/2019] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Advanced age is associated with lower use of drug treatment to prevent fractures, but concerns about comorbidities and prognosis increase the complexity of managing osteoporosis in this age group. OBJECTIVE To determine the association of disease definition, number of comorbidities, and prognosis with 5-year hip fracture probabilities among women who are 80 years and older. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study (4 US sites) included 1528 community-dwelling women identified as potential candidates for initiation of osteoporosis drug treatment. MAIN OUTCOMES AND MEASURES Women were contacted every 4 months to ascertain vital status and hip fracture. Five-year hip fracture probability was calculated accounting for competing mortality risk. Participants were classified into 2 distinct groups based on disease definition criteria proposed by the National Bone Health Alliance: with osteoporosis (n = 761) and without osteoporosis but at high fracture risk (n = 767). Comorbid conditions were assessed by self-report. Prognosis was estimated using a mortality prediction index. All analysis was performed between March 2018 and January 2019. RESULTS The study had 1528 participants, all of whom were women, with a mean (SD) age of 84.1 (3.4) years. During follow-up, 125 (8.0%) women experienced a hip fracture and 287 (18.8%) died before experiencing this event. Five-year mortality probability was 24.9% (95% CI, 21.8-28.1) among women with osteoporosis and 19.4% (95% CI, 16.6-22.3) among women without osteoporosis but at high fracture risk. In both groups, mortality probability similarly increased with more comorbidities and poorer prognosis. In contrast, 5-year hip fracture probability was 13.0% (95% CI, 10.7-15.5) among women with osteoporosis and 4.0% (95% CI, 2.8-5.6) among women without osteoporosis but at high fracture risk. The difference was most pronounced among women with more comorbidities or worse prognosis. For example, among women with 3 or more comorbid conditions, hip fracture probability was 18.1% (95% CI, 12.3-24.9) among women with osteoporosis vs 2.5% (95% CI, 1.3-4.2) among women without osteoporosis but at high fracture risk. CONCLUSIONS AND RELEVANCE Women 80 years and older who have osteoporosis, including those with more comorbidities or poorer prognosis, have a high 5-year probability of hip fracture despite accounting for competing mortality risk. In contrast, among women without osteoporosis but at high fracture risk, competing mortality risk far outweighs hip fracture probability, especially among those with more comorbidities or worse prognosis.
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Affiliation(s)
- Kristine E. Ensrud
- Department of Medicine, University of Minnesota, Minneapolis
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis
- Center for Chronic Disease Outcomes Research, VA Health Care System, Minneapolis, Minnesota
| | - Allyson M. Kats
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis
| | - Cynthia M. Boyd
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Susan J. Diem
- Department of Medicine, University of Minnesota, Minneapolis
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis
- Department of Medicine, VA Health Care System, Minneapolis, Minnesota
| | - John T. Schousboe
- HealthPartners Institute, Bloomington, Minnesota
- Division of Health Policy & Management, University of Minnesota, Minneapolis
| | - Brent C. Taylor
- Department of Medicine, University of Minnesota, Minneapolis
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis
- Center for Chronic Disease Outcomes Research, VA Health Care System, Minneapolis, Minnesota
| | | | - Katie L. Stone
- California Pacific Medical Center Research Institute, San Francisco
| | - Lisa Langsetmo
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis
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Imamura T, Tsurumoto T, Saiki K, Nishi K, Okamoto K, Manabe Y, Oyamada J, Ogami-Takamura K. Morphological profile of atypical femoral fractures: age-related changes to the cross-sectional geometry of the diaphysis. J Anat 2019; 235:892-902. [PMID: 31355449 DOI: 10.1111/joa.13060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2019] [Indexed: 12/14/2022] Open
Abstract
The use of bisphosphonates for osteoporosis patients has markedly decreased the incidence of femoral neck or trochanteric fractures. However, anti-osteoporosis drugs have been reported to increase the incidence of atypical femoral fractures, which involve stress fractures in the subtrochanteric region or the proximal diaphysis. In this study, the morphological characteristics of the cortical bone in human femoral diaphysis samples were analyzed from individuals who lived before bisphosphonate drugs were available in Japan. A total of 90 right femoral bones were arbitrarily selected (46 males and 44 females) from modern Japanese skeletal specimens. Full-length images of these femurs were acquired using a computed tomography scanner. An image processing method for binarization was used to calculate the threshold values of individual bones for determining their contours. The range between the lower end of the lesser trochanter and the adductor tubercle of each femur was divided at regular intervals to obtain 10 planes. The mean value of cortical bone thickness, periosteal border length, and the cortical cross-sectional area was evaluated for all planes. Moreover, the ratio of the area of the cortical bone to the total area of cross-section at the mid-diaphysis was calculated. A comparison between males and females demonstrated that most females had lower cortical bone area ratios at the mid-diaphysis. The femoral outer shape did not differ markedly according to age or sex; however, substantial individual differences were observed in the shape of the inner surface of the cortical bone. The cortical bone thickness and the cross-sectional area decreased with age in the femoral diaphysis; furthermore, in females, the decrease was higher for the former than for the latter. This may be due to a compensatory increase in the circumference of the femoral diaphysis. In addition, in about half of the subjects there was a discrepancy between the region with maximal value of the cortical bone thickness and that of the total cross-sectional area. Biological responses to mechanical stresses to the femoral diaphysis are thought not to be uniform. Bisphosphonates inhibit bone resorption and may promote non-physiological bone remodeling. Thus, a nonhomogeneous decrease in cortical thickness may be related to the fracture occurrence in the femoral diaphysis in some cases. Thus, long-term administration of bisphosphonates in patients with morphological vulnerability in the femoral cortical bones may increase the occurrence of atypical femoral fractures.
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Affiliation(s)
- Takeshi Imamura
- Department of Macroscopic Anatomy, Graduate School of Biomedical Science, Nagasaki University, Nagasaki, Japan
| | - Toshiyuki Tsurumoto
- Department of Macroscopic Anatomy, Graduate School of Biomedical Science, Nagasaki University, Nagasaki, Japan
| | - Kazunobu Saiki
- Department of Macroscopic Anatomy, Graduate School of Biomedical Science, Nagasaki University, Nagasaki, Japan
| | - Keita Nishi
- Department of Oral Anatomy and Dental Anthropology, Graduate School of Biomedical Science, Nagasaki University, Nagasaki, Japan
| | - Keishi Okamoto
- Department of Macroscopic Anatomy, Graduate School of Biomedical Science, Nagasaki University, Nagasaki, Japan
| | - Yoshitaka Manabe
- Department of Oral Anatomy and Dental Anthropology, Graduate School of Biomedical Science, Nagasaki University, Nagasaki, Japan
| | - Joichi Oyamada
- Department of Oral Anatomy and Dental Anthropology, Graduate School of Biomedical Science, Nagasaki University, Nagasaki, Japan
| | - Keiko Ogami-Takamura
- Department of Macroscopic Anatomy, Graduate School of Biomedical Science, Nagasaki University, Nagasaki, Japan
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Kang MG, Kim KI, Ihm SH, Rhee MY, Sohn IS, Lee HY, Park S, Jeon ES, Song JM, Pyun WB, Sung KC, Kim MH, Kim SH, Kim SY, Kim SJ, Kim EJ, Shin J, Lee SY, Chun KJ, Jeong JO, Chae SC, Yoo KD, Choi YJ, Park YH, Kim CH. Fimasartan versus perindopril with and without diuretics in the treatment of elderly patients with essential hypertension (Fimasartan in the Senior Subjects (FITNESS)): study protocol for a randomized controlled trial. Trials 2019; 20:389. [PMID: 31262348 PMCID: PMC6604456 DOI: 10.1186/s13063-019-3466-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 05/24/2019] [Indexed: 01/24/2023] Open
Abstract
Background Hypertension is an important risk factor for cardiovascular disease, even in the elderly. Fimasartan is a new non-peptide angiotensin II receptor blocker with a selective type I receptor blocking effect. The objective of this study is to confirm the safety and the non-inferiority of the blood pressure–lowering effect of fimasartan compared with those of perindopril, which has been proven safe and effective in elderly patients with hypertension. Methods This is a randomized, double-blind, active-controlled, two-parallel group, optional-titration, multicenter, phase 3 study comparing the efficacy and safety of fimasartan and perindopril arginine. The study population consists of individuals 70 years old or older with essential hypertension. The primary outcome will be a change in sitting systolic blood pressure from baseline after the administration of the investigational product for 8 weeks. The secondary outcomes will be a change in sitting diastolic blood pressure from baseline and changes in sitting systolic blood pressure and diastolic blood pressure from baseline after the administration of the investigational product for 4, 16, and 24 weeks. The sample size will be 119 subjects for each group to confer enough power to test for the primary outcome. Discussion Research to confirm the efficacy and safety of a new medicine compared with those of previously proven anti-hypertensive drugs is beneficial to guide physicians in the selection of therapeutic agents. If it is confirmed that the new drug is not inferior to the existing drug, the drug will be considered as an option in the treatment of hypertension in elderly patients. Trial registration ClinicalTrials.gov Identifier: NCT03246555, registered on July 25, 2017. Electronic supplementary material The online version of this article (10.1186/s13063-019-3466-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Min-Gu Kang
- Department of Internal Medicine, Chonnam National University Bitgoeul Hospital, Gwang-ju, 61748, Republic of Korea
| | - Kwang-Il Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Gumi-ro 166, Bundang-gu, Seongnam-si, Kyeongi-do, 463-707, Republic of Korea
| | - Sang Hyun Ihm
- Department of Internal Medicine, The Catholic University of Korea Bucheon ST. Mary's Hospital, 327, Sosa-ro, Bucheon-si, Gyeonggi-do, Republic of Korea
| | - Moo-Yong Rhee
- Cardiovascular Center, Dongguk University Ilsan Hospital, 27, Dongguk-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Il Suk Sohn
- Department of Cardiology, Kyung Hee University Hospital at Gangdong, 892, Dongnam-ro, Gangdong-gu, Seoul, Republic of Korea
| | - Hae-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Sungha Park
- Department of Internal Medicine, Yonsei University Health System, Severance Hospital, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Eun-Seok Jeon
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan, University School of Medicine, 81 Irwon-Ro Gangnam-gu, Seoul, Republic of Korea
| | - Jong-Min Song
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, Republic of Korea
| | - Wook Bum Pyun
- Department of Internal Medicine, Ewha Womans University Seoul Hospital, 260, Gonghangdae-ro, Gangseo-gu, Seoul, Republic of Korea
| | - Ki-Chul Sung
- Division of Cardiology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29, Saemunan-ro, Jongno-gu, Seoul, Republic of Korea
| | - Moo Hyun Kim
- Department of Internal Medicine, Dong-A University Hospital, 26, Daesingongwon-ro, Seo-gu, Busan, Republic of Korea
| | - Sang-Hyun Kim
- Department of Internal Medicine, Seoul National University Borame Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, Republic of Korea
| | - Seok-Yeon Kim
- Department of Internal Medicine, Seoul Medical Center, 156, Sinnae-ro, Jungnang-gu, Seoul, Republic of Korea
| | - Shin-Jae Kim
- Department of Internal Medicine, Ulsan University Hospital, 877, Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea
| | - Eung Ju Kim
- Department of Internal Medicine, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, Republic of Korea
| | - Jinho Shin
- Department of Internal Medicine, Hanyang University Hospital, Wangsimni-ro, Seongdong-gu, Seoul, Republic of Korea
| | - Sung Yun Lee
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, 170, Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Kook-Jin Chun
- Department of Internal Medicine, Pusan National University Yangsan Hospital, 20, Geumo-ro, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, Republic of Korea
| | - Jin-Ok Jeong
- Department of Internal Medicine, Chungnam National University Hospital, 282, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea.,Chungnam National University, 99 Daehak-ro, Yuseong-gu, Daejeon, 34134, Republic of Korea
| | - Shung Chull Chae
- Department of Internal Medicine, School of Medicine, Kyungpook National University, 130, Dongdeok-ro, Jung-gu, Daegu, Republic of Korea
| | - Ki Dong Yoo
- Department of Internal Medicine, The Catholic University of Korea, ST. Vincent's Hospital, 93-1, Jungbu-daero, Paldal-gu, Suwon-si, Gyeonggi-do, Republic of Korea
| | - Young Jin Choi
- Department of Internal Medicine, Sejong Hospital, 28, Hohyeon-ro 489beon-gil, Bucheon-si, Gyeonggi-do, Republic of Korea
| | - Yong Hwan Park
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, 158, Paryong-ro, Masanhoewon-gu, Changwon-si, Gyeongsangnam-do, Republic of Korea
| | - Cheol-Ho Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Gumi-ro 166, Bundang-gu, Seongnam-si, Kyeongi-do, 463-707, Republic of Korea.
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Naranjo Hernández A, Díaz del Campo Fontecha P, Aguado Acín MP, Arboleya Rodríguez L, Casado Burgos E, Castañeda S, Fiter Aresté J, Gifre L, Gómez Vaquero C, Candelas Rodríguez G, Francisco Hernández FM, Guañabens Gay N. Recomendaciones de la Sociedad Española de Reumatología sobre osteoporosis. ACTA ACUST UNITED AC 2019; 15:188-210. [DOI: 10.1016/j.reuma.2018.09.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/17/2018] [Accepted: 09/19/2018] [Indexed: 01/09/2023]
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131
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Guañabens N, Moro-Álvarez MJ, Casado E, Blanch-Rubió J, Gómez-Alonso C, Díaz-Guerra GM, Del Pino-Montes J, Valero Díaz de Lamadrid C, Peris P, Muñoz-Torres M. The next step after anti-osteoporotic drug discontinuation: an up-to-date review of sequential treatment. Endocrine 2019; 64:441-455. [PMID: 30963388 DOI: 10.1007/s12020-019-01919-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 03/29/2019] [Indexed: 12/16/2022]
Abstract
Several antiresorptive drugs, like bisphosphonates and denosumab, are currently available for the treatment of osteoporosis due to their evidenced efficacy in reducing fracture risk at mid-term. Osteoanabolic therapies, like teriparatide, whose treatment duration is limited to 2 years, have also shown efficacy in the reduction of fracture risk. However, depending on the severity of osteoporosis and the presence of other associated risk factors for fracture, some patients may require long-term treatment to preserve optimal bone strength and minimize bone fracture risk. Given the limited duration of some treatments, the fact that most of the antiresorptive drugs have not been assessed beyond 10 years, and the known long-term safety issues of these drugs, including atypical femoral fractures or osteonecrosis of the jaw, the long-term management of these patients may require an approach based on drug discontinuation and/or switching. In this regard, interest in sequential osteoporosis therapy, wherein drugs are initiated and discontinued over time, has grown in recent years, although the establishment of an optimal and individualized order of therapies remains controversial. This review reports the currently available clinical evidence on the discontinuation effects of different anti-osteoporotic drugs, as well as the clinical outcomes of the different sequential treatment regimens. The objective of this article is to present up-to-date practical knowledge on this area in order to provide guidance to the clinicians involved in the management of patients with osteoporosis.
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Affiliation(s)
- Núria Guañabens
- Metabolic Bone Diseases Unit, Department of Rheumatology, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Barcelona, Spain.
| | | | - Enrique Casado
- Rheumatology Department, Parc Taulí University Hospital, Autonomous University of Barcelona, Sabadell, Spain
| | | | - Carlos Gómez-Alonso
- Bone and Mineral Metabolism Unit, Central University Hospital of Asturias (HUCA), University of Oviedo, Oviedo, Spain
| | | | | | - Carmen Valero Díaz de Lamadrid
- University Hospital Marqués de Valdecilla, Research Institute Marqués de Valdecilla (IDIVAL), University of Cantabria, Santander, Spain
| | - Pilar Peris
- Metabolic Bone Diseases Unit, Department of Rheumatology, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Barcelona, Spain
| | - Manuel Muñoz-Torres
- Endocrinology and Nutrition Unit, Hospital Universitario San Cecilio de Granada, Department of Medicine, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria (Ibs.GRANADA), CIBERFES, Instituto de Salud Carlos III, Granada, Spain
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132
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Secondary fracture prevention: Drug treatment, fall prevention and nutrition requirements. Best Pract Res Clin Rheumatol 2019; 33:290-300. [PMID: 31547984 DOI: 10.1016/j.berh.2019.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In view of the high imminent risk for subsequent fractures, evaluation as early as possible after the fracture will result in early decisions about drug treatment, fall prevention and nutritional supplements. Drug treatment includes anti-resorptive and bone forming agents. Anti-resorptive therapy with broad spectrum fracture prevention and early anti-fracture effects are the first choice. In patients with multiple or severe VFs, the bone forming agent teriparatide should be considered. Adequate calcium and vitamin D are needed in all patients, together with appropriate nutrition, including adequate protein intake.
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Bover J, Ureña-Torres P, Laiz Alonso AM, Torregrosa JV, Rodríguez-García M, Castro-Alonso C, Górriz JL, Benito S, López-Báez V, Lloret Cora MJ, Cigarrán S, DaSilva I, Sánchez-Bayá M, Mateu Escudero S, Guirado L, Cannata-Andía J. Osteoporosis, densidad mineral ósea y complejo CKD-MBD (II): implicaciones terapéuticas. Nefrologia 2019; 39:227-242. [DOI: 10.1016/j.nefro.2018.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 09/13/2018] [Accepted: 10/31/2018] [Indexed: 12/23/2022] Open
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Fontalis A, Kenanidis E, Kotronias RA, Papachristou A, Anagnostis P, Potoupnis M, Tsiridis E. Current and emerging osteoporosis pharmacotherapy for women: state of the art therapies for preventing bone loss. Expert Opin Pharmacother 2019; 20:1123-1134. [PMID: 30958709 DOI: 10.1080/14656566.2019.1594772] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Pharmacological options to address the imbalance between bone resorption and accrual in osteoporosis include anti-resorptive and osteoanabolic agents. Unique biologic pathways such as the Wnt/β-catenin pathway have been targeted in the quest for new emerging therapeutic strategies. AREAS COVERED This review provides an overview of existing pharmacotherapy for osteoporosis in women and explore state-of-the-art and emerging therapies to prevent bone loss, with an emphasis on the mechanism of action, indications and side effects. EXPERT OPINION Bisphosphonates appear to be a reliable and cost-effective option, whereas denosumab has introduced a simpler dosing regimen and may achieve a linear increase in bone mineral density (BMD) with no plateau being observed, along with continuous anti-fracture efficacy. Abaloparatide, a parathyroid-hormone-related peptide (PTHrP)-analogue, approved by the FDA in April 2017, constitutes the first new anabolic osteoporosis drug in the US for nearly 15 years and has also proven its anti-fracture efficacy. Romosozumab, a sclerostin inhibitor, which induces bone formation and suppresses bone resorption, has also been developed and shown a significant reduction in fracture incidence; however, concerns have arisen with regard to increased cardiovascular risk.
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Affiliation(s)
- Andreas Fontalis
- a Department of Oncology and Metabolism , University of Sheffield Medical School , Sheffield , UK.,b Sheffield Teaching Hospitals NHS Foundation Trust , Northern General Hospital , Sheffield , UK
| | - Eustathios Kenanidis
- c Academic Orthopaedic Unit , Aristotle University Medical School, Papageorgiou General Hospital , Thessaloniki , Greece.,d Centre of Orthopaedic and Regenerative Medicine (CORE), Center for Interdisciplinary Research and Innovation (CIRI) , Aristotle University of Thessaloniki , Thessaloniki , Greece
| | - Rafail Angelos Kotronias
- e Division of Cardiovascular Medicine, Oxford University Clinical Academic Graduate School , University of Oxford , Oxford , UK
| | - Afroditi Papachristou
- f Pharmacy Department , Oxford University Hospitals NHS Foundation Trust , Oxford , UK
| | - Panagiotis Anagnostis
- d Centre of Orthopaedic and Regenerative Medicine (CORE), Center for Interdisciplinary Research and Innovation (CIRI) , Aristotle University of Thessaloniki , Thessaloniki , Greece.,g Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynaecology , Aristotle University Medical School , Thessaloniki , Greece
| | - Michael Potoupnis
- c Academic Orthopaedic Unit , Aristotle University Medical School, Papageorgiou General Hospital , Thessaloniki , Greece.,d Centre of Orthopaedic and Regenerative Medicine (CORE), Center for Interdisciplinary Research and Innovation (CIRI) , Aristotle University of Thessaloniki , Thessaloniki , Greece
| | - Eleftherios Tsiridis
- c Academic Orthopaedic Unit , Aristotle University Medical School, Papageorgiou General Hospital , Thessaloniki , Greece.,d Centre of Orthopaedic and Regenerative Medicine (CORE), Center for Interdisciplinary Research and Innovation (CIRI) , Aristotle University of Thessaloniki , Thessaloniki , Greece
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135
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Lauppe R, Åkesson KE, Ljunggren Ö, Spångéus A, Ortsäter G, Feudjo-Tepie M, Ström O. Differing impact of clinical factors on the risk of fracture in younger and older women in the general population and an osteoporosis clinic population. Arch Osteoporos 2019; 14:45. [PMID: 30963310 DOI: 10.1007/s11657-019-0592-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 03/08/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED This study assesses the impact of risk factors for fracture in women aged 80+ and 60-79. The results suggest that risk assessment which fits younger women may not be suited for the 80+ strata as many common risk factors are less predictive in the older compared to the younger cohort. PURPOSE This study assesses whether the impact of classical risk factors for fracture due to osteoporosis is different in women aged 80+ and women aged 60-79. Since most prior research on the contribution of risk factors is based on patients below 80 years of age, this study aims to fill this knowledge gap to increase the accuracy of risk assessment in the oldest old. METHODS Retrospective, observational cohort study using Swedish national health register data and BMD data from osteoporosis clinics. Women aged at least 60 were identified from a random sample of the general population and from the BMD databases and allocated to two populations representing patients at different stages of risk assessment. The relative impact of risk factors on fracture risk was assessed using multivariate competing risk regression with fracture as outcome and death as competing event. RESULTS A total of 163,329 women were included from the general population (52,499 aged 80+) and 22,378 from the BMD databases (4563 aged 80+). The clinical risk factors with relatively highest effect on fracture risk in the older patients were prior fracture and hip T-score below - 2.5 SD. Other included risk factors showed lower impact in the older compared to the younger strata. CONCLUSIONS This study confirms our understanding of the key risk factors for fracture: age, prior fracture, and a low T-score. Regarding remaining risk factors, risk assessment which fits younger women may not be suited for the 80+ strata as many common risk factors are less predictive in the older compared to the younger cohort.
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Affiliation(s)
| | - Kristina E Åkesson
- Department of Clinical Sciences and Skåne University Hospital, Lund University, Malmö, Sweden
| | | | | | | | | | - Oskar Ström
- Quantify Research, Stockholm, Sweden
- Karolinska Institutet, Stockholm, Sweden
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136
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Abstract
Antiresorptive drugs, such as the bisphosphonates and the RANKL inhibitor denosumab, are currently the most widely used osteoporosis medications. These drugs increase bone mineral density (BMD) and reduce the risk of vertebral (by 40-70%), nonvertebral (by 25-40%) and hip fractures (by 40-53%) in postmenopausal women with osteoporosis. Due to the risk of rare side-effects, the use of bisphosphonates has been limited to up to 10 years with oral bisphosphonates and 6 years with intravenous zoledronic acid. Despite their well-proven efficacy and safety, few women at high risk of fracture are started on treatment. Case finding strategies, such as fracture risk-based screening in primary care using the fracture risk assessment tool (FRAX) and Fracture Liaison Services, have proved effective in increasing treatment rates and reducing fracture rates. Recently, anabolic therapy with teriparatide was demonstrated to be superior to the bisphosphonate risedronate in preventing vertebral and clinical fractures in postmenopausal women with vertebral fracture. Treatment with the sclerostin antibody romosozumab increases BMD more profoundly and rapidly than alendronate and is also superior to alendronate in reducing the risk of vertebral and nonvertebral fracture in postmenopausal women with osteoporosis. For patients with severe osteoporosis and high fracture risk, bisphosphonates alone are unlikely to be able to provide long-term protection against fracture and restore BMD. For those patients, sequential treatment, starting with a bone-building drug (e.g. teriparatide), followed by an antiresorptive, will likely provide better long-term fracture prevention and should be the golden standard of future osteoporosis treatment.
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Affiliation(s)
- Mattias Lorentzon
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.,Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
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137
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Bouxsein ML, Eastell R, Lui LY, Wu LA, de Papp AE, Grauer A, Marin F, Cauley JA, Bauer DC, Black DM. Change in Bone Density and Reduction in Fracture Risk: A Meta-Regression of Published Trials. J Bone Miner Res 2019; 34:632-642. [PMID: 30674078 DOI: 10.1002/jbmr.3641] [Citation(s) in RCA: 172] [Impact Index Per Article: 34.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 08/22/2018] [Accepted: 09/11/2018] [Indexed: 12/26/2022]
Abstract
Meta-analyses conducted >15 years ago reported that improvements in bone mineral density (BMD) were associated with reduction in vertebral and nonvertebral fractures in osteoporosis trials. Numerous studies have been conducted since then, incorporating new therapies with different mechanisms of action and enrolling many more subjects. To extend these prior analyses, we conducted a meta-regression of 38 placebo-controlled trials of 19 therapeutic agents to determine the association between improvements in BMD and reductions in fracture risk. We used a linear model to examine the relationship between mean percent difference in BMD change between treatment and placebo groups and the logarithm of the relative risk. We found that greater improvements in BMD were strongly associated with greater reductions in vertebral and hip fractures but not nonvertebral fractures. For vertebral fracture, the r2 values for total hip, femoral neck, and lumbar spine BMD change were 0.56, 0.54, and 0.63, respectively (p ≤ 0.0002). For a 2% or 6% improvement in total hip BMD, we might expect a 28% or 66% reduction, respectively, in vertebral fracture risk. For hip fracture, the r2 values for total hip, femoral neck, and lumbar spine BMD change were 0.48 (p = 0.01), 0.42 (p = 0.02), and 0.22 (ns), respectively. For a 2% or 6% improvement in total hip BMD, we might expect a 16% or 40% reduction in hip fracture risk. In conclusion, our results extend prior observations that larger improvements in dual-energy X-ray absorptiometry (DXA)-based BMD are associated with greater reductions in fracture risk, particularly for vertebral and hip fractures. Although these results cannot be directly applied to predict the treatment benefit in an individual patient, they provide compelling evidence that improvements in BMD with osteoporosis therapies may be useful surrogate endpoints for fracture in trials of new therapeutic agents. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Mary L Bouxsein
- Center for Advanced Orthopedic Studies, Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Richard Eastell
- Academic Unit of Bone Metabolism, University of Sheffield, Sheffield, UK
| | - Li-Yung Lui
- California Pacific Medical Center, San Francisco, CA, USA
| | - Lucy A Wu
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | | | | | - Fernando Marin
- Eli Lilly and Company, Lilly Research Centre, Windlesham, UK
| | - Jane A Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Douglas C Bauer
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA.,Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Dennis M Black
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
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- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
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138
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Bruton's tyrosine kinase (Btk) inhibitor tirabrutinib suppresses osteoclastic bone resorption. Bone Rep 2019; 10:100201. [PMID: 30956999 PMCID: PMC6431727 DOI: 10.1016/j.bonr.2019.100201] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 02/12/2019] [Accepted: 03/11/2019] [Indexed: 12/02/2022] Open
Abstract
Osteoclasts are responsible for bone erosion in osteoporosis and rheumatoid arthritis (RA). Both Btk and Tec kinases have essential functions in osteoclast differentiation. Tirabrutinib is a highly potent and dual oral Btk/Tec inhibitor with an IC50 in the nmol/L range and significantly inhibits the M-CSF and RANKL-driven osteoclast differentiation. It was hypothesized that the in vitro activity of tirabrutinib could be demonstrated in mice bone resorption model. The RANKL model studies show that tirabrutinib significantly suppressed bone loss with the inhibition of serum TRAPCP5b and urinary CTX-1. Bone Mineral Density (BMD) loss in tirabrutinib-treated mice was 55% (P < .05), 87% (P < .001) and 88% (P < .001) for the 3, 10 and 30 mg/kg dose groups respectively. Btk and Tec are required for osteoclast differentiation and activation based on the genetic evidence obtained from Btk and Tec double deficient mice. Tirabrutinib may be a novel therapeutic target for bone diseases, such as osteoporosis and RA. Btk and Tec are activated by RANKL and indispensable for osteoclastogenesis. Tirabrutinib is a highly potent and dual oral Btk/Tec inhibitor. Osteoclast differentiation is activated by RANKL, M-CSF and ITAM. Tirabrutinib inhibited RANKL-induced osteolyrtic bone disease.
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139
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Díez-Pérez A, Marin F, Eriksen EF, Kendler DL, Krege JH, Delgado-Rodríguez M. Effects of teriparatide on hip and upper limb fractures in patients with osteoporosis: A systematic review and meta-analysis. Bone 2019; 120:1-8. [PMID: 30268814 DOI: 10.1016/j.bone.2018.09.020] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 09/18/2018] [Accepted: 09/24/2018] [Indexed: 02/07/2023]
Abstract
In randomized clinical trials (RCTs) with teriparatide, the number of patients with incident hip fractures was small and insufficiently powered to show statistically significant differences between groups. We, therefore, conducted a systematic review and meta-analysis of the efficacy of teriparatide in the reduction of hip and upper limb fractures in women and men with osteoporosis. A comprehensive search of databases until 22 November 2017 was conducted for RCTs of at least 6-month duration that reported non-spine fractures (hip, humerus, forearm, wrist), either as an efficacy or safety endpoint. Only RCTs that included patients with the approved treatment indications and dose for use of teriparatide were included; trials with off-label use of teriparatide were excluded. Two independent reviewers performed study selection and data extraction. Statistical procedures included Peto's method and Mantel-Haenszel with empirical correction, as most of the RCTs reported zero events in at least one of the treatment arms. Study results are expressed as odds ratios (OR) with 95% confidence intervals (CI). Publication bias and heterogeneity were evaluated with standard statistical tests. Twenty-three RCTs were included, 19 with an active-controlled arm (representing 64.9% of the patients included in the control group) and 11 double-blind, representing data on 8644 subjects, 3893 of them treated with teriparatide. Mean age (SD) was 67.0 (4.5) years, median treatment duration 18 months (range: 6 to 24 months). A total of 34 incident hip, 31 humerus, 31 forearm, and 62 wrist fractures were included. Meta-analysis results showed an OR (95% CI) for hip fractures of 0.44 (0.22-0.87; p = 0.019) in patients treated with teriparatide compared with controls. The effects on the risk of humerus [1.02 (0.50-2.08)], forearm [0.53 (0.26-1.08)] and wrist fractures [1.21 (0.72-2.04)] were not statistically significant (p > 0.05). This meta-analysis provides evidence of efficacy of teriparatide in reducing hip fractures by 56% in patients with osteoporosis.
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Affiliation(s)
- Adolfo Díez-Pérez
- Hospital del Mar-IMIM-UAB, Department of Internal Medicine, Barcelona, Spain; CIBERFES, Institute Carlos III, Barcelona, Spain.
| | | | - Erik F Eriksen
- Department of Clinical Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Norway
| | | | | | - Miguel Delgado-Rodríguez
- Department of Preventive Medicine and Public Health, University of Jaén, Spain; CIBERESP, Institute Carlos III, Madrid, Spain
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140
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Nishiguchi A, Taguchi T. Osteoclast-Responsive, Injectable Bone of Bisphosphonated-Nanocellulose that Regulates Osteoclast/Osteoblast Activity for Bone Regeneration. Biomacromolecules 2019; 20:1385-1393. [PMID: 30768248 DOI: 10.1021/acs.biomac.8b01767] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
An injectable bone may serve as a minimally invasive therapy for large orthopedic defects and osteoporosis and an alternative to allografting and surgical treatment. However, conventional bone substitutes lack the desirable biodegradability, bioresponsibility, and functionality to regulate the bone regeneration process. Here, we report an injectable, bioresponsive bone composed of bisphosphonate-modified nanocellulose (pNC) as a bone substitute for bone regeneration. Composites composed of nanofibrillated cellulose and β-tricalcium phosphate (β-TCP) mimic bone structures in which apatite reinforces collagen fibrils. Bisphosphonate groups on nanocellulose provide reversible, physical cross-linking with β-TCP, apatite formation, binding property to bone, and pH responsiveness. When the pH drops to ∼4.5, which corresponds to an osteoclast-induced pH decrease, pNC-β-TCP composite degrades and releases pNC. pNC suppresses osteoclast formation and pit formation. This osteoclast-responsive property allows for controlling the degradation rate of the composite. Moreover, the composite of pNC, α-tricalcium phosphate (α-TCP), and β-TCP enhances osteoblast differentiation. This injectable bone substitute of pNC that regulates osteoclast/osteoblast activity has enormous potential for the treatment of bone diseases and prevention of locomotive syndrome.
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Affiliation(s)
- Akihiro Nishiguchi
- Biomaterials Field, Research Center for Functional Materials , National Institute for Materials Science , 1-1 Namiki , Tsukuba , Ibaraki 305-0044 , Japan
| | - Tetsushi Taguchi
- Biomaterials Field, Research Center for Functional Materials , National Institute for Materials Science , 1-1 Namiki , Tsukuba , Ibaraki 305-0044 , Japan
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141
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Camacho PM, Petak SM, Binkley N, Clarke BL, Harris ST, Hurley DL, Kleerekoper M, Lewiecki EM, Miller PD, Narula HS, Pessah-Pollack R, Tangpricha V, Wimalawansa SJ, Watts NB. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS - 2016. Endocr Pract 2019; 22:1-42. [PMID: 27662240 DOI: 10.4158/ep161435.gl] [Citation(s) in RCA: 305] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ABBREVIATIONS AACE = American Association of Clinical Endocrinologists AFF = atypical femur fracture ASBMR = American Society for Bone and Mineral Research BEL = best evidence level BMD = bone mineral density BTM = bone turnover marker CBC = complete blood count CI = confidence interval DXA = dual-energy X-ray absorptiometry EL = evidence level FDA = U.S. Food and Drug Administration FLEX = Fracture Intervention Trial (FIT) Long-term Extension FRAX® = Fracture Risk Assessment Tool GFR = glomerular filtration rate GI = gastrointestinal HORIZON = Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly IOF = International Osteoporosis Foundation ISCD = International Society for Clinical Densitometry IU = international units IV = intravenous LSC = least significant change NBHA = National Bone Health Alliance NOF = National Osteoporosis Foundation 25(OH)D = 25-hydroxy vitamin D ONJ = osteonecrosis of the jaw PINP = serum carboxy-terminal propeptide of type I collagen PTH = parathyroid hormone R = recommendation RANK = receptor activator of nuclear factor kappa-B RANKL = receptor activator of nuclear factor kappa-B ligand RCT = randomized controlled trial RR = relative risk S-CTX = serum C-terminal telopeptide SQ = subcutaneous VFA = vertebral fracture assessment WHO = World Health Organization.
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142
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Kanis JA, Cooper C, Rizzoli R, Reginster JY. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 2019; 30:3-44. [PMID: 30324412 PMCID: PMC7026233 DOI: 10.1007/s00198-018-4704-5] [Citation(s) in RCA: 853] [Impact Index Per Article: 170.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 09/12/2018] [Indexed: 12/25/2022]
Abstract
Guidance is provided in a European setting on the assessment and treatment of postmenopausal women at risk from fractures due to osteoporosis. INTRODUCTION The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2013. This manuscript updates these in a European setting. METHODS Systematic reviews were updated. RESULTS The following areas are reviewed: the role of bone mineral density measurement for the diagnosis of osteoporosis and assessment of fracture risk; general and pharmacological management of osteoporosis; monitoring of treatment; assessment of fracture risk; case-finding strategies; investigation of patients; health economics of treatment. The update includes new information on the evaluation of bone microstructure evaluation in facture risk assessment, the role of FRAX® and Fracture Liaison Services in secondary fracture prevention, long-term effects on fracture risk of dietary intakes, and increased fracture risk on stopping drug treatment. CONCLUSIONS A platform is provided on which specific guidelines can be developed for national use.
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Affiliation(s)
- J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia.
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - R Rizzoli
- University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
| | - J-Y Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- Prince Mutaib Chair for Biomarkers of Osteoporosis, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
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143
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Lewiecki EM, Bilezikian JP, Giangregorio L, Greenspan SL, Khosla S, Kostenuik P, Krohn K, McClung MR, Miller PD, Pacifici R. Proceedings of the 2018 Santa Fe Bone Symposium: Advances in the Management of Osteoporosis. J Clin Densitom 2019; 22:1-19. [PMID: 30366683 DOI: 10.1016/j.jocd.2018.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 09/19/2018] [Indexed: 12/16/2022]
Abstract
The Santa Fe Bone Symposium is an annual meeting devoted to clinical applications of recent advances in skeletal research. The 19th Santa Fe Bone Symposium convened August 3-4, 2018, in Santa Fe, New Mexico, USA. Attendees included physicians of many specialties, fellows in training, advanced practice providers, clinical researchers, and bone density technologists. The format consisted of lectures, case presentations by endocrinology fellows, and panel discussions, with all involving extensive interactive discussions. Topics were diverse, including an evolutionary history of calcium homeostasis, osteoporosis treatment in the very old, optimizing outcomes with orthopedic surgery, microbiome and bone, new strategies for combination and sequential therapy of osteoporosis, exercise as medicine, manifestations of parathyroid hormone excess and deficiency, parathyroid hormone as a therapeutic agent, cell senescence and bone health, and managing patients outside clinical practice guidelines. The National Bone Health Alliance conducted a premeeting on development of fracture liaison services. A workshop was devoted to Bone Health TeleECHO (Bone Health Extension for Community Healthcare Outcomes), a strategy of ongoing medical education for healthcare professions to expand capacity to deliver best practice skeletal healthcare in underserved communities and reduce the osteoporosis treatment gap.
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Affiliation(s)
- E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA.
| | - John P Bilezikian
- Columbia University College of Physicians and Surgeons, NYC, NY, USA
| | - Lora Giangregorio
- University of Waterloo and Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
| | | | | | | | | | - Michael R McClung
- Oregon Osteoporosis Center, Portland, OR, USA; MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Paul D Miller
- University of Colorado Health Sciences Center, Denver, CO, USA
| | - Roberto Pacifici
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University, Atlanta, GA, USA
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144
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Balasubramanian A, Zhang J, Chen L, Wenkert D, Daigle SG, Grauer A, Curtis JR. Risk of subsequent fracture after prior fracture among older women. Osteoporos Int 2019; 30:79-92. [PMID: 30456571 PMCID: PMC6332293 DOI: 10.1007/s00198-018-4732-1] [Citation(s) in RCA: 194] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 10/03/2018] [Indexed: 01/22/2023]
Abstract
UNLABELLED Among 377,561 female Medicare beneficiaries who sustained a fracture, 10% had another fracture within 1 year, 18% within 2 years, and 31% within 5 years. Timely management to reduce risk of subsequent fracture is warranted following all nontraumatic fractures, including nonhip nonvertebral fractures, in older women. INTRODUCTION Prior fracture is a strong predictor of subsequent fracture; however, postfracture treatment rates are low. Quantifying imminent (12-24 month) risk of subsequent fracture in older women may clarify the need for early postfracture management. METHODS This retrospective cohort study used Medicare administrative claims data. Women ≥ 65 years who sustained a clinical fracture (clinical vertebral and nonvertebral fracture; index date) and were continuously enrolled for 1-year pre-index and ≥ 1-year (≥ 2 or ≥ 5 years for outcomes at those time points) post-index were included. Cumulative incidence of subsequent fracture was calculated from 30 days post-index to 1, 2, and 5 years post-index. For appendicular fractures, only those requiring hospitalization or surgical repair were counted. Death was considered a competing risk. RESULTS Among 377,561 women (210,621 and 10,969 for 2- and 5-year outcomes), cumulative risk of subsequent fracture was 10%, 18%, and 31% at 1, 2, and 5 years post-index, respectively. Among women age 65-74 years with initial clinical vertebral, hip, pelvis, femur, or clavicle fractures and all women ≥ 75 years regardless of initial fracture site (except ankle and tibia/fibula), 7-14% fractured again within 1 year depending on initial fracture site; risk rose to 15-26% within 2 years and 28-42% within 5 years. Risk of subsequent hip fracture exceeded 3% within 5 years in all women studied, except those < 75 years with an initial tibia/fibula or ankle fracture. CONCLUSIONS We observed a high and early risk of subsequent fracture following a broad array of initial fractures. Timely management with consideration of pharmacotherapy is warranted in older women following all fracture types evaluated.
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Affiliation(s)
| | - J Zhang
- University of Alabama at Birmingham, 510 20th Street South, Birmingham, AL, 35294, USA
| | - L Chen
- University of Alabama at Birmingham, 510 20th Street South, Birmingham, AL, 35294, USA
| | - D Wenkert
- Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA, 91320, USA
- Wenkert & Young, LLC, 2345 Mountain Crest Circle, Thousand Oaks, CA, 91362, USA
| | - S G Daigle
- University of Alabama at Birmingham, 510 20th Street South, Birmingham, AL, 35294, USA
| | - A Grauer
- Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA, 91320, USA
| | - J R Curtis
- University of Alabama at Birmingham, 510 20th Street South, Birmingham, AL, 35294, USA
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145
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Efficacy, cost, and aspects to take into account in the treatment of osteoporosis in the elderly. Rev Esp Geriatr Gerontol 2018; 54:156-167. [PMID: 30606499 DOI: 10.1016/j.regg.2018.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 11/19/2018] [Accepted: 11/26/2018] [Indexed: 11/22/2022]
Abstract
Age is one of the principal risk factors for development of frailty fractures. Age pyramids show a population that is becoming increasingly more elderly, with an increasing incidence of fractures, and the forecasts for the future are truly alarming. Adequate handling of these patients who are especially at risk, at both the preventive and care levels, with a well-defined orthogeriatric model is necessary to respond to this clinical challenge. The objective of this review is to analyze the efficacy of the different strategies for the handling of geriatric patients with fracture risk.
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146
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Mo J, Huang K, Wang X, Sheng X, Wang Q, Fang X, Fan S. The Sensitivity of Orthopaedic Surgeons to the Secondary Prevention of Fragility Fractures. J Bone Joint Surg Am 2018; 100:e153. [PMID: 30562300 DOI: 10.2106/jbjs.17.01297] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Orthopaedic surgeons must play an important role in the secondary prevention of fragility fractures; however, some surgeons are more aware than others of their responsibility regarding fracture prevention. The purpose of the present study was to identify which factors can lead to a higher sensitivity for fracture prevention. METHODS A cross-sectional survey was distributed to orthopaedic surgeons via online invitation or at academic conferences in China from July through October 2015. A total of 452 surgeons responded. As the primary outcome measure, we created a sensitivity scoring system for fracture prevention based on the respondents' answers to 5 questions regarding behavior in the following areas: risk-factor evaluation, pharmacologic therapy, nonpharmacologic therapy, patient education, and follow-up. Multivariable linear regression and multivariable logistic regression analyses were used to identify factors related to surgeon sensitivity to fracture prevention. RESULTS Very few surgeons reported having received adequate training regarding fracture prevention or reading guidelines or other fracture prevention literature (22% and 30%, respectively). Most respondents initiated pharmacologic or nonpharmacologic therapy (82% and 75%, respectively) for the treatment of confirmed osteoporosis among patients with fragility fractures, but only half performed a risk-factor evaluation, patient education, or timely patient follow-up (51%, 52%, and 48%, respectively). In the multivariable linear regression model, the orthopaedic surgeon's age (β = 0.09, p = 0.003), self-rated knowledge level regarding osteoporosis or related issues (β = 0.16, p < 0.001), self-perceived effectiveness in using preventive measures for patients with a fragility fracture (β = 0.62, p < 0.001), and use of clinical pathways for fragility fractures in his or her workplace (β = 1.24, p < 0.001) were independently associated with sensitivity scores for fracture prevention. Similar results were obtained from a multivariable logistic regression model. CONCLUSIONS In China, the sensitivity of orthopaedic surgeons to the secondary prevention of fragility fractures is relatively low. Implementation of a comprehensive prevention approach and targeted continuing medical education are required to encourage surgeons to take greater responsibility for screening, treating, educating, and following their patients with fragility fractures.
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Affiliation(s)
- Jian Mo
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China.,Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, People's Republic of China
| | - Kangmao Huang
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Xumeng Wang
- School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Xinyu Sheng
- School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Qiang Wang
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Xiangqian Fang
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Shunwu Fan
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
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147
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Qayoom I, Raina DB, Širka A, Tarasevičius Š, Tägil M, Kumar A, Lidgren L. Anabolic and antiresorptive actions of locally delivered bisphosphonates for bone repair: A review. Bone Joint Res 2018; 7:548-560. [PMID: 30464835 PMCID: PMC6215244 DOI: 10.1302/2046-3758.710.bjr-2018-0015.r2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
During the last decades, several research groups have used bisphosphonates for local application to counteract secondary bone resorption after bone grafting, to improve implant fixation or to control bone resorption caused by bone morphogenetic proteins (BMPs). We focused on zoledronate (a bisphosphonate) due to its greater antiresorptive potential over other bisphosphonates. Recently, it has become obvious that the carrier is of importance to modulate the concentration and elution profile of the zoledronic acid locally. Incorporating one fifth of the recommended systemic dose of zoledronate with different apatite matrices and types of bone defects has been shown to enhance bone regeneration significantly in vivo. We expect the local delivery of zoledronate to overcome the limitations and side effects associated with systemic usage; however, we need to know more about the bioavailability and the biological effects. The local use of BMP-2 and zoledronate as a combination has a proven additional effect on bone regeneration. This review focuses primarily on the local use of zoledronate alone, or in combination with bone anabolic factors, in various preclinical models mimicking different orthopaedic conditions. Cite this article: I. Qayoom, D. B. Raina, A. Širka, Š. Tarasevičius, M. Tägil, A. Kumar, L. Lidgren. Anabolic and antiresorptive actions of locally delivered bisphosphonates for bone repair: A review. Bone Joint Res 2018;7:548–560. DOI: 10.1302/2046-3758.710.BJR-2018-0015.R2.
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Affiliation(s)
- I Qayoom
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology, Kanpur, India
| | - D B Raina
- Department of Orthopedics, The Medical Faculty, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - A Širka
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Š Tarasevičius
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - M Tägil
- Department of Orthopedics, The Medical Faculty, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - A Kumar
- Department of Biological Sciences and Bioengineering; Centre for Environmental Sciences and Engineering; Centre for Nanosciences, Indian Institute of Technology Kanpur, Kanpur, India
| | - L Lidgren
- Department of Orthopedics, The Medical Faculty, Clinical Sciences Lund, Lund University, Lund, Sweden
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148
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van der Velde RY, Wyers CE, Geusens PPMM, van den Bergh JPW, de Vries F, Cooper C, van de Staa TP, Harvey NC. Incidence of subsequent fractures in the UK between 1990 and 2012 among individuals 50 years or older. Osteoporos Int 2018; 29:2469-2475. [PMID: 30030587 PMCID: PMC6205600 DOI: 10.1007/s00198-018-4636-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 07/09/2018] [Indexed: 10/28/2022]
Abstract
We studied the incidence of subsequent fractures in persons of 50+ years from 1990 to 2012 and the relative risk (RR) of subsequent fractures after an index femur/hip fracture, stratified per 5-year age band. Patients suffering a fracture have a high incidence of a subsequent fracture; the RR of subsequent fracture after a femur/hip fracture ranged from 2 to 7. INTRODUCTION Recent information on the risk of subsequent fractures after a broad range of index fractures in the UK population is scarce. We therefore studied the rates of subsequent fractures of the femur/hip, humerus, radius/ulna, vertebrae, rib, or pelvis after fractures at one of these sites from 1990 to 2012 in 3,156,347 UK men and women aged 50 years or over. METHODS We undertook a retrospective observational study using the UK Clinical Practice Research Datalink (CPRD). The incidence of subsequent fractures at a specific site was calculated by dividing the observed number of fractures by the number of person-years (py) at risk. The relative risk (RR) of subsequent fractures after a femur/hip fracture, by 5-year age band, was calculated by dividing the incidence of a specific subsequent fracture type by the incidence of first fractures at the same site in the same age group. RESULTS The highest subsequent fracture incidence after a femur/hip fracture was for humerus fracture in men (59.5/10.000 py) and radius/ulna fracture in women (117.2/10.000 py). After an index fracture of the radius/ulna, humerus fracture in men (59.3/10.000 py) and femur/hip fracture in women (82.4 per 10.000 py) were most frequent. The RR of fractures after a femur/hip fracture ranged from 2 to 7 and were highest in men and younger age groups. CONCLUSION Patients suffering a fracture have a high incidence of a subsequent fracture. Our findings demonstrate the importance of fracture prevention in patients with a history of a fracture by adequate medical diagnosis and treatment.
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Affiliation(s)
- R Y van der Velde
- Department of Internal Medicine, VieCuri Medical Centre, PO Box 1926, 5900 BX, Venlo, The Netherlands
- Department of Internal Medicine, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Centre (MUMC), PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - C E Wyers
- Department of Internal Medicine, VieCuri Medical Centre, PO Box 1926, 5900 BX, Venlo, The Netherlands
- Department of Internal Medicine, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Centre (MUMC), PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - P P M M Geusens
- Department of Internal Medicine, Subdivision Rheumatology, CAPHRI, Maastricht University Medical Centre (MUMC), PO Box 616, 6200 MD, Maastricht, The Netherlands
- Biomedical Research Centre, Hasselt University, Agoralaan - gebouw D, 3590, Diepenbeek, Belgium
| | - J P W van den Bergh
- Department of Internal Medicine, VieCuri Medical Centre, PO Box 1926, 5900 BX, Venlo, The Netherlands
- Department of Internal Medicine, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Centre (MUMC), PO Box 616, 6200 MD, Maastricht, The Netherlands
- Biomedical Research Centre, Hasselt University, Agoralaan - gebouw D, 3590, Diepenbeek, Belgium
| | - F de Vries
- Department of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- Department of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK.
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK.
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.
| | - T P van de Staa
- Department of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Health eResearch Centre, University of Manchester, Manchester, UK
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
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149
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Abstract
This paper reviews the research programme that went into the development of FRAX® and its impact in the 10 years since its release in 2008. INTRODUCTION Osteoporosis is defined on the measurement of bone mineral density though the clinical consequence is fracture. The sensitivity of bone mineral density measurements for fracture prediction is low, leading to the development of FRAX to better calculate the likelihood of fracture and target anti-osteoporosis treatments. METHODS The method used in this paper is literature review. RESULTS FRAX, developed over an 8-year period, was launched in 2008. Since the launch of FRAX, models have been made available for 64 countries and in 31 languages covering more than 80% of the world population. CONCLUSION FRAX provides an advance in fracture risk assessment and a reference technology platform for future improvements in performance characteristics.
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Affiliation(s)
- John A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
- Mary McKillop Research Institute, Australian Catholic University, Melbourne, Australia.
| | - Helena Johansson
- Mary McKillop Research Institute, Australian Catholic University, Melbourne, Australia
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Eugene V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
- Mellanby Centre for Bone Research, Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
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150
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Mugnier B, Daumas A, Couderc AL, Mizzi B, González T, Amrani A, Lévêque P, Aymes B, Argenson JN, Villani P. Clinical effectiveness of osteoporosis treatment in older patients: A fracture liaison service-based prospective study. J Women Aging 2018; 31:553-565. [PMID: 30295566 DOI: 10.1080/08952841.2018.1529473] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The clinical efficacy of anti-osteoporotic treatments in old patients is discussed. The aim of this study was to assess if the use of anti-osteoporotic treatments for the secondary prevention of osteoporotic fractures could reduce the risk of refractures in patients over 75 years old in a Fracture Liaison Service. In this population of frail, elderly patients presenting with a recent osteoporotic fracture, we observed that the refracture incidence was similar in the treated group and the untreated group during the first year. However, 30 months after the index fracture, the osteoporosis medication for a year or more reduced the incidence of refractures by 70%.
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Affiliation(s)
- Bénédicte Mugnier
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France
| | - Aurélie Daumas
- APHM, Hôpital La Timone, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France
| | - Anne-Laure Couderc
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France
| | - Barbara Mizzi
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France
| | - Thomas González
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France
| | - Anne Amrani
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France
| | - Pierre Lévêque
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France
| | - Brice Aymes
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France
| | - Jean-Nöel Argenson
- APHM, Hôpital Sainte Marguerite, Service de Chirurgie Orthopédique et Traumatologie, Marseille, France
| | - Patrick Villani
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France.,APHM, Hôpital La Timone, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France
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