AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS/AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS- 2020 UPDATE EXECUTIVE SUMMARY

Osteoporosis and fractures in rheumatoid arthritis

PURPOSE OF REVIEW

Rheumatoid arthritis (RA) is associated with increased risk for osteoporotic fracture. We highlight RA-specific risk factors for bone mineral density (BMD) loss and fractures and considerations regarding the diagnosis and treatment of osteoporosis in patients with RA.

RECENT FINDINGS

Anticitrullinated protein antibody (ACPA) positivity, although associated with low BMD in early RA, is not associated with accelerated BMD loss over time when compared to ACPA negative individuals. Studies have found reduced BMD in individuals on low doses of glucocorticoids (GCs). Poor functional status and frailty are additional important risk factors for low BMD and fractures. Heightened fracture risk in RA may be mitigated by tight disease control, and biologic therapies are associated with more stable BMD compared to nonbiologic therapies. Evidence-based guidelines specific for treating osteoporosis in patients with RA do not exist. Thus, treatment decisions are based on general osteoporosis guidelines, taking into account additional RA-specific risk factors.

SUMMARY

Recent studies have advanced knowledge of RA-specific risk factors for BMD loss and fractures. Future studies applying these findings to modify established fracture risk algorithms as well as evaluating osteoporosis treatments in RA cohorts are needed to reduce the risk of disabling fractures in these patients.

Predicting treatment recommendations in postmenopausal osteoporosis

We designed, implemented, and tested a clinical decision support system at the Research Center for the Study of Menopause and Osteoporosis within the University of Ferrara (Italy). As an independent module of our system, we implemented an original machine learning system for rule extraction, enriched with a hierarchical extraction methodology and a novel rule evaluation technique. Such a module is used in everyday operation protocol, and it allows physicians to receive suggestions for prevention and treatment of osteoporosis. In this paper, we design and execute an experiment based on two years of data, in order to evaluate and report the reliability of our suggestion system. Our results are encouraging, and in some cases reach expected accuracies of around 90%.

Osteoporosis guidelines from a rehabilitation perspective: systematic analysis and quality appraisal using AGREE II

INTRODUCTION

People affected by osteoporosis and fragility fractures often report disability and poor health-related quality of life. Albeit rehabilitation has a crucial role in older people, post-menopausal women and other subjects with high risk of fragility fractures, the rehabilitation perspective has been poorly investigated in the available guidelines for osteoporosis. The aim of this systematic review was to systematically evaluate the quality of guidelines for osteoporosis from a rehabilitation perspective.

EVIDENCE ACQUISITION

On May 2020, we performed a systematic search on medical literature of all guidelines published in the last 10 years on PubMed, Pedro, and international guideline databases. The study selection was based on key terms "exercise," "physical activity" or "rehabilitation." All authors independently assessed the methodological quality through the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, consisting of six domains (scope, stakeholder involvement, rigor and development, clarity of presentation, applicability, editorial independence).

EVIDENCE SYNTHESIS

Out of 331 documents retrieved, a total of 34 guidelines were selected after the screening phases. Twenty (58.8%) high quality guidelines were reported. According to AGREE II instrument, a mean score of 78.1±21.8% was reported for "scope and purpose" domain; for stakeholder involvement, the mean score was 58.1±22.1%; the rigor of development was good (mean score of 61.3±27.3%); for clarity of presentation the mean score was 79.4±20.3%; the applicability was poor (mean score of 30.9±25.2%); for editorial independence the mean score was 75.1±24.6%. Rehabilitation recommendations for osteoporotic patients were reported in 21 (61.8%) of the selected guidelines.

CONCLUSIONS

This is the first systematic analysis evaluating quality of the guidelines for osteoporosis using AGREE II instrument. Starting from a state of the art of the currently available evidence, we could conclude that therapeutic exercise at moderate to high intensity is encouraged by several guidelines for the management of people with osteoporosis and fragility fractures. More than half of guidelines were of high-quality. However, most guidelines are lacking specific indications about exercise features. This study might support the implementation of a rehabilitation perspective in the guidelines for osteoporotic patients.

Early Effects of Abaloparatide on Bone Formation and Resorption Indices in Postmenopausal Women With Osteoporosis

Anabolic osteoporosis drugs improve bone mineral density by increasing bone formation. The objective of this study was to evaluate the early effects of abaloparatide on indices of bone formation and to assess the effect of abaloparatide on modeling-based formation (MBF), remodeling-based formation (RBF), and overflow MBF (oMBF) in transiliac bone biopsies. In this open-label, single-arm study, 23 postmenopausal women with osteoporosis were treated with 80 μg abaloparatide daily. Subjects received double fluorochrome labels before treatment and before biopsy collection at 3 months. Change in dynamic histomorphometry indices in four bone envelopes were assessed. Median mineralizing surface per unit of bone surface (MS/BS) increased to 24.7%, 48.7%, 21.4%, and 16.3% of total surface after 3 months of abaloparatide treatment, representing 5.5-, 5.2-, 2.8-, and 12.9-fold changes, on cancellous, endocortical, intracortical, and periosteal surfaces (p < .001 versus baseline for all). Mineral apposition rate (MAR) was significantly increased only on intracortical surfaces. Bone formation rate (BFR/BS) was significantly increased on all four bone envelopes. Significant increases versus baseline were observed in MBF on cancellous, endocortical, and periosteal surfaces, for oMBF on cancellous and endocortical surfaces, and for RBF on cancellous, endocortical, and intracortical surfaces. Overall, modeling-based formation (MBF + oMBF) accounted for 37% and 23% of the increase in bone-forming surface on the endocortical and cancellous surfaces, respectively. Changes from baseline in serum biomarkers of bone turnover at either month 1 or month 3 were generally good surrogates for changes in histomorphometric endpoints. In conclusion, treatment with abaloparatide for 3 months stimulated bone formation on cancellous, endocortical, intracortical, and periosteal envelopes in transiliac bone biopsies obtained from postmenopausal women with osteoporosis. These increases reflected stimulation of both remodeling- and modeling-based bone formation, further elucidating the mechanisms by which abaloparatide improves bone mass and lowers fracture risk. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Menopausal osteoporosis: screening, prevention and treatment

Screening for osteoporosis in women can be based on age and weight, using the Osteoporosis Screening Tool for Asians and assessment for other risk factors such as early menopause, Chinese ethnicity and other secondary factors. Based on the resulting risk profile, women can be triaged to dual-energy X-ray absorptiometry (DEXA) scanning for definite diagnosis of osteoporosis. Treatment should be considered in women with previous fragility fractures, DEXA-diagnosed osteoporosis and high risk of fracture. Exercise improves muscle function, can help prevent falls and has moderate effects on improvements in bone mass. Women should ensure adequate calcium intake and vitamin D. Menopausal hormone therapy (MHT) effectively prevents osteoporosis and fractures, and should be encouraged in those aged < 50 years. For women aged < 60 years, MHT or tibolone can be considered, especially if they have vasomotor or genitourinary symptoms. Risedronate or bisphosphonates may then be reserved for those aged over 60 years.

Long-Term Follow-Up of Denosumab Discontinuers with Multiple Vertebral Fractures in the Real-World: A Case Series

Denosumab discontinuation is associated with rapid reversal of bone turnover suppression and with a considerable increase in fracture risk, including a risk for multiple vertebral fractures (MVF). Long-term follow-up of patients who sustained MVF after denosumab discontinuation has not been reported. This case-series was aimed to provide a long-term follow-up on the management and outcome of denosumab discontinuers who initially presented with multiple vertebral fractures. Denosumab discontinuers were identified from a computerized database of a large healthcare provider. Baseline and follow-up clinical, laboratory, and imaging data were obtained from the computerized database and electronic medical records. The post-denosumab discontinuers MVF patients consisted of 12 women aged 71±12. Osteoporotic fractures were prevalent before denosumab discontinuation in 6 of the patients. The majority received bisphosphonates before denosumab. MVF occurred 134±76 days after denosumab discontinuation. The patients were followed for a median of 36.5 (IQR 28.2, 42.5) months after MVF. Two patients passed-away. Two patients suffered recurrent vertebral fractures. Following MVF, patients were treated inconsistently with denosumab, teriparatide, oral, and intravenous bisphosphonates, in various sequences. Two patients underwent vertebroplasty/kyphoplasty. This long-term follow-up of real-world patients with MVF following denosumab discontinuation reveals that management is inconsistent, and recurrent fractures are not uncommon. It calls for clear management guidelines for patients with MVF after denosumab discontinuation and for special attention to this high-risk group.

Nutritional Supplements and Skeletal Health

PURPOSE OF REVIEW

Nutrition influences skeletal health throughout the lifespan, from the impact of maternal intakes during development, through the development of peak bone mass, to the rate of bone loss during aging. However, there are limited data available on the effects of nutritional supplements on bone density, let alone fracture risk. This review will assess the current literature, focusing on human studies, and emphasizing nutrients where bone density or fracture data are available.

RECENT FINDINGS

Calcium and vitamin D supplements, in combination, reduce fracture risk, particularly in populations with low intakes. Extensive recent analyses have supported the safety of these interventions at recommended intakes. There is growing evidence that specific isoflavones may improve bone density although fracture data are lacking. Multiple other nutrient supplements may benefit skeletal health, but data are limited. The effect size of nutrient interventions are relatively small, requiring large sample sizes for trials with bone outcomes, may be difficult to blind, and the impact of supplementation may depend on baseline intake. However, nutrition is the only intervention that can be implemented life long and on a population wide basis. Further investigation is needed into the potential benefits of nutritional supplements to determine in which settings supplements may add benefit in addition to dietary intakes.

Joint position statement on management of patient with osteoporosis during COVID-19 contingency from the AMMOM, CONAMEGER, FELAEN, FEMECOG, FEMECOT, and ICAAFYD

Infection by SARS-Cov-2 (COVID-19) has affected practically all the world. This joint position statement of Latin American Medical Societies provides an updated guide for the prevention, diagnosis, and treatment of osteoporotic patients in the face of possible clinical scenarios posed by the COVID-19 health crisis.

BACKGROUND

Infection by SARS-Cov-2 (COVID-19) has affected practically all the world. Characterized by high contagiousness, significative morbidity, and mortality in a segment of those infected, it has overwhelmed health services and forced to redirect resources to the emergency while impacting the attention of acute non-COVID-19 and many chronic conditions.

OBJECTIVE

The objective of this study is to provide an updated guide for the prevention, diagnosis, and treatment of osteoporotic patients in the face of possible clinical scenarios posed by the COVID-19 health crisis.

METHODS

A task force, of bone specialists with a wide range of disciplines in the field of osteoporosis and fragility fracture, was convened with the representation of several professional associations, namely, the Mexican Association of Bone and Mineral Metabolism (AMMOM), the National College of Geriatric Medicine (CONAMEGER), the Latin American Federation of Endocrinology (FELAEN), the Mexican Federation of Colleges of Obstetrics and Gynecology (FEMECOG), the Mexican Federation of Colleges of Orthopedics and Traumatology (FEMECOT), and the Institute of Applied Sciences for Physical Activity and Sports of the University of Guadalajara (ICAAFYD). Clinical evidence was collated, and an evidence report was rapidly generated and disseminated. After finding the gaps in the available evidence, a consensus opinion of experts was made. The resulting draft was reviewed and modified accordingly, in 4 rounds, by the participants.

RESULTS

The task force approved the initial guidance statements, with moderate and high consensus. These were combined, resulting in the final guidance statements on the (1) evaluation of fracture risk; (2) stratification of risk priorities; (3) indications of bone density scans and lab tests; (4) initiation and continuation of pharmacologic therapy; (5) interruptions of therapy; (6) treatment of patients with incident fracture; (7) physical therapy and fall prevention; and (8) nutritional interventions.

CONCLUSION

These guidance statements are provided to promote optimal care to patients at risk for osteoporosis and fracture, during the current COVID-19 pandemic. However, given the low level of available evidence and the rapidly evolving literature, this guidance is presented as a "living document" and future updates are anticipated.

The safety profile of denosumab in oncology beyond the safety of denosumab as an anti-osteoporotic agent: still more to learn

INTRODUCTION

Initially endorsed as an antiosteoporotic agent, denosumab ‒ human monoclonal antibody inhibiting the receptor activator of nuclear factor kappa-B ligand (RANKL)‒ has currently shown an anticancer potential, rationalizing its exploitation in oncology. A prerequisite for leveraging denosumab in oncology is a favorable safety profile.

AREAS COVERED

The present review provides an overview of the adverse events of denosumab in oncology, with a focus on hypocalcemia, medication-related osteonecrosis of the jaw, atypical femoral fracture(s), post-denosumab vertebral fractures, increased risk of infections, and excess of second primary cancer. Representative studies addressing the safety and efficacy of denosumab compared to bisphosphonates in oncology are summarized. Critical gaps in the literature concerning the safety of denosumab in oncology are highlighted as opposed to plenty of available safety data on denosumab as an antiosteoporotic agent.

EXPERT OPINION

Despite the generally acceptable safety profile of denosumab in oncology, many issues remain unresolved. Further research is mandatory to counteract current challenges, namely: (i) validation of risk factors for adverse events; (ii) elucidation of the pathophysiology of the adverse events in search of actionable molecular pathways; (iii) illumination of the association of denosumab with increased risk of infections and/or second primary cancer; (iv) establishment of optimal diagnostic, and therapeutic protocols.

Type-2 muscle fiber atrophy is associated with sarcopenia in elderly men with hip fracture

Sarcopenia is a common geriatric syndrome and can lead to falls and fragility fractures. It is associated with a decline of muscle fiber numbers and size. Muscle biopsies of the vastus lateralis muscle were taken from thirty-two patients with hip fracture (18 women and 14 men; mean age: 82.2 ± 6.2 years). Serial cross sections of skeletal muscle were labeled with myosin heavy chain slow (fiber type-1) and fast (fiber type-2) antibodies in order to measure the size, ratio and percentage of mixed fiber types. The presence of sarcopenia was defined according to the EWGSOP2 criteria by using BIA and handgrip strength measurement. Sarcopenia was identified in 5 patients (3 women and 2 men), probable-sarcopenia in 11 patients (4 women and 7 men). Significant differences in fiber diameter were found for fiber type-2 in men but not in women. Only 1-3% mixed fiber types were found in sarcopenic patients, indicating a final stage where reinnervation is not possible to occur anymore. Muscle fiber type-2 atrophy seems to be a histological marker for sarcopenia in men.

Osteoporosis and Osteoporotic Fracture Fact Sheet in Korea

BACKGROUND

The socioeconomic burdens of osteoporosis and related fractures have increased in parallel with population aging. The Korea Society of Bone and Mineral Research published fact sheets on these topics in 2017, 2018, and 2019. This study provides complied epidemiological data based on these fact sheets for understanding current status of osteoporosis in Korea.

METHODS

Data from the Korea National Health and Nutrition Examination Survey (2008-2011) performed by the Korea Centers for Disease Control and Prevention and from National Health Information database (2008-2016) by National Health Insurance Service of Korea was used for analyzing the prevalence and incidence of osteoporosis and related fractures, respectively, fatality rates after fractures, and prescription status of anti-osteoporotic medications (AOMs).

RESULTS

Among Korean adults aged ≥50 years, 22.4% and 47.9% had osteopenia or osteoporosis, respectively. Incidences of osteoporotic hip, vertebral, humerus, and distal radius fractures plateaued in 2013. The cumulative incidence of subsequent fractures gradually increased over 4 years of follow-up once an osteoporotic fracture occurred. Crude fatality rates in the first 12 months after hip fracture were 14.0% for women and 21.0% for men. Only 33.5% of patients with osteoporosis took AOMs, and even after an osteoporotic fracture, only 41.9% of patients took AOMs within the following 12 months. Despite a steady increase in AOM prescriptions of ~6% per annum, only 33.2% of patients were medication compliant (medication possession ratio ≥80%) at 12 months after treatment initiation.

CONCLUSIONS

Continuous efforts are required to diagnose patients at high risk of fracture and ensure proper management in Korea.

Comparison of efficacy and safety of Chinese patent medicine in the treatment of postmenopausal osteoporosis: A protocol for systematic review and network meta-analysis

BACKGROUND

Postmenopausal osteoporosis (PMOP) is the focus and difficult problem in the world at present, and we found that Chinese patent medicine(CPM) shown a more miraculous effect. Many kinds of Chinese patent medicine have been proved to be effective in the treatment of this disease, but it is still unclear which kind of Chinese patent medicine has the best effect. Therefore, we propose a network meta-analysis (NMA) protocol to observe the efficacy of various CPM for this disease and provide guidance for clinical practice.

METHODS

We will use the NMA method to complete this study. First, all the randomized controlled trials of CPM or CPM combined with western medicine in the treatment of PMOP were collected by searching all online Chinese and English databases. The information time limit is from the establishment of the database to August 30, 2020. Then 2 staff members will sift through all the literature and analyze the data using Stata and Winbugs.

RESULTS

Through this analysis, we will observe and rank the clinical effects of different CPM for PMOP. The main evaluation indexes include: New fracture, Quality of life, Severe side effects, Death from all causes. Secondary outcome indicators include Bone Mineral density, clinical efficiency, and some laboratory indicators, such as estradiol, serum calcium, serum, etc. CONCLUSION:: This study will rank the therapeutic effects of various proprietary Chinese medicines in the treatment of PMOP, which will be helpful in improving the PMOP treatment regimen.INPLASY registration number: INPLASY202090047.

Impact of iron overload on bone remodeling in thalassemia

INTRODUCTION

Iron overload, a state with excessive iron storage in the body, is a common complication in thalassemia patients which leads to multiple organ dysfunctions including the bone. Iron overload-induced bone disease is one of the most common and severe complications of thalassemia including osteoporosis. Currently, osteoporosis is still frequently found in thalassemia even with widely available iron chelation therapy.

STUDY SELECTION

Relevant publications published before December 2019 in PubMed database were reviewed. Both pre-clinical studies and clinical trials were obtained using iron overload, thalassemia, osteoporosis, osteoblast, and osteoclast as keywords.

RESULTS

Increased ROS production is a hallmark of iron overload-induced impaired bone remodeling. At the cellular level, oxidative stress affects bone remodeling by both osteoblast inhibition and osteoclast activation via many signaling pathways. In thalassemia patients, it has been shown that bone resorption was increased while bone formation was concurrently reduced.

CONCLUSION

In this review, reports on the cellular mechanisms of iron overload-associated bone remodeling are comprehensively summarized and presented to provide current understanding this pathological condition. Moreover, current treatments and potential interventions for attenuating bone remodeling in iron overload are also summarized to pave ways for the future discoveries of novel agents that alleviate this condition.