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Amiche MA, Abtahi S, Driessen JHM, Vestergaard P, de Vries F, Cadarette SM, Burden AM. Impact of cumulative exposure to high-dose oral glucocorticoids on fracture risk in Denmark: a population-based case-control study. Arch Osteoporos 2018; 13:30. [PMID: 29552730 PMCID: PMC5857556 DOI: 10.1007/s11657-018-0424-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 01/03/2018] [Indexed: 02/03/2023]
Abstract
UNLABELLED We examined the effect of cumulative exposure to high doses of oral glucocorticoids on fracture risk. Compared to short-course users (daily dose ≥ 15 mg + cumulative < 1 g), heavy users (daily dose ≥ 15 mg + cumulative dose ≥ 1 g) had the highest risk of fracture. These patients should be monitored for fracture management strategies. PURPOSE The effect of cumulative exposure to high daily doses of oral glucocorticoids on fracture risk remains debated. We therefore aimed to examine the hip fracture risk associated with short courses and heavy use of high-dosed oral glucocorticoids. METHODS We conducted a population-based case-control study using the Danish National Health Service data, 1996-2011. Cases were those aged ≥ 18 years who sustained a hip (primary outcome) fracture (n = 81,342). Vertebral and forearm fractures were considered in secondary analyses. Controls (matched 1:1) were those without a fracture. Average daily dose (DD) and total cumulative dose (CD) were calculated among current oral glucocorticoid users. Among patients with a high daily dose (DD ≥ 15 mg), we identified short-course users as those with a CD < 1 g and heavy users as those with a CD ≥ 1 g. We estimated adjusted odds ratio (adj.OR) of fracture with current glucocorticoid use compared to never-use, using conditional logistic regression. RESULTS A high DD (≥ 15 mg) and high CD (≥ 1 g) were independently associated with an increased hip fracture risk (adj.OR 2.5; 95% CI 2.2-2.9; adj.OR 1.6; 95% CI 1.5-1.8, respectively). However, the risk was substantially increased among heavy users (DD ≥ 15 mg and CD ≥ 1 g: adj.OR 2.9; 95% CI 2.5-3.4) as compared to short-course users (DD ≥ 15 mg and CD < 1 g: adj.OR 1.4; 95% CI 1.1-1.9). Associations were stronger for vertebral fractures, yet little association was identified for forearm fractures. CONCLUSION Among patients receiving a high DD (≥ 15 mg), heavy users (≥ 1 g CD) showed the most substantial increase in hip fracture risk. Among those receiving high DD, a threshold of 1 g CD may identify heavy users that are candidates for focused fracture management services.
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Affiliation(s)
- M. Amine Amiche
- 0000 0001 2157 2938grid.17063.33Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada
| | - Shahab Abtahi
- 0000 0004 0480 1382grid.412966.eDepartment of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands ,0000 0001 0481 6099grid.5012.6Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands
| | - Johanna H. M. Driessen
- 0000 0004 0480 1382grid.412966.eDepartment of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands ,0000 0001 0481 6099grid.5012.6Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands ,0000000120346234grid.5477.1Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands ,0000 0001 0481 6099grid.5012.6NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Peter Vestergaard
- 0000 0001 0742 471Xgrid.5117.2Department of Clinical Medicine, Aalborg University, Aalborg, Denmark ,0000 0004 0646 7349grid.27530.33Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Frank de Vries
- 0000 0004 0480 1382grid.412966.eDepartment of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands ,0000 0001 0481 6099grid.5012.6Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands ,0000000120346234grid.5477.1Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Suzanne M. Cadarette
- 0000 0001 2157 2938grid.17063.33Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada
| | - Andrea M. Burden
- 0000 0004 0480 1382grid.412966.eDepartment of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands ,0000 0001 0481 6099grid.5012.6Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands ,0000000120346234grid.5477.1Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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Spivey CA, Griffith J, Kaplan C, Postlethwaite A, Ganguli A, Wang J. A Retrospective Analysis of Corticosteroid Utilization Before Initiation of Biologic DMARDs Among Patients with Rheumatoid Arthritis in the United States. Rheumatol Ther 2017; 5:255-270. [PMID: 29204858 DOI: 10.1007/s40744-017-0089-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Understanding the effects of corticosteroid utilization prior to initiation of biologic disease-modifying antirheumatic drugs (DMARDs) can inform decision-makers on the appropriate use of these medications. This study examined treatment patterns and associated burden of corticosteroid utilization before initiation of biologic DMARDs among rheumatoid arthritis (RA) patients. METHODS A retrospective analysis was conducted of adult RA patients in the US MarketScan Database (2011-2015). The following patterns of corticosteroid utilization were analyzed: whether corticosteroids were used; duration of use (short/long duration defined as < or ≥ 3 months); and dosage (low as < 2.5, medium as 2.5 to < 7.5 and high as ≥ 7.5 mg/day). Effects of corticosteroid use on time to biologic DMARD initiation were examined using Cox proportional hazards models. Likelihood and number of adverse events were examined using logistic and negative binomial regression models. Generalized linear models were used to examine healthcare costs. Independent variables in all models included patient demographics and health characteristics. RESULTS A total of 25,542 patients were included (40.84% used corticosteroids). Lower hazard of biologic DMARD initiation was associated with corticosteroid use (hazard ratio = 0.89, 95% confidence interval = 0.83-0.96), long duration and lower dose. Corticosteroid users compared to non-users had higher incidence rates of various adverse events including cardiovascular events (P < 0.05). Higher likelihood of adverse events was associated with corticosteroid use and long duration of use, as was increased number of adverse events. Corticosteroid users had a greater annualized mean number of physician visits, hospitalizations, and emergency department (ED) visits than non-users in adjusted analysis. Corticosteroid users compared to non-users had higher mean costs for total healthcare, physician visits, hospitalizations, and ED visits. CONCLUSIONS Among patients with RA, corticosteroid utilization is associated with delayed initiation of biologic DMARDS and higher burden of adverse events and healthcare utilization/costs before the initiation of biologic DMARDs. FUNDING AbbVie Inc.
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Affiliation(s)
- Christina A Spivey
- University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA
| | - Jenny Griffith
- Health Economics and Outcomes Research, AbbVie, North Chicago, IL, USA
| | - Cameron Kaplan
- University of Tennessee Health Science Center College of Medicine, Memphis, TN, USA
| | - Arnold Postlethwaite
- University of Tennessee Health Science Center College of Medicine, Memphis, TN, USA
| | - Arijit Ganguli
- Health Economics and Outcomes Research, AbbVie, North Chicago, IL, USA
| | - Junling Wang
- University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA.
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153
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Compston J, Cooper A, Cooper C, Gittoes N, Gregson C, Harvey N, Hope S, Kanis JA, McCloskey EV, Poole KES, Reid DM, Selby P, Thompson F, Thurston A, Vine N. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos 2017; 12:43. [PMID: 28425085 PMCID: PMC5397452 DOI: 10.1007/s11657-017-0324-5] [Citation(s) in RCA: 517] [Impact Index Per Article: 73.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 03/07/2017] [Indexed: 02/03/2023]
Abstract
INTRODUCTION In 2008, the UK National Osteoporosis Guideline Group (NOGG) produced a guideline on the prevention and treatment of osteoporosis, with an update in 2013. This paper presents a major update of the guideline, the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women and men age 50 years or over. METHODS Where available, systematic reviews, meta-analyses and randomised controlled trials were used to provide the evidence base. Conclusions and recommendations were systematically graded according to the strength of the available evidence. RESULTS Review of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment, lifestyle measures and pharmacological interventions, duration and monitoring of bisphosphonate therapy, glucocorticoid-induced osteoporosis, osteoporosis in men, postfracture care and intervention thresholds. CONCLUSION The guideline, which has received accreditation from the National Institute of Health and Care Excellence (NICE), provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals who are involved in its management.
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Affiliation(s)
- J. Compston
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - A. Cooper
- Crawley Fracture Liaison Service, Crawley, Sussex, UK
| | - C. Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - N. Gittoes
- University Hospitals Birmingham NHS Foundation Trust, Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham & Birmingham Health Partners, Birmingham, UK
| | - C. Gregson
- Musculoskeletal Research Unit, University of Bristol and Royal United Hospital NHS Foundation Trust, Bath, UK
| | - N. Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - S. Hope
- Metabolic Bone, Nuffield Orthopaedic Hospital, Oxford, UK
| | - J. A. Kanis
- Centre for Metabolic Diseases, University of Sheffield Medical School, Sheffield, UK
| | | | - K. E. S. Poole
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - D. M. Reid
- Emeritus Professor of Rheumatology, University of Aberdeen, Aberdeen, UK
| | - P. Selby
- Metabolic Bone Disease, University of Manchester, Manchester, UK
| | | | | | - N. Vine
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - The National Osteoporosis Guideline Group (NOGG)
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
- Crawley Fracture Liaison Service, Crawley, Sussex, UK
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- University Hospitals Birmingham NHS Foundation Trust, Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham & Birmingham Health Partners, Birmingham, UK
- Musculoskeletal Research Unit, University of Bristol and Royal United Hospital NHS Foundation Trust, Bath, UK
- Metabolic Bone, Nuffield Orthopaedic Hospital, Oxford, UK
- Centre for Metabolic Diseases, University of Sheffield Medical School, Sheffield, UK
- Metabolic Bone, University of Sheffield, Sheffield, UK
- Emeritus Professor of Rheumatology, University of Aberdeen, Aberdeen, UK
- Metabolic Bone Disease, University of Manchester, Manchester, UK
- National Osteoporosis Society, Camerton, UK
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Vico-Alonso C, Maroñas-Jiménez L, Lozano-Morillo F. Management of Corticosteroid-Induced Osteoporosis: A Practical Approach for the Dermatologist. ACTAS DERMO-SIFILIOGRAFICAS 2017; 109:357-358. [PMID: 29162226 DOI: 10.1016/j.ad.2017.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 07/21/2017] [Accepted: 08/08/2017] [Indexed: 11/16/2022] Open
Affiliation(s)
- C Vico-Alonso
- Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, España.
| | - L Maroñas-Jiménez
- Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - F Lozano-Morillo
- Servicio de Reumatología, Hospital Universitario 12 de Octubre, Madrid, España
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Chen HL, Shen LJ, Hsu PN, Shen CY, Hall SA, Hsiao FY. Cumulative Burden of Glucocorticoid-related Adverse Events in Patients with Systemic Lupus Erythematosus: Findings from a 12-year Longitudinal Study. J Rheumatol 2017; 45:83-89. [PMID: 29142034 DOI: 10.3899/jrheum.160214] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this population-based study is to examine the adverse events (AE) associated with longitudinal systemic glucocorticoid (GC) use among an ethnic Chinese systemic lupus erythematosus (SLE) cohort. METHODS Our study subjects were patients with newly diagnosed SLE aged 18 and older who received at least 1 prescription of systemic GC between 2001 and 2012 from Taiwan's National Health Insurance Research Database (NHIRD). The earliest prescription date of systemic GC for each subject was defined as the index date. For each subject, we calculated the average prednisolone-equivalent dose and the medication possession ratio (MPR) of GC use every 90 days for each patient after the index date. Patients with a diagnosis of AE (defined by the International Classification of Diseases-9-Clinical Modification diagnosis code) during the followup were also identified from the NHIRD. Generalized estimating equations adjusted for propensity score were applied to examine the association between longitudinal GC use and risks of prespecified AE (musculoskeletal, gastrointestinal, ophthalmologic, infectious, cardiovascular, neuropsychiatric, metabolic, and dermatologic diseases). RESULTS We identified 11,288 patients with SLE (mean followup: 6.28 yrs). Higher doses and higher MPR of GC were associated with increased risk of osteonecrosis [adjusted OR (aOR) 2.87-9.09]. Similar results were found regarding the risk of osteoporosis (aOR 1.71-3.67), bacterial infection (aOR 2.12-3.89), Cushingoid syndrome (aOR 6.51-62.03), and sleep disorder (aOR 1.42-3.59). CONCLUSION To our knowledge, this is the first study to show that the dose and intensity of longitudinal use of GC were both associated with risk of AE among a nationwide Asian SLE cohort.
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Affiliation(s)
- Hung-Lin Chen
- From the Graduate Institute of Clinical Pharmacy, the Graduate Institute of Immunology, the Graduate Institute of Clinical Medicine, and the School of Pharmacy, College of Medicine, National Taiwan University; Department of Internal Medicine, and Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; Department of Epidemiology, Biogen, Cambridge, Massachusetts, USA.,H.L. Chen, MS, Research Associate, Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University; L.J. Shen, PhD, Associate Professor, Graduate Institute of Clinical Pharmacy, and School of Pharmacy, College of Medicine, National Taiwan University, and Director, Department of Pharmacy, National Taiwan University Hospital; P.N. Hsu, MD, PhD, Attending Physician, Department of Internal Medicine, National Taiwan University Hospital, and Professor, Graduate Institute of Immunology, College of Medicine, National Taiwan University; C.Y. Shen, MD, Visiting Physician, Department of Internal Medicine, National Taiwan University Hospital, and Doctoral Student, Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University; S.A. Hall, PhD, Associate Director, Department of Epidemiology, Biogen; F.Y. Hsiao, PhD, Associate Professor, Graduate Institute of Clinical Pharmacy, and School of Pharmacy, College of Medicine, National Taiwan University, and Adjunct Associate Researcher, Department of Pharmacy, National Taiwan University Hospital. H.L. Chen and L.J. Shen contributed equally as first authors
| | - Li-Jiuan Shen
- From the Graduate Institute of Clinical Pharmacy, the Graduate Institute of Immunology, the Graduate Institute of Clinical Medicine, and the School of Pharmacy, College of Medicine, National Taiwan University; Department of Internal Medicine, and Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; Department of Epidemiology, Biogen, Cambridge, Massachusetts, USA.,H.L. Chen, MS, Research Associate, Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University; L.J. Shen, PhD, Associate Professor, Graduate Institute of Clinical Pharmacy, and School of Pharmacy, College of Medicine, National Taiwan University, and Director, Department of Pharmacy, National Taiwan University Hospital; P.N. Hsu, MD, PhD, Attending Physician, Department of Internal Medicine, National Taiwan University Hospital, and Professor, Graduate Institute of Immunology, College of Medicine, National Taiwan University; C.Y. Shen, MD, Visiting Physician, Department of Internal Medicine, National Taiwan University Hospital, and Doctoral Student, Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University; S.A. Hall, PhD, Associate Director, Department of Epidemiology, Biogen; F.Y. Hsiao, PhD, Associate Professor, Graduate Institute of Clinical Pharmacy, and School of Pharmacy, College of Medicine, National Taiwan University, and Adjunct Associate Researcher, Department of Pharmacy, National Taiwan University Hospital. H.L. Chen and L.J. Shen contributed equally as first authors
| | - Ping-Ning Hsu
- From the Graduate Institute of Clinical Pharmacy, the Graduate Institute of Immunology, the Graduate Institute of Clinical Medicine, and the School of Pharmacy, College of Medicine, National Taiwan University; Department of Internal Medicine, and Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; Department of Epidemiology, Biogen, Cambridge, Massachusetts, USA.,H.L. Chen, MS, Research Associate, Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University; L.J. Shen, PhD, Associate Professor, Graduate Institute of Clinical Pharmacy, and School of Pharmacy, College of Medicine, National Taiwan University, and Director, Department of Pharmacy, National Taiwan University Hospital; P.N. Hsu, MD, PhD, Attending Physician, Department of Internal Medicine, National Taiwan University Hospital, and Professor, Graduate Institute of Immunology, College of Medicine, National Taiwan University; C.Y. Shen, MD, Visiting Physician, Department of Internal Medicine, National Taiwan University Hospital, and Doctoral Student, Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University; S.A. Hall, PhD, Associate Director, Department of Epidemiology, Biogen; F.Y. Hsiao, PhD, Associate Professor, Graduate Institute of Clinical Pharmacy, and School of Pharmacy, College of Medicine, National Taiwan University, and Adjunct Associate Researcher, Department of Pharmacy, National Taiwan University Hospital. H.L. Chen and L.J. Shen contributed equally as first authors
| | - Chieh-Yu Shen
- From the Graduate Institute of Clinical Pharmacy, the Graduate Institute of Immunology, the Graduate Institute of Clinical Medicine, and the School of Pharmacy, College of Medicine, National Taiwan University; Department of Internal Medicine, and Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; Department of Epidemiology, Biogen, Cambridge, Massachusetts, USA.,H.L. Chen, MS, Research Associate, Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University; L.J. Shen, PhD, Associate Professor, Graduate Institute of Clinical Pharmacy, and School of Pharmacy, College of Medicine, National Taiwan University, and Director, Department of Pharmacy, National Taiwan University Hospital; P.N. Hsu, MD, PhD, Attending Physician, Department of Internal Medicine, National Taiwan University Hospital, and Professor, Graduate Institute of Immunology, College of Medicine, National Taiwan University; C.Y. Shen, MD, Visiting Physician, Department of Internal Medicine, National Taiwan University Hospital, and Doctoral Student, Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University; S.A. Hall, PhD, Associate Director, Department of Epidemiology, Biogen; F.Y. Hsiao, PhD, Associate Professor, Graduate Institute of Clinical Pharmacy, and School of Pharmacy, College of Medicine, National Taiwan University, and Adjunct Associate Researcher, Department of Pharmacy, National Taiwan University Hospital. H.L. Chen and L.J. Shen contributed equally as first authors
| | - Susan A Hall
- From the Graduate Institute of Clinical Pharmacy, the Graduate Institute of Immunology, the Graduate Institute of Clinical Medicine, and the School of Pharmacy, College of Medicine, National Taiwan University; Department of Internal Medicine, and Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; Department of Epidemiology, Biogen, Cambridge, Massachusetts, USA.,H.L. Chen, MS, Research Associate, Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University; L.J. Shen, PhD, Associate Professor, Graduate Institute of Clinical Pharmacy, and School of Pharmacy, College of Medicine, National Taiwan University, and Director, Department of Pharmacy, National Taiwan University Hospital; P.N. Hsu, MD, PhD, Attending Physician, Department of Internal Medicine, National Taiwan University Hospital, and Professor, Graduate Institute of Immunology, College of Medicine, National Taiwan University; C.Y. Shen, MD, Visiting Physician, Department of Internal Medicine, National Taiwan University Hospital, and Doctoral Student, Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University; S.A. Hall, PhD, Associate Director, Department of Epidemiology, Biogen; F.Y. Hsiao, PhD, Associate Professor, Graduate Institute of Clinical Pharmacy, and School of Pharmacy, College of Medicine, National Taiwan University, and Adjunct Associate Researcher, Department of Pharmacy, National Taiwan University Hospital. H.L. Chen and L.J. Shen contributed equally as first authors
| | - Fei-Yuan Hsiao
- From the Graduate Institute of Clinical Pharmacy, the Graduate Institute of Immunology, the Graduate Institute of Clinical Medicine, and the School of Pharmacy, College of Medicine, National Taiwan University; Department of Internal Medicine, and Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; Department of Epidemiology, Biogen, Cambridge, Massachusetts, USA. .,H.L. Chen, MS, Research Associate, Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University; L.J. Shen, PhD, Associate Professor, Graduate Institute of Clinical Pharmacy, and School of Pharmacy, College of Medicine, National Taiwan University, and Director, Department of Pharmacy, National Taiwan University Hospital; P.N. Hsu, MD, PhD, Attending Physician, Department of Internal Medicine, National Taiwan University Hospital, and Professor, Graduate Institute of Immunology, College of Medicine, National Taiwan University; C.Y. Shen, MD, Visiting Physician, Department of Internal Medicine, National Taiwan University Hospital, and Doctoral Student, Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University; S.A. Hall, PhD, Associate Director, Department of Epidemiology, Biogen; F.Y. Hsiao, PhD, Associate Professor, Graduate Institute of Clinical Pharmacy, and School of Pharmacy, College of Medicine, National Taiwan University, and Adjunct Associate Researcher, Department of Pharmacy, National Taiwan University Hospital. H.L. Chen and L.J. Shen contributed equally as first authors.
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156
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Curtis EM, Moon RJ, Harvey NC, Cooper C. The impact of fragility fracture and approaches to osteoporosis risk assessment worldwide. Bone 2017; 104:29-38. [PMID: 28119181 PMCID: PMC5420448 DOI: 10.1016/j.bone.2017.01.024] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 01/20/2017] [Accepted: 01/20/2017] [Indexed: 02/08/2023]
Abstract
Osteoporosis constitutes a major public health problem, through its association with age-related fractures, particularly of the hip, vertebrae, distal forearm and humerus. Substantial geographic variation has been noted in the incidence of osteoporotic fractures worldwide, with Western populations (North America, Europe and Oceania), reporting increases in hip fracture throughout the second half of the 20th century, with a stabilisation or decline in the last two decades. In developing populations however, particularly in Asia, the rates of osteoporotic fracture appears to be increasing. The massive global burden consequent to osteoporosis means that fracture risk assessment should be a high priority among health measures considered by policy makers. The WHO operational definition of osteoporosis, based on a measurement of bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA), has been used globally since the mid-1990s. However, although this definition identifies those at greatest individual risk of fracture, in the population overall a greater total number of fractures occur in individuals with BMD values above the threshold for osteoporosis diagnosis. A number of web-based tools to enable the inclusion of clinical risk factors, with or without BMD, in fracture prediction algorithms have been developed to improve the identification of individuals at high fracture risk, the most commonly used globally being FRAX®. Access to DXA, osteoporosis risk assessment, case finding and treatment varies worldwide, but despite such advances studies indicate that a minority of men and women at high fracture risk receive treatment. Importantly, research is ongoing to demonstrate the clinical efficacy and cost-effectiveness of osteoporosis case finding and risk assessment strategies worldwide. The huge burden caused by osteoporosis related fractures to individuals, healthcare systems and societies should provide a clear impetus for the progression of such approaches.
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Affiliation(s)
- Elizabeth M Curtis
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK
| | - Rebecca J Moon
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK; Paediatric Endocrinology, Southampton University Hospitals NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK; NIHR Southampton Biomedical Research Centre, University of Southampton, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK; NIHR Southampton Biomedical Research Centre, University of Southampton, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK; NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford OX3 7LD, UK.
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157
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Carey JJ, Delaney MF. Utility of DXA for monitoring, technical aspects of DXA BMD measurement and precision testing. Bone 2017; 104:44-53. [PMID: 28554549 DOI: 10.1016/j.bone.2017.05.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 05/25/2017] [Accepted: 05/25/2017] [Indexed: 10/19/2022]
Abstract
Monitoring a patient's bone mineral density (BMD) is one of the main reasons for dual-energy X-ray absorptiometry (DXA) referral. It is widely recommended by clinical guidelines, and the accepted standard in practice for managing patients with osteoporosis and other disorders. Clinicians and DXA providers must be familiar with the scientific rationale and procedures involved in measurement science to obtain accurate and reproducible results. Their importance is critical to maximise the value of scan acquisition and interpretation. Scanning individual patients, with different needs and disorders, requires excellence in training, experience, and is more complex than just simply 'measuring BMD'. Over the past 3 decades many studies have validated the importance of monitoring BMD for fracture risk assessment, and for patients on osteoporosis treatment. New DXA features enhance the value of DXA monitoring today. Quality BMD measurement remains an essential component of patient care in osteoporosis and other disorders, playing a critical role in informed decision making for clinicians assessing and managing their patients. In this article we describe some of the technical aspects of measurement and discuss the utility of DXA for monitoring patients in clinical practice.
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Affiliation(s)
- John J Carey
- Department of Medicine, National University of Ireland Galway, Galway, Ireland; Department of Rheumatic Diseases, Galway University Hospitals, Ireland.
| | - Miriam F Delaney
- Department of Medicine, National University of Ireland Galway, Galway, Ireland
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158
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Oshagbemi OA, Driessen JHM, Pieffers A, Wouters EFM, Geusens P, Vestergaard P, van den Bergh J, Franssen FME, de Vries F. Use of systemic glucocorticoids and the risk of major osteoporotic fractures in patients with sarcoidosis. Osteoporos Int 2017. [PMID: 28638981 PMCID: PMC5624970 DOI: 10.1007/s00198-017-4115-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
UNLABELLED This study revealed the risk of major osteoporotic fracture in patients with sarcoidosis exposed to glucocorticoids. Current use of glucocorticoids was associated with a risk of fracture, with no difference between patients with and without sarcoidosis. Sarcoidosis per se was not associated with an increased fracture risk. INTRODUCTION Sarcoidosis is a multi-organ, chronic inflammatory, granulomatous disorder that most frequently affects the lungs, lymph nodes, skin, eyes, and liver, but may occur in any organ, including the bones. While oral glucocorticoids (GCs) are commonly used as initial treatment, little is known about the risk of major osteoporotic fractures in patients with sarcoidosis exposed to GCs. METHODS A case-control study was conducted using the Danish National Hospital Discharge Registry (NHDR) between January 1995 and December 2011. Conditional logistics regression models were used to derive adjusted odds ratios (OR) of major osteoporotic fractures in subjects with and without sarcoidosis stratified by average daily and cumulative dose exposures. RESULTS A total of 376,858 subjects with a major osteoporotic fracture and the same number of subjects without this event were identified (mean age 64.2 ± 19.5 years, 69% female). In patients with sarcoidosis (n = 124), current use of GC was associated with an increased risk of major osteoporotic fracture (adjusted (adj.) OR 1.74; 95% CI 1.17-2.58), which dropped to baseline levels after discontinuation. In subjects without sarcoidosis, this risk was comparable (adj. OR 1.36; 95% CI 1.32-1.40). In sarcoidosis patients, cumulative dose 1.0-4.9 g and >10 g prednisolone equivalents were associated with increased risk of major osteoporotic fracture (adj. OR 2.75; 95% CI 1.06-7.14 and 2.22; 95% CI 1.17-4.22, respectively), whereas a cumulative dose of <1.0 g and 5.0-9.9 g was not associated with major osteoporotic fracture risk. CONCLUSION Both in subjects with and without sarcoidosis, current expose to GC is associated with increased risk of major osteoporotic fractures, with no between-group difference. Sarcoidosis per se was not associated with increased fracture risk. Having sarcoidosis per se, i.e., if not treated with GC, is not a risk factor for fracture, and such patients may only need risk assessment when they commence GC therapy.
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Affiliation(s)
- O A Oshagbemi
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands
| | - J H M Driessen
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands
- Maastricht University Medical Centre+, Research School NUTRIM, Maastricht, The Netherlands
| | - A Pieffers
- Department of Clinical Pharmacy, Antonius Hospital, Sneek, The Netherlands
| | - E F M Wouters
- Department of Research and Education, CIRO, Horn, The Netherlands
- Department of Respiratory Medicines, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - P Geusens
- Biomedical Research Institute, Hasselt University, Hasselt, Belgium
- Department of Internal Medicines, Subdivision of Rheumatology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - P Vestergaard
- Department of Endocrinology and Internal Medicine (MEA), Aarhus University Hospital, Aarhus, Denmark
| | - J van den Bergh
- Maastricht University Medical Centre+, Research School NUTRIM, Maastricht, The Netherlands
- Department of Internal Medicines, Subdivision of Rheumatology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
- Department of Internal Medicine, Viecuri MC Venlo, Venlo, The Netherlands
| | - F M E Franssen
- Department of Research and Education, CIRO, Horn, The Netherlands
- Department of Respiratory Medicines, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - F de Vries
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands.
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands.
- Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands.
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, UK.
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159
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Outcomes of shoulder arthroplasty in haematopoietic stem cell transplant patients. INTERNATIONAL ORTHOPAEDICS 2017; 41:2555-2564. [PMID: 28791443 DOI: 10.1007/s00264-017-3553-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 06/20/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND With the growing population of patients undergoing haematopoietic stem cell transplants (HSCTs), the demand for shoulder arthroplasty (SA) in this population can be expected to increase. No studies in the literature have examined the outcomes of SA in HSCT patients. PATIENTS AND METHODS A retrospective review of 11 SAs in 10 patients with previous HSCT was performed. We characterized the clinical outcomes, survivorship, and peri-operative complication rates in patients who underwent SA after receiving a HSCT. We also performed a subanalysis based on implant and transplant type. RESULTS Seven of ten patients died with average two and five year post-operative patient survival rates of 70% +/- 14% and 47% +/- 17%, respectively. At average follow up of 4.2 years of the seven patients with two year followup, pain and range of motion improved with SA (p = 0.0625-0.2500). At final follow-up, five of seven shoulders were rated as satisfactory or excellent with modified Neer ratings. Two and five year survival rates free of re-operation were 100% +/- 0% and 67% +/- 27%, respectively. There were no other complications. No differences in outcomes were seen based on implant or transplant type besides RSA being associated with greater mortality risk (p = 0.0424, hazard ratio = 10.6). CONCLUSIONS Patients with previous HSCT who undergo SA can expect to have good pain relief, range of motion improvement, subjective satisfaction, and low peri-operative complication rate with appropriate choice of implant. However, surgeons must inform patients about realistic post-operative outcomes given the high post-operative mortality rate. LEVEL OF EVIDENCE Level IV, Prognosis.
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160
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Curtis EM, Moon RJ, Harvey NC, Cooper C. Reprint of: The impact of fragility fracture and approaches to osteoporosis risk assessment worldwide. Int J Orthop Trauma Nurs 2017; 26:7-17. [PMID: 28578992 PMCID: PMC5480618 DOI: 10.1016/j.ijotn.2017.04.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Osteoporosis constitutes a major public health problem, through its association with age-related fractures, particularly of the hip, vertebrae, distal forearm and humerus. Substantial geographic variation has been noted in the incidence of osteoporotic fractures worldwide, with Western populations (North America, Europe and Oceania), reporting increases in hip fracture throughout the second half of the 20th century, with a stabilisation or decline in the last two decades. In developing populations however, particularly in Asia, the rates of osteoporotic fracture appears to be increasing. The massive global burden consequent to osteoporosis means that fracture risk assessment should be a high priority amongst health measures considered by policy makers. The WHO operational definition of osteoporosis, based on a measurement of bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA), has been used globally since the mid-1990s. However, although this definition identifies those at greatest individual risk of fracture, in the population overall a greater total number of fractures occur in individuals with BMD values above threshold for osteoporosis diagnosis. A number of web-based tools to enable the inclusion of clinical risk factors, with or without BMD, in fracture prediction algorithms have been developed to improve the identification of individuals at high fracture risk, the most commonly used globally being FRAX®. Access to DXA, osteoporosis risk assessment, case finding and treatment varies worldwide, but despite such advances studies indicate that a minority of men and women at high fracture risk receive treatment. Importantly, research is ongoing to demonstrate the clinical efficacy and cost-effectiveness of osteoporosis case finding and risk assessment strategies worldwide. The huge burden caused by osteoporosis related fractures to individuals, healthcare systems and societies should provide a clear impetus for the progression of such approaches.
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Affiliation(s)
- Elizabeth M Curtis
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
| | - Rebecca J Moon
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK; Paediatric Endocrinology, Southampton University Hospitals NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK; NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK; NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK; NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, OX3 7LD, UK.
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161
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Kubota K, Kamisawa T, Okazaki K, Kawa S, Hirano K, Hirooka Y, Uchida K, Shiomi H, Ohara H, Shimizu K, Arakura N, Kanno A, Sakagami J, Itoi T, Ito T, Ueki T, Nishino T, Inui K, Mizuno N, Yoshida H, Sugiyama M, Iwasaki E, Irisawa A, Shimosegawa T, Takeyama Y, Chiba T. Low-dose maintenance steroid treatment could reduce the relapse rate in patients with type 1 autoimmune pancreatitis: a long-term Japanese multicenter analysis of 510 patients. J Gastroenterol 2017; 52:955-964. [PMID: 28062947 DOI: 10.1007/s00535-016-1302-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 12/20/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND The effect of maintenance steroid treatment (MST) in reducing the risk of relapse in patients with autoimmune pancreatitis (AIP) remains under debate. The aim of this study was to validate the effect of MST on AIP administered in accordance with the 2010 Japanese consensus guidelines. METHODS The clinical data of patients with (n = 510) from 22 high-volume centers in Japan were studied. The primary endpoints were the relapse rates (RRs) in patients administered MST versus those not administered MST. The secondary endpoints were the optimal dose and duration of MST in terms of steroid toxicity and the predictors of relapse. RESULTS The RRs were 10.0% within 1 year, 25.8% within 3 years and 35.1% within 5 years. The RR in the steroid therapy group reached a plateau at 42.7% at 7 years. In terms of the optimal dosage, the overall RR in the MST 5 mg/day group was 26.1%, which was significantly lower than that in the group which had discontinued steroid therapy (45.2%; p = 0.023) or was receiving MST at 2.5 mg/day (43.4%, p = 0.001). The RRs in the group receiving MST at ≥5 mg/day versus the patient group receiving MST at <5 mg/day were 10.6 vs. 10.3% within 1 year, 23.5 vs. 32.9% within 3 years and 32.2 vs. 41.3% within 5 years, respectively (log-rank, p = 0.028). The best cutoff value of the total steroid dose for serious steroid toxicity was 6405 mg, with a moderate accuracy of 0.717 determined using the area under the curve. Presence of diffuse pancreatic swelling [odds ratio OR) 1.745; p = 0.008) and MST at >5 mg/day were identified as predictors of relapse (OR 0.483; p = 0.001). CONCLUSIONS The RR could continue to increase for 7 years even under MST. Based on our analysis of the side effects of steroid therapy, MST at 5 mg/day for 2 (total 4625 mg) to 3 (total 6425 mg) years might be a rational and safe therapeutic strategy in terms of keeping the RR to <30% while avoiding potential steroid toxicity.
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Affiliation(s)
- Kensuke Kubota
- Department of Endoscopy, Yokohama City University Hospital, Yokohama, Japan
| | - Terumi Kamisawa
- Department of Internal Medicine, Tokyo Komagome Metropolitan Hospital, Tokyo, Japan.
| | - Kazuichi Okazaki
- Department of Gastroenterology and Hepatology, Kansai Medical University, Hirakata, Japan
| | - Shigeyuki Kawa
- Center for Health, Safety and Environmental Management, Shinshu University, Matsumoto, Japan
| | - Kenji Hirano
- Department of Gastroenterology, Graduate School of Medicine, Tokyo University, Tokyo, Japan
| | - Yoshiki Hirooka
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Kazushige Uchida
- Department of Gastroenterology and Hepatology, Kansai Medical University, Hirakata, Japan
| | - Hideyuki Shiomi
- Department of Gastroenterology, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Hirotaka Ohara
- Department of Community-Based Medical Education, Graduate School of Medicine, Nagoya City University, Nagoya, Japan
| | - Kyoko Shimizu
- Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Norikazu Arakura
- Department of Gastroenterology, Graduate School of Medicine, Shinshu University, Matsumoto, Japan
| | - Atsushi Kanno
- Department of Gastroenterology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Junichi Sakagami
- Department of Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takao Itoi
- Department of Gastroenterology, Tokyo Medical University, Tokyo, Japan
| | - Tetsuhide Ito
- Department of Medicine and Bioregulatory Science, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Toshiharu Ueki
- Department of Gastroenterology, Chikushi Hospital, Fukuoka University, Fukuoka, Japan
| | - Takayoshi Nishino
- Department of Gastroenterology, Yachiyo Hospital, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazuo Inui
- Department of Gastroenterology, Second Teaching Hospital, Fujita Health University, Toyoake, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center, Nagoya, Japan
| | - Hitoshi Yoshida
- Department of Gastroenterology, School of Medicine, Showa University, Tokyo, Japan
| | - Masanori Sugiyama
- Department of Surgery, School of Medicine, Kyorin University, Tokyo, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | - Atshishi Irisawa
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Fukushima, Japan
| | - Toru Shimosegawa
- Department of Gastroenterology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Yoshifumi Takeyama
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kinki University Faculty of Medicine, Osaka, Japan
| | - Tsutomu Chiba
- Gastroenterology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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162
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Adler RA. Glucocorticoid-Induced Osteoporosis and the New ACR Guideline. Clin Rev Bone Miner Metab 2017. [DOI: 10.1007/s12018-017-9234-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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163
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Horton DB, Haynes K, Denburg MR, Thacker MM, Rose CD, Putt ME, Leonard MB, Strom BL. Oral glucocorticoid use and osteonecrosis in children and adults with chronic inflammatory diseases: a population-based cohort study. BMJ Open 2017; 7:e016788. [PMID: 28733303 PMCID: PMC5642748 DOI: 10.1136/bmjopen-2017-016788] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES We studied oral glucocorticoids and osteonecrosis, a rare but serious bone disease, in individuals with various chronic inflammatory diseases. We hypothesised that we would find stronger associations in adults versus children and in people with autoimmune diseases. DESIGN Retrospective cohort study. SETTING Population-representative data (1994-2013) from general practices in the UK. PARTICIPANTS Children and adults diagnosed with asthma; inflammatory bowel disease; juvenile, psoriatic or rheumatoid arthritis; psoriasis; or systemic lupus. EXPOSURES Oral glucocorticoid patterns. PRIMARY AND SECONDARY OUTCOME MEASURES Diagnosed osteonecrosis (primary) and osteonecrosis plus clinical features (eg, symptoms, pain medication, surgical repair) (secondary). Discrete time failure models estimated the adjusted hazard ratio (aHR) of incident osteonecrosis following oral glucocorticoid exposure. Hypothesis testing was one sided (with corresponding 90% CI) since glucocorticoids were unlikely protective. RESULTS After adjusting for demographic, disease-related and health utilisation factors, glucocorticoid exposure was associated with osteonecrosis in adults (ages 18-49, aHR 2.1 (90% CI 1.5 to 2.9); ages ≥50, aHR 1.3 (90% CI 1.01 to 1.7)). However, low-dose glucocorticoids, corresponding to average doses <7.5 mg prednisolone daily and maximum doses <30 mg daily, were not associated with osteonecrosis in adults. Furthermore, even at high glucocorticoid doses, there was no evidence of increased osteonecrosis among glucocorticoid-exposed children (p=0.04 for interaction by age) (any glucocorticoid exposure, ages 2-9: aHR 1.1 (90% CI 0.7 to 1.7); ages 10-17: aHR 0.6 (90% CI 0.3 to 1.6)). Arthritis, inflammatory bowel disease and lupus were independently associated with osteonecrosis, but there was a similar dose relationship between glucocorticoids and osteonecrosis among adults with low-risk and high-risk diseases. CONCLUSIONS Glucocorticoid use was clearly associated with osteonecrosis in a dose-related fashion in adults, especially young adults, but this risk was not detectable in children. The absolute risk of glucocorticoid-associated osteonecrosis in the general paediatric population and in adults taking low glucocorticoid doses is at most extremely small.
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Affiliation(s)
- Daniel B Horton
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers School of Public Health, Rutgers Biomedical and Health Sciences, New Brunswick, New Jersey, USA
| | | | - Michelle R Denburg
- Division of Nephrology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mihir M Thacker
- Department of Orthopedics, Nemours A.I. duPont Hospital for Children, Thomas Jefferson University, Wilmington, Delaware, USA
| | - Carlos D Rose
- Division of Rheumatology, Department of Pediatrics, Nemours A.I. duPont Hospital for Children, Thomas Jefferson University, Wilmington, Delaware, USA
| | - Mary E Putt
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mary B Leonard
- Division of Nephrology, Departments of Pediatrics and Medicine, Stanford School of Medicine, Stanford University, Stanford, California, USA
| | - Brian L Strom
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Rutgers Biomedical and Health Sciences, Newark, New Jersey, USA
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164
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Skeletal assessment with finite element analysis: relevance, pitfalls and interpretation. Curr Opin Rheumatol 2017; 29:402-409. [PMID: 28376059 DOI: 10.1097/bor.0000000000000405] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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165
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Chambers AW, Lacy KW, Liow MHL, Manalo JPM, Freiberg AA, Kwon YM. Multiple Hip Intra-Articular Steroid Injections Increase Risk of Periprosthetic Joint Infection Compared With Single Injections. J Arthroplasty 2017; 32:1980-1983. [PMID: 28237216 DOI: 10.1016/j.arth.2017.01.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 01/04/2017] [Accepted: 01/17/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Patients with hip osteoarthritis often temporize their symptoms with multiple intra-articular steroid hip injections (IASHIs) before undergoing total hip arthroplasty (THA). Although there is recent evidence to suggest that IASHI can lead to an increased risk of future periprosthetic joint infection (PJI), the potential increase in risk of PJI after multiple IASHIs compared with single IASHI remains largely unknown. The aim of the study was to evaluate whether multiple IASHIs are associated with increased risk of PJI compared with single IASHI in THA patients. METHODS We evaluated 2 cohorts of patients consisting of 106 patients who received 2 or more IASHI in the year before THA and a matched group of 350 patients who received one IASHI in the 12 months before THA. RESULTS The single and multiply-injected patient cohorts had an infection rate of 2.0% and 6.6% (7/350 and 7/106), respectively (P = .04, odds ratio 3.30) and average follow-up of 28.9 and 24.2 months. The 2 cohorts did not differ with regard to age, gender, American Society of Anesthesiologist score, presence of diabetes mellitus, or body mass index. CONCLUSION In comparison with patients with single IASHI, multiple IASHIs are associated with an increased risk of PJI significantly higher than the elevated risk reported with single injection before THA. The present study findings would be clinically useful in counseling patients who are considering temporizing their symptoms with multiple IASHIs before undergoing THA.
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Affiliation(s)
- Andrew W Chambers
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kyle W Lacy
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ming Han Lincoln Liow
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John Paul M Manalo
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew A Freiberg
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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166
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Hadji P, Aapro MS, Body JJ, Gnant M, Brandi ML, Reginster JY, Zillikens MC, Glüer CC, de Villiers T, Baber R, Roodman GD, Cooper C, Langdahl B, Palacios S, Kanis J, Al-Daghri N, Nogues X, Eriksen EF, Kurth A, Rizzoli R, Coleman RE. Management of Aromatase Inhibitor-Associated Bone Loss (AIBL) in postmenopausal women with hormone sensitive breast cancer: Joint position statement of the IOF, CABS, ECTS, IEG, ESCEO IMS, and SIOG. J Bone Oncol 2017; 7:1-12. [PMID: 28413771 PMCID: PMC5384888 DOI: 10.1016/j.jbo.2017.03.001] [Citation(s) in RCA: 153] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 03/10/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Several guidelines have been reported for bone-directed treatment in women with early breast cancer (EBC) for averting fractures, particularly during aromatase inhibitor (AI) therapy. Recently, a number of studies on additional fracture related risk factors, new treatment options as well as real world studies demonstrating a much higher fracture rate than suggested by randomized clinical controlled trials (RCTs). Therefore, this updated algorithm was developed to better assess fracture risk and direct treatment as a position statement of several interdisciplinary cancer and bone societies involved in the management of AI-associated bone loss (AIBL). PATIENTS AND METHODS A systematic literature review identified recent advances in the management of AIBL. Results with individual agents were assessed based on trial design, size, follow-up, and safety. RESULTS Several fracture related risk factors in patients with EBC were identified. Although, the FRAX algorithm includes fracture risk factors (RF) in addition to BMD, it does not seem to adequately address the effects of AIBL. Several antiresorptive agents can prevent and treat AIBL. However, concerns regarding compliance and long-term safety remain. Overall, the evidence for fracture prevention is strongest for denosumab 60 mg s.c. every 6 months. Additionally, recent studies as well as an individual patient data meta-analysis of all available randomized trial data support additional anticancer benefits from adjuvant bisphosphonate treatment in postmenopausal women with a 34% relative risk reduction in bone metastasis and 17% relative risk decrease in breast cancer mortality that needs to be taken into account when advising on management of AIBL. CONCLUSIONS In all patients initiating AI treatment, fracture risk should be assessed and recommendation with regard to exercise and calcium/vitamin D supplementation given. Bone-directed therapy should be given to all patients with a T-score<-2.0 or with a T-score of <-1.5 SD with one additional RF, or with ≥2 risk factors (without BMD) for the duration of AI treatment. Patients with T-score>-1.5 SD and no risk factors should be managed based on BMD loss during the first year and the local guidelines for postmenopausal osteoporosis. Compliance should be regularly assessed as well as BMD on treatment after 12 - 24 months. Furthermore, because of the decreased incidence of bone recurrence and breast cancer specific mortality, adjuvant bisphosphonates are recommended for all postmenopausal women at significant risk of disease recurrence.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - John Kanis
- Catholic University of Australia, Melbourne, Australia and University of Sheffield, UK
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167
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Abstract
Bone health in children with rheumatic conditions may be compromised due to several factors related to the inflammatory disease state, delayed puberty, altered life style, including decreased physical activities, sun avoidance, suboptimal calcium and vitamin D intake, and medical treatments, mainly glucocorticoids and possibly some disease-modifying anti-rheumatic drugs. Low bone density or even fragility fractures could be asymptomatic; therefore, children with diseases of high inflammatory load, such as systemic onset juvenile idiopathic arthritis, juvenile dermatomyositis, systemic lupus erythematosus, and those requiring chronic glucocorticoids may benefit from routine screening of bone health. Most commonly used assessment tools are laboratory testing including serum 25-OH-vitamin D measurement and bone mineral density measurement by a variety of methods, dual-energy X-ray absorptiometry as the most widely used. Early disease control, use of steroid-sparing medications such as disease-modifying anti-rheumatic drugs and biologics, supplemental vitamin D and calcium, and promotion of weight-bearing physical activities can help optimize bone health. Additional treatment options for osteoporosis such as bisphosphonates are still controversial in children with chronic rheumatic diseases, especially those with decreased bone density without fragility fractures. This article reviews common risk factors leading to compromised bone health in children with chronic rheumatic diseases and discusses the general approach to prevention and treatment of bone fragility.
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168
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Kageyama G, Okano T, Yamamoto Y, Nishimura K, Sugiyama D, Saegusa J, Tsuji G, Kumagai S, Morinobu A. Very high frequency of fragility fractures associated with high-dose glucocorticoids in postmenopausal women: A retrospective study. Bone Rep 2017; 6:3-8. [PMID: 28377975 PMCID: PMC5365272 DOI: 10.1016/j.bonr.2016.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 11/10/2016] [Accepted: 11/16/2016] [Indexed: 01/22/2023] Open
Abstract
Purpose To evaluate the incidence of fragility fractures associated with high-dose glucocorticoid therapy in patients with systemic rheumatic disease. METHODS A retrospective study of patients who were treated with high-dose prednisolone (> 0.8 mg/kg) for systemic rheumatic disease at Kobe University Hospital from April 1988 to March 2012. The primary outcome was a major osteoporotic fracture (defined as a clinical vertebral, hip, forearm, or proximal humerus fracture) after high-dose glucocorticoid therapy. For postmenopausal women and men over 40 of age, the patient's fracture risk at the beginning of high-dose glucocorticoid therapy was assessed by the World Health Organization's Fracture Risk Assessment Tool (FRAX®). Results Of 229 patients (median age: 49 years), 57 suffered a fragility fracture during the observation period (median observation period: 1558 days). Of 84 premenopausal patients, 5 suffered a fracture. In contrast, of 86 postmenopausal female, 36 suffered a fracture. Fragility fractures were far more frequent than predicted by the FRAX® score. Patients with FRAX® scores over 8.3% had a particularly high risk of fracture. Conclusions Fragility fractures associated with high-dose glucocorticoid therapy are common among postmenopausal women. Extreme care should be taken especially for postmenopausal women when high-dose glucocorticoid therapy is required.
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Affiliation(s)
- Goichi Kageyama
- Department of Rheumatology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
- Department of Rheumatology, Kobe University Hospital, Kobe, Japan
| | - Takaichi Okano
- Department of Rheumatology, Kobe University Hospital, Kobe, Japan
| | - Yuzuru Yamamoto
- Department of Rheumatology, Kobe University Hospital, Kobe, Japan
| | | | - Daisuke Sugiyama
- Department of Preventive Medicine and Public Health, Keio University, Tokyo, Japan
| | - Jun Saegusa
- Department of Rheumatology, Kobe University Hospital, Kobe, Japan
| | - Goh Tsuji
- Department of Rheumatology, Shinko Hospital, Kobe, Japan
| | | | - Akio Morinobu
- Department of Rheumatology, Kobe University Hospital, Kobe, Japan
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169
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Abstract
BACKGROUND Inflammatory bowel disease (IBD) has been associated with increased risk of osteopenia and osteoporosis. Several risk factors contribute to this; however, studies evaluating their association have conflicting results. METHODS We conducted a cross-sectional study with prospective enrollment of adult ulcerative colitis patients attending the Gastroenterology Department of Sawai Man Singh Hospital, Jaipur Rajasthan between June 2015 and December 2015. Demographic data including age, gender, body mass index (BMI), disease duration, type of disease, prior steroid use and vitamin D levels were recorded and compared with bone mineral density (BMD) using dual-energy X-ray absorptiometry (DEXA). RESULTS Of the 55 patients enrolled, 41 (74.5%) had abnormal BMD; out of this, 19 (34.5%) had osteopenia and 22 (40.0%) had osteoporosis. In univariate analysis, disease duration and history of steroid use were observed as statistically significant. However, on multivariate analysis, only duration of disease was found to be a significant independent predictor of low BMD. Age, gender, BMI, low levels of vitamin D and steroid usage were not associated with low BMD. CONCLUSION Prevalence of low BMD is common in Indian ulcerative colitis patients. Prolonged disease duration appears to be the major risk factor.
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170
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Dalal AA, Duh MS, Gozalo L, Robitaille MN, Albers F, Yancey S, Ortega H, Forshag M, Lin X, Lefebvre P. Dose-Response Relationship Between Long-Term Systemic Corticosteroid Use and Related Complications in Patients with Severe Asthma. J Manag Care Spec Pharm 2017; 22:833-47. [PMID: 27348284 PMCID: PMC10397753 DOI: 10.18553/jmcp.2016.22.7.833] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Systemic corticosteroids are a leading cause of drug-related complications, yet little has been done to quantify the dose-response relationship between systemic corticosteroid exposure and complications in patients with severe asthma. OBJECTIVES To (a) evaluate the risk of developing systemic corticosteroid-related complications by corticosteroid exposure in severe asthma and (b) quantify the associated health care resource utilization and costs. METHODS This is a retrospective study using administrative claims data from a large commercial database between 2003 and 2014. Multivariate generalized estimating equation models were used to compare corticosteroid-related complications in patients continuously exposed to at least 5 mg of prednisone or equivalent for ≥ 6 months with a 1:1 ratio of propensity score-matched patients with asthma who did not use corticosteroids. RESULTS A total of 12,697 corticosteroid users and as many matched nonusers were identified. The odds of developing associated complications increased significantly in a dose-dependent manner with systemic corticosteroid exposure: odds ratios were 2.50, 2.95, and 3.32 (P values <0.05) for low (defined as < 5 mg/day), medium (≥ 5-10 mg/day), and high (>10 mg/day) exposure, respectively, relative to no exposure. Health care resource utilization increased significantly with levels of systemic corticosteroid exposure. Hence, incidence rate ratios for inpatient visits with low, medium, and high exposure relative to none were estimated to be 1.86, 2.40, and 3.37, respectively (P < 0.05). CONCLUSIONS A significant dose-response relationship was found between the long-term use of systemic corticosteroids and the risk of developing systemic corticosteroid-related complications in patients with severe asthma, resulting in increased burden and costs on the health care system that intensified with systemic corticosteroid exposure. DISCLOSURES Funding for this study was provided by GlaxoSmithKline, Study number H0-15-15930, to Analysis Group for the conduct of this study. Lefebvre, Duh, and Gozalo are employees of Analysis Group, a contract research organization that has received research grants from GlaxoSmithKline. Robitaille was employed by Analysis Group at the time of this study. Yancey, Forshag, Lin, and Albers are employees of GlaxoSmithKline and own company stock. Dalal and Ortega were employed by GlaxoSmithKline at the time of this study. Lefebvre had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Additionally, all listed authors meet the criteria for authorship set forth by the International Committee for Medical Journal Editors. Study concept and design were contributed by Dalal, Duh, Albers, Yancey, Ortega, Forshag, and Lefebvre. Data acquisition was by Dalal, Gozalo, Robitaille, Forshag, and Lefebvre and was analyzed and interpreted by Dalal, Gozalo, Robitaille, Albers, Yancey, Ortega, Forshag, and Lefebvre. The manuscript was drafted and approved by Dalal, Duh, Gozalo, Robitaille, Albers, Yancey, Ortega, Forshag, Lin, and Lefebvre.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Xiwu Lin
- 1 GlaxoSmithKline, Durham, North Carolina
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171
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Caplan A, Fett N, Rosenbach M, Werth VP, Micheletti RG. Prevention and management of glucocorticoid-induced side effects: A comprehensive review: A review of glucocorticoid pharmacology and bone health. J Am Acad Dermatol 2017; 76:1-9. [PMID: 27986132 DOI: 10.1016/j.jaad.2016.01.062] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 01/28/2016] [Accepted: 01/29/2016] [Indexed: 01/29/2023]
Abstract
Systemic glucocorticoids are an essential therapy for a range of conditions, but their multiple side effects can produce significant morbidity for patients. The objective of this review is to discuss these side effects while addressing 3 questions: 1) What dose and duration of glucocorticoid therapy should prompt concern for individual side effects?; 2) How should clinicians counsel patients about these complications?; and 3) How can these problems be prevented or managed? To accomplish these objectives, we have created a series of tables and algorithms based on a review of relevant data to guide counseling, prophylaxis, and management of 11 glucocorticoid side effects. The first article in this 4-part continuing medical education series begins with a review of glucocorticoid pharmacology followed by a discussion of bone health (ie, osteoporosis and osteonecrosis).
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Affiliation(s)
- Avrom Caplan
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicole Fett
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | - Misha Rosenbach
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Victoria P Werth
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert G Micheletti
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania.
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172
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Costello R, Patel R, Humphreys J, McBeth J, Dixon WG. Patient perceptions of glucocorticoid side effects: a cross-sectional survey of users in an online health community. BMJ Open 2017; 7:e014603. [PMID: 28373256 PMCID: PMC5387953 DOI: 10.1136/bmjopen-2016-014603] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES To identify the side effects most important to glucocorticoid (GC) users through a survey of a UK online health community (Healthunlocked.com). DESIGN Online cross-sectional survey. SETTING Participants were recruited through Healthunlocked.com, an online social network for health. PARTICIPANTS Adults who were currently taking GCs, or had taken GCs in the past month. METHOD Responders scored the importance of listed side effects from 1 to 10, with 10 being of high importance to them. For each side effect, histograms were plotted, and the median rating and IQR were determined. Side effects were ranked by median ranking (largest to smallest) and then IQR (smallest to largest). The scores were categorised as low (scores 1-3), medium (scores 4-7) and high (scores 8-10) importance. RESULTS 604 responders completed the survey. Histograms of side effect scores showed a skew towards high importance for weight gain, a U-shaped distribution for cardiovascular disease (CVD), diabetes, eye disease and infections, and a skew towards low importance for acne. When ranked, the side effect of most importance to responders was weight gain (median score=9, IQR 6-10) followed by insomnia and moon face with equal median score (8) and IQR (5-10). Three serious side effects, CVD, diabetes and infections, were ranked of lower importance overall but had wide ranging scores (median score=8, IQR 1-10). CONCLUSIONS The three most highly rated side effects were not clinically serious but remained important to patients, perhaps reflecting their impact on quality of life and high prevalence. This should be taken into consideration when discussing treatment options and planning future GC safety studies.
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Affiliation(s)
- Ruth Costello
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, School of Biological Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Rikesh Patel
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, School of Biological Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Jennifer Humphreys
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, School of Biological Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - John McBeth
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, School of Biological Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - William G Dixon
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, School of Biological Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Health eResearch Centre, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
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173
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Wilson JC, Sarsour K, Collinson N, Tuckwell K, Musselman D, Klearman M, Napalkov P, Jick SS, Stone JH, Meier CR. Incidence of outcomes potentially associated with corticosteroid therapy in patients with giant cell arteritis. Semin Arthritis Rheum 2017; 46:650-656. [DOI: 10.1016/j.semarthrit.2016.10.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 10/04/2016] [Accepted: 10/05/2016] [Indexed: 10/20/2022]
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Nakamura M, Ishiguro A, Muranaka T, Fukushima H, Yuki S, Ono K, Murai T, Matsuda C, Oba A, Itaya K, Sone T, Yagisawa M, Koike Y, Endo A, Tsukuda Y, Ono Y, Kudo T, Nagasaka A, Nishikawa S, Komatsu Y. A Prospective Observational Study on Effect of Short-Term Periodic Steroid Premedication on Bone Metabolism in Gastrointestinal Cancer (ESPRESSO-01). Oncologist 2017; 22:592-600. [PMID: 28341762 PMCID: PMC5423502 DOI: 10.1634/theoncologist.2016-0308] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 11/28/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND A multicenter prospective observational study evaluated the effect of gastrointestinal cancer chemotherapy with short-term periodic steroid premedication on bone metabolism. PATIENTS AND METHODS Seventy-four patients undergoing chemotherapy for gastrointestinal cancer were studied. The primary endpoints were changes in bone mineral densities (BMDs) and metabolic bone turnover 16 weeks after initiation of chemotherapy. BMDs, measured by dual-energy x-ray absorptiometry, and serum cross-linked N-telopeptides of type I collagen (sNTX), and bone alkaline phosphatase (sBAP) were assessed for evaluation of bone resorption and formation, respectively. RESULTS In 74.3% (55/74) of the patients, BMDs were significantly reduced at 16 weeks relative to baseline. The percent changes of BMD were -1.89% (95% confidence interval [CI], -2.67% to -1.11%: p < .0001) in the lumbar spine, -2.24% (95% CI, -3.59% to -0.89%: p = .002) in the total hip, and -2.05% (95% CI, -3.11% to -0.99%: p < .0001) in the femoral neck. Although there was no significant difference in sNTX levels during 16 weeks (p = .136), there was a significant increase in sBAP levels (p = .010). Decreased BMD was significantly linked to number of chemotherapy cycles (p = .02). There were no significant correlations between changes in BMDs and the primary site of malignancy, chemotherapy regimens, total cumulative steroid dose, steroid dose intensity, and additive steroid usage. CONCLUSION Gastrointestinal cancer chemotherapy with periodic glucocorticoid premedication was associated with reduced BMD and increased sBAP levels, which were linked to number of chemotherapy cycles but independent of primary site, chemotherapy regimen, duration, and additive steroid usage. The Oncologist 2017;22:592-600 IMPLICATIONS FOR PRACTICE: Bone health and the management of treatment-related bone loss are important for cancer care. The present study showed that a significant decrease in bone mineral density (BMD) and an increase in serum bone alkaline phosphatase levels occurred in gastrointestinal cancer patients receiving chemotherapy, which were linked to number of chemotherapy cycles but were independent of primary site, chemotherapy regimen, total steroid dose, and steroid dose intensity. Surprisingly, it seems that the decreasing BMD levels after only 16 weeks of chemotherapy for gastrointestinal cancer were comparable to that of 12-month adjuvant aromatase inhibitor therapy for early-stage breast cancer patients.
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Affiliation(s)
- Michio Nakamura
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Atsushi Ishiguro
- Department of Medical Oncology, Teine Keijinkai Hospital, Sapporo, Japan
| | - Tetsuhito Muranaka
- Division of Cancer Chemotherapy, Hokkaido University Hospital Cancer Center, Sapporo, Japan
| | - Hiraku Fukushima
- Department of Gastroenterology, Japan Community Health Care Organization Sapporo Hokushin Hospital, Sapporo, Japan
| | - Satoshi Yuki
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Kota Ono
- Hokkaido University Hospital Clinical Research and Medical Innovation Center, Sapporo, Japan
| | - Taichi Murai
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Chika Matsuda
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Ayane Oba
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Kazufumi Itaya
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Takayuki Sone
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Masataka Yagisawa
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Yuta Koike
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Ayana Endo
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Yoko Tsukuda
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Yuji Ono
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Takahiko Kudo
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Atsushi Nagasaka
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Shuji Nishikawa
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Yoshito Komatsu
- Division of Cancer Chemotherapy, Hokkaido University Hospital Cancer Center, Sapporo, Japan
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Bell JM, Shields MD, Watters J, Hamilton A, Beringer T, Elliott M, Quinlivan R, Tirupathi S, Blackwood B. Interventions to prevent and treat corticosteroid-induced osteoporosis and prevent osteoporotic fractures in Duchenne muscular dystrophy. Cochrane Database Syst Rev 2017; 1:CD010899. [PMID: 28117876 PMCID: PMC6464928 DOI: 10.1002/14651858.cd010899.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Corticosteroid treatment is considered the 'gold standard' for Duchenne muscular dystrophy (DMD); however, it is also known to induce osteoporosis and thus increase the risk of vertebral fragility fractures. Good practice in the care of those with DMD requires prevention of these adverse effects. Treatments to increase bone mineral density include bisphosphonates and vitamin D and calcium supplements, and in adolescents with pubertal delay, testosterone. Bone health management is an important part of lifelong care for patients with DMD. OBJECTIVES To assess the effects of interventions to prevent or treat osteoporosis in children and adults with DMD taking long-term corticosteroids; to assess the effects of these interventions on the frequency of vertebral fragility fractures and long-bone fractures, and on quality of life; and to assess adverse events. SEARCH METHODS On 12 September 2016, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL Plus to identify potentially eligible trials. We also searched the Web of Science ISI Proceedings (2001 to September 2016) and three clinical trials registries to identify unpublished studies and ongoing trials. We contacted correspondence authors of the included studies in the review to obtain information on unpublished studies or work in progress. SELECTION CRITERIA We considered for inclusion in the review randomised controlled trials (RCTs) and quasi-RCTs involving any bone health intervention for corticosteroid-induced osteoporosis and fragility fractures in children, adolescents, and adults with a confirmed diagnosis of DMD. The interventions might have included oral and intravenous bisphosphonates, vitamin D supplements, calcium supplements, dietary calcium, testosterone, and weight-bearing activity. DATA COLLECTION AND ANALYSIS Two review authors independently assessed reports and selected potential studies for inclusion, following standard Cochrane methodology. We contacted study authors to obtain further information for clarification on published work, unpublished studies, and work in progress. MAIN RESULTS We identified 18 potential studies, of which two, currently reported only as abstracts, met the inclusion criteria for this review. Too little information was available for us to present full results or adequately assess risk of bias. The participants were children aged five to 15 years with DMD, ambulant and non-ambulant. The interventions were risedronate versus no treatment in one trial (13 participants) and whole-body vibration versus a placebo device in the second (21 participants). Both studies reported improved bone mineral density with the active treatments, with no improvement in the control groups, but the abstracts did not compare treatment and control conditions. All children tolerated whole-body vibration treatment. No study provided information on adverse events. Two studies are ongoing: one investigating whole-body vibration, the other investigating zoledronic acid. AUTHORS' CONCLUSIONS We know of no high-quality evidence from RCTs to guide use of treatments to prevent or treat corticosteroid-induced osteoporosis and reduce the risk of fragility fractures in children and adults with DMD; only limited results from two trials reported in abstracts were available. We await formal trial reports. Findings from two ongoing relevant studies and two trials, for which only abstracts are available, will be important in future updates of this review.
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Affiliation(s)
- Jennifer M Bell
- Queen's University BelfastCentre for Experimental Medicine, School of Medicine, Dentistry and Biomedical SciencesRoom 02.041, 2nd FloorMulhouse, Grosvenor RoadBelfastNorthern IrelandUKBT12 6BJ
| | - Michael D Shields
- Queen's University BelfastCentre for Experimental Medicine, School of Medicine, Dentistry and Biomedical SciencesRoom 02.041, 2nd FloorMulhouse, Grosvenor RoadBelfastNorthern IrelandUKBT12 6BJ
| | - Janet Watters
- Belfast Health and Social Care TrustGP Out of Hours ServiceBelfastNorthern IrelandUK
| | - Alistair Hamilton
- Belfast Health and Social Care TrustWithers Orthopaedic CentreMusgrave Park Hospital, Royal Group of Hospitals,Stockman's LaneBelfastNorthern IrelandUK
| | - Timothy Beringer
- Belfast Health and Social Care TrustDepartment of Care for the ElderyFlorence Elliot CentreRoyal Victoria HospitalBelfastNorthern IrelandUKBT12 6BA
| | - Mark Elliott
- Musgrave Park Hospital, Belfast Health and Social Care TrustBelfastUK
| | - Rosaline Quinlivan
- UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery and Great Ormond StreetMRC Centre for Neuromuscular Diseases and Dubowitz Neuromuscular CentrePO Box 114LondonUKWC1B 3BN
| | - Sandya Tirupathi
- Royal Belfast Hospital for Sick ChildrenPaediatric Neurology180 Falls RoadBelfastUKBT12 6BE
| | - Bronagh Blackwood
- Queen's University BelfastCentre for Experimental Medicine, School of Medicine, Dentistry and Biomedical SciencesRoom 02.041, 2nd FloorMulhouse, Grosvenor RoadBelfastNorthern IrelandUKBT12 6BJ
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Songpatanasilp T, Sritara C, Kittisomprayoonkul W, Chaiumnuay S, Nimitphong H, Charatcharoenwitthaya N, Pongchaiyakul C, Namwongphrom S, Kitumnuaypong T, Srikam W, Dajpratham P, Kuptniratsaikul V, Jaisamrarn U, Tachatraisak K, Rojanasthien S, Damrongwanich P, Wajanavisit W, Pongprapai S, Ongphiphadhanakul B, Taechakraichana N. Thai Osteoporosis Foundation (TOPF) position statements on management of osteoporosis. Osteoporos Sarcopenia 2016; 2:191-207. [PMID: 30775487 PMCID: PMC6372784 DOI: 10.1016/j.afos.2016.10.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 10/05/2016] [Accepted: 10/06/2016] [Indexed: 01/07/2023] Open
Abstract
The adjusted incidence rate of hip fracture in Thailand has increased more than 31% from 1997 to 2006. Mortality and morbidity after hip fracture are also high. One year mortality after a hip fracture has increased from 18% in 1999 to 21% in 2007. The Thai Osteoporosis Foundation (TOPF) developed the first Clinical Practice Guideline (CPG) in 2002 and keeps updating the CPG since then. This latest version of the CPG is our attempt to provide comprehensive positional statement on the diagnosis, prevention and treatment of osteoporosis in Thailand. The study group who revised this position statement contains experts from the TOPF, Four Royal Colleges of Thailand, includes the Orthopaedic Surgeons, Gynecologists and Obstetricians, Physiatrists, Radiologists and 2 Associations of Endocrinologists and Rheumatologists which have involved in the management of patients with osteoporosis.
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Affiliation(s)
- T. Songpatanasilp
- Department of Orthopaedics, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - C. Sritara
- Nuclear Medicine Division, Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - W. Kittisomprayoonkul
- Department of Rehabilitation Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - S. Chaiumnuay
- Rheumatology Division, Department of Medicine, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - H. Nimitphong
- Endocrinology and Metabolism Division, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - N. Charatcharoenwitthaya
- Endocrinology and Metabolism Division, Department of Medicine, Faculty of Medicine, Thammasat University, Bangkok, Thailand
| | - C. Pongchaiyakul
- Endocrinology and Metabolism Division, Department of Medicine, Faculty of Medicine, Khonkean University, Khonkean, Thailand
| | - S. Namwongphrom
- Department of Radiology, Faculty of Medicine, Chiangmai University, Chiangmai, Thailand
| | - T. Kitumnuaypong
- Rheumatology Division, Department of Medicine, Rajavithi Hospital, Bangkok, Thailand
| | - W. Srikam
- Department of Rehabilitation Medicine, Faculty of Medicine, Thammasat University, Bangkok, Thailand
| | - P. Dajpratham
- Department of Rehabilitation Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - V. Kuptniratsaikul
- Department of Rehabilitation Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - U. Jaisamrarn
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - K. Tachatraisak
- Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - S. Rojanasthien
- Department of Orthopaedics, Faculty of Medicine, Chiangmai University, Chiangmai, Thailand
| | - P. Damrongwanich
- Department of Orthopaedics, Police General Hospital, Bangkok, Thailand
| | - W. Wajanavisit
- Department of Orthopaedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - S. Pongprapai
- Department of Rehabilitation Medicine, Vichaiyut Hospital, Bangkok, Thailand
| | - B. Ongphiphadhanakul
- Endocrinology and Metabolism Division, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - N. Taechakraichana
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Kanis JA, Harvey NC, Cooper C, Johansson H, Odén A, McCloskey EV. A systematic review of intervention thresholds based on FRAX : A report prepared for the National Osteoporosis Guideline Group and the International Osteoporosis Foundation. Arch Osteoporos 2016; 11:25. [PMID: 27465509 PMCID: PMC4978487 DOI: 10.1007/s11657-016-0278-z] [Citation(s) in RCA: 269] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 06/16/2016] [Indexed: 02/03/2023]
Abstract
UNLABELLED This systematic review identified assessment guidelines for osteoporosis that incorporate FRAX. The rationale for intervention thresholds is given in a minority of papers. Intervention thresholds (fixed or age-dependent) need to be country-specific. INTRODUCTION In most assessment guidelines, treatment for osteoporosis is recommended in individuals with prior fragility fractures, especially fractures at spine and hip. However, for those without prior fractures, the intervention thresholds can be derived using different methods. The aim of this report was to undertake a systematic review of the available information on the use of FRAX® in assessment guidelines, in particular the setting of thresholds and their validation. METHODS We identified 120 guidelines or academic papers that incorporated FRAX of which 38 provided no clear statement on how the fracture probabilities derived are to be used in decision-making in clinical practice. The remainder recommended a fixed intervention threshold (n = 58), most commonly as a component of more complex guidance (e.g. bone mineral density (BMD) thresholds) or an age-dependent threshold (n = 22). Two guidelines have adopted both age-dependent and fixed thresholds. RESULTS Fixed probability thresholds have ranged from 4 to 20 % for a major fracture and 1.3-5 % for hip fracture. More than one half (39) of the 58 publications identified utilised a threshold probability of 20 % for a major osteoporotic fracture, many of which also mention a hip fracture probability of 3 % as an alternative intervention threshold. In nearly all instances, no rationale is provided other than that this was the threshold used by the National Osteoporosis Foundation of the USA. Where undertaken, fixed probability thresholds have been determined from tests of discrimination (Hong Kong), health economic assessment (USA, Switzerland), to match the prevalence of osteoporosis (China) or to align with pre-existing guidelines or reimbursement criteria (Japan, Poland). Age-dependent intervention thresholds, first developed by the National Osteoporosis Guideline Group (NOGG), are based on the rationale that if a woman with a prior fragility fracture is eligible for treatment, then, at any given age, a man or woman with the same fracture probability but in the absence of a previous fracture (i.e. at the 'fracture threshold') should also be eligible. Under current NOGG guidelines, based on age-dependent probability thresholds, inequalities in access to therapy arise especially at older ages (≥70 years) depending on the presence or absence of a prior fracture. An alternative threshold using a hybrid model reduces this disparity. CONCLUSION The use of FRAX (fixed or age-dependent thresholds) as the gateway to assessment identifies individuals at high risk more effectively than the use of BMD. However, the setting of intervention thresholds needs to be country-specific.
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Affiliation(s)
- John A Kanis
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
- Institute of Health and Ageing, Australian Catholic University, Melbourne, Australia.
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Helena Johansson
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
| | - Anders Odén
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
| | - Eugene V McCloskey
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
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Balasubramanian A, Wade SW, Adler RA, Lin CJF, Maricic M, O'Malley CD, Saag K, Curtis JR. Glucocorticoid exposure and fracture risk in patients with new-onset rheumatoid arthritis. Osteoporos Int 2016; 27:3239-3249. [PMID: 27273113 DOI: 10.1007/s00198-016-3646-z] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 05/19/2016] [Indexed: 01/30/2023]
Abstract
UNLABELLED Retrospective claims analysis indicated that high levels of daily and cumulative doses of systemic glucocorticoids were associated with elevated fracture risk in a large cohort of new RA patients under age 65. Heightened risk began to decline within months of discontinuation. Findings were similar among patients age <50 years. INTRODUCTION We evaluated the impact of systemic glucocorticoid exposure on fracture risk among relatively young patients with new-onset rheumatoid arthritis (RA). METHODS Using administrative data, we identified 42,127 RA patients diagnosed January 1, 2005-December 31, 2012, age 18-64 years, with benefits coverage for ≥12 months before RA diagnosis. Follow-up extended to clinical fracture, cancer diagnosis, or December 31, 2012. Glucocorticoid users were new to therapy. Fracture incidence rates (IR) were stratified by glucocorticoid exposure expressed as prednisone equivalent doses. Cox's proportional hazards models estimated fracture risk adjusted for demographics and baseline clinical characteristics to assess dose-response relationships with current (daily) and prior (cumulative) dose, and by time since discontinuation. RESULTS Most patients (85 %) had glucocorticoid exposure. Exposed and unexposed patients were demographically similar (74 % female; mean age 49.7 and 48.8 years); 1 % had prior fracture. Fracture IRs (95 % confidence intervals) were 5 to 9 per 1000 person-years at doses <15 mg/day, 16.0 (11.0, 22.6) at doses ≥15 mg/day, and 13.4 (10.7, 16.7) at cumulative doses ≥5400 mg. Adjusted fracture risk was approximately 2-fold higher at highest dose levels compared with 0 mg/day current daily dose and <675 mg cumulative dose, respectively. Fracture risk was 29 % lower at 60-182 days post-discontinuation compared with ongoing use and was similar to unexposed patients by 12 months. Findings were similar among patients age <50 years. CONCLUSIONS Among younger, new-onset RA patients, fracture risk was significantly elevated at high levels of daily and cumulative dose, and was similar to unexposed patients by 12 months post-discontinuation.
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Affiliation(s)
| | - S W Wade
- Wade Outcomes Research and Consulting, 358 South 700 East, Suite B-432, Salt Lake City, UT, USA.
| | - R A Adler
- McGuire Veterans Affairs Medical Center and Virginia Commonwealth University, Richmond, VA, USA
| | - C J F Lin
- Amgen Inc., Thousand Oaks and San Francisco, CA, USA
| | - M Maricic
- University of Arizona School of Medicine, Tucson, AZ, USA
| | - C D O'Malley
- Amgen Inc., Thousand Oaks and San Francisco, CA, USA
| | - K Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
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Munson JC, Bynum JPW, Bell JE, Cantu R, McDonough C, Wang Q, Tosteson TD, Tosteson ANA. Patterns of Prescription Drug Use Before and After Fragility Fracture. JAMA Intern Med 2016; 176:1531-1538. [PMID: 27548843 PMCID: PMC5048505 DOI: 10.1001/jamainternmed.2016.4814] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Patients who have a fragility fracture are at high risk for subsequent fractures. Prescription drugs represent 1 factor that could be modified to reduce the risk of subsequent fracture. OBJECTIVE To describe the use of prescription drugs associated with fracture risk before and after fragility fracture. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study conducted between February 2015 and March 2016 using a 40% random sample of Medicare beneficiaries from 2007 through 2011 in general communities throughout the United States. A total of 168 133 community-dwelling Medicare beneficiaries who survived a fracture of the hip, shoulder, or wrist were included. Cohort members were required to be enrolled in fee-for-service Medicare with drug coverage (Parts A, B, and D) and to be community dwelling for at least 30 days in the immediate 4-month postfracture period. EXPOSURES Prescription drug use during the 4-month period before and after a fragility fracture. MAIN OUTCOMES AND MEASURES Prescription fills for drug classes associated with increased fracture risk were measured using Part D retail pharmacy claims. These were divided into 3 categories: drugs that increase fall risk; drugs that decrease bone density; and drugs with unclear fracture risk mechanism. Drugs that increase bone density were also tracked. RESULTS A total of 168 133 patients with a fragility fracture (141 569 women; 84.2%) met the inclusion criteria for this study; 91.8% were white. Across all fracture types, the mean (SD) age was 80.0 (7.7) years, and 53.2% of the fracture cohort was hospitalized at the time of the index fracture, although this varied significantly depending on fracture type (100% of hip fractures, 8.2% of wrist fractures, and 15.0% of shoulder fractures). The frequency of discharge to an institution for rehabilitation following hospitalization also varied by fracture type, but the mean (SD) duration of acute rehabilitation did not: 28.1 (19.8) days. Most patients were exposed to at least 1 nonopiate drug associated with increased fracture risk in the 4 months before fracture (77.1% of hip, 74.1% of wrist, and 75.9% of shoulder fractures). Approximately 7% of these patients discontinued this drug exposure after the fracture, but this was offset by new users after fracture. Consequently, the proportion of the cohort exposed following fracture was unchanged (80.5%, 74.3%, and 76.9% for hip, wrist, and shoulder, respectively). There was no change in the average number of fracture-associated drugs used. This same pattern of use before and after fracture was observed across all 3 drug mechanism categories. Use of drugs to strengthen bone density was uncommon (≤25%) both before and after fracture. CONCLUSIONS AND RELEVANCE Exposure to prescription drugs associated with fracture risk is infrequently reduced following fragility fracture occurrence. While some patients eliminate their exposure to drugs associated with fracture, an equal number initiate new high-risk drugs. This pattern suggests there is a missed opportunity to modify at least one factor contributing to secondary fractures.
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Affiliation(s)
- Jeffrey C Munson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire2Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Julie P W Bynum
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire2Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - John-Erik Bell
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire3Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Robert Cantu
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Qianfei Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Tor D Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire5Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire2Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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Kennedy CC, Papaioannou A, Adachi JD. Glucocorticoid-Induced Osteoporosis. WOMENS HEALTH 2016; 2:65-74. [DOI: 10.2217/17455057.2.1.65] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Glucocorticoids are widely used to treat several diseases; however, one of their major consequences is a deleterious effect on bone that may lead to glucocorticoid-induced osteoporosis. Fractures may begin to occur within 3 months of commencing oral glucocorticoid therapy, and may even occur in patients receiving low doses. The good news is that with effective management, bone loss and fractures can be prevented or greatly reduced in patients receiving glucocorticoids. Despite clear practice guidelines, glucocorticoid-induced osteoporosis often goes undiagnosed and untreated in many patients. In this article, a current overview of glucocorticoid-induced osteoporosis is provided, including how to recognize, prevent and treat osteoporosis in pre- and postmenopausal women receiving glucocorticoid therapy.
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Affiliation(s)
- Courtney C Kennedy
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada, Tel.: +1 416 907 4848
| | - Alexandra Papaioannou
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada, Tel.: +1 416 907 4848
| | - Jonathan D Adachi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada, Tel.: +1 416 907 4848
- Department of Medicine, St. Joseph's Hospital, 25 Charlton Avenue East, Suite 50, Hamilton, Ontario, Canada, L8N 1Y2, Tel.: +1 905 529 1317; Fax: +1 905 521 1297
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Singh JA, Hossain A, Kotb A, Oliveira A, Mudano AS, Grossman J, Winthrop K, Wells GA. Treatments for Lupus Nephritis: A Systematic Review and Network Metaanalysis. J Rheumatol 2016; 43:1801-1815. [PMID: 27585688 DOI: 10.3899/jrheum.160041] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To compare benefits and harms of lupus nephritis (LN) induction and maintenance treatments. METHODS We performed a systematic review and Bayesian network metaanalyses of randomized controlled trials (RCT) of immunosuppressive drugs or corticosteroids (CS) in LN. OR and 95% credible intervals (CrI) were calculated. RESULTS There were 65 RCT that met inclusion and exclusion criteria. Significantly lower risk of endstage renal disease (ESRD; 17 studies) was seen with cyclophosphamide (CYC; OR 0.49, 95% CrI 0.25-0.92) or CYC + azathioprine (AZA; OR 0.18, 95% CrI 0.05-0.57) compared with standard-dose CS, and with high-dose (HD) CYC (OR 0.16, 95% CrI 0.03-0.61) or CYC + AZA (OR 0.10, 95% CrI 0.03-0.34) compared with HD CS. HD CS was associated with higher risk of ESRD compared with CYC (OR 3.59, 95% CrI 1.30-9.86), AZA (OR 2.93, 95% CrI 1.08-8.10), or mycophenolate mofetil (MMF; OR 7.05, 95% CrI 1.66-31.91). Compared with CS, a significantly higher proportion of patients had renal response (14 studies) when treated with CYC (OR 1.98, 95% CrI 1.13-3.52), MMF (OR 2.42, 95% CrI 1.27-4.74), or tacrolimus (TAC; OR 4.20, 95% CrI 1.29-13.68). No differences were noted for the risk of malignancy (15 studies). The risk of herpes zoster (17 studies) was as follows: OR (95% CrI) MMF versus CS 4.38 (1.02-23.87), CYC versus CS 6.64 (1.97-25.71), TAC versus CS 9.11 (1.13-70.99), and CYC + AZA versus CS 8.46 (1.99-43.61). CONCLUSION Renal benefits and the risk of herpes zoster were higher for immunosuppressive drugs versus CS. Data on relative and absolute differences are now available, which can be incorporated into patient-physician discussions related to systemic lupus erythematosus medication use.
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Affiliation(s)
- Jasvinder A Singh
- From the Medicine Service, Veterans Affairs (VA) Medical Center; Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota; University of California at San Francisco, San Francisco, California; University of Oregon, Portland, Oregon, USA; Ottawa Heart Institute and the University of Ottawa, Ottawa, Ontario, Canada.J.A. Singh, MBBS, MPH, Medicine Service, VA Medical Center, and Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, and Department of Orthopedic Surgery, Mayo Clinic College of Medicine; A. Hossain, PhD, Ottawa Heart Institute and the University of Ottawa; A. Kotb, PhD, Ottawa Heart Institute and the University of Ottawa; A. Oliveira, PhD, Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; A.S. Mudano, MPH, Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; J. Grossman, MD, University of California at San Francisco; K. Winthrop, MD, MPH, University of Oregon; G.A. Wells, PhD, Ottawa Heart Institute and the University of Ottawa.
| | - Alomgir Hossain
- From the Medicine Service, Veterans Affairs (VA) Medical Center; Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota; University of California at San Francisco, San Francisco, California; University of Oregon, Portland, Oregon, USA; Ottawa Heart Institute and the University of Ottawa, Ottawa, Ontario, Canada.J.A. Singh, MBBS, MPH, Medicine Service, VA Medical Center, and Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, and Department of Orthopedic Surgery, Mayo Clinic College of Medicine; A. Hossain, PhD, Ottawa Heart Institute and the University of Ottawa; A. Kotb, PhD, Ottawa Heart Institute and the University of Ottawa; A. Oliveira, PhD, Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; A.S. Mudano, MPH, Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; J. Grossman, MD, University of California at San Francisco; K. Winthrop, MD, MPH, University of Oregon; G.A. Wells, PhD, Ottawa Heart Institute and the University of Ottawa
| | - Ahmed Kotb
- From the Medicine Service, Veterans Affairs (VA) Medical Center; Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota; University of California at San Francisco, San Francisco, California; University of Oregon, Portland, Oregon, USA; Ottawa Heart Institute and the University of Ottawa, Ottawa, Ontario, Canada.J.A. Singh, MBBS, MPH, Medicine Service, VA Medical Center, and Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, and Department of Orthopedic Surgery, Mayo Clinic College of Medicine; A. Hossain, PhD, Ottawa Heart Institute and the University of Ottawa; A. Kotb, PhD, Ottawa Heart Institute and the University of Ottawa; A. Oliveira, PhD, Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; A.S. Mudano, MPH, Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; J. Grossman, MD, University of California at San Francisco; K. Winthrop, MD, MPH, University of Oregon; G.A. Wells, PhD, Ottawa Heart Institute and the University of Ottawa
| | - Ana Oliveira
- From the Medicine Service, Veterans Affairs (VA) Medical Center; Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota; University of California at San Francisco, San Francisco, California; University of Oregon, Portland, Oregon, USA; Ottawa Heart Institute and the University of Ottawa, Ottawa, Ontario, Canada.J.A. Singh, MBBS, MPH, Medicine Service, VA Medical Center, and Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, and Department of Orthopedic Surgery, Mayo Clinic College of Medicine; A. Hossain, PhD, Ottawa Heart Institute and the University of Ottawa; A. Kotb, PhD, Ottawa Heart Institute and the University of Ottawa; A. Oliveira, PhD, Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; A.S. Mudano, MPH, Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; J. Grossman, MD, University of California at San Francisco; K. Winthrop, MD, MPH, University of Oregon; G.A. Wells, PhD, Ottawa Heart Institute and the University of Ottawa
| | - Amy S Mudano
- From the Medicine Service, Veterans Affairs (VA) Medical Center; Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota; University of California at San Francisco, San Francisco, California; University of Oregon, Portland, Oregon, USA; Ottawa Heart Institute and the University of Ottawa, Ottawa, Ontario, Canada.J.A. Singh, MBBS, MPH, Medicine Service, VA Medical Center, and Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, and Department of Orthopedic Surgery, Mayo Clinic College of Medicine; A. Hossain, PhD, Ottawa Heart Institute and the University of Ottawa; A. Kotb, PhD, Ottawa Heart Institute and the University of Ottawa; A. Oliveira, PhD, Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; A.S. Mudano, MPH, Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; J. Grossman, MD, University of California at San Francisco; K. Winthrop, MD, MPH, University of Oregon; G.A. Wells, PhD, Ottawa Heart Institute and the University of Ottawa
| | - Jennifer Grossman
- From the Medicine Service, Veterans Affairs (VA) Medical Center; Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota; University of California at San Francisco, San Francisco, California; University of Oregon, Portland, Oregon, USA; Ottawa Heart Institute and the University of Ottawa, Ottawa, Ontario, Canada.J.A. Singh, MBBS, MPH, Medicine Service, VA Medical Center, and Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, and Department of Orthopedic Surgery, Mayo Clinic College of Medicine; A. Hossain, PhD, Ottawa Heart Institute and the University of Ottawa; A. Kotb, PhD, Ottawa Heart Institute and the University of Ottawa; A. Oliveira, PhD, Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; A.S. Mudano, MPH, Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; J. Grossman, MD, University of California at San Francisco; K. Winthrop, MD, MPH, University of Oregon; G.A. Wells, PhD, Ottawa Heart Institute and the University of Ottawa
| | - Kevin Winthrop
- From the Medicine Service, Veterans Affairs (VA) Medical Center; Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota; University of California at San Francisco, San Francisco, California; University of Oregon, Portland, Oregon, USA; Ottawa Heart Institute and the University of Ottawa, Ottawa, Ontario, Canada.J.A. Singh, MBBS, MPH, Medicine Service, VA Medical Center, and Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, and Department of Orthopedic Surgery, Mayo Clinic College of Medicine; A. Hossain, PhD, Ottawa Heart Institute and the University of Ottawa; A. Kotb, PhD, Ottawa Heart Institute and the University of Ottawa; A. Oliveira, PhD, Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; A.S. Mudano, MPH, Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; J. Grossman, MD, University of California at San Francisco; K. Winthrop, MD, MPH, University of Oregon; G.A. Wells, PhD, Ottawa Heart Institute and the University of Ottawa
| | - George A Wells
- From the Medicine Service, Veterans Affairs (VA) Medical Center; Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota; University of California at San Francisco, San Francisco, California; University of Oregon, Portland, Oregon, USA; Ottawa Heart Institute and the University of Ottawa, Ottawa, Ontario, Canada.J.A. Singh, MBBS, MPH, Medicine Service, VA Medical Center, and Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, and Department of Orthopedic Surgery, Mayo Clinic College of Medicine; A. Hossain, PhD, Ottawa Heart Institute and the University of Ottawa; A. Kotb, PhD, Ottawa Heart Institute and the University of Ottawa; A. Oliveira, PhD, Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; A.S. Mudano, MPH, Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; J. Grossman, MD, University of California at San Francisco; K. Winthrop, MD, MPH, University of Oregon; G.A. Wells, PhD, Ottawa Heart Institute and the University of Ottawa
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Dicer ablation in osteoblasts by Runx2 driven cre-loxP recombination affects bone integrity, but not glucocorticoid-induced suppression of bone formation. Sci Rep 2016; 6:32112. [PMID: 27554624 PMCID: PMC4995469 DOI: 10.1038/srep32112] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 08/02/2016] [Indexed: 12/19/2022] Open
Abstract
Glucocorticoid-induced osteoporosis (GIO) is one of the major side effects of long-term glucocorticoid (GC) therapy mediated mainly via the suppression of bone formation and osteoblast differentiation independently of GC receptor (GR) dimerization. Since microRNAs play a critical role in osteoblast differentiation processes, we investigated the role of Dicer dependent microRNAs in the GC-induced suppression of osteoblast differentiation. MicroRNA sequencing of dexamethasone-treated wild-type and GR dimer-deficient mesenchymal stromal cells revealed GC-controlled miRNA expression in a GR dimer-dependent and GR dimer-independent manner. To determine the functional relevance of mature miRNAs in GC-induced osteoblast suppression, mice with an osteoblast-specific deletion of Dicer (DicerRunx2Cre) were exposed to glucocorticoids. In vitro generated Dicer-deficient osteoblasts were treated with dexamethasone and analyzed for proliferation, differentiation and mineralization capacity. In vivo, abrogation of Dicer-dependent miRNA biogenesis in osteoblasts led to growth retardation and impaired bone formation. However, subjecting these mice to GIO showed that bone formation was similar reduced in DicerRunx2Cre mice and littermate control mice upon GC treatment. In line, differentiation of Dicer deficient osteoblasts was suppressed to the same extent as wild type cells by GC treatment. Therefore, Dicer-dependent small RNA biogenesis in osteoblasts plays only a minor role in the pathogenesis of GC-induced inhibition of bone formation.
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183
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Okazaki R, Watanabe R, Inoue D. Osteoporosis Associated with Chronic Obstructive Pulmonary Disease. J Bone Metab 2016; 23:111-20. [PMID: 27622174 PMCID: PMC5018603 DOI: 10.11005/jbm.2016.23.3.111] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 07/02/2016] [Indexed: 12/23/2022] Open
Abstract
Recent epidemiological studies have revealed that osteoporosis is closely associated with common chronic diseases including diabetes, hypertension, chronic kidney disorders, and chronic obstructive pulmonary disease (COPD). COPD is a chronic inflammatory airway disease but now well known to be associated with various systemic comorbidities including osteoporosis. Osteoporosis and osteoporotic fractures are extremely common in COPD patients, which have significant impacts on their quality of life (QOL), activities of daily life (ADL), respiratory function, and possibly their prognosis. COPD-associated osteoporosis is however extremely under-recognized, hence undertreated. Recent studies have suggested that both decreased bone mineral density (BMD) and impaired bone quality compromise bone strength causing fractures in COPD. In COPD patients, various general clinical risk factors for osteoporosis are present including smoking, older age, low body weight, and physical inactivity. In addition, disease-related risk factors such as decreased pulmonary function, inflammation, glucocorticoid use and vitamin D deficiency/insufficiency have been linked to the development of osteoporosis in COPD. Increased awareness of osteoporosis in COPD, especially that of high prevalence of vertebral fractures is called upon among general physicians as well as pulmonologists. Routine screening for osteoporosis and risk assessment of fractures will enable physicians to diagnose COPD patients with comorbid osteoporosis at an early stage. Timely prevention of developing osteoporosis together with appropriate treatment of established osteoporosis may improve QOL and ADL of the COPD patients, preserve their lung function and eventually result in better prognosis in these patients.
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Affiliation(s)
- Ryo Okazaki
- Third Department of Medicine, Teikyo University Chiba Medical Center, Japan
| | - Reiko Watanabe
- Third Department of Medicine, Teikyo University Chiba Medical Center, Japan
| | - Daisuke Inoue
- Third Department of Medicine, Teikyo University Chiba Medical Center, Japan
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Oyinlola JO, Campbell J, Kousoulis AA. Is real world evidence influencing practice? A systematic review of CPRD research in NICE guidances. BMC Health Serv Res 2016; 16:299. [PMID: 27456701 PMCID: PMC4960862 DOI: 10.1186/s12913-016-1562-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 07/20/2016] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND There is currently limited evidence regarding the extent Real World Evidence (RWE) has directly impacted the health and social care systems. The aim of this review is to identify national guidelines or guidances published in England from 2000 onwards which have referenced studies using the governmental primary care data provider the Clinical Practice Research Datalink (CPRD). METHODS The methodology recommended by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed. Four databases were searched and documents of interest were identified through a search algorithm containing keywords relevant to CPRD. A search diary was maintained with the inclusion/exclusion decisions which were performed by two independent reviewers. RESULTS Twenty-five guidance documents were included in the final review (following screening and assessment for eligibility), referencing 43 different CPRD/GPRD studies, all published since 2007. The documents covered 12 disease areas, with the majority (N =7) relevant to diseases of the Central Nervous system (CNS). The 43 studies provided evidence of disease epidemiology, incidence/prevalence, pharmacoepidemiology, pharmacovigilance and health utilisation. CONCLUSIONS A slow uptake of RWE in clinical and therapeutic guidelines (as provided by UK governmental structures) was noticed. However, there seems to be an increasing trend in the use of healthcare system data to inform clinical practice, especially as the real world validity of clinical trials is being questioned. In order to accommodate this increasing demand and meet the paradigm shift expected, organisations need to work together to enable or improve data access, undertake translational and relevant research and establish sources of reliable evidence.
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Affiliation(s)
- Jessie O. Oyinlola
- Clinical Practice Research Datalink (CPRD), Medicines and Healthcare products Regulatory Agency, 151 Buckingham Palace Road, Victoria London, SW1W 9SZ UK
| | - Jennifer Campbell
- Clinical Practice Research Datalink (CPRD), Medicines and Healthcare products Regulatory Agency, 151 Buckingham Palace Road, Victoria London, SW1W 9SZ UK
| | - Antonis A. Kousoulis
- Clinical Practice Research Datalink (CPRD), Medicines and Healthcare products Regulatory Agency, 151 Buckingham Palace Road, Victoria London, SW1W 9SZ UK
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Shen G, Ren H, Qiu T, Liang D, Wei Q, Tang J, Zhang Z, Yao Z, Zhao W, Jiang X. Effect of glucocorticoid withdrawal on glucocorticoid inducing bone impairment. Biochem Biophys Res Commun 2016; 477:1059-1064. [PMID: 27402272 DOI: 10.1016/j.bbrc.2016.07.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 07/07/2016] [Indexed: 10/21/2022]
Abstract
Glucocorticoid (GC) withdrawal after a short-term use was common in clinical practice like immediate post-transplant period. However, previous studies without setting age-control group failed to determine whether the BMD recovery was sufficient and whether it is necessary to accept anti-osteoporosis therapy after GC withdrawal. The aim of this study was to investigate the effect of GC withdrawal on bone impairment in glucocorticoid-induced osteoporosis (GIOP) rats. Twenty-four female Sprague-Dawley rats (3 months' old) were randomly divided into two treatment groups: an untreated age-control group (Con, n = 12); another group receiving a dexamethasone injection (DEXA, n = 12). Animals in the Con group were euthanized at 3rd month (M3) and 6th month (M6), respectively. Six rats in the DEXA group were euthanized at 3rd month (M3), whereas GC intervention was withdrew in the remaining animals of DEXA group, which were euthanized at the end of 6th month (M6). Bone mass, bone microarchitecture, biomechanical properties of vertebrae, morphology, serum levels of PINP and β-CTX were evaluated. Compared with the Con(M3) group, the Con(M6) group showed significantly better bone quantity, morphology and quality. Compared with the Con(M3) group, the DEXA (M3) group showed significantly lower BMC, BMD, BS/TV, BV/TV, Tb.N, Tb.Th, vBMD, bone strength, compressive displacement, energy absorption capacity, PINP levels, β-CTX levels, and damaged trabecular morphology. And the same change trend was observed in the comparison between the Con(M6) group and DEXA (M6) group. Compared with the DEXA (M3) group, the DEXA (M6) group showed significantly higher BMC, BMD and AREA, but no significant difference in BS/TV, BV/TV, SMI, Tb.N, Tb.Th, Tb.Sp, vBMD, bone strength, bone stiffness, compressive displacement, energy absorption capacity, PINP levels, β-CTX levels, and improvement in trabecular morphology was observed. These results indicate that the reverse effect of GC withdrawal for 3 months on bone impairment in GIOP rats was insufficient, which implied that related anti-osteoporosis treatment might be still necessitated after GC withdrawal in clinical setting.
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Affiliation(s)
- Gengyang Shen
- Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
| | - Hui Ren
- Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
| | - Ting Qiu
- Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - De Liang
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Qiushi Wei
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Jingjing Tang
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Zhida Zhang
- Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Zhensong Yao
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Wenhua Zhao
- Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Xiaobing Jiang
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China; Laboratory Affiliated to National Key Discipline of Orthopaedic and Traumatology of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
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186
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Oral glucocorticoid therapy and all-cause and cause-specific mortality in patients with rheumatoid arthritis: a retrospective cohort study. Eur J Epidemiol 2016; 31:1045-1055. [PMID: 27256352 PMCID: PMC5065607 DOI: 10.1007/s10654-016-0167-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 05/22/2016] [Indexed: 01/01/2023]
Abstract
Previous studies of glucocorticoid (GC) therapy and mortality have had inconsistent results and have not considered possible perimortal bias—a type of protopathic bias where illness in the latter stages of life influences GC exposure, and might affect the observed relationship between GC use and death. This study aimed to investigate all-cause and cause-specific mortality in association with GC therapy in patients with rheumatoid arthritis (RA), and explore possible perimortal bias. A retrospective cohort study using the primary care electronic medical records. Oral GC exposure was identified from prescriptions. Mortality data were obtained from the UK Office for National Statistics. Multivariable Cox proportional hazards regression models assessed the association between GC use models and death. Several methods to explore perimortal bias were examined. The cohort included 16,762 patients. For ever GC use there was an adjusted hazard ratio for all-cause mortality of 1.97 (95 % CI 1.81–2.15). Current GC dose of below 5 mg per day (prednisolone equivalent dose) was not associated with an increased risk of death, but a dose–response association was seen for higher dose categories. The association between ever GC use and all-cause mortality was partly explained by perimortal bias. GC therapy was associated with an increased risk of mortality for all specific causes considered, albeit to a lesser extent for cardiovascular causes. GC use was associated with an increased risk of death in RA, at least partially explained by perimortal bias. Importantly, GC doses below 5 mg were not associated with an increased risk of death.
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187
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Abstract
The skeletal effects of inhaled glucocorticoids are poorly understood. Children with asthma treated with inhaled glucocorticoids have lower growth velocity, bone density, and adult height. Studies of adults with asthma have reported variable effects on BMD, although prospective studies have demonstrated bone loss after initiation of inhaled glucocorticoids in premenopausal women. There is a dose-response relationship between inhaled glucocorticoids and fracture risk in asthmatics; the risk of vertebral and non-vertebral fractures is greater in subjects treated with the highest doses in the majority of studies. Patients with COPD have lower BMD and higher fracture rates compared to controls, however, the majority of studies have not found an additional detrimental effect of inhaled glucocorticoids on bone. While the evidence is not conclusive, it supports using the lowest possible dose of inhaled glucocorticoids to treat patients with asthma and COPD and highlights the need for further research on this topic.
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Affiliation(s)
| | - Emily M. Stein
- Division of Endocrinology, Columbia University College of Physicians & Surgeons, 630 West 168 Street, PH8 West 864, New York, NY 10032, Phone (212) 305-0220, Fax (212) 305-6486
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188
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Bours S, de Vries F, van den Bergh JPW, Lalmohamed A, van Staa TP, Leufkens HGM, Geusens PPP, Drent M, Harvey NC. Risk of vertebral and non-vertebral fractures in patients with sarcoidosis: a population-based cohort. Osteoporos Int 2016; 27:1603-1610. [PMID: 26630976 PMCID: PMC4791462 DOI: 10.1007/s00198-015-3426-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 11/13/2015] [Indexed: 11/12/2022]
Abstract
UNLABELLED In this retrospective cohort study using the Clinical Practice Research Datalink (CPRD), patients with sarcoidosis have an increased risk of clinical vertebral fractures and when on recent treatment with oral glucocorticoids, also an increased risk of any fractures and osteoporotic fractures. INTRODUCTION Sarcoidosis is a chronic inflammatory disease, in which fragility fractures have been reported despite normal BMD. The aim of this study was to assess whether patients with sarcoidosis have an increased risk of clinical fractures compared to the general population. METHODS A retrospective cohort study was conducted using the CPRD. All patients with a CPRD code for sarcoidosis between January 1987 and September 2012 were included. Cox proportional hazards models were used to derive adjusted relative risks (RRs) of fractures in all sarcoidosis patients compared to matched controls, and within the sarcoidosis group according to use and dose of systemic glucocorticoids. RESULTS Five thousand seven hundred twenty-two sarcoidosis patients (mean age 48.0 years, 51 % females, mean follow-up 6.7 years) were identified. Compared to 28,704 matched controls, the risk of any fracture was not different in patients with sarcoidosis. However, the risk of clinical vertebral fractures was significantly increased (adj RR 1.77; 95 % CI 1.06-2.96) and the risk of non-vertebral fractures was decreased although marginally significant (adj RR 0.87; 95 % CI 0.77-0.99). Compared to sarcoidosis patients not taking glucocorticoids, recent use of systemic glucocorticoids was associated with an increased risk of any fracture (adj RR 1.50; 95 % CI 1.20-1.89) and of an osteoporotic fracture (adj RR 1.47; 95 % CI 1.07-2.02). CONCLUSIONS Patients with sarcoidosis have an increased risk of clinical vertebral fractures, and when using glucocorticoid therapy, an increased risk of any fractures and osteoporotic fractures. In contrast, the risk of non-vertebral fractures maybe decreased. Further investigation is needed to understand the underlying mechanisms of these contrasting effects on fracture risk.
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Affiliation(s)
- S Bours
- Department of Internal Medicine, Subdivision of Rheumatology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - F de Vries
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, The Netherlands.
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK.
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands.
- CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.
| | - J P W van den Bergh
- Department of Internal Medicine, Viecuri MC Venlo, Venlo, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
- Biomedical Research Institute, Hasselt University, Hasselt, Belgium
| | - A Lalmohamed
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T P van Staa
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, The Netherlands
- Farr Institute, University of Manchester, Manchester, UK
| | - H G M Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, The Netherlands
| | - P P P Geusens
- Department of Internal Medicine, Subdivision of Rheumatology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Biomedical Research Institute, Hasselt University, Hasselt, Belgium
| | - M Drent
- ILD Center of Excellence, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Pharmacology and Toxicology, FHML, University Maastricht, Maastricht, The Netherlands
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
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189
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Inoue D, Watanabe R, Okazaki R. COPD and osteoporosis: links, risks, and treatment challenges. Int J Chron Obstruct Pulmon Dis 2016; 11:637-48. [PMID: 27099481 PMCID: PMC4820217 DOI: 10.2147/copd.s79638] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory airway disease associated with various systemic comorbidities including osteoporosis. Osteoporosis and its related fractures are common and have significant impacts on quality of life and even respiratory function in patients with COPD. COPD-associated osteoporosis is however extremely undertreated. Recent studies have suggested that both decreased bone mineral density (BMD) and impaired bone quality contribute to bone fragility, causing fractures in COPD patients. Various clinical risk factors of osteoporosis in COPD patients, including older age, emaciation, physical inactivity, and vitamin D deficiency, have also been described. It is critically important for pulmonologists to be aware of the high prevalence of osteoporosis in COPD patients and evaluate them for such fracture risks. Routine screening for osteoporosis will enable physicians to diagnose COPD patients with comorbid osteoporosis at an early stage and give them appropriate treatment to prevent fracture, which may lead to improved quality of life as well as better long-term prognosis.
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Affiliation(s)
- Daisuke Inoue
- Division of Endocrinology and Metabolism, Third Department of Medicine, Teikyo University Chiba Medical Center, Ichihara, Chiba, Japan
| | - Reiko Watanabe
- Division of Endocrinology and Metabolism, Third Department of Medicine, Teikyo University Chiba Medical Center, Ichihara, Chiba, Japan
| | - Ryo Okazaki
- Division of Endocrinology and Metabolism, Third Department of Medicine, Teikyo University Chiba Medical Center, Ichihara, Chiba, Japan
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190
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Zengin Karahan S, Boz C, Kilic S, Can Usta N, Ozmenoglu M, Altunayoglu Cakmak V, Gazioglu S. Lack of Association between Pulse Steroid Therapy and Bone Mineral Density in Patients with Multiple Sclerosis. Mult Scler Int 2016; 2016:5794910. [PMID: 26966578 PMCID: PMC4757708 DOI: 10.1155/2016/5794910] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 12/07/2015] [Accepted: 12/13/2015] [Indexed: 11/17/2022] Open
Abstract
Multiple sclerosis (MS) has been associated with reduced bone mineral density (BMD). The purpose of this study was to determine the possible factors affecting BMD in patients with MS. We included consecutive 155 patients with MS and 90 age- and sex-matched control subjects. Patients with MS exhibited significantly lower T-scores and Z-scores in the femoral neck and trochanter compared to the controls. Ninety-four (61%) patients had reduced bone mass in either the lumbar spine or the femoral neck; of these, 64 (41.3%) had osteopenia and 30 (19.4%) had osteoporosis. The main factors affecting BMD were disability, duration of MS, and smoking. There was a negative relationship between femoral BMD and EDSS and disease duration. No association with lumbar BMD was determined. There were no correlations between BMD at any anatomic region and cumulative corticosteroid dose. BMD is significantly lower in patients with MS than in healthy controls. Reduced BMD in MS is mainly associated with disability and duration of the disease. Short courses of high dose steroid therapy did not result in an obvious negative impact on BMD in the lumbar spine and femoral neck in patients with MS.
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Affiliation(s)
| | - Cavit Boz
- Karadeniz Technical University, 61080 Trabzon, Turkey
| | - Sevgi Kilic
- Karadeniz Technical University, 61080 Trabzon, Turkey
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191
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Prevention and Treatment of Bone Disease in Systemic Lupus Erythematosus. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2016. [DOI: 10.1007/s40674-016-0034-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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192
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Balancing benefits and risks of glucocorticoids in rheumatic diseases and other inflammatory joint disorders: new insights from emerging data. An expert consensus paper from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Aging Clin Exp Res 2016; 28:1-16. [PMID: 26746234 DOI: 10.1007/s40520-015-0522-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 12/22/2015] [Indexed: 12/26/2022]
Abstract
PURPOSE This consensus review article considers the question of whether glucocorticoid (GC) therapy is still relevant in the treatment of rheumatic diseases, with a particular focus on rheumatoid arthritis (RA), and whether its side effects can be adequately managed. Recent basic and clinical research on the molecular, cellular and clinical effects of GCs have considerably advanced our knowledge in this field. An overview of the subject seems appropriate. METHODS This review is the result of a multidisciplinary expert working group, organised by European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis. The recent literature was surveyed and the salient evidence synthetized. RESULTS The pathophysiological basis of RA (and other inflammatory rheumatic diseases) now strongly implicates the adaptive immune system in addition to innate mechanisms. The molecular effect of GCs and differential GC sensitivity is better understood, although exploiting this knowledge is still in its infancy. The newer treatment strategies of early and aggressive control of RA have gr eatly improved clinical outcomes, but improvements are still possible. Newer targeted anti-inflammatory drugs have made an important impact, yet they too are associated with numerous side effects. DISCUSSION Short durations of moderate doses of GCs are generally well tolerated and have a positive benefit/risk ratio. Patients should be assessed for fracture risk and bone preserving agents and be prescribed calcium and vitamin D supplementation. CONCLUSIONS Within a strategy of a disease modifying approach to inflammatory disease, combination therapy including a GC is effective approach.
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194
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Ooi CJ, Makharia GK, Hilmi I, Gibson PR, Fock KM, Ahuja V, Ling KL, Lim WC, Thia KT, Wei SC, Leung WK, Koh PK, Gearry RB, Goh KL, Ouyang Q, Sollano J, Manatsathit S, de Silva HJ, Rerknimitr R, Pisespongsa P, Abu Hassan MR, Sung J, Hibi T, Boey CCM, Moran N, Leong RWL. Asia-Pacific consensus statements on Crohn's disease. Part 2: Management. J Gastroenterol Hepatol 2016; 31:56-68. [PMID: 25819311 DOI: 10.1111/jgh.12958] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2015] [Indexed: 02/05/2023]
Abstract
The Asia Pacific Working Group on Inflammatory Bowel Disease was established in Cebu, Philippines, at the Asia Pacific Digestive Week conference in 2006 under the auspices of the Asian Pacific Association of Gastroenterology (APAGE) with the goal of developing best management practices, coordinating research and raising awareness of IBD in the region. The consensus group previously published recommendations for the diagnosis and management of ulcerative colitis (UC) with specific relevance to the Asia-Pacific region. The present consensus statements were developed following a similar process to address the epidemiology, diagnosis and management of Crohn's disease (CD). The goals of these statements are to pool the pertinent literature specifically highlighting relevant data and conditions in the Asia-Pacific region relating to the economy, health systems, background infectious diseases, differential diagnoses and treatment availability. It does not intend to be all-comprehensive and future revisions are likely to be required in this ever-changing field.
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Affiliation(s)
- Choon Jin Ooi
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Ida Hilmi
- Division of Gastroenterology and Hepatology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Peter R Gibson
- Monash University Department of Medicine, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Kwong Ming Fock
- Department of Gastroenterology, Changi General Hospital, Singapore
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Khoon Lin Ling
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Wee Chian Lim
- Department of Gastroenterology, Tan Tock Seng Hospital, Singapore
| | - Kelvin T Thia
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Shu-chen Wei
- Department of Internal Medicine, National Taiwan University, Taipei, Taiwan
| | | | - Poh Koon Koh
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
| | - Richard B Gearry
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Khean Lee Goh
- Division of Gastroenterology and Hepatology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Qin Ouyang
- Division of Gastroenterology, Department of Internal Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jose Sollano
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Sathaporn Manatsathit
- Department of Medicine, Division of Gastroenterology, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - H Janaka de Silva
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Pises Pisespongsa
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Joseph Sung
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong
| | | | | | - Neil Moran
- Gastroenterology and Liver Services, Concord Hospital, Sydney, New South Wales, Australia
| | - Rupert W L Leong
- Gastroenterology and Liver Services, Concord Hospital, Sydney, New South Wales, Australia
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Abstract
Vertebral fractures are one of the most common fractures associated with skeletal fragility and can cause as much morbidity as hip fractures. However, the epidemiology of vertebral fractures differs from that of osteoporotic fractures at other skeletal sites in important ways, largely because only one quarter to one-third of vertebral fractures are recognized clinically at the time of their occurrence and otherwise require lateral spine imaging to be recognized. This article first reviews the prevalence and incidence of clinical and radiographic vertebral fractures in populations across the globe and secular trends in the incidence of vertebral fracture over time. Next, associations of vertebral fractures with measures of bone mineral density and bone microarchitecture are reviewed followed by associations of vertebral fracture with various textural measures of trabecular bone, including trabecular bone score. Finally, the article reviews clinical risk factors for vertebral fracture and the association of vertebral fractures with morbidity, mortality, and other subsequent adverse health outcomes.
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Affiliation(s)
- John T Schousboe
- Park Nicollet Osteoporosis Center, Park Nicollet Clinic, HealthPartners, Minneapolis, MN, USA; Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MD, USA.
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196
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Albaum JM, Lévesque LE, Gershon AS, Liu G, Cadarette SM. Glucocorticoid-induced osteoporosis management among seniors, by year, sex, and indication, 1996-2012. Osteoporos Int 2015; 26:2845-52. [PMID: 26138581 DOI: 10.1007/s00198-015-3200-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 06/05/2015] [Indexed: 01/30/2023]
Abstract
UNLABELLED We identified that glucocorticoid-induced osteoporosis management (bone mineral density testing or osteoporosis treatment) among seniors improved among men (2 to 23 %) and women (10 to 48 %) between 1996 and 2007, and then remained relatively stable through to 2012. Differences were also noted by indication (from a low of 21 % for respiratory conditions to a high of 41 % for rheumatic conditions). PURPOSE The aim of our study was to describe the proportion of chronic oral glucocorticoid (GC) users that receive osteoporosis management (bone mineral density test or osteoporosis treatment) by sex and over time. METHODS We identified community-dwelling older adults initiating chronic oral GC therapy in Ontario using pharmacy data from 1996 to 2012. Chronic GC use was defined as greater than or equal to two oral GC prescriptions dispensed and ≥450 mg prednisone equivalent over a 6-month period. Osteoporosis management within 6 months of starting chronic GC therapy was examined by sex, year, indication for therapy, and osteoporosis management history. Results were summarized using descriptive statistics. RESULTS We identified 72,099 men and 95,975 women starting chronic oral GC therapy (mean age = 74.9 years, SD = 6.5). Approximately two thirds of patients (65 %) received ≥900 mg within the 6-month chronic use window. GC-induced osteoporosis management increased from 2 to 23 % (men) and 10 to 48 % (women) between 1996 and 2007, and then remained relatively stable through to 2012. A higher proportion of patients with prior osteoporosis management were managed within 6 months (56 % men, 67 % women) of chronic GC use, compared to patients without prior management (12 % men, 23 % women). Patients with rheumatic disease were managed most commonly (41 %), and patients with respiratory conditions were managed least commonly (21 %). CONCLUSIONS GC-induced osteoporosis management improved significantly over time for both sexes yet remains low. Significant care gaps by sex and between clinical areas represent a missed opportunity for fracture prevention among patients requiring chronic GC therapy.
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Affiliation(s)
- J M Albaum
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, M5S 3M2, Canada
| | - L E Lévesque
- Queen's University, Kingston, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - A S Gershon
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - G Liu
- Queen's University, Kingston, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - S M Cadarette
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, M5S 3M2, Canada.
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.
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197
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Abstract
PURPOSE OF REVIEW This manuscript will provide a review of recent publications, examining the correlation of systemic lupus erythematosus (SLE) with changes in bone health and associated osteoporosis, highlighting prevalence, etiology, diagnosis, and treatment. RECENT FINDINGS Studies suggest that bone loss and fractures are associated with SLE, related not only to the disease itself, but also with low vitamin D and treatment side-effects. Understanding the mechanisms of glucocorticoids on bone and the immunologic relationship of vitamin D, as well as recognizing the role of chronic inflammation on bone, allows for better understanding of skeletal side-effects. Further awareness of the association of poor bone health has led to an increased need for prevention and treatment. New imaging and treatment are emerging, although not recommended currently. SUMMARY Loss of bone density culminating in osteoporosis and fracture is a frequent comorbidity in SLE patients at any age and is multifactorial in etiology. Awareness and diagnosis is crucial because of its prevalence and morbidity. Prevention is safe and effective in this high-risk population where diagnostic measures and interventions are underutilized and guidelines are lacking.
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Affiliation(s)
- Cuoghi Edens
- aDepartment of Pediatrics, Division of Pediatric Infectious Diseases and Rheumatology, Rainbow Babies and Children's Hospital bDepartment of Internal Medicine, Division of Rheumatology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
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198
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Belaya ZE, Hans D, Rozhinskaya LY, Dragunova NV, Sasonova NI, Solodovnikov AG, Tsoriev TT, Dzeranova LK, Melnichenko GA, Dedov II. The risk factors for fractures and trabecular bone-score value in patients with endogenous Cushing's syndrome. Arch Osteoporos 2015; 10:44. [PMID: 26608406 DOI: 10.1007/s11657-015-0244-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 10/22/2015] [Indexed: 02/03/2023]
Abstract
UNLABELLED In a cohort study of 182 consecutive patients with active endogenous Cushing's syndrome, the only predictor of fracture occurrence after adjustment for age, gender bone mineral density (BMD) and trabecular bone score (TBS) was 24-h urinary free cortisol (24hUFC) levels with a threshold of 1472 nmol/24 h (odds ratio, 3.00 (95% confidence interval (CI), 1.52-5.92); p = 0.002). INTRODUCTION The aim was to estimate the risk factors for fracture in subjects with endogenous Cushing's syndrome (CS) and to evaluate the value of the TBS in these patients. METHODS All enrolled patients with CS (n = 182) were interviewed in relation to low-traumatic fractures and underwent lateral X-ray imaging from T4 to L5. BMD measurements were performed using a DXA Prodigy device (GEHC Lunar, Madison, Wisconsin, USA). The TBS was derived retrospectively from existing BMD scans, blinded to clinical outcome, using TBS iNsight software v2.1 (Medimaps, Merignac, France). Urinary free cortisol (24hUFC) was measured by immunochemiluminescence assay (reference range, 60-413 nmol/24 h). RESULTS Among enrolled patients with CS (149 females; 33 males; mean age, 37.8 years (95% confidence interval, 34.2-39.1); 24hUFC, 2370 nmol/24 h (2087-2632), fractures were confirmed in 81 (44.5%) patients, with 70 suffering from vertebral fractures, which were multiple in 53 cases; 24 patients reported non-vertebral fractures. The mean spine TBS was 1.207 (1.187-1.228), and TBS Z-score was -1.86 (-2.07 to -1.65); area under the curve (AUC) was used to predict fracture (mean spine TBS) = 0.548 (95% CI, 0.454-0.641)). In the final regression model, the only predictor of fracture occurrence was 24hUFC levels (p = 0.001), with an increase of 1.041 (95% CI, 1.019-1.063), calculated for every 100 nmol/24-h cortisol elevation (AUC (24hUFC) = 0.705 (95% CI, 0.629-0.782)). CONCLUSIONS Young patients with CS have a low TBS. However, the only predictor of low traumatic fracture is the severity of the disease itself, indicated by high 24hUFC levels.
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Affiliation(s)
- Zhanna E Belaya
- The National Research Center for Endocrinology, 11, Dmitria Uljanova Str., Moscow, 117036, Russia.
| | - Didier Hans
- Center of Bone Diseases, Lausanne University Hospital, Lausanne, Switzerland
| | - Liudmila Y Rozhinskaya
- The National Research Center for Endocrinology, 11, Dmitria Uljanova Str., Moscow, 117036, Russia
| | - Natalia V Dragunova
- The National Research Center for Endocrinology, 11, Dmitria Uljanova Str., Moscow, 117036, Russia
| | - Natalia I Sasonova
- The National Research Center for Endocrinology, 11, Dmitria Uljanova Str., Moscow, 117036, Russia
| | | | - Timur T Tsoriev
- The National Research Center for Endocrinology, 11, Dmitria Uljanova Str., Moscow, 117036, Russia
| | - Larisa K Dzeranova
- The National Research Center for Endocrinology, 11, Dmitria Uljanova Str., Moscow, 117036, Russia
| | - Galina A Melnichenko
- The National Research Center for Endocrinology, 11, Dmitria Uljanova Str., Moscow, 117036, Russia
| | - Ivan I Dedov
- The National Research Center for Endocrinology, 11, Dmitria Uljanova Str., Moscow, 117036, Russia
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199
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Woods CP, Hazlehurst JM, Tomlinson JW. Glucocorticoids and non-alcoholic fatty liver disease. J Steroid Biochem Mol Biol 2015; 154:94-103. [PMID: 26241028 DOI: 10.1016/j.jsbmb.2015.07.020] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 07/28/2015] [Accepted: 07/29/2015] [Indexed: 12/12/2022]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the hepatic manifestation of the global obesity and metabolic disease epidemic and is rapidly becoming the leading cause of liver cirrhosis and indication for liver transplantation worldwide. The hallmark pathological finding in NAFLD is excess lipid accumulation within hepatocytes, but it is a spectrum of disease ranging from benign hepatic steatosis to steatohepatitis through to fibrosis, cirrhosis and risk of hepatocellular carcinoma. The exact pathophysiology remains unclear with a multi-hit hypothesis generally accepted as being required for inflammation and fibrosis to develop after initial steatosis. Glucocorticoids have been implicated in the pathogenesis of NAFLD across all stages. They have a diverse array of metabolic functions that have the potential to drive NAFLD acting on both liver and adipose tissue. In the fasting state, they are able to mobilize lipid, increasing fatty acid delivery and in the fed state can promote lipid accumulation. Their action is controlled at multiple levels and in this review will outline the evidence base for the role of GCs in the pathogenesis of NAFLD from cell systems, rodent models and clinical studies and describe interventional strategies that have been employed to modulate glucocorticoid action as a potential therapeutic strategy.
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Affiliation(s)
- Conor P Woods
- Oxford Centre for Diabetes Endocrinology & Metabolism (OCDEM), Churchill Hospital, Headington, Oxford, OX3 7LJ, UK
| | - Jonathon M Hazlehurst
- Oxford Centre for Diabetes Endocrinology & Metabolism (OCDEM), Churchill Hospital, Headington, Oxford, OX3 7LJ, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes Endocrinology & Metabolism (OCDEM), Churchill Hospital, Headington, Oxford, OX3 7LJ, UK.
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Comparison of immunosuppressive therapies for IgA nephropathy after tonsillectomy: three-course versus one-course steroid pulse combined with mizoribine. Int Urol Nephrol 2015; 47:1823-30. [PMID: 26433884 PMCID: PMC4628097 DOI: 10.1007/s11255-015-1118-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 09/19/2015] [Indexed: 01/08/2023]
Abstract
Purpose
It has been reported that steroid pulse therapy for IgA nephropathy improves renal prognosis. However, because of the side effects, steroid dose must be restricted to some cases. Treatment effects of steroid on cases already presenting with reduced renal function are unknown. In this study, we performed tonsillectomy in patients with IgA nephropathy and conducted a comparative study about subsequent immunosuppressive therapy.
Methods
Subjects were patients younger than 70 years of age diagnosed with IgA nephropathy by renal biopsy. Treatment protocols were a single-course steroid pulse combined with mizoribine during a period from August 2006 to June 2010 (Group A; n = 34) and a three-course steroid pulse during a period from July 2010 to March 2013 (Group B; n = 32). Primary end points were excretory amounts of proteinuria, disappearance of proteinuria and hematuria, and exacerbation of renal function. Results In both the groups, proteinuria decreased significantly 12 months after treatment, and no significant difference in alleviation effects on proteinuria was found between groups. eGFR increased significantly 12 months after treatment in Group A, whereas it tended to decrease in Group B. As for the preservation effect on eGFR, Group A showed significantly higher preservation of eGFR. Similar results were shown in the patients whose eGFR at the start of the treatment was less than 60 mL/min/1.73 m2. Conclusions Single-course steroid pulse therapy combined with mizoribine was considered to have a protective effect on the renal function in IgA nephropathy, especially accompanying renal dysfunction.
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