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Ward LM. A practical guide to the diagnosis and management of osteoporosis in childhood and adolescence. Front Endocrinol (Lausanne) 2024; 14:1266986. [PMID: 38374961 PMCID: PMC10875302 DOI: 10.3389/fendo.2023.1266986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/18/2023] [Indexed: 02/21/2024] Open
Abstract
Osteoporosis in childhood distinguishes itself from adulthood in four important ways: 1) challenges in distinguishing otherwise healthy children who have experienced fractures due to non-accidental injury or misfortunate during sports and play from those with an underlying bone fragility condition; 2) a preponderance of monogenic "early onset" osteoporotic conditions that unveil themselves during the pediatric years; 3) the unique potential, in those with residual growth and transient bone health threats, to reclaim bone density, structure, and strength without bone-targeted therapy; and 4) the need to benchmark bone health metrics to constantly evolving "normal targets", given the changes in bone size, shape, and metabolism that take place from birth through late adolescence. On this background, the pediatric osteoporosis field has evolved considerably over the last few decades, giving rise to a deeper understanding of the discrete genes implicated in childhood-onset osteoporosis, the natural history of bone fragility in the chronic illness setting and associated risk factors, effective diagnostic and monitoring pathways in different disease contexts, the importance of timely identification of candidates for osteoporosis treatment, and the benefits of early (during growth) rather than late (post-epiphyseal fusion) treatment. While there has been considerable progress, a number of unmet needs remain, the most urgent of which is to move beyond the monotherapeutic anti-resorptive landscape to the study and application of anabolic agents that are anticipated to not only improve bone mineral density but also increase long bone cross-sectional diameter (periosteal circumference). The purpose of this review is to provide a practical guide to the diagnosis and management of osteoporosis in children presenting to the clinic with fragility fractures, one that serves as a step-by-step "how to" reference for clinicians in their routine clinical journey. The article also provides a sightline to the future, emphasizing the clinical scenarios with the most urgent need for an expanded toolbox of effective osteoporosis agents in childhood.
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Affiliation(s)
- Leanne M. Ward
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
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2
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Ciancia S, Högler W, Sakkers RJB, Appelman-Dijkstra NM, Boot AM, Sas TCJ, Renes JS. Osteoporosis in children and adolescents: how to treat and monitor? Eur J Pediatr 2023; 182:501-511. [PMID: 36472650 DOI: 10.1007/s00431-022-04743-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 11/25/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
UNLABELLED Osteoporosis is a condition of increased bone fragility associated with fractures. Apart from primary genetic osteoporotic conditions, secondary osteoporosis in children is being increasingly recognized. As a result, there is growing interest in its prevention and treatment. Important goals of care are to prevent fractures, increase bone mass and trabecular and cortical thickness, reshape vertebral fractures, prevent (or correct) skeletal deformities, and improve mobility, independence, and quality of life. Secondary pediatric osteoporosis is often of multifactorial origin since affected children frequently have more than one acquired factor that is detrimental to bone health. Typical conditions causing osteoporosis are leukemias, progressive muscle or neurological disorders, as well as chronic inflammatory conditions and their treatment. Management of children with osteoporosis involves a multidisciplinary team involving pediatric experts from different subspecialties. With regard to prevention and early intervention, it is important to provide optimal management of any underlying systemic conditions including avoidance, or dose-reduction, of osteotoxic medications. Basic supporting life-style measures, such as appropriate nutrition, including adequate calcium intake and vitamin D, and physical activity are recommended, where possible. When pediatric treatment criteria for osteoporosis are met, antiresorptive drugs constitute the first pharmacological line treatment. CONCLUSION This clinical review focuses on the prevention, treatment, and follow-up of children with, or at risk of developing, osteoporosis and the transition from pediatric to adult care. WHAT IS KNOWN • Osteoporosis and associated fractures can cause significant morbidity and reduce the quality of life. • The developing skeleton has huge potential for recovery and reshaping, thus early detection of fractures, assessment of recovery potential, and treatment of children with osteoporosis can prevent future fractures, deformities, and scoliosis, improve function and mobility, and reduce pain. WHAT IS NEW • Osteoporosis in children and adolescents requires a multidisciplinary approach with a thorough assessment of recovery potential, and indication for therapy should be personalized. • Although bisphosphonates still represent the drug most commonly used to increase bone mass, improve mobility, and reduce pain and recurrence of fractures, new agents are being developed and could be beneficial in children with specific conditions.
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Affiliation(s)
- Silvia Ciancia
- Department of Pediatrics, Subdivision of Endocrinology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Wolfgang Högler
- Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Ralph J B Sakkers
- Department of Orthopedic Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Natasha M Appelman-Dijkstra
- Department of Internal Medicine, Subdivision of Endocrinology, Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
| | - Annemieke M Boot
- Department of Pediatrics, Subdivision of Endocrinology, University Medical Center Groningen, Beatrix Childrens Hospital, University of Groningen, Groningen, The Netherlands
| | - Theo C J Sas
- Department of Pediatrics, Subdivision of Endocrinology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands.,Center for Pediatric and Adult Diabetes Care and Research, Rotterdam, The Netherlands
| | - Judith S Renes
- Department of Pediatrics, Albert Schweitzer Hospital, Dordrecht, The Netherlands.,Dutch Growth Research Foundation, Rotterdam, The Netherlands
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3
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Zhao H, Ding Y, Yang J, Luo Y, Xu Z, Miao J. Efficacy and safety of bisphosphonates on childhood osteoporosis secondary to chronic illness or its treatment: a meta-analysis. Ther Adv Chronic Dis 2022; 13:20406223221129163. [PMID: 36225670 PMCID: PMC9549182 DOI: 10.1177/20406223221129163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 09/07/2022] [Indexed: 11/05/2022] Open
Abstract
Background: Bisphosphonates are a type of medication that prevents the loss of bone
density. Secondary childhood osteoporosis reduces bone strength and results
in an increased risk of fragility fracture. This meta-analysis aims to
explore the efficacy and safety of bisphosphonates on secondary childhood
osteoporosis. Methods: We performed a systematic search of PubMed, Cochrane library, and Web of
Science databases up to 31 July 2022 to screen for random clinical trials
(RCTs) on bisphosphonate treatment for childhood secondary osteoporosis.
Data from selected studies, mainly changes in lumbar spine (LS) bone mineral
density (BMD), changes in LS BMD Z-scores, fracture events,
and adverse events (AEs), were extracted and analyzed. Results: Nine RCTs (n = 429 in total) were included in our
meta-analysis. The meta-analysis indicated that bisphosphonates improved the
changes in LS BMD [mean difference (MD) = 0.04, 95% confidence intervals
(CIs) = 0.01–0.07, p < 0.01] and LS BMD
Z-scores [MD = 0.52, 95% CI = 0.23–0.81,
p < 0.01]. Use of bisphosphonates did not increase
the risk of AEs [odds ratio (OR) = 1.61, 95% CI = 0.87–2.99,
p = 0.13]. Subgroup analysis showed that routes of
administration, but not causes of secondary osteoporosis, might influence
the efficacy of bisphosphonates. IV bisphosphonates close to significantly
improved the incidence of fracture (OR = 0.34, 95% CI: 0.11–1.08,
p = 0.07). Conclusions: The use of bisphosphonates improves LS BMD without increasing AE rates, which
supports the clinical use of bisphosphonates in secondary childhood
osteoporosis. Further large RCTs are still warranted, especially for their
long-term effects on fracture rates.
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Affiliation(s)
| | | | - Jufei Yang
- Department of Pharmacy, The Children’s
Hospital, Zhejiang University School of Medicine and National Clinical
Research Center for Child Health, Hangzhou, China
| | - Yijun Luo
- Laboratory of Rheumatology & Institute of
TCM Clinical Basic Medicine, College of Basic Medical Science, Zhejiang
Chinese Medical University, Hangzhou, China
| | | | - Jing Miao
- Department of Pharmacy, The Children’s
Hospital, Zhejiang University School of Medicine and National Clinical
Research Center for Child Health, Hangzhou 310052, Zhejiang, China,Department of Pharmacy, The Children’s
Hospital, Zhejiang University School of Medicine and National Clinical
Research Center for Child Health, Hangzhou, China
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Galindo Zavala R, Bou-Torrent R, Mir-Perelló C, Martínez Regueira S, Magallares-López B, López-Corbeto M. Effectiveness and safety of bisphosphonates therapy in secondary osteoporosis in children. An Pediatr (Barc) 2022; 97:190-198. [DOI: 10.1016/j.anpede.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 09/30/2021] [Indexed: 10/16/2022] Open
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Lim A, Simm PJ, James S, Lee SLK, Zacharin M. Outcomes of Zoledronic Acid Use in Paediatric Conditions. Horm Res Paediatr 2021; 93:442-452. [PMID: 33508822 DOI: 10.1159/000512730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 10/29/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Limited evidence is available concerning experience with use of zoledronic acid (ZA) and treatment for conditions other than primary bone fragility. MATERIALS AND METHODS A retrospective review of all Royal Children Hospital patients who had been administered at least 1 dose of intravenous ZA from 2002 to 2015 was undertaken. RESULTS The audit included 309 children with 228 being treated for bone fragility conditions. Of the 228, 68 had height-adjusted lumbar spine bone mineral density Z-scores available over up to a 5-year period, and median increases were +2.0 SD (median absolute deviation = 0.9) (N = 36, p value for median increase of at least 0.5 in Z-score <0.001), for patients with osteogenesis imperfecta or other primary bone fragility disorders, +1.0 SD (0.9) (N = 14, p = 0.029), for immobility conditions, +0.5 SD (0.7) (N = 10, p = 0.399), and for glucocorticoid-induced secondary osteoporosis, +0.7 SD (0.6) (N = 8, p = 0.015). 81/309 children were treated for bone abnormality indications (e.g., avascular necrosis [AVN], fibrous dysplasia, and bone cysts). Of 39 with AVN, outcome data were available for 33, with joint integrity maintained for 24/33 from 6 to 24 months after last ZA, subjective reports (22/28) of reduced pain. Reduction in bone lesion size was seen in 2/4 patients with bone cysts within 12 months of ZA commencement. DISCUSSION/CONCLUSION This is the largest cohort of reported outcomes of ZA use in a paediatric population. Results demonstrate a good efficacy profile and associated improved bone density for osteoporotic conditions and stabilization of non-traumatic AVN with a low rate of joint collapse.
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Affiliation(s)
- Angelina Lim
- Hormone Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Centre for Medicine Use and Safety, Monash University, Melbourne, Victoria, Australia.,Department of Endocrinology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Peter J Simm
- Hormone Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Endocrinology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Simon James
- School of Information Technology, Deakin University, Melbourne, Victoria, Australia
| | - Samantha Lai-Ka Lee
- Hormone Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Endocrinology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Margaret Zacharin
- Hormone Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia, .,Department of Endocrinology, Royal Children's Hospital, Melbourne, Victoria, Australia,
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6
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Hara T, Hijikata Y, Matsubara Y, Watanabe N. Pharmacological interventions versus placebo, no treatment or usual care for osteoporosis in people with chronic kidney disease stages 3-5D. Cochrane Database Syst Rev 2021; 7:CD013424. [PMID: 34231877 PMCID: PMC8262129 DOI: 10.1002/14651858.cd013424.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is an independent risk factor for osteoporosis and is more prevalent among people with CKD than among people who do not have CKD. Although several drugs have been used to effectively treat osteoporosis in the general population, it is unclear whether they are also effective and safe for people with CKD, who have altered systemic mineral and bone metabolism. OBJECTIVES To assess the efficacy and safety of pharmacological interventions for osteoporosis in patients with CKD stages 3-5, and those undergoing dialysis (5D). SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 25 January 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials comparing any anti-osteoporotic drugs with a placebo, no treatment or usual care in patients with osteoporosis and CKD stages 3 to 5D were included. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed their quality using the risk of bias tool, and extracted data. The main outcomes were the incidence of fracture at any sites; mean change in the bone mineral density (BMD; measured using dual-energy radiographic absorptiometry (DXA)) of the femoral neck, total hip, lumbar spine, and distal radius; death from all causes; incidence of adverse events; and quality of life (QoL). Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS Seven studies involving 9164 randomised participants with osteoporosis and CKD stages 3 to 5D met the inclusion criteria; all participants were postmenopausal women. Five studies included patients with CKD stages 3-4, and two studies included patients with CKD stages 5 or 5D. Five pharmacological interventions were identified (abaloparatide, alendronate, denosumab, raloxifene, and teriparatide). All studies were judged to be at an overall high risk of bias. Among patients with CKD stages 3-4, anti-osteoporotic drugs may reduce the risk of vertebral fracture (RR 0.52, 95% CI 0.39 to 0.69; low certainty evidence). Anti-osteoporotic drugs probably makes little or no difference to the risk of clinical fracture (RR 0.91, 95% CI 0.79 to 1.05; moderate certainty evidence) and adverse events (RR 0.99, 95% CI 0.98 to 1.00; moderate certainty evidence). We were unable to incorporate studies into the meta-analyses for BMD at the femoral neck, lumbar spine and total hip as they only reported the percentage change in the BMD in the intervention group. Among patients with severe CKD stages 5 or 5D, it is uncertain whether anti-osteoporotic drug reduces the risk of clinical fracture (RR 0.33, 95% CI 0.01 to 7.87; very low certainty evidence). It is uncertain whether anti-osteoporotic drug improves the BMD at the femoral neck because the certainty of this evidence is very low (MD 0.01, 95% CI 0.00 to 0.02). Anti-osteoporotic drug may slightly improve the BMD at the lumbar spine (MD 0.03, 95% CI 0.03 to 0.04, low certainty evidence). No adverse events were reported in the included studies. It is uncertain whether anti-osteoporotic drug reduces the risk of death (RR 1.00, 95% CI 0.22 to 4.56; very low certainty evidence). AUTHORS' CONCLUSIONS Among patients with CKD stages 3-4, anti-osteoporotic drugs may reduce the risk of vertebral fracture in low certainty evidence. Anti-osteoporotic drugs make little or no difference to the risk of clinical fracture and adverse events in moderate certainty evidence. Among patients with CKD stages 5 and 5D, it is uncertain whether anti-osteoporotic drug reduces the risk of clinical fracture and death because the certainty of this evidence is very low. Anti-osteoporotic drug may slightly improve the BMD at the lumbar spine in low certainty evidence. It is uncertain whether anti-osteoporotic drug improves the BMD at the femoral neck because the certainty of this evidence is very low. Larger studies including men, paediatric patients or individuals with unstable CKD-mineral and bone disorder are required to assess the effect of each anti-osteoporotic drug at each stage of CKD.
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Affiliation(s)
- Takashi Hara
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Yasukazu Hijikata
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Yukiko Matsubara
- Department of Nephrology, Hiroshima University Hospital, Hiroshima, Japan
| | - Norio Watanabe
- Department of Psychiatry, Soseikai General Hospital, Kyoto, Japan
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7
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Hurley T, Zareen Z, Stewart P, McDonnell C, McDonald D, Molloy E. Bisphosphonate use in children with cerebral palsy. Cochrane Database Syst Rev 2021; 7:CD012756. [PMID: 34224134 PMCID: PMC8256778 DOI: 10.1002/14651858.cd012756.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cerebral palsy (CP) is a heterogeneous group of non-progressive disorders of posture or movement, caused by a lesion of the developing brain. Osteoporosis is common in children with cerebral palsy, particularly in children with reduced gross motor function, and leads to an increased risk of fractures. Gross motor function in children with CP can be categorised using a tool called the Gross Motor Function Classification System (GMFCS). Bisphosphonate increases bone mineral density (BMD) and reduces fracture rates. Bisphosphonate is used widely in the treatment of adult osteoporosis. However, the use of bisphosphonate in children with CP remains controversial, due to a paucity of evidence and a lack of recent trials examining the efficacy and safety of bisphosphonate use in this population. OBJECTIVES To examine the efficacy and safety of bisphosphonate therapy in the treatment of low BMD or secondary osteoporosis (or both) in children with cerebral palsy (GMFCS Levels III to V) who are under 18 years of age. SEARCH METHODS In September 2020, we searched CENTRAL, MEDLINE, Embase, six other databases, and two trial registers for relevant studies. We also searched the reference lists of relevant systematic reviews, trials, and case studies identified by the search, and contacted the authors of relevant studies in an attempt to identify unpublished literature. SELECTION CRITERIA All relevant randomised controlled trials (RCTs), and quasi-RCTs, comparing at least one bisphosphonate (given at any dose, orally or intravenously) with placebo or no drug, for the treatment of low BMD or osteoporosis in children up to 18 years old, with cerebral palsy (GMFCS Levels III to V). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We were unable to conduct any meta-analyses due to insufficient data, and therefore provide a narrative assessment of the results. MAIN RESULTS We found two relevant RCTs (34 participants). Both studies included participants with non-ambulatory CP or CP and osteoporosis. Participants in both studies were similar in severity of CP, age distribution, and sex distribution. The two trials used different bisphosphonate medications and different intervention durations, but further comparison of the interventions was not possible due to a lack of published data from one trial. One trial received funding and support from research, academic, and hospital foundations, with pharmaceutical companies providing components of the calcium and vitamin supplement; the other trial did not report sources of funding. We judged one study at an overall high risk of bias; the other as overall unclear risk of bias. PRIMARY OUTCOME Compared to placebo or no treatment, both studies provided very low certainty evidence of improved BMD at least four months post-intervention in children treated with bisphosphonate. Only one study (12 participants) provided sufficient detail to assess a measure of the effect, and reported an improvement at six months post-intervention in lumbar spine z-score (mean difference (MD) 18%, 95% confidence interval (CI) 6.57 to 29.43; very low certainty evidence). SECONDARY OUTCOMES Very low certainty evidence from one study found that bisphosphonate reduced serum N-telopeptides (NTX) more than placebo; the other study reported that both bisphosphonate plus alfacalcidol and alfacalcidol alone reduced NTX, but did not compare groups. One study reported inconclusive results between groups for serum bone-specific alkaline phosphatase (BAP). The other study reported that both bisphosphonate plus alfacalcidol and alfacalcidol alone reduced BAP, but did not compare groups. Neither study reported data for the effect of bisphosphonate treatment on changes in volumetric BMD in the distal radius or tibia, changes in fracture frequency, bone pain, or quality of life. One study reported that two participants had febrile events noted during their first dosing schedule, but no further adverse events were reported in either relevant study. AUTHORS' CONCLUSIONS Based on the available evidence, there is very low certainty evidence that bisphosphonate treatment may improve bone health in children with cerebral palsy. We could only include one study with 14 participants in the assessment of the effect size; therefore, the precision of the effect estimate is low. We could only evaluate one planned primary outcome, as there was insufficient detail reported in the relevant studies. Further research from RCTs on the effect and safety of bisphosphonate to improve bone health in children with cerebral palsy is required. These studies should clarify the optimal standard treatment regarding weight-bearing exercises, vitamin D and calcium supplementation, and should include fracture frequency as a primary outcome.
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Affiliation(s)
- Tim Hurley
- Department of Paediatrics, Trinity College Dublin, Dublin, Ireland
| | - Zunera Zareen
- Department of Paediatrics, Trinity College Dublin, Dublin, Ireland
- Department of Paediatrics, The National Children's Hospital, Dublin, Ireland
| | - Philip Stewart
- Department of Paediatrics, The National Children's Hospital, Dublin, Ireland
| | - Ciara McDonnell
- Department of Paediatric Endocrinology & Diabetes, The National Children's Hospital, Tallaght, Dublin, Ireland
| | - Denise McDonald
- Department of Paediatrics, The National Children's Hospital, Dublin, Ireland
| | - Eleanor Molloy
- Department of Paediatrics, Trinity College Dublin, Dublin, Ireland
- Department of Paediatrics, The National Children's Hospital, Dublin, Ireland
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Yoon JH, Choi Y, Lee Y, Yoo HW, Choi JH. Efficacy and safety of intravenous pamidronate infusion for treating osteoporosis in children and adolescents. Ann Pediatr Endocrinol Metab 2021; 26:105-111. [PMID: 34218632 PMCID: PMC8255864 DOI: 10.6065/apem.2040150.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/09/2020] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Osteoporosis is a skeletal disorder characterized by reduced bone mass that results in increased risk of fractures. Pediatric osteoporosis can be caused by monogenic diseases, chronic diseases, and/or their treatment. This study was performed to investigate the effect of pamidronate infusion on osteoporosis in children and adolescents. METHODS This study included 13 unrelated pediatric patients (10 males and 3 females) whose bone mineral density (BMD) z-score was <-2.0. Pamidronate was administered intravenously at a dosage of 1 mg/kg for 3 consecutive days every 4 months. Clinical and biochemical findings were reviewed retrospectively. The BMD values of the lumbar spine and femoral neck were assessed by dual energy x-ray absorptiometry at baseline and annually. RESULTS The underlying diseases were immobilization (62%), inflammatory bowel disease (23%), protein-losing enteropathy (8%), and idiopathic juvenile osteoporosis (8%). The mean age at the start of treatment was 12.7±4.3 years. Duration of treatment ranged from 12-50 months. The baseline height-standard deviation score (SDS) and weight-SDS were -2.01±2.08 and -2.60±1.62, respectively. The lumbar spine BMD z-scores improved significantly after 1 year of pamidronate treatment, but the femoral neck BMD z-scores did not. However, both z-scores had significantly increased by the end of treatment. CONCLUSION This study demonstrated that pamidronate treatment increased BMD in pediatric patients with osteoporosis with no significant adverse events. Further studies are required to better define the long-term efficacy and safety of pamidronate therapy in a large number of pediatric patients.
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Affiliation(s)
- Ji-Hee Yoon
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Yunha Choi
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Yena Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Han-Wook Yoo
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Ho Choi
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea,Address for correspondence: Jin-Ho Choi Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-Gil, SongpaGu, Seoul 05505, Korea
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9
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Galindo-Zavala R, Bou-Torrent R, Magallares-López B, Mir-Perelló C, Palmou-Fontana N, Sevilla-Pérez B, Medrano-San Ildefonso M, González-Fernández MI, Román-Pascual A, Alcañiz-Rodríguez P, Nieto-Gonzalez JC, López-Corbeto M, Graña-Gil J. Expert panel consensus recommendations for diagnosis and treatment of secondary osteoporosis in children. Pediatr Rheumatol Online J 2020; 18:20. [PMID: 32093703 PMCID: PMC7041118 DOI: 10.1186/s12969-020-0411-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/03/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Osteoporosis incidence in children is increasing due to the increased survival rate of patients suffering from chronic diseases and the increased use of drugs that can damage bones. Recent changes made to the definition of childhood osteoporosis, along with the lack of guidelines or national consensuses regarding its diagnosis and treatment, have resulted in a wide variability in the approaches used to treat this disease. For these reasons, the Osteogenesis Imperfecta and Childhood Osteoporosis Working Group of the Spanish Society of Pediatric Rheumatology has sounded the need for developing guidelines to standardize clinical practice with regard to this pathology. METHODS An expert panel comprised of 6 pediatricians and 5 rheumatologists carried out a qualitative literature review and provided recommendations based on evidence, when that was available, or on their own experience. The level of evidence was determined for each section using the Oxford Centre for Evidence-based Medicine (CEBM) system. A Delphi survey was conducted for those recommendations with an evidence level of IV or V. This survey was sent to all members of the SERPE. All recommendations that had a level of agreement higher or equal to 70% were included. RESULTS Fifty-one recommendations, categorized into eight sections, were obtained. Twenty-four of them presented an evidence level 4 or 5, and therefore a Delphi survey was conducted. This was submitted electronically and received a response rate of 40%. All recommendations submitted to the Delphi round obtained a level of agreement of 70% or higher and were therefore accepted. CONCLUSION In summary, we present herein guidelines for the prevention, diagnosis and treatment of secondary childhood osteoporosis based on the available evidence and expert clinical experience. We believe it can serve as a useful tool that will contribute to the standardization of clinical practice for this pathology. Prophylactic measures, early diagnosis and a proper therapeutic approach are essential to improving bone health, not only in children and adolescents, but also in the adults they will become in the future.
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Affiliation(s)
- Rocío Galindo-Zavala
- UGC Pediatría. Sección Reumatología Pediátrica, Hospital Regional Universitario de Málaga, Málaga, Spain.
| | - Rosa Bou-Torrent
- 0000 0001 0663 8628grid.411160.3Unidad de Reumatología Pediátrica, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Berta Magallares-López
- 0000 0004 1768 8905grid.413396.aServicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Concepción Mir-Perelló
- 0000 0004 1796 5984grid.411164.7Unidad de Pediatría, Sección Reumatología Pediátrica, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Natalia Palmou-Fontana
- 0000 0001 0627 4262grid.411325.0Unidad de Reumatología, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Belén Sevilla-Pérez
- UGC Pediatría, Sección Reumatología Pediátrica, Hospital Campus de la Salud, Granada, Spain
| | | | - Mª. Isabel González-Fernández
- 0000 0001 0360 9602grid.84393.35Unidad de Pediatría, Sección de Reumatología Pediátrica, Hospital La Fe, Valencia, Spain
| | | | - Paula Alcañiz-Rodríguez
- Unidad de Pediatría, Sección de Reumatología Pediátrica, Hospital Virgen de la Arriaxaca, Murcia, Spain
| | - Juan Carlos Nieto-Gonzalez
- 0000 0001 0277 7938grid.410526.4Servicio de Reumatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Mireia López-Corbeto
- 0000 0001 0675 8654grid.411083.fServicio de Reumatología Hospital Vall d’Hebron, Barcelona, Spain
| | - Jenaro Graña-Gil
- 0000 0004 1771 0279grid.411066.4Servicio de Reumatología, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain ,Osteogenesis Imperfecta and Secondary Osteoporosis Working Group from the Spanish Pediatric Rheumatology Society, Madrid, Spain
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10
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Singh P, Gothwal M, Yadav G, Singh K. Complete Androgen Insensitivity Syndrome: Dilemmas for Further Management after Gonadectomy. J Hum Reprod Sci 2020; 12:348-350. [PMID: 32038088 PMCID: PMC6937775 DOI: 10.4103/jhrs.jhrs_151_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 04/15/2019] [Accepted: 09/11/2019] [Indexed: 01/09/2023] Open
Abstract
Complete androgen insensitivity syndrome is a rare condition, wherein a genetic male is phenotypically female and is raised as a female. Treatement requires timely gonadectomy, need for long term hormonal replaceent therapy, psycological and genetic counseling. The type, dose, duration of hrt is not well studied. Reproductive issues also need to be addressed in these young woman. We report here a case of complete androgen insensitivity which posed a quandary for management of long term bone health. Review of literature for management is discussed. These cases are best managed by a multi-disciplenary team comprising of gynecologist, geneticist, endocrinologist and clinical psycologist or psychiatrist.
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Affiliation(s)
- Pratibha Singh
- Department of Obstetrics and Gynecology, AIIMS, Jodhpur, Rajasthan, India
| | - Meenakshi Gothwal
- Department of Obstetrics and Gynecology, AIIMS, Jodhpur, Rajasthan, India
| | - Garima Yadav
- Department of Obstetrics and Gynecology, AIIMS, Jodhpur, Rajasthan, India
| | - Kuldeep Singh
- Department of Paediatrics, AIIMS, Jodhpur, Rajasthan, India
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11
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Iolascon G, Paoletta M, Liguori S, Curci C, Moretti A. Neuromuscular Diseases and Bone. Front Endocrinol (Lausanne) 2019; 10:794. [PMID: 31824418 PMCID: PMC6886381 DOI: 10.3389/fendo.2019.00794] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 10/30/2019] [Indexed: 02/05/2023] Open
Abstract
Neuromuscular diseases (NMDs) are inherited or acquired conditions affecting skeletal muscles, motor nerves, or neuromuscular junctions. Most of them are characterized by a progressive damage of muscle fibers with reduced muscle strength, disability, and poor health-related quality of life of affected patients. In this scenario, skeletal health is usually compromised as a consequence of modified bone-muscle cross-talk including biomechanical and bio-humoral issues, resulting in increased risk of bone fragility and fractures. In addition, NMD patients frequently face nutritional issues, including malnutrition due to feeding disorders and swallowing problems that might affect bone health. Moreover, in these patients, low levels of physical activity or immobility are common and might lead to overweight or obesity that can also interfere with bone strength features. Also, vitamin D deficiency could play a critical role both in the pathogenesis and in the clinical scenario of many NMDs, suggesting that its correction could be useful in maintaining or enhancing bone health, especially in the early phases of NMDs. Last but not least, specific disease-modifying drugs, available for some NMDs, are frequently burdened with adverse effects on bone tissue. For example, glucocorticoid therapy, standard of care for many muscular dystrophies, prolongs long-term survival in treated patients; nevertheless, high dose and/or chronic use of these drugs are a common cause of secondary osteoporosis. This review addresses the current state of knowledge about the factors that play a role in determining bone alterations reported in NMDs, how these factors can modify the biological pathways underlying bone health, and which are the available interventions to manage bone involvement in patients affected by NMDs. Considering the complexity of care of these patients, an interdisciplinary and multimodal management strategy based on both pharmacological and non-pharmacological interventions is recommended, particularly targeting musculoskeletal issues that are closely related to functional independence as well as social implications.
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Affiliation(s)
- Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
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12
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Logan L, Haider S, Brauer C, Miettunen PM. Severe bilateral Legg-Calvé-Perthes resolved with pamidronate in combination with casts, physiotherapy and adductor tenotomy: a pictorial essay over 11 years. BMJ Case Rep 2019; 12:12/9/e229919. [PMID: 31537587 PMCID: PMC6754667 DOI: 10.1136/bcr-2019-229919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We describe an 11-year prospective clinical and radiologic course of a 6-year-old boy with bilateral Legg-Calvé-Perthes disease, who was treated with intravenous pamidronate (IV-PAM). His baseline radiographs showed grade IV avascular necrosis/Catterall stage IV, and at worst he progressed to lateral pillar/Herring stage C bilaterally. His disease initially was extremely functionally limiting with expected poor outcome with eventual joint replacement. Because IV-PAM stops bone breakdown and allows for ongoing bone formation while revascularisation of bone occurs, we hypothesised that IV-PAM could act as an adjunct to traditional treatment to help heal the femoral heads. Our patient received nine once monthly doses of IV-PAM (1 mg/kg/dose) over 13 months, along with Petrie/broomstick casts and physiotherapy. Remarkably, over time, his femoral heads healed. Now, at 11-year follow-up, he has excellent functional and radiologic outcome with congruence between femoral head and acetabulum, no residual osteonecrosis and minimal loss of femoral head sphericity.
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Affiliation(s)
- Lindsey Logan
- Pediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Seemab Haider
- Diagnostic Radiology, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Carmen Brauer
- Surgery, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Paivi Maria Miettunen
- Pediatric Rheumatology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Pediatrics, Alberta Children's Hospital, Calgary, Alberta, Canada
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13
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Hara T, Hijikata Y, Matsubara Y, Watanabe N. Pharmacological interventions for osteoporosis in people with chronic kidney disease stages 3‐5D. Cochrane Database Syst Rev 2019; 2019:CD013424. [PMCID: PMC6734171 DOI: 10.1002/14651858.cd013424] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: This review aims to assess the effects of pharmacological interventions for osteoporosis in patients with CKD stages 3‐5D.
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Affiliation(s)
- Takashi Hara
- Kyoto University Graduate School of Medicine/School of Public HealthDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoJapan606‐8501
| | - Yasukazu Hijikata
- Kyoto University Graduate School of Medicine/School of Public HealthDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoJapan606‐8501
| | - Yukiko Matsubara
- Keiai HospitalDepartment of Nephrology3‐10‐23 Mukaihara, Itabashi‐kuTokyoJapan173‐0036
| | - Norio Watanabe
- Kyoto University Graduate School of Medicine/School of Public HealthDepartment of Health Promotion and Human BehaviorYoshida Konoe‐cho, Sakyo‐kuKyotoJapan606‐8501
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14
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Rooney M, Bishop N, Davidson J, Beresford MW, Pilkington C, McDonagh J, Wyatt S, Gardner-Medwin J, Satyapal R, Clinch J, Foster H, Elliott M, Verghis R. The prevention and treatment of glucocorticoid-induced osteopaenia in juvenile rheumatic disease: A randomised double-blind controlled trial. EClinicalMedicine 2019; 12:79-87. [PMID: 31388666 PMCID: PMC6677647 DOI: 10.1016/j.eclinm.2019.06.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Children and young people (CYP) with chronic rheumatic conditions; Juvenile Idiopathic Arthritis, Juvenile Systemic Lupus Erythematosus, Juvenile Dermatomyositis and Juvenile Vasculitis, treated with steroids, have low bone density, increased fracture risk and are likely to have suboptimal peak bone mass. There is currently no evidence base for the management of steroid-induced bone loss in children with rheumatic diseases. METHODS We undertook a multi-centre double dummy double-blind randomised placebo controlled trial to investigate whether the bisphosphonate risedronate was superior to alfacalcidol or calcium and vitamin D supplementation in the prevention and treatment of steroid-induced osteopaenia in these children. Patients were stratified and randomised in a 1:1 ratio, into: placebo; alfacalcidol; risedronate. The primary outcome was the change in lumbar spine bone mineral density z score (LSaBMDz) measured by dual energy x-ray absorptiometry at one year. Secondary outcome was fracture rate. RESULTS Two hundred and seventeen patients were recruited to the study. Seventy seven placebo, 71 alfacalcidol, and 69 risedronate. Highly statistically significant differences were observed in the change in LSaBMDz between the placebo and risedronate groups; 0.274, 95% CI (0.061, 0.487) (p < 0.001) and between the risedronate and the alfacalcidol groups; 0.326 95% CI (0.109, 0.543) (p < 0.001). The difference observed between the alfacalcidol and placebo group was not statistically significant.Highly statistically significant differences were seen in the change in Total Body Less Head aBMD-Z Score between the placebo and risedronate groups (p < 0.01) but not between the alfacalcidol and risedronate groups. No significant differences in fracture frequency, adverse or serious adverse reactions were observed between the groups. CONCLUSIONS Children and adolescents receiving steroids for rheumatic diseases benefit from prophylactic treatment with bisphosphonates to increase LSaBMD. Alfacalcidol is ineffective.
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Affiliation(s)
- Madeleine Rooney
- Queens University of Belfast and Musgrave Park Hospital Belfast Hospital Trust, United Kingdom of Great Britain and Northern Ireland
- Corresponding author at: The Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, United Kingdom of Great Britain and Northern Ireland.
| | - Nick Bishop
- University of Sheffield and Sheffield Children's NHS Foundation Trust, United Kingdom of Great Britain and Northern Ireland
| | - Joyce Davidson
- Royal Edinburgh Hospital for Sick Children, United Kingdom of Great Britain and Northern Ireland
| | - Michael W. Beresford
- Clinical Academic Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Clarissa Pilkington
- Great Ormond Street Hospital London, United Kingdom of Great Britain and Northern Ireland
| | - Janet McDonagh
- Birmingham Children's Hospital NHS, University of Manchester, United Kingdom of Great Britain and Northern Ireland
| | - Sue Wyatt
- Leeds General Infirmary, United Kingdom of Great Britain and Northern Ireland
| | - Janet Gardner-Medwin
- University of Glasgow and Royal Hospital for Children, Glasgow, United Kingdom of Great Britain and Northern Ireland
| | - Rangaraj Satyapal
- Nottingham University Hospital, United Kingdom of Great Britain and Northern Ireland
| | - Jacqui Clinch
- Royal Bristol Hospital for Sick Children, United Kingdom of Great Britain and Northern Ireland
| | - Helen Foster
- Newcastle University and Great North Children's Hospital, Newcastle, United Kingdom of Great Britain and Northern Ireland
| | - Mark Elliott
- Belfast Hospital Trust, United Kingdom of Great Britain and Northern Ireland
| | - Rejina Verghis
- NI Clinical Trials Unit, United Kingdom of Great Britain and Northern Ireland
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15
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Wiedemann A, Renard E, Hernandez M, Dousset B, Brezin F, Lambert L, Weryha G, Feillet F. Annual Injection of Zoledronic Acid Improves Bone Status in Children with Cerebral Palsy and Rett Syndrome. Calcif Tissue Int 2019; 104:355-363. [PMID: 30554334 DOI: 10.1007/s00223-018-0505-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 12/07/2018] [Indexed: 12/27/2022]
Abstract
Osteoporosis is a common complication of cerebral palsy and Rett's syndrome. It is responsible for multiple fractures, bone pain, and impaired quality of life. In case of Rett's syndrome, a specific dysfunction of osteoblasts causes bone fragility. We observed the effects of annual zoledronic acid (ZA) infusion in a cohort of children with cerebral palsy and Rett's syndrome. 27 children under 18 years (19 with cerebral palsy and 8 girls with Rett syndrome confirmed by MCEP2 mutation) were treated with an annual injection of 0.1 mg/kg (max 4 mg) of ZA. Calcium and vitamin D were combined in all patients from the first injection of ZA. Dental examination was performed before treatment. Data were analyzed retrospectively. Bone mineral density was measured at diagnosis and yearly thereafter. Bone mass density (BMD) is decreased in patient with cerebral palsy and RS. One year after injection of ZA, we observe an increase of Lumbar spine BMD from - 2.99 to - 2.14 SD (p < 0.0001) and femoral BMD from - 4.26 to - 3.32 SD (p < 0.001) In the subgroup of patient with Rett syndrome, we also observe an increase from - 3.27 to 2.50 SD (p = 0.018) of Lumbar spine BMD. No fractures have been observed in our cohort since the first infusion. Side effects (flu-like syndrome and hypocalcemia) were more common in younger patients and after the first infusion. No serious complications were noticed. This study confirms the efficacy and the safety of an annual injection of ZA to improve bone status in children with cerebral palsy and Rett syndrome. No severe adverse effects were observed.
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Affiliation(s)
- Arnaud Wiedemann
- Centre de référence des erreurs innées du métabolisme, Hôpital d'Enfants, CHRU Nancy, Nancy, France.
- Réanimation pédiatrique spécialisée, Hôpital d'enfants, CHRU Nancy, Nancy, France.
- Faculté de médecine, INSERM U-1256, Vandoeuvre les Nancy, France.
| | - Emeline Renard
- Service de Médecine Infantile, Hôpital d'enfants, CHRU Nancy, Nancy, France
- Faculté de médecine, INSERM U-1256, Vandoeuvre les Nancy, France
| | | | | | - François Brezin
- Service de Médecine Infantile, Hôpital d'enfants, CHRU Nancy, Nancy, France
| | | | | | - François Feillet
- Centre de référence des erreurs innées du métabolisme, Hôpital d'Enfants, CHRU Nancy, Nancy, France
- Service de Médecine Infantile, Hôpital d'enfants, CHRU Nancy, Nancy, France
- Faculté de médecine, INSERM U-1256, Vandoeuvre les Nancy, France
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16
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Zamboni C, Carvalho MS, Pires EA, Durigan JR, Fucs PMDMB, Mercadante MT. ARE TRAUMATOLOGISTS TREATING OSTEOPOROSIS TO PREVENT NEW FRACTURES IN BRAZIL? ACTA ORTOPEDICA BRASILEIRA 2019; 26:384-387. [PMID: 30774511 PMCID: PMC6362685 DOI: 10.1590/1413-785220182606202125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objectives: To determine the proportion of traumatologists who investigate osteoporosis in elderly patients with fractures and recommend secondary prevention of osteoporotic fractures. Methods: We distributed questionnaires to 244 physicians attending the 2015 Brazilian Congress of Orthopedic Trauma. We determined the respondents’ profiles and assessed how they investigated and treated osteoporosis in elderly patients with fractures. Results: Overall, 32% of the respondents reported that their knowledge level regarding osteoporosis ranged from 0-5 (out of 0-10). In total, 42% of the participants reported that they usually requested DXA for elderly patients with fractures and less than 30% reported prescribing supplemental calcium and/or vitamin D. We considered physicians conducting a complete treatment for the patient as those who in addition to requesting DXA prescribed supplemental calcium, vitamin D, and specific medications for their elderly patients, and recommended non-pharmacological measures. Only 0.8% of the participants fulfilled all these criteria. In addition, 47% of the traumatologists reported that they did not treat osteoporosis directly but instead, referred osteoporotic patients to a qualified physician. Conclusion: Less than 50% of the surveyed traumatologists investigated and performed secondary prevention against osteoporotic fractures after treating an elderly patient with a fracture. Level of evidence III, Economic and Decision Analyses - Developing an Economic or Decisions Model.
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Affiliation(s)
- Caio Zamboni
- Department of Orthopedics and Traumatology, Santa Casa de Sao Paulo, SP, Brazil
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17
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Buxbaum NP, Robinson C, Sinaii N, Ling A, Curtis LM, Pavletic SZ, Baird K, Lodish MB. Impaired Bone Mineral Density in Pediatric Patients with Chronic Graft-versus-Host Disease. Biol Blood Marrow Transplant 2018; 24:1415-1423. [PMID: 29496562 PMCID: PMC6045967 DOI: 10.1016/j.bbmt.2018.02.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 02/15/2018] [Indexed: 11/18/2022]
Abstract
Pediatric allogeneic hematopoietic stem cell transplantation (AHSCT) recipients with chronic graft-versus-host disease (cGVHD) are at high risk for endocrinopathies, particularly impaired bone mineral density (BMD). However, rates of BMD impairment in pediatric AHSCT recipients with cGVHD have not been well documented. We report 33 patients with cGVHD who were referred to the National Institutes of Health (NIH) for the Natural History of Clinical and Biological Factors Determining Outcomes in Chronic Graft-versus-Host Disease Study (NCT 0092235) and underwent formal BMD assessment via dual-energy X-ray absorptiometry (DEXA). Not surprisingly, we found much higher rates of BMD impairment than previously reported for pediatric AHSCT recipients who were not stratified by the presence or absence of cGVHD. Most of these patients (73%) had a z-score ≤-2 in at least 1 anatomic site. Although we expected the rate to be higher than that observed for pediatric AHSCT recipients in studies that did not analyze patients with cGVHD separately, this rate is nonetheless extremely high. Furthermore, the overall rate of occult vertebral compression fractures (VCFs) in our cohort was 17%, and the rate was 23% in patients with at least 1 z-score of ≤-2. The rates of BMD impairment and VCF in our pediatric cohort were significantly higher than those seen in the adult AHSCT recipients who were concurrently enrolled on the same study at the NIH and had similar cGVHD severity. We found that older age at cGVHD diagnosis and a greater number of systemic therapies were associated with occult VCF. Moreover, the intensity of current immunosuppression negatively impacted lumbar spine and total hip BMD in this cohort. Our study, although limited by small patient numbers and lack of a control AHSCT recipient group without cGVHD, indicates that children with cGVHD are at a greater risk for BMD impairment than previously appreciated. Given the rising incidence of cGVHD in AHSCT recipients and our findings, we recommend that pre-AHSCT DEXA be incorporated into routine pediatric pretransplantation screening studies. A baseline DEXA study could facilitate longitudinal monitoring of BMD in children, who may be more susceptible than adults to the negative effects of AHSCT on BMD. In addition, given the high risk of BMD impairment in pediatric AHSCT recipients with cGVHD, such patients should undergo BMD evaluation upon developing cGVHD, with continued monitoring thereafter to allow intervention before progression of the BMD impairment to its severe manifestation, VCF.
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Affiliation(s)
- Nataliya P Buxbaum
- Experimental Transplantation and Immunology Branch, National Cancer Institute Center for Cancer Research, National Institutes of Health, Bethesda, Maryland.
| | - Cemre Robinson
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland; Skeletal Clinical Studies Unit, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
| | - Ninet Sinaii
- Biostatistics and Clinical Epidemiology Service, Warren Magnuson Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Alexander Ling
- Diagnostic Radiology Department, Warren Magnuson Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Lauren M Curtis
- Experimental Transplantation and Immunology Branch, National Cancer Institute Center for Cancer Research, National Institutes of Health, Bethesda, Maryland
| | - Steven Z Pavletic
- Experimental Transplantation and Immunology Branch, National Cancer Institute Center for Cancer Research, National Institutes of Health, Bethesda, Maryland
| | - Kristin Baird
- Pediatric Oncology Branch, National Cancer Institute, Center for Cancer Research, National Institutes of Health, Bethesda, Maryland; Division of Clinical Evaluation, Pharmacology and Toxicology, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Maya B Lodish
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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18
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Wood CL, Ahmed SF. Bone protective agents in children. Arch Dis Child 2018; 103:503-508. [PMID: 29066521 DOI: 10.1136/archdischild-2016-311820] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 09/25/2017] [Accepted: 09/28/2017] [Indexed: 12/24/2022]
Abstract
Evaluation of bone health in childhood is important to identify children who have inadequate bone mineralisation and who may benefit from interventions to decrease their risk of osteoporosis and subsequent fracture. There are no bone protective agents that are licensed specifically for the prevention and treatment of osteoporosis in children. In this review, we discuss the mechanism of action and use of bisphosphonates and other new and established bone protective agents in children.
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Affiliation(s)
- Claire Louise Wood
- Division of Developmental Biology, University of Edinburgh Roslin Institute, Roslin, Midlothian, UK.,John Walton Muscular Dystrophy Research Centre, Institute of Genetic Medicine, Newcastle upon Tyne, UK
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Glasgow, UK
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19
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Lambert AS, Rothenbuhler A, Charles P, Brailly-Tabard S, Trabado S, Célestin E, Durand E, Fontaine I, Miladi L, Wicart P, Bahi-Buisson N, Linglart A. Lower incidence of fracture after IV bisphosphonates in girls with Rett syndrome and severe bone fragility. PLoS One 2017; 12:e0186941. [PMID: 29073271 PMCID: PMC5658100 DOI: 10.1371/journal.pone.0186941] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 10/10/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Classic Rett Syndrome (RS) is a disabling condition mainly caused by MECP2 mutations. Girls with RS are at risk of developing bone fragility and fractures at a young age which results in pain and may seriously impair quality of life. OBJECTIVE To retrospectively assess the safety and efficacy of IV bisphosphonates on fracture, bone mineral density (BMD) and bone markers in RS girls with bone fragility. METHODS RS girls received either IV pamidronate (n = 19) or IV zoledronate (n = 1) for 2 years. RESULTS Of 20 patients studied (age: 12.5 years [6; 39]), 14 were non-ambulatory. The incidence of fracture decreased from 37 fractures in 20 patients, to 1 fracture during or after treatment (follow-up: 3.1 years [1.5; 5]). The spine BMD Z-score improved from -3.2 [-5.6; -0.1] to -2.2 [-3.8; 0.0], p = 0.0006. Most parents reported decreases in chronic pain and 2 patients started to walk. Urinary calcium excretion decreased from 0.7 [0.18; 1.5] to 0.2 [0.03; 0.67] mM/mM of creatinine (p = 0.0001). Pamidronate was well tolerated. CONCLUSION RS girls should be screened for impaired bone mineralization and preventive measures should be taken. In girls experiencing fractures, IV bisphosphonates constitute a beneficial adjuvant treatment to diminish the risk of fracture and restore bone density.
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Affiliation(s)
- Anne-Sophie Lambert
- APHP, Department of pediatric endocrinology and diabetology for children, Bicêtre Paris-Sud, Le Kremlin Bicêtre, France
- APHP, Reference center for rare disorders of calcium and phosphate metabolism, filière OSCAR and Plateforme d’Expertise Maladies Rares Paris-Sud, Bicêtre Paris-Sud, Le Kremlin Bicêtre, France
- * E-mail:
| | - Anya Rothenbuhler
- APHP, Department of pediatric endocrinology and diabetology for children, Bicêtre Paris-Sud, Le Kremlin Bicêtre, France
- APHP, Reference center for rare disorders of calcium and phosphate metabolism, filière OSCAR and Plateforme d’Expertise Maladies Rares Paris-Sud, Bicêtre Paris-Sud, Le Kremlin Bicêtre, France
| | - Perrine Charles
- APHP, Department of Genetics, Reference Centre for Intellectual Disabilities, Pitié-Salpêtrière, Paris, France
| | - Sylvie Brailly-Tabard
- APHP, Department of Genetics and Hormonology, Bicêtre Paris-Sud, Le Kremlin Bicêtre, France
| | - Séverine Trabado
- APHP, Department of Genetics and Hormonology, Bicêtre Paris-Sud, Le Kremlin Bicêtre, France
| | | | - Emmanuel Durand
- APHP, IR4M Unit, CNRS-Université Paris-Saclay, Orsay, France
| | | | - Lotfi Miladi
- APHP, Department of Pediatric Orthopedics, Necker-Enfants Malades, School of Medicine, University Paris Descartes Sorbonne Paris Cité, Paris, France
- APHP, Reference center for rare disorders of calcium and phosphate metabolism, filière OSCAR, Necker-Enfants Malades, Paris, France
| | - Philippe Wicart
- APHP, Department of Pediatric Orthopedics, Necker-Enfants Malades, School of Medicine, University Paris Descartes Sorbonne Paris Cité, Paris, France
- APHP, Reference center for rare disorders of calcium and phosphate metabolism, filière OSCAR, Necker-Enfants Malades, Paris, France
| | - Nadia Bahi-Buisson
- APHP, Rett Center, Necker-Enfants Malades, Paris, France
- APHP, Department of Pediatric Neurology, Necker-Enfants Malades, Paris, France
- INSERM UMR-1163, Laboratory of Embryology and Genetics of Congenital Malformations, Imagine Institute, Paris Descartes–Sorbonne Paris Cité University, Paris, France
| | - Agnès Linglart
- APHP, Department of pediatric endocrinology and diabetology for children, Bicêtre Paris-Sud, Le Kremlin Bicêtre, France
- APHP, Reference center for rare disorders of calcium and phosphate metabolism, filière OSCAR and Plateforme d’Expertise Maladies Rares Paris-Sud, Bicêtre Paris-Sud, Le Kremlin Bicêtre, France
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20
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Zareen Z, McDonnell C, Mc Donald D, Molloy E. Bisphosphonate use in children with cerebral palsy. Cochrane Database Syst Rev 2017; 2017:CD012756. [PMCID: PMC6483615 DOI: 10.1002/14651858.cd012756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To examine the efficacy and safety of bisphosphonate therapy in the treatment of low BMD or secondary osteoporosis (or both) in children with cerebral palsy (GMFCS Levels III to V) who are under 18 years of age.
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Affiliation(s)
| | - Ciara McDonnell
- The National Children’s Hospital, TallaghtDepartment of Paediatric Endocrinology & DiabetesDublinIreland24
| | - Denise Mc Donald
- The National Children’s Hospital, TallaghtDepartment of PaediatricsDublinIreland24
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21
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Bartlow CM, Oest ME, Mann KA, Zimmerman ND, Butt BB, Damron TA. PTH(1-34) and zoledronic acid have differing longitudinal effects on juvenile mouse femur strength and morphology. J Orthop Res 2017; 35:1707-1715. [PMID: 27653318 PMCID: PMC5489362 DOI: 10.1002/jor.23442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 09/15/2016] [Indexed: 02/04/2023]
Abstract
Treatment of secondary pediatric osteoporosis-particularly that due to chronic diseases, immobilization, and necessary medical treatments-is currently limited by a poor understanding of the long-term efficacy and safety of skeletal metabolism modifying drugs. This study aimed to characterize longitudinal effects of representative anabolic (parathyroid hormone, PTH) and anti-catabolic (zoledronic acid, ZA) drugs on skeletal morphology, mechanical strength, and growth in juvenile mice. BALB/cJ mice aged 4 weeks were given PTH(1-34) or vehicle (control) daily for 8 weeks, or 4 weekly doses of ZA, and evaluated at time points 0-26 weeks after treatment initiation. There were no enduring differences in body length or mass between treatment groups. ZA increased femur size as early as week 0, including increased distal femur bone volume and diaphyseal cross-sectional area, persisting through week 26. PTH treatment only transiently increased bone size, including distal femur volume at weeks 4-12. ZA decreased diaphyseal cortical tissue mineral density (TMD) at 12-26 weeks versus controls; PTH decreased TMD only at 2 weeks (vs. controls). ZA increased bending strength at 0-12 weeks and flexural strength at week 4 (vs. controls), but decreased flexural strength and modulus at week 26. PTH treatment increased bending strength only at 4 weeks, and did not affect flexural strength. Overall, ZA rapidly and persistently increased femur strength and size, but compromised bone material quality long-term. In healthy juvenile mice, limited-duration PTH treatment did not exert a strong anabolic effect, and had no adverse effects on femur strength, morphology, or growth. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1707-1715, 2017.
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Affiliation(s)
- Christopher M Bartlow
- Department of Orthopedic Surgery, Upstate Medical University, 750 East Adams Street, Syracuse, New York
| | - Megan E Oest
- Department of Orthopedic Surgery, Upstate Medical University, 750 East Adams Street, Syracuse, New York
| | - Kenneth A Mann
- Department of Orthopedic Surgery, Upstate Medical University, 750 East Adams Street, Syracuse, New York
| | - Nicholas D Zimmerman
- Department of Orthopedic Surgery, Upstate Medical University, 750 East Adams Street, Syracuse, New York
| | - Bilal B Butt
- Department of Orthopedic Surgery, Upstate Medical University, 750 East Adams Street, Syracuse, New York
| | - Timothy A Damron
- Department of Orthopedic Surgery, Upstate Medical University, 750 East Adams Street, Syracuse, New York
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Abstract
PURPOSE OF REVIEW Osteoporosis is an under-recognized complication of chronic illness in childhood. This review will summarize recent literature addressing the risk factors, evaluation, and treatment for early bone fragility. RECENT FINDINGS Criteria for the diagnosis of pediatric osteoporosis include the presence of low trauma vertebral fractures alone or the combination of low bone mineral density and several long bone fractures. Monitoring for bone health may include screening for vertebral fractures that are common but often asymptomatic. Pharmacologic agents should be offered to those with fragility fractures especially when spontaneous recovery is unlikely. Controversies persist about the optimal bisphosphonate agent, dose, and duration. Newer osteoporosis drugs have not yet been adequately tested in pediatrics, though clinical trials are underway. The prevalence of osteoporosis is increased in children with chronic illness. To reduce the frequency of fragility fractures requires increased attention to risk factors, early intervention, and additional research to optimize therapy and potentially prevent their occurrence.
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Affiliation(s)
- Monica Grover
- Department of Pediatrics, Division of Endocrinology, School of Medicine, Stanford University, Room H314, Stanford, CA, 94305, USA
| | - Laura K Bachrach
- Department of Pediatrics, Division of Endocrinology, School of Medicine, Stanford University, Room H314, Stanford, CA, 94305, USA.
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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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Cheng N, Park J, Olson J, Kwon T, Lee D, Lim R, Ha S, Kim R, Zhang X, Ting K, Tetradis S, Hong C. Effects of Bisphosphonate Administration on Cleft Bone Graft in a Rat Model. Cleft Palate Craniofac J 2017; 54:687-698. [PMID: 28094562 DOI: 10.1597/15-356] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE Bone grafts in patients with cleft lip and palate can undergo a significant amount of resorption. The aim of this study was to investigate the effects of bisphosphonates (BPs) on the success of bone grafts in rats. DESIGN Thirty-five female 15-week-old Fischer F344 Inbred rats were divided into the following experimental groups, each receiving bone grafts to repair an intraoral CSD: (1) Graft/saline: systemic administration of saline and (2) systemic administration of zoledronic acid immediately following surgery (graft/BP/T0), (3) 1 week postoperatively (graft/BP/T1), and (4) 3 weeks postoperatively (graft/BP/T2). As an additional control, the defect was left empty without bone graft. MAIN OUTCOME MEASURES Microcomputed tomography and histologic analyses were performed in addition to evaluation of osteoclasts through tartrate-resistant acid phosphatase staining. RESULTS Bone volume fraction (bone volume/tissue volume) for the delayed BP treatment groups (graft/BP/T1 = 45.4% ± 8.8%; graft/BP/T2 = 46.1% ± 12.4%) were significantly greater than that for the graft/saline group (31.0% ± 7.9%) and the graft/BP/T0 (27.6% ± 5.9%) 6 weeks postoperatively (P < .05). Hematoxylin and eosin staining confirmed an evident increase in bone volume and fusion of defect margins with existing palatal bone in the graft/BP/T1 and graft/BP/T2 groups. The graft/BP/T0 group showed the lowest bone volume with signs of acute inflammation. CONCLUSIONS Delayed BP administration following cleft bone graft surgery led to significant increase in bone volume and integration compared with saline controls. However, BP injection immediately after the surgery did not enhance bone volume, and rather, may negatively affect bone graft incorporation.
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Abstract
This article reviews the manifestations and risk factors associated with osteoporosis in childhood, the definition of osteoporosis and recommendations for monitoring and prevention. As well, this article discusses when a child should be considered a candidate for osteoporosis therapy, which agents should be prescribed, duration of therapy and side effects. There has been significant progress in our understanding of risk factors and the natural history of osteoporosis in children over the past number of years. This knowledge has fostered the development of logical approaches to the diagnosis, monitoring, and optimal timing of osteoporosis intervention in this setting. Current management strategies are predicated upon monitoring at-risk children to identify and then treat earlier rather than later signs of osteoporosis in those with limited potential for spontaneous recovery. On the other hand, trials addressing the prevention of the first-ever fracture are still needed for children who have both a high likelihood of developing fractures and less potential for recovery. This review focuses on the evidence that shapes the current approach to diagnosis, monitoring, and treatment of osteoporosis in childhood, with emphasis on the key pediatric-specific biological principles that are pivotal to the overall approach and on the main questions with which clinicians struggle on a daily basis. The scope of this article is to review the manifestations of and risk factors for primary and secondary osteoporosis in children, to discuss the definition of pediatric osteoporosis, and to summarize recommendations for monitoring and prevention of bone fragility. As well, this article reviews when a child is a candidate for osteoporosis therapy, which agents and doses should be prescribed, the duration of therapy, how the response to therapy is adjudicated, and the short- and long-term side effects. With this information, the bone health clinician will be poised to diagnose osteoporosis in children and to identify when children need osteoporosis therapy and the clinical outcomes that gauge efficacy and safety of treatment.
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Affiliation(s)
- L M Ward
- Pediatric Bone Health Clinical and Research Programs, Children's Hospital of Eastern Ontario, Ottawa, ON, K1H 8L1, Canada.
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada.
| | - V N Konji
- Pediatric Bone Health Clinical and Research Programs, Children's Hospital of Eastern Ontario, Ottawa, ON, K1H 8L1, Canada
| | - J Ma
- Pediatric Bone Health Clinical and Research Programs, Children's Hospital of Eastern Ontario, Ottawa, ON, K1H 8L1, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
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26
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Barral E, Freire Gómez X, Enríquez Merayo E, Casado Picón R, Bello Gutierrez P, de Inocencio Arocena J. Non-bacterial chronic osteomyelitis: experience in a tertiary hospital. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.anpede.2015.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Lim SW, Ahn JH, Choi A, Cho WH, Lee JA, Kim DH, Seo JH, Lim JS. Efficacy of pamidronate in pediatric osteosarcoma patients with low bone mineral density. Ann Pediatr Endocrinol Metab 2016; 21:21-5. [PMID: 27104175 PMCID: PMC4835557 DOI: 10.6065/apem.2016.21.1.21] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 12/15/2015] [Accepted: 01/05/2016] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Most surviving pediatric osteosarcoma patients experience osteoporosis, bone pain, and pathologic fracture during and after therapy. The aim of this study was to evaluate the efficacy and side effects of pamidronate therapy in these patients. METHODS Nine osteosarcoma patients (12.8±1.6 years of age; 5 boys and 4 girls) who had a history of nontraumatic fracture or severe pain after completing chemotherapy were included. Intravenous pamidronate (1.5 mg/kg) was given every 6 weeks for 4 to 6 cycles. Bone mineral density (BMD) of the lumbar spine was measured by dual-energy x-ray absorptiometry. Clinical outcomes including acute side effects were also evaluated. RESULTS After pamidronate treatments, all patients experienced decreased pain. Seven of 9 patients could walk without a crutch. The BMD of lumbar spine was increased by 0.108±0.062 mg/cm(2) after 8.4±1.0 months (n=8, P=0.017) and the mean z-score improved from -2.14±0.94 to -1.76±0.95 (P=0.161). Six patients (67%) had an acute-phase reaction, and 2 patients had symptomatic hypocalcemia. CONCLUSION Pamidronate appears to be safe and effective for the treatment of osteosarcoma in children with low BMD and bone pain.
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Affiliation(s)
- Se Won Lim
- Department of Pediatrics, Korea Cancer Center Hospital, Seoul, Korea
| | - Ju Hyun Ahn
- Department of Pediatrics, Korea Cancer Center Hospital, Seoul, Korea
| | - Aery Choi
- Department of Pediatrics, Korea Cancer Center Hospital, Seoul, Korea
| | - Wan Hyeong Cho
- Department of Orthopedic Surgery, Korea Cancer Center Hospital, Seoul, Korea
| | - Jun Ah Lee
- Department of Pediatrics, Korea Cancer Center Hospital, Seoul, Korea
| | - Dong Ho Kim
- Department of Pediatrics, Korea Cancer Center Hospital, Seoul, Korea
| | - Ju-Hee Seo
- Department of Pediatrics, Korea Cancer Center Hospital, Seoul, Korea
| | - Jung Sub Lim
- Department of Pediatrics, Korea Cancer Center Hospital, Seoul, Korea
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28
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Baroncelli GI, Bertelloni S. The use of bisphosphonates in pediatrics. Horm Res Paediatr 2015; 82:290-302. [PMID: 25376487 DOI: 10.1159/000365889] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 07/09/2014] [Indexed: 11/19/2022] Open
Abstract
Bisphosphonates are widely used for the prevention and treatment of osteoporosis in adulthood. In the last years, bisphosphonates have been increasingly used in pediatric patients for the treatment of a growing number of disorders associated with osteoporosis, resistant hypercalcemia or heterotopic calcifications. The use of bisphosphonates in pediatric patients has been proven safe; however, the risk of potential severe consequences into adulthood should be kept in mind. Well-defined criteria for bisphosphonates treatment in pediatric patients are not specified, therefore an accurate selection of patients who could benefit from bisphosphonates is mandatory. A strict follow-up of pediatric patients receiving long-term bisphosphonate therapy is strongly recommended. The purpose of this mini review is to provide a summary of current knowledge on some main general aspects of the structure, mechanisms of action, pharmacokinetics, and bioavailability of bisphosphonates, and to focus on the latest advances of bisphosphonate treatment in pediatric patients. Particular attention has been paid to the common and potential adverse effects of bisphosphonate treatment, and some suggestions concerning the clinical approach and general measures for bisphosphonate treatment in pediatric patients are reported.
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Affiliation(s)
- Giampiero I Baroncelli
- Pediatric Unit I, Department of Obstetrics, Gynecology and Pediatrics, University Hospital, Pisa, Italy
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29
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Petryk A, Kanakatti Shankar R, Giri N, Hollenberg AN, Rutter MM, Nathan B, Lodish M, Alter BP, Stratakis CA, Rose SR. Endocrine disorders in Fanconi anemia: recommendations for screening and treatment. J Clin Endocrinol Metab 2015; 100:803-11. [PMID: 25575015 PMCID: PMC4333044 DOI: 10.1210/jc.2014-4357] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
CONTEXT Endocrine problems are common in patients with Fanconi anemia (FA). About 80% of children and adults with FA have at least one endocrine abnormality, including short stature, GH deficiency, abnormal glucose or insulin metabolism, dyslipidemia, hypothyroidism, pubertal delay, hypogonadism, or impaired fertility. The goal of this report is to provide an overview of endocrine abnormalities and guidelines for routine screening and treatment to allow early diagnosis and timely intervention. EVIDENCE ACQUISITION This work is based on a comprehensive literature review, including relevant articles published between 1971 and 2014, and proceedings of a Consensus Conference held by the Fanconi Anemia Research Fund in 2013. EVIDENCE SYNTHESIS The panel of experts collected published evidence and discussed its relevance to reflect current information about the endocrine care of children and adults with FA before the Consensus Conference and through subsequent deliberations that led to the consensus. CONCLUSIONS Individuals with FA should be routinely screened for endocrine abnormalities, including evaluation of growth; glucose, insulin, and lipid metabolism; thyroid function; puberty; gonadal function; and bone mineral metabolism. Inclusion of an endocrinologist as part of the multidisciplinary patient care team is key to providing comprehensive care for patients with FA.
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Affiliation(s)
- Anna Petryk
- Division of Pediatric Endocrinology (A.P., B.N.), University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota 55454; Department of Pediatrics (R.K.S.), Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia 23229; Clinical Genetics Branch (N.G., B.P.A.), Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland 20850; Division of Endocrinology, Diabetes and Metabolism (A.N.H.), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts 02215; Division of Endocrinology (M.M.R., S.R.R.), Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio 45229; Pediatric Endocrinology Inter-Institute Training Program (M.L.), National Institutes of Health, Bethesda, Maryland 20892; and Section on Endocrinology and Genetics (M.L., C.A.S.), Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland 20892
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Eghbali-Fatourechi G. Bisphosphonate therapy in pediatric patients. J Diabetes Metab Disord 2014; 13:109. [PMID: 25551100 PMCID: PMC4279811 DOI: 10.1186/s40200-014-0109-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 11/04/2014] [Indexed: 01/18/2023]
Abstract
Although for many decades bisphosphonates were used for adult bone loss, bisphosphonate administration in pediatric patients is new and was initiated in the past 15-year. The indications for pediatric bisphosphonates was extended to childhood malignancies with bone involvement, after additional effects were unveiled for bisphosphonates with recent research. In this article we review childhood bone loss and conditions with bone involvement in which bisphosphonate therapy have been used. We also review mechanisms of action of bisphosphonates, and present indications of bisphosphonate therapy in pediatric patients based on results of clinical trials.
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Affiliation(s)
- Guiti Eghbali-Fatourechi
- Affiliate Professor of Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran ; Affiliate Faculty of University College of Omran and Tosseh, Hamedan, Iran
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Biggin A, Briody JN, Ormshaw E, Wong KKY, Bennetts BH, Munns CF. Fracture during intravenous bisphosphonate treatment in a child with osteogenesis imperfecta: an argument for a more frequent, low-dose treatment regimen. Horm Res Paediatr 2014; 81:204-10. [PMID: 24356182 DOI: 10.1159/000355111] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 08/19/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Intravenous bisphosphonate therapy is the mainstay of medical treatment in osteogenesis imperfecta (OI) and has been shown to increase bone mass, decrease bone pain, improve mobility, and reduce the incidence of fractures. Sclerotic metaphyseal lines parallel to the growth plate are seen on long bone radiographs following cyclical intravenous therapy. These areas create stress risers within the bone that may act as foci for subsequent fractures as exemplified in this clinical case. METHODS An 8-year-old girl with OI sustained a distal radial fracture following 3 years of treatment with 6-monthly intravenous zoledronate. Her diagnosis, response to treatment, and subsequent fracture at a sclerotic metaphyseal line is described. RESULTS Peripheral quantitative computer tomography was used to characterise the presence of multiple stress risers at the distal forearm. Trabecular bone mineral density fluctuated from 34 to 126% compared to neighbouring 2-mm regions. CONCLUSION There remain many unanswered questions about optimal bisphosphonate treatment regimens in children with OI. The formation of stress risers following intravenous bisphosphonate treatment raises the hypothesis that a more frequent and low-dose bisphosphonate regimen would provide more uniform dosing of bone in the growing child and reduce the likelihood of fractures compared to current treatment practices.
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Affiliation(s)
- Andrew Biggin
- Institute of Endocrinology and Diabetes, The Sydney Children's Hospitals Network, Westmead, N.S.W., Australia
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Abstract
Among the adverse events of glucocorticoid treatment are bone loss and fractures. Despite available, effective preventive measures, many patients receiving or initiating glucocorticoid therapy are not appropriately evaluated and treated for bone health and fracture risk. Populations with, or at risk of, glucocorticoid-induced osteoporosis (GIOP) to target for these measures are defined on the basis of dose and duration of glucocorticoid therapy and bone mineral density. That patients with GIOP should be treated as early as possible is generally agreed upon; however, diversity remains in intervention thresholds and management guidelines. The FRAX(®) algorithm provides a 10-year probability of fracture that can be adjusted according to glucocorticoid dose. There is no evidence that GIOP and postmenopausal osteoporosis respond differently to treatments. Available anti-osteoporotic therapies such as anti-resorptives including bisphosphonates and the bone anabolic agent teriparatide are effective for the management of GIOP. Prevention with calcium and vitamin D supplementation is less effective than specific anti-osteoporotic treatment. Anti-osteoporotic treatment should be stopped at the time of glucocorticoid cessation, unless the patient remains at increased risk of fracture.
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Abstract
Skeletal health is modulated by a variety of factors, including genetic makeup, hormonal axes, and environment. Across all ages, extremes of body weight may exert a deleterious effect on bone accretion and increase fracture risk. The incidence of both anorexia nervosa and obesity, each involving extreme alterations in body composition, is rising among youth, and secondary osteoporosis is increasingly being diagnosed among affected children and adolescents. Compared with the elderly, the definition of osteoporosis that stems from any underlying condition differs for the pediatric population and special precautions are required with regard to treatment of young patients. Early recognition and management of both underweight and overweight youth and the accompanying consequences on bone and mineral metabolism are essential for preservation of skeletal health, although prevention of bone loss and optimization of bone mineral accrual remain the most important protective measures.
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Affiliation(s)
- Shara R Bialo
- Division of Pediatric Endocrinology, Hasbro Children's Hospital/Alpert Medical School of Brown University, 593 Eddy Street, MPSII, Providence, RI, 02903, USA,
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Calcium and vitamin D for osteoprotection in children with new-onset nephrotic syndrome treated with steroids: a prospective, randomized, controlled, interventional study. Pediatr Nephrol 2014; 29:1025-32. [PMID: 24414607 DOI: 10.1007/s00467-013-2720-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 11/22/2013] [Accepted: 12/02/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND There are no robust guidelines on strategies to prevent the adverse skeletal effects of glucocorticoids in children. OBJECTIVES To evaluate the role of prophylactic calcium and vitamin D on bone health in children with new-onset nephrotic syndrome (NS) treated with short-term (12 weeks), high-dose glucocorticoids. METHODS Prospective, randomized, controlled, single blind, interventional study conducted on 41 steroid-naïve pre-pubertal children (29 boys, 12 girls). All children received prednisolone for 12 weeks (60 mg/m(2)/day daily for 6 weeks, followed by 40 mg/m(2)/day alternate days for 6 weeks). Recruited children were randomized into the intervention group (IG; vitamin D 1,000 IU/day and elemental calcium 500 mg/day) and the control group (CG). Bone mineral content (BMC) and bone mineral density (BMD) at the lumbar spine (L1-L4) were estimated at baseline and at 12 weeks. Mean percentage changes in BMC and BMD in IG and CG were compared. RESULTS Children in the IG showed an increase of 11.2 % in BMC versus the CG, who showed an 8.9 % fall (p < 0.0001). Net intervention-attributable difference in BMC was 20.1 %. BMD increased in both groups (IG 2.8 % vs CG 0.74 %), but the difference was not statistically significant (p = 0.27). CONCLUSIONS Short-term, high-dose glucocorticoid therapy decreases the BMC of the lumbar spine in steroid-naïve children with NS. Vitamin D and calcium co-administration not only prevents this decline, but also enhances BMC of the lumbar spine.
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Ooi HL, Briody J, Biggin A, Cowell CT, Munns CF. Intravenous zoledronic Acid given every 6 months in childhood osteoporosis. Horm Res Paediatr 2014; 80:179-84. [PMID: 24052046 DOI: 10.1159/000354303] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 07/05/2013] [Indexed: 11/19/2022] Open
Abstract
AIM To evaluate the safety and efficacy of 12 months of zoledronic acid (ZA) administered every 6 months to children with osteoporosis. METHODS Retrospective cohort study of 27 patients (16 male, 11 female) treated with ZA (0.05 mg/kg/dose) every 6 months for 1 year. 20 were immobile, 4 steroid-induced osteoporosis, 2 idiopathic osteoporosis and 1 neurofibromatosis type 1. 16 had long bone fractures and 12 had vertebral wedging at baseline. Mineral homeostasis, bone mineral density (BMD) and vertebral morphometry were evaluated at baseline and 12 months. Results were compared to published data on 3-monthly ZA treatment. RESULTS Median age at ZA start was 10.5 years (range 6.2-13.3). Following the first infusion, 2 developed asymptomatic hypocalcemic, 14 developed temperature > 38°C, 13 aches/pain and 6 nausea. At 12 months, there was reduction in bone turnover and improvement in BMD and vertebral shape. No patient fractured after starting ZA. Growth was normal. Outcomes were similar to 3-monthly ZA. CONCLUSION ZA administered 6-monthly was associated with acute phase reaction to the first dose and improvement in BMD, reduction in bone turnover and improved vertebral shape at 12 months.
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Affiliation(s)
- Hooi Leng Ooi
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, N.S.W., Australia
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Zhu ED, Louis L, Brooks DJ, Bouxsein ML, Demay MB. Effect of bisphosphonates on the rapidly growing male murine skeleton. Endocrinology 2014; 155:1188-96. [PMID: 24422540 PMCID: PMC3959604 DOI: 10.1210/en.2013-1993] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Bisphosphonates are effective for preventing and treating skeletal disorders associated with hyperresorption. Their safety and efficacy has been studied in adults where the growth plate is fused and there is no longitudinal bone growth and little appositional growth. Although bisphosphonate use in the pediatric population was pioneered for compassionate use in the treatment of osteogenesis imperfecta, they are being increasingly used for the treatment and prevention of bone loss in children at risk of hyperresorptive bone loss. However, the effect of these agents on the growing skeleton in disorders other than osteogenesis imperfecta has not been systematically compared. Studies were, therefore, undertaken to examine the consequences of bisphosphonate administration on the growth plate and skeletal microarchitecture during a period of rapid growth. C57Bl6/J male mice were treated from 18 to 38 days of age with vehicle, alendronate, pamidronate, zoledronate, or clodronate at doses selected to replicate those used in humans. Treatment with alendronate, pamidronate, and zoledronate, but not clodronate, led to a decrease in the number of chondrocytes per column in the hypertrophic chondrocyte layer. This was not associated with altered hypertrophic chondrocyte apoptosis or vascular invasion at the growth plate. The effects of pamidronate on trabecular microarchitecture were less beneficial than those of alendronate and zoledronate. Pamidronate did not increase cortical thickness or cortical area/total area relative to control mice. These studies suggest that bisphosphonate administration does not adversely affect skeletal growth. Long-term investigations are required to determine whether the differences observed among the agents examined impact biomechanical integrity of the growing skeleton.
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Affiliation(s)
- Eric D Zhu
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114
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Bhatt RN, Hibbert SA, Munns CF. The use of bisphosphonates in children: review of the literature and guidelines for dental management. Aust Dent J 2014; 59:9-19. [PMID: 24495226 DOI: 10.1111/adj.12140] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2013] [Indexed: 11/30/2022]
Abstract
Bisphosphonates are inhibitors of osteoclastic bone resorption with therapeutic benefit in a variety of bone disorders in both adults and children. While these agents have been routinely used in adults for the past three decades, their more recent introduction into paediatric medicine means there is a paucity of data on long-term safety and effects on dental development. There is uncertainty regarding the dental management of children treated with bisphosphonates, particularly when invasive dental procedures, such as extractions and oral surgical procedures, are required. There are limited data with which to make recommendations about the dental management of patients treated with bisphosphonates, and there are no published recommendations that specifically address paediatric patients. This paper aims to outline paediatric uses and adverse effects of bisphosphonates and present recommendations on the dental management of children receiving bisphosphonates.
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Affiliation(s)
- R N Bhatt
- Department of Orthodontics and Paediatric Dentistry, Westmead Centre for Oral Health, Westmead, New South Wales
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Liu D, Ahmet A, Ward L, Krishnamoorthy P, Mandelcorn ED, Leigh R, Brown JP, Cohen A, Kim H. A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy Asthma Clin Immunol 2013; 9:30. [PMID: 23947590 PMCID: PMC3765115 DOI: 10.1186/1710-1492-9-30] [Citation(s) in RCA: 688] [Impact Index Per Article: 62.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 07/25/2013] [Indexed: 02/06/2023] Open
Abstract
Systemic corticosteroids play an integral role in the management of many inflammatory and immunologic conditions, but these agents are also associated with serious risks. Osteoporosis, adrenal suppression, hyperglycemia, dyslipidemia, cardiovascular disease, Cushing’s syndrome, psychiatric disturbances and immunosuppression are among the more serious side effects noted with systemic corticosteroid therapy, particularly when used at high doses for prolonged periods. This comprehensive article reviews these adverse events and provides practical recommendations for their prevention and management based on both current literature and the clinical experience of the authors.
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Affiliation(s)
- Dora Liu
- Western University, London, ON, Canada.
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Rizzoli R, Adachi JD, Cooper C, Dere W, Devogelaer JP, Diez-Perez A, Kanis JA, Laslop A, Mitlak B, Papapoulos S, Ralston S, Reiter S, Werhya G, Reginster JY. Management of glucocorticoid-induced osteoporosis. Calcif Tissue Int 2012; 91:225-43. [PMID: 22878667 DOI: 10.1007/s00223-012-9630-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 05/29/2012] [Indexed: 01/05/2023]
Abstract
This review summarizes the available evidence-based data that form the basis for therapeutic intervention and covers the current status of glucocorticoid-induced osteoporosis (GIOP) management, regulatory requirements, and risk-assessment options. Glucocorticoids are known to cause bone loss and fractures, yet many patients receiving or initiating glucocorticoid therapy are not appropriately evaluated and treated. An European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis workshop was convened to discuss GIOP management and to provide a report by a panel of experts. An expert panel reviewed the available studies that discussed approved therapeutic agents, focusing on randomized and controlled clinical trials reporting on bone mineral density and/or fracture risk of at least 48 weeks' duration. There is no evidence that GIOP and postmenopausal osteoporosis respond differently to treatments. The FRAX algorithm can be adjusted according to glucocorticoid dose. Available antiosteoporotic therapies such as bisphosphonates and teriparatide are efficacious in GIOP management. Several other agents approved for the treatment of postmenopausal osteoporosis may become available for GIOP. It is advised to stop antiosteoporotic treatment after glucocorticoid cessation, unless the patient remains at increased risk of fracture. Calcium and vitamin D supplementation as an osteoporosis-prevention measure is less effective than specific antiosteoporotic treatment. Fracture end-point studies and additional studies investigating specific subpopulations (pediatric, premenopausal, or elderly patients) would strengthen the evidence base and facilitate the development of intervention thresholds and treatment guidelines.
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Affiliation(s)
- R Rizzoli
- Service of Bone Diseases, Geneva University Hospitals, Geneva, Switzerland.
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Abstract
UNLABELLED The prevalence and morbidity associated with osteoporosis and fractures in patients with spina bifida (SB) highlight the importance of osteoporosis prevention and treatment in early childhood; however, the issue has received little attention. The method for the selection of appropriate patients for drug treatment has not been clarified. OBJECTIVE To review the literature concerning fracture risks and low bone density in paediatric patients with SB. We looked for studies describing state-of-the-art treatments and for prevention of secondary osteoporosis. METHODS Articles were identified through a search in the electronic database (PUBMED) supplemented with reviews of the reference lists of selected papers. The main outcome measures were incidence of fractures and risk factors for fracture, an association between bone mineral density (BMD) and occurrence of fracture, risk factors of low BMD, and effects of pharmacological and non-pharmacological treatments on BMD and on the incidence of fractures. We considered as a secondary outcome the occurrence of fractures in relation to the mechanism of injury. RESULTS Results indicated that patients with SB are at increased risk for fractures and low BMD. Risk factors that may predispose patients to fractures include higher levels of neurological involvement, non-ambulatory status, physical inactivity, hypercalciuria, higher body fat levels, contractures, and a previous spontaneous fracture. Limitations were observed in the number and quality of studies concerning osteoporosis prevention and treatment in paediatric patients with SB. The safety and efficiency of drugs to treat osteoporosis in adults have not been evaluated satisfactorily in children with SB.
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Affiliation(s)
- Humberto Filipe Marreiros
- Correspondence to: Humberto Filipe Marreiros, Hospital Dona Estafania, Rua Jacinta Marto, 1169-045 Lisboa, Estremadura 1500-540, Portugal.
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Haffner D, Fischer DC. Can bisphosphonates play a role in the treatment of children with chronic kidney disease? Pediatr Nephrol 2011; 26:2111-9. [PMID: 21267600 DOI: 10.1007/s00467-010-1739-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Revised: 12/06/2010] [Accepted: 12/07/2010] [Indexed: 01/09/2023]
Abstract
In patients with chronic kidney disease (CKD) renal osteodystrophy, in the form of either low- or high-turnover bone disease, is quite common. While renal transplantation is expected to reverse renal osteodystrophy, long-term treatment with glucocorticoids before and/or after transplantation may lead to osteoporosis instead. Osteoporosis is defined as a skeletal disease with low bone mineral density, microarchitectural deterioration, and concomitant fragility. In adults, bisphosphonates are widely used to treat osteoporosis and other diseases associated with excessive bone resorption. In pediatric CKD patients the efficacy and safety of these drugs have not yet been addressed adequately and thus no evidence-based recommendations regarding the optimal type of bisphosphonate, dosage, or duration of therapy are available. Furthermore, while in adults the determination of areal bone mineral density is sufficient to diagnose osteoporosis, this is not the case in children. Instead, in pediatric patients, careful morphological assessment of bone structure and formation is required. Indeed, data from studies with uremic rats indicated that bisphosphonates, via a deceleration of bone turnover, have the potential not only to aggravate pre-existing adynamic bone disease, but also to impair longitudinal growth. Thus, the widespread use of bisphosphonates in children with CKD should be discouraged until the risks and benefits have been carefully elucidated in clinical trials.
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Affiliation(s)
- Dieter Haffner
- Department of Pediatrics, University Hospital of Rostock, Ernst-Heydemann-Strasse 8, 18057, Rostock, Germany.
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Bechtold-Dalla Pozza S. [Bone density measurements on growing skeletons and the clinical consequences]. Z Rheumatol 2011; 70:844-52. [PMID: 21989975 DOI: 10.1007/s00393-011-0803-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The measurement of bone mineral density (BMD) was established to judge the fracture risk in an individual. The most commonly used densitometric technique DXA is a two-dimensional method and reports BMD (bone mass/projection area), which increases during growth. Bone mineral density (in g/cm(3)), however, is almost stable and does not change with age or height. To analyze the data special pediatric references including data on age, sex and ethnicity are necessary as well as correction for height. Bone forms a unit with muscle. Bone responds to mechanical loading with increase in bone size and therefore adapts to the biomechanical needs. Therefore, interpretation of bone development data requires data on muscle development.The indication for bone mineral density measurement and result reporting should be made by and together with a pediatric specialist. The diagnosis of osteoporosis should not be made based solely on densitometric measurements. History of low trauma fracture is an important aspect for the definition. Besides DXA there exist further methods with advantages and disadvantages.
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Affiliation(s)
- S Bechtold-Dalla Pozza
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität München, München, Deutschland.
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Muraleva NA, Sadovoi MA, Kolosova NG. The effect of alendronate on bone tissue of senescent-accelerated OXYS rats. ADVANCES IN GERONTOLOGY 2011. [DOI: 10.1134/s2079057011040126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Wagner S, Poirot I, Vuillerot C, Berard C. Tolerance and effectiveness on pain control of Pamidronate® intravenous infusions in children with neuromuscular disorders. Ann Phys Rehabil Med 2011; 54:348-58. [PMID: 21840280 DOI: 10.1016/j.rehab.2011.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 07/01/2011] [Accepted: 07/02/2011] [Indexed: 11/30/2022]
Abstract
UNLABELLED Osteoporosis is a common complication in children with motor impairments. They have a higher risk of fractures (20% during their lifetime) mostly at femoral level. Furthermore, these children have pain yet no clear relation has been established between osteoporosis and pain. The efficacy of bisphosphonates has been validated in adults and for children with osteogenesis imperfecta (OI). However, its use in children with motor impairments has not yet been validated. PATIENTS AND METHODS Retrospective study on the medical charts of children presenting neurological diseases and motor impairments associated to secondary symptomatic osteoporosis. These children underwent treatment with Pamidronate(®) intravenous infusions (I.V.) in Lyon and Valence between 2002 and 2008. Data were collected on pain control, incidence and frequency of fractures and bone mass density (BMD). Data on adverse events were also collected to evaluate treatment's tolerance. RESULTS Twelve children's charts were studied for a total of 50 Pamidronate(®) I.V. infusions. Regarding treatment's efficacy, we observed a clear decrease and even total relief of the pain with improvement reported after 98% of perfusions. Regarding BMD, there was a real improvement after the treatment (e.g., lumbar BMD measures, -46.5% before treatment and -27% after treatment). The adverse events, flu-like syndrome, muscle pain and asymptomatic hypocalcemia, were minor and quickly reversible. CONCLUSION It seems quite essential to screen for osteoporosis-related pain in these children and treat them quickly to avoid a negative impact on their quality of life. Treatment with I.V. bisphosphonates has shown its relevance, yet practical modalities still need to be defined. It would be interesting but quite difficult to implement, in light of the positive effect of this study, a prospective, randomized, controlled, double-blind vs. placebo study on a large enough sample of patients.
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Affiliation(s)
- S Wagner
- L'Escale service de MPR pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, Bron, France.
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Abstract
Evaluation of the child with fractures is challenging, as no clear guidelines exist to distinguish traumatic from pathological fractures. Although most fractures in childhood are benign, recurrent fractures may be associated with a wide variety of primary skeletal diseases as well as secondary causes, necessitating a careful history and physical exam to guide the evaluation. There is no "gold standard" for the evaluation and treatment of children with fractures and low bone mineral density (BMD); therefore, the diagnosis of osteoporosis in a pediatric patient should be made using a combination of clinical and radiographic features. Interpretation of bone densitometry in growing patients presents a unique set of challenges because areal BMD measured by dual-energy x-ray absorptiometry depends on multiple dynamic variables. Interpretation of pediatric dual-energy x-ray absorptiometry should be based on Z-scores (sd scores compared to age, sex, and ethnicity-matched controls), using normative databases specific to the brand of densitometer and the patient population. Given the skeleton's ability to recover from low BMD through modeling and remodeling, optimizing management of underlying conditions leading to bone fragility is the initial step. Conservative measures including calcium and vitamin D supplementation and weight-bearing physical activity are important interventions that should not be overlooked. The use of bisphosphonates in children and adolescents is controversial due to lack of long-term efficacy and safety data and should be limited to clinical trials and compassionate therapy in children with significantly compromised quality of life. Close monitoring is required, and further study is necessary to assess their long-term safety and efficacy in children.
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Affiliation(s)
- Alison M Boyce
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892 -4320, USA.
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Abstract
Current evidence points to suboptimal bone health in children and adolescents with inflammatory bowel disease (IBD) when compared with their healthy peers. This compromise is evident from diagnosis. The clinical consequences and long-term outcome of this finding are still unknown. The mechanism of suboptimal bone health in children and adolescents with IBD lays mainly in reduced bone formation, but also reduced bone resorption, processes necessary for bone growth. Factors contributing to this derangement are inflammation, delayed growth and puberty, lean mass deficits, and use of glucocorticoids. We recognize that evidence is sparse on the topic of bone health in children and adolescents with IBD. In this clinical guideline, based on current evidence, we provide recommendations on screening and monitoring bone health in children and adolescents with IBD, including modalities to achieve this and their limitations; monitoring of parameters of growth, pubertal development, and reasons for concern; evaluation of vitamin D status and vitamin D and calcium intake; exercise; and nutritional support. We also report on the current evidence of the effect of biologics on bone health in children and adolescents with IBD, as well as the role of bone active medications such as bisphosphonates. Finally, we summarize the existing numerous gaps in knowledge and potential subjects for future research endeavors.
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Quinlivan R, Shaw N, Bushby K. 170th ENMC International Workshop: Bone protection for corticosteroid treated Duchenne muscular dystrophy. 27–29 November 2009, Naarden, The Netherlands. Neuromuscul Disord 2010; 20:761-9. [DOI: 10.1016/j.nmd.2010.07.272] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Revised: 07/04/2010] [Accepted: 07/08/2010] [Indexed: 01/06/2023]
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Sbrocchi AM, Forget S, Laforte D, Azouz EM, Rodd C. Zoledronic acid for the treatment of osteopenia in pediatric Crohn's disease. Pediatr Int 2010; 52:754-61. [PMID: 20524999 DOI: 10.1111/j.1442-200x.2010.03174.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pediatric patients with Crohn's disease often have low bone mass (osteopenia) for age. No randomized, placebo-controlled trials using zoledronic acid have ever been performed in this population. The objective of this study was to assess the efficacy of zoledronic acid in children with Crohn's disease and osteopenia. METHODS A double-blind, randomized, placebo-controlled design was used. Thirteen adolescents received either a single intravenous dose of zoledronic acid (0.066 mg/kg, max 4 mg, n= 7) or saline placebo (n= 6). The primary outcome was change in lumbar spine bone mineral density (LSBMD) z-score at 6 months. Secondary outcomes included bone markers and adverse events. RESULTS At 6 months, the change in LSBMD z-score was significantly higher in the zoledronic acid group compared to placebo (0.7 vs 0.1, P < 0.001). Volumetrically adjusted LSBMD z-score also significantly increased in the treated group. This significant difference persisted until 12 months. With zoledronic acid, urinary C-telopeptide excretion decreased by 50% at 6 months and remained suppressed at 12 months (P= 0.02), but no changes were observed with placebo. Both groups had similar adverse events which included transient fever, arthralgias, and nausea (3/7 treated, 2/6 placebo, P= NS). CONCLUSIONS In this study, zoledronic acid demonstrated a significant increase in LSBMD at 6 and 12 months following a well-tolerated infusion.
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Affiliation(s)
- Anne Marie Sbrocchi
- Division of Endocrinology, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada.
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Monti E, Mottes M, Fraschini P, Brunelli P, Forlino A, Venturi G, Doro F, Perlini S, Cavarzere P, Antoniazzi F. Current and emerging treatments for the management of osteogenesis imperfecta. Ther Clin Risk Manag 2010; 6:367-81. [PMID: 20856683 PMCID: PMC2940745 DOI: 10.2147/tcrm.s5932] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2010] [Indexed: 11/23/2022] Open
Abstract
Osteogenesis imperfecta (OI) is the most common bone genetic disorder and it is characterized by bone brittleness and various degrees of growth disorder. Clinical severity varies widely; nowadays eight types are distinguished and two new forms have been recently described although not yet classified. The approach to such a variable and heterogeneous disease should be global and therefore multidisciplinary. For simplicity, the objectives of treatment can be reduced to three typical situations: the lethal perinatal form (type II), in which the problem is survival at birth; the severe and moderate forms (types III-IX), in which the objective is 'autonomy'; and the mild form (type I), in which the aim is to reach 'normal life'. Three types of treatment are available: non-surgical management (physical therapy, rehabilitation, bracing and splinting), surgical management (intramedullary rod positioning, spinal and basilar impression surgery) and medical-pharmacological management (drugs to increase the strength of bone and decrease the number of fractures as bisphosphonates or growth hormone, depending on the type of OI). Suggestions and guidelines for a therapeutic approach are indicated and updated with the most recent findings in OI diagnosis and treatment.
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Affiliation(s)
- Elena Monti
- Department of Life Sciences and Reproduction, Pediatric Clinic University of Verona, Verona, Italy
| | - Monica Mottes
- Department of Life Sciences and Reproduction, Pediatric Clinic University of Verona, Verona, Italy
| | - Paolo Fraschini
- Istituto Di Ricovero e Cura a Carattere Scientifico, ‘E. Medea’, Associazione La Nostra Famiglia, Bosisio Parini (LC), Italy
| | | | - Antonella Forlino
- Department of Biochemistry “A. Castellani”, University of Pavia, Italy
| | - Giacomo Venturi
- Department of Life Sciences and Reproduction, Pediatric Clinic University of Verona, Verona, Italy
| | - Francesco Doro
- Department of Life Sciences and Reproduction, Pediatric Clinic University of Verona, Verona, Italy
| | - Silvia Perlini
- Department of Life Sciences and Reproduction, Pediatric Clinic University of Verona, Verona, Italy
| | - Paolo Cavarzere
- Department of Life Sciences and Reproduction, Pediatric Clinic University of Verona, Verona, Italy
| | - Franco Antoniazzi
- Department of Life Sciences and Reproduction, Pediatric Clinic University of Verona, Verona, Italy
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