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Krikelis M, Gazi S, Trovas G, Makris K, Chronopoulos E, Tournis S. Progression of multiple vertebral fractures after denosumab discontinuation under treatment with romosozumab. A case-report. Joint Bone Spine 2024; 91:105754. [PMID: 38942353 DOI: 10.1016/j.jbspin.2024.105754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 06/04/2024] [Accepted: 06/20/2024] [Indexed: 06/30/2024]
Abstract
INTRODUCTION Denosumab (Dmab) is widely used for the treatment of post-menopausal osteoporosis. Its discontinuation is sometimes accompanied by multiple vertebral fractures. Romosozumab (Rmab) has not been tested for its ability to prevent the rebound phenomenon. CASE PRESENTATION We present the case of a 68-year-old female patient with post-menopausal osteoporosis under treatment with Rmab who presented with multiple vertebral fractures after denosumab discontinuation. The addition of Rmab did not prevent new-onset rebound-associated vertebral fractures. The patient discontinued Rmab and Dmab was re-initiated. After six months, no new vertebral fractures occurred, bone mineral density increased and bone turnover markers remained suppressed. DISCUSSION Our clinical case illustrates the ineffectiveness of Rmab to prevent the multiple vertebral fracture cascade attributable to discontinuation of Dmab. We believe that treatment with Rmab might not be enough to prevent this phenomenon. Treatment with Dmab or possibly combination treatment with Dmab and Rmab could be another treatment option.
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Affiliation(s)
- Michail Krikelis
- Laboratory for Research of the Musculoskeletal System "Th. Garofalidis", Medical School, National and Kapodistrian University of Athens, KAT General Hospital, Kifissia, Athens, Greece; Rheumatology Department, KAT General Hospital, Kifissia, Athens, Greece
| | - Susana Gazi
- Rheumatology Department, KAT General Hospital, Kifissia, Athens, Greece
| | - Georgios Trovas
- Laboratory for Research of the Musculoskeletal System "Th. Garofalidis", Medical School, National and Kapodistrian University of Athens, KAT General Hospital, Kifissia, Athens, Greece
| | | | - Efstathios Chronopoulos
- Laboratory for Research of the Musculoskeletal System "Th. Garofalidis", Medical School, National and Kapodistrian University of Athens, KAT General Hospital, Kifissia, Athens, Greece
| | - Symeon Tournis
- Laboratory for Research of the Musculoskeletal System "Th. Garofalidis", Medical School, National and Kapodistrian University of Athens, KAT General Hospital, Kifissia, Athens, Greece.
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Farias V, Jerkovich F, Barragán AM, Pereyra A, Pernas MG, Abdala R, Longobardi V, Zanchetta MB. Three-year effect of bisphosphonates on bone mineral density after denosumab withdrawal: observations from a real-world study. JBMR Plus 2024; 8:ziae044. [PMID: 38764789 PMCID: PMC11102571 DOI: 10.1093/jbmrpl/ziae044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 11/10/2023] [Accepted: 11/29/2023] [Indexed: 05/21/2024] Open
Abstract
Data on long-term treatment regimens for preventing bone mineral density (BMD) loss that occurs after denosumab (Dmab) withdrawal are scarce. Our aim was to evaluate the long-term changes (12-36 months) in BMD and bone turnover markers in a group of postmenopausal women who had been treated with Dmab and received subsequent treatment with bisphosphonates. Secondary objectives were to evaluate factors associated with BMD loss, to compare the BMD change in patients who received oral vs intravenous bisphosphonates, and to assess the frequency of fragility fractures after Dmab discontinuation. The clinical data of 54 patients, 26 of whom had clinical and DXA assessments at 36 months, were analyzed. After 12 months, the mean LS BMD had decreased by 2.8% (±5.0), FN BMD by 1.9% (±5.8), and TH BMD by 1.9% (±3.7). After 36 months, LS BMD had decreased by 3.7% (±6.7), FN BMD by 2.5% (±7.1), and TH BMD by 3.6% (±5.2). C-terminal cross-linked telopeptide of type I collagen significantly increased during the first 12 months after Dmab withdrawal but then decreased at 36 months. BMD loss at 12 months was higher in patients with more than 30 months of Dmab treatment, but this difference was only statistically significant at FN (-3.3% vs -0.3%, P = .252 at LS, -3.3% vs 0.3%, P = .033 at FN, and -2.1% vs 0.9, P = .091 at TH). There were no statistically significant differences regarding the change in BMD at 12 and 36 months between oral and intravenous treatment. Seven patients suffered incidental vertebral fractures (clinical vertebral fractures: n = 6, morphometric fractures: n = 1) three of which were multiple. None of these patients were treated following international or institutional guidelines or recommendations. In summary, our study suggests that bisphosphonates can help maintain BMD for 36 months after Dmab discontinuation.
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Affiliation(s)
- Vanina Farias
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), ZP 1012, Buenos Aires, Argentina
- Cátedra de Osteología y Metabolismo Mineral, Universidad del Salvador, ZP 1012, Buenos Aires, Argentina
| | - Fernando Jerkovich
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), ZP 1012, Buenos Aires, Argentina
| | - Andrea Morejón Barragán
- Cátedra de Osteología y Metabolismo Mineral, Universidad del Salvador, ZP 1012, Buenos Aires, Argentina
| | - Alejandro Pereyra
- Cátedra de Osteología y Metabolismo Mineral, Universidad del Salvador, ZP 1012, Buenos Aires, Argentina
| | - Mariana González Pernas
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), ZP 1012, Buenos Aires, Argentina
| | - Rubén Abdala
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), ZP 1012, Buenos Aires, Argentina
| | - Vanesa Longobardi
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), ZP 1012, Buenos Aires, Argentina
- Cátedra de Osteología y Metabolismo Mineral, Universidad del Salvador, ZP 1012, Buenos Aires, Argentina
| | - María Belén Zanchetta
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), ZP 1012, Buenos Aires, Argentina
- Cátedra de Osteología y Metabolismo Mineral, Universidad del Salvador, ZP 1012, Buenos Aires, Argentina
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3
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Shen C, Oh HR, Park YR, Chen JH, Park BH, Park JH. Interaction between p21-activated kinase 4 and β-catenin as a novel pathway for PTH-dependent osteoblast activation. J Cell Physiol 2024; 239:e31245. [PMID: 38497504 DOI: 10.1002/jcp.31245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 02/21/2024] [Accepted: 02/22/2024] [Indexed: 03/19/2024]
Abstract
Parathyroid hormone (PTH) serves dual roles in bone metabolism, exhibiting both anabolic and catabolic effects. The anabolic properties of PTH have been utilized in the treatment of osteoporosis with proven efficacy in preventing fractures. Despite these benefits, PTH can be administered therapeutically for up to 2 years, and its use in patients with underlying malignancies remains a subject of ongoing debate. These considerations underscore the need for a more comprehensive understanding of the underlying mechanisms. p21-activated kinase 4 (PAK4) is involved in bone resorption and cancer-associated osteolysis; however, its role in osteoblast function and PTH action remains unknown. Therefore, in this study, we aimed to clarify the role of PAK4 in osteoblast function and its effects on PTH-induced anabolic activity. PAK4 enhanced MC3T3-E1 osteoblast viability and proliferation and upregulated cyclin D1 expression. PAK4 also augmented osteoblast differentiation, as indicated by increased mineralization found by alkaline phosphatase and Alizarin Red staining. Treatment with PTH (1-34), an active PTH fragment, stimulated PAK4 expression and phosphorylation in a protein kinase A-dependent manner. In addition, bone morphogenetic protein-2 (which is known to promote bone formation) increased phosphorylated PAK4 (p-PAK4) and PAK4 levels. PAK4 regulated the expression of both phosphorylated and total β-catenin, which are critical for osteoblast proliferation and differentiation. Moreover, p-PAK4 directly interacted with β-catenin, and disruption of β-catenin's binding to T-cell factor impaired PAK4- and PTH-induced osteoblast differentiation. Our findings elucidate the effect of PAK4 on enhancing bone formation in osteoblasts and its pivotal role in the anabolic activity of PTH mediated through its interaction with β-catenin. These insights improve the understanding of the mechanisms underlying PTH activity and should inform the development of more effective and safer osteoporosis treatments.
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Affiliation(s)
- Chen Shen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Jeonbuk National University Medical School, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Ha Ram Oh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Jeonbuk National University Medical School, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Young Ran Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Jeonbuk National University Medical School, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Jin Hong Chen
- Department of Endocrinology, Affiliated Hospital of Nantong University, China
| | - Byung-Hyun Park
- Department of Biochemistry, Jeonbuk National University Medical School, Jeonju, Republic of Korea
| | - Ji Hyun Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Jeonbuk National University Medical School, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
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Cosman F, Langdahl B, Leder BZ. Treatment Sequence for Osteoporosis. Endocr Pract 2024; 30:490-496. [PMID: 38311211 DOI: 10.1016/j.eprac.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 01/22/2024] [Accepted: 01/26/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Osteoporosis is a chronic progressive disease that requires lifelong monitoring and treatment. Sequencing from one treatment to another at different ages and stages of disease is an approach that can maximize benefits and avoid potential risks from long-term treatment with a single agent. OBJECTIVE This article reviews clinical trial data in postmenopausal women that evaluate the effects of antiresorptive agents followed by other antiresorptives, osteoanabolic agents followed by antiresorptives, and antiresorptives followed by osteoanabolic medications. METHODS Literature review and discussion. RESULTS When medications are discontinued, in the absence of sequential therapy, bone turnover rates return to baseline or above baseline, and bone loss occurs. The rate of bone loss differs for different treatments, with a very slow decline after stopping bisphosphonates and a particularly rapid decline after stopping denosumab. Careful attention to osteoporosis medication transitions can mitigate bone density loss and its consequences. For women who remain at high risk, switching from bisphosphonates to the more potent antiresorptive, denosumab, will result in further improvement in bone mineral density (BMD). When indicated, stopping denosumab can be accomplished safely by transition to an adequate bisphosphonate regimen. For high- and very-high-risk patients, treating with osteoanabolic agents first, followed by antiresorptive agents, produces substantially larger BMD gains than the reverse treatment sequence, with the biggest differences seen for BMD of the hip. CONCLUSION Awareness of the importance of treatment sequences can help improve osteoporosis care across the postmenopausal lifespan.
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Affiliation(s)
- Felicia Cosman
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York.
| | - Bente Langdahl
- Department of Endocrinology and Metabolic Bone Diseases, Aarhus University Hospital and Aarhus University, Aarhus, Denmark.
| | - Benjamin Z Leder
- Department of Medicine, Harvard Medical School, Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts.
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5
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Park-Min KH, Mun SH, Bockman R, McDonald MM. New Horizons: Translational Aspects of Osteomorphs. J Clin Endocrinol Metab 2024; 109:e1373-e1378. [PMID: 38060842 PMCID: PMC11031245 DOI: 10.1210/clinem/dgad711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Indexed: 04/21/2024]
Abstract
Osteomorphs are a newly described osteoclast lineage cell in mice, which are suggested to play a significant role in the maintenance of bone resorption. Preclinical investigations revealed that osteomorphs are generated through the fission of multinucleated bone-resorbing osteoclasts and can also re-fuse with existing osteoclasts. Modifications to RANKL signaling have been shown to alter cycles of fission and re-fusion of osteomorphs in mice. These novel findings were also shown to contribute to the rebound phenomenon after cessation of anti-RANKL therapy in mice. Moreover, the absence of osteomorph-specific genes in mice exhibits bone structural and quality phenotypes. Given these insights, it could be speculated that osteomorphs play a significant role in bone homeostasis, bone metabolic diseases, and response to therapeutics. In this review, we discuss these potential translational roles for osteomorphs. Importantly, we highlight the need for future preclinical and clinical studies to verify the presence of osteomorphs in humans and explore further the translational implications of this discovery.
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Affiliation(s)
- Kyung-Hyun Park-Min
- Arthritis and Tissue Degeneration Program, David Z. Rosensweig Genomics Research Center, Hospital for Special Surgery, New York, NY 10021, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
- BCMB Allied Program, Weill Cornell Graduate School of Medical Sciences, New York, NY 10021, USA
| | - Se Hwan Mun
- Research Institute of Women’s Health, Sookmyung Women's University, 140-742 Seoul, Korea
| | - Richard Bockman
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
- Endocrine Service, Hospital for Special Surgery, New York, NY 10021, USA
| | - Michelle M McDonald
- Skeletal Diseases Program, Garvan Institute of Medical Research, Darlinghurst, NSW 2010, Australia
- School of Medical Science, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
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Vanderniet JA, Szymczuk V, Högler W, Beck-Nielsen SS, Uday S, Merchant N, Crane JL, Ward LM, Boyce AM, Munns CF. Management of RANKL-mediated Disorders With Denosumab in Children and Adolescents: A Global Expert Guidance Document. J Clin Endocrinol Metab 2024; 109:1371-1382. [PMID: 38041865 PMCID: PMC11031248 DOI: 10.1210/clinem/dgad657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 11/07/2023] [Accepted: 11/09/2023] [Indexed: 12/04/2023]
Abstract
CONTEXT Denosumab is an effective treatment for many receptor activator of nuclear factor kappa-B ligand (RANKL)-mediated disorders but there are potential safety considerations and limited data to guide its use in children and adolescents. OBJECTIVE This document seeks to summarize the evidence and provide expert opinion on safe and appropriate use of denosumab in pediatric RANKL-mediated disorders. PARTICIPANTS Ten experts in pediatric bone and mineral medicine from 6 countries with experience in the use of denosumab participated in the creation of this document. EVIDENCE Data were sourced from the published literature, primarily consisting of case reports/series and review articles because of the lack of higher level evidence. Expert opinion of the authors was used substantially when no published data were available. CONCLUSION Denosumab is an effective treatment for RANKL-mediated disorders in children and adolescents but is often not curative and, in some cases, is best used in conjunction with surgical or other medical treatments. Careful multidisciplinary planning is required to define the goals of treatment and expert oversight needed to manage the risk of mineral abnormalities. Substantive, collaborative research efforts are needed to determine optimal treatment regimens and minimize risks.
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Affiliation(s)
- Joel A Vanderniet
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney and Institute of Endocrinology and Diabetes, The Children’s Hospital at Westmead, Sydney, NSW 2145, Australia
| | - Vivian Szymczuk
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20814, USA
| | - Wolfgang Högler
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz 4020, Austria
| | - Signe S Beck-Nielsen
- Centre for Rare Diseases, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus N DK-8200, Denmark
| | - Suma Uday
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's Hospital and Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TG, UK
| | - Nadia Merchant
- Division of Endocrinology and Diabetes, Children's National Hospital, Washington, DC 20010, USA
| | - Janet L Crane
- Department of Pediatrics and Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Leanne M Ward
- Department of Pediatrics, University of Ottawa and Division of Endocrinology, Children's Hospital of Eastern Ontario, Ottawa, Ontario K1H 8L1, Canada
| | - Alison M Boyce
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20814, USA
| | - Craig F Munns
- Child Health Research Centre and Mayne Academy of Paediatrics, University of Queensland, Brisbane, QLD 4101, Australia
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Grassi G, Ghielmetti A, Zampogna M, Chiodini I, Arosio M, Mantovani G, Eller Vainicher C. Zoledronate after denosumab discontinuation: Is repeated administrations more effective than single infusion? J Clin Endocrinol Metab 2024:dgae224. [PMID: 38609157 DOI: 10.1210/clinem/dgae224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/27/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND After Denosumab (Dmab) discontinuation C-terminal telopeptide (CTX) levels increase, bone mineral density (BMD) decreases and multiple vertebral fractures (FX) may occur with relevant impact on women's health. A sequential therapy with bisphosphonates is recommended and the European Calcified Tissue Society (ECTS) proposed repeated zoledronate (ZOL) administrations in patients with persistently high CTX levels, although the efficacy of this schedule is unknown. In this retrospective study we describe BMD changes and FX rate in 52 patients managed according to the ECTS recommendations. METHODS We measured CTX levels and administered ZOL after one month from Dmab withdrawal (t0). After 6 months (t1), we administered a second ZOL infusion, if CTX levels were ≥280 ng/L. BMD changes and FX rate were assessed on average after 17 months from Dmab withdrawal. RESULTS 75% of patients repeated ZOL infusion. In this group spine BMD declined significantly (-5.5 ± 5.6%), while it remained stable in the group with CTX levels <280 ng/L (-0.1 ± 5.5%, p = 0.008). All fractured patients (9.6%) had received >5 Dmab injections and two ZOL infusions. The BMD worsening after Dmab withdrawal was associated with CTX t1 (OR 2.9, IQR 1.3-6.6, p = 0.009) and spine BMD gain during Dmab therapy corrected for the number of Dmab injections (OR 3.0, IQR 1.2-7.2, p = 0.014). A CTX level at t1 > 212 ng/L had 100% sensitivity in predicting the BMD loss. CONCLUSIONS In patients with uncontrolled CTX levels after Dmab withdrawal, two ZOL infusions at 6 months apart do not prevent BMD loss and FX.
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Affiliation(s)
- Giorgia Grassi
- Endocrine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Ghielmetti
- Department of Clinical Sciences and Community Health, University of Milan, 20100, Milan, Italy
| | - Marta Zampogna
- Department of Clinical Sciences and Community Health, University of Milan, 20100, Milan, Italy
| | - Iacopo Chiodini
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy
- Unit of Endocrinology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Maura Arosio
- Endocrine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20100, Milan, Italy
| | - Giovanna Mantovani
- Endocrine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20100, Milan, Italy
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Moreno-Rabié C, Gaêta-Araujo H, Ferreira-Leite A, Coucke W, Gielen E, Van den Wyngaert T, Jacobs R. Local radiographic risk factors for MRONJ in osteoporotic patients undergoing tooth extraction. Oral Dis 2024; 30:1632-1642. [PMID: 36620873 DOI: 10.1111/odi.14496] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/02/2023] [Accepted: 01/05/2023] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To identify local radiographic risk factors for Medication-Related Osteonecrosis of the Jaws (MRONJ) in osteoporotic patients treated with antiresorptive drugs (ARD) and undergoing tooth extraction. MATERIAL AND METHODS Patients were included in this retrospective, longitudinal, case-control study, if having at least one administration of ARD, underwent tooth extraction(s), and had pre- and post-operative panoramic radiographs. Additionally, a matched control group was selected. Three calibrated, blinded, and independent observers assessed each tooth extraction site. Statistical analysis compared control against study group, and within the latter, sites MRONJ+ and MRONJ-. RESULTS In total, 120 patients (99 females/21 males) with 354 tooth extractions were included, from which nine patients (7.5%) and eleven tooth extraction sites (3.1%) developed MRONJ. When comparing control with study group, the latter showed significantly more thickened lamina dura, persistence of the alveolar socket, heterogeneous bone patterns, and sequestrum formation. In the study group, MRONJ developed significantly more in males (19%, p = 0.049), smokers (25%, p = 0.008), in the mandible (82%, p = 0.027), when identifying a radiolucent or sclerotic trabecular pattern (p = 0.004) or when extracting teeth with furcation involvement (p < 0.001), root remnants (p = 0.017), or unrestored caries lesions (p = 0.005). CONCLUSIONS Tooth extraction sites showing radiographic signs of chronic dental infection are prone to MRONJ.
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Affiliation(s)
- Catalina Moreno-Rabié
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Hugo Gaêta-Araujo
- Department of Stomatology, Public Oral Health and Forensic Dentistry, School of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - André Ferreira-Leite
- Department of Dentistry, Faculty of Health Sciences, University of Brasília, Brasilia, Brazil
| | - Wim Coucke
- Certified Freelance Statistician, Heverlee, Belgium
| | - Evelien Gielen
- Department of Geriatrics, Centre for Metabolic Bone Diseases, University Hospitals Leuven, Leuven, Belgium
- Geriatrics and Gerontology, Department of Public Health and Primary Care, Leuven, Belgium
| | - Tim Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Edegem, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Reinhilde Jacobs
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
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Tai TW, Chen HY, Shih CA, Huang CF, McCloskey E, Lee JK, Yeap SS, Cheung CL, Charatcharoenwitthaya N, Jaisamrarn U, Kuptniratsaikul V, Yang RS, Lin SY, Taguchi A, Mori S, Li-Yu J, Ang SB, Chan DC, Chan WS, Ng H, Chen JF, Tu ST, Chuang HH, Chang YF, Chen FP, Tsai KS, Ebeling PR, Marin F, Nistal Rodríguez FJ, Shi H, Hwang KR, Kim KK, Chung YS, Reid IR, Chandran M, Ferrari S, Lewiecki EM, Hew FL, Ho-Pham LT, Nguyen TV, Nguyen VH, Lekamwasam S, Pandey D, Bhadada S, Chen CH, Hwang JS, Wu CH. Asia-Pacific consensus on long-term and sequential therapy for osteoporosis. Osteoporos Sarcopenia 2024; 10:3-10. [PMID: 38690538 PMCID: PMC11056428 DOI: 10.1016/j.afos.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 02/09/2024] [Accepted: 02/17/2024] [Indexed: 05/02/2024] Open
Abstract
Objectives This study aimed to present the Asia-Pacific consensus on long-term and sequential therapy for osteoporosis, offering evidence-based recommendations for the effective management of this chronic condition. The primary focus is on achieving optimal fracture prevention through a comprehensive, individualized approach. Methods A panel of experts convened to develop consensus statements by synthesizing the current literature and leveraging clinical expertise. The review encompassed long-term anti-osteoporosis medication goals, first-line treatments for individuals at very high fracture risk, and the strategic integration of anabolic and antiresorptive agents in sequential therapy approaches. Results The panelists reached a consensus on 12 statements. Key recommendations included advocating for anabolic agents as the first-line treatment for individuals at very high fracture risk and transitioning to antiresorptive agents following the completion of anabolic therapy. Anabolic therapy remains an option for individuals experiencing new fractures or persistent high fracture risk despite antiresorptive treatment. In cases of inadequate response, the consensus recommended considering a switch to more potent medications. The consensus also addressed the management of medication-related complications, proposing alternatives instead of discontinuation of treatment. Conclusions This consensus provides a comprehensive, cost-effective strategy for fracture prevention with an emphasis on shared decision-making and the incorporation of country-specific case management systems, such as fracture liaison services. It serves as a valuable guide for healthcare professionals in the Asia-Pacific region, contributing to the ongoing evolution of osteoporosis management.
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Affiliation(s)
- Ta-Wei Tai
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsuan-Yu Chen
- Department of Orthopedic Surgery, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-An Shih
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chun-Feng Huang
- Division of Family Medicine, En Chu Kong Hospital, New Taipei City, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Leisure Services Management, Chaoyang University of Technology, Taichung, Taiwan
| | - Eugene McCloskey
- Division of Clinical Medicine, School of Medicine and Population Health, Mellanby Centre for Musculoskeletal Research, MRC Versus Arthritis Centre for Integrated Research in Musculoskeletal Ageing (CIMA), University of Sheffield, Sheffield, UK
| | - Joon-Kiong Lee
- Department of Orthopaedics, Beacon Hospital, Petaling Jaya, Selangor, Malaysia
| | - Swan Sim Yeap
- Department of Medicine, Subang Jaya Medical Centre, Subang Jaya, Selangor, Malaysia
| | - Ching-Lung Cheung
- Department of Pharmacology and Pharmacy, Centre for Genomic Sciences, The University of Hong Kong, Pokfulam, Hong Kong
| | | | - Unnop Jaisamrarn
- Center of Excellence in Menopause and Aging Women Health, Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Vilai Kuptniratsaikul
- Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Rong-Sen Yang
- Department of Orthopedic Surgery, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Yen Lin
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Orthopaedic Research Center, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
- School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Akira Taguchi
- Department of Oral and Maxillofacial Radiology, School of Dentistry, Matsumoto Dental University, Nagano, Japan
- Department of Hard Tissue Research, Graduate School of Oral Medicine, Matsumoto Dental University, Nagano, Japan
| | - Satoshi Mori
- Bone and Joint Surgery, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Julie Li-Yu
- Department of Medicine, Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | - Seng Bin Ang
- Menopause Unit and Family Medicine Service, KK Women's and Children's Hospital, Singapore
| | - Ding-Cheng Chan
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wai Sin Chan
- Department of Internal Medicine Orthopaedics, Centro Hospitalar Conde de Sao Januario, Macao, China
| | - Hou Ng
- Department of Internal Medicine, Centro Hospitalar Conde de Sao Januario, Macau, China
| | - Jung-Fu Chen
- Division of Metabolism and Endocrinology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shih-Te Tu
- Division of Endocrinology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Hai-Hua Chuang
- Department of Family Medicine, Taipei and Linkou Main Branches, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Metabolism and Obesity Institute, Taipei and Linkou Main Branches, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Industrial Engineering and Management, National Taipei University of Technology, Taipei, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yin-Fan Chang
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Fang-Ping Chen
- Department of Obstetrics and Gynecology, Osteoporosis Prevention and Treatment Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- Department of Medicine, College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan
| | - Keh-Sung Tsai
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Peter R. Ebeling
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Fernando Marin
- Department of Endocrinology, Hospital Universitario Quironsalud, Madrid, Spain
- Medical Sciences School, Universidad Europea, Madrid, Spain
| | | | - Huipeng Shi
- National Center for Orthopedics, Department of Orthooedics, Shanghai 6th People's Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Kyu Ri Hwang
- Department of Obstetrics & Gynecology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Kwang-Kyoun Kim
- Department of Orthopedic Surgery, Konyang University College of Medicine, Daejeon, Republic of Korea
| | - Yoon-Sok Chung
- Department of Endocrinology and Metabolism, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Ian R. Reid
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Manju Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore
| | - Serge Ferrari
- Service of Bone Diseases, Department of Medicine, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
| | - Fen Lee Hew
- Department of Medicine, Subang Jaya Medical Centre, Subang Jaya, Selangor, Malaysia
| | - Lan T. Ho-Pham
- BioMedical Research Center, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Viet Nam
| | - Tuan Van Nguyen
- Tâm Anh Research Institute, Ho Chi Minh City, Viet Nam
- School of Population Health, UNSW Medicine, UNSW Sydney, Australia
- Centre for Health Technologies, University of Technology Sydney (UTS), Sydney, Australia
| | - Van Hy Nguyen
- Orthopaedic Center, Hue Central Hospital, Hue City, Viet Nam
| | - Sarath Lekamwasam
- Department of Medicine, Faculty of Medicine, University of Ruhuna, Sri Lanka
| | | | | | - Chung-Hwan Chen
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Orthopaedic Research Center, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Orthopedics, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Orthopedics, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Ph.D. Program in Biomedical Engineering, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Institute of Medical Science and Technology, National Sun Yat-Sen University, Kaohsiung, Taiwan
- Graduate Institute of Animal Vaccine Technology, College of Veterinary Medicine, National Pingtung University of Science and Technology, Pingtung, Taiwan
- Graduate Institute of Materials Engineering, College of Engineering, National Pingtung University of Science and Technology, Pingtung, Taiwan
| | - Jawl-Shan Hwang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - Chih-Hsing Wu
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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10
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Coropciuc R, Moreno-Rabié C, De Vos W, Van de Casteele E, Marks L, Lenaerts V, Coppejans E, Lenssen O, Coopman R, Walschap J, Nadjmi N, Jacobs R, Politis C, Van den Wyngaert T. Navigating the complexities and controversies of medication-related osteonecrosis of the jaw (MRONJ): a critical update and consensus statement. Acta Chir Belg 2024; 124:1-11. [PMID: 38059301 DOI: 10.1080/00015458.2023.2291295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/29/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVES To provide a critical update identifying the knowledge gaps and controversies in medication-related osteonecrosis of the jaw (MRONJ) within the Belgian healthcare context and outline opportunities for improvement and research in these areas. METHODS A literature review was performed to identify guidelines from international clinical societies in oncology or oral and maxillofacial surgery on diagnosing, preventing, and treating MRONJ. The recommendations were critically assessed in light of recent developments in the field and confronted with the clinical experience of experts. RESULTS Despite progress in the diagnostic criteria of MRONJ, the continued need for an 8-week timeout period should be reconsidered. Furthermore, 3D imaging techniques should be introduced to improve diagnosis and staging. The staging system remains ambiguous regarding Stage 0 MRONJ, and ongoing confusion exists regarding the term non-exposed MRONJ. The prevention of MRONJ should be tailored, considering the individual patient's risk of MRONJ, frailty, and life expectancy. More research seems needed into the efficacy and safety of drug holidays, considering the risks of rebound remodeling on fractures. With renewed interest in surgical and adjunct management techniques, adequately designed clinical studies are needed to help translate trial outcomes into universally applicable treatment guidelines taking into account individual patient characteristics. CONCLUSIONS Important knowledge gaps remain and hamper the development of clinical guidelines. Several controversies were identified where consensus is lacking, and further harmonization between stakeholders is necessary. Finally, the need for randomized controlled comparative clinical trials in MRONJ resonates harder than ever to identify the best treatment for individual patients.
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Affiliation(s)
- Ruxandra Coropciuc
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Catalina Moreno-Rabié
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Imaging and Pathology, OMFS-IMPATH Research Group, Faculty of Medicine, University of Leuven, Leuven, Belgium
| | - Wouter De Vos
- Department of Oral and Maxillofacial Surgery, Antwerp University Hospital, Antwerp, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Elke Van de Casteele
- Department of Oral and Maxillofacial Surgery, Antwerp University Hospital, Antwerp, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Luc Marks
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Special Care Dentistry, Antwerp University Hospital, Antwerp, Belgium
| | - Vincent Lenaerts
- Department of Oral and Maxillofacial Surgery, VITAZ, Sint-Niklaas, Belgium
| | - Evy Coppejans
- Department of Oral and Maxillofacial Surgery, VITAZ, Sint-Niklaas, Belgium
| | - Olivier Lenssen
- Department of Oral and Maxillofacial Surgery, ZNA Middelheim, Antwerpen, Belgium
| | - Renaat Coopman
- Department of Oral and Maxillofacial and Plastic Surgery, University Hospital of Ghent, Ghent, Belgium
| | | | - Nasser Nadjmi
- Department of Oral and Maxillofacial Surgery, Antwerp University Hospital, Antwerp, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Reinhilde Jacobs
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Imaging and Pathology, OMFS-IMPATH Research Group, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Constantinus Politis
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Tim Van den Wyngaert
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Department of Nuclear Medicine, Antwerp University Hospital, Edegem, Belgium
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11
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Ramchand SK, Tsai JN, Lee H, Sassana-Khadka G, Jordan M, Ryan S, Leder BZ. The comparison of alendronate and raloxifene after denosumab (CARD) study: A comparative efficacy trial. Osteoporos Int 2024; 35:255-263. [PMID: 37798320 DOI: 10.1007/s00198-023-06932-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/25/2023] [Indexed: 10/07/2023]
Abstract
Denosumab discontinuation results in accelerated bone remodeling, decreased bone mineral density (BMD), and an increased risk of multiple vertebral fractures. Bisphosphonates are at least partially effective at inhibiting these consequences but there have been no randomized clinical trials assessing the efficacy of alternative antiresorptives. PURPOSE The aim of this study was to evaluate the comparative efficacy of alendronate and the SERM, raloxifene, in preventing the post-denosumab high-turnover bone loss. METHODS We conducted an open-label randomized controlled trial in which 51 postmenopausal women at increased risk of fracture were randomized with equal probability to receive 12-months of denosumab 60-mg 6-monthly followed by 12-months of either alendronate 70-mg weekly or raloxifene 60-mg daily. Serum bone remodeling markers were measured at 0,6,12,15,18, and 24 and areal BMD of the distal radius, spine, and hip were measured at 0,12,18 and 24 months. RESULTS After denosumab discontinuation, serum markers of bone remodeling remained suppressed when followed by alendronate, but gradually increased to baseline when followed by raloxifene. In the denosumab-to-alendronate group, denosumab-induced BMD gains were maintained at all sites whereas in the denosumab-to-raloxifene group, BMD decreased at the spine by 2.0% (95% CI -3.2 to -0.8, P = 0.003) and at the total hip by 1.2% (-2.1 to -0.4%, P = 0.008), but remained stable at the femoral neck and distal radius and above the original baseline at all sites. The decreases in spine and total hip BMD in the denosumab-to-raloxifene group (but not the femoral neck or distal radius) were significant when compared to the denosumab-to-alendronate group. CONCLUSIONS These results suggest that after one year of denosumab, one year of alendronate is better able to maintain the inhibition of bone remodeling and BMD gains than raloxifene.
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Affiliation(s)
- Sabashini K Ramchand
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA, USA.
| | - Joy N Tsai
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Hang Lee
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Grace Sassana-Khadka
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Mackenzie Jordan
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Savannah Ryan
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Benjamin Z Leder
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA, USA
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12
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Gani LU, Sritara C, Blank RD, Chen W, Gilmour J, Dhaliwal R, Gill R. Follow-up Bone Mineral Density Testing: 2023 Official Positions of the International Society for Clinical Densitometry. J Clin Densitom 2024; 27:101440. [PMID: 38007875 DOI: 10.1016/j.jocd.2023.101440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
Dual-energy X-ray absorptiometry (DXA) is the gold standard method for measuring bone mineral density (BMD) which is most strongly associated with fracture risk. BMD is therefore the basis for the World Health Organization's densitometric definition of osteoporosis. The International Society for Clinical Densitometry (ISCD) promotes best densitometry practices and its official positions reflect critical review of current evidence by domain experts. This document reports new official positions regarding follow-up DXA examinations based on a systematic review of literature published through December 2022. Adoption of official positions requires consensus agreement from an expert panel following a modified RAND protocol. Unless explicitly altered by the new position statements, prior ISCD official positions remain in force. This update reflects increased consideration of the clinical context prompting repeat examination. Follow-up DXA should be performed with pre-defined objectives when the results would have an impact on patient management. Testing intervals should be individualized according to the patient's age, sex, fracture risk and treatment history. Incident fractures and therapeutic approach are key considerations. Appropriately ordered and interpreted follow-up DXA examinations support diagnostic and therapeutic decision making, thereby contributing to excellent clinical care. Future research should address the complementary roles of clinical findings, imaging and laboratory testing to guide management.
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Affiliation(s)
- Linsey U Gani
- Department of Endocrinology, Changi General Hospital, Singapore.
| | - Chanika Sritara
- Nuclear Medicine Division, Department of Diagnostic and Therapeutic Radiology. Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - WeiWen Chen
- Department of Endocrinology, St Vincent's Hospital Sydney, Australia
| | - Julia Gilmour
- Division of Endocrinology, St Michael's Hospital, Department of Medicine, University of Toronto
| | - Ruban Dhaliwal
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School
| | - Ranjodh Gill
- Department of Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia
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13
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Clifton Goldney D, Pelegrin C, Jerkovich F, Longobardi V, Gonzalez Rodriguez E, Zanchetta MB. Twenty-four months of follow-up in women with rebound-associated vertebral fractures after discontinuation of denosumab: a single-centre case series. Osteoporos Int 2024; 35:165-171. [PMID: 37702746 DOI: 10.1007/s00198-023-06894-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/17/2023] [Indexed: 09/14/2023]
Abstract
Evidence on the management of rebound-associated vertebral fractures after denosumab discontinuation is scarce. This study describes seven patients retreated with denosumab, teriparatide or zoledronate for 24 months. Their bone mineral density remained stable or improved and no new fractures occurred suggesting that all three options might be adequate for their treatment. PURPOSE To describe the densitometric and biochemical changes achieved with osteoactive treatment after 24 months of follow-up in patients who suffered rebound-associated vertebral fractures (RAVFs) after Dmab discontinuation, and to report the occurrence of new vertebral and non-vertebral fractures. METHODS Patients with RAVFs who received retreatment (RT) for 24 months were included. Bone mineral density (BMD) was assessed by dual-energy x-ray absorptiometry at the lumbar spine (LS), femoral neck (FN) and total hip (TH), along with C-terminal cross-linked telopeptide of type I collagen, osteocalcin, and bone alkaline phosphatase. Data were collected at the start of the RT and after 24 months. RESULTS Seven female patients were included. RT consisted in Dmab (n = 3), teriparatide (TPT) (n = 3) and zoledronate (Zol) (n = 1). At 24 months, the mean BMD change was 2.2% at LS, 6.8% at FN and 3.8% at TH in the Dmab group, 7.5% at LS, 1.4% at FN and 3.7% at TH in the TPT group and, 5.0% at LS, 0.6% at FN and 3.9% at TH in the patient with Zol. After 24 months of follow-up, no patient suffered new fractures. CONCLUSION In this series of patients with RAVFs, we did not observe any new fractures and the BMD remained stable after 24 months of RT. Future studies are needed to evaluate the most suitable treatment approach after RAVFs but these preliminary data suggest that all denosumab, zoledronate and teriparatide might be adequate options.
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Affiliation(s)
| | - Carolina Pelegrin
- Instituto de Diagnostico E Investigaciones Metabólicas (IDIM), Buenos Aires, Argentina
| | - Fernando Jerkovich
- Instituto de Diagnostico E Investigaciones Metabólicas (IDIM), Buenos Aires, Argentina
| | - Vanesa Longobardi
- Instituto de Diagnostico E Investigaciones Metabólicas (IDIM), Buenos Aires, Argentina
- Cátedra de Osteología Y Metabolismo Mineral, Universidad del Salvador, Buenos Aires, Argentina
| | - Elena Gonzalez Rodriguez
- Interdisciplinary Center for Bone Diseases, Rheumatology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - María Belén Zanchetta
- Instituto de Diagnostico E Investigaciones Metabólicas (IDIM), Buenos Aires, Argentina.
- Cátedra de Osteología Y Metabolismo Mineral, Universidad del Salvador, Buenos Aires, Argentina.
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14
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Humphrey MB, Russell L, Danila MI, Fink HA, Guyatt G, Cannon M, Caplan L, Gore S, Grossman J, Hansen KE, Lane NE, Ma NS, Magrey M, McAlindon T, Robinson AB, Saha S, Womack C, Abdulhadi B, Charles JF, Cheah JTL, Chou S, Goyal I, Haseltine K, Jackson L, Mirza R, Moledina I, Punni E, Rinden T, Turgunbaev M, Wysham K, Turner AS, Uhl S. 2022 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Rheumatol 2023; 75:2088-2102. [PMID: 37845798 DOI: 10.1002/art.42646] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVE The objective is to update recommendations for prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) for patients with rheumatic or nonrheumatic conditions receiving >3 months treatment with glucocorticoids (GCs) ≥2.5 mg daily. METHODS An updated systematic literature review was performed for clinical questions on nonpharmacologic, pharmacologic treatments, discontinuation of medications, and sequential therapy. Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the certainty of evidence. A Voting Panel achieved ≥70% consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS For adults beginning or continuing >3 months of GC treatment, we strongly recommend as soon as possible after initiation of GCs, initial assessment of fracture risks with clinical fracture assessment, bone mineral density with vertebral fracture assessment or spinal x-ray, and Fracture Risk Assessment Tool if ≥40 years old. For adults at medium, high, or very high fracture risk, we strongly recommend pharmacologic treatment. Choice of oral or intravenous bisphosphonates, denosumab, or parathyroid hormone analogs should be made by shared decision-making. Anabolic agents are conditionally recommended as initial therapy for those with high and very high fracture risk. Recommendations are made for special populations, including children, people with organ transplants, people who may become pregnant, and people receiving very high-dose GC treatment. New recommendations for both discontinuation of osteoporosis therapy and sequential therapies are included. CONCLUSION This guideline provides direction for clinicians and patients making treatment decisions for management of GIOP. These recommendations should not be used to limit or deny access to therapies.
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Affiliation(s)
- Mary Beth Humphrey
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | - Maria I Danila
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Howard A Fink
- Geriatric Research Education and Clinical Center, VA Health Care System, Minneapolis, Minnesota
| | | | - Michael Cannon
- Arthritis Consultants of Tidewater, Virginia Beach, Virginia
| | | | | | | | | | | | - Nina S Ma
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora
| | - Marina Magrey
- Case Western Reserve University, MetroHealth, Cleveland, Ohio
| | | | | | | | | | - Basma Abdulhadi
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | | | - Jonathan T L Cheah
- UMass Memorial Health and UMass Chan Medical School, Worcester, Massachusetts
| | - Sharon Chou
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Itivrita Goyal
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | - Lesley Jackson
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Reza Mirza
- McMaster University, Hamilton, Ontario, Canada
| | - Iram Moledina
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Emma Punni
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | | | - Katherine Wysham
- VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Stacey Uhl
- ECRI Institute, Plymouth Meeting, Pennsylvania
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15
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Humphrey MB, Russell L, Danila MI, Fink HA, Guyatt G, Cannon M, Caplan L, Gore S, Grossman J, Hansen KE, Lane NE, Ma NS, Magrey M, McAlindon T, Robinson AB, Saha S, Womack C, Abdulhadi B, Charles JF, Cheah JTL, Chou S, Goyal I, Haseltine K, Jackson L, Mirza R, Moledina I, Punni E, Rinden T, Turgunbaev M, Wysham K, Turner AS, Uhl S. 2022 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Care Res (Hoboken) 2023; 75:2405-2419. [PMID: 37884467 DOI: 10.1002/acr.25240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 10/28/2023]
Abstract
OBJECTIVE The objective is to update recommendations for prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) for patients with rheumatic or nonrheumatic conditions receiving >3 months treatment with glucocorticoids (GCs) ≥2.5 mg daily. METHODS An updated systematic literature review was performed for clinical questions on nonpharmacologic, pharmacologic treatments, discontinuation of medications, and sequential therapy. Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the certainty of evidence. A Voting Panel achieved ≥70% consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS For adults beginning or continuing >3 months of GC treatment, we strongly recommend as soon as possible after initiation of GCs, initial assessment of fracture risks with clinical fracture assessment, bone mineral density with vertebral fracture assessment or spinal x-ray, and Fracture Risk Assessment Tool if ≥40 years old. For adults at medium, high, or very high fracture risk, we strongly recommend pharmacologic treatment. Choice of oral or intravenous bisphosphonates, denosumab, or parathyroid hormone analogs should be made by shared decision-making. Anabolic agents are conditionally recommended as initial therapy for those with high and very high fracture risk. Recommendations are made for special populations, including children, people with organ transplants, people who may become pregnant, and people receiving very high-dose GC treatment. New recommendations for both discontinuation of osteoporosis therapy and sequential therapies are included. CONCLUSION This guideline provides direction for clinicians and patients making treatment decisions for management of GIOP. These recommendations should not be used to limit or deny access to therapies.
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Affiliation(s)
- Mary Beth Humphrey
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | - Maria I Danila
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Howard A Fink
- Geriatric Research Education and Clinical Center, VA Health Care System, Minneapolis, Minnesota
| | | | - Michael Cannon
- Arthritis Consultants of Tidewater, Virginia Beach, Virginia
| | | | | | | | | | | | - Nina S Ma
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora
| | - Marina Magrey
- Case Western Reserve University, MetroHealth, Cleveland, Ohio
| | | | | | | | | | - Basma Abdulhadi
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | | | - Jonathan T L Cheah
- UMass Memorial Health and UMass Chan Medical School, Worcester, Massachusetts
| | - Sharon Chou
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Itivrita Goyal
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | - Lesley Jackson
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Reza Mirza
- McMaster University, Hamilton, Ontario, Canada
| | - Iram Moledina
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Emma Punni
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | | | - Katherine Wysham
- VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Stacey Uhl
- ECRI Institute, Plymouth Meeting, Pennsylvania
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16
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Affiliation(s)
- Marcella Donovan Walker
- From the Division of Endocrinology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Elizabeth Shane
- From the Division of Endocrinology, Department of Medicine, Columbia University Irving Medical Center, New York
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17
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Anastasilakis AD, Makras P, Polyzos SA, Papapoulos SE. The Five-Year Effect of a Single Zoledronate Infusion on Bone Mineral Density Following Denosumab Discontinuation in Women with Postmenopausal Osteoporosis. Calcif Tissue Int 2023; 113:469-473. [PMID: 37535102 DOI: 10.1007/s00223-023-01119-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 07/12/2023] [Indexed: 08/04/2023]
Abstract
The long-term effects of zoledronate treatment in women with postmenopausal osteoporosis who stop denosumab therapy when they become osteopenic are not known. In a prospective, randomized, controlled clinical trial we previously reported that a single intravenous infusion of zoledronate 5 mg given to such patients 6 months after the last denosumab injection effectively prevents bone loss in the majority of them for up to 3 years. The study was extended for an additional 2 years and included all 19 patients from one Trial Site of the total 27 patients originally randomized in the zoledronate arm. Baseline characteristics of this cohort treated with denosumab for 2.4 ± 0.2 years were not different from those of the whole initial cohort or from the patients who did not participate in this extension. At the end of 5 years 7 patients had become again osteoporotic requiring additional treatment, 9 remained osteopenic while 3 did not complete the study extension. Thus, more than half of the osteoporotic women who became osteopenic with denosumab treatment and stopped it, maintained the BMD gains 5 years after a single zoledronate infusion with no additional treatment. Whether these results are also applicable to patients treated with denosumab for longer periods remains to be established.
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Affiliation(s)
- Athanasios D Anastasilakis
- Department of Endocrinology, 424 Military General Hospital, Ring Road, 564 29 N. Efkarpia, Thessaloniki, Greece.
| | - Polyzois Makras
- Department of Endocrinology and Diabetes, 251 Hellenic Air Force & VA General Hospital, Athens, Greece
- Department of Medical Research, 251 Hellenic Air Force & VA General Hospital, Athens, Greece
| | - Stergios A Polyzos
- First Laboratory of Pharmacology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Socrates E Papapoulos
- Department of Medical Research, 251 Hellenic Air Force & VA General Hospital, Athens, Greece
- Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
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18
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Anastasilakis AD, Makras P, Paccou J, Bisbinas I, Polyzos SA, Papapoulos SE. Similarities and Differences in the Management of Patients with Osteoporotic Vertebral Fractures and Those with Rebound-Associated Vertebral Fractures Following Discontinuation of Denosumab. J Clin Med 2023; 12:5874. [PMID: 37762815 PMCID: PMC10532339 DOI: 10.3390/jcm12185874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/31/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Rebound-associated vertebral fractures (RVFx) following denosumab discontinuation are typically multiple, are commonly associated with acute sharp pain, increase the risk of imminent fractures, and are pathogenetically different from common osteoporotic vertebral fractures (VFx). A clinically relevant question is whether patients with RVFx should be managed differently from patients with osteoporotic VFx. To address this question, we performed a systematic search of the PubMed database, and we reviewed current evidence on the optimal management of patients with RVFx. For pain relief of patients with RVFx, potent analgesics, often opioids, are essential. Information on the effectiveness of braces in these patients is scarce. Vertebroplasty and kyphoplasty are strongly contraindicated as they confer a substantial risk for new VFx. Exercise may be helpful, but again evidence is lacking. In contrast to patients with osteoporotic VFx, in whom initial treatment with bone-forming agents is recommended, patients with RVFx should initiate treatment with potent antiresorptives. To summarize, patients who have sustained RVFx following denosumab discontinuation are at a very high risk for new fractures, especially VFx. The management of such patients requires a multidisciplinary approach that should not be restricted to pain relief and administration of antiosteoporotic medication, but should also include back protection, early mobilization, and appropriate exercise.
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Affiliation(s)
| | - Polyzois Makras
- Department of Endocrinology and Diabetes, 251 Hellenic Air Force & VA General Hospital, 115 25 Athens, Greece;
- Department of Medical Research, 251 Hellenic Air Force & VA General Hospital, 115 25 Athens, Greece;
| | - Julien Paccou
- Department of Rheumatology, University of Lille, 59000 Lille, France;
| | - Ilias Bisbinas
- First Department of Orthopaedics, 424 Military General Hospital, 564 29 Thessaloniki, Greece;
| | - Stergios A. Polyzos
- First Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece;
| | - Socrates E. Papapoulos
- Department of Medical Research, 251 Hellenic Air Force & VA General Hospital, 115 25 Athens, Greece;
- Center for Bone Quality, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
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19
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Iseri K, Mizobuchi M, Winzenrieth R, Humbert L, Saitou T, Kato T, Nakajima Y, Wakasa M, Shishido K, Honda H. Long-Term Effect of Denosumab on Bone Disease in Patients with CKD. Clin J Am Soc Nephrol 2023; 18:1195-1203. [PMID: 37314764 PMCID: PMC10564351 DOI: 10.2215/cjn.0000000000000213] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/06/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND The effect of long-term denosumab therapy and of denosumab discontinuation on the cortical bone of the hip regions in dialysis patients has not been studied. METHODS This retrospective study investigated the cortical and trabecular compartments and estimated strength indices of the hip region, obtained using 3D-SHAPER software, after a maximum of 5 years of denosumab therapy in 124 dialysis patients. A Wilcoxon signed-rank test was used to identify the differences in each parameter before and after denosumab initiation. Similarly, we investigated the changes in these parameters after denosumab discontinuation in 11 dialysis patients. RESULTS Integral and trabecular volumetric bone mineral densities (BMD) were significantly lower at the start of denosumab therapy than those in 1 year before denosumab initiation. After starting denosumab, areal BMD (median change +7.7% [interquartile range (IQR), +4.6 to +10.6]), cortical volumetric BMD (median change +3.4% [IQR, +1.0 to +4.7]), cortical surface BMD (median change +7.1% [IQR, +3.4 to +9.4]), and cortical thickness (median change +3.2% [IQR, +1.8 to +4.9]) showed a significantly higher trend for 3.5 years, which then stabilized at a higher value compared with baseline. A similar trend in the trabecular volumetric BMD (median change +9.8% [IQR, +3.8 to +15.7]) was observed over 2.5 years, with a higher value maintained thereafter. The whole area of the hip region improved after denosumab therapy. Similar trajectories were also found in the estimated strength indices. Conversely, at 1 year after denosumab discontinuation, these 3D parameters and estimated strength indices tended to largely worsen. The lateral aspect of the greater trochanter was the most pronounced location showing volumetric BMD loss. CONCLUSIONS The BMD of both cortical and trabecular components in the hip region was significantly higher after starting denosumab therapy. However, these measurements exhibited a trend of declining substantially after the discontinuation of denosumab.
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Affiliation(s)
- Ken Iseri
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Masahide Mizobuchi
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | | | | | - Tomohiro Saitou
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Tadashi Kato
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yutaka Nakajima
- Internal Medicine, Sekishin-kai Kawasaki Clinic, Kawasaki, Japan
| | - Mikio Wakasa
- Internal Medicine, Sekishin-kai Kawasaki Clinic, Kawasaki, Japan
| | - Kanji Shishido
- Internal Medicine, Sekishin-kai Kawasaki Clinic, Kawasaki, Japan
| | - Hirokazu Honda
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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20
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Thomasius F, Pesta D, Rittweger J. Adjuvant pharmacological strategies for the musculoskeletal system during long-term space missions. Br J Clin Pharmacol 2023. [PMID: 37559171 DOI: 10.1111/bcp.15877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/29/2023] [Accepted: 08/01/2023] [Indexed: 08/11/2023] Open
Abstract
Despite 2 h of daily exercise training, muscle wasting and bone loss are still present after 6-month missions to the international space station. Some crew members lose bone much faster than others. In preparation for missions to the Moon and Mars, space agencies are therefore reviewing their countermeasure portfolios. Here, we discuss the potential of current pharmacological strategies. Bone loss in space is fuelled by bone resorption. Alendronate, an oral bisphosphonate, reduced bone losses in experimental bed rest and space. However, gastrointestinal side effects precluded its further utilization in space. Zoledronate (a potent bisphosphonate), denosumab (RANKL antagonist) and romosozumab (sclerostin antagonist) are all administered via injection. They effectively suppress bone resorption and are routinely prescribed against osteoporosis. Their serious adverse effects, namely, osteonecrosis of the jaw and atypical femur fractures occur very rarely when the usage is limited to 1 or 2 years. Hence, utilization of one of these compounds may outweigh the bone risks of space travelling, in particular in those with high bone resorption rates. Muscle wasting in space is likely due to hampered muscle protein synthesis. Even though this might theoretically be countered by the synthesis-boosting effects of anabolic steroids, the practical grounds for such recommendation are currently weak. Moreover, they reveal their full potential only when combined with an anabolic exercise stimulus, for example, via strength training. It therefore seems that a combination of exercise and pharmacological countermeasures should be considered for musculoskeletal health on the way to the Moon and Mars and back.
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Affiliation(s)
| | - Dominik Pesta
- Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, Germany
- Centre for Endocrinology, Diabetes and Preventive Medicine (CEDP), University Hospital Cologne, Cologne, Germany
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Jörn Rittweger
- Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, Germany
- Department of Pediatrics and Adolescent Medicine, University Hospital Cologne, Cologne, Germany
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21
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Lee CC, Fu SH, Chen HM, Lin JW, Hsu CC, Lin SC, Hwang JS, Yang RS, Wu CH, Wang CY. The real-world adherence of the first-line anti-osteoporosis medications in Taiwan: Visualize the gap between reality and expectations. J Formos Med Assoc 2023; 122 Suppl 1:S55-S64. [PMID: 37302970 DOI: 10.1016/j.jfma.2023.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 04/06/2023] [Accepted: 05/21/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND Adherence to anti-osteoporosis medications (AOMs) is crucial. National Health Insurance (NHI) in Taiwan has its own rules of reimbursement rule for AOMs. The midterm adherence remained inconclusive. Here we investigated the adherence according to the initially used AOMs, for three consecutive years. METHODS The nationwide cohort study from 2008 to 2018, based on Taiwan's National Health Insurance Research Database, included 336,229 patients. Their adherence, indicated by medication possession ratio (MPR), to the initial AOMs was investigated yearly for three consecutive years. The overall MPRs (OMPR), including the switched AOMs, were also calculated in the first year. The Sankey diagram further visualized the patient flows toward different adherence according to the initial AOMs. RESULTS The OMPR in the first year improved if the patients used AOMs with longer dosing intervals. 100%, 68.9%, 40.7%, and 34.0% of the patients started the treatment with zoledronate, denosumab, alendronate, and raloxifene, respectively, had OMPR ≥75% in the first year. In the 3rd year, only 20.89%, 24.13%, and 12.83% of the patients continuously treated with zoledronate, denosumab, and alendronate, respectively, had MPR ≥75%. From the Sankey diagram, we also observed that patients who had poor adherence at one year were inclined to have poor adherence or discontinue antiosteoporosis treatment in the next year. CONCLUSION The initial AOMs and the observed adherence may provide clues for optimizing patient treatment. The real-world adherence in Taiwan was far from satisfactory in our study.
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Affiliation(s)
- Chia-Che Lee
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
| | - Shau-Huai Fu
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan; Department of Orthopedics, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan; Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ho-Min Chen
- Health Data Research Center, National Taiwan University, Taipei, Taiwan
| | - Jou-Wei Lin
- Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Douliu, Yunlin County, Taiwan
| | - Chih-Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, Taiwan; National Center for Geriatrics and Welfare Research, National Health Research Institutes, Yunlin County, Taiwan
| | - Sheng-Chieh Lin
- Department of Orthopedic Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Jawl-Shan Hwang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Rong-Sen Yang
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan; Department of Orthopaedics, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Hsing Wu
- Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Chen-Yu Wang
- National Center for Geriatrics and Welfare Research, National Health Research Institutes, Yunlin County, Taiwan; Department of Pharmacy, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan.
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22
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Coropciuc R, Coopman R, Garip M, Gielen E, Politis C, Van den Wyngaert T, Beuselinck B. Risk of medication-related osteonecrosis of the jaw after dental extractions in patients receiving antiresorptive agents - A retrospective study of 240 patients. Bone 2023; 170:116722. [PMID: 36858337 DOI: 10.1016/j.bone.2023.116722] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 02/16/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023]
Abstract
This study investigated the incidence, risk factors, and outcome of medication-related osteonecrosis of the jaw after dental extractions in patients receiving antiresorptive agents for osteoporosis or bone metastases. 240 patients with a median drug exposure of 43 months were retrospectively studied. The incidence of MRONJ after dental extraction in the osteoporosis cohort was 2.7 % per person-year (95 % CI 1.6-4.6 %) (n = 13/126), and for the bone metastases cohort 26.4 % per person-year (95 % CI 20.4-34.2 %) (n = 58/114). 92 % of MRONJ cases were stage 1. Dental infection as the reason for extraction increased the osteonecrosis risk in the osteoporosis (OR 22.77; 95 % CI 2.85-181.62; p = 0.003) and bone metastases cohorts (OR 2.72; 95 % CI 1.28-5.81; p = 0.010). Using leukocyte and platelet-rich fibrin reduced this risk by 84 % (p = 0.003), as did antibiotics use by 86-93 % (p = 0.013). Within the bone metastases cohort, an interval since last administration of at least 3 months reduced risk of MRONJ (OR 0.83; 95 % CI 0.72-0.97; p = 0.018). Mucosal healing occurred in 11/13 patients (84.6 %; 95 % CI 54.5-98.1 %) with osteoporosis and 31/58 patients (53.4 %; 95 % CI 40.0-66.7 %) with bone metastases. In conclusion, though the MRONJ risk in this selected population taking antiresorptive agents and presenting to the Oral Maxillofacial Surgery clinic for a dental extraction is considerable and higher in those with dental infections, preventive measures such as antibiotics and use of LRPF membranes may significantly reduce that risk.
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Affiliation(s)
- Ruxandra Coropciuc
- Department of Oral and Maxillofacial Surgery, University Hospital of Leuven, Belgium.
| | - Renaat Coopman
- Department of Oral and Maxillofacial and Plastic Surgery, University Hospital of Ghent, Belgium
| | - Melisa Garip
- Department of Oral and Maxillofacial Surgery, University Hospital of Leuven, Belgium
| | - Evelien Gielen
- Department of Geriatrics, University Hospital of Leuven, Belgium
| | - Constantinus Politis
- Department of Oral and Maxillofacial Surgery, University Hospital of Leuven, Belgium
| | | | - Benoit Beuselinck
- Department of Medical Oncology, University Hospital of Leuven, Belgium
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23
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Lerman MA, Francavilla M, Waqar‐Cowles L, Levine MA. Denosumab Treatment Does Not Halt Progression of Bone Lesions in Multicentric Carpotarsal Osteolysis Syndrome. JBMR Plus 2023; 7:e10729. [PMID: 37197321 PMCID: PMC10184019 DOI: 10.1002/jbm4.10729] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/11/2023] [Accepted: 02/01/2023] [Indexed: 02/10/2023] Open
Abstract
Here we report the use of denosumab, a monoclonal antibody against receptor activator of nuclear factor κB ligand (RANKL), as monotherapy for multicentric carpotarsal osteolysis syndrome (MCTO) in an 11.5-year-old male with a heterozygous missense mutation in MAFB (c.206C>T; p.Ser69Leu). We treated the subject with 0.5 mg/kg denosumab every 60-90 days for 47 months and monitored bone and mineral metabolism, kidney function, joint range of motion (ROM), and bone and joint morphology. Serum markers of bone turnover reduced rapidly, bone density increased, and renal function remained normal. Nevertheless, MCTO-related osteolysis and joint immobility progressed during denosumab treatment. Symptomatic hypercalcemia and protracted hypercalciuria occurred during weaning and after discontinuation of denosumab and required treatment with zoledronate. When expressed in vitro, the c.206C>T; p.Ser69Leu variant had increased protein stability and produced greater transactivation of a luciferase reporter under the control of the PTH gene promoter than did wild-type MafB. Based on our experience and that of others, denosumab does not appear to be efficacious for MCTO and carries a high risk of rebound hypercalcemia and/or hypercalciuria after drug discontinuation. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Melissa A. Lerman
- Division of RheumatologyThe Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - Michael Francavilla
- Department of RadiologyWhiddon College of Medicine, University of South AlabamaMobileALUSA
| | - Lindsay Waqar‐Cowles
- Division of RheumatologyThe Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - Michael A. Levine
- Division of Endocrinology and Diabetes and Center for Bone HealthThe Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
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Liebich G, Lamy O, Aubry-Rozier B, Gonzalez-Rodriguez E. Maintenance of bone resorption markers in the low premenopausal range during the year following denosumab discontinuation is associated to bone density preservation. The ReoLaus study. Bone 2023; 172:116764. [PMID: 37062514 DOI: 10.1016/j.bone.2023.116764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/17/2023] [Accepted: 04/11/2023] [Indexed: 04/18/2023]
Abstract
PURPOSE Denosumab discontinuation (DD) is associated with serum C-terminal X-linked telopeptides (sCTX) increase, bone mineral density (BMD) loss and vertebral fractures (VFs) risk increase. We compared clinical characteristics of women losing or not lumbar spine (LS) BMD one-year after DD, and their sCTX values at different time-points. METHODS We included women from the ReoLaus cohort having received ≥2 denosumab 60 mg injections, with three BMD measurements on the same device (before (DXA1), at the end of denosumab treatment (DXA2), and one-year after (DXA3)) and sCTX measured at different time-points. Losers (LS DXA3-DXA2 > 2.8 %) and stable groups were compared. RESULTS 63 postmenopausal women were included (mean age 64.2 ± 9.1 years, 7.9 ± 2.7 denosumab injections). 19 months after last denosumab injection, 65 % had lost LS BMD. Losers were younger, had lower BMD and higher sCTX before denosumab, received more injections and gained more BMD under denosumab, and had higher sCTX after DD. Same proportion of patients received bisphosphonates in both groups, but 11 (all in losers group) received ≥1 zoledronate infusion. Three women developed VFs in the losers group (none in the stable). Mean sCTX at 10 and 19 months were 590 ± 372 versus 221 ± 101, and 598 ± 324 versus 293 ± 157 ng/l, respectively (premenopausal range < 573 ng/l, p < 0.01 for both). LS BMD loss and sCTX levels measured at 10 and 19 months were correlated (r2 = 0.29, p = 0.10, and r2 = 0.16, p < 0.005). CONCLUSION Maintenance of BMD gained with denosumab is associated with sCTX in the low premenopausal range after DD. Whether this could be achieved by regular sCTX monitoring and adjustment of bisphosphonates doses or frequency administration needs to be confirmed by further studies.
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Affiliation(s)
- Giovanni Liebich
- Faculty of Biology and Medicine, Lausanne University, 1015 Lausanne, Switzerland
| | - Olivier Lamy
- Interdisciplinary Center for Bone Diseases, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; Service of Internal Medicine, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Bérengère Aubry-Rozier
- Interdisciplinary Center for Bone Diseases, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Elena Gonzalez-Rodriguez
- Interdisciplinary Center for Bone Diseases, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland.
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25
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Ferrari S, Langdahl B. Mechanisms underlying the long-term and withdrawal effects of denosumab therapy on bone. Nat Rev Rheumatol 2023; 19:307-317. [PMID: 37024711 DOI: 10.1038/s41584-023-00935-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 04/08/2023]
Abstract
Denosumab, a human monoclonal antibody against receptor activator of nuclear factor-κB ligand (RANKL), is a potent inhibitor of osteoclast differentiation and activity. As the first biologic drug used to treat osteoporosis, denosumab has shown potent anti-resorptive properties and anti-fracture efficacy. The effects of this drug are also unique compared with the effects of bisphosphonates: namely, long-term treatment with this drug results in a continuous gain of bone mineral density, whereas withdrawal of the drug results in a transient overshoot in bone turnover and rapid bone loss. Although the mechanisms for these specific effects remain incompletely understood, emerging experimental and clinical data have started to highlight potential biological and pharmacological mechanisms by which denosumab might affect osteoclasts, as well as osteoblasts, and cause both sustained bone gain and bone loss upon treatment cessation. This Perspective discusses those potential mechanisms and the future studies and clinical implications that might ensue from these findings.
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Affiliation(s)
- Serge Ferrari
- Service of Bone Diseases, Department of Medicine, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland.
| | - Bente Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
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Tai TW, Huang CF, Huang HK, Yang RS, Chen JF, Cheng TT, Chen FP, Chen CH, Chang YF, Hung WC, Han DS, Chan DC, Tsai CC, Chen IW, Chan WP, Chang HJ, Hwang JS, Wu CH. Clinical practice guidelines for the prevention and treatment of osteoporosis in Taiwan: 2022 update. J Formos Med Assoc 2023; 122 Suppl 1:S4-S13. [PMID: 36781371 DOI: 10.1016/j.jfma.2023.01.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/15/2023] [Accepted: 01/17/2023] [Indexed: 02/13/2023] Open
Abstract
Osteoporosis greatly increases the risk of fractures. Osteoporotic fractures negatively impact quality of life, increase the burden of care, and increase mortality. Taiwan is an area with a high prevalence of osteoporosis. This updated summary of guidelines has been developed by experts of the Taiwan Osteoporosis Association with the intention of reducing the risks of osteoporotic fractures and improving the quality of care for patients with osteoporosis. The updated guidelines compile the latest evidence to provide clinicians and other healthcare professionals with practical recommendations for the prevention, diagnosis, and management of osteoporosis under clinical settings in Taiwan.
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Affiliation(s)
- Ta-Wei Tai
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Skeleton Materials and Biocompatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chun-Feng Huang
- Division of Family Medicine, En Chu Kong Hospital, New Taipei City, Taiwan; Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Leisure Services Management, Chaoyang University of Technology, Taichung, Taiwan
| | - Huei-Kai Huang
- Department of Family Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Rong-Sen Yang
- Department of Orthopedics, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
| | - Jung-Fu Chen
- Division of Metabolism and Endocrinology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tien-Tsai Cheng
- Division of Rheumatology, Allergy, And Immunology, Chang Gung University and Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Fang-Ping Chen
- Department of Obstetrics and Gynecology, Osteoporosis Prevention and Treatment Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan; Department of Medicine, College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan
| | - Chung-Hwan Chen
- Orthopaedic Research Center, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Regeneration Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Orthopedics, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Orthopedics, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Musculoskeletal Regeneration Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan; Institute of Medical Science and Technology, National Sun Yat-Sen University, Kaohsiung, Taiwan; Graduate Institute of Animal Vaccine Technology, College of Veterinary Medicine, National Pingtung University of Science and Technology, Pingtung, Taiwan; Graduate Institute of Materials Engineering, College of Engineering, National Pingtung University of Science and Technology, Pingtung, Taiwan
| | - Yin-Fan Chang
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Chieh Hung
- Department of Family Medicine, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
| | - Der-Sheng Han
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital BeiHu Branch, Taipei, Taiwan
| | - Ding-Cheng Chan
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Chou Tsai
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - I-Wen Chen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan City, Taiwan
| | - Wing P Chan
- Department of Radiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | | | - Jawl-Shan Hwang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan City, Taiwan.
| | - Chih-Hsing Wu
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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27
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Affiliation(s)
- Susan M Ott
- University of Washington, Seattle, Washington
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