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Sumida K, Shrestha P, Mallisetty Y, Surbhi S, Thomas F, Streja E, Kalantar-Zadeh K, Kovesdy CP. Incident Diuretic Use and Subsequent Risk of Bone Fractures: A Large Nationwide Observational Study of US Veterans. Mayo Clin Proc 2024; 99:913-926. [PMID: 38573302 DOI: 10.1016/j.mayocp.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 04/05/2024]
Abstract
OBJECTIVE To investigate the association of incident use of diuretics with subsequent risk of incident bone fractures. PATIENTS AND METHODS In a nationwide cohort of 863,339 US veterans receiving care from the VA health care system between October 1, 2004, and September 30, 2006, with follow-up through June 30, 2018, we examined the association of incident diuretic use (overall, and separately by thiazide, loop, and potassium-sparing diuretics) with subsequent risk of incident bone fractures using multivariable Cox regression models while minimizing confounding by indication using a target trial emulation approach. RESULTS Patients were 63.3±12.9 years old; 93.5% (n=807,180) were male; and 27.1% (n=233,996) were diabetic. Their baseline estimated glomerular filtration rate was 84.4±16.5 mL/min per 1.73 m2. Among 863,339 patients, 424,386 (49.2%) newly initiated diuretics, of which 77.4% (n=328,524), 22.5% (n=95,457), and 0.1% (n=405) were thiazide, loop, and potassium-sparing diuretic users, respectively. After multivariable adjustments, incident diuretic use (vs non-use) was significantly associated with higher risk of incident fracture (adjusted HR [aHR], 1.14; 95% CI, 1.11 to 1.16). The association was most pronounced for loop diuretics (aHR, 1.39; 95% CI, 1.35 to 1.44) but less evident for thiazide diuretics (aHR, 1.08; 95% CI, 1.06 to 1.10) and was not significant for potassium-sparing diuretics (aHR, 0.97; 95% CI, 0.62 to 1.52). The diuretic-fracture association was more evident in younger (vs older) patients, those with (vs without) corticosteroid use, and those with lower (vs higher) serum sodium levels. CONCLUSION Incident use of diuretics, particularly loop diuretics, was independently associated with higher risk of incident bone fractures. Our findings suggest distinct pathophysiologic contributions of diuretics to bone metabolism and the need for careful attention to skeletal outcomes when initiating diuretics.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Prabin Shrestha
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Yamini Mallisetty
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Satya Surbhi
- Center for Health System Improvement, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Elani Streja
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine School of Medicine, Orange, CA, USA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine School of Medicine, Orange, CA, USA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA; Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA.
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Desbiens L, Khelifi N, Wang Y, Lavigne F, Beaulieu V, Sidibé A, Mac‐Way F. Thiazide Diuretics and Fracture Risk: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. JBMR Plus 2022; 6:e10683. [PMID: 36398110 PMCID: PMC9664541 DOI: 10.1002/jbm4.10683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 11/08/2022] Open
Abstract
Thiazide diuretics are commonly used antihypertensive agents. Until today, whether their use reduces fracture risk remains unclear. Our objective was to conduct a systematic review of thiazide diuretics' effects on fractures and bone mineral density (BMD) in randomized clinical trials (RCT) of adults. MEDLINE, EMBASE, CENTRAL, and the WHO's ICTRP registry were searched from inception to July 31, 2019. Two reviewers assessed studies for eligibility criteria: (i) RCTs; (ii) including adults; (iii) comparing thiazides, alone or in combination; (iv) to placebo or another medication; and (v) reporting fractures or BMD. Conference abstracts and studies comparing thiazides to antiresorptive or anabolic bone therapy were excluded. Bias was assessed using Cochrane Collaboration's Risk of Bias Tool-2. The primary outcome was fracture at any anatomical site. Secondary outcomes were osteoporotic fractures, hip fractures, and BMD at femoral neck, lumbar spine, and/or total hip. Fractures were pooled as risk ratios (RRs) using random-effect models. Prespecified subgroup analyses and post hoc sensitivity analyses were conducted. From 15,712 unique records screened, 32 trials (68,273 patients) met eligibility criteria. Thiazides were associated with decreased fractures at any site (RR = 0.87, 95% confidence interval [CI] 0.77-0.98; I 2 = 0%) and osteoporotic fractures (RR = 0.80; 95% CI 0.69-0.94; I 2 = 0%). Results were consistent in most subgroups and sensitivity analyses. Few studies reported hip fractures, and no association was found between thiazides and this outcome (RR = 0.84; 95% CI 0.67-1.04; I 2 = 0%). Only four studies reported BMD; a meta-analysis was not conducted because BMD reporting was inconsistent. Trials were deemed at low (3 studies, weight = 3%), some concerns (16 studies; 71%), or high (11 studies; 26%) risk of bias for the primary outcome. In conclusion, thiazide diuretics decreases the risk of fractures at any and at osteoporotic sites in a meta-analysis of RCTs. Additional studies are warranted in patients with high fracture risk. © 2022 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)
- Louis‐Charles Desbiens
- CHU de Québec Research CenterL'Hôtel‐Dieu de Québec HospitalQuebecCanada
- Department of Medicine, Faculty of MedicineLaval UniversityQuebecCanada
| | - Nada Khelifi
- CHU de Québec Research CenterL'Hôtel‐Dieu de Québec HospitalQuebecCanada
- Department of Medicine, Faculty of MedicineLaval UniversityQuebecCanada
| | - Yue‐Pei Wang
- CHU de Québec Research CenterL'Hôtel‐Dieu de Québec HospitalQuebecCanada
- Department of Medicine, Faculty of MedicineLaval UniversityQuebecCanada
| | - Felix Lavigne
- CHU de Québec Research CenterL'Hôtel‐Dieu de Québec HospitalQuebecCanada
- Department of Medicine, Faculty of MedicineLaval UniversityQuebecCanada
| | - Véronique Beaulieu
- CHU de Québec Research CenterL'Hôtel‐Dieu de Québec HospitalQuebecCanada
- Department of Medicine, Faculty of MedicineLaval UniversityQuebecCanada
| | - Aboubacar Sidibé
- CHU de Québec Research CenterL'Hôtel‐Dieu de Québec HospitalQuebecCanada
- Department of Medicine, Faculty of MedicineLaval UniversityQuebecCanada
| | - Fabrice Mac‐Way
- CHU de Québec Research CenterL'Hôtel‐Dieu de Québec HospitalQuebecCanada
- Department of Medicine, Faculty of MedicineLaval UniversityQuebecCanada
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Antihypertensive drugs demonstrate varying levels of hip fracture risk: A systematic review and meta-analysis. Injury 2022; 53:1098-1107. [PMID: 34627629 DOI: 10.1016/j.injury.2021.09.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 09/17/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE By aggregating the literature, we evaluated the association between use of specific antihypertensive drugs and the risk of hip fractures compared with nonuse. STUDY DESIGN AND SETTING We systematically searched the Pubmed, Embase, and Cochrane databases from inception of each database until July 30, 2020 to identify articles including patients 18 years of age or older reporting on the association between antihypertensive drugs and the risk of hip fracture. Antihypertensive drugs were restricted to thiazides; beta-blockers; calcium-channel blockers; angiotensin-converting enzyme (ACE) inhibitors; and angiotensin receptor blockers. Nonusers encompass all patients that are not using the specific antihypertensive drug that has been reported. Unadjusted odds ratios with 95% confidence intervals (CIs) of the association between antihypertensive drug use and hip fractures were reported. Meta-analysis was performed when a minimum of five studies were identified for each antihypertensive drug class. Quality assessment was done using ROBINS-I tool. The GRADE approach was used to evaluate the certainty of the evidence. RESULTS Of 962 citations, 22 observational studies were included; 9 studies had a cohort design and 13 studies were case-control studies. No randomized controlled trials were identified. We found very low certainty of evidence that both thiazides (pooled odds ratio: 0.85, 95% CI 0.73 to 0.99, p = 0.04) as well as beta-blockers (pooled odds ratio: 0.88, 95% CI 0.79 to 0.98, p = 0.02) were associated with a reduced hip fracture risk as compared to specific nonuse. One study, reporting on angiotensin receptor blockers, also suggested a protective effect for hip fractures, whereas we found conflicting findings in four studies for calcium-channel blockers and in two studies for ACE inhibitors. CONCLUSION Among 22 observational studies, we found very low certainty of evidence that, compared to specific nonuse of antihypertensive drugs, use of thiazides, beta-blockers, and angiotensin receptor blockers were associated with a reduced protective hip fracture risk, while conflicting findings for calcium-channel blockers and ACE inhibitors were found. Given the low quality of included studies, further research -randomized controlled trials- are needed to definitively assess the causal relationship between specific antihypertensive drug classes and (relatively infrequent) hip fractures.
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Charkos TG, Liu Y, Yang S. Thiazide diuretics and risk of hip fracture: A Bayesian meta-analysis of cohort studies. GLOBAL EPIDEMIOLOGY 2020. [DOI: 10.1016/j.gloepi.2020.100025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Mortensen SJ, Mohamadi A, Wright CL, Chan JJ, Weaver MJ, von Keudell A, Nazarian A. Medications as a Risk Factor for Fragility Hip Fractures: A Systematic Review and Meta-analysis. Calcif Tissue Int 2020; 107:1-9. [PMID: 32253446 DOI: 10.1007/s00223-020-00688-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/26/2020] [Indexed: 12/13/2022]
Abstract
Fragility hip fractures and their associated morbidity and mortality pose a global healthcare problem. Several pharmaceutical products have been postulated to alter bone architecture and contribute to fragility hip fractures. We searched four electronic databases from inception to September 2017. Inclusion criteria were the following: (1) adult patients with fragility hip fractures, (2) full text in English, (3) minimum one-year follow-up, and (4) reporting of at least one risk factor. To minimize heterogeneity among the studies, we performed subgroup analyses. Whenever heterogeneity remained significant, we employed random effect meta-analysis for data pooling. Thirty-eight studies were included, containing 1,244,155 subjects and 188,966 cases of fragility hip fractures. Following medications were significantly associated with fragility hip fractures: Antidepressants (OR 2.07, 95% CI 1.98-2.17), antiparkinsonian drugs (OR 2.21, 95% CI 1.15-4.24), antipsychotic drugs (OR 2.0, 95% CI 1.50-2.66), anxiolytic drugs (OR 1.44, 95% CI 1.19-1.75), benzodiazepines (OR 1.84, 95% CI 1.26-2.69), sedatives (OR 1.33, 95% CI 1.14-1.54), systemic corticosteroids (OR 1.65, 95% CI 1.37-1.99), H2 antagonists (OR 1.21, 95% CI 1.18-1.24), proton pump inhibitors (OR 1.41, 95% CI 1.16-1.71), and thyroid hormone (OR 1.29, 95% CI 1.13-1.47). Hormone replacement therapy with estrogen (HRT) was associated with decreased risk of hip fracture (OR 0.80, 95% CI 0.65-0.98). There are several medications associated with sustaining a fragility hip fracture. Medical interventions should be considered for patients on these medications, including information about osteoporosis and fracture prevention.
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Affiliation(s)
- Sharri J Mortensen
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Amin Mohamadi
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Casey L Wright
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Jimmy J Chan
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael J Weaver
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA, USA
| | - Arvind von Keudell
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA, USA
| | - Ara Nazarian
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia
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Charkos TG, Liu Y, Jin L, Yang S. Thiazide Use and Fracture Risk: An updated Bayesian Meta-Analysis. Sci Rep 2019; 9:19754. [PMID: 31874989 PMCID: PMC6930249 DOI: 10.1038/s41598-019-56108-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 12/05/2019] [Indexed: 12/16/2022] Open
Abstract
The association between thiazide use and fracture risk is still controversial. We conducted an updated meta-analysis on the association between thiazide use and fracture risk. We systematically searched PubMed, Embase, and Cochrane library databases for all types of human studies, including observational and experimental studies that were published up until July 2019. We also manually searched the reference lists of relevant studies. The pooled relative risks (RRs) with 95% credible interval (CrI) were calculated using a Bayesian hierarchical random effect model. A total of 19 case-control (N = 496,568 subjects) and 21 cohort studies (N = 4,418,602 subjects) were included in this meta-analysis. The pooled RR for fractures associated with thiazide use was 0.87 (95% CrI: 0.70–0.99) in case-control and 0.95 (95% CrI: 0.85–1.08) in cohort studies. The probabilities that thiazide use reduces any fracture risk by more than 0% were 93% in case-control studies and 72% in cohort studies. Significant heterogeneity was found for both case-control (p < 0.001, I2 = 75%) and cohort studies (p < 0.001, I2 = 97.2%). Thiazide use was associated with reduced fracture risk in case-control studies, but not in cohort studies. The associations demonstrated in case-control studies might be driven by inherent biases, such as selection bias and recall bias. Thus, thiazide use may not be a protective factor for fractures.
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Affiliation(s)
- Tesfaye Getachew Charkos
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, 130021, Jilin, China
| | - Yawen Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, 130021, Jilin, China
| | - Lina Jin
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, 130021, Jilin, China
| | - Shuman Yang
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, 130021, Jilin, China.
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Wang J, Su K, Sang W, Li L, Ma S. Thiazide Diuretics and the Incidence of Osteoporotic Fracture: A Systematic Review and Meta-Analysis of Cohort Studies. Front Pharmacol 2019; 10:1364. [PMID: 31824314 PMCID: PMC6881387 DOI: 10.3389/fphar.2019.01364] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 10/28/2019] [Indexed: 01/29/2023] Open
Abstract
Background: Thiazide diuretics may improve bone mineral density. However, results are inconsistent for studies evaluating the association between thiazides and risk of osteoporotic fracture. We performed an updated meta-analysis of cohort studies to determine the association between thiazides use and fracture risk. Methods: Relevant studies were identified via systematic search of PubMed and Embase. A random-effect model was used for meta-analysis. Subgroup analyses were performed to explore the potential influences of study characteristics on the outcome. Results: Seventeen cohort studies with 3,537,504 participants were included. The pooled results showed that use of thiazide diuretics at baseline did not significantly affect the risk of overall osteoporotic fracture incidence as compared with controls (risk ratio [RR]: 0.96, 95% confidence interval [CI]: 0.83 to 1.09, p = 0.51) with significant heterogeneity (p for Cochrane’s Q test < 0.001, I2 = 90%). Results of subgroup analyses indicated that general status of the participants may be an important determinant for the association between thiazide diuretics and subsequent risk of osteoporotic fracture. Use of thiazide diuretics was associated with significantly reduced risk of fracture in patients with acute status including new-onset stroke or spinal cord injury (RR: 0.70, 95% CI: 0.57 to 0.86, p < 0.001), but not in those with good conditions such as community-dwelling population or hypertensive patients (p for subgroup difference = 0.02). Conclusions: Use of thiazide diuretics is not associated with significantly affected risk of overall osteoporotic fracture. However, the association may be different according to the general status of the participants.
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Affiliation(s)
- Jun Wang
- The Second Department of Orthopedics, Cangzhou Central Hospital, Cangzhou, China
| | - Ke Su
- The Second Department of Orthopedics, Cangzhou Central Hospital, Cangzhou, China
| | - Weihua Sang
- The Second Department of Orthopedics, Cangzhou Central Hospital, Cangzhou, China
| | - Longjie Li
- The Second Department of Orthopedics, Cangzhou Central Hospital, Cangzhou, China
| | - Shiyun Ma
- The Second Department of Orthopedics, Cangzhou Central Hospital, Cangzhou, China
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Cheng L, Zhang K, Zhang Z. Effectiveness of thiazides on serum and urinary calcium levels and bone mineral density in patients with osteoporosis: a systematic review and meta-analysis. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:3929-3935. [PMID: 30532521 PMCID: PMC6241760 DOI: 10.2147/dddt.s179568] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective Osteoporosis is the most common metabolic bone disease and a major public health problem worldwide. Thiazides are widely used as antihypertensive agents with good tolerability and efficacy. Furthermore, thiazides have long been regarded as candidates for the prevention of postmenopausal bone loss. However, there is insufficient evidence that thiazides have a sustained beneficial effect on preserving bone mass and preventing osteoporosis to date. Materials and methods We searched the PubMed, the Cochrane Library, and Embase in June 2018 for randomized controlled trials on the use of thiazides to treat osteoporosis. Continuous outcomes are presented as the standardized mean difference (SMD) and 95% CI. Furthermore, P-values <0.05 were considered significant. Results Five trials with 756 patients were randomly assigned in the five trials included in this meta-analysis. Serum calcium level was higher in the thiazide group than in the control group (SMD 0.33, 95% CI [0.16, 0.50]), and urinary calcium level was significantly lower in the thiazide group (SMD −0.35, 95% CI [−0.52, −0.17]). There was no significant difference in bone mineral density between the two groups (SMD 0.19, 95% CI [−0.16, 0.54]). Conclusion Thiazides might play a role in preserving bone mass and be effective in the prevention and treatment of osteoporosis. Future high-quality trials are needed to confirm our findings in the future.
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Affiliation(s)
- Lei Cheng
- Department of Thyroid Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Keyan Zhang
- Department of Thyroid Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Zhenyong Zhang
- The Second Department of Clinical Oncology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China,
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Xiao X, Xu Y, Wu Q. Thiazide diuretic usage and risk of fracture: a meta-analysis of cohort studies. Osteoporos Int 2018; 29:1515-1524. [PMID: 29574519 DOI: 10.1007/s00198-018-4486-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 03/12/2018] [Indexed: 11/29/2022]
Abstract
UNLABELLED Inconsistent findings in regard to association between thiazide diuretic use and the risk of fracture have been reported during the past decade. This updated meta-analysis, which pooled data from 11 qualified prospective designed studies, found that thiazides have a significant protective effect on fracture risk. INTRODUCTION An updated comprehensive meta-analysis examine the association between thiazide diuretic use and therisk of fracture is needed. METHODS Cohort studies regarding thiazide diuretic exposure and the risk of fracture, published from inception to May 1 2017, were identified through MEDLINE, EMBASE, SCOPUS, and the Cochrane Database of Systematic Reviews. The literature search, study selection, study appraisal, and data extraction were pre-defined in the protocol and were independently conducted by two investigators. Due to the heterogeneity of the original studies, a random effects model was used to pool the confounder-adjusted relative risk (RR). RESULTS Eleven eligible cohort studies involving 2,193,160 participants were included for analysis. Overall, thiazide diuretic users, as compared with non-users, had a significant 14% reduction in the risk of all fractures (relative risk [RR], 0.86; 95% confidence interval [CI], 0.80-0.93; p = 0.009) and an 18% reduction in the risk of hip fracture (RR, 0.82; 95%CI, 0.80-0.93; p = 0.009). However, the effect size associated with thiazide use became slightly weaker when the analysis was limited to only high-quality original studies (quality score > 8) (RR, 0.89; 95%CI, 0.80-0.99; p = 0.005), studies with a larger sample size (> 10,000) (RR, 0.90; 95%CI, 0.80-1.00; p = 0.002), and studies published after 2007 (RR, 0.92; 95%CI, 0.82-1.02; p = 0.001). CONCLUSION Our findings indicate that thiazide diuretic use may convey a decreased risk of fracture and as such, the protective effect of this class of medicine should be considered when prescribing thiazide diuretics in clinical practice.
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Affiliation(s)
- X Xiao
- Nevada Institute of Personalized Medicine, University of Nevada Las Vegas, 4505 Maryland Parkway, Las Vegas, NV, 89154-4009, USA
- Department of Environmental and Occupational Health, School of Community Health Sciences, University of Nevada Las Vegas, 4505 Maryland Parkway, Las Vegas, NV, 89154-4009, USA
| | - Y Xu
- Nevada Institute of Personalized Medicine, University of Nevada Las Vegas, 4505 Maryland Parkway, Las Vegas, NV, 89154-4009, USA
- Department of Environmental and Occupational Health, School of Community Health Sciences, University of Nevada Las Vegas, 4505 Maryland Parkway, Las Vegas, NV, 89154-4009, USA
| | - Q Wu
- Nevada Institute of Personalized Medicine, University of Nevada Las Vegas, 4505 Maryland Parkway, Las Vegas, NV, 89154-4009, USA.
- Department of Environmental and Occupational Health, School of Community Health Sciences, University of Nevada Las Vegas, 4505 Maryland Parkway, Las Vegas, NV, 89154-4009, USA.
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De Vecchis R, Ariano C, Di Biase G, Noutsias M. Thiazides and Osteoporotic Spinal Fractures: A Suspected Linkage Investigated by Means of a Two-Center, Case-Control Study. J Clin Med Res 2017; 9:943-949. [PMID: 29038673 PMCID: PMC5633096 DOI: 10.14740/jocmr3193w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 09/22/2017] [Indexed: 01/23/2023] Open
Abstract
Background An alleged association of chronic use of thiazide diuretics with an increased risk of bone fragility fractures has been highlighted by a relatively recent prospective cohort study. However, the concept that thiazides exert a beneficial effect on osteoporosis is still a predominant view. This effect would be mediated by the decrease in renal clearance of calcium ions, a pharmacological feature recognized for a long time now to this class of drugs, as opposed to the increase in calcium urinary excretion attributed instead to loop diuretics, i.e. furosemide and similar drugs. The purpose of this retrospective study was to attempt to clarify whether regular use of thiazide diuretics as antihypertensive therapeutics is associated with a significantly increased risk of osteoporotic fractures in female patients aged 65 or over. Methods In this two-center retrospective study, we followed up a cohort of female patients with (n = 80) and without (n = 158) thiazide-induced hyponatremia. Results A total of 48 osteoporotic fractures were recorded during a median follow-up period of 57.5 months. By means of univariate regression analysis, an association was found between thiazide-induced hyponatremia and increased risk of vertebral fractures (odds ratio (OR): 7.6; 95% confidence interval (CI): 3.755 - 15.39; P < 0.0001). Multivariate regression analysis, however, showed that age (OR: 1.823; 95% CI: 1.211 - 2.743) and body mass index (OR: 0.156; 95% CI: 0.038 - 0.645) were the only independent predictors of osteoporotic fractures. No association of a history of thiazide-induced hyponatremia and risk of fracture was noticeable in the final model. Conclusions Because thiazide-induced hyponatremia was associated with spinal fractures in univariate but not multivariate analysis, a possible explanation is that hyponatremia may be a confounder of the relation between body mass and spinal fractures. Indeed, reduced body mass especially among elderly women with small body build may confer heightened risk of thiazide-induced hyponatremia because of decreased bone sodium available for exchange with the serum sodium. Thus, occurrence of hyponatremia could only serve as an indirect surrogate marker for osteoporosis risk.
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Affiliation(s)
- Renato De Vecchis
- Cardiology Unit, Presidio Sanitario Intermedio "Elena d'Aosta", via Cagnazzi 29, 80137 Napoli, Italy
| | - Carmelina Ariano
- Cardiology Unit, Presidio Sanitario Intermedio "Elena d'Aosta", via Cagnazzi 29, 80137 Napoli, Italy.,Division of Cardiology, Casa di Cura "Sollievo della Sofferenza", viale Cappuccini 2, 71013 San Giovanni Rotondo, Italy
| | - Giuseppina Di Biase
- Division of Geriatrics, Neurorehabilitation Unit, Clinic "S. Maria del Pozzo", via Pomigliano 40, 80049 Somma Vesuviana, Italy
| | - Michel Noutsias
- Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Straße 40, D-06120 Halle, Germany
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Lin SM, Yang SH, Cheng HY, Liang CC, Huang HK. Thiazide diuretics and the risk of hip fracture after stroke: a population-based propensity-matched cohort study using Taiwan's National Health Insurance Research Database. BMJ Open 2017; 7:e016992. [PMID: 28963293 PMCID: PMC5623561 DOI: 10.1136/bmjopen-2017-016992] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES This study aimed to investigate the association between thiazide use and the risk of hip fracture after stroke. SETTING A population-based, propensity-matched cohort study was conducted on the basis of Taiwan's National Health Insurance Research Database. PARTICIPANTS Patients with newly diagnosed ischaemic stroke between 2000 and 2011 were included. After propensity score matching, 7470 patients were included, of whom 3735 received thiazides and 3735 did not. OUTCOME MEASURES HRs for developing hip fractures within 2 years after stroke were calculated using Cox proportional hazards regression model with adjustments for sociodemographic and coexisting medical conditions. RESULTS Overall, patients using thiazides after stroke had a lower risk of hip fracture than those not using thiazides (8.5 vs 13.9 per 1000 person-years, adjusted HR=0.64, 95% CI 0.46 to 0.89, p=0.007). Further sensitivity analysis based on the duration of thiazide use revealed that the risk of hip fracture tended to decrease as the duration of exposure of thiazides increased. However, the effect was significant only in patients with long-term use of thiazides (using thiazides for >365 days within 2 years after stroke), with a 59% reduction in the risk of hip fracture when compared with patients not using thiazide (adjusted HR=0.41, 95% CI 0.22 to 0.79, p=0.008). CONCLUSIONS The long-term use of thiazides is associated with a decreased risk of hip fracture after stroke.
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Affiliation(s)
- Shu-Man Lin
- Department of Physical Medicine and Rehabilitation, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - Shih-Hsien Yang
- Department of Physical Medicine and Rehabilitation, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Hung-Yu Cheng
- Department of Physical Medicine and Rehabilitation, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - Chung-Chao Liang
- Department of Physical Medicine and Rehabilitation, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - Huei-Kai Huang
- Department of Family Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
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12
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Paik JM, Kim SC, Feskanich D, Choi HK, Solomon DH, Curhan GC. Gout and Risk of Fracture in Women: A Prospective Cohort Study. Arthritis Rheumatol 2017; 69:422-428. [PMID: 27589491 DOI: 10.1002/art.39852] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 08/18/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Uric acid may be linked to bone health through its antioxidant or prooxidant effects, thereby affecting bone resorption and formation, or through its dual inhibition of vitamin D activation and parathyroid hormone production. Results of prior studies on the relationship between uric acid and bone mineral density have been conflicting. This prospective study was undertaken to examine the relationship between gout, a disease characterized by hyperuricemia and inflammation, and risk of hip or wrist fracture in women. METHODS We conducted a prospective observational study of gout and risk of incident wrist and hip fracture in women participating in the Nurses' Health Study (n = 103,799 at baseline, with 14 years of follow-up for the wrist fracture analysis and 22 years of follow-up for the hip fracture analysis). Gout history and incident cases of wrist and hip fracture were assessed by biennial questionnaire. Cox proportional hazards models were used to simultaneously adjust for potential confounders. RESULTS In this cohort, there were 3,769 incident wrist fractures (1990-2004) and 2,147 incident hip fractures (1990-2012), with 107 wrist fractures and 117 hip fractures occurring in participants with gout. In those women with a history of gout compared with women without gout, the multivariable-adjusted relative risk of wrist fracture was 1.12 (95% confidence interval [95% CI] 0.92-1.36) and the multivariable-adjusted relative risk of hip fracture was 1.38 (95% CI 1.14-1.68). CONCLUSION In women, a history of gout is associated with a modestly increased risk of hip fracture, but not significantly associated with a risk of wrist fracture.
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Affiliation(s)
- Julie M Paik
- Brigham and Women's Hospital, Harvard Medical School, and Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Seoyoung C Kim
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Diane Feskanich
- Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Hyon K Choi
- Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel H Solomon
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Gary C Curhan
- Brigham and Women's Hospital, Harvard Medical School, and Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Thiazide diuretics and the risk of osteoporotic fractures in hypertensive patients. Results from the Swedish Primary Care Cardiovascular Database. J Hypertens 2017; 35:188-197. [DOI: 10.1097/hjh.0000000000001124] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Paik JM, Rosen HN, Gordon CM, Curhan GC. Diuretic Use and Risk of Vertebral Fracture in Women. Am J Med 2016; 129:1299-1306. [PMID: 27542612 PMCID: PMC5118092 DOI: 10.1016/j.amjmed.2016.07.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 07/09/2016] [Accepted: 07/12/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Vertebral fracture is the most common type of osteoporotic fracture. While thiazide diuretics, which are commonly prescribed for the treatment of hypertension, decrease calciuria, they may also induce hyponatremia, which has been associated with increased vertebral fracture risk. Loop diuretics increase calciuria, which would reduce bone mineral density and increase vertebral fracture risk, but they rarely cause hyponatremia. Recent studies on diuretics and fractures did not include or specifically examine vertebral fracture. The few studies of diuretics and vertebral fracture have been limited by cases defined by self-report or administrative data, relatively small number of cases, study design that was not prospective, and lack of long-term follow-up with updated information on diuretic use. METHODS We conducted a prospective cohort study of thiazide diuretic use, loop diuretic use, and risk of incident clinical vertebral fracture in 55,780 women, 55-82 years of age, participating in the Nurses' Health Study, without a prior history of any fracture. Diuretic use was assessed by questionnaire every 4 years. Self-reported vertebral fracture was confirmed by medical record review. Cox proportional-hazards models were used to simultaneously adjust for potential confounders. RESULTS Our analysis included 420 incident vertebral fracture cases documented between 2002 and 2012. The multivariate-adjusted relative risk of clinical vertebral fracture for women taking thiazides compared with women not taking thiazides was 1.47 (95% confidence interval, 1.18-1.85). The multivariate adjusted relative risk of vertebral fracture for women taking loop diuretics compared with women not taking loop diuretics was 1.59 (95% confidence interval, 1.12-2.25). CONCLUSION Thiazide diuretics and loop diuretics are each independently associated with increased risk of vertebral fracture in women.
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Affiliation(s)
- Julie M. Paik
- Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
- Renal Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Harold N. Rosen
- Endocrinology Division, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Catherine M. Gordon
- Division of Adolescent and Transition Medicine, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Gary C. Curhan
- Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
- Renal Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA
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15
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Zaheer S, de Boer I, Allison M, Brown JM, Psaty BM, Robinson-Cohen C, Ix JH, Kestenbaum B, Siscovick D, Vaidya A. Parathyroid Hormone and the Use of Diuretics and Calcium-Channel Blockers: The Multi-Ethnic Study of Atherosclerosis. J Bone Miner Res 2016; 31:1137-45. [PMID: 26748479 PMCID: PMC5424889 DOI: 10.1002/jbmr.2779] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 12/21/2015] [Accepted: 01/04/2016] [Indexed: 01/05/2023]
Abstract
Thiazide diuretic (TZ) use is associated with higher bone mineral density, whereas loop diuretic (LD) use is associated with lower bone density and incident fracture. Dihydropyridine-sensitive calcium channels are expressed on parathyroid cells and may play a role in parathyroid hormone (PTH) regulation. The potential for diuretics and calcium-channel blockers (CCBs) to modulate PTH and calcium homeostasis may represent a mechanism by which they influence skeletal outcomes. We hypothesized that the use of LD and dihydropyridine CCBs is associated with higher PTH, and TZ use is associated with lower PTH. We conducted cross-sectional analyses of participants treated for hypertension in the Multi-Ethnic Study of Atherosclerosis who did not have primary hyperparathyroidism or chronic kidney disease (n = 1888). We used adjusted regression models to evaluate the independent association between TZ, LD, and CCB medication classes and PTH. TZ use was associated with lower PTH when compared with non-TZ use (44.4 versus 46.9 pg/mL, p = 0.02), whereas the use of LD and CCBs was associated with higher PTH when compared with non-users of each medication class (LD: 60.7 versus 45.5 pg/mL, p < 0.0001; CCB: 49.5 versus. 44.4 pg/mL, p < 0.0001). Adjusted regression models confirmed independent associations between TZ use and lower PTH (β = -3.2 pg/mL, p = 0.0007), and LD or CCB use and higher PTH (LD: β = +12.0 pg/mL, p < 0.0001; CCB: +3.7 pg/mL, p < 0.0001). Among CCB users, the use of dihydropyridines was independently associated with higher PTH (β = +5.0 pg/mL, p < 0.0001), whereas non-dihydropyridine use was not (β = +0.58 pg/mL, p = 0.68). We conclude that in a large community-based cohort with normal kidney function, TZ use is associated with lower PTH, whereas LD and dihydropyridine CCB use is associated with higher PTH. These associations may provide a mechanistic explanation linking use of these medications to the development of skeletal outcomes. © 2016 American Society for Bone and Mineral Research.
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Affiliation(s)
- Sarah Zaheer
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ian de Boer
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Matthew Allison
- Division of Preventive Medicine, University of California, San Diego, CA, USA
| | - Jenifer M Brown
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Bruce M Psaty
- Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle, WA, USA
| | - Cassianne Robinson-Cohen
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
- Kidney Research Institute, University of Washington, Seattle, WA, USA
| | - Joachim H Ix
- Division of Nephrology-Hypertension, University of California, San Diego, CA, USA
| | - Bryan Kestenbaum
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
- Kidney Research Institute, University of Washington, Seattle, WA, USA
| | | | - Anand Vaidya
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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16
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Kruse C, Eiken P, Vestergaard P. Optimal age of commencing and discontinuing thiazide therapy to protect against fractures. Osteoporos Int 2016; 27:1875-85. [PMID: 26659068 DOI: 10.1007/s00198-015-3451-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 12/02/2015] [Indexed: 11/28/2022]
Abstract
UNLABELLED A study of national Danish patient data with regard to thiazide diuretics vs. non-treatment. We find that after age 83 years, thiazides increase the 10-year risk of major fractures. We also find that thiazides can be stopped after 63 years old to possibly protect against fracture occurrence. INTRODUCTION The purpose of this study was to retrospectively examine the optimal age for commencing and discontinuing thiazide therapy to protect from osteoporotic fractures. METHODS A population-based, retrospective matched cohort study was done using national data of 2.93 million Danish subjects. Ten-year crude and adjusted age-grouped hazard ratios (HRs) of fracture occurrence were stratified by age of commencing thiazides compared to non-exposure. Separate analyses were done on Anatomical Therapeutic Chemical Classification System (ATC) codes C03AA and C03AA + C03AB compiled. Ten-year crude HRs of fracture occurrence for discontinuing vs. continuing thiazides were estimated and stratified by age for the two groups. RESULTS For C03AB alone (97.1 % of thiazide prescriptions), adjusted 10-year HRs of fracture occurrence were significantly increased for thiazide commencement after age 83 years and comparable to non-exposure for commencement between ages 50 and 83 years. For C03AA + C03AB, 10-year adjusted HRs of fracture occurrence were significantly increased from ages 73 years and upwards. Crude 10-year HRs of fracture occurrence were significantly decreased for discontinuing vs. continuing thiazides at or after age 63 years for C03AB and age 77 years for C03AA + C03AB. CONCLUSIONS No significantly protective effect of thiazides was found on fracture occurrence compared to non-users, but evidence that thiazides increase the 10-year adjusted HR risk of fractures if prescribed after the age of 83 years for C03AB and 73 years for C03AA + C03AB. Discontinuing thiazides at or after age 63 years for C03AB or 77 years for C03AA & C03AB significantly decreases the 10-year risk of fractures compared to continuing thiazides. Further prospective studies are warranted.
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Affiliation(s)
- C Kruse
- Department of Endocrinology, Aalborg University Hospital, Hobrovej 19, 9100, Aalborg, Denmark.
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark.
| | - P Eiken
- Department of Cardiology, Nephrology and Endocrinology, Nordsjaellands Hospital, Hilleroed, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - P Vestergaard
- Department of Endocrinology, Aalborg University Hospital, Hobrovej 19, 9100, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
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17
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Carbone LD, Hovey KM, Andrews CA, Thomas F, Sorensen MD, Crandall CJ, Watts NB, Bethel M, Johnson KC. Urinary Tract Stones and Osteoporosis: Findings From the Women's Health Initiative. J Bone Miner Res 2015; 30:2096-102. [PMID: 25990099 PMCID: PMC5618440 DOI: 10.1002/jbmr.2553] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 05/07/2015] [Accepted: 05/10/2015] [Indexed: 12/13/2022]
Abstract
Kidney and bladder stones (urinary tract stones) and osteoporosis are prevalent, serious conditions for postmenopausal women. Men with kidney stones are at increased risk of osteoporosis; however, the relationship of urinary tract stones to osteoporosis in postmenopausal women has not been established. The purpose of this study was to determine whether urinary tract stones are an independent risk factor for changes in bone mineral density (BMD) and incident fractures in women in the Women's Health Initiative (WHI). Data were obtained from 150,689 women in the Observational Study and Clinical Trials of the WHI with information on urinary tract stones status: 9856 of these women reported urinary tract stones at baseline and/or incident urinary tract stones during follow-up. Cox regression models were used to determine the association of urinary tract stones with incident fractures and linear mixed models were used to investigate the relationship of urinary tract stones with changes in BMD that occurred during WHI. Follow-up was over an average of 8 years. Models were adjusted for demographic and clinical factors, medication use, and dietary histories. In unadjusted models there was a significant association of urinary tract stones with incident total fractures (HR 1.10; 95% CI, 1.04 to 1.17). However, in covariate adjusted analyses, urinary tract stones were not significantly related to changes in BMD at any skeletal site or to incident fractures. In conclusion, urinary tract stones in postmenopausal women are not an independent risk factor for osteoporosis.
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Affiliation(s)
- Laura D Carbone
- Subspecialty Service, Department of Veterans Affairs Medical Center, Augusta, GA, USA.,Department of Medicine, Section of Rheumatology, Georgia Regents University, Augusta, GA, USA
| | - Kathleen M Hovey
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Christopher A Andrews
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Fridtjof Thomas
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mathew D Sorensen
- Division of Urology, VA Puget Sound Health Care System, Department of Veterans Affairs Medical Center, Seattle, WA, USA.,Department of Urology, School of Medicine, University of Washington, Seattle, WA, USA
| | - Carolyn J Crandall
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Nelson B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA
| | - Monique Bethel
- Subspecialty Service, Department of Veterans Affairs Medical Center, Augusta, GA, USA.,Department of Medicine, Section of Rheumatology, Georgia Regents University, Augusta, GA, USA
| | - Karen C Johnson
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
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18
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Mirza F, Canalis E. Management of endocrine disease: Secondary osteoporosis: pathophysiology and management. Eur J Endocrinol 2015; 173:R131-51. [PMID: 25971649 PMCID: PMC4534332 DOI: 10.1530/eje-15-0118] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 05/12/2015] [Indexed: 12/14/2022]
Abstract
Osteoporosis is a skeletal disorder characterized by decreased mass and compromised bone strength predisposing to an increased risk of fractures. Although idiopathic osteoporosis is the most common form of osteoporosis, secondary factors may contribute to the bone loss and increased fracture risk in patients presenting with fragility fractures or osteoporosis. Several medical conditions and medications significantly increase the risk for bone loss and skeletal fragility. This review focuses on some of the common causes of osteoporosis, addressing the underlying mechanisms, diagnostic approach and treatment of low bone mass in the presence of these conditions.
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Affiliation(s)
- Faryal Mirza
- Division of Endocrinology and MetabolismDepartments of MedicineOrthopaedic SurgeryUConn Musculoskeletal Institute, UConn Health, 263 Farmington Avenue, Farmington, Connecticut 06030-5456, USA
| | - Ernesto Canalis
- Division of Endocrinology and MetabolismDepartments of MedicineOrthopaedic SurgeryUConn Musculoskeletal Institute, UConn Health, 263 Farmington Avenue, Farmington, Connecticut 06030-5456, USA Division of Endocrinology and MetabolismDepartments of MedicineOrthopaedic SurgeryUConn Musculoskeletal Institute, UConn Health, 263 Farmington Avenue, Farmington, Connecticut 06030-5456, USA
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19
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Caudarella R, Vescini F, Rizzoli E, Ulivieri FM. The Effect of Thiazides on Bone Markers, Bone Mineral Density and Fractures. Clin Rev Bone Miner Metab 2015. [DOI: 10.1007/s12018-015-9190-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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20
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Sotunde OF, Kruger HS, Wright HH, Havemann-Nel L, Kruger IM, Wentzel-Viljoen E, Kruger A, Tieland M. Lean Mass Appears to Be More Strongly Associated with Bone Health than Fat Mass in Urban Black South African Women. J Nutr Health Aging 2015; 19:628-36. [PMID: 26054499 DOI: 10.1007/s12603-015-0492-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To examine the association between body composition (fat mass, lean mass and body mass index, BMI) and bone health (bone mineral density, BMD and fracture risk) in urban black South African women. DESIGN A cross sectional study examining associations between body composition, dietary intake (food frequency questionnaire), habitual physical activity (Activity energy expenditure (AEE) measured using an accelerometer with combined heart rate monitor and physical activity questionnaire) and bone health (BMD using dual-energy X ray absorptiometry, DXA and fracture risk). SETTING Urban community dwellers from Ikageng in the North-West Province of South Africa. PARTICIPANTS One hundred and eighty nine (189) healthy postmenopausal women aged ≥43 years. RESULTS Fat mass and lean mass were significantly associated with BMD and fracture risk when adjusted for potential confounders. However, lean mass and not fat mass remained significantly associated with femoral neck BMD (β = 0.49, p <0.001), spine BMD (β = 0.48, p< 0.0001) and hip BMD (β = 0.59, p< 0.0001). Lean mass was also negatively associated with fracture risk (β = -0.19 p =0.04) when both lean and fat mass were in the same model. CONCLUSION Lean mass and fat mass were positively associated with femoral neck, spine and hip BMDs and negatively associated with fracture risk in urban black South African women. Our finding suggests that increasing lean mass rather than fat mass is beneficial to bone health. Our study emphasises the importance of positive lifestyle changes, intake of calcium from dairy and adequate weight to maintain and improve bone health of postmenopausal women.
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Affiliation(s)
- O F Sotunde
- OF Sotunde, North-West University, Potchefstroom, Centre of Excellence for Nutrition, 1 Hoffman Street, , North-West 2520, South Africa, +27781532055,
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21
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Kann PH, Hadji P, Bergmann RS. [Pharmacogenic osteoporosis beyond cortisone. Proton pump inhibitors, glitazones and diuretics]. Z Rheumatol 2015; 73:323-8. [PMID: 24728601 DOI: 10.1007/s00393-013-1286-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND [corrected] There are many drugs which can cause osteoporosis or at least favor its initiation. The effect of hormones and drugs with antihormonal activity, such as glucocorticoids and aromatase inhibitors, on initiation of osteoporosis is well known. In addition, proton pump inhibitors, glitazones and diuretics also influence the formation of osteoporosis. MATERIAL AND METHODS The results of currently available studies on the correlation between proton pump inhibitors, glitazones and diuretics on formation of osteoporosis were evaluated and summarized. RESULTS Proton pump inhibitors and glitazones increase the risk for osteoporotic fractures. Loop diuretics may slightly increase fracture risk, whereas thiazides were shown to be osteoprotective by reducing fracture probability on a relevant scale. CONCLUSION Proton pump inhibitors should not be prescribed without serious consideration and then only as long as necessary. Alternatively, the administration of the less effective H2 antagonists should be considered when possible due to the reduction of acid secretion. Because the long-term intake of thiazides is associated with a clinically relevant reduction in the risk of fractures and they are economic and well-tolerated, prescription can be thoroughly recommended within the framework of differential diagnostic considerations in an appropriate clinical context. The briefly increased risk of falling immediately after starting diuretic therapy is the only point which needs to be considered.
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Affiliation(s)
- P H Kann
- Zentrum für Innere Medizin - Bereich Endokrinologie & Diabetologie, Philipps-Universität Marburg/Universitätsklinikum Marburg UKGM, 35033, Marburg, Deutschland,
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Abstract
PURPOSE OF REVIEW To review the recent publications describing the link between pediatric nephrolithiasis and bone metabolism. RECENT FINDINGS Nephrolithiasis incidence is increasing in children and is associated with low bone mineral density (BMD). Affected children are conceptually at risk for fractures and osteoporosis. In addition to abnormal calcium metabolism, inflammation, genetic makeup and dietary habits are being recognized as important factors in the pathophysiology of nephrolithiasis and low bone density. Findings from retrospective reviews suggest that low BMD in children may be improved with citrate or thiazide treatment. SUMMARY The healthcare burden from low BMD with subsequent osteoporosis and fracture risk is immense with potential far-reaching effects in patient quality of life and healthcare expense. Bone mass is acquired in the pediatric age range, thus it is important to identify and treat at-risk children. Retrospective reviews in pediatric patients indicate that citrate or thiazide diuretic treatment may improve BMD. We now understand that a relationship exists between nephrolithiasis and low BMD. To improve healthcare for our current patients as well as protect their future health it is important to identify low BMD and initiate strategies to improve BMD in 'at-risk' children.
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Abstract
Hypercalciuria is the most common metabolic abnormality found in patients with calcium-containing kidney stones. Patients with hypercalciuria often excrete more calcium than they absorb, indicating a net loss of total-body calcium. The source of this additional urinary calcium is almost certainly the skeleton, the largest repository of calcium in the body. Hypercalciuric stone formers exhibit decreased bone mineral density (BMD), which is correlated with the increase in urine calcium excretion. The decreased BMD also correlates with an increase in markers of bone turnover as well as increased fractures. In humans, it is difficult to determine the cause of the decreased BMD in hypercalciuric stone formers. To study the effect of hypercalciuria on bone, we utilized our genetic hypercalciuric stone-forming (GHS) rats, which were developed through successive inbreeding of the most hypercalciuric Sprague-Dawley rats. GHS rats excrete significantly more urinary calcium than similarly fed controls, and all the GHS rats form kidney stones while control rats do not. The hypercalciuria is due to a systemic dysregulation of calcium homeostasis, with increased intestinal calcium absorption, enhanced bone mineral resorption, and decreased renal tubule calcium reabsorption associated with an increase in vitamin D receptors in all these target tissues. We recently found that GHS rats fed an ample calcium diet have reduced BMD and that their bones are more fracture-prone, indicating an intrinsic disorder of bone not secondary to diet. Using this model, we should better understand the pathogenesis of hypercalciuria and stone formation in humans to ultimately improve the bone health of patients with kidney stones.
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Affiliation(s)
- Nancy S Krieger
- Division of Nephrology, Department of Medicine, University of Rochester School of Medicine, 601 Elmwood Ave., Box 675, Rochester, NY, 14642, USA,
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Abstract
Calcium is an important participant in many physiologic processes including coagulation, cell membrane transfer, hormone release, neuromuscular activation, and myocardial contraction. The body cooperates in a sophisticated web of hormonally mediated interactions to maintain stable extracellular calcium levels. Calcium is vital for skeletal mineralization, and perturbations in extracellular calcium may be corrected at the expense of bone strength and integrity. The aim of this review is to delineate our current understanding of idiopathic hypercalciuria in the context of bone health, specifically its definition, etiology, epidemiology, laboratory evaluation, and potential therapeutic management.
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Affiliation(s)
- Laura E Ryan
- Center for Women's Health, Division of Endocrinology, Diabetes and Metabolism, The Ohio State University, Columbus, 43210, USA.
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Choi WJ, Ford ES, Curhan G, Rankin JI, Choi HK. Independent association of serum retinol and β-carotene levels with hyperuricemia: A national population study. Arthritis Care Res (Hoboken) 2012; 64:389-96. [PMID: 22076806 DOI: 10.1002/acr.20692] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Uses of synthetic vitamin A derivatives (e.g., isotretinoin used for severe acne) and high doses of preformed vitamin A have been implicated in the pathogenesis of hyperuricemia and gout, whereas a trial reported that β-carotene may lower serum uric acid (UA) levels. We evaluated the potential population impact of these factors on serum UA in a nationally representative sample of US adults. METHODS Using data from 14,349 participants ages ≥20 years in the Third National Health and Nutrition Examination Survey (1988-1994), we examined the relationship between serum retinol, β-carotene, and UA levels using weighted linear regression. Additionally, we examined the relationship with hyperuricemia using weighted logistic regression. RESULTS Serum UA levels increased linearly with increasing serum retinol levels, whereas serum UA levels decreased with increasing serum β-carotene levels. After adjusting for age, sex, dietary factors, and other potential confounders, the serum UA level differences from the bottom (referent) to the top quintiles of serum retinol levels were 0, 0.16, 0.32, 0.43, and 0.71 mg/dl (P for trend <0.001), and for β-carotene were 0, -0.15, -0.29, -0.27, and -0.40 mg/dl (P for trend <0.001), respectively. Similarly, the multivariate odds ratios of hyperuricemia from the bottom (referent) to top quintiles of serum retinol levels were 1.00, 1.30, 1.83, 2.09, and 3.22 (P for trend <0.001) and for β-carotene were 1.00, 0.85, 0.68, 0.73, and 0.54 (P for trend <0.001), respectively. The graded associations persisted across subgroups according to cross-classification by both serum retinol and β-carotene levels. CONCLUSION These nationally representative data raise concerns that vitamin A supplementation and food fortification may contribute to the high frequency of hyperuricemia in the US population, whereas β-carotene intake may be beneficial against hyperuricemia. The use of β-carotene as a novel preventive treatment for gout deserves further investigation.
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Affiliation(s)
- Woo-Joo Choi
- Arthritis Research Centre of Canada, Vancouver, British Columbia, Canada
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Khalili H, Huang ES, Jacobson BC, Camargo CA, Feskanich D, Chan AT. Use of proton pump inhibitors and risk of hip fracture in relation to dietary and lifestyle factors: a prospective cohort study. BMJ 2012; 344:e372. [PMID: 22294756 PMCID: PMC3269660 DOI: 10.1136/bmj.e372] [Citation(s) in RCA: 150] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To examine the association between chronic use of proton pump inhibitors (PPIs) and risk of hip fracture. DESIGN Prospective cohort study. SETTING Nurses' Health Study, which originally recruited from the 11 most populous states in the US. PARTICIPANTS 79,899 postmenopausal women enrolled in the Nurses' Health Study who provided data on the use of PPIs and other risk factors biennially since 2000 and were followed up to 1 June 2008. MAIN OUTCOME MEASURE Incident hip fracture RESULTS During 565,786 person years of follow-up, we documented 893 incident hip fractures. The absolute risk of hip fracture among regular users of PPIs was 2.02 events per 1000 person years, compared with 1.51 events per 1000 person years among non-users. Compared with non-users, the risk of hip fracture among women who regularly used PPIs for at least two years was 35% higher (age adjusted hazard ratio 1.35 (95% confidence interval 1.13 to 1.62)), with longer use associated with increasing risk (P(trend)<0.01). Adjustment for risk factors, including body mass index, physical activity, and intake of calcium did not materially alter this association (hazard ratio 1.36 (1.13 to 1.63)). These associations were also not changed after accounting for reasons for PPI use. The relation between PPI use and fracture differed by smoking history (P(interaction)=0.03). Among current and former smokers, PPI use was associated with greater than 50% increase in risk of fracture, with a multivariate hazard ratio for fracture of 1.51 (1.20 to 1.91). In contrast, among women who never smoked there was no association (multivariate hazard ratio 1.06 (0.77 to 1.46)). In a meta-analysis of these results with 10 prior studies, the pooled odds ratio of hip fracture associated with PPI use was 1.30 (1.25 to 1.36). CONCLUSION Chronic use of PPIs is associated with increased risk of hip fracture, particularly among women with a history of smoking.
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Affiliation(s)
- Hamed Khalili
- Gastroenterology Unit, Massachusetts General Hospital, Boston, MA 02114, USA
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Abstract
BACKGROUND Thiazide diuretics are one of the most commonly prescribed antihypertensive agents worldwide. Thiazides reduce urinary calcium excretion. Chronic ingestion of thiazides is associated with higher bone mineral density. It has been suggested that thiazides may prevent hip fracture. However, there are concerns that diuretics, by increasing the risk of fall in elderly, could potentially negate its beneficial effects on hip fracture. OBJECTIVES To assess any association between the use of thiazide diuretics and the risk of hip fracture in adults. SEARCH STRATEGY We searched eligible studies up to December 2008 in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), International Pharmaceutical Abstracts, the Database of Abstracts of Review of Effects (DARE) and reference lists of previous reviews and included studies. SELECTION CRITERIA All randomized controlled trials and observational studies, which assessed the association between thiazide diuretic use and hip fracture. DATA COLLECTION AND ANALYSIS Two review authors independently applied the selection criteria, extracted data and assessed risk of bias of each study selected. The results were summarized descriptively and quantitatively. Cohort studies and case control studies were analysed separately. MAIN RESULTS No randomized control trials were found. Twenty-one observational studies with nearly four hundred thousand participants were included. Six of them were cohort studies and 15 were case-control studies. Two cohort studies appear to involve the same cohort so there were only 5 unique ones. The risk of bias was assessed with the Newcastle-Ottawa Scale (NOS). Five cohort studies had low risk of bias and one had moderate risk of bias. Seven case control studies had low risk of bias and 8 had moderate risk of bias. Meta-analysis of cohort studies showed that thiazide use was associated with a reduction in risk of hip fracture by 24%, pooled RR 0.76 (95% CI 0.64-0.89; p = 0.0009). We chose not to provide a pooled summary statistics for case-control studies because of high heterogeneity (Tau(2) = 0.03, I(2) = 62%, p = 0.0008). AUTHORS' CONCLUSIONS Thiazides appear to reduce the risk of hip fracture based on observational studies. Randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
- Koko Aung
- Department of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, MC 7879, San Antonio, Texas, USA, 78229
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Bushinsky DA, Willett T, Asplin JR, Culbertson C, Che SPY, Grynpas M. Chlorthalidone improves vertebral bone quality in genetic hypercalciuric stone-forming rats. J Bone Miner Res 2011; 26:1904-12. [PMID: 21351146 PMCID: PMC4493760 DOI: 10.1002/jbmr.374] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We have bred a strain of rats to maximize urine (u) calcium (Ca) excretion and model hypercalciuric nephrolithiasis. These genetic hypercalciuric stone-forming (GHS) rats excrete more uCa than control Sprague-Dawley rats, uniformly form kidney stones, and similar to patients, demonstrate lower bone mineral density. Clinically, thiazide diuretics reduce uCa and prevent stone formation; however, whether they benefit bone is not clear. We used GHS rats to test the hypothesis that the thiazide diuretic chlorthalidone (CTD) would have a favorable effect on bone density and quality. Twenty GHS rats received a fixed amount of a 1.2% Ca diet, and half also were fed CTD (4 to 5 mg/kg/d). Rats fed CTD had a marked reduction in uCa. The axial and appendicular skeletons were studied. An increase in trabecular mineralization was observed with CTD compared with controls. CTD also improved the architecture of trabecular bone. Using micro-computed tomography (µCT), trabecular bone volume (BV/TV), trabecular thickness, and trabecular number were increased with CTD. A significant increase in trabecular thickness with CTD was confirmed by static histomorphometry. CTD also improved the connectivity of trabecular bone. Significant improvements in vertebral strength and stiffness were measured by vertebral compression. Conversely, a slight loss of bending strength was detected in the femoral diaphysis with CTD. Thus results obtained in hypercalciuric rats suggest that CTD can favorably influence vertebral fracture risk. CTD did not alter formation parameters, suggesting that the improved vertebral bone strength was due to decreased bone resorption and retention of bone structure.
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Affiliation(s)
- David A Bushinsky
- Nephrology Division, Department of Medicine, University of Rochester School of Medicine, Rochester, NY 14642, USA.
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Abstract
Nephrolithiasis remains a formidable health problem in the United States and worldwide. A very important but underaddressed area in nephrolithiasis is the accompanying bone disease. Epidemiologic studies have shown that osteoporotic fractures occur more frequently in patients with nephrolithiasis than in the general population. Decreased bone mineral density and defects in bone remodeling are commonly encountered in patients with calcium nephrolithiasis. The pathophysiologic connection of bone defects to kidney stones is unknown. Hypercalciuria and hypocitraturia are two important risk factors for stone disease, and treatments with thiazide diuretics and alkali, respectively, have been shown to be useful in preventing stone recurrence in small prospective trials. However, no studies have examined the efficacy of these agents or other therapies in preventing continued bone loss in calcium stone formers. This manuscript reviews the epidemiology, pathophysiology, and potential treatments of bone disease in patients with nephrolithiasis.
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Olmos JM, Hernández JL, Martínez J, Castillo J, Valero C, Pérez Pajares I, Nan D, González-Macías J. Bone turnover markers and bone mineral density in hypertensive postmenopausal women on treatment. Maturitas 2010; 65:396-402. [DOI: 10.1016/j.maturitas.2010.01.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2009] [Revised: 01/07/2010] [Accepted: 01/08/2010] [Indexed: 01/22/2023]
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Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ 2009; 338:b1665. [PMID: 19454737 PMCID: PMC2684577 DOI: 10.1136/bmj.b1665] [Citation(s) in RCA: 1849] [Impact Index Per Article: 123.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/23/2009] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To determine the quantitative efficacy of different classes of blood pressure lowering drugs in preventing coronary heart disease (CHD) and stroke, and who should receive treatment. DESIGN Meta-analysis. Data source Medline (1966-2007). STUDY SELECTION Randomised trials of blood pressure lowering drugs recording CHD events and strokes. 108 trials studied differences in blood pressure between study drug and placebo (or control group not receiving the study drug) ("blood pressure difference trials"), and 46 trials compared drugs ("drug comparison trials"). Seven trials with three randomised groups fell into both categories. The results were interpreted in the context of those expected from the largest published meta-analysis of cohort studies, totalling 958 000 people. PARTICIPANTS 464 000 people defined into three mutually exclusive categories: participants with no history of vascular disease, a history of CHD, or a history of stroke. RESULTS In the blood pressure difference trials beta blockers had a special effect over and above that due to blood pressure reduction in preventing recurrent CHD events in people with a history of CHD: risk reduction 29% (95% confidence interval 22% to 34%) compared with 15% (11% to 19%) in trials of other drugs. The extra effect was limited to a few years after myocardial infarction, with a risk reduction of 31% compared with 13% in people with CHD with no recent infarct (P=0.04). In the other blood pressure difference trials (excluding CHD events in trials of beta blockers in people with CHD), there was a 22% reduction in CHD events (17% to 27%) and a 41% (33% to 48%) reduction in stroke for a blood pressure reduction of 10 mm Hg systolic or 5 mm Hg diastolic, similar to the reductions of 25% (CHD) and 36% (stroke) expected for the same difference in blood pressure from the cohort study meta-analysis, indicating that the benefit is explained by blood pressure reduction itself. The five main classes of blood pressure lowering drugs (thiazides, beta blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers) were similarly effective (within a few percentage points) in preventing CHD events and strokes, with the exception that calcium channel blockers had a greater preventive effect on stroke (relative risk 0.92, 95% confidence interval 0.85 to 0.98). The percentage reductions in CHD events and stroke were similar in people with and without cardiovascular disease and regardless of blood pressure before treatment (down to 110 mm Hg systolic and 70 mm Hg diastolic). Combining our results with those from two other studies (the meta-analyses of blood pressure cohort studies and of trials determining the blood pressure lowering effects of drugs according to dose) showed that in people aged 60-69 with a diastolic blood pressure before treatment of 90 mm Hg, three drugs at half standard dose in combination reduced the risk of CHD by an estimated 46% and of stroke by 62%; one drug at standard dose had about half this effect. The present meta-analysis also showed that drugs other than calcium channel blockers (with the exception of non-cardioselective beta blockers) reduced the incidence of heart failure by 24% (19% to 28%) and calcium channel blockers by 19% (6% to 31%). CONCLUSIONS With the exception of the extra protective effect of beta blockers given shortly after a myocardial infarction and the minor additional effect of calcium channel blockers in preventing stroke, all the classes of blood pressure lowering drugs have a similar effect in reducing CHD events and stroke for a given reduction in blood pressure so excluding material pleiotropic effects. The proportional reduction in cardiovascular disease events was the same or similar regardless of pretreatment blood pressure and the presence or absence of existing cardiovascular disease. Guidelines on the use of blood pressure lowering drugs can be simplified so that drugs are offered to people with all levels of blood pressure. Our results indicate the importance of lowering blood pressure in everyone over a certain age, rather than measuring it in everyone and treating it in some.
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Affiliation(s)
- M R Law
- Centre for Environmental and Preventive Medicine, Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine, Queen Mary University of London, London EC1M 6BQ.
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Do thiazides worsen metabolic syndrome and renal disease? The pivotal roles for hyperuricemia and hypokalemia. Curr Opin Nephrol Hypertens 2009; 17:470-6. [PMID: 18695387 DOI: 10.1097/mnh.0b013e328305b9a5] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW The aims of this article are to review the current controversies related to the use of thiazide diuretics as first-line treatment of hypertension and to discuss the causal roles for hyperuricemia and hypokalemia on the adverse consequences of thiazide usage. RECENT FINDINGS Thiazides significantly reduce morbidity and mortality in hypertensive subjects. There remains, however, debate about thiazide usage as first-line treatment of hypertension. This negative impact of thiazides may be partially attributed to the ability of thiazides to exacerbate features of metabolic syndrome or increase the risk for developing diabetes. Several clinical trials suggest that thiazide-induced hyperuricemia and hypokalemia may account for some of these negative effects. Thiazide treatment is also associated with a decline of renal function in spite of a lowering blood pressure. In this review, we discuss the clinical and experimental evidence supporting a potential role of hyperuricemia and hypokalemia on the development of renal injury and worsening of the metabolic syndrome. SUMMARY Hyperuricemia and hypokalemia may have pivotal roles in the exacerbation of the metabolic syndrome in response to thiazides. We propose that controlling serum uric acid and serum potassium could improve thiazide efficacy and also reduce its risk for inducing metabolic syndrome or diabetes.
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Bone Disease and Idiopathic Hypercalciuria. Clin Rev Bone Miner Metab 2008. [DOI: 10.1007/s12018-008-9023-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Ott SM, LaCroix AZ, Scholes D, Ichikawa LE, Wu K. Effects of three years of low-dose thiazides on mineral metabolism in healthy elderly persons. Osteoporos Int 2008; 19:1315-22. [PMID: 18425402 DOI: 10.1007/s00198-008-0612-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2007] [Accepted: 12/12/2007] [Indexed: 10/22/2022]
Abstract
UNLABELLED In this clinical trial of 12.5 or 25 mg/day of hydrochlorothiazide, the urine calcium showed significant decreases from placebo in men at one year, but the effects had waned by 3 years. Serum bicarbonate was consistently greater in the thiazide than in the placebo groups throughout the three years. These effects could be beneficial to the skeleton. INTRODUCTION Previous studies have shown increased bone density and reduced risk of fracture in patients taking thiazide diuretics. The long-term effects of low-dose thiazides on mineral metabolism have not been reported in normal subjects. METHODS We conducted a randomized, double-blinded trial in normals aged 60-79 years, using hydrochlorothiazide 12.5 or 25 mg/d or placebo for three years. Subjects were encouraged to maintain calcium intake of 1,000 to 1,500 mg/day. Measurements of serum and urine calcium metabolism were done at baseline, six months, and yearly. Data were analyzed in 88 men and 177 women who had taken study medication. Adjusted change in the measurements from baseline to one and three years were compared among groups. RESULTS The calcium intake increased in all groups. Urine calcium per day was significantly lower in thiazide than placebo groups in men at one year but not at three years; in women the changes were not significantly different. Serum bicarbonate was higher in thiazide compared to placebo groups at one and three years. No changes were seen in serum calcium, phosphate, parathyroid hormone, sodium or magnesium. CONCLUSIONS The results suggest that both increased calcium availability from a hypocalciuric effect and reduction in acid-induced bone buffering could be mechanisms for the beneficial skeletal effects.
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Affiliation(s)
- S M Ott
- University of Washington, 1959 NE Pacific Street, P. O. Box 356426, Seattle, WA 98195-6426, USA.
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Hall GC, McMahon AD. Comparative study of modified release alpha-blocker exposure in elderly patients with fractures. Pharmacoepidemiol Drug Saf 2007; 16:901-7. [PMID: 17443863 DOI: 10.1002/pds.1402] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
PURPOSE Standard formulation alpha-blocker use has been associated with an increased risk of hypotension-related adverse events, particularly with cardiovascular indications and on treatment initiation. We investigated the association between those fractures that are commonly due to falls and modified-release doxasozin exposure. METHODS A case-control study using UK primary care records (the THIN database) showed that 6540 cases aged 50 years or older had a record of first fracture of the hip/femur, humerus or wrist after May 2001; 26 495 controls had no fracture and were matched on practice, year of birth and sex. Exclusions for the primary analysis were previous benign prostatic hypertrophy (BPH), lower urinary tract symptoms (LUTS) or prostate cancer, major trauma at the time of the case's fracture, or a history of falls. Conditional logistic regression estimated the association between modified-release doxasozin treatment and the occurrence of fractures. RESULTS No increased risk of fractures was associated with current use of modified-release doxasozin, adjusted odds ratios (ORs) 0.90 (95%CI 0.68, 1.19); previous use, adjusted OR 0.92 (95%CI 0.73, 1.16) or the start of a treatment episode (</=28 days), crude OR 0.57 (0.17, 1.92). Including those with a history of BPH, LUTS and prostatic carcinoma had little effect, adjusted OR for current use was 0.95 (95%CI 0.74, 1.21). No significant increased risk of fractures was associated with the start of standard preparation alpha-blockers, crude OR 1.42 (95%CI 0.65, 3.07). CONCLUSIONS We found no association between modified-release doxasozin use and fractured hip/femur, humerus or wrist in those without a recent history of falls, or trauma.
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Bolland MJ, Ames RW, Horne AM, Orr-Walker BJ, Gamble GD, Reid IR. The effect of treatment with a thiazide diuretic for 4 years on bone density in normal postmenopausal women. Osteoporos Int 2007; 18:479-86. [PMID: 17120180 DOI: 10.1007/s00198-006-0259-y] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2006] [Accepted: 10/16/2006] [Indexed: 02/07/2023]
Abstract
SUMMARY We performed a 2-year extension of our previous 2-year randomized controlled trial of the effects of hydrochlorothiazide on bone mineral density. The improvements in bone density seen in the first 2 years were sustained throughout the extension study. Thiazides provide a further option in the prevention of postmenopausal bone loss. INTRODUCTION Thiazide diuretics reduce urinary calcium excretion and therefore might prevent osteoporosis. Previously we reported a 2-year randomized controlled trial of hydrochlorothiazide treatment in 185 postmenopausal women that showed positive benefits of hydrochlorothiazide on bone density. Here, we report the results of a 2-year extension to that study. METHODS Of 185 healthy postmenopausal women, 122 agreed to continue in a double-blinded 2-year extension taking 50 mg hydrochlorothiazide or placebo daily. Measurements of bone density occurred every 6 months and of calcium metabolism at 2 and 4 years. RESULTS The improvements in bone density seen in the first 2 years of the trial were sustained throughout the extension. There were significant between-groups differences in the change in bone density over 4 years at the total body (0.9%, P<0.001), legs (1.0%, P=0.002), mid-forearm (1.1%, P=0.03), and ultradistal forearm (1.4%, P=0.04). At the lumbar spine (0.9%, P=0.76) and femoral neck (0.4%, P=0.53) the between-groups differences did not reach statistical significance. CONCLUSIONS Hydrochlorothiazide produces small positive benefits on cortical bone density that are sustained for at least the first 4 years of treatment. They provide a further option in the prevention of postmenopausal bone loss, especially for women with hypertension or a history of kidney stones.
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Affiliation(s)
- M J Bolland
- Department of Medicine, University of Auckland, Auckland, New Zealand.
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Bulpitt CJ, Peters R, Staessen JA, Thijs L, De Vernejoul MC, Fletcher AE, Beckett NS. Fracture risk and the use of a diuretic (indapamide SR) +/- perindopril: a substudy of the Hypertension in the Very Elderly Trial (HYVET). Trials 2006; 7:33. [PMID: 17177983 PMCID: PMC1769508 DOI: 10.1186/1745-6215-7-33] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2006] [Accepted: 12/19/2006] [Indexed: 11/10/2022] Open
Abstract
Background The Hypertension in the Very Elderly Trial (HYVET) is a placebo controlled double blind trial of treating hypertension with indapamide Slow Release (SR) ± perindopril in subjects over the age of 80 years. The primary endpoints are stroke (fatal and non fatal). In view of the fact that thiazide diuretics and indapamide reduce urinary calcium and may increase bone mineral density, a fracture sub study was designed to investigate whether or not the trial anti-hypertensive treatment will reduce the fracture rate in very elderly hypertensive subjects. Methods In the trial considerable care is taken to ascertain any fractures and to identify risk factors for fracture, such as falls, co-morbidity, drug treatment, smoking and drinking habits, levels of activity, biochemical abnormalities, cardiac irregularities, impaired cognitive function and symptoms of orthostatic hypotension. Potential results The trial is expected to provide 10,500 patient years of follow-up. Given a fracture rate of 40/1000 patient years and a 20% difference in fracture rate, the power of the sub study is 58% to detect this difference at the 5% level of significance. The corresponding power for a reduction of 25% is 78%. Conclusion The trial is well under way, expected to complete in 2009, and on target to detect, if present, the above differences in fracture rate.
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Affiliation(s)
| | - Ruth Peters
- Faculty of Medicine, Imperial College London, UK
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Durosier C, Hans D, Krieg MA, Schott AM. Prediction and discrimination of osteoporotic hip fracture in postmenopausal women. J Clin Densitom 2006; 9:475-95. [PMID: 17097535 DOI: 10.1016/j.jocd.2006.06.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2006] [Revised: 04/06/2006] [Accepted: 06/01/2006] [Indexed: 12/19/2022]
Abstract
Osteoporotic hip fractures increase dramatically with age and are responsible for considerable morbidity and mortality. Several treatments to prevent the occurrence of hip fracture have been validated in large randomized trials and the current challenge is to improve the identification of individuals at high risk of fracture who would benefit from therapeutic or preventive intervention. We have performed an exhaustive literature review on hip fracture predictors, focusing primarily on clinical risk factors, dual X-ray absorptiometry (DXA), quantitative ultrasound, and bone markers. This review is based on original articles and meta-analyses. We have selected studies that aim both to predict the risk of hip fracture and to discriminate individuals with or without fracture. We have included only postmenopausal women in our review. For studies involving both men and women, only results concerning women have been considered. Regarding clinical factors, only prospective studies have been taken into account. Predictive factors have been used as stand-alone tools to predict hip fracture or sequentially through successive selection processes or by combination into risk scores. There is still much debate as to whether or not the combination of these various parameters, as risk scores or as sequential or concurrent combinations, could help to better predict hip fracture. There are conflicting results on whether or not such combinations provide improvement over each method alone. Sequential combination of bone mineral density and ultrasound parameters might be cost-effective compared with DXA alone, because of fewer bone mineral density measurements. However, use of multiple techniques may increase costs. One problem that precludes comparison of most published studies is that they use either relative risk, or absolute risk, or sensitivity and specificity. The absolute risk of individuals given their risk factors and bone assessment results would be a more appropriate model for decision-making than relative risk. Currently, a group appointed by the World Health Organization and lead by Professor John Kanis is working on such a model. It will therefore be possible to further assess the best choice of threshold to optimize the number of women needed to screen for each country and each treatment.
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Affiliation(s)
- Claire Durosier
- Nuclear Medicine Division, Geneva University Hospital, Geneva, Switzerland; Medical Information Department, Lyon University Hospital, Lyon, France
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Wiens M, Etminan M, Gill SS, Takkouche B. Effects of antihypertensive drug treatments on fracture outcomes: a meta-analysis of observational studies. J Intern Med 2006; 260:350-62. [PMID: 16961672 DOI: 10.1111/j.1365-2796.2006.01695.x] [Citation(s) in RCA: 130] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To quantitatively pool findings from observational studies on the risk of fracture outcomes associated with exposure to five antihypertensive drug classes: angiotensin-converting enzyme (ACE) inhibitors, diuretics (in particular thiazide diuretics), beta-blockers, calcium-channel blockers and alpha-blockers. DESIGN Systematic review and meta-analysis. DATA SOURCES Publications listed in the MEDLINE, EMBASE and LILACS databases, the ISI proceedings, and bibliographies of retrieved articles. Sources were searched from the earliest possible dates through December 2005. REVIEW METHODS We included case-control and cohort studies presenting relative risks and confidence intervals (CIs) for the association between exposure to antihypertensive agents and fracture outcomes. Data were extracted onto a standardized computer worksheet. Study quality was assessed using a 10-point questionnaire specific to case-control or cohort study design. RESULTS Fifty-four studies were identified. Pooled estimates were computed using the software HEpiMA. The pooled relative risk (RR) of any fracture with use of thiazide diuretics was 0.86 (95% CI 0.81-0.92) and 1.14 (95% CI 0.84-1.54) with use of nonthiazide diuretics. There was a statistically significant reduction of any fracture with use of beta-blockers, (RR 0.86, 95% CI 0.70-0.98). The one study with ACE inhibitor data showed protection (RR 0.81, 95% CI 0.73-0.89). No significant associations were found between fractures and exposure to alpha-blockers or calcium-channel blockers. CONCLUSIONS Thiazide diuretics and beta-blockers appear to lower the risk of fractures in older adults. However, these agents cannot be recommended as preventive therapies for fractures until data from randomized controlled trials have established their efficacy. Patients who use these inexpensive drugs as treatments for hypertension may also benefit from a reduction in fracture risk.
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Affiliation(s)
- M Wiens
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada.
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Albertsson D, Gause-Nilsson I, Mellström D, Eggertsen R. Risk group for hip fracture in elderly women identified by primary care questionnaire--clinical implications. Ups J Med Sci 2006; 111:179-87. [PMID: 16961173 DOI: 10.3109/2000-1967-034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Every fourth Swedish woman suffers hip fracture during life-time. Several methods for fall and fracture prevention are known. In this study we identify women at high hip fracture risk in a primary care population, describing their needs for possible fracture prevention as well. METHODS Cross-sectional questionnaire study for self-assessment by randomly chosen elderly women (n=100) over 70 years of age in a Primary health Care district at 1998. Questionnaire was designed from previous validated study. Follow-up study after three years performed at 2001. RESULTS Response rate was 92% (n=92, mean age 78) and 90% (n=83) answered the main 40 questions. 30% had at least two of four major risk factors for hip fracture; age over 80 years, body weight below 60 kg, recent fall and previous fragility fracture. The recall ability for at least two of these four risk factors was 93% in follow-up study after three years (relative risk = 8.0 with 95% confidence interval 3.5 to 18). 34% of the women had experienced any fracture since the age of 50. Only 22% of the women with previous fragility fracture had any pharmacological treatment for osteoporosis. 26% had falls in the preceding 12 months, mainly at home. Needs for fracture prevention were found in 34% (27 women). CONCLUSIONS Age, weight, recent falls or previous fragility fracture were common and important clinical risk factors for hip fracture with good recall ability after three years. By using this questionnaire in a Primary health Care district we identified women at high fracture risk. Needs for fracture prevention were observed for one third.
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Huopio J, Honkanen R, Jurvelin J, Saarikoski S, Alhava E, Kröger H. Role of chronic health disorders in perimenopausal fractures. Osteoporos Int 2005; 16:1404-11. [PMID: 15739033 DOI: 10.1007/s00198-005-1851-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2004] [Accepted: 01/10/2005] [Indexed: 10/25/2022]
Abstract
Only a few studies have examined the risk of individual chronic health disorders on perimenopausal (i.e., around menopause) fractures in a single study. We evaluated the effect of chronic illnesses on fracture rate in a prospective cohort study of 3,078 women. These women were a stratified sample from the population base of 14,220 women aged 47-56 years and residing in the province of Kuopio in eastern Finland in 1989. Data on physician-diagnosed chronic diseases were collected by a baseline questionnaire in 1989. For certain diseases, questionnaire information of self-reported chronic disorders were compared with drug reimbursement data provided by the Social Insurance Institution of Finland. Axial bone mineral density (BMD) measurements from the femoral neck and lumbar spine were performed in 1989-91. Two hundred sixty-five (265) women experienced at least one fracture during the follow-up period of 3.6 years (SD+/-0.78). The first fracture during the follow-up period was taken to be the end-point event. The risk of follow-up fracture for an individual health disorder was estimated with the Cox's proportional hazards model. Several chronic health disorders increased the fracture risk in perimenopausal women. However, hypertension was a statistically significant (p=0.018) risk factor for fracture (adjusted hazard ratio [HR], 1.4; 95% confidence interval [CI], 1.1-1.9), especially in overweight and obese (body mass index > or =28) women (HR, 2.0; 95% CI, 1.4-3.0). In addition, coronary heart disease (adjusted HR, 1.76; 95% CI, 1.13-2.76), hyperthyroidism (adjusted HR, 1.7; 95% CI, 1.0-2.9), epilepsy (adjusted HR, 2.0; 95% CI, 1.1-3.6), alcoholism (adjusted HR, 3.5; 95% CI, 1.3-9.5) and chronic hepatic disease (adjusted HR, 5.2; 95% CI, 1.7-16.4) predicted fracture. BMD was either normal or even elevated in disease groups. However, women with a fracture during the follow-up usually had decreased bone density, although the difference was statistically significant only in women with hypertension and hyperthyroidism. We conclude that hypertension, coronary heart disease, alcoholism, epilepsy and hyperthyroidism can markedly increase the risk of fracture in perimenopausal women and should be taken into account when assessing the risk of future fracture in an individual patient. Furthermore, in contrast to previous data, obesity alone does not increase the risk of perimenopausal fracture, but in association with hypertension the risk seems to be markedly elevated.
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Affiliation(s)
- Jukka Huopio
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland.
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Giannini S, Nobile M, Sella S, Dalle Carbonare L. Bone disease in primary hypercalciuria. Crit Rev Clin Lab Sci 2005; 42:229-48. [PMID: 16047539 DOI: 10.1080/10408360590913533] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Primary hypercalciuria (PH) is very often accompanied by some degree of bone demineralization. The most frequent clinical condition in which this association has been observed is calcium nephrolithiasis. In patients affected by this disorder, bone density is very frequently low, and increased susceptibility to fragility fractures is reported. The very poor definition of this bone disease from a histomorphometric point of view is a crucial aspect. At present, the most common finding seems to be a low bone turnover condition. Many factors are involved in the complex relationships between bone loss and PH. Since bone loss was mainly reported in patients with fasting hypercalciuria, a primary alteration in bone metabolism was proposed as a cause of both hypercalciuria and bone demineralization. This hypothesis was strengthened by the observation that some bone resorbing-cytokines, such as interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor nechrosis factor-alpha (TNF-alpha), are high in hypercalciuric patients. An excessive response to the acid load induced by dietary protein intake seems to be an additional factor explaining a primitive alteration of bone. The intestine plays a major role in the clinical course of bone disease in PH. Patients with absorptive hypercalciuria less frequently show bone disease, and a reduction in dietary calcium greatly increases the probability of bone loss in PH subjects. It has recently been reported that greater bone loss is associated with a larger increase in intestinal calcium absorption in PH patients. Considering the absence of parathyroid hormone (PTH) alterations, it was proposed that this is not a compensatory phenomenon, but probably the marker of disturbed cell calcium transport, involving both intestinal and bone tissues. While renal hypercalciuria is rather uncommon, the kidney still seems to play a role in the pathogenesis of bone loss in PH patients, possibly via the effect of mild-to-moderate urinary phosphate loss with secondary hypophosphatemia. In conclusion, bone loss is very common in PH patients. Even if most of the factors involved in this process have been identified, many aspects of this intriguing clinical condition remain to be elucidated.
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Affiliation(s)
- Sandro Giannini
- Department of Medical and Surgical Sciences, University of Padova, Italy.
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Law PH, Sun Y, Bhattacharya SK, Chhokar VS, Weber KT. Diuretics and Bone Loss in Rats With Aldosteronism. J Am Coll Cardiol 2005; 46:142-6. [PMID: 15992648 DOI: 10.1016/j.jacc.2005.03.055] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2004] [Revised: 01/21/2005] [Accepted: 03/17/2005] [Indexed: 11/20/2022]
Abstract
OBJECTIVES We hypothesized that the increased urinary Ca2+ and Mg2+ excretion and bone loss that accompanies aldosteronism is aggravated with furosemide and is attenuated by spironolactone. BACKGROUND Furosemide, a loop diuretic, is commonly used in patients with congestive heart failure (CHF), in which chronic, inappropriate (dietary Na+) elevations in plasma aldosterone (ALDO) and a catabolic state that includes bone wasting are expected. METHODS In age- and gender-matched, untreated controls, four weeks of aldosterone/salt treatment (ALDO/salt, 0.75 microg/h + 1% NaCl/0.4% KCl in drinking water), four weeks of ALDO/salt + furosemide (40 mg/kg in prepared food), and four weeks of ALDO/salt + furosemide + spironolactone (200 mg/kg/day in divided doses by twice-daily gavage), we monitored: 24-h urinary Ca2+ and Mg2+ excretion; plasma-ionized [Ca2+]o and [Mg2+]o, K+, and parathyroid hormone (PTH); and bone mineral density (BMD) in the femur. RESULTS The ALDO/salt increased (p < 0.05) urinary Ca2+ and Mg2+ excretion (4,969 +/- 1,078 and 3,856 +/- 440 microg/24 h, respectively) compared with controls (896 +/- 138 and 970 +/- 137 microg/24 h, respectively); furosemide co-treatment further increased (p < 0.05) urinary Ca2+ and Mg2+ excretion (6,976 +/- 648 and 6,199 +/- 759 microg/24 h, respectively), whereas spironolactone co-treatment attenuated (p < 0.05) these incremental losses (4,003 +/- 515 and 3,915 +/- 972 microg/24 h). Plasma [Ca2+]o was reduced (p < 0.05) at week 4 ALDO/salt + furosemide and was accompanied by hypokalemia (<3.4 mmol/l) that were rescued by spironolactone. Plasma PTH was increased (p < 0.05) compared with controls (30 +/- 4 vs. 11 +/- 3 pg/ml, respectively), whereas BMD was decreased (p < 0.05) with ALDO/salt and ALDO/salt + furosemide, but not with spironolactone co-treatment. CONCLUSIONS In aldosteronism, hypercalciuria and hypermagnesuria and accompanying decrease in plasma-ionized [Ca2+]o and [Mg2+]o lead to hyperparathyroidism that accounts for bone wasting. Furosemide exaggerates these losses, whereas its combination with spironolactone attenuates these responses to prevent bone loss.
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Affiliation(s)
- Peter H Law
- Division of Cardiovascular Diseases, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA
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Kelsey JL, Prill MM, Keegan THM, Tanner HE, Bernstein AL, Quesenberry CP, Sidney S. Reducing the risk for distal forearm fracture: preserve bone mass, slow down, and don't fall! Osteoporos Int 2005; 16:681-90. [PMID: 15517189 DOI: 10.1007/s00198-004-1745-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2004] [Accepted: 08/03/2004] [Indexed: 11/24/2022]
Abstract
A case-control study of 1,150 female and male distal forearm cases and 2,331 controls of age 45 years and older was undertaken from 1996-2001 in five Northern California Kaiser Permanente Medical Centers. Most information on possible risk factors was obtained by an interviewer-administered questionnaire, supplemented by a few tests of lower extremity neurological function. Previous fractures since 45 years of age, a rough marker of osteoporosis, were associated with an increased risk (adjusted odds ratio [OR] [95% confidence interval] = 1.48 [1.20-1.84 ] per previous fracture). Several factors thought to protect against low bone mass were associated with a reduced risk, including current use of menopausal hormone therapy (adjusted OR = 0.60 [0.49-0.74]), ever used thiazide diuretics or water pills for at least 1 year (adjusted OR = 0.79 [0.64-0.97]), high body mass index (weight in kg/height in m2) (adjusted OR = 0.96 [0.89-1.04] per 5 unit increase), and high dietary calcium intake (adjusted OR = 0.88 [0.75-1.03] per 500 mg/day). Falls in the past year and conditions associated with falling, such as epilepsy and/or use of seizure medication (adjusted OR = 2.07 [1.35-3.17]) and a history of practitioner-diagnosed depression (adjusted OR = 1.40 [1.13-1.73]), were associated with increased risks. Having difficulty performing physical functions and all lower-extremity problems measured in this study were associated with reduced risks. The results from this and other studies indicate that distal forearm fractures tend to occur in people with low bone mass who are otherwise in relatively good health and are physically active, but who are somewhat prone to falling (particularly on an outstretched hand), and whose movements are not slowed by lower extremity problems and other debilities. Thus, measures to decrease fall frequency and to slow down the pace of relatively healthy people with low bone mass should lead to a lower frequency of distal forearm fracture.
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Affiliation(s)
- Jennifer L Kelsey
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California, USA.
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Nicolet-Barousse L, Blanchard A, Roux C, Pietri L, Bloch-Faure M, Kolta S, Chappard C, Geoffroy V, Morieux C, Jeunemaitre X, Shull GE, Meneton P, Paillard M, Houillier P, De Vernejoul MC. Inactivation of the Na-Cl co-transporter (NCC) gene is associated with high BMD through both renal and bone mechanisms: analysis of patients with Gitelman syndrome and Ncc null mice. J Bone Miner Res 2005; 20:799-808. [PMID: 15824853 DOI: 10.1359/jbmr.041238] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2004] [Revised: 09/07/2004] [Accepted: 12/22/2004] [Indexed: 11/18/2022]
Abstract
UNLABELLED Chronic thiazide treatment is associated with high BMD. We report that patients and mice with null mutations in the thiazide-sensitive NaCl cotransporter (NCC) have higher renal tubular Ca reabsorption, higher BMD, and lower bone remodeling than controls, as well as abnormalities in Ca metabolism, mainly caused by Mg depletion. INTRODUCTION Chronic thiazide treatment decreases urinary Ca excretion (UVCa) and increases BMD. To understand the underlying mechanisms, Ca and bone metabolism were studied in two models of genetic inactivation of the thiazide-sensitive NaCl cotransporter (NCC): patients with Gitelman syndrome (GS) and Ncc knockout (Ncc(-/-)) mice. MATERIALS AND METHODS Ca metabolism was analyzed in GS patients and Ncc(-/-) mice under conditions of low dietary Ca. BMD was measured by DXA in patients and mice, and bone histomorphometry was analyzed in mice. RESULTS GS patients had low plasma Mg. They exhibited reduced UVCa, but similar serum Ca and GFR as control subjects, suggesting increased renal Ca reabsorption. Blood PTH was lower despite lower serum ionized Ca, and Mg repletion almost corrected both relative hypoparathyroidism and low UVCa. BMD was significantly increased in GS patients at both lumbar (+7%) and femoral (+16%) sites, and osteocalcin was reduced. In Ncc(-/-) mice, serum Ca and GFR were unchanged, but UVCa was reduced and PTH was elevated; Mg repletion largely corrected both abnormalities. Trabecular and cortical BMD were higher than in Ncc(+/+) mice (+4% and +5%, respectively), and despite elevated PTH, were associated with higher cortical thickness and lower endosteal osteoclastic surface. CONCLUSIONS Higher BMD is observed in GS patients and Ncc(-/-) mice. Relative hypoparathyroidism (human) and bone resistance to PTH (mice), mainly caused by Mg depletion, can explain the low bone remodeling and normal/low serum Ca despite increased renal Ca reabsorption.
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Affiliation(s)
- Laurence Nicolet-Barousse
- Département de Physiologie, Hôpital Européen George Pompidou, Institut National de la Santé et de la Recherche Médicale INSERM U.652, IFR 58, Université Paris V, Paris, France
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Rejnmark L, Vestergaard P, Mosekilde L. Reduced fracture risk in users of thiazide diuretics. Calcif Tissue Int 2005; 76:167-75. [PMID: 15719207 DOI: 10.1007/s00223-004-0084-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2004] [Accepted: 09/14/2004] [Indexed: 10/25/2022]
Abstract
Thiazide diuretics (TD) reduce renal calcium excretion and may increase bone mineral density. A reduced fracture risk has been reported in some but not all studies. The aim of this study was to assess fracture risk in users of TD. The study design was nationwide population-based pharmacoepidemiological case-control study with fracture in year 2000 as outcome and use of TD during the previous 5 years as the exposure variable. Individual use of TD was derived from the Danish National Pharmacological Database and related to fracture data from the National Hospital Discharge Register. These data were combined with information on use of other drugs, social status, working status, income, educational status, contacts with general practitioners and practicing specialists, and comorbidity. A total of 64,699 patients (age = 40 years) who sustained a fracture during the year 2000 were compared to 194,111 age- and gender-matched controls. After adjustment for potential confounders, current use of TD was associated with a 10% (95% confidence interval [CI], 7% to 12%) reduced risk of any fracture and a 17% (95% CI 11% to 23%) reduced risk of forearm fractures. In former TD users, the risk reduction was slightly less pronounced. Similar results were found in men and women, and in subjects younger or > or = 65 years of age. Dose-effect analysis revealed a decreased risk of any fracture and fractures at the forearm and hip with an increased number of redeemed defined daily dosages (DDDs) of TD. Therefore, use of more than 2000 DDD was associated with a 19% (95% CI 10% to 27%) decreased hip fracture risk. We conclude that use of TD is associated with a significantly reduced fracture risk.
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Affiliation(s)
- L Rejnmark
- Department of Endocrinology and Metabolism, Aarhus University Hospital, Aarhus Sygehus, Tage Hansens Gade 2, DK-8000 Aarhus C, Denmark.
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Abstract
Osteoporosis is a leading public health threat affecting approximately 44 million people in the United States. Most of the therapies for this disease work to prevent further bone loss, improve bone mineral density, and reduce the risk of fractures. These agents, however, have not been proved to increase bone formation significantly. Therefore, the ideal agent would not only improve bone strength by decreasing bone breakdown, but also promote bone formation in the ultimate quest to prevent fractures. The 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) have become an area of research in the battle against osteoporosis. Two mechanisms for beneficial effects of statins on bones have been proposed, and although in vitro, in vivo, and animal studies have shown positive effects on bone mineralization and reductions in bone resorption, clinical data on surrogate markers and fracture rates are conflicting. The inherent problems with observational studies also must be addressed. Until that time, the use of statins in the prevention of fractures or the treatment of osteoporosis requires further study.
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Affiliation(s)
- Michael J Gonyeau
- Department of Pharmacy Practice, School of Pharmacy, Northeastern University, Boston, Massachusetts 02115, USA.
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Hodgson SF, Watts NB, Bilezikian JP, Clarke BL, Gray TK, Harris DW, Johnston CC, Kleerekoper M, Lindsay R, Luckey MM, McClung MR, Nankin HR, Petak SM, Recker RR. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the prevention and treatment of postmenopausal osteoporosis: 2001 edition, with selected updates for 2003. Endocr Pract 2004; 9:544-64. [PMID: 14715483 DOI: 10.4158/ep.9.6.544] [Citation(s) in RCA: 285] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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