Prevention and treatment of glucocorticoid-induced osteoporosis

Efficacy of denosumab on bisphosphonate-treated osteoporosis and osteopenia in systemic rheumatic disease patients receiving glucocorticoids

INTRODUCTION

Evidence on second-line agents for osteoporosis and osteopenia associated with glucocorticoid use after first-line bisphosphonate therapy is limited. We, therefore, examine the efficacy of denosumab on bisphosphonate-treated osteoporosis and osteopenia in Japanese systemic rheumatic disease (SRD) patients receiving glucocorticoids.

MATERIALS AND METHODS

Glucocorticoid-treated SRD patients with a pre-existing fragility fracture, either lumbar spine (LS) or femoral neck (FN) bone mineral density (BMD) T-score of ≤ -2.5 or of ≤ -1.5 without a significant increase in BMD in the past year despite oral bisphosphonate therapy were enrolled in this study. They were randomized to switch to 60 mg subcutaneous denosumab every six months (switching group) or to continue the bisphosphonate (continuing group). The primary endpoint was the percent change from baseline in BMD at the LS and FN at week 52.

RESULTS

Of the 39 subjects, 19 were assigned to the switching group and 20 to the continuing group. The switching group showed significant increases in LS BMD (5.7% vs. 1.1%, p = 0.002) and FN BMD (4.2% vs. -0.3%, p = 0.008) at week 52 than the continuing group, with a significant decrease in serum tartrate-resistant acid phosphatase 5b (-28.1% vs. 7.0%, p < 0.001) and improved patient satisfaction.

CONCLUSION

Switching to denosumab demonstrated greater efficacy than continuing bisphosphonates in increasing BMD, inhibiting osteoclast activation, and enhancing patient satisfaction in Japanese bisphosphonate-treated osteoporosis and osteopenia patients with concomitant SRD receiving glucocorticoids.

A System to Determine Risk of Osteoporosis in Patients With Autoimmune Hepatitis

BACKGROUND & AIMS

Osteoporosis is a feared complication of autoimmune hepatitis (AIH), but bone disease has not been well studied in these patients. We aimed to identify specific risk factors for osteoporosis in patients with AIH and to develop a scoring system that could be used to identify patients with increased risk of osteoporosis.

METHODS

We performed a retrospective cross-sectional study of 211 patients (mean age, 56.8 years; 79.1% women) in Germany with a diagnosis of AIH from 2012 through 2017 and an indication for assessment of bone mineral status. The patients underwent bone mineral density measurements by dual energy X-ray absorptiometry. A subgroup of 99 patients underwent a second measurement. We used logistic regression to identify patient and clinical factors associated with the presence of osteoporosis. We developed a weighted sum score for estimating risk of osteoporosis and tested it in development (n = 141) and validation (n = 70) sets of patients.

RESULTS

According to dual energy X-ray absorptiometry measurements, 15.6% of patients had osteoporosis 42.9% were in the range for osteopenia. The prevalence of osteoporosis in patients 50 years or older was 19.2%. Univariate and logistic regression analyses showed that age older than 54 years, duration of glucocorticoid use >90 months, body mass index <23 kg/m² and transient elastography values >8 kPA increased risk of osteoporosis 13.8-fold, 6.2-fold, 5.9-fold, and 3.0-fold, respectively. Based on these factors, we developed an index that identified patients at low-, moderate-, and high-risk of osteoporosis with an area under the curve of 0.811. Of the patients with a second osteodensitometry measurement, the rate of bone loss progression ranged from 2.7% after 1 year to 8.4% after 7 years (mean bone loss, 1.2% per year).

CONCLUSIONS

Almost 20% of patients with AIH older than 50 years have osteoporosis. Older age, duration of corticosteroid use, low body mass index, and liver fibrosis are independent risk factors for bone loss.

Patient satisfaction and efficacy of switching from weekly bisphosphonates to monthly minodronate for treatment and prevention of glucocorticoid-induced osteoporosis in Japanese patients with systemic rheumatic diseases: a randomized, clinical trial

The randomized, clinical trial demonstrated that switching to monthly minodronate from weekly alendronate and risedronate provides greater increases in patients' satisfaction and bone mineral density and more substantial decreases in a bone resorption marker than continuing weekly alendronate and risedronate in patients with systemic rheumatic diseases on glucocorticoid therapy.

PURPOSE

Osteoporosis and associated fractures are major concerns for patients with systemic rheumatic diseases on long-term glucocorticoid therapy. Bisphosphonates increase bone mineral density (BMD) and reduce the frequency of vertebral fractures, but they are associated with poor adherence. The effects of monthly oral minodronate on patients' satisfaction, BMD, and bone turnover markers were investigated in patients with systemic rheumatic diseases on glucocorticoids and weekly oral alendronate or risedronate.

METHODS

Study patients with systemic rheumatic diseases on oral glucocorticoids and weekly alendronate 35 mg or risedronate 17.5 mg were randomly assigned either to switch to minodronate 50 mg every 4 weeks or to continue the currently taking weekly bisphosphonate for 52 weeks after a 24-week run-in period.Patients were stratified by hospital site, sex, and menopausal status in women at enrollment. The primary endpoint was the difference between the proportions of patients who responded very satisfactory or satisfactory for the current bisphosphonate therapy at weeks 48 and 76 between the two groups. Secondary endpoints included percentage changes in lumbar spine BMD and bone turnover markers from the time of starting allocated treatment.

RESULTS

Monthly minodronate was superior to weekly alendronate or risedronate for patients' satisfaction, the increase of lumbar spine BMD, and suppression of serum tartrate-resistant acid phosphatase 5b at week 76.

CONCLUSIONS

Monthly minodronate is more acceptable and may be more effective than weekly alendronate or risedronate for prevention and treatment of bone loss in patients with systemic rheumatic diseases on glucocorticoid therapy.

Bisphosphonates and glucocorticoid-induced osteoporosis: cons

During the use of glucocorticoids (GCs), both vertebral and nonvertebral fracture risk are increased, due to the direct and indirect negative effects of GCs on bone, muscles, and the activity of the underlying inflammatory diseases. Inhibition of bone formation and increased apoptosis of osteocytes play a consistent and crucial role in the pathogenesis of glucocorticoid-induced osteoporosis (GIO), while changes in bone resorption during GC-use are variable. To prevent fractures, important general measures include using the lowest possible dose of GCs, treating the underlying disease adequately, a healthy life style, adequate calcium and vitamin D supplementation, and regular exercise. Although it has been shown that bisphosphonates reduce vertebral fractures during the first 2 years of GC-treatment, there are no data on long-term use of bisphosphonates during GC-treatment. Of some concern in GIO, bisphosphonates reduce bone turnover, including bone formation, which is already downregulated by GCs. In contrast, the use of the anabolic agent teriparatide is more effective in reducing vertebral fractures than alendronate. In summary, bisphosphonates remain the first choice in the first two years of treatment in GC-treated patients with high fracture risk, but their long-term effects on bone quality and fracture risk reduction remain uncertain.

United States adults meeting 2010 American College of Rheumatology criteria for treatment and prevention of glucocorticoid-induced osteoporosis

OBJECTIVE

The American College of Rheumatology (ACR) updated its guidelines on the prevention and treatment of glucocorticoid-induced osteoporosis (GIO) in 2010. An unknown proportion of US adults at risk of fracture due to glucocorticoid use would be recommended antiosteoporosis pharmaceutical (AOP) therapies based on the ACR guidelines.

METHODS

Using the 2005-2010 National Health and Nutrition Examination Survey (NHANES) data for postmenopausal women (PMW), and men age ≥50 years reporting current glucocorticoid use, we categorized individuals according to ACR criteria for low, medium, and high fracture risk (<10%, ≥10%, and ≥20%, respectively) and provided percentages of treatment recommendations for chronic (≥90 days) medium and all high-risk patients.

RESULTS

Glucocorticoids were used by 1.66% of PMW and 1.65% of men age ≥50 years. Of these patients, 0.80% of PMW and 0.45% of men age ≥50 years were at high risk of fracture. A majority of PMW (81.2%) and men age ≥50 years (75.8%) were chronic glucocorticoid users. In patients for whom treatment recommendations could be made, 64.9% of PMW and 51.9% of men age ≥50 years would be recommended therapy, but only 28.4% of PMW and 9.7% of men age ≥50 years reported AOP use.

CONCLUSION

Based on the NHANES (2005-2010) data, we estimate glucocorticoid use in >1.5 million US PMW and men age ≥50 years. Treatment would be recommended in at least 50% of this population based on the 2010 ACR guidelines. Self-reported AOP use was documented in <30%, suggesting a treatment gap in the management of GIO in the US before the guideline release.

A randomized trial of a mailed intervention and self-scheduling to improve osteoporosis screening in postmenopausal women

Guidelines recommend bone density screening with dual-energy X-ray absorptiometry (DXA) in women 65 years or older, but <30% of eligible women undergo DXA testing. There is a need to identify a systematic, effective, and generalizable way to improve osteoporosis screening. A group randomized, controlled trial of women ≥65 years old with no DXA in the past 4 years, randomized to receive intervention materials (patient osteoporosis brochure and a letter explaining how to self-schedule a DXA scan) versus usual care (control) was undertaken. Outcome of interest was DXA completion. Of 2997 women meeting inclusion criteria, 977 were randomized to the intervention group. A total of 17.3% of women in the intervention group completed a DXA, compared to 5.2% in the control group (12.1% difference, p < 0.0001). When including only those medically appropriate, we found a difference of 19% between the two groups (p < 0.0001). DXA receipt was greater in main clinic patients compared to satellite clinic patients (20.9% main clinic versus 10.1% satellite clinic). The cost to print and mail the intervention was $0.79 per patient, per mailing. The number of women to whom intervention needed to be mailed to yield one extra DXA performed was 9, at a cost of $7.11. DXA scan completion was significantly improved through use of a mailed osteoporosis brochure and the availability for patients to self-schedule. This simple approach may be an effective component of a multifaceted quality improvement program to increase rates of osteoporosis screening.

Effects of glucocorticoid treatment on bone strength

Glucocorticoids (GCs) are prescribed for the treatment of several diseases, but their long-term use causes osteoporosis. Current research suggests that GCs suppress the canonical Wnt/beta pathway, resulting in decreased expression of critical bone proteins. This study examined how bone structure and strength of high bone mass (HBM) mice and low density lipoprotein receptor-related protein 5 (LRP5) knockout (KO+/-) mice are affected by GC treatment in comparison to wild-type (WT) mice, and if changes were specific to either trabecular or cortical bone. Mice were treated with either prednisone or placebo. The femurs and L4 vertebral bodies were analyzed by micro-CT for structure and mechanically tested to determine strength and apparent material strength properties. Differences in all measured variables corresponding to GC treatment and genotype were tested using two-way ANOVA. GC treatment caused decreased structural strength parameters, weakened apparent material strength properties, and disruption of bone structure in HBM, but not LRP5+/- or WT, mice. Despite treatment-related loss, trabecular bone structure and strength remained elevated as compared to LRP5+/- and WT mice. In HBM femurs, both cortical and trabecular structure, but not strength parameters, were negatively affected by treatment. In HBM vertebral bodies, both structural and strength parameters were negatively affected by treatment.

Bone health in a tertiary-care gastroenterology and hepatology population

BACKGROUND

Glucocorticoid use is a major risk factor for osteoporosis. Overall rates of glucocorticoid use and bone health preventive measures in gastroenterology and hepatology populations are unknown.

AIMS

We aimed to determine the rates of glucocorticoid use and bone health preventive measures, to evaluate an education-based quality improvement initiative on bone health and to assess improvement in health-care practices of providers in regard to bone health recommendations.

METHODS

A cross-sectional survey was offered to all patients visiting a tertiary care gastroenterology and hepatology clinic. A bone health education intervention was performed, followed by a repeat cross-sectional survey. Pearson's Chi-square test statistic was used to evaluate interval improvement in bone health recommendations with the intervention. Predictive multiple logistic regression modeling was used to determine factors that influenced bone health recommendations by providers.

RESULTS

A total of 552 patients and 725 patients completed the pre and post-intervention questionnaires, respectively. The prevalence of glucocorticoid use was 12.9%. Bone health recommendations to patients on glucocorticoids did not improve with the intervention (63.0% vs. 55.4%, p = 0.42). The strongest predictor of bone health recommendations was autoimmune hepatitis (OR 6.60 95%CI 3.13, 13.90), followed by inflammatory bowel disease (OR 6.06 95%CI 3.92, 9.38), liver disease (OR 3.70 95%CI 2.45, 5.59), current smoking (OR 3.31 95%CI 2.32, 4.73) and history of osteoporosis/osteopenia (OR 2.72 95%CI 1.83, 4.03).

CONCLUSIONS

In spite of risk factors for osteoporosis in patients with digestive diseases, health-care practices by providers in regard to bone health recommendations warrant further improvement.

Prevention of glucocorticoid-induced osteoporosis

Glucocorticoid-induced osteoporosis is the most common cause of secondary osteoporosis. The role of the Wnt signaling pathway in bone formation and the ratio of receptor activator for NF-kappaB ligand versus osteoprotegerin in bone resorption are exciting new insights. The absolute fracture risk helps both clinicians and patients to interpret the results of bone density measurement, which may have a positive influence on adherence to therapy. The bisphosphonates alendronate and risedronate are the first-line treatment in the prevention of glucocorticoid-induced osteoporosis, because both increase the bone mineral density of the spine and hips and reduce the vertebral fracture rate. Treatment with the anabolic agent parathyroid hormone (1 - 34) strongly stimulates bone turnover, and seems to be superior to treatment with alendronate. It might be attractive for glucocorticoid-treated patients with new vertebral fractures during treatment with bisphosphonates, and/or with severe fracture risk.

Distinct features of dehydrocorticosterone reduction into corticosterone in the liver and duodenum of the domestic fowl (Gallus gallus domesticus)

The mammalian 11-beta hydroxysteroid dehydrogenase type 1 (11 betaHSD1) reduces glucocorticoids (GC) at C11 from the 11-keto-GC nonactive form to the 11-hydroxy-GC active form, an action essential for survival. Whereas GC metabolism at C11 and the role of 11 betaHSD1 are studied extensively in mammals, information about these in birds is scattered. Herein, we report the GC bidirectional metabolism in chickens. In hens' liver and duodenal mucosa, 11 betaHSD1-like mRNA expression was detected; and 11 betaHSD1-like immunoreactivity was found linked to membranes of hepatocytes and duodenal enterocytes. With either NADH or NADPH, the membranal fraction of liver and duodenal mucosa converted dehydrocorticosterone (A) into corticosterone (B) with K(m) (1.1-8.7 microM) and V(max) (10-40 pmol/mg protein/min) values similar to those reported for mammalian 11 betaHSD1. In the presence of NADP(+) or NAD(+), these membranal fractions oxidized B into A. With either NADPH or NADH, the cytosol of chicken liver and duodenal mucosa reduced A into B (K(m) of 1.1 - 2.3 microM and V(max) of 260-960 pmol/mg protein/min). These cytosolic fractions did not convert any amount of B into A when incubated with either NADP(+) or NAD(+). This may suggest that chicken liver and duodenal mucosa express 11 betaHSD1 that is a membrane-bound oxoreductase which uses both NADPH/NADP(+) and NADH/NAD(+) as cosubstrates. The substantial reduction of A into B (but no conversion of B into A) found in the cytosol is most likely executed by a unidirectional soluble reductase, different than 11 betaHSD1.