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Anastasilaki E, Paccou J, Gkastaris K, Anastasilakis AD. Glucocorticoid-induced osteoporosis: an overview with focus on its prevention and management. Hormones (Athens) 2023; 22:611-622. [PMID: 37755658 DOI: 10.1007/s42000-023-00491-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 09/18/2023] [Indexed: 09/28/2023]
Abstract
The widespread use of glucocorticoids (GCs) contributes to the effective management of several diseases and conditions. However, it comes at a price in the case of the bones causing glucocorticoid-induced osteoporosis (GIOP), the most common cause of secondary osteoporosis and fractures. Several scientific societies have issued comprehensive guidelines on the optimal management of patients receiving GCs with the aim of providing answers to three fundamental questions, namely, whom to treat, when to treat, and how to treat. Both common ground and different approaches exist among them. General preventive measures should start along with GC initiation, and the duration of GC therapy should be limited to the minimal effective range. A pre-existing fracture, age, gender, menopausal status, dose, and duration of GC treatment are key factors in the decision to initiate antiosteoporotic medication. Oral bisphosphonates are typically regarded as the first-line treatment choice for GIOP partly due to their cost-effectiveness. Denosumab is another valid option, but an "exit strategy" should be considered before its initiation due to the risk of rebound-associated vertebral fractures upon its discontinuation. Since impaired bone formation represents the main mechanism by which GCs negatively affect skeletal health, osteoanabolic therapies appear to be pathophysiologically the more appropriate and appealing option, although cost considerations currently limit their use to selected severe cases. Regardless of the agent selected to mitigate the impact of GCs on the skeleton, what is most crucial is that the treating physician correctly stratifies the risk and intervenes at the right time.
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Affiliation(s)
| | - Julien Paccou
- Univ. Lille, CHU Lille, MABlab ULR 4490, Department of Rheumatology, 59000, Lille, France
| | | | - Athanasios D Anastasilakis
- Department of Endocrinology, 424 Military General Hospital, Ring Road, 564 29 N. Efkarpia, Thessaloniki, Greece.
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Laurent MR, Goemaere S, Verroken C, Bergmann P, Body JJ, Bruyère O, Cavalier E, Rozenberg S, Lapauw B, Gielen E. Prevention and Treatment of Glucocorticoid-Induced Osteoporosis in Adults: Consensus Recommendations From the Belgian Bone Club. Front Endocrinol (Lausanne) 2022; 13:908727. [PMID: 35757436 PMCID: PMC9219603 DOI: 10.3389/fendo.2022.908727] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/02/2022] [Indexed: 01/13/2023] Open
Abstract
Glucocorticoids are effective immunomodulatory drugs used for many inflammatory disorders as well as in transplant recipients. However, both iatrogenic and endogenous glucocorticoid excess are also associated with several side effects including an increased risk of osteoporosis and fractures. Glucocorticoid-induced osteoporosis (GIOP) is a common secondary cause of osteoporosis in adults. Despite availability of clear evidence and international guidelines for the prevention of GIOP, a large treatment gap remains. In this narrative review, the Belgian Bone Club (BBC) updates its 2006 consensus recommendations for the prevention and treatment of GIOP in adults. The pathophysiology of GIOP is multifactorial. The BBC strongly advises non-pharmacological measures including physical exercise, smoking cessation and avoidance of alcohol abuse in all adults at risk for osteoporosis. Glucocorticoids are associated with impaired intestinal calcium absorption; the BBC therefore strongly recommend sufficient calcium intake and avoidance of vitamin D deficiency. We recommend assessment of fracture risk, taking age, sex, menopausal status, prior fractures, glucocorticoid dose, other clinical risk factors and bone mineral density into account. Placebo-controlled randomized controlled trials have demonstrated the efficacy of alendronate, risedronate, zoledronate, denosumab and teriparatide in GIOP. We suggest monitoring by dual-energy X-ray absorptiometry (DXA) and vertebral fracture identification one year after glucocorticoid initiation. The trabecular bone score might be considered during DXA monitoring. Extended femur scans might be considered at the time of DXA imaging in glucocorticoid users on long-term (≥ 3 years) antiresorptive therapy. Bone turnover markers may be considered for monitoring treatment with anti-resorptive or osteoanabolic drugs in GIOP. Although the pathophysiology of solid organ and hematopoietic stem cell transplantation-induced osteoporosis extends beyond GIOP alone, the BBC recommends similar evaluation, prevention, treatment and follow-up principles in these patients. Efforts to close the treatment gap in GIOP and implement available effective fracture prevention strategies into clinical practice in primary, secondary and tertiary care are urgently needed.
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Affiliation(s)
- Michaël R. Laurent
- Centre for Metabolic Bone Diseases, Department of Geriatrics, University Hospitals Leuven, Leuven, Belgium
- Department of Geriatrics, Imelda Hospital, Bonheiden, Belgium
| | - Stefan Goemaere
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
| | - Charlotte Verroken
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
- Department of Endocrinology and Metabolism, Ghent University Hospital, Ghent, Belgium
| | - Pierre Bergmann
- Department of Nuclear Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Olivier Bruyère
- WHO Collaborating Center for Public Health Aspects of Musculoskeletal Health and Ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liège, CHU de Liège, Liège, Belgium
| | - Serge Rozenberg
- Department of Gynaecology and Obstetrics, Université Libre de Bruxelles, Brussels, Belgium
| | - Bruno Lapauw
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
- Department of Endocrinology and Metabolism, Ghent University Hospital, Ghent, Belgium
| | - Evelien Gielen
- Centre for Metabolic Bone Diseases, Department of Geriatrics, University Hospitals Leuven, Leuven, Belgium
- Gerontology and Geriatrics section, Department of Public Health and Primary Care, University Hospitals Leuven and KU Leuven, Leuven, Belgium
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Treatment of Glucocorticoid-Induced Osteoporosis and Risk Factors for New Vertebral Fractures in Female Patients with Autoimmune Diseases. J Osteoporos 2021; 2021:5515653. [PMID: 34733465 PMCID: PMC8560280 DOI: 10.1155/2021/5515653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 10/16/2021] [Indexed: 11/18/2022] Open
Abstract
We aimed to evaluate the compliance of physicians with the 2014 guidelines of the Japanese Society for Bone and Mineral Research, for the prevention and treatment of glucocorticoid (GC) induced osteoporosis (GIO) and to investigate the risk of fracture and other associated risk factors in bisphosphonate-treated patients. We evaluated 90 female patients with nonrheumatoid arthritis autoimmune diseases who received long-term GC treatment (≥12 months). Clinical characteristics, including age, GC dose, history of fragility fractures, osteoporosis treatments, as well as lumbar (L2-L4) and femoral neck bone mineral density, were collected from the patients' medical charts. New vertebral fractures during the study period were evaluated using thoracic and lumbar spine radiographs by quantitative measurements. The GIO score was calculated for each patient according to 2014 Japanese guidelines. Of the 90 patients evaluated, 60 were indicated for osteoporosis treatment, based on the 2014 guidelines of Japan. We observed a high compliance rate, with 93% of patients receiving osteoporosis treatment and 50% receiving bisphosphonates. In total, eight patients developed new vertebral fractures during the study, six of whom received bisphosphonates. In bisphosphonate-treated patients, fracture risk was associated with GC treatment and a lack of active vitamin D3 supplementation. The compliance rate with the updated Japanese 2014 guidelines at our institution was very high. Large randomized controlled trials are needed to confirm our findings that suggest that active vitamin D3 should be used in combination with bisphosphonates for the treatment of GIO to reduce fracture risk.
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Kobza AO, Herman D, Papaioannou A, Lau AN, Adachi JD. Understanding and Managing Corticosteroid-Induced Osteoporosis. Open Access Rheumatol 2021; 13:177-190. [PMID: 34239333 PMCID: PMC8259736 DOI: 10.2147/oarrr.s282606] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/03/2021] [Indexed: 11/23/2022] Open
Abstract
Glucocorticoids are effective immunosuppressants used in a wide variety of diseases. Their use results in secondary osteoporosis in about 30–50% of chronic glucocorticoid users. Glucocorticoids cause a rapid decline in bone strength within the first 3–6 months mostly due to increased bone resorption by osteoclasts. This is followed by a more gradual loss of bone partly due to decreased osteoblastogenesis and osteoblast and osteocyte apoptosis. The loss of bone strength induced by glucocorticoids is not fully captured by bone mineral density measurements. Other tools such as the trabecular bone score and advanced imaging techniques give insight into bone quality; however, these are not used widely in clinical practice. Glucocorticoid-induced osteoporosis should be seen as a widely preventable disease. Currently, only about 15% of chronic glucocorticoid users are receiving optimal care. Glucocorticoids should be prescribed at the lowest dose and shortest duration. All patients should be counselled on lifestyle measures to maintain bone strength including nutrition and weight-bearing exercise. Pharmacological therapy should be considered for all patients at moderate to high risk of fracture as there is evidence for the prevention of bone loss and fractures with a favourable safety profile. Oral bisphosphonates are the current mainstay of therapy, whereas osteoanabolic agents may be considered for those at highest risk of fracture.
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Affiliation(s)
- Alexandra O Kobza
- Division of Rheumatology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Deena Herman
- Division of Rheumatology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Alexandra Papaioannou
- Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Arthur N Lau
- Division of Rheumatology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jonathan D Adachi
- Division of Rheumatology, Department of Medicine, McMaster University, Hamilton, ON, Canada
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Frara S, Allora A, di Filippo L, Formenti AM, Loli P, Polizzi E, Tradati D, Ulivieri FM, Giustina A. Osteopathy in mild adrenal Cushing's syndrome and Cushing disease. Best Pract Res Clin Endocrinol Metab 2021; 35:101515. [PMID: 33795196 DOI: 10.1016/j.beem.2021.101515] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pathophysiology and effects of endogenous glucocorticoid (GC) excess on skeletal endpoints as well as awareness and management of bone fragility are reviewed. Cushing's syndrome (CS) increase the risk of fracture affecting prevalently bone quality. Bone antiresorptive agents (SERMs, bisphosphonates and denosumab) as well as teriparatide increase bone mineral density and in some instances reduce fracture risk. Awareness and management of bone health in CS can be improved.
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Affiliation(s)
- Stefano Frara
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Agnese Allora
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Luigi di Filippo
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Anna Maria Formenti
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Paola Loli
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Daniele Tradati
- Department of Orthopedics and Traumatology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Fabio Massimo Ulivieri
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy.
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Pereira RMR, Perez MO, Paula AP, Moreira C, Castro CHM, Zerbini CAF, Domiciano DS, de Azevedo E, Mendonca LMC, Shinzato MM, da Rocha-Loures MAA, Radominski S, Szejnfeld VL. Guidelines for the prevention and treatment of glucocorticoid-induced osteoporosis: an update of Brazilian Society of Rheumatology (2020). Arch Osteoporos 2021; 16:49. [PMID: 33646403 DOI: 10.1007/s11657-021-00902-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 02/01/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED The Brazilian guidelines for prevention and treatment of glucocorticoid-induced osteoporosis were updated and important topics were included such as assessment of risk fracture using FRAX Brazil, use of denosumab, and also recommendations for the use of glucocorticoid pulse therapy and inhaled glucocortiocoid. INTRODUCTION Glucocorticoids (GCs) are used in almost all medical specialties and the incidences of vertebral/nonvertebral fractures range from 30 to 50% in individuals treated with GCs for over 3 months. Thus, osteoporosis and frailty fractures should be prevented and treated in patients initiating treatment or already being treated with GCs. The Committee for Osteoporosis and Bone Metabolic Disorders of the Brazilian Society of Rheumatology (BSR) established in 2012 the Brazilian Guidelines for glucocorticoid-induced osteoporosis (GIO). Herein, we provide a comprehensive update of the original guidelines based on improved available scientific evidence and/or expert experience. METHODS From March to June 2020, the Osteoporosis Committee of the BRS had meetings to update the questions presented in the first consensus (2012). Thus, twenty-six questions considered essential for the preparation of the recommendations were selected. A systematic literature review based on real-life scenarios was undertaken to answer the proposed questions. The MEDLINE, EMBASE, and SCOPUS databases were searched using specific search keywords. RESULTS Based on the review and expert opinion, the recommendations were updated for each of the 26 questions. We included 48 new bibliographic references that became available after the date of the publication of the first version of the consensus. CONCLUSION We updated the Brazilian guidelines for the prevention/treatment of GIO. New topics were added in this update, such as the assessment of risk fracture using FRAX Brazil, the use of denosumab, and approaches for the treatment of children and adolescents. Furthermore, we included recommendations for the use of inhaled GCs and GC pulse therapy in clinical settings.
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Affiliation(s)
- Rosa M R Pereira
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3° andar, sala 3193, Sao Paulo, SP, 01246-903, Brazil.
| | - Mariana O Perez
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3° andar, sala 3193, Sao Paulo, SP, 01246-903, Brazil
| | - Ana Patrícia Paula
- Rheumatology Division, Faculdade de Ciências da Saúde, Universidade de Brasilia (UnB), Brasilia, DF, Brazil
| | - Caio Moreira
- Rheumatology Division, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Charlles H M Castro
- Rheumatology Division, Universidade Federal de Sao Paulo-Escola Paulista de Medicina, Sao Paulo, SP, Brazil
| | - Cristiano A F Zerbini
- Rheumatology Division, Centro Paulista de Investigação Clínica, Sao Paulo, SP, Brazil
| | - Diogo S Domiciano
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3° andar, sala 3193, Sao Paulo, SP, 01246-903, Brazil
| | - Elaine de Azevedo
- Rheumatology Division, Hospital do Servidor Público Estadual de Sao Paulo, Sao Paulo, SP, Brazil
| | - Laura M C Mendonca
- Rheumatology Division, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Marcia Midore Shinzato
- Rheumatology Division, Faculdade de Ciências da Saúde da Universidade Federal da Grande Dourados, Dourados, MS, Brazil
| | | | - Sebastião Radominski
- Rheumatology Division, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brazil
| | - Vera L Szejnfeld
- Rheumatology Division, Universidade Federal de Sao Paulo-Escola Paulista de Medicina, Sao Paulo, SP, Brazil
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Nasomyont N, Keefe C, Tian C, Hornung L, Khoury J, Tilden JC, Hochwalt P, Jackson E, Rybalsky I, Wong BL, Rutter MM. Safety and efficacy of teriparatide treatment for severe osteoporosis in patients with Duchenne muscular dystrophy. Osteoporos Int 2020; 31:2449-2459. [PMID: 32676823 DOI: 10.1007/s00198-020-05549-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 07/08/2020] [Indexed: 01/07/2023]
Abstract
UNLABELLED Osteoporosis is a major concern in patients with Duchenne muscular dystrophy. In this novel study of teriparatide treatment in 6 patients with severe osteoporosis, bone health (fractures, vertebral morphometry, and DXA) remained stable, with no adverse events. These findings will help inform future osteoporosis research in this challenging population. INTRODUCTION Despite standard therapy with vitamin D and bisphosphonates (BP), many patients with Duchenne muscular dystrophy (DMD) continue to sustain fragility fractures due to long-term glucocorticoid treatment and limited mobility. We aimed to evaluate the safety and efficacy of teriparatide for the treatment of severe osteoporosis in adolescent and young adult patients with DMD. METHODS We prospectively treated 6 patients with DMD who had severe osteoporosis with teriparatide 20 mcg subcutaneously daily for 1-2 years. Inclusion criteria were long-term glucocorticoid therapy, and severe osteoporosis despite treatment with BP, or intolerance to BP. We examined long bone and vertebral fracture outcomes, including vertebral morphometry measures, bone mineral density and content, bone formation markers, safety indices, and adverse events. RESULTS The mean age at teriparatide start was 17.9 years (range 13.9-22.1 years). All 6 patients were on daily glucocorticoids (mean ± SD; duration 10.9 ± 2.5 years) and 5 were non-ambulatory. Five patients had been treated with BP for 7.9 ± 4.2 years. All had vertebral and a history of long bone fragility fractures at baseline. Vertebral heights and Genant fracture grading remained stable. Long bone fracture rate appeared to decrease (from 0.84/year to 0.09/year); one patient sustained a long bone fracture at 6 months of treatment. Trajectories for change in bone mineral density and content were not different post- vs. pre-teriparatide. Procollagen type 1 amino-terminal propeptide (P1NP) increased, while laboratory safety indices remained stable and non-concerning. No adverse events were observed. CONCLUSION In six patients with DMD treated with teriparatide for severe osteoporosis, we observed stable bone health and modest increases in P1NP, without safety concerns. Further studies are needed to better understand teriparatide efficacy for treatment of osteoporosis in patients with DMD.
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Affiliation(s)
- N Nasomyont
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7012, Cincinnati, OH, 45229-3026, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - C Keefe
- Diabetes and Endocrinology, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - C Tian
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - L Hornung
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J Khoury
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7012, Cincinnati, OH, 45229-3026, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - P Hochwalt
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - E Jackson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - I Rybalsky
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - B L Wong
- Department of Pediatrics, University of Massachusetts Memorial Children's Medical Center, University of Massachusetts Medical School, Worcester, MA, USA
| | - M M Rutter
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7012, Cincinnati, OH, 45229-3026, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Soen S, Yamamoto K, Takeuchi T, Tanaka Y, Tanaka S, Ito M, Nakano T, Hagino H, Hirakawa A, Matsumoto T. Minodronate combined with alfacalcidol versus alfacalcidol alone for glucocorticoid-induced osteoporosis: a multicenter, randomized, comparative study. J Bone Miner Metab 2020; 38:511-521. [PMID: 31970477 DOI: 10.1007/s00774-019-01077-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 12/17/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION This study compared the clinical usefulness of minodronate (50 mg/4 weeks) plus alfacalcidol (1 μg/day) (Group M) with that of alfacalcidol alone (1 μg/day) (Group A) for treating glucocorticoid-induced osteoporosis. MATERIALS AND METHODS The primary endpoints were the changes from baseline in lumbar spine (LS) bone mineral density (BMD) and the cumulative incidence of vertebral fracture at 24 months; secondary endpoints included the changes from baseline in total hip (TH) BMD and bone turnover markers. RESULTS Of 164 patients enrolled, 152 (Group M, n = 75; Group A, n = 77) were included in the analysis of efficacy. At each time point and at 24 months, LS BMD and TH BMD were significantly higher in Group M than in Group A. The 152 patients were divided into two subgroups that were previously treated with glucocorticoids for ≤ 3 months or > 3 months. In both subgroups, the changes from baseline in LS BMD and TH BMD from baseline at 24 months had increased more in Group M than in Group A. There were no differences found in the incidence of vertebral fracture between the groups, because the number of enrolled patients was lesser than that initially expected. In Group M, both bone formation and resorption markers significantly decreased from baseline at 3 months and maintained at 6, 12, and 24 months. CONCLUSIONS Minodronate plus alfacalcidol was more effective than alfacalcidol alone in increasing BMD and was effective in increasing BMD for both prevention and treatment. Therefore, minodronate can be a good candidate drug for the treatment of glucocorticoid-induced osteoporosis.
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Affiliation(s)
- Satoshi Soen
- Department of Orthopaedic Surgery and Rheumatology, KINDAI University Nara Hospital, Nara, Japan.
| | - Kazuhiko Yamamoto
- Department of Allergy and Rheumatology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masako Ito
- Nagasaki Study Center, The Open University of Japan, Nagasaki, Japan
| | - Tetsuo Nakano
- Department of Orthopaedic Surgery, Tamana Central Hospital, Kumamoto, Japan
| | - Hiroshi Hagino
- School of Health ScienceFaculty of Medicine, Tottori University, Tottori, Japan
| | - Akihiro Hirakawa
- Department of Biostatistics and Bioinformatics, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshio Matsumoto
- Fujii Memorial Institute of Medical Sciences, Tokushima University, Tokushima, Japan
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Palmer SC, Chung EYM, McGregor DO, Bachmann F, Strippoli GFM. Interventions for preventing bone disease in kidney transplant recipients. Cochrane Database Syst Rev 2019; 10:CD005015. [PMID: 31637698 PMCID: PMC6803293 DOI: 10.1002/14651858.cd005015.pub4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND People who have chronic kidney disease (CKD) have important changes to bone structure, strength, and metabolism. Children experience bone deformity, pain, and delayed or impaired growth. Adults experience limb and vertebral fractures, avascular necrosis, and pain. The fracture risk after kidney transplantation is four times that of the general population and is related to Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) occurring with end-stage kidney failure, steroid-induced bone loss, and persistent hyperparathyroidism after transplantation. Fractures may reduce quality of life and lead to being unable to work or contribute to community roles and responsibilities. Earlier versions of this review have found low certainty evidence for effects of treatment. This is an update of a review first published in 2005 and updated in 2007. OBJECTIVES This review update evaluates the benefits and harms of interventions for preventing bone disease following kidney transplantation. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 16 May 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA RCTs and quasi-RCTs evaluating treatments for bone disease among kidney transplant recipients of any age were eligible. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial risks of bias and extracted data. Statistical analyses were performed using random effects meta-analysis. The risk estimates were expressed as a risk ratio (RR) for dichotomous variables and mean difference (MD) for continuous outcomes together with the corresponding 95% confidence interval (CI). The primary efficacy outcome was bone fracture. The primary safety outcome was acute graft rejection. Secondary outcomes included death (all cause and cardiovascular), myocardial infarction, stroke, musculoskeletal disorders (e.g. skeletal deformity, bone pain), graft loss, nausea, hyper- or hypocalcaemia, kidney function, serum parathyroid hormone (PTH), and bone mineral density (BMD). MAIN RESULTS In this 2019 update, 65 studies (involving 3598 participants) were eligible; 45 studies contributed data to our meta-analyses (2698 participants). Treatments included bisphosphonates, vitamin D compounds, teriparatide, denosumab, cinacalcet, parathyroidectomy, and calcitonin. Median duration of follow-up was 12 months. Forty-three studies evaluated bone density or bone-related biomarkers, with more recent studies evaluating proteinuria and hyperparathyroidism. Bisphosphonate therapy was usually commenced in the perioperative transplantation period (within 3 weeks) and regardless of BMD. Risks of bias were generally high or unclear leading to lower certainty in the results. A single study reported outcomes among 60 children and adolescents. Studies were not designed to measure treatment effects on fracture, death or cardiovascular outcomes, or graft loss.Compared to placebo, bisphosphonate therapy administered over 12 months in transplant recipients may prevent fracture (RR 0.62, 95% CI 0.38 to 1.01; low certainty evidence) although the 95% CI included the possibility that bisphosphonate therapy might make little or no difference. Fracture events were principally vertebral fractures identified during routine radiographic surveillance. It was uncertain whether any other drug class decreased fracture (low or very low certainty evidence). It was uncertain whether interventions for bone disease in kidney transplantation reduce all-cause or cardiovascular death, myocardial infarction or stroke, or graft loss in very low certainty evidence. Bisphosphonate therapy may decrease acute graft rejection (RR 0.70, 95% CI 0.55 to 0.89; low certainty evidence), while it is uncertain whether any other treatment impacts graft rejection (very low certainty evidence). Bisphosphonate therapy may reduce bone pain (RR 0.20, 95% CI 0.04 to 0.93; very low certainty evidence), while it was very uncertain whether bisphosphonates prevent spinal deformity or avascular bone necrosis (very low certainty evidence). Bisphosphonates may increase to risk of hypocalcaemia (RR 5.59, 95% CI 1.00 to 31.06; low certainty evidence). It was uncertain whether vitamin D compounds had any effect on skeletal, cardiovascular, death, or transplant function outcomes (very low certainty or absence of evidence). Evidence for the benefits and harms of all other treatments was of very low certainty. Evidence for children and young adolescents was sparse. AUTHORS' CONCLUSIONS Bisphosphonate therapy may reduce fracture and bone pain after kidney transplantation, however low certainty in the evidence indicates it is possible that treatment may make little or no difference. It is uncertain whether bisphosphonate therapy or other bone treatments prevent other skeletal complications after kidney transplantation, including spinal deformity or avascular bone necrosis. The effects of bone treatment for children and adolescents after kidney transplantation are very uncertain.
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Affiliation(s)
- Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Edmund YM Chung
- Royal North Shore HospitalDepartment of Medicine48 Provincial RoadSydneyNSWAustralia2070
| | - David O McGregor
- Christchurch HospitalDepartment of NephrologyPrivate Bag 4710ChristchurchNew Zealand8001
| | - Friederike Bachmann
- Charité University Medicine BerlinDepartment of Nephrology and Medical Intensive CareCharitéplatz 1BerlinGermany10117
| | - Giovanni FM Strippoli
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- DiaverumMedical Scientific OfficeLundSweden
- Diaverum AcademyBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
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Adami G, Rahn EJ, Saag KG. Glucocorticoid-induced osteoporosis: from clinical trials to clinical practice. Ther Adv Musculoskelet Dis 2019; 11:1759720X19876468. [PMID: 31565078 PMCID: PMC6755635 DOI: 10.1177/1759720x19876468] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 08/26/2019] [Indexed: 01/15/2023] Open
Abstract
Glucocorticoid-induced osteoporosis (GIOP) is the most common form of secondary
osteoporosis. To date, six large randomized controlled clinical trials on the
efficacy of pharmaceutical treatment in GIOP have been conducted. All of these
studies have focused predominately on bone mineral density outcomes, and none of
them have been statistically powered to address fracture endpoints. The purpose
of this review is to highlight differences in the design and results within
these large randomized GIOP clinical trials, and how these differences might
affect clinical decisions. Differences between studies in trial design,
populations studied, and variable efficacy impact the comparability and
generalizability of these findings, and ultimately should affect practitioners’
behavior. We review the clinical trials that provide the best quality evidence
on comparative efficacy and safety of GIOP treatments. We also propose
suggestions on the design of future GIOP clinical trials with attention to
improved generalizability, and, ideally, study designs that might achieve
fracture outcomes.
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Affiliation(s)
- Giovanni Adami
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 510 20th Street South, Faculty Office Tower 820D, Birmingham, AL 35294, USA
| | - Elizabeth J Rahn
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kenneth G Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
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Reid IR. Bisphosphonates for Prevention of Bone Loss in Glucocorticoid-Treated Young People. EClinicalMedicine 2019; 12:8-9. [PMID: 31414078 PMCID: PMC6686132 DOI: 10.1016/j.eclinm.2019.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 07/04/2019] [Indexed: 01/09/2023] Open
Affiliation(s)
- Ian R. Reid
- Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand.
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12
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Adami G, Saag KG. Glucocorticoid-induced osteoporosis: 2019 concise clinical review. Osteoporos Int 2019; 30:1145-1156. [PMID: 30805679 DOI: 10.1007/s00198-019-04906-x] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 02/14/2019] [Indexed: 12/11/2022]
Abstract
Glucocorticoids remain widely used for many medical conditions, and fractures are the most serious common adverse event related to long-term glucocorticoid use. Glucocorticoid-induced osteoporosis (GIOP) develops in a time- and dose-dependent manner, but even at low doses, an increased risk of fragility fracture may be observed even within the first month of treatment. GIOP is mediated by multiple pathophysiologic mechanisms resulting in an inhibition of bone formation and an increase in bone resorption. The clinical assessment of GIOP has potential pitfalls since dual-energy X-ray absorptiometry (DXA) may underestimate the risk of fracture in patients treated with glucocorticoids. Many national organizations have developed guidelines for assessing fracture risk and treating patients with, or at risk for, GIOP. These groups advocate both antiresorptive agents and bone-forming agents based predominately on their efficacy in improving bone mineral density. Oral bisphosphonates are generally the first-line therapy for GIOP in most patients due to their proven efficacy, good safety, and low cost. For those patients at greater risk of fracture, teriparatide should be considered earlier, based on its ability to significantly reduce vertebral fractures when compared with alendronate. GIOP remains a major public health concern that is at least partially preventable with current and potential future therapeutic options.
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Affiliation(s)
- G Adami
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 510 20th Street South, Faculty Office Tower 820D, Birmingham, AL, 35294, USA
- Rheumatology Unit, University of Verona, Pz Scuro 10, 37135, Verona, Italy
| | - K G Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 510 20th Street South, Faculty Office Tower 820D, Birmingham, AL, 35294, USA.
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Uruc V, Duman IG, Davul S, Özden R, Gonenci R, Gokce H, Dokuyucu R, Akdag A. The Effect of Cape on Steroid Induced Osteonecrosis of the Femoral Head in Rat Model. J HARD TISSUE BIOL 2018. [DOI: 10.2485/jhtb.27.237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Vedat Uruc
- Department of Orthopedics and Traumatology, Medical Faculty, Mustafa Kemal University
| | - Ibrahim Gokhan Duman
- Department of Orthopedics and Traumatology, Medical Faculty, Mustafa Kemal University
| | - Serkan Davul
- Department of Orthopedics and Traumatology, Medical Faculty, Mustafa Kemal University
| | - Raif Özden
- Department of Orthopedics and Traumatology, Medical Faculty, Mustafa Kemal University
| | | | - Hasan Gokce
- Department of Pathology, Medical Faculty, Mustafa Kemal University
| | - Recep Dokuyucu
- Department of Physiology, Medical Faculty, Mustafa Kemal University
| | - Abdurrahman Akdag
- Department of Chemistry, Science and Arts Faculty, Mustafa Kemal University
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He H, Wang C, Tang Q, Yang F, Xu Y. Possible mechanisms of prednisolone-induced osteoporosis in zebrafish larva. Biomed Pharmacother 2018; 101:981-987. [PMID: 29635908 DOI: 10.1016/j.biopha.2018.02.082] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 01/06/2018] [Accepted: 02/19/2018] [Indexed: 11/19/2022] Open
Abstract
Glucocorticoid-induced osteoporosis (GIOP) is a serious clinical bone disease that results from the long-term consumption of glucocorticoids or glucocorticoid-like drugs. Although many studies have attempted to determine the mechanisms of GIOP, they are still unclear. In this study, we established a zebrafish model of glucocorticoid-like drug-induced osteoporosis by treating larvae with prednisolone. We then quantified the expression of a selection of extracellular matrix (ECM)-, osteoblast-, and osteoclast-related genes. Our results showed that at 15 days post fertilization, zebrafish larvae treated with 25 μM prednisolone are a suitable model for GIOP, not only owing to the decrease in robust bone mass but also because of significant alterations in gene expression. The quantification of the expression of ECM-, osteoblast-, and osteoclast- related genes revealed that mmp9 and mmp13 were significantly upregulated and entpd5a, acp5a, and sost were significantly downregulated. These genes may be a target for future research into GIOP. Our study thus provides new insights into GIOP.
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Affiliation(s)
- Hanliang He
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China
| | - Chunqing Wang
- Department of Orthopaedics, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, China
| | - Qifeng Tang
- The Benq Medical Center of Suzhou, Suzhou 215000, China
| | - Fan Yang
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China
| | - Youjia Xu
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China.
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Beebe K, Magee K, McNulty A, Stahlecker J, Salzberg D, Miller H, Mirea L, Adams R, Ngwube A. Vitamin D deficiency and outcomes in pediatric hematopoietic stem cell transplantation. Pediatr Blood Cancer 2018; 65. [PMID: 28960811 DOI: 10.1002/pbc.26817] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 08/10/2017] [Accepted: 08/17/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pediatric patients undergoing hematopoietic stem cell transplantation (HSCT) are frequently diagnosed with vitamin D deficiency, which may impact outcomes. OBJECTIVES To estimate the prevalence of vitamin D deficiency and examine its association with short-term survival in pediatric HSCT patients. METHODS Patients undergoing HSCT at Phoenix Children's Hospital were retrospectively identified. Routine serum 25-hydroxyvitamin D measurements were described prior to transplant and at 100 days and 1-year post-HSCT. Associations of pre-HSCT vitamin D groups (i.e., normal ≥30 ng/ml, insufficient 20-29 ng/ml, and deficient <30 ng/ml) with demographics, clinical factors, and outcomes were examined using nonparametric tests and Cox proportional hazards analyses. RESULTS Among 72 study subjects, the median vitamin D pre-HSCT was 26 ng/ml (range: 19-34 ng/ml). Levels were insufficient and deficient in 25 (35%) and 20 (28%) patients, respectively, with only two (3%) patients on supplemental therapy pre-HSCT. Despite supplemental therapy provided to 46 (74%) subjects, insufficient/deficient rates did not significantly change between pre-HSCT and 100 days post-HSCT, but mean vitamin D levels significantly increased by 1-year post-HSCT (P = 0.01).Vitamin D pre-HSCT was not associated with the development of acute or chronic graft-versus-host disease (GVHD) or delayed engraftment. Overall 1-year survival was significantly lower for patients with deficient (65%) compared to normal (93%) pre-HSCT vitamin D (P = 0.001). CONCLUSION Suboptimal vitamin D levels are common in pediatric patients scheduled to receive HSCT and are associated with lower overall 1-year survival. Further study is warranted to delineate the mechanisms underlying the role of vitamin D in successful HSCT.
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Affiliation(s)
- Kristen Beebe
- Center for Cancer and Blood Disorder, Phoenix Children's Hospital, Phoenix, Arizona
| | - Kyrie Magee
- Center for Cancer and Blood Disorder, Phoenix Children's Hospital, Phoenix, Arizona
| | - Annmarie McNulty
- Center for Cancer and Blood Disorder, Phoenix Children's Hospital, Phoenix, Arizona
| | - Jennifer Stahlecker
- Center for Cancer and Blood Disorder, Phoenix Children's Hospital, Phoenix, Arizona
| | - Dana Salzberg
- Center for Cancer and Blood Disorder, Phoenix Children's Hospital, Phoenix, Arizona
| | - Holly Miller
- Center for Cancer and Blood Disorder, Phoenix Children's Hospital, Phoenix, Arizona
| | - Lucia Mirea
- Center for Cancer and Blood Disorder, Phoenix Children's Hospital, Phoenix, Arizona
| | - Roberta Adams
- Center for Cancer and Blood Disorder, Phoenix Children's Hospital, Phoenix, Arizona
| | - Alexander Ngwube
- Center for Cancer and Blood Disorder, Phoenix Children's Hospital, Phoenix, Arizona
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Tanaka Y, Mori H, Aoki T, Atsumi T, Kawahito Y, Nakayama H, Tohma S, Yamanishi Y, Hasegawa H, Tanimura K, Negoro N, Ueki Y, Kawakami A, Eguchi K, Saito K, Okada Y. Analysis of bone metabolism during early stage and clinical benefits of early intervention with alendronate in patients with systemic rheumatic diseases treated with high-dose glucocorticoid: Early DIagnosis and Treatment of OsteopoRosis in Japan (EDITOR-J) study. J Bone Miner Metab 2016; 34:646-654. [PMID: 26308708 DOI: 10.1007/s00774-015-0709-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 07/22/2015] [Indexed: 11/28/2022]
Abstract
We conducted a prospective multicenter study to assess early changes in the dynamics of bone metabolism in patients with systemic connective tissue diseases following commencement of high-dose glucocorticoid therapy and the benefits of early treatment with bisphosphonate and vitamin D analogue. The subjects of this randomized controlled trial were 106 female patients with systemic connective tissue diseases treated for the first time with glucocorticoids at doses equivalent to prednisolone ≥20 mg/day (age ≥ 18 years). One week after initiation of glucocorticoid therapy, patients were randomly assigned to treatment with alfacalcidol at 1 μg/day (n = 33), alendronate 35 mg/week (n = 37), and alfacalcidol plus alendronate (n = 36). The primary endpoints were changes in lumbar spine bone density at 6 months of treatment and the frequency of bone fracture at 12 months. Commencement of glucocorticoid therapy was associated with a rapid and marked bone resorption within 1 week. The combination of alfacalcidol and alendronate administered after the first week of glucocorticoid therapy halted the pathological processes affecting bone metabolism, increased bone density, and reduced the incidence of bone fracture over a period of 12 months. Taken together, the use of the combination of alfacalcidol and alendronate improved bone metabolism, increased bone density, and significantly reduced the incidence of bone fracture during 1-year high-dose glucocorticoid therapy.
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Affiliation(s)
- Yoshiya Tanaka
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
| | - Hiroko Mori
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
| | - Takatoshi Aoki
- Department of Radiology, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Tatsuya Atsumi
- Department of Internal Medicine, Hokkaido University, Sapporo, Japan
| | - Yutaka Kawahito
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hisanori Nakayama
- Department of Rheumatology, Sagamihara National Hospital, National Hospital Organization, Sagamihara, Kanagawa, Japan
| | - Shigeto Tohma
- Department of Rheumatology, Sagamihara National Hospital, National Hospital Organization, Sagamihara, Kanagawa, Japan
| | - Yuji Yamanishi
- Department of Rheumatology, Hiroshima Rheumatology Clinic, Hiroshima, Japan
| | - Hitoshi Hasegawa
- Department of Bioregulatory Medicine, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | | | - Nobuo Negoro
- Clinical Immunology and Rheumatology, Osaka City University, Osaka, Japan
| | - Yukitaka Ueki
- Department of Internal Medicine, Sasebo Central Hospital, Nagasaki, Japan
| | - Atsushi Kawakami
- Unit of Translational Medicine, Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Katsumi Eguchi
- Unit of Translational Medicine, Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazuyoshi Saito
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
| | - Yosuke Okada
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan.
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van der Goes MC, Strehl C, Buttgereit F, Bijlsma JW, Jacobs JW. Can adverse effects of glucocorticoid therapy be prevented and treated? Expert Opin Pharmacother 2016; 17:2129-2133. [DOI: 10.1080/14656566.2016.1232390] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Level of Adherence to Prophylactic Osteoporosis Medication amongst Patients with Polymyalgia Rheumatica and Giant Cell Arteritis: A Cross-Sectional Study. Int J Rheumatol 2015; 2015:783709. [PMID: 26491449 PMCID: PMC4603323 DOI: 10.1155/2015/783709] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 09/13/2015] [Indexed: 01/01/2023] Open
Abstract
Objective. To estimate level of adherence to oral calcium and vitamin D supplementation as well as bisphosphonate amongst patients with PMR and GCA treated with glucocorticoids. Method. A total of 138 patients with the diagnosis of PMR and/or GCA registered in our department in December 2013. In this cross-sectional study we interviewed all the patients to measure level of adherence to calcium and vitamin D, as well as bisphosphonates. Results. Out of the 118 included patients, 88.9% of them were adherent to their prescription. Only 2 patients (1.7%) did not take calcium and vitamin D at all and 10 patients (8.5%) took their medication infrequently, 9 and 1 out of 10 patients took the medication 50-100% of the time and less than 50% of the prescribed dose, respectively. Sixty-one patients received additional treatment with bisphosphonate and 96.6% were adherent to this therapy. The remaining 3.4% of the patients did not take the medication at all. Forgetfulness, adverse side effects, and lack of understanding of treatment benefits were the most significant causes for nonadherence to calcium and vitamin D. Conclusions. Contrary to what we expected this study found that adherence to osteoporosis preventive medication in patients with PMR and GCA was high.
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Ozdem S, Yılmaz VT, Ozdem SS, Donmez L, Cetinkaya R, Suleymanlar G, Ersoy FF. Is Klotho F352V Polymorphism the Missing Piece of the Bone Loss Puzzle in Renal Transplant Recipients? Pharmacology 2015; 95:271-8. [PMID: 26022923 DOI: 10.1159/000398812] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 04/09/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Bone disorders are next to cardiovascular problems in frequency in renal transplant (RT) recipients. Reduction in 1,25-dihydroxycholecalciferol (1,25D) levels is among the reasons causing bone loss in these patients. Klotho (KL) serves as a co-receptor for fibroblast growth factor 23 (FGF23), and functions in vitamin D metabolism. KL polymorphisms have been identified in several studies, and phenylalanine to valine substitution at amino acid position 352 seemed to be important to KL function. We investigated KL F352V polymorphism and its relation with 1,25D levels in RT recipients. METHODS The study included 25 RT recipients (8 female, 17 male) and 26 (14 female, 12 male) healthy control subjects who were wild (FF) phenotypes in terms of KL F352V polymorphism. RT recipients with (FV, n = 11) and without (FF, n = 14) a heterozygote polymorphism were determined with high resolution DNA melting analysis of KL F352V polymorphism. Serum 1,25D levels were measured using the RIA method. RESULTS RT recipients with FV phenotype had significantly lower 1,25D levels (17.58 ± 18.38 pg/ml) compared to recipients with FF phenotype (44.91 ± 24.68 pg/ml) and control subjects (28.24 ± 12.13 pg/ml). 1,25D levels in RT recipients with FF phenotype were significantly higher than control subjects. CONCLUSIONS KL F352V polymorphism may increase the expression of FGF23 co-receptor, KL protein and thus may decrease renal expression of 1α-hydroxylase, and/or stimulate 24-hydroxylase in RT recipients. The resultant decrease 1,25D levels may participate in bone loss in these patients.
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Affiliation(s)
- Sebahat Ozdem
- Departments of Medical Biochemistry, Akdeniz University Medical School, Antalya, Turkey
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Kenanidis E, Potoupnis ME, Kakoulidis P, Leonidou A, Sakellariou GT, Sayegh FE, Tsiridis E. Management of glucocorticoid-induced osteoporosis: clinical data in relation to disease demographics, bone mineral density and fracture risk. Expert Opin Drug Saf 2015; 14:1035-53. [PMID: 25952267 DOI: 10.1517/14740338.2015.1040387] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Glucocorticoid-induced osteoporosis (GIOP) is the most common type of secondary osteoporosis. Patient selection and the treatment choice remain to be controversial. None of the proposed management guidelines are widely accepted. We evaluate the available clinical data, the efficacy of current medication and we propose an overall algorithm for managing GIOP. AREAS COVERED This article provides a critical review of in vivo and clinical evidence regarding GIOP and developing evidence-based algorithm of treatment. Data base used includes MEDLINE® (1950 to May 2014). EXPERT OPINION Patient-specific treatment is the gold standard of care. Glucocorticoid (GC)-treated patients must comply with a healthy lifestyle and receive 1000 mg of calcium and at least 800 mg of Vitamin D daily. Bisphosphonate (BP) therapy is the current standard of care for prevention and treatment of GIOP. Most of bisphosphonates demonstrated benefit in lumbar bone mineral density (BMD) and some in hip BMD. Alendronate, risedronate and zoledronate showed vertebral anti-fracture efficacy in postmenopausal women and men. Scarce data however when compared head to head with BP efficacy. In post-menopausal women, early antiresorptive BP treatment appears to be efficient and safe. In premenopausal women and patients at high risk of fracture receiving long-term GC therapy however, teriparitide may be advised alternatively.
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Affiliation(s)
- Eustathios Kenanidis
- Aristotle University Medical School, Academic Orthopaedic Unit , Thessaloniki , Greece
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Liu H, Cui J, Feng W, Lv S, Du J, Sun J, Han X, Wang Z, Lu X, Yimin, Oda K, Amizuka N, Li M. Local administration of calcitriol positively influences bone remodeling and maturation during restoration of mandibular bone defects in rats. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2014; 49:14-24. [PMID: 25686922 DOI: 10.1016/j.msec.2014.12.064] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 11/26/2014] [Accepted: 12/17/2014] [Indexed: 11/28/2022]
Abstract
The aim of this study was to investigate the influence of calcitriol on osteoinduction following local administration into mandibular bone defects. Calcitriol-loaded absorbable collagen membrane scaffolds were prepared using the polydopamine coating method and characterized by scanning electron microscopy. Composite scaffolds were implanted into rat mandibular bone defects in the following groups: no graft material (control), bare collagen membrane (CM group), collagen membrane bearing polydopamine coating (DOP/CM group), and collagen membrane bearing polydopamine coating absorbed with calcitriol (CAL/DOP/CM group). At 1, 2, 4 and 8weeks post-surgery, the osteogenic potential of calcitriol was examined by histological and immunohistochemical methods. Following in vivo implantation, calcitriol-loaded composite scaffolds underwent rapid degradation with pronounced replacement by new bone and induced reunion of the bone marrow cavity. Calcitriol showed strong potential in inhibiting osteoclastogenesis and promotion of osteogenic differentiation at weeks 1, and 2. Furthermore, statistical analysis revealed that the newly formed bone volume in the CAL/DOP/CM group was significantly higher than other groups at weeks 1, and 2. At weeks 4, and 8, the CAL/DOP/CM group showed more mineralized bone and uniform collagen structure. These data suggest that local administration of calcitriol is promising in promoting osteogenesis and mineralization for restoration of mandibular bone defects.
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Affiliation(s)
- Hongrui Liu
- Department of Bone Metabolism, School of Stomatology Shandong University, Shandong Provincial Key Laboratory of Oral Biomedicine, Jinan, China
| | - Jian Cui
- Department of Bone Metabolism, School of Stomatology Shandong University, Shandong Provincial Key Laboratory of Oral Biomedicine, Jinan, China
| | - Wei Feng
- Department of Bone Metabolism, School of Stomatology Shandong University, Shandong Provincial Key Laboratory of Oral Biomedicine, Jinan, China
| | - Shengyu Lv
- Department of Bone Metabolism, School of Stomatology Shandong University, Shandong Provincial Key Laboratory of Oral Biomedicine, Jinan, China
| | - Juan Du
- Department of Bone Metabolism, School of Stomatology Shandong University, Shandong Provincial Key Laboratory of Oral Biomedicine, Jinan, China
| | - Jing Sun
- Department of Bone Metabolism, School of Stomatology Shandong University, Shandong Provincial Key Laboratory of Oral Biomedicine, Jinan, China
| | - Xiuchun Han
- Department of Bone Metabolism, School of Stomatology Shandong University, Shandong Provincial Key Laboratory of Oral Biomedicine, Jinan, China
| | - Zhenming Wang
- Key Lab of Advanced Technologies of Materials, Ministry of Education, School of Materials Science and Engineering, Southwest Jiaotong University, Chengdu, Sichuan, China
| | - Xiong Lu
- Key Lab of Advanced Technologies of Materials, Ministry of Education, School of Materials Science and Engineering, Southwest Jiaotong University, Chengdu, Sichuan, China
| | - Yimin
- Department of Advanced Medicine, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kimimitsu Oda
- Division of Biochemistry, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Norio Amizuka
- Department of Developmental Biology of Hard Tissue, Graduate School of Dental Medicine, Hokkaido University, Sapporo, Japan
| | - Minqi Li
- Department of Bone Metabolism, School of Stomatology Shandong University, Shandong Provincial Key Laboratory of Oral Biomedicine, Jinan, China.
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Abboskhujaeva LS, Ismailov SI, Alikhanova NM. Efficacy of strontium ranelate in combination with a D-hormone analog for the treatment of postmenopausal osteoporosis. Drugs R D 2014; 14:315-24. [PMID: 25480348 PMCID: PMC4269821 DOI: 10.1007/s40268-014-0069-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Vitamin D supplements are recommended in individuals with vitamin D insufficiency and established osteoporosis to reduce risk of fracture and falling. Active vitamin D metabolites have been found to be more effective for fall prevention than native vitamin D. OBJECTIVES The aim of this study was to compare the efficacy of strontium ranelate in combination with alfacalcidol and strontium ranelate alone on bone mineral density (BMD) and fall risk in postmenopausal women with osteoporosis. METHODS A total of 48 women (mean age 62.4 years) with postmenopausal osteoporosis were randomized to strontium ranelate monotherapy 2 g/day (n = 16), strontium ranelate 2 g/day plus alfacalcidol 1 μg (n = 16) or control (n = 16) and followed for 6 months. All women received calcium and vitamin D3 supplements. BMD was measured at the lumbar spine and proximal femora at the beginning and end of therapy. Patients performed functional tests such as the "up and go" and chair rising tests to estimate risk of fall status. Biochemical markers of bone turnover were also assessed. RESULTS Statistically significant increases in BMD compared with baseline values and the control group were observed in both strontium ranelate treatment groups. Increases were also statistically significant in the strontium ranelate combination group compared with strontium ranelate alone. Strontium ranelate combination therapy for 6 months improved patients' ability to perform functional tests as well as increasing the number of women capable of performing the tests. No significant changes were observed in women receiving strontium ranelate monotherapy or in the control group. Serum levels of β-CrossLaps, a marker of bone resorption, were significantly reduced compared with control in both strontium ranelate groups. A significantly greater reduction was observed in the strontium ranelate combination group compared with strontium ranelate alone (24.0%; P = 0.008). Increases in type 1 procollagen total N-terminal propeptide (TP1NP), a marker of bone formation, reached statistical significance in both strontium ranelate groups compared with baseline. CONCLUSION Strontium ranelate and alfacalcidol combination therapy improves bone quality, fall risk and markers of bone turnover to a greater extent than strontium ranelate alone in patients with established osteoporosis.
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Affiliation(s)
- Lola S. Abboskhujaeva
- Center for the Scientific and Clinical Study of Endocrinology, 56 Mirzo-Ulugbek str., 100125 Tashkent, Uzbekistan
- Public Health Ministry, Tashkent, Uzbekistan
| | - Saydiganikhodja I. Ismailov
- Center for the Scientific and Clinical Study of Endocrinology, 56 Mirzo-Ulugbek str., 100125 Tashkent, Uzbekistan
- Public Health Ministry, Tashkent, Uzbekistan
| | - Nodira M. Alikhanova
- Center for the Scientific and Clinical Study of Endocrinology, 56 Mirzo-Ulugbek str., 100125 Tashkent, Uzbekistan
- Public Health Ministry, Tashkent, Uzbekistan
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van der Goes MC, Jacobs JW, Bijlsma JW. The value of glucocorticoid co-therapy in different rheumatic diseases--positive and adverse effects. Arthritis Res Ther 2014; 16 Suppl 2:S2. [PMID: 25608693 PMCID: PMC4249491 DOI: 10.1186/ar4686] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Glucocorticoids play a pivotal role in the management of many inflammatory rheumatic diseases. The therapeutic effects range from pain relief in arthritides, to disease-modifying effects in early rheumatoid arthritis, and to strong immunosuppressive actions in vasculitides and systemic lupus erythematosus. There are multiple indications that adverse effects are more frequent with the longer use of glucocorticoids and use of higher dosages, but high-quality data on the occurrence of adverse effects are scarce especially for dosages above 10 mg prednisone daily. The underlying rheumatic disease, disease activity, risk factors and individual responsiveness of the patient should guide treatment decisions. Monitoring for adverse effects should also be tailored to the patient. Continuously balancing the benefits and risks of glucocorticoid therapy is recommended. There is an ongoing quest for new drugs with glucocorticoid actions without the potential to cause harmful effects, such as selective glucocorticoid receptor agonists, but the application of a new compound in clinical practice will probably not occur within the next few years. In the meantime, basic research on glucocorticoid effects and detailed reports on therapeutic efficacy and occurrence of adverse effects will be valuable in weighing benefits and risks in clinical practice.
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Abstract
Among the adverse events of glucocorticoid treatment are bone loss and fractures. Despite available, effective preventive measures, many patients receiving or initiating glucocorticoid therapy are not appropriately evaluated and treated for bone health and fracture risk. Populations with, or at risk of, glucocorticoid-induced osteoporosis (GIOP) to target for these measures are defined on the basis of dose and duration of glucocorticoid therapy and bone mineral density. That patients with GIOP should be treated as early as possible is generally agreed upon; however, diversity remains in intervention thresholds and management guidelines. The FRAX(®) algorithm provides a 10-year probability of fracture that can be adjusted according to glucocorticoid dose. There is no evidence that GIOP and postmenopausal osteoporosis respond differently to treatments. Available anti-osteoporotic therapies such as anti-resorptives including bisphosphonates and the bone anabolic agent teriparatide are effective for the management of GIOP. Prevention with calcium and vitamin D supplementation is less effective than specific anti-osteoporotic treatment. Anti-osteoporotic treatment should be stopped at the time of glucocorticoid cessation, unless the patient remains at increased risk of fracture.
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Suzuki Y, Nawata H, Soen S, Fujiwara S, Nakayama H, Tanaka I, Ozono K, Sagawa A, Takayanagi R, Tanaka H, Miki T, Masunari N, Tanaka Y. Guidelines on the management and treatment of glucocorticoid-induced osteoporosis of the Japanese Society for Bone and Mineral Research: 2014 update. J Bone Miner Metab 2014; 32:337-50. [PMID: 24818875 DOI: 10.1007/s00774-014-0586-6] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 03/03/2014] [Indexed: 01/29/2023]
Affiliation(s)
- Yasuo Suzuki
- Committee for the Revision of Guidelines on the Management and Treatment of Glucocorticoid-Induced Osteoporosis of the Japanese Society for Bone and Mineral Research, Kobe, Japan,
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Kuchuk NO, Hoes JN, Bijlsma JWJ, Jacobs JWG. Glucocorticoid-induced osteoporosis: an overview. ACTA ACUST UNITED AC 2014. [DOI: 10.2217/ijr.14.24] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
Glucocorticoids are widely used internationally for the treatment of inflammatory disease, such as rheumatoid arthritis (RA). Although the benefit of glucocorticoids in RA on both disease activity and severity are well known, there remain unanswered questions about the overall bone safety of chronic low-dose glucocorticoids in RA. Debate exists about the merits of glucocorticoids for bone health on the basis of their benefits in promoting activity and reducing proinflammatory cytokines. Overall current evidence supports the view that bone loss is a disease related both to RA and to glucocorticoid use independently. Calcium and vitamin D, along with prescription antiosteoporosis therapies, particularly bisphosphonates and teriparatide, play an important role in stabilizing bone mineral density and potentially lowering spinal fracture risk at the spine. International guidelines provide pathways for appropriate prevention of glucocorticoid-induced osteoporosis (GIOP). Despite the evidence and these guidelines, many patients do not receive adequate management to prevent GIOP.
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Affiliation(s)
- Kenneth G Saag
- Divisions of Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Inoue K, Hamano T, Nango N, Matsui I, Tomida K, Mikami S, Fujii N, Nakano C, Obi Y, Shimomura A, Kusunoki Y, Rakugi H, Isaka Y, Tsubakihara Y. Multidetector-row computed tomography is useful to evaluate the therapeutic effects of bisphosphonates in glucocorticoid-induced osteoporosis. J Bone Miner Metab 2014; 32:271-80. [PMID: 23832575 DOI: 10.1007/s00774-013-0485-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 05/20/2013] [Indexed: 11/25/2022]
Abstract
Osteoporosis is one of the major complications of glucocorticoid therapy. Osteoporosis is usually defined by the levels of bone mineral density (BMD) assessed by dual energy X-ray absorptiometry (DEXA); however, glucocorticoids often induce fractures in patients with normal BMD. Thus, novel diagnostic approaches are required. In this study, we examined whether multidetector-row computed tomography (MDCT) is useful to assess the bone status in glucocorticoid-induced osteoporosis (GIO). Because bisphosphonates have been proven to prevent bone fracture in GIO, we tried to detect the therapeutic effects of bisphosphonates in GIO by MDCT. Fifteen Japanese patients with immunoglobulin A nephropathy who had normal renal function were enrolled in this open-label randomized trial. Patients were randomly divided into three groups-calcitriol (VD), menatetrenone (VK), or bisphosphonate (Bis). Bone conditions were analyzed twice by three different methods-bone turnover markers, DEXA, and MDCT-at the start and 6 months after the start of therapy. Both bone markers and DEXA could not detect significant differences among the therapeutic groups; however, MDCT-based analyses detected the preventive effects of bisphosphonates in GIO. Compared to VD, Bis improved structural indices, such as bone volume fraction, trabecular separation, marrow star volume, and structure model index whereas the difference between VD and VK was not significant. Finite element analysis revealed that simulated fracture load in the Bis group was significantly improved. These findings suggested that MDCT-based assessment is superior to bone markers and/or DEXA in assessing the therapeutic effect of bisphosphonates on GIO.
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Affiliation(s)
- Kazunori Inoue
- Department of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
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Bisphosphonates for the prevention and treatment of osteoporosis in patients with rheumatic diseases: a systematic review and meta-analysis. PLoS One 2013; 8:e80890. [PMID: 24324644 PMCID: PMC3855695 DOI: 10.1371/journal.pone.0080890] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 10/08/2013] [Indexed: 11/21/2022] Open
Abstract
Background While bisphosphonates (BPs) are commonly used in clinical treatment for osteoporosis, their roles on osteoporosis treatment for rheumatic patients remain unclear. We performed a meta-analysis to evaluate the efficacy of BPs on fractures prevention and bone mass preserving in rheumatic patients. Methodology/Principal Findings We searched PubMed, EmBase, and the Cochrane Central Register of Controlled Trials for relevant literatures with a time limit of Jan. 6, 2012. All randomized clinical trials of BPs for adult rheumatic patients with a follow-up of 6 months or more were included. We calculated relative risks (RRs) for fractures and weighted mean difference (WMD) for percent change of bone mineral density (BMD). Twenty trials were included for analysis. The RR in rheumatic patients treated with BPs was 0.61 (95%CI [0.44, 0.83], P = 0.002) for vertebral fractures, and 0.49 (95%CI [0.23, 1.02], P = 0.06) for non-vertebral fractures. The WMD of BMD change in the lumbar spine was 3.72% (95%CI [2.72, 4.72], P<0.001) at 6 months, 3.67% (95%CI [2.84, 4.50], P<0.001) at 12 months, 3.64% (95%CI [2.59, 4.69], P<0.001) at 24 months, and 5.87% (95%CI [4.59, 7.15], P<0.001) at 36 months in patients using BPs, as compared with those treated with calcium, vitamin D or calcitonin. In subgroup analyses, rheumatic patients using BPs for osteoporosis prevention had greater WMD than those using BPs for treating osteoporosis at 6 months (4.53% vs. 2.73%, P = 0.05) and 12 months (4.93% vs. 2.91%, P = 0.01). Conclusions/Significance In both short-term and middle-term, BPs can preserve bone mass and reduce the incidence of vertebral fractures in rheumatic patients, mainly for those who have GC consumption. The efficacy of BPs is better when using BPs to prevent rather than to treat osteoporosis in rheumatic patients.
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Duru N, van der Goes MC, Jacobs JWG, Andrews T, Boers M, Buttgereit F, Caeyers N, Cutolo M, Halliday S, Da Silva JAP, Kirwan JR, Ray D, Rovensky J, Severijns G, Westhovens R, Bijlsma JWJ. EULAR evidence-based and consensus-based recommendations on the management of medium to high-dose glucocorticoid therapy in rheumatic diseases. Ann Rheum Dis 2013; 72:1905-13. [PMID: 23873876 DOI: 10.1136/annrheumdis-2013-203249] [Citation(s) in RCA: 171] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
To develop recommendations for the management of medium to high-dose (ie, >7.5 mg but ≤100 mg prednisone equivalent daily) systemic glucocorticoid (GC) therapy in rheumatic diseases. A multidisciplinary EULAR task force was formed, including rheumatic patients. After discussing the results of a general initial search on risks of GC therapy, each participant contributed 10 propositions on key clinical topics concerning the safe use of medium to high-dose GCs. The final recommendations were selected via a Delphi consensus approach. A systematic literature search of PubMed, EMBASE and Cochrane Library was used to identify evidence concerning each of the propositions. The strength of recommendation was given according to research evidence, clinical expertise and patient preference. The 10 propositions regarded patient education and informing general practitioners, preventive measures for osteoporosis, optimal GC starting dosages, risk-benefit ratio of GC treatment, GC sparing therapy, screening for comorbidity, and monitoring for adverse effects. In general, evidence supporting the recommendations proved to be surprisingly weak. One of the recommendations was rejected, because of conflicting literature data. Nine final recommendations for the management of medium to high-dose systemic GC therapy in rheumatic diseases were selected and evaluated with their strengths of recommendations. Robust evidence was often lacking; a research agenda was created.
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Affiliation(s)
- N Duru
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, , Utrecht, The Netherlands
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Consider the risk of fracture in the individual when using pharmacological agents to prevent or treat corticosteroid-induced osteoporosis. DRUGS & THERAPY PERSPECTIVES 2013. [DOI: 10.1007/s40267-012-0003-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Rizzoli R, Adachi JD, Cooper C, Dere W, Devogelaer JP, Diez-Perez A, Kanis JA, Laslop A, Mitlak B, Papapoulos S, Ralston S, Reiter S, Werhya G, Reginster JY. Management of glucocorticoid-induced osteoporosis. Calcif Tissue Int 2012; 91:225-43. [PMID: 22878667 DOI: 10.1007/s00223-012-9630-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 05/29/2012] [Indexed: 01/05/2023]
Abstract
This review summarizes the available evidence-based data that form the basis for therapeutic intervention and covers the current status of glucocorticoid-induced osteoporosis (GIOP) management, regulatory requirements, and risk-assessment options. Glucocorticoids are known to cause bone loss and fractures, yet many patients receiving or initiating glucocorticoid therapy are not appropriately evaluated and treated. An European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis workshop was convened to discuss GIOP management and to provide a report by a panel of experts. An expert panel reviewed the available studies that discussed approved therapeutic agents, focusing on randomized and controlled clinical trials reporting on bone mineral density and/or fracture risk of at least 48 weeks' duration. There is no evidence that GIOP and postmenopausal osteoporosis respond differently to treatments. The FRAX algorithm can be adjusted according to glucocorticoid dose. Available antiosteoporotic therapies such as bisphosphonates and teriparatide are efficacious in GIOP management. Several other agents approved for the treatment of postmenopausal osteoporosis may become available for GIOP. It is advised to stop antiosteoporotic treatment after glucocorticoid cessation, unless the patient remains at increased risk of fracture. Calcium and vitamin D supplementation as an osteoporosis-prevention measure is less effective than specific antiosteoporotic treatment. Fracture end-point studies and additional studies investigating specific subpopulations (pediatric, premenopausal, or elderly patients) would strengthen the evidence base and facilitate the development of intervention thresholds and treatment guidelines.
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Affiliation(s)
- R Rizzoli
- Service of Bone Diseases, Geneva University Hospitals, Geneva, Switzerland.
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Abstract
Long-term corticosteroid treatment is the most common secondary cause of bone loss. Patients treated with long-term corticosteroid therapy may develop osteopenia or osteoporosis, and many have fractures. It is difficult to predict which corticosteroid-treated patients will develop significant skeletal complications because of variability in the underlying diseases treated with corticosteroids, and because of variation in corticosteroid dose over time. Corticosteroid therapy causes an alteration in the ratio between osteoprotegerin (OPG) and receptor activator of nuclear factor κ B (RANK) ligand (RANKL), which leads to early increased bone resorption for the first 3-6 months, with long-term treatment leading primarily to suppression of bone formation. Recently published recommendations advise the use of bisphosphonates or teriparatide in high-risk patients, depending on fracture risk assessed by bone mineral density testing. This article gives an update of current knowledge regarding the pathophysiology, clinical presentation and evaluation, and prevention and treatment of patients with corticosteroid-induced osteoporosis.
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Stein EM, Ortiz D, Jin Z, McMahon DJ, Shane E. Prevention of fractures after solid organ transplantation: a meta-analysis. J Clin Endocrinol Metab 2011; 96:3457-65. [PMID: 21849532 PMCID: PMC3205901 DOI: 10.1210/jc.2011-1448] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Bone loss and fracture are serious sequelae of organ transplantation, particularly in the first posttransplant year. Most interventional studies have been inadequately powered to detect effects on fracture. OBJECTIVE The objective of the study was to determine whether treatment with bisphosphonates (BP) or active vitamin D analogs (vitD) during the first year after transplantation reduces fracture risk and estimate the effect of these interventions on bone loss. DATA SOURCES Sources included PUBMED, MEDLINE, Cochrane Library, and abstracts from scientific meetings (presented 2003-2010). STUDY SELECTION Randomized controlled clinical trials of BP or vitD in solid organ transplant recipients were included if treatment was initiated at the time of transplantation and fracture data were collected. DATA EXTRACTION Two investigators independently extracted data and rated study quality. Fixed effect and random-effects models were used to obtain pooled estimates. DATA SYNTHESIS Eleven studies of 780 transplant recipients (134 fractures) were included. Treatment with BP or vitD reduced the number of subjects with fracture [odds ratio (OR) 0.50 (0.29, 0.83)] and number of vertebral fractures, [OR 0.24 (0.07, 0.78)]. An increase in bone mineral density at the lumbar spine [2.98% (1.31, 4.64)] and femoral neck [3.05% (2.16, 3.93)] was found with treatment. When BP trials (nine studies, 625 subjects) were examined separately, there was a reduction in number of subjects with fractures [OR 0.53 (0.30, 0.91)] but no significant reduction in vertebral fractures [OR 0.34 (0.09, 1.24)]. CONCLUSIONS Treatment with BP or vitD during the first year after solid organ transplant was associated with a reduction in the number of subjects with fractures and fewer vertebral fractures.
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Affiliation(s)
- Emily M Stein
- Division of Endocrinology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA
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Hoes JN, Van der Goes MC, Jacobs JWG, Lafeber FPGJ, Bijlsma JWJ, Van Roon JAG. Changes in macrophage inhibitory factor correlate with changes in bone mineral density in glucocorticoid-treated patients with rheumatoid arthritis. Rheumatology (Oxford) 2011; 50:1921-4. [DOI: 10.1093/rheumatology/ker268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kaneko K, Kawai S. [Mechanisms and therapeutics of glucocorticoid-induced osteoporosis]. ACTA ACUST UNITED AC 2011; 34:138-48. [PMID: 21720102 DOI: 10.2177/jsci.34.138] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Mechanisms of glucocorticoid-induced osteoporosis (GIOP) are categorized into local and systemic effects. In the local mechanisms, direct inhibitory effect of glucocorticoid on bone formation is thought to be one of the important mechanisms of GIOP. In contrast, secondary hyperparathyroidism induced by negative balance of calcium due to inhibition of absorption and increase of excretion is an important systemic mechanism of GIOP. Other mechanisms of GIOP are also shown in this review. From clinical points of view, serum markers for evaluation of GIOP have been discussed. Osteocalcin, procollagen type I N-terminal peptide, and bone-specific alkaline phosphatase as markers of bone formation are decreased in GIOP. Collagen I N-terminal telopeptide and tartrate resistent acid phosphatase isoform 5b as markers of bone resorption are increased in GIOP. Clinical guidelines have recommended that bisphosphonate is the first choice for the treatment of GIOP. Teriparatide is recombinant human parathyroid hormone 1-34, which should be considered as a therapeutic option for those at high risk of bone fracture. Denosumab, an anti receptor activator of nuclear factor-β ligand approved as a drug for postmenopausal osteoporosis was also effective for GIOP in clinical trials.
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Affiliation(s)
- Kaichi Kaneko
- Division of Rheumatology, Department of Internal Medicine (Omori), Toho University School of Medicine, Tokyo, Japan
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Saito M, Marumo K, Ushiku C, Kato S, Sakai S, Hayakawa N, Mihara M, Shiraishi A. Effects of alfacalcidol on mechanical properties and collagen cross-links of the femoral diaphysis in glucocorticoid-treated rats. Calcif Tissue Int 2011; 88:314-24. [PMID: 21327766 DOI: 10.1007/s00223-011-9472-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Accepted: 09/14/2010] [Indexed: 01/22/2023]
Abstract
Bone fragility is increased in glucocorticoid (GC)-induced osteopenia even though GC-treated patients have higher bone mineral density (BMD), suggesting that the impaired bone quality may affect bone strength. This study was conducted to clarify the effects of GC on bone strength and collagen cross-links of adult rats and the effect of coadministration of alfacalcidol (ALF), a prodrug of active vitamin D(3). Six-month-old male Wistar-Imamichi rats (n = 32) were divided into the following four groups with equal average body weight: (1) 4-week age-matched controls, (2) 4-week GC (prednisolone, 10 mg/kg daily, i.m.) with concomitant administration of vehicle, (3) 4-week GC with concomitant administration of ALF (0.05 μg/kg daily, p.o.), and (4) 4-week GC with concomitant administration of ALF (0.1 μg/kg daily, p.o.). At the end of treatment, BMD, collagen cross-links, mechanical properties of the femoral midshaft, bone metabolic markers, and biochemical parameters were analyzed. In the GC group, femoral bone strength decreased without any change of BMD. This was accompanied by a decrease in the content of enzymatic cross-links. ALF (0.1 μg/kg) inhibited the GC-induced reduction in bone strength. The content of mature cross-links in the 0.1-μg/kg ALF group was significantly higher than that in the GC group. GC treatment caused a decrease in bone metabolic markers and serum calcium levels, which was counteracted by ALF coadministration. Preventive treatment with ALF inhibited the deterioration of bone mechanical properties primarily in association with the restoration of enzymatic cross-link formation and amelioration of the adverse effects of GC treatment on calcium metabolism.
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Affiliation(s)
- Mitsuru Saito
- Department of Orthopedic Surgery, Jikei University School of Medicine, 3-25-8, Nishi-Skinbaski, Minato-ku, Tokyo 105-8461, Japan.
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Hoes JN, Jacobs JWG, Buttgereit F, Bijlsma JWJ. Current view of glucocorticoid co-therapy with DMARDs in rheumatoid arthritis. Nat Rev Rheumatol 2011; 6:693-702. [PMID: 21119718 DOI: 10.1038/nrrheum.2010.179] [Citation(s) in RCA: 108] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Glucocorticoids are widely used anti-inflammatory and immunosuppressive drugs for rheumatoid arthritis (RA). The disease-modifying potential of low to medium doses of glucocorticoids has been reconfirmed in the past decade, and co-administration of DMARDs and glucocorticoids has become standard in many treatment protocols, especially those for early disease stages but also for long-standing RA. The glucocorticoid regimens used range from continuous low doses to intermittent high doses. Studies of the rationale for and clinical use of glucocorticoids as co-therapy with DMARDs in RA have shown that this approach has a place in modern (tight control) treatment strategies, and that glucocorticoid co-therapy has disease-modifying effects during the first 2 years of treatment in patients with early RA. Furthermore, medium and high doses of glucocorticoids are useful for bridging the interval between initiation of DMARDs and onset of their therapeutic effect. Intra-articular glucocorticoids give good local control and have been used in tight control strategies. New glucocorticoid compounds are becoming available for clinical use that might have an enhanced risk:benefit ratio. Better monitoring of glucocorticoid use will also improve this ratio, and help to allay both patient and rheumatologist concerns about treatment-related adverse effects.
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Affiliation(s)
- Jos N Hoes
- University Medical Center Utrecht, Department of Rheumatology & Clinical Immunology, F02.127, PO Box 85500, 3508 GA Utrecht, The Netherlands.
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Kirigaya D, Nakayama T, Ishizaki T, Ikeda S, Satoh T. Management and treatment of osteoporosis in patients receiving long-term glucocorticoid treatment: current status of adherence to clinical guidelines and related factors. Intern Med 2011; 50:2793-800. [PMID: 22082891 DOI: 10.2169/internalmedicine.50.5266] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the adherence of guidelines for the management and treatment of glucocorticoid-induced osteoporosis, and to investigate whether it is associated with factors such as age, gender, glucocorticoid dose, physician specialty, and size of facility. METHODS This was a cross-sectional study utilizing administrative data from a database of health insurance claims (2004-2007); 2,368 patients who received glucocorticoid treatment for ≥90 days were extracted. The guideline adherence was determined by evaluations based on glucocorticoid prescription dose, prescription of anti-osteoporosis drugs, and whether or not bone mineral density was measured. RESULTS Overall proportion of guideline adherence was 23.3%. In cases in which the equivalent dose of prednisolone was <5 mg/d and ≥5 mg/d, the adherence was 8.3% and 30.5% respectively. Factors correlating with low adherence included young age, male gender, and lower glucocorticoid doses. Surgery and otolaryngology specialties had lower adherence than internal medicine. Smaller clinical facilities had lower adherence than larger facilities. CONCLUSION The adherence of guidelines for the management and treatment of glucocorticoid-induced osteoporosis is still low, and improvements in treatment quality can be expected through education of patient groups and medical care providers with large deviations from the guidelines.
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Affiliation(s)
- Daijun Kirigaya
- Japan Association for Development of Community Medicine, Japan
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Bone health in a tertiary-care gastroenterology and hepatology population. Dig Dis Sci 2010; 55:2263-9. [PMID: 20127169 PMCID: PMC2894281 DOI: 10.1007/s10620-010-1130-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Accepted: 01/11/2010] [Indexed: 01/09/2023]
Abstract
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.
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Matsubara M, Yamachika E, Tsujigiwa H, Mizukawa N, Ueno T, Murakami J, Ishida N, Kaneda Y, Shirasu N, Takagi S. Suppressive effects of 1,4-dihydroxy-2-naphthoic acid administration on bone resorption. Osteoporos Int 2010; 21:1437-47. [PMID: 19813044 DOI: 10.1007/s00198-009-1075-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Accepted: 08/26/2009] [Indexed: 12/16/2022]
Abstract
SUMMARY The main component of the metabolic by-products of fermentation by Propionibacterium freudenreichii ET-3 is 1,4-dihydroxy-2-naphthoic acid (DHNA), which has a naphthoquinone skeleton, as in vitamin K2. This study showed that DHNA improved bone mass reduction with osteoporosis model mice caused by FK506. INTRODUCTION Growth of the intestinal bacterium Lactobacillus bifidus is specifically facilitated by DHNA. The present study used osteoporosis model mice to investigate the effects of DHNA on bone remodeling. METHODS FK506, an immunosuppressant, was used to prepare osteoporosis model mice. Thirty mice were divided into three groups: FK group, FK+DHNA group, and control group. In the FK group, FK506 was administered to induce bone mass reduction. In the FK-DHNA group, FK506 and DHNA were administered concurrently to observe improvements in bone mass reduction. To ascertain systemic and local effects of DHNA, we investigated systemic pathological changes in colon, kidney function and cytokine dynamics, and morphological and organic changes in bone and osteoclast dynamics as assessed by culture experiments. RESULTS Compared to the FK group without DHNA, colon damage and kidney dysfunction were milder for FK+DHNA group, and production of inflammatory cytokines (interleukin (IL)-1beta, IL-6 and tumor necrosis factor (TNF)-alpha) was more suppressed. Furthermore, compared to the group without DHNA, histological analyses and radiography showed that bone resorption was suppressed for the DHNA group. Culture experiments using osteoclasts from murine bone marrow showed osteoclast suppression for the DHNA group compared to the group without DHNA. CONCLUSION These results show that DHNA has some effects for improving bone mass reduction caused by FK506.
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Affiliation(s)
- M Matsubara
- Department of Oral and Maxillofacial Reconstructive Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Sikata-cho, Okayama City, 7008525, Japan.
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Grossman JM, Gordon R, Ranganath VK, Deal C, Caplan L, Chen W, Curtis JR, Furst DE, McMahon M, Patkar NM, Volkmann E, Saag KG. American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis Care Res (Hoboken) 2010; 62:1515-26. [PMID: 20662044 DOI: 10.1002/acr.20295] [Citation(s) in RCA: 478] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Accepted: 07/06/2010] [Indexed: 12/25/2022]
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Peppone LJ, Hebl S, Purnell JQ, Reid ME, Rosier RN, Mustian KM, Palesh OG, Huston AJ, Ling MN, Morrow GR. The efficacy of calcitriol therapy in the management of bone loss and fractures: a qualitative review. Osteoporos Int 2010; 21:1133-49. [PMID: 19960185 PMCID: PMC3063996 DOI: 10.1007/s00198-009-1136-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Accepted: 10/27/2009] [Indexed: 11/25/2022]
Abstract
UNLABELLED Osteoporosis, a skeletal disorder characterized by a reduction in bone strength, increases fracture risk. Primary osteoporosis is usually a result of reduced bone mineral density as a consequence of natural aging. Secondary osteoporosis is usually a result of a disease, such as cystic fibrosis, or medical treatment, such as corticosteroids or cancer treatment. INTRODUCTION Currently, ten million Americans are osteoporotic and an additional 34 million have the precursor condition, osteopenia. Osteoporosis leads to 1.5 million fractures and 500,000 hospitalizations annually. Osteoporosis-related fractures increase mortality and reduce quality of life. Calcitriol, the active form of vitamin D, regulates intestinal calcium absorption, among other actions. During the past four decades, many clinical trials investigating the effect of calcitriol on bone loss have been performed. METHODS We conducted a systematic qualitative review of clinical trials that assessed calcitriol for the treatment of osteoporosis and bone loss. In these clinical trials, calcitriol was used as a monotherapy and in combination with other therapeutic bone agents. RESULTS AND CONCLUSION Studies using calcitriol monotherapy, although not conclusive, found that calcitriol slowed the rate of bone loss in a variety of populations. Calcitriol in combination with other therapeutic bone agents was shown to have additional bone-preserving effects when compared to the use of therapeutic bone agents alone. A common side-effect of calcitriol therapy was hypercalcemia and hypercalciuria, but the degree of hypercalcemia was mild. Recent research found that intermittent dosing can reduce hypercalcemia rates. Calcitriol, alone or in combination with other agents, should be considered for the therapy of osteoporosis.
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Affiliation(s)
- L J Peppone
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA.
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Takei T, Itabashi M, Tsukada M, Sugiura H, Moriyama T, Kojima C, Shiohira S, Shimizu A, Karasawa K, Amemiya N, Kawanishi K, Ogawa T, Uchida K, Tsuchiya K, Nitta K. Risedronate therapy for the prevention of steroid-induced osteoporosis in patients with minimal-change nephrotic syndrome. Intern Med 2010; 49:2065-70. [PMID: 20930431 DOI: 10.2169/internalmedicine.49.3707] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Minimal-change nephrotic syndrome (MCNS) is treated by the administration of prednisolone (PSL) at high doses. Steroid-induced osteoporosis is a serious adverse effect of this drug. METHODS Patients with MCNS were randomly assigned to two groups, the risedronate (2.5 mg/day) + alfacalcidol (0.25 µg/day) group (n=20) and the alfacalcidol (0.25 µg/day)-alone group (n=20). All the patients had received PSL and the clinical characteristics were compared between the two groups at baseline and at 12 months. RESULTS A significant decrease of the mean bone mineral density (BMD) of the lumbar spine from 0.710±0.162 (g/cm(2)) to 0.588±0.125 was observed in the alfacalcidol-alone group (p=0.02), while no such decrease of the bone mineral density was found in the risedronate + alfacalcidol group (0.663±0.169 at baseline and 0.626±0.129 at 12 months). No significant differences in the results of other biochemical tests performed at the baseline and at 12 months were observed between the two groups. The likelihood of development of steroid-induced osteoporosis was influenced by the cumulative dose of PSL, the mean BMD at the baseline, occurrence of disease relapse, and risedronate therapy. CONCLUSION Risedronate appears to be effective in preventing steroid-induced osteoporosis. It is necessary to use bisphosphonates to maintain the BMD in patients with MCNS receiving prolonged steroid therapy.
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Affiliation(s)
- Takashi Takei
- Department of Medicine, Kidney Center, Tokyo Women's Medical University.
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Bitto A, Burnett BP, Polito F, Levy RM, Marini H, Di Stefano V, Irrera N, Armbruster MA, Minutoli L, Altavilla D, Squadrito F. Genistein aglycone reverses glucocorticoid-induced osteoporosis and increases bone breaking strength in rats: a comparative study with alendronate. Br J Pharmacol 2009; 156:1287-95. [PMID: 19302595 DOI: 10.1111/j.1476-5381.2008.00100.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE Glucocorticoid-induced osteoporosis (GIO) is the leading cause of secondary osteoporosis. Clinical evidence suggests a role for genistein aglycone in the treatment of post-menopausal osteopenia although proof of efficacy in comparison with currently available treatments is still lacking. To clarify this issue, we investigated the effects of genistein on bone compared with alendronate in experimental GIO. EXPERIMENTAL APPROACH A total of 28 female Sprague-Dawley rats were used. GIO was induced by daily injections of methylprednisolone (MP; 30 mg x kg(-1) s.c.) for 60 days. Sham GIO animals (Sham-MP) were injected daily with the MP vehicle. At the end of the osteoporosis development period, MP rats were randomized to receive: vehicle (n= 7), genistein aglycone (5 mg x kg(-1) s.c.; n= 7) or alendronate (0.03 mg x kg(-1) s.c.; n= 7). Treatment lasted 60 days. Sham-MP animals were treated with vehicle for an additional 60 days. At the beginning and at the end of treatments, animals were examined for bone mineral density and bone mineral content. Bone-alkaline phosphatase and carboxy-terminal collagen cross links were determined; femurs were removed and tested for breaking strength and histology. KEY RESULTS Genistein aglycone showed a greater increase in bone mineral density, bone mineral content and in breaking strength than alendronate and significantly increased bone-alkaline phosphatase (bone formation marker), reduced carboxy-terminal collagen cross links (bone resorption marker), compared with alendronate. Both treatments improved bone histology and the histological score. CONCLUSION AND IMPLICATIONS The results strongly suggest that the genistein aglycone might be an alternative therapy for the management of secondary osteoporosis.
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Affiliation(s)
- A Bitto
- Department of Clinical and Experimental Medicine and Pharmacology, Section of Pharmacology, University of Messina, Messina, Italy
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Kitazaki S, Mitsuyama K, Masuda J, Harada K, Yamasaki H, Kuwaki K, Takedatsu H, Sugiyama G, Tsuruta O, Sata M. Clinical trial: comparison of alendronate and alfacalcidol in glucocorticoid-associated osteoporosis in patients with ulcerative colitis. Aliment Pharmacol Ther 2009; 29:424-30. [PMID: 19035979 DOI: 10.1111/j.1365-2036.2008.03899.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Bone loss is often observed in patients with ulcerative colitis, particularly if they require glucocorticoids. AIM To determine whether the bisphosphonate, alendronate, is safe and effective in preserving bone mass compared to the active vitamin D3, alfacalcidol, in ulcerative colitis patients receiving glucocorticoids. METHODS Thirty-nine patients with ulcerative colitis and treated with glucocorticoids were randomized to receive alendronate (5 mg/day) or alfacalcidol (1 microg/day) daily for 12 months. Loss of bone mass was evaluated by bone mineral density, bone resorption by urinary N-telopeptide for type I collagen, and bone formation by serum bone alkaline phosphatase. RESULTS Alendronate, but not alfacalcidol, significantly increased bone mineral density in the lumbar spine. Alendronate decreased serum bone alkaline phosphatase levels, but alfacalcidol did not. Urinary N-telopeptide for type I collagen levels decreased in both groups, but were significantly lower in the alendronate group. There were no significant differences in the adverse events in the two groups. CONCLUSION Our study indicates that alendronate is a safe, well-tolerated and more effective therapy than alfacalcidol for preventing glucocorticoid-associated bone loss in patients with ulcerative colitis.
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Affiliation(s)
- S Kitazaki
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
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Potential of alfacalcidol for reducing increased risk of falls and fractures. Rheumatol Int 2009; 29:1177-85. [PMID: 19159932 DOI: 10.1007/s00296-008-0835-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Accepted: 12/12/2008] [Indexed: 10/21/2022]
Abstract
There are no general accepted strategies for combined drug treatments in osteoporosis, while in other important chronic diseases combinations of different medications are used as a rule to improve therapeutic results and reduce the risk of adverse events. It is suggested that the success of combined treatments is related to the different modes of action of the respective single therapies. On the other hand it was shown that a strong antiresorptive bisphosphonate is able to blunt at least in part the effects of anabolic parathyroid hormone peptides Calcitriol, the active vitamin D-hormone and its prodrug alfacalcidol lead to pleiotropic effects on bone remodelling (antiresorptive, anabolic and enhancing mineralization) and in addition to effects on other important target tissues (e.g. gut, parathyroid glands, muscle). With active D-analogs significant improvements in the therapeutic outcome of osteoporosis can be achieved by the resulting improvements of bone quality, calcium absorption and risk reduction of falling. The same beneficial effects cannot be achieved with plain vitamin D due to feedback controlled, limited renal activation or insufficient conversion in the elderly with impairment of renal function. Accordingly alfacalcidol, approved as a treatment for different forms of osteoporosis, is besides adoption as a mono-therapy an interesting candidate for combined therapies. There are interesting preclinical trials and clinical pilote studies in the literature proving that a parallel therapy with selectively anti-osteoclastic bisphophonates and pleiotropically acting D-analogs is able to optimize therapeutic results in osteoporosis. In the AAC-Trial (Alfacalcidol-Alendronate-Combined) we studied 90 patients with established osteoporosis (57 women, 33 men) over two years after alternate allocation to three treatment arms (alfacalcidol plus calcium, alendronate plus plain vitamin D and Ca, and alendronate plus alfacalcidol and Ca). During the 2-year-study we observed the significantly highest lumbar spine and hip BMD increases in the combined treatment group (p < 0.001). The number of patients with new vertebral and non-vertebral fractures after 2 years was 9 with alfacalcidol alone, 10 with alfacalcidol and plain vitamin D and 2 in the group receiving alendronate plus alfacalidol (p < 0.02). Furthermore there was a lower rate of falls and an earlier reduction in back pain in the patients treated with the active combination. This trial confirms the demonstrated highly significant advantages of this combined treatment regimen used in the pilote studies. Especially in patients with severe osteoporosis this interesting combination of two substances with complete different mechanisms of action should be taken into consideration.
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Kolar P, Buttgereit F. Evidenzbasierte EULAR-Empfehlungen zum Management einer systemischen Glukokortikoid-Therapie bei rheumatischen Erkrankungen. Z Rheumatol 2009; 68:349-52. [DOI: 10.1007/s00393-008-0420-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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