1
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Orhadje E, Berg K, Hauser B, Ralston SH. Clinical Features, Incidence and Treatment Outcome in Pregnancy-Associated Osteoporosis: A Single-Centre Experience over Two Decades. Calcif Tissue Int 2023; 113:591-596. [PMID: 37819437 PMCID: PMC10673946 DOI: 10.1007/s00223-023-01139-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/09/2023] [Indexed: 10/13/2023]
Abstract
Pregnancy-associated osteoporosis (PAO) is a rare syndrome which typically presents with vertebral fractures during pregnancy or lactation. The medical records of sixteen patients with PAO who presented to a specialist clinic at the Western General Hospital in Edinburgh over a 20-year period were reviewed to evaluate the mode of presentation, potential risk factors and response to treatment. The most common presentation was back pain occurring in 13/16 (81.2%) individuals due to multiple vertebral fractures. The diagnosis was usually made postpartum and in 12/16 individuals (75.0%), PAO presented during the woman's first pregnancy. Medicines which could have contributed to the development of PAO included thromboprophylaxis therapies in 8 subjects (50.0%), inhaled or injected corticosteroids in 5 (31.3%), anticonvulsants in 2 (12.5%) and a LHRH agonist in 1 (6.3%). Five individuals reported a family history of osteoporosis, and two pregnancies were complicated by hyperemesis gravidarum. Treatments administered included calcium and vitamin D supplements, bisphosphonates and teriparatide. Bone mineral density increased following the diagnosis in all cases, regardless of treatment given. One patient had further fracture during follow-up, but four patients had subsequent pregnancies without fractures. We estimated that in this locality, the incidence of PAO was 6.8/100,000 pregnancies with a point prevalence of 4.1 per 100,000 women. This case series indicates the importance of family history of osteoporosis and thromboprophylaxis drugs as risk factors for PAO while also demonstrating that the reductions in bone density tend to reverse with time, irrespective of the treatment given.
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Affiliation(s)
- Elizabeth Orhadje
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Kathryn Berg
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Barbara Hauser
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Stuart H Ralston
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Western General Hospital, Edinburgh, UK.
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2
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Misiorowski W. Pregnancy- and lactation-related osteoporosis: an important topic also for rheumatologists. Reumatologia 2023; 61:223-224. [PMID: 37745142 PMCID: PMC10515126 DOI: 10.5114/reum/171597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 09/26/2023] Open
Abstract
<b>Objectives</b>
<b>Material and methods</b>
<b>Results</b>
<b>Conclusions</b>
<b></b>
<b></b>
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Affiliation(s)
- Waldemar Misiorowski
- Department of Endocrinology, Centre of Postgraduate Medical Education, Bielanski Hospital, Warsaw, Poland
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3
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Scioscia MF, Zanchetta MB. Recent Insights into Pregnancy and Lactation-Associated Osteoporosis (PLO). Int J Womens Health 2023; 15:1227-1238. [PMID: 37551335 PMCID: PMC10404404 DOI: 10.2147/ijwh.s366254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/11/2023] [Indexed: 08/09/2023] Open
Abstract
During pregnancy and lactation, female physiology adapts to fulfill the fetal and neonatal calcium and phosphorus requirements. The physiological changes that take place during these periods do not affect maternal skeleton resistance to fracture in most of the cases. However, there is a small percentage of women that do experience fragility fractures during these times of life. Pregnancy and lactation-associated osteoporosis (PLO) is an infrequent condition defined by the occurrence of non-traumatic fractures - most frequently vertebral - during the third trimester of gestation and/or the first months of postpartum. Its physiopathology has not yet been completely elucidated. Several authors have reported that risk factors for secondary osteoporosis might be present in up to 80% of the cases of PLO patients. According to recent studies, genetic factors might also play a relevant role in PLO. Given its rarity, the available literature on this condition is limited. Most of the published data consist on case reports and case series articles. There are not any randomized controlled trials regarding this disorder. Although there is consensus about discontinuation of lactation and calcium and vitamin D supplementation as the first steps in the treatment of these patients, there is still controversy regarding the long-term and/or pharmacological management of this condition. Recent data on the use of teriparatide in this population looks promising. In this review, we aimed to revise and summarize current knowledge about the physiopathology and management of PLO.
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Affiliation(s)
- Maria Florencia Scioscia
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), Universidad del Salvador, Buenos Aires, ZC 1012, Argentina
| | - Maria Belen Zanchetta
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), Universidad del Salvador, Buenos Aires, ZC 1012, Argentina
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4
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Diaz Dilernia F, Estefan M, Zanotti G. Pathological femoral neck fracture in a male patient due to non-simultaneous bilateral transient hip osteoporosis: A case report: Statements and Declarations. J Clin Orthop Trauma 2023; 42:102207. [PMID: 37529549 PMCID: PMC10388589 DOI: 10.1016/j.jcot.2023.102207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 04/11/2023] [Accepted: 06/24/2023] [Indexed: 08/03/2023] Open
Abstract
We report a case of a 31-year-old man who developed a non-simultaneous bilateral transient hip osteoporosis (THO) complicated with an atraumatic undisplaced pathological femoral neck fracture (FNF) of his left hip. He was successfully treated with internal fixation on the left hip, and a follow-up Magnetic Resonance Imaging evidenced satisfactory resolution on the right side. Diagnosis and management of THO are usually challenging as symptoms before pathological FNFs might be misdiagnosed. This case highlights the importance of suspecting pathological FNFs when pain persists despite conservative treatment. Finally, surgical treatment is strongly recommended if a pathological FNF is confirmed. Level of evidence Level IV.
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Affiliation(s)
- Fernando Diaz Dilernia
- Adult Hip and Knee Reconstructive Surgery, Division of Orthopaedic Surgery, Department of Surgery, Queen's University & Kingston Health Sciences Centre, Kingston, Ontario, Canada, K7L 2V7
| | - Martin Estefan
- Hip Surgery Unit, Institute of Orthopaedics “Carlos E. Ottolenghi”, Italian Hospital of Buenos Aires, Buenos Aires, C1199ACK, Argentina
| | - Gerardo Zanotti
- Hip Surgery Unit, Institute of Orthopaedics “Carlos E. Ottolenghi”, Italian Hospital of Buenos Aires, Buenos Aires, C1199ACK, Argentina
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Wang GX, Han JH, Zhou RZ, Gao CP. Response of vertebral fractures to treatment with denosumab in a patient with postpartum osteoporosis: a case report and literature review. J Int Med Res 2023; 51:3000605231187951. [PMID: 37523158 PMCID: PMC10392288 DOI: 10.1177/03000605231187951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023] Open
Abstract
Postpartum osteoporosis (PO) is a rare condition characterized by low bone mineral density (BMD) and an increased risk of vertebral fragility fracture. We encountered a 34-year-old woman who developed back pain 1 week after delivery. Magnetic resonance imaging of the lumbar spine revealed three vertebral compression fractures. Pretreatment BMD evaluation by dual-energy X-ray absorptiometry revealed a low T-score and Z-score (-2.0 and -2.0, respectively; BMD, 0.876 g/cm2) in the affected region of the spine. The patient was diagnosed with PO and treated with subcutaneous injection of denosumab 60 mg (Prolia; Amgen, Inc., Thousand Oaks, CA, USA) every 6 months. After two treatments, the BMD had significantly increased and the back pain was improved; the patient therefore decided to terminate the treatment. Two months later, her back pain worsened and BMD decreased as measured by dual-energy X-ray absorptiometry examination of the lumbar spine. Therefore, the patient resumed treatment with denosumab, and the BMD of the lumbar spine increased after another two treatments. Therefore, we consider denosumab to be promising in the management of PO with respect to increased BMD and decreased pain.
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Affiliation(s)
- Guan-Xi Wang
- Department of Radiology, Songshan Hospital of Qingdao University Medical College, Qingdao, China
| | - Jin-Hua Han
- Department of Radiology, Qingdao Central Hospital, Qingdao, China
| | - Rui-Zhi Zhou
- Department of Radiology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chuan-Ping Gao
- Department of Radiology, the Affiliated Hospital of Qingdao University, Qingdao, China
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Peltz-Sinvani N, Raz HM, Klein P, Ish-Shalom S, Vered I, Tripto-Shkolnik L. Pregnancy- and lactation-induced osteoporosis: a social-media-based survey. BMC Pregnancy Childbirth 2023; 23:311. [PMID: 37131133 PMCID: PMC10152747 DOI: 10.1186/s12884-023-05639-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/24/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Pregnancy- and lactation-induced osteoporosis (PLO) presenting as spinal fractures is rare, and the spectrum of clinical presentation, risk factors and pathophysiology are incompletely understood. The aim of this study was to delineate clinical parameters, risk factors and osteoporosis-related quality of life (QOL) of women with PLO. METHODS Participants of a social-media (WhatsApp) PLO group and mothers of a parents' WhatsApp group (control group) were offered to fill a questionnaire, including an osteoporosis-related QOL section. The groups were compared using the independent Students t test for numerical variables, and the Chi-square test or Fisher's exact test for categorical variables. RESULTS Twenty-seven women with PLO and 43 in the control group (aged 36.2 ± 4.7 and 38.8 ± 4.3 years, respectively, p = 0.04) participated. Among women with PLO, more than 5 vertebrae were involved in 13 (48%), 4 vertebrae in 6 (22%), and 3 or fewer vertebrae in 8 (30%). Among the 24 women with relevant data, 21 (88%) had nontraumatic fractures; 3 (13%) women had fractures during pregnancy, and the remaining during the early postpartum period. Diagnosis was delayed for over 16 weeks for 11 (41%) women; 16 (67%) received teriparatide. Significantly lower proportions of women in the PLO group engaged in physical activity over 2 hours/week, before and during pregnancy (37 vs. 67%, p < 0.015 and 11 vs. 44%, p < 0.003, respectively). A lower proportion of the PLO than the control group reported calcium supplementation during pregnancy (7% vs. 30%, p = 0.03) and a higher proportion reported treatment with low-molecular-weight-heparin during pregnancy (p = 0.03). Eighteen (67%) of the PLO group expressed fear of fractures and 15 (56%) fear of falls, compared to none and 2%, respectively, of the control group (p < 0.00001 for both). CONCLUSIONS Most of the women with PLO who responded to our survey reported spinal fractures involving multiple vertebrae, delayed diagnosis, and treatment with teriparatide. Compared to a control group, they reported less physical activity and impaired QOL. For this uncommon yet severe condition, a multidisciplinary effort should be exerted for early identification and treatment, to alleviate back pain, prevent subsequent fractures and improve QOL.
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Affiliation(s)
- Naama Peltz-Sinvani
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Hadar Milloh Raz
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pinchas Klein
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Iris Vered
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liana Tripto-Shkolnik
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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7
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Pregnancy-Associated Osteoporosis: A Literature Review. Clin Rev Bone Miner Metab 2023. [DOI: 10.1007/s12018-023-09287-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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8
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Athonvarangkul D, Wysolmerski JJ. Crosstalk within a brain-breast-bone axis regulates mineral and skeletal metabolism during lactation. Front Physiol 2023; 14:1121579. [PMID: 36875035 PMCID: PMC9979219 DOI: 10.3389/fphys.2023.1121579] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 01/27/2023] [Indexed: 02/18/2023] Open
Abstract
To support the increased calcium demands for milk production during lactation, a dramatic and reversible physiological response occurs to alter bone and mineral metabolism. This coordinated process involves a brain-breast-bone axis that integrates hormonal signals that allow for adequate calcium delivery to milk yet also protects the maternal skeletal from excessive bone loss or decreases in bone quality or function. Here, we review the current knowledge on the crosstalk between the hypothalamus, mammary gland, and skeleton during lactation. We discuss the rare entity of pregnancy and lactation associated osteoporosis and consider how the physiology of bone turnover in lactation may impact the pathophysiology of postmenopausal osteoporosis. Further understanding of the regulators of bone loss during lactation, particularly in humans, may provide insights into new therapies for osteoporosis and other diseases of excess bone loss.
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Affiliation(s)
- Diana Athonvarangkul
- Section of Endocrinology and Metabolism, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
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9
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Treurniet S, Bevers MSAM, Wyers CE, Micha D, Teunissen BP, Elting MW, van den Bergh JP, Eekhoff EMW. Bone Microarchitecture and Strength Changes During Teriparatide and Zoledronic Acid Treatment in a Patient with Pregnancy and Lactation-Associated Osteoporosis with Multiple Vertebral Fractures. Calcif Tissue Int 2023; 112:621-627. [PMID: 36764958 PMCID: PMC10106348 DOI: 10.1007/s00223-023-01066-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 01/26/2023] [Indexed: 02/12/2023]
Abstract
Pregnancy- and lactation-associated osteoporosis (PLO) is a rare form of osteoporosis, of which the pathogenesis and best treatment options are unclear. In this report, we describe the case of a 34-year old woman diagnosed with severe osteoporosis and multiple vertebral fractures after her first pregnancy, who was subsequently treated with teriparatide (TPTD) and zoledronic acid (ZA). We describe the clinical features, imaging examination, and genetic analysis. Substantial improvements were observed in areal and volumetric bone mineral density (BMD), microarchitecture, and strength between 7 and 40 months postpartum as assessed by dual-energy X-ray absorptiometry at the total hip and spine and by high-resolution peripheral quantitative CT at the distal radius and tibiae. At the hip, spine, and distal radius, these improvements were mainly enabled by treatment with TPTD and ZA, while at the distal tibiae, physiological recovery and postpartum physiotherapy due to leg pain after stumbling may have played a major role. Additionally, the findings show that, despite the improvements, BMD, microarchitecture, and strength remained severely impaired in comparison with healthy age- and gender-matched controls at 40 months postpartum. Genetic analysis showed no monogenic cause for osteoporosis, and it is suggested that PLO in this woman could have a polygenic origin with possible susceptibility based on familiar occurrence of osteoporosis.
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Affiliation(s)
- Sanne Treurniet
- Department of Internal Medicine Section Endocrinology, Rare Bone Disease Center, Amsterdam, Movement Sciences, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Melissa S A M Bevers
- Department of Internal Medicine, VieCuri Medical Center, Venlo, The Netherlands
- NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Caroline E Wyers
- Department of Internal Medicine, VieCuri Medical Center, Venlo, The Netherlands
- NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Internal Medicine, Subdivision of Rheumatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dimitra Micha
- Department of Human Genetics, Amsterdam Movement Sciences, Amsterdam Rare Bone Disease/Amsterdam Bone Center, Amsterdam University Medical Center, location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Bernd P Teunissen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mariet W Elting
- Department of Human Genetics, Amsterdam Movement Sciences, Amsterdam Rare Bone Disease/Amsterdam Bone Center, Amsterdam University Medical Center, location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Joop P van den Bergh
- Department of Internal Medicine, VieCuri Medical Center, Venlo, The Netherlands
- NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Internal Medicine, Subdivision of Rheumatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Elisabeth M W Eekhoff
- Department of Internal Medicine Section Endocrinology, Rare Bone Disease Center, Amsterdam, Movement Sciences, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
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10
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Pregnancy and Lactation-Associated Osteoporosis Successfully Treated with Romosozumab: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2022; 59:medicina59010019. [PMID: 36676643 PMCID: PMC9862917 DOI: 10.3390/medicina59010019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 12/15/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022]
Abstract
Pregnancy- and lactation-associated osteoporosis (PLO) is a rare type of premenopausal osteoporosis that occurs mainly in the third trimester or immediately after delivery; one of its most common symptoms is back pain caused by a vertebral fracture. The pathogenesis of PLO is unclear, and there is no accepted consensus regarding the treatment of PLO. Although treatments with drugs such as bisphosphonate, strontium ranelate, denosumab, and teriparatide were reported, there is no report of a patient with PLO treated with romosozumab. We present the first case of a patient with PLO treated with romosozumab following 4-month teriparatide treatment. A 34-year-old primiparous and breastfeeding Japanese woman experienced severe low back pain 1 month postdelivery. She was diagnosed with PLO on the basis of low bone marrow density (BMD) and multiple vertebral fractures with no identified cause of secondary osteoporosis. She was treated with teriparatide injection for 4 months, but the treatment was discontinued because of the patient feeling severe nausea after every teriparatide injection and the appearance of new vertebral fractures. Thereafter, we used romosozumab for 12 months. After the romosozumab treatment, her BMD was increased from the baseline by 23.6% at L1-L4, 6.2% at the femoral neck, and 11.2% at the total hip. Treating PLO with 12-month romosozumab after 4 months of teriparatide injection remarkably increased the BMD of the lumbar spine, femoral neck, and total hip without subsequent fracture. Romosozumab has potential as a therapeutic option to improve the BMD and reduce the subsequent fracture risk of patients with PLO.
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11
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Muacevic A, Adler JR, Varma A. Pregnancy- and Lactation-Associated Osteoporotic Vertebral Fracture: A Case Report. Cureus 2022; 14:e31322. [PMID: 36514667 PMCID: PMC9733823 DOI: 10.7759/cureus.31322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 11/10/2022] [Indexed: 11/11/2022] Open
Abstract
The report details an instance of a 29-year-old postpartum female who presented to us after six months of delivery and had symptoms of severe back pain since the sixth month of pregnancy. The pain was located in the lower thoracic and lumbar regions. It got aggravated by standing or walking and got relieved by lying down. The pain was radiating from the back to both lower limbs. On examination, forward rounding of the upper back, i.e., kyphosis, was seen, for which the patient was advised to get an X-ray, which was suggestive of severe osteopenia with wedging of L1-L4 vertebrae. For a thorough assessment, MRI was performed, which confirmed exaggerated kyphosis at L1 and L2 with mild scoliosis in the thoracolumbar region. The patient was advised to take calcium and vitamin D supplements with bisphosphonates. A monthly checkup was advised. After four months, the symptoms of the patient were partially eased. On investigation, the serum calcium and phosphorous levels were found to be within the normal range.
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12
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Siva S, Liao Q, Abbas A, Periasamy K. Bilateral atraumatic femoral neck fractures resulting from transient osteoporosis of the hip. BMJ Case Rep 2022; 15:e247967. [PMID: 36253010 PMCID: PMC9577900 DOI: 10.1136/bcr-2021-247967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
A woman in her mid-30s presented to the orthopaedic team, unable to mobilise, shortly after her caesarean section. On questioning, she reported 10 weeks of atraumatic right hip pain. A radiograph revealed a displaced right subcapital neck of femur fracture. An MRI confirmed this, as well as identifying a minimally displaced left subcapital neck of femur fracture. She underwent a right total hip replacement and internal fixation of the left hip. A dual energy X-ray absorptiometry (DEXA) scan showed severe osteoporosis, and a diagnosis of transient osteoporosis of the hip was made. She was seen by the bone metabolism team and given calcium and vitamin D medication. Although atraumatic hip fractures are rare in young patients, disproportionate or persisting hip pain in pregnant patients should raise the index of suspicion and prompt further investigation in the form of an MRI. This will allow timely management of hip fractures and improve patient outcomes.
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Affiliation(s)
- Soorya Siva
- Orthopaedics, Wishaw General Hospital, Wishaw, UK
| | - Quintin Liao
- Orthopaedics, Wishaw General Hospital, Wishaw, UK
| | - Ammar Abbas
- Orthopaedics, Wishaw General Hospital, Wishaw, UK
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13
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Toba M, Terauchi M, Moriwaki M, Obayashi S, Miyasaka N, Fushimi K. Fractures within 2 years of an obstetric hospitalization: analysis of nationwide administrative data in Japan. J Bone Miner Metab 2022; 40:748-754. [PMID: 35690967 DOI: 10.1007/s00774-022-01336-4] [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: 08/04/2021] [Accepted: 04/15/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Pregnancy- and lactation-associated osteoporosis (PLO) is a condition in which young women develop fractures during pregnancy or breastfeeding. Though PLO is a severely debilitating disease, its pathophysiology and epidemiology have not been clarified and its treatment has not been established. We aimed to identify the incidence and factors associated with fractures occurring within 2 years following an obstetric hospitalization. MATERIALS AND METHODS We extracted data on fractures occurring within 2 years of an obstetric hospitalization from the Japanese Diagnosis Procedure Combination database. We analyzed the implementation of bone mineral density and bone metabolism marker tests, prescription status, and factors associated with fractures occurring within 2 years of an obstetric hospitalization. RESULTS Among 837,347 patients with a history of obstetric hospitalization from 2010 to 2014, 379 patients had a history of hospitalization due to a fracture occurring within 2 years (4.5/10,000 pregnancies). Among the patients with fractures occurring within 2 years of an obstetric hospitalization, 6.7% underwent bone mineral quantification or a bone metabolism marker test, and 7.5% were prescribed a lactation inhibitor or osteoporosis treatment. Factors associated with fractures occurring within 2 years following an obstetric hospitalization identified included Cushing syndrome, Charlson Comorbidity Index score ≥ 1, age ≥ 40 years old at pregnancy, smoking history, and steroid administration. CONCLUSION We investigated fracture cases occurring within 2 years of an obstetrics hospitalization. This finding may be useful in selecting preventative measures for patients at risk of fractures within 2 years after obstetric hospitalization, including PLO.
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Affiliation(s)
- Mikayo Toba
- Quality Management Center, Tokyo Medical and Dental University, Yushima 1-5-45, Bunkyo, Tokyo, 113-8510, Japan
| | - Masakazu Terauchi
- Department of Women's Health, Tokyo Medical and Dental University, Yushima 1-5-45, Bunkyo, Tokyo, 113-8510, Japan
| | - Mutsuko Moriwaki
- Quality Management Center, Tokyo Medical and Dental University, Yushima 1-5-45, Bunkyo, Tokyo, 113-8510, Japan
| | - Satoshi Obayashi
- Department of Obstetrics and Gynecology, Dokkyo Medical University School of Medicine, 880, Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Naoyuki Miyasaka
- Department of Comprehensive Reproductive Medicine, Graduate School of Medicine, Tokyo Medical and Dental University, Yushima1-5-45, Bunkyo, Tokyo, 113-8510, Japan
| | - Kiyohide Fushimi
- Quality Management Center, Tokyo Medical and Dental University, Yushima 1-5-45, Bunkyo, Tokyo, 113-8510, Japan.
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, Yushima1-5-45, Bunkyo, Tokyo, 113-8510, Japan.
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14
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Hadji P, Mouzakiti N, Kyvernitakis I. Effect of Teriparatide on Subsequent Fracture and Bone Mineral Density in 47 Women with Pregnancy- and Lactation-associated Osteoporosis and Vertebral Fractures. Geburtshilfe Frauenheilkd 2022; 82:619-626. [PMID: 35903718 PMCID: PMC9315397 DOI: 10.1055/a-1816-6700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 04/01/2022] [Indexed: 10/27/2022] Open
Abstract
Abstract
Introduction Pregnancy- and lactation-associated osteoporosis (PLO) with predominantly vertebral fractures is a rare but severe disease which can occur in the last trimester of
pregnancy or postpartum. The aim of the present study was to assess the impact of teriparatide on subsequent fractures and bone mineral density (BMD) in patients with PLO.
Materials and Methods A total of 47 patients with PLO and postpartum spinal fractures (mean: 4 fractures) undergoing treatment with teriparatide were investigated. The data
collection period was set between 2006 and 2018. All patients received a subcutaneous injection of 20 µg teriparatide once a day for 24 months as well as individually adapted vitamin D
supplementation. After 24 months of treatment, all women received no further treatment and either had regular menstrual cycles or took oral contraceptives. Fractures were confirmed by X-ray
or MRI. Changes in BMD from baseline were examined using serial DXA measurements.
Results After 24 months of teriparatide treatment, we could demonstrate an increase in BMD at the lumbar spine, femoral neck and total hip of + 30.1%, + 11.7% and + 12.2%
respectively (p < 0.001 for all). At 12 months after cessation of treatment, BMD remained stable compared to the 24-month measurements at the lumbar spine, femoral neck and total hip
which showed non-significant changes of + 1.4%, + 2.6% and + 4.1% respectively. Out of the 47 patients with PLO with a mean of 4 existing fractures, 4 patients (7.8%) sustained a subsequent
fracture, two after 3 – 5 months of treatment and two at > 6 months of treatment.
Conclusion 24 months of treatment with teriparatide in women with PLO and multiple vertebral fractures significantly increased BMD, predominantly BMD of the spine. As patients were
premenopausal, there was no significant decrease in BMD in the following 12 months after cessation of treatment.
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Affiliation(s)
- Peyman Hadji
- Frankfurt Centre for Bone Health, Frankfurt, Germany
- Philipps-University of Marburg, Marburg, Germany
| | - Niki Mouzakiti
- Dpt. of Obstetrics and Gynaecology, Centre for Ultrasound and Prenatal Medicine, Buergerhospital and Clementine Childrenʼs Hospital Frankfurt a. M., Dr. Senckenberg Foundation and
Johann-Wolfgang-Goethe University of Frankfurt, Frankfurt, Germany
| | - Ioannis Kyvernitakis
- Dpt. Of Obstetrics and Prenatal Medicine, Asklepios Clinic Barmbek, University of Semmelweis, Hamburg, Germany
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15
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Abstract
Pregnancy-associated osteoporosis (PAO) is a rare condition of skeletal fragility affecting women in pregnancy or the postpartum period. During normal pregnancy and lactation, substantial changes in calcium metabolism and skeletal physiology occur in order to meet the demands of the developing foetus. Whilst these adaptations are reversible and generally of no clinical consequence for the mother, a small number of women will develop osteoporosis and suffer fragility fractures. Vertebral fractures occur most commonly in PAO and are often multiple. Due to the rarity of PAO, systematic study to date has been limited. Aetiology is poorly understood, but traditional osteoporosis risk factors and genetic factors are likely to play a role. A small number of cases may be due to an underlying metabolic bone disorder or monogenic condition. Management of PAO is challenging, due both to a poor evidence base and the fact that spontaneous improvement in BMD is known to occur once pregnancy and lactation are complete. Bisphosphonates, denosumab and teriparatide have all been used in individual patients, but the data supporting their use are currently limited.
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16
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Abstract
PURPOSE Osteoporosis in pregnancy is an uncommon disease and there is little information regarding its pathogenesis and its effects on the skeleton. This review aims to describe changes in mineral metabolism during pregnancy and lactation as well as their clinical impact. METHODS We performed a narrative review of the literature using the PubMed and Google Scholar databases for articles published from 1955 to 2021. RESULTS Mineral metabolism in the mother must adapt to the demand created by the fetus and the placenta, which together absorb calcium and other minerals from the mother to mineralize the developing fetal skeleton; analyses of iliac bone biopsies at the beginning and end of pregnancy have shown that pregnancy significantly modifies maternal bone status. The greatest demand for calcium for the maternal skeleton occurs during lactation; women who breastfeed have an even greater loss of calcium to produce milk. However, it is controversial whether breastfeeding can increase the risk of osteoporotic fractures, and the possible mechanism is considerably complicated. Osteoporosis in pregnancy is an uncommon disease characterized by the occurrence of fragility fractures, most commonly in the vertebral column, in the third trimester of pregnancy, or early postpartum. The pathogenesis of PLO remains unclear owing to its rarity; DXA provides a sensitive and specific method for diagnosing osteoporosis by measuring BMD, one of the parameters that allow a better understanding of fracture risk. One limitation is the controversy in using radiation in pregnant women and the risk to the embryo/fetus; a safe alternative can be MRI. CONCLUSION Pregnancy and lactation alter the maternal bone status; without a balance in metabolism, this may cause an increased risk of fracture due to changes in BMD. There is little information on BMD during pregnancy; more clinical studies are required to elucidate if this represents a risk factor for osteoporosis.
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17
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Herath M, Cohen A, Ebeling PR, Milat F. Dilemmas in the Management of Osteoporosis in Younger Adults. JBMR Plus 2022; 6:e10594. [PMID: 35079682 PMCID: PMC8771004 DOI: 10.1002/jbm4.10594] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 12/02/2021] [Accepted: 12/12/2021] [Indexed: 11/16/2022] Open
Abstract
Osteoporosis in premenopausal women and men younger than 50 years is challenging to diagnose and treat. There are many barriers to optimal management of osteoporosis in younger adults, further enhanced by a limited research focus on this cohort. Herein we describe dilemmas commonly encountered in diagnosis, investigation, and management of osteoporosis in younger adults. We also provide a suggested framework, based on the limited available evidence and supported by clinical experience, for the diagnosis, assessment, and management of osteoporosis in this cohort. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Madhuni Herath
- Department of Endocrinology Monash Health Clayton Victoria Australia
- Centre for Endocrinology & Metabolism Hudson Institute of Medical Research Clayton Victoria Australia
- Department of Medicine, School of Clinical Sciences Monash University Clayton Victoria Australia
| | - Adi Cohen
- Department of Medicine Columbia University College of Physicians & Surgeons New York NY USA
| | - Peter R. Ebeling
- Department of Endocrinology Monash Health Clayton Victoria Australia
- Department of Medicine, School of Clinical Sciences Monash University Clayton Victoria Australia
| | - Frances Milat
- Department of Endocrinology Monash Health Clayton Victoria Australia
- Centre for Endocrinology & Metabolism Hudson Institute of Medical Research Clayton Victoria Australia
- Department of Medicine, School of Clinical Sciences Monash University Clayton Victoria Australia
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18
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Mills EG, Yang L, Nielsen MF, Kassem M, Dhillo WS, Comninos AN. The Relationship Between Bone and Reproductive Hormones Beyond Estrogens and Androgens. Endocr Rev 2021; 42:691-719. [PMID: 33901271 PMCID: PMC8599211 DOI: 10.1210/endrev/bnab015] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Indexed: 12/20/2022]
Abstract
Reproductive hormones play a crucial role in the growth and maintenance of the mammalian skeleton. Indeed, the biological significance for this hormonal regulation of skeletal homeostasis is best illustrated by common clinical reproductive disorders, such as primary ovarian insufficiency, hypothalamic amenorrhea, congenital hypogonadotropic hypogonadism, and early menopause, which contribute to the clinical burden of low bone mineral density and increased risk for fragility fracture. Emerging evidence relating to traditional reproductive hormones and the recent discovery of newer reproductive neuropeptides and hormones has deepened our understanding of the interaction between bone and the reproductive system. In this review, we provide a contemporary summary of the literature examining the relationship between bone biology and reproductive signals that extend beyond estrogens and androgens, and include kisspeptin, gonadotropin-releasing hormone, follicle-stimulating hormone, luteinizing hormone, prolactin, progesterone, inhibin, activin, and relaxin. A comprehensive and up-to-date review of the recent basic and clinical research advances is essential given the prevalence of clinical reproductive disorders, the emerging roles of upstream reproductive hormones in bone physiology, as well as the urgent need to develop novel safe and effective therapies for bone fragility in a rapidly aging population.
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Affiliation(s)
- Edouard G Mills
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Lisa Yang
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Morten F Nielsen
- Department of Endocrinology, University Hospital of Odense & institute of Clinical Research, University of Southern Denmark, 5000 Odense C, Denmark
| | - Moustapha Kassem
- Department of Endocrinology, University Hospital of Odense & institute of Clinical Research, University of Southern Denmark, 5000 Odense C, Denmark.,Faculty of Health and Medical Sciences, Department of Cellular and Molecular Medicine, University of Copenhagen, 2200 Copenhagen N, Denmark
| | - Waljit S Dhillo
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK.,Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Alexander N Comninos
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK.,Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK.,Endocrine Bone Unit, Imperial College Healthcare NHS Trust, London, UK
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19
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Qian Y, Wang L, Yu L, Huang W. Pregnancy- and lactation-associated osteoporosis with vertebral fractures: a systematic review. BMC Musculoskelet Disord 2021; 22:926. [PMID: 34732196 PMCID: PMC8567545 DOI: 10.1186/s12891-021-04776-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 10/06/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND To review, analyze and characterize the pregnancy and lactation-related osteoporosis (PLO) with vertebral fractures based on the extraction data in the previous studies. METHODS A comprehensive literature search of electronic databases including the PubMed, Embase and Web of Science was conducted from January 1st,1990 to December 1st, 2020. The enrolled data were pooled to analyze the baseline characteristics, clinical features, risk factors and treatment options. RESULTS A total of 65 articles with 338 cases were enrolled for data extraction. The enrolled cases aged from 19 to 47 years, with a mean value of 35.7 years old. The average body mass index (BMI) was 22.2 kg/m2 ranged from 16.0 to 39.0 kg/m2. Of the 173 cases, 149 cases with vertebral fractures occurred in the first pregnancy, 19 cases in the second pregnancy, four cases in the third pregnancy and one case in the fourth pregnancy. Up to 91.5% of the back pain occurred within the last 3 months of pregnancy and the first 3 months after delivery. The most involved vertebral levels were L2, L1 and T12 accounting for 32.6% of all the fractures. The average fracture numbers were 4.4 levels per patient. The lumbar Z-scores were mostly recorded with a mean value of - 3.2 ranged from - 7.8 to 0. CONCLUSIONS PLO with vertebral fractures is a rare clinical entity, which is more likely to occur in older and thinner pregnant women. Back pain is the clinical complaint and mostly occurs in the late pregnancy and early lactation periods. Most vertebral fractures appear in the first pregnancy but it can occur in any time of pregnancy. Thoracolumbar region is the mostly involved region. As compared with postmenopausal osteoporotic fractures, PLO usually has multiple levels fractures. Bisphosphonates are the most widely used treatment so far, however, many factors need to be taken into account to decide which drug to choose in PLO and further studies are necessary for clear recommendation in the future.
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Affiliation(s)
- Ying Qian
- Endocrinology Department, 960 Hospital of People’s Liberation Army, NO.25 Shifan Road, Jinan, Shandong 250031 People’s Republic of China
| | - Lei Wang
- Orthopaedic Department, 960 Hospital of People’s Liberation Army, NO.25 Shifan Road, Jinan, Shandong 250031 People’s Republic of China
| | - Lili Yu
- Medical Information Department, 960 Hospital of People’s Liberation Army, NO.25 Shifan Road, Jinan, Shandong 250031 People’s Republic of China
| | - Weimin Huang
- Orthopaedic Department, 960 Hospital of People’s Liberation Army, NO.25 Shifan Road, Jinan, Shandong 250031 People’s Republic of China
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20
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Lee S, Hong N, Kim KJ, Park CH, Lee J, Rhee Y. Bone Density After Teriparatide Discontinuation With or Without Antiresorptive Therapy in Pregnancy- and Lactation-Associated Osteoporosis. Calcif Tissue Int 2021; 109:544-553. [PMID: 34037833 DOI: 10.1007/s00223-021-00869-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/18/2021] [Indexed: 02/07/2023]
Abstract
Pregnancy- and lactation-associated osteoporosis (PLO) is a rare and severe disorder that causes low-trauma or spontaneous fractures, most commonly multiple vertebral fractures, in the late pregnancy or lactation period [1]. In severe PLO, teriparatide (TPTD) might aid in bone mineral density (BMD) recovery and subsequent fracture risk reduction. However, it is unclear whether TPTD can be discontinued without sequential antiresorptive therapy (ART) in premenopausal women with PLO. In this retrospective cohort study, we investigated the changes in BMD in premenopausal women with PLO treated with TPTD 20 mcg daily with or without sequential ART. Data for 67 patients diagnosed with PLO from 2007 through 2017 were reviewed. Among 43 women with annual follow-up dual-energy X-ray absorptiometry data for 3 years, 33 were treated with TPTD (median 12 months) with (TPTD-ART, n = 13; median, 18 months) or without (TPTD-no ART, n = 20) sequential ART. The two groups showed no differences in the mean age (31 vs. 31 years), body mass index (BMI, 20.5 vs. 21.0 kg/m2), and baseline lumbar spine (LS) BMD (0.666 vs. 0.707 g/cm2; p > 0.05 for all). LSBMD increased at 1, 2, and 3 years from baseline in both the TPTD-ART (14.1%, 21.8%, and 24.0%, respectively) and TPTD-no ART (17.3%, 24.1%, and 23.4%, respectively) groups, without significant between-group differences. Similar results were observed for the total hip BMD. LSBMD gain at 3 years did not differ by ART use (adjusted β, 0.40; p = 0.874) in univariable and multivariable models adjusted for age, BMI, and baseline LSBMD. In summary, BMD gain by TPTD administration in premenopausal women with PLO can be well maintained without sequential ART treatment.
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Affiliation(s)
- Seunghyun Lee
- Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Namki Hong
- Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Kyoung Jin Kim
- Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Chung Hyun Park
- Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Jooyeon Lee
- Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Yumie Rhee
- Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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21
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Stumpf U, Kraus M, Hadji P. Influence of denosumab on bone mineral density in a severe case of pregnancy-associated osteoporosis. Osteoporos Int 2021; 32:2383-2387. [PMID: 34041561 PMCID: PMC8563672 DOI: 10.1007/s00198-021-06008-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/12/2021] [Indexed: 11/28/2022]
Abstract
Pregnancy and lactation-associated osteoporosis (PLO) with predominantly subsequent vertebral fracture is a rare but severe disease with an estimated incidence of 0.4 in 100,000. In the past, patients with PLO have been predominantly treated with oral and i.v. bisphosphonates to reduce subsequent fracture risk. Hereby, the use of bisphosphonates in premenopausal women is controversial, as bisphosphonates know to persist in bone for many years and can be exposed and circulate in maternal serum and subsequently pass the placenta barrier and may have a detrimental effect on fetal bone health. Here we report the effects of denosumab on the bone mineral density (BMD) and subsequent fracture risk in PLO. In this case presentation, denosumab was administered postpartum with 3000 IE vitamin D and 1000 mg of calcium daily in a patient with PLO and vertebral fracture of L1 and L4. After 18 months of treatment with denosumab, we could demonstrate a clinical significant increase of BMD at the lumbar spine, femoral neck, and total hip of 32.2%, 13.0%, and 11.5% respectively with no further subsequent fractures. As the patient had regular menstrual cycles and considered a further pregnancy, denosumab treatment was terminated and soon a second pregnancy occurred. After the second pregnancy, BMD decreased at the lumbar spine, femur neck, and total hip by -8.8%, -6.9%, and -7.0% respectively compared to the maximum values during treatment with denosumab, but was still significantly higher compared to baseline levels with no further fractures.
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Affiliation(s)
- U Stumpf
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Campus Innenstadt, Nussbaumstrasse, 20 80336, Munich, Germany.
| | - M Kraus
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Campus Innenstadt, Nussbaumstrasse, 20 80336, Munich, Germany
| | - P Hadji
- Frankfurt Center of Bone Health, Frankfurt, Germany and Philipps-University of Marburg, Marburg, Germany
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22
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Lampropoulou-Adamidou K, Trovas G, Triantafyllopoulos IK, Yavropoulou MP, Anastasilakis AD, Anagnostis P, Toulis KA, Makris K, Gazi S, Balanika A, Tournis S. Teriparatide Treatment in Patients with Pregnancy- and Lactation-Associated Osteoporosis. Calcif Tissue Int 2021; 109:554-562. [PMID: 34132853 DOI: 10.1007/s00223-021-00871-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 05/31/2021] [Indexed: 10/21/2022]
Abstract
Pregnancy- and lactation-associated osteoporosis (PLO) is a rare disease, presenting in most cases with severe back pain due to low energy vertebral fractures (VFs). Our purpose was to assess the effect of teriparatide (TPTD) vs. conventional management on areal bone mineral density (aBMD) and trabecular bone score (TBS) in patients with PLO. A multicenter retrospective cohort study concerning premenopausal women with PLO. Nineteen women were treated with TPTD (20 μg/day) (group A) plus calcium and vitamin D and eight women with calcium and vitamin D only (group B) for up to 24 months. The primary end-point was between group differences in lumbar spine (LS) and total hip (TH) aBMD, and TBS at 12 and 24 months. Patients in group A had sustained a median of 4.0 VFs (3-9) vs. 2.5 VFs (1-10) in group B (p = 0.02). At 12 months, patients on TPTD vs. controls achieved a mean aBMD increase of 20.9 ± 11.9% vs. 6.2 ± 4.8% at the LS (p < 0.001), 10.0 ± 11.6% vs. 5.8 ± 2.8% at the TH (p = 0.43), and 6.7 ± 6.9% vs. 0.9 ± 3.7% in TBS (p = 0.09), respectively. At 24 months, seven patients on TPTD and six controls achieved a mean LS aBMD increase of 32.9 ± 13.4% vs. 12.2 ± 4.2% (p = 0.001). P1NP levels during the first month of TPTD treatment were positively correlated with the 1-year LS aBMD change (r = 0.68, p = 0.03). No new clinical fractures occurred while on-treatment. In patients with PLO, TPTD treatment resulted in significantly greater increases in LS aBMD compared with calcium and vitamin D supplementation at 12 and 24 months.
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Affiliation(s)
- Kalliopi Lampropoulou-Adamidou
- Laboratory for the Research of Musculoskeletal System "Th. Garofalidis", School of Medicine, National and Kapodistrian University of Athens, KAT General Hospital, Athinas 10th Str. 14561, Athens, Greece
| | - Georgios Trovas
- Laboratory for the Research of Musculoskeletal System "Th. Garofalidis", School of Medicine, National and Kapodistrian University of Athens, KAT General Hospital, Athinas 10th Str. 14561, Athens, Greece
| | - Ioannis K Triantafyllopoulos
- Laboratory for the Research of Musculoskeletal System "Th. Garofalidis", School of Medicine, National and Kapodistrian University of Athens, KAT General Hospital, Athinas 10th Str. 14561, Athens, Greece
- 5th Orthopaedic Department, HYGEIA Hospital, Athens, Greece
| | - Maria P Yavropoulou
- Endocrinology Unit, 1st Department of Propaedeutic and Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Panagiotis Anagnostis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | | | - Sousana Gazi
- Rheumatology Department, KAT General Hospital, Athens, Greece
| | - Alexia Balanika
- Department of Computed Tomography, Asklepeion Voulas Hospital, Athens, Greece
| | - Symeon Tournis
- Laboratory for the Research of Musculoskeletal System "Th. Garofalidis", School of Medicine, National and Kapodistrian University of Athens, KAT General Hospital, Athinas 10th Str. 14561, Athens, Greece.
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23
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Faraji A, Shomali Z, Yoosefi S. Pregnancy-Associated Osteoporosis Presented with Femoral Neck Fracture: A Case Report and Literature Review. Galen Med J 2021; 9:e1750. [PMID: 34466586 PMCID: PMC8343783 DOI: 10.31661/gmj.v9i0.1750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 04/05/2020] [Accepted: 05/26/2020] [Indexed: 11/30/2022] Open
Abstract
Background:
Pregnancy-associated osteoporosis (PAO) is a rare condition characterized by reduced bone mineral density during the third trimester or lactation. Multiple risk factors, such as genetic, sedentariness, and 25-hydroxy vitamin D deficiency, are associated with PAO. In the majority of cases, PAO is presented with a compression fracture in vertebras, but in our case, it presented with a fracture of the femoral neck. Case Presentation: A 29-year-old, gravida one woman, developed right hip joint pain during the gestational age 34 weeks who referred to our clinic. Despite conservative management, the pain intensified. The patient delivered a healthy neonate in the 38th week of gestation and afterward underwent magnetic resonance imaging of the pelvic, revealing a bruised bone in the femoral neck. Since she had developed a femoral neck fracture during the postpartum period, she underwent open reduction and fixation of the femoral neck. Dual-energy X-ray absorptiometry (DEXA) revealed osteoporosis of the vertebras and femoral neck. She received calcium supplements and alendronate, and the pain was relieved. On 2-year and 4-year follow-up, she was found to be osteopenic with significant improvement in DEXA indices.
Conclusion: PAO is a rare condition among young women. This condition should be kept in mind when hip joint or back pain is encountered during pregnancy.
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Affiliation(s)
- Azam Faraji
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Shomali
- Obstetrics and gynaecology Department, Medical School, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sedigeh Yoosefi
- Maternal-Fetal Medicine Research Center, Perinatology Department, Shiraz University of Medical Sciences, Shiraz, Iran
- Correspondence to: Sedigeh Yoosefi, Maternal-Fetal Medicine Research Center, Perinatology Department, Shiraz University of Medical Sciences, Shiraz, Iran Telephone Number: +989173036014 Email Address:
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24
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Abstract
In premenopausal women, bone mineral density measurement by dual-energy X-ray absorptiometry should not be used as the sole guide for diagnosis or treatment of osteoporosis, universal screening with bone mineral density is not advised and the World Health Organization classification of bone status should not be applied. A diagnosis of premenopausal osteoporosis is reserved for those with evidence of fragility and may also be considered in women with low bone mass and an ongoing secondary cause of osteoporosis. Idiopathic osteoporosis in young women is rare. A thorough evaluation of secondary causes is indicated in all patients, with glucocorticoid treatment a common secondary cause of low bone mass and osteoporosis. Hypoestrogenism may be the primary cause of low bone mass and contribute to excessive bone loss in many conditions associated with premenopausal osteoporosis, and should be treated unless contra-indicated. The mainstay of treatment in premenopausal females with low bone mass includes risk factor reduction, advocating a healthy, active lifestyle and optimal treatment of secondary causes of bone loss. The safety of bone-specific therapy, especially long term and during pregnancy, remains uncertain. Bisphosphonates, teriparatide, denosumab and estrogen treatment increase bone density in premenopausal women with osteoporosis, but there are no study data confirming short-term fracture prevention with use of these agents.
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Affiliation(s)
- M Conradie
- Department of Medicine, Division of Endocrinology, Stellenbosch University, Cape Town, South Africa
| | - T de Villiers
- Medi-Clinic, Cape Town, South Africa.,Department of Obstetrics and Gynecology, Stellenbosch University, Cape Town, South Africa
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25
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Scioscia MF, Vidal M, Sarli M, Guelman R, Danilowicz K, Mana D, Longobardi V, Zanchetta MB. Severe Bone Microarchitecture Impairment in Women With Pregnancy and Lactation-Associated Osteoporosis. J Endocr Soc 2021; 5:bvab031. [PMID: 33860131 PMCID: PMC8035983 DOI: 10.1210/jendso/bvab031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Indexed: 11/19/2022] Open
Abstract
Context Pregnancy- and lactation-associated osteoporosis (PLO) is a rare condition characterized by fragility fractures, mostly vertebral, during the third trimester of pregnancy or the early postpartum period. Objective The aim of this study was to evaluate bone microarchitecture in women with PLO to better understand the pathophysiology of this disease. Methods In this retrospective study, we included women with PLO referred to our bone center between November 2007 and July 2012. We assessed bone mineral density (BMD) by dual-energy x-ray absorptiometry, bone turnover markers, and bone microarchitecture by high-resolution peripheral quantitative computed tomography. Results were compared with a control group of healthy lactating women. Results Of the 7 primiparous patients with PLO, 6 suffered vertebral fractures and 1 developed a hip fracture during the seventh month of gestation. Fractures occurred within the eighth month of pregnancy and the fourth month post partum; vertebral fractures were multiple in 85.7%. Major or minor risk factors for osteoporosis were present in 86% of our patients. Trabecular density, number, and thickness were 34%, 20% and 22% lower than controls (P < .01, P = .01, and P = .01, respectively). Cortical parameters were also deteriorated but to a lesser extent. Conclusion In comparison with healthy lactating women, patients with PLO presented severe deterioration of bone trabecular and cortical microarchitecture. This significant compromise may explain the occurrence of multiple fractures in these otherwise healthy young women. Further prospective studies are needed to determine whether bone microarchitecture might be able to be restored in the future.
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Affiliation(s)
- Maria Florencia Scioscia
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), Universidad del Salvador, ZC 1012 Buenos Aires, Argentina
| | - Maritza Vidal
- Centro de Diagnóstico de Osteoporosis y Enfermedades Reumáticas (CEDOR), San Isidro 15047, Lima, Peru
| | - Marcelo Sarli
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), Universidad del Salvador, ZC 1012 Buenos Aires, Argentina
| | - Rodolfo Guelman
- Servicio de Endocrinología del Hospital Italiano de Buenos Aires, Sector Osteopatías Metabólicas, 1199 Buenos Aires, Argentina
| | - Karina Danilowicz
- División de Endocrinología, Hospital de Clínicas, Universidad de Buenos Aires, 1120 Buenos Aires, Argentina
| | - Daniela Mana
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), Universidad del Salvador, ZC 1012 Buenos Aires, Argentina
| | - Vanesa Longobardi
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), Universidad del Salvador, ZC 1012 Buenos Aires, Argentina
| | - María Belén Zanchetta
- Instituto de Diagnóstico e Investigaciones Metabólicas (IDIM), Universidad del Salvador, ZC 1012 Buenos Aires, Argentina
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26
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Yıldız AE, Özbalcı AB, Ergen FB, Aydıngöz Ü. Pregnancy- and lactation-associated vertebral compression fractures: MRI prevalence and characteristics. Osteoporos Int 2021; 32:981-989. [PMID: 33236194 DOI: 10.1007/s00198-020-05754-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/18/2020] [Indexed: 12/11/2022]
Abstract
UNLABELLED The frequency of pregnancy- and lactation-associated vertebral compression fractures (PLVCFs) is not known. This study showed that MRI prevalence of PLVCFs was approximately 0.5% in females ≥ 15 and < 40 years of age over a 48-month period. PLVCFs did not display MRI features distinguishing them from other vertebral insufficiency fractures. PURPOSE We aimed to investigate the MRI prevalence and characteristics of pregnancy- and lactation-associated vertebral compression fractures (PLVCFs). METHODS This retrospective cross-sectional observational study included all thoracic, lumbar, or thoracolumbar MRI examinations performed in our hospital (or at outside centers and referred to us for consultation) of females ≥ 15 and < 40 years of age during a 48-month period. Two radiologists independently reviewed all images for vertebral compression fractures and their disagreement was resolved by a third blinded senior radiologist with 24 years of dedicated musculoskeletal radiology experience. MRI features of PLVCFs (early/late stage, height loss, endplate involvement, retropulsion) were noted. RESULTS A total of 1484 MRI examinations-including 50 consultations from outside centers-of 1260 females (mean age, 27.7 years; range, 15-39) were included. Interobserver agreement of the two junior radiologists was substantial (κ = 0.607; 95% CI, 0.545-0.669). Vertebral compression fractures were identified in 177 of thoracic (n = 210), lumbar (n = 900), or thoracolumbar MRI (n = 374) examinations. Six women (7 MRI examinations; 4.0% of MRIs with vertebral fractures) had PLVCFs diagnosed on MRI (prevalence, 0.47%; mean age, 31 years; age range, 25-37). Number of fractured vertebrae in cases with PLVCF ranged between 1 and 11 (mean, 5.6). DEXA, available in all patients with PLVCFs, verified osteopenia/osteoporosis in four of six patients. CONCLUSION PLVCFs have an MRI prevalence of approximately 0.5% in the target population and do not display distinguishing features from other insufficiency type vertebral compression fractures.
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Affiliation(s)
- A E Yıldız
- Department of Radiology, Hacettepe University School of Medicine, Sihhiye, 06100, Ankara, Turkey.
| | - A B Özbalcı
- Department of Radiology, Ondokuz Mayıs University School of Medicine, Atakum, 55139, Samsun, Turkey
| | - F B Ergen
- Department of Radiology, Hacettepe University School of Medicine, Sihhiye, 06100, Ankara, Turkey
| | - Ü Aydıngöz
- Department of Radiology, Hacettepe University School of Medicine, Sihhiye, 06100, Ankara, Turkey
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Bai X, Wang G, Xu G, Wang B. Malleolar fracture in pregnancy and lactation-associated osteoporosis: a case report and literature review. Arch Osteoporos 2021; 16:36. [PMID: 33611644 DOI: 10.1007/s11657-021-00908-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 02/05/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The incidence of fractures in pregnancy and lactation-associated osteoporosis (PLO) is very low. Some fracture cases of PLO are associated with vertebral compression fractures, while malleolar fractures in patients with PLO are rarely reported before. CASE REPORT A 31-year-old Han Chinese patient presented with a malleolar fracture 3 months after delivery, while she was still breastfeeding. Temporary closed reduction and plaster external fixation were performed in the emergency room. Then the patient was admitted to the orthopedic trauma ward for surgery and diagnosed as PLO by dual-energy X-ray absorptiometry (DEXA). After preoperative evaluation, the patient underwent open reduction and internal fixation. With the diagnosis of PLO, the patient was treated with weaning, bisphosphonate, and supplementation of calcium carbonate and vitamin D. During the 12-month follow-up period, the results of DEXA and laboratory examination improved gradually, and the internal fixation was removed 12 months after surgery. CONCLUSION Orthopedic doctors should not ignore the possibility of PLO to avoid misdiagnosis of perinatal women with fractures. Improvement of functional recovery of fractures can be achieved with accurate diagnosis and individual treatment.
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Affiliation(s)
- Xiaodong Bai
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Gang Wang
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Guoqiang Xu
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Baojun Wang
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China.
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The Effect of Type and Daily Doses of Insulin to Treatment Success in Type 2 Diabetes Patients who are Receiving Basal-bolus Insulin Therapy. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2020; 54:416-423. [PMID: 33364880 PMCID: PMC7751243 DOI: 10.14744/semb.2018.58234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 12/19/2018] [Indexed: 11/20/2022]
Abstract
Objectives The present study aims to compare different types of insulin concerning treatment success and insulin dose requirement in type 2 diabetes patients who were receiving basal-bolus insulin therapy and to evaluate the causes of treatment failure despite high doses of insulin. Methods In our retrospective study, 198 type 2 diabetes patients who were receiving basal-bolus insulin therapy included. Patients were divided into three groups according to the insulin types (Group 1: short and long-acting analogue insulin users (n=83), Group 2: short and long-acting human regular insulin users (n=58), Group 3: human regular insulin + long-acting analogue insulin users (57)). Demographic data and daily insulin doses were recorded from the patient follow-up files. These data and the rates of achievement of the target HbA1c levels were also compared between groups. In addition, insulin doses of the patients whose glycemic targets could and could not be achieved were compared. Results In this study, 123 (62.1%) of the 198 patients were female and 65 (47.9 %) were male. The mean age of the three groups was 55.81±8.1, 58.3±8.9, 58.3±8.8, respectively. HbA1C values were 8.72±1.65% in group 1, 9.0±1.98% in group 2 and 9.05±2.24% in group 3. The rates of achievement HbA1c value below 7% were 27.7% in analogue insulin group, 25.9% human regular insulin group and 31.6% in regular + analogue insulin group (p >0.05). There were no significant differences in daily basal and bolus insulin doses, total daily and per kg insulin doses and basal-bolus rates between groups. Higher total daily insulin doses were determined in patients who could not achieve target glycemic values than achieved it in group 1 and 2. Higher basal insulin doses were determined in patients who could not achieve target glycemic values than could achieved it in group 3. Conclusion In our study, in which we did not find any significant difference in the dose analysis between analogue and regular insulin, the findings showed that high insulin doses might not be sufficient for glycemic control. The underlying causes should be investigated and correctible reasons should be eliminated in these patients.
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Transient Osteoporosis of the Hip: A Case Report. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2020; 54:505-507. [PMID: 33364895 PMCID: PMC7751251 DOI: 10.14744/semb.2019.26879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 04/29/2019] [Indexed: 11/20/2022]
Abstract
Transient osteoporosis of the hip, idiopathic, is a table, beginning with hip pain without a history of trauma, usually self-limiting and seen in middle-aged men and pregnant women. In this case report, a male patient who was admitted because of hip pain and detected transient osteoporosis go the hip was discussed. The purpose of the case presentation is to emphasize the necessity of transient osteoporosis of the hip in the differential diagnosis of sudden onset of hip pain and to review the literature on this subject.
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Cerit ET, Cerit M. A case of pregnancy and lactation associated osteoporosis in the third pregnancy; robust response to teriparatide despite delayed administration. Bone Rep 2020; 13:100706. [PMID: 32884982 PMCID: PMC7451846 DOI: 10.1016/j.bonr.2020.100706] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/08/2020] [Accepted: 07/30/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Pregnancy and lactation associated osteoporosis (PLO) is a rare condition that may present with fragility fractures occurring for the first time in pregnancy or postpartum period while breastfeeding. Here, we report a rare case of PLO in the 3rd pregnancy treated with teriparatide. CASE REPORT A 35-year-old woman who presented with back pain (visual analogue scale; VAS = 10/10) two months after her third delivery. PLO was diagnosed from multiple vertebral fragility fractures and low bone mineral density (BMD). She was treated with teriparatide and her pain significantly reduced in the second month. After 12 months of teriparatide treatment, her BMD increased 18.1% from the baseline. CONCLUSION PLO should be considered in patients who complain with back pain during late pregnancy and postpartum period. Weaning off breastfeeding and supplementation of calcium/vitamin D should be the first recommendation as conventional treatment after the diagnosis of PLO. Teriparatide may be an effective option to improve the recovery of BMD If there is not enough improvement with conventional treatment.
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Affiliation(s)
- Ethem Turgay Cerit
- Ankara Memorial Hospital, Endocrinology and Metabolism Department, Ankara, Turkey
| | - Mahinur Cerit
- Gazi University Faculty of Medicine, Radiology Department, Ankara, Turkey
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Zagouri F, Dedes N, Papatheodoridi A, Liontos M, Dimopoulos MA. Supportive medication in cancer during pregnancy. BMC Pregnancy Childbirth 2020; 20:747. [PMID: 33261562 PMCID: PMC7706269 DOI: 10.1186/s12884-020-03432-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 11/16/2020] [Indexed: 02/08/2023] Open
Abstract
While pregnancy-related malignancies are quite rare, their incidence is increasing and thus affecting more and more women nowadays. Their management, however, with both chemotherapy and supportive agents remains quite challenging and it seems crucial to define the optimal treatment for this special population. Concerning supportive medication, it is clinically significant to determine whether commonly used agents, including Granulocyte Colony-Stimulating Factors, Erythropoiesis-stimulating agents, Bisphosphonates, Anticoagulation agents, Antiemetics and Glucocorticoids are indeed effective in ameliorating chemotherapy side effects. Meanwhile, it is of great importance that the administration of any of these agents is safe for both mother and fetus. This review aims to provide a précis of the current literature regarding both safety and efficacy of all categories of supportive medication during pregnancy.
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Affiliation(s)
- Flora Zagouri
- Haematology - Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Vasilissis Sofias 80, 11528, Athens, Greece.
| | - Nikolaos Dedes
- Haematology - Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Vasilissis Sofias 80, 11528, Athens, Greece
| | - Alkistis Papatheodoridi
- Haematology - Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Vasilissis Sofias 80, 11528, Athens, Greece
| | - Michael Liontos
- Haematology - Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Vasilissis Sofias 80, 11528, Athens, Greece
| | - Meletios Athanasios Dimopoulos
- Haematology - Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Vasilissis Sofias 80, 11528, Athens, Greece
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Wang G, Bai X. Barton Fracture of the Distal Radius in Pregnancy and Lactation-Associated Osteoporosis: A Case Report and Literature Review. Int J Gen Med 2020; 13:1043-1049. [PMID: 33192088 PMCID: PMC7656778 DOI: 10.2147/ijgm.s278536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/15/2020] [Indexed: 01/09/2023] Open
Abstract
Objective Pregnancy and lactation-associated osteoporosis (PLO) is very rare, which typically occurs during the third trimester or during lactation. Many cases of PLO are associated with vertebral compression fractures or hip fractures, while distal radius fractures in patients with PLO are rarely reported. Case Report A 36-year-old patient presented with Barton fracture at 37 weeks of gestation. Temporary closed reduction and plaster external fixation were performed in emergency room. At 38 weeks of gestation, she gave birth to a healthy boy and began breastfeeding after delivery. Three days after delivery, the patient was admitted to the orthopedic ward for surgery and was diagnosed as PLO. The patient underwent open reduction and internal fixation and treated with weaning and supplementation of calcium carbonate and vitamin D. During the 1-year follow-up period, the results of laboratory tests and bone mineral density gradually returned to normal. Conclusion Clinicians should be alert to the possibility of PLO to avoid missed diagnosis. Accurate diagnosis and individualized treatment are of great significance for relieving pain and functional recovery of patients.
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Affiliation(s)
- Gang Wang
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, People's Republic of China
| | - Xiaodong Bai
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, People's Republic of China
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Paoletta M, Moretti A, Liguori S, Bertone M, Toro G, Iolascon G. Transient osteoporosis of the hip and subclinical hypothyroidism: an unusual dangerous duet? Case report and pathogenetic hypothesis. BMC Musculoskelet Disord 2020; 21:543. [PMID: 32791961 PMCID: PMC7427076 DOI: 10.1186/s12891-020-03574-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/06/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Transient osteoporosis of the hip (TOH) is a rare and temporary clinical condition characterised by bone marrow edema (BME), severe pain, and functional limitation. It commonly occurs in middle-aged men or in women in the last trimester of pregnancy. TOH usually resolves with conservative therapy but may predispose to hip fracture or progression to avascular necrosis (AVN). Etiology is still unclear, although several pathophysiological mechanisms underpinning this condition has been proposed. We describe the management of an unusual case of TOH occurred in a patient with subclinical hypothyroidism. CASE PRESENTATION A clinical case of a 46-year-old man with severe pain in the left anterior thigh is presented. After a comprehensive clinical and radiological approach, a TOH was diagnosed. Moreover, biochemical assessment suggested the presence of subclinical hypothyroidism. After 3 months of treatment with clodronate, physical therapy and hormone replacement therapy (HRT) a significant improvement of clinical and radiological outcomes was observed. CONCLUSION Several pathological conditions have been related to development of TOH. In our case, we suggested for the first time a role of subclinical hypothyroidism as novel contributory factor for the onset of this condition, providing pathophysiological mechanisms and a scientific rationale for pharmacological treatment.
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Affiliation(s)
- Marco Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Via De Crecchio 4, 80138, Naples, Italy
| | - Antimo Moretti
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Via De Crecchio 4, 80138, Naples, Italy.
| | - Sara Liguori
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Via De Crecchio 4, 80138, Naples, Italy
| | - Matteo Bertone
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Via De Crecchio 4, 80138, Naples, Italy
| | - Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Via De Crecchio 4, 80138, Naples, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Via De Crecchio 4, 80138, Naples, Italy
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Atypical pregnancy-associated osteoporosis of the patella: a case report. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Cohen A, Kamanda-Kosseh M, Dempster DW, Zhou H, Müller R, Goff E, Colon I, Bucovsky M, Stubby J, Nickolas TL, Stein EM, Recker RR, Lappe JM, Shane E. Women With Pregnancy and Lactation-Associated Osteoporosis (PLO) Have Low Bone Remodeling Rates at the Tissue Level. J Bone Miner Res 2019; 34:1552-1561. [PMID: 31348548 PMCID: PMC6744311 DOI: 10.1002/jbmr.3750] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 03/19/2019] [Accepted: 04/21/2019] [Indexed: 01/19/2023]
Abstract
Pregnancy and lactation-associated osteoporosis (PLO) is a rare, severe, early form of osteoporosis in which young women present with fractures, usually multiple vertebral fractures, during late pregnancy or lactation. In studies of idiopathic osteoporosis (IOP) in premenopausal women, we enrolled 78 women with low-trauma fractures and 40 healthy controls, all with normal menses and no secondary cause of bone loss. In 15 of the affected women, the PLO subgroup, fractures had occurred during late pregnancy or lactation. We hypothesized that clinical, bone structural, and metabolic characteristics would differ between women with PLO and those with (non-PLO) IOP and controls. All were evaluated > 12 months postpartum, when structural and remodeling characteristics would be expected to reflect baseline premenopausal status rather than transient postpartum changes. As previously reported, affected subjects (PLO and IOP) had BMD and microarchitectural deficiencies compared to controls. Women with PLO did not differ from those with IOP in terms of age, BMI, body fat, menarcheal age, parity, or age at first pregnancy. However, women with PLO had a more severe clinical presentation than those with IOP: more fractures (5.5 ± 3.3 versus 2.6 ± 2.1; p = 0.005); more vertebral fractures (80% versus 17%; p < 0.001); and higher prevalence of multiple fractures. BMD deficits were more profound and cortical width tended to be lower in PLO. PLO subjects also had significantly lower tissue-level mineral apposition rate and bone formation rates (0.005 ± 0.005 versus 0.011 ± 0.010 mm2 /mm/year; p = 0.006), as well as lower serum P1NP (33 ± 12 versus 44 ± 18 µg/L; p = 0.02) and CTX (257 ± 102 versus 355 ± 193 pg/mL; p = 0.01) than IOP. The finding that women with PLO have a low bone remodeling state assessed more than a year postpartum increases our understanding of the pathogenic mechanism of PLO. We conclude that women with PLO may have underlying osteoblast functional deficits which could affect their therapeutic response to osteoanabolic medications. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Adi Cohen
- Department of Medicine, Division of Endocrinology, Columbia University Irving Medical Center, New York, NY, USA
| | - Mafo Kamanda-Kosseh
- Department of Medicine, Division of Endocrinology, Columbia University Irving Medical Center, New York, NY, USA
| | - David W Dempster
- Department of Clinical Pathology and Cell Biology, Columbia University, New York, NY, USA.,Regional Bone Center, Helen Hayes Hospital, West Haverstraw, NY, USA
| | - Hua Zhou
- Regional Bone Center, Helen Hayes Hospital, West Haverstraw, NY, USA
| | - Ralph Müller
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Elliott Goff
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Ivelisse Colon
- Department of Medicine, Division of Endocrinology, Columbia University Irving Medical Center, New York, NY, USA
| | - Mariana Bucovsky
- Department of Medicine, Division of Endocrinology, Columbia University Irving Medical Center, New York, NY, USA
| | - Julie Stubby
- Department of Clinical Pathology and Cell Biology, Columbia University, New York, NY, USA
| | - Thomas L Nickolas
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Emily M Stein
- Division of Endocrinology, Hospital for Special Surgery, New York, NY, USA
| | - Robert R Recker
- Department of Medicine, Division of Endocrinology, Creighton University school of Medicine, Omaha, NE, USA
| | - Joan M Lappe
- Department of Medicine and College of Nursing, Creighton University school of Medicine, Omaha, NE, USA
| | - Elizabeth Shane
- Department of Medicine, Division of Endocrinology, Columbia University Irving Medical Center, New York, NY, USA
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Gehlen M, Lazarescu AD, Hinz C, Schwarz-Eywill M, Pfeifer M, Balasingam S, Maier A. Long-term outcome of patients with pregnancy and lactation-associated osteoporosis (PLO) with a particular focus on quality of life. Clin Rheumatol 2019; 38:3575-3583. [DOI: 10.1007/s10067-019-04758-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/16/2019] [Accepted: 08/20/2019] [Indexed: 12/12/2022]
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Comparison of Efficacy of Pharmacologic Treatments in Pregnancy- and Lactation-Associated Osteoporosis. Clin Rev Bone Miner Metab 2019. [DOI: 10.1007/s12018-019-09262-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hardcastle SA, Yahya F, Bhalla AK. Pregnancy-associated osteoporosis: a UK case series and literature review. Osteoporos Int 2019; 30:939-948. [PMID: 30671611 DOI: 10.1007/s00198-019-04842-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 01/03/2019] [Indexed: 11/26/2022]
Abstract
Mini Abstract: Pregnancy-associated osteoporosis (PAO) is a rare syndrome affecting women during late pregnancy and the early postpartum period. We set out to review the clinical features of ten cases of PAO from a single UK centre. Patients had attended the Royal National Hospital for Rheumatic Diseases, Bath (RNHRD) between January 2000 and June 2016. The principal criterion for inclusion was the occurrence of low trauma fractures either during pregnancy or the immediate post-partum period. Data were obtained from retrospective review of medical notes. Bone mineral density (BMD) was measured using dual-energy X-ray absorptiometry (Hologic ®Discovery system) at the lumbar spine and hip. Data pertaining to the pregnancy, as well as type and duration of treatment received, were reviewed. All ten cases presented with vertebral fractures. In four patients, no risk factors for fracture other than pregnancy or breastfeeding could be identified. Four patients were found to have vitamin D insufficiency at the time of diagnosis, and a further two patients had received treatment with low molecular weight heparin (LMWH). In one case, further investigation led to a diagnosis of osteogenesis imperfecta (OI) confirmed on genetic testing. In terms of treatment, eight out of the ten patients in this series received a bisphosphonate, most commonly risedronate due to its relatively short skeletal retention time. Clinicians should be aware of PAO, a rare but recognised complication of pregnancy. The condition should be especially considered in women presenting with new onset back pain in pregnancy or the postpartum period.
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Affiliation(s)
- S A Hardcastle
- Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK.
| | - F Yahya
- Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK
- Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - A K Bhalla
- Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK
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Combination Therapy of Conventional and Korean Medicine for Multiple Vertebral Compression Fractures Associated with Postpartum Osteoporosis: A Case Report. JOURNAL OF ACUPUNCTURE RESEARCH 2018. [DOI: 10.13045/jar.2018.00241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Abstract
A 33-year-old woman in the 6th month postpartum and breast-feeding period suffered from acute thoracolumbar pain for 1 month. She presented with slightly decreased serum calcium level. Other laboratory assessments were unremarkable. Considering the worsening symptom and her strong demand to exclude potential malignancy, F-FDG PET/CT was performed. Multiple FDG-avid foci in the thoracic and lumbar vertebra were detected on FDG PET, corresponding to vertebral compression fractures on CT, and diffuse FDG uptake was seen within bilateral breast, and dual-X ray absorptiometry showed markedly decreased bone mineral density, all of which supported the diagnosis of pregnancy and lactation-associated osteoporosis.
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Ijuin A, Yoshikata H, Asano R, Tsuburai T, Kikuchi R, Sakakibara H. Teriparatide and denosumab treatment for pregnancy and lactation-associated osteoporosis with multiple vertebral fractures: A case study. Taiwan J Obstet Gynecol 2018; 56:863-866. [PMID: 29241936 DOI: 10.1016/j.tjog.2017.10.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2017] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Pregnancy and lactation-associated osteoporosis (PLO) is a rare disease, which can lead to vertebral fractures in women of reproductive age. No treatment strategy for PLO has been established. Here we report a case of PLO treated with teriparatide followed by denosumab, in which remarkable improvement in bone mineral density (BMD) was achieved. CASE REPORT A 27-year-old woman experienced severe back pain two weeks after her first delivery. PLO was diagnosed from her low BMD and multiple vertebral compression fractures. She was treated with teriparatide for 6 months, followed by denosumab. After 1 year, her BMD increase from baseline was 16.5% in L2∼4 and her pain had been relieved. CONCLUSION In addition to weaning, administration of teriparatide followed by denosumab led to remarkable improvement in the patient's symptoms and BMD. Therefore, we regard this method as a promising choice for the treatment of PLO.
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Affiliation(s)
- Akifumi Ijuin
- Department of Obstetrics and Gynecology, Yokohama City University Hospital, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Hiromi Yoshikata
- Department of Obstetrics and Gynecology, Yokohama City University Hospital, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan; Yoshikata Obstetrics and Gynecology Clinic, 2430, Kozukue-cho, Kohoku-ku, Yokohama, Kanagawa, 222-0036, Japan
| | - Ryoko Asano
- Department of Obstetrics and Gynecology, Yokohama City University Hospital, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Taku Tsuburai
- Department of Obstetrics and Gynecology, Yokohama City University Hospital, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Ritsuko Kikuchi
- Department of Obstetrics and Gynecology, Yokohama City University Hospital, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Hideya Sakakibara
- Department of Obstetrics and Gynecology, Yokohama City University Hospital, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan; Department of Gynecology, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan.
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Clinical characteristics and bisphosphonates treatment of rare pregnancy- and lactation-associated osteoporosis. Clin Rheumatol 2018; 37:3141-3150. [PMID: 29946989 DOI: 10.1007/s10067-018-4185-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/12/2018] [Accepted: 06/19/2018] [Indexed: 12/11/2022]
Abstract
Pregnancy- and lactation-associated osteoporosis (PLO) is a rare disorder with poorly known etiology, pathophysiology, and therapy. We aimed to investigate the clinical characteristics of PLO and evaluate the effectiveness and safety of bisphosphonates on it. A total of 12 patients were diagnosed with PLO on the basis of medical history, bone mineral density (BMD), and/or fragility fractures during pregnancy and lactation. We investigated the clinical, biochemical, and radiological characteristics of patients. We assessed the effects of alendronate or zoledronic acid through observing the changes of bone turnover biomarkers and BMD during the treatment. Secondary osteoporosis was excluded by comprehensive differential diagnosis. The mean age of these patients was 31 ± 5 years old. All of these patients presented severe back pain. Multiple vertebral compression fractures (VCFs) were found in 10 patients, and the median (P25th, P75th) number of compressed vertebra was 3 (3, 5). Ten patients had vitamin D insufficiency or deficiency. Serum level of bone resorption marker (β-CTX with mean of 0.68 ± 0.41 ng/ml) was moderately higher than the normal range. BMD at lumbar spine, femoral neck, and total hip were low as 0.894 ± 0.153 g/cm2, 0.728 ± 0.090 g/cm2, and 0.728 ± 0.080 g/cm2, respectively. Either alendronate or zoledronic acid could effectively relieve bone pain, reduce β-CTX level, and increase BMD. PLO is a rare type of osteoporosis, which was characterized by increased bone resorption and decreased BMD, even VCFs. Bisphosphonate therapy was well tolerated and effective in management of PLO, but needed to be further verified in randomized controlled trial.
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Abstract
PURPOSE OF REVIEW The scope of this review was to review the newest developments in the context of the existing knowledge on premenopausal bone fragility. Fragility fractures are common in postmenopausal women and men and diagnostic criteria for osteoporosis have been agreed and multiple pharmacological treatments have been developed over the last 25 years. In premenopausal women, fragility fractures and very low bone mass are uncommon and osteoporosis in premenopausal women has therefore attracted much less interest. RECENT FINDINGS Recent studies have highlighted that lifestyle and dietary habits affect premenopausal bone mass. Bone mass may be improved by sufficient intake of calcium and vitamin D together with increased physical activity in premenopausal women with idiopathic osteoporosis. If pharmacological treatment is needed, teriparatide has been demonstrated to efficiently increase bone mass; however, no fracture studies and no comparative studies against antiresorptive therapies have been conducted. Pregnancy affects bone turnover and mass significantly, but pregnancy-associated osteoporosis is a rare and heterogeneous condition. SUMMARY The diagnosis of osteoporosis should only be considered in premenopausal women with existing fragility fractures, diseases or treatments known to cause bone loss or fractures. Secondary causes of osteoporosis should be corrected or treated if possible. The women should be recommended sufficient intake of calcium and vitamin and physical activity. In women with recurrent fractures or secondary causes that cannot be eliminated, for example glucocorticoid or cancer treatment, pharmacological intervention with bisphosphonates or teriparatide (not in the case of cancer) may be considered.
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Kyvernitakis I, Reuter TC, Hellmeyer L, Hars O, Hadji P. Subsequent fracture risk of women with pregnancy and lactation-associated osteoporosis after a median of 6 years of follow-up. Osteoporos Int 2018; 29:135-142. [PMID: 28965212 DOI: 10.1007/s00198-017-4239-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 09/21/2017] [Indexed: 12/22/2022]
Abstract
Almost a quarter of patients with PAO will sustain a subsequent fracture; patients need to be informed about potential risks before deciding for further pregnancies. INTRODUCTION Pregnancy and lactation-associated osteoporosis (PAO) is a severe type of premenopausal osteoporosis which predominantly occurs in the last trimester of pregnancy or immediately postpartum. Long-term follow-up data including subsequent fracture risk have yet to be reported. METHODS This single-center prospective cohort study investigated the subsequent fracture risk of all 107 patients with PAO who were referred to our institution. RESULTS Overall, 107 presented with at least one fracture. Each patient sustained on average four fractures most commonly at the thoracolumbar spine. During a median of 6 years of follow-up, 26 (24.3%) of patients who had a fracture at baseline reported a subsequent fracture. Overall, 30 PAO patients (28%) reported a further pregnancy. In subsequent pregnancies, 6 (20%) of patients reported a subsequent fracture. Patients with up to 1 vs. > 1 fracture at time of diagnosis showed a 3 (10%) and 25 (27%) subsequent fracture rate, respectively (p = 0.047). There was a significant correlation between the number of fractures at time of diagnosis and subsequent fracture risk (N = 26,p= 0.56, p = 0.003). CONCLUSIONS Almost a quarter of patients with PAO will sustain a subsequent fracture, and this fracture risk correlates with the number of fractures at time of diagnosis. Patients with PAO need to be informed about their potential subsequent fracture risk before deciding for further pregnancies.
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Affiliation(s)
- I Kyvernitakis
- Department of Obstetrics and Gynecology, Buergerhospital and Clementine Kinderhospital Frankfurt, Goethe-University of Frankfurt, Nibelungenallee 37-41, 60318, Frankfurt a.M., Germany.
- Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany.
| | - T C Reuter
- Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany
| | - L Hellmeyer
- Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany
- Department of Obstetrics and Gynecology, Vivantes Klinikum Berlin, Berlin, Germany
| | - O Hars
- Stastistical Institute, Berlin, Germany
| | - P Hadji
- Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany
- German Reference Centre for Pregnancy-Associated Osteoporosis, Department of Osteoporosis, Endocrinology and Reproductive Medicine, Frankfurt, Germany
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Drabkin A, Rothman MS, Wassenaar E, Mascolo M, Mehler PS. Assessment and clinical management of bone disease in adults with eating disorders: a review. J Eat Disord 2017; 5:42. [PMID: 29214023 PMCID: PMC5713040 DOI: 10.1186/s40337-017-0172-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 09/08/2017] [Indexed: 01/09/2023] Open
Abstract
AIM To review current medical literature regarding the causes and clinical management options for low bone mineral density (BMD) in adult patients with eating disorders. BACKGROUND Low bone mineral density is a common complication of eating disorders with potentially lifelong debilitating consequences. Definitive, rigorous guidelines for screening, prevention and management are lacking. This article intends to provide a review of the literature to date and current options for prevention and treatment. METHODS Current, peer-reviewed literature was reviewed, interpreted and summarized. CONCLUSION Any patient with lower than average BMD should weight restore and in premenopausal females, spontaneous menses should resume. Adequate vitamin D and calcium supplementation is important. Weight-bearing exercise should be avoided unless cautiously monitored by a treatment team in the setting of weight restoration. If a patient has a Z-score less than expected for age with a high fracture risk or likelihood of ongoing BMD loss, physiologic transdermal estrogen plus oral progesterone, bisphosphonates (alendronate or risedronate) or teriparatide could be considered. Other agents, such as denosumab and testosterone in men, have not been tested in eating-disordered populations and should only be trialed on an empiric basis if there is a high clinical concern for fractures or worsening bone mineral density. A rigorous peer-based approach to establish guidelines for evaluation and management of low bone mineral density is needed in this neglected subspecialty of eating disorders.
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Affiliation(s)
- Anne Drabkin
- Denver Health and Hospital Authority, 660 Bannock MC 4000, Denver, CO 80204 USA
| | - Micol S. Rothman
- University of Colorado Hospital, Anschutz Medical Campus, 13001 E 17th Pl, Aurora, CO 80045 USA
| | | | - Margherita Mascolo
- Denver Health and Hospital Authority, 660 Bannock MC 4000, Denver, CO 80204 USA
| | - Philip S. Mehler
- Denver Health and Hospital Authority, 660 Bannock MC 4000, Denver, CO 80204 USA
- Eating Recovery Center, 7351 E. Lowry Blvd. Suite 200, Denver, CO 80230 USA
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Zhang M, Chen P, Li B, Du J, Pan T, Chen J. Approach to the patient with pregnancy and lactation-associated osteoporosis: A case report and a review of the literature. Medicine (Baltimore) 2017; 96:e8671. [PMID: 29145296 PMCID: PMC5704841 DOI: 10.1097/md.0000000000008671] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Pregnancy and lactation-associated osteoporosis (PLO) is very rare, but it can cause severe vertebral compression fractures with disabling back pain. Although it is a rare, PLO must be kept in mind in the differential diagnosis in patients presenting with low back pain during or after pregnancy. PATIENT CONCERNS A 23-year-old woman who suffered from lumbago and fractures in the vertebral column 1 month after delivery. DIAGNOSIS Pregnancy and lactation-associated osteoporosis. INTERVENTIONS Combination therapy of calcium and vitamin D were used for treatment, as well as regular follow-up. OUTCOMES The patient's back pain had decreased significantly, the bone metabolic index, bone mineral density (BMD) had improved and she did not experience any recurrence. LESSONS Early diagnosis and treatment of calcium and vitamin D, as well as the efficacy of PLO intervention monitoring and evaluation are critical for the success of treatment.
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Affiliation(s)
- Min Zhang
- Department of Eldly Endocrinology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital
| | - Ping Chen
- Department of Eldly Endocrinology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital
| | - Bin Li
- Department of Eldly Endocrinology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital
| | - Juan Du
- Department of Eldly Endocrinology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital
| | - Ting Pan
- Department of Endocrinology, Zigong No. 4 People's Hospital, Sichuan, China
| | - Jingyan Chen
- Department of Eldly Endocrinology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital
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Asadipooya K, Graves L, Greene LW. Transient osteoporosis of the hip: review of the literature. Osteoporos Int 2017; 28:1805-1816. [PMID: 28314897 DOI: 10.1007/s00198-017-3952-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 01/30/2017] [Indexed: 11/26/2022]
Abstract
Transient osteoporosis of the hip (TOH) is a temporary clinical condition of unknown etiology which usually resolves with conservative therapy though may be complicated by fracture or progression to avascular necrosis (AVN). TOH may be slightly more prevalent in men but when it occurs in women, it is most often seen in the latter part of pregnancy. Though fracture is a rare complication of TOH when it occurs, it is most often associated with TOH occurring in pregnancy. Magnetic resonance imaging (MRI) is the best method to diagnosis TOH. Low signal intensity on T1-weighted images, high signal intensity on T2-weighted images, and homogenous pattern of edema (the femoral head and/or neck) with normal subchondral area are in favor of TOH. A shortened course to recovery is reported by use of bisphosphonates, calcitonin, or teriparatide. Based on reported cases, core decompression is not superior to medical therapy. Transient osteoporosis of the hip, which often has no known etiology, usually resolves with conservative therapy but may predispose the patient to fracture or avascular necrosis. Diagnostic method of choice is magnetic resonance imaging. Bisphosphonates, calcitonin, or teriparatide are reported as a useful approach to reduce duration of recovery.
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Affiliation(s)
- K Asadipooya
- Fellow in Endocrinology and Metabolism, NYU School of Medicine, New York, NY, USA
- Division of Endocrinology and Metabolism, NYU Langone Medical Center, 522 1st Ave, Smilow 707B, New York, NY, 10016-6402, USA
| | - L Graves
- Division of Metabolism, Endocrinology and Genetics, Department of Internal Medicine, Endocrinology and Genetics MS 2024, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA.
| | - L W Greene
- Medicine (Endocrinology) and ObGyn, Co-Director of Osteoporosis and Metabolic Bone Disease, Department of Medicine, NYU School of Medicine, New York, NY, USA
- Division of Endocrinology and Metabolism, NYU Langone Medical Center, 650 First Avenue, 7th floor, New York, NY, 10016, USA
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Abstract
Most premenopausal women with low trauma fracture(s) or low bone mineral density have a secondary cause of osteoporosis or bone loss. Where possible, treatment of the underlying cause should be the focus of management. Premenopausal women with an ongoing cause of bone loss and those who have had, or continue to have, low trauma fractures may require pharmacologic intervention. Clinical trials provide evidence of benefits of bisphosphonates and teriparatide for bone mineral density in several types of premenopausal osteoporosis, but studies are small and do not provide evidence regarding fracture risk reduction.
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Affiliation(s)
- Adi Cohen
- Division of Endocrinology, Department of Medicine, Columbia University Medical Center, Columbia University, College of Physicians & Surgeons, PH8-864, 630 West 168th Street, New York, NY 10032, USA.
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Sánchez A, Zanchetta MB, Danilowicz K. Two cases of pregnancy- and lactation- associated osteoporosis successfully treated with denosumab. ACTA ACUST UNITED AC 2017; 13:244-246. [PMID: 28228791 DOI: 10.11138/ccmbm/2016.13.3.244] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Case 1. A 35-year-old woman in the 8th month of her first pregnancy suffered acute lumbar pain that persisted for 4 months. In the 5th month postpartum an acute increase in the low back pain led to a MRI which showed recent deformity in L1 and deformities of undetermined time of evolution in L2, L4, and L5. Laboratory evaluation did not reveal metabolic derangements. She had low bone mineral density (BMD, DXA) and severe deterioration of the microarchitecture of distal appendicular bone (HR-pQCT). Kyphoplasty of all 4 vertebrae was performed in 2 stages, and treatment with subcutaneous denosumab, 60 mg every 6 months, was begun. There was rapid and almost complete improvement in pain. An increase in trabecular bone was documented with HR-pQCT. Case 2. A 33-year-old mother who was breastfeeding her first-born child experimented acute dorsal pain. RMI revealed partial compression fractures in vertebrae D5-7. Her axial BMD was low. There was no family history of osteoporosis, and causes of secondary osteoporosis were ruled out. Her pain slowly subsided with conservative measures, oral analgesics, and nasal calcitonin. Then, treatment with oral strontium ranelate was prescribed; after 3 months serum alkaline phosphatase and osteocalcin had not increased, and after one year lumbar bone mineral density (BMD) was unchanged. Treatment was switched to subcutaneous denosumab. After one year, lumbar BMD had increased 14%, and the pain had almost completely subsided.
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Pregnancy-related osteoporosis and spinal fractures. Obstet Gynecol Sci 2017; 60:133-137. [PMID: 28217686 PMCID: PMC5313358 DOI: 10.5468/ogs.2017.60.1.133] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/22/2016] [Accepted: 07/27/2016] [Indexed: 11/08/2022] Open
Abstract
Pregnancy-related osteoporosis is a very rare condition characterized by the occurrence of fracture during pregnancy or the puerperium. Despite its relative rarity, it can be a dangerous condition that causes severe back pain, height loss and disability. Normal physiologic changes during pregnancy, genetic or racial difference, obstetrical history and obstetrical disease, such as preterm labor or pregnancy-induced hypertension, are presumed risk factors of pregnancy-related osteooporosis. However, exact etiology and pathogenesis are uncertain. The management and natural history are still poorly defined. Traditional medications for osteoporosis are calcium/vitamin D and bisphosphonate. Concerns with bisphosphonate include accumulation in bone and fetal exposure in subsequent pregnancies. The newly developed medication, teriparatide, has shown good results. We report six cases of pregnancy-related osteoporosis and spinal fracture with literature review.
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