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Kobayashi T, Morimoto T, Ito K, Mawatari M, Shimazaki T. Denosumab vs. bisphosphonates in primary osteoporosis: a meta-analysis of comparative safety in randomized controlled trials. Osteoporos Int 2024; 35:1377-1393. [PMID: 38733394 DOI: 10.1007/s00198-024-07118-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 05/03/2024] [Indexed: 05/13/2024]
Abstract
Denosumab and bisphosphonates for primary osteoporosis are generally well-tolerated, but their comparative safety remains unclear. We aimed to explore the comparative safety of denosumab and bisphosphonates in primary osteoporosis. Databases such as PubMed and Google Scholar were searched for relevant peer-reviewed randomized controlled trials published in English (as of December 2023). Trials comparing adverse events (AE) between denosumab and bisphosphonates in patients with primary osteoporosis were investigated. Data were pooled using a fixed- or random-effects model to determine the risk ratios (RR) and 95% confidence intervals (CIs) for various AEs in patients treated with denosumab in comparison to patients treated with bisphosphonates. Eleven trials (5,545 patients; follow-up period: 12-24 months) were included in this meta-analysis. All trials had a risk of bias (e.g., reporting bias linked to secondary endpoints and selection bias linked to random allocation). In comparison to bisphosphonates, denosumab was significantly associated with less withdrawal due to AEs (RR = 0.49; 95% CI 0.34-0.71), more five-point major adverse cardiovascular events (RR = 2.05; 95% CI 1.03-4.09), more cardiovascular AEs (RR = 1.61; 95% CI 1.07-2.41), more infections (RR = 1.14; 95% CI 1.02-1.27), more upper respiratory tract infections (RR = 1.56; 95% CI 1.08-2.25), less vertebral fractures (RR = 0.54; 95% CI 0.31-0.93), and less abdominal pain (RR = 0.44;95% CI 0.22-0.87). We explored the comparative safety of denosumab and bisphosphonates for primary osteoporosis, some of which could be attributed to their beneficial effects. However, all trials had a risk of bias. Further investigations are required to confirm our results.
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Affiliation(s)
- Takaomi Kobayashi
- Department of Orthopaedic Surgery, Taku City Hospital, Saga, Japan.
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan.
- Department of Preventive Medicine, Faculty of Medicine, Saga University, Saga, Japan.
- Department of Clinical Research, Amagi Chuo Hospital, Fukuoka, Japan.
| | - Tadatsugu Morimoto
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Koji Ito
- Department of Orthopaedic Surgery, Taku City Hospital, Saga, Japan
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Masaaki Mawatari
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Takafumi Shimazaki
- Department of Orthopaedic Surgery, Taku City Hospital, Saga, Japan
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
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Yahyavi SK, Holt R, Knudsen NK, Andreassen CH, Sejling C, Meddis A, Kjaer SK, Schwarz P, Jensen JEB, Torp-Pedersen C, Juul A, Selmer C, Blomberg Jensen M. Cancer risk in patients treated with denosumab compared with alendronate: A population-based cohort study. Bone 2024; 182:117053. [PMID: 38395247 DOI: 10.1016/j.bone.2024.117053] [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: 09/27/2023] [Revised: 01/17/2024] [Accepted: 02/19/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Antiresorptive treatment is currently used in millions of patients with osteoporosis and cancer worldwide. Early studies of denosumab suggested a small signal in ovarian cancer incidence and emerging data suggest that denosumab stimulates germ cell proliferation in the gonads. This study aims to determine the association between the use of denosumab and the risk of reproductive cancers compared with the use of alendronate. RESEARCH DESIGN AND METHODS Using a cohort study design, we used the Danish nationwide registries to identify a population of subjects ≥50 years of age during 2010-2017 who started denosumab after being on alendronate treatment for at least six months. The cohort was matched 1:2 with patients who had been treated with alendronate alone for at least six months. The risk of reproductive cancers and the risk difference between groups were estimated using the Longitudinal Targeted Maximum Likelihood Estimation (L-TMLE) method. RESULTS We identified 6054 Danish individuals who underwent treatment with denosumab. These individuals were matched with 12,108 receiving alendronate. The absolute risk of reproductive cancer was 1.05 % (95 % CI 0.75-1.34) after three years for denosumab users and was not different 0.03 % (-0.34-0.39) than for alendronate users. In supplemental analyses, there was no increased risk of non-reproductive cancers associated with the use of denosumab (risk difference of 0.54 % (-0.41-1.19). Analysis comparing denosumab users with the general population gave similar results. CONCLUSION There was no difference in the risk of cancer following treatment with denosumab compared to treatment with alendronate assessed after a short follow-up of 3 years.
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Affiliation(s)
- Sam Kafai Yahyavi
- Division of Translational Endocrinology, Department of Endocrinology and Internal Medicine, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark; Group of Skeletal, Mineral, and Gonadal Endocrinology, Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Denmark
| | - Rune Holt
- Division of Translational Endocrinology, Department of Endocrinology and Internal Medicine, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark; Group of Skeletal, Mineral, and Gonadal Endocrinology, Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Denmark
| | - Nadia Krarup Knudsen
- Division of Translational Endocrinology, Department of Endocrinology and Internal Medicine, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark; Group of Skeletal, Mineral, and Gonadal Endocrinology, Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Denmark
| | - Christine Hjorth Andreassen
- Division of Translational Endocrinology, Department of Endocrinology and Internal Medicine, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark; Group of Skeletal, Mineral, and Gonadal Endocrinology, Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Denmark
| | - Christoffer Sejling
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Alessandra Meddis
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Susanne K Kjaer
- Department of Gynaecology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Danish Cancer Institute, Unit of Virus, Lifestyle and Genes, Copenhagen, Denmark
| | - Peter Schwarz
- Department of Endocrinology and Metabolism, Rigshospitalet, University of Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jens-Erik Beck Jensen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjaellands Hospital, Denmark; Department of Public Health, University of Copenhagen, Denmark
| | - Anders Juul
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; International Centre for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Christian Selmer
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Endocrinology, Bispebjerg University Hospital, Copenhagen, Denmark.
| | - Martin Blomberg Jensen
- Division of Translational Endocrinology, Department of Endocrinology and Internal Medicine, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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Abstract
Since the receptor activator of nuclear factor-kappa B ligand (RANKL), its cognate receptor activator of nuclear factor-kappa B (RANK), and the decoy receptor osteoprotegerin (OPG) were discovered, a number of studies have uncovered the crucial role of the RANKL-RANK-OPG pathway in controlling the key aspect of bone homeostasis, the immune system, inflammation, cancer, and other systems under pathophysiological condition. These findings have expanded the understanding of the multifunctional biology of the RANKL-RANK-OPG pathway and led to the development of therapeutic potential targeting this pathway. The successful development and application of anti-RANKL antibody in treating diseases causing bone loss validates the utility of therapeutic approaches based on the modulation of this pathway. Moreover, recent studies have demonstrated the involvement of the RANKL-RANK pathway in osteoblast differentiation and bone formation, shedding light on the RANKL-RANK dual signaling in coupling bone resorption and bone formation. In this review, we will summarize the current understanding of the RANKL-RANK-OPG system in the context of the bone and the immune system as well as the impact of this pathway in disease conditions, including cancer development and metastasis.
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Affiliation(s)
- Noriko Takegahara
- Departments of Pathology and Laboratory Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Hyunsoo Kim
- Departments of Pathology and Laboratory Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Yongwon Choi
- Departments of Pathology and Laboratory Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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Zhao J, Qiu H, Lin Y. Denosumab is not associated with risk of malignancy? More evidence is needed. Osteoporos Int 2021; 32:2133-2134. [PMID: 34383098 DOI: 10.1007/s00198-021-05988-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 05/03/2021] [Indexed: 10/20/2022]
Affiliation(s)
- J Zhao
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - H Qiu
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Y Lin
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.
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Rosenberg D, Avni T, Tsvetov G, Gafter-Gvili A, Diker-Cohen T. Denosumab is not associated with risk of malignancy: systematic review and meta-analysis of randomized controlled trials. Osteoporos Int 2021; 32:2131. [PMID: 34383097 DOI: 10.1007/s00198-021-06033-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/13/2021] [Indexed: 11/25/2022]
Affiliation(s)
- D Rosenberg
- Medicine A, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel.
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel.
| | - T Avni
- Medicine A, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
- Diabetes and Metabolism, Rabin Medical Center - Beilinson Hospital, Institute of Endocrinology, Petah Tikva, Israel
| | - G Tsvetov
- Diabetes and Metabolism, Rabin Medical Center - Beilinson Hospital, Institute of Endocrinology, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A Gafter-Gvili
- Medicine A, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - T Diker-Cohen
- Medicine A, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
- Diabetes and Metabolism, Rabin Medical Center - Beilinson Hospital, Institute of Endocrinology, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Lleo A, Gershwin ME. Targeting the RANK/RANKL pathway in autoimmune disease and malignancy: future perspectives. Expert Rev Clin Immunol 2021; 17:933-936. [PMID: 34425712 DOI: 10.1080/1744666x.2021.1971972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Ana Lleo
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - M Eric Gershwin
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California at Davis, Davis, CA, USA
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Noble JA, McKenna MJ, Crowley RK. Should denosumab treatment for osteoporosis be continued indefinitely? Ther Adv Endocrinol Metab 2021; 12:20420188211010052. [PMID: 34104392 PMCID: PMC8072936 DOI: 10.1177/20420188211010052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 03/24/2021] [Indexed: 12/15/2022] Open
Abstract
Denosumab was approved for the treatment of postmenopausal osteoporosis in 2010, based on the FREEDOM study, which indicated a benefit in terms of increased bone mineral density and reduced risk of major osteoporotic fracture. In the initial clinical studies it was noted that discontinuation of denosumab can lead to a rebound of bone turnover markers and loss of accrued bone mineral density. An increased risk of fractures (multiple vertebral fractures in particular) associated with discontinuation was noted after approval and marketing of denosumab. For many patients experiencing gain in bone mineral density and fracture prevention while taking denosumab, there is no reason to stop therapy. However, discontinuation of denosumab may happen due to non-adherence; potential lack of efficacy in an individual; where reimbursement for therapy is limited to those with bone mineral density in the osteoporosis range, when assessment reveals this has been exceeded; or patient or physician concern regarding side effects. This review paper aims to discuss these concerns and to summarize the data available to date regarding sequential osteoporosis therapy following denosumab cessation to reduce the risk of multiple vertebral fracture.
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Affiliation(s)
- Jane A. Noble
- Department of Endocrinology, St Vincent’s University Hospital, Dublin, Ireland
| | - Malachi J. McKenna
- St Vincent’s Private Hospital, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Belfield, Dublin, Ireland
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