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Ramchand SK, Leder BZ. Sequential Therapy for the Long-Term Treatment of Postmenopausal Osteoporosis. J Clin Endocrinol Metab 2024; 109:303-311. [PMID: 37610985 DOI: 10.1210/clinem/dgad496] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/03/2023] [Accepted: 08/21/2023] [Indexed: 08/25/2023]
Abstract
Osteoporosis is a chronic condition characterized by decreased bone mass, loss of skeletal integrity, and increased susceptibility to fracture. Drugs used to treat osteoporosis can be classified as those that block bone resorption (antiresorptive), stimulate bone formation (anabolic), or do both. While all currently approved medications reduce the risk of fragility fractures in high-risk populations, they are generally unable to fully restore bone strength in most patients with established disease. Thus, the majority of patients require disease management over many years. Unfortunately, the continuous use of a single drug has limitations, both in terms of efficacy and safety, and so sequential therapy is commonly required. Given the expanding list of pharmacological agents currently available, careful consideration needs to be given as to which drugs to use and in what sequence. This review will evaluate the differential effects of antiresorptive, bone-forming, and dual-acting drugs when used in specific sequences and will explore the current evidence favoring the initial use of bone-forming/dual-acting drugs followed by antiresorptive medications. This review will also examine the notion that long-term treatment with an antiresorptive drug may diminish the efficacy of subsequent treatment with a bone-forming/dual-acting drug. Finally, this review will explore the current evidence pertaining to the specific issue of how to best prevent the clinical ramifications of denosumab cessation.
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Affiliation(s)
- Sabashini K Ramchand
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA 02114, USA
| | - Benjamin Z Leder
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA 02114, USA
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2
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Humphrey MB, Russell L, Danila MI, Fink HA, Guyatt G, Cannon M, Caplan L, Gore S, Grossman J, Hansen KE, Lane NE, Ma NS, Magrey M, McAlindon T, Robinson AB, Saha S, Womack C, Abdulhadi B, Charles JF, Cheah JTL, Chou S, Goyal I, Haseltine K, Jackson L, Mirza R, Moledina I, Punni E, Rinden T, Turgunbaev M, Wysham K, Turner AS, Uhl S. 2022 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Rheumatol 2023; 75:2088-2102. [PMID: 37845798 DOI: 10.1002/art.42646] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVE The objective is to update recommendations for prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) for patients with rheumatic or nonrheumatic conditions receiving >3 months treatment with glucocorticoids (GCs) ≥2.5 mg daily. METHODS An updated systematic literature review was performed for clinical questions on nonpharmacologic, pharmacologic treatments, discontinuation of medications, and sequential therapy. Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the certainty of evidence. A Voting Panel achieved ≥70% consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS For adults beginning or continuing >3 months of GC treatment, we strongly recommend as soon as possible after initiation of GCs, initial assessment of fracture risks with clinical fracture assessment, bone mineral density with vertebral fracture assessment or spinal x-ray, and Fracture Risk Assessment Tool if ≥40 years old. For adults at medium, high, or very high fracture risk, we strongly recommend pharmacologic treatment. Choice of oral or intravenous bisphosphonates, denosumab, or parathyroid hormone analogs should be made by shared decision-making. Anabolic agents are conditionally recommended as initial therapy for those with high and very high fracture risk. Recommendations are made for special populations, including children, people with organ transplants, people who may become pregnant, and people receiving very high-dose GC treatment. New recommendations for both discontinuation of osteoporosis therapy and sequential therapies are included. CONCLUSION This guideline provides direction for clinicians and patients making treatment decisions for management of GIOP. These recommendations should not be used to limit or deny access to therapies.
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Affiliation(s)
- Mary Beth Humphrey
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | - Maria I Danila
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Howard A Fink
- Geriatric Research Education and Clinical Center, VA Health Care System, Minneapolis, Minnesota
| | | | - Michael Cannon
- Arthritis Consultants of Tidewater, Virginia Beach, Virginia
| | | | | | | | | | | | - Nina S Ma
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora
| | - Marina Magrey
- Case Western Reserve University, MetroHealth, Cleveland, Ohio
| | | | | | | | | | - Basma Abdulhadi
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | | | - Jonathan T L Cheah
- UMass Memorial Health and UMass Chan Medical School, Worcester, Massachusetts
| | - Sharon Chou
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Itivrita Goyal
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | - Lesley Jackson
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Reza Mirza
- McMaster University, Hamilton, Ontario, Canada
| | - Iram Moledina
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Emma Punni
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | | | - Katherine Wysham
- VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Stacey Uhl
- ECRI Institute, Plymouth Meeting, Pennsylvania
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3
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Humphrey MB, Russell L, Danila MI, Fink HA, Guyatt G, Cannon M, Caplan L, Gore S, Grossman J, Hansen KE, Lane NE, Ma NS, Magrey M, McAlindon T, Robinson AB, Saha S, Womack C, Abdulhadi B, Charles JF, Cheah JTL, Chou S, Goyal I, Haseltine K, Jackson L, Mirza R, Moledina I, Punni E, Rinden T, Turgunbaev M, Wysham K, Turner AS, Uhl S. 2022 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Care Res (Hoboken) 2023; 75:2405-2419. [PMID: 37884467 DOI: 10.1002/acr.25240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 10/28/2023]
Abstract
OBJECTIVE The objective is to update recommendations for prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) for patients with rheumatic or nonrheumatic conditions receiving >3 months treatment with glucocorticoids (GCs) ≥2.5 mg daily. METHODS An updated systematic literature review was performed for clinical questions on nonpharmacologic, pharmacologic treatments, discontinuation of medications, and sequential therapy. Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the certainty of evidence. A Voting Panel achieved ≥70% consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS For adults beginning or continuing >3 months of GC treatment, we strongly recommend as soon as possible after initiation of GCs, initial assessment of fracture risks with clinical fracture assessment, bone mineral density with vertebral fracture assessment or spinal x-ray, and Fracture Risk Assessment Tool if ≥40 years old. For adults at medium, high, or very high fracture risk, we strongly recommend pharmacologic treatment. Choice of oral or intravenous bisphosphonates, denosumab, or parathyroid hormone analogs should be made by shared decision-making. Anabolic agents are conditionally recommended as initial therapy for those with high and very high fracture risk. Recommendations are made for special populations, including children, people with organ transplants, people who may become pregnant, and people receiving very high-dose GC treatment. New recommendations for both discontinuation of osteoporosis therapy and sequential therapies are included. CONCLUSION This guideline provides direction for clinicians and patients making treatment decisions for management of GIOP. These recommendations should not be used to limit or deny access to therapies.
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Affiliation(s)
- Mary Beth Humphrey
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | - Maria I Danila
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Howard A Fink
- Geriatric Research Education and Clinical Center, VA Health Care System, Minneapolis, Minnesota
| | | | - Michael Cannon
- Arthritis Consultants of Tidewater, Virginia Beach, Virginia
| | | | | | | | | | | | - Nina S Ma
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora
| | - Marina Magrey
- Case Western Reserve University, MetroHealth, Cleveland, Ohio
| | | | | | | | | | - Basma Abdulhadi
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | | | - Jonathan T L Cheah
- UMass Memorial Health and UMass Chan Medical School, Worcester, Massachusetts
| | - Sharon Chou
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Itivrita Goyal
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | - Lesley Jackson
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Reza Mirza
- McMaster University, Hamilton, Ontario, Canada
| | - Iram Moledina
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Emma Punni
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | | | - Katherine Wysham
- VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Stacey Uhl
- ECRI Institute, Plymouth Meeting, Pennsylvania
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Abdulelah AA, Haddad BI, Alhajahjeh AA, AlQirem LM, El-amayreh L. The Risk of Developing Osteosarcoma After Teriparatide Use: A Systematic Review. Orthop Res Rev 2023; 15:191-198. [PMID: 37791038 PMCID: PMC10544053 DOI: 10.2147/orr.s408718] [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: 02/15/2023] [Accepted: 09/13/2023] [Indexed: 10/05/2023] Open
Abstract
Teriparatide is a recombinant human parathyroid hormone analog with anabolic mechanism of action utilized in the treatment of osteoporosis with well-established clinical efficacy. Its use is significantly hindered due to label warnings resulting from pre-clinical rat studies demonstrating an increased risk of osteosarcoma. However, clinical trials and post-marketing surveillance studies did not demonstrate any increased risk of osteosarcoma, even after prolonged periods of surveillance reaching up to 15 years, with most of the identified cases of osteosarcomas being solitary and predominantly attributed to other factors. This systematic review provides a comprehensive overview of the currently available literature and provides the highest level of clinical evidence towards demonstrating the lack of any substantial evidence towards osteosarcoma development in patients utilizing TPTD.
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Affiliation(s)
| | - Bassem I Haddad
- Department of Special Surgery, Division of Orthopedics, School of Medicine, the University of Jordan, Amman, Jordan
| | | | - Lina M AlQirem
- School of Medicine, the University of Jordan, Amman, Jordan
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Ramchand SK, David NL, Lee H, Bruce M, Bouxsein ML, Tsai JN, Leder BZ. The Effect of Zoledronic Acid on Bone Microarchitecture and Strength after Denosumab and Teriparatide Administration: DATA-HD Study Extension. J Bone Miner Res 2023; 38:26-34. [PMID: 36333954 PMCID: PMC10098948 DOI: 10.1002/jbmr.4737] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/12/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
The combination of denosumab and teriparatide is an effective treatment strategy in postmenopausal osteoporosis, though skeletal gains are promptly lost when these agents are discontinued. In the DATA-HD study, we reported that a single dose of zoledronic acid (ZOL) maintains the increases in areal spine and hip bone mineral density (BMD) achieved with this combination for at least 12 months. The capacity of ZOL to maintain corresponding improvements in peripheral volumetric BMD and microarchitecture, however, has not been reported. In the 15-month DATA-HD study, 76 postmenopausal osteoporotic women were randomized to receive 9 months of teriparatide (20-μg or 40-μg daily) overlapped with denosumab (60 mg at months 3 and 9). In the Extension study, 53 participants received a single dose of ZOL (5 mg intravenously) 24-35 weeks after the last denosumab dose. We measured volumetric BMD and microarchitecture at the distal radius and tibia using high-resolution peripheral quantitative computed tomography at months 27 and 42. Despite ZOL administration, total and cortical BMD gradually decreased over 27 months resulting in values similar to baseline at the radius but still significantly above baseline at the tibia. At both sites, cortical porosity decreased to values below pretreatment baseline at month 27 but then increased from month 27 to 42. There were no significant changes in trabecular parameters throughout the 27-month post-ZOL observation period. Stiffness and failure load, at both sites, decreased progressively from month 15 42 though remained above baseline at the tibia. These findings suggest that in contrast to the largely maintained gains in dual-energy X-ray absorptiometry (DXA)-derived spine and hip BMD, a single dose of ZOL was not as effective in maintaining the gains in volumetric peripheral bone density and microarchitecture produced by 15 months of overlapping treatment with denosumab and teriparatide. Alternative therapeutic approaches that can fully maintain improvements in peripheral bone parameters require further study. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Sabashini K Ramchand
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA, USA.,Department of Medicine, Endocrine Unit, Austin Hospital, The University of Melbourne, Victoria, Australia
| | - Natalie L David
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Hang Lee
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Bruce
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Mary L Bouxsein
- Department of Orthopedic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Joy N Tsai
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Benjamin Z Leder
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA, USA
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Improvement in Glucocorticoid-Induced Osteoporosis on Switching from Bisphosphonates to Once-Weekly Teriparatide: A Randomized Open-Label Trial. J Clin Med 2022; 12:jcm12010292. [PMID: 36615091 PMCID: PMC9820936 DOI: 10.3390/jcm12010292] [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: 12/02/2022] [Revised: 12/26/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022] Open
Abstract
This randomized, open-label, multicenter, parallel study imitating real-world clinical practice assessed the effect of switching to weekly teriparatide in patients with glucocorticoid-induced osteoporosis (GIO) with a lumbar spine/proximal femur bone mineral density (BMD) T-score ≤ -2.0 or ≤-1.0 and a fragility fracture. Forty-four patients were randomized. The mean durations of the corticosteroid and bisphosphonate administrations were 90.0 and 51.3 months. The baseline BMD at L1-L4 was 0.828 and 0.826 g/cm2 in Groups B (bisphosphonate) and T (teriparatide); at the femur (total), these values were 0.689 and 0.661 g/cm2. The mean change in BMD was numerically higher with teriparatide vs. bisphosphonate but not statistically significant. The mean percentage changes from baseline in BMD at L1-L4 after a 72-week treatment were 0.5% and 4.1% in Groups B and T. The incidence of new fractures was higher in the patients taking bisphosphonates vs. those receiving once-weekly teriparatide at 72 weeks (18.2% vs. 11.8%) and 144 weeks (22.7% vs. 17.6%). The mean percentage change in femur (trochanter) BMD (0.035 [0.007-0.063]; p = 0.02) was significantly greater with teriparatide vs. bisphosphonates. Adverse events (AEs) were more frequent with teriparatide vs. bisphosphonates. Switching to once-weekly teriparatide tended to increase lumbar spine BMD and reduce the occurrence of new fractures vs. bisphosphonates.
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Teriparatide treatment in severe osteoporosis - a controlled 10-year follow-up study. BMC Musculoskelet Disord 2022; 23:1011. [PMID: 36424580 PMCID: PMC9686095 DOI: 10.1186/s12891-022-05987-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 11/15/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Teriparatide was the first anabolic agent recommended for the treatment of osteoporosis. Long-term real-world, controlled studies are not available. The purpose was to evaluate the long-term effects of treatment with teriparatide on fractures and Health Related Quality of Life in subjects with established osteoporosis in comparison with placebo treated patients with osteoporosis and the general population. METHODS A 10-year follow-up was performed after a prospective, open-labelled study with teriparatide 20 μg given subcutaneously daily for a mean of 18 months (range 14-24 months) in 40 women, mean age 69 years, with osteoporosis and vertebral compression. Placebo treated women, n = 25, mean age 60 years, from a randomized, double-blind, placebo-controlled growth hormone trial with daily subcutaneous injections for 18 months, with osteoporosis were used as controls. Dual energy x-ray absorptiometry and questionnaires were performed at start, after 18 months, after 36 months and after 10 years. Women, n = 233, of similar age from a random population sample, also served as controls and were followed in parallel. All fractures were X-ray verified. RESULTS Fractures decreased from 100 to 35% in the teriparatide treated patients (p < 0.0001) to similar levels as in the population sample, 25 to 28% at start and after 10 years, respectively. Bone mineral density increased on teriparatide but returned to levels at treatment start after 10 years. Health Related Quality of Life was lower in the teriparatide group than in the population (p < 0.001) before and, after treatment and at 10 years. CONCLUSIONS Anabolic hormonal treatment with teriparatide reduced fracture prevalence to similar levels as in the general population at 10 years' follow-up. Health Related Quality of Life was low in osteoporosis and unaffected by bone specific treatment.
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Krege JH, Gilsenan AW, Komacko JL, Kellier‐Steele N. Teriparatide and osteosarcoma risk: history, science, elimination of boxed warning, and other label updates. JBMR Plus 2022; 6:e10665. [PMID: 36111201 PMCID: PMC9465003 DOI: 10.1002/jbm4.10665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 07/01/2022] [Accepted: 07/14/2022] [Indexed: 11/19/2022] Open
Abstract
The phase 3 trials of the bone anabolic drug teriparatide were prematurely terminated because of a preclinical finding of osteosarcoma in rats treated with high doses of teriparatide for near lifetime. Even so, results from these and subsequent clinical trials showed efficacy and tolerability. Based on the phase 3 results and additional preclinical investigations, Forteo (teriparatide) was approved for use in the United States with an indication for the treatment of osteoporosis in patients at high risk for fracture, a boxed warning regarding potential risk of osteosarcoma, a 2‐year lifetime limitation of use, other risk mitigations, and a requirement to assess for risk of osteosarcoma in humans treated with teriparatide. Subsequent investigations included five real‐world studies directed at assessing a connection between teriparatide and osteosarcoma risk in humans. The early studies did not identify an increased risk of osteosarcoma but were inadequate to sufficiently characterize risk, given the low incidence of this rare form of bone cancer. Learning from these efforts, two studies were undertaken using claims data to identify large cohorts of patients treated with teriparatide and assess whether these patients were found to have osteosarcoma by linking pharmacy claims data with data from cancer registries. These studies showed no increase in osteosarcoma in patients using teriparatide compared with unexposed groups, as well as to the expected population‐based background incidence of the disease. Based on this real‐world evidence and the totality of data collected from postmarketing use and other clinical investigations, the label was updated in 2020. The changes included addition of information from large observational studies using real‐world evidence, removal of the boxed warning, and a revision of the 2‐year lifetime limitation. Thus, observational studies with large sample sizes using real‐world data can provide supportive evidence to facilitate regulatory decisions including the elimination of a boxed warning. © 2022 Eli Lilly and Company. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Kellier-Steele N, Casso D, Anderson A, Oliveria SA, Motsko S. Assessing the incidence of osteosarcoma among teriparatide-treated patients using linkage of commercial pharmacy and state cancer registry data, contributing to the removal of boxed warning and other labeling changes. Bone 2022; 160:116394. [PMID: 35318162 DOI: 10.1016/j.bone.2022.116394] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Teriparatide, a recombinant human parathyroid hormone analogue, is associated with increased bone mineral density and a decreased risk of fractures. A dose-dependent increase in the incidence of osteosarcoma was observed in toxicology studies conducted in rats. The primary objective of this study was to estimate the incidence of osteosarcoma over a 10-year period among teriparatide-treated patients versus patients unexposed to teriparatide with osteoporosis and patients in the general population using national pharmacy dispensing data linked with data from participating state cancer registries (SCRs) in the US. METHODS Patients aged 18 years or older with a dispensed teriparatide prescription formed two different cohorts: Teriparatide-Osteoporosis (Teriparatide-OP) was formed by matching teriparatide patients to unexposed patients with osteoporosis and Teriparatide-General Population (Teriparatide-GP) was formed by matching teriparatide patients to general population patients with a dispensed prescription for a medication other than teriparatide. Matching was performed using select demographics and other variables. Study cohorts were linked to SCR data to ascertain osteosarcoma status. To account for missing outcome data from non-participating SCRs, two analytic approaches were used: the first adjusted the person-time at-risk using a coverage fraction and the second restricted the analyses to patients from states with participating SCRs. RESULTS There were 18 osteosarcoma cases across four study cohorts: the same three cases in the Teriparatide-OP and Teriparatide-GP cohorts, six cases in the Osteoporosis cohort, and nine cases in the General Population cohort. For the analysis using the coverage fraction the incidence rate ratio (IRR) comparing the Teriparatide-OP and Teriparatide-GP cohorts to the Osteoporosis and General Population cohorts was 1.0 (95% CI: 0.2, 4.5) and 1.3 (95% CI: 0.2, 5.1), respectively. When restricting the analysis to patients from states with participating SCRs, the IRR was 0.6 (95% CI: 0.1, 3.6) and 0.8 (95% CI 0.1, 4.0), respectively. CONCLUSION The estimates of association between teriparatide and osteosarcoma were imprecise due to the small number of observed osteosarcoma cases. However, the incidence of osteosarcoma observed in each study cohort was within the expected range given background rates for the US general population. The evidence generated by this study, in conjunction with other real-world studies evaluating the risk of osteosarcoma, was used to support changes to the US teriparatide label (including removal of the black box warning regarding potential risk of osteosarcoma) and expand treatment options for patients with osteoporosis.
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Paschalis EP, Gamsjaeger S, Burr DB. Bone quality in an ovariectomized monkey animal model treated with two doses of teriparatide for either 18 months, or 12 months followed by withdrawal for 6 months. Bone 2022; 158:116366. [PMID: 35167989 DOI: 10.1016/j.bone.2022.116366] [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: 12/14/2021] [Revised: 01/27/2022] [Accepted: 02/08/2022] [Indexed: 11/28/2022]
Abstract
Previous studies of ovariectomized (OVX) monkeys, treated with recombinant human parathyroid hormone (PTH) (1-34) at 1 or 5 μg/kg/day for 18 months or for 12 months followed by 6 months withdrawal from treatment, displayed significant changes in geometry, histomorphometry, and bone quality, but without strict tissue age criteria, of the midshaft humerus. Since bone quality significantly depends on tissue age among other factors, the aim of the present study was to establish the bone-turnover independent effects of two doses of PTH, as well as the effects of treatment withdrawal on bone quality by measuring bone material composition at precisely known tissue ages ranging from osteoid, to mineralized tissue older than 373 days. Raman microspectroscopic analysis of bone tissue from the mid-shaft humerus of OVX monkeys demonstrated that the clinically relevant dose of PTH administered for 18 months reverses the effects of ovariectomy on bone quality when compared against SHAM. Both doses investigated in this study restore the mineralization regulation mechanisms to SHAM levels. The study also showed that the beneficial effects induced by 12 months of clinically relevant PTH therapy were sustained after six months of therapy withdrawal.
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Affiliation(s)
- E P Paschalis
- Ludwig Boltzmann Institute for Osteology, at the Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Vienna, Austria.
| | - S Gamsjaeger
- Ludwig Boltzmann Institute for Osteology, at the Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Vienna, Austria
| | - D B Burr
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, IN 46202, USA; Department of Biomedical Engineering, Indiana University-Purdue University, Indianapolis (IUPUI), Indianapolis, IN 46202, USA
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Yen CC, Liu YW, Chang GRL, Lan YW, Kao YT, Cheng SN, Chen W, Chen CM. Therapeutic Effects of Kefir Peptides on Hemophilia-Induced Osteoporosis in Mice With Deficient Coagulation Factor VIII. Front Cell Dev Biol 2022; 10:794198. [PMID: 35252176 PMCID: PMC8894723 DOI: 10.3389/fcell.2022.794198] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/19/2022] [Indexed: 12/29/2022] Open
Abstract
Osteoporosis is a clinically prevalent comorbidity in patients with hemophilia. A preventive effect of kefir peptides (KPs) on postmenopausal osteoporosis has been proved. The aim of this study was to evaluate the therapeutic effect of KPs for the treatment of osteoporosis in coagulation factor VIII (FVIII) gene knockout mice (F8KO), a model of hemophilia A. In this study, male F8KO mice at 20 weeks of age were orally administered different doses of KPs for 8 weeks. The therapeutic effects of KPs were shown in the femoral trabeculae and the 4th lumbar vertebrae, which increased the trabecular bone mineral density (BMD), bone volume (Tb.BV/TV), and trabecular number (Tb.N) and decreased the trabecular separation (Tb.Sp), and they were also observed in the femoral cortical bones, in which the mechanical properties were enhanced in a dose-dependent manner. Characterization of receptor activator of nuclear factor κB ligand (RANKL), osteoprotegerin (OPG), and interleukin 6 (IL-6) demonstrated that the serum RANKL/OPG ratio and IL-6 levels were significantly decreased in the F8KO mice after the KP treatment. Tartrate-resistant acid phosphatase (TRAP) staining of mature osteoclasts indicated that the therapeutic effect of KPs in F8KO mice was associated with the functions of KPs to inhibit RANKL-induced osteoclastogenesis by reducing serum RANKL/OPG ratio and IL-6 secretion. The present study is the first to address the potentials of KPs for the treatment of hemophilia-induced osteoporosis in mice and it also provides useful information for the application of KPs as a complementary therapy for the treatment of osteoporosis in hemophilic patients.
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Affiliation(s)
- Chih-Ching Yen
- Department of Life Sciences, and Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Internal Medicine, China Medical University Hospita, College of Health Care, China Medical University, Taichung, Taiwan
| | - Yao-Wen Liu
- Department of Life Sciences, and Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Gary Ro-Lin Chang
- Department of Life Sciences, and Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Ying-Wei Lan
- Department of Life Sciences, and Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Yung-Tsung Kao
- Department of Life Sciences, and Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
- Ph.D. Program in Tissue Engineering and Regenerative Medicine, National Health Research Institutes and National Chung Hsing University, Taichung, Taiwan
| | - Shin-Nan Cheng
- Department of Pediatrics, Department of Medical Research, Tungs’ Taichung Metroharbor Hospital, Taichung, Taiwan
| | - Wei Chen
- Division of Pulmonary and Critical Care Medicine, Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Chuan-Mu Chen
- Department of Life Sciences, and Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
- The iEGG and Animal Biotechnology Center, National Chung Hsing University, Taichung, Taiwan
- Rong Hsing Research Center for Translational Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- *Correspondence: Chuan-Mu Chen,
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12
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Chen CH, Elsalmawy AH, Ish-Shalom S, Lim SJ, AlAli NS, Cunha-Borges JL, Yang H, Casas N, Altan L, Belaya Z, Marin F, Moll T, Gurbuz S, Brnabic A, Pavo I, Florez S. The Effect of Teriparatide Treatment on the Risk of Fragility Fractures in Postmenopausal Women with Osteoporosis: Results from the Asian and Latin America Fracture Observational Study (ALAFOS). Calcif Tissue Int 2022; 110:74-86. [PMID: 34415388 PMCID: PMC8732800 DOI: 10.1007/s00223-021-00895-4] [Citation(s) in RCA: 4] [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: 06/09/2021] [Accepted: 07/20/2021] [Indexed: 01/04/2023]
Abstract
The Asian and Latin America Fracture Observational Study (ALAFOS) is a prospective, observational, single-arm study conducted in 20 countries across Asia, Latin America and the Middle East. ALAFOS evaluated new clinical vertebral and non-vertebral fragility fractures in relation to time on teriparatide, in postmenopausal women with osteoporosis in real-life clinical practice. Clinical fragility fractures, back pain, and health-related quality of life (HRQoL) were recorded in 6-month intervals for ≤ 24 months during teriparatide treatment and up to 12-months post-treatment. Data were analysed with piecewise exponential regression with inverse probability weighting for time to event outcomes and mixed-model repeated measures for back pain and HRQoL. 3054 postmenopausal women started teriparatide and attended ≥ one follow-up visit (mean [SD] age 72.5 [10.4] years). The median (95% CI) time to treatment discontinuation was 22.0 months (21.2, 22.8). During the treatment period, 111 patients (3.6%) sustained 126 clinical fractures (2.98 fractures/100 patient-years). Rates of new clinical fragility fractures were significantly decreased during the > 6-12, > 12-18, and > 18-24-month periods, as compared with the first 6 months of treatment (hazard ratio [HR] 0.57; 95% CI 0.37, 0.88; p = 0.012; HR 0.35; 95% CI 0.19, 0.62; p < 0.001; HR 0.43; 95% CI 0.23, 0.83; p = 0.011; respectively). Patients also reported an improvement in back pain and HRQoL (p < 0.001). These results provide data on the real-world effectiveness of teriparatide in the ALAFOS regions and are consistent with other studies showing reduction of fractures after 6 months of teriparatide treatment. These results should be interpreted in the context of the noncontrolled design of this observational study.
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Affiliation(s)
- Chung-Hwan Chen
- Department of Orthopedics and Orthopedic Research Center, Kaohsiung Municipal Ta-Tung Hospital and Kaohsiung Medical University Hospital, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Regeneration Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Abdulaziz H Elsalmawy
- Department of Trauma and Orthopedic Surgery, Al Noor Specialized Hospital Makkah, Mecca, Saudi Arabia
| | | | - Seung-Jae Lim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Nadia S AlAli
- Endocrinology Unit, Amiri Hospital, MOH, Kuwait City, Kuwait
| | | | - Huilin Yang
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China
| | | | - Lale Altan
- Department of Physical Medicine and Rehabilitation, Uludağ University School of Medicine, Bursa, Turkey
| | - Zhanna Belaya
- Department of Neuroendocrinology and Bone Disease, The National Medical Research Center for Endocrinology, Moscow, Russia
| | | | | | | | | | - Imre Pavo
- Eli Lilly and Company, Indianapolis, USA
| | - Sandra Florez
- Eli Lilly and Company, Indianapolis, USA.
- Pain and Palliative Care Department, Universidad de la Sabana, Chía, Colombia.
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13
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Davis S, Simpson E, Hamilton J, James MMS, Rawdin A, Wong R, Goka E, Gittoes N, Selby P. Denosumab, raloxifene, romosozumab and teriparatide to prevent osteoporotic fragility fractures: a systematic review and economic evaluation. Health Technol Assess 2021; 24:1-314. [PMID: 32588816 DOI: 10.3310/hta24290] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture. OBJECTIVES The objectives were to evaluate the clinical effectiveness, safety and cost-effectiveness of non-bisphosphonates {denosumab [Prolia®; Amgen Inc., Thousand Oaks, CA, USA], raloxifene [Evista®; Daiichi Sankyo Company, Ltd, Tokyo, Japan], romosozumab [Evenity®; Union Chimique Belge (UCB) S.A. (Brussels, Belgium) and Amgen Inc.] and teriparatide [Forsteo®; Eli Lilly and Company, Indianapolis, IN, USA]}, compared with each other, bisphosphonates or no treatment, for the prevention of fragility fracture. DATA SOURCES For the clinical effectiveness review, nine electronic databases (including MEDLINE, EMBASE and the World Health Organization International Clinical Trials Registry Platform) were searched up to July 2018. REVIEW METHODS A systematic review and network meta-analysis of fracture and femoral neck bone mineral density were conducted. A review of published economic analyses was undertaken and a model previously used to evaluate bisphosphonates was adapted. Discrete event simulation was used to estimate lifetime costs and quality-adjusted life-years for a simulated cohort of patients with heterogeneous characteristics. This was done for each non-bisphosphonate treatment, a strategy of no treatment, and the five bisphosphonate treatments previously evaluated. The model was populated with effectiveness evidence from the systematic review and network meta-analysis. All other parameters were estimated from published sources. An NHS and Personal Social Services perspective was taken, and costs and benefits were discounted at 3.5% per annum. Fracture risk was estimated from patient characteristics using the QFracture® (QFracture-2012 open source revision 38, Clinrisk Ltd, Leeds, UK) and FRAX® (web version 3.9, University of Sheffield, Sheffield, UK) tools. The relationship between fracture risk and incremental net monetary benefit was estimated using non-parametric regression. A probabilistic sensitivity analysis and scenario analyses were used to assess uncertainty. RESULTS Fifty-two randomised controlled trials of non-bisphosphonates were included in the clinical effectiveness systematic review and an additional 51 randomised controlled trials of bisphosphonates were included in the network meta-analysis. All treatments had beneficial effects compared with placebo for vertebral, non-vertebral and hip fractures, with hazard ratios varying from 0.23 to 0.94, depending on treatment and fracture type. The effects on vertebral fractures and the percentage change in bone mineral density were statistically significant for all treatments. The rate of serious adverse events varied across trials (0-33%), with most between-group differences not being statistically significant for comparisons with placebo/no active treatment, non-bisphosphonates or bisphosphonates. The incremental cost-effectiveness ratios were > £20,000 per quality-adjusted life-year for all non-bisphosphonate interventions compared with no treatment across the range of QFracture and FRAX scores expected in the population eligible for fracture risk assessment. The incremental cost-effectiveness ratio for denosumab may fall below £30,000 per quality-adjusted life-year at very high levels of risk or for high-risk patients with specific characteristics. Raloxifene was dominated by no treatment (resulted in fewer quality-adjusted life-years) in most risk categories. LIMITATIONS The incremental cost-effectiveness ratios are uncertain for very high-risk patients. CONCLUSIONS Non-bisphosphonates are effective in preventing fragility fractures, but the incremental cost-effectiveness ratios are generally greater than the commonly applied threshold of £20,000-30,000 per quality-adjusted life-year. STUDY REGISTRATION This study is registered as PROSPERO CRD42018107651. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 29. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Sarah Davis
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Simpson
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Marrissa Martyn-St James
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Rawdin
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ruth Wong
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Edward Goka
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Neil Gittoes
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Peter Selby
- School of Medical Sciences, University of Manchester, Manchester, UK
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14
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Chen Q, Xia C, Shi B, Chen C, Yang C, Mao G, Shi F. Extracorporeal Shock Wave Combined with Teriparatide-Loaded Hydrogel Injection Promotes Segmental Bone Defects Healing in Osteoporosis. Tissue Eng Regen Med 2021; 18:1021-1033. [PMID: 34427911 DOI: 10.1007/s13770-021-00381-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/09/2021] [Accepted: 07/25/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Osteoporosis is a systemic bone disease characterized by decreased bone density and deterioration of bone microstructure, leading to an increased probability of fragility fractures. Once segmental bone defect occurs, it is easy to cause delayed union and nonunion. METHODS The aim of this study is to investigate the efficacy of extracorporeal shock wave (ESW) and teriparatide-loaded hydrogel (T-Gel) combined strategy on the cell activity and differentiation of osteoporosis derived bone marrow mesenchymal stem cells (OP-BMSCs) in vitro and bone regeneration in osteoporotic segmental bone defects in vivo. RESULTS In vitro, the strategy of combining ESW and T-Gel significantly enhanced OP-BMSCs proliferation, survival, migration, and osteogenic differentiation by up-regulating the alkaline phosphatase activity, mineralization, and expression of runt-related transcription factor-2, type I collagen, osteocalcin, and osteopontin. In the segmental bone defect models of osteoporotic rabbits, Micro-CT evaluation and histological observation demonstrated this ESW-combined with T-Gel injection significantly induced bone healing by enhancing the osteogenic activity of the local microenvironment in osteoporotic defects. CONCLUSION In conclusion, ESW-combined with T-Gel injection could regulate the poor osteogenic microenvironment in osteoporotic defects and show potential for enhancing fragility fractures healing.
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Affiliation(s)
- Qi Chen
- Department of Orthopedic Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, 310014, People's Republic of China
| | - Chen Xia
- Department of Orthopedic Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, 310014, People's Republic of China
| | - Binbin Shi
- Department of Orthopedic Surgery, Tongxiang First People's Hospital, Tongxiang, 314500, People's Republic of China
| | - Chuyong Chen
- Department of Orthopedic Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, 310014, People's Republic of China
| | - Chen Yang
- Department of Orthopedic Surgery, No 1 People's Hospital of AkeSu, AkeSu, 843000, Xinjiang, People's Republic of China
| | - Guangfeng Mao
- Department of Orthopedic Surgery, The Third People Hospital of Zhuji, Shaoxing, 310014, People's Republic of China
| | - Fangfang Shi
- Department of Hematology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, 310014, People's Republic of China.
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15
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Ramchand SK, David NL, Lee H, Eastell R, Tsai JN, Leder BZ. Efficacy of Zoledronic Acid in Maintaining Areal and Volumetric Bone Density After Combined Denosumab and Teriparatide Administration: DATA-HD Study Extension. J Bone Miner Res 2021; 36:921-930. [PMID: 33507574 DOI: 10.1002/jbmr.4259] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 01/04/2021] [Accepted: 01/20/2021] [Indexed: 12/25/2022]
Abstract
Combined teriparatide and denosumab rapidly and substantially increases bone mineral density (BMD) at all anatomic sites. Discontinuation of denosumab however, results in high-turnover bone loss and increased fracture risk. The optimal way to prevent this bone loss remains undefined. This study is a preplanned extension of the DATA-HD study, where postmenopausal women with osteoporosis were randomized to receive 9 months of either 20 μg or 40 μg of teriparatide daily overlapping with denosumab (60 mg administered at months 3 and 9). At the completion of this 15-month study, women were invited to enroll in the DATA-HD Extension where they received a single dose of zoledronic acid (5 mg) 24 to 35 weeks after the last denosumab dose. Areal BMD and bone turnover markers were measured at month 27 and 42 (12 and 27 months after zoledronic acid, respectively) and spine and hip volumetric bone density by quantitative CT was measured at month 42. Fifty-three women enrolled in the DATA-HD Extension. At the femoral neck and total hip, the mean 5.6% and 5.1% gains in BMD achieved from month 0 to 15 were maintained both 12 and 27 months after zoledronic acid administration. At the spine, the mean 13.6% gain in BMD achieved from month 0 to 15 was maintained for the first 12 months but modestly decreased thereafter, resulting in a 3.0% reduction (95% CI, -4.0% to -2.0%, p < .0001) 27 months after zoledronic acid. The pattern of BMD changes between months 15 and 42 were qualitatively similar in the 20-μg and 40-μg groups. A single dose of zoledronic acid effectively maintains the large and rapid total hip and femoral neck BMD increases achieved with combination teriparatide/denosumab therapy for at least 27 months following the transition. Spine BMD was also largely, though not fully, maintained during this period. These data suggest that the DATA-HD Extension regimen may be an effective strategy in the long-term management of patients at high risk of fragility fracture. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Sabashini K Ramchand
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA, USA.,Department of Medicine, Endocrine Unit, Austin Hospital, The University of Melbourne, Heidelberg, VIC, Australia
| | - Natalie L David
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Hang Lee
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Richard Eastell
- Academic Unit of Bone Metabolism, University of Sheffield, Sheffield, UK
| | - Joy N Tsai
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Benjamin Z Leder
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA, USA
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16
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Ripamonti CI, Napoli N. Are We Ready to Use Teriparatide to Treat Medication-Related Osteonecrosis of the Jaw in Clinical Practice? J Clin Oncol 2020; 38:2949-2951. [DOI: 10.1200/jco.20.01633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2020] [Indexed: 08/30/2023] Open
Affiliation(s)
- Carla I. Ripamonti
- Supportive Care in Cancer Unit, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Nicola Napoli
- Unit of Endocrinology and Diabetes, Department of Medicine, Campus Bio-Medico, University of Rome, Rome, Italy
- Division of Bone and Mineral Diseases, Washington University in St. Louis, St. Louis, MO
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17
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Chen S, Guo R, Xie C, Liang Q, Xiao X. Biomimetic mineralization of nanocrystalline hydroxyapatites on aminated modified polylactic acid microspheres to develop a novel drug delivery system for alendronate. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2020; 110:110655. [DOI: 10.1016/j.msec.2020.110655] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/25/2019] [Accepted: 01/06/2020] [Indexed: 12/15/2022]
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18
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Cipriani C, Bilezikian JP. Osteoanabolics Versus Antiresorptives: Which First? J Clin Endocrinol Metab 2020; 105:5645619. [PMID: 31782489 DOI: 10.1210/clinem/dgz238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 11/28/2019] [Indexed: 02/13/2023]
Affiliation(s)
- Cristiana Cipriani
- Department of Clinical, Internal Medicine, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - John P Bilezikian
- Metabolic Bone Diseases Unit, Division of Endocrinology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
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19
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Tuli G, Buganza R, Tessaris D, Einaudi S, Matarazzo P, de Sanctis L. Teriparatide (rhPTH 1-34) treatment in the pediatric age: long-term efficacy and safety data in a cohort with genetic hypoparathyroidism. Endocrine 2020; 67:457-465. [PMID: 31705387 DOI: 10.1007/s12020-019-02128-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 10/30/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hypoparathyroidism is characterized by the absence or inadequately low circulating concentrations of the parathyroid hormone, resulting in hypocalcemia, hyperphosphatemia, and elevated fractional excretion of calcium in the urine. The use of activated vitamin D analogs and calcium supplements represent conventional therapy. Subcutaneous recombinant human parathormone [rhPTH(1-34)] has been proposed as a substitutive treatment, even to avoid side effects of vitamin D and calcium. OBJECTIVE To assess the long-term safety and efficacy of rhPTH(1-34) in a pediatric cohort of patients with genetic hypoparathyroidism. METHODS The study is a 9.2-year self-controlled study of six pediatric patients (four males and two females, aged 9.4 ± 5.2) with DiGeorge, hypoparathyroidism-deafness-renal dysplasia (HDR) or autoimmune-candidiasis-polyendocrinopathy-ectodermal-dysplasia (APECED) syndrome, associated with autoimmune intestinal malabsorption in a patient. The presence of clinical signs of hypocalcemia and biochemical parameters, such as calcium, phosphate, alkaline phosphatase in the blood and calcium-creatinine ratio in urine, were compared during conventional treatment and rhPTH(1-34) (teriparatide, 12.5 μg twice daily). RESULTS The rhPTH(1-34) treatment allowed a reduction, although not always a complete suspension, of calcium supplementation and a slight reduction of calcitriol therapy. The number of tetanic episodes was reduced in four patients during the rhPTH(1-34) treatment. Mean blood calcium, alkaline phosphatase, and phosphate did not significantly change, while a significant reduction of the urinary calcium-to-creatinine ratio (0.55 ± 0.32 vs 0.16 ± 0.09, p = 0.03) was obtained. Renal ultrasound examination showed a worsening in three patients, while it did not change in the remaining three subjects during the follow-up. CONCLUSIONS In children with syndromic hypoparathyroidism presented here, replacement therapy with rhPTH(1-34) allowed to maintain adequate levels of the calcium and phosphate in the blood, normalize urinary calcium excretion, and reduce tetanic episodes. In patients with low compliance to conventional therapy or intestinal malabsorption, the use of rhPTH(1-34) could be considered, also to reduce the side effects of treatment with vitamin D and calcium.
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Affiliation(s)
- Gerdi Tuli
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, City of Health and Science University Hospital of Turin, Turin, Italy.
- Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy.
| | - Raffaele Buganza
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, City of Health and Science University Hospital of Turin, Turin, Italy
- Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Daniele Tessaris
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, City of Health and Science University Hospital of Turin, Turin, Italy
- Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Silvia Einaudi
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, City of Health and Science University Hospital of Turin, Turin, Italy
- Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Patrizia Matarazzo
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, City of Health and Science University Hospital of Turin, Turin, Italy
- Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Luisa de Sanctis
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, City of Health and Science University Hospital of Turin, Turin, Italy
- Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
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20
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Cunha-Borges JL, Mier GM, Casas N, Medina A, Molina JF, García ML, Oliveria LG, Caselato MS, Cruz AC, Ippolito V, Flórez S. Baseline characteristics of postmenopausal women with osteoporosis treated with teriparatide in a real-world setting in Latin America: a subregional analysis from the Asia and Latin America Fracture Observational Study (ALAFOS). Adv Rheumatol 2019; 59:46. [PMID: 31703737 DOI: 10.1186/s42358-019-0088-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 09/26/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Osteoporosis is a major healthcare concern in Latin America. Factors such as changing demographics, fragmented healthcare systems, and financial considerations may result in a huge increase in the burden of osteoporosis in this region. The aim of this article is to describe the baseline clinical characteristics and fracture history of patients who are prescribed teriparatide in normal clinical practice in Latin America. METHODS We conducted a prospective, multinational, observational study (the Asia and Latin America Fracture Observational Study [ALAFOS]) in 20 countries worldwide to assess the incidence of fractures in postmenopausal women with osteoporosis receiving teriparatide as a part of routine clinical practice in a real-world setting. In this subregional analysis of the ALAFOS study, we report the clinical characteristics, fracture history, risk factors for osteoporosis, comorbidities, previous osteoporosis therapies and health-related quality of life measures at baseline for patients from the four participant Latin American countries: Argentina, Brazil, Colombia, and Mexico. RESULTS The Latin America subregional cohort included 546 postmenopausal women (mean [SD] age: 71.0 [10.1] years; range: 40-94 years), constituting 18% of the ALAFOS total population. The baseline mean (SD) bone mineral density T-scores were - 3.02 (1.23) at the lumbar spine and - 2.31 (0.96) at the femoral neck; 62.8% of patients had a history of low trauma fracture after the age of 40 years and 39.7% of patients had experienced ≥1 fall in the past year. Osteoporosis medications were used by 70.9% of patients before initiating teriparatide. The median (Q1, Q3) EQ-5D-5 L Visual Analog Scale (VAS) scores for perceived health status at baseline was 70 (50, 80). The mean (SD) worst back pain numeric rating scale score for the overall Latin American cohort was 4.3 (3.4) at baseline. CONCLUSIONS This baseline analysis of the Latin America subregion of the ALAFOS study indicates that patients who are prescribed teriparatide in the four participant countries had severe osteoporosis and high prevalence of fractures. They also had back pain and poor health-related quality of life. The proportions of patients with severe or extreme problems on the EQ-5D-5 L individual domains were lower than those in the overall ALAFOS study population.
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Affiliation(s)
| | | | | | - Adriana Medina
- Sociedad de Cirugía de Bogotá - Hospital Universitario de San José, Bogotá, Colombia
| | | | | | | | | | | | | | - Sandra Flórez
- Eli Lilly Interamerica, Transversal 18 No. 96-41, Piso 6, Bogotá, Colombia. .,Pain and Palliative Care Unit, Universidad de la Sabana, Bogotá, Colombia.
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21
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Minisola S, Cipriani C, Grotta GD, Colangelo L, Occhiuto M, Biondi P, Sonato C, Vigna E, Cilli M, Pepe J. Update on the safety and efficacy of teriparatide in the treatment of osteoporosis. Ther Adv Musculoskelet Dis 2019; 11:1759720X19877994. [PMID: 31632472 PMCID: PMC6778993 DOI: 10.1177/1759720x19877994] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 08/29/2019] [Indexed: 12/14/2022] Open
Abstract
Following the completion of the Fracture Prevention Trial, teriparatide was approved by the United States Food and Drug Administration and the European Medicine Agency as the first therapeutic anabolic agent for the treatment of postmenopausal women with severe osteoporosis. It subsequently received additional approval for the treatment of osteoporosis in men, and for the treatment of osteoporosis associated with glucocorticoid therapy in men and women at risk of fracture. In this review, we summarize the most important data concerning PTH 1-34 therapy before 2016 in the treatment of osteoporosis, and report some outstanding results published in the last 2 years. New data on safety will also discussed, together with the state of art of nonclassical utilization. Finally, in view of the recent approval of biosimilars, possible future landscapes are discussed.
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Affiliation(s)
- Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Viale del Policlinico, 155, Rome, 00161, Italy
| | - Cristiana Cipriani
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy
| | - Giada Della Grotta
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy
| | - Luciano Colangelo
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy
| | - Marco Occhiuto
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy
| | - Piergianni Biondi
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy
| | - Chiara Sonato
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy
| | - Evelina Vigna
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy
| | - Mirella Cilli
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy
| | - Jessica Pepe
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy
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Chen CH, Elsalmawy AH, Ish-Shalom S, Lim SJ, Al-Ali NS, Cunha-Borges JL, Yang H, Casas N, Altan L, Moll T, Gurbuz S, Brnabic AJM, Burge RT, Marin F. Study description and baseline characteristics of the population enrolled in a multinational, observational study of teriparatide in postmenopausal women with osteoporosis: the Asia and Latin America Fracture Observational Study (ALAFOS). Curr Med Res Opin 2019; 35:1041-1049. [PMID: 30474449 DOI: 10.1080/03007995.2018.1552576] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To describe the study design and baseline patient characteristics of the Asia and Latin America Fracture Observational Study (ALAFOS) to better understand the profile of patients receiving teriparatide during the course of routine clinical practice in Asia, Latin America, the Middle East and Russia. METHODS Prospective, observational, non-interventional study in postmenopausal women with osteoporosis who are prescribed teriparatide for up to 24 months, according to local medical standards, with a 12 month post-treatment follow-up. MEASURES Demographics, risk factors for osteoporosis and fractures, history of fracture, prior osteoporosis medications, comorbidities, physical function, back pain and quality of life (QoL). RESULTS In total 3031 postmenopausal women (mean age 72.5 years) recruited at 152 sites in 20 countries were analyzed; 62.9% had a history of fragility fracture after age 40 (33.0% of patients with spinal, 14.2% with hip fractures). The mean (SD) bone mineral density T-scores at baseline were -3.06 (1.40) and -2.60 (1.05) at the lumbar spine and femoral neck, respectively. At entry, 43.7% of patients were naïve to prior osteoporosis treatments; 40.5% of patients reported ≥1 fall in the past year. The median (Q1; Q3) EuroQoL Visual Analog Scale (EQ-VAS) for perceived overall health status was 60 (50; 80). The mean (SD) worst back pain Numeric Rating Scale in the last 24 hours was 4.6 (3.3). CONCLUSIONS Our data indicates that patients who were prescribed teriparatide in the ALAFOS participant countries had severe osteoporosis, high prevalence of fractures, disabling back pain and poor QoL. The frequency of patients receiving prior osteoporosis medications was lower than in previous observational studies conducted in other locations.
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Affiliation(s)
- Chung-Hwan Chen
- a Department of Orthopedics , College of Medicine and Kaohsiung Medical University Hospital, Kaohsiung Medical University , Kaohsiung City , Taiwan
| | - Abdulaziz H Elsalmawy
- b Department of Trauma and Orthopedic Surgery , Al Noor Specialized Hospital Makkah , Mecca , Saudi Arabia
| | | | - Seung-Jae Lim
- d Department of Orthopedic Surgery , Sungkyunkwan University School of Medicine , Seoul , South Korea
| | | | - Joao L Cunha-Borges
- f Faculty of Medicine , Universidade Católica de Brasília , Brasilia , Brazil
| | - Huilin Yang
- g Department of Orthopedics , The First Affiliated Hospital of Soochow University , Suzhou , China
| | - Noemí Casas
- h Riesgo de Fractura CAYRE , Bogotá , Colombia
| | - Lale Altan
- i Department of Physical Medicine and Rehabilitation , Uludağ University School of Medicine , Bursa , Turkey
| | - Thomas Moll
- j Lilly Research Center , Windlesham , United Kingdom
| | - Sirel Gurbuz
- k Lilly Research Laboratories , Indianapolis , IN , USA
| | | | - Russel T Burge
- k Lilly Research Laboratories , Indianapolis , IN , USA
- l Winkle College of Pharmacy , University of Cincinnati , Cincinnati , OH , USA
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23
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Makras P, Anastasilakis AD, Antypas G, Chronopoulos E, Kaskani EG, Matsouka A, Patrikos DK, Stathopoulos KD, Tournis S, Trovas G, Kosmidis C. The 2018 Guidelines for the diagnosis and treatment of osteoporosis in Greece. Arch Osteoporos 2019; 14:39. [PMID: 30877479 DOI: 10.1007/s11657-019-0584-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 02/25/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED We report the updated guidelines for the management of osteoporosis in Greece, which include guidance on fracture risk assessment, diagnosis-pharmacological treatment-follow-up of osteoporosis based on updated information, and national evidence from Greek clinical practice and the healthcare setting. PURPOSE The purpose of this report was to update the Guidelines for the Management of Osteoporosis in Greece that was published in 2011. METHODS In line with the GRADE system, the working group initially defined the main clinical questions that should be addressed when dealing with the diagnosis and management of osteoporosis in clinical practice in Greece. Following a literature review and discussion on the experience gained from the implementation of the 2011 Guidelines transmitted through the national electronic prescription network, the Hellenic Society for the Study of Bone Metabolism (HSSBM) uploaded an initial draft for an open dialogue with the relevant registered medical societies and associations on the electronic platform of the Greek Ministry of Health. After revisions, the Central Health Council approved the final document. RESULTS The 2018 Guidelines provide comprehensive recommendations on the issues of the timing of fracture risk evaluation and dual-energy X-ray absorptiometry (DXA) measurement, interpretation of the DXA results, the diagnostic work-up for osteoporosis, the timing as well as the suggested medications for osteoporosis treatment, and the follow-up methodology employed during osteoporosis treatment. CONCLUSIONS These updated guidelines were designed to offer valid guidance on fracture risk assessment, diagnosis-pharmacological treatment-follow-up of osteoporosis based on updated information and national evidence from clinical practice and the healthcare setting. Clinical judgment is essential in the management of every individual patient for the purpose of achieving the optimal outcome in the safest possible way.
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Affiliation(s)
- Polyzois Makras
- Department of Endocrinology and Diabetes and Department of Medical Research, 251 Hellenic Air Force General Hospital, 3 Kanellopoulou St., 115 25, Goudi, Athens, Greece. .,Hellenic Society for the Study of Bone Metabolism, Athens, Greece.
| | - Athanasios D Anastasilakis
- Hellenic Society for the Study of Bone Metabolism, Athens, Greece.,Department of Endocrinology, 424 General Military Hospital, Thessaloniki, Greece
| | - George Antypas
- Hellenic Society for the Study of Bone Metabolism, Athens, Greece.,Department of Orthopedics, "St. Panteleimon" General Hospital of Nikaia, Piraeus, Greece
| | - Efstathios Chronopoulos
- Hellenic Society for the Study of Bone Metabolism, Athens, Greece.,2nd University Orthopaedic Department, Athens Medical School, National and Kapodistrian University, Athens, Greece
| | - Evangelia G Kaskani
- Hellenic Society for the Study of Bone Metabolism, Athens, Greece.,1st Health Division of Attica, Chalandri Health Centre Athens, Chalandri, Greece
| | | | - Dimos K Patrikos
- Hellenic Society for the Study of Bone Metabolism, Athens, Greece.,"Metropolitan" General Hospital, Piraeus, Greece
| | - Konstantinos D Stathopoulos
- Hellenic Society for the Study of Bone Metabolism, Athens, Greece.,Post-Graduate Course on Bone Metabolic Diseases, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Symeon Tournis
- Hellenic Society for the Study of Bone Metabolism, Athens, Greece.,Laboratory for Research of the Musculoskeletal System "Th. Garofalidis", Medical School, KAT Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George Trovas
- Laboratory for Research of the Musculoskeletal System "Th. Garofalidis", Medical School, KAT Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Christos Kosmidis
- Hellenic Society for the Study of Bone Metabolism, Athens, Greece.,1st Health District of Attica, Alexandras Health Centre, Athens, Greece
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24
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Aloumanis K, Kapetanos G, Alexandridis T, Drossinos V, Papaioannou N. Conducting an observational study during an economic crisis: analysis of the treatment and follow-up phase of Greek patients participating in the ExFOS study. Hormones (Athens) 2018; 17:531-540. [PMID: 30430458 DOI: 10.1007/s42000-018-0077-6] [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: 06/20/2018] [Accepted: 10/29/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE We present the subanalysis of the Greek cohort of the Extended Forsteo Observational Study (ExFOS), a multicenter, non-interventional, prospective, observational study evaluating the effect of teriparatide on fractures, back pain (BP), health-related quality of life (HR-QoL), and safety and compliance, in patients with osteoporosis treated for up to 24 months, with a post-treatment follow-up of at least 18 months. DESIGN A total of 439 osteoporotic patients (92.2% female) were enrolled in Greece. New or worsened fractures, based on their physicians' assessment, as well as patients' self-assessment of HR-QoL and BP, compliance, and safety profile, were captured by validated questionnaires. RESULTS In the ExFOS Greek cohort, fracture rates were low and mean bone mineral density (BMD) was numerically improved. Compliance with teriparatide remained high throughout the study, with 81.5% of subjects completing treatment. Only 0.7% of patients reported discontinuation due to adverse effects. A sustainable improvement in patient-perceived BP and HRQoL throughout treatment and follow-up was similar to that achieved by the European Forsteo Observational Study (EFOS). A lower than expected percentage of patients using antiresorptives following teriparatide was recorded. CONCLUSIONS ExFOS reproduces the outcomes of EFOS, with a 6.5-year time interval between studies, in comparable cohorts of osteoporotic patients. Data should be interpreted in the context of observational study data collection, although summary statistics computed at each time point may overstate drug effect.
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Affiliation(s)
- Kyriakos Aloumanis
- Department of Medical Research, Pharmaserve Lilly, 15th Km National Road Athens-Lamia, Kifissia, Greece.
| | - G Kapetanos
- Papageorgiou General Hospital, 3rd Orthopedics University Clinic, Thessaloniki, Greece
| | - T Alexandridis
- Endocrine Division, Department of Medicine, Patras University Hospital, Patras, Greece
| | - V Drossinos
- Department of Medical Research, Pharmaserve Lilly, 15th Km National Road Athens-Lamia, Kifissia, Greece
| | - N Papaioannou
- Musculoskeletal Diseases Research Laboratory, Athens General Hospital "KAT", Kifissia, Greece
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