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McLaurin WS, Francisco BJ, Hooker KJ, Sheshashayee N, Khan MTF, Triana RR, Rao MB, Pressey JG, Krishnan DG. Antiresorptive and anti-angiogenic drug therapy in the pediatric population with reference to medication-related osteonecrosis of the jaw. Int J Oral Maxillofac Surg 2024; 53:496-502. [PMID: 38030483 DOI: 10.1016/j.ijom.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 11/03/2023] [Accepted: 11/08/2023] [Indexed: 12/01/2023]
Abstract
The objective of this study was to identify the prevalence of osteonecrosis of the jaw in a pediatric population with systemic therapeutic exposure to an antiresorptive, anti-angiogenic, and/or immunomodulating drug (ARAID), and in particular in the subgroup of patients who had undergone invasive dental treatment. This was a retrospective cohort study performed at a single center. The investigation included pediatric patients who had undergone systemic therapy with ARAIDs and who began receiving ARAID therapy at ≤16 years of age. The study included 482 patients who received ARAIDs between January 2011 and January 2021. The most common medication class was bisphosphonates (45.0%), followed by mTOR inhibitors (30.1%) and anti-angiogenics (17.8%). No diagnosis of osteonecrosis of the jaw was observed. From this population, 26 patients were noted to have undergone invasive dental treatment. The duration from treatment to the invasive procedure ranged from 0 to 5.9 years. Medication-related osteonecrosis of the jaw is extremely rare among the pediatric population - much less common when compared to the adult population. Prospective cohort studies and continued evaluation will help determine the incidence and prevalence of medication-related osteonecrosis of the jaw in pediatric patients.
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Affiliation(s)
- W S McLaurin
- Division of Oral and Maxillofacial Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - B J Francisco
- Division of Pediatric Hematology-Oncology, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - K J Hooker
- Department of Chemistry and Chemical Biology, Rensselaer Polytechnic Institute, Troy, NY, USA
| | - N Sheshashayee
- Department of Environmental and Public Health Sciences, Division of Biostatistics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - M T F Khan
- Department of Mathematics and Statistics, Cleveland State University, Cleveland, OH, USA
| | - R R Triana
- Division of Oral and Maxillofacial Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - M B Rao
- Department of Environmental and Public Health Sciences, Division of Biostatistics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - J G Pressey
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - D G Krishnan
- Division of Oral and Maxillofacial Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Castillo EJ, Jiron JM, Croft CS, Freehill DG, Castillo CM, Kura J, Yarrow JF, Bhattacharyya I, Kimmel DB, Aguirre JI. Intermittent parathyroid hormone enhances the healing of medication-related osteonecrosis of the jaw lesions in rice rats. Front Med (Lausanne) 2023; 10:1179350. [PMID: 37404809 PMCID: PMC10315582 DOI: 10.3389/fmed.2023.1179350] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 05/26/2023] [Indexed: 07/06/2023] Open
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a potentially severe adverse event in patients treated with antiresorptives. Management of MRONJ is challenging, and no non-antibiotic, established medical treatment exists. Intermittent parathyroid hormone (iPTH) has been used off-label to treat MRONJ with favorable results. However, its medical efficacy has rarely been substantiated in clinical or preclinical experiments. Using a validated rice rat, infection-based model of MRONJ, we evaluated the effects of iPTH on established MRONJ. We hypothesize that iPTH contributes to MRONJ resolution by enhancing alveolar bone turnover and healing oral soft tissues. Eighty-four rice rats began a standard rodent chow diet at age 4 weeks to induce localized periodontitis. Rats were simultaneously randomized to receive saline (vehicle, VEH) or zoledronic acid (ZOL, 80 μg/kg IV) every 4 weeks. Oral exams were conducted bi-weekly to assign a gross quadrant grade (GQG, 0-4) to evaluate any lesion at the lingual aspect of the interdental space between maxillary molar (M2) and M3. 14 of 20 VEH-treated rice rats (70%) developed maxillary localized periodontitis with GQG 2-3 after 30 ± 10 weeks of saline. Additionally, 40 of 64 ZOL-treated rice rats with periodontitis developed MRONJ-like lesions after 30 ± 10 weeks of ZOL treatment. Rice rats with localized periodontitis or MRONJ-like lesions were treated with saline or iPTH (40 μg/kg) subcutaneously (SC) 3 times/week For 6 weeks until euthanasia. We found that iPTH -treated ZOL rats had a lower prevalence of MRONJ (p < 0.001), with lower severity extent of oral lesions (p = 0.003) and percentage of empty osteocyte lacunae (p < 0.001). ZOL rats treated with iPTH displayed a higher osteoblast surface (p < 0.001), more osteoblasts (p < 0.001), higher osteoclast surface (p < 0.001) and more osteoclasts (p = 0.002) at alveolar bone surfaces than ZOL/VEH rats. Greater gingival epithelial thickness and epithelial cell proliferation rate was found in the oral mucosa and gingiva of ZOL/PTH rats than in ZOL/VEH rats (p < 0.001). Our data suggest that iPTH is an efficacious non-operative medicinal therapy that accelerates oral healing and enhances the resolution of MRONJ lesions in ZOL-treated rice rats.
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Affiliation(s)
- E. J. Castillo
- Department of Physiological Sciences, University of Florida, Gainesville, FL, United States
| | - J. M. Jiron
- Department of Physiological Sciences, University of Florida, Gainesville, FL, United States
| | - C. S. Croft
- Department of Physiological Sciences, University of Florida, Gainesville, FL, United States
| | - D. G. Freehill
- Department of Physiological Sciences, University of Florida, Gainesville, FL, United States
| | - C. M. Castillo
- Department of Physiological Sciences, University of Florida, Gainesville, FL, United States
| | - J. Kura
- VA Medical Center, Research Service, Gainesville, FL, United States
| | - J. F. Yarrow
- VA Medical Center, Research Service, Gainesville, FL, United States
| | - I. Bhattacharyya
- Department of Oral and Maxillofacial Diagnostic Sciences, College of Dentistry, University of Florida, Gainesville, FL, United States
| | - D. B. Kimmel
- Department of Physiological Sciences, University of Florida, Gainesville, FL, United States
| | - J. Ignacio Aguirre
- Department of Physiological Sciences, University of Florida, Gainesville, FL, United States
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Kammerhofer G, Vegh D, Bányai D, Végh Á, Joob-Fancsaly A, Hermann P, Geczi Z, Hegedus T, Somogyi KS, Bencze B, Biczó Z, Juhász DH, Zaborszky P, Ujpál M, Vaszilkó MT, Németh Z. Association between Hyperglycemia and Medication-Related Osteonecrosis of the Jaw (MRONJ). J Clin Med 2023; 12:jcm12082976. [PMID: 37109314 PMCID: PMC10144577 DOI: 10.3390/jcm12082976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/12/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Medication-related osteonecrosis of the jaw (MRONJ) is a type of jawbone necrosis caused by the use of drugs for some types of cancer and osteoporosis. The current study aimed to evaluate the associations between hyperglycemia and the development of medication-related osteonecrosis of the jaw. METHODS Our research group investigated data collected between 1 January 2019 and 31 December 2020. A total of 260 patients were selected from the Inpatient Care Unit, Department of Oromaxillofacial Surgery and Stomatology, Semmelweis University. Fasting glucose data were used and included in the study. RESULTS Approximately 40% of the necrosis group and 21% of the control group presented with hyperglycemia. There was a significant association between hyperglycemia and MRONJ (p < 0.05, p = 0.003). Vascular anomaly and immune dysfunction caused by hyperglycemia can lead to necrosis after tooth extraction. Necrosis is more common in the mandible (75.0%) and in the case of parenteral antiresorptive treatment (intravenous Zoledronate and subcutaneous Denosumab). Hyperglycemia is a more relevant risk factor than bad oral habits (26.7%). CONCLUSIONS Ischemia is a complication of abnormal glucose levels, a possible risk factor for necrosis development. Hence, uncontrolled or poorly regulated plasma glucose levels can significantly increase the risk of jawbone necrosis after invasive dental or oral surgical interventions.
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Affiliation(s)
- Gabor Kammerhofer
- Department of Oromaxillofacial Surgery and Stomatology, Semmelweis University, 1088 Budapest, Hungary
- Diabetes-Dental Working Group, Semmelweis University, 1088 Budapest, Hungary
| | - Daniel Vegh
- Diabetes-Dental Working Group, Semmelweis University, 1088 Budapest, Hungary
- Department of Prosthodontics, Semmelweis University, 1088 Budapest, Hungary
| | - Dorottya Bányai
- Diabetes-Dental Working Group, Semmelweis University, 1088 Budapest, Hungary
- Department of Paediatric Dentistry and Orthodontics, Semmelweis University, 1088 Budapest, Hungary
| | - Ádám Végh
- Diabetes-Dental Working Group, Semmelweis University, 1088 Budapest, Hungary
- Department of Oral Diagnostics, Semmelweis University, 1088 Budapest, Hungary
| | - Arpad Joob-Fancsaly
- Department of Oromaxillofacial Surgery and Stomatology, Semmelweis University, 1088 Budapest, Hungary
- Diabetes-Dental Working Group, Semmelweis University, 1088 Budapest, Hungary
| | - Peter Hermann
- Diabetes-Dental Working Group, Semmelweis University, 1088 Budapest, Hungary
- Department of Prosthodontics, Semmelweis University, 1088 Budapest, Hungary
| | - Zoltan Geczi
- Diabetes-Dental Working Group, Semmelweis University, 1088 Budapest, Hungary
- Department of Prosthodontics, Semmelweis University, 1088 Budapest, Hungary
| | - Tamas Hegedus
- Diabetes-Dental Working Group, Semmelweis University, 1088 Budapest, Hungary
- Department of Prosthodontics, Semmelweis University, 1088 Budapest, Hungary
| | - Kata Sara Somogyi
- Diabetes-Dental Working Group, Semmelweis University, 1088 Budapest, Hungary
- Department of Prosthodontics, Semmelweis University, 1088 Budapest, Hungary
| | - Bulcsú Bencze
- Diabetes-Dental Working Group, Semmelweis University, 1088 Budapest, Hungary
- Department of Prosthodontics, Semmelweis University, 1088 Budapest, Hungary
| | - Zita Biczó
- Department of Oromaxillofacial Surgery and Stomatology, Semmelweis University, 1088 Budapest, Hungary
- Diabetes-Dental Working Group, Semmelweis University, 1088 Budapest, Hungary
| | - Donát Huba Juhász
- Diabetes-Dental Working Group, Semmelweis University, 1088 Budapest, Hungary
- Faculty of Dentistry, Semmelweis University, 1088 Budapest, Hungary
| | - Péter Zaborszky
- Diabetes-Dental Working Group, Semmelweis University, 1088 Budapest, Hungary
- Faculty of Dentistry, Semmelweis University, 1088 Budapest, Hungary
| | - Márta Ujpál
- Department of Oromaxillofacial Surgery and Stomatology, Semmelweis University, 1088 Budapest, Hungary
- Diabetes-Dental Working Group, Semmelweis University, 1088 Budapest, Hungary
| | - Mihály Tamás Vaszilkó
- Department of Oromaxillofacial Surgery and Stomatology, Semmelweis University, 1088 Budapest, Hungary
- Diabetes-Dental Working Group, Semmelweis University, 1088 Budapest, Hungary
| | - Zsolt Németh
- Department of Oromaxillofacial Surgery and Stomatology, Semmelweis University, 1088 Budapest, Hungary
- Diabetes-Dental Working Group, Semmelweis University, 1088 Budapest, Hungary
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Dhabhar B. Cancer Treatment-Induced Bone Loss: Role of Denosumab in Non-Metastatic Breast Cancer. BREAST CANCER: TARGETS AND THERAPY 2022; 14:163-173. [PMID: 35860287 PMCID: PMC9292456 DOI: 10.2147/bctt.s353332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/25/2022] [Indexed: 12/09/2022]
Abstract
Chemotherapeutic agents, endocrine therapy and radiotherapy used in the management of breast cancer are known to cause decreased bone mineral density, and thus, increased incidence of fractures. A majority (~60%) of the breast cancer patients in India are either estrogen (ER) or progesterone hormone receptor (PR) positive. Adjuvant treatment with aromatase inhibitors (AIs) is the treatment mainstay for hormone-sensitive disease in postmenopausal (PM) women, with reduced bone mineral density (BMD), which results in increased fracture rates. Zoledronic acid, alendronate, risedronate and denosumab have been the agents of choice for managing bone loss. Denosumab 60 mg is approved for gaining bone mass in women with breast cancer who are at high risk for fracture following adjuvant AI treatment. The phase III HALT-BC data indicate an improvement in BMD with denosumab and a 50% reduction in clinical fractures, with significant improvements seen at the lumbar spine, distal third of the radius, and total hip. Denosumab has several advantages over other bone modifying agents such as subcutaneous self-administration by the patient themselves, no requirement of hospitalization, no dose modifications in renal impairment, and low incidence of acute phase anaphylactic reactions. We review the available evidence of denosumab for managing bone loss in non-metastatic breast cancer patients.
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Affiliation(s)
- Boman Dhabhar
- Department of Medical Oncology, Fortis Hospital, Mumbai, India
- Correspondence: Boman Dhabhar, Consultant, Medical Oncology, Fortis Hospital, Mulund, Mumbai, 400078, Maharashtra, India, Email
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Meta-Analysis of Two Human RNA-seq Datasets to Determine Periodontitis Diagnostic Biomarkers and Drug Target Candidates. Int J Mol Sci 2022; 23:ijms23105580. [PMID: 35628390 PMCID: PMC9145972 DOI: 10.3390/ijms23105580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 02/01/2023] Open
Abstract
Periodontitis is a chronic inflammatory oral disease that affects approximately 42% of adults 30 years of age or older in the United States. In response to microbial dysbiosis within the periodontal pockets surrounding teeth, the host immune system generates an inflammatory environment in which soft tissue and alveolar bone destruction occur. The objective of this study was to identify diagnostic biomarkers and the mechanistic drivers of inflammation in periodontitis to identify drugs that may be repurposed to treat chronic inflammation. A meta-analysis comprised of two independent RNA-seq datasets was performed. RNA-seq analysis, signal pathway impact analysis, protein-protein interaction analysis, and drug target analysis were performed to identify the critical pathways and key players that initiate inflammation in periodontitis as well as to predict potential drug targets. Seventy-eight differentially expressed genes, 10 significantly impacted signaling pathways, and 10 hub proteins in periodontal gingival tissue were identified. The top 10 drugs that may be repurposed for treating periodontitis were then predicted from the gene expression and pathway data. The efficacy of these drugs in treating periodontitis has yet to be investigated. However, this analysis indicates that these drugs may serve as potential therapeutics to treat inflammation in gingival tissue affected by periodontitis.
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Castillo EJ, Croft S, Jiron JM, Aguirre JI. Bone Structural, Biomechanical and Histomorphometric Characteristics of the Hindlimb Skeleton in the Marsh Rice Rat (Oryzomys palustris). Anat Rec (Hoboken) 2022; 305:3133-3149. [PMID: 35090092 PMCID: PMC10394686 DOI: 10.1002/ar.24876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/30/2021] [Accepted: 12/21/2021] [Indexed: 11/12/2022]
Abstract
INTRODUCTION The rice rat (Oryzomys palustris) is a non-conventional laboratory rodent species used to model some human bone disorders. However, no studies have been conducted to characterize the postcranial skeleton. Therefore, we aimed to investigate age- and gender-related features of the hindlimb skeleton of this species. METHODS We used femurs and tibiae from 94 rats of both genders aged 4-28 wks. Bone mineral content (BMC), volumetric bone mineral density (vBMD), and biomechanical properties were determined in femurs. In addition, bone histomorphometry of tibiae was conducted to assess bone cell activities and bone turnover over time. RESULTS Bone length, total metaphysis BMC and vBMD, mid-diaphyseal BMC and vBMD, cortical thickness, and cortical area progressively augmented with age. Whereas the increase in these parameters plateaued at age 16-22 wks in female rats, they continued to rise to age 28 wks in male rats. Furthermore, bone strength parameters increased with age, with few differences between genders. We also observed a rapid decrease in longitudinal growth between ages 4-16 wks. Whereas young rats had a greater bone formation rate and bone turnover, older rice rats had greater bone volume and trabecular thickness, with no differences between genders. CONCLUSIONS 1) Sexual dimorphism in the rice rat becomes grossly evident at age 16 wks; 2) the age-related increases in bone mass, structural cortical parameters, and in some biomechanical property parameters plateau at an older age in male than in female rats; and 3) bone growth and remodeling significantly decreased with age irrespective of the gender.
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Affiliation(s)
- E J Castillo
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL
| | - S Croft
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL
| | - J M Jiron
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL
| | - J I Aguirre
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL
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Li CH, Lü ZR, Zhao ZD, Wang XY, Leng HJ, Niu Y, Wang MP. Nitazoxanide, an Antiprotozoal Drug, Reduces Bone Loss in Ovariectomized Mice by Inhibition of RANKL-Induced Osteoclastogenesis. Front Pharmacol 2021; 12:781640. [PMID: 34955850 PMCID: PMC8696474 DOI: 10.3389/fphar.2021.781640] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/22/2021] [Indexed: 01/19/2023] Open
Abstract
Nitazoxanide (NTZ) is an FDA-approved anti-parasitic drug with broad-spectrum anti-infective, anti-inflammatory, and antineoplastic potential. However, its regulatory effects on osteoclastogenesis and the underlying mechanisms remain unclear. The present study found that NTZ potently inhibited osteoclast formation at the early stage of receptor activator of NF-κB ligand-induced osteoclastogenesis in a concentration-dependent manner at a non-growth inhibitory concentration. NTZ suppressed actin ring formation and decreased osteoclast marker gene expression, including TRAP, MMP9, and cathepsin K. NTZ significantly impaired the bone resorption activity of osteoclasts. In vivo, ovariectomized mice were treated with 50, 100 and 200 mg/kg/d NTZ for 3 months. NTZ (100 mg/kg/d) administration markedly reduced ovariectomy-induced bone loss by suppressing osteoclast activity. Mechanistically, osteoclastogenesis blockade elicited by NTZ resulted from inhibition of STAT3 phosphorylation, and reduction of the Ca2+ fluorescence intensity and NFATc1 expression. NTZ weakened the binding between STAT3 and the NFATc1 promoter region. Furthermore, enforced NFATc1 expression partly rescued the impaired osteoclast differentiation in NTZ-treated RAW264.7 cells. In summary, NTZ could inhibit osteoclastogenesis and bone loss through modulation of the receptor activator of NF-κB ligand-induced STAT3-NFATc1 signaling pathway, which might be a potential alternative treatment regimen against bone destruction-related diseases including osteoporosis.
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Affiliation(s)
- Chang-hong Li
- Department of Rheumatology and Immunology, Peking University Third Hospital, Beijing, China
- Osteoporosis and Bone Metabolic Diseases Center, Peking University Third Hospital, Beijing, China
| | - Zi-rui Lü
- Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Zhen-da Zhao
- Osteoporosis and Bone Metabolic Diseases Center, Peking University Third Hospital, Beijing, China
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Xin-yu Wang
- Department of Rheumatology and Immunology, Peking University Third Hospital, Beijing, China
| | - Hui-jie Leng
- Osteoporosis and Bone Metabolic Diseases Center, Peking University Third Hospital, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Yan Niu
- Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Mo-pei Wang
- Osteoporosis and Bone Metabolic Diseases Center, Peking University Third Hospital, Beijing, China
- Department of Tumor Chemotherapy and Radiation Sickness, Peking University Third Hospital, Beijing, China
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Aguirre JI, Castillo EJ, Kimmel DB. Biologic and pathologic aspects of osteocytes in the setting of medication-related osteonecrosis of the jaw (MRONJ). Bone 2021; 153:116168. [PMID: 34487892 PMCID: PMC8478908 DOI: 10.1016/j.bone.2021.116168] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/02/2021] [Accepted: 08/31/2021] [Indexed: 02/08/2023]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a potentially severe, debilitating condition affecting patients with cancer and patients with osteoporosis who have been treated with powerful antiresorptives (pARs) or angiogenesis inhibitors (AgIs). Oral risk factors associated with the development of MRONJ include tooth extraction and inflammatory dental disease (e.g., periodontitis, periapical infection). In bone tissues, osteocytes play a bidirectional role in which they not only act as the "receiver" of systemic signals from blood vessels, such as hormones and drugs, or local signals from the mineralized matrix as it is deformed, but they also play a critical role as "transmitter" of signals to the cells that execute bone modeling and remodeling (osteoclasts, osteoblasts and lining cells). When the survival capacity of osteocytes is overwhelmed, they can die. Osteocyte death has been associated with several pathological conditions. Whereas the causes and mechanisms of osteocyte death have been studied in conditions like osteonecrosis of the femoral head (ONFH), few studies of the causes and mechanisms of osteocyte death have been done in MRONJ. The three forms of cell death that affect most of the different cells in the body (apoptosis, autophagy, and necrosis) have been recognized in osteocytes. Notably, necroptosis, a form of regulated cell death with "a necrotic cell death phenotype," has also been identified as a form of cell death in osteocytes under certain pathologic conditions. Improving the understanding of osteocyte death in MRONJ may be critical for preventing disease and developing treatment approaches. In this review, we intend to provide insight into the biology of osteocytes, cell death, in general, and osteocyte death, in particular, and discuss hypothetical mechanisms involved in osteocyte death associated with MRONJ.
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Affiliation(s)
- J I Aguirre
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - E J Castillo
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - D B Kimmel
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America
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Aguirre JI, Castillo EJ, Kimmel DB. Preclinical models of medication-related osteonecrosis of the jaw (MRONJ). Bone 2021; 153:116184. [PMID: 34520898 PMCID: PMC8743993 DOI: 10.1016/j.bone.2021.116184] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/15/2021] [Accepted: 09/07/2021] [Indexed: 01/20/2023]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a potentially severe adverse event affecting patients with cancer and patients with osteoporosis who have been treated with powerful antiresorptives (pARs) or angiogenesis inhibitors (AgIs). pARs, including nitrogen-containing bisphosphonates (N-BPs; e.g., zoledronic acid, alendronate) and anti-RANKL antibodies (e.g., denosumab), are used to manage bone metastases in patients with cancer or to prevent fragility fractures in patients with osteoporosis. Though significant advances have been made in understanding MRONJ, its pathophysiology is still not fully elucidated. Multiple species have been used in preclinical MRONJ research, including the rat, mouse, rice rat, rabbit, dog, sheep, and pig. Animal research has contributed immensely to advancing the MRONJ field, particularly, but not limited to, in developing models and investigating risk factors that were first observed in humans. MRONJ models have been developed using clinically relevant doses of systemic risk factors, like N-BPs, anti-RANKL antibodies, or AgIs. Specific local oral risk factors first noted in humans, including tooth extraction and inflammatory dental disease (e.g., periodontitis, periapical infection, etc.), were then added. Research in rodents, particularly the rat, and, to some extent, the mouse, across multiple laboratories, has contributed to establishing multiple relevant and complementary preclinical models. Models in larger species produced accurate clinical and histopathologic outcomes suggesting a potential role for confirming specific crucial findings from rodent research. We view the current state of animal models for MRONJ as good. The rodent models are now reliable enough to produce large numbers of MRONJ cases that could be applied in experiments testing treatment modalities. The course of MRONJ, including stage 0 MRONJ, is characterized well enough that basic studies of the molecular or enzyme-level findings in different MRONJ stages are possible. This review provides a current overview of the existing models of MRONJ, their more significant features and findings, and important instances of their application in preclinical research.
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Affiliation(s)
- J I Aguirre
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - E J Castillo
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - D B Kimmel
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America
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Ikesue H, Doi K, Morimoto M, Hirabatake M, Muroi N, Yamamoto S, Takenobu T, Hashida T. Risk evaluation of denosumab and zoledronic acid for medication-related osteonecrosis of the jaw in patients with bone metastases: a propensity score-matched analysis. Support Care Cancer 2021; 30:2341-2348. [PMID: 34738163 PMCID: PMC8794983 DOI: 10.1007/s00520-021-06634-7] [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] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 10/16/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE This study evaluated the risk of medication-related osteonecrosis of the jaw (MRONJ) in patients with cancer who received denosumab or zoledronic acid (ZA) for treating bone metastasis. METHODS The medical records of patients were retrospectively reviewed. Patients who did not undergo a dental examination at baseline were excluded. The primary endpoint was a comparison of the risk of developing MRONJ between the denosumab and ZA groups. Propensity score matching was used to control for baseline differences between patient characteristics and compare outcomes for both groups. RESULTS Among the 799 patients enrolled, 58 (7.3%) developed MRONJ. The incidence of MRONJ was significantly higher in the denosumab group than in the ZA group (9.6% [39/406] vs. 4.8% [19/393], p = 0.009). Multivariate Cox proportional hazards regression analysis revealed that denosumab treatment (hazard ratio [HR], 2.89; 95% confidence interval [CI], 1.65-5.25; p < 0.001) and tooth extraction after starting ZA or denosumab (HR, 4.26; 95% CI, 2.38-7.44; p < 0.001) were significant risk factors for MRONJ. Propensity score-matched analysis confirmed that the risk of developing MRONJ was significantly higher in the denosumab group than in the ZA group (HR, 2.34; 95% CI, 1.17-5.01; p = 0.016). CONCLUSION The results of this study suggest that denosumab poses a significant risk for developing MRONJ in patients treated for bone metastasis, and thus these patients require close monitoring.
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Affiliation(s)
- Hiroaki Ikesue
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Kohei Doi
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Mayu Morimoto
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Masaki Hirabatake
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Nobuyuki Muroi
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Shinsuke Yamamoto
- Department of Oral and Maxillofacial Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Toshihiko Takenobu
- Department of Oral and Maxillofacial Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Tohru Hashida
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
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Castillo EJ, Messer JG, Abraham AM, Jiron JM, Alekseyenko AV, Israel R, Thomas S, Gonzalez-Perez GM, Croft S, Gohel A, Bhattacharyya I, Yarrow JF, Novince CM, Kimmel DB, Aguirre JI. Preventing or controlling periodontitis reduces the occurrence of osteonecrosis of the jaw (ONJ) in rice rats (Oryzomys palustris). Bone 2021; 145:115866. [PMID: 33515777 PMCID: PMC8265021 DOI: 10.1016/j.bone.2021.115866] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 01/08/2021] [Accepted: 01/24/2021] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Osteonecrosis of the jaw (ONJ) is an adverse event that requires association of both systemic risk factors, such as powerful anti-resorptives (pARs; e.g. zoledronic acid [ZOL]), and local oral risk factors (e.g. tooth extraction, periodontitis). Whereas optimal oral health prior to initiate pARs is recognized as critically important for minimizing ONJ risk, the efficacy of preventive/maintenance measures in patients who are taking pARs is understudied. Rice rats fed a standard diet (STD), rich in insoluble fiber, develop localized periodontitis. STD-rats with localized periodontitis treated with ZOL for 18-24 wk develop ONJ. Hence, we hypothesized that controlling/preventing localized periodontitis in the ZOL-treated rats, reduces ONJ occurrence. METHODS We used two approaches to attempt reducing periodontitis prevalence: 1) periodontal cleaning (PC); and 2) replacing the STD-diet with a nutritionally-equivalent diet high in soluble fiber (SF). 75 four-week-old male rats were weight-randomized into five groups (n = 15) in a 24-week experiment. Three groups ate the STD-diet and two the high SF-diet. STD-diet groups received intravenous (IV) vehicle (VEH) q4wks (STD + VEH), 80 μg/kg ZOL q4wks IV (STD + ZOL), or ZOL plus PC q2wks (STD + ZOL + PC). The SF-diet groups received VEH (SF + VEH) or ZOL (SF + ZOL). Jaws were processed for histopathology and evaluated for ONJ prevalence and tissue-level periodontitis. RESULTS 1) 40% of STD + VEH rats developed maxillary localized periodontitis with no ONJ; 2) 50% of STD + ZOL rats developed ONJ; 3) 7% of STD + ZOL + PC rats developed ONJ (p < 0.01 vs. STD + ZOL); and 4) one SF + ZOL rat developed localized periodontitis, and no SF + VEH or SF + ZOL rats developed ONJ (p < 0.001 vs. STD + ZOL). CONCLUSIONS 1) Periodontal cleaning in ZOL-treated rats decreases localized periodontitis severity and reduces ONJ prevalence; and 2) feeding a SF-diet to ZOL-treated rats reduces both incidence of localized periodontitis and ONJ. Our data indicates strong oral microbial community shifts according to oral health condition and trends in the shifts associated with diet.
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Affiliation(s)
- E J Castillo
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - J G Messer
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America
| | - A M Abraham
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America
| | - J M Jiron
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - A V Alekseyenko
- Department of Oral Health Sciences, Medical University of South Carolina College of Dental Medicine, Charleston, SC, United States of America; Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, United States of America; Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, Charleston, SC, United States of America.
| | - R Israel
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - S Thomas
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - G M Gonzalez-Perez
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - S Croft
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - A Gohel
- Department of Oral & Maxillofacial Diagnostic Sciences, College of Dentistry, UF, United States of America.
| | - I Bhattacharyya
- Department of Oral & Maxillofacial Diagnostic Sciences, College of Dentistry, UF, United States of America.
| | - J F Yarrow
- VA Medical Center, Research Service, Gainesville, FL, United States of America; Division of Endocrinology, Diabetes, and Metabolism, UF College of Medicine, Gainesville, FL, United States of America.
| | - C M Novince
- Department of Oral Health Sciences, Medical University of South Carolina College of Dental Medicine, Charleston, SC, United States of America.
| | - D B Kimmel
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America
| | - J I Aguirre
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
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12
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Ikesue H, Doi K, Morimoto M, Hirabatake M, Muroi N, Yamamoto S, Takenobu T, Hashida T. Switching from zoledronic acid to denosumab increases the risk for developing medication-related osteonecrosis of the jaw in patients with bone metastases. Cancer Chemother Pharmacol 2021; 87:871-877. [PMID: 33791853 PMCID: PMC8110486 DOI: 10.1007/s00280-021-04262-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 03/16/2021] [Indexed: 01/02/2023]
Abstract
Purpose Switch from zoledronic acid (ZA) to denosumab may increase the risk of medication-related osteonecrosis of the jaw (MRONJ) owing to the additive effect of denosumab on the jawbone and residual ZA activities. We evaluated the risk of developing MRONJ in patients who received ZA, denosumab, or ZA-to-denosumab for the treatment of bone metastases. Methods The medical charts of patients with cancer who received denosumab or ZA for bone metastases were retrospectively reviewed. Patients who did not undergo a dental examination at baseline were excluded. Primary endpoint was the evaluation of the risk of developing MRONJ in the ZA-to-denosumab group. Secondary endpoints were probability of MRONJ and the relationship between risk factors and the time to the development of MRONJ. Results Among the 795 patients included in this study, 65 (8.2%) developed MRONJ. The incidence of MRONJ was significantly higher in the ZA-to-denosumab group than in the ZA group [7/43 (16.3%) vs. 19/350 (5.4%), p = 0.007]. Multivariate Cox proportional hazards regression analysis revealed that denosumab treatment [hazard ratio (HR), 2.41; 95% confidence interval (CI), 1.37–4.39; p = 0.002], ZA-to-denosumab treatment (HR, 4.36; 95% CI, 1.63–10.54, p = 0.005), tooth extraction after starting ZA or denosumab (HR, 4.86; 95% CI, 2.75–8.36; p < 0.001), and concomitant use of antiangiogenic agents (HR, 1.78; 95% CI, 1.06–2.96; p = 0.030) were significant risk factors for MRONJ. Conclusion Our results suggest that switching from ZA to denosumab significantly increases the risk for developing MRONJ in patients with bone metastases. Supplementary Information The online version contains supplementary material available at 10.1007/s00280-021-04262-w.
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Affiliation(s)
- Hiroaki Ikesue
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Kohei Doi
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Mayu Morimoto
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Masaki Hirabatake
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Nobuyuki Muroi
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Shinsuke Yamamoto
- Department of Oral and Maxillofacial Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Toshihiko Takenobu
- Department of Oral and Maxillofacial Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tohru Hashida
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
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13
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Ikesue H, Mouri M, Tomita H, Hirabatake M, Ikemura M, Muroi N, Yamamoto S, Takenobu T, Tomii K, Kawakita M, Katoh H, Ishikawa T, Yasui H, Hashida T. Associated characteristics and treatment outcomes of medication-related osteonecrosis of the jaw in patients receiving denosumab or zoledronic acid for bone metastases. Support Care Cancer 2021; 29:4763-4772. [PMID: 33527228 PMCID: PMC8236436 DOI: 10.1007/s00520-021-06018-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 01/19/2021] [Indexed: 12/13/2022]
Abstract
Purpose This study aimed to evaluate the association between clinical characteristics and development of medication-related osteonecrosis of the jaw (MRONJ) in patients who underwent dental examinations before the initiation of treatment with denosumab or zoledronic acid, which are bone-modifying agents (BMAs), for bone metastases. Additionally, the clinical outcomes of patients who developed MRONJ were evaluated along with the time to resolution of MRONJ. Methods The medical charts of patients with cancer who received denosumab or zoledronic acid for bone metastases between January 2012 and September 2016 were retrospectively reviewed. Patients were excluded if they did not undergo a dental examination at baseline. Results Among the 374 included patients, 34 (9.1%) developed MRONJ. The incidence of MRONJ was significantly higher in the denosumab group than in the zoledronic acid (27/215 [12.6%] vs 7/159 [4.4%], P = 0.006) group. Multivariate Cox proportional hazards regression analysis revealed that denosumab treatment, older age, and tooth extraction before and after starting BMA treatments were significantly associated with developing MRONJ. The time to resolution of MRONJ was significantly shorter for patients who received denosumab (median 26.8 months) than for those who received zoledronic acid (median not reached; P = 0.024). Conclusion The results of this study suggest that treatment with denosumab, age > 65 years, and tooth extraction before and after starting BMA treatments are significantly associated with developing MRONJ in patients undergoing treatment for bone metastases. However, MRONJ caused by denosumab resolves faster than that caused by zoledronic acid.
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Affiliation(s)
- Hiroaki Ikesue
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-2-1, Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan.
- Graduate School of Pharmaceutical Sciences, Kobe Gakuin University, 1-1-3 Minatojima, Chuo-ku, Kobe, 650-8586, Japan.
| | - Moe Mouri
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-2-1, Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
- Department of Pharmacy, Kishiwada City Hospital, 1001, Gakuhara-cho, Kishiwada-shi, Osaka, 596-8501, Japan
| | - Hideaki Tomita
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-2-1, Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Masaki Hirabatake
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-2-1, Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Mai Ikemura
- Division of Education and Research Promotion for Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Kobe Gakuin University, 1-1-3 Minatojima, Chuo-ku, Kobe, 650-8586, Japan
| | - Nobuyuki Muroi
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-2-1, Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
- Graduate School of Pharmaceutical Sciences, Kobe Gakuin University, 1-1-3 Minatojima, Chuo-ku, Kobe, 650-8586, Japan
| | - Shinsuke Yamamoto
- Department of Oral and Maxillofacial Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Toshihiko Takenobu
- Department of Oral and Maxillofacial Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Keisuke Tomii
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Mutsushi Kawakita
- Department of Urology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hironori Katoh
- Department of Breast Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Takayuki Ishikawa
- Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hisateru Yasui
- Department of Medical Oncology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tohru Hashida
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-2-1, Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
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Clark P, Carlos Rivera F, Méndez Sánchez L, Mendoza Gutiérrez CF, Vargas Neri JL, Carrillo Vázquez SM, Xibillé Friedmann DX, Alvarado Ceballos A, Aguilera Zepeda JM, Mercado Cárdenas V, Ávila Armengol H. Severe osteoporosis: Principles for pharmacological therapy in Mexico. REUMATOLOGIA CLINICA 2021; 17:97-105. [PMID: 31113739 DOI: 10.1016/j.reuma.2019.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/01/2019] [Accepted: 04/04/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND This article presents evidence and recommendations regarding the efficacy and safety of the approved and available therapies in Mexico to treat severe or established osteoporosis with the aim of developing a position regarding therapeutics in this stage of the disease, according to the descriptive cards of the National Drug Formulary of the National General Health Council of Mexico. METHODS We performed a systematic and narrative review of the evidence of teriparatide and denosumab, from their pharmacological profile, effectiveness, and safety derived from clinical trials, as well as an analysis of the general recommendations of the national and international clinical practice guidelines. RESULTS The evidence establishes that teriparatide and denosumab belong to different therapeutic classes, with biologically opposed mechanisms of action and indications of use, which are clearly differentiated in their respective national codes, therefore these drugs cannot be substitutable or interchangeable in severe osteoporosis therapy. Both represent the best options currently available for this stage of the disease; being similar in their efficacy in preventing new vertebral fragility fractures, with an RR of .35 (CI 95%; .22-.55) for teriparatide, and .32 (CI 95%: .26-.41) for denosumab. The absolute risk reduction is higher with teriparatide 9.3% (21 months) compared with denosumab at 4.8% (36 months). CONCLUSIONS Our results agree with the recommendations available in national and international clinical practice guidelines, with both therapies proposed as a sequential, but not a substitute, treatment.
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Affiliation(s)
- Patricia Clark
- Unidad de Epidemiología Clínica, Hospital Infantil de México Federico Gómez-Facultad de Medicina de la Universidad Nacional Autónoma de México, Ciudad de México, México; Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de México, México.
| | | | - Lucía Méndez Sánchez
- Unidad de Epidemiología Clínica, Hospital Infantil de México Federico Gómez-Facultad de Medicina de la Universidad Nacional Autónoma de México, Ciudad de México, México; Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Carlos Fernando Mendoza Gutiérrez
- Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de México, México; R A C Salud Consultores, S.A. de C.V., Ciudad de México, México
| | - Jessica Liliana Vargas Neri
- Unidad de Epidemiología Clínica, Hospital Infantil de México Federico Gómez-Facultad de Medicina de la Universidad Nacional Autónoma de México, Ciudad de México, México; Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Sandra Miriam Carrillo Vázquez
- Hospital Regional Primero de Octubre del ISSSTE, Ciudad de México, México; Colegio Mexicano de Reumatología, Ciudad de México, México
| | - Daniel Xavier Xibillé Friedmann
- Departamento de Investigación y Capacitación, Servicios de Salud de Morelos, Morelos, México; Colegio Mexicano de Reumatología, Ciudad de México, México
| | - Ariana Alvarado Ceballos
- Hospital Ángeles Mocel, Ciudad de México, México; Colegio Mexicano de Ortopedia y Traumatología, Ciudad de México, México
| | - José Manuel Aguilera Zepeda
- Academia Mexicana de Cirugía, Ciudad de México, México; Colegio Mexicano de Ortopedia y Traumatología, Ciudad de México, México
| | - Víctor Mercado Cárdenas
- Clínica Integral de Menopausia, Centro Médico Dalinde, Ciudad de México, México; Asociación Mexicana de Metabolismo Óseo y Mineral (AMMOM), Ciudad de México, México
| | - Hilario Ávila Armengol
- Servicio de Reumatología, Hospital Civil Dr. Juan I. Menchaca, Guadalajara, México; Asociación Mexicana de Metabolismo Óseo y Mineral (AMMOM), Ciudad de México, México
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15
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Cerrato A, Zanette G, Boccuto M, Angelini A, Valente M, Bacci C. Actinomyces and MRONJ: A retrospective study and a literature review. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2020; 122:499-504. [PMID: 32827811 DOI: 10.1016/j.jormas.2020.07.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/13/2020] [Accepted: 07/27/2020] [Indexed: 11/30/2022]
Abstract
The AAOMS in 2014 changed from BRONJ to the term Medication-Related Osteonecrosis of the Jaw (MRONJ), because of the growing number of osteonecrosis cases associated with other antiresorptive and antiangiogenic therapies. Even if the drugs involved are different, the histopathological findings are the same. Colonies of Actinomyces are encountered in most cases. The aim of the present study is to report on Actinomyces prevalence among the cases of MRONJ, taking into consideration also antiresorptive and antiangiogenic therapies in the literature and in our sample between 2005 and 2020. The review was performed using the database Medline the linkage between Actinomyces infection and MRONJ. The retrospective study was conducted on patients between with clinical and radiological manifestations of MRONJ May 2005 and February 2020. A total of 42 articles were found, 30 publications have been taken into consideration for the review. A total of 114 patients have been examined at the Padua Hospital. A total of 101 oncological patients presented the histological confirmation of MRONJ. 83 specimens revealed the presence of Actinomyces infection (82.18%). Actinomyces-associated lesions are frequent and present a wide spectrum of clinical manifestation.
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Affiliation(s)
- A Cerrato
- Unit of Oral Medicine, Pathology and Surgery, Section of Clinical Dentistry, Department of neurosciences, Italy
| | - G Zanette
- Unit of Anesthesiology, Section of Clinical Dentistry, Department of Neurosciences, Italy
| | - M Boccuto
- Unit of Oral Medicine, Pathology and Surgery, Section of Clinical Dentistry, Department of neurosciences, Italy
| | - A Angelini
- Cardiovascular Pathology, University of Padova Medical School, University of Padova, Italy
| | - M Valente
- Cardiovascular Pathology, University of Padova Medical School, University of Padova, Italy
| | - C Bacci
- Unit of Oral Medicine, Pathology and Surgery, Section of Clinical Dentistry, Department of neurosciences, Italy.
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16
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Limones A, Sáez-Alcaide LM, Díaz-Parreño SA, Helm A, Bornstein MM, Molinero-Mourelle P. Medication-related osteonecrosis of the jaws (MRONJ) in cancer patients treated with denosumab VS. zoledronic acid: A systematic review and meta-analysis. Med Oral Patol Oral Cir Bucal 2020; 25:e326-e336. [PMID: 32271321 PMCID: PMC7211372 DOI: 10.4317/medoral.23324] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 02/17/2020] [Indexed: 12/14/2022] Open
Abstract
Background The aim of the present study was to analyse the incidence, risk ratio (RR) and prognoses of two types of medication-related osteonecrosis of the jaws (MRONJ): denosumab-related osteonecrosis of the jaws (DRONJ) and Bisphosphonate-Related Osteonecrosis of the Jaws (BRONJ) in cancer patients under treatment with denosumab or zoledronic acid (ZA).
Material and Methods An electronic and manual search was conducted for randomized controlled trials (RCTs) until May 2019. Assessment of the identified studies, risk of bias and data extraction were performed independently by two reviewers. The incidence of DRONJ and BRONJ and the RR to develop MRONJ were calculated at 1 year, 2 years and 3 years of exposure. It was also calculated the odds ratio (OR) of their respective prognoses. They were calculated normalizing the values of the individual studies to 1 year, 2 years or 3 years when necessary through robust regression models using a statistical program.
Results From 1.277 references identified, 8 RCTs were included, which comprised a total of 13.857 patients with a variety of neoplasms. The incidence of DRONJ in cancer patients under treatment with denosumab ranged from 0.5 to 2.1% after 1 year, 1.1 to 3.0% after 2 years, and 1.3 to 3.2% after 3 years of exposure. The incidence of BRONJ in cancer patients under treatment with ZA ranged from 0.4 to 1.6% after 1 year of exposure, 0.8 to 2.1% after 2 years, and 1.0 to 2.3% after 3 years of exposure. Statistically significant differences were found between denosumab and ZA in the risk of developing MRONJ after 1, 2 and 3 years of exposure. Nevertheless, there were no significant differences in terms of patient prognosis.
Conclusions Denosumab is associated with a significantly higher risk of developing MRONJ compared to ZA. Nevertheless, no differences were found in its prognoses. Key words:Denosumab, zoledronic acid, bisphosphonate-associated osteonecrosis of the Jaws, medication-related osteonecrosis of the jaws, neoplasms.
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17
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Messer JG, Castillo EJ, Abraham AM, Jiron JM, Israel R, Yarrow JF, Thomas S, Reynolds MC, Wnek RD, Jorgensen M, Wanionok N, Van Poznak C, Bhattacharyya I, Kimmel DB, Aguirre JI. Anti-vascular endothelial growth factor antibody monotherapy causes destructive advanced periodontitis in rice rats (Oryzomys palustris). Bone 2020; 130:115141. [PMID: 31707108 PMCID: PMC6941430 DOI: 10.1016/j.bone.2019.115141] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 10/15/2019] [Accepted: 11/04/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Angiogenesis inhibitors (AgI) are commonly used in combination chemotherapy protocols to treat cancer, and have been linked to osteonecrosis of the jaw (ONJ). However, it is unknown if AgI therapy alone is sufficient to induce ONJ. We have previously established an ONJ model in rice rats with localized periodontitis that receive zoledronic acid (ZOL). The purpose of this study was to use this model to determine the role of anti-vascular endothelial growth factor A (anti-VEGF) antibody treatment of rice rats with localized maxillary periodontitis. We hypothesized that rice rats with localized maxillary periodontitis given anti-VEGF monotherapy will develop oral lesions that resemble ONJ, defined by exposed, necrotic alveolar bone. METHODS At age 4 weeks, 45 male rice rats were randomized into three groups (n = 15): 1) VEH (saline), 2) ZOL (80 μg/kg body weight, intravenously once monthly), and 3) anti-VEGF (5 mg B20-4.1.1/kg body weight, subcutaneously twice weekly). After 24 weeks, rats were euthanized, jaws were excised and a high-resolution photograph of each quadrant was taken to assign a severity grade based on gross appearance. Jaws were then fixed, scanned by MicroCT, decalcified and sectioned for histopathologic and immunohistochemical analyses. RESULTS 40-80% of the rats in the three groups developed gross oral lesions. 50% of ZOL rats developed ONJ. In contrast, 80% of the anti-VEGF rats developed destructive advanced periodontitis that was characterized by extreme alveolar bone loss and fibrosis. Anti-VEGF rats never developed exposed, necrotic bone. Furthermore, only anti-VEGF rats developed mild to severe mandibular periodontitis. Compared to VEH rats, more T-cells were found in periodontal lesions of anti-VEGF rats and more cells of the monocyte lineage were found in ONJ lesions of ZOL rats. CONCLUSIONS Anti-VEGF monotherapy administered to a validated rodent model of ONJ caused a destructive advanced form of periodontitis that differed significantly from ONJ.
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Affiliation(s)
- J G Messer
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - E J Castillo
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - A M Abraham
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - J M Jiron
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - R Israel
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - J F Yarrow
- Research Service, VA Medical Center, Gainesville, FL, United States of America; Division of Endocrinology, Diabetes, and Metabolism, University of Florida College of Medicine, Gainesville, FL, United States of America.
| | - S Thomas
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - M C Reynolds
- Research Service, VA Medical Center, Gainesville, FL, United States of America
| | - R D Wnek
- Research Service, VA Medical Center, Gainesville, FL, United States of America
| | - M Jorgensen
- Department of Pediatrics, College of Medicine, UF, United States of America.
| | - N Wanionok
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America
| | - C Van Poznak
- University of Michigan, Ann Arbor, MI, United States of America.
| | - I Bhattacharyya
- Department of Oral & Maxillofacial Diagnostic Sciences, College of Dentistry, UF, United States of America.
| | - D B Kimmel
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - J I Aguirre
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
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Pharmacogenetics of medication-related osteonecrosis of the jaw: a systematic review and meta-analysis. Int J Oral Maxillofac Surg 2019; 49:298-309. [PMID: 31445964 DOI: 10.1016/j.ijom.2019.07.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/23/2019] [Accepted: 07/25/2019] [Indexed: 02/05/2023]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a severe complication that can develop in patients treated with anti-resorptive drugs. Although the pathogenesis of MRONJ is still unclear, genetic factors have a demonstrated important role. Thus, the aim of this study was to perform a systematic review on the pharmacogenetics of MRONJ. Studies published until March 2019 were retrieved from eight databases and were selected by two independent reviewers. Evidence on several genetic polymorphisms was summarized and a meta-analysis was conducted when possible. Fourteen studies involving 1515 participants were eligible for systematic review. For CYP2C8 rs1934951, no significant difference was observed between the MRONJ and non-MRONJ groups (odds ratio (OR) 2.04, 95% confidence interval (CI) 0.88-4.73, P=0.09). However, a subgroup analysis based on only multiple myeloma status showed a positive association (OR 3.64, 95% CI 1.29-10.30, P=0.01). PPARG rs1152003 was not differently distributed between groups (OR 0.25, 95% CI 0.01-9.92, P=0.46). Also, VEGF rs3025039 was found to be correlated with the occurrence of MRONJ (OR 0.35, 95% CI 0.15-0.82, P=0.02). CYP2C8 rs1934951 (in multiple myeloma patients) and VEGF rs3025039 are associated with the development of MRONJ in patients treated with bisphosphonates. The results are promising and call for new trials with a larger sample to further explore this growing field.
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Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society* Clinical Practice Guideline. J Clin Endocrinol Metab 2019; 104:1595-1622. [PMID: 30907953 DOI: 10.1210/jc.2019-00221] [Citation(s) in RCA: 392] [Impact Index Per Article: 78.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 01/28/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective is to formulate clinical practice guidelines for the pharmacological management of osteoporosis in postmenopausal women. CONCLUSIONS Evidence from clinical trials and insights from clinical experience with pharmacologic therapies for osteoporosis were critically evaluated in formulating this guideline for the management of postmenopausal osteoporosis. Patient preferences, data on adherence and persistence, and risks and benefits from the patient and provider perspectives were also considered in writing committee deliberations. A consensus by the Writing Committee members was achieved for four management principles: (i) The risk of future fractures in postmenopausal women should be determined using country-specific assessment tools to guide decision-making. (ii) Patient preferences should be incorporated into treatment planning. (iii) Nutritional and lifestyle interventions and fall prevention should accompany all pharmacologic regimens to reduce fracture risk. (iv) Multiple pharmacologic therapies are capable of reducing fracture rates in postmenopausal women at risk with acceptable risk-benefit and safety profiles.
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Affiliation(s)
| | | | - Dennis M Black
- University of California San Francisco, San Francisco, California
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minnesota
| | - Dolores Shoback
- Endocrine Research Unit, San Francisco Veterans Affairs Medical Center, San Francisco, California
- Department of Medicine, University of California San Francisco, San Francisco, California
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20
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Messer JG, Jiron JM, Mendieta Calle JL, Castillo EJ, Israel R, Phillips EG, Yarrow JF, Van Poznak C, Kesavalu L, Kimmel DB, Aguirre JI. Zoledronate treatment duration is linked to bisphosphonate-related osteonecrosis of the jaw prevalence in rice rats with generalized periodontitis. Oral Dis 2019; 25:1116-1135. [PMID: 30712276 PMCID: PMC6487955 DOI: 10.1111/odi.13052] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 01/23/2019] [Accepted: 01/27/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To determine the extent that zoledronate (ZOL) dose and duration is associated with bisphosphonate-related osteonecrosis of the jaw (BRONJ) prevalence in rice rats with generalized periodontitis (PD), characterize structural and tissue-level features of BRONJ-like lesions in this model, and examine the specific anti-resorptive role of ZOL in BRONJ. MATERIALS AND METHODS Rice rats (n = 228) consumed high sucrose-casein diet to enhance generalized PD. Groups of rats received 0, 8, 20, 50 or 125 µg/kg IV ZOL/4 weeks encompassing osteoporosis and oncology ZOL doses. Rats from each dose group (n = 9-16) were necropsied after 12, 18, 24 and 30 weeks of treatment. BRONJ-like lesion prevalence and tissue-level features were assessed grossly, histopathologically and by MicroCT. ZOL bone turnover effects were assessed by femoral peripheral quantitative computed tomography, serum bone turnover marker ELISAs and osteoclast immunolabelling. RESULTS Prevalence of BRONJ-like lesions was significantly associated with (a) ZOL treatment duration, but plateaued at the lowest oncologic dose, and (b) there was a similar dose-related plateau in the systemic anti-resorptive effect of ZOL. ZOL and BRONJ-like lesions also altered the structural and tissue-level features of the jaw. CONCLUSION The relationship between BRONJ-like lesion prevalence and ZOL dose and duration varies depending on the co- or pre-existing oral risk factor. At clinically relevant doses of ZOL, BRONJ-like lesions are associated with anti-resorptive activity.
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Affiliation(s)
- Jonathan G Messer
- Department of Physiological Sciences, University of Florida, Gainesville, Florida
| | - Jessica M Jiron
- Department of Physiological Sciences, University of Florida, Gainesville, Florida
| | | | - Evelyn J Castillo
- Department of Physiological Sciences, University of Florida, Gainesville, Florida
| | - Ronnie Israel
- Department of Physiological Sciences, University of Florida, Gainesville, Florida
| | - Ean G Phillips
- Research Service, VA Medical Center, Gainesville, Florida
| | | | | | - Lakshmyya Kesavalu
- Department of Periodontology and Oral Biology, College of Dentistry, Gainesville, Florida
| | - Donald B Kimmel
- Department of Physiological Sciences, University of Florida, Gainesville, Florida
| | - J Ignacio Aguirre
- Department of Physiological Sciences, University of Florida, Gainesville, Florida
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21
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Diniz-Freitas M, Fernández-Feijoo J, Diz Dios P, Pousa X, Limeres J. Denosumab-related osteonecrosis of the jaw following non-surgical periodontal therapy: A case report. J Clin Periodontol 2018; 45:570-577. [DOI: 10.1111/jcpe.12882] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2018] [Indexed: 01/28/2023]
Affiliation(s)
- Márcio Diniz-Freitas
- Medical-Surgical Dentistry Research Group (OMEQUI); Health Research Institute of Santiago de Compostela (IDIS); University of Santiago de Compostela (USC); Santiago de Compostela Spain
| | - Javier Fernández-Feijoo
- Medical-Surgical Dentistry Research Group (OMEQUI); Health Research Institute of Santiago de Compostela (IDIS); University of Santiago de Compostela (USC); Santiago de Compostela Spain
| | - Pedro Diz Dios
- Medical-Surgical Dentistry Research Group (OMEQUI); Health Research Institute of Santiago de Compostela (IDIS); University of Santiago de Compostela (USC); Santiago de Compostela Spain
| | - Xiana Pousa
- Periodontology Unit; School of Medicine and Dentistry; University of Santiago de Compostela (USC); Santiago de Compostela Spain
| | - Jacobo Limeres
- Medical-Surgical Dentistry Research Group (OMEQUI); Health Research Institute of Santiago de Compostela (IDIS); University of Santiago de Compostela (USC); Santiago de Compostela Spain
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22
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Messer JG, Mendieta Calle JL, Jiron JM, Castillo EJ, Van Poznak C, Bhattacharyya N, Kimmel DB, Aguirre JI. Zoledronic acid increases the prevalence of medication-related osteonecrosis of the jaw in a dose dependent manner in rice rats (Oryzomys palustris) with localized periodontitis. Bone 2018; 108:79-88. [PMID: 29289789 PMCID: PMC5828169 DOI: 10.1016/j.bone.2017.12.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 12/15/2017] [Accepted: 12/27/2017] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Investigate role of dose/duration of zoledronic acid (ZOL), a powerful anti-resorptive (pAR), on prevalence of medication-related osteonecrosis of the jaw (MRONJ) in rice rats (Oryzomys palustris), a species with natural susceptibility to food impaction-induced localized periodontitis (FILP). We hypothesize that ZOL induces MRONJ lesions in rice rats with FILP, and that the prevalence of MRONJ rises with increasing dose and duration of ZOL treatment. METHODS We performed a toxicology experiment with clinically-relevant doses of ZOL in female rats (N=230) fed standard (STD) rodent chow. At age 4weeks (baseline), 12 rats were necropsied. The rest were randomized into five groups that began to receive 0, 8, 20, 50 or 125μg/kg ZOL IV/q 4weeks. After 12, 18, 24 and 30weeks, subgroups (N=9-16) from each of the dose groups were necropsied. High-resolution macroscopic photos of all jaw quadrants were given a gross quadrant grade (GQG) (0-4 or MRONJ) that classified FILP lesion severity and determined presence of gross MRONJ. Quadrants with GQG≥1 were examined histopathologically. Logistic regression analysis (ZOL dose/duration) of MRONJ prevalence was completed. RESULTS We found: 1) 75% of 0μg/kg ZOL rats developed FILP lesions; 2) baseline rats and rats treated with 0μg/kg ZOL had no MRONJ; 3) 29 gross MRONJ cases were identified; 4) all gross MRONJ cases were confirmed histopathologically by the observation of exposed necrotic bone, and 53 new cases were discovered (total=82); 5) ZOL dose (P<0.001), but not duration (P=0.326), was a significant predictor of MRONJ prevalence; 6) 13% prevalence of gross MRONJ among all rats, with 22% prevalence among rats exposed to ZOL oncologic doses (20-125μg/kg); 7) 38% prevalence of histopathologic MRONJ among all rats, with 73% prevalence among rats exposed to ZOL oncologic doses. CONCLUSIONS This is the first experiment to show a dose response relationship between clinically relevant doses of ZOL and MRONJ prevalence.
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Affiliation(s)
- J G Messer
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States.
| | - J L Mendieta Calle
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States.
| | - J M Jiron
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States.
| | - E J Castillo
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States.
| | - C Van Poznak
- University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, United States.
| | - N Bhattacharyya
- Department of Oral & Maxillofacial Diagnostic Sciences, College of Dentistry, UF, United States.
| | - D B Kimmel
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States
| | - J I Aguirre
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States.
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Hoefert S, Yuan A, Munz A, Grimm M, Elayouti A, Reinert S. Clinical course and therapeutic outcomes of operatively and non-operatively managed patients with denosumab-related osteonecrosis of the jaw (DRONJ). J Craniomaxillofac Surg 2017; 45:570-578. [DOI: 10.1016/j.jcms.2017.01.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 11/28/2016] [Accepted: 01/16/2017] [Indexed: 10/20/2022] Open
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Khan AA, Morrison A, Kendler DL, Rizzoli R, Hanley DA, Felsenberg D, McCauley LK, O'Ryan F, Reid IR, Ruggiero SL, Taguchi A, Tetradis S, Watts NB, Brandi ML, Peters E, Guise T, Eastell R, Cheung AM, Morin SN, Masri B, Cooper C, Morgan SL, Obermayer-Pietsch B, Langdahl BL, Dabagh RA, Davison KS, Sándor GK, Josse RG, Bhandari M, El Rabbany M, Pierroz DD, Sulimani R, Saunders DP, Brown JP, Compston J. Case-Based Review of Osteonecrosis of the Jaw (ONJ) and Application of the International Recommendations for Management From the International Task Force on ONJ. J Clin Densitom 2017; 20:8-24. [PMID: 27956123 DOI: 10.1016/j.jocd.2016.09.005] [Citation(s) in RCA: 138] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Osteonecrosis of the jaw (ONJ) has been associated with antiresorptive therapy in both oncology and osteoporosis patients. This debilitating condition is very rare and advances in diagnosis and management may now effectively reduce the risk of its development and offer valuable treatment options for affected patients. This paper provides a case-based review of ONJ and application of the International Task Force on ONJ (referred to as the "Task Force") recommendations for the diagnosis and management of ONJ. The Task Force was supported by 14 international societies and achieved consensus from representatives of these multidisciplinary societies on key issues pertaining to the diagnosis and management of ONJ. The frequency of ONJ in oncology patients receiving oncology doses of bisphosphonate (BP) or denosumab is estimated at 1%-15%, and the frequency in the osteoporosis patient population receiving much lower doses of BP or denosumab is estimated at 0.001%-0.01%. Although the diagnosis of ONJ is primarily clinical, imaging may be helpful in confirming the diagnosis and staging. In those with multiple risk factors for ONJ for whom major invasive oral surgery is being planned, interruption of BP or denosumab therapy (in cancer patients) is advised, if possible, before surgery, until the surgical site heals. Major oral surgery in this context could include multiple extractions if surgical extractions are required, not simple forceps extractions. ONJ development may be reduced by optimizing oral hygiene and postoperatively using topical and systemic antibiotics as appropriate. Periodontal disease should be managed before starting oncology doses of BP or denosumab. Local debridement may be successful in disease unresponsive to conservative therapy. Successful surgical intervention has been reported in those with stage 3 disease; less severe disease is best managed conservatively. Teriparatide may be helpful in healing ONJ lesions and may be considered in osteoporosis patients at a high fracture risk in the absence of contraindications. Resumption of BP or denosumab therapy following healing of ONJ lesions is recommended, and there have not been reports of subsequent local recurrence.
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Affiliation(s)
- Aliya A Khan
- Department of Medicine, Divisions of Endocrinology and Metabolism and Geriatrics, McMaster University, Hamilton, ON, Canada.
| | - Archie Morrison
- Division of Oral and Maxillofacial Surgery, Dalhousie University, Halifax, NS, Canada
| | - David L Kendler
- Department of Medicine, Division of Endocrinology, University of British Columbia, Vancouver, BC, Canada
| | - Rene Rizzoli
- Division of Bone Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - David A Hanley
- Departments of Medicine, Community Health Sciences and Oncology, University of Calgary, Calgary, AB, Canada
| | - Dieter Felsenberg
- Centre of Muscle & Bone Research, Charité-University Medicine Berlin, Campus Benjamin Franklin, Free University & Humboldt University Berlin, Berlin, Germany
| | - Laurie K McCauley
- Department of Periodontics and Oral Medicine, University of Michigan School of Dentistry, Ann Arbor, MI, USA
| | - Felice O'Ryan
- Division of Maxillofacial Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Ian R Reid
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Salvatore L Ruggiero
- Division of Oral and Maxillofacial Surgery, Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA; Stony Brook School of Dental Medicine, Stony Brook, NY, USA; New York Center for Orthognathic and Maxillofacial Surgery, New York, NY, USA
| | - Akira Taguchi
- Department of Oral and Maxillofacial Radiology, School of Dentistry, Matsumoto Dental University, Shojiri, Japan
| | - Sotirios Tetradis
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| | - Nelson B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA
| | - Maria Luisa Brandi
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Edmund Peters
- Department of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Teresa Guise
- Department of Medicine, Division of Endocrinology at Indiana University, Indianapolis, IN, USA
| | - Richard Eastell
- Department of Human Metabolism, University of Sheffield, Sheffield, UK
| | - Angela M Cheung
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Centre of Excellence in Skeletal Health Assessment, Joint Department of Medical Imaging, University Health Network (UHN), Toronto, ON, Canada; Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Suzanne N Morin
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Basel Masri
- Jordan Osteoporosis Center, Jordan Hospital & Medical Center, Amman, Jordan
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK; NIHR Nutrition Biomedical Research Centre, University of Southampton, Southampton, UK; NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - Sarah L Morgan
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham Osteoporosis Prevention and Treatment Clinic, Birmingham, AL, USA
| | - Barbara Obermayer-Pietsch
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Bente L Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Rana Al Dabagh
- Faculty of Dentistry, University of Toronto, Toronto, Canada
| | - K Shawn Davison
- Department of Education, University of Victoria,Victoria, BC, Canada
| | - George K Sándor
- Department of Oral and Maxillofacial Surgery, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Robert G Josse
- Division of Endocrinology and Metabolism, University of Toronto, Toronto, ON, Canada
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | | | | | - Riad Sulimani
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Deborah P Saunders
- Department of Dental Oncology, Northeast Cancer Centre/Health Science North, Sudbury, ON, Canada
| | - Jacques P Brown
- Rheumatology Division, CHU de Québec Research Centre, Laval University, Quebec City, QC, Canada
| | - Juliet Compston
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
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Denosumab Related Osteonecrosis of the Jaw with Spontaneous Necrosis of the Soft Palate: Report of a Life Threatening Case. Case Rep Dent 2016; 2016:5070187. [PMID: 27648313 PMCID: PMC5018314 DOI: 10.1155/2016/5070187] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 05/25/2016] [Accepted: 05/26/2016] [Indexed: 01/20/2023] Open
Abstract
Bisphosphonates have been used for years in the treatment of patients with distant bony metastasis and in the prevention of osteoporosis. One of main side effects of these medications is the development of bisphosphonate related osteonecrosis of the jaw (BRONJ) in a small subset of patients. A new class of medications with a shorter half-life, known as receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitors, was introduced with the hopes of avoiding this side effect. However, reports of osteonecrosis of the jaw after the use of RANKL inhibitors have also been documented. We report on a patient who developed a life threatening osteonecrosis of the jaw with sepsis shortly after switching from a bisphosphonate to a RANKL inhibitor for osteoporosis treatment. This patient developed several soft tissue defects including spontaneous necrosis of the soft palate. To our knowledge this is the first time this presentation has been described.
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de Souza Póvoa RC, Marlierè DAA, da Silveira HM, Pires FR. Denosumab-related osteonecrosis of the jaws: successful management with a conservative surgical approach. SPECIAL CARE IN DENTISTRY 2016; 36:231-6. [PMID: 26859582 DOI: 10.1111/scd.12168] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Denosumab-related osteonecrosis of the jaws (DRONJ) is a recently described entity that shares many common clinical and radiological features with bisphosphonate-related osteonecrosis of the jaws (BRONJ). The aim of the present study is to report a case of DRONJ affecting the anterior mandible of a 58-year-old male treated with denosumab to prevent skeletal-related events associated with prostate cancer. Conservative surgery in conjunction with antibiotic therapy and discontinuation of denosumab use were effective in managing the condition and the patient remains free of clinical and radiological changes after a 38 month follow-up.
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Affiliation(s)
| | - Daniel Amaral Alves Marlierè
- Resident, Oral and Maxillofacial Surgery, Pedro Ernesto University Hospital, State University of Rio de Janeiro, Brazil
| | - Henrique Martins da Silveira
- Adjunct Professor, Oral and Maxillofacial Surgery, Pedro Ernesto University Hospital, State University of Rio de Janeiro, Brazil
| | - Fábio Ramoa Pires
- Associate Professor, Oral Pathology, School of Dentistry, State University of Rio de Janeiro, Brazil
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Domschke C, Schuetz F. Side effects of bone-targeted therapies in advanced breast cancer. ACTA ACUST UNITED AC 2015; 9:332-6. [PMID: 25759613 DOI: 10.1159/000368844] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In up to 75% of cases, advanced breast cancer patients eventually develop bone metastases with often debilitating skeletal-related events (SREs). Osteoclast inhibitors are commonly used as therapeutic mainstay with clinical studies showing superiority of denosumab over bisphosphonates (e.g., zoledronate) for the prevention of SREs. The present review discusses the adverse event profile of these agents, and addresses the prevention and management of untoward side effects. Adverse events associated with osteoclast inhibitors comprise osteonecrosis of the jaw and hypocalcemia. Hypocalcemia is more common with denosumab, particularly in severe renal dysfunction. During therapy, the appropriate prevention of these adverse events includes close attention to dental health, avoidance of invasive dental procedures, supplementation with calcium and vitamin D unless patients are hypercalcemic, and regular monitoring of relevant serum values. Relating to the risk of nephrotoxicity, bisphosphonates but not denosumab have been incriminated. Therefore, serum creatinine levels should be checked prior to each dose of zoledronate, and in severe renal dysfunction (creatinine clearance < 30 ml/min) zoledronate is contraindicated anyway. Acute-phase reactions are particularly linked to bisphosphonates. Consequently, if these adverse events predominate, switching to denosumab is recommended.
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Affiliation(s)
- Christoph Domschke
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian Schuetz
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Heidelberg, Germany
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Johnson RW, Schipani E, Giaccia AJ. HIF targets in bone remodeling and metastatic disease. Pharmacol Ther 2015; 150:169-77. [PMID: 25681658 DOI: 10.1016/j.pharmthera.2015.02.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 01/21/2015] [Indexed: 12/16/2022]
Abstract
The bone marrow is a hypoxic microenvironment that is rich in growth factors and blood vessels and is readily colonized by tumor cells disseminated from numerous cancers including tumors of the breast, prostate, lung, and skin. The origin of metastatic growth promoting factors for tumor cells disseminated to the bone marrow is derived from multiple sources: the bone matrix, which is a reservoir for growth factors, and cells residing in the marrow and along bone surfaces, such as osteoblasts, osteoclasts, macrophages, and T cells, which secrete cytokines and chemokines. Low oxygen levels within the bone marrow induce hypoxia signaling pathways such as hypoxia inducible factor (HIF), which is regulated by oxygen requiring prolyl hydroxylases (PHDs) and von Hippel-Lindau (VHL) tumor suppressor. These hypoxia signaling pathways have profound effects on bone development and homeostasis. Likewise, hypoxic conditions observed in local breast and prostate tumors point to a role for hypoxia-inducible genes in metastasis to and colonization of the bone marrow. This review will explore the role of hypoxia-regulated factors in bone development and remodeling, and how these elements may contribute to solid tumor metastasis to the bone.
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Affiliation(s)
- Rachelle W Johnson
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, United States
| | - Ernestina Schipani
- Department of Orthopaedic Surgery, Medical School, University of Michigan, Ann Arbor, MI, United States; Department of Medicine and Endocrinology, Medical School, University of Michigan, Ann Arbor, MI, United States
| | - Amato J Giaccia
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, United States.
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Boquete-Castro A, Gómez-Moreno G, Calvo-Guirado JL, Aguilar-Salvatierra A, Delgado-Ruiz RA. Denosumab and osteonecrosis of the jaw. A systematic analysis of events reported in clinical trials. Clin Oral Implants Res 2015; 27:367-75. [DOI: 10.1111/clr.12556] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2014] [Indexed: 01/22/2023]
Affiliation(s)
- Ana Boquete-Castro
- Department of Pharmacological Research in Dentistry; Faculty of Dentistry; University of Granada; Granada Spain
| | - Gerardo Gómez-Moreno
- Department of Pharmacological Research in Dentistry; Periodontology and Implant Dentistry; Special Care in Dentistry; Faculty of Dentistry; University of Granada; Granada Spain
| | - José Luis Calvo-Guirado
- Department of Implant Dentistry; Implant Dentistry and Biomaterials; School of Medicine and Dentistry; University of Murcia; Murcia Spain
| | - Antonio Aguilar-Salvatierra
- Department of Pharmacological Research in Dentistry; Periodontology and Implant Dentistry; Faculty of Dentistry; University of Granada; Granada Spain
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Khan AA, Morrison A, Hanley DA, Felsenberg D, McCauley LK, O'Ryan F, Reid IR, Ruggiero SL, Taguchi A, Tetradis S, Watts NB, Brandi ML, Peters E, Guise T, Eastell R, Cheung AM, Morin SN, Masri B, Cooper C, Morgan SL, Obermayer-Pietsch B, Langdahl BL, Al Dabagh R, Davison KS, Kendler DL, Sándor GK, Josse RG, Bhandari M, El Rabbany M, Pierroz DD, Sulimani R, Saunders DP, Brown JP, Compston J. Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensus. J Bone Miner Res 2015; 30:3-23. [PMID: 25414052 DOI: 10.1002/jbmr.2405] [Citation(s) in RCA: 818] [Impact Index Per Article: 90.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 11/03/2014] [Accepted: 11/05/2014] [Indexed: 11/08/2022]
Abstract
This work provides a systematic review of the literature from January 2003 to April 2014 pertaining to the incidence, pathophysiology, diagnosis, and treatment of osteonecrosis of the jaw (ONJ), and offers recommendations for its management based on multidisciplinary international consensus. ONJ is associated with oncology-dose parenteral antiresorptive therapy of bisphosphonates (BP) and denosumab (Dmab). The incidence of ONJ is greatest in the oncology patient population (1% to 15%), where high doses of these medications are used at frequent intervals. In the osteoporosis patient population, the incidence of ONJ is estimated at 0.001% to 0.01%, marginally higher than the incidence in the general population (<0.001%). New insights into the pathophysiology of ONJ include antiresorptive effects of BPs and Dmab, effects of BPs on gamma delta T-cells and on monocyte and macrophage function, as well as the role of local bacterial infection, inflammation, and necrosis. Advances in imaging include the use of cone beam computerized tomography assessing cortical and cancellous architecture with lower radiation exposure, magnetic resonance imaging, bone scanning, and positron emission tomography, although plain films often suffice. Other risk factors for ONJ include glucocorticoid use, maxillary or mandibular bone surgery, poor oral hygiene, chronic inflammation, diabetes mellitus, ill-fitting dentures, as well as other drugs, including antiangiogenic agents. Prevention strategies for ONJ include elimination or stabilization of oral disease prior to initiation of antiresorptive agents, as well as maintenance of good oral hygiene. In those patients at high risk for the development of ONJ, including cancer patients receiving high-dose BP or Dmab therapy, consideration should be given to withholding antiresorptive therapy following extensive oral surgery until the surgical site heals with mature mucosal coverage. Management of ONJ is based on the stage of the disease, size of the lesions, and the presence of contributing drug therapy and comorbidity. Conservative therapy includes topical antibiotic oral rinses and systemic antibiotic therapy. Localized surgical debridement is indicated in advanced nonresponsive disease and has been successful. Early data have suggested enhanced osseous wound healing with teriparatide in those without contraindications for its use. Experimental therapy includes bone marrow stem cell intralesional transplantation, low-level laser therapy, local platelet-derived growth factor application, hyperbaric oxygen, and tissue grafting.
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Capozzi A, Lello S, Pontecorvi A. The inhibition of RANK-ligand in the management of postmenopausal osteoporosis and related fractures: the role of denosumab. Gynecol Endocrinol 2014; 30:403-8. [PMID: 24592987 DOI: 10.3109/09513590.2014.892067] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
There is great interest in new treatments of osteoporosis owing to general ageing of population and increased risk for fragility fractures in the elderly. Current therapies show a good efficacy in improving bone quality and bone density, but, in spite of a certain reduction in fracture rate, according to each treatment, the problem of osteoporotic fractures is yet far from to be solved. Moreover, some treatments may produce different side effects. Denosumab (Dmab), a receptor activator of nuclear factor kappa-B ligand (RANKL)-inhibitor, is an agent recently introduced in clinical practice for treatment of osteoporosis of postmenopausal women. Dmab has improved bone mineral density and prevented new vertebral and non-vertebral fractures with a similar efficacy in comparison with alendronate. Many clinical studies showed Dmab produces also significant improvement versus placebo in bone quality as indicated by decreasing markers of bone turnover. Patients using Dmab reported less risk of AFF (Atypical Femoral Fractures) and ONJ (Osteonecrosis of the Jaw) with an increased number of cellulitis. Here, we review articles using Dmab for female post-menopausal osteoporosis.
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Affiliation(s)
- Anna Capozzi
- Department of Endocrinology and Metabolism, Catholic University of Rome , Rome , Italy and
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Effect of antiresorptive drugs on bony turnover in the jaw: denosumab compared with bisphosphonates. Br J Oral Maxillofac Surg 2014; 52:308-13. [DOI: 10.1016/j.bjoms.2014.01.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 01/31/2014] [Indexed: 11/22/2022]
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Rementer CW, Wu M, Buranaphatthana W, Yang HYL, Scatena M, Giachelli CM. An inducible, ligand-independent receptor activator of NF-κB gene to control osteoclast differentiation from monocytic precursors. PLoS One 2013; 8:e84465. [PMID: 24386387 PMCID: PMC3874012 DOI: 10.1371/journal.pone.0084465] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 11/22/2013] [Indexed: 12/28/2022] Open
Abstract
Osteoclasts are bone-resorbing cells that are critical for the normal formation and maintenance of teeth and skeleton. Osteoclast deficiency can contribute to heterotopic ossification (HO), a pathology that is particularly detrimental to the mechanical functions of joints, valves and blood vessels. On the other hand, osteoclast over-activity is a major cause of osteoporosis. A reliable method for controlled generation of osteoclasts would be useful as a potential autologous cell therapy for HO, as well as high-throughput drug screening for anti-osteoporotic drugs. In this report, we describe the development of a cell engineering approach to control monocytic precursor cell differentiation to osteoclasts. Oligomerization of receptor activator of nuclear factor κB (RANK) is known to be essential for osteoclast differentiation from monocyte/macrophage precursors. We engineered a murine monocytic cell line, RAW264.7 to express a fusion protein comprising the intracellular RANK signaling domain and FK506-derived dimerization domains that bind to a small molecule chemical inducer of dimerization (CID). Virally infected cells expressing this fusion protein were treated with CID and dose-dependent induction of tartrate-resistant acid phosphatase activity, as well as multinucleated osteoclast formation were observed. Furthermore, NF-κB signaling was upregulated in a CID-dependent fashion, demonstrating effective RANK intracellular signaling. Functionally CID-induced osteoclasts had robust mineral resorptive activity in both two-dimensional and three-dimensional in vitro resorption assays. In addition, the CID-induced osteoclasts have the same life span as native RANKL-induced osteoclasts. Most importantly and crucially, the engineered cells differentiated into osteoclasts that were resistant to the potent osteoclast inhibitor, osteoprotegerin. Taken together, these studies are the first to describe a method for inducible control of monocytic precursor differentiation to osteoclasts that may be useful for future development of an engineered autologous cell therapy as well as high-throughput drug testing systems to treat diseases of osteoclast over-activity that are independent of osteoprotegerin.
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Affiliation(s)
- Cameron W. Rementer
- Department of Bioengineering, University of Washington, Seattle, Washington, United States of America
| | - Meiting Wu
- Department of Bioengineering, University of Washington, Seattle, Washington, United States of America
| | - Worakanya Buranaphatthana
- Department of Oral Health Sciences, University of Washington, Seattle, Washington, United States of America
| | - Hsueh-Ying L. Yang
- Department of Bioengineering, University of Washington, Seattle, Washington, United States of America
| | - Marta Scatena
- Department of Bioengineering, University of Washington, Seattle, Washington, United States of America
| | - Cecilia M. Giachelli
- Department of Bioengineering, University of Washington, Seattle, Washington, United States of America
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Rossini M, Adami S, Viapiana O, Tripi G, Zanotti R, Ortolani R, Vella A, Troplini S, Gatti D. Acute phase response after zoledronic acid is associated with long-term effects on white blood cells. Calcif Tissue Int 2013; 93:249-52. [PMID: 23748711 DOI: 10.1007/s00223-013-9750-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Accepted: 05/15/2013] [Indexed: 10/26/2022]
Abstract
We have recently reported a long-lasting decrease in circulating γδ T cells in osteoporotic patients on oral amino-bisphosphonates (N-BPs). Here we verify whether these changes are associated with the occurrence of acute phase response (APR) to intravenous (IV) zoledronic acid (ZOL) or changes of other circulating white blood cells (WBC). WBC count was obtained before and 1 year after a single IV administration of 5 mg ZOL in 36 osteoporotic patients (mean age 72 ± 9, range 45-86 years) without other relevant diseases; 12 of 36 patients developed the classical APR. After 1 year in the patients who experienced an APR, but not in the others, a significant decrease not only of γδ T cells (-30 %), but also of total lymphocytes (-11 %) and eosinophils (-27 %), was observed. The mechanism leading to the observed decrease of circulating lymphocytes and eosinophils remains unclear, but our observation opens a new frontier for the understanding of the immunoeffects of N-BPs.
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Affiliation(s)
- Maurizio Rossini
- Rheumatology Section, Department of Medicine, University of Verona, Italy.
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Verron E, Bouler JM. Is bisphosphonate therapy compromised by the emergence of adverse bone disorders? Drug Discov Today 2013; 19:312-9. [PMID: 23974069 DOI: 10.1016/j.drudis.2013.08.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 07/12/2013] [Accepted: 08/14/2013] [Indexed: 01/22/2023]
Abstract
Bisphosphonates (BPs) are the preferred class of antiresorptive agents used for the treatment of osteoporosis and bone metastases. Recently, an increasing number of clinical reports concerning osteonecrosis of the jaw and atypical fractures have suggested a link between prolonged use of BPs and these adverse bone events, which are exceptionally difficult to treat. Even though these side effects were mainly observed in patients with metastases, osteoporotic patients might become increasingly affected by these conditions with the increasing use of injectable BPs. Could these severe adverse bone events compromise the use of BPs? The development of these unfavorable conditions as a consequence of oversuppression of bone resorption could raise concern regarding the use of therapeutic strategies involving antiresorptive drugs.
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Affiliation(s)
- E Verron
- Université de Nantes, INSERM UMR 791, LIOAD, Faculté de Chirurgie Dentaire, BP 84215, 44042 Nantes Cedex 1, France.
| | - J M Bouler
- Université de Nantes, INSERM UMR 791, LIOAD, Faculté de Chirurgie Dentaire, BP 84215, 44042 Nantes Cedex 1, France
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Van den Wyngaert T, Delforge M, Doyen C, Duck L, Wouters K, Delabaye I, Wouters C, Wildiers H. Prospective observational study of treatment pattern, effectiveness and safety of zoledronic acid therapy beyond 24 months in patients with multiple myeloma or bone metastases from solid tumors. Support Care Cancer 2013; 21:3483-90. [PMID: 23955094 DOI: 10.1007/s00520-013-1934-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 08/05/2013] [Indexed: 11/24/2022]
Abstract
PURPOSE To study the treatment patterns, effectiveness and safety of zoledronic acid (ZOL) beyond 2 years of therapy, given the paucity of data on long-term treatment in daily clinical practice. METHODS Patients with multiple myeloma (MM) or solid tumor bone metastases (STM) and at least 24 months of regular q3-4w ZOL therapy were followed prospectively for an additional 18 months beyond the 24 months required for study entry. End-points included ZOL exposure, incidence of skeletal related events (SRE), and safety. RESULTS In all, 298 evaluable patients were enrolled. The mean continuation rate of ZOL was 90.6%. Exposure to ZOL decreased with time in all patients, but was lower (50.0% vs. 67.6%; p<0.001) and with higher discontinuation rates (incidence rate ratio [IRR]=1.95; p=0.002) in MM compared to the STM group. ZOL suppressed the rate of SREs similarly during the study as compared to before inclusion (0.12 vs. 0.13 events per person-year; p=0.7). At 18 months, 84.5% remained SRE-free. In STM patients, persistent ZOL therapy was associated with lower SRE risk (hazard ratio [HR]=0.42; p=0.01), but not in MM. Renal deterioration occurred in 3.7% and osteonecrosis of the jaw (ONJ) developed in 6.0%, with dental trauma increasing ONJ risk (HR=4.67; p=0.002). CONCLUSIONS Beyond 2 years of therapy, treatment patterns of ZOL were heterogeneous and SRE rates were low. The safety profile of ZOL was acceptable, and interrupting ZOL in patients with solid tumors was associated with a higher risk of SREs.
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Affiliation(s)
- T Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium,
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Anghel R, Bachmann A, Bekşac M, Brodowicz T, Finek J, Komadina R, Krzemieniecki K, Lang I, Marencak J, von Moos R, Pecherstorfer M, Rordorf T, Vrbanec D, Zielinski C. Expert opinion 2011 on the use of new anti-resorptive agents in the prevention of skeletal-related events in metastatic bone disease. Wien Klin Wochenschr 2013; 125:439-47. [PMID: 23832237 DOI: 10.1007/s00508-013-0385-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 05/23/2013] [Indexed: 02/02/2023]
Abstract
Bisphosphonates have been a mainstay in the treatment of cancer-related bone disease and have greatly reduced the risk of skeletal complications. More recently, clinical studies suggested additional benefits of denosumab over zoledronic acid in the prevention of skeletal related events. Similar adverse event profiles have been reported for bisphosphonates and denosumab, with infrequent occurrences of osteonecrosis of the jaw with both agents, higher incidence of renal deterioration with zoledronic acid, and higher incidence of hypocalcaemia with denosumab. Based on current evidence, the American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) guidelines do not recommend one drug class over the other in patients with metastatic bone disease. Denosumab, however, may present advantages over bisphosphonates in patients suffering from chronic renal insufficiency. Further research and growing clinical experience will refine the evidence based on which decisions in daily clinical practice can be taken.
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Malan J, Ettinger K, Naumann E, Beirne OR. The relationship of denosumab pharmacology and osteonecrosis of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 114:671-6. [PMID: 23159111 DOI: 10.1016/j.oooo.2012.08.439] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Revised: 07/09/2012] [Accepted: 08/06/2012] [Indexed: 01/06/2023]
Abstract
Denosumab is a new bone antiresorptive agent that has received approval by the Food and Drug Administration for use in patients with osteoporosis and metastatic cancer to the bones. Like the bisphosponates that are used as antiresorptive medications, denosumab has been associated with osteonecrosis of the jaws (ONJ). However, because the pharmacodynamics and pharmacokinetics of denosumab differ from that of the bisphosphonates, ONJ related to denosumab may resolve more rapidly with a drug holiday than bisphosphonate-related osteonecrosis of the jaws (BRONJ). This paper describes the management of a patient who developed ONJ while receiving denosumab, reviews the incidence of ONJ associated with denosumab, and compares the pharmacology of denosumab and the bisphosphonates. Because the effects of denosumab on bone turnover are more rapidly reversible than the effects of the bisphosphonates, ONJ related to denosumab may resolve more quickly with a drug holiday than BRONJ.
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Qi WX, Tang LN, He AN, Yao Y, Shen Z. Risk of osteonecrosis of the jaw in cancer patients receiving denosumab: a meta-analysis of seven randomized controlled trials. Int J Clin Oncol 2013; 19:403-10. [PMID: 23605142 DOI: 10.1007/s10147-013-0561-6] [Citation(s) in RCA: 129] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 04/09/2013] [Indexed: 01/18/2023]
Abstract
AIMS The aim of this study is to gain a better understanding of the overall incidence and risk of osteonecrosis of the jaw (ONJ) in cancer patients receiving denosumab. METHODS We performed a meta-analysis of relevant randomized controlled trials identified in Pubmed, Embase, and Cochrane databases. Abstracts presented at the conferences were also searched. Overall incidence rates, relative risk (RR), and 95 % confidence intervals (CI) were calculated employing fixed- or random-effects models depending on the heterogeneity of the included trials. RESULTS A total of 8963 patients with a variety of solid tumors from 7 randomized controlled trials (RCTs) were included for the meta-analysis. The overall incidence of ONJ in cancer patients receiving denosumab was 1.7 % [95 % CI: 0.9-3.1 %]. Also, the use of denosumab was associated with significantly increased risk of ONJ in comparison with bisphosphonates (BPs)/placebo treatment (RR 1.61, 95 % CI: 1.05-2.48, P = 0.029). Subgroup analysis based on controlled therapies demonstrated an increased risk of ONJ in denosumab therapy, when compared with BPs (RR 1.48, 95 % CI: 0.96-2.29, P = 0.078) or placebo (RR 16.28, 95 % CI: 1.68-158.05, P = 0.017). Similar results were observed in prostate cancer (RR 3.358, 95 % CI: 1.573-7.166, P = 0.002) while there was a non-significantly increased risk of denosumab-related osteonecrosis of the jaw (DONJ) in non-prostate cancers (RR 1.142, 95 % CI: 0.678-1.921, P = 0.618). CONCLUSIONS The use of denosumab is associated with an increased risk of developing ONJ when compared with BP treatment or placebo, although the increased risk was not statistically significant between denosumab and BP treatment. Further studies are still needed to establish guidelines for the prevention and effective treatment of ONJ.
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Affiliation(s)
- Wei-Xiang Qi
- Department of Oncology, The Sixth People's Hospital, Shanghai Jiao Tong University, No. 600, Yishan Road, Shanghai, 200233, China
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Affiliation(s)
- M Neale Weitzmann
- Atlanta Department of Veterans Affairs Medical Center, Decatur, GA, USA.
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Aguirre JI, Akhter MP, Kimmel DB, Pingel JE, Williams A, Jorgensen M, Kesavalu L, Wronski TJ. Oncologic doses of zoledronic acid induce osteonecrosis of the jaw-like lesions in rice rats (Oryzomys palustris) with periodontitis. J Bone Miner Res 2012; 27:2130-43. [PMID: 22623376 PMCID: PMC3436957 DOI: 10.1002/jbmr.1669] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Though osteonecrosis of the jaw (ONJ) is temporally-associated with the use of nitrogen-containing bisphosphonates (N-BPs), a cause-and-effect relationship has not yet been established. We hypothesize that ONJ is a two-stage process in which: (1) risk factors initiate pathologic processes in the oral cavity that lead to a supranormal rate of hard tissue necrosis; and (2) powerful antiresorptives reduce the rate of removal of necrotic bone sufficiently to allow its net accumulation in the jaw. To test this hypothesis, we used the rice rat model of periodontitis. At age 28 days, rats (n = 15/group) were placed on a high-sucrose and casein diet to exacerbate the development of periodontitis. Animals were injected subcutaneously (SC) biweekly with vehicle or alendronate (ALN, 15 µg/kg), or IV once monthly with vehicle, a low dose (LD) of zoledronic acid (ZOL), or a high dose (HD) of ZOL and sacrificed after 6, 12, 18, and 24 weeks. Mandibles and maxillae were analyzed to determine the effects on the: (1) progression of periodontitis; (2) integrity of alveolar bone; (3) status of bone resorption and formation; (4) vascularity; and (5) osteocyte viability. We found that only HD-ZOL induced ONJ-like lesions in mandibles of rice rats after 18 and 24 weeks of treatment. These lesions were characterized by areas of exposed necrotic alveolar bone, osteolysis, a honeycomb-like appearance of the alveolar bone, presence of bacterial colonies, and periodontal tissue destruction. In addition, inhibition of bone formation, a paradoxical abolition of the antiresorptive effect of only HD-ZOL, increased osteocyte necrosis/apoptosis, and decreased blood vessel number were found after 18 and/or 24 weeks. Our study suggests that only HD-ZOL exacerbates the inflammatory response and periodontal tissue damage in rice rats, inducing bone lesions that resemble ONJ.
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Affiliation(s)
- J Ignacio Aguirre
- Department of Physiological Sciences, University of Florida, Gainesville, FL, USA.
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Epstein MS, Ephros HD, Epstein JB. Review of current literature and implications of RANKL inhibitors for oral health care providers. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 116:e437-42. [PMID: 22901640 DOI: 10.1016/j.oooo.2012.01.046] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Revised: 01/09/2012] [Accepted: 01/30/2012] [Indexed: 12/20/2022]
Abstract
Bisphosphonates (BPs) were the first class of drugs commonly used to prevent skeletal-related events (SRE) in patients with osteoporosis, multiple myeloma (MM), or solid tumors with metastases to bone. A new alternative class of agents, receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitors, are now available for use in these indications and have the potential to replace intravenous BPs. This paper presents a review of the current literature on denosumab and its association with osteonecrosis of the jaw (ONJ). Denosumab is a RANKL inhibitor that has recently been approved for the prevention of SRE for the same indications as BPs except for MM. Although the overall frequency of denosumab-related ONJ may be similar or higher than estimates of the occurrence rate of bisphosphonate-related ONJ, evidence continues to support appropriate planning and preventive care can reduce the likelihood of adverse effects, including osteonecrosis.
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Affiliation(s)
- Matthew S Epstein
- Oral and Maxillofacial Surgery Resident, St. Joseph's Regional Medical Center, Paterson, New Jersey.
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Steger GG, Bartsch R. Denosumab for the treatment of bone metastases in breast cancer: evidence and opinion. Ther Adv Med Oncol 2011; 3:233-43. [PMID: 21957430 DOI: 10.1177/1758834011412656] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Denosumab, a fully human monoclonal antibody, targets the receptor activator of nuclear factor-kappaB (RANK) ligand, a protein essential for osteoclast differentiation, activity and survival. Loss of osteoclasts from the bone surface reduces bone turnover and bone loss in malignant and benign diseases. In breast cancer, bone metastases are frequently observed; cancer treatment-induced bone loss (CTIBL) may result as a consequence of endocrine treatment or chemotherapy. Furthermore, preclinical studies suggest a direct role of the RANK/RANK-ligand pathway in breast tumorigenesis. This paper reviews preclinical and clinical data on denosumab in breast cancer. MATERIALS AND METHODS Studies were identified through the Medline database. Key search terms included: AMG-162, bisphosphonates, denosumab, RANK-ligand and zoledronic acid. Information available in abstract form only was retrieved from major oncology meetings, such as the American Society of Clinical Oncology (ASCO) annual meeting, ASCO breast meeting, European Cancer Organization, European Society of Medical Oncology and the San Antonio Breast Cancer Symposium. RESULTS Denosumab was consistently well tolerated throughout clinical trials, although the observed incidence of osteonecrosis of the jaw was comparable to that with bisphosphonates. Efficacy as determined by a reduction of skeletal-related events was at least equal to zoledronic acid, and superior in one phase III study conducted in patients with metastatic breast cancer. Clinical trials investigating the role of denosumab for the prevention of CTIBL and breast cancer recurrences are currently ongoing. CONCLUSION In conclusion, denosumab appears to be an effective and safe treatment option in patients with bone metastases from breast cancer with the potential of also preventing CTIBL.
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Affiliation(s)
- Guenther G Steger
- Department of Medicine, Clinical Division of Oncology, Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria
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Lemound J, Eckardt A, Kokemüller H, von See C, Voss PJ, Tavassol F, Rücker M, Rana M, Gellrich NC. Bisphosphonate-associated osteonecrosis of the mandible: reliable soft tissue reconstruction using a local myofascial flap. Clin Oral Investig 2011; 16:1143-52. [DOI: 10.1007/s00784-011-0596-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 07/18/2011] [Indexed: 01/06/2023]
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Wood SL, Brown JE. Skeletal metastasis in renal cell carcinoma: current and future management options. Cancer Treat Rev 2011; 38:284-91. [PMID: 21802857 DOI: 10.1016/j.ctrv.2011.06.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2011] [Revised: 06/25/2011] [Accepted: 06/29/2011] [Indexed: 01/06/2023]
Abstract
Metastasis to the skeleton is common in advanced renal cancer and leads to debilitating skeletal complications including severe pain, increased fracture rate and spinal cord compression. The incidence of renal cell carcinoma is increasing by around 2% per year and recent advances in targeted anti-angiogenic therapy for advanced disease are expected to lead to longer survival times. The clinical management of metastatic bone disease in renal cell carcinoma therefore merits greater focus than hitherto. Bone metastases arising from renal cancer are highly osteolytic and particularly destructive. Fortunately, the continuing development of anti-resorptive drugs is revolutionising the medical management of metastatic bone disease across many tumour types and making a major impact on quality of life. The bisphosphonate zoledronic acid is now licensed for use in advanced renal cell carcinoma and appears to yield a greater benefit in terms of reduction in skeletal related events than in bone metastases arising from other tumour types. Drugs which are directed at specific targets in the bone metastasis pathway are in development, including denosumab, a fully human monoclonal antibody against receptor activator of nuclear factor kappa B ligand, which has recently been licensed in the United States for use in renal cell carcinoma, with European licensing expected soon. This review examines the increasing options for treatment of metastatic bone disease in renal cell carcinoma, with a focus on drug-based advances and progress in the development of existing and new biomarkers to support clinical management.
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Affiliation(s)
- Steven L Wood
- Cancer Research UK Clinical Centre at Leeds, University of Leeds, St. James's Hospital, UK.
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