Secondary osteoporosis: pathophysiology & diagnosis

Navigating Post-Traumatic Osteoporosis: A Comprehensive Review of Epidemiology, Pathophysiology, Diagnosis, Treatment, and Future Directions

Post-traumatic osteoporosis (PTO) presents a significant challenge in clinical practice, characterized by demineralization and decreased skeletal integrity following severe traumatic injuries. This literature review manuscript addresses the knowledge gaps surrounding PTO, encompassing its epidemiology, pathophysiology, risk factors, diagnosis, treatment, prognosis, and future directions. This review emphasizes the complexity of the etiology of PTO, highlighting the dysregulation of biomineralization processes, inflammatory cytokine involvement, hormonal imbalances, glucocorticoid effects, vitamin D deficiency, and disuse osteoporosis. Moreover, it underscores the importance of multidisciplinary approaches for risk mitigation and advocates for improved diagnostic strategies to differentiate PTO from other musculoskeletal pathologies. This manuscript discusses various treatment modalities, including pharmacotherapy, dietary management, and physical rehabilitation, while also acknowledging the limited evidence on their long-term effectiveness and outcomes in PTO patients. Future directions in research are outlined, emphasizing the need for a deeper understanding of the molecular mechanisms underlying PTO and the evaluation of treatment strategies' efficacy. Overall, this review provides a comprehensive overview of PTO and highlights avenues for future investigation to enhance clinical management and patient outcomes.

Risk Factors for the Occurrence and Severity of Vertebral Fractures in Inflammatory Bowel Disease Patients: A Nationwide Population-Based Cohort Study

BACKGROUND

The risk of vertebral fractures is increased in inflammatory bowel disease (IBD) patients. However, whether the severity of vertebral fractures differs between IBD patients and the general population, or between patients with Crohn's disease (CD) and ulcerative colitis (UC), is unknown.

METHODS

We investigated risk factors associated with the occurrence and severity of vertebral fractures in IBD patients using The National Healthcare Insurance Service (NHIS) database. We defined the patients who underwent vertebroplasty or kyphoplasty after being diagnosed with a vertebral fracture as having a severe vertebral fracture than those with only diagnosis codes.

RESULTS

From 2008 to 2018, there were 33,778 patients with IBD (24,370 UC patients and 9,408 CD patients) and 101,265 patients in the reference population. The incidence rate ratio of vertebral fractures in the IBD patients was 1.27 per 1,000 person-years (95% confidence interval [CI], 1.26-1.27). The risk of vertebral fracture was higher in CD and UC patients than in the matched reference group (hazard ratio [HR], 1.59; 95% CI, 1.31-1.92; P < 0.001 and HR, 1.26; 95% CI, 1.14-1.41; P < 0.001, respectively). In a multivariate analysis, the occurrence of vertebral fracture was associated with CD (HR, 1.31; 95% CI, 1.08-1.59; P = 0.006), older age (CD: HR, 1.09; 95% CI, 1.08-1.09; P < 0.001 and UC: HR, 1.09; 95% CI, 1.08-1.09; P < 0.001), female sex (CD: HR, 1.81; 95% CI, 1.63-2.01; P < 0.001 and UC: HR, 2.02; 95% CI, 1.83-2.22; P < 0.001), high Charlson Comorbidity Index (CCI) score (CD: HR, 1.42; 95% CI, 1.23-1.63; P < 0.001 and UC: HR, 1.46; 95% CI, 1.29-1.65, P < 0.001), and long-term steroid use (CD: HR, 3.71; 95% CI, 2.84-3.37; P < 0.001 and UC: HR, 3.88; 95% CI, 3.07-4.91; P < 0.001). The severity of vertebral fractures was associated with IBD (CD: HR, 1.82; 95% CI, 1.17-2.83; P = 0.008 and UC: HR, 1.49; 95% CI, 1.17-1.89; P < 0.001) and older age (HR, 1.06; 95% CI, 1.05-1.07; P < 0.001).

CONCLUSION

Vertebral fractures occur frequently and more severely in IBD patients, particularly those with CD. Therefore, we suggest monitoring of bone density, regular vitamin D supply, and reducing the use of corticosteroids to prevent vertebral fractures in IBD patients who are older, female, or have comorbidities.

Quercetin protects against iron overload-induced osteoporosis through activating the Nrf2/HO-1 pathway

AIMS

Eucommia is the tree bark of Eucommia japonica, family Eucommiaceae. In traditional Chinese medicine, Eucommia is often used to treat osteoporosis. Quercetin (QUE), a major flavonoid extract of Eucommia japonica, has been reported to have anti-osteoporosis effects. However, there are no studies reporting the mechanism of QUE in the treatment of iron overload-induced osteoporosis. This study set out to investigate the therapeutic effects of QUE against iron overload-induced bone loss and its potential molecular mechanisms.

MATERIALS AND METHODS

In vitro, MC3T3-E1 cells were used to study the effects of QUE on osteogenic differentiation, anti-apoptosis and anti-oxidative stress damage in an iron overload environment (FAC 200 μM). In vivo, we constructed an iron overload mouse model by injecting iron dextrose intraperitoneally and assessed the osteoprotective effects of QUE by Micro-CT and histological analysis.

KEY FINDINGS

In vitro, we found that QUE increased the ALP activity of MC3T3-E1 cells in iron overload environment, promoted the formation of bone mineralized nodules and upregulated the expression of Runx2 and Osterix. In addition, QUE was able to reduce FAC-induced apoptosis and ROS production, down-regulated the expression of Caspase3 and Bax, and up-regulated the expression of Bcl-2. In further studies, we found that QUE activated the Nrf2/HO-1 signaling pathway and attenuated FAC-induced oxidative stress damage. The results of the in vivo study showed that QUE was able to reduce iron deposition induced by iron dextrose and attenuate bone loss.

SIGNIFICANCE

Our results suggested that QUE protects against iron overload-induced osteoporosis by activating the Nrf2/HO-1 signaling pathway.

Osteoporosis: An Update on Screening, Diagnosis, Evaluation, and Treatment

Osteoporosis screening, diagnosis, and treatment have gained much attention in the health care community over the past 2 decades. During this time, creation of multispecialty awareness programs (eg, "Own the Bone," American Orthopedic Association; "Capture the Fracture," International Osteoporosis Foundation) and improvements in diagnostic protocols have been evident. Significant advances in technology have elucidated elements of genetic predisposition for decreased bone mineral density in the aging population. Additionally, several novel drug therapies have entered the market and provide more options for primary care and osteoporosis specialists to medically manage patients at risk for fragility fractures. Despite this, adherence to osteoporosis screening and treatment protocols has been surprisingly low by health care practitioners, including orthopedic surgeons. Continued awareness and education of this skeletal disorder is crucial to effectively care for our aging population. [Orthopedics. 2023;46(1):e20-e26.].

The osteo-metabolic phenotype of COVID-19: an update

CONTEXT

In the multifaceted COVID-19 clinical scenario characterized by a multi-system disorder with negative implications not only on respiratory function but also on cardiac, hematological, neurological and endocrine-metabolic systems, a distinctive osteo-metabolic phenotype with an independent influence on disease severity and recovery of patients affected was early reported.

AIM

To summarize and update the main evidences regarding the distinct components of this phenotype in acute and Long COVID-19, reinforcing its clinical relevance and discussing the main pathophysiological and clinical-therapeutic implications of the most recent reported findings.

RESULTS

This emerging phenotype is characterized by a widespread acute hypocalcemia and hypovitaminosis D with an impaired compensatory parathyroid hormone response, and a high prevalence of skeletal complications such as vertebral fractures. The clinical relevance of this osteo-metabolic phenotype on acute COVID-19 is well characterized, and novel seminal evidences are progressively highlighting its importance also in predicting patient's long-term outcomes and Long COVID-19 occurrence.

CONCLUSIONS

These findings reinforced the central role of a multidisciplinary team, including endocrinologists, in evaluating these patients for a proactive search of each aspect of the osteo-metabolic phenotype components since they may represent suitable therapeutic targets to prevent SARS-CoV-2 infection, poor COVID-19 outcomes, Long COVID-19 occurrence and even possibly better responses to COVID-19 vaccination.

Vertebral fractures at hospitalization predict impaired respiratory function during follow-up of COVID-19 survivors

PURPOSE

Morphometric vertebral fractures (VFs) have been recently reported as an important component of the endocrine phenotype of COVID-19 and emerging data show negative respiratory sequelae at long-term follow-up in COVID-19 survivors. The aim of this study was to evaluate the impact of VFs on respiratory function in COVID-19 survivors.

METHODS

We included patients referred to our Hospital Emergency Department and re-evaluated during follow-up. VFs were detected on lateral chest X-rays on admission using a qualitative and semiquantitative assessment and pulmonary function tests were obtained by Jaeger-MasterScreen-Analyzer Unit 6 months after discharge.

RESULTS

Fifty patients were included. Median age was 66 years and 66% were males. No respiratory function data were available at COVID-19 diagnosis. VFs were detected in 16 (32%) patients. No differences between fractured and non-fractured patients regarding age and sex were observed. Although no difference was observed between VF and non-VF patient groups in the severity of pneumonia as assessed by Radiological-Assessment-of-Lung-Edema score at admission, (5 vs. 6, p = 0.69), patients with VFs were characterized as compared to those without VFs by lower Forced Vital Capacity (FVC, 2.9 vs. 3.6 L, p = 0.006; 85% vs. 110% of predicted, respectively, p = 0.001), Forced Expiratory Volume 1st s (FEV1, 2.2 vs. 2.8 L, p = 0.005; 92% vs. 110% of predicted, respectively, p = 0.001) and Diffusing Capacity of the Lungs for Carbon Monoxide (DLCO 5.83 vs. 6.98 mmol/min/kPa, p = 0.036, 59% vs. 86.3% of predicted, respectively, p = 0.043) at 6-month follow up.

CONCLUSIONS

VFs, expression of the endocrine phenotype of the disease, appear to influence medium-term impaired respiratory function of COVID-19 survivors which may significantly influence their recovery. Therefore, our findings suggest that a VFs assessment at baseline may help in identifying patients needing a more intensive respiratory follow-up and patients showing persistent respiratory impairment without evidence of pulmonary disease may benefit from VFs assessment to preventing the vicious circle of further fractures and respiratory deterioration.

High Risk of Fractures Within 7 Years of Diagnosis in Asian Patients With Inflammatory Bowel Diseases

BACKGROUND & AIMS

In this nationwide population-based study, we investigated the risk of vertebral and hip fractures in patients with inflammatory bowel disease (IBD).

METHODS

Using data from the Korean National Health Insurance claims database gathered between 2007 and 2016, we calculated the incidence rate ratios (IRRs) of vertebral and hip fractures in patients with newly diagnosed IBD (n = 18,228; 64.1% male, 65.9% ulcerative colitis) compared with an age- and sex-matched control population (matching ratio, 1:10; n = 186,871).

RESULTS

During a median follow-up period of 4.5 years, the incidence rate and IRR of vertebral and hip fractures in patients with IBD were 2.88 per 1000 person-years and 1.24 (95% CI, 1.08-1.42), respectively. The cumulative risk of vertebral and hip fractures in IBD patients was 0.6%, 1.4%, and 1.9% at 2, 5, and 7 years after diagnosis, respectively, and this risk of fracture in IBD patients was higher than that in matched controls (P = .002). The use of corticosteroids further increased the risk of fractures in IBD patients (IRR, 1.37; 95% CI, 1.13-1.65) compared with matched controls. The risk of fractures was significantly higher in patients with Crohn's disease (CD) (IRR, 1.56; 95% CI, 1.19-2.04) than in matched controls, and this risk remained higher in patients with CD without corticosteroid exposure (IRR, 1.62; 95% CI, 1.12-2.34). The risk of fracture increased with age and was particularly high in females and in those with comorbidities.

CONCLUSIONS

The risk of fractures was significantly high in newly diagnosed IBD patients, especially in those with CD regardless of corticosteroid exposure.

Osteoporosis: A Step-by-Step Case-Based Study

Osteoporosis is a common disease that affects our elderly population. This disease usually gets undiagnosed for an extended period. Osteoporosis increases the risk of fracture in our elderly population and increases morbidity. The cost associated with osteoporosis does carry a substantial burden in our society. Here, we present a case of osteoporosis with a fracture diagnosed in clinical settings. We discuss different etiology, pathophysiology, and treatment options available to treat this medical condition.

Vitamin D and Platelets: A Menacing Duo in COVID-19 and Potential Relation to Bone Remodeling

Global data correlate severe vitamin D deficiency with COVID-19-associated coagulopathy, further suggesting the presence of a hypercoagulable state in severe COVID-19 patients, which could promote thrombosis in the lungs and in other organs. The feedback loop between COVID-19-associated coagulopathy and vitamin D also involves platelets (PLTs), since vitamin D deficiency stimulates PLT activation and aggregation and increases fibrinolysis and thrombosis. Vitamin D and PLTs share and play specific roles not only in coagulation and thrombosis but also during inflammation, endothelial dysfunction, and immune response. Additionally, another ‘fil rouge’ between vitamin D and PLTs is represented by their role in mineral metabolism and bone health, since vitamin D deficiency, low PLT count, and altered PLT-related parameters are linked to abnormal bone remodeling in certain pathological conditions, such as osteoporosis (OP). Hence, it is possible to speculate that severe COVID-19 patients are characterized by the presence of several predisposing factors to bone fragility and OP that may be monitored to avoid potential complications. Here, we hypothesize different pervasive actions of vitamin D and PLT association in COVID-19, also allowing for potential preliminary information on bone health status during COVID-19 infection.

Advances in the occurrence and biotherapy of osteoporosis

Osteoporosis (OP) is a bone metabolic disease, is characterized by degeneration of bone structure and decreased bone mass. It happens in more than 1/3 women and 1/5 men of over than 50 years old, which affects the health and lives of people. The main mechanism of OP is mainly that the dynamic balance between the bone formation and resorption is broken, so that bone resorption is more than bone formation. It is prone to result in bone metabolism disorder. There are many precipitating factor such as elder age, low hormone level, genetic factors and bad hobbies. At the same time, the occurrence of the OP and its complications has different degrees of impact on people's quality of life. Based on the current understanding of the OP, we summarized the etiology, current clinical drugs and potential targeting therapy for OP. Although the research have made many progress in explore what is the novel mechanism and how to improve the effect, there are still many problems in the treatment method that limit its application prospects and need to be solved. In this review, we mainly focus on the mechanism of OP and related research on the targeted treatment of OP. Hopefully, our summary will provide a reference to develop some novel strategies for the target therapy of OP.

Radiological Thoracic Vertebral Fractures are Highly Prevalent in COVID-19 and Predict Disease Outcomes

CONTEXT AND OBJECTIVE

COVID-19 has become the most relevant medical issue globally. Despite several studies that have investigated clinical characteristics of COVID-19 patients, no data have been reported on the prevalence of vertebral fractures (VFs). Since VFs may influence cardiorespiratory function and disease outcomes, the aim of this study was to assess VFs prevalence and clinical impact in COVID-19.

DESIGN AND PATIENTS

This was a retrospective cohort study performed at San Raffaele Hospital, a tertiary health care hospital in Italy. We included COVID-19 patients for whom lateral chest x-rays at emergency department were available. VFs were detected using a semiquantitative evaluation of vertebral shape on chest x-rays.

RESULTS

A total of 114 patients were included in this study and thoracic VFs were detected in 41 patients (36%). Patients with VFs were older and more frequently affected by hypertension and coronary artery disease (P < 0.001, P = 0.007, P = 0.034; respectively). Thirty-six (88%) patients in VFs+ group compared to 54 (74%) in VFs- group were hospitalized (P = 0.08). Patients with VFs more frequently required noninvasive mechanical ventilation compared with those without VFs (P = 0.02). Mortality was 22% in VFs+ group and 10% in VFs- group (P = 0.07). In particular, mortality was higher in patients with severe VFs compared with those with moderate and mild VFs (P = 0.04).

CONCLUSIONS

VFs may integrate the cardiorespiratory risk of COVID-19 patients, being a useful and easy to measure clinical marker of fragility and poor prognosis. We suggest that morphometric thoracic vertebral evaluation should be performed in all suspected COVID-19 patients undergoing chest x-rays.

Lactobacillus Fermentum ZS40 prevents secondary osteoporosis in Wistar Rat

Using retinoic acid to inducer, we successfully established a rat model of secondary osteoporosis and verified the preventive effect of Lactobacillus fermentum ZS40 (ZS40) on secondary osteoporosis. Serum biochemical indicators showed that ZS40 can effectively slow down bone resorption caused by retinoic acid, increase blood content of calcium, phosphorus, bone alkaline phosphatase, bone gla protein, and insulin-like growth factor 1, and decrease blood content of tartrate-resistant acid phosphatase (TRAP) 5b. qRT-PCR results showed that ZS40 could upregulate mRNA expressions of β-catenin, Wnt10b, Lrp5, Lrp6, Runx2, ALP, RANKL, and OPG, and downregulate mRNA expression of DKK1, RANK, TRACP, and CTSK in the rats' spinal cord. Results following TRAP staining showed that ZS40 could slow down retinoic acid-induced formation of osteoclasts. Micro-CT results showed that ZS40 could reduce Tb.Sp, increase BV/TV, Tb.N, Tb.Th, and ultimately increase bone mineral density of rats in vivo. These findings indicate that ZS40 might have a potential role in preventing retinoic acid-induced secondary osteoporosis in vivo.

Altered levels of BMD, PRL, BAP and TRACP-5b in male chronic patients with schizophrenia

Bone mineral density (BMD) has been found to decrease in schizophrenia patients. We examined BMD and the levels of prolactin (PRL), bone alkaline phosphatase (BAP) and tartrate resistant acid phosphatase isoform 5b (TRACP-5b) in male chronic schizophrenia patients and compared them with healthy controls in a Chinese Han population, which has not been reported before. Male patients with chronic schizophrenia (SPs; n = 79) and healthy controls (HCs; n  = 56) were recruited. BMD and plasma PRL, BAP and TRACP-5b levels were measured and compared between the two groups. The SPs group was further divided into two subgroups: the elevated PRL group (PRL ≥ 25 ng/ml, EPRL; n  = 38) and the normal PRL group (PRL < 25 ng/ml, NPRL; n = 41) in accordance with PRL levels. The levels of BAP and TRACP-5b were measured using sandwich enzyme-linked immunosorbent assay (ELISA) while serum PRL was measured with an Access Immunoassay Analyzer. BMD was determined by quantitative computed tomography. BMD levels significantly decreased and serum PRL and TRACP-5b levels were significantly higher in male chronic schizophrenia patients. The EPRL group had remarkably lower BMD and BAP level and higher TRACP-5b levels compared with the NPRL group and HCs. Moreover, there was a negative correlation between BMD and TRACP-5b in the EPRL group. We found that BMD, BAP and TRACP-5b levels in the EPRL group were significantly different than HCs and the NPRL group. PRL levels in schizophrenia patients may be related to BMD and bone metabolism. Monitoring BMD and markers of bone metabolism in clinical practice may therefore be helpful to understand the bone health status of schizophrenia patients.

Effect of subclinical hyperthyroidism on osteoporosis: A meta-analysis of cohort studies

OBJECTIVE

The effect of subclinical hyperthyroidism (SH) on bone mineral density (BMD) remains unclear, as do the linking mechanisms. This review aims to investigate the relationship between SH and bone loss in terms of the gender-dependent effects of SH on BMD.

METHODS

The PUBMED, EMBASE, OVID, MEDLINE, SINOMED and COCHRANE LIBRARY databases (inception to August 12, 2019) were searched for cohort studies investigating the effects of SH on BMD. Eligible studies were subjected to qualitative and quantitative analysis using a random-effects model meta-analysis with the Cochrane systematic evaluation method.

RESULTS

Twelve cohort studies involving 275,086 participants who were followed for 3 months to 13 years were included based on predefined inclusion and exclusion criteria. The results indicated that SH did not affect lumbar spine BMD in females or males. However, a significant reduction in femoral neck BMD was observed in females, but not in males. Further, there was a significant increase in hip fractures events in both females and males with SH.

CONCLUSIONS

The present findings indicate that SH is significantly associated with hip fracture risk, and therefore, it is important to assess the risk of fractures in patients with SH. Future studies should focus on methods for accurately determining this risk in patients with SH and providing them with timely and efficient diagnosis and treatment.

Association between high levels of gynoid fat and the increase of bone mineral density in women

Introduction: In women, bone mineral density (BMD) is related to age, estrogenic action, and appendicular skeletal muscle mass (ASMM). The gynoid fat distribution is linked to estrogenic action.Objective: This study aimed to assess whether an increase of gynoid fat is associated with high BMD independent of age and ASMM.Methods: An observational study was performed in women aged between 20 and 79 years. Fat mass, ASMM, and BMD were measured with dual-energy X-ray absorptiometry. The binned scatterplots and multivariate linear regression models were used to study the relationship between hip BMD and age, height, android fat, gynoid fat, and ASMM.Results: Of 673 women invited, 596 accepted to participate. Their mean age was 55.4 ± 12.8 years, weight 63.4 ± 9.4 kg, height 1.61 ± 0.06 m, body mass index 24.54 ± 3.59 kg/m², average hip BMD 0.914 ± 0.122 g/cm², android fat 2.12 ± 0.83 kg, gynoid fat 4.54 ± 1.07 kg, and ASMM 15.15 ± 1.97 kg. The final regression model included age (linear coefficient -0.004; 95% confidence interval [CI]: -0.005 to -0.003; p < 0.001), ASMM (linear coefficient 0.013; 95% CI: 0.009 to 0.018; p < 0.001), and gynoid fat (linear coefficient 0.013; 95% CI: 0.005 to 0.022; p < 0.002).Conclusion: Gynoid fat is associated with BMD in the hip independently of age and ASMM.

Effects of denosumab on bone mineral density and bone turnover markers in rheumatoid arthritis patients switching from bisphosphonates

Background

To compare the efficacy of 12-month denosumab treatment on bone mineral density (BMD) and bone turnover markers (BTMs) between treatment-naïve osteoporosis patients with rheumatoid arthritis (RA) and those with previous bisphosphonate (BP) therapy.

Methods

A total of 36 RA patients with osteoporosis completed 12-month follow-up. Twenty-five patients were osteoporotic treatment-naïve (naïve group), and 11 patients were previously treated with BPs (switch group) (average 7.9 years). BMD and BTMs were measured before and 6 and 12 months after treatment.

Results

BTM levels were higher in the naïve group at baseline. However, the same level of suppression was achieved at 6 months in both groups. Spine BMD increased significantly in both groups. There was no significant difference in the mean percent changes of BMD of the spine (naïve group: 6.8 ± 0.8, switch group: 5.1 ± 1.5), femoral neck (2.9 ± 1.4, 2.9 ± 1.3), and total hip (1.7 ± 0.9, 1.4 ± 1.1) between these two groups at 12 months.

Conclusions

The effects of denosumab on BMD and BTMs of the switch group after long-term BP treatment are comparable to those of the naïve group in RA patients. Thus, switching BPs to denosumab is one of the useful options to treat osteoporosis with RA.

Risk of osteoporosis and fracture in victims with burn injury

Osteoporosis is a well-known bone disorder affecting people worldwide. Patients with osteoporosis have an increased risk of bone fracture. This study provides new information on the risk of developing osteoporosis post burn injury and the risk of fracture among those with osteoporosis developed.

INTRODUCTION

The relationship between burn injury and hip fracture risk is unclear. Population-based evaluation on relationships between burn injury and osteoporosis development and subsequent fractures is limited. We conducted a retrospective cohort study as the investigation.

METHODS

From the insurance data of Taiwan, we established a cohort of 43,532 patients with a burn injury in 2000-2012 and a comparison cohort of 174,124 individuals without such an injury, frequency matched by sex, age, and diagnosis date. Both cohorts were followed up to the end of 2013 to evaluate the occurrence of osteoporosis and hip fracture.

RESULTS

The incidence of osteoporosis was greater in the burn cohort than in the comparison cohort (6.40 vs. 4.75 per 1,000 person-years) with an adjusted IRR of 1.35 (95% confidence interval = 1.32-1.39). The incidence rates in both cohorts were greater in women than in men, increased with age, income, and Charlson comorbidity index. Patients with burns involving 20%-49% of total body surface area and with burns confined to the lower/upper limbs had the greatest incidence rates, 8.32 and 8.58 per 1,000 person-years, respectively. Osteoporosis incidence increased further to 22.7 per 1,000 person-years for burn victims with comorbid diabetes. The risk of fracture was over five-fold greater for burn victims with osteoporosis developed than for comparisons without osteoporosis.

CONCLUSION

Patients who have a burn injury deserve prevention intervention to reduce the risk of osteoporosis and fracture.

The Association between Polypharmacy and Hip Fracture in Osteoporotic Women: A Nested Case-Control Study in South Korea

BACKGROUND AND OBJECTIVE

Polypharmacy, regarded as an indicator of potentially inappropriate medications (PIMs), may lead to a higher risk of serious health consequences in elderly patients with osteoporosis. Thus, this study aimed to analyze the association between polypharmacy and hip fracture in patients with osteoporosis because only a limited number of studies have reported on this association, with inconsistent results to date.

METHODS

In this nested case-control study using a population-based sample cohort, the target cases were female patients with hip fracture diagnosed with osteoporosis and aged ≥ 50 years. Polypharmacy (prescription of an average of five or more daily drugs), PIMs for hip fracture (such as benzodiazepines and glucocorticoids), Charlson Comorbidity Index (CCI) score, and other comorbidities were analyzed during the year preceding the diagnosis of hip fracture. Adjusted odds ratios (ORs) for hip fracture for the variables were also analyzed.

RESULTS

The cases (n = 1003) showed higher exposure rates to polypharmacy, glucocorticoids, and benzodiazepines, and had more severe comorbidity statuses compared with the controls. The ORs for hip fracture adjusted for confounders increased with polypharmacy level, with persistent statistical significance in most analyses. The ORs (95% confidence intervals), with reference to the 0 to < 1 drug group, were 1.65 (1.31-2.08) and 2.11 (1.12-3.96) for the 5 to < 10 and 10 + drug groups, respectively, with adjustment for PIMs, and 1.34 (1.04-1.72) and 1.45 (0.76-2.80) for the 5 to < 10 and 10 + drug groups, respectively, with adjustment for PIMs and CCI score.

CONCLUSIONS

The results suggest that polypharmacy is associated with an increased risk of hip fracture after adjustment for confounders in patients with osteoporosis. These results highlight the importance of polypharmacy management in preventing hip fractures in patients with osteoporosis.

Role of nutritional vitamin D in osteoporosis treatment

Osteoporosis is a systemic skeletal disorder characterized by a decrease in bone mass and microarchitectural deterioration of bone tissue. The World Health Organization has defined osteoporosis as a decrease in bone mass (50%) and bony quality (50%). Vitamin D, a steroid hormone, is crucial for skeletal health and in mineral metabolism. Its direct action on osteoblasts and osteoclasts and interaction with nonskeletal tissues help in maintaining a balance between bone turnover and bone growth. Vitamin D affects the activity of osteoblasts, osteoclasts, and osteocytes, suggesting that it affects bone formation, bone resorption, and bone quality. At physiological concentrations, active vitamin D maintains a normal rate of bone resorption and formation through the RANKL/OPG signal. However, active vitamin D at pharmacological concentration inhibits bone resorption at a higher rate than that of bone formation, which influences the bone quality and quantity. Nutritional vitamin D rather than active vitamin D activates osteoblasts and maintains serum 25(OH)D₃ concentration. Despite many unanswered questions, much data support nutritional vitamin D use in osteoporosis patients. This article emphasizes the role of nutritional vitamin D replacement in different turnover status (high or low bone turnover disorders) of osteoporosis together with either anti-resorptive (Bisphosphonate, Denosumab et.) or anabolic (Teriparatide) agents when osteoporosis persists.

Bone Health in Adrenal Disorders

Secondary osteoporosis resulting from specific clinical disorders may be potentially reversible, and thus continuous efforts to find and adequately treat the secondary causes of skeletal fragility are critical to ameliorate fracture risk and to avoid unnecessary treatment with anti-osteoporotic drugs. Among the hyperfunctional adrenal masses, Cushing's syndrome, pheochromocytoma, and primary aldosteronism are receiving particularly great attention due to their high morbidity and mortality mainly by increasing cardiovascular risk. Interestingly, there is accumulating experimental and clinical evidence that adrenal hormones may have direct detrimental effects on bone metabolism as well. Thus, the present review discusses the possibility of adrenal disorders, especially focusing on pheochromocytoma and primary aldosteronism, as secondary causes of osteoporosis.

Young and healthy C57BL/6 J mice performing sprint interval training reveal gender- and site-specific changes to the cortical bone

Physical exercise is considered to impede the bone loss associated with physiological ageing however, a training program that efficiently leads to bone accrual in the healthy does not yet exist. We turned to the C57BL/6 J mouse and designed a sprint interval training for treadmill that was tailored to the individual performance limits. It consisted of four weeks with five training sessions each, followed by another four weeks with three. After completion of the training period, mice were sacrificed and the hind legs were analyzed via µCT and MRI for changes in bone parameters and muscle volume, respectively. Increased performance limits in both sexes confirmed an effect of the treadmill training. However, while male tibiae after eight weeks revealed a significant reduction of cortical bone mass at the distal metaphysis, the cross sectional analysis of female tibiae showed a transient decrease of cortical bone mass after four weeks that was reversed into a significant accrual after eight weeks of training and occurred over the entire length of the tibia. The observed net reduction of female bone mass after four weeks of training is suggestive of a remodelling process which may be delayed in the males.

β‑Ecdysterone promotes autophagy and inhibits apoptosis in osteoporotic rats

Osteoporosis is an aging process of skeletal tissues with characteristics of reductions in bone mass and microarchitectural deterioration of bone tissue. The present study aimed to investigate the effects of glucocorticoid-induced osteoporosis on osteoblasts and to examine the roles of β-ecdysterone (β-Ecd) involved. In the present study, an in vivo model of osteoporosis was established through the subcutaneous implantation of prednisolone (PRED) into Sprague-Dawley rats, with or without a subcutaneous injection of β-Ecd (5 or 10 mg/kg body weight). Expression of Beclin-1 and microtubule-associated protein 1A/1B-light chain 3I/II and apoptosis in lumbar vertebrae tissues was measured by immunofluorescence and TUNEL assays, respectively. Serum concentration of calcium and phosphorus, and the activity of tartrate-resistant acid phosphatase (TRAP) and alkaline phosphatase (ALP) were measured by biochemical assay. Reverse transcription-quantitative polymerase chain reaction and western blotting was used for detect the expression of related genes and proteins. PRED treatment inhibited bone formation by decreasing bone mineral density, and suppressing the expression of Runt-related transcription factor 2 and bone morphogenetic protein 2, while enhancing the activity of alkaline phosphatase, upregulating the expression of receptor activator of nuclear factor-κB ligand, and increasing the serum content of calcium, phosphorus and tartrate-resistant acid phosphatase in rats. Additionally, PRED was revealed to inhibit autophagy through the downregulation of Beclin-1, autophagy protein 5 and microtubule-associated protein 1A/1B-light chain 3I/II expression, whereas it induced the apoptosis, through the activation of caspase-3 and the suppression of apoptosis regulator BCL2 expression. Notably, the PRED-induced alterations in bone formation, autophagy and apoptosis were revealed to be attenuated by β-Ecd administration. In conclusion, the findings of the present study suggested that β-Ecd may be a promising candidate for the development of therapeutic strategies for the treatment of osteoporosis, through the induction of autophagy and the inhibition of apoptosis in vivo.

Sprint Interval Training Induces A Sexual Dimorphism but does not Improve Peak Bone Mass in Young and Healthy Mice

Elevated peak bone mass in early adulthood reduces the risk for osteoporotic fractures at old age. As sports participation has been correlated with elevated peak bone masses, we aimed to establish a training program that would efficiently stimulate bone accrual in healthy young mice. We combined voluntary treadmill running with sprint interval training modalities that were tailored to the individual performance limits and were of either high or intermediate intensity. Adolescent male and female STR/ort mice underwent 8 weeks of training before the hind legs were analyzed for cortical and trabecular bone parameters and biomechanical strength. Sprint interval training led to increased running speeds, confirming an efficient training. However, males and females responded differently. The males improved their running speeds in response to intermediate intensities only and accrued cortical bone at the expense of mechanical strength. High training intensities induced a significant loss of trabecular bone. The female bones showed neither adverse nor beneficial effects in response to either training intensities. Speculations about the failure to improve geometric alongside mechanical bone properties include the possibility that our training lacked sufficient axial loading, that high cardio-vascular strains adversely affect bone growth and that there are physiological limits to bone accrual.

Boron supplementation improves bone health of non-obese diabetic mice

Diabetes Mellitus is a condition that predisposes a higher risk for the development of osteoporosis. The objective of this study was to investigate the influence of boron supplementation on bone microstructure and strength in control and non-obese diabetic mice for 30days. The animals were supplemented with 40μg/0,5ml of boron solution and controls received 0,5ml of distilled water daily. We evaluated the biochemical parameters: total calcium, phosphorus, magnesium and boron; bone analysis: bone computed microtomography, and biomechanical assay with a three point test on the femur. This study consisted of 28 animals divided into four groups: Group water control - Ctrl (n=10), Group boron control - Ctrl±B (n=8), Group diabetic water - Diab (n=5) and Group diabetic boron - Diab±B (n=5). The results showed that cortical bone volume and the trabecular bone volume fraction were higher for Diab±B and Ctrl±B compared to the Diab and Ctrl groups (p≤0,05). The trabecular specific bone surface was greater for the Diab±B group, and the trabecular thickness and structure model index had the worst values for the Diab group. The boron serum concentrations were higher for the Diab±B group compared to non-supplemented groups. The magnesium concentration was lower for Diab and Diab±B compared with controls. The biomechanical test on the femur revealed maintenance of parameters of the bone strength in animals Diab±B compared to the Diab group and controls. The results suggest that boron supplementation improves parameters related to bone strength and microstructure of cortical and trabecular bone in diabetic animals and the controls that were supplemented.

Nanotechnology Treatment Options for Osteoporosis and Its Corresponding Consequences

Unfortunately, osteoporosis, as a worldwide disease, is challenging human health with treatment only available for the symptoms of osteoporosis without managing the disease itself. Osteoporosis can be linked as the common cause of fractures and increased mortality among post-menopausal women, men, and the elderly. Regrettably, due to osteoporosis, incidents of fractures are more frequent among the presented populations and can be afflictive for carrying out everyday life activities. Current treatments of osteoporosis encompass changing lifestyles, taking orthopedic drugs, and invasive surgeries. However, these treatment options are not long lasting and can lead to complications after post-surgical life. Therefore, to solve this impairment, researchers have turned to nanotechnologies and nanomaterials to create innovative and alternative treatments associated with the consequences of osteoporosis. This review article provides an introduction to osteoporotic compression vertebral fractures (OVCFs) and current clinical treatments, along with the rationale and efficacy of utilizing nanomaterials to modify and improve biomaterials or instruments. The methods of applying bioactive agents (bone morphogenetic protein-2 (BMP-2), parathyroid hormone 1-34 (PTH 1-34)), as well as 3D printing will be presented from an osteoporosis treatment perspective. Additionally, the application of nanoparticles and nanotube arrays onto the current surgical treatments and orthopedic drug administration methods addressed will show that these systems reinforce a better mechanical performance and provide precise and slow-releasing drug delivery for better osseointegration, bone regeneration, and bone strength. In summary, nanomaterials can be seen as an alternative and more effective treatment for individuals with osteoporosis.

Metabolic Bone Disease in the Post-transplant Population: Preventative and Therapeutic Measures

Post-transplant bone disease contributes significantly to patients' morbidity and mortality after transplantation and has an impact on their quality of life. This article discusses the major contributors to mechanisms causing bone loss, highlighting the role of preexisting disease in both kidney and liver failure and contributions from glucocorticoids and calcineurin inhibitors. Suggested monitoring and investigations are reviewed as well as treatment as far as the current literature supports, emphasizing the difference between kidney and liver recipients.

Relationship between antipsychotic medication, serum prolactin levels and osteoporosis/osteoporotic fractures in patients with schizophrenia: a critical literature review

INTRODUCTION

Using an antipsychotic medication can increase prolactin (PRL) levels, causing hyperprolactinemia (HPRL). Although the occurrence of osteoporosis within the population of patients with schizophrenia has been recognized, the precise nature of the association between antipsychotic treatment, PRL, osteoporosis, and the disease itself seems to be elusive.

AREAS COVERED

The aim of this review is to critically review the literature regarding the association between osteoporosis and PRL and to summarize the available evidence with respect to the impact of PRL-elevating antipsychotics on bone mineral density (BMD) and fractures in non-elderly patients with schizophrenia.

EXPERT OPINION

Although long-standing HPRL can have an impact on the rate of bone metabolism and, when associated with hypogonadism, may lead to decreased bone density in both female and male subjects, the relative contribution of antipsychotic-induced HPRL in bone mineral loss in patients with schizophrenia remains unclear. Methodological shortcomings of existing studies, including the lack of prospective data and the focus on measurements of BMD instead of bone turnover markers, preclude definitive conclusions regarding the relationship between PRL-raising antipsychotics and BMD loss in patients with schizophrenia. Therefore, more well conducted prospective trials of these biomarkers are necessary to establish the precise relationship between antipsychotics, PRL levels and osteoporosis/osteoporotic risk.

The Vestibular System: A Newly Identified Regulator of Bone Homeostasis Acting Through the Sympathetic Nervous System

The vestibular system is a small bilateral structure located in the inner ear, known as the organ of balance and spatial orientation. It senses head orientation and motion, as well as body motion in the three dimensions of our environment. It is also involved in non-motor functions such as postural control of blood pressure. These regulations are mediated via anatomical projections from vestibular nuclei to brainstem autonomic centers and are involved in the maintenance of cardiovascular function via sympathetic nerves. Age-associated dysfunction of the vestibular organ contributes to an increased incidence of falls, whereas muscle atrophy, reduced physical activity, cellular aging, and gonadal deficiency contribute to bone loss. Recent studies in rodents suggest that vestibular dysfunction might also alter bone remodeling and mass more directly, by affecting the outflow of sympathetic nervous signals to the skeleton and other tissues. This review will summarize the findings supporting the influence of vestibular signals on bone homeostasis, and the potential clinical relevance of these findings.

The Pathophysiology and Treatment of Osteoporosis

PURPOSE

The objectives of this article are to review the pathophysiology of bone loss associated with aging and to review current pharmacologic approaches for the treatment of osteoporosis.

METHODS

A literature search with PubMed was performed with the terms osteoporosis and pathophysiology and osteoporosis and treatment and limited to studies written in English that were published within the preceding 10 years. Given the large number of studies identified, we selectively reviewed those studies that contained primary data related to osteoporosis pathophysiology or osteoporosis pharmacologic treatments and references included within selected studies identified from abstract review.

FINDINGS

Published studies have consistently reported that osteoporosis in older adults is caused by an imbalance of bone resorption in excess of bone formation. The dominant factor leading to bone loss in older adults appears to be gonadal sex steroid deficiency, with multiple genetic and biochemical factors, such as vitamin D deficiency or hyperparathyroidism, that may accelerate bone loss. Conditions that adversely affect growth and development may limit development of peak bone mass and accelerate subsequent bone loss. Studies of bone microarchitecture have shown that trabecular bone loss begins in the third decade of life, before gonadal sex steroid deficiency develops, whereas cortical loss typically begins in the sixth decade, about the time of menopause in women and about the same age in men. Antiresorptive agents for the treatment of osteoporosis act primarily by limiting osteoclast activity, whereas osteoanabolic agents, such as teriparatide, act primarily by stimulating osteoblastic bone formation. Clinical investigation of new compounds for the treatment of osteoporosis is mainly directed to those that stimulate bone formation or differentially decrease bone resorption more than bone formation. Therapies for osteoporosis are associated with adverse effects, but in patients at high risk of fracture, the benefits generally far outweigh the risks.

IMPLICATIONS

Current osteoporosis therapies mitigate or reverse the loss of bone associated with age-related decreases of gonadal sex steroids, increase bone strength, and reduce fracture risk. With improved knowledge of the pathophysiology of osteoporosis, new targets for therapeutic intervention have been identified. Clinical investigations of potential new treatments for osteoporosis are primarily directed to stimulating osteoblastic bone formation or to modulating the balance of bone resorption and formation in ways that improve bone strength.

Switching of oral bisphosphonates to denosumab in chronic glucocorticoid users: a 12-month randomized controlled trial

OBJECTIVES

To evaluate the effect of switching from oral bisphosphonates to denosumab on bone mineral density (BMD) in long-term glucocorticoid users.

METHODS

Adult patients who were receiving long-term prednisolone (≥2.5 mg/day for ≥1 year) and oral bisphosphonates (≥2 years) were recruited. Participants were randomized to either continue oral bisphosphonates or switch to denosumab (60 mg subcutaneously every 6 months) for 12 months. Serial BMD (lumbar spine, hip) and bone turnover markers (serum osteocalcin, P1NP, β-CTX) were measured.

RESULTS

42 women were recruited (age 54.7±12.9 years; 21 shifted to denosumab and 21 continued on bisphosphonates). The duration of prednisolone therapy was 101±66.3 months and the daily dose was 4.4±2.1 mg. Baseline demographic data, osteoporosis risk factors, and BMD at various sites were similar between the two groups of patients. At month 12, BMD of the spine and hip increased by +3.4±0.9% (p=0.002) and +1.4±0.6% (p=0.03), respectively, in the denosumab group; whereas the corresponding change was +1.5±0.4% (p=0.001) and +0.80±0.5% (p=0.12) in the bisphosphonate group. The spinal BMD at month 12 was significantly higher in the denosumab than bisphosphonate group after adjustment for baseline BMD and β-CTX values, and other confounding factors (p=0.01). Bone turnover markers (β-CTX and P1NP) were more strongly suppressed by denosumab than the bisphosphonates. Minor infections were more common in denosumab-treated patients while other adverse events occurred at similar frequencies between the two groups.

CONCLUSIONS

In patients receiving long-term glucocorticoids, switching from oral bisphosphonates to denosumab resulted in greater gain of the spinal BMD and suppression of bone turnover markers after 12 months of therapy. The results have to be confirmed by a larger clinical trial with fracture as endpoint.