236th ENMC International Workshop Bone protective therapy in Duchenne muscular dystrophy: Determining the feasibility and standards of clinical trials Hoofddorp, The Netherlands, 1-3 June 2018

Cross-Sectional Study of Knee Bone Mineral Density and Fragility Fractures in Patients with Neurological Injuries and Neuromuscular Disorders

BACKGROUND

Patients with neurological injury and neuromuscular disorders are at increased risk for osteoporosis and fragility fracture. This cross-sectional study investigated whether knee bone mineral density (BMD) correlates with fragility fracture in patients with neurological injury and neuromuscular injuries.

METHODOLOGY

In this retrospective chart review, 435 participants underwent dual-energy X-ray absorptiometry (DXA) for BMD analysis. Distal femur and proximal tibial BMD measurements were performed as per the Toronto protocol. Spine, hip, and forearm DXA was performed following the standards of the International Society of Clinical Densitometry, 2019. Blinded and independent clinical evaluations and laboratory exams were performed. Participants were divided into groups with and without fracture confirmed by clinical history and radiography.

RESULTS

Distal femur and proximal tibial BMD were measured in 288/435 (66.2%) participants. Osteoporosis was noted in 138/288 (47.9%) patients. Fractures occurred in 95/435 participants (21.8%), including one fracture in 64/435 participants (14.7%), two fractures in 24/435 participants (5.5%), and greater than two fractures in 7/435 patients (1.6%). Fractures were noted in 23/54 (42.6%) participants with post-polio syndrome, 21/66 with brain injury (31.8%), 3/10 (30%) with brain injury and spinal cord injury, 24/98 (24.5%) with neuromuscular disorders, 9/52 (17.3%) with nontraumatic spinal cord injury, and 15/155 (9.7%) with traumatic spinal cord injury. The median BMD of the knee and hip was lower in participants with fractures. Distal femur and proximal tibial BMD (odds ratio [OR] = 0.02, 95% confidence interval [CI]: 0.01-0.45) remained independently associated with fragility fracture in multivariable analysis.

CONCLUSION

Proximal tibial and distal femur BMD measurements offered additional information on neurological injury and neuromuscular disorders.

Adult North Star Network (ANSN): Consensus Guideline For The Standard Of Care Of Adults With Duchenne Muscular Dystrophy

There are growing numbers of adults with Duchenne Muscular Dystrophy living well into their fourth decade. These patients have complex medical needs that to date have not been addressed in the International standards of care. We sought to create a consensus based standard of care through a series of multi-disciplinary workshops with specialists from a wide range of clinical areas: Neurology, Cardiology, Respiratory Medicine, Gastroenterology, Endocrinology, Palliative Care Medicine, Rehabilitation, Renal, Anaesthetics and Clinical Psychology. Detailed reports of evidence reviewed and the consensus building process were produced following each workshop and condensed into this final document which was approved by all members of the Adult North Star Network including service users. The aim of this document is to provide a framework to improve clinical services and multi-disciplinary care for adults living with Duchenne Muscular Dystrophy.

A survey of the feasibility of developing osteoporosis clinical trials in Duchenne muscular dystrophy: Survey of the opinion of young people with Duchenne muscular dystrophy, families and clinicians

BACKGROUND/AIMS

Given the extent of osteoporosis in people with Duchenne muscular dystrophy treated with glucocorticoids and the limited evidence of bone-protective therapies, clinical trials are needed. We conducted surveys to obtain the opinion of young people with Duchenne muscular dystrophy, parents/guardians and neuromuscular clinicians on the feasibility of osteoporosis clinical trials in this population.

METHODS

Online surveys were sent to three groups: (a) people with a confirmed diagnosis of Duchenne muscular dystrophy (≥14 years), (b) parents and guardians and (c) neuromuscular clinicians in the UK NorthStar Clinical Network. Surveys (a) and (b) were distributed via the UK Duchenne muscular dystrophy Registry.

RESULTS

Survey respondents included 52 people with Duchenne muscular dystrophy with a median age of 17 years (range: 14, 40) and 183 parents/guardians. Fourteen out of 23 (61%) NorthStar centres responded. Of the 52 people with Duchenne muscular dystrophy, 13 (25%) were very concerned about their bone health and 21 (40%) were slightly concerned. Of the 183 parents/guardians, 75 (41%) were very concerned about their son's bone health and 90 (49%) were slightly concerned. Fractures and quality of life were the top two main outcome measures identified by people with Duchenne muscular dystrophy. Fractures and bone density were the top two main outcome measures identified by parents/guardians and neuromuscular clinicians. Thirty percent of people with Duchenne muscular dystrophy and 40% of parents/guardians would not take part if an osteoporosis trial involved a placebo that was administered parenterally. Only 2 of the 14 NorthStar centres (14%) would enrol people with Duchenne muscular dystrophy if a parenteral placebo was used in an osteoporosis trial in Duchenne muscular dystrophy.

CONCLUSION

There is great awareness of bone health and the need for bone-protective trials among people with Duchenne muscular dystrophy and their carers. However, a proportion of people with Duchenne muscular dystrophy and parents are reluctant to participate in a placebo-controlled osteoporosis trial that included a parenteral therapy. A larger proportion of health care experts are unwilling to enrol their patients in such a trial. Our finding is relevant for the design of bone-protective studies in Duchenne muscular dystrophy.

Efficacy of corticosteroid in decreasing scoliosis and extending time to loss of ambulation in a single clinic: an effectiveness trial

PURPOSE

Pharmacologic doses of corticosteroid (CS) have been shown to ameliorate the progression of Duchenne muscular dystrophy (DMD) preserving strength, pulmonary function and ambulation as well as reducing the incidence of scoliosis. However, there are serious side effects of CS, which may impact dose tolerance. The purpose of this study was to compare the magnitude of positive CS effects on patients in our clinic to those reported in the literature.

METHODS

We retrospectively reviewed medical records and radiographs of 142 DMD patients who were seen between 1st January 1991 and 31st December 2017.

RESULTS

In total, 101 boys met study inclusion criteria. Of these 32 were steroid naïve, 37 took the recommended dose (standard of care, SOC) of Prednisone or Deflazacort, and 32 took a lower dose (LD). Following initiation of CS, both treatment groups showed an increase in weight velocity and decrease in linear growth velocity. Although there was a trend to later loss of ambulation (LOA) in the SOC group relative to the naïve group by one year, this was not significant, however, a small subgroup of boys on Deflazacort showed a 3.4 year later LOA than the naïve group. The incidence of scoliosis was reduced from 69% in the naïve, to 41% in the LD and 47% in the SOC group.

CONCLUSIONS

Although there was a reduction in the incidence of scoliosis, it was not as robust as seen elsewhere. Many published studies have inadequate data on scoliosis probably due to the lack of inclusion of orthopaedists in the study group.

LEVEL OF EVIDENCE

IV.