Glucocorticoid induced osteoporosis

New insights into dairy management and the prevention and treatment of osteoporosis: The shift from single nutrient to dairy matrix effects-A review

Dairy is recognized as a good source of calcium, which is important for preventing osteoporosis. However, the relationship between milk and bone health is more complex than just calcium supplementation. It is unwise to focus solely on observing the effects of a single nutrient. Lactose, proteins, and vitamins in milk, as well as fatty acids, oligosaccharides, and exosomes, all work together with calcium to enhance its bioavailability and utilization efficiency through various mechanisms. We evaluate the roles of dairy nutrients and active ingredients in maintaining bone homeostasis from the perspective of the dairy matrix effects. Special attention is given to threshold effects, synergistic effects, and associations with the gut-bone axis. We also summarize the associations between probiotic/prebiotic milk, low-fat/high-fat milk, lactose-free milk, and fortified milk with a reduced risk of osteoporosis and discuss the potential benefits and controversies of these dairy products. Moreover, we examine the role of dairy products in increasing peak bone mass during adolescence and reducing bone loss in old age. It provides a theoretical reference for the use of dairy products in the accurate prevention and management of osteoporosis and related chronic diseases and offers personalized dietary recommendations for bone health in different populations.

Side effects of chronic systemic glucocorticoid therapy: what dermatologists should know

In dermatologists' clinical practice, the use of systemic glucocorticoids is recurrent for the management of different comorbidities that require chronic immunosuppression. The prescription of this medication requires caution and basic clinical knowledge due to the several adverse effects inherent to the treatment. However, different doubts may arise or inappropriate conduct may be adopted due to the lack of objective and specific guidelines for the screening, prophylaxis and management of complications from chronic corticosteroid therapy. Considering this problem, the authors carried out a narrative review of the literature to gather up-to-date data on adverse effects secondary to the chronic use of systemic glucocorticoids. The broad approach to this topic made it possible to review the pathophysiology and risk factors for these complications, as well as to develop updated orientation that can be used as a learning tool and quick reference for dermatologists during their clinical practice with glucocorticoids.

Lumbar vertebral bone density is decreased in horses with pituitary pars intermedia dysfunction

BACKGROUND

Pathological fractures have been reported in equids with pituitary pars intermedia dysfunction (PPID) but their prevalence and pathogenesis is unknown.

OBJECTIVES

To compare: (1) bone mineral density (BMD) in weight bearing and nonweight bearing bones in PPID+ equids and aged and young PPID- controls; and (2) biomechanical properties of the fourth lumbar vertebral body in PPID+ equids and aged PPID- equids.

STUDY DESIGN

Case-control study: five PPID+ equids and six aged and four young PPID- control horses.

METHODS

PPID status was based on clinical signs and necropsy examination of the pituitary gland (PG). The lumbar vertebral column, right front third metacarpus (MC3), left hind third metatarsus (MT3), and PG were removed after euthanasia. BMD was determined by quantitative computed tomography of regions of interest (ROI) in each bone and biomechanical testing was performed on the fourth lumbar vertebral body. Serum concentrations of parathormone (PTH), ionised Ca++ , 25-hydroxyvitamin D, and osteocalcin (OC) were also measured. Data were analysed using one-way ANOVA and correlation analyses.

RESULTS

BMD of trabecular and cortical regions of interest (ROI) of the third, fourth (L4), and fifth lumbar vertebrae were significantly lower in PPID+ equids as compared with aged (p < 0. 001) and young (p < 0.01) PPID- controls. In contrast, no differences were found in BMD of trabecular or cortical ROIs of MC3 and MT3 between groups. No differences were detected in force at fracture, displacement at fracture, Young's modulus or strain of L4 between PPID+ and aged PPID- horses. No differences were found in serum PTH, ionised Ca++ , 25-hydroxyvitamin D, or OC concentrations between groups.

MAIN LIMITATIONS

Limited number of equids studied and variation in test results.

CONCLUSIONS

BMD of nonweight bearing bones can be decreased with PPID and could increase risk of developing pathological fractures.

Assessment of Awareness and Knowledge about Osteoporosis in Relation to Health Prevention among Patients Treated in Osteoporosis Clinics

The increasing incidence of osteoporosis indicates that the disease is a serious public health problem, with about 200 million people being affected worldwide. The aims of this research are to assess the awareness and knowledge about osteoporosis in relation to risk factors, health condition, supplementation used, socio-demographic factors and other variables among osteoporosis patients. The study was conducted in 2016-2018 in osteoporosis clinics in Poland. The study involved 312 patients with a diagnosis of osteoporosis. In the diagnostic survey method, the authors' own questionnaire was used. The results indicate that the more frequent the symptoms associated with the disease, the lower the general self-assessment of the health condition of the respondents (rho = -0.682, p < 0.001). In addition, almost half of the respondents stated that their knowledge of osteoporosis is negligible. Moreover, the use of dietary supplements significantly differentiated respondents in terms of health self-assessed (p < 0.001), and it is noteworthy that users of dietary supplements assessed their health significantly better. We also saw a statistically significant relationship between the self-assessment of knowledge about osteoporosis and the use of dietary supplements (p < 0.001). Accordingly, significantly more respondents rating their knowledge as good or very good used dietary supplements. The conducted study demonstrates the need to educate patients and implement educational programs at central and provincial levels to improve patient knowledge concerning the disease. Supporting adaptation to chronic diseases and appropriate therapeutic management may contribute to improved osteoporosis treatment and enhanced patient quality of life.

Effects of genistein aglycone in glucocorticoid induced osteoporosis: A randomized clinical trial in comparison with alendronate

Glucocorticoid-induced osteoporosis (GIO) complicates the clinical management of patients subjected to long-term glucocorticoid use. This study explored the effects of genistein on bone loss in a randomized double-blind alendronate-controlled trial in postmenopausal women with GIO. 200 postmenopausal women (taking at least 5 mg of prednisone equivalents) since 3 months, or more, and expected to continue for at least other 12 months, were randomized to receive genistein (54 mg/day daily) or alendronate (70 mg once a week) for 24 months. Both groups received also Calcium and Vitamin D3 supplementation. Median bone mineral density (BMD) at the antero-posterior lumbar spine significantly increased from 0.75 g/cm² at baseline to 0.77 g/cm² at 1 year and 0.79 g/cm² at 2 years in alendronate-treated patients and from 0.77 g/cm² at baseline to 0.79 g/cm² at 12 months and to 0.80 g/cm² at 24 months in genistein recipients. No difference was observed between the two treatments. Median BMD at the femoral neck increased from 0.67 g/cm² at baseline to 0.68 g/cm² at 1 year and 0.69 g/cm² at 2 years in alendronate-treated patients and from 0.68 g/cm² at baseline to 0.70 g/cm² at 12 months and to 0.71 g/cm² at 24 months in genistein recipients. No difference was observed between alendronate and genistein groups in BMD. Regarding bone markers genistein and alendronate statistically decreased c-terminal telopeptide, while osteocalcin, bone-ALP, and sclerostin showed greater changes in genistein treated patients. This randomized clinical trial suggests that genistein aglycone represents an additional therapeutic option for patients with GIO.

Interleukin 6 promotes BMP9-induced osteoblastic differentiation through Stat3/mTORC1 in mouse embryonic fibroblasts

Interleukin 6 (IL-6) plays a dual role in regulating bone metabolism, although the concrete mechanism is unclear. Bone morphogenetic protein 9 (BMP9) is one of the most potent osteogenic inducers, and a promising alternative for bone tissue engineering. The relationship between IL-6 and BMP9 in osteogenic differentiation remains to be elucidated, and the osteoblastic potential of BMP9 needs to be enhanced to overcome certain shortcomings of BMP9. In this study, we used real-time PCR, western blot, immunofluorescent stain, fetal limb culture and cranial defects repair model to explore the IL-6 role in BMP9-induced osteogenic differentiation in mouse embryonic fibroblasts (MEFs). We found that the rat serum level of IL-6 was increased in the dexamethasone-induced osteoporosis model, and IL-6 expression was detectable in several progenitor cells and MEFs. BMP9 upregulated IL-6 in MEFs, and the BMP9-induced osteoblastic markers were elevated by IL-6, but reduced by IL-6 knockdown. BMP9 and/or IL-6 both activated mTOR, and the IL-6 effect on BMP9-induced osteoblastic markers and bone formation were reduced greatly by mTOR inhibition. Raptor was up-regulated by IL-6 and/or BMP9 specifically, and the osteoblastic markers induced by IL-6 and/or BMP9 were reduced by Raptor knockdown. Meanwhile, Stat-3 was activated by IL-6 and/or BMP9, and the increase of Raptor or osteoblastic markers by IL-6 and/or BMP9 were reduced by Stat-3 inhibition. The Raptor promoter activity was regulated by p-Stat-3. Our finding suggested that IL-6 can promote the BMP9 osteoblastic potential, which may be mediated through activating Stat-3/mTORC1 pathway.

The potential mechanism of the microbiota-gut-bone axis in osteoporosis: a review

Osteoporosis is the prevalent metabolic bone disease characterized by a decrease in bone quantity and/or quality and an increase in skeletal fragility, which increases susceptibility to fractures. Osteoporotic fractures severely affect the patients' quality of life and mortality. A plethora of evidences have suggested that the alterations in gut microbiome are associated with the changes in bone mass and microstructure. We summarized pre-clinical and clinical studies to elucidate the underlying mechanism of gut microbiota in osteoporosis. Probiotics, prebiotics, and traditional Chinese medicine may reverse the gut microbiota dysbiosis and consequently improve bone metabolism. However, the causality of gut microbiota on bone metabolism need to be investigated more in depth. In the present review, we focused on the potential mechanism of the microbiota-gut-bone axis and the positive therapeutic effect of probiotics, prebiotics, and traditional Chinese medicine on osteoporosis. Overall, the current scientific literatures support that the gut microbiota may be a novel therapeutic target in treatment of osteoporosis and fracture prevention.

Systemic glucocorticoid prescriptions pattern and factors of inappropriate use in primary care institutions of Southwest China

Background

Inappropriate use of glucocorticoids in primary care institutions is serious. It not only causes economic burden, but leads to many adverse reactions. The purpose of this study is to explore systemic glucocorticoid prescription pattern and factors of inappropriate use in primary care institutions.

Methods

This is a retrospective study. Systemic glucocorticoids prescribed in 58 primary care institutions in Guizhou province of Southwest China in 2020 were selected from the Health Information System. All prescriptions were classified as appropriate or inappropriate use. Inappropriate use was classified into the following two categories: (a) Inappropriate indications; (b) Inappropriate selection of glucocorticoids. Multivariate analysis was used to explore the factors associated with inappropriate use of systemic glucocorticoids.

Results

A total of 63,315 glucocorticoid prescriptions were included in the analysis. Diseases of the respiratory system (60.8%) and diseases of the skin and subcutaneous tissue (23.1%) were the most common indications for use. Injections (89.8%) predominated and dexamethasone (86.5%) was the most prescribed glucocorticoid. 68.2% of all prescriptions were inappropriate. Compared to physicians with a college degree, physicians with a junior college (OR: 1.12, 95% CI: 1.08-1.17) and technical secondary education (OR: 1.12, 95% CI:1.05-1.19) were more likely to prescribe glucocorticoids inappropriately as were attending physicians (OR: 1.12, 95% CI: 1.01-1.25) and resident physicians (OR: 1.31, 95% CI: 1.15-1.48) compared to associate chief physicians. The risk of inappropriate glucocorticoid use was highest in patients 65 years of age and older (OR: 6.00, 95% CI: 5.62-6.40). In contrast, prescriptions given by injection were more likely to be used inappropriately than those given orally (OR: 0.44, 95% CI: 0.41-0.46).

Conclusion

Inappropriate use of systemic glucocorticoids without appropriate indications was extremely prominent in primary care institutions of Guizhou Province, especially in diseases of the respiratory system and among the elderly. The risk of inappropriate glucocorticoid use was highest in patients 65 years of age and older. It is important to note that physicians younger than 33, with more than 40 years of service, and attending or residents were more likely to inappropriately prescribe glucocorticoids.

Crosstalk between bone and other organs

Bone has long been considered as a silent organ that provides a reservoir of calcium and phosphorus, traditionally. Recently, further study of bone has revealed additional functions as an endocrine organ connecting systemic organs of the whole body. Communication between bone and other organs participates in most physiological and pathological events and is responsible for the maintenance of homeostasis. Here, we present an overview of the crosstalk between bone and other organs. Furthermore, we describe the factors mediating the crosstalk and review the mechanisms in the development of potential associated diseases. These connections shed new light on the pathogenesis of systemic diseases and provide novel potential targets for the treatment of systemic diseases.

Treatment of Glucocorticoid-Induced Osteoporosis and Risk Factors for New Vertebral Fractures in Female Patients with Autoimmune Diseases

We aimed to evaluate the compliance of physicians with the 2014 guidelines of the Japanese Society for Bone and Mineral Research, for the prevention and treatment of glucocorticoid (GC) induced osteoporosis (GIO) and to investigate the risk of fracture and other associated risk factors in bisphosphonate-treated patients. We evaluated 90 female patients with nonrheumatoid arthritis autoimmune diseases who received long-term GC treatment (≥12 months). Clinical characteristics, including age, GC dose, history of fragility fractures, osteoporosis treatments, as well as lumbar (L2-L4) and femoral neck bone mineral density, were collected from the patients' medical charts. New vertebral fractures during the study period were evaluated using thoracic and lumbar spine radiographs by quantitative measurements. The GIO score was calculated for each patient according to 2014 Japanese guidelines. Of the 90 patients evaluated, 60 were indicated for osteoporosis treatment, based on the 2014 guidelines of Japan. We observed a high compliance rate, with 93% of patients receiving osteoporosis treatment and 50% receiving bisphosphonates. In total, eight patients developed new vertebral fractures during the study, six of whom received bisphosphonates. In bisphosphonate-treated patients, fracture risk was associated with GC treatment and a lack of active vitamin D3 supplementation. The compliance rate with the updated Japanese 2014 guidelines at our institution was very high. Large randomized controlled trials are needed to confirm our findings that suggest that active vitamin D3 should be used in combination with bisphosphonates for the treatment of GIO to reduce fracture risk.

Update on Glucocorticoid Induced Osteoporosis

Glucocorticoids are used to treat many autoimmune and inflammatory diseases. However, an adverse systemic effect is a deleterious effect on bone, which may lead to glucocorticoid-induced osteoporosis, characterized by a rapid and transient increase in bone resorption and fracture risk, which may increase rapidly within 3 months of commencing oral glucocorticoids. Therefore, early risk assessment and intervention are crucial for preventing fractures in patients receiving glucocorticoids. Recent practice guidelines recommend an assessment for fracture risk in patients beginning or receiving glucocorticoids for more than 3 months, and they have suggested fracture risk assessment tool values for identifying patients who need preventive treatment. Bisphosphonates are currently the recommended first-line therapy for the prevention and treatment of glucocorticoid-induced osteoporosis. These have been shown to increase the bone mineral density in the spine and hip and to decrease the incidence of vertebral fractures. Recently, a more potent antiresorptive agent, denosumab, has been shown to increase the bone density in patients receiving glucocorticoids. Teriparatide has been shown to have a preventive effect on vertebral fractures, but not on nonvertebral fractures. In this article we aimed to provide an update on glucocorticoid-induced osteoporosis by focusing on the assessment of its risk and treatment options.

Management of glucocorticoid-induced osteoporosis

Long-term glucocorticoid (GC) therapy is frequently indicated to treat autoimmune and chronic inflammatory diseases in daily clinical practice. Two of the most devastating untoward effects are bone loss and fractures. Doses as low as 2.5 mg of prednisone for more than 3 months can impair bone integrity. Population at risk is defined based on the dose and duration of GC therapy and should be stratified according to FRAX (Fracture Risk Assessment Tool), major osteoporotic fracture, prior fractures, and bone mineral density values (BMD). General measures include to prescribe the lowest dose of GC to control the underlying disease for the shortest possible time, maintain adequate vitamin D levels and calcium intake, maintain mobility, and prescribe a bone acting agent in patients at high risk of fracture. These agents include oral and intravenous bisphosphonates, denosumab, and teriparatide.

Therapies for Preventing Bone Loss with Glucocorticoid Treatment

PURPOSE OF REVIEW

We aim to critically review recent recommendations regarding preventative strategies for glucocorticoid-induced osteoporosis and provide a summary of key evidence regarding available interventions.

RECENT FINDINGS

Lifestyle optimization remains the hallmark of bone health preservation. Early initiation of anti-osteoporotic agents in the setting of glucocorticoid exposure is essential, guided by appropriate risk stratification. Recommendations for calcium and vitamin D intake optimization are well-supported across all risk strata. Bisphosphonates are the mainstay of pharmacological therapy. Newer agents such as denosumab and teriparatide have demonstrated comparative benefit in terms of incident fracture risk reduction and bone mineral density preservation, with comparable adverse events. With due consideration to cost, resource availability, and patient values and preferences, these agents may warrant use as the first-line agents in this setting. Glucocorticoid-induced osteoporosis remains preventable and warrants early and targeted evidence-based therapy.

Glucocorticoids and Trabecular Bone Score

TBS (Trabecular Bone Score) is the latest tool for clinicians to evaluate bone micro-architecture based on a pixel greyscale, which is provided by lumbar dual-energy X-ray absorptiometry (DXA). Its use enhances fracture prediction in addition to DXA-BMD (Bone Mineral Density). This is independent of fracture risk assessment (FRAX) and DXA results. We present a narrative review regarding the connection between TBS and Glucocorticoids (GC), either as a drug used for different conditions or as a tumor-produced endogenous excess.

TBS is a better discriminator for GC-induced vertebral fractures compared to DXA-BMD. This aspect is similarly available for patients with osteoporosis diagnosed by DXA. TBS is inversely correlated with the cumulative dose of GC (systemic or inhaled), with disease duration, and positively correlated with respiratory function in patients with asthma. Low TBS values are found in females with a T-score at the hip within the osteoporosis range, with diabetes mellitus, or who use GC. Lumbar TBS is a screening tool in menopausal women with type 2 diabetes mellitus. TBS is an independent parameter that provides information regarding skeleton deterioration in diabetic patients receiving GC therapy in a manner complementary to DXA-BMD. TBS might become an essential step regarding the adrenalectomy decision in patients with adrenal incidentaloma in whom autonomous cortisol secretion might damage bone micro-architecture. TBS currently represents a standard tool of fracture risk evaluation in patients receiving GC therapy or with endogenous Cushing’s syndrome, a tool easy to be applied by different practitioners since GCs are largely used

Efficacy and safety of 18 anti-osteoporotic drugs in the treatment of patients with osteoporosis caused by glucocorticoid: A network meta-analysis of randomized controlled trials

Background

Glucocorticoids are widely used in a variety of diseases, especially autoimmune diseases and inflammatory diseases, so the incidence of glucocorticoid-induced osteoporosis is high all over the world.

Objectives

The purpose of this paper is to use the method of network meta-analysis (NMA) to compare the efficacy of anti-osteoporosis drugs directly and indirectly, and to explore the advantages of various anti-osteoporosis drugs based on the current evidence.

Methods

We searched PubMed, Embase and Cochrane Library for randomized controlled trials (RCTs), of glucocorticoid-induced osteoporosis (GIOP) and compared the efficacy and safety of these drugs by NMA. The risk ratio (RR) and its 95% confidence interval (CI) are used as the influence index of discontinuous data, and the standardized mean difference (SMD) and its 95% CI are used as the influence index of continuous data. The statistical heterogeneity was evaluated by the calculated estimated variance (τ²), and the efficacy and safety of drugs were ranked by the surface under the cumulative ranking curve (SUCRA). The main outcome of this study was the incidence of vertebral fracture after taking several different types of drugs, and the secondary results were the incidence of non-vertebral fracture and adverse events, mean percentage change of lumbar spine (LS) and total hip (TH)bone mineral density (BMD) from baseline to at least 12 months.

Results

Among the different types of anti-GIOP, teriparatide (SUCRA 95.9%) has the lowest incidence of vertebral fracture; ibandronate (SUCRA 75.2%) has the lowest incidence of non-vertebral fracture; raloxifene (SUCRA 98.5%) has the best effect in increasing LS BMD; denosumab (SUCRA 99.7%) is the best in increasing TH BMD; calcitonin (SUCRA 92.4%) has the lowest incidence of serious adverse events.

Conclusions

Teriparatide and ibandronate are effective drugs to reduce the risk of vertebral and non-vertebral fractures in patients with GIOP. In addition, long-term use of raloxifene and denosumab can increase the BMD of LS and TH.