Alendronate and indapamide alone or in combination in the management of hypercalciuria associated with osteoporosis: a randomized controlled trial of two drugs and three treatments

Pharmacological interventions for preventing complications in patients with idiopathic hypercalciuria: A systematic review

OBJECTIVE

To assess the effects of pharmacological interventions in patients with idiopathic hypercalciuria.

METHODS

We performed a search of multiple databases, trial registries, grey literature and conference proceedings up to October 2019. We included randomized and quasi-randomized controlled trials that examined any pharmacological intervention for preventing complications of idiopathic hypercalciuria (given for at least four months and six of follow-up). The primary outcomes were stone-free patients, urinary symptoms and severe adverse events.

RESULTS

We included five RCTs (n=446 patients, all adults, 4 in individuals with kidney stones and 1 in postmenopausal women with osteoporosis). Diuretics were likely to increase the number of stone-free patients (RR 1.61, 95% CI 1.33-1.96, moderate quality of evidence (QoE)); 274 more stone-free patients/1000 patients treated (95% CI: 148-432) and produced a slight decrease in the stone formation rate (mean difference -0.18, 95% CI -0.30 to -0.06, low QoE); 180 fewer stones/year/1000 patients treated (95% CI: 300 r to 60). No data on urinary symptoms were reported. The association between diuretic use and severe adverse events was uncertain (RR 5.00, 95% CI 0.60-41.88, very low QoE); 4 more severe adverse events/1000 patients treated (95% CI: 0 fewer to 39 more).

CONCLUSIONS

The addition of diuretics to a normal or modified diet probably reduces the number of stone recurrences and may decrease the stone formation rate. It is uncertain whether diuretics increase the occurrence of severe adverse events. There were no studies investigating other outcomes or in children.

Role of hormone replacement therapy in relieving oral dryness symptoms in postmenopausal women: a case control study

BACKGROUND

To evaluate the efficacy of hormone replacement therapy in relieving oral symptoms in postmenopausal women presenting with genitourinary symptoms along with oral dryness.

METHODS

A case-control study was conducted after selecting 60 postmenopausal women. Oral dryness status of all the patients was evaluated with the help of questionnaire related to oral dryness. These subjects were divided into case group and control group on the basis of response to questionnaire of oral dryness. Unstimulated saliva samples were obtained and analyzed for estimation of salivary estradiol levels by enzyme linked immune sorbent assay technique. After analyzing the result of salivary estradiol levels, case group was subjected to hormone replacement therapy (HRT). The patients were followed up for their response towards oral dryness as well as salivary estradiol levels after the therapy.

RESULTS

The mean salivary estradiol level before HRT was significantly more among control group as compared to case group (p value < 0.001). Most of the patients complained of dry mouth (26 out of 30); reduced amount of saliva in the mouth (25 out of 30); dry mouth at night (28 out of 30); dry mouth during the day (25 out of 30) before HRT. These complains were significantly reduced after the therapy. The mean salivary estradiol in the case group levels increased significantly after HRT (p value < 0.001).

CONCLUSION

The salivary estradiol levels were reduced in post menopausal women with the complain of xerostomia as compared to those without the complain of xerostomia. Further these levels can be recovered with the help of hormone replacement therapy.

The Effects of Osteoporotic and Non-osteoporotic Medications on Fracture Risk and Bone Mineral Density

Osteoporosis is a highly prevalent bone disease affecting more than 37.5 million individuals in the European Union (EU) and the  United States of America (USA). It is characterized by low bone mineral density (BMD), impaired bone quality, and loss of structural and biomechanical properties, resulting in reduced bone strength. An increase in morbidity and mortality is seen in patients with osteoporosis, caused by the approximately 3.5 million new osteoporotic fractures occurring every year in the EU. Currently, different medications are available for the treatment of osteoporosis, including anti-resorptive and osteoanabolic medications. Bisphosphonates, which belong to the anti-resorptive medications, are the standard treatment for osteoporosis based on their positive effects on bone, long-term experience, and low costs. However, not only medications used for the treatment of osteoporosis can affect bone: several other medications are suggested to have an effect on bone as well, especially on fracture risk and BMD. Knowledge about the positive and negative effects of different medications on both fracture risk and BMD is important, as it can contribute to an improvement in osteoporosis prevention and treatment in general, and, even more importantly, to the individual's health. In this review, we therefore discuss the effects of both osteoporotic and non-osteoporotic medications on fracture risk and BMD. In addition, we discuss the underlying mechanisms of action.

Pharmacological interventions for preventing complications in patients with idiopathic hypercalciuria: A systematic review

OBJECTIVE

To assess the effects of pharmacological interventions in patients with idiopathic hypercalciuria.

METHODS

We performed a search of multiple databases, trial registries, grey literature and conference proceedings up to October 2019. We included randomized and quasi-randomized controlled trials that examined any pharmacological intervention for preventing complications of idiopathic hypercalciuria (given for at least four months and six of follow-up). The primary outcomes were stone-free patients, urinary symptoms and severe adverse events.

RESULTS

We included five RCTs (n=446 patients, all adults, 4 in individuals with kidney stones and 1 in postmenopausal women with osteoporosis). Diuretics were likely to increase the number of stone-free patients (RR 1.61, 95% CI 1.33-1.96, moderate quality of evidence (QoE)); 274 more stone-free patients/1000 patients treated (95% CI: 148-432) and produced a slight decrease in the stone formation rate (mean difference -0.18, 95% CI -0.30 to -0.06, low QoE); 180 fewer stones/year/1000 patients treated (95% CI: 300 r to 60). No data on urinary symptoms were reported. The association between diuretic use and severe adverse events was uncertain (RR 5.00, 95% CI 0.60-41.88, very low QoE); 4 more severe adverse events/1000 patients treated (95% CI: 0 fewer to 39 more).

CONCLUSIONS

The addition of diuretics to a normal or modified diet probably reduces the number of stone recurrences and may decrease the stone formation rate. It is uncertain whether diuretics increase the occurrence of severe adverse events. There were no studies investigating other outcomes or in children.

Bisphosphonates and management of kidney stones and bone disease

PURPOSE OF REVIEW

Kidney stones are strongly associated with low bone density and bone fracture. Clinical management focuses on prevention of kidney stones and bone fracture. We reviewed literature of kidney stones and bone disease with a special focus on updates in therapeutic strategies. We will review the literature regarding dietary management, supplements, and medications and emphasize the recent studies on bisphosphonates and kidney stone management.

RECENT FINDINGS

Bisphosphonate medications are commonly used in management of low bone density. Previous studies showed that they reduce urinary calcium. A recent large prospective study found that bisphosphonates may reduce the risk of kidney stones in individuals who have low bone density. In addition to lowering urinary calcium, a recent study found that bisphosphonates may act as an inhibitor in the urinary space.

SUMMARY

There are multiple dietary and pharmacologic strategies that can be considered for kidney stones and bone disease, such as low salt and normal calcium diet, as well as thiazides, alkali, and bisphosphonate medications. Bisphosphonates may have an important role in reducing bone resorption and reducing overall risk of kidney stone and bone disease.

Effect of bisphosphonates on the crystallization of stone-forming salts in synthetic urine

Purpose

We investigated the inhibitory effect of bisphosphonates (BPs) on the crystallization of calcium oxalate monohydrate (COM), calcium phosphate (CaP), and magnesium ammonium phosphate (MAP) in synthetic urine, aiming to see 1) which specific BPs work best on a particular type of crystal and 2) what is the lowest concentration of BPs that inhibits crystal formation.

Materials and Methods

Crystals from synthetic urine were exposed to different concentrations of BPs. Urinary turbidity was used as a marker of crystallization and was measured by spectrophotometry by use of a validated method in our laboratory. The percent inhibitory activity (IA) was calculated by using the formula: (a−b )/a×100, where a is baseline maximal turbidity and b is maximal turbidity with various concentrations of medication. Potassium citrate and magnesium citrate were used as positive controls.

Results

At the lowest dose of 0.001 mg/mL, risedronate induced the highest IA of 37% on CaP, whereas ibandronate had the strongest IA on COM (24%). To initiate the inhibition of MAP crystallization, risedronate required a two-fold higher concentration (0.002 mg/mL) to reach 30% IA, whereas etidronate required a four-fold higher concentration (0.004 mg/mL) to reach 42% IA.

Conclusions

BPs are good inhibitors of crystallization in synthetic urine, with risedronate and ibandronate being the most potent. At a low clinically acceptable dose, their highest inhibitory action was on CaP and COM crystals. Higher doses were needed to prevent MAP crystallization. Further investigation of the use of BPs in kidney stone prevention is warranted.

Vitamin D and Kidney Stones

This review explores the relationship between vitamin D supplementation and lithogenesis. A causal relationship has been assumed despite myriad studies demonstrating that therapeutic doses of vitamin D do not increase lithogenic risk. Select stone formers may be at increased risk for recurrence with vitamin D supplementation, possibly from CYP24A1 gene mutations. Additionally, the evidence for who is vitamin D deficient, and the benefits of supplementation in those not at risk for rickets, is sparse. Concerns may be avoidable as vitamin D screening appears unnecessary in most patients, and superior pharmacology is available which increases bone density, while decreasing stone formation.

A network meta-analysis on the short-term efficacy and adverse events of different anti-osteoporosis drugs for the treatment of postmenopausal osteoporosis

A network meta-analysis was conducted to compare the short-term efficacy and adverse events of different drugs for the treatment of postmenopausal osteoporosis (PMO), providing a more effective treatment for PMO. We initially searched through various databases like PubMed, Cochrane Library, and EMBASE from inception till October 2016. All randomized controlled trials (RCTs) of drugs for the treatment of PMO were included for direct and indirect comparison. A combination of direct and indirect evidence of different inhibitors of anti-diabetic drugs for treatment of PMO were considered for calculating the weighted mean difference (WMD) value or odd ratio (OR) value and to draw surface under the cumulative ranking (SUCRA) curves. Twenty-seven RCTs were ultimately incorporated into this network meta-analysis comprising of 48 200 patients suffering from PMO. The network meta-analysis revealed that compared with placebo, alendronate had better efficacy on improving bone mineral density (BMD) at lumbar spine, femoral neck, and total hip. Risedronate and raloxifene had relatively lower incidence of new vertebral fractures. The SUCRA analysis showed that alendronate had better efficacy on improving BMD, risedronate could significantly decrease the incidence of fresh fracture and bazedoxifene was relatively safe. The available evidence suggested that alendronate and risedronate might be the superior choices for the treatment of PMO, while bazedoxifene was a comparatively safer option for patients.

Low Bone Density and Bisphosphonate Use and the Risk of Kidney Stones

BACKGROUND AND OBJECTIVES

Previous studies have demonstrated lower bone density in patients with kidney stones, but no longitudinal studies have evaluated kidney stone risk in individuals with low bone density. Small studies with short follow-up reported reduced 24-hour urine calcium excretion with bisphosphonate use. We examined history of low bone density and bisphosphonate use and the risk of incident kidney stone as well as the association with 24-hour calcium excretion.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a prospective analysis of 96,092 women in the Nurses' Health Study II. We used Cox proportional hazards models to adjust for age, body mass index, thiazide use, fluid intake, supplemental calcium use, and dietary factors. We also conducted a cross-sectional analysis of 2294 participants using multivariable linear regression to compare 24-hour urinary calcium excretion between participants with and without a history of low bone density, and among 458 participants with low bone density, with and without bisphosphonate use.

RESULTS

We identified 2564 incident stones during 1,179,860 person-years of follow-up. The multivariable adjusted relative risk for an incident kidney stone for participants with history of low bone density compared with participants without was 1.39 (95% confidence interval [95% CI], 1.20 to 1.62). Among participants with low bone density, the multivariable adjusted relative risk for an incident kidney stone for bisphosphonate users was 0.68 (95% CI, 0.48 to 0.98). In the cross-sectional analysis of 24-hour urine calcium excretion, the multivariable adjusted mean difference in 24-hour calcium was 10 mg/d (95% CI, 1 to 19) higher for participants with history of low bone density. However, among participants with history of low bone density, there was no association between bisphosphonate use and 24-hour calcium with multivariable adjusted mean difference in 24-hour calcium of -2 mg/d (95% CI, -25 to 20).

CONCLUSIONS

Low bone density is an independent risk factor for incident kidney stone and is associated with higher 24-hour urine calcium excretion. Among participants with low bone density, bisphosphonate use was associated with lower risk of incident kidney stone but was not independently associated with 24-hour urine calcium excretion.

Medical management of urinary calculi: up to date 2016

Nephrolithiasis (NL) is one of the most prevalent nontransmissible diseases in western countries. It is being associated with other frequent diseases, including osteoporosis, cardiovascular disease, hypertension, diabetes mellitus, through a putative common link with metabolic syndrome and insulin resistance or altered mineral metabolism. This review will focus on classification, physicochemical basis, risk factors, laboratory and imaging investigations, medical management.Classification as to stone composition includes calcium, uric acid (UA), cystine (Cys), infected, 2-8 dihydroxyadenine and rare NL. According to pathophysiology, NL is classified as primary, secondary to systemic diseases or drugs, caused by renal or metabolic hereditary disorders.A stone can only form in supersaturated environment, and this is sufficient in UA, Cys and infected NL, but not in Ca-NL, which results from the imbalance between supersaturation and inhibition. All types are characterized by derangements of peculiar risk factors. Laboratory investigations aim at identifying type of NL, underlying risk factors and state of saturation, and pathophysiology. This justifies a rationale therapy able to dissolve some types of stones and/or produce reduction in recurrence rate in others.Medical management includes alkali and allopurinol for UA nephrolithiasis (UA-NL), thiols and alkali in Cys-NL, dietary and pharmacological intervention for Ca-NL. Thiazides and alkaline citrate salts are the most widely used drugs in Ca-NL, where they proved efficient to prevent new stones. Other drugs have only been used in particular subsets.Proper medical management and modern urological approaches have already notably improved clinical outcomes. Future studies will further clarify mechanisms of NL with expected new and targeted therapeutic options.

Management of endocrine disease: Secondary osteoporosis: pathophysiology and management

Osteoporosis is a skeletal disorder characterized by decreased mass and compromised bone strength predisposing to an increased risk of fractures. Although idiopathic osteoporosis is the most common form of osteoporosis, secondary factors may contribute to the bone loss and increased fracture risk in patients presenting with fragility fractures or osteoporosis. Several medical conditions and medications significantly increase the risk for bone loss and skeletal fragility. This review focuses on some of the common causes of osteoporosis, addressing the underlying mechanisms, diagnostic approach and treatment of low bone mass in the presence of these conditions.

Calcium nephrolithiasis and bone demineralization: pathophysiology, diagnosis, and medical management

PURPOSE OF REVIEW

To establish the relationship between calcium nephrolithiasis, bone densitometry scoring, and bone mineral density (BMD) loss according to bone turnover markers (BTMs) and urinary metabolites.

RECENT FINDINGS

Patients with recurrent calcium nephrolithiasis and idiopathic fasting hypercalciuria (urinary calcium/creatinine ratio >0.11) are more likely to have BMD loss that may lead to osteopenia or osteoporosis. In these patients, BTMs may be used as a surrogate for both bone health and stone recurrence. Suspect higher lithogenic states when calcium stone formers have serum beta-crosslaps (resorptive marker) greater than 0.311 ng/ml, serum osteocalcin (formative marker) greater than 13.2 ng/ml, and beta-crosslaps/osteocalcin ratio greater than 0.024.

SUMMARY

Patients with recurrent calcium nephrolithiasis and fasting hypercalciuria have a higher incidence of osteopenia and osteoporosis, measured by the dual-energy X-ray absorptiometry. These patients present not only with hypercalciuria and increased BTMs (mainly resorptive), but also up to 30% have hypocitraturia and increased urinary calcium/citrate ratio (>0.25). On the basis of these results, a diagnostic algorithm was created, classifying hypercalciurics according to their fasting calcium/creatinine and calcium/citrate ratio. Medical therapy for these patients is aimed at improving the dietary habits (normocalcemic, low salt, low animal protein diet), prescribing combinations of potassium citrate, thiazides, and bisphosphonates, and correcting bone and urinary abnormalities that may lower future skeletal and kidney stone risk.

Pediatric nephrolithiasis and the link to bone metabolism

PURPOSE OF REVIEW

To review the recent publications describing the link between pediatric nephrolithiasis and bone metabolism.

RECENT FINDINGS

Nephrolithiasis incidence is increasing in children and is associated with low bone mineral density (BMD). Affected children are conceptually at risk for fractures and osteoporosis. In addition to abnormal calcium metabolism, inflammation, genetic makeup and dietary habits are being recognized as important factors in the pathophysiology of nephrolithiasis and low bone density. Findings from retrospective reviews suggest that low BMD in children may be improved with citrate or thiazide treatment.

SUMMARY

The healthcare burden from low BMD with subsequent osteoporosis and fracture risk is immense with potential far-reaching effects in patient quality of life and healthcare expense. Bone mass is acquired in the pediatric age range, thus it is important to identify and treat at-risk children. Retrospective reviews in pediatric patients indicate that citrate or thiazide diuretic treatment may improve BMD. We now understand that a relationship exists between nephrolithiasis and low BMD. To improve healthcare for our current patients as well as protect their future health it is important to identify low BMD and initiate strategies to improve BMD in 'at-risk' children.

Kidney stones: an update on current pharmacological management and future directions

INTRODUCTION

Kidney stones are a common problem worldwide with substantial morbidities and economic costs. Medical therapy reduces stone recurrence significantly. Much progress has been made in the last several decades in improving therapy of stone disease.

AREAS COVERED

This review discusses i) the effect of medical expulsive therapy on spontaneous stone passage, ii) pharmacotherapy in the prevention of stone recurrence and iii) future directions in the treatment of kidney stone disease.

EXPERT OPINION

Fluid intake to promote urine volume of at least 2.5 L each day is essential to prevent stone formation. Dietary recommendations should be adjusted based on individual metabolic abnormalities. Properly dosed thiazide treatment is the standard therapy for calcium stone formers with idiopathic hypercalciuria. Potassium alkali therapy is considered for hypocitraturia, but caution should be taken to prevent potential risk of calcium phosphate stone formation. For absorptive hyperoxaluria, low oxalate diet and increased dietary calcium intake are recommended. Pyridoxine has been shown effective in some cases of primary hyperoxaluria type I. Allopurinol is used in calcium oxalate stone formers with hyperuricosuria. Treatment of cystine stones remains challenging. Tiopronin can be used if urinary alkalinization and adequate fluid intake are insufficient. For struvite stones, complete surgical removal coupled with appropriate antibiotic therapy is necessary.

Bone and metabolic markers in women with recurrent calcium stones

Purpose

The target of our work was to study several biochemical parameters in phospho-calcic and bone metabolism in blood and urine and the bone mineral density of women with recurrent calcium nephrolithiasis.

Materials and Methods

We conducted a cross-sectional study with a control group of 85 women divided into 3 groups: group 1 consisted of 25 women without a history of nephrolithiasis, group 2 consisted of 35 women with only one episode of calcium nephrolithiasis, and group 3 consisted of 25 women with a history of recurrent calcium nephrolithiasis. Blood and urine biochemical study was performed, including markers related to lithiasis, and a bone mineral density study was done by use of bone densitometry.

Results

Patients in group 3 showed statistically significantly elevated calciuria (15.4 mg/dL), fasting calcium/creatinine ratio (0.14), and 24-hour calcium/creatinine ratio (0.21) compared with groups 1 and 2. Moreover, this group of women with recurrent calcium nephrolithiasis had significantly elevated values of beta-crosslaps, a bone resorption marker, compared with groups 1 and 2 (p=0.000) and showed more bone mineral density loss than did these groups.

Conclusions

Recurrent calcium nephrolithiasis in women has a significant association with bone mineral density loss and with values of calciuria, both fasting and 24-hour.

Calcium renal lithiasis: metabolic diagnosis and medical treatment

Calcium renal lithiasis is a frequent condition that affects the worldwide population and has a high recurrence rate. Different metabolic changes may trigger the onset of calcium stone disorders, such as hypercalciuria, hyperoxaluria, hyperuricosuria, hypocitraturia and others. There are also other very prevalent disorders that are associated with calcium calculi, such as arterial hypertension, obesity and loss of bone mineral density. A correct diagnosis needs to be obtained through examining the serum and urinary parameters of mineral metabolism in order to carry out adequate prevention and treatment of this condition. Once the metabolic diagnosis is known, it is possible to establish dietary and pharmacological treatment that may enable monitoring of the disease and prevent recurrence of stone formation. Some advances in treating this pathological condition have been made, and these include use of sodium alendronate in patients with calcium renal lithiasis and osteopenia/osteoporosis, or use of a combination of a thiazide with a bisphosphonate. In summary, calcium renal lithiasis often requires multidrug treatment with strict control and follow-up of patients.

Bisphosphonates in the management of idiopathic hypercalciuria associated with osteoporosis: a new trick from an old drug

Idiopathic hypercalciuria (IHC) is defined as a 24-hour urinary calcium excretion that exceeds 4 mg/kg/day, regardless of gender and in absence of systemic diseases or pharmacological treatments that may cause normocalcemic hypercalciuria (eg sarcoidosis, normocalcemic primary hyperparathyroidism, vitamin D intoxication, hyperthyroidism). Patients with IHC and nephrolithiasis often present increased bone turnover, decreased bone mineral density (BMD) and increased susceptibility to fragility fractures. Although the pathogenesis of IHC seems complex and multifactorial, recent evidences suggest that cells involved in bone resorption may play a critical role in the chain of events leading to the excessive urinary calcium excretion. Therefore, it has been proposed that bisphosphonates, potent inhibitors of bone resorption, may have beneficial effects in hypercalciuric patients with low BMD. This manuscript reports recent findings regarding the role of bone tissue in the pathogenesis of IHC, and supports the use of bisphosphonates in such conditions. It also reviews the literature on the effects of bisphosphonates in subjects with osteoporosis-associated IHC.

Hyponatremia independent of osteoporosis is associated with fracture occurrence

BACKGROUND AND OBJECTIVES

Mild hyponatremia has traditionally been considered benign, but it may be associated with gait and attention deficits and an increased risk of falls that may result in fracture. A retrospective study was conducted to quantify the association of hyponatremia with fracture occurrence and to examine whether this relationship is independent of osteoporosis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study analyzed 1408 consecutive female patients who underwent bone mineral density measurement (Lunar IDXA) between September 1, 2006 and April 11, 2007 and who had available laboratory data. Self reported fracture occurrence was confirmed by radiology report or attendance at a fracture clinic. The significance and independence of the association of hyponatremia with fracture was quantified using logistic regression.

RESULTS

The mean (SD) serum sodium ([Na(+)]) was 140.6 (3.0) mmol/L; 59 (4.2%) had [Na(+)] < 135 mmol/L. Forty-five percent of subjects were osteoporotic and 18% had a prior fracture. Hyponatremia was present in 8.7% of those with versus 3.2% of those without a confirmed fracture (P < 0.001). On multivariate logistic regression analysis controlling for age, T-score, chronic kidney disease stage, osteoporotic risk factors (amenorrhea, family history, regular steroid use, smoking history, alcohol use, history of liver disease, and low-calcium diet), and osteoporosis treatments (calcium and vitamin D supplements, antiresorptives, and hormonal replacement therapy), [Na(+)] < 135 versus [Na(+)] >or= 135 mmol/L remained significantly and independently associated with fracture occurrence (P < 0.01).

CONCLUSIONS

Mild hyponatremia may be a readily identifiable and potentially modifiable risk factor for fracture.