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Evidence based Latin American Guidelines of clinical practice on prevention, diagnosis, management and treatment of glucocorticoid induced osteoporosis. A 2022 update : This manuscript has been produced under the auspices of the Committee of National Societies (CNS) and the Committee of Scientific Advisors (CSA) of the International Osteoporosis Foundation (IOF). Aging Clin Exp Res 2022; 34:2591-2602. [PMID: 36348222 DOI: 10.1007/s40520-022-02261-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/16/2022] [Indexed: 11/11/2022]
Abstract
Guidelines and recommendations developed and endorsed by the International Osteoporosis Foundation (IOF) are intended to provide guidance for particular pattern of practice for physicians who usually prescribe glucocorticoid (GC) therapy, and not to dictate the care of a particular patient. Adherence to the recommendations within this guideline is voluntary and the ultimate determination regarding their application should be made by the physician in light of each patient's circumstances. Guidelines and recommendations are intended to promote a desirable outcome but cannot guarantee any specific outcome. This guideline and its recommendations are not intended to dictate payment, reimbursement or insurance decisions. Guidelines and recommendations are subjected to periodic revisions as a consequence of the evolution of medicine, technology and clinical practice. A panel of Latin American (LATAM) experts specialized in osteoporosis with recognized clinical experience in managing patients with glucocorticoid-induced osteoporosis (GIO) met to produce evidence-based LATAM recommendations for the diagnosis and management of GIO. These guidelines are particularly intended to general practitioners and primary care physicians who prescribe GC treatments in LATAM to guide their daily clinical practice in terms of evaluation, prevention and treatment of GIO. These recommendations were based on systematic literature review using MEDLINE, EMBASE, SCOPUS and COCHRANE Library database during the period from 2012 to 2021. Randomized clinical trials (RCT), systematic reviews of RCT, controlled observational studies, guidelines and consensus were considered. Based on the review and expert opinion the panel members voted recommendations during two successive rounds of voting by panel members. Agreements for each statement were considered if a concordance of at least 70% was achieved following Delphi methodology. Grading of recommendations was made according to the Oxford Centre for the Evidence-based Medicine (EBM) criteria. Among five GIO guidelines and consensus initially identified, two of them (American College of Rheumatology 2017 and the Brazilian Guidelines 2021) were selected for comparison considering the latter as the most current guides in the LATAM region. Based on this methodology fifty statements were issued. All of them but four (1.20, 1.21, 1.23 and 4.2) attained agreement.
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Song BW, Kim AR, Kim MA, Kim HS, Lee SG. Status of Glucocorticoid-Induced Osteoporosis Preventive Care in Korea: A Retrospective Cohort Study on the Korean National Health Insurance Service Database. Medicina (B Aires) 2022; 58:medicina58020324. [PMID: 35208647 PMCID: PMC8879589 DOI: 10.3390/medicina58020324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 02/11/2022] [Accepted: 02/17/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: It is crucial to prevent osteoporosis in patients receiving long-term glucocorticoid (GC) treatment. This study aimed to investigate the frequency and associated factors of preventive care for glucocorticoid-induced osteoporosis (GIOP) in Korea. Materials and Methods: Using the Korean National Health Insurance Service database, we identified 37,133 individuals aged ≥ 20 years who commenced long-term (≥90 days) oral GC between 2011 and 2012. High-quality GIOP preventive care was defined as either a bone mineral density (BMD) test, calcium and/or vitamin D supplementation, or prescription osteoporosis medications within 6 months of GC initiation. Multivariable logistic regression models were used to calculate odds ratios (ORs) for associated factors for high-quality GIOP preventive care. Results: The mean age was 49.8 years, and 18,476 (49.8%) patients were female. The frequency of high-quality GIOP preventive care was only 3.68% (BMD test, 1.46%; osteoporosis medications, 1.65%; calcium/vitamin D, 1.63%). Increasing age (OR = 2.53, p < 0.001; 40–49 years, OR = 3.99, p < 0.001; 50–59 years, OR = 5.17, p < 0.001; 60–69 years, OR = 8.07, p < 0.001; ≥70 years, respectively), systemic autoimmune disease (OR = 3.08, p < 0.001), rural residence (OR = 1.19, p = 0.046), concomitant hyperthyroidism (OR = 1.58, p = 0.007), and malignancy (OR = 1.59, p < 0.001) were significantly associated with a higher likelihood of receiving high-quality GIOP preventive care. Male sex (OR = 0.26, p < 0.001) and GC prescription in primary care clinics and nursing hospitals (OR = 0.66, p < 0.001) were associated with a lower rate of high-quality GIOP preventive care. Conclusions: Most Korean patients treated with GC did not receive appropriate preventive care for GIOP in real-world practice. More efforts are needed by clinicians to prevent, screen, and treat GIOP.
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Affiliation(s)
- Byung-Wook Song
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan 49241, Korea; (B.-W.S.); (A.-R.K.)
- Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Korea
| | - A-Ran Kim
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan 49241, Korea; (B.-W.S.); (A.-R.K.)
- Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Korea
| | - Min-A Kim
- Department of Data Science, Hanmi Pharm. Co., Ltd., Seoul 05545, Korea; (M.-A.K.); (H.-S.K.)
| | - Ho-Seob Kim
- Department of Data Science, Hanmi Pharm. Co., Ltd., Seoul 05545, Korea; (M.-A.K.); (H.-S.K.)
| | - Seung-Geun Lee
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan 49241, Korea; (B.-W.S.); (A.-R.K.)
- Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Korea
- Correspondence:
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Cheng CH, Chen LR, Chen KH. Osteoporosis Due to Hormone Imbalance: An Overview of the Effects of Estrogen Deficiency and Glucocorticoid Overuse on Bone Turnover. Int J Mol Sci 2022; 23:ijms23031376. [PMID: 35163300 PMCID: PMC8836058 DOI: 10.3390/ijms23031376] [Citation(s) in RCA: 143] [Impact Index Per Article: 71.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 02/07/2023] Open
Abstract
Osteoporosis is a serious health issue among aging postmenopausal women. The majority of postmenopausal women with osteoporosis have bone loss related to estrogen deficiency. The rapid bone loss results from an increase in bone turnover with an imbalance between bone resorption and bone formation. Osteoporosis can also result from excessive glucocorticoid usage, which induces bone demineralization with significant changes of spatial heterogeneities of bone at microscale, indicating potential risk of fracture. This review is a summary of current literature about the molecular mechanisms of actions, the risk factors, and treatment of estrogen deficiency related osteoporosis (EDOP) and glucocorticoid induced osteoporosis (GIOP). Estrogen binds with estrogen receptor to promote the expression of osteoprotegerin (OPG), and to suppress the action of nuclear factor-κβ ligand (RANKL), thus inhibiting osteoclast formation and bone resorptive activity. It can also activate Wnt/β-catenin signaling to increase osteogenesis, and upregulate BMP signaling to promote mesenchymal stem cell differentiation from pre-osteoblasts to osteoblasts, rather than adipocytes. The lack of estrogen will alter the expression of estrogen target genes, increasing the secretion of IL-1, IL-6, and tumor necrosis factor (TNF). On the other hand, excessive glucocorticoids interfere the canonical BMP pathway and inhibit Wnt protein production, causing mesenchymal progenitor cells to differentiate toward adipocytes rather than osteoblasts. It can also increase RANKL/OPG ratio to promote bone resorption by enhancing the maturation and activation of osteoclast. Moreover, excess glucocorticoids are associated with osteoblast and osteocyte apoptosis, resulting in declined bone formation. The main focuses of treatment for EDOP and GIOP are somewhat different. Avoiding excessive glucocorticoid use is mandatory in patients with GIOP. In contrast, appropriate estrogen supplement is deemed the primary treatment for females with EDOP of various causes. Other pharmacological treatments include bisphosphonate, teriparatide, and RANKL inhibitors. Nevertheless, more detailed actions of EDOP and GIOP along with the safety and effectiveness of medications for treating osteoporosis warrant further investigation.
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Affiliation(s)
- Chu-Han Cheng
- Department of Physical Medicine and Rehabilitation, Mackay Memorial Hospital, Taipei 104, Taiwan; (C.-H.C.); (L.-R.C.)
| | - Li-Ru Chen
- Department of Physical Medicine and Rehabilitation, Mackay Memorial Hospital, Taipei 104, Taiwan; (C.-H.C.); (L.-R.C.)
- Department of Mechanical Engineering, National Yang Ming Chiao Tung University, Hsinchu 300, Taiwan
| | - Kuo-Hu Chen
- Department of Obstetrics and Gynecology, Taipei Tzu-Chi Hospital, The Buddhist Tzu-Chi Medical Foundation, Taipei 231, Taiwan
- School of Medicine, Tzu-Chi University, Hualien 970, Taiwan
- Correspondence: ; Tel.: +886-2-66289779
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Pereira RMR, Perez MO, Paula AP, Moreira C, Castro CHM, Zerbini CAF, Domiciano DS, de Azevedo E, Mendonca LMC, Shinzato MM, da Rocha-Loures MAA, Radominski S, Szejnfeld VL. Guidelines for the prevention and treatment of glucocorticoid-induced osteoporosis: an update of Brazilian Society of Rheumatology (2020). Arch Osteoporos 2021; 16:49. [PMID: 33646403 DOI: 10.1007/s11657-021-00902-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 02/01/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED The Brazilian guidelines for prevention and treatment of glucocorticoid-induced osteoporosis were updated and important topics were included such as assessment of risk fracture using FRAX Brazil, use of denosumab, and also recommendations for the use of glucocorticoid pulse therapy and inhaled glucocortiocoid. INTRODUCTION Glucocorticoids (GCs) are used in almost all medical specialties and the incidences of vertebral/nonvertebral fractures range from 30 to 50% in individuals treated with GCs for over 3 months. Thus, osteoporosis and frailty fractures should be prevented and treated in patients initiating treatment or already being treated with GCs. The Committee for Osteoporosis and Bone Metabolic Disorders of the Brazilian Society of Rheumatology (BSR) established in 2012 the Brazilian Guidelines for glucocorticoid-induced osteoporosis (GIO). Herein, we provide a comprehensive update of the original guidelines based on improved available scientific evidence and/or expert experience. METHODS From March to June 2020, the Osteoporosis Committee of the BRS had meetings to update the questions presented in the first consensus (2012). Thus, twenty-six questions considered essential for the preparation of the recommendations were selected. A systematic literature review based on real-life scenarios was undertaken to answer the proposed questions. The MEDLINE, EMBASE, and SCOPUS databases were searched using specific search keywords. RESULTS Based on the review and expert opinion, the recommendations were updated for each of the 26 questions. We included 48 new bibliographic references that became available after the date of the publication of the first version of the consensus. CONCLUSION We updated the Brazilian guidelines for the prevention/treatment of GIO. New topics were added in this update, such as the assessment of risk fracture using FRAX Brazil, the use of denosumab, and approaches for the treatment of children and adolescents. Furthermore, we included recommendations for the use of inhaled GCs and GC pulse therapy in clinical settings.
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Affiliation(s)
- Rosa M R Pereira
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3° andar, sala 3193, Sao Paulo, SP, 01246-903, Brazil.
| | - Mariana O Perez
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3° andar, sala 3193, Sao Paulo, SP, 01246-903, Brazil
| | - Ana Patrícia Paula
- Rheumatology Division, Faculdade de Ciências da Saúde, Universidade de Brasilia (UnB), Brasilia, DF, Brazil
| | - Caio Moreira
- Rheumatology Division, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Charlles H M Castro
- Rheumatology Division, Universidade Federal de Sao Paulo-Escola Paulista de Medicina, Sao Paulo, SP, Brazil
| | - Cristiano A F Zerbini
- Rheumatology Division, Centro Paulista de Investigação Clínica, Sao Paulo, SP, Brazil
| | - Diogo S Domiciano
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3° andar, sala 3193, Sao Paulo, SP, 01246-903, Brazil
| | - Elaine de Azevedo
- Rheumatology Division, Hospital do Servidor Público Estadual de Sao Paulo, Sao Paulo, SP, Brazil
| | - Laura M C Mendonca
- Rheumatology Division, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Marcia Midore Shinzato
- Rheumatology Division, Faculdade de Ciências da Saúde da Universidade Federal da Grande Dourados, Dourados, MS, Brazil
| | | | - Sebastião Radominski
- Rheumatology Division, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brazil
| | - Vera L Szejnfeld
- Rheumatology Division, Universidade Federal de Sao Paulo-Escola Paulista de Medicina, Sao Paulo, SP, Brazil
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Lucinda LMF, Aarestrup BJV, Reboredo MM, Pains TDA, Chaves RZ, Reis JEP, Louzada MJQ, Guerra MO. Evaluation of the anti-osteoporotic effect of Ginkgo biloba L. in Wistar rats with glucocorticoid-induced-osteoporosis by bone densitometry using dual-energy x-ray absorptiometry (DEXA) and mechanical testing. AN ACAD BRAS CIENC 2017; 89:2833-2841. [PMID: 29044313 DOI: 10.1590/0001-3765201720160479] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 01/01/2017] [Indexed: 11/22/2022] Open
Abstract
Evaluate the effect of the extract of Ginkgo biloba in the bone alkaline phosphatase, bone mineral density, in the mechanical properties of the tibia in rats with glucocorticoid-induced-osteoporosis. After osteoporosis induction, the rats were divided into five groups: Osteoporosis; EGb1 (28 mg/Kg); EGb2 (56 mg/Kg); alendronate (0.2 mg/animal) and control. The animals were treated during 20 and 30 days. The control group was compared with the osteoporosis's (Student's t-test), while the other were analyzed by ANOVA test followed by Tukey/Dunnett'T3 (p<0.05). In the osteoporosis group the bone alkaline phosphatase, bone mineral density, the bone stiffness, the maximum load and the resilience were reduced. The bone alkaline phosphatase values increased in the EGb1 and EGb2 groups (30 days). In addition, in the EGb2 and alendronate groups (20 and 30 days) the bone mineral density increased. The extract of Ginkgo biloba restored bone alkaline phosphatase and bone mineral density using dual-energy x-ray absorptiometry.
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Affiliation(s)
- Leda M F Lucinda
- Centro de Biologia da Reprodução, Universidade Federal de Juiz de Fora/UFJF, São Pedro, Caixa Postal 328, 36001-970 Juiz de Fora, MG, Brazil
| | - Beatriz J V Aarestrup
- Centro de Biologia da Reprodução, Universidade Federal de Juiz de Fora/UFJF, São Pedro, Caixa Postal 328, 36001-970 Juiz de Fora, MG, Brazil
| | - Maycon M Reboredo
- Centro de Biologia da Reprodução, Universidade Federal de Juiz de Fora/UFJF, São Pedro, Caixa Postal 328, 36001-970 Juiz de Fora, MG, Brazil
| | - Thais D A Pains
- Faculdade de Medicina, Universidade Federal de Juiz de Fora/UFJF, Avenida Eugênio do Nascimento, s/n, Caixa Postal 328, 36001-970 Juiz de Fora, MG, Brazil
| | - Raphael Z Chaves
- Faculdade de Medicina, Universidade Federal de Juiz de Fora/UFJF, Avenida Eugênio do Nascimento, s/n, Caixa Postal 328, 36001-970 Juiz de Fora, MG, Brazil
| | - João E P Reis
- Centro de Biologia da Reprodução, Universidade Federal de Juiz de Fora/UFJF, São Pedro, Caixa Postal 328, 36001-970 Juiz de Fora, MG, Brazil
| | - Mário J Q Louzada
- Faculdade de Medicina Veterinária de Araçatuba, Universidade do Estado de São Paulo/UNESP, Rua Clovis Pestana, 793, 16050-680 Araçatuba, SP, Brazil
| | - Martha O Guerra
- Centro de Biologia da Reprodução, Universidade Federal de Juiz de Fora/UFJF, São Pedro, Caixa Postal 328, 36001-970 Juiz de Fora, MG, Brazil
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Korpi-Steiner N, Milhorn D, Hammett-Stabler C. Osteoporosis in men. Clin Biochem 2014; 47:950-9. [PMID: 24726494 DOI: 10.1016/j.clinbiochem.2014.03.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 03/24/2014] [Accepted: 03/29/2014] [Indexed: 12/11/2022]
Abstract
Osteoporosis in men causes significant morbidity and mortality. Bone health declines gradually, often insidiously; and in light of the advancing aging population poses a serious public health issue that is not well recognized. Studies of the past decade have expanded our understanding of the events within, as well as the regulation of, bone remodeling and provided better insight into the physiology and pathophysiology specific to the adult male skeleton. The clinical measurement of bone mineral density using dual-energy X-ray absorptiometry remains the gold standard for diagnosis of osteoporosis in males; and fracture risk assessment is now recognized as a preferred approach to guide treatment decisions. Utilizing surrogate end-points such as increasing bone mineral density and decreasing concentrations of bone resorption markers, clinical trials have demonstrated efficacy in pharmacological treatment of osteoporosis in the adult male. Unfortunately, few studies have evaluated the anti-fracture benefits in this population. Measurement of bone turnover markers may be an additional tool to monitor therapeutic responsiveness in addition to the measurement of bone mineral density.
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Affiliation(s)
- Nichole Korpi-Steiner
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Denise Milhorn
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Catherine Hammett-Stabler
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA.
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Ethgen O, de Lemos Esteves F, Bruyere O, Reginster JY. What do we know about the safety of corticosteroids in rheumatoid arthritis? Curr Med Res Opin 2013; 29:1147-60. [PMID: 23790244 DOI: 10.1185/03007995.2013.818531] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Clear information is still lacking on the safety of corticosteroids (GCs) therapy in RA despite six decades of clinical experience. SCOPE We performed a literature search in Ovid MEDLINE from January 2000 to December 2012. Our Population Intervention Comparator Outcomes (PICO) strategy search was: rheumatoid arthritis [Population], corticosteroids or glucocorticoids [Intervention], any comparison [Comparator], adverse effects [Outcome]. Studies were selected if they reported any measure of association between GCs intake and potential adverse effects in RA patients. FINDINGS We identified 1030 papers and selected for analysis 26 observational studies and six systematic reviews. The major side effects of GCs in RA are bone loss, risk of cardiovascular events and risk of infections as evidenced by large observational studies and not necessarily RCTs. Others associations were reported with herpes zoster, tuberculosis, hyperglycemia, cutaneous abnormalities, gastrointestinal perforation, respiratory infection and self-reported health problems such as cushingoid phenotype, ecchymosis, parchment-like skin, epistaxis, weight gain and sleep disturbance. Other potential adverse effects of GCs were studied but no association was found. These included psychological disorders, dermatophytosis, brain diseases, interstitial lung disease, memory deficit, metabolic syndrome, lymphoma, non-Hodgkin's lymphoma, renal function and cerebrovascular accidents. Most of the evidence emanates from observational researches and the inherent limitations of such data should be kept in mind. CONCLUSION Recent observational data and systematic reviews suggest that GCs can lead to relatively alarming and burdensome side effects in RA. This is particularly true for patients who have longer term and higher dose therapies. GCs are largely used in RA and knowing their safety profile is essential to improve patients care. The design of new therapeutic strategies intended to minimize the daily dosing of GCs while conserving their beneficial effect should be encouraged.
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Affiliation(s)
- Olivier Ethgen
- Department of Public Health Sciences, Epidemiology and Health Economics, University of Liège, Liège, Belgium.
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Derakhshanian H, Djalali M, Djazayery A, Nourijelyani K, Ghadbeigi S, Pishva H, Saedisomeolia A, Bahremand A, Dehpour AR. Quercetin prevents experimental glucocorticoid-induced osteoporosis: a comparative study with alendronate. Can J Physiol Pharmacol 2013; 91:380-5. [DOI: 10.1139/cjpp-2012-0190] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Glucocorticoid-induced osteoporosis (GIO) is the most common type of secondary osteoporosis. The aim of this study was to compare the efficacy of quercetin, a plant-derived flavonoid, with alendronate in the prevention of GIO. Fifty-six Sprague–Dawley rats were randomly distributed among 7 groups (8 rats per group) and treated for 6 weeks with one of the following: (i) normal saline; (ii) 40 mg methylprednisolone sodium succinate (MP)/kg body mass; (iii) MP + 40 μg alendronate/kg; (iv) MP + 50 mg quercetin/kg; (v) MP + 40 μg alendronate/kg + 50 mg quercetin/kg; (vi) MP + 150 mg quercetin/kg; and (vii) MP + 40 μg alendronate/kg + 150 mg quercetin/kg. MP and alendronate were injected subcutaneously and quercetin was administered by oral gavage 3 days a week. At the end of the study, femur breaking strength was significantly decreased as a consequence of MP injection. This decrease was completely compensated for in groups receiving 50 mg quercetin/kg plus alendronate, and 150 mg quercetin/kg with or without alendronate. Quercetin noticeably elevated osteocalcin as a bone formation marker, while alendronate did not show such an effect. In addition, administration of 150 mg quercetin/kg increased femoral trabecular and cortical thickness by 36% and 22%, respectively, compared with the MP-treated group. These data suggest that 150 mg quercetin/kg, alone or in combination with alendronate, can completely prevent GIO through its bone formation stimulatory effect.
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Affiliation(s)
- Hoda Derakhshanian
- Department of Nutrition and Biochemistry, School of Public Health, Tehran University of Medical Sciences, PO Box 14155-6446 Tehran, Iran
| | - Mahmoud Djalali
- Department of Nutrition and Biochemistry, School of Public Health, Tehran University of Medical Sciences, PO Box 14155-6446 Tehran, Iran
| | - Abolghassem Djazayery
- Department of Nutrition and Biochemistry, School of Public Health, Tehran University of Medical Sciences, PO Box 14155-6446 Tehran, Iran
| | - Keramat Nourijelyani
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Sajad Ghadbeigi
- Department of Medicinal Chemistry, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamideh Pishva
- Department of Nutrition and Biochemistry, School of Public Health, Tehran University of Medical Sciences, PO Box 14155-6446 Tehran, Iran
| | - Ahmad Saedisomeolia
- Department of Nutrition and Biochemistry, School of Public Health, Tehran University of Medical Sciences, PO Box 14155-6446 Tehran, Iran
| | - Arash Bahremand
- Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Reza Dehpour
- Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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McKeown E, Bykerk VP, De Leon F, Bonner A, Thorne C, Hitchon CA, Boire G, Haraoui B, Ferland DS, Keystone EC, Pope JE. Quality assurance study of the use of preventative therapies in glucocorticoid-induced osteoporosis in early inflammatory arthritis: results from the CATCH cohort. Rheumatology (Oxford) 2012; 51:1662-9. [DOI: 10.1093/rheumatology/kes079] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Davidson ZE, Walker KZ, Truby H. Clinical review: Do glucocorticosteroids alter vitamin D status? A systematic review with meta-analyses of observational studies. J Clin Endocrinol Metab 2012; 97:738-44. [PMID: 22188740 DOI: 10.1210/jc.2011-2757] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
CONTEXT Vitamin D supplementation is an important adjunct therapy for the prevention and management of glucocorticoid-induced osteoporosis. There has been little exploration of the relationship between glucocorticosteroid (GCS) use and serum 25-hydroxyvitamin D [25(OH)D]. OBJECTIVE The aim of this study was to systematically explore how serum 25(OH)D is altered in adult patients receiving GCS. DATA SOURCES We reviewed Medline and Cinahl databases between January 1970 and August 2011. STUDY SELECTION Experimental studies were included where 25(OH)D was measured in patients more than 18 yr of age receiving GCS therapy. Studies were excluded if patients received at least 400 IU/d (10 μg/d) vitamin D, if GCS treatment was less than 2-wk duration, if more than 50% of the study population received GCS for renal or hepatic disease or after transplant, or if the study population included patients with Cushing's syndrome. A consensus method was used to classify studies. Of identified studies, 3% met the selection criteria. DATA EXTRACTION Data were extracted by a single author. Study quality was assessed using criteria developed by the American Dietetic Association. DATA SYNTHESIS The weighted mean 25(OH)D (by sample size or sd) was 22.4 [95% confidence interval (CI), 19.4, 25.3] ng/ml and 21.0 (95% CI, 13.5, 28.5) ng/ml, respectively. Random effects meta-analysis was used to compare serum 25(OH)D in patients treated with GCS compared to steroid-naive controls (either healthy or with active disease) and in patients before and after GCS administration. Serum 25(OH)D in GCS users was on average -0.5 (95% CI, -1.0, -0.1) ng/ml lower than in healthy controls (P=0.03; I2=56.4%). Serum 25(OH)D did not differ between GCS users and disease controls [standardized mean difference=0.0 (95% CI, -0.2, 0.3) ng/ml; P=0.793; I2=16.2%]. CONCLUSION The suboptimal concentrations of serum 25(OH)D found in adults receiving GCS are inadequate for prevention and management of glucocorticoid-induced osteoporosis. Recommendations for vitamin D supplementation should be adjusted accordingly.
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Affiliation(s)
- Zoe E Davidson
- Monash University, Department of Nutrition and Dietetics, Southern Clinical School of Medicine, Monash Medical Centre, Level 5, Block E, 246 Clayton Road, Clayton, Victoria, Australia 3168.
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Vitamin D: Lessons from the Veterans Population. J Am Med Dir Assoc 2011; 12:257-62. [DOI: 10.1016/j.jamda.2010.08.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Accepted: 08/10/2010] [Indexed: 11/23/2022]
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Caplan L, Hines AE, Williams E, Prochazka AV, Saag KG, Cunningham F, Hutt E. An observational study of glucocorticoid-induced osteoporosis prophylaxis in a national cohort of male veterans with rheumatoid arthritis. Osteoporos Int 2011; 22:305-15. [PMID: 20358362 DOI: 10.1007/s00198-010-1201-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Accepted: 01/25/2010] [Indexed: 10/19/2022]
Abstract
UNLABELLED We applied regression techniques to a large cohort of patients to understand why certain patients are prescribed medications to prevent glucocorticoid-induced osteoporosis (GIO). Rates of prescriptions to prevent osteoporosis were low. The presence of drugs and disorders associated with osteoporosis and gastrointestinal conditions actually are associated with a decreased likelihood of receiving osteoporosis-preventing medications. INTRODUCTION To understand why some patients are prescribed medications to prevent GIO while other patients are not, we examined whether there is an association among osteoporosis-inducing medical conditions or medications and prescriptions for osteoporosis prophylaxis in a large cohort of rheumatoid arthritis patients on chronic glucocorticoids. METHODS Department of Veterans' Affairs national administrative databases were used to construct a cohort (n = 9,605) and provide the data for this study. Multivariate logistic regression was performed to determine medical conditions and medications associated with dispensing of GIO-preventive medications, controlling for sociodemographic variables, comorbidities, glucocorticoid dosage, prior fractures, and rheumatoid arthritis severity. A subanalysis examined predictors of early GIO prevention. RESULTS Subjects were more likely to receive GIO prophylaxis if they were older, African American, treated with multiple antirheumatic disease-modifying drugs, or received greater glucocorticoid exposure. The prescription of certain drug classes (loop diuretics and anticonvulsants) and conditions (malignancy, renal insufficiency, alcohol abuse, and hepatic disease) were associated with lower likelihood of GIO prophylaxis, despite putative links between these agents/conditions and osteoporosis. The presence of gastrointestinal disorders dramatically decreased likelihood of GIO prophylaxis. Few characteristics predicted the dispensing of GIO-preventing medications within 7 days of the initial glucocorticoid start date. CONCLUSIONS Rates of prescriptions to prevent osteoporosis in a cohort of older men with rheumatoid arthritis on chronic glucocorticoids were low. Gastrointestinal disorders and drugs and disorders potentially linked to osteoporosis are associated with diminished odds of being prescribed GIO-preventing medications.
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Affiliation(s)
- L Caplan
- Denver VA Medical Center, 1055 Clermont St, Research 151, Denver, CO 80220, USA.
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Payer J, Brazdilova K, Jackuliak P. Management of glucocorticoid-induced osteoporosis: prevalence, and emerging treatment options. Drug Healthc Patient Saf 2010; 2:49-59. [PMID: 21701617 PMCID: PMC3108700 DOI: 10.2147/dhps.s7197] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Indexed: 01/28/2023] Open
Abstract
An excess amount of glucocorticoids represents the primary and most frequent etiological factor influencing secondary osteoporosis. Patients receiving glucocorticoids, but also those with the endogenous form of hypercorticism, are at high risk for the loss of bone density, with the subsequent occurrence of pathological fractures. In this review, we summarize the currently available methods of prevention and the treatment of glucocorticoid-induced osteoporosis. We also include a proposal for both a prophylactic and therapeutic approach that takes into account the risk factors typical for long-term users of glucocorticoids.
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Affiliation(s)
- Juraj Payer
- 5th Department of Internal Medicine, Medical Faculty of Comenius University and Faculty Hospital Bratislava, Bratislava, Slovakia
| | - Kristina Brazdilova
- 5th Department of Internal Medicine, Medical Faculty of Comenius University and Faculty Hospital Bratislava, Bratislava, Slovakia
| | - Peter Jackuliak
- 5th Department of Internal Medicine, Medical Faculty of Comenius University and Faculty Hospital Bratislava, Bratislava, Slovakia
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Factors influencing fracture risk, T score, and management of osteoporosis in patients with rheumatoid arthritis in the Consortium of Rheumatology Researchers of North America (CORRONA) registry. J Clin Rheumatol 2009; 15:155-60. [PMID: 19363452 DOI: 10.1097/rhu.0b013e3181a5679d] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study examined a wide array of clinical factors to evaluate their influence on fracture risk and T scores in women with rheumatoid arthritis (RA) and determine if women with RA who are at risk for osteoporosis (OP) are adequately treated with OP medications. METHODS Data from 8419 female RA patients participating in the Consortium of Rheumatology Researchers of North America registry from March 02, 2006 to August 15, 2006 was evaluated. Covariates included medication subgroups, demographic, and clinical parameters. Lumbar spine and hip T scores and fracture rates were studied in relation to the variables. Use of OP medications in patients with OP risk factors was also evaluated. RESULTS Postmenopausal status and higher modified health assessment questionnaire score (mHAQ) had a negative effect on lumbar spine score,while marriage, education, and body mass index had a positive effect. A similar trend was found with hip T scores. Increase in overall fracture risk correlated with postmenopausal status, mHAQ, and prednisone use, while tumor necrosis factor monotherapy was associated with decreased overall fracture risk. mHAQ was also associated with nonhip/nonspine fractures. Eighty percent of patients had at least 1 risk factor for OP, but only 32% were on OP medications. Only 54% of patients with 3 risk factors were on OP medication. CONCLUSIONS In RA, postmenopausal status, mHAQ, and prednisone use were associated with a higher overall fracture risk. Women with RA who were at risk for OP may have been inadequately treated with OP medications.
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Screening and Treatment of Glucocorticoid-Induced Osteoporosis in Rheumatoid Arthritis Patients in an Urban Multispecialty Practice. J Clin Rheumatol 2009; 15:61-4. [DOI: 10.1097/rhu.0b013e31819b65bd] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Duyvendak M, Naunton M, van Roon EN, Bruyn GAW, Brouwers JRBJ. Systematic review of trends in prophylaxis of corticosteroid-induced osteoporosis: the need for standard audit guidelines. Osteoporos Int 2008; 19:1379-94. [PMID: 18629573 DOI: 10.1007/s00198-008-0598-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2007] [Accepted: 02/18/2008] [Indexed: 10/21/2022]
Abstract
UNLABELLED Corticosteroid-induced osteoporosis (CIOP) is currently undertreated. Systematic review of the literature revealed that the percentage of patients treated adequately is dependent on study quality. Therefore, it remains unknown whether adherence to the guidelines is really so poor. Five major quality criteria provide the standard for future studies on this scope. INTRODUCTION It has recently been stated that the degree of prophylaxis of corticosteroid-induced osteoporosis (CIOP) is low and effort should be put into determining reasons for non-prescribing of preventive agents. The aim of this study was to identify: how many studies adequately audit the prevalent guideline; the longitudinal trends in prevention of CIOP; which patient groups appear to be most undertreated; and which intervention strategies are effective. METHODS We performed a comprehensive search of MEDLINE and systematically recorded the outcomes and quality of published studies, using five major criteria. RESULTS Twenty-four studies were included in the analysis. The quality of the included studies was poor (31%) or moderate (37%). There was a longitudinal increase in quality of the studies and percentage of prevention. Multivariable linear regression showed that the quality of the study was the only independent predictor of the prevention rate reported in the study. CONCLUSIONS The results show undertreatment of CIOP might be due to insufficient quality of the studies rather than poor practice or failure to recognise the right patients. Future interventions should comply with five major quality criteria, and a multifaceted approach is required in order to make an impact on the underprescribing of CIOP prophylaxis.
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Affiliation(s)
- M Duyvendak
- Department of Pharmacotherapy and Pharmaceutical Care, University of Groningen, Ant. Deusinglaan 1, 9713 AV, Groningen, The Netherlands.
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Olszynski WP, Davison KS. Alendronate for the treatment of osteoporosis in men. Expert Opin Pharmacother 2008; 9:491-8. [PMID: 18220499 DOI: 10.1517/14656566.9.3.491] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Men have higher rates of osteoporosis and suffer fragility fractures more often than previously believed. Fracture-related morbidity and mortality in men is substantially higher than in women. OBJECTIVE To investigate alendronate for treating osteoporosis in men. METHODS Search limited to 'men' and 'English'; keywords were 'osteoporosis' or 'bone density' or 'fracture' and 'alendronate'. RESULTS/CONCLUSIONS Alendronate is an amino-bisphosphonate with proved efficacy for increasing bone mineral density in men with idiopathic or secondary osteoporosis and has demonstrated an ability to prevent vertebral fractures in men with low bone mass. There are trends for alendronate to decrease the risk of non-vertebral fracture, but larger trials are needed to conclusively establish this benefit. Alendronate is a well-tolerated and comparatively safe drug with an attractive once-a-week dosing regimen.
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Mazziotti G, Giustina A, Canalis E, Bilezikian JP. Glucocorticoid-Induced osteoporosis: clinical and therapeutic aspects. ACTA ACUST UNITED AC 2007; 51:1404-12. [DOI: 10.1590/s0004-27302007000800028] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2007] [Accepted: 07/30/2007] [Indexed: 12/19/2022]
Abstract
Glucocorticoid-induced osteoporosis (GIO) is the most common form of secondary osteoporosis. Fractures, which are often asymptomatic, may occur in as many as 30_50% of patients receiving chronic glucocorticoid therapy. Vertebral fractures occur early after exposure to glucocorticoids, at a time when bone mineral density (BMD) declines rapidly. Fractures tend to occur at higher BMD levels than in women with postmenopausal osteoporosis. Glucocorticoids have direct and indirect effects on the skeleton. They impair the replication, differentiation, and function of osteoblasts and induce the apoptosis of mature osteoblasts and osteocytes. These effects lead to a suppression of bone formation, a central feature in the pathogenesis of GIO. Glucocorticoids also favor osteoclastogenesis and as a consequence increase bone resorption. Bisphosphonates are the most effective of the various therapies that have been assessed for the management of GIO. Anabolic therapeutic strategies are under investigation. Teriparatide seems to be also efficacious for the treatment of patients with GIO.
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Canalis E, Mazziotti G, Giustina A, Bilezikian JP. Glucocorticoid-induced osteoporosis: pathophysiology and therapy. Osteoporos Int 2007; 18:1319-28. [PMID: 17566815 DOI: 10.1007/s00198-007-0394-0] [Citation(s) in RCA: 691] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2007] [Accepted: 04/30/2007] [Indexed: 12/11/2022]
Abstract
Glucocorticoid-induced osteoporosis (GIO) is the most common form of secondary osteoporosis. Fractures, which are often asymptomatic, may occur in as many as 30-50% of patients receiving chronic glucocorticoid therapy. Vertebral fractures occur early after exposure to glucocorticoids, at a time when bone mineral density (BMD) declines rapidly. Fractures tend to occur at higher BMD levels than in women with postmenopausal osteoporosis. In human subjects, the early rapid decline in BMD is followed by a slower progressive decline in BMD. Glucocorticoids have direct and indirect effects on the skeleton. The primary effects are on osteoblasts and osteocytes. Glucocorticoids impair the replication, differentiation and function of osteoblasts and induce the apoptosis of mature osteoblasts and osteocytes. These effects lead to a suppression of bone formation, a central feature in the pathogenesis of GIO. Glucocorticoids also favor osteoclastogenesis and as a consequence increase bone resorption. Bisphosphonates are effective in the prevention and treatment of GIO. Anabolic therapeutic strategies are under investigation.
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Affiliation(s)
- E Canalis
- Saint Francis Hospital and Medical Center, Hartford, CT 060105, USA
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Abstract
PURPOSE OF REVIEW Glucocorticoids are widely used, often long term, and a major side effect is osteoporosis and increased risk of fracture. This review considers how common is the problem, the patients who are most at risk, our current understanding of mechanisms, and how to prevent and effectively treat glucocorticoid-induced osteoporosis. The actions currently being undertaken in clinical practice are reviewed. RECENT FINDINGS Glucocorticoid-induced osteoporosis is an increasing problem that occurs not only in those on high-dose therapy. Advances in our knowledge of the cellular and cytokine mechanisms of bone turnover and glucocorticoid mechanisms of action are leading to a better understanding of how glucocorticoids affect bone cells and novel ways of prevention. Although there are effective treatments to prevent and control glucocorticoid-induced osteoporosis as well as guidelines for their use, they are still not being applied in routine clinical practice. SUMMARY Glucocorticoid-induced osteoporosis is a significant problem. Although our understanding of effective prevention and treatment strategies is improving, there needs to be better implementation of these strategies.
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Affiliation(s)
- Anthony D Woolf
- Institute of Health and Social Care Research, Peninsula Medical School, Universities of Exeter and Plymouth and Duchess of Cornwall Centre for Osteoporosis, Department of Rheumatology, Royal Cornwall Hospital, Truro, UK.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2007. [DOI: 10.1002/pds.1374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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