Long-term treatment of osteoporosis in postmenopausal women: a review from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) and the International Osteoporosis Foundation (IOF)

Mapping knowledge landscapes and emerging trends of the links between osteoarthritis and osteoporosis: A bibliometric analysis

Background

Osteoarthritis has the characteristics of degenerative changes in articular cartilage and secondary osteoporosis, and it is a common chronic irreversible joint disease. In addition to affecting articular cartilage, subchondral bone, joint capsule and synovial membrane also undergo pathological changes during the development of the disease. Multiple studies have revealed that patients with osteoarthritis were found to have a significantly increased risk of osteoporosis, which also contributes to the progression of osteoarthritis. However, in the current existing studies, we found that no scholars have used bibliometric analysis in the study of the relationship between osteoarthritis and osteoporosis. From the perspective of bibliometrics, this study summarizes in detail the degree of cooperation between countries, research institutions, authors, and related journals in the field of osteoarthritis and osteoporosis research and their respective influence. In this way, the evolution of knowledge structure, the change of research focus and the hot topics with research potential in the future can be further visualized and analyzed.

Methods

Search the Web of Science core collection in Science Citation Index Expanded for articles and reviews of research on osteoarthritis and osteoporosis from 1998 to 2021. Bibliometric tools such as VOSviewer, CiteSpace, were be frequently used in our study. They are mainly used to analyze collaborations between countries, research institutions, and publication authors. Meantime, co-citation analysis of journals, co-occurrence analysis of keywords and subject categories will also be reflected in the study.

Results

According to the search strategy, 1,078 publications were included during the period 1998-2021. And the number of annual publications on the relationship between osteoarthritis and osteoporosis is on the rise. The United States has achieved the most and contributed the most in this field and the Boston University was the most prolific institution. For the statistical analysis of published publications, Reginster JY had the highest number of publications, while Felson DT had the highest co-citation frequency. Respectively, Osteoarthritis And Cartilage was the most productive journal in this area of research. The keywords "inflammation," "expression," and "mesenchymal stem cells" may also be the development trend and research hotspot of the future research direction in this field.

Conclusions

In our study, the relationship between osteoarthritis and osteoporosis was analyzed by using literature measurement. These analysis results can lead researchers to learn more directly about the trend in this area and provide guidance for determining popular research directions.

Human serum albumin-based nanoparticles alter raloxifene administration and improve bioavailability

Osteoporosis is a disease that reduces bone mass and microarchitecture, which makes bones fragile. Postmenopausal osteoporosis occurs due to estrogen deficiency. Raloxifene is a selective estrogen receptor modulator used to treat postmenopausal osteoporosis. However, it has a low bioavailability, which requires long-term, high-dose raloxifene administration to be effective and causes several side effects. Herein, raloxifene was encapsulated in human serum albumin (HSA)-based nanoparticles (Ral/HSA/PSS NPs) as an intravenous-injection pharmaceutical formulation to increase its bioavailability and reduce the treatment dosage and time. In vitro results indicated that raloxifene molecules were well distributed in HSA-based nanoparticles as an amorphous state, and the resulting raloxifene formulation was stabile during long-term storage duration. The Ral/HSA/PSS NPs were both biocompatible and hemocompatible with a decreased cytotoxicity of high-dose raloxifene. Moreover, the intravenous administration of the prepared Ral/HSA/PSS NPs to rats improved raloxifene bioavailability and improved its half-life in plasma. These raloxifene-loaded nanoparticles may be a potential nanomedicine candidate for treating postmenopausal osteoporosis with lower raloxifene dosages.

Biomimetic injectable hydrogel microspheres with enhanced lubrication and controllable drug release for the treatment of osteoarthritis

The occurrence of osteoarthritis (OA) is highly associated with the reduced lubrication property of the joint, where a progressive and irreversible damage of the articular cartilage and consecutive inflammatory response dominate the mechanism. In this study, bioinspired by the super-lubrication property of cartilage and catecholamine chemistry of mussel, we successfully developed injectable hydrogel microspheres with enhanced lubrication and controllable drug release for OA treatment. Particularly, the lubricating microspheres (GelMA@DMA-MPC) were fabricated by dip coating a self-adhesive polymer (DMA-MPC, synthesized by free radical copolymerization) on superficial surface of photo-crosslinked methacrylate gelatin hydrogel microspheres (GelMA, prepared via microfluidic technology), and encapsulated with an anti-inflammatory drug of diclofenac sodium (DS) to achieve the dual-functional performance. The tribological test and drug release test showed the enhanced lubrication and sustained drug release of the GelMA@DMA-MPC microspheres. In addition, the functionalized microspheres were intra-articularly injected into the rat knee joint with an OA model, and the biological tests including qRT-PCR, immunofluorescence staining assay, X-ray radiography and histological staining assay all revealed that the biocompatible microspheres provided significant therapeutic effect against the development of OA. In summary, the injectable hydrogel microspheres developed herein greatly improved lubrication and achieved sustained local drug release, therefore representing a facile and promising technique for the treatment of OA.

The effect of table olive wastewater extract administration on the adult ovariectomised rat model of osteoporosis

Recent efforts for alternative non-pharmaceutical treatments for postmenopausal osteoporosis are focused on nutritional measures. The aim of this study was to investigate the effect of table olive wastewater extract (OE) administration on bone mineral density (BMD) and biomechanical strength in ovariectomised rats. Thirty mature 9-month-old female Wistar rats were separated into three groups of ten: Control, Ovariectomised (OVX) and OVX + OE. BMD was measured before ovariectomy, 3 and 6 months afterwards. At the end of the study, blood, both femurs and tibias, internal organs and abdominal fat were collected. After 3 months, the percentage changes from baseline of the total and proximal tibial BMD of the OVX + OE group were both higher compared with the OVX group (P < 0·005). Similar results were found after 6 months, when the percentage changes from baseline of the total and proximal tibial BMD of the OVX + OE group were both higher compared with the OVX group (P < 0·005). Biomechanical testing of the femurs did not reveal any statistically significant difference between the groups. Body weights throughout the study, organs' and abdominal fat ratios to final body weight and blood results (alanine aminotransferase (ALT), gamma-glutamyltransferase (γ-GT), total cholesterol, HDL-cholesterol, LDL-cholesterol, Ca and P) were within normal limits and did not show any significant difference between the treated and untreated groups. As a conclusion, the administration of OE for 6 months protected tibial BMD loss in comparison with the untreated OVX group without causing adverse effects.

Design and development of a commercially viable in situ nanoemulgel for the treatment of postmenopausal osteoporosis

Aim: To investigate the potential of a thermosensitive intranasal formulation of raloxifene hydrochloride (RH) for systemic delivery with the possibility of enhanced bioavailability and anti-osteoporotic efficacy. Methods: In this work, a commercially scalable nanoemulsion in thermosensitive gel, aligned with better clinical acceptability, has been developed and evaluated. Results: A significant 7.4-fold improvement in bioavailability of RH was recorded when compared with marketed tablets. Likewise, in vivo pharmacodynamics studies suggested 162% enhanced bone density and significantly improved biochemical markers compared with per-oral marketed tablet. Conclusion: The formulation, being safe and patient compliant, successfully tuned anti-osteoporotic effects with improved therapeutic performance. Further, the work provided an exceptional lead to carry out the study in clinical settings.

Postmenopausal osteoporosis: Assessment and management

Osteoporosis increases the risk of fractures, which are associated with increased mortality and lower quality of life. Patients with prevalent fracture are at high risk to of sustaining another one. Optimal protein and calcium intakes, and vitamin D supplies, together with regular weight bearing physical exercise are the corner stones of fracture prevention. Evidence for anti-fracture efficacy of pharmacological interventions relies on results from randomised controlled trials in postmenopausal women with fractures as the primary outcome. Treatments with bone resorption inhibitors, like bisphosphonates or denosumab, and bone formation stimulator like teriparatide, reduce vertebral and non-vertebral fracture risk. A reduction in vertebral fracture risk can already be detected within a year after starting therapy.

Phospholipid-Coated Mesoporous Silica Nanoparticles Acting as Lubricating Drug Nanocarriers

Osteoarthritis (OA) is a severe disease caused by wear and inflammation of joints. In this study, phospholipid-coated mesoporous silica nanoparticles (MSNs@lip) were prepared in order to treat OA at an early stage. The phospholipid layer has excellent lubrication capability in aqueous media due to the hydration lubrication mechanism, while mesoporous silica nanoparticles (MSNs) act as effective drug nanocarriers. The MSNs@lip were characterized by scanning electron microscope, transmission electron microscope, Fourier transform infrared spectrum, X-ray photoelectron spectrum, thermogravimetric analysis and dynamic light scattering techniques to confirm that the phospholipid layer was coated onto the surface of MSNs successfully. A series of tribological tests were performed under different experimental conditions, and the results showed that MSNs@lip with multi-layers of phospholipids greatly reduced the friction coefficient in comparison with MSNs. Additionally, MSNs@lip demonstrated sustained drug release behavior and were biocompatible based on CCK-8 assay using MC3T3-E1 cells. The MSNs@lip developed in the present study, acting as effective lubricating drug nanocarriers, may represent a promising strategy to treat early stage OA by lubrication enhancement and drug delivery therapy.

Development of an mHealth Application for Women Newly Diagnosed with Osteoporosis without Preceding Fractures: A Participatory Design Approach

mHealth is a useful tool to improve health outcome within chronic disease management. However, mHealth is not implemented in the field of postmenopausal osteoporosis even though it is a major worldwide health challenge. Therefore, this study aims to design and develop an mHealth app to support women in self-management of osteoporosis when they are diagnosed without preceding fractures. Participatory design is conducted in three phases. Based on identified needs in the first phase, a prototype is designed and developed in an iterative process in the second phase before the mHealth app is tested in the third phase. This paper focuses on the user activities in phase two and describes how a team of researchers, women, physicians, healthcare professionals, and app designers are involved in the participatory design process. The study shows that participatory design is a viable approach when developing an mHealth app for women with asymptomatic osteoporosis. Results obtained from the workshops and laboratory tests demonstrate the importance of feedback from users in the iterative process, as well as the participation of users and app designers in workshops and laboratory tests to enable mutual learning when developing new mHealth solutions. The regular member-checks and involvement of users helped to identify challenges associated with providing healthcare services through an app.

Differentiating the Causes of Spontaneous Rib Fracture After Breast Cancer

Spontaneous rib fracture after treatment for primary breast cancer is not uncommon. Although metastatic disease accounts for about 30% of spontaneous rib fractures and should constitute the first line of diagnostic investigation, other possible contributors include primary osteoporosis or secondary osteoporosis resulting from cancer treatments. Chemotherapy-induced menopause, aromatase inhibitors, radiation therapy, and long-term bisphosphonate use can all contribute to bone fragility, including spontaneous rib fractures in the latter 3. Drawing on recent breast cancer practice guidelines as well as population-based studies of fracture risk for women with a history of breast cancer and systematic reviews, this Perspective will provide an update on recent developments in understanding how to differentiate the possible reasons for non-traumatic rib fracture in women treated for breast cancer. In addition to describing the various possible causes of spontaneous rib fracture, the recommended medical and imaging procedures for differentiating among the potential causes will be presented.

The Association Between Long-Term Bisphosphonate Use and the Risk of Fracture Among Women Aged 50 or Older with Osteoporosis

BACKGROUND

Osteoporosis is a prevalent disease, and bisphosphonates can effectively reduce the risk of osteoporotic fractures. However, the association between the length of the medication treatment and the risk of fractures remains unclear. The purpose of this study was to evaluate the association between long-term bisphosphonate use (treatment duration ≥5 years) and the risk of fractures among women with osteoporosis aged 50 or older.

MATERIALS AND METHODS

We conducted a retrospective cohort study by using the 2001-2011 National Health Insurance Research Database in Taiwan. We included women who were 50 years or older, who had a diagnosis of osteoporosis, and who were newly initiating oral bisphosphonates between January 1, 2002 and December 31, 2003. The index date was the date of the first dispensing of oral bisphosphonate during the enrollment period. Women were considered to be using bisphosphonates until they had a gap in supply of more than 3 months. We classified bisphosphonate use as long term (≥5 years) and regular (<5 years) based on its length of use. The dependent variable was the time to the first observed clinical fracture. Cox-proportional hazard regression models were used to evaluate the association between long-term bisphosphonate use and the risk of fractures.

RESULTS

The study included 1342 women with a mean age of 71 years. Of them, 83 (6.2%) were long-term bisphosphonate users. A total of 185 (13.8%) had a fracture. After adjustments, long-term bisphosphonate use was not associated with a lower risk of fractures than was regular bisphosphonate use (adjusted hazard ratio: 1.49, 95% CI: 0.91-2.45).

CONCLUSION

This study found no evidence of a lower risk of fractures to be associated with long-term bisphosphonate use among women aged 50 or older with osteoporosis in Taiwan. Orthopedists as well as other healthcare providers should be aware of the limited benefits of long-term bisphosphonate use.

The association between vitamin D status and parameters for bone density and quality is modified by body mass index

The association of vitamin D status with bone mineral density (BMD) and Quantitative Ultrasound measurements (QUS) has been inconsistent in previous studies, probably caused by moderating effects. This study explored (1) the association of vitamin D status with QUS and BMD, and (2) whether these associations were modified by body mass index (BMI), age, gender, or physical activity. Two-independent cohorts of the Longitudinal Aging Study Amsterdam (LASA-I, 1995/1996, aged ≥65; LASA-II, 2008/2009, aged 61-71) and baseline measurement of the B-vitamins for the prevention of osteoporotic fractures (B-PROOF) study (2008-2011, aged 65+) were used. QUS measurements [broadband ultrasound attenuation (BUA) and speed of sound (SOS)] were performed at the calcaneus in all three cohorts (N = 1,235, N = 365, N = 1319); BMD was measured by Dual X-ray absorptiometry (DXA) in B-PROOF (N = 1,162 and 1,192 for specific sites) and LASA-I (N = 492 and 503). The associations of vitamin D status with BUA and BMD were modified by BMI. Only in persons with low-to-normal BMI (<25 kg/m(2)) and serum 25(OH)D <25 nmol/L was associated with lower BUA as compared to the reference group (≥50 nmol/L) in LASA-I and B-PROOF. Furthermore, in LASA-I, these individuals had lower BMD at the hip and lumbar spine. In LASA-II, no associations with BUA were observed. Vitamin D status was not associated with SOS, and these associations were not modified by the effect modifiers tested. The association between vitamin D status and BUA and BMD was modified by BMI in the older-aged cohorts: there was only an association in individuals with BMI <25 kg/m(2).

2015 Guidelines for Osteoporosis in Saudi Arabia: Recommendations from the Saudi Osteoporosis Society

BACKGROUND AND OBJECTIVES

To provide guidelines for medical professionals in Saudi Arabia regarding osteoporosis.

DESIGN AND SETTINGS

A panel of 14 local experts in osteoporosis assembled to provide consensus based on the strength of evidence and expert opinions on osteoporosis treatment.

PATIENTS AND METHODS

The Saudi Osteoporosis Society (SOS) formed a panel of experts who performed an extensive published studies search to formulate recommendations regarding prevention, diagnosis, and treatment of osteoporosis in Saudi Arabia. Both local and international published studies were utilized whenever available.

RESULTS

Dual x-ray absorptiometry (DXA) scanning is still the golden standard for assessing bone mineral density (BMD). In the absence of local, country-specific fracture risk assessment tool (FRAX), the SOS recommends using the USA (White) version of the FRAX tool. All women above 60 years of age should be evaluated for BMD. This is because the panel recognized that osteoporosis and osteoporotic fractures occur at a younger age in Saudi Arabia. Hormone replacement therapy (HRT) is not recommended for treating postmenopausal women with osteoporosis. BMD evaluation should be performed 1-2 years after initiating intervention, and the assessment of bone turnover biomarkers should be performed whenever available to determine the efficacy of intervention.

CONCLUSION

All Saudi women above the age of 60 years must undergo a BMD assessment using DXA. Therapy decisions should be formulated with the use of the USA (White) version of the FRAX tool.

The application of health technology assessment in osteoporosis

Because of the high costs to patients, health care payers and to society, it is important to allocate healthcare resources appropriately and efficiently. Health technology assessment aims to evaluate the clinical, economic, social, and ethical implications of a disease, and its prevention and treatment to guide national healthcare policies (e.g. clinical and research investment, reimbursement decisions). In this chapter, we review the various aspects of health technology assessment in osteoporosis, including epidemiology and burden of disease, and assessment of the cost-effectiveness of the treatment of osteoporosis and the prevention of fracture. Health technology assessment indicates an immense burden of osteoporotic fractures for patients and society that is set to increase as the number of elderly people increases. Prevention and treatment of osteoporosis have been shown to be a cost-effective way of allocating scarce healthcare resources.

Efficacy and safety of currently marketed anti-osteoporosis medications

During the past 2 decades, many interventions were proven effective in the management of postmenopausal osteoporosis. The objective of an anti-osteoporosis treatment is to reduce fracture rates, ideally at all skeletal sites (i.e. spine, hip, and other non-spine). The armamentarium against osteoporosis includes anti-resorptive agents (i.e. bisphosphonates, selective estrogen receptor modulators and denosumab), bone-forming agents (i.e. peptides from the parathyroid hormone family) and one agent with a dual mechanism of action (i.e. strontium ranelate). All these medications combine antifracture efficacy with a reasonable benefit/risk profile. However, the choice of a particular chemical entity, in one individual patient is based on the knowledge and expertise of the physician. Prioritization of drugs should be based on the individual profile of the patient, the severity of osteoporosis and the specific contraindications, warnings and precautions of use of the various available medications.

Future directions for new medical entities in osteoporosis

Odanacatib, a selective cathepsin K inhibitor, decreases bone resorption, whereas osteoclast number increases and bone formation is maintained, perhaps even increased on some cortical surfaces. In a phase 2 clinical trial, post-menopausal women receiving odanacatib presented a sustained reduction of bone resorption markers, whereas procollagen type 1 N-terminal propeptide returned to normal. In turn areal bone mineral density increased continuously at both spine and hip for up to 5 years. Blosozumab and romosozumab are sclerostin neutralizing antibodies that exert potent anabolic effects on both trabecular and cortical compartments. A phase 2 clinical trial has reported areal bone mineral density gains at spine and hip that were greater with romosozumab compared with placebo, but also with teriparatide. It also showed that antagonizing sclerostin results in a transient stimulation of bone formation but progressive inhibition of bone resorption. Other new medical entities that are promising for the treatment of osteoporosis include abaloparatide, a parathyroid hormone-related analogue with improved bone formation-resorption ratio.

Management of osteoporosis of the oldest old

This consensus article reviews the diagnosis and treatment of osteoporosis in geriatric populations. Specifically, it reviews the risk assessment and intervention thresholds, the impact of nutritional deficiencies, fall prevention strategies, pharmacological treatments and their safety considerations, the risks of sub-optimal treatment adherence and strategies for its improvement.

INTRODUCTION

This consensus article reviews the therapeutic strategies and management options for the treatment of osteoporosis of the oldest old. This vulnerable segment (persons over 80 years of age) stands to gain substantially from effective anti-osteoporosis treatment, but the under-prescription of these treatments is frequent.

METHODS

This report is the result of an ESCEO (European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis) expert working group, which explores some of the reasons for this and presents the arguments to counter these beliefs. The risk assessment of older individuals is briefly reviewed along with the differences between some intervention guidelines. The current evidence on the impact of nutritional deficiencies (i.e. calcium, protein and vitamin D) is presented, as are strategies to prevent falls. One possible reason for the under-prescription of pharmacological treatments for osteoporosis in the oldest old is the perception that anti-fracture efficacy requires long-term treatment. However, a review of the data shows convincing anti-fracture efficacy already by 12 months.

RESULTS

The safety profiles of these pharmacological agents are generally satisfactory in this patient segment provided a few precautions are followed.

CONCLUSION

These patients should be considered for particular consultation/follow-up procedures in the effort to convince on the benefits of treatment and to allay fears of adverse drug reactions, since poor adherence is a major problem for the success of a strategy for osteoporosis and limits cost-effectiveness.

CCR2 elimination in mice results in larger and stronger tibial bones but bone loss is not attenuated following ovariectomy or muscle denervation

Bone loss due to age and disuse contributes to osteoporosis and increases fracture risk. It has been hypothesized that such bone loss can be attenuated by modulation of the C-C chemokine receptor 2 (CCR2) and/or its ligands. The objectives of this study were to examine the effects of genetic elimination of CCR2 on cortical and trabecular bones in the mouse tibia and how bone loss was impacted following disuse and estrogen loss. Female CCR2 knockout (CCR2(-/-)) and wildtype mice underwent ovariectomy (OVX) or denervation of musculature adjacent to the tibia (DEN) to induce bone loss. Cortical and trabecular structural properties as well as mechanical properties (i.e., strength) of tibial bones were measured. Compared to wildtype mice, CCR2(-/-) mice had tibiae that were up to 9% larger and stronger; these differences could be explained mainly by the 17% greater body mass (P < 0.001) of CCR2(-/-) mice. The majority of the tibia's structural and functional responses to OVX and DEN were similar regardless of the lack or presence of CCR2, indicating that CCR2 is not protective against bone loss per se. These findings indicate that while CCR2(-/-) mice do have larger and stronger bones than do wildtype mice, there is minimal evidence that CCR2 elimination provides protection against bone loss during disuse and estrogen loss.

Prevention of rheumatic diseases: strategies, caveats, and future directions

Rheumatic diseases affect a significant portion of the population and lead to increased health care costs, disability, and premature mortality; effective preventive measures for these diseases could lead to substantial improvements in public health. Natural history studies show that for most rheumatic diseases there is a period of preclinical disease development during which abnormal biomarkers or other processes can be detected. These changes are useful to understand mechanisms of disease pathogenesis; in addition, they may be applied to estimate a personal risk of future disease while individuals are still relatively asymptomatic and ultimately be used to identify individuals who may be targeted for preventive interventions.

Comparative effects of teriparatide and ibandronate on spine bone mineral density (BMD) and microarchitecture (TBS) in postmenopausal women with osteoporosis: a 2-year open-label study

Treatment effects over 2 years of teriparatide vs. ibandronate in postmenopausal women with osteoporosis were compared using lumbar spine bone mineral density (BMD) and trabecular bone score (TBS). Teriparatide induced larger increases in BMD and TBS compared to ibandronate, suggesting a more pronounced effect on bone microarchitecture of the bone anabolic drug.

INTRODUCTION

The trabecular bone score (TBS) is an index of bone microarchitecture, independent of bone mineral density (BMD), calculated from anteroposterior spine dual X-ray absorptiometry (DXA) scans. The potential role of TBS for monitoring treatment response with bone-active substances is not established. The aim of this study was to compare the effects of recombinant human 1-34 parathyroid hormone (teriparatide) and the bisphosphonate ibandronate (IBN), on lumbar spine (LS) BMD and TBS in postmenopausal women with osteoporosis.

METHODS

Two patient groups with matched age, body mass index (BMI), and baseline LS BMD, treated with either daily subcutaneous teriparatide (N = 65) or quarterly intravenous IBN (N = 122) during 2 years and with available LS BMD measurements at baseline and 2 years after treatment initiation were compared.

RESULTS

Baseline characteristics (overall mean ± SD) were similar between groups in terms of age 67.9 ± 7.4 years, body mass index 23.8 ± 3.8 kg/m(2), BMD L1-L4 0.741 ± 0.100 g/cm(2), and TBS 1.208 ± 0.100. Over 24 months, teriparatide induced a significantly larger increase in LS BMD and TBS than IBN (+7.6 % ± 6.3 vs. +2.9 % ± 3.3 and +4.3 % ± 6.6 vs. +0.3 % ± 4.1, respectively; P < 0.0001 for both). LS BMD and TBS were only weakly correlated at baseline (r (2) = 0.04) with no correlation between the changes in BMD and TBS over 24 months.

CONCLUSIONS

In postmenopausal women with osteoporosis, a 2-year treatment with teriparatide led to a significantly larger increase in LS BMD and TBS than IBN, suggesting that teriparatide had more pronounced effects on bone microarchitecture than IBN.

Selectivity in bone targeting with multivalent dendritic polyanion dye conjugates

Targeting bone with anionic macromolecules is a potent approach for the development of novel diagnostics and therapeutics for bone related diseases. A highly efficient modular synthesis of dendritic polyglycerol (dPG) polyanion dye conjugates, namely, sulfates, sulfonates, carboxylates, phosphates, phosphonates, and bisphosphonates via click chemistry is presented. By investigating the microarchitecture of stained bone sections with confocal laser scanning microscopy, the bisphosphonate, phosphonate, and phosphate functionalized polymers are identified as strongly penetrating compounds, whereas sulfates, sulfonates, and carboxylates reveal a weaker binding to hydroxyapatite (HA) but a more pronounced affinity toward collagen. In a quantitative HA binding assay, the affinity of the dPG sulfonate, sulfate, and carboxylate toward collagen and the exceptional high HA affinity of the phosphorous containing polyelectrolytes are validated. This shows the potential of dendritic polyphosphates and phosphonates as alternatives to the commonly employed bisphosphonate modification. In cytotoxicity studies with murine fibroblasts, the conjugates have no significant effect on the cell viability at 10(-5) m. All polyanions are taken up into the cells within 24 h. The presented synthetic approach allows versatile extensions for preparing conjugates for selective bone imaging applications, tissue engineering, and drug delivery.

Update on long-term treatment with bisphosphonates for postmenopausal osteoporosis: a systematic review

INTRODUCTION

Osteoporosis is a progressive skeletal disorder that requires long-term treatment. However, there is little guidance regarding optimal treatment duration and what the treatment discontinuation and retreatment criteria should be. Given that bisphosphonates are the most commonly prescribed class of agent for the treatment of osteoporosis, we reviewed the long-term data relating to these therapies and discussed the considerations for using bisphosphonates in postmenopausal women with osteoporosis.

METHODS

A PubMed search, using the search terms 'bisphosphonate', 'postmenopausal osteoporosis' and 'long term' and/or 'extension' was conducted in January 2013. Results from nine controlled studies that prospectively assessed alendronate, risedronate, ibandronate or zoledronic acid in women with postmenopausal osteoporosis were reviewed.

FINDINGS

Clinical studies in postmenopausal women with osteoporosis showed that long-term use of bisphosphonates resulted in persistent antifracture and bone mineral density (BMD) increasing effects beyond 3 years of treatment. No unexpected adverse events were identified in these studies and the long-term tolerability profiles of bisphosphonates remain favorable. Data from the withdrawal extension studies of alendronate and zoledronic acid also showed that residual fracture benefits were seen in patients who discontinued treatment for 3 to 5 years after an initial 3- to 5-year treatment period. BMD monitoring and fracture risk assessments should be conducted regularly to determine whether treatment could be stopped or should be reinitiated. Patients exhibiting T-scores<-2.5 or who have suffered a new fracture while on treatment should continue treatment, while patients with T-scores>-2.5 could be considered for discontinuation of active treatment while undergoing continued monitoring of their bone health. The duration and potential discontinuation of treatment should be personalized for individual patients based on their response to treatment, fracture risk and comorbidities.

Health technology assessment in osteoporosis

We review the various aspects of health technology assessment in osteoporosis, including epidemiology and burden of disease, and assessment of the cost-effectiveness of recent advances in the treatment of osteoporosis and the prevention of fracture, in the context of the allocation of health-care resources by decision makers in osteoporosis. This article was prepared on the basis of a symposium held by the Belgian Bone Club and the discussions surrounding that meeting and is based on a review and critical appraisal of the literature. Epidemiological studies confirm the immense burden of osteoporotic fractures for patients and society, with lifetime risks of any fracture of the hip, spine, and forearm of around 40 % for women and 13 % for men. The economic impact is also large; for example, Europe's six largest countries spent €31 billion on osteoporotic fractures in 2010. Moreover, the burden is expected to increase in the future with demographic changes and increasing life expectancy. Recent advances in the management of osteoporosis include novel treatments, better fracture-risk assessment notably via fracture risk algorithms, and improved adherence to medication. Economic evaluation can inform decision makers in health care on the cost-effectiveness of the various interventions. Cost-effectiveness analyses suggest that the recent advances in the prevention and treatment of osteoporosis may constitute an efficient basis for the allocation of scarce health-care resources. In summary, health technology assessment is increasingly used in the field of osteoporosis and could be very useful to help decision makers efficiently allocate health-care resources.

A review on strontium ranelate long-term antifracture efficacy in the treatment of postmenopausal osteoporosis

Osteoporotic fractures are one of the major causes of increased morbidity and mortality in postmenopausal women and the overall aging population. One of the major issues in the management of postmenopausal osteoporosis is to find a safe and effective treatment in the long term (>3 years) to achieve and maintain a reduction in the risk of fracture. Strontium ranelate (PROTELOS(®)) is a relatively novel drug, currently approved in Europe for the treatment of postmenopausal osteoporosis. Strontium ranelate is the first agent of a new therapeutic class in osteoporosis, capable of both promoting bone formation and, to a lesser extent, inhibiting bone resorption. This uncoupling in bone turnover results in a net gain in bone mineral density (BMD), bone quality improvement and reduction in risk of vertebral and nonvertebral fractures, as initially demonstrated in the preplanned long-term registrative trials SOTI (Spinal Osteoporosis Therapeutic Intervention) and TROPOS (Treatment of Peripheral Osteoporosis) at 5 years. Recently, open-label extensions of the SOTI and TROPOS trials up to 8 and, recently, 10 years have confirmed the sustained efficacy of strontium ranelate in increasing BMD, the long-term safety profile and the high compliance to treatment, independently from baseline BMD or other risk factors for osteoporotic fractures. Recent economic impact analyses have proved that long-term treatment with strontium ranelate is highly cost effective, especially in women older than 70 years of age. Histomorphometric analyses in animals and humans participating in the phase III trials have proved that the quality of mineralization is preserved in the long term and bone microarchitecture is ameliorated, with increased bone strength. Thus, strontium ranelate has been confirmed to be an effective compound for the long-term, chronic treatment of postmenopausal osteoporosis.

Safety concerns with the long-term management of osteoporosis

INTRODUCTION

Postmenopausal osteoporosis is a chronic disease that exerts a significant burden on both individuals and the community. Hence, there is a requirement for long-term treatment to be associated with a positive benefit-risk balance.

AREAS COVERED

In this descriptive review, the long-term safety of calcitonin, selective estrogen receptor modulators (SERMs), bisphosphonates, denosumab and strontium ranelate was reviewed based on randomized controlled trials of 3 years or longer supplemented by extension study data and data from large, observational studies.

EXPERT OPINION

Rare adverse events become apparent with all currently available treatments for osteoporosis with long-term therapy. Due to the rarity of these adverse events and to the worldwide burden of osteoporosis, the benefit-risk balance remains in favor of the beneficial effects of treatment on an outcome rather than the probability of an adverse effect. No single antiosteoporosis agent is appropriate for all patients. Treatment decisions should be made on an individual basis, taking into account the relative benefits and risks in different patient populations.

Vitamin D supplementation in elderly or postmenopausal women: a 2013 update of the 2008 recommendations from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO)

BACKGROUND

Vitamin D insufficiency has deleterious consequences on health outcomes. In elderly or postmenopausal women, it may exacerbate osteoporosis.

SCOPE

There is currently no clear consensus on definitions of vitamin D insufficiency or minimal targets for vitamin D concentrations and proposed targets vary with the population. In view of the potential confusion for practitioners on when to treat and what to achieve, the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) convened a meeting to provide recommendations for clinical practice, to ensure the optimal management of elderly and postmenopausal women with regard to vitamin D supplementation.

FINDINGS

Vitamin D has both skeletal and extra-skeletal benefits. Patients with serum 25-hydroxyvitamin D (25-(OH)D) levels <50 nmol/L have increased bone turnover, bone loss, and possibly mineralization defects compared with patients with levels >50 nmol/L. Similar relationships have been reported for frailty, nonvertebral and hip fracture, and all-cause mortality, with poorer outcomes at <50 nmol/L.

CONCLUSION

The ESCEO recommends that 50 nmol/L (i.e. 20 ng/mL) should be the minimal serum 25-(OH)D concentration at the population level and in patients with osteoporosis to ensure optimal bone health. Below this threshold, supplementation is recommended at 800 to 1000 IU/day. Vitamin D supplementation is safe up to 10,000 IU/day (upper limit of safety) resulting in an upper limit of adequacy of 125 nmol/L 25-(OH)D. Daily consumption of calcium- and vitamin-D-fortified food products (e.g. yoghurt or milk) can help improve vitamin D intake. Above the threshold of 50 nmol/L, there is no clear evidence for additional benefits of supplementation. On the other hand, in fragile elderly subjects who are at elevated risk for falls and fracture, the ESCEO recommends a minimal serum 25-(OH)D level of 75 nmol/L (i.e. 30 ng/mL), for the greatest impact on fracture.

The use of raloxifene in osteoporosis treatment

INTRODUCTION

Osteoporosis is a common disease characterized by the occurrence of fragility fractures. Major osteoporotic fractures are associated with decreased quality of life and high costs.

AREAS COVERED

This review summarizes clinical data on raloxifene (RLX), a second generation selective estrogen-receptor modulator (SERM), currently approved for the treatment of postmenopausal osteoporosis. RLX has estrogen effects on bone and lipid profile, whereas it has anti-estrogen effects on uterus and breast cells. Its main side effects are hot flushes and venous thromboembolism. Literature searches were conducted to retrieve articles reporting RLX clinical trial data. For comparison of safety and efficacy, post-marketing studies on RLX were included.

EXPERT OPINION

RLX is effective in reducing vertebral fracture risk in osteoporotic women, it is safe and its ability to prevent breast cancer has to be considered in the analyses of cost/effect and of the ideal candidate to this treatment. RLX has to be avoided in patients with previous history of venous thromboembolism.