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Kiafzezi D, Stamati A, Karagiannis T, Goulis DG, Christoforidis A. Burosumab Efficacy and Safety in Patients with X-Linked Hypophosphatemia: Systematic Review and Meta-analysis of Real-World Data. Calcif Tissue Int 2024; 115:229-241. [PMID: 39008126 DOI: 10.1007/s00223-024-01250-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 06/18/2024] [Indexed: 07/16/2024]
Abstract
To assess the efficacy and safety of burosumab in children and adults with X-linked hypophosphatemia based on real-world evidence. MEDLINE (via PubMed) and Cochrane Library were searched until 18 October 2023 for single-arm (before-after) studies. Registries including Clinicaltrials.gov, EU Clinical Trials, WHO International Clinical Trials Registry Platform, and conference abstracts. The outcomes were a change in serum phosphorus concentrations and change in RSS, a change in serum ALP, bone-specific ALP, a change in the ratio of Tubular maximum reabsorption of Phosphate to Glomerular Filtrate rate, a change in serum 1,25(OH)2D and 25(OH)2D concentrations, change in height Z-score, McMaster Universities Osteoarthritis Index (WOMAC) and safety outcomes. An inverse variance random-effects meta-analysis was applied for data synthesis. Fifteen studies (289 participants) were included. Burosumab treatment improved serum phosphate concentrations [mean difference 0.88 mg/dl, 95% confidence interval 0.70 to 1.07, I2 = 92%), Rickets Severity score (mean difference - 1.86, 95% confidence interval - 2.5 to - 1.21, I2 = 71%), serum alkaline phosphate concentrations (mean difference - 1.86, 95% confidence interval - 2.5 to - 1.21, I2 = 71%), serum 1,25(OH)2D concentrations (mean difference 18.91 pg/ml, 95% confidence interval 6.39 to 31.43, I2 = 96%) and renal phosphate reabsorption (mean difference 1.22 mg/dl, 95% confidence interval 0.70 to 1.74, I2 93%). Burosumab treatment improved overall clinical and laboratory findings in patients with X-linked hypophosphatemia.
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Affiliation(s)
- Damiani Kiafzezi
- Postgraduate Program "Research Methodology in Medicine and Health Sciences", Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Athina Stamati
- School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Thomas Karagiannis
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Diabetes Centre, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, 541 24, Thessaloniki, Greece
| | - Athanasios Christoforidis
- 1st Paediatric Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Ippokratio General Hospital, Thessaloniki, Greece
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Wang K, Zhang R, Chen Z, Bai Y, He Q. Meta-analysis and systematic review: burosumab as a promising treatment for children with X-linked hypophosphatemia. Front Endocrinol (Lausanne) 2024; 15:1414509. [PMID: 39211452 PMCID: PMC11357961 DOI: 10.3389/fendo.2024.1414509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 07/08/2024] [Indexed: 09/04/2024] Open
Abstract
Objective The aim of this study was to evaluate the effectiveness of burosumab therapy in children with X-Linked Hypophosphatemia (XLH). Materials and methods We systematically reviewed literature from PubMed, Web of Science, The Cochrane Library, and Embase up until January 2024, using EndNote Web for study organization. The Newcastle-Ottawa scale guided quality assessment, while Revman software was used for data analysis and visualization. Study selection, quality evaluation, and data aggregation were independently performed by three researchers. Results The meta-analysis encompassed ten studies, including eight cohort studies that examined burosumab's impact pre- and post-administration, and two randomized controlled trials comparing burosumab to standard therapy. The evidence from this review suggests burosumab's superiority in managing XLH in pediatric populations, particularly in improving key biochemical markers including 1,25-dihydroxyvitamin D (1,25-(OH)2D), phosphorus, and alkaline phosphatase (ALP), alongside improvements in the renal tubular maximum reabsorption rate of phosphate to glomerular filtration rate (TmP/GFR), and significant skeletal improvements as indicated by the rickets severity score (RSS) and the 6-minute walk test (6MWT). However, the long-term safety and effects, including height and quality of life (QOL) data, remains to be elucidated. Conclusions Burosumab has shown significant therapeutic effectiveness in treating children with XLH, highlighting its potential as a key treatment option.
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Affiliation(s)
| | | | | | - Yi Bai
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School & Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Qing He
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School & Hospital of Stomatology, Wuhan University, Wuhan, China
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Takashi Y, Kawanami D, Fukumoto S. Recent advances in fibroblast growth factor 23-related hypophosphatemic disorders. Curr Opin Endocrinol Diabetes Obes 2024; 31:170-175. [PMID: 38687287 DOI: 10.1097/med.0000000000000866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
PURPOSE OF REVIEW Fibroblast growth factor 23 (FGF23) is a hormone to reduce blood phosphate concentration. Excessive actions of FGF23 induce FGF23-related hypophosphatemic disorders, such as X-linked hypophosphatemic rickets (XLH) and tumor-induced osteomalacia (TIO). We will summarize recent advances in the diagnosis and treatment of FGF23-related hypophosphatemic disorders. RECENT FINDINGS The measurement of blood FGF23 is useful to make a diagnosis of FGF23-related hypophosphatemic disorders. It was reported that many patients with FGF23-related hypophosphatemic disorders, especially TIO, were misdiagnosed, therefore, it is necessary to enhance the awareness of these diseases. A novel method to inhibit excessive actions of FGF23 by a human monoclonal antibody for FGF23, burosumab, has been approved in several countries. In more long-term observation than clinical trials, burosumab has also been shown to improve biochemical abnormalities and symptoms of rickets/osteomalacia. Following these advances, several registries and consensus recommendations on FGF23-related hypophosphatemic disorders, especially XLH, have been established in each country or region. SUMMARY Further long-term effects of burosumab and the precise mechanism of FGF23 overproduction in patients with FGF23-related hypophosphatemic disorders need to be clarified in the future studies.
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Affiliation(s)
- Yuichi Takashi
- Department of Endocrinology and Diabetes, Fukuoka University School of Medicine
| | - Daiji Kawanami
- Department of Endocrinology and Diabetes, Fukuoka University School of Medicine
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Martínez-Heredia L, Canelo-Moreno JM, García-Fontana B, Muñoz-Torres M. Non-Classical Effects of FGF23: Molecular and Clinical Features. Int J Mol Sci 2024; 25:4875. [PMID: 38732094 PMCID: PMC11084844 DOI: 10.3390/ijms25094875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 04/21/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
This article reviews the role of fibroblast growth factor 23 (FGF23) protein in phosphate metabolism, highlighting its regulation of vitamin D, parathyroid hormone, and bone metabolism. Although it was traditionally thought that phosphate-calcium homeostasis was controlled exclusively by parathyroid hormone (PTH) and calcitriol, pathophysiological studies revealed the influence of FGF23. This protein, expressed mainly in bone, inhibits the renal reabsorption of phosphate and calcitriol formation, mediated by the α-klotho co-receptor. In addition to its role in phosphate metabolism, FGF23 exhibits pleiotropic effects in non-renal systems such as the cardiovascular, immune, and metabolic systems, including the regulation of gene expression and cardiac fibrosis. Although it has been proposed as a biomarker and therapeutic target, the inhibition of FGF23 poses challenges due to its potential side effects. However, the approval of drugs such as burosumab represents a milestone in the treatment of FGF23-related diseases.
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Affiliation(s)
- Luis Martínez-Heredia
- Instituto de Investigación Biosanitaria de Granada, 18014 Granada, Spain;
- Biomedical Research Network in Fragility and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | | | - Beatriz García-Fontana
- Instituto de Investigación Biosanitaria de Granada, 18014 Granada, Spain;
- Biomedical Research Network in Fragility and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Endocrinology and Nutrition Unit, University Hospital Clínico San Cecilio, 18016 Granada, Spain
- Department of Cell Biology, University of Granada, 18016 Granada, Spain
| | - Manuel Muñoz-Torres
- Instituto de Investigación Biosanitaria de Granada, 18014 Granada, Spain;
- Biomedical Research Network in Fragility and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Endocrinology and Nutrition Unit, University Hospital Clínico San Cecilio, 18016 Granada, Spain
- Department of Medicine, University of Granada, 18016 Granada, Spain
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Insogna KL, Sullivan R, Parziale S, Deng Y, Carrano D, Simpson C, Dufour S, Carpenter T, Petersen KF. Effect of Burosumab on Muscle Function and Strength, and Rates of ATP Synthesis in Skeletal Muscle in Adults With XLH. J Clin Endocrinol Metab 2024; 109:e1061-e1071. [PMID: 37930769 DOI: 10.1210/clinem/dgad642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/05/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
CONTEXT In clinical trials, burosumab ameliorates symptoms of pain, fatigue, and stiffness and improves performance on certain muscle function studies in patients with X-linked hypophosphatemia (XLH). OBJECTIVE This work aimed to determine if burosumab increases adenosine triphosphate (ATP) synthesis in skeletal muscle of treatment-naive adults with XLH, and if so, whether that correlates with improved muscle function. METHODS Ten untreated, symptomatic adults with XLH had ATP synthesis rates measured in the right calf using the 31P magnetic resonance spectroscopy saturation transfer technique. Baseline muscle function tests and symptoms of pain, fatigue, stiffness, and lower-extremity joint pain were quantified. All participants were treated with burosumab, 1 mg/kg every 4 weeks for 12 weeks. ATP synthesis rates and muscle function tests were repeated 2 weeks ("peak") and 4 weeks ("trough") after the third dose of burosumab. RESULTS All symptoms improved with treatment. Performance on the 6-Minute Walk Test (6MWT) and Sit to Stand (STS) tests also improved. Muscle strength and ATP synthesis rates did not change over the 3 months of the study. When individuals whose performances on the 6MWT and STS test were at or better than the median outcome for those tests were compared to those whose outcomes were below the median, no difference was observed in the rate of change in ATP synthesis. Intracellular muscle concentrations of phosphate were normal. CONCLUSION The improvement in the 6MWT and STS test without changes in muscle strength or ATP synthesis rates suggests that reductions in pain, fatigue, and stiffness may partly explain the improved performance. Intracellular phosphate in skeletal muscle is insulated from hypophosphatemia in XLH.
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Affiliation(s)
- Karl L Insogna
- Department of Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, CT 06520-8020, USA
| | - Rebecca Sullivan
- Department of Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, CT 06520-8020, USA
| | - Stephen Parziale
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT 06510, USA
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT 06510, USA
| | - Diana Carrano
- Rehabilitation Supervisor, Yale New Haven Hospital, New Haven, CT 06510, USA
| | - Christine Simpson
- Department of Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, CT 06520-8020, USA
| | - Sylvie Dufour
- Department of Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, CT 06520-8020, USA
| | - Thomas Carpenter
- Department of Pediatrics, Section of Endocrinology, Yale School of Medicine, New Haven, CT 06510, USA
| | - Kitt Falk Petersen
- Department of Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, CT 06520-8020, USA
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Vaisbich MH, de Cillo ACP, Silva BCC, DÁlva CB, de Carvalho ÉH, de Almeida JMCM, Marques LLM, Ribeiro M, da Silva MBM, de Medeiros PFV, Mendes PH. Real-world data of Brazilian adults with X-linked hypophosphatemia (XLH) treated with burosumab and comparison with other worldwide cohorts. Mol Genet Genomic Med 2024; 12:e2387. [PMID: 38337160 PMCID: PMC10858313 DOI: 10.1002/mgg3.2387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/23/2023] [Accepted: 01/17/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Disease-related variants in PHEX cause XLH by an increase of fibroblast growth factor 23 (FGF23) circulating levels, resulting in hypophosphatemia and 1,25(OH)2 vitamin D deficiency. XLH manifests in early life with rickets and persists in adulthood with osseous and extraosseous manifestations. Conventional therapy (oral phosphate and calcitriol) improves some symptoms, but evidence show that it is not completely effective, and it can lead to nephrocalcinosis (NC) and hyperparathyroidism (HPT). Burosumab (anti-FGF23 antibody) has shown to be effective and safety in the clinical trials. METHODS The current real-world collaborative study evaluated genetic, clinical and laboratory data of XLH Brazilian adult patients treated with burosumab. RESULTS Nineteen unrelated patients were studied. Patients reported pain, limb deformities and claudication, before burosumab initiation. 78% of them were previously treated with conventional therapy. The severity of the disease was moderate to severe (15 patients with score >5). At the baseline, 3 patients presented NC (16.7%) and 12 HPT (63%). After 16 ± 8.4 months under burosumab, we observed a significant: increase in stature (p = 0.02), in serum phosphate from 1.90 ± 0.43 to 2.67 ± 0.52 mg/dL (p = 0.02); in TmP/GFR from 1.30 ± 0.46 to 2.27 ± 0.64 mg/dL (p = 0.0001), in 1,25 (OH)2 D from 50.5 ± 23.3 to 71.1 ± 19.1 pg/mL (p = 0.03), and a decrease in iPTH from 86.8 ± 37.4 pg/mL to 66.5 ± 31.1 (p = 0.002). Nineteen variants were found (10 novel). HPT tended to develop in patients with truncated PHEX variants (p = 0.06). CONCLUSIONS This study confirms the efficacy and safety of burosumab on XLH adult patients observed in clinical trials. Additionally, we observed a decrease in iPTH levels in patients with moderate to severe HPT at the baseline.
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Affiliation(s)
| | | | - Bárbara Campolina C. Silva
- Hospital Felício Rocho, Osteometabolism Unit of Santa Casa de Belo HorizonteProfessor of Medicine at University Center of Belo Horizonte – UNIBHBelo HorizonteBrazil
| | | | - Érico Higino de Carvalho
- Instituto de Medicina Integrada Professor Fernado Figueira, recifeFederal University of PernambucoRecifeBrazil
| | | | | | - Marcia Ribeiro
- Genetic Unit of Federal University of Rio de JaneiroRio de JaneiroBrazil
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Yoon SH, Passarella P. Recurrent Soft Tissue Infections Associated With Burosumab Therapy in X-Linked Hypophosphatemic Rickets. JCEM CASE REPORTS 2023; 1:luad120. [PMID: 37954837 PMCID: PMC10634627 DOI: 10.1210/jcemcr/luad120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Indexed: 11/14/2023]
Abstract
X-linked hypophosphatemic rickets (XLH) is a genetic disorder characterized by elevated fibroblast growth factor 23 (FGF23), resulting in renal phosphate wasting and inadequate bone mineralization. Burosumab, a monoclonal antibody that inhibits FGF23 activity, has shown promise in improving renal phosphate reabsorption and clinical outcomes in XLH patients. However, the potential side effects of burosumab, particularly its impact on immune function and susceptibility to infections, remain a subject of concern. In this case report, we describe a 57-year-old male individual with XLH who experienced recurrent soft tissue infections while receiving burosumab therapy. The infections included an olecranon abscess, a cervical retropharyngeal phlegmon with a sternocleidomastoid abscess, and suprapubic cellulitis, all of which were treated with antibiotic therapy. Following discontinuation of burosumab therapy, the patient did not experience further soft tissue infections. These observations suggest a potential association between burosumab therapy and an increased risk of soft tissue infections. Mechanistically, disruption of the FGF23-Klotho signaling axis may lead to impaired humoral immunity mediated by B lymphocytes and compromised innate immune response mediated by macrophages. Further investigation is warranted to better understand the immunological effects of burosumab and its implications for infectious complications in XLH patients.
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Affiliation(s)
- Sean Ho Yoon
- Department of Endocrinology, Albany Medical Center, Albany, NY 12208, USA
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Kamenicky P, Briot K, Brandi ML, Cohen-Solal M, Crowley RK, Keen R, Kolta S, Lachmann RH, Lecoq AL, Ralston SH, Walsh JS, Rylands AJ, Williams A, Sun W, Nixon A, Nixon M, Javaid MK. Benefit of burosumab in adults with X-linked hypophosphataemia (XLH) is maintained with long-term treatment. RMD Open 2023; 9:rmdopen-2022-002676. [PMID: 36854566 PMCID: PMC9980374 DOI: 10.1136/rmdopen-2022-002676] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 01/02/2023] [Indexed: 03/02/2023] Open
Abstract
OBJECTIVES To report the impact of continued burosumab treatment on clinical laboratory tests of efficacy, patient-reported outcomes (PROs) and ambulatory function in adults with X-linked hypophosphataemia who continued from a 96-week phase 3 study into a 48-week open-label extension. METHODS Eligible participants from the phase 3 study continued on the burosumab regimen received at the end of the phase 3 study for a further 48 weeks (n=31). Some (not all) received compassionate burosumab treatment between the two studies (a period of 6-18 months). The primary efficacy outcome was fasting serum phosphate concentration; secondary outcomes were serum 1,25 dihydroxyvitamin D concentration, renal phosphate reabsorption, PROs and ambulatory function. RESULTS Improvements in fasting serum phosphate, serum 1,25 dihydroxyvitamin D and renal phosphate reabsorption at 96 weeks were maintained through the 48-week extension. Improvements were also maintained in stiffness and physical function measured using the Western Ontario and McMaster Universities Osteoarthritis Index, pain and fatigue endpoints measuring using the Brief Pain Inventory short-form and Brief Pain Inventory, respectively, and in ambulatory function (6-Minute Walk Test).A post-hoc exploratory analysis exploring outcomes in participants who discontinued burosumab treatment between the studies (n=7) and those who received at least one dose (n=23) indicated that the benefits of burosumab on clinical laboratory tests of efficacy, PROs and ambulatory function may be lost when treatment is interrupted but recover over time when treatment is reinstated. CONCLUSION Continued treatment with burosumab appears necessary for sustained clinical benefit. TRIAL REGISTRATION NUMBERS Phase 3: NCT02526160; open-label extension: NCT03920072.
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Affiliation(s)
- Peter Kamenicky
- Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital Bicêtre, Paris, France
| | - Karine Briot
- Service de Rhumatologie, Hôpital Cochin, Paris, France
| | | | - Martine Cohen-Solal
- INSERM U1132 BIOSCAR, Service de Rhumatologie, Hôpital Lariboisiere, Université de Paris, Paris, France
| | - Rachel K Crowley
- Rare Disease Clinical Trial Network, University College Dublin School of Medicine, Dublin, Ireland.,Department of Endocrinology, St Vincent's University Hospital, Dublin, Ireland
| | - Richard Keen
- Metabolic Bone Disease Unit, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Sami Kolta
- INSERM U1153, Service de Rhumatologie, Hôpital Cochin, Paris, France
| | - Robin H Lachmann
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Anne-Lise Lecoq
- Physiologie et Physiopathologie Endocriniennes, Assistance Publique - Hôpitaux de Paris, Paris, France.,Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital Bicêtre, Paris, France
| | - Stuart H Ralston
- Medical Research Council Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Jennifer S Walsh
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Angela J Rylands
- Health Economics and Outcomes Research Department, Kyowa Kirin International PLC, Marlow, UK
| | - Angela Williams
- Health Economics and Outcomes Research Department, Kyowa Kirin International PLC, Marlow, UK
| | - Wei Sun
- Biostatistics Department, Kyowa Kirin Pharmaceutical Development, Inc, Princeton, New Jersey, USA
| | | | | | - Muhammad K Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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Osteomalacia Is Not a Single Disease. Int J Mol Sci 2022; 23:ijms232314896. [PMID: 36499221 PMCID: PMC9740398 DOI: 10.3390/ijms232314896] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/18/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
Among bone-material qualities, mineralization is pivotal in conferring stiffness and toughness to the bone. Osteomalacia, a disease ensuing from inadequate mineralization of the skeleton, is caused by different processes leading to decreased available mineral (calcium and/or phosphate) or enzymatic alterations. Vitamin D deficiency, which remains the major cause of altered mineralization leading to inadequate intestinal calcium and phosphate absorption, may be also associated with other conditions primarily responsible for abnormal mineralization. Given the reality of widespread vitamin D inadequacy, a full biochemical assessment of mineral metabolism is always necessary to rule out or confirm other conditions. Both too-high or too-low serum alkaline phosphatase (ALP) levels are important for diagnosis. Osteomalacic syndrome is reversible, at least in part, by specific treatment. Osteomalacia and bone mineralization themselves constitute largely unexplored fields of research. The true prevalence of the different forms of osteomalacia and the recovery after proper therapy have yet to be determined in the real world. Although non-invasive techniques to assess bone mineralization are not available in clinical practice, the systematic assessment of bone quality could help in refining the diagnosis and guiding the treatment. This review summarizes what is known of osteomalacia recent therapeutic developments and highlights the future issues of research in this field.
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