Meta-analyses of therapies for postmenopausal osteoporosis. IX: Summary of meta-analyses of therapies for postmenopausal osteoporosis

Should major trauma fractures be part of a fracture liaison service's remit: a cost-benefit estimate

The refracture rate after major trauma is approximately half (57%) the refracture rate after a minimal trauma injury. Extending Fracture Liaison Service activity to include major trauma patients creates significant additional direct cost, but remains essentially cost neutral if notional savings through refracture risk reduction are taken into account.

PURPOSE

To compare the 3-year refracture rate following minimal trauma (MT) and non-minimal trauma (non-MT) injuries and evaluate the cost of extending fracture liaison service (FLS) operations to non-MT presentations.

METHODS

Patients aged 50, or above presenting to the John Hunter Hospital with a fracture in calendar year 2018 were identified through the Integrated Patient Management System (IPMS) of the Hunter New England Health Service's (HNEHS), and re-presentation to any HNEHS facility over the following 3 years monitored. The refracture rate of MT and non-MT presentations was compared and analysed using Cox proportional hazards regression models. The cost of including non-MT patients was estimated through the use of a previously conducted micro-costing analysis. The operational fidelity of the FLS to the previous estimate was confirmed by comparing the 3-year refracture rate of MT presentations in the two studies.

RESULTS

The 3-year refracture rate following a MT injury was 8% and after non-MT injury 4.5%. Extension of FLS activities to include non-MT patients in 2022 would have cost an additional $198,326 AUD with a notional loss/saving of $ - 26,625/ + 26,913 AUD through refracture risk reduction. No clinically available characteristic at presentation predictive of increased refracture risk was identified.

CONCLUSION

The 3-year refracture after a non-MT injury is about half (57%) that of the refracture rate after a MT injury. Extending FLS activity to non-MT patients incurs a significant additional direct cost but remains cost neutral if notional savings gained through reduction in refracture risk are taken into account.

Osteoporosis management in adults with schizophrenia following index hip fracture event: a 10-year population-based retrospective cohort study, Ontario, Canada

Little is known about the incidence of osteoporosis testing and treatment in individuals with schizophrenia, who may be more likely to fracture. Using competing risk models, we found that schizophrenia was associated with lower incidence of testing or treatment. Implications are for understanding barriers and solutions for this disadvantaged group.

PURPOSE

Evidence suggests that individuals with schizophrenia may be more likely to experience hip fractures than the general population; however, little is known about osteoporosis management in this disadvantaged subpopulation. Our study objective was to compare bone mineral density (BMD) testing and pharmacologic treatment in hip fracture patients with versus without schizophrenia.

METHODS

This was a retrospective population-based cohort study leveraging health administrative databases, and individuals aged 66-105 years with hip fracture between fiscal years 2009 and 2018 in Ontario, Canada. Schizophrenia was ascertained using a validated algorithm. The outcome was a composite measure of (1) pharmacologic prescription for osteoporosis; or (2) a BMD test. Inferential analyses were conducted using Fine-Gray subdistribution hazard regression, with mortality as the competing event.

RESULTS

A total of 52,722 individuals aged 66 to 105 years who sustained an index hip fracture in Ontario during the study period were identified, of whom 1890 (3.6%) had schizophrenia. Hip fracture patients with vs without schizophrenia were more likely to be long-term care residents (44.3% vs. 18.1%; standardized difference, 0.59), frail (62.5% vs. 36.5%; standardized difference, 0.54) and without a primary care provider (9.2% vs. 4.8%; standardized difference, 0.18). In Fine-Gray models, schizophrenia was associated with a lower incidence of testing or treatment (0.795 (0.721, 0.877)).

CONCLUSIONS

In this population-based retrospective cohort study, a schizophrenia diagnosis among hip fracture patients was associated with a lower incidence of testing or treatment, after accounting for mortality, and several enabling and predisposing factors. Further research is required to investigate barriers to osteoporosis management in this disadvantaged population.

Study of Active Phytochemicals and Mechanisms of Cnidii Fructus in Treating Osteoporosis Based on HPLC-Q-TOF-MS/MS and Network Pharmacology

INTRODUCTION

This study aimed to clarify the anti-osteoporosis mechanism of Cnidii Fructus (CF) via network pharmacology and experimental verification.

METHODS

HPLC fingerprints combined with HPLC-Q-TOF-MS/MS analysis confirmed common components (CCS) of CF. Then, network pharmacology was used to investigate the anti-OP mechanism of CF, including potential anti-OP phytochemicals, potential targets, and related signalling pathway. Molecular docking analysis was carried on investigating the protein-ligand interactions. Finally, in vitro experiments were performed to verify anti-OP mechanism of CF.

RESULTS

In this study, 17 compounds from CF were identified by HPLC-Q-TOF-MS/MS and HPLC fingerprints and then were further screened key compounds and potential targets by PPI analysis, ingredient-target network and hub network. The key compounds were SCZ10 (Diosmin), SCZ16 (Pabulenol), SCZ6 (Osthenol), SCZ8 (Bergaptol) and SCZ4 (Xanthotoxol). The potential targets were SRC, MAPK1, PIK3CA, AKT1 and HSP90AA1. Molecular docking further analysis indicated that the five key compounds have a good binding affinity with related proteins. CCK8 assays, TRAP staining experiments, and ALP activity assays concluded that osthenol and bergaptol inhibited osteoclast formation and promoted osteoblast bone formation to improve osteoporosis.

CONCLUSION

Based on network pharmacology and in vitro experiments analysis, this study revealed that CF possessed an anti-OP effect, and its potential therapeutic effect may be involved with osthenol and bergaptol from CF.

Evaluation of costs, osteoporosis treatment, and re-fractures in German collaborative orthogeriatric care after fragility fractures

Orthogeriatric co-management (OGCM) may provide benefits for geriatric fragility fracture patients in terms of more frequent osteoporosis treatment and fewer re-fractures. Yet, we did not find higher costs in OGCM hospitals for re-fractures or antiosteoporotic medication for most fracture sites within 12 months, although antiosteoporotic medication was more often prescribed.

PURPOSE

Evidence suggests benefits of orthogeriatric co-management (OGCM) for hip fracture patients. Yet, evidence for other fractures is rare. The aim of our study was to conduct an evaluation of economic and health outcomes after the German OGCM for geriatric fragility fracture patients.

METHODS

This retrospective cohort study was based on German health and long-term care insurance data. Individuals were 80 years and older, sustained a fragility fracture in 2014-2018, and were treated in hospitals certified for OGCM (ATZ group), providing OGCM without certification (OGCM group) or usual care (control group). Healthcare costs from payer perspective, prescribed medications, and re-fractures were investigated within 6 and 12 months. We used weighted gamma and two-part models and applied entropy balancing to account for the lack of randomization. All analyses were stratified per fracture site.

RESULTS

We observed 206,273 patients within 12-month follow-up, of whom 14,100 were treated in ATZ, 133,353 in OGCM, and 58,820 in other hospitals. Total average inpatient costs per patient were significantly higher in the OGCM and particularly ATZ group for all fracture sites, compared to control group. We did not find significant differences in costs for re-fractures or antiosteoporotic medication for most fracture sites, although antiosteoporotic medication was significantly more often observed in the OGCM and particularly ATZ group for hip, pelvic, and humerus fractures.

CONCLUSION

The observed healthcare costs were higher in ATZ and OGCM hospitals within 12 months. Antiosteoporotic medication was prescribed more often in both groups for most fracture sites, although the corresponding medication costs did not increase.

Nondestructive and high-resolution monitoring of inflammation-type skull defects regeneration on adult zebrafish with optical coherence tomography

Optimized animal models and effective imaging techniques are exceedingly important to study cranial defects in bone loss due to chronic inflammation. In this study, the assessment procedure on a zebrafish inflammation-type skull defects model was monitored in vivo with spectral-domain optical coherence tomography (SD-OCT), and the efficacy of etidronate disodium in bone regeneration was assessed. An acute skull defect injury model was established in adult zebrafish using a stereotaxic craniotomy device. SD-OCT imaging was performed immediately following the mechanical injury. Both SD-OCT and immunohistochemistry results demonstrated an increase in inflammation-induced skull destruction within 5 days, which was confirmed by pathological experiments.

In vitro mechanical analysis of X-shaped femoroplasty with polymethyl methacrylate boundary a fall on the greater trochanter. Injury 2023;54 Suppl 6:110747. [PMID: 38143120 DOI: 10.1016/j.injury.2023.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

To evaluate with mechanical testing (MT) using synthetic femurs, an X-shaped femoroplasty technique with polymethyl methacrylate (PMMA), analyzing the results applied to the prophylaxis of proximal femur (PF) fractures caused by low-energy trauma. MT was performed simulating a fall on the greater trochanter, using fifteen Sawbones™ models. They were divided into three experimental groups (n = 5): control (DP) group, drilled without augmentation (DWA) group, and X-shaped augmentation (DX) group. Maximum load, stiffness, absorbed energy and displacement were analyzed primarily in all groups; and secondarily then, morphology and fracture type were verified in all groups while PMMA volume, temperature and time polymerization were analyzed only in the DX group. The MT results obtained for synthetic models respectively in the DP, DWA, and DX groups were: mean maximum load (5562.0 ± 464.8) N, (4798.0 ± 121.2) N, and (7132.0 ± 206.9) N; mean stiffness values (673 ± 64.34) N/mm, (636 ± 8.7) N/mm, and (738 ± 17.13) N/mm, and mean absorbed energy values (36,203 ± 3819) N.mm, (27,617 ± 3011) N.mm, (44,762 ± 3219) N.mm; mean displacement values (13.6 ± 1.45) N, (11.1 ± 0.5) N, and (13.2 ± 0.69) N. The mean volume, temperature reached during filling in the DX group were 9.8 mL, 42.54ºC with 1' 56" of polymerization. The fracture types were similar between the DP and DWA groups, affecting the trochanteric region, as distinctly to those in the DX group, which were restricted to the femoral neck. The values obtained in MT showed statistical significance when analyzed by one-way ANOVA (5%) for maximum load, stiffness, and absorbed energy between groups. In conclusion, X-shaped PMMA augmentation presents a protective biomechanical characteristic against PF fractures generated in synthetic models by boundary a fall on the greater trochanter.

Health-Economic Evaluation of the German Osteoporotic Fracture Prevention Program in Rural Areas (OFRA): Mobility and Falls Prevention Classes, Examination of Bone Health, and Consultation on Safety in the Living Environment

BACKGROUND

Fragility fractures are one of the leading causes of disability in older adults. Yet, evidence for effectiveness and cost-effectiveness of preventive approaches combining bone health and fall prevention is rare.

OBJECTIVE

To conduct a health-economic evaluation of the German osteoporotic fracture prevention program in rural areas (OFRA).

DESIGN

Secondary cluster-randomized intervention study based on routine data.

PARTICIPANTS

All districts in five federal states in Germany were cluster-randomized as intervention or control districts. OFRA was offered to community-living (a) women aged 75-79 years or (b) women and men aged 70-84 years with a prior fragility fracture in the intervention districts. Individuals who meet these criteria in the control districts were assigned to the control group.

INTERVENTION

OFRA comprised mobility and falls prevention classes, examination of bone health by bone density measurement, and consultation on safety in the home living environment.

MAIN MEASURES

We measured health-care costs and effectiveness in terms of time to fragility fracture or death within 1 year after initial contact, based on health insurance claims data. Implementation costs were recorded by the intervention performers. We calculated an incremental cost-effectiveness ratio (ICER) and employed the net-benefit approach to construct a cost-effectiveness acceptability curve (CEAC).

KEY RESULTS

There were 9408 individuals in the intervention group and 27,318 in the control group. Mean time to fragility fracture or death (difference: 0.82 days) and health-care costs (difference: 111.73€, p < .01) were reduced, but mean intervention costs (difference: 260.10€) increased total costs (difference: 148.37€, p < .001) in the intervention group. The ICER per fracture-free year of survival was 66,094.63€. The CEAC showed no acceptable probability of cost-effectiveness at a reasonable willingness to pay.

CONCLUSION

OFRA showed reduced rates of fragility fractures, but had high implementation costs, resulting in an unfavorable ICER. The cost-effectiveness of OFRA may improve with a longer follow-up.

Effectiveness of whole-body vibration on bone mineral density in postmenopausal women: a systematic review and meta-analysis of randomized controlled trials

The present study observed significant effects of whole-body vibration (WBV) on bone mineral density (BMD) in postmenopausal women, with high-quality evidence for high-frequency, low-magnitude, and high-cumulative-dose use. The aim was to update a previous systematic review with meta-analysis to observe the effects of WBV on BMD in postmenopausal women. For the meta-analysis, the weighted mean difference between WBV and control groups, or WBV and conventional exercise, was used for the area of bone mineral density (aBMD) of the lumbar spine, femoral neck, total hip, trochanter, intertrochanter, and Ward's area, or volumetric trabecular bone mineral density (vBMDt) of the radius and tibia. Methodological quality was assessed using the PEDro scale and the quality of evidence using the GRADE system. In total, 23 studies were included in the systematic review and 20 in the meta-analysis. Thirteen studies showed high methodological quality. WBV compared with control groups showed significant effects on aBMD in the primary analysis (lumbar spine and trochanter), sensitivity (lumbar spine), side-alternating vibration (lumbar spine and trochanter), synchronous vibration (lumbar spine), low frequency and high magnitude (lumbar spine and trochanter), high frequency and low magnitude (lumbar spine), high frequency and high magnitude (lumbar spine, trochanter, and Ward's area), high cumulative dose and low magnitude (lumbar spine), low cumulative dose and high magnitude (lumbar spine and trochanter), and positioning with semi-flexed knees (trochanter). Of these results, only high frequency associated with low magnitude and high cumulative dose with low magnitude showed high-quality evidence. At this time, considering the high quality of evidence, it is possible to recommend WBV using high frequency (≈ 30 Hz), low magnitude (≈ 0.3 g), and high cumulative dose (≈ 7000 min) to improve lumbar spine aBMD in postmenopausal women. Other parameters, although promising, need to be better investigated, considering, when applicable, the safety of the participants, especially in vibrations with higher magnitudes (≥ 1 g).

Bone regeneration: A message from clinical medicine and basic science

Population aging is a global phenomenon and with it, the number of bone fractures increases due to higher incidences of osteoporosis. Bone fractures in the elderly increase the risk of bedridden status and mortality. Therefore, the control of osteoporosis and bone fracture is important for healthy life expectancy, and the fundamental understanding of its pathogenesis and its application in treatment is of great social significance. To solve these clinical problems, it is necessary to integrate clinical medicine and basic research. Bone regeneration after a fracture is an essential function of the living body. The prevailing view is that a small number of resident skeletal stem cells are solely responsible for regenerative capacity. Although these cells have long been considered to be in the bone marrow, it has been shown that they are also present in the growth plate and periosteum. More recently, distinct types of cells in the bone marrow, including bone marrow stromal cells, osteoblast progenitor cells, and osteoblasts, have been shown to participate in bone regeneration. Interestingly, the cellular plasticity of differentiated cells, rather than active recruitment of resident stem cell populations, may largely account for regeneration of bone tissues; terminally differentiated cells de-differentiate into a stem cell-like state, and then re-differentiate into regenerating bone. In this review, we discuss the clinical risk and preventive therapy of bone fractures and the current concept of bone regeneration in basic mechanical insights, which may prove useful to both clinicians and researchers.

Timing of surgery for internal fixation of intracapsular hip fractures and complications at 1 year; a 32 year clinical study of 2,366 patients at a single center

BACKGROUND

Timing of hip fracture surgery for the internal fixation of an intracapsular fracture remains controversial and few studies to date have been able to determine the optimum time to surgery in minimizing osteonecrosis and non-union with intracapsular fractures after fixation.

METHODS

Using a local hip fracture database managed by the senior author over a 32 year period, those who underwent osteosynthesis following intracapsular fractures were assessed for risk of development of non-union and osteonecrosis. Multivariate regression analysis was performed focusing on factors that were predictive of complications. Patient demographics, time from injury to surgery, fixation method, fracture pattern and complications at one year were reported. The primary outcome was whether delay to surgery contributed to risk of complications, defined as non-union or osteonecrosis. Secondary outcomes assessed the contribution of other factors to these complications.

RESULTS

2,366 patients were identified with an average age of 74.7 years and 66.5% were female. 1189 (50.3%) of fractures were displaced. 481 (20.3%) had a complication at one year following fixation. 78 (3.3%) were fixed by DHS, 6 (0.3%) by cephalomedullary nail, (1257) 53.1% by cannulated screws and 1025 (43.3%) by Targon® screw. Multivariate regression revealed no significant correlation between delay to surgery and complication rates (OR 0.99, 95% CI 0.99, 1.01, p = 0.55). Significant variables include female sex (OR 2.03, 95% CI 1.58, 2.62, p<0.0001), fracture displacement (OR 4.8, 95% CI 3.79, 6.14, p<0.0001), independent mobility (OR 0.64, 95% CI 0.47, 0.87, p = 0.004) and use of Targon® screws compared to parallel screws (OR 0.61, 95% CI 0.48, 0.76, p<0.0001).

CONCLUSIONS

Our study demonstrates no relationship between timing of surgery for fixation of intracapsular fracture and complication rates. Female sex and fracture displacement increased risk of complications whereas independent mobility and use of Targon® screw device in comparison to parallel screws were protective against non-union but not avascular necrosis.

Effects of Raloxifene and tibial loading on bone mass and mechanics in male and female mice

Purpose: Raloxifene (RAL) is a selective estrogen receptor modulator (SERM) that has previously been shown to cause acellular benefits to bone tissue. Due to these improvements, RAL was combined with targeted tibial loading to assess if RAL treatment during periods of active bone formation would allow for further mechanical enhancements.Methods: Structural, mechanical, and microstructural effects were assessed in bone from C57BL/6 mice that were treated with RAL (0.5 mg/kg), tibial loading, or both for 6 weeks, beginning at 10 weeks of age.Results:Ex vivo microcomputed tomography (CT) images indicated RAL and loading work together to improve bone mass and architecture, especially within the cancellous region of males. Increases in cancellous bone volume fraction were heavily driven by increases in trabecular thickness, though there were some effects on trabecular spacing and number. In the cortical regions, RAL and loading both increased cross-sectional area, cortical area, and cortical thickness. Whole-bone mechanical testing primarily indicated the effects of loading. Further characterization through Raman spectroscopy and nanoindentation showed load-based changes in mineralization and micromechanics, while both loading and RAL caused changes in the secondary collagen structure. In contrast to males, in females, there were large load-based effects in the cancellous and cortical regions, resulting in increased whole-bone mechanical properties. RAL had less of an effect on cancellous and cortical architecture, though some effects were still present.Conclusion: RAL and loading work together to impact bone architecture and mechanical integrity, leading to greater improvements than either treatment individually.

[Value of a nomogram model based on IDEAL-IQ for predicting early bone mass loss]

OBJECTIVE

To assess the diagnostic efficiency of a nomogram model based on iterative decomposition of water and fat with echo asymmetry and least-squares estimation- iron quantification (IDEAL- IQ) for predicting early bone loss of the lumbar vertebrae.

METHODS

Fifty-nine volunteers and patients with osteoporosis underwent examinations with both dual-energy X-ray absorptiometry (DXA) to determine bone mineral density (BMD) of L1-4 vertebrae and lumbar magnetic resonance imaging (MRI) with IDEAL-IQ sequence for measurement of bone marrow FF of L1-4 vertebrae. According to the results of DXA, the subjects were divided into normal bone mass group (n=23) and osteopenia group (n=36). The FF values of the two groups were compared and the diagnostic efficacy of the FF value was evaluated using ROC curve analysis. Multivariate logistic regression analysis was used to identify the independent factors for predicting bone mass loss, and a visual nomogram model was constructed and its diagnostic efficiency was assessed.

RESULTS

The FF value of the vertebrae was significant lower in normal bone mass group than in osteopenia group [(38.84±6.75)% vs (51.96±7.65)%, P < 0.05). ROC curve analysis showed that the AUC of the FF value for differentiating normal bone mass and osteopenia was 0.797 with a cutoff value of 46.85%, a sensitivity of 73.91% and a specificity of 80.56%. Multivariate logistics regression analysis identified the FF value, age and BMI as the independent factors for predicting bone mass loss. The diagnostic AUC of the nomogram model was 0.954 (95% CI: 0.806-0.957), and the predicted probability of the model was in good agreement with the actual probability. Decision curve analysis showed that the nomogram model could provide more net benefit than the FF vale alone.

CONCLUSION

FF value of MRI IDEAL- IQ sequence can reflect bone marrow fat content of the vertebral body, and the nomogram model incorporating the FF value, age, and BMI can further improve the predictive efficiency to provide a visual modality for predicting early bone mass loss.

A randomized, controlled trial of once-weekly teriparatide injection versus alendronate in patients at high risk of osteoporotic fracture: primary results of the Japanese Osteoporosis Intervention Trial-05

In this randomized, controlled trial, treatment with once-weekly subcutaneous injection of teriparatide for 72 weeks was found to be associated with a significant reduction in the incidence of morphometric vertebral fractures compared with alendronate in women with primary osteoporosis who were at high risk of fracture.

INTRODUCTION

To determine whether the anti-fracture efficacy of teriparatide is superior to that of alendronate, a prospective, randomized, open-label, blinded-endpoint trial was performed.

METHODS

Japanese women aged at least 75 years were eligible for the study if they had primary osteoporosis and were at high risk of fracture. Patients were randomly assigned in a 1:1 ratio to receive sequential therapy (once-weekly subcutaneous injection of teriparatide 56.5 μg for 72 weeks followed by alendronate for 48 weeks) or monotherapy with alendronate for 120 weeks. The primary endpoint was the incidence of morphometric vertebral fractures at 72 weeks (at the end of teriparatide treatment).

RESULTS

Between October 2014 and December 2017, 1011 patients (505 in the teriparatide group and 506 in the alendronate group) were enrolled. Of these, 778 patients (351 and 427, respectively) were included in the primary analysis. The incidence of morphometric vertebral fractures was significantly lower in the teriparatide group (56 per 419.9 person-years, annual incidence rate 0.1334) than in the alendronate group (96 per 553.6 person-years, annual incidence rate 0.1734), with a rate ratio of 0.78 (95% confidence interval 0.61 to 0.99, P = 0.04). In both groups, adverse events were most frequently reported in the following system organ classes: infections and infestations, gastrointestinal disorders, and musculoskeletal and connective tissue disorders.

CONCLUSION

Once-weekly subcutaneous injection of teriparatide significantly reduced the incidence of morphometric vertebral fractures compared with alendronate in women with primary osteoporosis who were at high risk of fracture.

TRIAL REGISTRATION

jRCTs031180235 and UMIN000015573, March 12, 2019.

FRAX without BMD can be used to risk-stratify Veterans who recently sustained a low trauma non-vertebral/non-hip fracture

We evaluated the fracture risk assessment tool (FRAX) without bone mineral density (BMD) in predicting treatment recommendations for patients with a recent low trauma fracture other than hip or vertebral. The concordance, sensitivity, and specificity were 75.6%, 67.3%, and 78.2%, respectively. FRAX without BMD can be used after a fracture to expedite treatment.

INTRODUCTION

The objective of this study was to evaluate the performance of the fracture risk assessment tool (FRAX) without bone mineral density (BMD) in predicting treatment recommendations for patients who recently sustained a low trauma fracture other than hip or vertebral.

METHODS

We utilized a clinical database established by the Fracture Liaison Service at the Durham Veterans Affairs Medical Center to identify male and female Veterans age ≥ 50 years who sustained a low trauma non-hip/non-vertebral fracture and underwent dual-energy x-ray absorptiometry (DXA) between October 2013 and April 2018. FRAX without BMD (FRAX-BMI) and FRAX with BMD (FRAX-BMD) were calculated for the 229 patients identified, and whether or not they met the National Osteoporosis Foundation (NOF) guideline treatment thresholds was compared.

RESULTS

There were 55 (24.0%) patients that met criteria for treatment based on NOF guideline established FRAX-BMD thresholds including 27 (11.8%) patients with osteoporosis by DXA. The concordance of FRAX-BMI in predicting treatment recommendations was 75.6% with a sensitivity of 67.3% and a specificity of 78.2%. The area under the curve (AUC) of FRAX-BMI hip fracture risk was 0.79. Assessment/treatment thresholds for hip fracture risk of 1% < FRAX-BMI < 4% were proposed to maximize sensitivity and specificity.

CONCLUSION

Among patients who sustained a low trauma non-hip/non-vertebral fracture, FRAX-BMI can be used to stratify risk and identify high-risk patients who could be treated without DXA, low-risk patients who may not need treatment, and intermediate-risk patients to undergo DXA testing.

Extent of and reasons for osteoporosis medication non-adherence among veterans and feasibility of a pilot text message reminder intervention

We determined the extent of and reasons for non-adherence to oral bisphosphonates among veterans and conducted a pilot text message reminder application aimed at the most commonly cited reason for non-adherence. The intervention was found to be acceptable and feasible.

PURPOSE

To evaluate the extent of and reasons for non-adherence to oral bisphosphonates among veterans and to assess the acceptability and feasibility of a pilot text message reminder application.

METHODS

We surveyed 105 veterans initiating oral bisphosphonates for osteoporosis/osteopenia within the prior 18 months utilizing a validated self-report measure adapted for osteoporosis. Additionally, we conducted a pilot text message reminder to determine feasibility in 12 veterans who were initiating or were currently non-adherent to oral bisphosphonates.

RESULTS

Of the 43 (40.9% response rate) completed surveys, the most common reasons for non-adherence were "I forgot" (37.5%), "I had other medications to take" (20.5%), "my bones are not weak" (18.4%), "I felt well" (18.4%), and "I worried about taking them for the rest of my life" (17.9%). Median MPR for the 49 (46.7%) non-adherent (MPR < 0.80) veterans was 0.35 (IQR 0.21-0.64). Of veterans offered a weekly automated text message reminder, 12 (50%) accepted. Nine of these 12 veterans reported that the text message reminders did "very well" at reminding them to take their medication and would recommend the application to other patients/family/friends. The median 6-month MPR for the reminder group was 0.96 (IQR 0.54-1.00).

CONCLUSION

Half the veterans in our sample were taking insufficient doses of oral bisphosphonates to attain the full benefit of fracture risk reduction. Reasons for poor adherence included forgetfulness, polypharmacy, and misconceptions about osteoporosis. A pilot text message reminder intervention targeted to one of the most commonly cited reasons was found to be acceptable and feasible among veterans.

The effect of exercise intensity on bone in postmenopausal women (part 2): A meta-analysis

BACKGROUND

Previous reviews have concluded that exercise has only modest effects on bone mineral density (BMD) in postmenopausal women. Despite the well-recognized strong positive relationship between load magnitude and bone response observed from animal research, the majority of human trials have examined the effects of only low to moderate intensity exercise on bone. We speculated that meta-analysing according to intensity may reveal a more potent exercise effect at higher intensity.

OBJECTIVES

To determine the effects of low, moderate and high intensity exercise on BMD at the spine and hip in postmenopausal women.

METHODS

Electronic databases and reference lists were searched for RCTs that examined the effect of exercise compared to control on DXA-derived lumbar spine, femoral neck or total hip BMD in healthy postmenopausal women. Interventions were classified as low, moderate or high intensity and pooled based on classification. Mean differences (MD) were calculated using random effects models and a risk of bias analysis was undertaken. To determine the effect of different exercise types (resistance and impact training) on BMD outcomes, subgroup analyses for all intensity categories and outcomes were conducted. Separate meta-analyses were undertaken to examine the influence of adding exercise to a bone medication intervention and to examine exercise effects on fracture risk.

RESULTS

Fifty-three trials, testing 63 interventions (19 low, 40 moderate, 4 high intensity) were included. At the lumbar spine, high intensity exercise yielded greater BMD effects (MD = 0.031 g/cm² 95% CI [0.012, 0.049], p = 0.002) than moderate (MD = 0.012 g/cm² 95% CI [0.008, 0.017], p < 0.001) and low intensity (MD = 0.010 g/cm² 95% CI [0.005, 0.015], p < 0.001). Low and moderate intensity exercise was equally effective at the femoral neck (low: 0.011 g/cm² 95% CI [0.006, 0.016], p < 0.001; moderate: 0.011 g/cm² 95% CI [0.007, 0.015], p < 0.001), but no effect of high-intensity exercise was observed. Moderate intensity exercise increased total hip BMD (0.008 g/cm² 95% CI [0.004, 0.012], p < 0.001), but low intensity did not. There were insufficient data to meta-analyse the effect of high intensity exercise at the total hip. Resistance training, potentially in combination with impact training, appears to be the most effective osteogenic stimulus at the spine and hip. Findings from meta-regression analyses were not informative and no influence of exercise on medication efficacy was observed. Risk of bias was mainly low or unclear due to insufficient information reported.

CONCLUSION

High intensity exercise is a more effective stimulus for lumbar spine BMD than low or moderate intensity, but not femoral neck BMD, however, the latter finding may be due to lack of power. While data from high-intensity exercise interventions are limited, the current comprehensive meta-analysis demonstrates the same positive relationship between load magnitude and bone response in humans that is observed in animal research. Findings have implications for optimal exercise prescription for osteoporosis in postmenopausal women.

STUDY REGISTRATION

Registered on PROSPERO (CRD42018117254).

Evaluation of the quality of published SCI clinical practice guidelines using the AGREE II instrument: Results from Can-SCIP expert panel

INTRODUCTION

Spinal cord injury (SCI) is a complex condition with substantial adverse personal, social and economic impacts necessitating evidence-based inter-professional care. To date, limited studies have assessed the quality of clinical practice guidelines (CPGs) within SCI. The aim of this study is to evaluate the quality of the development process and methodological rigour of published SCI CPGs across the care continuum from pre-hospital to community-based care.

METHODS

Electronic health databases and indexes were searched to identify English or French language CPGs within SCI published within the last nine years with specific evidence-based recommendations applicable to the Canadian health care setting. Eligible CPGs were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

RESULTS

A total of forty-one CPGs that met the inclusion criteria were appraised by at least four raters. There was high variability in quality. Twenty-seven CPGs achieved a good rigour of development domain score of >70%. Other standardized mean domain scores were scope and purpose (85.32%), stakeholder involvement (65.03%), clarity of presentation (84.81%), applicability (55.55%) and editorial independence (75.83%). The agreement between appraisers (intraclass correlation coefficient) was high (intraclass correlation coefficient > 0.80).

CONCLUSION

There is a paucity of CPGs that address community-based specialized rehabilitation and community reintegration. Furthermore, many CPGs only focus on a single impairment at one time point in the care continuum. As SCI is a complex condition that results in multimorbidity and requires health monitoring and intervention across the lifespan, a rigorously developed CPG that addresses high-quality, interprofessional comprehensive care is needed.

Comprehensive Study of the Risk Factors for Medication-Related Osteonecrosis of the Jaw Based on the Japanese Adverse Drug Event Report Database

Medication-related osteonecrosis of the jaw (MRONJ) is associated with many drugs, including bisphosphonates (BPs). BPs are associated with atypical femoral fractures and osteonecrosis of the external auditory canal. Thus, many drugs are reported to cause adverse effects on bone. This study aimed to investigate the effects of drugs and patient backgrounds regarding osteonecrosis-related side effects, including MRONJ. This study used a large voluntary reporting database, namely, the Japanese Adverse Drug Event Report database. First, we searched for risk factors related to MRONJ using volcano plots and logistic regression analysis. Next, we searched for bone-necrosis-related side effects using principal component and cluster analysis. Factors that were significantly associated with MRONJ included eight types of BPs and denosumab, prednisolone, sunitinib, eldecalcitol, raloxifene, letrozole, doxifluridine, exemestane, radium chloride, medroxyprogesterone, female, elderly, and short stature. Furthermore, antiresorptive agents (i.e., BPs and denosumab) tended to induce MRONJ and atypical femoral fractures by affecting osteoclasts. We believe these findings will help medical personnel manage the side effects of many medications.

Randomized head-to-head comparison of minodronic acid and raloxifene for fracture incidence in postmenopausal Japanese women: the Japanese Osteoporosis Intervention Trial (JOINT)-04

AIMS

We conducted a head-to-head randomized trial of minodronate, a bisphosphonate, and raloxifene, a selective estrogen receptor modulator, to obtain clinical evidence and information about their efficacy and safety.

METHODS

The Japanese Osteoporosis Intervention Trial protocol number 4 (JOINT-04) trial is a multi-center, open-labeled, blinded endpoints, head-to-head randomized trial of minodronate and raloxifene. Ambulatory elderly women with osteoporosis (age, >60 years) were randomly allocated to the raloxifene or minodronate group by central registration. The co-primary endpoints included any one of osteoporotic fractures (vertebral, humeral, femoral, and radial fractures), vertebral fractures, and major osteoporotic fractures (clinical vertebral, humeral, femoral, and radial fractures). The biological effects of each drug, patients' quality of life, and drug safety were assessed based on the secondary outcomes. This study was registered at the University Hospital Medical Information Network-Clinical Trials Registry (UMIN-CTR) under trial identification number UMIN000005433.

RESULTS

A total of 3896 patients were randomized to the minodronate and raloxifene groups, and drug efficacy assessments were performed for 3247 patients (1623 and 1624 patients, respectively). Among these patients, 1176 and 1187 patients received allocated treatment for 2 years. The incidence rate ratios for osteoporotic, vertebral, and major osteoporotic fractures in the minodronate group were 0.94 (95% CI: 0.78-1.13, p = .494), 0.86 (95% CI: 0.70-1.05, p = .147), and 1.22 (95% CI: 0.86-1.74, p = .274), respectively. Compared to the raloxifene group, the minodronate group showed significantly increased bone mineral density of the lumbar spine for each visit (6 months: p = .007, 12 months: p = .0003, 24 months: p<.0001). Also, serious adverse reactions were observed for four and six patients in the minodronate and raloxifene groups, respectively.

CONCLUSIONS

Overall, there were no statistical differences in the incidence rates of osteoporotic, vertebral, or major osteoporotic fractures between the two groups. Serious adverse reactions were rare in both groups.

A 3i hip fracture liaison service with nurse and physician co-management is cost-effective when implemented as a standard clinical program

A hip fracture liaison service that was implemented in 2 hospitals in Alberta, Canada, co-managed by a nurse and physician, was cost-effective and improved initiation of osteoporosis medication following hip fracture.

PURPOSE/INTRODUCTION

To determine cost-effectiveness of a 3i hip fracture liaison service (H-FLS) with 12-month follow-up, co-managed by a nurse and physician, when implemented into standard practice.

METHODS

The cost-effectiveness analysis compared those receiving the H-FLS to a simulated usual care group using a decision analytic model that incorporated Markov processes. We estimated incremental costs and effectiveness (based on quality-adjusted life years (QALYs) gained) using a lifetime horizon and a healthcare payer perspective. The H-FLS program provided data regarding population at risk, treatment rates, persistence, and intervention costs. We also performed deterministic and probabilistic sensitivity analyses.

RESULTS

One thousand two hundred fifty-two patients were included in the H-FLS between June 2015 and March 2018; 69% were female; the average age was 80 ± 11 years. Anti-absorptive treatment following fracture was initiated in 59.6% (95% CI: 55.7-63.5) H-FLS patients relative to 20.9% (95% CI: 13.3-28.5%) receiving usual care (from our published work). Based on modeled cohort simulation cost-effectiveness analysis (CEA), every 1000 H-FLS patients would experience 12 fewer hip fractures and 37 fewer total fragility fractures than patients receiving usual care. Over the study horizon, the H-FLS led to only a $54 incremental cost/patient with a modest gain of 8 QALYs/1000 patients. The incremental cost-effectiveness ratio (ICER) of $6750/QALY gained was less than the $27,000 cost-effectiveness threshold. Eliminating the 9-month follow-up resulted in incremental savings of $218/patient while also reducing 6-month follow-ups increased cost-savings to $378/patient. Probabilistic sensitivity analyses suggested that the H-FLS would either be cost-saving (60%) or cost-effective (40%).

CONCLUSION

A H-FLS implemented into standard practice significantly improved anti-absorptive medication use; a cohort simulation cost-effectiveness analysis (CEA) suggested that the H-FLS was cost-effective with potential to become cost-savings.

Real-world Adherence and Persistence with Bisphosphonate Therapy in Postmenopausal Women: A Systematic Review

PURPOSE

Bisphosphonate therapy is a well-established and effective treatment for postmenopausal osteoporosis and the prevention of osteoporotic fracture. However, poor adherence to and poor persistence with bisphosphonate therapy may reduce its benefits. Previous studies have documented the poor rates of adherence and persistence among postmenopausal women with osteoporosis. The objective of this systematic literature review was to evaluate adherence, persistence, and the impact of adherence and persistence on fracture risk in postmenopausal women with diagnosed osteoporosis.

METHODS

Articles eligible for review included observational studies of the real-world use of bisphosphonates in 23 countries and were identified by using MEDLINE, EMBASE, IMSEAR (Index Medicus for South-East Asia Region), and LILACS (Latin American and Caribbean Health Sciences Database).

FINDINGS

We identified and evaluated 10 studies that assessed bisphosphonate adherence by measuring medication possession ratio (MPR), persistence, and/or the impact of adherence and persistence on fracture risk. Mean MPR at 1 year ranged from 54% to 71% in the 3 studies that reported this assessment of adherence, and 40%-85% of patients at 1 year were adherent, defined as an MPR ≥80%, in the 8 studies that reported this end point. At 1 year, rates of persistence ranged from 28% to 74%. Rates of adherence and persistence were highest with agents requiring less frequent administration and typically declined over time. Fracture rates were significantly lower among adherent women with MPRs ≥80% compared with women with MPRs <80%.

IMPLICATIONS

Our results show that suboptimal adherence to and persistence with bisphosphonate therapy in postmenopausal women are common and increase the risk of fracture. Additional research is needed to identify and incorporate effective strategies for improving adherence to bisphosphonates in postmenopausal women.

Design of a randomized trial of teriparatide followed by alendronate: Japanese Osteoporosis Intervention Trial-05 (JOINT-05)

INTRODUCTION

Despite advances in drug treatment, the optimal treatment strategy for severe osteoporosis remains uncertain.

MATERIALS AND METHODS

This article reports the design and rationale for the Japanese Osteoporosis Intervention Trial-05 (JOINT-05), a randomized, controlled trial that compares the efficacy and safety of teriparatide followed by alendronate with alendronate monotherapy for severe osteoporosis.

RESULTS

Postmenopausal women aged at least 75 years were eligible for the study if they were at high risk of fracture. Patients were recruited from 113 institutions in Japan between October 2014 and December 2017. They were randomly assigned in a 1:1 ratio to the sequential therapy arm (once-weekly subcutaneous injections of teriparatide 56.5 μg for 72 weeks followed by alendronate for 48 weeks) or monotherapy arm (alendronate for 120 weeks). The regimens for alendronate are 5 mg (orally administered once daily), 35 mg (orally administered once weekly), or 900 μg (intravenously administered once every 4 weeks). The primary endpoint is the incidence of morphometric vertebral fracture at 72 weeks. The secondary endpoints include the incidence of morphometric vertebral fracture at 120 weeks; incidence of morphometric vertebral or non-vertebral fractures at 72 and 120 weeks; incidence of clinical vertebral fracture at 72 and 120 weeks; changes in bone mineral density, quality of life scores (EuroQol 5 Dimensions and the Japanese Osteoporosis Quality of Life Questionnaire short form), and a visual analog scale for back pain; and adverse events.

CONCLUSION

We reported the design and rationale for the JOINT-05. The trial is registered with the Japan Registry of Clinical Trials (jRCTs031180235) and the University Hospital Medical Information Network-Clinical Trials Registry (UMIN000015573).

Cost-effectiveness analyses of interventions to improve osteoporosis care in France

Osteoporosis (OP) is responsible for an important economic burden, but OP care is far from meeting therapeutic guidelines. Some interventions were effective to improve OP management. Our objective was to evaluate the cost-effectiveness of these interventions. Structural interventions and interventions consisting in sending educational material were dominant strategies.

PURPOSE

Osteoporosis (OP) causes many osteoporotic fractures worldwide and an important economic burden as a result. OP care is far from meeting treatment guidelines, but in a recent meta-analysis, we showed that some interventions were effective to improve appropriate bone mineral density (BMD) and treatment prescriptions. In the context of limited resources, it is of major importance to measure these interventions' efficiency. Our objective was to evaluate the cost-effectiveness of existing effective intervention types.

METHODS

We used a decision tree incorporating Markov models to compare costs and benefits (quality-adjusted life-years or QALYs) between usual care and three intervention types: structural (I), direct educational through conversation (II), and indirect educational by sending material (III). We adopted the collectivity perspective and chose a 30-year time horizon. The model included efficacy of interventions and risk of further fracture or death, depending on BMD T-score results and OP management, obtained from published literature. The model was populated to reflect a French setting. Deterministic and probabilistic sensitivity analyses were conducted. Costs were presented in 2018 euros (€).

RESULTS

Interventions type I and III were dominant strategies compared with usual care (cost-saving with a QALY gain). Our results were consistent through sensitivity analyses.

CONCLUSION

Our results suggest that structural interventions and indirect interventions to improve OP care (BMD and OP treatment prescription), in women 50 years old with a first fragility fracture, were dominant strategies.

Vindoline Inhibits RANKL-Induced Osteoclastogenesis and Prevents Ovariectomy-Induced Bone Loss in Mice

Osteolytic bone diseases, for example postmenopausal osteoporosis, arise from the imbalances between osteoclasts and osteoblasts in the bone remodeling process, whereby osteoclastic bone resorption greatly exceeds osteoblastic bone formation resulting in severe bone loss and deterioration in bone structure and microarchitecture. Therefore, the identification of agents that can inhibit osteoclast formation and/or function for the treatment of osteolytic bone disease has been the focus of bone and orthopedic research. Vindoline (Vin), an indole alkaloid extracted from the medicinal plant Catharanthus roseus, has been shown to possess extensive biological and pharmacological benefits, but its effects on bone metabolism remains to be documented. Our study demonstrated for the first time, that Vin could inhibit osteoclast differentiation from bone marrow macrophages (BMMs) precursor cells as well as mature osteoclastic bone resorption. We further determined that the underlying molecular mechanism of action of Vin is in part due to its inhibitory effect against the activation of MAPK including p38, JNK, and ERK and intracellular reactive oxygen species (ROS) production. This effect ultimately suppressed the induction of c-Fos and NFATc1, which consequently downregulated the expression of the genes required for osteoclast formation and bone resorption. Consistent with our in vitro findings, in vivo administration of Vin protected mice against ovariectomy (OVX)-induced bone loss and trabecular bone deterioration. These results provided promising evidence for the potential therapeutic application of Vin as a novel treatment option against osteolytic diseases.

Five-year refracture rates of a province-wide fracture liaison service

We examined the 5-year refracture rate of 6543 patients and found an overall rate of 9.7%. Adjusted analysis showed that presenting with multiple fractures was an indicator of a higher refracture risk; while presenting with an ankle fracture was associated with a lower refracture risk.

INTRODUCTION

To examine refractures among patients screened in a province-wide fracture liaison service (FLS).

METHODS

We assessed the 5-year refracture rate of fragility fracture patients aged 50+ who were screened at 37 FLS fracture clinics in Ontario, Canada. Refracture was defined as a new hip, pelvis, spine, distal radius, or proximal humerus fracture. Kaplan-Meier curves and Cox proportional hazards model adjusting for age, sex, and index fracture type were used to examine refracture rates.

RESULTS

The 5-year refracture rate of 6543 patients was 9.7%. Those presenting with multiple fractures at baseline (i.e., two or more fractures occurring simultaneously) had the highest refracture rate of 19.6%. As compared to the 50-65 age group, refracture risk increased monotonically with age group (66-70 years: HR = 1.3, CI 95%, 1.0-1.7; 71-80 years: HR = 1.7, CI 1.4-2.1; 81+ years: HR = 3.0, CI 2.4-3.7). Relative to distal radius, presenting with multiple fractures at screening was associated with a higher risk of refracture (HR = 2.3 CI 1.6-3.1), while presenting with an ankle fracture was associated with a lower risk of refracture (HR = 0.7 CI 0.6-0.9). Sex was not a statistically significant predictor of refracture risk in this cohort (HR = 1.2, CI 1.0-1.5).

CONCLUSIONS

One in ten patients in our cohort refractured within 5 years after baseline. Presenting with multiple fractures was an indicator of a higher refracture risk, while presenting with an ankle fracture was associated with a lower refracture risk. A more targeted FLS approach may be appropriate for patients at a higher refracture risk.

Cost-Effectiveness of Osteoporosis Interventions to Improve Quality of Care After Upper Extremity Fracture: Results From a Randomized Trial (C-STOP Trial)

We assessed the cost-effectiveness of two models of osteoporosis care after upper extremity fragility fracture using a high-intensity Fracture Liaison Service (FLS) Case-Manager intervention versus a low-intensity FLS (ie, Active Control), and both relative to usual care. This analysis used data from a pragmatic patient-level parallel-arm comparative effectiveness trial of 361 community-dwelling participants 50 years or older with upper extremity fractures undertaken at a Canadian academic hospital. We used a decision-analytic Markov model to evaluate the cost-effectiveness of the three treatment alternatives. The perspective was health service payer; the analytical horizon was lifetime; costs and health outcomes were discounted by 3%. Costs were expressed in 2016 Canadian dollars (CAD) and the health effect was measured by quality adjusted life years (QALYs). The average age of enrolled patients was 63 years and 89% were female. Per patient cost of the Case Manager and Active Control interventions were $66CAD and $18CAD, respectively. Compared to the Active Control, the Case Manager saved $333,000, gained seven QALYs, and averted nine additional fractures per 1000 patients. Compared to usual care, the Case Manager saved $564,000, gained 14 QALYs, and incurred 18 fewer fractures per 1000 patients, whereas the Active Control saved $231,000, gained seven QALYs, and incurred nine fewer fractures per 1000 patients. Although both interventions dominated usual care, the Case Manager intervention also dominated the Active Control. In 5000 probabilistic simulations, the probability that the Case Manager intervention was cost-effective was greater than 75% whereas the Active Control intervention was cost-effective in less than 20% of simulations. In summary, although the adoption of either of these approaches into clinical settings should lead to cost savings, reduced fractures, and increased quality-adjusted life for older adults following upper extremity fracture, the Case Manager intervention would be the most likely to be cost-effective. © 2019 American Society for Bone and Mineral Research.

Alendronate induced chorioretinitis: The importance of meticulous assessments

Purpose

To report a case of presumed bilateral chorioretinitis secondary to alendronate therapy.

Observations

A 71-year-old female presented to the clinic in July 2017 with six months history of difficulty in reading along with floaters in both eyes which were more severe in the right eye. Past medical and surgical history revealed a history of hypertension, gout, hyperthyroidism, osteoporosis, and humerus fracture. She was started on alendronate three months before developing ocular symptoms. On ocular examination, best corrected visual acuity was 20/30 in the right and 20/25 in the left eye. Slit-lamp examination demonstrated normal anterior chamber examination in both eyes. Dilated fundus examination revealed geographic chorioretinal lesions around the optic nerve head in both eyes, more extensively in the right eye; and superior and temporal to the macula in the right eye. Past ocular records in February 2015 did not reveal any such findings. Fundus autofluorescence demonstrated hyper-autofluorescence in the peripapillary lesions in both eyes. The lesion adjacent to the macula in right eye displayed mixed hyper and hypo-autofluorescence. Fluorescein angiography showed combined hyper- and hypo-fluorescence compatible with window defect, staining and blockage. However, no leakage was appreciated in the macula, peripapillary, and peripheral lesions in both eyes. Optical coherence tomography scan showed septate hyporeflective intraretinal spaces in the right eye.

Conclusion and importance

The index report underscore the importance of considering alendronate as an etiologic cause of chorioretinitis, especially in subjects with atypical lesions developing after alendronate therapy. We, therefore, recommend discontinuation of this medication in subjects who develop chorioretinitis after employing this medication.

European guidance for the diagnosis and management of osteoporosis in postmenopausal women

Guidance is provided in a European setting on the assessment and treatment of postmenopausal women at risk from fractures due to osteoporosis.

INTRODUCTION

The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2013. This manuscript updates these in a European setting.

METHODS

Systematic reviews were updated.

RESULTS

The following areas are reviewed: the role of bone mineral density measurement for the diagnosis of osteoporosis and assessment of fracture risk; general and pharmacological management of osteoporosis; monitoring of treatment; assessment of fracture risk; case-finding strategies; investigation of patients; health economics of treatment. The update includes new information on the evaluation of bone microstructure evaluation in facture risk assessment, the role of FRAX® and Fracture Liaison Services in secondary fracture prevention, long-term effects on fracture risk of dietary intakes, and increased fracture risk on stopping drug treatment.

CONCLUSIONS

A platform is provided on which specific guidelines can be developed for national use.

Abaloparatide is an Effective Treatment Option for Postmenopausal Osteoporosis: Review of the Number Needed to Treat Compared with Teriparatide

Abaloparatide (ABL) is a 34-amino acid peptide designed to be a selective activator of the parathyroid hormone receptor type 1 signaling pathway. In the Abaloparatide Comparator Trial In Vertebral Endpoints (ACTIVE), subcutaneous ABL reduced the risk of new vertebral, nonvertebral, clinical, and major osteoporotic fracture compared with placebo and of major osteoporotic fracture compared with teriparatide. To further evaluate the effectiveness of ABL, we calculated the number needed to treat (NNT) to prevent one fracture using ACTIVE data. To estimate the potential effectiveness of ABL in populations at higher fracture risk than in ACTIVE, we calculated NNT for vertebral fracture using reference populations from historical placebo-controlled trials, assuming an 86% relative risk reduction in vertebral fracture with ABL treatment as observed in ACTIVE. NNT was calculated as the reciprocal of the absolute risk reduction in ACTIVE. The projected NNT for ABL in other populations was calculated based on incidence rate (IR) for vertebral fractures in the placebo arms of the FREEDOM (placebo IR 7.2%), FIT-1 (placebo IR 15.0%), and FIT-2 (placebo IR 3.8%) trials. NNT for ABL in ACTIVE was 28 for vertebral, 55 for nonvertebral, 37 for clinical, and 34 for major osteoporotic fracture. NNT for these fracture types for teriparatide in ACTIVE were 30, 92, 59, and 75, respectively. Using placebo IRs from FREEDOM, FIT-1, and FIT-2, projected NNTs for vertebral fracture with ABL were 17, 8, and 31. These data are useful for further evaluating ABL for the treatment of osteoporosis in postmenopausal women.

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.

Factors related to intentional non-initiation of bisphosphonate treatment in patients with a high fracture risk in primary care: a qualitative study

BACKGROUND

Adherence to osteoporosis treatment is crucial for good treatment effects. However, adherence has been shown to be poor and a substantial part of the patients don't even initiate treatment. This study aimed to gain insight into the considerations of both osteoporosis patients and general practitioners (GP) concerning intentional non-initiation of bisphosphonate treatment.

METHODS

Osteoporosis patients and GPs were recruited from the SALT Osteoporosis Study and a transmural fracture liaison service, both carried out in the Netherlands. Using questionnaires, we identified non-starters and starters of bisphosphonate treatment. Semi-structured interviews were conducted to gain a detailed overview of all considerations until saturation of the data was reached. Starters were asked to reflect on the considerations that were brought forward by the non-starters. Interviews were open coded and the codes were classified into main themes and subthemes using an inductive approach.

RESULTS

16 non-starters, 10 starters, and 13 GPs were interviewed. We identified three main themes: insufficient medical advice, attitudes towards medication use including concerns about side effects, and disease awareness. From patients' as well as GPs' perspective, insufficient or ambiguous information from the GP influenced the decision of the non-starters to not start bisphosphonates. In contrast, starters were either properly informed, or they collected information themselves. Patients' aversion towards medication, fear of side effects, and a low risk perception also contributed to not starting the medication, whereas starters were aware of their fracture risk and were confident of the outcome of the treatment. Concerns about osteoporosis treatment and its side effects were also expressed by several GPs. Some GPs appeared to have a limited understanding of the current osteoporosis guidelines and the indications for treatment.

CONCLUSIONS

Many reasons we found for not starting bisphosphonate treatment were related to the patients or the GPs themselves being insufficiently informed. Attitudes of the GPs were shown to play a role in the decision of patients not to start treatment. Interventions need to be developed that are aimed at GPs, and at education of patients.

THERAPY OF ENDOCRINE DISEASE: Denosumab vs bisphosphonates for the treatment of postmenopausal osteoporosis

The most widely used medications for the treatment of osteoporosis are currently bisphosphonates (BPs) and denosumab (Dmab). Both are antiresorptives, thus targeting the osteoclast and inhibiting bone resorption. Dmab achieves greater suppression of bone turnover and greater increases of bone mineral density (BMD) at all skeletal sites, both in naïve and pretreated patients. No superiority on fracture risk reduction has been documented so far. In long-term administration, BPs reach a plateau in BMD response after 2-3 years, especially at the hip, while BMD increases progressively for as long as Dmab is administered. Both BPs and Dmab are generally considered safe, although they have been correlated to rare adverse events, such as osteonecrosis of the jaw and atypical femoral fractures. Dmab should be preferred in patients with impaired renal function. BPs are embedded in the bone, from which they are slowly released during bone remodeling, therefore continuing to act for years after their discontinuation. In contrast, Dmab discontinuation fully and rapidly reverses its effects on bone markers and BMD and increases the risk for fractures; therefore, Dmab discontinuation should be discouraged, especially in previously treatment-naïve patients, regardless of the conventional fracture risk. In case of discontinuation, other treatment, mainly BPs, should immediately follow, although the optimal sequential treatment strategy is yet to be defined. Combination of teriparatide with Dmab or zoledronic acid, but not alendronate, provides increased BMD gains at all sites. In conclusion, both BPs and Dmab are safe and efficient therapeutic options although their particularities should be carefully considered in an individual basis.

Whole Body Vibration Exposure on Markers of Bone Turnover, Body Composition, and Physical Functioning in Breast Cancer Patients Receiving Aromatase Inhibitor Therapy: A Randomized Controlled Trial

Introduction: Women with breast cancer are often prescribed aromatase inhibitors, which can cause rapid loss of bone mass leading to significant potential for morbidity. Vibration training has been shown to be helpful in reducing bone turnover in postmenopausal women without cancer. Aim: To examine the effect of vibration stimulus on markers of bone turnover in breast cancer patients receiving aromatase inhibitors. Methods: Thirty-one breast cancer survivors undergoing treatment with aromatase inhibitors were randomized to vibration stimulus (n = 14) or usual care control (n = 17). Low-frequency and low-magnitude vibration stimulus (27-32 Hz, 0.3g) was delivered in supervised sessions via standing on a vibration platform for 20 minutes, 3 times per week for 12 weeks. The primary outcome was blood markers of bone resorption (serum N-telopeptide X/creatine) and formation (serum type 1 procollagen N-terminal propeptide; P1NP). Other study outcomes body composition as well as measures of physical functioning. Outcomes were compared between groups using analysis of covariance adjusted for baseline values as well as time on aromatase inhibitors. Outcomes: On average, participants were 61.5 years old and overweight (ie, body mass index = 28.5 kg/m²). Following vibration training, there was no significant difference between groups for bone resorption (adjusted group difference 0.5, P = .929) or formation (adjusted group difference 5.3, P = .286). There were also no changes in any measure of physical functioning body composition. Conclusions: Short-term low-magnitude vibration stimulus does not appear to be useful for reducing markers of bone turnover secondary to aromatase inhibitors in breast cancer patients; nor is it useful in improving physical function or symptoms. However, further investigations with larger samples and higher doses of vibration are warranted. Trial Registration: Australian and New Zealand Clinical Trials Registry (ACTRN12611001094965).

Cepharanthine Prevents Estrogen Deficiency-Induced Bone Loss by Inhibiting Bone Resorption

Osteoporosis is a common health problem worldwide caused by an imbalance of bone formation vs. bone resorption. However, current therapeutic approaches aimed at enhancing bone formation or suppressing bone resorption still have some limitations. In this study, we demonstrated for the first time that cepharanthine (CEP, derived from Stephania cepharantha Hayata) exerted a protective effect on estrogen deficiency-induced bone loss. This protective effect was confirmed to be achieved through inhibition of bone resorption in vivo, rather than through enhancement of bone formation in vivo. Furthermore, the in vitro study revealed that CEP attenuated receptor activator of nuclear factor κB ligand (RANKL)-induced osteoclast formation, and suppressed bone resorption by impairing the c-Jun N-terminal kinase (JNK) and phosphatidylinositol 3-kinase (PI3K)-AKT signaling pathways. The inhibitory effect of CEP could be partly reversed by treatment with anisomycin (a JNK and p38 agonist) and/or SC79 (an AKT agonist) in vitro. Our results thus indicated that CEP could prevent estrogen deficiency-induced bone loss by inhibiting osteoclastogenesis. Hence, CEP might be a novel therapeutic agent for anti-osteoporosis therapy.

Real-world evidence of raloxifene versus alendronate in preventing non-vertebral fractures in Japanese women with osteoporosis: retrospective analysis of a hospital claims database

We conducted a retrospective cohort study using a de-identified hospital administrative claims database to assess the risk of non-vertebral fracture in Japanese women with osteoporosis treated with raloxifene compared with alendronate. The study included Japanese women ≥50 years of age with newly initiated alendronate or raloxifene treatment between July 2008 and March 2013 (index date was defined as the day of first prescription for alendronate or raloxifene), and had any claim with an osteoporosis definition during the study period. A total of 37,056 patients in the database initiated treatment, and there were 4802 and 1250 patients included in the alendronate and raloxifene analysis groups, respectively. The mean observation period in the alendronate group (529.2 days) was significantly longer than that for the raloxifene group (473.5 days, P < 0.001). Non-vertebral fractures accumulated linearly, at a similar rate, for both study drugs: incidence at 1 year was 2.83 and 2.64% for the alendronate and raloxifene groups, respectively. For the relative risk of non-vertebral fracture within 1 year, the adjusted hazard ratio was 0.933 for raloxifene versus alendronate, indicating that the relative risk of non-vertebral fracture was similar for the two drugs. The effectiveness of raloxifene in preventing non-vertebral fractures in Japanese women with osteoporosis was similar to that of alendronate. Therefore, raloxifene may be worthy of consideration as an alternative treatment.

Effectiveness of anti-osteoporotic drugs to prevent secondary fragility fractures: systematic review and meta-analysis

Patients with osteoporotic fractures have an increased risk for secondary fractures. However, a rigorous study that assesses the effectiveness of individual osteoporotic drugs in preventing subsequent fractures is lacking. The purpose of this review was to analyze the effectiveness of anti-osteoporotic drugs in preventing secondary fractures. We searched for randomized controlled trials that showed the incidence of secondary fractures while using anti-osteoporotic drugs (bisphosphonates, selective estrogen receptor modulators, parathyroid hormone (PTH), or calcitonin) in MEDLINE, Embase.com , and Cochrane Central Register databases. We estimated risk ratios (RR) and numbers needed to treat (NNT) to prevent secondary fractures. Twenty-six studies met our eligibility criteria. There was a significant reduction in RR (0.38-0.77) after the use of anti-osteoporotic drugs for secondary vertebral fractures. Bisphosphonates and PTH significantly reduced the risk of a secondary non-vertebral fracture (RR 0.59 and 0.64). PTH needed the fewest number of patients to be treated to prevent a secondary vertebral fracture (NNT: 56). Our study demonstrated the effectiveness of anti-osteoporotic agents included in our systematic review in preventing secondary vertebral fractures. Bisphosphonates and PTH were most effective in preventing non-vertebral fractures. We suggest that clinicians should prescribe these drugs to prevent secondary vertebral/non-vertebral fractures.

β-Estradiol antagonizes the inhibitory effects of caffeine in BMMSCs via the ERβ-mediated cAMP-dependent PKA pathway

Caffeine negatively mediates bone homeostasis to cause bone loss and even osteoporosis. This phenomenon occurs in postmenopausal women with estrogen deficiency but not in healthy young women. In this study, we determined whether the effects of caffeine on bone homeostasis were antagonized by estrogen and the underlying mechanisms. In particular, because high levels of cAMP, an important second messenger, have been observed in postmenopausal women suffering from osteoporosis, we examined the role of cAMP in the effects of caffeine on bone homeostasis. In vivo study showed that caffeine accelerated bone loss in osteoporotic rats, whereas β-estradiol blunted the negative effect of caffeine on bone. In vitro study, we harvested bone marrow-derived mesenchymal stromal cells (BMMSCs) from osteoporotic rats. We found that caffeine and β-estradiol inversely affected BMMCSs proliferation, apoptosis, osteogenic lineage commitment, extracellular matrix synthesis and mineralization. These parameters were assessed according to the expression levels of osteogenic markers, alkaline phosphatase activity and Alizarin red staining. The deleterious effects of caffeine on BMMSCs were blunted by β-estradiol. The cAMP-dependent PKA pathway was found to be involved in regulating caffeine/β-estradiol-mediated cell growth, survival and osteogenesis. Additionally, after estrogen receptor (ER) β knockdown, the antagonistic effects of β-estradiol on caffeine were nearly abolished. These results indicated that by binding to ERβ, β-estradiol antagonizes the negative impacts of caffeine on cell growth and osteogenic differentiation in BMMSCs through the cAMP-dependent PKA signaling pathway.

Evaluating Atypical Features of Femur Fractures: How Change in Radiological Criteria Influenced Incidence and Demography of Atypical Femur Fractures in a Community Setting

Identification of atypical femoral fractures (AFFs) can be challenging. To assist in the radiological assessment, an American Society for Bone and Mineral Research (ASBMR) Task Force developed a case definition for AFFs in 2010, revising it in 2013. How the revised definition performs in a community setting compared with the 2010 definition is unknown. We applied the 2013 criteria to 372 femoral fractures that occurred between January 1, 1996, and June 30, 2009, employing two independent expert physician reviewers. We used radiographs that had been categorized in a previous study on the incidence of atypical fractures using 2010 ASMBR criteria (BEAK1). In this follow-up study (BEAK2), the same reviewers reviewed all previously identified femoral shaft fractures (FSFs) (n = 197) and distal femur fractures (n = 131) plus a 15% random sample of intertrochanteric fractures (n = 49). After initial review, agreement between the two reviewers ranged from 63% to 100% for specific features, and 84% of radiographs received the same overall classification. Fewer fractures met the 2013 compared with 2010 ASMBR case definition of AFFs (37 per 2013 criteria versus 74 per 2010 criteria). Forty-three radiographs (58%) categorized as AFFs according to 2010 criteria were no longer AFFs when 2013 criteria were applied, and an additional 12 non-atypical FSFs according to 2010 criteria were reclassified as AFFs according to 2013 criteria. The major cause of AFF reclassification was the change in the definition of transverse configuration. The modification of the comminution, non-traumatic, and periosteal/endosteal thickness criteria resulted in the reclassification of non-atypical FSFs to AFFs. Incidence rate of AFFs according to 2013 ASBMR criteria was lower overall during the 13 years of observation than when the 2010 ASBMR criteria were applied, although we saw a slight increase starting in 2000. As in BEAK1, we found that those with AFFs were younger, more often female, and had a higher exposure rate to bisphosphonates than those with non-atypical FSFs. As we continue to unravel the demographics of those who suffer from AFFs, our study adds information about how the change in criteria influences epidemiological work. © 2017 American Society for Bone and Mineral Research.

Addition of a fracture risk assessment to a coordinator's role improved treatment rates within 6 months of screening in a fragility fracture screening program

We evaluated the impact of a more intensive version of an existing post-fracture coordinator-based fracture prevention program and found that the addition of a full-risk assessment improved treatment rates. These findings provide additional support for more intensive programs aimed at reducing the risk of re-fractures.

INTRODUCTION

Evidence-based guidelines support coordinator-based programs to improve post-fracture osteoporosis guideline uptake, with more intensive programs including bone mineral density (BMD) testing and/or treatment being associated with better patient outcomes. The purpose of this study was to evaluate the impact of a more intensive version (BMD "fast track") of an existing provincial coordinator-based program.

METHODS

We compared two versions of the program that screened treatment naïve fragility fracture patients (>50 years). Cases came from the BMD fast track program that included full fracture risk assessment and communication of relevant guidelines to the primary care provider (PCP). Matched controls were selected from the usual care program matching according to age, sex, fracture type, and date. Two matching techniques were used: traditional (hard) matching (TM) and propensity score matching (PS). The outcomes were treatment initiation with bone sparing medication, BMD testing rate, and the rate of returning to discuss the test results with a PCP.

RESULTS

The program improvements led to a significant improvement in treatment initiation within 6 months from 16 % (controls based on PS) or 21 % (controls based on TM) to 32 % (cases). Ninety percent of patients in the BMD fast track program returned to their PCP to discuss bone health in the cases versus 60 % of the controls (for TM and PS). BMD testing occurred in 96 % of cases compared to the 66 (TM) or 65 % (PS) of the matched controls.

CONCLUSIONS

Addition of a full-risk assessment to a coordinator-based program significantly improved treatment rates within 6 months of screening.

Long-term hormone therapy for perimenopausal and postmenopausal women

BACKGROUND: Hormone therapy (HT) is widely provided for control of menopausal symptoms and has been used for the management and prevention of cardiovascular disease, osteoporosis and dementia in older women. This is an updated version of a Cochrane review first published in 2005. OBJECTIVES: To assess effects of long-term HT (at least 1 year's duration) on mortality, cardiovascular outcomes, cancer, gallbladder disease, fracture and cognition in perimenopausal and postmenopausal women during and after cessation of treatment. SEARCH METHODS: We searched the following databases to September 2016: Cochrane Gynaecology and Fertility Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and PsycINFO. We searched the registers of ongoing trials and reference lists provided in previous studies and systematic reviews. SELECTION CRITERIA: We included randomised double-blinded studies of HT versus placebo, taken for at least 1 year by perimenopausal or postmenopausal women. HT included oestrogens, with or without progestogens, via the oral, transdermal, subcutaneous or intranasal route. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, assessed risk of bias and extracted data. We calculated risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data, along with 95% confidence intervals (CIs). We assessed the quality of the evidence by using GRADE methods. MAIN RESULTS: We included 22 studies involving 43,637 women. We derived nearly 70% of the data from two well-conducted studies (HERS 1998; WHI 1998). Most participants were postmenopausal American women with at least some degree of comorbidity, and mean participant age in most studies was over 60 years. None of the studies focused on perimenopausal women.In relatively healthy postmenopausal women (i.e. generally fit, without overt disease), combined continuous HT increased the risk of a coronary event (after 1 year's use: from 2 per 1000 to between 3 and 7 per 1000), venous thromboembolism (after 1 year's use: from 2 per 1000 to between 4 and 11 per 1000), stroke (after 3 years' use: from 6 per 1000 to between 6 and 12 per 1000), breast cancer (after 5.6 years' use: from 19 per 1000 to between 20 and 30 per 1000), gallbladder disease (after 5.6 years' use: from 27 per 1000 to between 38 and 60 per 1000) and death from lung cancer (after 5.6 years' use plus 2.4 years' additional follow-up: from 5 per 1000 to between 6 and 13 per 1000).Oestrogen-only HT increased the risk of venous thromboembolism (after 1 to 2 years' use: from 2 per 1000 to 2 to 10 per 1000; after 7 years' use: from 16 per 1000 to 16 to 28 per 1000), stroke (after 7 years' use: from 24 per 1000 to between 25 and 40 per 1000) and gallbladder disease (after 7 years' use: from 27 per 1000 to between 38 and 60 per 1000) but reduced the risk of breast cancer (after 7 years' use: from 25 per 1000 to between 15 and 25 per 1000) and clinical fracture (after 7 years' use: from 141 per 1000 to between 92 and 113 per 1000) and did not increase the risk of coronary events at any follow-up time.Women over 65 years of age who were relatively healthy and taking continuous combined HT showed an increase in the incidence of dementia (after 4 years' use: from 9 per 1000 to 11 to 30 per 1000). Among women with cardiovascular disease, use of combined continuous HT significantly increased the risk of venous thromboembolism (at 1 year's use: from 3 per 1000 to between 3 and 29 per 1000). Women taking HT had a significantly decreased incidence of fracture with long-term use.Risk of fracture was the only outcome for which strong evidence showed clinical benefit derived from HT (after 5.6 years' use of combined HT: from 111 per 1000 to between 79 and 96 per 1000; after 7.1 years' use of oestrogen-only HT: from 141 per 1000 to between 92 and 113 per 1000). Researchers found no strong evidence that HT has a clinically meaningful impact on the incidence of colorectal cancer.One trial analysed subgroups of 2839 relatively healthy women 50 to 59 years of age who were taking combined continuous HT and 1637 who were taking oestrogen-only HT versus similar-sized placebo groups. The only significantly increased risk reported was for venous thromboembolism in women taking combined continuous HT: Their absolute risk remained low, at less than 1/500. However, other differences in risk cannot be excluded, as this study was not designed to have the power to detect differences between groups of women within 10 years of menopause.For most studies, risk of bias was low in most domains. The overall quality of evidence for the main comparisons was moderate. The main limitation in the quality of evidence was that only about 30% of women were 50 to 59 years old at baseline, which is the age at which women are most likely to consider HT for vasomotor symptoms. AUTHORS' CONCLUSIONS: Women with intolerable menopausal symptoms may wish to weigh the benefits of symptom relief against the small absolute risk of harm arising from short-term use of low-dose HT, provided they do not have specific contraindications. HT may be unsuitable for some women, including those at increased risk of cardiovascular disease, increased risk of thromboembolic disease (such as those with obesity or a history of venous thrombosis) or increased risk of some types of cancer (such as breast cancer, in women with a uterus). The risk of endometrial cancer among women with a uterus taking oestrogen-only HT is well documented.HT is not indicated for primary or secondary prevention of cardiovascular disease or dementia, nor for prevention of deterioration of cognitive function in postmenopausal women. Although HT is considered effective for the prevention of postmenopausal osteoporosis, it is generally recommended as an option only for women at significant risk for whom non-oestrogen therapies are unsuitable. Data are insufficient for assessment of the risk of long-term HT use in perimenopausal women and in postmenopausal women younger than 50 years of age.

How Can Osteoporosis Patients Benefit More from Their Therapy? Adherence Issues with Bisphosphonate Therapy

Objective:

To review the evidence on adherence with bisphosphonates and evolving dosing strategies for osteoporosis treatment.

Data Sources:

Articles were identified by searching MEDLINE (1975–December 2005) using the following terms: osteoporosis, postmenopausal, fracture, adherence, compliance, persistence, drug therapy, bisphosphonates, alendronate, risedronate, ibandronate, and zoledronate. Additional data included bibliographies from identified articles.

Study Selection and Data Extraction:

All pertinent English-language articles that discussed adherence issues in patients with osteoporosis were included. Both those that reviewed overall issues of medication adherence in osteoporosis and those that focused specifically on adherence to bisphosphonates were included, as were articles that addressed strategies for overcoming nonadherence.

Data Synthesis:

Inadequate diagnosis and treatment of osteoporosis result in a higher risk of fractures than is necessary. Even patients who are diagnosed and beginning treatment often do not persist with their osteoporosis medication because they perceive their fracture risk to be low and, given the asymptomatic nature of osteoporosis, do not experience the benefit of symptom reduction after taking the drugs. Factors that affect adherence to osteoporosis therapy include drug costs, adverse effects, dosing frequency, disease education, patient follow-up, and patient involvement in treatment decisions.

Conclusions:

By considering and implementing strategies that can improve adherence and persistence, primary care providers and pharmacists (via counseling) may enhance long-term outcomes for patients with osteoporosis.

The osteoporotic fracture prevention program in rural areas (OFRA): a protocol for a cluster-randomized health care fund driven intervention in a routine health care setting

Background

Fragility fractures are one of the leading causes for disability in old people. The main underlying mechanisms are osteoporosis and falls. Evidence-based measures to prevent either falls or fractures are available. However, coordinated preventive approaches combining bone health and fall prevention are rare.

The objective of the study is to evaluate a health care fund driven program, which encourages insured persons to adhere to national guidelines regarding bone health and physical activity and falls prevention. The health care fund cooperates with the ‘German Association of Rural Women’ and the ‘German Gymnastics Association’. The program consists of mobility and falls prevention classes, the examination of bone health by a DXA scan, and a consultation about ‘safety in the living environment’.

Methods

Cluster-randomized study in 47 intervention and 143 control districts in 5 federal states of Germany. The program is offered to a) community-living women and men aged 70 to <85 years with a prior fragility fracture or b) community-living women aged 75 to <80 years. Within two years more than 10,000 persons will be directly contacted and motivated to make use of the components of the program. The primary outcome is a combined measure of incident osteoporotic fractures. Secondary outcomes include the rate of referrals to a mobility and falls prevention class or a bone mass density measurement. An economic evaluation will be conducted.

Discussion

The study evaluates a complex preventive intervention in a routine health care setting which may serve as model for similar approaches in other areas or countries.

Trial registration

DRKS-ID: DRKS00009000; date of registration: 06.08.2015

Effects of whole body vibration on bone mineral density in postmenopausal women: a systematic review and meta-analysis

This systematic review and meta-analysis of randomized controlled trials (RCTs) identified significant effects of whole body vibration (WBV) on bone mineral density (BMD) of the lumbar spine (in the sensitivity analysis and seven subgroup analyses), femoral neck (in one subgroup analysis), and trochanter (four subgroup analyses) in postmenopausal women, but not other measurements of BMD.

INTRODUCTION

Interventions using WBV training have been conducted in postmenopausal women, aimed at increasing BMD; however, the results are contradictory. Our objective is to conduct a systematic review and meta-analysis of RCTs examining WBV effect on BMD.

METHODS

RCTs were considered eligible, with follow-up ≥6 months, which verified the effects of WBV on the BMD of postmenopausal women. The calculations of the meta-analysis were performed through the weighted mean difference between the WBV and control groups, or the WBV and combined training, through the absolute change between pre- and post-intervention in the areal bone mineral density (aBMD) or trabecular volumetric bone mineral density (vBMDt).

RESULTS

Fifteen RCTs were included in the meta-analysis. No differences were observed in the primary analysis. WBV was found to improve aBMD compared with the control group, after exclusion of studies with low quality methodological (lumbar spine), when excluding the studies which combined WBV with medication or combined training (lumbar spine), with the use of low frequency and high magnitude (lumbar spine and trochanter), high frequency and low magnitude (lumbar spine), high cumulative dose and low magnitude (lumbar spine), low cumulative dose and high magnitude (lumbar spine and trochanter), with semi-flexed knee (lumbar spine, femoral neck, and trochanter), and side-alternating type of vibration (lumbar spine and trochanter).

CONCLUSIONS

Despite WBV presenting potential to act as a coadjuvant in the prevention or treatment of osteoporosis, especially for aBMD of the lumbar spine, the ideal intervention is not yet clear. Our subgroup analyses helped to demonstrate the various factors which appear to influence the effects of WBV on BMD, contributing to clinical practice and the definition of protocols for future interventions.

Long-Term Use of Bisphosphonates in Osteoporosis

The rate of bone turnover increases around the time of menopause, and new bone may be remodeled before it is has been completely mineralized. If this is left untreated, osteoporosis often develops, leading to fractures, particularly of the spine and hip, which represent an enormous burden in terms of suffering, healthcare expenditure, disabilities and death. Bisphosphonates are potent inhibitors of bone resorption, which slow or arrest progressive bone loss. Continuous treatment with bisphosphonates reduces bone turnover, improves bone microarchitecture and increases bone mass, leading to greater mechanical strength and reduced fracture risk. Since osteoporosis is a chronic, progressive condition, treatment has to continue for many years. Therefore, the efficacy and safety of bisphosphonates, particularly alendronate and risedronate, have been evaluated in many thousands of patients for up to 10 years of continuous use. These drugs remain the cornerstone of osteoporosis treatment and appear to have favorable safety and efficacy profiles throughout long-term usage.

Osteoporosis drug effects on cortical and trabecular bone microstructure: a review of HR-pQCT analyses

With the development of new non-invasive analytical techniques and particularly the advent of high-resolution peripheral quantitative computed tomography (HRpQCT) it is possible to assess cortical and trabecular bone changes under the effects of ageing, diseases and treatments. In the present study, we reviewed the treatment-related effects on bone parameters assessed by HRpQCT imaging. We identified 12 full-length articles published in peer-reviewed journals describing treatment-induced changes assessed by HRpQCT. The design of these studies varied a lot in terms of duration and methodology: some of them were open-labelled, others were double-blind, placebo-controlled or double-blind, double-dummy, active controlled. In addition, the sample size in these studies ranged from 11 to 324 patients. Motion artifacts occurring during data acquisition were sometimes a real challenge particularly at the radius leading sometimes to exclude the analysis at the radius due to the uninterpretability of microstructural parameters. Responses to therapies were treatment-specific and divergent effects in cortical and trabecular bone with antiresorptive or anabolic agents were observed. Standardization of bone microarchitecture parameters (including porosity) and bone strength estimates by finite element analysis (FEA) are mandatory. The additional value of microarchitecture and FEA estimates changes with therapies in terms of improvement in fracture outcomes which have to be adequately assessed in clinical trials with fracture end point. Data from these reviewed studies advance our understanding of the microstructural consequences of osteoporosis and highlight potential differences in bone quality outcomes within therapies.

A randomised controlled trial of low-dose aspirin for the prevention of fractures in healthy older people: protocol for the ASPREE-Fracture substudy

BACKGROUND

Disability, mortality and healthcare burden from fractures in older people is a growing problem worldwide. Observational studies suggest that aspirin may reduce fracture risk. While these studies provide room for optimism, randomised controlled trials are needed. This paper describes the rationale and design of the ASPirin in Reducing Events in the Elderly (ASPREE)-Fracture substudy, which aims to determine whether daily low-dose aspirin decreases fracture risk in healthy older people.

METHODS

ASPREE is a double-blind, randomised, placebo-controlled primary prevention trial designed to assess whether daily active treatment using low-dose aspirin extends the duration of disability-free and dementia-free life in 19 000 healthy older people recruited from Australian and US community settings. This substudy extends the ASPREE trial data collection to determine the effect of daily low-dose aspirin on fracture and fall-related hospital presentation risk in the 16 500 ASPREE participants aged ≥70 years recruited in Australia. The intervention is a once daily dose of enteric-coated aspirin (100 mg) versus a matching placebo, randomised on a 1:1 basis. The primary outcome for this substudy is the occurrence of any fracture-vertebral, hip and non-vert-non-hip-occurring post randomisation. Fall-related hospital presentations are a secondary outcome.

DISCUSSION

This substudy will determine whether a widely available, simple and inexpensive health intervention-aspirin-reduces the risk of fractures in older Australians. If it is demonstrated to safely reduce the risk of fractures and serious falls, it is possible that aspirin might provide a means of fracture prevention.

TRIAL REGISTRATION NUMBER

The protocol for this substudy is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12615000347561).

The treatment of severe postmenopausal osteoporosis : a review of current and emerging therapeutic options

Several chemical entities have shown their ability to reduce axial and/or appendicular fractures in patients with osteoporosis. Since patients who have experienced a previous fracture are at high risk for subsequent vertebral or hip fracture, it is of prime importance to treat such patients with medications that have unequivocally demonstrated their ability to reduce fracture rates in patients with prevalent fractures. Results obtained with calcium and vitamin D, in this particular population, are not fully satisfactory and these medications are probably better used in conjunction with other therapeutic regimens. Bisphosphonates have shown their ability to reduce vertebral (alendronate, risedronate, ibandronate) and non-vertebral (alendronate, risedronate) fractures in patients with established osteoporosis. Raloxifene has also shown similar properties, notwithstanding its effect on non-vertebral fractures, which has only been derived from a post hoc analysis limited to patients with prevalent severe vertebral fractures at baseline. This compound also has interesting non-skeletal benefits, including effects on the breast and heart. Teriparatide, a bone-forming agent, promptly reduces the rate of vertebral and all non-vertebral fractures, without significant adverse effects. Strontium ranelate, the first agent shown to concomitantly decrease bone resorption and stimulate bone formation, has also shown its ability to reduce rates of vertebral and non-vertebral fractures in patients with established osteoporosis. It significantly reduces hip fractures in elderly individuals at high risk for such events. Its safety profile is also excellent.