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Ward LM. A practical guide to the diagnosis and management of osteoporosis in childhood and adolescence. Front Endocrinol (Lausanne) 2024; 14:1266986. [PMID: 38374961 PMCID: PMC10875302 DOI: 10.3389/fendo.2023.1266986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/18/2023] [Indexed: 02/21/2024] Open
Abstract
Osteoporosis in childhood distinguishes itself from adulthood in four important ways: 1) challenges in distinguishing otherwise healthy children who have experienced fractures due to non-accidental injury or misfortunate during sports and play from those with an underlying bone fragility condition; 2) a preponderance of monogenic "early onset" osteoporotic conditions that unveil themselves during the pediatric years; 3) the unique potential, in those with residual growth and transient bone health threats, to reclaim bone density, structure, and strength without bone-targeted therapy; and 4) the need to benchmark bone health metrics to constantly evolving "normal targets", given the changes in bone size, shape, and metabolism that take place from birth through late adolescence. On this background, the pediatric osteoporosis field has evolved considerably over the last few decades, giving rise to a deeper understanding of the discrete genes implicated in childhood-onset osteoporosis, the natural history of bone fragility in the chronic illness setting and associated risk factors, effective diagnostic and monitoring pathways in different disease contexts, the importance of timely identification of candidates for osteoporosis treatment, and the benefits of early (during growth) rather than late (post-epiphyseal fusion) treatment. While there has been considerable progress, a number of unmet needs remain, the most urgent of which is to move beyond the monotherapeutic anti-resorptive landscape to the study and application of anabolic agents that are anticipated to not only improve bone mineral density but also increase long bone cross-sectional diameter (periosteal circumference). The purpose of this review is to provide a practical guide to the diagnosis and management of osteoporosis in children presenting to the clinic with fragility fractures, one that serves as a step-by-step "how to" reference for clinicians in their routine clinical journey. The article also provides a sightline to the future, emphasizing the clinical scenarios with the most urgent need for an expanded toolbox of effective osteoporosis agents in childhood.
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Affiliation(s)
- Leanne M. Ward
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
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2
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Arora MK. Pediatric Osteoporosis. Indian J Orthop 2023; 57:225-229. [PMID: 38107818 PMCID: PMC10721774 DOI: 10.1007/s43465-023-01062-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 11/14/2023] [Indexed: 12/19/2023]
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3
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Soares MQS, Van Dessel J, Jacobs R, Ferreira GZ, da Silva Santos PS, Nicolielo LF, Duarte MAH, Rubira‐Bullen IRF. High doses of zoledronic acid induce differential effects on femur and jawbone microstructure. Clin Exp Dent Res 2022; 8:1487-1495. [PMID: 35933703 PMCID: PMC9760133 DOI: 10.1002/cre2.643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES The aim of this study is to investigate the long-term effects on jaw and femur bone induced by oncologic doses of zoledronic acid in a young rat model. MATERIAL AND METHODS Six 12-week-old male Wistar rats received zoledronic acid (0.6 mg/kg) and six control rats received saline solution in the same volume. Compounds were administered intraperitoneally in five doses every 28 days. Euthanasia was performed 150 days after therapy onset. After animal sacrifice, their mandibles and femurs were scanned ex vivo using a high-resolution (14 μm) micro-computed tomography. Morphometric bone parameters were calculated using CT-Analyzer (Bruker, Belgium) between the first and second mandibular molars and in the distal femur metaphysis and epiphysis. RESULTS The treatment group as compared to the controls showed a significantly (p < .05) increased bone quantity (↑BV/TV, ↓Po[Tot], ↑Tb.Th), bone density (↑TMD, ↑BMD), and osteosclerosis of the trabecular bone (↓Tb.Sp, ↓Conn.Dn, ↓Tb.Pf, ↓SMI) in all anatomical sites. Bone remodeling suppression due to zoledronic acid treatment was more pronounced (p < .05) in the femoral metaphysis relative to the mandible and epiphysis. The exploratory linear discriminant analysis showed that for the mandible, it was mainly the bone quantity-related morphometric indices (BV/TV and Tb.Th), while for the femoral epiphysis and metaphysis, it was bone structure-related (Tb.Pf and Tb.N), which are of primary importance to study the treatment effect. CONCLUSION High doses of bisphosphonates can differently affect the bone quantity, density, and structure in long bones and jawbones. In the metaphysis, bone changes were primarily concentrated in the region of the growth plate. Future studies may consider the use of bone morphometric indices to evaluate the effect of bisphosphonates.
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Affiliation(s)
- Mariana Q. S. Soares
- Department of Surgery, Stomatology, Pathology and Radiology, Bauru School of DentistryUniversity of São PauloBauruBrazil,OMFS‐IMPATH Research Group, Department of Imaging and PathologyFaculty of Medicine, KU Leuven and Oral and Maxillofacial Surgery, University Hospitals LeuvenLeuvenBelgium,Division of Oral RadiologyFaculdade São Leopoldo Mandic, Instituto de Pesquisa São Leopoldo MandicCampinasBrazil
| | - Jeroen Van Dessel
- Department of Surgery, Stomatology, Pathology and Radiology, Bauru School of DentistryUniversity of São PauloBauruBrazil,OMFS‐IMPATH Research Group, Department of Imaging and PathologyFaculty of Medicine, KU Leuven and Oral and Maxillofacial Surgery, University Hospitals LeuvenLeuvenBelgium
| | - Reinhilde Jacobs
- OMFS‐IMPATH Research Group, Department of Imaging and PathologyFaculty of Medicine, KU Leuven and Oral and Maxillofacial Surgery, University Hospitals LeuvenLeuvenBelgium,Department of Dental MedicineKarolinska InstitutetStockholmSweden
| | - Gustavo Z. Ferreira
- Department of Surgery, Stomatology, Pathology and Radiology, Bauru School of DentistryUniversity of São PauloBauruBrazil,Department of Surgery and Stomatology, School of DentistryUniversity Center of MaringáMaringáBrazil
| | - Paulo Sérgio da Silva Santos
- Department of Surgery, Stomatology, Pathology and Radiology, Bauru School of DentistryUniversity of São PauloBauruBrazil
| | - Laura F. P. Nicolielo
- OMFS‐IMPATH Research Group, Department of Imaging and PathologyFaculty of Medicine, KU Leuven and Oral and Maxillofacial Surgery, University Hospitals LeuvenLeuvenBelgium
| | - Marco A. H. Duarte
- Department of Dentistry, Endodontics and Dental Materials, Bauru School of DentistryUniversity of São PauloBauruBrazil
| | - Izabel R. F. Rubira‐Bullen
- Department of Surgery, Stomatology, Pathology and Radiology, Bauru School of DentistryUniversity of São PauloBauruBrazil
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Zhang Y, Hu J, Lin X, Sun L, Yan S, Zhang Q, Jiang Y, Wang O, Xia W, Xing X, Li M. Skeletal outcomes of patients with osteogenesis imperfecta during drug holiday of bisphosphonates: a real-world study. Front Endocrinol (Lausanne) 2022; 13:901925. [PMID: 36225201 PMCID: PMC9549175 DOI: 10.3389/fendo.2022.901925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/10/2022] [Indexed: 12/04/2022] Open
Abstract
PURPOSE This study aimed to investigate the skeletal outcomes of patients with osteogenesis imperfecta (OI) who received bisphosphonate (BP) treatment and entered drug holiday after achieving an age- and sex-specific bone mineral density (BMD) reference. METHODS Patients with OI receiving BP treatment were enrolled when they entered drug holidays of BPs. The skeletal outcomes were evaluated in detail during the drug holiday, including BMD, X-ray of the bone, bone fracture incidence, and bone turnover biomarkers. The pathogenic mutations of OI were identified by next-generation sequencing and confirmed by Sanger sequencing. RESULTS A total of 149 OI patients (127 juveniles and 22 adults) who entered drug holidays after nearly 4 years of BP treatment were included. Areal BMD at the lumbar spine increased from 0.934 ± 0.151 to 0.990 ± 0.142 g/cm2 and was stable in the second (1.029 ± 0.176 g/cm2) and third years (1.023 ± 0.174 g/cm2) of BP drug holidays, and BMD at the femoral neck, trochanter, and total hip had no significant change, but it was gradually inferior to that of the same-gender juveniles in the second and third years of the drug holiday. BMD at the lumbar spine and proximal hip did not change and was inferior to that of the same-gender adults. The average time of fractures fluctuated from 0.18 to 0.08 per year in juveniles, while only one adult suffered from a fracture during BP drug holidays. Bone turnover markers were in the normal range, except for a mildly high level of β-carboxy-terminal cross-linked telopeptide of type 1 collagen in the juvenile group. A total of 17 (11.4%) patients received BP retreatment because of bone loss during the drug holiday. OI type III and type IV and COL1A2 mutation were correlated to a longer duration of BP treatment to enter drug holidays (all p < 0.05). Old age at initial treatment (OR, 1.056) and OI type III (OR, 10.880) were correlated to a higher risk of BP retreatment. CONCLUSIONS OI patients will undergo nearly 4 years of BP treatment to achieve drug holidays. During the 3 years of the drug holiday, the patients' BMD is stable, and fracture incidence does not increase significantly. Patients are more inclined to need retreatment during drug holidays owing to the late start of BP treatment and more severe OI phenotypes.
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Affiliation(s)
- Yongze Zhang
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
- Department of Endocrinology, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jing Hu
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Xiaoyun Lin
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Lei Sun
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Sunjie Yan
- Department of Endocrinology, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Qian Zhang
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Yan Jiang
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Ou Wang
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Weibo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Xiaoping Xing
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Mei Li
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
- *Correspondence: Mei Li,
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Abstract
Osteogenesis imperfecta (OI) is a disease characterised by altered bone tissue material properties together with abnormal micro and macro-architecture and thus bone fragility, increased bone turnover and hyperosteocytosis. Increasingly appreciated are the soft tissue changes, sarcopenia in particular. Approaches to treatment are now multidisciplinary, with bisphosphonates having been the primary pharmacological intervention over the last 20 years. Whilst meta-analyses suggest that anti-fracture efficacy across the life course is equivocal, there is good evidence that for children bisphosphonates reduce fracture risk, increase vertebral size and improve vertebral shape, as well as improving motor function and mobility. The genetics of OI continues to provide insights into the molecular pathogenesis of the disease, although the pathophysiology is less clear. The complexity of the multi-scale interactions of bone tissue with cellular function are gradually being disentangled, but the fundamental question of why increased tissue brittleness should be associated with so many other changes is unclear; ER stress, pro-inflammatory cytokines, accelerated senesence and altered matrix component release might all contribute, but a unifying hypothesis remains elusive. New approaches to therapy are focussed on increasing bone mass, following the paradigm established by the treatment of postmenopausal osteoporosis. For adults, this brings the prospect of restoring previously lost bone - for children, particularly at the severe end of the spectrum, the possibility of further reducing fracture frequency and possibly altering growth and long term function are attractive. The alternatives that might affect tissue brittleness are autophagy enhancement (through the removal of abnormal type I collagen aggregates) and stem cell transplantation - both still at the preclinical stage of assessment. Preclinical assessment is not supportive of targeting inflammatory pathways, although understanding why TGFb signalling is increased, and whether that presents a treatment target in OI, remains to be established.
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Affiliation(s)
- Fawaz Arshad
- Academic Unit of Child Health, Sheffield Children's Hospital, Department of Oncology and Metabolism, University of Sheffield, S10 2TH, UK
| | - Nick Bishop
- Academic Unit of Child Health, Sheffield Children's Hospital, Department of Oncology and Metabolism, University of Sheffield, S10 2TH, UK.
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6
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Zhou W, van Rooij JGJ, Ebeling PR, Verkerk AJMH, Zillikens MC. The Genetics of Atypical Femur Fractures-a Systematic Review. Curr Osteoporos Rep 2021; 19:123-130. [PMID: 33587247 PMCID: PMC8016774 DOI: 10.1007/s11914-021-00658-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Atypical femur fractures (AFFs) are rare subtrochanteric or diaphyseal fractures regarded as side effects of bisphosphonates (BPs), possibly with a genetic background. Here, we summarize the most recent knowledge about genetics of AFFs. RECENT FINDINGS AFF has been reported in 57 patients with seven different monogenic bone disorders including hypophosphatasia and osteogenesis imperfecta; 56.1% had never used BPs, while 17.5% were diagnosed with the disorder only after the AFF. Gene mutation finding in familial and sporadic cases identified possible AFF-related variants in the GGPS1 and ATRAID genes respectively. Functional follow-up studies of mutant proteins showed possible roles in AFF. A recent small genome-wide association study on 51 AFF cases did not identify significant hits associated with AFF. Recent findings have strengthened the hypothesis that AFFs have underlying genetic components but more studies are needed in AFF families and larger cohorts of sporadic cases to confirm previous results and/or find novel gene variants involved in the pathogenesis of AFFs.
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Affiliation(s)
- Wei Zhou
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeroen G J van Rooij
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Neurology & Alzheimer Center, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Australia
| | - Annemieke J M H Verkerk
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - M Carola Zillikens
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
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7
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Sakka SD, Cheung MS. Management of primary and secondary osteoporosis in children. Ther Adv Musculoskelet Dis 2020; 12:1759720X20969262. [PMID: 33224280 PMCID: PMC7649886 DOI: 10.1177/1759720x20969262] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 10/05/2020] [Indexed: 12/13/2022] Open
Abstract
Osteoporosis in children differs from adults in terms of definition, diagnosis, monitoring and treatment options. Primary osteoporosis comprises primarily of osteogenesis imperfecta (OI), but there are significant other causes of bone fragility in children that require treatment. Secondary osteoporosis can be a result of muscle disuse, iatrogenic causes, such as steroids, chronic inflammation, delayed or arrested puberty and thalassaemia major. Investigations involve bone biochemistry, dual-energy X-ray absorptiometry scan for bone densitometry and vertebral fracture assessment, radiographic assessment of the spine and, in some cases, quantitative computed tomography (QCT) or peripheral QCT. It is important that bone mineral density (BMD) results are adjusted based on age, gender and height, in order to reflect size corrections in children. Genetics are being used increasingly for the diagnosis and classification of various cases of primary osteoporosis. Bone turnover markers are used less frequently in children, but can be helpful in monitoring treatment and transiliac bone biopsy can assist in the diagnosis of atypical cases of osteoporosis. The management of children with osteoporosis requires a multidisciplinary team of health professionals with expertise in paediatric bone disease. The prevention and treatment of fragility fractures and improvement of the quality of life of patients are important aims of a specialised service. The drugs used most commonly in children are bisphosphonates, that, with timely treatment, can give good results in improving BMD and reshaping vertebral fractures. The data regarding their effect on reducing long bone fractures are equivocal. Denosumab is being used increasingly for various conditions with mixed results. There are more drugs trialled in adults, but these are not yet licenced for children. Increasing awareness of risk factors for paediatric osteoporosis, screening and referral to a specialist team for appropriate management can lead to early detection and treatment of asymptomatic fractures and prevention of further bone damage.
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Affiliation(s)
- Sophia D Sakka
- Department of Endocrinology and Diabetes, Evelina London Children's Hospital, 3rd Floor, Becket House, Westminster Bridge Road, SE1 7EH, London, UK
| | - Moira S Cheung
- Department of Endocrinology and Diabetes, Evelina London Children's Hospital, London, UK
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8
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Affiliation(s)
- Emily Kraus
- Department of Orthopaedic Surgery (E.K.) and Division of Endocrinology, Department of Pediatrics (L.K.B. and M.G.), Stanford University School of Medicine, Stanford, California
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Simm PJ, Biggin A, Zacharin MR, Rodda CP, Tham E, Siafarikas A, Jefferies C, Hofman PL, Jensen DE, Woodhead H, Brown J, Wheeler BJ, Brookes D, Lafferty A, Munns CF. Consensus guidelines on the use of bisphosphonate therapy in children and adolescents. J Paediatr Child Health 2018; 54:223-233. [PMID: 29504223 DOI: 10.1111/jpc.13768] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 07/28/2017] [Accepted: 08/17/2017] [Indexed: 12/21/2022]
Abstract
Bisphosphonate therapy is the mainstay of pharmacological intervention in young people with skeletal fragility. The evidence of its use in a variety of conditions remains limited despite over three decades of clinical experience. On behalf of the Australasian Paediatric Endocrine Group, this evidence-based consensus guideline presents recommendations and discusses the graded evidence (using the GRADE system) for these recommendations. Primary bone fragility disorders such as osteogenesis imperfecta are considered separately from osteoporosis secondary to other clinical conditions (such as cerebral palsy, Duchenne muscular dystrophy). The use of bisphosphonates in non-fragility conditions, such as fibrous dysplasia, avascular necrosis, bone cysts and hypercalcaemia, is also discussed. While these guidelines provide an evidence-based approach where possible, further research is required in all clinical applications in order to strengthen the recommendations made.
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Affiliation(s)
- Peter J Simm
- Department of Endocrinology and Diabetes, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Biggin
- Institute of Endocrinology and Diabetes, Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
| | - Margaret R Zacharin
- Department of Endocrinology and Diabetes, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Christine P Rodda
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Australian Institute for Musculoskeletal Research, Sunshine Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Sunshine Hospital, Melbourne, Victoria, Australia
| | - Elaine Tham
- Department of Endocrinology and Diabetes, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Aris Siafarikas
- Department of Endocrinology and Diabetes, Princess Margaret Hospital, Perth, Western Australia, Australia.,School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia.,Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia.,Institute for Health Research, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Craig Jefferies
- Department of Endocrinology and Diabetes, Starship Children's Health, Auckland, New Zealand
| | - Paul L Hofman
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Diane E Jensen
- Children's Health Queensland, Hospital and Health Services District, South Brisbane, Queensland, Australia.,Centre for Children's Health Research, University of Queensland, Brisbane, Queensland, Australia
| | - Helen Woodhead
- Department of Endocrinology and Diabetes, Sydney Children's Hospital, Sydney, New South Wales, Australia.,Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Justin Brown
- Department of Paediatric Endocrinology, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Benjamin J Wheeler
- Women's and Children's Health, University of Otago, Dunedin, New Zealand
| | - Denise Brookes
- Centre for Children's Health Research, University of Queensland, Brisbane, Queensland, Australia
| | - Antony Lafferty
- Department of Paediatrics, Canberra Hospital, Canberra, Australian Capital Territory, Australia.,Department of Paediatrics and Child Health, Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - Craig F Munns
- Institute of Endocrinology and Diabetes, Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
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10
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Abstract
Osteogenesis imperfecta (OI) is the most common inherited form of bone fragility and includes a heterogenous group of genetic disorders which most commonly result from defects associated with type 1 collagen. 85%-90% of cases are inherited in an autosomal dominant manner and are caused by mutations in the COL1A1 and COL1A2 genes, leading to quantitative or qualitative defects in type 1 collagen. In the last decade, defects in several other proteins involved in the normal processing of type 1 collagen have been described. Recent advances in genetics have called for reconsideration of the classification of OI, however, most recent classifications align with the classic clinical classification by Sillence. The hallmark of the disease is bone fragility but other tissues are also affected. Intravenous bisphosphonates (BPs) are the most widely used intervention, having significant favorable effects regarding areal bone mineral density (BMD) and vertebral reshaping following fractures in growing children. BPs have a modest effect in long bone fracture incidence, their effects in adults with OI concerns only BMD, while there are reports of subtrochanteric fractures resembling atypical femoral fractures. Other therapies showing promising results include denosumab, teriparatide, sclerostin inhibition, combination therapy with antiresorptive and anabolic drugs and TGF-β inhibition. Gene targeting approaches are under evaluation. More research is needed to delineate the best therapeutic approach in this heterogeneous disease.
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Affiliation(s)
- Symeon Tournis
- Laboratory for Research of the Musculoskeletal System 'Th. Garofalidis', KAT Hospital, University of Athens, Athens, Greece.
| | - Anastasia D Dede
- Laboratory for Research of the Musculoskeletal System 'Th. Garofalidis', KAT Hospital, University of Athens, Athens, Greece; Department of Endocrinology and Diabetes, Chelsea and Westminster Hospital, London, UK
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11
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Uday S, Gaston CL, Rogers L, Parry M, Joffe J, Pearson J, Sutton D, Grimer R, Högler W. Osteonecrosis of the Jaw and Rebound Hypercalcemia in Young People Treated With Denosumab for Giant Cell Tumor of Bone. J Clin Endocrinol Metab 2018; 103:596-603. [PMID: 29211870 DOI: 10.1210/jc.2017-02025] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 11/28/2017] [Indexed: 11/19/2022]
Abstract
CONTEXT Denosumab, an inhibitor of receptor activator of nuclear factor κ-B ligand, is an approved treatment of giant cell tumor of bone (GCTB) in adults and "skeletally mature" adolescents. Safety concerns include oversuppression of bone remodelling, with risk of osteonecrosis of the jaw (ONJ) and atypical femur fractures during treatment in adults and rebound hypercalcemia after treatment cessation in children. To date, ONJ has never been reported in children or adolescents. OBJECTIVES To describe serious adverse effects during and following high-dose denosumab therapy in GCTB patients. PATIENTS Two adolescents (14 and 15 years) and a young adult (40 years) received fixed-dose denosumab for GCTB for 1.3 to 4 years (cumulative dose, 47 to 98 mg/kg), which was stopped because of development of ONJ in one adolescent and bilateral femoral cortical stress reactions in the young adult. All three patients developed rebound hypercalcemia with acute kidney injury 5.5 to 7 months after denosumab cessation. RESULTS The ONJ necessitated surgical debridement. Rebound hypercalcemia (serum calcium, 3.1 to 4.3 mmol/L) was unresponsive to hyperhydration alone, requiring repeated doses of calcitonin or intravenous bisphosphonate treatment. Hypercalcemia recurred in two patients within 4 weeks, with normal serum calcium profiles thereafter. All patients were naive to chemotherapy, radiotherapy, bisphosphonates, and corticosteroids and were metastases free, confirming the causative role of denosumab in these complications. CONCLUSION These suppression-release effects of high-dose denosumab on bone remodeling raise questions about safety of fixed dosing and treatment duration. In young people, weight-adjusted dosing and safety monitoring during and after antiresorptive therapy is required.
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Affiliation(s)
- Suma Uday
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, West Midlands B4 6NH, United Kingdom
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Czar Louie Gaston
- Department of Orthopaedics, Philippine General Hospital, 1000 Manila, Philippines
| | - Luke Rogers
- Department of Medical Oncology, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield HX3 0PW, United Kingdom
| | - Michael Parry
- Department of Orthopaedic Oncology, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham B31 2AP, United Kingdom
| | - Johnathan Joffe
- Department of Medical Oncology, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield HX3 0PW, United Kingdom
| | - John Pearson
- Department of Maxillofacial Surgery, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield HD3 3EA, United Kingdom
| | - David Sutton
- Department of Maxillofacial Surgery, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield HD3 3EA, United Kingdom
| | - Robert Grimer
- Department of Orthopaedic Oncology, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham B31 2AP, United Kingdom
| | - Wolfgang Högler
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, West Midlands B4 6NH, United Kingdom
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
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12
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Bacon S, Crowley R. Developments in rare bone diseases and mineral disorders. Ther Adv Chronic Dis 2018; 9:51-60. [PMID: 29344330 PMCID: PMC5761943 DOI: 10.1177/2040622317739538] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 10/04/2017] [Indexed: 12/16/2022] Open
Abstract
In the last decade, there have been a number of significant advances made in the field of rare bone diseases. In this review, we discuss the expansion of the classification system for osteogenesis imperfecta (OI) and the resultant increase in therapeutic options available for management of OI. Bisphosphonates remain the most widely used intervention for OI, although the effect on fracture rate reduction is equivocal. We review the other therapies showing promising results, including denosumab, teriparatide, sclerostin, transforming growth factor β inhibition and gene targeted approaches. X-linked hypophosphataemia (XLH) is the most common heritable form of osteomalacia and rickets caused by a mutation in the phosphate regulating endopeptidase gene resulting in elevated serum fibroblast growth factor 23 (FGF23) and decreased renal phosphate reabsorption. The traditional treatment is phosphate replacement. We discuss the development of a human anti-FGF23 antibody (KRN23) as a promising development in the treatment of XLH. The current management of primary hypoparathyroidism is replacement with calcium and active vitamin D. This can be associated with under or over replacement and its inherent complications. We review the use of recombinant parathyroid hormone (1-84), which can significantly reduce the requirements for calcium and vitamin D resulting in greater safety and quality of life for individuals with hypoparathyroidism. The use of receptor activator of nuclear factor κB ligand infusions in the treatment of a particular form of osteopetrosis and enzyme replacement therapy for hypophosphatasia are also discussed.
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Tan JY, Seow CJ. Management of atypical femoral fracture in a patient with osteogenesis imperfecta. BMJ Case Rep 2017; 2017:bcr-2017-221835. [PMID: 29269360 DOI: 10.1136/bcr-2017-221835] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Osteogenesis imperfecta (OI) is a generalised connective tissue disorder associated with low bone mass, bone fragility and increased susceptibility to fractures. First-line treatment to improve bone mineral density (BMD) is usually with bisphosphonates but long-term usage has been associated with uncommon complications such as atypical femoral fractures (AFF). Treatment with teriparatide in this situation has been reported with positive outcomes. However, choice of treatment after 2 years of teriparatide has not been well studied or reported. We describe a patient with OI treated with bisphosphonates for 9 years, who then suffered a spontaneous AFF, was subsequently started on teriparatide for 2 years followed by 6 monthly Denosumab. 1 year post-treatment with Denosumab, there was significant improvement in BMD, good fracture healing and no new fractures. This case highlights the potential use of denosumab following 2 years of teriparatide treatment in patients with OI with AFF.
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Affiliation(s)
- Jing Yuan Tan
- Endocrinology, National University Singapore Yong Loo Lin School of Medicine, Singapore, Singapore
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Abstract
PURPOSE OF REVIEW Here we summarize the diagnosis of osteogenesis imperfecta, discuss newly discovered genes involved in osteogenesis imperfecta, and review the management of this disease in children and adults. RECENT FINDINGS Mutations in the two genes coding for collagen type I, COL1A1 and COL1A2, are the most common cause of osteogenesis imperfecta. In the past 10 years, defects in at least 17 other genes have been identified as responsible for osteogenesis imperfecta phenotypes, with either dominant or recessive transmission. Intravenous bisphosphonate infusions are the most widely used medical treatment. This has a marked effect on vertebra in growing children and can lead to vertebral reshaping after compression fractures. However, bisphosphonates are less effective for preventing long-bone fractures. At the moment, new therapies are under investigation. SUMMARY Despite advances in the diagnosis and treatment of osteogenesis imperfecta, more research is needed. Bisphosphonate treatment decreases long-bone fracture rates, but such fractures are still frequent. New antiresorptive and anabolic agents are being investigated but efficacy and safety of these drugs, especially in children, need to be better established before they can be used in clinical practice.
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Affiliation(s)
- Telma Palomo
- aBone and Mineral Unit, Division of Endocrinology, Universidade Federal de São Paulo, Brazil bAcademic Unit of Bone Metabolism, University of Sheffield, Sheffield, United Kingdom
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