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Händel MN, Cardoso I, von Bülow C, Rohde JF, Ussing A, Nielsen SM, Christensen R, Body JJ, Brandi ML, Diez-Perez A, Hadji P, Javaid MK, Lems WF, Nogues X, Roux C, Minisola S, Kurth A, Thomas T, Prieto-Alhambra D, Ferrari SL, Langdahl B, Abrahamsen B. Fracture risk reduction and safety by osteoporosis treatment compared with placebo or active comparator in postmenopausal women: systematic review, network meta-analysis, and meta-regression analysis of randomised clinical trials. BMJ 2023; 381:e068033. [PMID: 37130601 PMCID: PMC10152340 DOI: 10.1136/bmj-2021-068033] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVE To review the comparative effectiveness of osteoporosis treatments, including the bone anabolic agents, abaloparatide and romosozumab, on reducing the risk of fractures in postmenopausal women, and to characterise the effect of antiosteoporosis drug treatments on the risk of fractures according to baseline risk factors. DESIGN Systematic review, network meta-analysis, and meta-regression analysis of randomised clinical trials. DATA SOURCES Medline, Embase, and Cochrane Library to identify randomised controlled trials published between 1 January 1996 and 24 November 2021 that examined the effect of bisphosphonates, denosumab, selective oestrogen receptor modulators, parathyroid hormone receptor agonists, and romosozumab compared with placebo or active comparator. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials that included non-Asian postmenopausal women with no restriction on age, when interventions looked at bone quality in a broad perspective. The primary outcome was clinical fractures. Secondary outcomes were vertebral, non-vertebral, hip, and major osteoporotic fractures, all cause mortality, adverse events, and serious cardiovascular adverse events. RESULTS The results were based on 69 trials (>80 000 patients). For clinical fractures, synthesis of the results showed a protective effect of bisphosphonates, parathyroid hormone receptor agonists, and romosozumab compared with placebo. Compared with parathyroid hormone receptor agonists, bisphosphonates were less effective in reducing clinical fractures (odds ratio 1.49, 95% confidence interval 1.12 to 2.00). Compared with parathyroid hormone receptor agonists and romosozumab, denosumab was less effective in reducing clinical fractures (odds ratio 1.85, 1.18 to 2.92 for denosumab v parathyroid hormone receptor agonists and 1.56, 1.02 to 2.39 for denosumab v romosozumab). An effect of all treatments on vertebral fractures compared with placebo was found. In the active treatment comparisons, denosumab, parathyroid hormone receptor agonists, and romosozumab were more effective than oral bisphosphonates in preventing vertebral fractures. The effect of all treatments was unaffected by baseline risk indicators, except for antiresorptive treatments that showed a greater reduction of clinical fractures compared with placebo with increasing mean age (number of studies=17; β=0.98, 95% confidence interval 0.96 to 0.99). No harm outcomes were seen. The certainty in the effect estimates was moderate to low for all individual outcomes, mainly because of limitations in reporting, nominally indicating a serious risk of bias and imprecision. CONCLUSIONS The evidence indicated a benefit of a range of treatments for osteoporosis in postmenopausal women for clinical and vertebral fractures. Bone anabolic treatments were more effective than bisphosphonates in the prevention of clinical and vertebral fractures, irrespective of baseline risk indicators. Hence this analysis provided no clinical evidence for restricting the use of anabolic treatment to patients with a very high risk of fractures. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019128391.
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Affiliation(s)
- Mina Nicole Händel
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
- Department of Clinical Research, Odense Patient Data Explorative Network, University of Southern Denmark, Odense, Denmark
| | - Isabel Cardoso
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
| | - Cecilie von Bülow
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
- Occupational Science, User Perspectives and Community-Based Interventions, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Jeanett Friis Rohde
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
| | - Anja Ussing
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
| | - Sabrina Mai Nielsen
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Robin Christensen
- Parker Institute, Bispebjerg and Frederiksberg Hospital, 2000 Frederiksberg, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Adolfo Diez-Perez
- Department of Internal Medicine, Institut Hospital del Mar of Medical Investigation, Autonomous University of Barcelona and CIBERFES (Frailty and Healthy Aging Research Network), Instituto Carlos III, Barcelona, Spain
| | - Peyman Hadji
- Frankfurt Centre of Bone Health, Frankfurt and Philipps-University of Marburg, Marburg, Germany
| | - Muhammad Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Xavier Nogues
- IMIM (Hospital del Mar Medical Research Institute), Parc de Salut Mar, Pompeu Fabra University, Barcelona, Spain
| | - Christian Roux
- INSERM U 1153, Hospital Paris-Centre, University of Paris, Paris, France
| | - Salvatore Minisola
- Department of Clinical, Internal, Anaesthesiologic, and Cardiovascular Sciences, Rome University, Rome, Italy
| | - Andreas Kurth
- Department of Orthopaedic and Trauma Surgery, Marienhaus Klinikum Mainz, Major Teaching Hospital, University Medicine Mainz, Mainz, Germany
| | - Thierry Thomas
- Université Jean Monnet Saint-Étienne, CHU de Saint-Etienne, Rheumatology Department, INSERM U1059, F-42023, Saint-Etienne, France
| | - Daniel Prieto-Alhambra
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Bente Langdahl
- Departments of Clinical Medicine and of Endocrinology and Internal Medicine, Aarhus University, Aarhus, Denmark
| | - Bo Abrahamsen
- Department of Clinical Research, Odense Patient Data Explorative Network, University of Southern Denmark, Odense, Denmark
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
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Medical optimization of osteoporosis for adult spinal deformity surgery: a state-of-the-art evidence-based review of current pharmacotherapy. Spine Deform 2022; 11:579-596. [PMID: 36454531 DOI: 10.1007/s43390-022-00621-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 11/19/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE Osteoporosis is a common, but challenging phenomenon to overcome in adult spinal deformity (ASD) surgery. Several pharmacological agents are at the surgeon's disposal to optimize the osteoporotic patient prior to undergoing extensive reconstruction. Familiarity with these medications will allow the surgeon to make informed decisions on selecting the most appropriate adjuncts for each individual patient. METHODS A comprehensive literature review was conducted in PubMed from September 2021 to April 2022. Studies were selected that contained combinations of various terms including osteoporosis, specific medications, spine surgery, fusion, cage subsidence, screw loosening, pull-out, junctional kyphosis/failure. RESULTS Bisphosphonates, denosumab, selective estrogen receptor modulators, teriparatide, abaloparatide and romosozumab are all pharmacological agents currently available for adjunctive use. While these medications have been shown to have beneficial effects on improving bone mineral density in the osteoporotic patient, varying evidence is available on their specific effects in the context of extensive spine surgery. There is still a lack of human studies with use of the newer agents. CONCLUSION Bisphosphonates are first-line agents due to their low cost and robust evidence behind their utility. However, in the absence of contraindications, optimizing bone quality with anabolic medications should be strongly considered in preparation for spinal deformity surgeries due to their beneficial and favorable effects on fusion and hardware compared to the anti-resorptive medications.
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Tsourdi E, Drake MT. Pros and Cons of Skeletal Medications in the COVID-19 Era. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2022; 8:56-69. [PMID: 35875832 PMCID: PMC9287705 DOI: 10.1007/s40674-022-00192-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 11/29/2022]
Abstract
Purpose of Review This review provides an overview regarding osteoporosis therapies during the COVID-19 pandemic. Recent Findings The COVID-19 pandemic has disrupted treatments for osteoporosis and resulted in decreased adherence particularly for parenteral regimens. Osteoporosis medications are safe and effective during the pandemic and should be continued whenever possible. Bisphosphonates have long-lasting effects on bone turnover such that delays in their administration are unlikely to be harmful to skeletal health. In contrast, interruption of denosumab treatment is strongly discouraged because of rapid loss of bone mass and an associated increased risk for rebound vertebral fractures. When osteoanabolic treatments cannot be continued during the pandemic, change to an oral bisphosphonate is advised. Preclinical data suggest possible beneficial effects of some therapies against COVID-19, but require validation in clinical studies. Vitamin D deficiency is associated with a more severe COVID-19 clinical course but data supporting improvements in outcomes with vitamin D supplementation are lacking. Summary The impact of the COVID-19 pandemic on long-term bone health remains unknown but focused interventions to ensure osteoporosis treatment initiation/maintenance should be implemented. Future studies are needed to determine whether osteoporosis medications have an impact on SARS-CoV-2 pathophysiology and COVID-19 clinical outcomes.
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Affiliation(s)
- Elena Tsourdi
- Department of Medicine III, Universitätsklinikum Dresden, Dresden, Germany
- Center for Healthy Aging, Universitätsklinikum Dresden, Dresden, Germany
| | - Matthew T. Drake
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN USA
- Division of Endocrinology and Robert and Arlene Kogod Center On Aging, Mayo Clinic College of Medicine, Rochester, MN 55905 USA
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4
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Jahan N, Jones C, Rahman RL. Endocrine prevention of breast cancer. Mol Cell Endocrinol 2021; 530:111284. [PMID: 33882282 DOI: 10.1016/j.mce.2021.111284] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/04/2021] [Accepted: 04/12/2021] [Indexed: 01/01/2023]
Abstract
Breast cancer (BC) is the most common non-cutaneous malignancy among women worldwide and is a significant cause of morbidity, mortality, and national health care expenditure. Unfortunately, with few exceptions like alcohol consumption, obesity, and physical activity, most BC risk factors are unmodifiable. Antiestrogen endocrine therapy, commonly known as BC chemoprevention, is an effective method of BC prevention. In multiple randomized trials, two selective estrogen receptor modulators - tamoxifen and raloxifene, and two aromatase inhibitors - exemestane and anastrozole have reduced BC incidence by 50%-65% in high-risk women. An estimated 15% of the US women between 35 and 79 years of age may qualify as high risk for BC, yet a small percentage of these women will ever have a formal BC risk assessment or a discussion of endocrine prevention options. The etiology of underutilization of endocrine prevention of BC is multifactorial - infrequent use of BC risk assessment tools in the primary care settings, insufficient knowledge of BC risk assessment tools and antiestrogen agents among primary care providers, concerns of side effects, inadequate time for counseling during primary care visit, and lack of predictive biomarkers may play significant roles. Many small studies incorporating risk assessment tools and decision-making aids showed minimal success in enhancing endocrine prevention. One critical factor for underutilization of endocrine prevention is low uptake of endocrine prevention by high-risk women even when appropriately recommended. Furthermore, adherence to BC endocrine prevention is unsatisfactorily low. Despite the current infrequent usage, endocrine prevention has the potential to reduce the public health burden of BC significantly. Innovative approaches like finding new agents, alternative dosing and schedule of currently available agents, transdermal medication delivery, increased public and professional awareness, and policymakers' commitments may bring the desired changes.
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Affiliation(s)
- Nusrat Jahan
- Division of Hematology-Oncology, Department of Internal Medicine, Texas Tech University Health Sciences Center, 3601 4th St, Lubbock, Tx, 79430, USA.
| | - Catherine Jones
- Division of Hematology-Oncology, Department of Internal Medicine, Texas Tech University Health Sciences Center, 3601 4th St, Lubbock, Tx, 79430, USA
| | - Rakhshanda Layeequr Rahman
- Department of Surgery, Texas Tech University Health Sciences Center, 3601 4th St, Lubbock, Tx, 79430, USA
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Ball S, Arevalo M, Juarez E, Payne JD, Jones C. Breast cancer chemoprevention: An update on current practice and opportunities for primary care physicians. Prev Med 2019; 129:105834. [PMID: 31494144 DOI: 10.1016/j.ypmed.2019.105834] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 09/01/2019] [Accepted: 09/05/2019] [Indexed: 12/15/2022]
Abstract
Several risk assessment models have been validated for the estimation of risk of breast cancer in women. Chemoprevention through hormonal therapy is an effective way to reduce the incidence of breast cancer in women with high risk. Selective estrogen receptor modulators, tamoxifen and raloxifene, are approved for this indication by the United States Food and Drug Administration, and aromatase inhibitors have also shown promise in recent studies. These medications are generally well tolerated, except for reported increased rates of fractures and venous thromboembolic events. Despite strong recommendations from several regulatory bodies, advocacy for chemoprevention has been inadequate in practice, more so among the primary care physicians. Studies have identified several barriers in physicians, patients, and the system, contributing to this problem. Lack of knowledge about risk assessment models and chemoprevention options preclude physicians from prescribing these medications with confidence. Fear of potential adverse events, confusion regarding the purpose of the therapy, and need for continued adherence for five years are among the principal reasons for reduced chemoprevention uptake and early discontinuation among patients. Multifaceted interventions directed at education and training of health care professionals, proper counseling of women at high risk, and promotion of the development of improved medications might help ensure better chemoprevention uptake in the target population.
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Affiliation(s)
- Somedeb Ball
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
| | - Meily Arevalo
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Edna Juarez
- Department of Internal Medicine, Memorial Medical Center, Las Cruces, NM, USA
| | - J Drew Payne
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Catherine Jones
- Division of Hematology and Medical Oncology, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Owens DK, Davidson KW, Krist AH, Barry MJ, Cabana M, Caughey AB, Doubeni CA, Epling JW, Kubik M, Landefeld CS, Mangione CM, Pbert L, Silverstein M, Tseng CW, Wong JB. Medication Use to Reduce Risk of Breast Cancer: US Preventive Services Task Force Recommendation Statement. JAMA 2019; 322:857-867. [PMID: 31479144 DOI: 10.1001/jama.2019.11885] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Breast cancer is the most common nonskin cancer among women in the United States and the second leading cause of cancer death. The median age at diagnosis is 62 years, and an estimated 1 in 8 women will develop breast cancer at some point in their lifetime. African American women are more likely to die of breast cancer compared with women of other races. OBJECTIVE To update the 2013 US Preventive Services Task Force (USPSTF) recommendation on medications for risk reduction of primary breast cancer. EVIDENCE REVIEW The USPSTF reviewed evidence on the accuracy of risk assessment methods to identify women who could benefit from risk-reducing medications for breast cancer, as well as evidence on the effectiveness, adverse effects, and subgroup variations of these medications. The USPSTF reviewed evidence from randomized trials, observational studies, and diagnostic accuracy studies of risk stratification models in women without preexisting breast cancer or ductal carcinoma in situ. FINDINGS The USPSTF found convincing evidence that risk assessment tools can predict the number of cases of breast cancer expected to develop in a population. However, these risk assessment tools perform modestly at best in discriminating between individual women who will or will not develop breast cancer. The USPSTF found convincing evidence that risk-reducing medications (tamoxifen, raloxifene, or aromatase inhibitors) provide at least a moderate benefit in reducing risk for invasive estrogen receptor-positive breast cancer in postmenopausal women at increased risk for breast cancer. The USPSTF found that the benefits of taking tamoxifen, raloxifene, and aromatase inhibitors to reduce risk for breast cancer are no greater than small in women not at increased risk for the disease. The USPSTF found convincing evidence that tamoxifen and raloxifene and adequate evidence that aromatase inhibitors are associated with small to moderate harms. Overall, the USPSTF determined that the net benefit of taking medications to reduce risk of breast cancer is larger in women who have a greater risk for developing breast cancer. CONCLUSIONS AND RECOMMENDATION The USPSTF recommends that clinicians offer to prescribe risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, to women who are at increased risk for breast cancer and at low risk for adverse medication effects. (B recommendation) The USPSTF recommends against the routine use of risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, in women who are not at increased risk for breast cancer. (D recommendation) This recommendation applies to asymptomatic women 35 years and older, including women with previous benign breast lesions on biopsy (such as atypical ductal or lobular hyperplasia and lobular carcinoma in situ). This recommendation does not apply to women who have a current or previous diagnosis of breast cancer or ductal carcinoma in situ.
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Affiliation(s)
| | - Douglas K Owens
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Stanford University, Stanford, California
| | - Karina W Davidson
- Feinstein Institute for Medical Research at Northwell Health, Manhasset, New York
| | - Alex H Krist
- Fairfax Family Practice Residency, Fairfax, Virginia
- Virginia Commonwealth University, Richmond
| | | | | | | | | | | | | | | | | | - Lori Pbert
- University of Massachusetts Medical School, Worcester
| | | | - Chien-Wen Tseng
- University of Hawaii, Honolulu
- Pacific Health Research and Education Institute, Honolulu, Hawaii
| | - John B Wong
- Tufts University School of Medicine, Boston, Massachusetts
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Nelson HD, Fu R, Zakher B, Pappas M, McDonagh M. Medication Use for the Risk Reduction of Primary Breast Cancer in Women: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2019; 322:868-886. [PMID: 31479143 DOI: 10.1001/jama.2019.5780] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Medications to reduce risk of breast cancer are effective for women at increased risk but also cause adverse effects. OBJECTIVE To update the 2013 US Preventive Services Task Force systematic review on medications to reduce risk of primary (first diagnosis) invasive breast cancer in women. DATA SOURCES Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, EMBASE, and MEDLINE (January 1, 2013, to February 1, 2019); manual review of reference lists. STUDY SELECTION Discriminatory accuracy studies of breast cancer risk assessment methods; randomized clinical trials of tamoxifen, raloxifene, and aromatase inhibitors for primary breast cancer prevention; studies of medication adverse effects. DATA EXTRACTION AND SYNTHESIS Investigators abstracted data on methods, participant characteristics, eligibility criteria, outcome ascertainment, and follow-up. Results of individual trials were combined by using a profile likelihood random-effects model. MAIN OUTCOMES AND MEASURES Probability of breast cancer in individuals (area under the receiver operating characteristic curve [AUC]); incidence of breast cancer, fractures, thromboembolic events, coronary heart disease events, stroke, endometrial cancer, and cataracts; and mortality. RESULTS A total of 46 studies (82 articles [>5 million participants]) were included. Eighteen risk assessment methods in 25 studies reported low accuracy in predicting the probability of breast cancer in individuals (AUC, 0.55-0.65). In placebo-controlled trials, tamoxifen (risk ratio [RR], 0.69 [95% CI, 0.59-0.84]; 4 trials [n = 28 421]), raloxifene (RR, 0.44 [95% CI, 0.24-0.80]; 2 trials [n = 17 806]), and the aromatase inhibitors exemestane and anastrozole (RR, 0.45 [95% CI, 0.26-0.70]; 2 trials [n = 8424]) were associated with a lower incidence of invasive breast cancer. Risk for invasive breast cancer was higher for raloxifene than tamoxifen in 1 trial after long-term follow-up (RR, 1.24 [95% CI, 1.05-1.47]; n = 19 747). Raloxifene was associated with lower risk for vertebral fractures (RR, 0.61 [95% CI, 0.53-0.73]; 2 trials [n = 16 929]) and tamoxifen was associated with lower risk for nonvertebral fractures (RR, 0.66 [95% CI, 0.45-0.98]; 1 trial [n = 13 388]) compared with placebo. Tamoxifen and raloxifene were associated with increased thromboembolic events compared with placebo; tamoxifen was associated with more events than raloxifene. Tamoxifen was associated with higher risk of endometrial cancer and cataracts compared with placebo. Symptomatic effects (eg, vasomotor, musculoskeletal) varied by medication. CONCLUSIONS AND RELEVANCE Tamoxifen, raloxifene, and aromatase inhibitors were associated with lower risk of primary invasive breast cancer in women but also were associated with adverse effects that differed between medications. Risk stratification methods to identify patients with increased breast cancer risk demonstrated low accuracy.
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Affiliation(s)
- Heidi D Nelson
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
| | - Rongwei Fu
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
- School of Public Health, Oregon Health & Science University, Portland
| | - Bernadette Zakher
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
- School of Public Health, Oregon Health & Science University, Portland
| | - Miranda Pappas
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
| | - Marian McDonagh
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
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Fink HA, MacDonald R, Forte ML, Rosebush CE, Ensrud KE, Schousboe JT, Nelson VA, Ullman K, Butler M, Olson CM, Taylor BC, Brasure M, Wilt TJ. Long-Term Drug Therapy and Drug Discontinuations and Holidays for Osteoporosis Fracture Prevention: A Systematic Review. Ann Intern Med 2019; 171:37-50. [PMID: 31009947 DOI: 10.7326/m19-0533] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Optimal long-term osteoporosis drug treatment (ODT) is uncertain. PURPOSE To summarize the effects of long-term ODT and ODT discontinuation and holidays. DATA SOURCES Electronic bibliographic databases (January 1995 to October 2018) and systematic review bibliographies. STUDY SELECTION 48 studies that enrolled men or postmenopausal women aged 50 years or older who were being investigated or treated for fracture prevention, compared long-term ODT (>3 years) versus control or ODT continuation versus discontinuation, reported incident fractures (for trials) or harms (for trials and observational studies), and had low or medium risk of bias (ROB). DATA EXTRACTION Two reviewers independently rated ROB and strength of evidence (SOE). One extracted data; another verified accuracy. DATA SYNTHESIS Thirty-five trials (9 unique studies) and 13 observational studies (11 unique studies) had low or medium ROB. In women with osteoporosis, 4 years of alendronate reduced clinical fractures (hazard ratio [HR], 0.64 [95% CI, 0.50 to 0.82]) and radiographic vertebral fractures (both moderate SOE), whereas 4 years of raloxifene reduced vertebral but not nonvertebral fractures. In women with osteopenia or osteoporosis, 6 years of zoledronic acid reduced clinical fractures (HR, 0.73 [CI, 0.60 to 0.90]), including nonvertebral fractures (high SOE) and clinical vertebral fractures (moderate SOE). Long-term bisphosphonates increased risk for 2 rare harms: atypical femoral fractures (low SOE) and osteonecrosis of the jaw (mostly low SOE). In women with unspecified osteoporosis status, 5 to 7 years of hormone therapy reduced clinical fractures (high SOE), including hip fractures (moderate SOE), but increased serious harms. After 3 to 5 years of treatment, bisphosphonate continuation versus discontinuation reduced radiographic vertebral fractures (zoledronic acid; low SOE) and clinical vertebral fractures (alendronate; moderate SOE) but not nonvertebral fractures (low SOE). LIMITATION No trials studied men, clinical fracture data were sparse, methods for estimating harms were heterogeneous, and no trials compared sequential treatments or different durations of drug holidays. CONCLUSION Long-term alendronate and zoledronic acid therapies reduce fracture risk in women with osteoporosis. Long-term bisphosphonate treatment may increase risk for rare adverse events, and continuing treatment beyond 3 to 5 years may reduce risk for vertebral fractures. Long-term hormone therapy reduces hip fracture risks but has serious harms. PRIMARY FUNDING SOURCE National Institutes of Health and Agency for Healthcare Research and Quality. (PROSPERO: CRD42018087006).
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Affiliation(s)
- Howard A Fink
- University of Minnesota and Minneapolis VA Health Care System, Minneapolis, Minnesota (H.A.F., R.M., K.E.E., K.U., B.C.T., T.J.W.)
| | - Roderick MacDonald
- University of Minnesota and Minneapolis VA Health Care System, Minneapolis, Minnesota (H.A.F., R.M., K.E.E., K.U., B.C.T., T.J.W.)
| | - Mary L Forte
- University of Minnesota, Minneapolis, Minnesota (M.L.F., C.E.R., V.A.N., M.B., C.M.O., M.B.)
| | - Christina E Rosebush
- University of Minnesota, Minneapolis, Minnesota (M.L.F., C.E.R., V.A.N., M.B., C.M.O., M.B.)
| | - Kristine E Ensrud
- University of Minnesota and Minneapolis VA Health Care System, Minneapolis, Minnesota (H.A.F., R.M., K.E.E., K.U., B.C.T., T.J.W.)
| | - John T Schousboe
- University of Minnesota, Minneapolis, and HealthPartners, Bloomington, Minnesota (J.T.S.)
| | - Victoria A Nelson
- University of Minnesota, Minneapolis, Minnesota (M.L.F., C.E.R., V.A.N., M.B., C.M.O., M.B.)
| | - Kristen Ullman
- University of Minnesota and Minneapolis VA Health Care System, Minneapolis, Minnesota (H.A.F., R.M., K.E.E., K.U., B.C.T., T.J.W.)
| | - Mary Butler
- University of Minnesota, Minneapolis, Minnesota (M.L.F., C.E.R., V.A.N., M.B., C.M.O., M.B.)
| | - Carin M Olson
- University of Minnesota, Minneapolis, Minnesota (M.L.F., C.E.R., V.A.N., M.B., C.M.O., M.B.)
| | - Brent C Taylor
- University of Minnesota and Minneapolis VA Health Care System, Minneapolis, Minnesota (H.A.F., R.M., K.E.E., K.U., B.C.T., T.J.W.)
| | - Michelle Brasure
- University of Minnesota, Minneapolis, Minnesota (M.L.F., C.E.R., V.A.N., M.B., C.M.O., M.B.)
| | - Timothy J Wilt
- University of Minnesota and Minneapolis VA Health Care System, Minneapolis, Minnesota (H.A.F., R.M., K.E.E., K.U., B.C.T., T.J.W.)
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Khaw KT. Elizabeth Barrett-Connor: Instrumental Contributor to the Understanding of Midlife Well-being and Health in Both Women and Men. Diabetes Care 2019; 42:502-506. [PMID: 30894382 DOI: 10.2337/dci19-0004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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10
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Kelly RR, McDonald LT, Jensen NR, Sidles SJ, LaRue AC. Impacts of Psychological Stress on Osteoporosis: Clinical Implications and Treatment Interactions. Front Psychiatry 2019; 10:200. [PMID: 31024360 PMCID: PMC6465575 DOI: 10.3389/fpsyt.2019.00200] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 03/20/2019] [Indexed: 02/06/2023] Open
Abstract
The significant biochemical and physiological effects of psychological stress are beginning to be recognized as exacerbating common diseases, including osteoporosis. This review discusses the current evidence for psychological stress-associated mental health disorders as risk factors for osteoporosis, the mechanisms that may link these conditions, and potential implications for treatment. Traditional, alternative, and adjunctive therapies are discussed. This review is not intended to provide therapeutic recommendations, but, rather, the goal of this review is to delineate potential interactions of psychological stress and osteoporosis and to highlight potential multi-system implications of pharmacological interventions. Review of the current literature identifies several potentially overlapping mechanistic pathways that may be of interest (e.g., glucocorticoid signaling, insulin-like growth factor signaling, serotonin signaling) for further basic and clinical research. Current literature also supports the potential for cross-effects of therapeutics for osteoporosis and mental health disorders. While studies examining a direct link between osteoporosis and chronic psychological stress are limited, the studies reviewed herein suggest that a multi-factorial, personalized approach should be considered for improved patient outcomes in populations experiencing psychological stress, particularly those at high-risk for development of osteoporosis.
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Affiliation(s)
- Ryan R Kelly
- Research Services, Ralph H. Johnson VA Medical Center, Charleston, SC, United States.,Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Lindsay T McDonald
- Research Services, Ralph H. Johnson VA Medical Center, Charleston, SC, United States.,Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Nathaniel R Jensen
- Research Services, Ralph H. Johnson VA Medical Center, Charleston, SC, United States.,Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Sara J Sidles
- Research Services, Ralph H. Johnson VA Medical Center, Charleston, SC, United States.,Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Amanda C LaRue
- Research Services, Ralph H. Johnson VA Medical Center, Charleston, SC, United States.,Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, SC, United States
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11
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Viswanathan M, Reddy S, Berkman N, Cullen K, Middleton JC, Nicholson WK, Kahwati LC. Screening to Prevent Osteoporotic Fractures: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2018; 319:2532-2551. [PMID: 29946734 DOI: 10.1001/jama.2018.6537] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Osteoporotic fractures cause significant morbidity and mortality. OBJECTIVE To update the evidence on screening and treatment to prevent osteoporotic fractures for the US Preventive Services Task Force. DATA SOURCES PubMed, the Cochrane Library, EMBASE, and trial registries (November 1, 2009, through October 1, 2016) and surveillance of the literature (through March 23, 2018); bibliographies from articles. STUDY SELECTION Adults 40 years and older; screening cohorts without prevalent low-trauma fractures or treatment cohorts with increased fracture risk; studies assessing screening, bone measurement tests or clinical risk assessments, pharmacologic treatment. DATA EXTRACTION AND SYNTHESIS Dual, independent review of titles/abstracts and full-text articles; study quality rating; random-effects meta-analysis. MAIN OUTCOMES AND MEASURES Incident fractures and related morbidity and mortality, diagnostic and predictive accuracy, harms of screening or treatment. RESULTS One hundred sixty-eight fair- or good-quality articles were included. One randomized clinical trial (RCT) (n = 12 483) comparing screening with no screening reported fewer hip fractures (2.6% vs 3.5%; hazard ratio [HR], 0.72 [95% CI, 0.59-0.89]) but no other statistically significant benefits or harms. The accuracy of bone measurement tests to identify osteoporosis varied (area under the curve [AUC], 0.32-0.89). The pooled accuracy of clinical risk assessments for identifying osteoporosis ranged from AUC of 0.65 to 0.76 in women and from 0.76 to 0.80 in men; the accuracy for predicting fractures was similar. For women, bisphosphonates, parathyroid hormone, raloxifene, and denosumab were associated with a lower risk of vertebral fractures (9 trials [n = 23 690]; relative risks [RRs] from 0.32-0.64). Bisphosphonates (8 RCTs [n = 16 438]; pooled RR, 0.84 [95% CI, 0.76-0.92]) and denosumab (1 RCT [n = 7868]; RR, 0.80 [95% CI, 0.67-0.95]) were associated with a lower risk of nonvertebral fractures. Denosumab reduced the risk of hip fracture (1 RCT [n = 7868]; RR, 0.60 [95% CI, 0.37-0.97]), but bisphosphonates did not have a statistically significant association (3 RCTs [n = 8988]; pooled RR, 0.70 [95% CI, 0.44-1.11]). Evidence was limited for men: zoledronic acid reduced the risk of radiographic vertebral fractures (1 RCT [n = 1199]; RR, 0.33 [95% CI, 0.16-0.70]); no studies demonstrated reductions in clinical or hip fractures. Bisphosphonates were not consistently associated with reported harms other than deep vein thrombosis (raloxifene vs placebo; 3 RCTs [n = 5839]; RR, 2.14 [95% CI, 0.99-4.66]). CONCLUSIONS AND RELEVANCE In women, screening to prevent osteoporotic fractures may reduce hip fractures, and treatment reduced the risk of vertebral and nonvertebral fractures; there was not consistent evidence of treatment harms. The accuracy of bone measurement tests or clinical risk assessments for identifying osteoporosis or predicting fractures varied from very poor to good.
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Affiliation(s)
- Meera Viswanathan
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Shivani Reddy
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Nancy Berkman
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Katie Cullen
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Jennifer Cook Middleton
- RTI International, Research Triangle Park, North Carolina
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Wanda K Nicholson
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill
| | - Leila C Kahwati
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
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12
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Caplan L, Hansen KE, Saag KG. Response to the American College of Physicians Osteoporosis Guideline, 2017 Update. Arthritis Rheumatol 2017; 69:2097-2101. [PMID: 28881479 DOI: 10.1002/art.40305] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 08/25/2017] [Indexed: 01/07/2023]
Affiliation(s)
- Liron Caplan
- University of Colorado Denver School of Medicine and Denver Veterans Affairs Medical Center, Denver, Colorado
| | - Karen E Hansen
- University of Wisconsin School of Medicine & Public Health, Madison
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13
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Vogel VG. Raloxifene: A Selective Estrogen Receptor Modulator for Reducing the Risk of Invasive Breast Cancer in Postmenopausal Women. WOMENS HEALTH 2016; 3:139-53. [DOI: 10.2217/17455057.3.2.139] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Raloxifene hydrochloride is a selective estrogen receptor modulator that has antiestrogenic effects on breast and endometrial tissue and estrogenic effects on bone, lipid metabolism and blood clotting. Tamoxifen is the prototypical selective estrogen receptor modulator and reduces the risk of both in situ and invasive breast cancers by half when compared with placebo. The limitations on the use of tamoxifen for breast cancer risk reduction relate to its well-known, but rare, side effects. A number of clinical trials have established the benefit of raloxifene on osteoporosis and fracture. Raloxifene significantly improves serum lipids and serum markers of cardiovascular disease risk, but has no significant effect on the risk of primary coronary events. In several osteoporosis trials and the Raloxifene Use for The Heart (RUTH) trial, raloxifene decreased the risk of estrogen receptor-positive breast cancer by 44–90%. In the Study of Tamoxifen And Raloxifene (STAR) trial, the effect of raloxifene on invasive breast cancer was equivalent to that of tamoxifen, with more favorable effects on uterine malignancy and clotting events. Symptomatic side effects are acceptable. In total, the available data indicate that raloxifene represents an acceptable alternative to tamoxifen for the reduction of the risk of postmenopausal breast cancer in high-risk women. The potential market for a compound shown to reduce the risk of breast cancer in postmenopausal women who are at increased risk for breast cancer is more than 10 million women in the USA alone.
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Affiliation(s)
- Victor G Vogel
- UPMC Cancer Center Magee-Women's Hospital, 300 Halket Street, Room 3524, Pittsburgh, PA 15213, USA, Tel.: +1 412 641 6500; Fax: +1 412 641 6461
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14
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Lin T, Yan SG, Cai XZ, Ying ZM, Yuan FZ, Zuo X. Alendronate versus Raloxifene for Postmenopausal Women: A Meta-Analysis of Seven Head-to-Head Randomized Controlled Trials. Int J Endocrinol 2014; 2014:796510. [PMID: 24511313 PMCID: PMC3912893 DOI: 10.1155/2014/796510] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 10/31/2013] [Indexed: 11/29/2022] Open
Abstract
Purpose. The aim of this study was to directly compare the efficacy and the safety of the two agents for postmenopausal women. Methods/Principal Findings. Electronic databases were searched for relevant articles that met our predefined inclusion criteria. Seven randomized controlled trials (RCTs) involving 4054 women were identified and included. Although Aln was more effective than Rlx in increasing bone mineral density (BMD), no statistical differences were observed in reducing the risk of neither vertebral fractures (P = 0.45) nor nonvertebral fractures (P = 0.87) up to two-year followup. Aln reduced the risk of vasomotor (P = 0.006) but increased the risk of diarrhea compared to Rlx (P = 0.01). Our subgroup analysis further indicated the difference between Aln and Rlx in fracture risk and was not materially altered by the administration pattern, the age. The weekly strategy of Aln would further reduce the upper gastrointestinal (GI) disorders and might gain more bone mass increment at lumbar spine compared to its daily treatment. Conclusion. There was no evidence of difference of fracture risk reduction between Aln and Rlx. In addition, age did not obviously influence their relative antifracture efficacy. For Aln the weekly strategy would further reduce the upper GI disorders and gain more bone mass increment compared to the daily treatment. During clinical decision making, the patients' adherence and the related side-effects associated with both drugs should also be taken into account.
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Affiliation(s)
- Tiao Lin
- Department of Orthopaedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, China
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19014, USA
| | - Shi-Gui Yan
- Department of Orthopaedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, China
| | - Xun-Zi Cai
- Department of Orthopaedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, China
- *Xun-Zi Cai:
| | - Zhi-Min Ying
- Department of Orthopaedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, China
| | - Fu-Zhen Yuan
- Department of Orthopaedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, China
| | - Xi Zuo
- Department of Epidemiology and Biostatistics, School of Public Health, Drexel University, Philadelphia, PA 19102, USA
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15
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Visvanathan K, Hurley P, Bantug E, Brown P, Col NF, Cuzick J, Davidson NE, DeCensi A, Fabian C, Ford L, Garber J, Katapodi M, Kramer B, Morrow M, Parker B, Runowicz C, Vogel VG, Wade JL, Lippman SM. Use of Pharmacologic Interventions for Breast Cancer Risk Reduction: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol 2013; 31:2942-62. [DOI: 10.1200/jco.2013.49.3122] [Citation(s) in RCA: 242] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Purpose To update the 2009 American Society of Clinical Oncology guideline on pharmacologic interventions for breast cancer (BC) risk reduction. Methods A systematic review of randomized controlled trials and meta-analyses published from June 2007 through June 2012 was completed using MEDLINE and Cochrane Collaboration Library. Primary outcome of interest was BC incidence (invasive and noninvasive). Secondary outcomes included BC mortality, adverse events, and net health benefits. Guideline recommendations were revised based on an Update Committee's review of the literature. Results Nineteen articles met the selection criteria. Six chemoprevention agents were identified: tamoxifen, raloxifene, arzoxifene, lasofoxifene, exemestane, and anastrozole. Recommendations In women at increased risk of BC age ≥ 35 years, tamoxifen (20 mg per day for 5 years) should be discussed as an option to reduce the risk of estrogen receptor (ER) –positive BC. In postmenopausal women, raloxifene (60 mg per day for 5 years) and exemestane (25 mg per day for 5 years) should also be discussed as options for BC risk reduction. Those at increased BC risk are defined as individuals with a 5-year projected absolute risk of BC ≥ 1.66% (based on the National Cancer Institute BC Risk Assessment Tool or an equivalent measure) or women diagnosed with lobular carcinoma in situ. Use of other selective ER modulators or other aromatase inhibitors to lower BC risk is not recommended outside of a clinical trial. Health care providers are encouraged to discuss the option of chemoprevention among women at increased BC risk. The discussion should include the specific risks and benefits associated with each chemopreventive agent.
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Affiliation(s)
- Kala Visvanathan
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Patricia Hurley
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Elissa Bantug
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Powel Brown
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Nananda F. Col
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Jack Cuzick
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Nancy E. Davidson
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Andrea DeCensi
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Carol Fabian
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Leslie Ford
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Judy Garber
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Maria Katapodi
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Barnett Kramer
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Monica Morrow
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Barbara Parker
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Carolyn Runowicz
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Victor G. Vogel
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - James L. Wade
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Scott M. Lippman
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
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Abstract
The pattern of lifelong changes in bone mass in women characterized in several publications generally shows that peak adult bone mass is achieved at about the end of adolescence or later, and begins to decline as menopause approaches. Uncertainties remain regarding the exact age at which peak bone mass is reached and when it starts to decline. The data indicate that the onset of rapid bone loss in healthy women begins at about two years before the last menses and is complete at about four to five years after the last menses. The bone loss at the spine, total body, and femoral neck over these years is equal to about one T-score and is largely irreversible after it occurs. This presentation examines the data on these questions and focuses on the perimenopausal pattern of rapid bone loss and the implications for identifying and managing the later-life risk of fracture.
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Affiliation(s)
- Robert R Recker
- Osteoporosis Research Center, Creighton University, Omaha, Nebraska 68131, USA.
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Sanchez-Barcelo EJ, Mediavilla MD, Alonso-Gonzalez C, Reiter RJ. Melatonin uses in oncology: breast cancer prevention and reduction of the side effects of chemotherapy and radiation. Expert Opin Investig Drugs 2012; 21:819-31. [PMID: 22500582 DOI: 10.1517/13543784.2012.681045] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION The possible oncostatic properties of melatonin on different types of neoplasias have been studied especially in hormone-dependent adenocarcinomas. Despite the promising results of these experimental investigations, the use of melatonin in breast cancer treatment in humans is still uncommon. AREAS COVERED This article reviews the usefulness of this indoleamine for specific aspects of breast cancer management, particularly in reference to melatonin's antiestrogenic and antioxidant properties: i) treatments oriented to breast cancer prevention, especially when the risk factors are obesity, steroid hormone treatment or chronodisruption by exposure to light at night (LAN); ii) treatment of the side effects associated with chemo- or radiotherapy. EXPERT OPINION The clinical utility of melatonin depends on the appropriate identification of its actions. Because of its SERM (selective estrogen receptor modulators) and SEEM (selective estrogen enzyme modulators) properties, and its virtual absence of contraindications, melatonin could be an excellent adjuvant with the drugs currently used for breast cancer prevention (antiestrogens and antiaromatases). The antioxidant actions also make melatonin a suitable treatment to reduce oxidative stress associated with chemotherapy, especially with anthracyclines, and radiotherapy.
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18
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Body JJ, Bergmann P, Boonen S, Devogelaer JP, Gielen E, Goemaere S, Kaufman JM, Rozenberg S, Reginster JY. Extraskeletal benefits and risks of calcium, vitamin D and anti-osteoporosis medications. Osteoporos Int 2012; 23 Suppl 1:S1-23. [PMID: 22311111 PMCID: PMC3273686 DOI: 10.1007/s00198-011-1891-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Accepted: 12/19/2011] [Indexed: 12/11/2022]
Abstract
UNLABELLED Drugs used for the prevention and the treatment of osteoporosis exert various favourable and unfavourable extra-skeletal effects whose importance is increasingly recognized notably for treatment selection. INTRODUCTION The therapeutic armamentarium for the prevention and the treatment of osteoporosis is increasingly large, and possible extra-skeletal effects of available drugs could influence the choice of a particular compound. METHODS The present document is the result of a national consensus, based on a systematic and critical review of the literature. RESULTS Observational research has suggested an inverse relationship between calcium intake and cardiovascular diseases, notably through an effect on blood pressure, but recent data suggest a possible deleterious effect of calcium supplements on cardiovascular risk. Many diverse studies have implicated vitamin D in the pathogenesis of clinically important non-skeletal functions or diseases, especially muscle function, cardiovascular disease, autoimmune diseases and common cancers. The possible effects of oral or intravenous bisphosphonates are well-known. They have been associated with an increased risk of oesophageal cancer or atrial fibrillation, but large-scale studies have not found any association with bisphosphonate use. Selective oestrogen receptor modulators have demonstrated favourable or unfavourable extra-skeletal effects that vary between compounds. Strontium ranelate has a limited number of non-skeletal effects. A reported increase in the risk of venous thromboembolism is not found in observational studies, and very rare cases of cutaneous hypersensitivity reactions have been reported. Denosumab has been introduced recently, and its extra-skeletal effects still have to be assessed. CONCLUSION Several non-skeletal effects of bone drugs are well demonstrated and influence treatment choices.
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Affiliation(s)
- J.-J. Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - P. Bergmann
- Department of Radioisotopes, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - S. Boonen
- Center for Metabolic Bone Diseases, Katholieke University Leuven, Leuven, Belgium
| | - J.-P. Devogelaer
- Department of Rheumatology, Saint Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - E. Gielen
- Gerontology and Geriatrics Section, Department of Experimental Medicine, K.U.Leuven, Leuven, Belgium
| | - S. Goemaere
- Department of Rheumatology and Endocrinology, State University of Gent, Gent, Belgium
| | - J.-M. Kaufman
- Department of Endocrinology, State University of Gent, Gent, Belgium
| | - S. Rozenberg
- Department of Gynaecology–Obstetrics, Université Libre de Bruxelles, Brussels, Belgium
| | - J.-Y. Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- Bone and Cartilage Metabolism Research Unit, CHU Centre-Ville, Policliniques L. BRULL, Quai Godefroid Kurth 45 (9ème étage), 4020 Liege, Belgium
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19
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Gagné L, Maizes V. Osteoporosis. Integr Med (Encinitas) 2012. [DOI: 10.1016/b978-1-4377-1793-8.00037-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
BACKGROUND Due to the chronic nature of osteoporosis and the risk of invasive breast cancer, raloxifene 60 mg/day (raloxifene) is intended to be used for long-term treatment (treatment >3 years). SCOPE We review available information concerning long-term use of raloxifene, present several new analyses, and report new data from patients who underwent iliac crest bone biopsies after 8 years of raloxifene therapy. The most important studies were the Multiple Outcomes of Raloxifene Evaluation (MORE) followed by the Continued Outcomes of Raloxifene Evaluation (CORE). FINDINGS The primary endpoint in MORE was incidence of vertebral fracture, and the difference between the raloxifene and placebo groups for this endpoint widened during 4 years of therapy, with the relative risk reduction during the fourth year of the study being similar to the relative risk reduction during years 0 to 3 of the study. Continued raloxifene treatment is necessary to preserve bone mineral density (BMD). In MORE, raloxifene lowered markers of bone turnover to a premenopausal reference interval. Biopsies from three patients treated with raloxifene for 8 years showed normal bone and bone cells and double label in all specimens. Invasive breast cancer risk is a clinical consideration in postmenopausal women with osteoporosis, and invasive breast cancer risk reduction was the primary endpoint in CORE. In MORE and CORE, the benefit of raloxifene versus placebo in incidence of invasive breast cancer increased with greater duration of therapy up to 8 years. CONCLUSIONS The long-term use of raloxifene has been evaluated through changes in fracture risk reduction, BMD, markers of bone turnover, iliac crest bone biopsies, and invasive breast cancer risk reduction.
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Affiliation(s)
- Robert R Recker
- Osteoporosis Research Center, Creighton University, Omaha, NE, USA
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Ko SS, Jordan VC. Treatment of osteoporosis and reduction in risk of invasive breast cancer in postmenopausal women with raloxifene. Expert Opin Pharmacother 2011; 12:657-74. [PMID: 21294695 DOI: 10.1517/14656566.2011.557360] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Raloxifene, a non-steroidal selective estrogen receptor modulator (SERM), offers a new dimension for the treatment and prevention of osteoporosis and risk reduction of invasive breast cancer in postmenopausal populations at high risk. Both osteoporosis and breast cancer are important public health issues for postmenopausal women. It is well known that estrogen and estrogen receptors play an important role in the pathogenesis of both diseases. Initially, hormone replacement therapy (HRT) was used for the purpose of preventing and treating postmenopausal osteoporosis. However, HRT significantly contributed to an increase in breast cancer risk. The SERM, raloxifene, is used for the prevention and for the treatment of postmenopausal osteoporosis and reducing the risk of invasive breast cancer in postmenopausal women. AREAS COVERED This article reviews the emerging evidence of the efficacy of raloxifene in postmenopausal women, summarizes the results and places in perspective their therapeutic uses for women having either a high risk of osteoporosis or breast cancer. Emerging clinical evidence suggests bisphosphonates, currently used as drugs for the treatment of osteoporosis, may also reduce breast cancer risk. The status of other SERMs and bisphosphonates are included for completeness. A Medline search of raloxifene, osteoporosis, breast cancer and SERMs was used to derive a database of 355 references. EXPERT OPINION Readers will understand the value of raloxifene to prevent osteoporosis and breast cancer in postmenopausal women. Although most women do not require pharmacotherapy for menopausal symptoms, many are severely affected by osteoporosis or breast cancer at and beyond menopause and, for such women, pharmacologic intervention is important if they are to retain an acceptable quality of life. It is reasonable to use raloxifene or bisphosphonate as an appropriate drug that targets symptom-free postmenopausal women for treatment and prevention of osteoporosis but raloxifene is proven to reduce the incidence of invasive breast cancer.
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Affiliation(s)
- Seung Sang Ko
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Department of Oncology, 3970 Reservoir Rd. N.W., Washington, DC 20057, USA
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Breast cancer, stem cells and sex hormones. Part 3: The impact of the menopause and hormone replacement. Maturitas 2011; 68:129-36. [DOI: 10.1016/j.maturitas.2010.11.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Revised: 11/08/2010] [Accepted: 11/08/2010] [Indexed: 01/16/2023]
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Management of patients with incident fractures during osteoporosis treatment. Joint Bone Spine 2010; 77 Suppl 2:S133-8. [DOI: 10.1016/s1297-319x(10)70009-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Miller PD, Derman RJ. What is the best balance of benefits and risks among anti-resorptive therapies for postmenopausal osteoporosis? Osteoporos Int 2010; 21:1793-802. [PMID: 20309524 DOI: 10.1007/s00198-010-1208-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 01/25/2010] [Indexed: 12/18/2022]
Abstract
Pharmacologic osteoporosis therapy, particularly anti-resorptives, is recommended in postmenopausal women with clinical risk factors for fracture. Treatment decisions should be made based on the relative benefit-risk profile in different patient populations. Emerging options [e.g., selective estrogen receptor modulators (SERMs) and denosumab] may hold promise for providing protection from bone loss and for fracture risk reduction.Osteoporosis, the most common clinical disorder of bone metabolism, is characterized by low bone mineral density, deterioration of microarchitecture, and a consequent increase in bone fragility and risk of fracture. Pharmacologic therapy is recommended in postmenopausal women with clinical risk factors for fracture and includes anti-resorptive agents such as bisphosphonates, hormone therapy, SERMs, and calcitonin. The anabolic agent teriparatide (parathyroid hormone) is usually reserved for high-risk patients or those with glucocorticoid-induced osteoporosis. Strontium ranelate, available outside the USA, has both anti-resorptive and anabolic properties. Supplementation with calcium and vitamin D is recommended for all women aged 50 years and older. Bisphosphonates are often considered first-line therapy for osteoporosis and have the largest base of clinical trial data showing efficacy for global fracture risk reduction. Low-dose hormone therapy is appropriate for younger women who are experiencing other menopausal symptoms. In women for whom bisphosphonates are not appropriate or not tolerated or in younger postmenopausal women who have a low risk for hip fracture, SERMs are a suitable treatment option. Calcitonin is designated for patients who are unable or unwilling to tolerate other osteoporosis agents. Emerging options, including newer SERMs (e.g., bazedoxifene and lasofoxifene) and the monoclonal antibody denosumab, may hold promise for providing protection from bone loss and for fracture risk reduction. Because no single agent is appropriate for all patients, treatment decisions should be made on an individual basis, taking into account the relative benefits and risks in different patient populations.
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Affiliation(s)
- P D Miller
- Colorado Center for Bone Research, 3190 South Wadsworth Blvd, Lakewood, CO 80227, USA.
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Messalli EM, Scaffa C. Long-term safety and efficacy of raloxifene in the prevention and treatment of postmenopausal osteoporosis: an update. Int J Womens Health 2010; 1:11-20. [PMID: 21072271 PMCID: PMC2971719 DOI: 10.2147/ijwh.s3894] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The integrity of bone tissue and its remodeling that occurs throughout life requires a coordinated activity of osteoblasts and osteoclasts. The decreased estrogen circulating level during postmenopausal transition, with a prevalence of osteoclastic activity over osteoblastic activity, represents the main cause of bone loss and osteoporosis. Osteoporosis is a chronic disease requiring long-term therapy and it is important to evaluate the efficacy and safety of treatments over several years, as the fear of health risks is a common reason for discontinuing therapy. Raloxifene is a selective estrogen receptor modulator (SERM) leading to estrogen-agonist effects in some tissues and estrogen-antagonist effects in others. Raloxifene is effective to prevent and treat postmenopausal vertebral osteoporosis, with reduction of spine fractures and, in post-hoc analyses, non-spine fractures in high-risk subjects. Moreover, raloxifene reduces the risk of invasive breast cancer and improves the levels of serum lipoprotein but with an increased risk of venous thromboembolism and fatal stroke, without significant change in the incidence of coronary events. For these reasons the overall risk-benefit profile is favorable. Therefore, when considering the use of raloxifene in a postmenopausal woman, we should take into account the osteoporosis-related individual risk and weigh the potential benefits, skeletal and extra-skeletal, against the health risks.
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Affiliation(s)
- Enrico M Messalli
- Department of Gynaecology, Obstetrics and Reproductive Medicine, Second University of Naples, Largo Madonna delle Grazie 1, Naples, Italy
| | - Cono Scaffa
- Department of Gynaecology, Obstetrics and Reproductive Medicine, Second University of Naples, Largo Madonna delle Grazie 1, Naples, Italy
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Alfonzo R, Reyna E, Guerra M, Mejia J, Reyna N, Torres D, Santos J, Schloeter J. Concentraciones de lípidos y lipoproteínas en menopáusicas tratadas con raloxifeno. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2010. [DOI: 10.1016/j.gine.2009.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Lewiecki EM. Current and emerging pharmacologic therapies for the management of postmenopausal osteoporosis. J Womens Health (Larchmt) 2010; 18:1615-26. [PMID: 19857095 DOI: 10.1089/jwh.2008.1086] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Postmenopausal osteoporosis is an asymptomatic skeletal disease that is often underdiagnosed and undertreated. Osteoporotic fractures are associated with substantial morbidity and mortality and impaired quality of life-socially, emotionally, and financially. Considering the growing burden of osteoporotic fractures worldwide, there remains an ongoing need for progress in the diagnosis of osteoporosis, identification of individuals at high fracture risk, and treatment to prevent fractures. Adequate intake of calcium and vitamin D is recommended as baseline therapy for osteoporosis prevention and treatment. Available pharmacological agents for the management of postmenopausal osteoporosis may not be appropriate for all women. Oral bisphosphonates are generally considered first-line therapy for patients with osteoporosis, but their use may be limited by gastrointestinal side effects. Other agents include hormone therapy, the selective estrogen receptor modulator (SERM) raloxifene, salmon calcitonin, teriparatide (human recombinant parathyroid hormone), and strontium ranelate (in some countries). Factors that may contribute to poor compliance and persistence with current osteoporosis therapies include drug intolerance, complexity of dosing regimens, and poor understanding of the relative benefit and risk with treatment. Emerging therapies for postmenopausal osteoporosis include novel SERMs (bazedoxifene, lasofoxifene, ospemifene, arzoxifene) and denosumab. Because SERMs can display mixed functional estrogen receptor agonist or antagonist activity depending on the target tissue, they may confer beneficial effects on bone with limited stimulation of other tissues (e.g., breast, endometrium). Clinical investigation of these promising new agents is ongoing to evaluate efficacy and safety, with the goal of developing effective strategies to maximize long-term tolerance, compliance, and persistence with therapy.
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Affiliation(s)
- E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, University of New Mexico School of Medicine, Albuquerque, New Mexico 87106, USA.
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Abstract
OBJECTIVE Women without versus those with vertebral fracture may have different benefits and risks during raloxifene treatment. Our objective was to compare the effects of raloxifene to decrease risk for vertebral fracture and invasive breast cancer with its effect to increase risk for venous thromboembolism in postmenopausal women without or with baseline vertebral fracture. RESEARCH DESIGN AND METHODS The Multiple Outcomes of Raloxifene Evaluation trial included postmenopausal women with osteoporosis randomized to placebo, raloxifene 60 mg/day, or raloxifene 120 mg/day for 4 years. The protocol specified subgroups based on whether or not patients had a vertebral fracture at baseline. Absolute differences between placebo and raloxifene 60 mg/day (the approved dose) for endpoints in these groups were defined as the incidence in the raloxifene group minus the incidence in the placebo group. RESULTS Raloxifene decreased the incidence of vertebral fracture and invasive breast cancer while increasing the incidence of venous thromboembolism. All treatment by vertebral fracture status interaction p-values were greater than 0.13, indicating that the effect of raloxifene on these outcomes was not significantly different between patients without versus those with vertebral fractures. In women without baseline vertebral fracture, absolute risk differences between the raloxifene and placebo group included vertebral fracture -2.83%, invasive breast cancer -1.21%, and venous thromboembolism +0.28%. In women with baseline vertebral fracture, absolute risk differences between raloxifene and placebo group included vertebral fracture -8.21%, invasive breast cancer -0.75% and venous thromboembolism +0.91%. The analysis had limited power to test whether raloxifene had a significantly different effect on venous thromboembolism in women without versus those with a vertebral fracture. CONCLUSIONS In women without and in those with vertebral fractures at baseline, the effects of raloxifene to decrease vertebral fracture and invasive breast cancer were greater than its effects to increase venous thromboembolism.
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Abstract
Evidence exists for the potential protective effects of circulating ovarian hormones in stroke, and oestrogen reduces brain damage in animal ischaemia models. However, a recent clinical trial indicated that HRT (hormone-replacement therapy) increased the incidence of stroke in post-menopausal women, and detrimental effects of oestrogen on stroke outcome have been identified in a meta-analysis of HRT trials and in pre-clinical research studies. Therefore oestrogen is not an agent that can be promoted as a potential stroke therapy. Many published reviews have reported the neuroprotective effects of oestrogen in stroke, but have failed to include information on the detrimental effects. This issue is addressed in the present review, along with potential mechanisms of action, and the translational capacity of pre-clinical research.
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Visvanathan K, Chlebowski RT, Hurley P, Col NF, Ropka M, Collyar D, Morrow M, Runowicz C, Pritchard KI, Hagerty K, Arun B, Garber J, Vogel VG, Wade JL, Brown P, Cuzick J, Kramer BS, Lippman SM. American society of clinical oncology clinical practice guideline update on the use of pharmacologic interventions including tamoxifen, raloxifene, and aromatase inhibition for breast cancer risk reduction. J Clin Oncol 2009; 27:3235-58. [PMID: 19470930 DOI: 10.1200/jco.2008.20.5179] [Citation(s) in RCA: 220] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE To update the 2002 American Society of Clinical Oncology guideline on pharmacologic interventions for breast cancer (BC) risk reduction. METHODS A literature search identified relevant randomized trials published since 2002. Primary outcome of interest was BC incidence (invasive and noninvasive). Secondary outcomes included BC mortality, adverse events, and net health benefits. An expert panel reviewed the literature and developed updated consensus guidelines. Results Seventeen articles met inclusion criteria. In premenopausal women, tamoxifen for 5 years reduces the risk of BC for at least 10 years, particularly estrogen receptor (ER) -positive invasive tumors. Women < or = 50 years of age experience fewer serious side effects. Vascular and vasomotor events do not persist post-treatment across all ages. In postmenopausal women, raloxifene and tamoxifen reduce the risk of ER-positive invasive BC with equal efficacy. Raloxifene is associated with a lower risk of thromboembolic disease, benign uterine conditions, and cataracts than tamoxifen in postmenopausal women. No evidence exists establishing whether a reduction in BC risk from either agent translates into reduced BC mortality. Recommendations In women at increased risk for BC, tamoxifen (20 mg/d for 5 years) may be offered to reduce the risk of invasive ER-positive BC, with benefits for at least 10 years. In postmenopausal women, raloxifene (60 mg/d for 5 years) may also be considered. Use of aromatase inhibitors, fenretinide, or other selective estrogen receptor modulators to lower BC risk is not recommended outside of a clinical trial. Discussion of risks and benefits of preventive agents by health providers is critical to patient decision making.
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Affiliation(s)
- Kala Visvanathan
- Cancer Policy and Clinical Affairs, 2318 Mill Rd, Suite 800, Alexandria, VA 22314, USA
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Vogel VG. Managing the risk of invasive breast cancer in women at risk for breast cancer and osteoporosis: the role of raloxifene. Clin Interv Aging 2009; 3:601-9. [PMID: 19281053 PMCID: PMC2682393 DOI: 10.2147/cia.s3344] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Raloxifene hydrochloride is a selective estrogen receptor modulator (SERM) that has antiestrogenic effects on breast and endometrial tissue and estrogenic effects on bone, lipid metabolism, and blood clotting. Raloxifene significantly improves serum lipids and serum markers of cardiovascular disease risk, but it has no significant effect on the risk of primary coronary events. A meta-analysis of randomized, double-blind, placebo-controlled trials of raloxifene for osteoporosis showed the odds of fracture risk were 0.60 (95% confidence interval [CI] = 0.49–0.74) for raloxifene 60 mg/day compared with placebo. During 8 years of follow-up in an osteoporosis trial, the raloxifene group had a 76% reduction in the incidence of invasive ER-positive breast cancer compared with the placebo group. In the STAR trial, the incidence of invasive breast cancer was 4.30 per 1000 women-years with raloxifene and 4.41 per 1000 with tamoxifen; RR = 1.02; 95% CI, 0.82–1.28. The effect of raloxifene on invasive breast cancer was, therefore, equivalent to that of tamoxifen with more favorable rates of adverse effects including uterine malignancy and clotting events. Millions of postmenopausal women could derive net benefit from raloxifene through reduced rates of fracture and invasive breast cancer.
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Affiliation(s)
- Victor G Vogel
- The University of Pittsburgh Cancer Institute, Magee-Womens Hospital, 300 Halket Street, Pittsburgh, PA 15213, USA.
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Abstract
In the Study of Tamoxifen and Raloxifene (STAR) trial, postmenopausal women at increased risk of breast cancer received either oral tamoxifen (20 mg/day) or raloxifene (60 mg/day) over 5 years. There were an equal number of cases of invasive breast cancer in women assigned to tamoxifen and raloxifene. There were fewer cases of noninvasive breast cancer in the tamoxifen group than in the raloxifene group (risk ratio [RR]: 1.40; 95% confidence interval [CI]: 0.98-2.02). There were more cases of uterine cancer with tamoxifen than with raloxifene (RR: 0.62; 95% CI: 0.35-1.08). Thromboembolic events occurred less often in the raloxifene group (RR: 0.70; 95% CI: 0.54-0.91) and there were fewer cataracts and cataract surgeries in the women taking raloxifene (RR: 0.79; 95% CI: 0.68-0.92). The STAR trial has shown that raloxifene is as effective as tamoxifen in reducing the risk of invasive breast cancer and has a lower risk of adverse events but a nonstatistically significant higher risk of noninvasive breast cancer. The risk of other cancers, fractures, ischemic heart disease and stroke is similar for both drugs.
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Affiliation(s)
- Victor G Vogel
- University of Pittsburgh Cancer Institute, Magee-Womens Hospital, Pittsburgh, PA 15213-3180, USA.
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A selective estrogen receptor modulator inhibits TNF-alpha-induced apoptosis by activating ERK1/2 signaling pathway in vascular endothelial cells. Vascul Pharmacol 2009; 51:21-8. [PMID: 19275968 DOI: 10.1016/j.vph.2009.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Revised: 01/01/2009] [Accepted: 01/21/2009] [Indexed: 11/23/2022]
Abstract
Tumor necrosis factor (TNF-alpha) is a pleiotropic cytokine exerting both inflammatory and cell death activity and is thought to play a role in the pathogenesis of atherosclerosis. The present study was designed to examine whether the raloxifene analogue, LY117018 could inhibit TNF-alpha-induced apoptosis in vascular endothelial cells and to clarify the involved mechanisms. Apoptosis of endothelial cells was determined by DNA fragmentation assay and the activation of caspase-3. LY117018 significantly inhibited TNF-alpha-induced caspase-3 activation and cell DNA fragmentation levels in bovine carotid artery endothelial cells. The inhibitory effect of LY117018 was abolished by an estrogen receptor antagonist ICI 182,780. p38 MAPK, JNK, ERK1/2 and Akt have been shown to act as apoptotic or anti-apoptotic signals. TNF-alpha stimulated the phosphorylation levels of p38 MAPK, JNK, ERK1/2 and Akt in vascular endothelial cells. TNF-alpha-induced apoptosis was significantly decreased by SB203580, a p38 MAPK inhibitor or SP600125, a JNK inhibitor, but was enhanced by an ERK1/2 pathway inhibitor, PD98059 or a PI3-kinase/Akt pathway inhibitor, wortmannin. The anti-apoptotic effect of LY117018 was abrogated only by PD98059 but was not affected by the inhibitors for p38 MAPK, JNK, or Akt. LY117018 stimulated the further increase in phosphorylation of ERK1/2 in TNF-alpha treated endothelial cells but it did not affect phosphorylation levels of p38 MAPK, JNK or Akt. These results suggest that LY 110718 prevents caspase-3 dependent apoptosis induced by TNF-alpha in vascular endothelial cells through activation of the estrogen receptors and the ERK1/2 signaling pathway.
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Bläuer M, Heinonen PK, Rovio P, Ylikomi T. Effects of tamoxifen and raloxifene on normal human endometrial cells in an organotypic in vitro model. Eur J Pharmacol 2008; 592:13-8. [PMID: 18638473 DOI: 10.1016/j.ejphar.2008.06.091] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Revised: 06/16/2008] [Accepted: 06/27/2008] [Indexed: 11/17/2022]
Abstract
The selective estrogen receptor modulator tamoxifen is widely used in breast cancer therapy though its use is associated with an elevated risk of endometrial carcinoma. An organotypic culture model was employed here to examine the effects of tamoxifen and raloxifene, a related compound with no known adverse uterine effects, on epithelial cells of the premenopausal human endometrium. Changes in the expression levels of the proliferation marker Ki67, and estrogen and progesterone receptors were evaluated. No change in the Ki67 index compared to untreated controls was detected in cultures exposed to tamoxifen or tamoxifen+estradiol. In response to tamoxifen, the level of progesterone receptor-expressing organoids was shown to vary markedly between individual samples, whereas no change in estrogen receptor expression could be demonstrated. A significant decrease in Ki67 expression was observed in raloxifene-exposed cultures. Raloxifene or raloxifene+estradiol had no effect on progesterone receptor expression. The expression of estrogen receptor was markedly inhibited in response to raloxifene or raloxifene+estradiol in all but two samples displaying an intense estrogen receptor labelling. The present observations add to current clinical data on the respective estrogen receptor agonist and antagonist activities of tamoxifen and raloxifene on the human uterus by providing novel insights into the interindividual variation in cellular responses. Our organotypic model may have uses as an alternative to animal experimentation in preclinical screening of the endometrial effects of selective estrogen receptor modulators and may serve as a tool in personalized medicine by identifying patients with an increased risk of developing endometrial pathologies.
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Affiliation(s)
- Merja Bläuer
- Department of Cell Biology, FI-33014, University of Tampere, Finland.
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Martineti V, Silvestri S, Tonelli F, Brandi ML. Control of colon cancer development and progression by selected estrogen receptor modulators. Expert Rev Endocrinol Metab 2008; 3:503-511. [PMID: 30290437 DOI: 10.1586/17446651.3.4.503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Estrogens behave as protective agents on the development of colorectal cancer, and hormonal-replacement therapy is associated with an increased survival rate in women with this disease, indicating that estrogenic therapy correlates with a better prognosis. The protective effect of estrogens on Fcolorectal cancer development and progression is presumably related to the expression of estrogen receptors in colon mucosa, with the estrogen receptor-β isoform being the predominant one. This observation suggests that estrogen receptor-β could have an inhibitory effect on colorectal cancer cell proliferation and a regulatory effect on colonic mucosa cell growth, opening the discussion on a pharmacologic approach to colorectal cancer prevention and therapy based on estrogenic compounds.
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Affiliation(s)
- Valentina Martineti
- a Department of Internal Medicine, School of Medicine, University of Florence, Viale Pieraccini 6, 50139 Firenze, Italy.
| | - Sandra Silvestri
- b Specialist in Endocrinology and Metabolic Disease, Expert Clinical Research Physician, Internal Medicine, Eli Lilly Italia S.p.A., Via Gramsci 731, 50019 Sesto Fiorentino, FI, Italy.
| | - Francesco Tonelli
- c Department of Clinical Physiopathology, School of Medicine - University of Florence, Viale Morgagni 85, 50134 Firenze, Italy.
| | - Maria Luisa Brandi
- d Department of Internal Medicine, School of Medicine - University of Florence, Viale Pieraccini 6, 50139 Firenze, Italy.
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Lee WL, Chao HT, Cheng MH, Wang PH. Rationale for using raloxifene to prevent both osteoporosis and breast cancer in postmenopausal women. Maturitas 2008; 60:92-107. [PMID: 18534794 DOI: 10.1016/j.maturitas.2008.04.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2007] [Revised: 04/05/2008] [Accepted: 04/14/2008] [Indexed: 11/27/2022]
Abstract
Both osteoporosis with fracture and breast cancer are important health issues for postmenopausal women. It is well known that estrogen and estrogen receptors (ERs) play an important role in the pathogenesis of both diseases. In past decades, hormone therapy (HT), mainly estrogen plus progestin (EPT), has been frequently used for the purpose of preventing and treating postmenopausal osteoporosis because of its efficacy, but it also contributes to a significant increase in breast cancer. Currently, there is a dilemma regarding the use of estrogen for postmenopausal women. Fortunately, an increasing understanding of the action of estrogen has led ultimately to the design of new drugs that work by virtue of their interaction with the ER; these drugs have come to be known as selective estrogen receptor modulators (SERMs), and are not only effective in preventing osteoporosis and managing those with osteoporosis, but also in decreasing the incidence of breast cancer. Among these SERMs, raloxifene may be the most attractive agent based on the evidence from five recent large trials (Multiple Outcomes of Raloxifene Evaluation [MORE], Continuing Outcomes Relevant to Evista [CORE], Raloxifene Use for the Heart [RUTH], Study of Tamoxifen and Raloxifene [STAR], and Evista Versus Alendronate [EVA]). The former three trials showed that raloxifene not only decreases the incidence of osteoporosis-associated fractures, but also has efficacy in breast cancer prevention. The head-to-head comparison with the anti-fracture agent alendronate (EVA trial) and the chemoprevention agent tamoxifen (STAR trial) further confirmed that raloxifene is a better choice. We concluded that since there is an absence of a therapeutic effect on relieving climacteric symptoms and there is the presence of a potential risk of thromboembolism in the use of raloxifene, this drug can be prescribed for clear indications, such as the management of osteoporosis, the prevention of fracture, and decreasing the incidence of invasive breast cancer, with careful monitoring for thromboembolism. It is reasonable to use raloxifene as an appropriate medicine that targets climacteric symptom-free postmenopausal women because of its overall favorable risk-benefit safety profile using the global index proposed by the Women's Health Initiation (WHI).
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Affiliation(s)
- Wen-Ling Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Chen Hsin Rehabilitation Center-Taipei, Taiwan
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Scafonas A, Reszka AA, Kimmel DB, Hou XS, Su Q, Birzin ET, Kim S, Chen HY, Tan Q, Roher SP, Dininno F, Hammond ML, Rodan GA, Towler DA, Schmidt A. Agonist-like SERM effects on ERalpha-mediated repression of MMP1 promoter activity predict in vivo effects on bone and uterus. J Steroid Biochem Mol Biol 2008; 110:197-206. [PMID: 18508261 DOI: 10.1016/j.jsbmb.2007.10.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Accepted: 10/25/2007] [Indexed: 10/22/2022]
Abstract
Estradiol receptors (ER), ERalpha and ERbeta, are ligand-dependent transcription factors that regulate gene expression. Human and murine genetics suggest that ERalpha is the key target for estradiol action on bone, uterus and breast. To date, the molecular mode of action of estradiol and selective estradiol receptor modulators (SERMs) on bone is not fully understood. This is exemplified by a lack of in vitro assays that reliably predict SERM agonist activities in vivo. We hypothesized that ligand-dependent ERalpha transrepression, via protein-protein interactions at AP1, may predict estrogenic effects on bone. We modeled this using the MMP1 promoter, which encodes an AP1 binding site. We show that ICI-182780, raloxifene, 4-hydroxytamoxifen and estradiol all exhibit differential agonistic activities on the MMP1 promoter by suppressing activity by 20-80%. Transrepression efficacy and potency correlated with both uterotrophic (R(2)=0.98) and osteoprotective (R(2)=0.80) potential in the ovariectomized rat. This identifies MMP1 promoter transrepression as an agonist activity commonly shared by AF2 agonists and "antagonists" alike. Mutation analysis showed that the repression by estradiol and SERMs required correct amino acid sequences in the AF-2 domain. For instance, L540Q AF2 mutation did not alter responses to raloxifene, although it greatly increased responses to ICI-182780 (threefold) and reduced estradiol's effect by 20%. Furthermore, all tested ligands repressed the MMP1 promoter through the L540Q mutant with identical efficacy. Together, these data suggest that estradiol and SERMs share common agonist transcriptional activity via protein-protein interactions at AP1.
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Affiliation(s)
- Angela Scafonas
- Molecular Endocrinology, Merck Research Laboratories, West Point, 770 Sumneytown Pike, PA 19486, USA
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Sun S. Bone disease drug discovery: examining the interactions between osteoblast and osteoclast. Expert Opin Ther Targets 2008; 12:239-51. [DOI: 10.1517/14728222.12.2.239] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Inoue D. [Current and future prospects for anti-osteoporotic drugs]. Nihon Yakurigaku Zasshi 2007; 130:206-9. [PMID: 17878616 DOI: 10.1254/fpj.130.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
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Affiliation(s)
- Wendy Y Chen
- Channing Laboratory, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA.
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Gold DT, Silverman SL. Do estrogen or selective estrogen receptor modulators improve quality of life for women with postmenopausal osteoporosis? Curr Osteoporos Rep 2007; 5:3-7. [PMID: 17320021 DOI: 10.1007/bf02938616] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Osteoporotic fractures result in significant deficits in health-related quality of life (HRQOL). The accumulation of deficits resulting from osteoporosis and fractures is now recognized as a major cause of reduced HRQOL in women after the menopause and in later life. Some of these same postmenopausal women may also have deficits in HRQOL related to vasomotor symptoms during the menopausal transition. Although estrogen therapy has not been shown to improve overall HRQOL in late postmenopausal women in randomized, controlled trials, it may improve menopausal symptoms. In contrast, selective estrogen receptor modulators (SERMs) such as raloxifene may increase vasomotor symptoms. Although estrogen is not indicated for the primary prevention of osteoporosis, estrogen therapy may be considered for the postmenopausal woman at risk of osteoporotic fracture who is symptomatic and who is not at high risk of breast cancer or cardiovascular events. Raloxifene decreases risk of invasive breast cancer and may be considered in women at high risk of breast cancer. Decision making about osteoporosis treatment should also consider the impact of the treatment on HRQOL.
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Affiliation(s)
- Deborah T Gold
- Department of Psychiatry, Center for the Study of Aging and Human Development, Box 3003, Duke University Medical Center, Durham, NC 27710, USA.
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Sikoski P, Register TC, Lees CJ, Lundeen S, Hutchison J, Brown KH, Cline JM. Effects of two novel selective estrogen receptor modulators, raloxifene, tamoxifen, and ethinyl estradiol on the uterus, vagina and breast in ovariectomized cynomolgus monkeys (Macaca fascicularis). Am J Obstet Gynecol 2007; 196:75.e1-7. [PMID: 17240242 DOI: 10.1016/j.ajog.2006.09.038] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2006] [Revised: 07/25/2006] [Accepted: 09/26/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Assess effects of 2 novel selective estrogen receptor modulators on the reproductive system. STUDY DESIGN Adult, ovariectomized, female Macaca fascicularis, n = 3 per group, orally dosed for 12 weeks with vehicle; selective estrogen receptor modulator 393 (2, 4, or 8 mg/kg/day); selective estrogen receptor modulator 379 (4 mg/kg per day); raloxifene (3 mg/kg per day); tamoxifen (1 mg/kg per day); or ethinyl estradiol (3 microg/kg per day). Outcomes included organ weights, histopathology, plasma lipids, and bone biomarkers. RESULTS Novel selective estrogen receptor modulators tested did not alter uterine weight or endometrial histology. Tamoxifen and ethinyl estradiol increased uterine weight 2- to 3-fold (P <.05) and endometrial glandular proliferation 5- to 6-fold (P < .05). Adrenal weight was 50% higher in the tamoxifen group. Ethinyl estradiol increased breast lobular epithelial proliferation 6-fold (P < .05). Selective estrogen receptor modulators 393 and ethinyl estradiol decreased bone biomarkers. CONCLUSION The results for raloxifene, tamoxifen, and ethinyl estradiol are consistent with previous findings, and results for selective estrogen receptor modulator 393 and selective estrogen receptor modulator 379 indicate potential for tissue selectivity.
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Affiliation(s)
- Paul Sikoski
- Department of Pathology, Section on Comparative Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Lippman ME, Cummings SR, Disch DP, Mershon JL, Dowsett SA, Cauley JA, Martino S. Effect of Raloxifene on the Incidence of Invasive Breast Cancer in Postmenopausal Women with Osteoporosis Categorized by Breast Cancer Risk. Clin Cancer Res 2006; 12:5242-7. [PMID: 16951244 DOI: 10.1158/1078-0432.ccr-06-0688] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To assess the effect of raloxifene, indicated for osteoporosis treatment and prevention, on invasive breast cancer in subgroups of postmenopausal women defined by risk factors for breast cancer. EXPERIMENTAL DESIGN Data from the 4-year Multiple Outcomes of Raloxifene Evaluation (MORE) trial (N=7,705) and a follow-up study, the 4-year Continuing Outcomes Relevant to Evista (CORE) trial (N=4,011), were analyzed. Prespecified subgroups were defined by age (>or=65 versus<65 years), age at menopause (>or=49 versus<49 years), body mass index (>or=25 versus<25 kg/m2), family history of breast cancer (yes/no), serum estradiol level (5-10 versus<5, >10 versus<5 pmol/L), prior estrogen therapy (yes/no), and bone mass at MORE baseline, and 5-year predicted risk, assessed using the modified Gail model (>or=1.67 versus<1.67%), at CORE baseline. Time-to-first invasive breast cancer was analyzed using Cox proportional hazards models. RESULTS In the placebo group, older age, higher estradiol level, and a family history of breast cancer were associated with an increased breast cancer risk (P<0.05). Raloxifene therapy was associated with a reduced breast cancer risk in both women at lower and those at higher breast cancer risk. Hazard ratio point estimates were 0.11 to 0.67, corresponding to a 33% to 89% reduction in breast cancer risk with raloxifene versus placebo. The therapy by family history interaction was significant (P=0.04). CONCLUSIONS Raloxifene therapy was associated with a reduced risk of invasive breast cancer in postmenopausal women irrespective of the presence/absence of risk factors; its effect was greater in women with a family history of breast cancer.
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Affiliation(s)
- Marc E Lippman
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109, USA.
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Goldstein SR. Not all selective estrogen response modulators are created equal: update on lasofoxifene. Int J Gynecol Cancer 2006; 16 Suppl 2:504. [PMID: 17010058 DOI: 10.1111/j.1525-1438.2006.00681.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- S R Goldstein
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, USA
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Abstract
Osteoporotic fractures are emerging as a major public health problem in the aging population. Fractures result in increased morbidity, mortality and health expenditures. This article reviews current evidence for the management of common issues following osteoporotic fractures in older adults including: (1) thromboembolism prevention; (2) delirium prevention; (3) pain management; (4) rehabilitation; (5) assessing the cause of fracture; and (6) prevention of subsequent fractures. Areas for practice improvement and further research are highlighted.
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Affiliation(s)
- Cathleen S Colón-Emeric
- Center for the Study of Aging and Human Development, Duke University Medical Center and the Durham VA Medical Center Geriatrics Research Education and Clinical Center, Duke University Medical Center, Durham, NC 27710, USA.
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Ling S, Komesaroff P, Sudhir K. Cellular mechanisms underlying the cardiovascular actions of oestrogens. Clin Sci (Lond) 2006; 111:107-18. [PMID: 16831130 DOI: 10.1042/cs20050084] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Although pre-menopausal women enjoy relative cardiovascular protection, hormone (oestrogen±progestin)-replacement therapy has not shown cardiovascular benefits in post-menopausal women, suggesting that the effects of oestrogens on the cardiovascular system are much more complex than previously expected. Endothelial cells, smooth muscle cells, cardiac myocytes and fibroblasts, the cellular components of blood vessels and the heart, play important roles in cardiovascular health and disease. During the development and progression of cardiovascular disease, changes occur both in the structure and function of these cells, resulting in a wide range of abnormalities, which affect growth, death and physiological function. These cells contain functional oestrogen receptors and are targets for oestrogen action. This review focuses on recent studies on the effects of oestrogen on cardiovascular cell function. Oestrogens, particularly 17β-oestradiol, exert multiple effects on cardiovascular cells, and these effects may contribute to the gender-associated protection against cardiovascular diseases.
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Affiliation(s)
- Shanhong Ling
- Department of Medicine, Central and Eastern Clinical School, Monash University, Commercial Road, Prahran, Melbourne, VIC 3181, Australia
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Abstract
UNLABELLED Recently, selective estrogen receptor modulators have been developed for the management of osteoporosis based on antiosteoclastic properties similar to that of estrogens but with a safety profile including potential benefits on the breast, heart, and cognitive function. Raloxifene, the first selective estrogen receptor modulator to be marketed for the treatment of osteoporosis has shown reduction in spinal fracture risk in patients with low bone mineral density with (48%) or without (35%) prevalent vertebral fracture. Raloxifene also reduces nonvertebral fractures in high risk patients (47%). The decrease in Type I procollagen N-terminal propeptide at 1 year accounts for 28% of the total reduction in vertebral fracture risk. Raloxifene reduced the risk of estrogen receptor-positive invasive breast cancer by 84%. Among subjects with increased cardiovascular risk at baseline, those assigned to raloxifene had a 40% decrease in the risk of cardiovascular events compared with placebo. The definite anti-fracture efficacy of raloxifene at the spine, its plausible effect on non-spine fracture in high-risk patients and its beneficial effect on breast and heart make this compound an interesting approach for women presenting with osteoporosis. LEVEL OF EVIDENCE Therapeutic study, level II (lesser quality randomized controlled trial [eg, < 80% followup, no blinding, or improper randomization]). See the Guidelines for Authors for a complete description of the levels of evidence.
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Affiliation(s)
- Jean-Yves Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège and the World Health Organization Collaborating Centre for Public Health Aspects of Bone Diseases, Liège, Belgium.
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Botsis D, Christodoulakos G, Papagianni V, Lambrinoudaki I, Aravantinos L, Makrakis E, Creatsas G. The effect of raloxifene and tibolone on the uterine blood flow and endometrial thickness: A transvaginal Doppler study. Maturitas 2006; 53:362-8. [PMID: 16159701 DOI: 10.1016/j.maturitas.2005.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2005] [Revised: 06/27/2005] [Accepted: 06/29/2005] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To evaluate and compare the effect of different than classical hormone therapy medications, such as raloxifene and tibolone, on the uterine arteries and endometrium of postmenopausal women using transvaginal ultrasonography. METHODS The prospective study included 62 healthy, postmenopausal women recruited from the Menopausal Clinic of the 2nd Department of Obstetrics and Gynecology of the University of Athens. Subjects were randomly allocated to receive raloxifene HCl in a daily dose of 60 mg orally (Group A-31 women) or tibolone in a daily dose of 2.5 mg orally (Group B-31 women). The study period was 6 months and all subjects were assessed using transvaginal ultrasonography before treatment initiation as well as after 3 and 6 months for evaluation of the endometrial thickness and the pulsatility (PI) and resistance (RI) indices at the level of the uterine arteries. RESULTS No significant differences in RI, PI and endometrial thickness were observed in the raloxifene group during the 6-month treatment. In the tibolone group, PI and RI values decreased linearly from baseline to the end of the study, whereas the endometrial thickness was significantly increased during the first 3 months remaining unaltered thereafter. Comparisons between the two study groups revealed significant percent change of values in the pre-treatment to month-3 period and no difference with regard to pre-treatment, month-3 and month-6 absolute values. CONCLUSION Raloxifene and tibolone exert dissimilar effects on uterine blood supply parameters and endometrial thickness.
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Affiliation(s)
- Dimitrios Botsis
- 2nd Department of Obstetrics and Gynecology, University of Athens, Aretaieion Hospital, 76 Vas. Sofias Av., Athens 11528, Greece
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