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Grosso A, Cerveri I, Cazzoletti L, Zanolin ME, Mattioli V, Piloni D, Gini E, Albicini F, Ronzoni V, Jarvis D, Janson C, Corsico AG. Inhaled corticosteroids and risk of osteoporosis in late-middle-aged subjects: a multicenter European cohort study. Minerva Med 2023; 114:15-21. [PMID: 34114441 DOI: 10.23736/s0026-4806.21.07431-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Inhaled corticosteroids have been widely used for the regular treatment of asthma and chronic obstructive pulmonary diseases (COPD) over the past few decades. To date, studies investigating the effects of inhaled corticosteroids (ICS) on bone in populations including asthma and COPD patients, show conflicting results. The skeletal effects of ICS remain poorly understood. We assessed the association between ICS exposure and self-reported osteoporosis diagnosis in a European cohort study. METHODS The analysis was carried out by using clinical and questionnaire data available for subjects participating in the ECRHS III (European Community Respiratory Health Survey) with age >55 years. RESULTS Among the 3004 enrolled subjects, 245 were ICS users with an exposure ≥12 months. Osteoporosis was reported by 16 subjects in the ICS group (6.5%) and by 167 in the not exposed group (6.1%). The adjusted risk of osteoporosis in ICS users (≥12 months) was not greater in exposed subjects when compared with the unexposed ones (OR=1.02, 95CI%: 0.51, 2.03). The same result was observed even when considering in the analysis a longer exposure to the ICS use (≥36.5 months, the median ICS exposure for all subjects). History of COPD, use of oral corticosteroids, Body Mass Index, smoking and physical activity did not show any evidence of an association with osteoporosis. CONCLUSIONS Our study did not show any significant association between long- term ICS use and self-reported diagnosis of osteoporosis in subjects aged >55 years. To explore the real effect of ICS on bone status, further studies are needed, especially in the long-term ICS exposure.
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Affiliation(s)
- Amelia Grosso
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy -
| | - Isa Cerveri
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Lucia Cazzoletti
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Maria E Zanolin
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Veronica Mattioli
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Davide Piloni
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Erica Gini
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Federica Albicini
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Vanessa Ronzoni
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Debbie Jarvis
- Department of Population Health and Occupational Diseases, National Heart and Lung Institute, Imperial College London, London, UK
| | - Christer Janson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Angelo G Corsico
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
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Sendrasoa FA, Ranaivo IM, Raherivelo AJ, Rapelanoro Rabenja F, Ramarozatovo LS. Adverse Effects of Long-Term Oral Corticosteroids in the Department of Dermatology, Antananarivo, Madagascar. Clin Cosmet Investig Dermatol 2021; 14:1337-1341. [PMID: 34594123 PMCID: PMC8478084 DOI: 10.2147/ccid.s332201] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 09/13/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Long-term oral corticosteroids have an important role in dermatological care in Madagascar. However, significant adverse effects have been associated with continuous exposure to oral corticosteroids. OBJECTIVE We aim to assess the adverse effects of long-term corticosteroid therapy in patients seen in the Department of Dermatology at the University Hospital Joseph Raseta Befelatanana Antananarivo (UH/JRB), Madagascar, and to identify the risk factors associated with these adverse effects. METHODS A cross-sectional study was conducted during 4 months to assess the adverse effects of long-term corticosteroid therapy in patients seen in the Department of Dermatology. Patients treated with oral corticosteroids for more than 3 months were included in our study. RESULTS The prevalence of long-term use of oral corticosteroids in the Department of Dermatology of UH/JRB was 34.28%. A total of 51 patients were included and adverse effects occurred in 64.70% of this population. Repetitive infections and cutaneous adverse reactions were the most frequent adverse effects, in 23.52% and 11.76% of cases, respectively. There were no correlations between age, gender, type of disease treated, the molecule used or daily dose and the risk of adverse effects. Patients who received a corticosteroid dose of more than 40 mg daily (longer than 3 months) or a high cumulative dose of corticosteroids had a high risk of adverse effects. CONCLUSION Repetitive infections and cutaneous adverse reactions are the most frequent adverse effects of long-term oral corticosteroid use. Prescribing the lowest effective dose may reduce the risk of these adverse effects. Furthermore, prevention of the adverse effects of corticosteroids through diet, calcium and vitamin D supplementation is strongly recommended during long-term oral corticosteroid therapy.
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Affiliation(s)
| | - Irina Mamisoa Ranaivo
- Department of Dermatology, Faculty of Medicine, University of Antananarivo, Antananarivo, Madagascar
| | | | | | - Lala Soavina Ramarozatovo
- Department of Dermatology, Faculty of Medicine, University of Antananarivo, Antananarivo, Madagascar
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Chen Y, Zhu J, Zhou Y, Peng J, Wang B. Efficacy and Safety of Denosumab in Osteoporosis or Low Bone Mineral Density Postmenopausal Women. Front Pharmacol 2021; 12:588095. [PMID: 33935694 PMCID: PMC8080120 DOI: 10.3389/fphar.2021.588095] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 02/05/2021] [Indexed: 11/13/2022] Open
Abstract
Denosumab, a human monoclonal antibody, acts against the receptor activator of nuclear factor-κB ligand and is a promising antiresorptive agent in patients with osteoporosis. This study aimed to update the efficacy and safety of denosumab vs. placebo in osteoporosis or low bone mineral density (BMD) postmenopausal women. PubMed, Embase, Cochrane library, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) reporting the efficacy and safety data of denosumab vs. placebo in osteoporosis or low BMD postmenopausal women. A random-effects model was used to calculate pooled weight mean differences (WMDs) or relative risks (RRs) with corresponding 95% confidence intervals (CIs) for treatment effectiveness of denosumab vs. placebo. Eleven RCTs including 12,013 postmenopausal women with osteoporosis or low BMD were preferred for the final meta-analysis. The summary results indicated that the percentage change of BMD in the denosumab group was greater than that of BMD in placebo at 1/3 radius (WMD: 3.43; 95%CI: 3.24–3.62; p < 0.001), femoral neck (WMD: 3.05; 95%CI: 1.78–4.33; p < 0.001), lumbar spine (WMD: 6.25; 95%CI: 4.59–7.92; p < 0.001), total hip (WMD: 4.36; 95%CI: 4.07–4.66; p < 0.001), trochanter (WMD: 6.00; 95%CI: 5.95–6.05; p < 0.001), and total body (WMD: 3.20; 95%CI: 2.03–4.38; p < 0.001). Moreover, denosumab therapy significantly reduced the risk of clinical fractures (RR: 0.57; 95%CI: 0.51–0.63; p < 0.001), nonvertebral fracture (RR: 0.83; 95%CI: 0.70–0.97; p = 0.018), vertebral fracture (RR: 0.32; 95%CI: 0.25–0.40; p < 0.001), and hip fracture (RR: 0.61; 95%CI: 0.37–0.98; p = 0.042). Finally, denosumab did not cause excess risks of adverse events. These findings suggested that postmenopausal women receiving denosumab had increased BMDs and reduced fractures at various sites without inducing any adverse events.
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Affiliation(s)
- Yi Chen
- Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Jun Zhu
- Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Yiqin Zhou
- Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Jinhui Peng
- Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Bo Wang
- Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
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Patel MS, Gutman MJ, Abboud JA. Orthopaedic Considerations Following COVID-19: Lessons from the 2003 SARS Outbreak. JBJS Rev 2020; 8:e2000052. [PMID: 32759612 DOI: 10.2106/jbjs.rvw.20.00052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Manan S Patel
- 1Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Wang Y, Ding H, Wang X, Wei Z, Feng S. Associated Factors for Osteoporosis and Fracture in Chinese Elderly. Med Sci Monit 2019; 25:5580-5588. [PMID: 31350990 PMCID: PMC6681684 DOI: 10.12659/msm.914182] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background The factors associated with osteoporosis are poorly understood in the Chinese population. This study aimed to examine the factors associated with osteoporosis and with fractures in a Chinese elderly population. Material/Methods This was a cross-sectional study of elderly people living in Tianjin between 2012 and 2014. Bone mineral density was measured by dual X-ray absorptiometry. The subjects completed a questionnaire about lifestyle habits, personal and family medical history, calcium intake, and exercising. Data were gathered on occurrence of fracture at 5 years or August 2018, whichever occurred first. Results There were 298 individuals with osteoporosis (18.5% male, median age 67 years) and 397 without (46.3% male, median age 62 years). Male sex (OR=0.051, 95% CI: 0.021–0.126), age (OR=1.049, 95% CI: 1.099–1.202), being divorced/widowed (OR=2.445, 95% CI: 1.219-4.904), digestive ulcer history (OR=3.805, 95% CI: 1.539–9.405), family history of hunchback (OR=2.659, 95% CI: 1.145–6.175), family history of osteoarthropathy (OR=4.222, 95% CI: 2.128–8.375), fracture history (OR=2.138, 95% CI: 1.307–3.496), drinking green tea (OR=0.352, 95% CI: 0.217–0.574), and exercising (OR=0.303, 95% CI: 0.193–0.475) were independently associated with osteoporosis. Digestive ulcer history (OR=3.183, 95% CI: 1.178–8.5992), exercising (OR=0.354, 95% CI: 0.139–0.903), and taking calcium supplements during follow-up (OR=0.262, 95% CI: 0.112–0.611) were independently associated with fractures in patients with osteoporosis. Conclusions Female sex, age, marital status, history of digestive ulcer and fracture, and family history of hunchback and osteoarthropathy are associated with osteoporosis among elderly subjects, while drinking green tea and exercising are inversely associated. Among the patients with osteoporosis, a history of digestive ulcer is associated with fractures, while exercising and taking calcium supplements are inversely associated.
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Affiliation(s)
- Yuqiang Wang
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin, China (mainland).,Department of Orthopedic Surgery, Affiliated Hospital of Logistics, University of Chinese Armed Police Force, Tianjin, China (mainland)
| | - Han Ding
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin, China (mainland)
| | - Xiaohua Wang
- Department of Neurological, Intensive Care Unit, Tianjin Huanhu Hospital, Tianjin, China (mainland)
| | - Zhijian Wei
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin, China (mainland)
| | - Shiqing Feng
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin, China (mainland)
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Chen YW, Ramsook AH, Coxson HO, Bon J, Reid WD. Prevalence and Risk Factors for Osteoporosis in Individuals With COPD: A Systematic Review and Meta-analysis. Chest 2019; 156:1092-1110. [PMID: 31352034 DOI: 10.1016/j.chest.2019.06.036] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 05/10/2019] [Accepted: 06/21/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Osteoporosis is prevalent in individuals with COPD. Updated evidence is required to complement the previous systematic review on this topic to provide best practice. The aim of this systematic review and meta-analysis was to quantitatively synthesize data from studies with respect to the prevalence and risk factors for osteoporosis among individuals with COPD. METHODS EMBASE, CINAHL, MEDLINE, and PubMed databases were searched for articles containing the key words "COPD," "osteoporosis," "prevalence," and "risk factor." Eligibility screening, data extraction, and quality assessment of the retrieved articles were conducted independently by two reviewers. Meta-analyses were performed to determine osteoporosis prevalence and risk factors in individuals with COPD. Meta-regression analyses were conducted to explore the sources of heterogeneity. RESULTS The pooled global prevalence from 58 studies was 38% (95% CI, 34-43). The presence of COPD increased the likelihood of having osteoporosis (OR, 2.83). Other significant risk factors for osteoporosis in COPD patients were BMI < 18.5 kg/m2 (OR, 4.26) and the presence of sarcopenia (OR, 3.65). CONCLUSIONS Osteoporosis is prevalent in individuals with COPD, and the prevalence seems to be high and similar in many countries. Patients with COPD should be screened for osteoporosis and contributing risk factors.
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Affiliation(s)
- Yi-Wen Chen
- Department of Sports Medicine, China Medical University, Taichung, Taiwan.
| | - Andrew H Ramsook
- Department of Physical Therapy, Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada
| | - Harvey O Coxson
- Department of Radiology, Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada
| | - Jessica Bon
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA; VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - W Darlene Reid
- Department of Physical Therapy, Faculty of Medicine, Interdepartment Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; KITE - Toronto Rehab-University Health Network, Toronto, ON, Canada
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Gonçalves PA, Dos Santos Neves R, Neto LV, Madeira M, Guimarães FS, Mendonça LMC, Lopes AJ, Farias MLF. Inhaled glucocorticoids are associated with vertebral fractures in COPD patients. J Bone Miner Metab 2018; 36:454-461. [PMID: 28766137 DOI: 10.1007/s00774-017-0854-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 06/20/2017] [Indexed: 11/29/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is an independent risk factor for osteoporosis. Oral glucocorticoids are deleterious to bone; however, the impact of inhaled glucocorticoids (ICS) remains unclear. Our objective was to determine whether ICS contribute to osteoporosis and fragility fractures. Sixty-one COPD patients, 35 current users of ICS and 26 who had never received glucocorticoids, were evaluated for bone mineral density (BMD) and body composition and underwent vertebral fracture assessment (VFA). The risk factors for bone disease considered for analysis were age, gender, ICS use, body mass index (BMI), muscle mass index (MMI), and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) category. The Fracture Risk Assessment Tool (FRAX) calculation tool for the Brazilian population was also employed. The groups did not differ regarding gender, BMI, MMI, GOLD class, lowest values of the BMD T-score and Z-score, prevalence of osteoporosis, or low BMD for age. Vertebral fractures were identified via VFA in seven patients using ICS and in none of those not receiving glucocorticoids (p = 0.02). There was a trend for an association between MMI and osteoporosis (p = 0.05) and for a progressive decrease in the BMD Z-score according to the COPD severity assessed via the GOLD score (p = 0.08). Vertebral fractures were not associated with osteoporosis (p = 0.69) or low MMI (p = 0.12). The fracture risk was not estimated by FRAX. ICS may lead to bone fragility before a significant decrease in BMD. Low muscle mass and COPD severity may contribute to bone disease.
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Affiliation(s)
- Pedro Assed Gonçalves
- Division of Endocrinology, Federal University of Rio de Janeiro (UFRJ), Rua da Passagem, 75, Apt. 603, Bloco A, Botafogo, Rio de Janeiro, RJ, 22.290-030, Brazil.
| | - Rafael Dos Santos Neves
- Rehabilitation Sciences Post-Graduation Program, Augusto Motta University Center (UNISUAM), Rio de Janeiro, Brazil
| | - Leonardo Vieira Neto
- Division of Endocrinology, Federal University of Rio de Janeiro (UFRJ), Rua da Passagem, 75, Apt. 603, Bloco A, Botafogo, Rio de Janeiro, RJ, 22.290-030, Brazil
| | - Miguel Madeira
- Division of Endocrinology, Federal University of Rio de Janeiro (UFRJ), Rua da Passagem, 75, Apt. 603, Bloco A, Botafogo, Rio de Janeiro, RJ, 22.290-030, Brazil
| | - Fernando Silva Guimarães
- Rehabilitation Sciences Post-Graduation Program, Augusto Motta University Center (UNISUAM), Rio de Janeiro, Brazil
| | | | - Agnaldo Jose Lopes
- Rehabilitation Sciences Post-Graduation Program, Augusto Motta University Center (UNISUAM), Rio de Janeiro, Brazil
- Division of Pneumology, State University of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Maria Lucia Fleiuss Farias
- Division of Endocrinology, Federal University of Rio de Janeiro (UFRJ), Rua da Passagem, 75, Apt. 603, Bloco A, Botafogo, Rio de Janeiro, RJ, 22.290-030, Brazil
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Oshagbemi OA, Burden AM, Shudofsky KN, Driessen JHM, Vestergaard P, Krings A, Franssen FME, van den Bergh J, de Vries F. Use of high-dose intermittent systemic glucocorticoids and the risk of fracture in patients with chronic obstructive pulmonary disease. Bone 2018; 110:238-243. [PMID: 29462672 DOI: 10.1016/j.bone.2018.02.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 01/18/2018] [Accepted: 02/13/2018] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) is characterised by persistent airflow obstruction and respiratory symptoms. While short course systemic GCs are prescribed in patients with acute COPD exacerbations, little is known of the risk of fractures with intermittent exposure to high-dose GC and the effect of proxies of disease severity. METHODS A case-control study was conducted using the Danish National Hospital Discharge Registry (NHDR) between January 1996 to December 2011. Conditional logistics regression models were used to derive adjusted odds ratios (OR) risk of fractures in subjects with COPD stratified by intermittent high-dose, and proxies of disease severity. RESULT A total of 635,536 cases and the same number of controls were identified (mean age 67.5±13.8, 65% female). COPD patients with intermittent use of high average daily dose oral glucocorticoids did not have an increased risk of any, osteoporotic, hip or clinically symptomatic vertebral fracture compared to non-COPD patients (adj. OR 0.65; 95% CI: 0.50-0.86, 0.70; 95% CI: 0.70-0.99, 1.17; 95% CI: 0.59-2.32, 1.98; 95% CI: 0.59-6.65 respectively). We identified an elevated risk of osteoporotic fracture among patients who visited the emergency unit (adj. OR 1.47; 95% CI 1.20-1.79) or were hospitalised in the past year for COPD (adj. OR 1.76; 95% CI 1.66-1.85). Current GC use among COPD patients was associated with an increased risk of osteoporotic, hip and clinically symptomatic vertebral fractures compared to patients without COPD. CONCLUSION Intermittent high-dose GCs was not associated with an increased risk of any, osteoporotic, hip or clinically symptomatic vertebral fractures in patients with COPD. Current GC use was however associated with an increased risk of hip and clinically symptomatic vertebral fractures. Therefore, emphasis on prophylactic treatment of fractures may not be essential in patients with COPD receiving intermittent dose of GCs, whereas this should be considered for high-dose long-term users with advanced COPD disease stage, postmenopausal women and men over 40years.
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Affiliation(s)
- Olorunfemi A Oshagbemi
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands
| | - Andrea M Burden
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands
| | - Kimberly N Shudofsky
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Clinical Pharmacy, Atrium Medical Centre, Heerlen, The Netherlands
| | - Johanna H M Driessen
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands; NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Peter Vestergaard
- Departments of Clinical Medicine and Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Andreas Krings
- Department of Clinical Pharmacy, Atrium Medical Centre, Heerlen, The Netherlands
| | - Frits M E Franssen
- Department of Research and Education, CIRO+, Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands
| | - Joop van den Bergh
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; REVAL - Rehabilitation Research Centre and BIOMED - Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Frank de Vries
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands; MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, United Kingdom.
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Caplan A, Fett N, Rosenbach M, Werth VP, Micheletti RG. Prevention and management of glucocorticoid-induced side effects: A comprehensive review: A review of glucocorticoid pharmacology and bone health. J Am Acad Dermatol 2017; 76:1-9. [PMID: 27986132 DOI: 10.1016/j.jaad.2016.01.062] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 01/28/2016] [Accepted: 01/29/2016] [Indexed: 01/29/2023]
Abstract
Systemic glucocorticoids are an essential therapy for a range of conditions, but their multiple side effects can produce significant morbidity for patients. The objective of this review is to discuss these side effects while addressing 3 questions: 1) What dose and duration of glucocorticoid therapy should prompt concern for individual side effects?; 2) How should clinicians counsel patients about these complications?; and 3) How can these problems be prevented or managed? To accomplish these objectives, we have created a series of tables and algorithms based on a review of relevant data to guide counseling, prophylaxis, and management of 11 glucocorticoid side effects. The first article in this 4-part continuing medical education series begins with a review of glucocorticoid pharmacology followed by a discussion of bone health (ie, osteoporosis and osteonecrosis).
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Affiliation(s)
- Avrom Caplan
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicole Fett
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | - Misha Rosenbach
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Victoria P Werth
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert G Micheletti
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania.
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10
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Okazaki R, Watanabe R, Inoue D. Osteoporosis Associated with Chronic Obstructive Pulmonary Disease. J Bone Metab 2016; 23:111-20. [PMID: 27622174 PMCID: PMC5018603 DOI: 10.11005/jbm.2016.23.3.111] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 07/02/2016] [Indexed: 12/23/2022] Open
Abstract
Recent epidemiological studies have revealed that osteoporosis is closely associated with common chronic diseases including diabetes, hypertension, chronic kidney disorders, and chronic obstructive pulmonary disease (COPD). COPD is a chronic inflammatory airway disease but now well known to be associated with various systemic comorbidities including osteoporosis. Osteoporosis and osteoporotic fractures are extremely common in COPD patients, which have significant impacts on their quality of life (QOL), activities of daily life (ADL), respiratory function, and possibly their prognosis. COPD-associated osteoporosis is however extremely under-recognized, hence undertreated. Recent studies have suggested that both decreased bone mineral density (BMD) and impaired bone quality compromise bone strength causing fractures in COPD. In COPD patients, various general clinical risk factors for osteoporosis are present including smoking, older age, low body weight, and physical inactivity. In addition, disease-related risk factors such as decreased pulmonary function, inflammation, glucocorticoid use and vitamin D deficiency/insufficiency have been linked to the development of osteoporosis in COPD. Increased awareness of osteoporosis in COPD, especially that of high prevalence of vertebral fractures is called upon among general physicians as well as pulmonologists. Routine screening for osteoporosis and risk assessment of fractures will enable physicians to diagnose COPD patients with comorbid osteoporosis at an early stage. Timely prevention of developing osteoporosis together with appropriate treatment of established osteoporosis may improve QOL and ADL of the COPD patients, preserve their lung function and eventually result in better prognosis in these patients.
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Affiliation(s)
- Ryo Okazaki
- Third Department of Medicine, Teikyo University Chiba Medical Center, Japan
| | - Reiko Watanabe
- Third Department of Medicine, Teikyo University Chiba Medical Center, Japan
| | - Daisuke Inoue
- Third Department of Medicine, Teikyo University Chiba Medical Center, Japan
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Liu SF, Kuo HC, Liu GH, Ho SC, Chang HC, Huang HT, Chen YM, Huang KT, Chen KY, Fang WF, Lin MC. Inhaled corticosteroids can reduce osteoporosis in female patients with COPD. Int J Chron Obstruct Pulmon Dis 2016; 11:1607-14. [PMID: 27478374 PMCID: PMC4951067 DOI: 10.2147/copd.s106054] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Whether the use of inhaled corticosteroids (ICSs) in patients with COPD can protect from osteoporosis remains undetermined. The aim of this study is to assess the incidence of osteoporosis in patients with COPD with ICS use and without. Patients and methods This is a retrospective cohort and population-based study in which we extracted newly diagnosed female patients with COPD between 1997 and 2009 from Taiwan’s National Health Insurance (TNHI) database between 1996 and 2011 (International Classification of Diseases, Ninth Revision – Clinical Modification [ICD-9-CM] 491, 492, 496). The patients with COPD were defined by the presence of two or more diagnostic codes for COPD within 12 months on either inpatient or outpatient service claims submitted to TNHI. Patients were excluded if they were younger than 40 years or if osteoporosis had been diagnosed prior to the diagnosis of COPD and cases of asthma (ICD-9 CM code 493.X) before the index date. These enrolled patients were followed up till 2011, and the incidence of osteoporosis was determined. The Cox proportional hazards regression model was also used to estimate hazard ratios (HRs) for incidences of lung cancer. Results Totally, 10,723 patients with COPD, including ICS users (n=812) and nonusers (n=9,911), were enrolled. The incidence rate of osteoporosis per 100,000 person years is 4,395 in nonusers and 2,709 in ICS users (HR: 0.73, 95% confidence interval [CI]: 0.63–084). The higher ICS dose is associated with lower risk of osteoporosis (0 mg to ≤20 mg, HR: 0.84, 95% CI: 0.69–1.04; >20 mg to ≤60 mg, HR: 0.78, 95% CI: 0.59–1.04; and >60 mg, HR: 0.72, 95% CI: 0.55–0.96; P for trend =0.0023) after adjusting for age, income, and medications. The cumulative osteoporosis probability significantly decreased among the ICS users when compared with the nonusers (P<0.001). Conclusion Female patients with COPD using ICS have a dose–response protective effect for osteoporosis.
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Affiliation(s)
- Shih-Feng Liu
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine; Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital; Chang Gung University College of Medicine
| | - Ho-Chang Kuo
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine; Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital; Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital
| | | | - Shu-Chen Ho
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital
| | - Huang-Chih Chang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine; Chang Gung University College of Medicine
| | - Hung-Tu Huang
- Department of Anatomy, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, Republic of China
| | - Yu-Mu Chen
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine
| | - Kuo-Tung Huang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine; Chang Gung University College of Medicine
| | - Kuan-Yi Chen
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital
| | - Wen-Feng Fang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine; Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital; Chang Gung University College of Medicine
| | - Meng-Chih Lin
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine; Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital; Chang Gung University College of Medicine
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Inoue D, Watanabe R, Okazaki R. COPD and osteoporosis: links, risks, and treatment challenges. Int J Chron Obstruct Pulmon Dis 2016; 11:637-48. [PMID: 27099481 PMCID: PMC4820217 DOI: 10.2147/copd.s79638] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory airway disease associated with various systemic comorbidities including osteoporosis. Osteoporosis and its related fractures are common and have significant impacts on quality of life and even respiratory function in patients with COPD. COPD-associated osteoporosis is however extremely undertreated. Recent studies have suggested that both decreased bone mineral density (BMD) and impaired bone quality contribute to bone fragility, causing fractures in COPD patients. Various clinical risk factors of osteoporosis in COPD patients, including older age, emaciation, physical inactivity, and vitamin D deficiency, have also been described. It is critically important for pulmonologists to be aware of the high prevalence of osteoporosis in COPD patients and evaluate them for such fracture risks. Routine screening for osteoporosis will enable physicians to diagnose COPD patients with comorbid osteoporosis at an early stage and give them appropriate treatment to prevent fracture, which may lead to improved quality of life as well as better long-term prognosis.
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Affiliation(s)
- Daisuke Inoue
- Division of Endocrinology and Metabolism, Third Department of Medicine, Teikyo University Chiba Medical Center, Ichihara, Chiba, Japan
| | - Reiko Watanabe
- Division of Endocrinology and Metabolism, Third Department of Medicine, Teikyo University Chiba Medical Center, Ichihara, Chiba, Japan
| | - Ryo Okazaki
- Division of Endocrinology and Metabolism, Third Department of Medicine, Teikyo University Chiba Medical Center, Ichihara, Chiba, Japan
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13
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Rawal J, McPhail MJW, Ratnayake G, Chan P, Moxham J, Harridge SDR, Hart N, Montgomery HE, Puthucheary ZA. A pilot study of change in fracture risk in patients with acute respiratory distress syndrome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:165. [PMID: 25888496 PMCID: PMC4411936 DOI: 10.1186/s13054-015-0892-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 03/20/2015] [Indexed: 01/17/2023]
Abstract
Introduction Acute skeletal muscle wasting is a major contributor to post critical illness physical impairment. However, the bone response remains uncharacterized. We prospectively investigated the early changes in bone mineral density (BMD) and fracture risk in critical illness. Methods Patients were prospectively recruited ≤24 hours following intensive care unit (ICU) admission to a university teaching or a community hospital (August 2009 to April 2011). All were aged >18 years and expected to be intubated for >48 hours, spend >7 days in critical care and survive ICU admission. Forty-six patients were studied (55.3% male), with a mean age of 54.4 years (95% confidence interval (CI): 49.1 to 59.6) and an APACHE II score of 23.9 (95% CI: 22.4 to 25.5). Calcaneal dual X-ray absorptiometry (DXA) assessment of BMD was performed on day 1 and 10. Increase in fracture risk was calculated from the change in T-score. Results BMD did not change between day 1 and 10 in the cohort overall (0.434 (95% CI: 0.405 to 0.463) versus 0.425 g/cm2 (95% CI: 0.399 to 0.450), P = 0.58). Multivariable logistical regression revealed admission corrected calcium (odds ratio (OR): 1.980 (95% CI: 1.089 to 3.609), P = 0.026) and admission PaO2-to-FiO2 ratio (OR: 0.916 (95% CI: 0.833 to 0.998), P = 0.044) to be associated with >2% loss of BMD. Patients with acute respiratory distress syndrome had a greater loss in BMD than those without (−2.81% (95% CI: −5.73 to 0.118%), n = 34 versus 2.40% (95% CI: 0.204 to 4.586%), n = 12, P = 0.029). In the 34 patients with acute respiratory distress syndrome, fracture risk increased by 19.4% (95% CI: 13.9 to 25.0%). Conclusions Patients with acute respiratory distress syndrome demonstrated early and rapid bone demineralisation with associated increase in fracture risk. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0892-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jaikitry Rawal
- Institute of Health and Human Performance, University College London, Room 443, 74 Huntley Street, London, WC1E 6AU, UK.
| | - Mark J W McPhail
- Department of Hepatology and Gastroenterology, St Mary's Hospital, Imperial College London, praed street, London, W2 1NY, UK. .,Institute of Liver Studies, King's College Hospital NHS Foundation Trust, denmark hill, London, SE59RS, UK.
| | - Gamumu Ratnayake
- NIHR Comprehensive Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, Westminster Bridge Road, London, SE17EH, UK.
| | - Pearl Chan
- Institute of Health and Human Performance, University College London, Room 443, 74 Huntley Street, London, WC1E 6AU, UK.
| | - John Moxham
- King's College London School of Medicine, denmark hill, London, SE59RS, UK.
| | - Stephen D R Harridge
- Centre of Human and Aerospace Physiological Sciences, King's College London, Great Maze Pond, London, SE1 9RT, UK.
| | - Nicholas Hart
- NIHR Comprehensive Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, Westminster Bridge Road, London, SE17EH, UK.
| | - Hugh E Montgomery
- Institute of Health and Human Performance, University College London, Room 443, 74 Huntley Street, London, WC1E 6AU, UK.
| | - Zudin A Puthucheary
- Institute of Health and Human Performance, University College London, Room 443, 74 Huntley Street, London, WC1E 6AU, UK. .,Division of Respiratory and Critical Care, National University Hospital, 1E Lower Kent Ridge Road, Singapore, 119228, Singapore.
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14
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Musculoskeletal disorders in chronic obstructive pulmonary disease. BIOMED RESEARCH INTERNATIONAL 2014; 2014:965764. [PMID: 24783225 PMCID: PMC3982416 DOI: 10.1155/2014/965764] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 02/13/2014] [Indexed: 12/17/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by airway obstruction and inflammation but also accompanied by several extrapulmonary consequences, such as skeletal muscle weakness and osteoporosis. Skeletal muscle weakness is of major concern, since it leads to poor functional capacity, impaired health status, increased healthcare utilization, and even mortality, independently of lung function. Osteoporosis leads to fractures and is associated with increased mortality, functional decline, loss of quality of life, and need for institutionalization. Therefore, the presence of the combination of these comorbidities will have a negative impact on daily life in patients with COPD. In this review, we will focus on these two comorbidities, their prevalence in COPD, combined risk factors, and pathogenesis. We will try to prove the clustering of these comorbidities and discuss possible preventive or therapeutic strategies.
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15
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EL-Gazzar AG, Abdalla ME, Almahdy MA. Study of Osteoporosis in chronic obstructive pulmonary disease. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2013. [DOI: 10.1016/j.ejcdt.2013.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Liang B, Feng Y. The association of low bone mineral density with systemic inflammation in clinically stable COPD. Endocrine 2012; 42:190-5. [PMID: 22198912 DOI: 10.1007/s12020-011-9583-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 12/07/2011] [Indexed: 02/05/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is known to be a systemic inflammatory disease which affects the function of many organs, and the low bone mineral density (BMD) may be the result of systemic inflammation. The aim of the present study was to explore the association of BMD with systemic inflammation in patients with clinically stable COPD. BMD and inflammatory markers, including C-reactive protein, tumor necrosis factor-alpha (TNF-α), and interleukin-6 (IL-6), were determined in all the recruited patients with clinically stable COPD. The patients were classified according to T scores, and the relationship between BMD with markers of systemic inflammation and that with other osteoporosis risk factors was assessed. There were no differences in age, female sex, body composition, tobacco exposure, and the use of respiratory medications among these groups. As the abnormality of BMD went severer, COPD patients with osteoporosis had significantly higher levels of systemic inflammation than those with either normal BMD or osteopenia. The presence of systemic inflammation was associated with a greater likelihood of low BMD, and multivariate logistic regression analysis showed that TNF-α and IL-6 were independent predictors of low BMD. It can be concluded that systemic inflammation is a significantly independent predictor of low BMD in patients with clinically stable COPD.
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Affiliation(s)
- Binmiao Liang
- Department of Respiratory Medicine, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
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Ruas G, Fatureto MC, Santana JH, Di Lorenzo VAP, Jamami M. Avaliação da prevalência de osteoporose e fraturas vertebrais em pacientes portadores de doença pulmonar obstrutiva crônica. FISIOTERAPIA EM MOVIMENTO 2012. [DOI: 10.1590/s0103-51502012000200015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUÇÃO: A osteoporose é uma doença progressiva que contribui para o surgimento de fraturas vertebrais. OBJETIVOS: Avaliar a prevalência da osteoporose, fraturas vertebrais e intensidade da dor nas regiões da coluna vertebral em pacientes com DPOC moderada e grave, além de verificar se há relação entre tais variáveis e a gravidade da obstrução pulmonar. MATERIAIS E MÉTODOS: Foram avaliados 34 indivíduos portadores de DPOC (GDPOC) e 33 indivíduos saudáveis (GC), por meio da densitometria óssea e radiografias da coluna torácica e lombar. RESULTADOS: Não houve diferenças significativas intergrupos nos dados antropométricos. O GDPOC apresentou valores menores nas variáveis espirométricas, na densidade mineral óssea (DMO) e no escore-T, quando comparado com o GC (p < 0,05; Teste t Student); além disso, não se observou correlação entre VEF1 e DMO e escore-T (Correlação de Pearson, p > 0,05). Verificou-se uma alta prevalência de osteoporose, sendo que 20 indivíduos (59%) com obstrução moderada apresentaram na coluna lombar, l (3%) no colo do fêmur e l (3%) no trocânter; 4 (12%) com obstrução pulmonar grave na coluna lombar, l (3%) no colo do fêmur e l (3%) no trocânter. Vinte indivíduos (59%) do GDPOC com osteoporose apresentaram fraturas de graus I e II, 4 (12%) grau III (k = 0,90; IC: 95%) e 3 indivíduos do GDPOC relataram presença de dor com intensidade "leve" na região toracolombar, enquanto 21 apresentaram fraturas vertebrais osteoporóticas assintomáticas. CONCLUSÃO Concluímos que os indivíduos com DPOC de moderada a grave apresentaram, além do comprometimento pulmonar, diminuição da DMO e fraturas vertebrais osteoporóticas, o que indica a necessidade de se adotar medidas de prevenção da osteoporose nesses pacientes.
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18
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Graat-Verboom L, Smeenk FWJM, van den Borne BEEM, Spruit MA, Donkers-van Rossum AB, Aarts RPM, Wouters EFM. Risk factors for osteoporosis in Caucasian patients with moderate chronic obstructive pulmonary disease: a case control study. Bone 2012; 50:1234-9. [PMID: 22426499 DOI: 10.1016/j.bone.2012.02.638] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 02/23/2012] [Accepted: 02/29/2012] [Indexed: 01/10/2023]
Abstract
The prevalence of osteoporosis is high in chronic obstructive pulmonary disease (COPD) patients. The gold standard for the diagnosis of osteoporosis is bone mineral density (BMD) measurements as assessed by dual energy absorptiometry (DXA) scanning as well as vertebral fractures as assessed by instant vertebral assessment (IVA). The aim of this study was to compare COPD GOLD II patients (that is, patients with moderate COPD, stage II, according to the GOLD classification) with osteoporosis (cases) to COPD GOLD II patients without osteoporosis (controls) to identify risk factors for osteoporosis. The diagnosis of osteoporosis was based on BMD and vertebral fractures. Cases (n=49) were matched for gender, age and forced expiratory volume in the first second to controls (n=49). We assessed pulmonary function, body composition, vitamin D, emphysema score (by high-resolution computer tomography), medical history and medication use in all patients. Variables that were significantly different between the cases and controls were included in a logistic regression analysis. COPD patients with osteoporosis had a significantly lower body mass index (BMI) and higher residual volume as the percentage of total lung capacity (RV%TLC) compared to COPD patients without osteoporosis. Decreasing BMI and increasing RV%TLC increased the odds ratio for osteoporosis. Overweight and obese BMI values were protective for osteoporosis. Screening for osteoporosis should be performed even in moderate COPD patients, especially in those with a low BMI and/or a high RV%TLC.
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Affiliation(s)
- Lidwien Graat-Verboom
- Department of Respiratory Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands.
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Abstract
PURPOSE OF REVIEW Several large epidemiologic studies have shown an association between chronic obstructive pulmonary disease (COPD) and osteoporosis. Recent studies have further implied an emphysema-specific association with low bone mineral density independent of obstruction severity. RECENT FINDINGS This review will outline the studies demonstrating an independent association between radiographic emphysema and decreased bone mineral density and will discuss potential disease mechanisms, including systemic inflammation and immune-mediated factors, linking these disease processes. SUMMARY Radiographic emphysema should be considered an independent risk factor in studies examining the mechanisms underlying COPD-related bone loss. Future research focused on the relationship between emphysema and low bone mineral density could provide mechanistic insight and result in the development of targeted therapies designed to halt progression of both disease processes.
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20
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Graat-Verboom L, van den Borne BEEM, Smeenk FWJM, Spruit MA, Wouters EFM. Osteoporosis in COPD outpatients based on bone mineral density and vertebral fractures. J Bone Miner Res 2011; 26:561-8. [PMID: 20878771 DOI: 10.1002/jbmr.257] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
One of the extrapulmonary effects of chronic obstructive pulmonary disease (COPD) is osteoporosis. Osteoporosis is characterized by a low bone mineral density (BMD) and microarchitectural deterioration. Most studies in COPD patients use dual-energy X-ray absorptiometry (DXA) only to determine osteoporosis; therefore, microarchitectural changes without a low BMD are missed. The aim of this study was to determine the prevalence and correlates of osteoporosis in COPD patients based on DXA, spinal X-rays, and combinations thereof. DXA and spinal X-rays were obtained and pulmonary function tests, body composition, 6-minute walking distance, medical history, and medication use were assessed in 255 clinically stable COPD outpatients of a large teaching hospital in the Netherlands. Half of all patients had radiologic evidence of osteoporosis. Combining the results of DXA with spinal X-rays augmented the proportion of COPD patients with osteoporosis compared with both methods separately. The prevalence of osteoporosis was not significantly different after stratification for Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) stage. Most patients with osteoporosis did not receive pharmacologic treatment. Age, body mass index (BMI), and parathyroid hormone (PTH) level were significant independent correlates for osteoporosis. Chest physicians should be aware of the high prevalence of osteoporosis in patients with COPD, even in the presence of a low GOLD score, as well as especially in elder COPD patients with a low BMI and/or an increased PTH level.
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Affiliation(s)
- Lidwien Graat-Verboom
- Department of Respiratory Medicine, Catharina Hospital Eindhoven, Eindhoven, the Netherlands.
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21
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El-Darouti MA, Mashaly HM, El-Nabarawy E, El-Tawdy AM, Fawzy MM, Salem DSE, El-Kaffas KMH, El Sayed DAM. Comparative study of the effect of a daily steroid regimen versus a weekly oral pulse steroid regimen on morphological changes, blood sugar, bone mineral density and suprarenal gland activity. J DERMATOL TREAT 2010; 23:4-10. [PMID: 20819024 DOI: 10.3109/09546634.2010.487887] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The most serious side effects of systemic steroids include osteoporosis and suprarenal suppression. Many steroid regimens have been suggested to minimize these side effects; one of them is oral steroid pulse therapy. OBJECTIVE To compare the side effects of a daily oral steroid regimen versus a weekly oral steroid pulse regimen on bone mineral density and suprarenal suppression. METHODS Thirty patients with different skin diseases were divided into two groups: 15 for oral daily steroids (ODS) (group 1) and 15 for weekly oral pulse steroids (WOPS) (group 2). They were evaluated for bone mineral density (measured by DEXA) and suprarenal suppression (measured by serum cortisol level), morphological changes and blood sugar. Treatment was continued for 6 months to 3 years. RESULTS Cushingoid features in group 1 were observed in 73%, yet they were not detectable in group 2. Disturbed blood sugar in group 1 was 33% and 0% in group 2. The serum cortisol level was lower in patients on ODS than those on WOPS. The effect of WOPS on bone mineral density was very limited in comparison with the ODS. CONCLUSION Weekly oral steroid pulse therapy induces no significant bone loss and no suprarenal suppression and can be an alternative option in the treatment of chronic disorders requiring long-term oral steroid therapy.
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Kulak CAM, Borba VC, Jorgetti V, Dos Reis LM, Liu XS, Kimmel DB, Kulak J, Rabelo LM, Zhou H, Guo XE, Bilezikian JP, Boguszewski CL, Dempster DW. Skeletal microstructural abnormalities in postmenopausal women with chronic obstructive pulmonary disease. J Bone Miner Res 2010; 25:1931-40. [PMID: 20564248 DOI: 10.1002/jbmr.88] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is associated with osteoporosis and fragility fractures. The objectives of this study were to assess static and dynamic indices of cancellous and cortical bone structure in postmenopausal women with COPD. Twenty women with COPD who had not received chronic oral glucocorticoids underwent bone biopsies after double tetracycline labeling. Biopsies were analyzed by histomorphometry and µCT and compared with age-matched controls. Distribution of the patients according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) was: Type I (15%), Type II (40%), Type III (30%), and Type IV (15%). Mean (±SD) cancellous bone volume (15.20 ± 5.91 versus 21.34 ± 5.53%, p = .01), trabecular number (1.31 ± 0.26 versus 1.77 ± 0.51/mm, p = .003), and trabecular thickness (141 ± 23 versus 174 ± 36 µm, p = .006) were lower in patients than in controls. Connectivity density was lower in COPD (5.56 ± 2.78 versus 7.94 ± 3.08/mm, p = .04), and correlated negatively with smoking (r = -0.67; p = .0005). Trabecular separation (785 ± 183 versus 614 ± 36 µm, p = .01) and cortical porosity (4.11 ± 1.02 versus 2.32 ± 0.94 voids/mm(2); p < .0001) were higher in COPD while cortical width (458 ± 214 versus 762 ± 240 µm; p < .0001) was lower. Dynamic parameters showed significantly lower mineral apposition rate in COPD (0.56 ± 0.16 versus 0.66 ± 0.12 µm/day; p = .01). Patients with more severe disease, GOLD III and IV, presented lower bone formation rate than GOLD I and II (0.028 ± 0.009 versus 0.016+ 0.011 µm(3)/µm(2)/day; p = 04). This is the first evaluation of bone microstructure and remodeling in COPD. The skeletal abnormalities seen in cancellous and cortical bone provide an explanation for the high prevalence of vertebral fractures in this disease.
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Affiliation(s)
- Carolina A M Kulak
- Endocrine Division SEMPR, Department of Internal Medicine, Clinical Hospital of the Federal University of Parana, Curitiba, Brazil.
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Graat-Verboom L, Spruit MA, van den Borne BEEM, Smeenk FWJM, Martens EJ, Lunde R, Wouters EFM. Correlates of osteoporosis in chronic obstructive pulmonary disease: An underestimated systemic component. Respir Med 2010; 103:1143-51. [PMID: 19304474 DOI: 10.1016/j.rmed.2009.02.014] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Revised: 02/10/2009] [Accepted: 02/22/2009] [Indexed: 01/10/2023]
Abstract
RATIONALE Chronic obstructive pulmonary disease (COPD) patients are at increased risk of osteoporosis. Osteoporosis is under diagnosed and under treated in these patients and the underlying mechanisms remain unclear. To date, screening recommendations for osteoporosis in COPD patients are not available. OBJECTIVES To examine the prevalence of drug treatment of bone abnormalities as well as the clinical determinants of osteoporosis in COPD. METHODS COPD patients (n=554) consecutively entering pulmonary rehabilitation were included in this cross-sectional study. Medical history, current medication use, smoking status, lung function, bone mineral density, body composition and other clinical characteristics were assessed before entering pulmonary rehabilitation. Univariate- and multivariate multinomial logistic regression analyses were used to determine correlates of osteoporosis. MAIN RESULTS Twenty-one percent of patients had osteoporosis and 41% had osteopenia. Osteoporosis was pharmacologically under treated (82% of osteoporotic patients were not receiving bone medication). Independent predictors of osteoporosis were cachexia (OR: 12.1; 95%CI: 4.5-32.7; p<0.001), age between 55 and 65 years (OR: 6.0; 95%CI: 2.2-16.3; p<0.001) and over 65 years (OR: 11.7; 95%CI: 4.1-33.1; p=<0.001). Overweight (OR: 0.1; 95%CI: 0.05-0.4; p=0.001) and obesity (OR: 0.78; 95%CI: 0.02-0.4; p=0.002) showed a substantial protective effect. CONCLUSIONS The majority of COPD patients with osteoporosis entering pulmonary rehabilitation did not receive pharmacological treatment for osteoporosis. Cachectic COPD patients should be screened for osteoporosis, especially when over 55 years of age.
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Affiliation(s)
- Lidwien Graat-Verboom
- Department of Respiratory Medicine, University Medical Centre Maastricht, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands.
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Madsen H, Brixen K, Hallas J. Screening, prevention and treatment of osteoporosis in patients with chronic obstructive pulmonary disease â a population-based database study. CLINICAL RESPIRATORY JOURNAL 2010; 4:22-9. [DOI: 10.1111/j.1752-699x.2009.00138.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Franco CB, Paz-Filho G, Gomes PE, Nascimento VB, Kulak CAM, Boguszewski CL, Borba VZC. Chronic obstructive pulmonary disease is associated with osteoporosis and low levels of vitamin D. Osteoporos Int 2009; 20:1881-7. [PMID: 19300892 DOI: 10.1007/s00198-009-0890-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2008] [Accepted: 01/21/2009] [Indexed: 10/21/2022]
Abstract
UNLABELLED We did a cross-sectional analysis of chronic pulmonary obstructive disease (COPD) patients without chronic use of systemic glucocorticoids (CUG). Osteoporosis was found in 51% and bone mineral density (BMD) was correlated with severity of disease. Low levels of vitamin D were found in 94%. All COPD patients may benefit from vitamin D supplementation and screening for low BMD. INTRODUCTION Patients with chronic pulmonary obstructive disease have low bone mineral density, caused by chronic use of systemic glucocorticoids and hypovitaminosis D. However, patients without CUG may also have low BMD. METHODS We performed a cross-sectional analysis in 49 patients (21 men, 28 postmenopausal women), with COPD without CUG, from Brazil (25 degrees 25' S). Several markers of bone metabolism were measured, plus BMD. Osteoporosis risk factors and history of fractures were investigated. Respiratory function was assessed by venous gasometry, spirometry, and oximetry. BMD results were compared to those of 40 healthy non-smokers controls. RESULTS COPD patients had lower BMD at all sites (p < 0.01). Osteoporosis was observed in 51%. BMD independently correlated with stage of disease (lumbar spine, R = 0.38, p = 0.01; total femur, R = 0.36, p = 0.01; femoral neck, R = 0.40, p < 0.01). Ninety-four percent had low levels of vitamin D (<30 ng/mL) and 67% had secondary hyperparathyroidism. Vitamin D was correlated with oxygen saturation (R = 0.36, p = 0.01), with lower levels in those with saturation <88% (p = 0.01). CONCLUSION Patients with COPD without CUG have increased risk for osteoporosis. Such patients have hypovitaminosis D, which is correlated with the severity of disease. Screening for low BMD and vitamin D supplementation may be warranted to all COPD patients.
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Affiliation(s)
- C B Franco
- Serviço de Endocrinologia e Metabologia do Hospital de Clínicas da Universidade Federal do Paraná (SEMPR), Curitiba, Brazil, CEP: 80030-110
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Langhammer A, Forsmo S, Syversen U. Long-term therapy in COPD: any evidence of adverse effect on bone? Int J Chron Obstruct Pulmon Dis 2009; 4:365-80. [PMID: 19888355 PMCID: PMC2771707 DOI: 10.2147/copd.s4797] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Patients with COPD have high risk for osteoporosis and fractures. Hip and vertebral fractures might impair mobility, and vertebral fractures further reduce lung function. This review discusses the evidence of bone loss due to medical treatment opposed to disease severity and risk factors for COPD, and therapeutic options for the prevention and treatment of osteoporosis in these patients. A review of the English-language literature was conducted using the MEDLINE database until June 2009. Currently used bronchodilators probably lack adverse effect on bone. Oral corticosteroids (OCS) increase bone resorption and decrease bone formation in a dose response relationship, but the fracture risk is increased more than reflected by bone densitometry. Inhaled corticosteroids (ICS) have been associated with both increased bone loss and fracture risk. This might be a result of confounding by disease severity, but high doses of ICS have similar effects as equipotent doses of OCS. The life-style factors should be modified, use of regular OCS avoided and use of ICS restricted to those with evidenced effect and probably kept at moderate doses. The health care should actively reveal risk factors, include bone densitometry in fracture risk evaluation, and give adequate prevention and treatment for osteoporosis.
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Affiliation(s)
- Arnulf Langhammer
- HUNT Research Centre, Department of Public Health and General Practice, Norwegian University of Science and Technology (NTNU), Verdal, Norway.
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Vondracek SF, Voelkel NF, McDermott MT, Valdez C. The relationship between adipokines, body composition, and bone density in men with chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2009; 4:267-77. [PMID: 19657401 PMCID: PMC2719257 DOI: 10.2147/copd.s2745] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Osteoporosis is common in patients with chronic obstructive pulmonary disease (COPD). Data regarding the relationship between adipokines and bone mineral density (BMD) in this population is lacking. The purpose of this pilot study was to determine associations between the adipokines tumor necrosis factor-alpha (TNF-α), leptin, adiponectin and resistin, body composition, and BMD in men with severe COPD. This was a cross-sectional study of men with severe COPD who visited the University of Colorado Hospital COPD Center. Bone density and parameters of body composition were measured by dual-energy X-ray absorptiometry. Twenty-three men were included (mean age = 66 years, mean percent predicted forced expiratory volume in one second = 32%). On bivariate analysis, there was no association between TNF-α and BMD. Parameters of body composition and serum concentrations of leptin and adiponectin were significantly associated with total hip and spine bone density. However, with partial correlation analysis, total body mass was the only independent predictor of total hip BMD, explaining approximately 50% of the variability. Overall, 18 out of 23 men enrolled (78%) had low bone density by T-score, and nine (39%) were classified as having osteoporosis. The men with osteoporosis had lower parameters of body composition, lower mean serum leptin concentrations, and a greater impairment in measures of lung function compared to the men without osteoporosis. We conclude that the effect of adipokines on BMD does not appear to be independent of body mass. However, larger studies are needed to further evaluate the relationship between adipokines, body weight, and BMD in patients with COPD.
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Affiliation(s)
- Sheryl F Vondracek
- Department of Clinical Pharmacy, University of Colorado Denver, Aurora, CO, USA.
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Bolton C, Cannings-John R, Edwards P, Ionescu A, Evans W, Pettit R, Faulkner T, Stone M, Shale D. What community measurements can be used to predict bone disease in patients with COPD? Respir Med 2008; 102:651-7. [DOI: 10.1016/j.rmed.2007.12.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2007] [Revised: 12/19/2007] [Accepted: 12/21/2007] [Indexed: 11/28/2022]
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Cytokines, bone turnover markers and weight change in candidates for lung transplantation. Pulm Pharmacol Ther 2007; 21:188-95. [PMID: 17419084 DOI: 10.1016/j.pupt.2007.02.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2006] [Revised: 02/02/2007] [Accepted: 02/07/2007] [Indexed: 11/21/2022]
Abstract
Weight loss in chronic obstructive pulmonary disease (COPD) is associated with increased morbidity and may negatively affect bone mineral density. Increased serum levels of cytokines such as tumour necrosis factor (TNF)-alpha have been associated with weight loss and with bone resorption. We studied the association between systemic inflammation, markers for bone turnover and recent weight change in underweight (n=48) and normal-weight patients (n=23) candidates for lung transplantation where the majority (56%) had COPD. Osteoporosis or osteopenia was present in all the diagnostic groups. The resulting model of linear regression in COPD patients showed that for the 1-CTP (a marker of bone resorption) model, the total variation of 61% was explained by recent weight change, sTNF-alpha receptor(R)II, dose of prednisolon and age. The resulting model of linear regression in the whole group of patients showed that the total variation of 72% was explained by recent weight change, sTNF-alpha RI, diagnosis (COPD/other diagnosis), dose of prednisolon and C-reactive protein. In conclusion, our results showed that serum concentration of 1-CTP was positively associated with sTNF-alpha receptor II and negatively with recent weight change in patients with advanced COPD. Recent weight loss in both the underweight and normal-weight patients showed to be a more important contributor than recent weight loss only in underweight patients for explaining variations in 1-CTP.
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Cruse LM, Valeriano J, Vasey FB, Carter JD. Prevalence of evaluation and treatment of glucocorticoid-induced osteoporosis in men. J Clin Rheumatol 2007; 12:221-5. [PMID: 17023807 DOI: 10.1097/01.rhu.0000242778.65766.22] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Screening and treatment of glucocorticoid- induced osteoporosis in male patients is less than recommended despite available screening and therapies. OBJECTIVES We determined if men treated with long-term oral glucocorticoid therapy for any reason receive assessment and therapy for the prevention and treatment of glucocorticoid-induced osteoporosis. METHODS A retrospective computer-generated chart review was performed involving all men given prednisone from January 2002 through July 2002. There were 370 patients evaluated from the James A. Haley Veterans Affairs Hospital, Tampa, Florida, a large teaching hospital for the University of South Florida College of Medicine. Charts were reviewed for bone mineral density testing; dose, duration, and indication of glucocorticoid therapy; age of the patients as of January 2002;continuous or intermittent dosing; history of fracture; bone loss prevention medication use, including bisphosphonate, calcitonin, testosterone replacement therapy, calcium, and vitamin D; and the steroid-prescribing and screening practitioner's specialty and sex. RESULTS Of the 370 men, 258 used 7.5 mg prednisone or more daily and 295 used glucocorticoids for more than 3 months. Of the 370 men, 163 had a bone mineral density test; 87 were treated with a bisphosphonate. Calcium and vitamin D were given to half of the patients. Of the patients with a normal T-score, 13 of 55 were treated with a bisphosphonate (24%) compared with 24 of 40 (60%) with an osteopenic score and 14 of 21 (67%) with osteoporosis. Of the 46 patients with no score available but indication that it had been ordered or otherwise addressed, 23 patients were treated empirically with a bisphosphonate. Rheumatology screened 75% of their patients, whereas primary care screened 30% of their patients. CONCLUSIONS Bone mineral density testing was performed or ordered for less than half of the glucocorticoid-treated patients and less than one third were taking bisphosphonate therapy. Further intervention is needed to increase prevention of glucocorticoid-induced osteoporosis and subsequent risk of fracture.
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Affiliation(s)
- Laura M Cruse
- University of South Florida College of Medicine, Department of Rheumatology, Tampa, Florida 33612, USA.
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Vondracek SF, Hemstreet BA. Is there an optimal corticosteroid regimen for the management of an acute exacerbation of chronic obstructive pulmonary disease? Pharmacotherapy 2006; 26:522-32. [PMID: 16553512 DOI: 10.1592/phco.26.4.522] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Systemic corticosteroids are standard of care for the management of an acute exacerbation of chronic obstructive pulmonary disease (COPD). Several prospective, randomized trials demonstrated modest improvements in patient outcomes when short courses of systemic corticosteroids were used. However, the most appropriate dosage regimen remains controversial, as the corticosteroid regimens used in these trials differed greatly, and no studies have directly compared medium-, high-, and low-dose regimens. In addition, data are lacking on the safety, efficacy, and appropriate dosing of systemic corticosteroids in women and in patients with an acute exacerbation of COPD and concomitant pneumonia or severe respiratory failure. Systemic corticosteroid use is associated with several adverse effects that are dose and/or duration dependent. Evidence suggests that higher dose corticosteroid regimens may place patients at increased short-term and long-term risk, without additional clinical benefit. Tapering of systemic corticosteroid regimens, although a common practice, is unnecessary in most circumstances. The risk for hypothalamic-pituitary-adrenal-axis suppression is negligible when low-dose, short-course corticosteroid regimens are used, and no evidence exists to suggest that abruptly stopping a low-dose steroid regimen will increase the risk of disease relapse. Still, no studies have directly compared tapered and non-tapered regimens in patients with an acute exacerbation of COPD. Consistent with clinical guideline recommendations, safety and efficacy data support the use of low-dose corticosteroid regimens such as prednisone 40 mg orally once/day for 10-14 days in most patients with an acute exacerbation of COPD. Further studies are needed to clarify the optimal systemic corticosteroid regimen for an acute exacerbation of COPD.
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Affiliation(s)
- Sheryl F Vondracek
- Department of Clinical Pharmacy, University of Colorado at Denver and Health Sciences Center, Denver, Colorado 80262, USA.
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Vondracek SF, Hemstreet BA. Retrospective evaluation of systemic corticosteroids for the management of acute exacerbations of chronic obstructive pulmonary disease. Am J Health Syst Pharm 2006; 63:645-52. [PMID: 16554288 DOI: 10.2146/ajhp050316] [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] [Indexed: 01/13/2023] Open
Abstract
PURPOSE The use of systemic corticosteroids for the management of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) was studied. METHODS Medical charts of patients admitted to the hospital between July 2002 and November 2003 with a primary diagnosis of AECOPD were retrospectively reviewed. The primary objective was to characterize the drug, dosage, route, frequency, and duration of systemic corticosteroids prescribed for the management of AECOPD. The secondary objective was to compare the mean length of stay (LOS) and 30-day relapse rate between patients who received lower and higher dosages of corticosteroids. RESULTS One hundred forty-five admissions (123 patients) for AECOPD (mean +/- S.D. age, 65 +/- 11 years) were evaluated. Higher dosages of systemic corticosteroids (>80 mg of prednisone equivalent [PE] per day) were prescribed for 51% and i.v. therapy for 56% of admissions. The mean +/- S.D. total systemic corticosteroid exposure during hospitalization for all admissions was 759 +/- 971 mg of PE (mean +/- S.D. daily exposure = 134 +/- 111 mg of PE per day). The mean LOS was significantly longer for the higher-dosage group than for the lower-dosage group (6.1 versus 4.2 days, p = 0.0004). A tapered regimen was prescribed for 79% of discharges. Twenty-seven percent of the discharges with routine follow-up care had a relapse of disease within 30 days. CONCLUSION This retrospective observational study confirmed a wide variability in the dosages of systemic corticosteroids for the inpatient management of AECOPD, including the use of higher dosages and tapered regimens. Prospective randomized studies are needed to determine the most effective regimen of systemic corticosteroids in patients with AECOPD.
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Affiliation(s)
- Sheryl F Vondracek
- Department of Clinical Pharmacy, University of Colorado Health Sciences Center, 4200 E. Ninth Avenue, Denver, CO 80262, USA.
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De Vries F, Bracke M, Leufkens HGM, Lammers JWJ, Cooper C, Van Staa TP. Fracture risk with intermittent high-dose oral glucocorticoid therapy. ACTA ACUST UNITED AC 2006; 56:208-14. [PMID: 17195223 DOI: 10.1002/art.22294] [Citation(s) in RCA: 191] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate the risk of fracture in patients receiving intermittent therapy with high-dose oral glucocorticoids (GCs). METHODS The study group comprised 191,752 patients from the UK General Practice Database who were 40 years of age and older and received therapy with GCs. The followup time period was divided into the categories of "current" and "no exposure." The daily dose and cumulative dose for each time period were determined. Relative risks were estimated using Cox proportional hazards models, adjusted for age, sex, body mass index, smoking, disease history, and drug history. Fractures of the radius/ulna, humerus, rib, femur/hip, pelvis, or vertebrae were included in the evaluation. RESULTS Patients who intermittently received high-dose GCs (daily dose > or =15 mg) and had no or little previous exposure to GCs (cumulative exposure < or =1 gm) had a small increased risk of osteoporotic (but not hip/femur) fracture; this risk increased substantially with increasing cumulative exposure. Among patients who received a daily dose > or =30 mg and whose cumulative exposure was >5 gm, the relative risk (RR) of osteoporotic fracture was 3.63 (95% confidence interval [95% CI] 2.54-5.20), the RR of fracture of the hip/femur was 3.13 (95% CI 1.49-6.59), and the RR of vertebral fracture was 14.42 (95% CI 8.29-25.08). CONCLUSION Intermittent use of high-dose oral GCs (daily dose > or =15 mg and cumulative exposure < or =1 gm) may result in a small increased risk of osteoporotic fracture. Conversely, patients who receive several courses of high-dose GCs (daily dose > or =15 mg and cumulative exposure >1 gm) have a substantially increased risk of fracture.
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Ionescu AA. When should we suspect osteoporosis in patients with chronic airways disease? Chron Respir Dis 2005; 2:1-2. [PMID: 16279741 DOI: 10.1191/1479972305cd059ed] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Verea-Hernández H. [Corticosteroids in exacerbations of chronic obstructive pulmonary disease: yes, but less]. Arch Bronconeumol 2005; 41:641; author reply 641. [PMID: 16324607 DOI: 10.1016/s1579-2129(06)60300-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
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Verea-Hernández H. Corticoides en las exacerbaciones de la EPOC: sí, pero menos. Arch Bronconeumol 2005. [DOI: 10.1157/13081255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Lau EMC, Chan FWK, Hui DSC, Wu AKL, Leung PC. Reduced bone mineral density in male Severe Acute Respiratory Syndrome (SARS) patients in Hong Kong. Bone 2005; 37:420-4. [PMID: 15993669 PMCID: PMC7103402 DOI: 10.1016/j.bone.2005.04.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2004] [Revised: 01/23/2005] [Accepted: 04/22/2005] [Indexed: 10/31/2022]
Abstract
During the Severe Acute Respiratory Syndrome (SARS) outbreak in Hong Kong in 2003, patients were treated with very high doses of corticosteroid and ribavirin. The detrimental effects of such treatment on the bone mineral density (BMD) of SARS patients are unknown. To compare the BMD of SARS patients with normal range data, a cross-sectional survey was conducted. The bone mineral density of 224 patients with SARS, who were treated with an average of 2753 mg (SD = 2152 mg) prednisolone and 29,344 mg (SD = 15,849 mg) of ribavirin was compared to normal data. Six percent of men had a hip BMD Z score of < or =-2 (P = 0.057 for testing the hypothesis that >2.5% of subjects should have a Z score of < or =-2). Moreover, there was a negative association (r = -0.25, P = 0.023) between the duration of steroid therapy and BMD in men. We conclude that male SARS patients had lower BMD at the hip than normal controls, and this could be attributed to prolonged steroid therapy.
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Affiliation(s)
- E M C Lau
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong.
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Komerik N, Akkaya A, Yildiz M, Buyukkaplan US, Kuru L. Oral health in patients on inhaled corticosteroid treatment. Oral Dis 2005; 11:303-8. [PMID: 16120117 DOI: 10.1111/j.1601-0825.2005.01122.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the effects of long-term inhaled corticosteroids on bone mineral density (BMD) of the mandible in relation with the tooth loss. DESIGN Cross sectional analytic study. SUBJECTS AND METHODS Patients (n = 30) with chronic obstructive pulmonary disease under inhaled corticosteroid therapy for at least 1 year were compared with sex- and age-matched healthy controls (n = 30). BMD of the mandible was measured by dual-energy X-ray absorptiometry. The clinical examination included recording the number of teeth present together with periodontal condition. Levels of serum osteocalcin, alkaline phosphatase, calcium, phosphorus and cortisol were also assessed. RESULTS BMD of the mandible in patients on corticosteroid treatment was significantly lower than that in the control group (P = 0.001). Patients under treatment had more missing teeth than the control group but the difference did not reach statistical significance. The two groups exhibited similar clinical parameters of periodontal condition. Significantly lower levels of osteocalcin (P < 0.0001), calcium (P = 0.004) and cortisol (P = 0.03) were observed in the patients on corticosteroid treatment. CONCLUSION Long-term use of inhaled corticosteroids may impair bone metabolism and lead to a marked decrease in the mandibular BMD.
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Affiliation(s)
- N Komerik
- Department of Oral Surgery, Faculty of Dentistry, Suleyman Demirel University, Isparta, Turkey.
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Mineo TC, Ambrogi V, Mineo D, Fabbri A, Fabbrini E, Massoud R. Bone Mineral Density Improvement After Lung Volume Reduction Surgery for Severe Emphysema. Chest 2005; 127:1960-6. [PMID: 15947308 DOI: 10.1378/chest.127.6.1960] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND In patients with severe emphysema, bone mineral density (BMD) is reduced and the risk of osteoporosis is increased. STUDY OBJECTIVES To identify the impact of lung volume reduction surgery on BMD. DESIGN Prospective cohort study. SETTING University hospital. PATIENTS AND INTERVENTIONS Forty emphysematous patients, all receiving oral steroid therapy, underwent bilateral lung volume reduction surgery. Thirty similar patients, who refused the operation, followed a standard respiratory rehabilitation program. MEASUREMENTS All subjects were evaluated pretreatment and 12 months posttreatment for respiratory function, nutritional status, and bone-related biochemical parameters. BMD was assessed by dual-energy radiograph absorptiometry. RESULTS After surgery, we observed significant improvements in respiratory function (FEV1, + 18.8% [p < 0.01]; residual volume [RV], -29.6% [p < 0.001]; diffusing capacity of the lung for carbon monoxide [Dlco], + 21.6% [p < 0.01]) nutritional parameters (fat-free mass, + 6.0% [p < 0.01]), levels of bone-related hormones (free-testosterone, + 20.5% [p < 0.01]; parathormone, -11.2% [p < 0.01]), bone turnover markers (osteocalcin, -12.7% [p < 0.05]; bone-alkaline-phosphatase, -14.0% [p < 0.05]; beta-crosslaps, -33.6% [p < 0.001]), BMD (lumbar, + 8.8% [p < 0.01]; femoral, + 5.5% [p < 0.01]), and T-score (lumbar, + 21.0% [p < 0.01]; femoral, + 12.4% [p < 0.01]) with reduction in osteoporosis rate (50 to 25%). Nineteen patients who had undergone surgery were able to discontinue treatment with oral steroids. These subjects showed a more significant improvement in BMD (lumbar, + 9.6%; femoral, + 6.8%; p < 0.001) and T-score (lumbar, + 27.3%; femoral, + 14.3%; p < 0.001). The remaining 21 patients who had undergone surgery experienced significant improvement compared to respiratory rehabilitation subjects despite continued therapy with oral steroids (BMD: lumbar, + 4.5% vs -0.7%, respectively [p < 0.01]; femoral, + 2.7% vs -1.1%, respectively [p < 0.05]; T-score: lumbar, + 14 vs -2.1, respectively [p < 0.01]; femoral, + 7.4 vs -2.7, respectively [p < 0.01]). The increase in lumbar BMD was correlated with the surgical reduction of RV (p = 0.02) and with the increase in Dlco (p = 0.01) and fat-free mass (p = 0.01). CONCLUSIONS Lung volume reduction surgery significantly improves BMD compared to respiratory rehabilitation therapy, even in patients requiring oral steroids. The increase in BMD correlates with RV, Dlco, and fat-free mass, suggesting that the restoration of respiratory dynamics, gas exchange, and nutritional status induces improvement in bone metabolism and mineral content.
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Toogood JH. Asthma and therapeutics: inhaled corticosteroids, corticosteroid osteoporosis, and the risk of fracture in chronic asthma. Allergy Asthma Clin Immunol 2005; 1:28-33. [PMID: 20529232 PMCID: PMC3225820 DOI: 10.1186/1710-1492-1-1-28] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Current guidelines for the diagnosis and treatment of osteoporosis do not address the risks to bone density and the likelihood of fracture that may be associated with inhaled corticosteroid treatment for asthma. This review outlines an approach to the use of bone densitometry in clinical practice for the diagnosis, prevention, and treatment of osteoporosis in asthmatic patients receiving inhaled corticosteroid therapy.
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Affiliation(s)
- John H Toogood
- Emeritus Professor of Medicine, University of Western Ontario, Division of Clinical Immunology and Allergy, Department of Medicine, London Health Sciences Centre, London, Ontario
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Scanlon PD, Connett JE, Wise RA, Tashkin DP, Madhok T, Skeans M, Carpenter PC, Bailey WC, Buist AS, Eichenhorn M, Kanner RE, Weinmann G. Loss of bone density with inhaled triamcinolone in Lung Health Study II. Am J Respir Crit Care Med 2004; 170:1302-9. [PMID: 15374846 DOI: 10.1164/rccm.200310-1349oc] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Inhaled glucocorticosteroids (ICS) are commonly prescribed for chronic obstructive pulmonary disease. No adverse effect on bone mineral density (BMD) has been proven. In a randomized double-blind, placebo-controlled trial at seven centers in North America, we recruited 412 current smokers or recent quitters with mild to moderate chronic obstructive pulmonary disease. They used inhaled triamcinolone acetonide, 600 mcg, or placebo, twice daily. We measured femoral neck and lumbar spine BMD at baseline and after 1 and 3 years, and serum osteocalcin at baseline, 3 months, 1 year, and 3 years. After 3 years, BMD at the femoral neck decreased 1.78% more with ICS than with placebo (p < 0.001). More participants in the ICS group experienced 6% or more loss of femoral neck BMD (p = 0.002). Lumbar spine BMD increased in the placebo group by 0.98% but decreased by 0.35% in the ICS group (a difference of 1.33%, p = 0.007). Changes in osteocalcin did not correlate with changes in BMD. Fractures, lost height, or osteoporosis diagnoses were not increased among ICS users compared with placebo users. In summary, the use of inhaled triamcinolone acetonide was associated with loss of BMD at the femoral neck and lumbar spine after 3 years of treatment.
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Gluck O, Colice G. Recognizing and treating glucocorticoid-induced osteoporosis in patients with pulmonary diseases. Chest 2004; 125:1859-76. [PMID: 15136401 DOI: 10.1378/chest.125.5.1859] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Glucocorticoids are frequently used to treat patients with pulmonary diseases, but continuous long-term use of glucocorticoids may lead to significant bone loss and an increased risk of fragility fractures. Patients with certain lung diseases, regardless of pharmacotherapy-particularly COPD and cystic fibrosis-and patients waiting for lung transplantation are also at increased risk of osteoporosis. Fragility fractures, especially of the hip, will have substantial effects on the health and well-being of older patients. Vertebral collapse and kyphosis secondary to glucocorticoid-induced osteoporosis (GIO) may affect lung function. Identification of patients with osteopenia, osteoporosis, or fragility fractures related to osteoporosis is strongly recommended and should lead to appropriate treatment. Prevention of GIO in patients receiving continuous oral glucocorticoids is also recommended. In patients receiving either high-dose inhaled glucocorticoids or low- to medium-dose inhaled glucocorticoids with frequent courses of oral glucocorticoids, bone mineral density measurements should be performed to screen for osteopenia and osteoporosis. A bisphosphonate (risedronate or alendronate), calcium and vitamin D supplementation, and lifestyle modifications are recommended for the prevention and treatment of GIO.
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Affiliation(s)
- Oscar Gluck
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
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Førli L, Halse J, Haug E, Bjørtuft Ø, Vatn M, Kofstad J, Boe J. Vitamin D deficiency, bone mineral density and weight in patients with advanced pulmonary disease. J Intern Med 2004; 256:56-62. [PMID: 15189366 DOI: 10.1111/j.1365-2796.2004.01337.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To study the influence of underweight, body composition and vitamin D deficiency on bone mineral density in patients with advanced pulmonary disease. DESIGN Cross-sectional study with time span for inclusion set at 5 years. SETTING The clinical work and biochemical analyses were carried out at Rikshospitalet University Hospital, Norway. Analyses for vitamin D metabolites and bone markers were carried out at Aker University Hospital, and bone measurements at Clinic of Osteoporosis. SUBJECTS Seventy-one candidates for lung transplantation (63% chronic obstructive pulmonary disease, 42 underweight and 29 normal weight) were included. MAIN OUTCOME MEASURES Body composition, bone mineral density at lumbar spine and femur neck, serum concentration of calcidiol and vitamin D intake. RESULTS Subnormal calcidiol levels were present in 52% of the underweight patients and 69% of the normal-weight patients. The resulting models of linear regression showed that for the lumbar spine T scores model, the total variation of 16.7% was explained by group (underweight/normal weight), sex and age. For the femur neck T scores model, the total variation of 20.4% was explained by the interaction of underweight and vitamin D deficiency (with borderline significance) and by arm muscle circumference percentage of standard. In patients with normal calcidiol levels, the median intake of vitamin D was 17 microg in the underweight patients and 11 microg in the normal-weight patients. CONCLUSIONS Vitamin D deficiency was common in both underweight and normal-weight patients, but only in the underweight patients, an association between vitamin D deficiency and reduced femur neck T scores was indicated.
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Affiliation(s)
- L Førli
- Department of Respiratory Medicine, Rikshospitalet, Oslo, Norway.
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