1
|
Lau WCY, Cheung CL, Man KKC, Chan EW, Sing CW, Lip GYH, Siu CW, Lam JKY, Lee ACH, Wong ICK. Association Between Treatment With Apixaban, Dabigatran, Rivaroxaban, or Warfarin and Risk for Osteoporotic Fractures Among Patients With Atrial Fibrillation: A Population-Based Cohort Study. Ann Intern Med 2020; 173:1-9. [PMID: 32423351 DOI: 10.7326/m19-3671] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND It is unclear whether anticoagulant type is associated with the risk for osteoporotic fracture, a deleterious complication of anticoagulants among patients with atrial fibrillation (AF). OBJECTIVE To compare the risk for osteoporotic fracture between anticoagulants. DESIGN Population-based cohort study. SETTING Territory-wide electronic health record database of the Hong Kong Hospital Authority. PARTICIPANTS Patients newly diagnosed with AF between 2010 and 2017 who received a new prescription for warfarin or a direct oral anticoagulant (DOAC) (apixaban, dabigatran, or rivaroxaban). Follow-up ended on 31 December 2018. MEASUREMENTS Osteoporotic hip and vertebral fractures in anticoagulant users were compared using propensity score-weighted cumulative incidence differences (CIDs). RESULTS There were 23 515 patients identified (3241 apixaban users, 6867 dabigatran users, 3866 rivaroxaban users, and 9541 warfarin users). Overall mean age was 74.4 years (SD, 10.8), ranging from 73.1 years (warfarin) to 77.9 years (apixaban). Over a median follow-up of 423 days, 401 fractures were identified (crude event number [weighted rate per 100 patient-years]: apixaban, 53 [0.82]; dabigatran, 95 [0.76]; rivaroxaban, 57 [0.67]; and warfarin, 196 [1.11]). After 24-month follow-up, DOAC use was associated with a lower risk for fracture than warfarin use (apixaban CID, -0.88% [95% CI, -1.66% to -0.21%]; dabigatran CID, -0.81% [CI, -1.34% to -0.23%]; and rivaroxaban CID, -1.13% [CI, -1.67% to -0.53%]). No differences were seen in all head-to-head comparisons between DOACs at 24 months (apixaban vs. dabigatran CID, -0.06% [CI, -0.69% to 0.49%]; rivaroxaban vs. dabigatran CID, -0.32% [CI, -0.84% to 0.18%]; and rivaroxaban vs. apixaban CID, -0.25% [CI, -0.86% to 0.40%]). LIMITATION Residual confounding is possible. CONCLUSION Among patients with AF, DOAC use may result in a lower risk for osteoporotic fracture compared with warfarin use. Fracture risk does not seem to be altered by the choice of DOAC. These findings may help inform the benefit-risk assessment when choosing between anticoagulants. PRIMARY FUNDING SOURCE The University of Hong Kong and University College London Strategic Partnership Fund.
Collapse
Affiliation(s)
- Wallis C Y Lau
- UCL School of Pharmacy, London, United Kingdom, and Centre for Safe Medication and Practice Research, The University of Hong Kong, Hong Kong, China (W.C.L., K.K.M.)
| | - Ching-Lung Cheung
- Centre for Safe Medication and Practice Research, The University of Hong Kong, Hong Kong, China (C.C., E.W.C., C.W.S.)
| | - Kenneth K C Man
- UCL School of Pharmacy, London, United Kingdom, and Centre for Safe Medication and Practice Research, The University of Hong Kong, Hong Kong, China (W.C.L., K.K.M.)
| | - Esther W Chan
- Centre for Safe Medication and Practice Research, The University of Hong Kong, Hong Kong, China (C.C., E.W.C., C.W.S.)
| | - Chor Wing Sing
- Centre for Safe Medication and Practice Research, The University of Hong Kong, Hong Kong, China (C.C., E.W.C., C.W.S.)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom, and Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark (G.Y.L.)
| | - Chung-Wah Siu
- Queen Mary Hospital, The University of Hong Kong, Hong Kong, China (C.S.)
| | - Joanne K Y Lam
- Osteoporosis Centre, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China (J.K.L., A.C.L.)
| | - Alan C H Lee
- Osteoporosis Centre, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China (J.K.L., A.C.L.)
| | - Ian C K Wong
- UCL School of Pharmacy, London, United Kingdom, Centre for Safe Medication and Practice Research, The University of Hong Kong, Hong Kong, and The University of Hong Kong Shenzhen Hospital, Shenzhen, Guangdong, China (I.C.W.)
| |
Collapse
|
2
|
Lutsey PL, Norby FL, Ensrud KE, MacLehose RF, Diem SJ, Chen LY, Alonso A. Association of Anticoagulant Therapy With Risk of Fracture Among Patients With Atrial Fibrillation. JAMA Intern Med 2020; 180:245-253. [PMID: 31764956 PMCID: PMC6902159 DOI: 10.1001/jamainternmed.2019.5679] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Warfarin is prescribed to patients with atrial fibrillation (AF) for the prevention of cardioembolic complications. Whether warfarin adversely affects bone health is controversial. The availability of alternate direct oral anticoagulant (DOAC) options now make it possible to evaluate the comparative safety of warfarin in association with fracture risk. OBJECTIVE To test the hypothesis that, among patients with nonvalvular AF, use of DOACs vs warfarin is associated with lower risk of incident fracture. DESIGN, SETTING, AND PARTICIPANTS This comparative effectiveness cohort study used the MarketScan administrative claims databases to identify patients with nonvalvular AF and who were prescribed oral anticoagulants from January 1, 2010, through September 30, 2015. To reduce confounding, patients were matched on age, sex, CHA2DS2-VASc (congestive heart failure, hypertension, age [>65 years = 1 point; >75 years = 2 points], diabetes, and previous stroke/transient ischemic attack [2 points], vascular disease) score, and high-dimensional propensity scores. The final analysis included 167 275 patients with AF. Data were analyzed from February 27, 2019 to September 18, 2019. EXPOSURES Warfarin and DOACs (dabigatran etexilate, rivaroxaban, and apixaban). MAIN OUTCOMES AND MEASURES Incident hip fracture, fracture requiring hospitalization, and all clinical fractures (identified using inpatient or outpatient claims) defined by International Classification of Diseases, Ninth Revision, Clinical Modification codes. RESULTS In the study population of 167 275 patients with AF (38.0% women and 62.0% men; mean [SD] age, 68.9 [12.5] years), a total of 817 hip fractures, 2013 hospitalized fractures, and 7294 total fractures occurred during a mean (SD) follow-up of 16.9 (13.7) months. In multivariable-adjusted, propensity score-matched Cox proportional hazards regression models, relative to new users of warfarin, new users of DOACs tended to be at lower risk of fractures requiring hospitalization (hazard ratio [HR], 0.87; 95% CI, 0.79-0.96) and all clinical fractures (HR, 0.93; 95% CI, 0.88-0.98), whereas the association with hip fractures (HR, 0.91; 95% CI, 0.78-1.07) was not statistically significant. When comparing individual DOACs with warfarin, the strongest findings were for apixaban (HR for hip fracture, 0.67 [95% CI, 0.45-0.98]; HR for fractures requiring hospitalization, 0.60 [95% CI, 0.47-0.78]; and HR for all clinical fractures, 0.86 [95% CI, 0.75-0.98]). In subgroup analyses, DOACs appeared more beneficial among patients with AF who also had a diagnosis of osteoporosis than among those without a diagnosis of osteoporosis. CONCLUSIONS AND RELEVANCE In this real-world population of 167 275 patients with AF, use of DOACs-particularly apixaban-compared with warfarin use was associated with lower fracture risk. These associations were more pronounced among patients with a diagnosis of osteoporosis. Given the potential adverse effects of warfarin on bone health, these findings suggest that caution should be used when prescribing warfarin to patients with AF at high risk of fracture.
Collapse
Affiliation(s)
- Pamela L Lutsey
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis
| | - Faye L Norby
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis
| | - Kristine E Ensrud
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis.,Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota School of Medicine, Minneapolis
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis
| | - Susan J Diem
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota School of Medicine, Minneapolis
| | - Lin Y Chen
- Department of Medicine, University of Minnesota School of Medicine, Minneapolis
| | - Alvaro Alonso
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| |
Collapse
|
3
|
Gu ZC, Zhou LY, Shen L, Zhang C, Pu J, Lin HW, Liu XY. Non-vitamin K Antagonist Oral Anticoagulants vs. Warfarin at Risk of Fractures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Front Pharmacol 2018; 9:348. [PMID: 29692734 PMCID: PMC5903161 DOI: 10.3389/fphar.2018.00348] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 03/26/2018] [Indexed: 01/31/2023] Open
Abstract
Warfarin is a traditional oral anticoagulant for preventing thrombotic events in patients with atrial fibrillation (AF) and venous thromboembolism. Along with the widespread clinical use, the potential association between warfarin use and fracture risk have been addressed gradually. Non-vitamin K antagonist oral anticoagulants (NOACs), targeting thrombin or Xa factor, have been recommended as an optimal alternative due to their favorable property of thromboembolism prophylaxis and reduced bleeding risk. However, evidence of the fracture risk with NOACs use is limited. Therefore, the present study investigated this issue by a meta-analysis. Medline, Embase, Cochrane Library and the ClinicalTrials.gov Website were searched for randomized controlled trials (RCTs) that reported the fracture data of NOACs and warfarin. The primacy outcome was a composite of any fracture. Summary relative risks (RRs) and 95% confidence intervals (CIs) were calculated using random- or fixed-effects models according to between-study heterogeneity. Heterogeneity was assessed through I2 test and Q statistic, and the number of patients needed to treat (NNT) was calculated based on fracture incidence. Subgroup analyses were conducted according to individual NOACs, indications, and duration of follow up. Finally, 12 RCTs involving 89,549 patients were included, among which 44,816 (50%) receiving NOACs and 44,733 (50%) receiving warfarin. Overall, 1,139 (1.3%) patients including 515 NOACs users (1.1%) and 624 warfarin users (1.4%) developed fracture. Risk of fracture was significantly lower in NOACs compared to warfarin (RR: 0.82, 95%CI: 0.73–0.93, P = 0.001), with a NNT of 333. No significantly decreased risk was detected according to fracture sites. Subgroup analysis confirmed that the estimate of decreased fracture risk was derived mainly from AF patients receiving long-term anticoagulation treatment. The meta-regression did not detect any potential confounding on fracture risk. No heterogeneity between the studies (I2 = 15.0%) and no publication bias was identified. In conclusion, the use of NOACs was associated with a lower risk of fracture compared to warfarin, but with a relatively low absolute risk reduction. Therefore, screening for the fracture risk should be considered before initiating anticoagulation treatment. For patients who are at high risk of fracture or expected long-term treatment of anticoagulation, NOACs may represent a preferable alternative to warfarin.
Collapse
Affiliation(s)
- Zhi-Chun Gu
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Ling-Yun Zhou
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Long Shen
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Chi Zhang
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jun Pu
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Hou-Wen Lin
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiao-Yan Liu
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| |
Collapse
|
4
|
Norby FL, Bengtson LGS, Lutsey PL, Chen LY, MacLehose RF, Chamberlain AM, Rapson I, Alonso A. Comparative effectiveness of rivaroxaban versus warfarin or dabigatran for the treatment of patients with non-valvular atrial fibrillation. BMC Cardiovasc Disord 2017; 17:238. [PMID: 28874129 PMCID: PMC5585896 DOI: 10.1186/s12872-017-0672-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 08/24/2017] [Indexed: 02/07/2023] Open
Abstract
Background Rivaroxaban is an oral anticoagulant approved in the US for prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF). We determined the effectiveness and associated risks of rivaroxaban versus other oral anticoagulants in a large real-world population. Methods We selected NVAF patients initiating oral anticoagulant use in 2010–2014 enrolled in MarketScan databases. Rivaroxaban users were matched with warfarin and dabigatran users by age, sex, enrolment date, anticoagulant initiation date, and high-dimensional propensity score. Study endpoints, including ischemic stroke, intracranial bleeding (ICB), myocardial infarction (MI), and gastrointestinal (GI) bleeding, were identified from inpatient diagnostic codes. Multivariable Cox models were used to assess associations between type of anticoagulant and outcomes. Results The analysis included 44,340 rivaroxaban users matched to 89,400 warfarin and 16,957 dabigatran users (38% female, mean age 70) with 12 months of mean follow-up. Anticoagulant-naïve rivaroxaban initiators, but not those switching from warfarin, had lower risk of ischemic stroke [hazard ratio (HR) (95% confidence interval (CI)): 0.75 (0.62, 0.91)] and ICB [HR (95%CI): 0.55, (0.39, 0.78)] than warfarin users. In contrast, anticoagulant-experienced rivaroxaban initiators had higher risk of GI bleeding than warfarin users [HR (95%CI): 1.55 (1.32, 1.83)]. Endpoint rates were similar when comparing anticoagulant-naïve rivaroxaban and dabigatran initiators, with the exception of higher GI bleeding risk in rivaroxaban users [HR (95%CI) 1.28 (1.06, 1.54)]. There were no significant differences in the risk of MI among the comparison groups. Conclusion In this large real-world sample of NVAF patients, effectiveness and risks of rivaroxaban versus warfarin differed by prior anticoagulant status, while effectiveness of rivaroxaban versus dabigatran differed in GI bleeding risk. Electronic supplementary material The online version of this article (10.1186/s12872-017-0672-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Faye L Norby
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, 1300 S 2nd St, Suite 300, Minneapolis, MN, 55454, USA.
| | - Lindsay G S Bengtson
- Health Economics and Outcomes Research, Life Sciences, Optum, Eden Prairie, MN, USA
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, 1300 S 2nd St, Suite 300, Minneapolis, MN, 55454, USA
| | - Lin Y Chen
- Cardiac Arrhythmia Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, 1300 S 2nd St, Suite 300, Minneapolis, MN, 55454, USA
| | | | - Ian Rapson
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, 1300 S 2nd St, Suite 300, Minneapolis, MN, 55454, USA
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| |
Collapse
|
5
|
Donaldson CJ, Harrington DJ. Therapeutic warfarin use and the extrahepatic functions of vitamin K-dependent proteins. Br J Biomed Sci 2017; 74:163-169. [PMID: 28657840 DOI: 10.1080/09674845.2017.1336854] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The impact of warfarin therapy on the functions of extrahepatic vitamin K-dependent proteins (VKDP) is less clearly understood and less widely recognised in clinical practice than that on the hepatic counterparts (clotting factors II, VII, IX and X). Warfarin inhibits osteocalcin, an abundant extrahepatic VKDP involved in the mineralisation and maturation of bone and thus, primarily by this mechanism, may have an adverse effect on bone health. Whilst some studies do link warfarin use to an increase in osteoporosis and fracture risk others have not. Warfarin also inhibits the extrahepatic VKDP matrix gla protein (MGP) which acts to prevent ectopic calcification of the vasculature. Studies have consistently found a correlation between warfarin use and vascular calcification with inhibition of MGP believed to be the main cause. Inhibition of MGP also appears to explain warfarin's well established teratogenic effect. Further adverse effects may also arise from warfarin's inhibition of other known extrahepatic VKDPs. The available evidence is intriguing, and suggests that the impact of warfarin on the extrahepatic functions of vitamin K-dependent proteins warrants further careful consideration.
Collapse
Affiliation(s)
- C J Donaldson
- a Faculty of Life Sciences and Medicine , King's College London , London , UK
| | - D J Harrington
- b The Nutristasis Unit, Viapath, St. Thomas' Hospital , London , UK.,c Division of Women's Health , School of Medicine, King's College London , London , UK
| |
Collapse
|
6
|
Pearson DA. Bone Health and Osteoporosis: The Role of Vitamin K and Potential Antagonism by Anticoagulants. Nutr Clin Pract 2017; 22:517-44. [PMID: 17906277 DOI: 10.1177/0115426507022005517] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Vitamin K's effects extend beyond blood clotting to include a role in bone metabolism and potential protection against osteoporosis. Vitamin K is required for the gamma-carboxylation of osteocalcin. Likewise, this gamma-carboxylation also occurs in the liver for several coagulation proteins. This mechanism is interrupted by coumarin-based anticoagulants in both the liver and bone. METHODS A thorough review of the literature on vitamin K, osteocalcin and their role in bone metabolism and osteoporosis, as well as the potential bone effects of anticoagulant therapy was conducted. CONCLUSIONS Epidemiological studies and clinical trials consistently indicate that vitamin K has a positive effect on bone mineral density and decreases fracture risk. Typical dietary intakes of vitamin K are below the levels associated with better BMD and reduced fracture risk; thus issues of increasing dietary intakes, supplementation, and/or fortification arise. To effectively address these issues, large-scale, intervention trials of vitamin K are needed. The effects of coumarin-based anticoagulants on bone health are more ambiguous, with retrospective studies suggesting that long-term therapy adversely affects vertebral BMD and fracture risk. Anticoagulants that do not affect vitamin K metabolism are now available and make clinical trials feasible to answer the question of whether coumarins adversely affect bone. The research suggests that at a minimum, clinicians should carefully assess anticoagulated patients for osteoporosis risk, monitor BMD, and refer them to dietitians for dietary and supplement advice on bone health. Further research is needed to make more efficacious decisions about vitamin K intake, anticoagulant therapy, and bone health.
Collapse
Affiliation(s)
- Debra A Pearson
- University of Wisconsin-Green Bay, Department of Human Biology, Nutritional Sciences, 2420 Nicolet Drive, Green Bay, WI 54311, USA.
| |
Collapse
|
7
|
Avila ML, Pullenayegum E, Williams S, Shammas A, Stimec J, Sochett E, Marr K, Brandão LR. Timing of low bone mineral density and predictors of bone mineral density trajectory in children on long-term warfarin: a longitudinal study. Osteoporos Int 2016; 27:1547-1557. [PMID: 26572757 DOI: 10.1007/s00198-015-3411-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 11/05/2015] [Indexed: 01/06/2023]
Abstract
UNLABELLED We studied bone mineral density (BMD) of children exposed to long-term warfarin. BMD Z-scores ≤ -2.0 were estimated to occur in less than one fifth of the patients after 10 years of warfarin exposure, and BMI and growth hormone deficiency predicted BMD changes over time. These predictors can help identify high-risk patients. INTRODUCTION Children with chronic diseases are at increased risk of developing thrombosis, which may require long-term warfarin therapy. Warfarin could further jeopardize the bone health of a population already at risk for bone fragility. Our objective was to investigate the occurrence and timing of low bone mineral density (BMD) and the predictors that influence BMD trajectory in children receiving warfarin for >1 year. METHODS We analyzed the results of an institutional protocol that includes dual-energy X-ray absorptiometry, with or without spinal X-rays and laboratory biomarkers, as required. RESULTS Low BMD (age, sex, race, and height-for-age-Z-score adjusted BMD Z-score ≤ -2.0) was detected in 13 % (9/70) of the patients at some point during their follow-up; these patients were more likely to have complex underlying medical conditions and low body mass index (BMI) percentile. BMD Z-scores remained within normal range in 87 % of children. Survival analysis showed that the estimated 10-year abnormal BMD-free rate for the entire group was 81 % (95 % confidence interval [CI] 69 to 93 %). Trajectory analysis revealed that BMI percentiles at baseline and growth hormone deficiency (GHD) were associated with lower BMD Z-scores at the first assessment, whereas baseline BMI percentile was the only predictor of BMD Z-score over time. CONCLUSIONS Our findings identified BMI and GHD as risk factors influencing BMD in children exposed to long-term warfarin, creating an opportunity for early detection and intervention in these patients.
Collapse
Affiliation(s)
- M L Avila
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, M5G-1X8, ON, Canada
| | - E Pullenayegum
- Child Health Evaluative Sciences, The Hospital for Sick Children, University of Toronto, Toronto, M5G-1X8, ON, Canada
| | - S Williams
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, M5G-1X8, ON, Canada
| | - A Shammas
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, M5G-1X8, ON, Canada
| | - J Stimec
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, M5G-1X8, ON, Canada
| | - E Sochett
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, M5G-1X8, ON, Canada
| | - K Marr
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, M5G-1X8, ON, Canada
| | - L R Brandão
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, M5G-1X8, ON, Canada.
| |
Collapse
|
8
|
Fusaro M, Gallieni M, Rebora P, Rizzo MA, Luise MC, Riva H, Bertoli S, Conte F, Stella A, Ondei P, Rossi E, Valsecchi MG, Santoro A, Genovesi S. Atrial fibrillation and low vitamin D levels are associated with severe vascular calcifications in hemodialysis patients. J Nephrol 2015; 29:419-426. [DOI: 10.1007/s40620-015-0236-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 09/19/2015] [Indexed: 10/22/2022]
|
9
|
|
10
|
Veronese N, Bano G, Bertozzo G, Granziera S, Solmi M, Manzato E, Sergi G, Cohen AT, Correll CU. Vitamin K antagonists' use and fracture risk: results from a systematic review and meta-analysis. J Thromb Haemost 2015; 13:1665-75. [PMID: 26179400 DOI: 10.1111/jth.13052] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 06/28/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND Although vitamin K antagonists (VKAs) lower serum values of bone deposition markers, the link with osteoporosis and fractures remains controversial. OBJECTIVES To assess whether the use of VKAs is associated with an increased prevalence and/or incidence of osteoporosis, fractures, or lower bone mineral density (BMD) values. METHODS We conducted a systematic PubMed and EMBASE literature search until August 31, 2014, and a meta-analysis of cross-sectional and longitudinal studies investigating fractures and BMD, comparing patients treated with VKAs and healthy controls (HCs) or with patients with medical illness (medical controls, MCs). Standardized mean differences ± 95% and confidence intervals (CIs) were calculated for BMD, and risk ratios (RRs) were calculated for prevalent and incident fractures. RESULTS Of 4597 initial hits, 21 studies were eligible, including 79 663 individuals treated with VKAs vs. 597,348 controls. Compared with HCs, VKA-treated individuals showed significantly higher fracture risk in cross-sectional (three studies; RR = 1.24; 95% CI: 1.12-1.39, P < 0.0001) and longitudinal studies (seven studies; RR = 1.09; 95% CI: 1.01-1.18, P = 0.03) and more incident hip fractures (four studies; RR = 1.17; 95% CI: 1.05-1.31, P = 0.003). Analyzing studies that matched VKA participants with HCs (four studies), both these findings in longitudinal studies became non-significant. Notably, the VKA and MC group had similar BMD values at all investigated sites. Compared with HCs, a single study showed significantly lower spine T-scores in the VKA-treated group (standardized mean difference = - 0.45; 95% CI: - 0.75, - 0.14, P = 0.004). CONCLUSION VKAs neither increased prospectively-assessed fracture risk compared with MCs when matching eliminated confounding factors nor reduced BMD beyond effects of medical illness. Future studies, using careful matching and/or adequate MC groups, are needed to further clarify the short- and long-term effects of VKAs on bone health.
Collapse
Affiliation(s)
- N Veronese
- Department of Medicine, Geriatrics Section, University of Padova, Padova, Italy
| | - G Bano
- Department of Medicine, Geriatrics Section, University of Padova, Padova, Italy
| | - G Bertozzo
- Department of Medicine, Geriatrics Section, University of Padova, Padova, Italy
| | - S Granziera
- Department of Medicine, Geriatrics Section, University of Padova, Padova, Italy
| | - M Solmi
- Department of Neurosciences, University of Padova, Padova, Italy
| | - E Manzato
- Department of Medicine, Geriatrics Section, University of Padova, Padova, Italy
- National Research Council, Aging Branch, Institute of Neuroscience, Padova, Italy
| | - G Sergi
- Department of Medicine, Geriatrics Section, University of Padova, Padova, Italy
| | - A T Cohen
- Department of Hematological Medicine, Guys and St. Thomas' NHS Foundation Trust, London, UK
| | - C U Correll
- Psychiatry Research, The Zucker Hillside Hospital, North Shore - Long Island Jewish Health System, Glen Oaks, NY, USA
- Hofstra North Shore LIJ School of Medicine, Hempstead, NY, USA
- The Feinstein Institute for Medical Research, Manhasset, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| |
Collapse
|
11
|
Fusaro M, Dalle Carbonare L, Dusso A, Arcidiacono MV, Valenti MT, Aghi A, Pasho S, Gallieni M. Differential Effects of Dabigatran and Warfarin on Bone Volume and Structure in Rats with Normal Renal Function. PLoS One 2015; 10:e0133847. [PMID: 26241483 PMCID: PMC4524674 DOI: 10.1371/journal.pone.0133847] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 07/03/2015] [Indexed: 01/03/2023] Open
Abstract
Background Warfarin, a widely used anticoagulant, is a vitamin K antagonist impairing the activity of vitamin K-dependent Bone Gla Protein (BGP or Osteocalcin) and Matrix Gla Protein (MGP). Because dabigatran, a new anticoagulant, has no effect on vitamin K metabolism, the aim of this study was to compare the impact of warfarin and dabigatran administration on bone structure and vascular calcification. Methods Rats with normal renal function received for 6 weeks warfarin, dabigatran or placebo. Bone was evaluated immuno-histochemically and hystomorphometrically after double labelling with declomycin and calcein. Aorta and iliac arteries were examined histologically. Results Histomorphometric analysis of femur and vertebrae showed significantly decreased bone volume and increased trabecular separation in rats treated with warfarin. Vertebra analysis showed that the trabecular number was higher in dabigatran treated rats. Osteoblast activity and resorption parameters were similar among groups, except for maximum erosion depth, which was higher in warfarin treated rats, suggesting a higher osteoclastic activity. Therefore, warfarin treatment was also associated with higher bone formation rate/bone surface and activation frequency. Warfarin treatment may cause an increased bone turnover characterized by increased remodelling cycles, with stronger osteoclast activity compared to the other groups. There were no differences among experimental groups in calcium deposition either in aortic or iliac arteries. Conclusions These findings suggest for the first time that dabigatran has a better bone safety profile than warfarin, as warfarin treatment affects bone by reducing trabecular size and structure, increasing turnover and reducing mineralization. These differences could potentially result in a lower incidence of fractures in dabigatran treated patients.
Collapse
Affiliation(s)
- Maria Fusaro
- National Research Council (CNR)–Neuroscience Institute, Padova, Italy
- * E-mail:
| | - Luca Dalle Carbonare
- Department of Medicine, Section of Internal Medicine D, University of Verona, Verona, Italy
| | - Adriana Dusso
- Division of Experimental Nephrology, IRB Lleida (Lleida Institute for Biomedical Research), Lleida, Spain
| | - Maria Vittoria Arcidiacono
- Division of Experimental Nephrology, IRB Lleida (Lleida Institute for Biomedical Research), Lleida, Spain
| | - Maria Teresa Valenti
- Department of Medicine, Section of Internal Medicine D, University of Verona, Verona, Italy
| | - Andrea Aghi
- Nephrology Unit, University of Padua, Padua, Italy
| | - Sabina Pasho
- Nephrology and Dialysis Unit, Ospedale San Carlo Borromeo and Department of Clinical and Biomedical Sciences "Luigi Sacco", University of Milano, Milano, Italy
| | - Maurizio Gallieni
- Nephrology and Dialysis Unit, Ospedale San Carlo Borromeo and Department of Clinical and Biomedical Sciences "Luigi Sacco", University of Milano, Milano, Italy
- Department of Clinical and Biomedical Sciences "Luigi Sacco", University of Milano, Milano, Italy
| |
Collapse
|
12
|
Sugiyama T, Kugimiya F, Kono S, Kim YT, Oda H. Warfarin use and fracture risk: an evidence-based mechanistic insight. Osteoporos Int 2015; 26:1231-2. [PMID: 25300528 DOI: 10.1007/s00198-014-2912-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 09/19/2014] [Indexed: 01/08/2023]
Affiliation(s)
- T Sugiyama
- Department of Orthopaedic Surgery, Saitama Medical University, 38 Morohongo, Moroyama, Saitama, 350-0495, Japan,
| | | | | | | | | |
Collapse
|
13
|
Misra D, Zhang Y, Peloquin C, Choi HK, Kiel DP, Neogi T. Incident long-term warfarin use and risk of osteoporotic fractures: propensity-score matched cohort of elders with new onset atrial fibrillation. Osteoporos Int 2014; 25:1677-84. [PMID: 24833176 PMCID: PMC4180421 DOI: 10.1007/s00198-014-2662-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 08/21/2013] [Indexed: 10/25/2022]
Abstract
UNLABELLED Association between warfarin use and fracture risk is unclear. We examined the association between long-term warfarin use and fracture risk at the hip, spine, and wrist in elders. No significant association was found between long-term warfarin use and fracture risk, despite biological plausibility. INTRODUCTION Prior studies examining the association of warfarin use and osteoporotic fractures have been conflicting, potentially related to methodological limitations. Thus, we examined the association of long-term warfarin use with risk of hip, spine, and wrist fractures among older adults with atrial fibrillation, attempting to address prior methodologic challenges. METHODS We included men and women ≥ 65 years of age with incident atrial fibrillation and without prior history of fractures from The Health Improvement Network followed between 2000 and 2010. Long-term warfarin use was defined in two ways: (1) warfarin use ≥ 1 year; (2) warfarin use ≥ 3 years. Propensity-score matched cohorts of warfarin users and nonusers were created to evaluate the association between long-term warfarin use and risk of hip, spine, and wrist fractures separately as well as combined, using Cox-proportional hazards regression models. RESULTS Among >20,000 participants with incident atrial fibrillation, the hazard ratios (HR) for hip fracture with warfarin use ≥ 1 and ≥ 3 years, respectively, were 1.08 (95%CI 0.87, 1.35) and 1.13 (95% CI 0.84, 1.50). Similarly, no significant associations were observed between long-term warfarin use and risk of spine or wrist fracture. When risk of any fracture was assessed with warfarin use, no association was found [HR for warfarin use ≥ 1 year 0.92 (95%CI 0.77, 1.10); HR for warfarin use ≥ 3 years 1.12 (95%CI 0.88, 1.43)]. CONCLUSIONS Long-term warfarin use among elders with atrial fibrillation was not associated with increased risk of osteoporotic fractures and therefore does not appear to necessitate additional surveillance or prophylaxis.
Collapse
Affiliation(s)
- D Misra
- Boston University School of Medicine, 650 Albany St, Suite X-200, Clinical Epidemiology Unit, Boston, MA, 02118, USA,
| | | | | | | | | | | |
Collapse
|
14
|
Willems BAG, Vermeer C, Reutelingsperger CPM, Schurgers LJ. The realm of vitamin K dependent proteins: shifting from coagulation toward calcification. Mol Nutr Food Res 2014; 58:1620-35. [PMID: 24668744 DOI: 10.1002/mnfr.201300743] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 12/27/2013] [Accepted: 01/01/2014] [Indexed: 12/20/2022]
Abstract
In the past few decades vitamin K has emerged from a single-function "haemostasis vitamin" to a "multi-function vitamin." The use of vitamin K antagonists (VKA) inevitably showed that the inhibition was not restricted to vitamin K dependent coagulation factors but also synthesis of functional extrahepatic vitamin K dependent proteins (VKDPs), thereby eliciting undesired side effects. Vascular calcification is one of the recently revealed detrimental effects of VKA. The discovery that VKDPs are involved in vascular calcification has propelled our mechanistic understanding of this process and has opened novel avenues for diagnosis and treatment. This review addresses mechanisms of VKDPs and their significance for physiological and pathological calcification.
Collapse
Affiliation(s)
- Brecht A G Willems
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands; VitaK BV, Maastricht University, Maastricht, The Netherlands
| | | | | | | |
Collapse
|
15
|
A population-based case-control study: proton pump inhibition and risk of hip fracture by use of bisphosphonate. J Gastroenterol 2013; 48:1016-22. [PMID: 23307040 DOI: 10.1007/s00535-012-0722-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 11/17/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND Studies on the risk of osteoporotic fractures related to the use of proton pump inhibitors (PPIs) have been inconsistent. One recent cohort study reported that there was an interaction between PPIs and bisphosphonates (BPs). Thus we performed a case-control study aimed at evaluating the risk of hip fractures related to PPIs and exploring the interaction between PPIs and BPs. METHODS A case-control study was performed using the Korean Health Insurance Review and Assessment Service database from 2005 January to 2006 June. The cases were all incident hip fractures identified from July 2005 to June 2006, and up to four controls were matched to each case by age, gender, and osteoporosis. Conditional logistic regression was used to calculate the adjusted odds ratio (aOR) and its 95 % confidence intervals. RESULTS A total of 24,710 cases were identified and 98,642 controls were matched to the cases. The aOR and its 95 % CI of hip fractures related to the use of PPIs was 1.34 (95 % CI 1.24-1.44). When the study participants were stratified according to BP use, the aOR was 1.30 (95 % CI 1.19-1.42) in BP non-users, which was significantly different from the 1.71 (95 % CI 1.31-2.23) of BP users. Only BP users showed a decreasing tendency toward fracture risk as exposure to PPI became less recent, and a trend of increasing risk with increasing cumulative doses. CONCLUSIONS Our results suggest that the mechanism for increased risk of hip fracture by PPIs may arise mainly from interaction of BP and PPIs.
Collapse
|
16
|
Inhibition of osteoblastic differentiation by warfarin and 18-α-glycyrrhetinic acid. Arch Pharm Res 2011; 34:1381-7. [PMID: 21910061 DOI: 10.1007/s12272-011-0819-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 05/30/2011] [Accepted: 05/30/2011] [Indexed: 10/17/2022]
Abstract
Anticoagulation therapy with vitamin K antagonists such as warfarin is widely used to prevent and treat stroke in patients with chronic atrial fibrillation or mechanical heart valves. Because vitamin K is an essential factor for ggg-carboxylation of osteocalcin, vitamin K antagonists might cause bone loss. Although the association between warfarin use and bone metabolism is still controversial, several studies show that bone mineral density is decreased and fracture risk is increased with warfarin therapy. Meanwhile, attenuation of gap junctional communication (GJC) by warfarin is reported in rat liver epithelial cells. However, the effect of warfarin on osteoblasts, in which GJC is important for osteoblastic differentiation, remains unknown. Here we investigated whether warfarin has an inhibitory effect on osteoblastic differentiation using an osteoblastic cell line (C2C12). Warfarin and 18-α-glycyrrhetinic acid (AGA), which is known as a nontoxic reversible GJC inhibitor, had the same effect on osteoblastic differentiation. Warfarin and AGA inhibited the bone morphogenetic protein (BMP)2-induced mRNA levels of alkaline phosphatase (ALP), collagen I α1, osteocalcin (OC) and osterix, which are specific markers for osteoblastic differentiation, in a dose-dependent manner. Moreover, the activities of OC- and ALP-luciferase reporters, which are induced by BMP2, and the transcriptional activity of Runx2 on OC and ALP promoters were inhibited by warfarin and AGA. The amount and activity of ALP induced by BMP2 were also decreased by warfarin and AGA. These results suggest that warfarin and AGA, a GJC inhibitor, have an inhibitory effect on osteoblastic differentiation.
Collapse
|
17
|
Fusaro M, Crepaldi G, Maggi S, Galli F, D'Angelo A, Calò L, Giannini S, Miozzo D, Gallieni M. Vitamin K, bone fractures, and vascular calcifications in chronic kidney disease: an important but poorly studied relationship. J Endocrinol Invest 2011; 34:317-23. [PMID: 21088475 DOI: 10.1007/bf03347093] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Vitamin K denotes a group of lipophilic vitamins determining post-translational modification of proteins. There are 2 main forms of vitamin K: vitamin K1 (phylloquinone, found in vegetables); vitamin K2 (menaquinone, produced by bacteria in the intestine and in fermented foods). Vitamin K stores are limited in humans, but it can be recycled. Vitamin K1 is principally transported to the liver, regulating the production of coagulation factors. Vitamin K2, instead, is also transported to extra-hepatic tissues, such as bone and arteries, regulating the activity of matrix Gla-protein (MGP) and osteocalcin [bone Gla-protein (BGP)]. In patients with chronic kidney disease (CKD), cardiovascular mortality is the first cause of death. Some pathogenetic mechanisms of vascular calcification (such as hyperparathyroidism, hyperphosphatemia, hypercalcemia, role of vitamin D) have been widely investigated, but the potential role of vitamin K is still uncertain. Vitamin K could play a key role, as it transforms glutamic acid residues into γ-carboxyglutamic acid, through a carboxylation process, makings both MGP (cMGP) and BGP (cBGP) biologically active. cMGP inhibits vascular calcifications (VC), while cBGP has an important role for a proper mineralization process. Uncarboxylated MGP and BGP (ucMGP and ucBGP) concentrations are indirect markers of vitamin K2 deficiency. The purpose of this review is to analyze the current literature to understand the relationship between vitamin K2 status, fragility fractures and VC in CKD patients. This analysis could be of help in planning investigations of Vitamin K status and its possible supplementation in CKD patients to avert fragility fractures and VC.
Collapse
Affiliation(s)
- M Fusaro
- Department of Medical and Surgical Sciences, Clinica Medica 1, University of Padua, Policlinico IV piano, Via Giustiniani, 2, 35128 Padua, Italy.
| | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Motyl KJ, McCabe LR, Schwartz AV. Bone and glucose metabolism: a two-way street. Arch Biochem Biophys 2010; 503:2-10. [PMID: 20682281 DOI: 10.1016/j.abb.2010.07.030] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Revised: 07/27/2010] [Accepted: 07/29/2010] [Indexed: 12/20/2022]
Abstract
Evidence from rodent models indicates that undercarboxylated osteocalcin (ucOC), a product of osteoblasts, is a hormone affecting insulin production by the pancreas and insulin sensitivity in peripheral tissues, at least in part through enhanced secretion of adiponectin from adipocytes. Clinical research to test whether this relationship is found in humans is just beginning to emerge. Cross-sectional studies confirm associations between total osteocalcin (OC), ucOC and glucose metabolism but cannot distinguish causality. To date, longitudinal studies have not provided a consistent picture of the effects of ucOC or OC on fasting glucose and insulin sensitivity. Further exploration into the physiological and mechanistic effects of ucOC and OC, in rodent models and clinical studies, is necessary to determine to what extent the skeleton regulates energy metabolism in humans.
Collapse
Affiliation(s)
- Katherine J Motyl
- Department of Physiology, Michigan State University, East Lansing, MI 48824, USA
| | | | | |
Collapse
|
19
|
Rezaieyazdi Z, Falsoleiman H, Khajehdaluee M, Saghafi M, Mokhtari-Amirmajdi E. Reduced bone density in patients on long-term warfarin. Int J Rheum Dis 2010; 12:130-5. [PMID: 20374330 DOI: 10.1111/j.1756-185x.2009.01395.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AIM Vitamin K is an essential factor for carboxylation of bone matrix protein. Low vitamin K may be associated with reduced bone mineral density (BMD). The issue of whether long-term sodium warfarin therapy as oral anticoagulant that antagonizes vitamin K, results in decreased bone density, is controversial. Our purpose in this study was to assess the effects of warfarin on BMD. METHODS We performed a case control study survey of bone density in 70 patients with rheumatic valvular heart disease 'mechanical valve replacement' on long-term warfarin compared with 103 randomly selected matched controls. RESULTS There was a marked reduction in BMD (g/cm(2)) and T-score of lumbar spine between patients and controls (P = 0.048, 0.005). Duration of warfarin use was the only risk factor of significant importance respectively on spinal T-score (P < 0.03). CONCLUSIONS Screening of patients on long-term warfarin for reduced bone density should be considered. We strongly suggest the prophylactic use of calcium-vitamin D supplements for these patients.
Collapse
Affiliation(s)
- Zahra Rezaieyazdi
- Department of Rheumatology, Mashhad University of Medical Sciences, Mashhad, Iran.
| | | | | | | | | |
Collapse
|
20
|
Abstract
The objective of this study was to critically assess studies regarding proton pump inhibitors (PPIs) and fractures. A MEDLINE search was conducted to identify relevant articles. Three case-control studies assessed fractures and PPI use. A study of all subjects with fracture in Denmark in 2000 revealed adjusted OR=1.18 (1.12-1.43) for PPI use within the last year (hip fracture OR=1.45,1.28-1.65); no dose-response relationship was identified. A study of hip fractures in UK patients > or =50 years found adjusted OR=1.44 (1.30-1.59) for >1 year of PPIs; duration and average daily dose were significantly associated with fracture risk: adjusted OR for >1.75 times average daily dose for >1 year was 2.65 (1.80-3.90). A study of vertebral, wrist, and hip fractures in Manitoba patients > or =50 years found adjusted OR=0.99 (0.90-1.11) for > or =1 year of continuous PPI; association became significant > or =7 years (OR=1.92, 1.16-3.18). Consistency of some positive results in all studies, the dose and/or duration response in two studies, the possibility that acid inhibition may decrease calcium absorption, and association with histamine(2)-receptor antagonists in some studies support a causal association. The low magnitude of the association (ORs<2), lack of dose-response in one study, lack of association with histamine(2)-receptor antagonists in one study, lack of experimental evidence documenting a mechanism, and inability to assess potential confounding factors limit statements regarding causality. As with all medications, PPIs should be used for appropriate indications and not in higher doses or longer durations than necessary to achieve the desired outcomes.
Collapse
|
21
|
Hip fracture and proton pump inhibitor therapy: position statement. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2009; 22:855-8. [PMID: 19009722 DOI: 10.1155/2008/284165] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
22
|
Moayyedi P, Cranney A. Hip fracture and proton pump inhibitor therapy: balancing the evidence for benefit and harm. Am J Gastroenterol 2008; 103:2428-31. [PMID: 18855852 DOI: 10.1111/j.1572-0241.2008.02031.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gastroenterology is full of examples of drugs being enthusiastically promoted only to be withdrawn or prescription curtailed once the harms of the medication are realized. Cox-2 inhibitors, alosetron, and tegaserod are all recent examples of this phenomenon. The problem is that potential harms of drugs are being highlighted in the medical literature all the time and it can be difficult to determine whether these represent a genuine risk to our patients or are just spurious epidemiological associations. The association between proton pump inhibitor therapy and hip fracture is a good illustration of this dilemma. We use this example to highlight an approach that can be taken to critically evaluate the evidence for harms of medication.
Collapse
Affiliation(s)
- Paul Moayyedi
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | |
Collapse
|
23
|
Woo C, Chang LL, Ewing SK, Bauer DC. Single-point assessment of warfarin use and risk of osteoporosis in elderly men. J Am Geriatr Soc 2008; 56:1171-6. [PMID: 18547361 DOI: 10.1111/j.1532-5415.2008.01786.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine whether warfarin use, assessed at a single point in time, is associated with bone mineral density (BMD), rates of bone loss, and fracture risk in older men. DESIGN Secondary analysis of data from a prospective cohort study. SETTING Six U.S. clinical centers. PARTICIPANTS Five thousand five hundred thirty-three community-dwelling, ambulatory men aged 65 and older with baseline warfarin use data. MEASUREMENTS Warfarin use was assessed as current use of warfarin at baseline using an electronic medication coding dictionary. BMD was measured at the hip and spine at baseline, and hip BMD was repeated at a follow-up visit 3.4 years later. Self-reported nonspine fractures were centrally adjudicated. RESULTS At baseline, the average age of the participants was 73.6 +/- 5.9, and 321 (5.8%) were taking warfarin. Warfarin users had similar baseline BMD as nonusers (n=5,212) at the hip and spine (total hip 0.966 +/- 0.008 vs 0.959 +/- 0.002 g/cm(2), P=.37; total spine 1.079 +/- 0.010 vs 1.074 +/- 0.003 g/cm(2), P=.64). Of subjects with BMD at both visits, warfarin users (n=150) also had similar annualized bone loss at the total hip as nonusers (n=2,683) (-0.509 +/- 0.082 vs -0.421 +/- 0.019%/year, P=.29). During a mean follow-up of 5.1 years, the risk of nonspine fracture was similar in warfarin users and nonusers (adjusted hazard ratio=1.06, 95% confidence interval=0.68-1.65). CONCLUSION In this cohort of elderly men, current warfarin use was not associated with lower BMD, accelerated bone loss, or higher nonspine fracture risk.
Collapse
Affiliation(s)
- Claudine Woo
- San Francisco Coordinating Center, California Pacific Medical Center Research Institute, San Francisco, California, USA.
| | | | | | | | | |
Collapse
|
24
|
Hara K, Kobayashi M, Akiyama Y. Influence of bone osteocalcin levels on bone loss induced by ovariectomy in rats. J Bone Miner Metab 2007; 25:345-53. [PMID: 17968486 DOI: 10.1007/s00774-007-0781-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2006] [Accepted: 04/10/2007] [Indexed: 10/22/2022]
Abstract
To investigate the role of osteocalcin (OC) in bones, bone parameters in warfarin (WF)-treated rats after ovariectomy (OVX) were compared with those in intact rats. Rats were divided into an intact group and WF-treated group. Warfarin was orally given to rats for 16 weeks, and then OVX was performed and rats in the WF-treated groups continued receiving WF. Twelve weeks after OVX, bone properties were observed. The diaphysial bone OC level in the WF group was 10%-14% of the normal level at the preoperative point and 12 weeks after surgery. On comparison of the intact and WF groups before surgery, no significant differences were noted in bone mass parameters or mechanical properties, but 12 weeks after surgery, the diaphysial bone mineral content (BMC), bone area, and cortical thickness (Cth) were significantly higher in the WF-sham group than in the intact-sham group. Ovariectomy significantly decreased the diaphysial BMC, bone mineral density (BMD), Cth, and maximum load, and increased the endosteal perimeter in the WF group. In the intact group, no such OVX-induced changes were noted, and the metaphysial bone area and the endosteal and periosteal perimeters were increased by OVX. The CO(3)/PO(4) ratio in the femur measured by Fourier-transform infrared imaging using reflection preparations was higher in the WF-sham group than the intact-sham group, and higher in the intact-OVX group than the intact-sham group, but no significant difference was noted between the WF-sham and WF-OVX groups. It has been reported that CO(3)(-) is contained in new bone and decreases with mineral maturation. These data suggest that long-term reduction in bone OC levels may induce the formation of immature bone, which is easily resorbed with changes in bone metabolism such as OVX, and that OC may be one of the factors affecting bone turnover.
Collapse
Affiliation(s)
- Kuniko Hara
- Pharmacological Evaluation, Applied Drug Research Department, Clinical Research Center, Eisai Co., Ltd., 4-6-10 Koishikawa, Bunkyo-ku, Tokyo 112-8088, Japan.
| | | | | |
Collapse
|
25
|
Bereznicki LR, Peterson GM, Jackson SL, Jeffrey EC. The risks of warfarin use in the elderly. Expert Opin Drug Saf 2006; 5:417-31. [PMID: 16610970 DOI: 10.1517/14740338.5.3.417] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The use of warfarin in the elderly, particularly for stroke prevention in chronic atrial fibrillation, is steadily increasing. Although the benefits of warfarin are greatest in the elderly, so are the risk of adverse outcomes and the difficulties of anticoagulant management. Clinical systems need to improve to counter this therapeutic dilemma, as warfarin is likely to remain the only widely available oral anticoagulant for the foreseeable future. Aspects that require attention are: the careful selection of patients in whom treatment with warfarin is appropriate; initiating therapy in a low dose (e.g., 2.5-5 mg/day); thorough education of patients and carers; close monitoring, especially with any change in the patient's regular drug therapy; involving patients more in the management of their warfarin therapy (self-monitoring/management in suitable patients); and ongoing review of the appropriateness of therapy as circumstances change.
Collapse
Affiliation(s)
- Luke R Bereznicki
- Unit for Medication Outcomes Research and Education, School of Pharmacy, University of Tasmania, Hobart, Tasmania, Australia
| | | | | | | |
Collapse
|
26
|
Current awareness in pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2003; 12:431-46. [PMID: 12899122 DOI: 10.1002/pds.791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|