Drug-induced osteoporosis in the older adult

Atraumatic Fractures in Multi-Morbid Older Adults: A Series of Five Cases and Review of Literature

Atraumatic fractures (ATFs) are a fragility fracture subtype with occasional medicolegal issues. ATFs are defined as fractures because of a "low-energy mechanism that is usually considered incapable of producing a fracture." They are an underreported disorder, with epidemiological variations. ATF phenomena were previously reported not only in older adults, but also in children, young adults, older adults, and animals. This study is a short retrospective case series exploring atraumatic fractures in a tertiary care university hospital. Over a period of two years, a total of seven ATF cases were identified. However, only five fulfilled the inclusion criteria. Local causes of pathologic fractures (e.g., metastasis) and elder abuse or neglect were excluded. Comparison of the cases' clinical profile, fracture profile, and management was done. All five cases were frail females with significant osteotoxic burdens from medications and multi-morbidities. ATF presentations included typical (as pain) and atypical (as painless, loud crack, and sudden giveaway) symptomatology. One ATF had a coincident unexplained aseptic fever. Three cases had more than one fracture (fracture cascade), confirmed and followed up by x-rays. All the cases were managed conservatively except for one case that underwent hip hemiarthroplasty. Plans of care included managing the osteotoxic multi-morbidities burden, focusing on the whole body, not only on the fracture or bone. The study provided insights about challenges in presentations of ATF (as the bone fracture acute phase reaction: osteogenic aseptic fever). Risk factors are classically assumed to be osteoporosis, but it is usually systemic and multifactorial. A high risk of fracture warning sign could help decrease ATF occurrence or fracture cascades. Four ATF categories were detected to help healthcare systems identify high-risk patients and raise awareness among medical staff, families, and caregivers. Future studies of the at-risk groups are needed to understand ATF knowledge gaps, challenges, and the best treatments.

Proton pump inhibitors and mandibular bone quality: A preliminary study

OBJECTIVES

Proton pump inhibitors (PPI) provide a long-lasting anti-acidic effect by inhibiting the proton pump, and they are one of the most commonly prescribed drugs worldwide. PPIs adversely affect the bone structure via deficiency of vitamins and minerals. The aim of this study was to investigate the possible PPI-induced bone changes in the mandible on panoramic radiographs with the methods of fractal analysis and panoramic morphometric indices.

METHODS

Panoramic radiographs of 402 patients were used (201 PPI users, 201 control group). Fractal analysis was performed on 4 regions of interests (ROI): 1- upper part of the ramus, 2- angulus, 3- anterior of the mental foramen, 4- distal of the middle ramus. Also, the panoramic mandibular index (PMI), mandibular cortical width (MCW), and Klemetti index (KI) were performed on radiographs.

RESULTS

There were significant differences in terms of ROI3, MCW, and KI between the control and study groups (p < 0.05) while there was no significant difference for ROI1, ROI2, ROI4, and PMI (p > 0.05). Males were severely affected than females.

CONCLUSIONS

Osteoporotic changes were detected in the trabecular and cortical bone in the mental foramen region in PPI users with fractal analysis and morphometric indices, while there were no differences for mandibular ramus and angulus regions according to fractal analysis.

Prevalence of polypharmacy and associated factors in older adults living in Rio Branco, Acre, Brazil: a cross-sectional population-based study, 2014

OBJECTIVE

To analyze polypharmacy prevalence and associated factors in older adults living in Rio Branco, Acre, Brazil, in 2014.

METHODS

This was a cross-sectional population-based study using complex sampling with older adults. Polypharmacy was defined as concomitant use of five or more medications.

RESULTS

Polypharmacy prevalence was 14.9% (95%CI 11.8;18.6), positively associated with females (OR=2.29 - 95%CI 1.41;3.74), white race/skin color (OR=1.61 - 95%CI 1.10;2.38), dependence (OR=1.65 - 95%CI 1.05;2.60), change in eating habits/dieting (OR=1.66 - 95%CI 1.16;2.36), hospitalization in the last 12 months (OR=1.61 - 95%CI 1.02;2.53) and presence of the following self-reported morbidities: systemic arterial hypertension (OR=2.40 - 95%CI 1.33;4.34), diabetes mellitus (OR=2.17 - 95%CI 1.23;3.84), osteoporosis (OR=2.92 - 95%CI 1.84;4.64) and heart problems (OR=2.94 - 95%CI 1.90;4.56).

CONCLUSION

This study found that polypharmacy in the older adults was associated with demographic and health conditions.

Antiviral therapy and the development of osteopenia/osteoporosis among Asians with chronic hepatitis B

BACKGROUND

Recent studies have suggested a potential increase in the incidence of osteoporosis for patients receiving tenofovir disoproxil fumarate (TDF), but this issue remains controversial.

METHODS

The retrospective cohort study of 1224 Asian chronic hepatitis B (CHB) patients greater than 18 years without baseline osteopenia/osteoporosis seen at four US centers from 2008 to 2016. Patients were categorized into three groups-treatment-naive patients who initiated therapy with TDF (1) or entecavir (ETV) (2), or untreated patients (3). Patients were followed until the development of osteopenia/osteoporosis or end of the study.

RESULTS

Of the 1224 study patients, 276 were treated with TDF, 335 with ETV, and 613 were untreated. The prevalence of cirrhosis was lower for untreated patients (2.6% vs 16.3% for TDF and 17.6% for ETV; P < 0.001). The 8-year cumulative incidence rate of osteopenia/osteoporosis was 13.17% for TDF, 15.09% for ETV, and 10.17% for untreated patients, with no statistically significant difference among the three groups ( P = 0.218). On multivariate Cox regression controlling for demographics, osteoporosis risk factors, albumin, and hepatitis B virus (HBV) DNA levels, neither TDF (adjusted hazard ratio [HR] = 0.74; 95% confidence interval [CI]: 0.34 and 1.59) nor ETV (adjusted HR = 0.98; 95% CI: 0.51 and 1.90) were associated with increased osteopenia/osteoporosis risk compared with untreated patients.

CONCLUSIONS

Our retrospective study suggests that there is no significant increase in the incidence of osteopenia/osteoporosis for patients with CHB treated with TDF or ETV during a median follow-up of about 4 to 5 years. However, further study with longer follow-up is needed as an anti-HBV therapy, which is often lifelong or long-term and the development of osteopenia/osteoporosis can be a slow process.

Characteristics and diagnostic workup of the patient at risk to sustain fragility fracture

The human body undergoes several physiological adaptations as a result of the aging process. Amongst other organs, the skeleton is also affected and when bone fragility is present, an increase in both morbidity and mortality has been reported. Identification of risk factors to calculate the probability for a given patient to develop a fragility fracture it is therefore of paramount importance. Moreover, the existence of an in house protocol for diagnostic work up using biochemical tests and imaging investigations is essential. In the herein study we discuss a diagnostic protocol that has been developed in our clinic based on knowledge from the literature and our clinical experience.

Risk of Fracture and the Concomitant Use of Bisphosphonates With Osteoporosis-Inducing Medications

Objective: To review the literature on the concomitant use of bisphosphonates and medications that can influence bone metabolism and potentially attenuate bisphosphonate antifracture efficacy. Data Sources: MEDLINE and CINAHL were searched for articles published in English through December 2014 using the following terms: bisphosphonates, bone density conservation agents, acid-suppressive therapy, levothyroxine, thiazolidinediones (TZDs), selective serotonin reuptake inhibitors (SSRIs), bone fractures. Study Selection and Data Extraction: Studies were included if they reported results of concomitant use of any listed medications with bisphosphonates and risk of fractures and focused on women. Articles that focused generally on the use of one of the listed medications and fractures without explicitly examining the potential antifracture efficacy or attenuation of bisphosphonates were excluded. Data Synthesis: A total of 6 relevant studies were identified. Four epidemiological studies reported a statistically significant dose-dependent increase in the risk of fractures when bisphosphonates and acid-suppressive drugs were used together. One post hoc analysis of clinical trial data suggested no attenuation of the antifracture effects of bisphosphonates when used concomitantly with acid-suppressive therapy. One study involving bisphosphonates and SSRIs noted a statistically significant association between fracture risk and SSRI use. No study examining TZDs or levothyroxine with bisphosphonates was identified. Conclusions: Existing research suggests potential attenuation of bisphosphonate antifracture efficacy among patients taking acid-suppressive medications. Based on their pharmacological actions, TZDs, SSRIs, and levothyroxine have similar implications. The paucity of evidence in the literature associating the attenuation of bisphosphonate antifracture efficacy when combined with other medications suggests that further investigation is needed.

A favorable risk-benefit analysis of high dose thyroid for treatment of bipolar disorders with regard to osteoporosis

High dose thyroid hormone has been in use since the 1930s for the treatment of affective disorders. Despite numerous papers showing benefit, the lack of negative trials and its inclusion in multiple treatment guidelines, high dose thyroid has yet to find wide spread use. The major objection to the use of high dose thyroid is the myth that it causes osteoporosis. This paper reviews the literature surrounding the use of high dose thyroid, both in endocrinology and in psychiatry. High dose thyroid does not appear to be a significant risk factor for osteoporosis while other widely employed psychiatric medications do pose a risk. Psychiatrists are uniquely qualified to do the risk-benefit analyses of high dose thyroid for the treatment of the bipolar I, bipolar II and bipolar NOS. Other specialties do not have the requisite knowledge of the risks of alterative medications or of the mortality and morbidity of the bipolar disorders to do a full risk benefit analysis.

Osteoporosis piece of multi-morbidity puzzle in geriatric care

Osteoporosis frequently coexists with other chronic diseases and syndromes of aging, and therefore multimorbidity interactions can potentially complicate its evaluation and treatment. This article reviews osteoporosis comorbidity interactions with select common diseases of aging including cardiovascular, neurologic, and geriatric syndromes, and select commonly used medications by older adults. Using depression as a case example, we describe the complex relationship between osteoporosis, mood, and antidepressant medications, and the implications of these interactions for patients and clinicians.