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Conway KM, Grosse SD, Ouyang L, Street N, Romitti PA. Direct costs of adhering to selected Duchenne muscular dystrophy Care Considerations: Estimates from a midwestern state. Muscle Nerve 2022; 65:574-580. [PMID: 35064961 PMCID: PMC9109677 DOI: 10.1002/mus.27505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/12/2022] [Accepted: 01/15/2022] [Indexed: 11/10/2022]
Abstract
INTRODUCTION/AIMS The multidisciplinary Duchenne muscular dystrophy (DMD) Care Considerations were developed to standardize care and improve outcomes. We provide cumulative cost estimates for selected key preventive (ie, excluding new molecular therapies and acute care) elements of the care considerations in eight domains (neuromuscular, rehabilitation, respiratory, cardiac, orthopedic, gastrointestinal, endocrine, psychosocial management) independent of completeness of uptake or provision of nonpreventive care. METHODS We used de-identified insurance claims data from a large midwestern commercial health insurer during 2018. We used Current Procedural Terminology and national drug codes to extract unit costs for clinical encounters representing key preventive elements of the DMD Care Considerations. We projected per-patient cumulative costs from ages 5 to 25 years for these elements by multiplying a schedule of recommended frequencies of preventive services by unit costs in 2018 US dollars. RESULTS Assuming a diagnosis at age 5 years, independent ambulation until age 11, and survival until age 25, we estimated 670 billable clinical events. The 20-year per-patient cumulative cost was $174 701 with prednisone ($2.3 million with deflazacort) and an expected total of $12 643 ($29 194) for out-of-pocket expenses associated with those events and medications. DISCUSSION Standardized monitoring of disease progression and treatments may reduce overall costs of illness. Costs associated with these services would be needed to quantify potential savings. Our approach demonstrates a method to estimate costs associated with implementation of preventive care schedules.
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Affiliation(s)
- Kristin M Conway
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, Iowa, USA
| | - Scott D Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lijing Ouyang
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Natalie Street
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Paul A Romitti
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, Iowa, USA
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2
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Ciancia S, van Rijn RR, Högler W, Appelman-Dijkstra NM, Boot AM, Sas TCJ, Renes JS. Osteoporosis in children and adolescents: when to suspect and how to diagnose it. Eur J Pediatr 2022; 181:2549-2561. [PMID: 35384509 PMCID: PMC9192469 DOI: 10.1007/s00431-022-04455-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 02/07/2023]
Abstract
UNLABELLED Early recognition of osteoporosis in children and adolescents is important in order to establish an appropriate diagnosis of the underlying condition and to initiate treatment if necessary. In this review, we present the diagnostic work-up, and its pitfalls, of pediatric patients suspected of osteoporosis including a careful collection of the medical and personal history, a complete physical examination, biochemical data, molecular genetics, and imaging techniques. The most recent and relevant literature has been reviewed to offer a broad overview on the topic. Genetic and acquired pediatric bone disorders are relatively common and cause substantial morbidity. In recent years, there has been significant progress in the understanding of the genetic and molecular mechanistic basis of bone fragility and in the identification of acquired causes of osteoporosis in children. Specifically, drugs that can negatively impact bone health (e.g. steroids) and immobilization related to acute and chronic diseases (e.g. Duchenne muscular dystrophy) represent major risk factors for the development of secondary osteoporosis and therefore an indication to screen for bone mineral density and vertebral fractures. Long-term studies in children chronically treated with steroids have resulted in the development of systematic approaches to diagnose and manage pediatric osteoporosis. CONCLUSIONS Osteoporosis in children requires consultation with and/or referral to a pediatric bone specialist. This is particularly relevant since children possess the unique ability for spontaneous and medication-assisted recovery, including reshaping of vertebral fractures. As such, pediatricians have an opportunity to improve bone mass accrual and musculoskeletal health in osteoporotic children. WHAT IS KNOWN • Both genetic and acquired pediatric disorders can compromise bone health and predispose to fractures early in life. • The identification of children at risk of osteoporosis is essential to make a timely diagnosis and start the treatment, if necessary. WHAT IS NEW • Pediatricians have an opportunity to improve bone mass accrual and musculoskeletal health in osteoporotic children and children at risk of osteoporosis. • We offer an extensive but concise overview about the risk factors for osteoporosis and the diagnostic work-up (and its pitfalls) of pediatric patients suspected of osteoporosis.
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Affiliation(s)
- Silvia Ciancia
- Department of Pediatrics, Subdivision of Endocrinology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Rick R. van Rijn
- grid.7177.60000000084992262Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Wolfgang Högler
- grid.9970.70000 0001 1941 5140Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Natasha M. Appelman-Dijkstra
- grid.10419.3d0000000089452978Department of Internal Medicine, Subdivision of Endocrinology, Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
| | - Annemieke M. Boot
- grid.4830.f0000 0004 0407 1981Department of Pediatrics, Subdivision of Endocrinology, University Medical Center Groningen, Beatrix Children’s Hospital, University of Groningen, Groningen, The Netherlands
| | - Theo C. J. Sas
- grid.416135.40000 0004 0649 0805Department of Pediatrics, Subdivision of Endocrinology, Erasmus University Medical Center, Sophia Children’s Hospital, Rotterdam, The Netherlands ,Diabeter, Center for Pediatric and Adult Diabetes Care and Research, Rotterdam, The Netherlands
| | - Judith S. Renes
- grid.416135.40000 0004 0649 0805Department of Pediatrics, Subdivision of Endocrinology, Erasmus University Medical Center, Sophia Children’s Hospital, Rotterdam, The Netherlands
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Suthar R, Reddy BVC, Malviya M, Sirari T, Attri SV, Patial A, Tageja M, Didwal G, Khandelwal NK, Saini AG, Saini L, Sahu JK, Dayal D, Sankhyan N. Bone density and bone health alteration in boys with Duchenne Muscular Dystrophy: a prospective observational study. J Pediatr Endocrinol Metab 2021; 34:573-581. [PMID: 33838091 DOI: 10.1515/jpem-2020-0680] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 01/14/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Boys with Duchenne Muscular Dystrophy (DMD) are at increased risk for compromised bone health, manifesting as low-impact trauma long bone fractures and vertebral compression fractures. METHODS In a prospective observational study, we studied bone health parameters in North Indian boys with DMD. We consecutively enrolled ambulatory boys with DMD on glucocorticoid therapy. Bone health was evaluated with X-ray spine, Dual-energy X-ray absorptiometry (DXA), serum calcium, vitamin D3 (25[OH]D), 1,25-dihyroxyvitamin D3 (1,25[OH]2D3), serum osteocalcin, osteopontin, and N terminal telopeptide of type 1 collagen (Ntx) levels. RESULTS A total of 76 boys with DMD were enrolled. The median age was 8.5 (interquartile range [IQR] 7.04-10.77) years. Among these, seven (9.2%) boys had long bone fractures, and four (5.3%) had vertebral compression fractures. Fifty-four (71%) boys underwent DXA scan, and among these 31 (57%) had low bone mineral density (BMD, ≤-2 z-score) at the lumbar spine. The mean BMD z-score at the lumbar spine was -2.3 (95% confidence interval [CI] = -1.8, -2.8), and at the femoral neck was -2.5 (95% CI = -2, -2.9). 25(OH)D levels were deficient in 68 (89.5%, n=76) boys, and 1,25(OH)2D3 levels were deficient in all. Mean serum osteocalcin levels were 0.68 ± 0.38 ng/mL (n=54), serum osteopontin levels were 8.6 ± 4.6 pg/mL (n=54) and serum Ntx levels were 891 ± 476 nmol/L (n=54). Boys with low BMD received glucocorticoids for longer duration, in comparison to those with normal BMD (median, IQR [16.9 (6-34) months vs. 7.8 (4.8-13.4) months]; p=0.04). CONCLUSIONS Bone health is compromised in North Indian boys with DMD. BMD at the lumbar spine is reduced in more than half of boys with DMD and nearly all had vitamin D deficiency on regular vitamin D supplements. Longer duration of glucocorticoid therapy is a risk factor for low BMD in our cohort.
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Affiliation(s)
- Renu Suthar
- Pediatric Neurology Unit, Department of Pediatrics, APC, PGIMER, Chandigarh, India
| | - B V Chaithanya Reddy
- Pediatric Neurology Unit, Department of Pediatrics, APC, PGIMER, Chandigarh, India
| | - Manisha Malviya
- Pediatric Neurology Unit, Department of Pediatrics, APC, PGIMER, Chandigarh, India
| | - Titiksha Sirari
- Pediatric Neurology Unit, Department of Pediatrics, APC, PGIMER, Chandigarh, India
| | - Savita Verma Attri
- Pediatric Biochemistry Unit, Department of Pediatrics, APC, PGIMER, Chandigarh, India
| | - Ajay Patial
- Pediatric Biochemistry Unit, Department of Pediatrics, APC, PGIMER, Chandigarh, India
| | - Minni Tageja
- Pediatric Biochemistry Unit, Department of Pediatrics, APC, PGIMER, Chandigarh, India
| | - Gunjan Didwal
- Pediatric Biochemistry Unit, Department of Pediatrics, APC, PGIMER, Chandigarh, India
| | | | - Arushi G Saini
- Pediatric Neurology Unit, Department of Pediatrics, APC, PGIMER, Chandigarh, India
| | - Lokesh Saini
- Pediatric Neurology Unit, Department of Pediatrics, APC, PGIMER, Chandigarh, India
| | - Jitendra K Sahu
- Pediatric Neurology Unit, Department of Pediatrics, APC, PGIMER, Chandigarh, India
| | - Devi Dayal
- Pediatric Endocrinology Unit, Department of Pediatrics, APC, PGIMER, Chandigarh, India
| | - Naveen Sankhyan
- Pediatric Neurology Unit, Department of Pediatrics, APC, PGIMER, Chandigarh, India
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Chrzanowska JA, Bubula L, Noczyńska A, Zubkiewicz-Kucharska A. To increase body height and muscle strength - one medicine for two diseases? Case report of a boy with Silver-Russell syndrome and Duchenne muscular dystrophy. Pediatr Endocrinol Diabetes Metab 2021; 27:298-304. [PMID: 34928109 PMCID: PMC10226341 DOI: 10.5114/pedm.2021.107724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/25/2021] [Indexed: 11/17/2022]
Abstract
The coexistence of 2 genetic diseases can mutually modify their course. We describe the case of a 10-year-old boy with Sliver-Russell syndrome (SRS) and Duchenne muscular dystrophy (DMD). The patient's short stature, which is part of the clinical picture of both diseases, has been additionally aggravated by the steroid therapy, which is necessary to delay the progression of DMD. From the age of 9 years, the patient was treated with recombinant human growth hormone (rhGH) for 18 months. The following study discusses whether rhGH therapy in a child with SRS and DMD may alleviate or worsen the course of DMD, and how it affects carbohydrate metabolism disorders.
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Affiliation(s)
- Joanna A. Chrzanowska
- Department of Endocrinology and Diabetology of the Developmental Age, Medical University of Wroclaw, Poland
| | - Lidia Bubula
- Student Scientific Club at the Department of Endocrinology and Diabetology of the Developmental Age, Medical University of Wroclaw, Poland
| | - Anna Noczyńska
- Department of Endocrinology and Diabetology of the Developmental Age, Medical University of Wroclaw, Poland
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Alayi T, Tawalbeh SM, Ogundele M, Smith HR, Samsel AM, Barbieri ML, Hathout Y. Tandem Mass Tag-Based Serum Proteome Profiling for Biomarker Discovery in Young Duchenne Muscular Dystrophy Boys. ACS OMEGA 2020; 5:26504-26517. [PMID: 33110978 PMCID: PMC7581259 DOI: 10.1021/acsomega.0c03206] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/23/2020] [Indexed: 06/11/2023]
Abstract
Blood-accessible molecular biomarkers are becoming highly attractive tools to assess disease progression and response to therapies in Duchenne muscular dystrophy (DMD) especially in very young patients for whom other outcome measures remain subjective and challenging. In this study, we have standardized a highly specific and reproducible multiplexing mass spectrometry method using the tandem mass tag (TMT) strategy in combination with depletion of abundant proteins from serum and high-pH reversed-phase peptide fractionation. Differential proteome profiling of 4 year-old DMD boys (n = 9) and age-matched healthy controls (n = 9) identified 38 elevated and 50 decreased serum proteins (adjusted P < 0.05, FDR <0.05) in the DMD group relative to the healthy control group. As expected, we confirmed previously reported biomarkers but also identified novel biomarkers. These included novel muscle injury-associated biomarkers such as telethonin, smoothelin-like protein 1, cofilin-1, and plectin, additional muscle-specific enzymes such as UTP-glucose-1-phosphate uridylyltransferase, aspartate aminotransferase, pyruvate kinase PKM, lactotransferrin, tissue alpha-l-fucosidase, pantetheinase, and ficolin-1, and some pro-inflammatory and cell adhesion-associated biomarkers such as leukosialin, macrophage receptor MARCO, vitronectin, galectin-3-binding protein, and ProSAAS. The workflow including serum depletion, sample processing, and mass spectrometry analysis was found to be reproducible and stable over time with CV < 20%. Furthermore, the method was found to be superior in terms of specificity compared to other multiplexing affinity-based methods. These findings demonstrate the specificity and reliability of TMT-based mass spectrometry methods in detection and identification of serum biomarkers in presymptomatic young DMD patients.
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Affiliation(s)
- Tchilabalo
D. Alayi
- Department
of Pharmaceutical Science, School of Pharmacy and Pharmaceutical Sciences, Binghamton University−SUNY, Johnson City, New York 13790, United States
| | - Shefa M. Tawalbeh
- Department
of Pharmaceutical Science, School of Pharmacy and Pharmaceutical Sciences, Binghamton University−SUNY, Johnson City, New York 13790, United States
- Department
of Biomedical Engineering, Binghamton University−SUNY, 4400 Vestal Pkwy E, Binghamton, New York 13902, United States
| | - Michael Ogundele
- Department
of Pharmaceutical Science, School of Pharmacy and Pharmaceutical Sciences, Binghamton University−SUNY, Johnson City, New York 13790, United States
- Department
of Biomedical Engineering, Binghamton University−SUNY, 4400 Vestal Pkwy E, Binghamton, New York 13902, United States
| | - Holly R. Smith
- Department
of Pharmaceutical Science, School of Pharmacy and Pharmaceutical Sciences, Binghamton University−SUNY, Johnson City, New York 13790, United States
- Department
of Biochemistry, Binghamton University−SUNY, 4400 Vestal Pkwy E, Binghamton, New York 13902, United States
| | - Alison M. Samsel
- Department
of Pharmaceutical Science, School of Pharmacy and Pharmaceutical Sciences, Binghamton University−SUNY, Johnson City, New York 13790, United States
| | - Marissa L. Barbieri
- Department
of Pharmaceutical Science, School of Pharmacy and Pharmaceutical Sciences, Binghamton University−SUNY, Johnson City, New York 13790, United States
| | - Yetrib Hathout
- Department
of Pharmaceutical Science, School of Pharmacy and Pharmaceutical Sciences, Binghamton University−SUNY, Johnson City, New York 13790, United States
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6
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Annexstad EJ, Bollerslev J, Westvik J, Myhre AG, Godang K, Holm I, Rasmussen M. The role of delayed bone age in the evaluation of stature and bone health in glucocorticoid treated patients with Duchenne muscular dystrophy. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2019; 2019:4. [PMID: 31889957 PMCID: PMC6927168 DOI: 10.1186/s13633-019-0070-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/23/2019] [Indexed: 12/17/2022]
Abstract
Background Low bone mineral density and an increased risk of appendicular and vertebral fractures are well-established consequences of Duchenne muscular dystrophy (DMD) and the risk of fractures is exacerbated by long-term glucocorticoid treatment. Monitoring of endocrine and skeletal health and timely intervention in at-risk patients is important in the management of children with DMD. Methods As part of the Norwegian Duchenne muscular dystrophy cohort study, we examined the skeletal maturation of 62 boys less than 18 years old, both currently glucocorticoid treated (n = 44), previously treated (n = 6) and naïve (n = 12). The relationship between bone age, height and bone mineral density (BMD) Z-scores was explored. Results The participants in the glucocorticoid treated group were short in stature and puberty was delayed. Bone age was significantly delayed, and the delay increased with age and duration of treatment. The difference in height between glucocorticoid treated and naïve boys was no longer significant when height was corrected for delayed skeletal maturation. Mean BMD Z-scores fell below − 2 before 12 years of age in the glucocorticoid treated group, with scores significantly correlated with age, duration of treatment and pubertal development. When BMD Z-scores were corrected for by retarded bone age, the increase in BMD Z-scores was significant for all age groups. Conclusion Our results suggest that skeletal maturation should be assessed in the evaluation of short stature and bone health in GC treated boys with DMD, as failing to consider delayed bone age leads to underestimation of BMD Z-scores and potentially overestimation of fracture risk.
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Affiliation(s)
- E J Annexstad
- 1Department of Neurology, Unit for Congenital and Inherited Neuromuscular Disorders, Oslo University Hospital, PoBox 4950, Nydalen, 0424 Oslo, Norway.,2Faculty of Medicine, University of Oslo, Oslo, Norway.,3Department of Clinical Neurosciences for Children, Oslo University Hospital, Oslo, Norway.,8Children's Department, Ostfold Hospital Trust, Sarpsborg, Norway
| | - J Bollerslev
- 4Department of Endocrinology, Section of Specialized Endocrinology, Oslo University Hospital Rikshospitalet, Oslo, Norway.,2Faculty of Medicine, University of Oslo, Oslo, Norway
| | - J Westvik
- 5Department of Radiology, Section for Paediatric Radiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - A G Myhre
- Frambu Resource Centre for Rare Disorders, Siggerud, Norway
| | - K Godang
- 4Department of Endocrinology, Section of Specialized Endocrinology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - I Holm
- 2Faculty of Medicine, University of Oslo, Oslo, Norway.,7Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - M Rasmussen
- 1Department of Neurology, Unit for Congenital and Inherited Neuromuscular Disorders, Oslo University Hospital, PoBox 4950, Nydalen, 0424 Oslo, Norway.,3Department of Clinical Neurosciences for Children, Oslo University Hospital, Oslo, Norway
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Di Marco M, Joseph S, Horrocks I, Ahmed SF, Wong SC. Fractures and bone health in Duchenne muscular dystrophy in Scotland. Neuromuscul Disord 2019; 29:342. [PMID: 30935748 DOI: 10.1016/j.nmd.2019.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- M Di Marco
- Scottish Muscle Network, Queen Elizabeth University Hospital, Glasgow
| | - S Joseph
- Developmental Endocrinology Research Group, Royal Hospital for Children, Glasgow; Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow
| | - I Horrocks
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow
| | - S F Ahmed
- Developmental Endocrinology Research Group, Royal Hospital for Children, Glasgow
| | - S C Wong
- Developmental Endocrinology Research Group, Royal Hospital for Children, Glasgow.
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Ward LM, Weber DR. Growth, pubertal development, and skeletal health in boys with Duchenne Muscular Dystrophy. Curr Opin Endocrinol Diabetes Obes 2019; 26:39-48. [PMID: 30507696 PMCID: PMC6402320 DOI: 10.1097/med.0000000000000456] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Glucocorticoid therapy is currently the most widely used treatment for Duchenne muscular dystrophy (DMD), having consistently shown to prolong ambulation by 2 years, reduce the frequency of scoliosis, and improve cardiorespiratory function. Among the most frequent side effects of glucocorticoids are fractures due to osteoporosis, linear growth retardation or arrest, and pubertal delay, the subjects of this review. RECENT FINDINGS The diagnosis of osteoporosis has shifted in recent years away from a bone mineral density-centric to a fracture-focused approach, with particular emphasis on early vertebral fracture identification (one of the key triggers for osteoporosis intervention). Delayed puberty should be addressed in an age-appropriate manner, with numerous options available for sex steroid replacement. Growth impairment, however, is a more challenging complication of glucocorticoid-treated DMD, one that is most likely best addressed through growth-sparing therapies that target the dystrophinopathy. SUMMARY With glucocorticoid prescription an increasingly prevalent component of DMD care, early attention to management of osteoporosis and delayed puberty are important components of multidisciplinary and anticipatory care. The treatment of short stature remains controversial, with no accepted therapy currently available to over-ride the toxic effects of glucocorticoids on the growth axis.
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Affiliation(s)
- Leanne M. Ward
- Division of Endocrinology and Metabolism, Children’s Hospital of Eastern Ontario, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - David R. Weber
- Division of Endocrinology and Diabetes, Golisano Children’s Hospital, University of Rochester Medical Centre, Rochester, New York, USA
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