Greater Calcium Intake is Associated with Better Bone Health Measured by Quantitative Ultrasound of the Phalanges in Pediatric Patients Treated with Anticonvulsant Drugs

Drug-induced osteoporosis and mechanisms of bone tissue regeneration through trace elements

Osteoporosis is associated with an imbalance in bone formation, with certain drugs used in disease treatment being implicated in its development. Supplementation with trace elements may contribute to bone regeneration, offering an alternative approach by enhancing bone mineral density (BMD) and thereby thwarting the onset of osteoporosis. This review aims to assess the mechanisms through which trace elements such as copper (Cu), iron (Fe), selenium (Se), manganese (Mn), and zinc (Zn) are linked to increased bone mass, thus mitigating the effects of pharmaceuticals. Our findings underscore that the use of drugs such as aromatase inhibitors (AIs), proton pump inhibitors (PPIs), antiretrovirals, glucocorticoids, opioids, or anticonvulsants can result in decreased BMD, a primary contributor to osteoporosis. Research indicates that essential elements like Cu, Fe, Se, Mn, and Zn, through various mechanisms, can bolster BMD and forestall the onset of the disease, owing to their protective effects. Consequently, our study recommends a minimum daily intake of these essential minerals for patients undergoing treatment with the aforementioned drugs, as the diverse mechanisms governing the effects of trace elements Cu, Fe, Mn, Se, and Zn facilitate bone remodeling.

Effects of antiepileptic therapy on bone mineral status evaluated by phalangeal quantitative ultrasound in pediatric patients with epilepsy and motor impairment

BACKGROUND

In epileptic patients with motor disability, it's difficult to disentangle the effects of antiepileptic drugs (AEDs) on bone health from those provoked by impaired mobility. The aim of this study was to evaluate the effects of AEDs on bone mineral status by phalangeal quantitative ultrasound (QUS), a no-radiation and non-invasive method, in pediatric patients with motor impairment and epilepsy.

METHODS

We enrolled 56 patients (31 females, 25 males) with epilepsy and motor impairment and 24 children with only motor disability (13 females, 11 males). Patients were stratified by Gross Motor Function Classification System Scale (GMFCS) in 4 groups: group A1 with epilepsy and mild motor impairment (GMFCS levels I-II), group A2 with only mild motor impairment, group B1 with epilepsy and severe motor impairment (GMFCS levels III-V), group B2 with only severe motor impairment. The bone mineral status was evaluated by phalangeal QUS and amplitude-dependent speed of sound (AD-SoS) Z-score was calculated for each patient.

RESULTS

The four groups showed no significant differences in age, gender and 25-hydroxyvitamin D levels. The group B1 had a statistically lower amplitude-dependent speed of sound Z-score as compared to group A2 (P<0.05). The multivariate analysis of independent factors revealed a significant correlation between amplitude-dependent speed of sound Z-score and Gross Motor Function Classification System levels (P=0.004). The mean Z-score value decreased by 0.53, increasing the motor impairment.

CONCLUSIONS

The bone mineral status measured as AD-SoS strongly correlates with severity of motor disability evaluated by GMFCS as compared to antiepileptic therapy and 25-hydroxyvitamin D levels.

Dietary intake and nutritional status of people with epilepsy: A systematic review

PURPOSE

In people with epilepsy achieving optimal dietary intake may be hampered by psychological and physical comorbidities associated with seizures, medication use, socioeconomic disadvantage and the use of therapeutic diets. This systematic review aimed to evaluate the reported dietary intake and nutritional status of children and adults with epilepsy.

METHODS

A systematic literature search was completed across Ovid MEDLINE, EMBASE and CINAHL (all from inception to 4 November 2021). We included studies that reported dietary intake in adults and children diagnosed with epilepsy compared with local reference ranges, control groups or general populations. Studies using interventions and therapeutic diets were excluded. Risk of bias was assessed using the Study Quality Assessment Tools by the National Heart, Lung and Blood Institute. A descriptive analysis was performed due to the heterogenous nature of the data.

RESULTS

The initial search returned 1214 articles. Full-text screening was completed for 98 studies and 19 studies met eligibility criteria and were included for extraction. These comprised of seven paediatric studies, eight adult studies and four studies that included both adult and paediatric cohorts. Sample size of cases in each study ranged from 17 to 3,220. Vitamin A, C, D and folate were the most frequently reported vitamins. Calcium, iron and zinc were the most commonly reported minerals. Most studies showed that people with epilepsy had poorer dietary intake and nutritional status compared with control groups or reference standards.

CONCLUSION

There were limited studies on dietary intake and nutritional status in people with epilepsy. Most available studies suggested poorer status compared to non-epilepsy controls. The development of a validated dietary assessment tool specifically for epilepsy cohorts would enable comparison of findings across studies, and aid with appropriately tailoring nutrition advice to individuals with epilepsy.

Anticonvulsant use and bone health in a population-based study of men and women: cross-sectional data from the Geelong Osteoporosis Study

Background

Anticonvulsant use has been linked to bone deficits in specific patient populations. We studied the association between anticonvulsant use and bone health in a population-based sample of men and women.

Methods

Data from 926 men (24-73 yr) and 1070 women (21-94 yr) participating in the Geelong Osteoporosis Study were included. Bone mineral density (BMD, g/cm²) of the PA-spine and total hip was measured using dual-energy X-ray absorptiometry (Lunar). Bone quality was determined using quantitative heel ultrasound (QUS). Anthropometry was conducted and socioeconomic status was determined. Medication and lifestyle information was obtained via questionnaire. Linear regression was used to test associations between anticonvulsant use and bone health before and after adjustment for potential confounders.

Results

Seventeen (1.8%) men and 20 (1.9%) women reported anticonvulsant use. In men, anticonvulsant users had 9.1% lower adjusted mean BMD at the spine and hip compared to non-users. Body mass index was an effect modifier at the spine. Anticonvulsant users also had 1.8% lower speed of sound (SOS), 10.6% lower broadband ultrasound attenuation (BUA) and 13.7% lower stiffness index (SI) compared to non-users. In women, BMD tended to be lower at the hip compared to non-users as with the bone quality measure, BUA. No significant associations were observed at the spine or the other bone quality measures, SOS and SI.

Conclusion

Our data suggest that bone quantity and quality, assessed using BMD and QUS, are lower for men and possibly women who use anticonvulsants. While further exploration into potential mechanisms is needed, our findings suggest that monitoring bone health among users of anticonvulsants is warranted.

Adequacy of calcium intake in Spanish population according age groups

This review shows the estimated calcium intake in Spain in recent years. Our results indicate that adolescents and the elderly are at risk of insufficient calcium intake. By using the national and the European recommendations, this work contributes to map and compare population's dietary calcium intake in the European countries. PURPOSE AND METHODS : The present work aims to examine calcium intake in the healthy Spanish population of any age and analyze its adequacy to the calcium Recommended Dietary Intake (RDI) for different groups in Spanish population, as well to the Adequate Intake (AI) or Population Reference Intake (PRI) estimated by European Food Safety Authority (EFSA). Forty-three studies published in the last 5 years were eligible for review. RESULTS AND CONCLUSIONS: The results show that infants and children exceed Spanish and EFSA dietary recommendations, adults meet more that 80% of the RDI and EFSA recommendations, and the estimated average calcium intake in the adolescent and elderly groups does not reach 75% of the recommended intake. Representative national studies with a common methodology to estimate calcium intake are needed.

Vitamin D deficiency in pediatric patients using antiepileptic drugs: systematic review with meta-analysis

OBJECTIVES

To measure the prevalence of vitamin D deficiency (through the 25-hydroxyvitamin D metabolite) in pediatric patients using antiepileptic drugs.

SOURCE OF DATA

Meta-analysis of studies identified through search in the PubMed, Embase, LILACS, and Cochrane Library databases, on February 19, 2019.

SUMMARY OF DATA

A total of 748 articles were identified, 29 of which were relevant to the objectives of this study. The prevalence of vitamin D deficiency found was 0.32 (95% CI=0.25-0.41; I²=92%, p<0.01). In the subgroup analyses, the most significant results were observed in the group of patients using cytochrome P450-inducing antiepileptic drugs, with a prevalence of 0.33 (95% CI=0.21-0.47; I²=86%, p<0.01) and, considering the study design, in the subgroup of cohort studies, with a prevalence of 0.52 (95% CI=0.40-0.64; I²=76%, p<0.01).

CONCLUSIONS

Taking into account the deleterious effects of vitamin D deficiency on the bone health of individuals using antiepileptic drugs, it is suggested to include in their care 25-hydroxyvitamin D monitoring, cholecalciferol supplementation, and treatment of the deficiency, when present.

Karate Training Improves Skeletal Status Assessed by Quantitative Ultrasound in Girls and Premenopausal Women

PURPOSE

The aim of the study was to assess the influence of regular karate training on the skeletal status evaluated by quantitative ultrasound (QUS) in females.

METHODS

A group of 132 karate training girls and women at mean age 19.57 (standard deviation [SD] 7.64) yr (range 7.3-45.3 yr) and 322 age-, sex- and body size-matched controls were enrolled into the study. Mean training duration in the karate group was 7.52 (SD 5.05) yr and mean training frequency was 2.97 (SD 1.21) per wk. The QUS measurements were performed at hand proximal phalanges, using a DBM Sonic 1200 (IGEA, Carpi, Italy) sonographic device, which measures amplitude-dependent speed of sound (Ad-SoS [m/s]).

RESULTS

The results of Ad-SoS obtained in karatekas were generally higher than in controls with significant difference for prepubertal girls (1966.2 [SD 46.2] vs 1942.7 [SD 38.4]; p < 0.05) and for adult women (2124.4 [SD 48.0] vs 2105.3 [SD 54.0]; p < 0.05).

CONCLUSIONS

Regular karate training is a factor that is positively associated with results of the QUS measurements at hand phalanges in exercising females and its impact is most strongly pronounced in prepuberty and adulthood.

Effects of valproic acid on skeletal metabolism in children with epilepsy: a systematic evaluation and meta-analysis based on 14 studies

BACKGROUND

Previous studies have reported that long-term use of valproic acid can cause changes in bone metabolism in children. We conducted this meta-analysis to determine the effects of valproic acid on bone metabolism and bone mineral density (BMD) in children with epilepsy.

METHODS

Studies were searched from the databases of PubMed, Embase, Ovid, Cochrance Library, Springer Link and Web of Science. The effects of valproic acid on bone metabolism indicators and BMD were assessed through calculating the standardized mean difference (SMD) with 95% confidence interval (CI).

RESULTS

Fourteen studies with 987 individuals were included in this analysis. The long-term use of valproic acid did not affect the levels of serum calcium (p = 0.99), phosphorus (p = 0.28), ALP (p = 0.76), PTH (p = 0.36) and osteocalcin (p = 0.72), but it led to a decrease in 25-OH-VitD (p = 0.01) and BMD (p = 0.002 for the vertebra; p = 0.004 for the femur) in treating children with epilepsy.

CONCLUSION

Long-term use of valproic acid in treating children with epilepsy can lead to a reduction in 25-OH-VitD and BMD. Measurements of 25-OH-VitD and BMD should be performed regularly in children taking the drug to detect early osteopenia caused by the drug.

Valproate decreases vitamin D levels in pediatric patients with epilepsy

PURPOSE

To compare Vitamin D (Vit D) levels in children with epilepsy on valproate monotherapy with healthy controls.

METHODS

A meta-analysis performed on articles identified from PubMed and Web of Science online databases evaluated using National Institute of Health National Heart, Lung, and Blood Institute Study Quality Assessment Tools. Subgroup analyses and publication bias assessments were also performed.

RESULTS

Eleven publications were eligible based on inclusion/exclusion criteria for the meta-analysis. Results noted a decrease in the mean Vit D level in children with epilepsy on valproate monotherapy compared with healthy children with a Standard Mean Difference = -0.313 [-0.457, -0.169]. Cumulative meta-analysis showed progressive negative effect of valproate therapy on Vit D levels across time. Other antiepileptic medications caused a similar effect on Vit D status. There was no evidence of publication bias in the analyses. Type of study design and country of origin introduced heterogeneities into the meta-analyses.

CONCLUSION

This meta-analysis provides evidence that long-term therapy with valproate causes a decrease in Vit D levels in children. Therefore, in children with a seizure disorder on long-term valproate therapy, 25-OH-Vit D levels should be monitored and appropriate supplementation implemented if levels are deficient.

The Impact of Psychotropic Medications on Bone Health in Youth

PURPOSE OF REVIEW

Psychotropics are prescribed to youth at rapidly growing rates and may negatively impact bone health. Little awareness exists of this association among prescribing providers. Childhood and adolescence are critical times for bone development. Understanding these effects and their management is important to informed psychotropic use.

RECENT FINDINGS

Through a variety of mechanisms, antidepressants, benzodiazepines, mood stabilizers, neuroleptics, and stimulants may all negatively impact pediatric bone health. This confers added risk of osteoporosis in a population already at high risk for suboptimal bone health. Awareness of psychotropic-mediated effects on pediatric bone development is clinically relevant to the use and monitoring of these agents. Clinicians can manage these effects through informed consent, vitamin D supplementation, lifestyle modifications, and reducing polypharmacy. For mood stabilizers, vitamin D level monitoring and secondary prevention is indicated. Future longitudinal studies and development of monitoring guidelines regarding psychotropic impact on bone health are necessary.