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Glueck CJ, Freiberg RA, Wang P. Familial Thrombophilia Is Associated With Primary Multifocal Osteonecrosis: A Case-Control Study of 40 Patients. Orthopedics 2023; 46:164-168. [PMID: 36623277 DOI: 10.3928/01477447-20230104-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
To characterize pathoetiologic associations of heritable thrombophilia-hypofibrinolysis with idiopathic (primary) multifocal osteonecrosis (ON) (≥3 ON anatomic sites), we prospectively studied 28 women and 12 men with primary multifocal ON compared with 27 women and 24 men with primary nonmultifocal ON (<3 sites) and 110 healthy controls without ON. The 40 cases with primary multifocal ON differed from controls for 3 familial thrombophilias: Factor V Leiden heterozygosity (6 of 40 [15%] vs 2 of 109 [2%], P=.002), G20210A prothrombin gene heterozygosity (6 of 40 [15%] vs 3 of 110 [3%], P=.011), and high (>150%) Factor VIII (8 of 40 [20%] vs 7 of 103 [7%], P=.031). These case-control familial coagulation differences paralleled those in 51 concurrently evaluated cases with primary nonmulti-focal ON, 7 of 51 (14%) of whom had Factor V Leiden heterozygosity vs 2% of controls (P=.005) and 14 of 44 (32%) of whom had high Factor VIII vs 7 of 103 (7%) of controls (P=.0002). Recognition of familial thrombophilia as a common pathoetiology of primary multifocal ON provides an opportunity for early anticoagulation (before joint collapse), allowing both prophylaxis and therapy aimed at relieving pain and slowing or stopping progression of the disease to joint collapse. [Orthopedics. 202X;XX(X):xx-xx.].
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Badescu MC, Rezus E, Ciocoiu M, Badulescu OV, Butnariu LI, Popescu D, Bratoiu I, Rezus C. Osteonecrosis of the Jaws in Patients with Hereditary Thrombophilia/Hypofibrinolysis-From Pathophysiology to Therapeutic Implications. Int J Mol Sci 2022; 23:ijms23020640. [PMID: 35054824 PMCID: PMC8776054 DOI: 10.3390/ijms23020640] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 12/29/2021] [Accepted: 01/04/2022] [Indexed: 12/24/2022] Open
Abstract
Osteonecrosis of the jaws (ONJ) usually has a clear etiology. Local infection or trauma, radiotherapy and drugs that disrupt the vascular supply or bone turnover in the jaws are its major contributors. The thrombotic occlusion of the bone’s venous outflow that occurs in individuals with hereditary thrombophilia and/or hypofibrinolysis has a less known impact on jaw health and healing capability. Our research provides the most comprehensive, up-to-date and systematized information on the prevalence and significance of hereditary thrombophilia and/or hypofibrinolysis states in ONJ. We found that hereditary prothrombotic abnormalities are common in patients with ONJ refractory to conventional medical and dental treatments. Thrombophilia traits usually coexist with hypofibrinolysis traits. We also found that frequently acquired prothrombotic abnormalities coexist with hereditary ones and enhance their negative effect on the bone. Therefore, we recommend a personalized therapeutic approach that addresses, in particular, the modifiable risk factors of ONJ. Patients will have clear benefits, as they will be relieved of persistent pain and repeated dental procedures.
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Affiliation(s)
- Minerva Codruta Badescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.P.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Elena Rezus
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
- I Rheumatology Clinic, Clinical Rehabilitation Hospital, 14 Pantelimon Halipa Street, 700661 Iasi, Romania
- Correspondence: (E.R.); (O.V.B.)
| | - Manuela Ciocoiu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
| | - Oana Viola Badulescu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
- Hematology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
- Correspondence: (E.R.); (O.V.B.)
| | - Lacramioara Ionela Butnariu
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
| | - Diana Popescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.P.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Ioana Bratoiu
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
- I Rheumatology Clinic, Clinical Rehabilitation Hospital, 14 Pantelimon Halipa Street, 700661 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.P.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
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Rezus E, Tamba BI, Badescu MC, Popescu D, Bratoiu I, Rezus C. Osteonecrosis of the Femoral Head in Patients with Hypercoagulability-From Pathophysiology to Therapeutic Implications. Int J Mol Sci 2021; 22:ijms22136801. [PMID: 34202897 PMCID: PMC8268880 DOI: 10.3390/ijms22136801] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 12/24/2022] Open
Abstract
Osteonecrosis of the femoral head (ONFH) is a debilitating disease with major social and economic impacts. It frequently affects relatively young adults and has a predilection for rapid progression to femoral head collapse and end-stage hip arthritis. If not diagnosed and treated properly in the early stages, ONFH has devastating consequences and leads to mandatory total hip arthroplasty. The pathophysiology of non-traumatic ONFH is very complex and not fully understood. While multiple risk factors have been associated with secondary ONFH, there are still many cases in which a clear etiology cannot be established. Recognition of the prothrombotic state as part of the etiopathogeny of primary ONFH provides an opportunity for early medical intervention, with implications for both prophylaxis and therapy aimed at slowing or stopping the progression of the disease. Hereditary thrombophilia and hypofibrinolysis are associated with thrombotic occlusion of bone vessels. Anticoagulant treatment can change the natural course of the disease and improve patients' quality of life. The present work focused on highlighting the association between hereditary thrombophilia/hypofibrinolysis states and ONFH, emphasizing the importance of identifying this condition. We have also provided strong arguments to support the efficiency and safety of anticoagulant treatment in the early stages of the disease, encouraging etiological diagnosis and prompt therapeutic intervention. In the era of direct oral anticoagulants, new therapeutic options have become available, enabling better long-term compliance.
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Affiliation(s)
- Elena Rezus
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy Iași, 16 University Street, 700115 Iasi, Romania; (E.R.); (I.B.)
- I Rheumatology Clinic, Clinical Rehabilitation Hospital, 14 Pantelimon Halipa Street, 700661 Iasi, Romania
| | - Bogdan Ionel Tamba
- Advanced Center for Research and Development in Experimental Medicine (CEMEX), “Grigore T. Popa” University of Medicine and Pharmacy Iasi, 9-13 Mihail Kogălniceanu Street, 700454 Iasi, Romania;
| | - Minerva Codruta Badescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (D.P.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
- Correspondence:
| | - Diana Popescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (D.P.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Ioana Bratoiu
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy Iași, 16 University Street, 700115 Iasi, Romania; (E.R.); (I.B.)
- I Rheumatology Clinic, Clinical Rehabilitation Hospital, 14 Pantelimon Halipa Street, 700661 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (D.P.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
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Kuhlen M, Kunstreich M, Gökbuget N. Osteonecrosis in Adults With Acute Lymphoblastic Leukemia: An Unmet Clinical Need. Hemasphere 2021; 5:e544. [PMID: 33718802 PMCID: PMC7951118 DOI: 10.1097/hs9.0000000000000544] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/13/2021] [Indexed: 11/26/2022] Open
Abstract
Osteonecrosis is a serious complication of antileukemic therapy associated with severe pain and reduced mobility, ultimately leading to joint destruction and significant long-term morbidity. The 5-year cumulative incidence of osteonecrosis ranges from 11% to 20% in adolescents and young adults to 3% to 8% in patients aged 30 years and older. Most symptomatic patients have multiple joints affected, which in turn poses a risk factor for developing severe osteonecrosis. Osteonecrosis has a multifactorial genesis. Treatment-associated risk factors for developing osteonecrosis depend on the therapeutic context including the use of glucocorticosteroids and the simultaneous and/or intensified use of asparaginase (ASP) which may, among others, exert its effect on blood supply to the bone through hypertriglyceridemia, hypercholesterolemia, and hypertension. Allogeneic hematopoietic stem cell transplantation, bloodstream infections, and genetic factors may additionally impact the risk of osteonecrosis. In this article, the authors used the best available evidence in the literature to develop management recommendations for the use in the context of steroid and asparaginase containing regimens. These considerations may be helpful for similar treatment approaches.
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Affiliation(s)
- Michaela Kuhlen
- Swabian Children’s Cancer Center, Paediatric and Adolescent Medicine, University Medical Center Augsburg, Germany
| | - Marina Kunstreich
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
| | - Nicola Gökbuget
- Department of Medicine II, Hematology/Oncology, University Hospital, Goethe University, Frankfurt, Germany
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Glueck CJ, Freiberg RA, Wang P. Long-term Anticoagulation Prevents Progression of Stages I and II Primary Osteonecrosis of the Hip in Patients With Familial Thrombophilia. Orthopedics 2020; 43:e208-e214. [PMID: 32271930 DOI: 10.3928/01477447-20200404-06] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 04/01/2019] [Indexed: 02/03/2023]
Abstract
The authors prospectively assessed long-term anticoagulation outcomes (≥3 years) for 9 patients meeting 4 inclusion criteria: pretreatment Ficat stage I or II primary hip osteonecrosis (ON), factor V Leiden or prothrombin G20210A heterozygosity, no contraindication to anticoagulation, and 90-day participation in an initial enoxaparin 60 mg/d protocol. The primary endpoint was prevention of hip collapse (Ficat stage III or IV). The secondary endpoint was pain relief. After 90 days of enoxaparin 60 mg/d, anticoagulation was continued for 8 patients: 4 receiving warfarin (international normalized ratio targeted to 2 to 2.5; 11.5, 13, 14.5, and 21 years), 1 receiving enoxaparin 120 mg/d (11.5 years), and 3 receiving novel oral anticoagulants (5, 6, and 8 years). Radiographs were obtained before treatment; at 3 to 4, 6 to 8, and 12 to 14 months; and then annually. By selection, 8 patients had factor V Leiden heterozygosity and 1 had prothrombin G202010A heterozygosity. Of their 13 hips (Ficat I or II at entry), 12 remained Ficat I or II after 12±5 years (range, 5.5-21 years) of continuous anticoagulation and follow-up; 1 hip radiographically normalized. None of the 13 hips progressed to collapse (Ficat III or IV). Six patients became symptom free after the first 3 months of receiving enoxaparin, 1 after 6 months of anticoagulation, and 1 after 10 months of anticoagulation; all 8 patients remained symptom free with anticoagulation. Anticoagulation for primary hip ON before hip collapse in patients with familial thrombophilia may change the natural history of ON because most untreated patients with ON have joint collapse and total joint replacement within 2 years of original symptoms. [Orthopedics. 2020;43(4):e208-e214.].
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Haydock MM, Elhamdani S, Alsharedi M. Long-term direct oral anticoagulation in primary osteonecrosis with elevated plasminogen activation inhibitor. SAGE Open Med Case Rep 2019; 7:2050313X19827747. [PMID: 30783528 PMCID: PMC6366292 DOI: 10.1177/2050313x19827747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 01/10/2019] [Indexed: 11/17/2022] Open
Abstract
Osteonecrosis is a pathological condition that could lead to a debilitating physical disease and impede daily activities. It is generally categorised into aetiology - primary (idiopathic) or secondary. When direct damage to the bone vasculature or direct injury of the bone marrow is related to an identifiable cause such as traumatic injuries, steroid or bisphosphonate use, increased alcohol intake, sickle cell disease, autoimmune diseases, chemotherapy or malignancy, it is categorised as secondary osteonecrosis. On the other hand, osteonecrosis wherein the mechanisms of development are not fully understood is categorised as primary or idiopathic osteonecrosis. This category includes inherited thrombophilia and hypofibrinolysis as potential causes. There are no clear guidelines or general agreements about anticoagulation treatment and duration in primary osteonecrosis due to thrombophilia or hypofibrinolysis. We report a case of primary osteonecrosis associated with hypofibrinolysis and successful control with lifelong direct oral anticoagulation therapy.
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Affiliation(s)
| | | | - Mohamed Alsharedi
- Joan C Edwards School of Medicine, Marshall University, Huntington, WV, USA
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Testosterone Therapy, Thrombophilia, Venous Thromboembolism, and Thrombotic Events. J Clin Med 2018; 8:jcm8010011. [PMID: 30577621 PMCID: PMC6352146 DOI: 10.3390/jcm8010011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 12/11/2018] [Accepted: 12/18/2018] [Indexed: 01/24/2023] Open
Abstract
In our sequential studies of 67 and 21 patients, testosterone therapy (TT) interacted with thrombophilia⁻hypofibrinolysis, leading to venous thromboembolism (VTE). Compared to 111 VTE controls not taking TT (VTE-no TT), the 67 and 21 cases were more likely (p < 0.05 for all) to have Factor V Leiden (FVL) heterogeneity (24% and 33% vs. 12%), the lupus anticoagulant (14% and 33% vs. 4%), and high lipoprotein(a) (33% vs. 13%, n = 21). After a first VTE and continuing TT, 11 thrombophilic cases had a second VTE despite adequate anticoagulation, 6 of whom, still anticoagulated, had a third VTE. The greatest density of thrombotic events was at three months after starting TT, with a rapid decline by 10 months. From <1 to 8 months after starting TT, 65% of VTE occurred, which may reflect TT-induced depletion of susceptible thrombophilic patients, leaving a winnowed residual group with fewer VTE events despite the continuation of TT. Before starting TT, we suggest screening for FVL, lipoprotein(a), and the lupus anticoagulant to identify patients at increased VTE risk, with an adverse risk-to-benefit ratio for TT. We suggest that TT should not be started in patients with known thrombophilia⁻hypofibrinolysis, and should not be continued after a first VTE. When TT is given to patients with thrombophilia⁻hypofibrinolysis, VTE may occur and then recur despite adequate anticoagulation.
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Khan AM, Choi J, Freiberg RA, Glueck CJ, Goldenberg N, Wang P. T786C Mutation in the Endothelial Nitric Oxide Synthase Gene in Patients With Primary Osteonecrosis. Orthopedics 2017; 40:e898-e903. [PMID: 28877324 DOI: 10.3928/01477447-20170824-03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 07/31/2017] [Indexed: 02/03/2023]
Abstract
Mutations in the T786C endothelial nitric oxide synthase gene (eNOS) are associated with osteonecrosis and Prinzmetal's angina. Nitric oxide is necessary for bone health and ameliorates Prinzmetal's angina. This study compared mutations of T786C eNOS in 146 patients with primary osteonecrosis, 114 patients with Prinzmetal's angina, and 83 normal control subjects. Patients with osteonecrosis had more mutant eNOS alleles than control subjects (42% vs 22%, respectively; P<.0001) but had the same number of mutant alleles as patients with Prinzmetal's angina (42% vs 41%, respectively; P=.7), who in turn had more mutant eNOS alleles than control subjects (41% vs 22%, respectively; P=.0001). Of 146 patients with primary osteonecrosis, 65 (45%) had none of the 5 thrombophilias (Factor V Leiden heterozygosity, high levels of Factors VIII and XI, anticardiolipin antibody immunoglobulin M, and homocysteine) that otherwise distinguished patients with osteonecrosis from control subjects (P<.05). No associations were found between eNOS hetero-homozygosity and the 5 major thrombophilias in primary osteonecrosis. Of the 65 patients who had osteonecrosis but no major thrombophilias, for 41 (28% of the total sample of 146), eNOS hetero-homozygosity was the only abnormality. Normalization of nitric oxide levels with l-arginine 9 g/d or l-citrulline 800 mg/d, both of which relieve vasospastic angina in Prinzmetal's angina, which has the same eNOS genotype as primary osteonecrosis, may slow or stop the progression of osteonecrosis. Placebo-controlled trials of patients with primary osteonecrosis who are hetero-homozygous for the T786C eNOS mutation and have no major thrombophilias are needed to assess the safety and efficacy of this treatment. [Orthopedics. 2017; 40(5):e898-e903.].
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Kuhlen M, Kunstreich M, Krull K, Meisel R, Borkhardt A. Osteonecrosis in children and adolescents with acute lymphoblastic leukemia: a therapeutic challenge. Blood Adv 2017; 1:981-994. [PMID: 29296741 PMCID: PMC5737600 DOI: 10.1182/bloodadvances.2017007286] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 05/18/2017] [Indexed: 01/19/2023] Open
Abstract
Osteonecrosis (ON) represents one of the most common and debilitating sequelae of antileukemic treatment in children and adolescents with acute lymphoblastic leukemia (ALL). Systematic screening strategies can focus on early detection and intervention to prevent ON from progressing to stages associated with pain and functional impairment. These strategies hold promise for reducing ON-associated morbidity without the risk of impairing leukemia control. Herein, we critically reviewed clinical data on pharmacological, nonpharmacological/nonsurgical, and surgical (including cellular) treatment options for ON, which are covered in the literature and/or are conceivable based on the supposed underlying ON pathophysiology. Prevention of ON progression is of paramount importance, and attempts seem to be more effective in early (precollapse) disease status than in late-stage (collapse) ON. Based on the results of ongoing prospective magnetic resonance imaging screening studies, which will hopefully identify those patients with a high risk of ON progression and debilitating sequelae, prospective interventional studies are urgently needed. Although there is still a lack of high-quality studies, based on currently available data, core decompression surgery combined with cellular therapies (eg, employing mesenchymal stem cells) appears most promising for preventing joint infraction in children at high risk of developing late-stage ON.
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Affiliation(s)
- Michaela Kuhlen
- Department of Pediatric Oncology, Hematology, and Clinical Immunology, Center for Child and Adolescent Health, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Marina Kunstreich
- Department of Pediatric Oncology, Hematology, and Clinical Immunology, Center for Child and Adolescent Health, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Kathinka Krull
- Department of Pediatric Oncology, Hematology, and Clinical Immunology, Center for Child and Adolescent Health, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Roland Meisel
- Department of Pediatric Oncology, Hematology, and Clinical Immunology, Center for Child and Adolescent Health, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Arndt Borkhardt
- Department of Pediatric Oncology, Hematology, and Clinical Immunology, Center for Child and Adolescent Health, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
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Jarman MI, Lee K, Kanevsky A, Min S, Schlam I, Mahida C, Huda A, Milgrom A, Goldenberg N, Glueck CJ, Wang P. Case report: primary osteonecrosis associated with thrombophilia-hypofibrinolysis and worsened by testosterone therapy. BMC HEMATOLOGY 2017; 17:5. [PMID: 28361003 PMCID: PMC5368894 DOI: 10.1186/s12878-017-0076-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 03/17/2017] [Indexed: 11/29/2022]
Abstract
Background Familial and acquired thrombophilia are often etiologic for idiopathic hip and jaw osteonecrosis (ON), and testosterone therapy (TT) can interact with thrombophilia, worsening ON. Case presentation Case 1: A 62-year-old Caucasian male (previous deep venous thrombosis), on warfarin 1 year for atrial fibrillation (AF), had non-specific right hip-abdominal pain for 2 years. CT scan revealed bilateral femoral head ON without collapse. Coagulation studies revealed Factor V Leiden (FVL) heterozygosity, 4G/4G plasminogen activator inhibitor (PAI) homozygosity, high anti-cardiolipin (ACLA) IgM antibodies, and endothelial nitric oxide (NO) synthase (eNOS) T786C homozygosity (reduced conversion of L-arginine to NO, required for bone health). Apixaban 5 mg twice daily was substituted for warfarin; and L-arginine 9 g/day was started to increase NO. On Apixaban for 8 months, he became asymptomatic. Case 2: A 32-year-old hypogonadal Caucasian male had 10 years of unexplained tooth loss, progressing to primary jaw ON with cavitation 8 months after starting TT gel 50 mg/day. Coagulation studies revealed FVL heterozygosity, PAI 4G/4G homozygosity, and the lupus anticoagulant. TT was discontinued. Jaw pain was sharply reduced within 2 months. Conclusions Idiopathic ON, often caused by thrombophilia-hypofibrinolysis, is worsened by TT, and its progression may be slowed or stopped by discontinuation of TT and, thereafter, anticoagulation. Recognition of thrombophilia-hypofibrinolysis before joint collapse facilitates anticoagulation which may stop ON, preserving joints.
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Affiliation(s)
- Michael Ian Jarman
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Kevin Lee
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Ariel Kanevsky
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Sarah Min
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Ilana Schlam
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Chris Mahida
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Ali Huda
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Alexander Milgrom
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Naila Goldenberg
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Charles J Glueck
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
| | - Ping Wang
- Jewish Hospital, Internal Medicine Resident Graduate Medical Education Department, 4777 East Galbraith Road, Cincinnati, OH 45236 USA
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Treatable high homocysteine alone or in concert with five other thrombophilias in 1014 patients with thrombotic events. Blood Coagul Fibrinolysis 2016; 26:736-42. [PMID: 25699608 DOI: 10.1097/mbc.0000000000000276] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In 1014 patients with thrombotic events, we determined how often treatable high serum homocysteine alone, or in concert with five other thrombophilias, was associated with thrombotic events. We studied 1014 outpatients sequentially referred for evaluation of thrombotic events, all having six measures of thrombophilia--three PCR (methylenetetrahydrofolate reductase C677T-A1298C, factor V Leiden G506A, prothrombin G20210A), and three serologic (factors VIII, XI, homocysteine). Of the 1014 patients, 198 (20%) had atherothrombosis, 199 (20%) ocular vascular thrombosis, 211 (21%) osteonecrosis, 180 (18%) pseudotumor cerebri, and 123 (12%) recurrent miscarriage. In 434 of 1014 (43%) patients, all six thrombophilic measures were normal. High homocysteine, present in 126 of 1014 patients (12.4%), was the sole thrombophilia in 50 (5%), accompanied only by methylenetetrahydrofolate reductase homozygosity-compound heterozygosity in 22 (2.2%), and accompanied by other thrombophilias in 54 (5%). Patients were more likely than 110 healthy controls to have high homocysteine (12 vs. 5%; P = 0.02) and high factor VIII (21 vs. 7%; P = 0.0003). On treatment for a median of 18 months with L-methyl folate (5 mg), vitamin B6 (100 mg), and vitamin B12 (2 mg/day), in 74 homocysteinemic patients, median homocysteine fell from 15.6 to 10.0 μmol/l (P < 0.0001), and in 56 (76%), homocysteine fell to normal on treatment. When homocysteinemia was the sole thrombophilia, normalization of homocysteine was accompanied by freedom from new thrombotic events in 38 of 41 patients (93%). In evaluation of 1014 patients with thrombotic events, 126 (12%) had treatable high serum homocysteine, and in 50 (5%), high homocysteine was the sole treatable thrombophilia.
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Glueck CJ, Riaz R, Prince M, Freiberg RA, Wang P. Testosterone Therapy Can Interact With Thrombophilia, Leading to Osteonecrosis. Orthopedics 2015; 38:e1073-8. [PMID: 26652327 DOI: 10.3928/01477447-20151120-03] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 04/08/2015] [Indexed: 02/03/2023]
Abstract
Although this effect is not widely recognized, testosterone therapy can interact with thrombophilia, causing osteonecrosis. In 12 men and 4 women who had idiopathic osteonecrosis a median of 6 months after the onset of testosterone therapy, the authors examined the interaction between testosterone therapy and previously undiagnosed thrombophilia. The authors hypothesized that patients who had osteonecrosis after starting testosterone therapy were more likely than 110 normal control subjects or 48 patients who had osteonecrosis and were not receiving testosterone therapy to have thrombophilia. Measures of thrombophilia included Factor V Leiden, prothrombin, PAI-1 gene mutations, Factor VIII, Factor XI, anticardiolipin antibody immunoglobulin G or immunoglobulin M, and homocysteine values. In 10 cases, osteonecrosis occurred 6 months or less after the onset of testosterone therapy, and in all 16 cases, it occurred after a median of 6 months of testosterone therapy. Of the 16 cases, 5 (31%) were Factor V Leiden heterozygotes vs 2 of 109 (2%) healthy control subjects (P=.0003) and 4 of 48 patients who had osteonecrosis and were not receiving testosterone therapy (P=.04). Of the 16 cases, 4 (25%) had high (>150%) Factor VIII levels vs 7 of 103 (7%) healthy control subjects (P=.04), and 3 (19%) had high (>150%) Factor XI levels vs 3 of 101 (3%) healthy control subjects (P=.03). Of the 16 patients with osteonecrosis, 14 (88%) had at least 1 abnormal procoagulant value (of the 8 measured) vs 47 of 110 (43%) healthy control subjects (P=.0009). Of the 5 men whose serum estradiol level was measured while they were receiving testosterone therapy, this level was high (≥42.6 pg/mL) in 4. When testosterone therapy is given to patients with thrombophilia, they are at increased risk for osteonecrosis.
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