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Ali DS, Khan AA, Brandi ML. Effective strategies for pregnancy and lactation-associated osteoporosis: teriparatide use in focus. Endocrine 2024:10.1007/s12020-024-03946-6. [PMID: 39008200 DOI: 10.1007/s12020-024-03946-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 06/26/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION Pregnancy and lactation-associated osteoporosis (PLO) is a rare condition characterized by fragility fractures occurring during late pregnancy or lactation, primarily affecting the spine and causing significant morbidity and back pain. PLO can lead to mobility impairment and work incapacity, with recovery taking up to several years. Due to the lack of clinical trials, treatment strategies remain poorly defined, historically focusing on calcium supplements, vitamin D, and weaning from breastfeeding. However, recent attention has turned to teriparatide (TPD) as an option due to its anabolic properties and potential suitability for women of childbearing age. METHODS This review evaluates TPD's use in PLO treatment, using published systematic reviews and case studies. Over 300 cases with PLO were identified through PubMed, Google Scholar, and Cochrane searches until August 2023. RESULTS We identified 175 cases with PLO treated with TPD alone or followed by antiresorptive therapy. Most women (85.7%) were primiparas. The mean ± SD duration of TPD use was 15 ± 6 months. Among the study patients, 91.4% used TPD alone, while 8.6% (15/175) utilized sequential therapy. Approximately 93% of our cohort exhibited potential risk factors for PLO. Despite the increased risk of recurrent fractures in PLO, only 14.7% (20/175) of those treated with TPD sustained new fractures during a 9-month to 9 years' follow-up period. The mean ± SD percent increase in BMD at the LS was 21.14% ± 7.4%, and at the FN it was 12.1% ± 9.3%. The baseline Z-scores at the LS ranged from -3.3 (-3.7 to -2.7), while the baseline Z-scores at the FN ranged from -2.0 (-2.7 to -1.5). CONCLUSION This review emphasizes PLO severity, advocating for increased awareness and timely interventions. TPD emerges as a promising therapeutic option in certain cases.
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Affiliation(s)
- Dalal S Ali
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada.
| | - Aliya A Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Maria Luisa Brandi
- Fondazione FIRMO Onlus; Italian Foundation for the Research on Bone Diseases, Florence, Italy
- Donatello Bone Clinic, Villa Donatello Hospital, Sesto Fiorentino, Italy
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Anagnostis P, Lampropoulou-Adamidou K, Bosdou JK, Trovas G, Galanis P, Chronopoulos E, Goulis DG, Tournis S. Comparative Effectiveness of Therapeutic Interventions in Pregnancy and Lactation-Associated Osteoporosis: A Systematic Review and Meta-analysis. J Clin Endocrinol Metab 2024; 109:879-901. [PMID: 37708365 PMCID: PMC10876413 DOI: 10.1210/clinem/dgad548] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/09/2023] [Accepted: 09/12/2023] [Indexed: 09/16/2023]
Abstract
CONTEXT The optimal management of pregnancy and lactation-associated osteoporosis (PLO) has not been designated. OBJECTIVE To systematically review the best available evidence regarding the effect of different therapeutic interventions on bone mineral density (BMD) and risk of fractures in these patients. METHODS A comprehensive search was conducted in PubMed/Scopus databases until December 20, 2022. Data were expressed as weighted mean difference (WMD) with 95% CI. The I2 index was employed for heterogeneity. Studies conducted in women with PLO who received any antiosteoporosis therapy were included. Studies including women with secondary causes of osteoporosis or with transient osteoporosis of the hip were excluded. Data extraction was independently completed by 2 researchers. RESULTS Sixty-six studies were included in the qualitative analysis (n = 451 [follow-up time range 6-264 months; age range 19-42 years]). The increase in lumbar spine (LS) BMD with calcium/vitamin D (CaD), bisphosphonates, and teriparatide was 2.0% to 7.5%, 5.0% to 41.5%, and 8.0% to 24.4% at 12 months, and 11.0% to 12.2%, 10.2% to 171.9%, and 24.1% to 32.9% at 24 months, respectively. Femoral neck (FN) BMD increased by 6.1% with CaD, and by 0.7% to 18% and 8.4% to 18.6% with bisphosphonates and teriparatide (18-24 months), respectively. Meta-analysis was performed for 2 interventional studies only. Teriparatide induced a greater increase in LS and FN BMD than CaD (WMD 11.5%, 95% CI 4.9-18.0%, I2 50.9%, and 5.4%, 95% CI 1.2-9.6%, I2 8.1%, respectively). CONCLUSION Due to high heterogeneity and lack of robust comparative data, no safe conclusions can be made regarding the optimal therapeutic intervention in women with PLO.
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Affiliation(s)
- Panagiotis Anagnostis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki 56403, Greece
| | - Kalliopi Lampropoulou-Adamidou
- Laboratory for the Research of Musculoskeletal System “Th. Garofalidis”, School of Medicine, National and Kapodistrian University of Athens, KAT General Hospital, Athens 14561, Greece
| | - Julia K Bosdou
- Unit for Human Reproduction, 1st Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki 11527, Greece
| | - Georgios Trovas
- Laboratory for the Research of Musculoskeletal System “Th. Garofalidis”, School of Medicine, National and Kapodistrian University of Athens, KAT General Hospital, Athens 14561, Greece
| | - Petros Galanis
- Clinical Epidemiology Laboratory, Faculty of Nursing, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Efstathios Chronopoulos
- Laboratory for the Research of Musculoskeletal System “Th. Garofalidis”, School of Medicine, National and Kapodistrian University of Athens, KAT General Hospital, Athens 14561, Greece
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki 56403, Greece
| | - Symeon Tournis
- Laboratory for the Research of Musculoskeletal System “Th. Garofalidis”, School of Medicine, National and Kapodistrian University of Athens, KAT General Hospital, Athens 14561, Greece
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Qian Y, Wang L, Yu L, Huang W. Pregnancy- and lactation-associated osteoporosis with vertebral fractures: a systematic review. BMC Musculoskelet Disord 2021; 22:926. [PMID: 34732196 PMCID: PMC8567545 DOI: 10.1186/s12891-021-04776-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 10/06/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND To review, analyze and characterize the pregnancy and lactation-related osteoporosis (PLO) with vertebral fractures based on the extraction data in the previous studies. METHODS A comprehensive literature search of electronic databases including the PubMed, Embase and Web of Science was conducted from January 1st,1990 to December 1st, 2020. The enrolled data were pooled to analyze the baseline characteristics, clinical features, risk factors and treatment options. RESULTS A total of 65 articles with 338 cases were enrolled for data extraction. The enrolled cases aged from 19 to 47 years, with a mean value of 35.7 years old. The average body mass index (BMI) was 22.2 kg/m2 ranged from 16.0 to 39.0 kg/m2. Of the 173 cases, 149 cases with vertebral fractures occurred in the first pregnancy, 19 cases in the second pregnancy, four cases in the third pregnancy and one case in the fourth pregnancy. Up to 91.5% of the back pain occurred within the last 3 months of pregnancy and the first 3 months after delivery. The most involved vertebral levels were L2, L1 and T12 accounting for 32.6% of all the fractures. The average fracture numbers were 4.4 levels per patient. The lumbar Z-scores were mostly recorded with a mean value of - 3.2 ranged from - 7.8 to 0. CONCLUSIONS PLO with vertebral fractures is a rare clinical entity, which is more likely to occur in older and thinner pregnant women. Back pain is the clinical complaint and mostly occurs in the late pregnancy and early lactation periods. Most vertebral fractures appear in the first pregnancy but it can occur in any time of pregnancy. Thoracolumbar region is the mostly involved region. As compared with postmenopausal osteoporotic fractures, PLO usually has multiple levels fractures. Bisphosphonates are the most widely used treatment so far, however, many factors need to be taken into account to decide which drug to choose in PLO and further studies are necessary for clear recommendation in the future.
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Affiliation(s)
- Ying Qian
- Endocrinology Department, 960 Hospital of People’s Liberation Army, NO.25 Shifan Road, Jinan, Shandong 250031 People’s Republic of China
| | - Lei Wang
- Orthopaedic Department, 960 Hospital of People’s Liberation Army, NO.25 Shifan Road, Jinan, Shandong 250031 People’s Republic of China
| | - Lili Yu
- Medical Information Department, 960 Hospital of People’s Liberation Army, NO.25 Shifan Road, Jinan, Shandong 250031 People’s Republic of China
| | - Weimin Huang
- Orthopaedic Department, 960 Hospital of People’s Liberation Army, NO.25 Shifan Road, Jinan, Shandong 250031 People’s Republic of China
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Stumpf U, Kraus M, Hadji P. Influence of denosumab on bone mineral density in a severe case of pregnancy-associated osteoporosis. Osteoporos Int 2021; 32:2383-2387. [PMID: 34041561 PMCID: PMC8563672 DOI: 10.1007/s00198-021-06008-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/12/2021] [Indexed: 11/28/2022]
Abstract
Pregnancy and lactation-associated osteoporosis (PLO) with predominantly subsequent vertebral fracture is a rare but severe disease with an estimated incidence of 0.4 in 100,000. In the past, patients with PLO have been predominantly treated with oral and i.v. bisphosphonates to reduce subsequent fracture risk. Hereby, the use of bisphosphonates in premenopausal women is controversial, as bisphosphonates know to persist in bone for many years and can be exposed and circulate in maternal serum and subsequently pass the placenta barrier and may have a detrimental effect on fetal bone health. Here we report the effects of denosumab on the bone mineral density (BMD) and subsequent fracture risk in PLO. In this case presentation, denosumab was administered postpartum with 3000 IE vitamin D and 1000 mg of calcium daily in a patient with PLO and vertebral fracture of L1 and L4. After 18 months of treatment with denosumab, we could demonstrate a clinical significant increase of BMD at the lumbar spine, femoral neck, and total hip of 32.2%, 13.0%, and 11.5% respectively with no further subsequent fractures. As the patient had regular menstrual cycles and considered a further pregnancy, denosumab treatment was terminated and soon a second pregnancy occurred. After the second pregnancy, BMD decreased at the lumbar spine, femur neck, and total hip by -8.8%, -6.9%, and -7.0% respectively compared to the maximum values during treatment with denosumab, but was still significantly higher compared to baseline levels with no further fractures.
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Affiliation(s)
- U Stumpf
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Campus Innenstadt, Nussbaumstrasse, 20 80336, Munich, Germany.
| | - M Kraus
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Campus Innenstadt, Nussbaumstrasse, 20 80336, Munich, Germany
| | - P Hadji
- Frankfurt Center of Bone Health, Frankfurt, Germany and Philipps-University of Marburg, Marburg, Germany
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Capozzi A, Scambia G, Lello S. Bone metabolism in pregnancy and lactation. Minerva Obstet Gynecol 2021; 73:697-703. [PMID: 34180616 DOI: 10.23736/s2724-606x.21.04905-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Different hormonal mechanisms regulate bone metabolism during pregnancy and lactation. In both those periods of life, a fine modulation of calcium metabolism is necessary to meet the needs of foetus and newborn. METHODS We review scientific literature on the topic "osteoporosis", "pregnancy" and "lactation", evaluating the most relevant data from original articles, reviews and meta-analyses. EVIDENCE SYNTHESIS Pregnancy- and lactation-associated bone loss and related fractures rarely occur and, generally, clinicians have to manage it case to case, since there is not a unique guideline. Fortunately, bone mineral density (BMD) usually tends to recover within 12 months after weaning, thus, it could be reasonable waiting of assessing the effective magnitude of bone mass regain before starting any pharmacological treatment. CONCLUSIONS Osteoporosis and/or fragility fractures remain uncommon events associated with gestation and/or breastfeeding. The management of bone loss and/or fractures during those periods is generally conservative and a tailored approach is advisable in the absence of any specific recommendation in this field.
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Affiliation(s)
- Anna Capozzi
- Department of Women and Child Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy -
| | - Giovanni Scambia
- Department of Women and Child Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Stefano Lello
- Department of Women and Child Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Yıldız AE, Özbalcı AB, Ergen FB, Aydıngöz Ü. Pregnancy- and lactation-associated vertebral compression fractures: MRI prevalence and characteristics. Osteoporos Int 2021; 32:981-989. [PMID: 33236194 DOI: 10.1007/s00198-020-05754-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/18/2020] [Indexed: 12/11/2022]
Abstract
UNLABELLED The frequency of pregnancy- and lactation-associated vertebral compression fractures (PLVCFs) is not known. This study showed that MRI prevalence of PLVCFs was approximately 0.5% in females ≥ 15 and < 40 years of age over a 48-month period. PLVCFs did not display MRI features distinguishing them from other vertebral insufficiency fractures. PURPOSE We aimed to investigate the MRI prevalence and characteristics of pregnancy- and lactation-associated vertebral compression fractures (PLVCFs). METHODS This retrospective cross-sectional observational study included all thoracic, lumbar, or thoracolumbar MRI examinations performed in our hospital (or at outside centers and referred to us for consultation) of females ≥ 15 and < 40 years of age during a 48-month period. Two radiologists independently reviewed all images for vertebral compression fractures and their disagreement was resolved by a third blinded senior radiologist with 24 years of dedicated musculoskeletal radiology experience. MRI features of PLVCFs (early/late stage, height loss, endplate involvement, retropulsion) were noted. RESULTS A total of 1484 MRI examinations-including 50 consultations from outside centers-of 1260 females (mean age, 27.7 years; range, 15-39) were included. Interobserver agreement of the two junior radiologists was substantial (κ = 0.607; 95% CI, 0.545-0.669). Vertebral compression fractures were identified in 177 of thoracic (n = 210), lumbar (n = 900), or thoracolumbar MRI (n = 374) examinations. Six women (7 MRI examinations; 4.0% of MRIs with vertebral fractures) had PLVCFs diagnosed on MRI (prevalence, 0.47%; mean age, 31 years; age range, 25-37). Number of fractured vertebrae in cases with PLVCF ranged between 1 and 11 (mean, 5.6). DEXA, available in all patients with PLVCFs, verified osteopenia/osteoporosis in four of six patients. CONCLUSION PLVCFs have an MRI prevalence of approximately 0.5% in the target population and do not display distinguishing features from other insufficiency type vertebral compression fractures.
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Affiliation(s)
- A E Yıldız
- Department of Radiology, Hacettepe University School of Medicine, Sihhiye, 06100, Ankara, Turkey.
| | - A B Özbalcı
- Department of Radiology, Ondokuz Mayıs University School of Medicine, Atakum, 55139, Samsun, Turkey
| | - F B Ergen
- Department of Radiology, Hacettepe University School of Medicine, Sihhiye, 06100, Ankara, Turkey
| | - Ü Aydıngöz
- Department of Radiology, Hacettepe University School of Medicine, Sihhiye, 06100, Ankara, Turkey
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Ozturk G, Akpinar P, Karamanlioglu AD, Ozkan FU, Aktas I. Pregnancy-related osteoporotic vertebral compression fractures in two patients treated with low-molecular-weight heparin during pregnancy: case reports. Gynecol Endocrinol 2018; 34:378-380. [PMID: 29069943 DOI: 10.1080/09513590.2017.1393064] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Pregnancy-related osteoporosis (PRO) is an uncommon metabolic bone disease that can result in vertebral fragility fractures. Here we report two cases of young women who had been previously treated with LMWH-enoxaparin and were diagnosed with PRO with vertebral fragility fractures after delivery. In first case report, a 33-year-old primigravid woman who was treated with 40 mg/day of enoxaparin for eight months to prevent venous thromboembolism was presented. After delivery, Dual energy X ray absorptiometry (DEXA) revealed osteoporosis in lumbar and femoral neck region. In magnetic resonance imaging (MRI), T4-T7 thoracic vertebral height losses were detected. In second case report, a 28-year-old primigravid woman which was treated with 40 mg/day enoxparin from the second month to the birth was presented. Osteoporosis in lumbar region was detected by DEXA. MRI revealed T12-L1 and L5 vertebral height losses. In conclusion, PRO can cause severe low back pain and should be considered in differential diagnosis. A detailed medical history should be essential to detect relationship between LMWH and PRO.
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Affiliation(s)
- Gulcan Ozturk
- a Fatih Sultan Mehmet Training and Research Hospital , Istanbul , Turkey
| | - Pinar Akpinar
- a Fatih Sultan Mehmet Training and Research Hospital , Istanbul , Turkey
| | | | - Feyza Unlu Ozkan
- a Fatih Sultan Mehmet Training and Research Hospital , Istanbul , Turkey
| | - Ilknur Aktas
- a Fatih Sultan Mehmet Training and Research Hospital , Istanbul , Turkey
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