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Giustina A, Bilezikian JP, Adler RA, Banfi G, Bikle DD, Binkley NC, Bollerslev J, Bouillon R, Brandi ML, Casanueva FF, di Filippo L, Donini LM, Ebeling PR, Fuleihan GEH, Fassio A, Frara S, Jones G, Marcocci C, Martineau AR, Minisola S, Napoli N, Procopio M, Rizzoli R, Schafer AL, Sempos CT, Ulivieri FM, Virtanen JK. Consensus Statement on Vitamin D Status Assessment and Supplementation: Whys, Whens, and Hows. Endocr Rev 2024:bnae009. [PMID: 38676447 DOI: 10.1210/endrev/bnae009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Indexed: 04/28/2024]
Abstract
The 6th International Conference, "Controversies in Vitamin D," was convened to discuss controversial topics, such as vitamin D metabolism, assessment, actions, and supplementation. Novel insights into vitamin D mechanisms of action suggest links with conditions that do not depend only on reduced solar exposure or diet intake and that can be detected with distinctive noncanonical vitamin D metabolites. Optimal 25-hydroxyvitamin D (25(OH)D) levels remain debated. Varying recommendations from different societies arise from evaluating different clinical or public health approaches. The lack of assay standardization also poses challenges in interpreting data from available studies, hindering rational data pooling and meta-analyses. Beyond the well-known skeletal features, interest in vitamin D's extraskeletal effects has led to clinical trials on cancer, cardiovascular risk, respiratory effects, autoimmune diseases, diabetes, and mortality. The initial negative results are likely due to enrollment of vitamin D-replete individuals. Subsequent post hoc analyses have suggested, nevertheless, potential benefits in reducing cancer incidence, autoimmune diseases, cardiovascular events, and diabetes. Oral administration of vitamin D is the preferred route. Parenteral administration is reserved for specific clinical situations. Cholecalciferol is favored due to safety and minimal monitoring requirements. Calcifediol may be used in certain conditions, while calcitriol should be limited to specific disorders in which the active metabolite is not readily produced in vivo. Further studies are needed to investigate vitamin D effects in relation to the different recommended 25(OH)D levels and the efficacy of the different supplementary formulations in achieving biochemical and clinical outcomes within the multifaced skeletal and extraskeletal potential effects of vitamin D.
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Affiliation(s)
- Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and IRCCS Hospital, Milan 20132, Italy
| | - John P Bilezikian
- Department of Medicine, Vagelos College of Physicians and Surgeons, New York, NY 10032, USA
| | - Robert A Adler
- Richmond Veterans Affairs Medical Center and Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Giuseppe Banfi
- IRCCS Galeazzi Sant'Ambrogio Hospital, Milano 20161, Italy
- San Raffaele Vita-Salute University, Milan 20132, Italy
| | - Daniel D Bikle
- Department of Medicine, University of California and San Francisco Veterans Affairs Health Center, San Francisco, CA 94121-1545, USA
- Department of Endocrinology, University of California and San Francisco Veterans Affairs Health Center, San Francisco, CA 94121-1545, USA
| | - Neil C Binkley
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53726, USA
| | | | - Roger Bouillon
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, 3000 Leuven, Belgium
| | - Maria Luisa Brandi
- Italian Foundation for the Research on Bone Diseases (F.I.R.M.O.), Florence 50129, Italy
| | - Felipe F Casanueva
- Department of Medicine, Instituto de Investigación Sanitaria (IDIS), Complejo Hospitalario Universitario and CIBER de Fisiopatologia de la Obesidad y Nutricion (CIBERobn), Santiago de Compostela University, Santiago de Compostela 15706, Spain
| | - Luigi di Filippo
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and IRCCS Hospital, Milan 20132, Italy
| | - Lorenzo M Donini
- Department of Experimental Medicine, Sapienza University, Rome 00161, Italy
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton 3168, Australia
| | - Ghada El-Hajj Fuleihan
- Calcium Metabolism and Osteoporosis Program, WHO CC for Metabolic Bone Disorders, Division of Endocrinology, American University of Beirut, Beirut 1107 2020, Lebanon
| | - Angelo Fassio
- Rheumatology Unit, University of Verona, Verona 37129, Italy
| | - Stefano Frara
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and IRCCS Hospital, Milan 20132, Italy
| | - Glenville Jones
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, ON K7L 3N6, Canada
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa 56126, Italy
| | - Adrian R Martineau
- Faculty of Medicine and Dentistry, Queen Mary University of London, London E1 4NS, UK
| | - Salvatore Minisola
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome 00161, Italy
| | - Nicola Napoli
- Unit of Endocrinology and Diabetes Campus Bio-Medico, University of Rome, Rome 00128, Italy
| | - Massimo Procopio
- Division of Endocrinology, Diabetology and Metabolic Diseases, "Molinette" Hospital, University of Turin, Turin 10126, Italy
| | - René Rizzoli
- Geneva University Hospitals and Faculty of Medicine, Geneva 1205, Switzerland
| | - Anne L Schafer
- Department of Medicine, University of California and San Francisco Veterans Affairs Health Center, San Francisco, CA 94121-1545, USA
| | | | - Fabio Massimo Ulivieri
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and IRCCS Hospital, Milan 20132, Italy
| | - Jyrki K Virtanen
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio FI-70211, Finland
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Giustina A, di Filippo L, Facciorusso A, Adler RA, Binkley N, Bollerslev J, Bouillon R, Casanueva FF, Cavestro GM, Chakhtoura M, Conte C, Donini LM, Ebeling PR, Fassio A, Frara S, Gagnon C, Latella G, Marcocci C, Mechanick JI, Minisola S, Rizzoli R, Santini F, Shaker JL, Sempos C, Ulivieri FM, Virtanen JK, Napoli N, Schafer AL, Bilezikian JP. Correction: Vitamin D status and supplementation before and after Bariatric Surgery: Recommendations based on a systematic review and meta‑analysis. Rev Endocr Metab Disord 2024; 25:447-448. [PMID: 38502455 PMCID: PMC10950986 DOI: 10.1007/s11154-023-09837-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Affiliation(s)
- Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy.
| | - Luigi di Filippo
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
| | - Antonio Facciorusso
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Robert A Adler
- Richmond Veterans Affairs Medical Center and Virginia Commonwealth University, Richmond, VA, USA
| | | | | | - Roger Bouillon
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases, Metabolism and Ageing, 3000 KU, Leuven, Belgium
| | - Felipe F Casanueva
- Molecular Endocrinology Group, Instituto de Investigacion Sanitaria (IDIS), Complejo Hospitalario Universitario de Santiago (CHUS/SERGAS). CIBER de Fisiopatologia de La Obesidad y Nutricion (CIBERobn), Instituto de Salud Carlos III, Madrid, Spain
| | - Giulia Martina Cavestro
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marlene Chakhtoura
- Calcium Metabolism and Osteoporosis Program, American University of Beirut-Medical Center, Beirut, Lebanon
| | - Caterina Conte
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Via Di Val Cannuta 247, 00166, Rome, Italy
| | - Lorenzo M Donini
- Experimental Medicine Department, Sapienza University, Rome, Italy
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Australia
| | - Angelo Fassio
- Rheumatology Unit, University of Verona, Verona, Italy
| | - Stefano Frara
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
| | - Claudia Gagnon
- Department of Medicine, Université Laval, Quebec City, Canada
| | - Giovanni Latella
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Jeffrey I Mechanick
- Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | | | - René Rizzoli
- Service of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Ferruccio Santini
- Obesity and Lipodystrophy Center, University Hospital of Pisa, Pisa, Italy
| | - Joseph L Shaker
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Fabio Massimo Ulivieri
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
| | - Jyrki K Virtanen
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - Nicola Napoli
- Department of Medicine and Surgery, Research Unit of Endocrinology and Diabetes, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128, Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128, Roma, Italy
| | - Anne L Schafer
- University of California, San Francisco and the San Francisco Veterans Affairs Health Care System, San Francisco, USA
| | - John P Bilezikian
- Department of Medicine, Endocrinology Division, Vagelos College of Physicians and Surgeons Columbia University, New York, NY, USA
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Dhaliwal R, Kendler D, Saag K, Ing SW, Singer A, Adler RA, Pearman L, Wang Y, Mitlak B. Response rates for lumbar spine, total hip, and femoral neck bone mineral density in men treated with abaloparatide: results from the ATOM study. JBMR Plus 2024; 8:ziae009. [PMID: 38505522 PMCID: PMC10945712 DOI: 10.1093/jbmrpl/ziae009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/07/2023] [Accepted: 12/17/2023] [Indexed: 03/21/2024] Open
Abstract
Osteoporosis in men is an underappreciated public health issue, accounting for approximately 30% of the societal burden of osteoporosis. Although the prevalence of osteoporosis in men is lower, fracture-related morbidity and mortality rates exceed those of women. Abaloparatide is a synthetic, 34-amino acid peptide with homology to human parathyroid hormone-related protein (PTHrP), which favors bone formation by selective activation of PTH receptor type 1. In the Abaloparatide for the Treatment of Men With Osteoporosis (ATOM; NCT03512262) trial, 228 men with primary or hypogonadism-associated osteoporosis were randomized to receive subcutaneous injections of abaloparatide 80 μg or placebo. Abaloparatide significantly improved LS, TH, and FN BMD when compared with placebo. In this prespecified analysis, the proportion of men with a percent change from baseline of >0%, >3%, and > 6% in BMD at the LS, TH, and FN at 3, 6, and 12 mo and/or a shift in T-score category (based on LS and TH T-scores) at 12 mo was compared between the abaloparatide and placebo groups in ATOM. There were significantly more men with a BMD gain of >3% at all 3 anatomical sites in the abaloparatide than placebo group at month 6 (18/122 [14.8%] vs 1/70 [1.4%], P = .002) and at month 12 (38/119 [31.9%] vs 1/66 [1.5%], P < .0001). At month 3, more men treated with abaloparatide than placebo had a > 3% BMD increase at the LS (82/134 [61.2%] vs 21/68 [30.9%], P < .0001). A greater proportion of men treated with abaloparatide had an improvement in T-score category from osteoporosis to low BMD or normal when compared with placebo. In conclusion, use of abaloparatide compared with placebo for 12 mo resulted in significant and rapid improvements in BMD in men with osteoporosis from the ATOM study.
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Affiliation(s)
- Ruban Dhaliwal
- Metabolic Bone Disease Center, State University of New York Upstate Medical University, Syracuse, NY 13210, United States
| | - David Kendler
- Division of Endocrinology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
| | - Kenneth Saag
- Division of Clinical Immunology and Rheumatology, The University of Alabama at Birmingham, Birmingham, AL 35294, United States
| | - Steven W Ing
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Andrea Singer
- Department of Obstetrics and Gynecology, MedStar Georgetown University Hospital, Washington, DC 20007, United States
| | - Robert A Adler
- Department of Endocrinology and Metabolism at the Department of Veteran's Affairs, Richmond Veterans Affairs Medical Center-Richmond, VA 23249, United States
| | - Leny Pearman
- Medical Affairs, Radius Health, Inc., Boston, MA 02210, United States
| | - Yamei Wang
- Department of Biostatistics, Radius Health, Inc., Boston, MA 02210, United States
| | - Bruce Mitlak
- Discovery Sciences, Radius Health, Inc., Boston, MA 02210, United States
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Giustina A, di Filippo L, Facciorusso A, Adler RA, Binkley N, Bollerslev J, Bouillon R, Casanueva FF, Cavestro GM, Chakhtoura M, Conte C, Donini LM, Ebeling PR, Fassio A, Frara S, Gagnon C, Latella G, Marcocci C, Mechanick JI, Minisola S, Rizzoli R, Santini F, Shaker JL, Sempos C, Ulivieri FM, Virtanen JK, Napoli N, Schafer AL, Bilezikian JP. Vitamin D status and supplementation before and after Bariatric Surgery: Recommendations based on a systematic review and meta-analysis. Rev Endocr Metab Disord 2023; 24:1011-1029. [PMID: 37665480 PMCID: PMC10698146 DOI: 10.1007/s11154-023-09831-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2023] [Indexed: 09/05/2023]
Abstract
Bariatric surgery is associated with a postoperative reduction of 25(OH) vitamin D levels (25(OH)D) and with skeletal complications. Currently, guidelines for 25(OH)D assessment and vitamin D supplementation in bariatric patients, pre- and post-surgery, are still lacking. The aim of this work is to analyse systematically the published experience on 25(OH)D status and vitamin D supplementation, pre- and post-surgery, and to propose, on this basis, recommendations for management. Preoperatively, 18 studies including 2,869 patients were evaluated. Prevalence of vitamin D insufficiency as defined by 25(OH)D < 30 ng/mL (75 nmol/L) was 85%, whereas when defined by 25(OH)D < 20 ng/mL (50 nmol/L) was 57%. The median preoperative 25(OH)D level was 19.75 ng/mL. After surgery, 39 studies including 5,296 patients were analysed and among those undergoing either malabsorptive or restrictive procedures, a lower rate of vitamin D insufficiency and higher 25(OH)D levels postoperatively were observed in patients treated with high-dose oral vitamin D supplementation, defined as ≥ 2,000 IU/daily (mostly D3-formulation), compared with low-doses (< 2,000 IU/daily). Our recommendations based on this systematic review and meta-analysis should help clinical practice in the assessment and management of vitamin D status before and after bariatric surgery. Assessment of vitamin D should be performed pre- and postoperatively in all patients undergoing bariatric surgery. Regardless of the type of procedure, high-dose supplementation is recommended in patients after bariatric surgery.
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Affiliation(s)
- Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy.
| | - Luigi di Filippo
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
| | - Antonio Facciorusso
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Robert A Adler
- Richmond Veterans Affairs Medical Center and Virginia Commonwealth University, Richmond, VA, USA
| | | | | | - Roger Bouillon
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases, Metabolism and Ageing, 3000 KU, Leuven, Belgium
| | - Felipe F Casanueva
- Molecular Endocrinology Group, Instituto de Investigacion Sanitaria (IDIS), Complejo Hospitalario Universitario de Santiago (CHUS/SERGAS). CIBER de Fisiopatologia de La Obesidad y Nutricion (CIBERobn), Instituto de Salud Carlos III, Madrid, Spain
| | - Giulia Martina Cavestro
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marlene Chakhtoura
- Calcium Metabolism and Osteoporosis Program, American University of Beirut-Medical Center, Beirut, Lebanon
| | - Caterina Conte
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Via Di Val Cannuta 247, 00166, Rome, Italy
| | - Lorenzo M Donini
- Experimental Medicine Department, Sapienza University, Rome, Italy
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Australia
| | - Angelo Fassio
- Rheumatology Unit, University of Verona, Verona, Italy
| | - Stefano Frara
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
| | - Claudia Gagnon
- Department of Medicine, Université Laval, Quebec City, Canada
| | - Giovanni Latella
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Jeffrey I Mechanick
- Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | | | - René Rizzoli
- Service of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Ferruccio Santini
- Obesity and Lipodystrophy Center, University Hospital of Pisa, Pisa, Italy
| | - Joseph L Shaker
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Fabio Massimo Ulivieri
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
| | - Jyrki K Virtanen
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - Nicola Napoli
- Department of Medicine and Surgery, Research Unit of Endocrinology and Diabetes, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128, Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128, Roma, Italy
| | - Anne L Schafer
- University of California, San Francisco and the San Francisco Veterans Affairs Health Care System, San Francisco, USA
| | - John P Bilezikian
- Department of Medicine, Endocrinology Division, Vagelos College of Physicians and Surgeons Columbia University, New York, NY, USA
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Hardy Abeloos C, Solan A, Perez CA, Maisonet OG, Cronstein BA, Adler RA, Goldberg J, Gerber NK. A Phase II, Randomized, Double Blind, Placebo Controlled Study of the Safety and Efficacy of a Caffeine-Based Antifibrosis Cream in Patients with Breast Cancer Undergoing Radiation Therapy. Int J Radiat Oncol Biol Phys 2023; 117:e177-e178. [PMID: 37784794 DOI: 10.1016/j.ijrobp.2023.06.1026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Radiation induced fibrosis (RIF) is a common long term adverse event in patients undergoing post-mastectomy radiation therapy (PMRT) which can cause capsular contracture, implant loss, and reconstruction complications in women with implant-based breast reconstruction. At a molecular level, adenosine is a driver of RIF. Preclinical data have shown that pharmacologic blockade of the adenosine A2A Receptor (A2AR) in mice as well as an A2AR knockout mouse model prevented skin fibrosis associated with radiation injury. Caffeine is an A2AR antagonist which has been shown to block the development of hepatic fibrosis in liver disease patients. We present a phase II placebo controlled clinical trial to evaluate whether a caffeine-based cream can prevent RIF and thus reduce the rates of reconstructive complications in patients with tissue expander-based reconstruction requiring PMRT. MATERIALS/METHODS Women ≥ 18 years old with breast carcinoma stage 0-III status post mastectomy with tissue expander-based reconstruction who require PMRT to the chest wall +/- the regional nodes are being enrolled. The target accrual is 60 patients. Boost field to the chest wall, scar and/or nodal region is allowed. Patients with inflammatory breast cancer or those requiring skin bolus are excluded. Prior to starting radiation, patients will be randomized to placebo vs. caffeine cream and they will be instructed to apply the cream twice a day starting on the first day of radiation treatment and continuing daily for the duration of radiation until the removal of tissue expanders. The primary study endpoint is reconstructive complications requiring rehospitalization or reoperation by 2 years post radiation including reconstructive failure with or without reconstruction. A safety endpoint of grade ≥ 2 acute radiation dermatitis will also serve as a co-primary endpoint. Secondary endpoints are wound infection/cellulitis, hematoma, seroma, threatened exposure, wound dehiscence, implant leakage, rupture, and or deflation, and capsular contracture that do not meet criteria for the primary endpoint. Clinician rated cosmesis, local recurrence, regional recurrence, distant metastasis and survival up to 4 years are additional secondary endpoints. Exploratory endpoint includes the use of shear wave elastography (SWE) as a potential tool to quantitatively measure post irradiation fibrosis. Correlative aims include assessing epidermal thickness and fat layer thickness from tissue obtained at time of implant exchange for association with the development of fibrosis. The primary efficacy endpoint will be estimated using Kaplan Meier methods from date of randomization. Treatment comparisons will be based on a 2-sided log rank chi-square test and the hazard ratio will be estimated with 95% confidence intervals. The study started accruing in 12/2019 and is estimated to end by 04/2024. As of January 2023, 67% (40/60 patients) of the planned patients have been enrolled. RESULTS To be determined. CONCLUSION To be determined.
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Affiliation(s)
| | - A Solan
- NYU Grossman School of Medicine, New York City, NY
| | - C A Perez
- NYU Grossman School of Medicine, New York City, NY
| | - O G Maisonet
- Department of Radiation Oncology, NYU Langone Health and Perlmutter Cancer Center, New York, NY
| | | | - R A Adler
- NYU Grossman School of Medicine, New York City, NY
| | | | - N K Gerber
- Department of Radiation Oncology, NYU Langone Health, New York, NY
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Gorgey AS, Khalil RE, Carter W, Ballance B, Gill R, Khan R, Goetz L, Lavis T, Sima AP, Adler RA. Effects of two different paradigms of electrical stimulation exercise on cardio-metabolic risk factors after spinal cord injury. A randomized clinical trial. Front Neurol 2023; 14:1254760. [PMID: 37808500 PMCID: PMC10556465 DOI: 10.3389/fneur.2023.1254760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/30/2023] [Indexed: 10/10/2023] Open
Abstract
Objective To examine the combined effects of neuromuscular electrical stimulation-resistance training (NMES-RT) and functional electrical stimulation-lower extremity cycling (FES-LEC) compared to passive movement training (PMT) and FES-LEC in adults with SCI on (1) oxygen uptake (VO2), insulin sensitivity and glucose disposal in adults with SCI; (2) Metabolic and inflammatory biomarkers; (3) skeletal muscle, intramuscular fat (IMF) and visceral adipose tissue (VAT) cross-sectional areas (CSAs). Materials and methods Thirty-three participants with chronic SCI (AIS A-C) were randomized to 24 weeks of NMES-RT + FES or PMT + FES. The NMES-RT + FES group underwent 12 weeks of evoked surface NMES-RT using ankle weights followed by an additional 12 weeks of progressive FES-LEC. The control group, PMT + FES performed 12 weeks of passive leg extension movements followed by an additional 12 weeks of FES-LEC. Measurements were performed at baseline (BL; week 0), post-intervention 1 (P1; week 13) and post-intervention 2 (P2; week 25) and included FES-VO2 measurements, insulin sensitivity and glucose effectiveness using the intravenous glucose tolerance test; anthropometrics and whole and regional body composition assessment using dual energy x-ray absorptiometry (DXA) and magnetic resonance imaging to measure muscle, IMF and VAT CSAs. Results Twenty-seven participants completed both phases of the study. NMES-RT + FES group showed a trend of a greater VO2 peak in P1 [p = 0.08; but not in P2 (p = 0.25)] compared to PMT + FES. There was a time effect of both groups in leg VO2 peak. Neither intervention elicited significant changes in insulin, glucose, or inflammatory biomarkers. There were modest changes in leg lean mass following PMT + FES group. Robust hypertrophy of whole thigh muscle CSA, absolute thigh muscle CSA and knee extensor CSA were noted in the NMES-RT + FES group compared to PMT + FES at P1. PMT + FES resulted in muscle hypertrophy at P2. NMES-RT + FES resulted in a decrease in total VAT CSA at P1. Conclusion NMES-RT yielded a greater peak leg VO2 and decrease in total VAT compared to PMT. The addition of 12 weeks of FES-LEC in both groups modestly impacted leg VO2 peak. The addition of FES-LEC to NMES-RT did not yield additional increases in muscle CSA, suggesting a ceiling effect on signaling pathways following NMES-RT. Clinical trial registration identifier NCT02660073.
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Affiliation(s)
- Ashraf S. Gorgey
- Spinal Cord Injury and Disorders, Richmond VA Medical Center, Richmond, VA, United States
- Department of Physical Medicine & Rehabilitation, Virginia Commonwealth University, Richmond, VA, United States
| | - Refka E. Khalil
- Spinal Cord Injury and Disorders, Richmond VA Medical Center, Richmond, VA, United States
| | - William Carter
- Department of Physical Medicine & Rehabilitation, Virginia Commonwealth University, Richmond, VA, United States
| | - Boyd Ballance
- Spinal Cord Injury and Disorders, Richmond VA Medical Center, Richmond, VA, United States
| | - Ranjodh Gill
- Endocrinology Service, Richmond VA Medical Center, Richmond, VA, United States
- Endocrine Division, School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Rehan Khan
- Radiology Service, Richmond VA Medical Center, Richmond, VA, United States
| | - Lance Goetz
- Spinal Cord Injury and Disorders, Richmond VA Medical Center, Richmond, VA, United States
- Department of Physical Medicine & Rehabilitation, Virginia Commonwealth University, Richmond, VA, United States
| | - Timothy Lavis
- Spinal Cord Injury and Disorders, Richmond VA Medical Center, Richmond, VA, United States
- Department of Physical Medicine & Rehabilitation, Virginia Commonwealth University, Richmond, VA, United States
| | - Adam P. Sima
- Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Robert A. Adler
- Endocrinology Service, Richmond VA Medical Center, Richmond, VA, United States
- Endocrine Division, School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
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Adler RA. Osteoporosis Treatment: Decreased Mortality Too? J Clin Endocrinol Metab 2023; 108:e48-e49. [PMID: 36520976 DOI: 10.1210/clinem/dgac723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Robert A Adler
- Endocrinology Section, Central Virginia Veterans Affairs Health Care System, Virginia Commonwealth University, Richmond, Virginia 23249, USA
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8
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Gorgey AS, Goldsmith JA, Khalil RE, Liu XH, Pan J, Cardozo C, Adler RA. Predictors of muscle hypertrophy responsiveness to electrically evoked resistance training after spinal cord injury. Eur J Appl Physiol 2023; 123:479-493. [PMID: 36305973 DOI: 10.1007/s00421-022-05069-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 10/08/2022] [Indexed: 11/03/2022]
Abstract
The purpose of the study was to identify potential predictors of muscle hypertrophy responsiveness following neuromuscular electrical stimulation resistance training (NMES-RT) in persons with chronic spinal cord injury (SCI). Data for twenty individuals with motor complete SCI who completed twice weekly NMES-RT lasting 12-16 weeks as part of their participation in one of two separate clinical trials were pooled and retrospectively analyzed. Magnetic resonance imaging (MRI) was used to measure muscle cross-sectional area (CSA) of the whole thigh and knee extensor muscle before and after NMES-RT. Muscle biopsies and fasting biomarkers were also measured. Following the completion of the respective NMES-RT trials, participants were classified into either high-responders (n = 8; muscle CSA > 20%) or low-responders (n = 12; muscle CSA < 20%) based on whole thigh muscle CSA hypertrophy. Whole thigh muscle and knee extensors CSAs were significantly greater (P < 0.0001) in high-responders (29 ± 7% and 47 ± 15%, respectively) compared to low-responders (12 ± 3% and 19 ± 6%, respectively). There were no differences in total caloric intake or macronutrient intake between groups. Extensor spasticity was lower in the high-responders compared to the low-responders as was the dosage of baclofen. Prior to the intervention, the high-responders had greater body mass compared to the low-responders with SCI (87.8 ± 13.7 vs. 70.4 ± 15.8 kg; P = 0.012), body mass index (BMI: 27.6 ± 2.7 vs. 22.9 ± 6.0 kg/m2; P = 0.04), as well as greater percentage in whole body and regional fat mass (P < 0.05). Furthermore, high-responders had a 69% greater increase (P = 0.086) in total Akt protein expression than low-responders. High-responders also exhibited reduced circulating IGF-1 with a concomitant increase in IGFBP-3. Exploratory analyses revealed upregulation of mRNAs for muscle hypertrophy markers [IRS-1, Akt, mTOR] and downregulation of protein degradation markers [myostatin, MurF-1, and PDK4] in the high-responders compared to low-responders. The findings indicate that body composition, spasticity, baclofen usage, and multiple signaling pathways (anabolic and catabolic) are involved in the differential muscle hypertrophy response to NMES-RT in persons with chronic SCI.
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Affiliation(s)
- Ashraf S Gorgey
- Spinal Cord Injury and Disorders Service, Central Virginia VA Health Care System, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA.
- Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA.
| | - Jacob A Goldsmith
- Spinal Cord Injury and Disorders Service, Central Virginia VA Health Care System, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Refka E Khalil
- Spinal Cord Injury and Disorders Service, Central Virginia VA Health Care System, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Xin-Hua Liu
- National Center for the Medical Consequences of Spinal Cord Injury and Medical and Surgical Service, James J Peters VA Medical Center, Bronx, NY, USA
- Department of Medicine, Icahn School of Medicine, New York, NY, USA
| | - Jiangping Pan
- National Center for the Medical Consequences of Spinal Cord Injury and Medical and Surgical Service, James J Peters VA Medical Center, Bronx, NY, USA
- Department of Medicine, Icahn School of Medicine, New York, NY, USA
| | - Christopher Cardozo
- National Center for the Medical Consequences of Spinal Cord Injury and Medical and Surgical Service, James J Peters VA Medical Center, Bronx, NY, USA
- Department of Medicine, Icahn School of Medicine, New York, NY, USA
| | - Robert A Adler
- Endocrinology Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
- Endocrine Division, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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9
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Gorgey AS, Khalil RE, Alrubaye M, Gill R, Rivers J, Goetz LL, Cifu DX, Castillo T, Caruso D, Lavis TD, Lesnefsky EJ, Cardozo CC, Adler RA. Testosterone and long pulse width stimulation (TLPS) for denervated muscles after spinal cord injury: a study protocol of randomised clinical trial. BMJ Open 2022; 12:e064748. [PMID: 36198461 PMCID: PMC9535184 DOI: 10.1136/bmjopen-2022-064748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Long pulse width stimulation (LPWS; 120-150 ms) has the potential to stimulate denervated muscles and to restore muscle size in denervated people with spinal cord injury (SCI). We will determine if testosterone treatment (TT)+LPWS would increase skeletal muscle size, leg lean mass and improve overall metabolic health in persons with SCI with denervation. We hypothesise that the 1-year TT+LPWS will upregulate protein synthesis pathways, downregulate protein degradation pathways and increase overall mitochondrial health. METHODS AND ANALYSIS Twenty-four male participants (aged 18-70 years with chronic SCI) with denervation of both knee extensor muscles and tolerance to the LPWS paradigm will be randomised into either TT+neuromuscular electrical stimulation via telehealth or TT+LPWS. The training sessions will be twice weekly for 1 year. Measurements will be conducted 1 week prior training (baseline; week 0), 6 months following training (postintervention 1) and 1 week after the end of 1 year of training (postintervention 2). Measurements will include body composition assessment using anthropometry, dual X-ray absorptiometry and MRI to measure size of different muscle groups. Metabolic profile will include measuring of basal metabolic rate, followed by blood drawn to measure fasting biomarkers similar to hemoglobin A1c, lipid panels, C reactive protein, interleukin-6 and free fatty acids and then intravenous glucose tolerance test to test for insulin sensitivity and glucose effectiveness. Finally, muscle biopsy will be captured to measure protein expression and intracellular signalling; and mitochondrial electron transport chain function. The participants will fill out 3 days dietary record to monitor their energy intake on a weekly basis. ETHICS AND DISSEMINATION The study was approved by Institutional Review Board of the McGuire Research Institute (ID # 02189). Dissemination plans will include the Veteran Health Administration and its practitioners, the national SCI/D services office, the general healthcare community and the veteran population, as well as the entire SCI community via submitting quarterly letters or peer-review articles. TRIAL REGISTRATION NUMBER NCT03345576.
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Affiliation(s)
- Ashraf S Gorgey
- Spinal Cord Injury Service and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Refka E Khalil
- Spinal Cord Injury Service and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Malak Alrubaye
- Spinal Cord Injury Service and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Ranjodh Gill
- Endocrine Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Jeannie Rivers
- Spinal Cord Injury Service and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Lance L Goetz
- Spinal Cord Injury Service and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - David X Cifu
- Physical Medicine and Rehab, Commonwealth of Virginia, Richmond, Virginia, USA
| | - Teodoro Castillo
- Spinal Cord Injury Service and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Deborah Caruso
- Spinal Cord Injury Service and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Timothy D Lavis
- Spinal Cord Injury Service and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Edward J Lesnefsky
- Cardiology Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Christopher C Cardozo
- National Center for the Medical Consequences of Spinal Cord Injury and Medical and Surgical Service, James J Peters VA Medical Center, Bronx, New York, USA
| | - Robert A Adler
- Endocrine Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
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10
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Bilezikian JP, Formenti AM, Adler RA, Binkley N, Bouillon R, Lazaretti-Castro M, Marcocci C, Napoli N, Rizzoli R, Giustina A. Vitamin D: Dosing, levels, form, and route of administration: Does one approach fit all? Rev Endocr Metab Disord 2021; 22:1201-1218. [PMID: 34940947 PMCID: PMC8696970 DOI: 10.1007/s11154-021-09693-7] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/02/2021] [Indexed: 02/07/2023]
Abstract
The 4th International Conference on Controversies in Vitamin D was held as a virtual meeting in September, 2020, gathering together leading international scientific and medical experts in vitamin D. Since vitamin D has a crucial role in skeletal and extra-skeletal systems, the aim of the Conference was to discuss improved management of vitamin D dosing, therapeutic levels and form or route of administration in the general population and in different clinical conditions. A tailored approach, based on the specific mechanisms underlying vitamin D deficiency in different diseases that were discussed, was recommended. Specifically, in comparison to healthy populations, higher levels of vitamin D and greater amounts of vitamin D were deemed necessary in osteoporosis, diabetes mellitus, obesity (particularly after bariatric surgery), and in those treated with glucocorticoids. Emerging and still open issues were related to target vitamin D levels and the role of vitamin D supplementation in COVID-19 since low vitamin D may predispose to SARS-CoV-2 infection and to worse COVID-19 outcomes. Finally, whereas oral daily cholecalciferol appears to be the preferred choice for vitamin D supplementation in the general population, and in most clinical conditions, active vitamin D analogs may be indicated in patients with hypoparathyroidism and severe kidney and liver insufficiency. Parenteral vitamin D administration could be helpful in malabsorption syndromes or in states of vitamin D resistance.Specific guidelines for desired levels of vitamin D should be tailored to the different conditions affecting vitamin D metabolism with the goal to define disease-specific normative values.
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Affiliation(s)
- John P Bilezikian
- Department of Medicine, Endocrinology Division, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Anna Maria Formenti
- Institute of Endocrine and Metabolic Sciences, San Raffaele, Vita-Salute University and IRCCS Hospital, Milano, Italy
| | - Robert A Adler
- McGuire Veterans Affairs Medical Center and Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | | | - Roger Bouillon
- Laboratory of Clinical and Experimental Endocrinology, Department of chronic diseases, metabolism and ageing, Leuven, KU, Belgium
| | - Marise Lazaretti-Castro
- Division of Endocrinology, Escola Paulista de Medicina - Universidade Federal de Sao Paulo (EPM-UNIFESP), Sao Paulo, Brazil
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Nicola Napoli
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University of Rome, Rome, Italy
| | - Rene Rizzoli
- Service of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, San Raffaele, Vita-Salute University and IRCCS Hospital, Milano, Italy.
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11
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Colón-Emeric CS, Lee R, Pieper CF, Lyles KW, Zullig LL, Nelson RE, Robinson K, Igwe I, Jadhav J, Adler RA. Protocol for the models of primary osteoporosis screening in men (MOPS) cluster randomized trial. Contemp Clin Trials 2021; 112:106634. [PMID: 34844000 DOI: 10.1016/j.cct.2021.106634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/15/2021] [Accepted: 11/22/2021] [Indexed: 11/25/2022]
Abstract
Current guidelines recommend primary osteoporosis screening for at-risk men to reduce the morbidity, mortality, and cost associated with osteoporotic fractures. However, analyses in a national Veterans Health Administration cohort of over 4,000,000 men demonstrated that primary osteoporosis screening as it is currently operationalized does not benefit most older Veterans due to inefficient targeting and low subsequent treatment and adherence rates. The overall objective of this study is to determine whether a new model of primary osteoporosis screening reduces fracture risk compared to usual care. We are conducting a pragmatic group randomized trial of 38 primary care teams assigned to usual care or a Bone Health Service (BHS) screening model in which screening and adherence activities are managed by a centralized expert team. The study will: 1) compare the impact of the BHS model on patient-level outcomes strongly associated with fracture rates (eligible proportion screened, proportion meeting treatment criteria who receive osteoporosis medications, medication adherence, and femoral neck bone mineral density); 2) quantify the impact on provider and facility-level outcomes including change in DXA volume, change in metabolic bone disease clinic volume, and PACT provider time and satisfaction; and 3) estimate the impact on health system and policy outcomes using Markov models of screening program cost per quality adjusted life year based from health system and societal perspectives.
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Affiliation(s)
- Cathleen S Colón-Emeric
- Durham VA Geriatric Research Education and Clinical Center and Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), 508 Fulton St. Durham, NC 27705, USA; Duke University School of Medicine, Box 3003 DUMC, Durham, NC 27710, USA.
| | - Richard Lee
- Durham VA Geriatric Research Education and Clinical Center and Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), 508 Fulton St. Durham, NC 27705, USA; Duke University School of Medicine, Box 3003 DUMC, Durham, NC 27710, USA
| | - Carl F Pieper
- Duke University School of Medicine, Box 3003 DUMC, Durham, NC 27710, USA
| | - Kenneth W Lyles
- Durham VA Geriatric Research Education and Clinical Center and Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), 508 Fulton St. Durham, NC 27705, USA; Duke University School of Medicine, Box 3003 DUMC, Durham, NC 27710, USA
| | - Leah L Zullig
- Durham VA Geriatric Research Education and Clinical Center and Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), 508 Fulton St. Durham, NC 27705, USA; Duke University School of Medicine, Box 3003 DUMC, Durham, NC 27710, USA
| | - Richard E Nelson
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City VA Health Care System, 500 Foothills Drive, Salt Lake City, UT 84148, USA; University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132, USA
| | - Katina Robinson
- Durham VA Geriatric Research Education and Clinical Center and Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), 508 Fulton St. Durham, NC 27705, USA
| | - Ivuoma Igwe
- Durham VA Geriatric Research Education and Clinical Center and Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), 508 Fulton St. Durham, NC 27705, USA
| | - Jyotsna Jadhav
- Durham VA Geriatric Research Education and Clinical Center and Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), 508 Fulton St. Durham, NC 27705, USA
| | - Robert A Adler
- Hunter Holmes McGuire VA Medical Center, 1201 Broad Rock Blvd, Richmond, VA 23249, USA
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12
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Gorgey AS, Khalil RE, Gill R, Khan R, Adler RA. Effects of dose de-escalation following testosterone treatment and evoked resistance exercise on body composition, metabolic profile, and neuromuscular parameters in persons with spinal cord injury. Physiol Rep 2021; 9:e15089. [PMID: 34713983 PMCID: PMC8554770 DOI: 10.14814/phy2.15089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 11/24/2022] Open
Abstract
The dose de-escalation (DD) effects of testosterone and evoked resistance training (RT) on body composition, cardiometabolic, and neuromuscular variables were investigated. Thirteen men with chronic complete spinal cord injury (SCI) were followed for additional 16 weeks after receiving either testosterone treatment only (TT) or TT+RT. During the 16-week DD period, the TT+RT group underwent a program of once weekly electrical stimulation with gradually decreasing ankle weights and testosterone patches of 2 mg day-1 (TT+RT group). The TT only group did not receive any intervention throughout the detraining period (no-TT group). Body composition was tested using anthropometrics, dual energy X-ray absorptiometry, and magnetic resonance imaging. After an overnight fast, basal metabolic rate (BMR), lipid panel, serum testosterone, inflammatory biomarkers, glucose effectiveness, and insulin sensitivity were measured. Finally, peak isometric and isokinetic torques were measured only in the TT+RT group. All measurements were conducted at the beginning and at the end of DD. Absolute thigh muscle cross-sectional areas (CSAs) demonstrated interaction effects (p < 0.05) between the TT+RT (-8.15%, -6.5%) and no-TT (2.3%, 4.4%) groups. Similarly, absolute knee extensor muscle CSA demonstrated interaction effects (p < 0.05) between the TT+RT (-11%, -7.0%) and no-TT (2.6%, 3.8%) groups. There was a trend (p = 0.07) of increasing visceral adipose tissue (VAT) CSAs in the TT+RT (18%) and in the no-TT (16% cm2 ) groups. There was an interaction (p = 0.005) between TT+RT (decreased by 3.7%) and no-TT groups (increased by 9.0%) in BMR. No interactions were evident between groups over time for biomarkers related to carbohydrate, lipid metabolism, or inflammation. Finally, there were no changes (p > 0.05) in peak isometric or isokinetic torques and rise time following 16 weeks of the DD period in the TT+RT group. TT+RT during 16 weeks of DD was minimally effective at preventing detraining relative to no-TT on muscle size, BMR, and VAT. However, neuromuscular gains were successfully maintained.
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Affiliation(s)
- Ashraf S. Gorgey
- Spinal Cord Injury and Disorders CenterHunter Holmes McGuire VAMCRichmondVirginiaUSA
- Department of Physical Medicine & RehabilitationVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Refka E. Khalil
- Spinal Cord Injury and Disorders CenterHunter Holmes McGuire VAMCRichmondVirginiaUSA
| | - Ranjodh Gill
- Endocrinology ServiceHunter Holmes McGuire VA Medical CenterRichmondVirginiaUSA
- Endocrine DivisionVirginia Commonwealth University School of MedicineRichmondVirginiaUSA
| | - Rehan Khan
- Radiology ServiceHunter Holmes McGuire VA Medical CenterRichmondVirginiaUSA
| | - Robert A. Adler
- Endocrinology ServiceHunter Holmes McGuire VA Medical CenterRichmondVirginiaUSA
- Endocrine DivisionVirginia Commonwealth University School of MedicineRichmondVirginiaUSA
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13
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Holman ME, Chang G, Ghatas MP, Saha PK, Zhang X, Khan MR, Sima AP, Adler RA, Gorgey AS. Bone and non-contractile soft tissue changes following open kinetic chain resistance training and testosterone treatment in spinal cord injury: an exploratory study. Osteoporos Int 2021; 32:1321-1332. [PMID: 33443609 DOI: 10.1007/s00198-020-05778-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 12/04/2020] [Indexed: 01/30/2023]
Abstract
UNLABELLED Twenty men with spinal cord injury (SCI) were randomized into two 16-week intervention groups receiving testosterone treatment (TT) or TT combined with resistance training (TT + RT). TT + RT appears to hold the potential to reverse or slow down bone loss following SCI if provided over a longer period. INTRODUCTION Persons with SCI experience bone loss below the level of injury. The combined effects of resistance training and TT on bone quality following SCI remain unknown. METHODS Men with SCI were randomized into 16-week treatments receiving TT or TT + RT. Magnetic resonance imaging (MRI) of the right lower extremity before participation and post-intervention was used to visualize the proximal, middle, and distal femoral shaft, the quadriceps tendon, and the intermuscular fascia of the quadriceps. For the TT + RT group, MRI microarchitecture techniques were utilized to elucidate trabecular changes around the knee. Individual mixed models were used to estimate effect sizes. RESULTS Twenty participants completed the pilot trial. A small effect for yellow marrow in the distal femur was indicated as increases following TT and decreases following TT + RT were observed. Another small effect was observed as the TT + RT group displayed greater increases in intermuscular fascia length than the TT arm. Distal femur trabecular changes for the TT + RT group were generally small in effect (decreased trabecular thickness variability, spacing, and spacing variability; increased network area). Medium effects were generally observed in the proximal tibia (increased plate width, trabecular thickness, and network area; decreased trabecular spacing and spacing variability). CONCLUSIONS This pilot suggests longer TT + RT interventions may be a viable rehabilitation technique to combat bone loss following SCI. CLINICAL TRIAL REGISTRATION Registered with clinicaltrials.gov : NCT01652040 (07/27/2012).
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Affiliation(s)
- M E Holman
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VAMC, Richmond, VA, 23249, USA
| | - G Chang
- Department of Radiology, NYU School of Medicine, New York, NY, 10016, USA
| | - M P Ghatas
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VAMC, Richmond, VA, 23249, USA
| | - P K Saha
- Department of Electrical and Computer Engineering, University of Iowa, Iowa City, IA, 52242, USA
- Department of Radiology, University of Iowa, Iowa City, IA, 52242, USA
| | - X Zhang
- Department of Electrical and Computer Engineering, University of Iowa, Iowa City, IA, 52242, USA
| | - M R Khan
- Department of Radiology, Hunter Holmes McGuire VAMC, Richmond, VA, 23249, USA
| | - A P Sima
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, 23284, USA
| | - R A Adler
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VAMC, Richmond, VA, 23249, USA
| | - A S Gorgey
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VAMC, Richmond, VA, 23249, USA.
- Department of Physical Medicine & Rehabilitation, Virginia Commonwealth University, Richmond, VA, 23284, USA.
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14
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Abstract
As SARS-CoV-2 stunned and overtook everyone's lives, multiple daily briefings, protocols, policies and incident command committees were mobilized to provide frontline staff with the tools, supplies and infrastructure needed to address the COVID-19 pandemic. Medical resources were immediately shifted. In light of the necessity for self-isolation, telemedicine was expanded, although there has been concern than non-pandemic disorders were being ignored. Ambulatory care services such as bone densitometry and osteoporosis centered clinics came to a near halt. Progress with fracture prevention has been challenged. Despite the prolonged pandemic and the consequent sense of exhaustion, we must re-engage with chronic bone health concerns and fracture prevention. Creating triaging systems for bone mineral testing and in person visits, treating individuals designated as high risk of fracture using fracture risk assessment tools such as FRAX, maintaining telemedicine, leveraging other bone health care team members to monitor and care for osteoporotic patients, and re-engaging our primary care colleagues will remain paramount but challenging. The pandemic persists. Thus, we will summarize what we have learned about COVID-19 and bone health and provide a framework for osteoporosis diagnosis, treatment, and follow-up with the extended COVID-19 pandemic. The goal is to preserve bone health, with focused interventions to sustain osteoporosis screening and treatment initiation/maintenance rates.
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Affiliation(s)
- R R Narla
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
- Division of Endocrinology, Metabolism and Nutrition, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - R A Adler
- Endocrinology and Metabolism Section (111P), McGuire Veterans Affairs Medical Center, Central Virginia Veterans Affairs Health Care System, 1201 Broad Rock Boulevard, Richmond, VA, 23249, USA.
- Division of Endocrinology, Metabolism, and Diabetes Mellitus, Virginia Commonwealth University, Richmond, VA, USA.
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15
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Abstract
Bisphosphonates remain a first-line treatment for osteoporosis and decrease vertebral and hip fractures without side effects in most patients. With extended treatment, osteonecrosis of the jaw and atypical femoral fracture occur rarely, but fear of side effects has led to not starting or discontinuing treatment. Atrial fibrillation and uveitis are less appreciated by the general public, but their rare incidence must be recognized. A strategy for safe long-term treatment is provided based on 2 major studies. Interruption of treatment after 3 to 5 years is possible for some patients, but those remaining at high fracture risk require longer term therapy.
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Affiliation(s)
- Robert A Adler
- Endocrinology and Metabolism Section, Central Virginia Veterans Affairs Health Care System, Richmond, VA, USA; Division of Endocrinology, Virginia Commonwealth University, Richmond, VA, USA.
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16
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Giustina A, Bouillon R, Binkley N, Sempos C, Adler RA, Bollerslev J, Dawson-Hughes B, Ebeling PR, Feldman D, Heijboer A, Jones G, Kovacs CS, Lazaretti-Castro M, Lips P, Marcocci C, Minisola S, Napoli N, Rizzoli R, Scragg R, White JH, Formenti AM, Bilezikian JP. Controversies in Vitamin D: A Statement From the Third International Conference. JBMR Plus 2020; 4:e10417. [PMID: 33354643 PMCID: PMC7745884 DOI: 10.1002/jbm4.10417] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/18/2020] [Accepted: 09/20/2020] [Indexed: 12/19/2022] Open
Abstract
The Third International Conference on Controversies in Vitamin D was held in Gubbio, Italy, September 10–13, 2019. The conference was held as a follow‐up to previous meetings held in 2017 and 2018 to address topics of controversy in vitamin D research. The specific topics were selected by the steering committee of the conference and based upon areas that remain controversial from the preceding conferences. Other topics were selected anew that reflect specific topics that have surfaced since the last international conference. Consensus was achieved after formal presentations and open discussions among experts. As will be detailed in this article, consensus was achieved with regard to the following: the importance and prevalence of nutritional rickets, amounts of vitamin D that are typically generated by sun exposure, worldwide prevalence of vitamin D deficiency, the importance of circulating concentrations of 25OHD as the best index of vitamin D stores, definitions and thresholds of vitamin D deficiency, and efficacy of vitamin D analogues in the treatment of psoriasis. Areas of uncertainly and controversy include the following: daily doses of vitamin D needed to maintain a normal level of 25OHD in the general population, recommendations for supplementation in patients with metabolic bone diseases, cutaneous production of vitamin D by UVB exposure, hepatic regulation of 25OHD metabolites, definition of vitamin D excess, vitamin D deficiency in acute illness, vitamin D requirements during reproduction, potential for a broad spectrum of cellular and organ activities under the influence of the vitamin D receptor, and potential links between vitamin D and major human diseases. With specific regard to the latter area, the proceedings of the conference led to recommendations for areas in need of further investigation through appropriately designed intervention trials. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, San Raffaele, Vita-Salute University and IRCCS Hospital Milan Italy
| | - Roger Bouillon
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases Metabolism and Ageing KU Leuven Leuven Belgium
| | - Neil Binkley
- Osteoporosis Clinical Research Program on Aging, University of Wisconsin Madison WI USA
| | | | - Robert A Adler
- McGuire Veterans Affairs Medical Center and Virginia Commonwealth University School of Medicine Richmond VA USA
| | - Jens Bollerslev
- Section of Specialized Endocrinology, Department of Endocrinology, Oslo University Hospital, Rikshospitalet, Oslo, Norway, and Faculty of Medicine University of Oslo Oslo Norway
| | - Bess Dawson-Hughes
- Jean Mayer USDA Nutrition Research Center on Aging Tufts University Boston MA USA
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences Monash University Calyton Victoria Australia
| | - David Feldman
- Department of Medicine Stanford University School of Medicine Stanford CA USA
| | - Annemieke Heijboer
- Endocrine Laboratory, Department of Clinical Chemistry Amsterdam UMC, Vrije Universiteit Amsterdam and University of Amsterdam, Amsterdam Gastroenterology & Metabolism Amsterdam The Netherlands
| | - Glenville Jones
- Department of Biomedical and Molecular Sciences Queen's University Kingston Ontario Canada
| | - Christopher S Kovacs
- Faculty of Medicine Memorial University of Newfoundland St. John's Newfoundland and Labrador Canada
| | - Marise Lazaretti-Castro
- Division of Endocrinology Escola Paulista de Medicina-Universidade Federal de Sao Paulo (EPM-UNIFESP) São Paulo Brazil
| | - Paul Lips
- Department of Internal Medicine, Endocrine Section Amsterdam University Medical Center Amsterdam The Netherlands
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine University of Pisa Pisa Italy
| | - Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines University of Rome "Sapienza" Rome Italy
| | - Nicola Napoli
- Unit of Endocrinology and Diabetes Campus Bio-Medico, University of Rome Rome Italy.,Division of Bone and Mineral Diseases Washington University in St. Louis St. Louis MO USA
| | - Rene Rizzoli
- Service of Bone Diseases Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - Robert Scragg
- School of Population Health University of Auckland Auckland New Zealand
| | - John H White
- Department of Physiology McGill University Montreal Quebec Canada
| | - Anna Maria Formenti
- Institute of Endocrine and Metabolic Sciences, San Raffaele, Vita-Salute University and IRCCS Hospital Milan Italy
| | - John P Bilezikian
- Department of Medicine, Endocrinology Division, College of Physicians and Surgeons Columbia University New York NY USA
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17
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Ifon DE, Ghatas MP, Davis JC, Khalil RE, Adler RA, Gorgey AS. Long-term effect of intrathecal baclofen treatment on bone health and body composition after spinal cord injury: A case matched report. World J Orthop 2020; 11:453-464. [PMID: 33134108 PMCID: PMC7582109 DOI: 10.5312/wjo.v11.i10.453] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/15/2020] [Accepted: 09/10/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Severe spasticity may negatively impact functionality and quality of life after spinal cord injury (SCI). Intrathecal baclofen treatment (IBT) is effectively used to manage severe spasticity and reduce comorbidities. However, long-term IBT may have a negative effect on bone mineral content (BMC), bone mineral density (BMD) and body composition (such as percentage fat mass and lean body mass). We demonstrated the negative effects of long-term IBT use in a single case compared with two non-IBT users.
CASE SUMMARY A 46-year old Caucasian male Veteran (case) with a 21 year history of complete tetraplegia (complete C6 SCI) was implanted with IBT for 20 years. The case was matched to two participants with different time since injuries [2 (match 1) and 13 (match 2) years] without IBT. Knee BMC and BMD at the epiphysis and metaphysis of the distal femur and proximal tibia were evaluated using dual knee and the dual femur modules of GE Lunar iDXA software. Total and leg body composition assessments were also conducted for the three participants. Potential effect of long-term IBT was demonstrated by changes in BMD, consistent with bone demineralization, at the distal femur and proximal tibia and changes in percentage fat mass and lean mass of legs. The case showed 113% lower BMD at the distal femur, and 78.1% lower at the proximal tibia compared to match 1, moreover the case showed 45% lower BMD at the distal femur, and no observed changes at the proximal tibia compared to match 2. The case had 27.1% and 16.5% greater leg %fat mass compared to match 1 and match 2, respectively. Furthermore, the case had 17.4% and 11.8% lower % leg lean mass compared to match 1 and match 2, respectively.
CONCLUSION Long-term IBT may impact bone health and body composition parameters in persons with complete SCI. It may be prudent to encourage regular screening of individuals on long-term IBT considering the prevalence of osteoporosis related fractures, cardiovascular diseases, and metabolic disorders in this population.
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Affiliation(s)
- Dora E Ifon
- Spinal Cord Injury and Disorders Center, Central Virginia VA Health Care System, Richmond, VA 23249, United States
| | - Mina P Ghatas
- Spinal Cord Injury and Disorders Center, Central Virginia VA Health Care System, Richmond, VA 23249, United States
| | - John C Davis
- Spinal Cord Injury and Disorders Center, Central Virginia VA Health Care System, Richmond, VA 23249, United States
| | - Refka E Khalil
- Spinal Cord Injury and Disorders Center, Central Virginia VA Health Care System, Richmond, VA 23249, United States
| | - Robert A Adler
- Medical Service, Central Virginia VA Health Care System, Richmond, VA 23249, United States
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Metabolism, Virginia Commonwealth University, Richmond, VA 23298, United States
| | - Ashraf S Gorgey
- Spinal Cord Injury and Disorders Center, Central Virginia VA Health Care System, Richmond, VA 23249, United States
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA 23298, United States
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18
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Gorgey AS, Graham ZA, Adler RA, Lesnefsky EJ, Cardozo CP. Effects Of Testosterone And Resistance Training On Protein Expression And Mitochondrial Functions Following Spinal Cord Injury. Med Sci Sports Exerc 2020. [DOI: 10.1249/01.mss.0000670872.13112.6f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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19
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Holman ME, Sima AP, Chang G, Adler RA, Gorgey AS. Trabecular Bone Quality In Spinal Cord Injury Following Open Chain Resistance Training And Testosterone Replacement. Med Sci Sports Exerc 2020. [DOI: 10.1249/01.mss.0000670876.66213.4a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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20
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Gorgey AS, Graham ZA, Chen Q, Rivers J, Adler RA, Lesnefsky EJ, Cardozo CP. Sixteen weeks of testosterone with or without evoked resistance training on protein expression, fiber hypertrophy and mitochondrial health after spinal cord injury. J Appl Physiol (1985) 2020; 128:1487-1496. [PMID: 32352341 DOI: 10.1152/japplphysiol.00865.2019] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
We investigated the effects of testosterone replacement therapy (TRT) with and without evoked resistance training (RT) on protein expression of key metabolic and hypertrophy regulators, muscle fiber cross-sectional area (CSA), and markers of mitochondrial health after spinal cord injury (SCI). Twenty-two men with chronic motor complete SCI were randomly assigned to either TRT + RT (n = 11) or TRT (n = 11) for 16 wk. TRT + RT men underwent twice weekly progressive RT using electrical stimulation with ankle weights. TRT was administered via testosterone patches (2-6 mg/day). Muscle biopsies were obtained before and after 16 wk from the right vastus lateralis. Expression of proteins associated with oxidative muscles and mechanical loading (PGC-1α and FAK), muscle hypertrophy (total and phosphorylated Akt, total and phosphorylated mTOR), and cellular metabolism (total and phosphorylated AMPK and GLUT4) were evaluated. Immunohistochemistry analysis was performed to measure fiber CSA and succinate dehydrogenase (SDH) activity as well as mitochondrial citrate synthase (CS) activity and complex III (CIII) activities. TRT + RT demonstrated a robust 27.5% increase in average fiber CSA compared with a -9% decrease following TRT only (P = 0.01). GLUT4 protein expression was elevated in the TRT + RT group compared with TRT only (P = 0.005). Total Akt (P = 0.06) and phosphorylated Akt Ser389 (P = 0.049) were also elevated in the TRT + RT group. Mitochondrial activity of SDH (P = 0.03) and CS (P = 0.006) increased in the TRT + RT group, with no changes in the TRT-only group. Sixteen weeks of TRT with RT resulted in fiber hypertrophy and beneficial changes in markers of skeletal muscle health and function.NEW & NOTEWORTHY Fiber cross-sectional area (CSA), protein expression, mitochondrial citrate synthase (CS), and succinate dehydrogenase (SDH) were measured following 16 wk of low-dose testosterone replacement therapy (TRT) with and without electrically evoked resistance training (RT) in men with spinal cord injury (SCI). Fiber CSA and protein expression of total GLUT4, total Akt, and phosphorylated Akt increased following TRT + RT but not in the TRT-only group. Mitochondrial CS and SDH increased after TRT + RT but not in TRT-only group.
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Affiliation(s)
- Ashraf S Gorgey
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia.,Virginia Commonwealth University, Department of Physical Medicine and Rehabilitation, Richmond, Virginia
| | - Zachary A Graham
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,Department of Cell, Developmental, and Integrative Biology, University of Alabama-Birmingham, Birmingham, Alabama
| | - Qun Chen
- Medical Service, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia.,Division of Cardiology, Department of Internal Medicine, Pauley Heart Center Virginia Commonwealth University, Richmond, Virginia
| | - Jeannie Rivers
- Surgery Service, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia
| | - Robert A Adler
- Endocrinology Service, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia.,Endocrine Division, Virginia Commonwealth University School of Medicine¸ Richmond, Virginia
| | - Edward J Lesnefsky
- Medical Service, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia.,Division of Cardiology, Department of Internal Medicine, Pauley Heart Center Virginia Commonwealth University, Richmond, Virginia
| | - Christopher P Cardozo
- Center for the Medical Consequences of Spinal Cord Injury, James J. Peters Veterans Affairs Medical Center, Bronx, New York.,Icahn School of Medicine at Mt. Sinai, New York, New York
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21
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Ogunwale AN, Colon-Emeric CS, Sloane R, Adler RA, Lyles KW, Lee RH. Acetylcholinesterase Inhibitors Are Associated with Reduced Fracture Risk among Older Veterans with Dementia. J Bone Miner Res 2020; 35:440-445. [PMID: 31711264 PMCID: PMC7215241 DOI: 10.1002/jbmr.3916] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/16/2019] [Accepted: 11/02/2019] [Indexed: 12/29/2022]
Abstract
Acetylcholinesterase inhibitors (AChEIs) have been noted to increase bone density and quality in mice. Human studies are limited but suggest an association with improved bone healing after hip fracture. We examined the relationship between AChEI use and fracture risk in a national cohort of 360,015 male veterans aged 65 to 99 years with dementia but without prior fracture using Veterans Affairs (VA) hospital, Medicare, and pharmacy records from 2000 to 2010. Diagnosis of dementia, any clinical fracture (excluding facial and digital), comorbidities, and medications were identified using ICD-9 and drug class codes. Cox proportional hazard models considering AChEI use as a time-varying covariate and adjusting for fall and fracture risk factors compared the time-to-fracture in AChEI users versus non-AChEI users. Potential confounders included demographics (age, race, body mass index), comorbidities associated with fracture or falls (diabetes, lung disease, stroke, Parkinson's, seizures, etc.) and medications associated with fracture or falls (bisphosphonates, glucocorticoids, androgen deprivation therapy [ADT], proton pump inhibitors [PPIs], selective serotonin receptor inhibitors [SSRIs], etc.). Competing mortality risk was considered using the methods of Fine and Gray. To account for persistent effects on bone density or quality that might confer protection after stopping the medication, we completed a secondary analysis using the medication possession ratio (MPR) as a continuous variable in logistic regression models and also compared MPR increments of 10% to minimal/no use (MPR 0 to <0.10). Among older veterans with diagnosis of dementia, 20.1% suffered a fracture over an average of 4.6 years of follow-up. Overall, 42.3% of the cohort were prescribed AChEIs during the study period. The hazard of any fracture among AChEI users compared with those on other/no dementia medications was significantly lower in fully adjusted models (hazard ratio [HR] = 0.81; 95% confidence interval [CI] 0.75-0.88). After considering competing mortality risk, fracture risk remained 18% lower in veterans using AChEIs (HR = 0.82; 95% CI 0.76-0.89). © 2019 American Society for Bone and Mineral Research. Published 2019. This article is a U.S. Government work and is in the public domain in the USA.
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Affiliation(s)
- Abayomi N Ogunwale
- Department of Medicine, Duke University, Durham, NC, USA.,Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Cathleen S Colon-Emeric
- Department of Medicine, Duke University, Durham, NC, USA.,Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Richard Sloane
- Department of Medicine, Duke University, Durham, NC, USA.,Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Robert A Adler
- Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA.,Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Kenneth W Lyles
- Department of Medicine, Duke University, Durham, NC, USA.,Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Richard H Lee
- Department of Medicine, Duke University, Durham, NC, USA.,Durham Veterans Affairs Medical Center, Durham, NC, USA
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22
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Giustina A, Adler RA, Binkley N, Bollerslev J, Bouillon R, Dawson-Hughes B, Ebeling PR, Feldman D, Formenti AM, Lazaretti-Castro M, Marcocci C, Rizzoli R, Sempos CT, Bilezikian JP. Consensus statement from 2 nd International Conference on Controversies in Vitamin D. Rev Endocr Metab Disord 2020; 21:89-116. [PMID: 32180081 PMCID: PMC7113202 DOI: 10.1007/s11154-019-09532-w] [Citation(s) in RCA: 146] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The 2nd International Conference on Controversies in Vitamin D was held in Monteriggioni (Siena), Italy, September 11-14, 2018. The aim of this meeting was to address ongoing controversies and timely topics in vitamin D research, to review available data related to these topics and controversies, to promote discussion to help resolve lingering issues and ultimately to suggest a research agenda to clarify areas of uncertainty. Several issues from the first conference, held in 2017, were revisited, such as assays used to determine serum 25-hydroxyvitamin D [25(OH)D] concentration, which remains a critical and controversial issue for defining vitamin D status. Definitions of vitamin D nutritional status (i.e. sufficiency, insufficiency and deficiency) were also revisited. New areas were reviewed, including vitamin D threshold values and how they should be defined in the context of specific diseases, sources of vitamin D and risk factors associated with vitamin D deficiency. Non-skeletal aspects related to vitamin D were also discussed, including the reproductive system, neurology, chronic kidney disease and falls. The therapeutic role of vitamin D and findings from recent clinical trials were also addressed. The topics were considered by 3 focus groups and divided into three main areas: 1) "Laboratory": assays and threshold values to define vitamin D status; 2) "Clinical": sources of vitamin D and risk factors and role of vitamin D in non-skeletal disease and 3) "Therapeutics": controversial issues on observational studies and recent randomized controlled trials. In this report, we present a summary of our findings.
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Affiliation(s)
- A Giustina
- Chair of Endocrinology, School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Division of Endocrinology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - R A Adler
- McGuire Veterans Affairs Medical Center and Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - N Binkley
- Osteoporosis Clinical Research Program and Institute on Aging, University of Wisconsin-Madison, Madison, WI, USA
| | - J Bollerslev
- Section of Specialized Endocrinology, Department of Endocrinology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - R Bouillon
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases, Metabolism and Ageing, Leuven, KU, Belgium
| | - B Dawson-Hughes
- Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA
| | - P R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - D Feldman
- Department of Medicine, Endocrinology Division, Stanford University School of Medicine, Stanford, CA, USA
| | - A M Formenti
- Chair of Endocrinology, School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Division of Endocrinology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - M Lazaretti-Castro
- Division of Endocrinology, Escola Paulista de Medicina - Universidade Federal de Sao Paulo (EPM-UNIFESP), Sao Paulo, Brazil
| | - C Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - R Rizzoli
- Divison of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - C T Sempos
- Vitamin D Standardization Program LLC, Havre de Grace, MD, USA
| | - J P Bilezikian
- Department of Medicine, Endocrinology Division, College of Physicians and Surgeons, Columbia University, New York, NY, USA.
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23
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Conley RB, Adib G, Adler RA, Åkesson KE, Alexander IM, Amenta KC, Blank RD, Brox WT, Carmody EE, Chapman-Novakofski K, Clarke BL, Cody KM, Cooper C, Crandall CJ, Dirschl DR, Eagen TJ, Elderkin AL, Fujita M, Greenspan SL, Halbout P, Hochberg MC, Javaid M, Jeray KJ, Kearns AE, King T, Koinis TF, Koontz JS, Kužma M, Lindsey C, Lorentzon M, Lyritis GP, Michaud LB, Miciano A, Morin SN, Mujahid N, Napoli N, Olenginski TP, Puzas JE, Rizou S, Rosen CJ, Saag K, Thompson E, Tosi LL, Tracer H, Khosla S, Kiel DP. Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition. J Bone Miner Res 2020; 35:36-52. [PMID: 31538675 DOI: 10.1002/jbmr.3877] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/08/2019] [Accepted: 09/11/2019] [Indexed: 12/13/2022]
Abstract
Osteoporosis-related fractures are undertreated, due in part to misinformation about recommended approaches to patient care and discrepancies among treatment guidelines. To help bridge this gap and improve patient outcomes, the American Society for Bone and Mineral Research assembled a multistakeholder coalition to develop clinical recommendations for the optimal prevention of secondary fracture among people aged 65 years and older with a hip or vertebral fracture. The coalition developed 13 recommendations (7 primary and 6 secondary) strongly supported by the empirical literature. The coalition recommends increased communication with patients regarding fracture risk, mortality and morbidity outcomes, and fracture risk reduction. Risk assessment (including fall history) should occur at regular intervals with referral to physical and/or occupational therapy as appropriate. Oral, intravenous, and subcutaneous pharmacotherapies are efficacious and can reduce risk of future fracture. Patients need education, however, about the benefits and risks of both treatment and not receiving treatment. Oral bisphosphonates alendronate and risedronate are first-line options and are generally well tolerated; otherwise, intravenous zoledronic acid and subcutaneous denosumab can be considered. Anabolic agents are expensive but may be beneficial for selected patients at high risk. Optimal duration of pharmacotherapy is unknown but because the risk for second fractures is highest in the early post-fracture period, prompt treatment is recommended. Adequate dietary or supplemental vitamin D and calcium intake should be assured. Individuals being treated for osteoporosis should be reevaluated for fracture risk routinely, including via patient education about osteoporosis and fractures and monitoring for adverse treatment effects. Patients should be strongly encouraged to avoid tobacco, consume alcohol in moderation at most, and engage in regular exercise and fall prevention strategies. Finally, referral to endocrinologists or other osteoporosis specialists may be warranted for individuals who experience repeated fracture or bone loss and those with complicating comorbidities (eg, hyperparathyroidism, chronic kidney disease). © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
| | | | | | | | - Ivy M Alexander
- UConn School of Nursing, University of Connecticut, Storrs, CT, USA
| | - Kelly C Amenta
- Department of Physician Assistant Studies, Mercyhurst University, Erie, PA, USA
| | - Robert D Blank
- Department of Endocrinology, Metabolism and Clinical Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA.,Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
| | | | - Emily E Carmody
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Bart L Clarke
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Douglas R Dirschl
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago Medicine, Chicago, IL, USA
| | | | - Ann L Elderkin
- American Society for Bone and Mineral Research, Washington, DC, USA
| | - Masaki Fujita
- Science Department, International Osteoporosis Foundation, Nyon, Switzerland
| | - Susan L Greenspan
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Marc C Hochberg
- Division of Rheumatology, University of Maryland School of Medicine and VA Maryland Health Care System, Baltimore, MD, USA
| | - Muhammad Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, USA
| | - Kyle J Jeray
- Prisma Health - Upstate (formerly Greenville Health System), Greenville, SC, USA
| | - Ann E Kearns
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Toby King
- US Bone and Joint Initiative, Rosemont, IL, USA
| | | | - Jennifer Scott Koontz
- Orthopedics & Sports Medicine, Newton Medical Center, Newton, KS, USA.,Department of Family and Community Medicine, University of Kansas School of Medicine, Wichita, KS, USA
| | - Martin Kužma
- 5th Department of Internal Medicine, University Hospital, Comenius University, Bratislava, Slovakia
| | - Carleen Lindsey
- Bones, Backs and Balance, LLC, Bristol Physical Therapy, LLC, Bristol, CT, USA
| | - Mattias Lorentzon
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia.,Department of Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden.,Geriatric Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | | | | | | | - Nadia Mujahid
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Nicola Napoli
- Department of Nutrition and Metabolic Disorders, Campus Bio-Medico University of Rome, Rome, Italy.,Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | | | - J Edward Puzas
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Clifford J Rosen
- Tufts University School of Medicine, Boston, MA, USA.,Maine Medical Center Research Institute, Portland, ME, USA
| | - Kenneth Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Laura L Tosi
- Department of Orthopaedic Surgery and Sports Medicine, Children's National Hospital, Washington, DC, USA
| | - Howard Tracer
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, MD, USA
| | - Sundeep Khosla
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Douglas P Kiel
- Harvard Medical School, Musculoskeletal Research Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
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24
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Lee RH, Sloane R, Pieper C, Lyles KW, Adler RA, Van Houtven C, LaFleur J, Colón-Emeric C. Glycemic Control and Insulin Treatment Alter Fracture Risk in Older Men With Type 2 Diabetes Mellitus. J Bone Miner Res 2019; 34:2045-2051. [PMID: 31269274 PMCID: PMC6854289 DOI: 10.1002/jbmr.3826] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 06/04/2019] [Accepted: 06/11/2019] [Indexed: 12/23/2022]
Abstract
Diabetes mellitus among older men has been associated with increased bone mineral density but paradoxically increased fracture risk. Given the interactions among medication treatment, glycemic control, and diabetes-associated comorbidities, the relative effects of each factor remains unclear. This retrospective study includes 652,901 male veterans aged ≥65 years with diabetes and baseline hemoglobin A1c (HbA1c) value. All subjects received primary care in the Veterans Health Administration (VHA) from 2000 to 2010. Administrative data included ICD9 diagnoses and pharmacy records and was linked to Medicare fee-for-service data. Hazard ratios (HR) for any clinical fracture and hip fracture were calculated using competing risk hazards models, adjusted for fracture risk factors including age, race/ethnicity, body mass index (BMI), alcohol and tobacco use, rheumatoid arthritis, corticosteroid use, as well as diabetes-related comorbidities including cardiovascular disease, chronic kidney disease, and peripheral neuropathy. HbA1c <6.5% was associated with a higher risk of any clinical fracture (HR = 1.08, 95% confidence interval [CI] 1.06-1.11) compared with the reference HbA1c of 7.5% to 8.5%. Fracture risk was not increased among those with A1c ≥8.5%, nor among those with A1c 6.5% to 7.5%. Use of insulin was independently associated with greater risk of fracture (HR = 1.10, 95% CI 1.07-1.12). There was a significant interaction between insulin use and HbA1c level, (p < 0.001), such that those using insulin with HbA1c <6.5% had HR = 1.23 and those with HbA1c 6.5% to 7.5% had HR = 1.15. Metformin use was associated with decreased fracture risk (HR = 0.88, 95% CI 0.87-0.90). We conclude that among older men with diabetes, those with HbA1c lower than 6.5% are at increased risk for any clinical and hip fracture. Insulin use is associated with higher fracture risk, especially among those with tight glycemic control. Our findings demonstrate the importance of the treatment regimen and avoiding hypoglycemia for fracture prevention in older men with diabetes. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Richard H Lee
- Duke University, Durham, NC, USA.,Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Richard Sloane
- Duke University, Durham, NC, USA.,Durham Veterans Affairs Medical Center, Durham, NC, USA
| | | | - Kenneth W Lyles
- Duke University, Durham, NC, USA.,Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Robert A Adler
- Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA.,Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Courtney Van Houtven
- Duke University, Durham, NC, USA.,Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Joanne LaFleur
- University of Utah, Salt Lake City, UT, USA.,Salt Lake City Veterans Affairs Medical Center, Salt Lake City, UT, USA
| | - Cathleen Colón-Emeric
- Duke University, Durham, NC, USA.,Durham Veterans Affairs Medical Center, Durham, NC, USA
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25
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Gorgey AS, Khalil RE, Gill R, Gater DR, Lavis TD, Cardozo CP, Adler RA. Low-Dose Testosterone and Evoked Resistance Exercise after Spinal Cord Injury on Cardio-Metabolic Risk Factors: An Open-Label Randomized Clinical Trial. J Neurotrauma 2019; 36:2631-2645. [PMID: 30794084 DOI: 10.1089/neu.2018.6136] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The purpose of the work is to investigate the effects of low-dose testosterone replacement therapy (TRT) and evoked resistance training (RT) on body composition and metabolic variables after spinal cord injury (SCI). Twenty-two individuals with chronic motor complete SCI (ages 18-50 years) were randomly assigned to either TRT+RT (n = 11) or TRT (n = 11) for 16 weeks following a 4 -week delayed entry period. TRT+RT men underwent twice weekly progressive RT using electrical stimulation with ankle weights. TRT was administered via testosterone patches (2-6 mg/day). Body composition was tested using anthropometrics, dual energy x-ray absorptiometry, and magnetic resonance imaging. After an overnight fast, basal metabolic rate (BMR), lipid panel, serum testosterone, adiponectin, inflammatory and anabolic biomarkers (insulin-like growth factor-1 and insulin-like growth factor-binding protein 3 [IGFBP-3]), glucose effectiveness (Sg), and insulin sensitivity (Si) were measured. Total body lean mass (LM; 2.7 kg, p < 0.0001), whole muscle (p < 0.0001), and whole muscle knee extensor cross-sectional areas (CSAs; p < 0.0001) increased in the TRT+RT group, with no changes in the TRT group. Visceral adiposity decreased (p = 0.049) in the TRT group, with a trend in the TRT+RT (p = 0.07) group. There was a trend (p = 0.050) of a 14-17% increase in BMR following TRT+RT. Sg showed a trend (p = 0.07) to improvement by 28.5-31.5% following both interventions. IGFBP-3 increased (p = 0.0001) while IL-6 decreased (p = 0.039) following both interventions, and TRT+RT suppressed adiponectin (p = 0.024). TRT+RT resulted in an increase in LM and whole thigh and knee extensor muscle CSAs, with an increase in BMR and suppressed adiponectin. Low-dose TRT may mediate modest effects on visceral adipose tissue, Sg, IGFBP-3, and IL-6, independent of changes in LM.
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Affiliation(s)
- Ashraf S Gorgey
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia
| | - Refka E Khalil
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia
| | - Ranjodh Gill
- Endocrinology Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia
- Endocrine Division, Virginia Commonwealth University, Richmond, Virginia
| | - David R Gater
- Department of Physical Medicine and Rehabilitation, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Timothy D Lavis
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia
| | - Christopher P Cardozo
- National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, New York
- Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Robert A Adler
- Endocrinology Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia
- Endocrine Division, Virginia Commonwealth University, Richmond, Virginia
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Gorgey AS, Khalil RE, Davis JC, Carter W, Gill R, Rivers J, Khan R, Goetz LL, Castillo T, Lavis T, Sima AP, Lesnefsky EJ, Cardozo CC, Adler RA. Skeletal muscle hypertrophy and attenuation of cardio-metabolic risk factors (SHARC) using functional electrical stimulation-lower extremity cycling in persons with spinal cord injury: study protocol for a randomized clinical trial. Trials 2019; 20:526. [PMID: 31443727 PMCID: PMC6708188 DOI: 10.1186/s13063-019-3560-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 07/06/2019] [Indexed: 12/16/2022] Open
Abstract
Background Persons with spinal cord injury (SCI) are at heightened risks of developing unfavorable cardiometabolic consequences due to physical inactivity. Functional electrical stimulation (FES) and surface neuromuscular electrical stimulation (NMES)-resistance training (RT) have emerged as effective rehabilitation methods that can exercise muscles below the level of injury and attenuate cardio-metabolic risk factors. Our aims are to determine the impact of 12 weeks of NMES + 12 weeks of FES-lower extremity cycling (LEC) compared to 12 weeks of passive movement + 12 weeks of FES-LEC on: (1) oxygen uptake (VO2), insulin sensitivity, and glucose disposal in adults with SCI; (2) skeletal muscle size, intramuscular fat (IMF), and visceral adipose tissue (VAT); and (3) protein expression of energy metabolism, protein molecules involved in insulin signaling, muscle hypertrophy, and oxygen uptake and electron transport chain (ETC) activities. Methods/Design Forty-eight persons aged 18–65 years with chronic (> 1 year) SCI/D (AIS A-C) at the C5-L2 levels, equally sub-grouped by cervical or sub-cervical injury levels and time since injury, will be randomized into either the NMES + FES group or Passive + FES (control group). The NMES + FES group will undergo 12 weeks of evoked RT using twice-weekly NMES and ankle weights followed by twice-weekly progressive FES-LEC for an additional 12 weeks. The control group will undergo 12 weeks of passive movement followed by 12 weeks of progressive FES-LEC. Measurements will be performed at baseline (B; week 0), post-intervention 1 (P1; week 13), and post-intervention 2 (P2; week 25), and will include: VO2 measurements, insulin sensitivity, and glucose effectiveness using intravenous glucose tolerance test; magnetic resonance imaging to measure muscle, IMF, and VAT areas; muscle biopsy to measure protein expression and intracellular signaling; and mitochondrial ETC function. Discussion Training through NMES + RT may evoke muscle hypertrophy and positively impact oxygen uptake, insulin sensitivity, and glucose effectiveness. This may result in beneficial outcomes on metabolic activity, body composition profile, mitochondrial ETC, and intracellular signaling related to insulin action and muscle hypertrophy. In the future, NMES-RT may be added to FES-LEC to improve the workloads achieved in the rehabilitation of persons with SCI and further decrease muscle wasting and cardio-metabolic risks. Trial registration ClinicalTrials.gov, NCT02660073. Registered on 21 Jan 2016.
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Affiliation(s)
- Ashraf S Gorgey
- Spinal Cord Injury & Disorders Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA. .,Department of Physical Medicine & Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA.
| | - Refka E Khalil
- Spinal Cord Injury & Disorders Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - John C Davis
- Spinal Cord Injury & Disorders Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - William Carter
- Department of Physical Medicine & Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA
| | - Ranjodh Gill
- Endocrinology Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA.,Endocrine Division, School of Medicine Virginia Commonwealth University, Richmond, VA, USA
| | - Jeannie Rivers
- Endocrine Division, School of Medicine Virginia Commonwealth University, Richmond, VA, USA
| | - Rehan Khan
- Radiology Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Lance L Goetz
- Spinal Cord Injury & Disorders Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA.,Department of Physical Medicine & Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA
| | - Teodoro Castillo
- Spinal Cord Injury & Disorders Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA.,Department of Physical Medicine & Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA
| | - Timothy Lavis
- Spinal Cord Injury & Disorders Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA.,Department of Physical Medicine & Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA
| | - Adam P Sima
- Department of Biostatistics, School of Medicine Virginia Commonwealth University, Richmond, VA, USA
| | - Edward J Lesnefsky
- Cardiology Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA.,Division of Cardiology, Department of Internal Medicine, Pauley Heart Center Virginia Commonwealth University, Richmond, VA, USA
| | - Christopher C Cardozo
- Center for the Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, NY, USA.,Departments of Medicine and Rehabilitation Medicine, Icahn School of Medicine, New York, NY, USA
| | - Robert A Adler
- Endocrinology Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA.,Endocrine Division, School of Medicine Virginia Commonwealth University, Richmond, VA, USA
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Solimeo SL, McCoy K, Reisinger HS, Adler RA, Vaughan Sarrazin M. Factors Associated With Osteoporosis Care of Men Hospitalized for Hip Fracture: A Retrospective Cohort Study. JBMR Plus 2019; 3:e10198. [PMID: 31667454 PMCID: PMC6808329 DOI: 10.1002/jbm4.10198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/02/2019] [Accepted: 04/14/2019] [Indexed: 01/04/2023] Open
Abstract
Rates of postfracture DXA and pharmacotherapy appear to be declining despite their known benefits in fracture reduction. We sought to identify factors associated with osteoporosis care among male veterans aged 50 years and older after hip fracture and to evaluate trends in rates of care with an observational cohort design using US Department of Veterans Affairs’ (VA) inpatient, pharmacy, and outpatient encounters and Centers for Medicare and Medicaid Services outpatient pharmacy claims (2007 to 2014) from men aged 50 years and older treated for hip fracture (N = 7317). We used the Cox proportional hazards model with random effects for the admitting facility. A sensitivity analysis was performed for a subset of patients aged 65 to 99 dually enrolled in Medicare (
N = 5821). Overall, approximately 13% of patients had evidence of osteoporosis care within one year of fracture. In the adjusted model, rural residence was associated with lower likelihood of care, and several comorbidities were associated with higher likelihood of receiving care. In sensitivity analyses of patients dually enrolled in Medicare, rural residence remained associated with lower likelihood of osteoporosis care. Overall rates of care decreased over time, but rates of DXA in the VA remained stable. These findings highlight the ongoing problem of low rates of postfracture care among a population with the highest risk of future fracture and its associated morbidity and mortality. The rural disparity in care and differences in rates of care across healthcare delivery systems illustrates the importance of healthcare delivery systems in promoting pharmacotherapy and DXA after sentinel events. Because the VA removes a majority of cost barriers to care, this integrated healthcare system may outperform the private sector in access to care. However, declining rates of pharmacotherapy imply knowledge gaps that undermine quality care. © 2019 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Samantha L Solimeo
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System Iowa City IA USA.,Primary Care Data Analytics Team-Iowa City, Iowa City VA Health Care System Iowa City IA USA.,Department of Internal Medicine Carver College of Medicine, University of Iowa Iowa City IA USA
| | - Kimberly McCoy
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System Iowa City IA USA.,Primary Care Data Analytics Team-Iowa City, Iowa City VA Health Care System Iowa City IA USA
| | - Heather Schacht Reisinger
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System Iowa City IA USA.,Department of Internal Medicine Carver College of Medicine, University of Iowa Iowa City IA USA
| | - Robert A Adler
- Hunter Holmes McGuire VA Medical Center Richmond VA USA.,Department of Internal Medicine Division of Endocrinology, Diabetes & Metabolism, Virginia Commonwealth University Richmond VA USA
| | - Mary Vaughan Sarrazin
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System Iowa City IA USA.,Primary Care Data Analytics Team-Iowa City, Iowa City VA Health Care System Iowa City IA USA.,Department of Internal Medicine Carver College of Medicine, University of Iowa Iowa City IA USA
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Gorgey AS, Khalil RE, Gill R, Cardozo CP, Adler RA. Effects of Testosterone and Resistance Training on Anabolic and Inflammatory Biomarkers Following Spinal Cord Injury. Med Sci Sports Exerc 2019. [DOI: 10.1249/01.mss.0000562958.80247.65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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29
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Giustina A, Adler RA, Binkley N, Bouillon R, Ebeling PR, Lazaretti-Castro M, Marcocci C, Rizzoli R, Sempos CT, Bilezikian JP. Controversies in Vitamin D: Summary Statement From an International Conference. J Clin Endocrinol Metab 2019; 104:234-240. [PMID: 30383226 DOI: 10.1210/jc.2018-01414] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/26/2018] [Indexed: 12/14/2022]
Abstract
CONTEXT Vitamin D is classically recognized as a regulator of calcium and phosphorus metabolism. Recent advances in the measurement of vitamin D metabolites, diagnosis of vitamin D deficiency, and clinical observations have led to an appreciation that along with its role in skeletal metabolism, vitamin D may well have an important role in nonclassical settings. Measurement of the circulating form of vitamin D that best describes total body stores, namely 25-hydroxyvitamin D, can be unreliable despite many sophisticated methodologies that have been proposed and implemented. Likewise, evidence from clinical studies showing a beneficial role of vitamin D in different disease states has been controversial and at times speculative. Moreover, the target concentrations of 25-hydroxyvitamin D to address a number of putative links between vitamin D inadequacy and nonskeletal diseases are further areas of uncertainty. SETTING To address these issues, an international conference on "Controversies in Vitamin D" was held in Pisa, Italy, in June 2017. Three main topics were addressed: (i) vitamin D assays and the definition of hypovitaminosis D; (ii) skeletal and extraskeletal effects of vitamin D; (iii) therapeutics of vitamin D. RESULTS This report provides a summary of the deliberations of the expert panels of the conference. CONCLUSIONS Despite great advances in our appreciation of vitamin D metabolism, measurements, biological actions on classical and nonclassical tissues, and therapeutics, all of which this report summarizes, much more work remains to be done so that our knowledge base can become even more secure.
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Affiliation(s)
- Andrea Giustina
- Endocrinology and Metabolism, Vita-Salute San Raffaele University, Milano, Italy
| | - Robert A Adler
- McGuire Veterans Affairs Medical Center and Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Neil Binkley
- Osteoporosis Clinical Research Program and Institute on Aging, University of Wisconsin-Madison, Madison, Wisconsin
| | - Roger Bouillon
- Department of Chronic Diseases, Metabolism and Ageing, Laboratory of Clinical and Experimental Endocrinology, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Marise Lazaretti-Castro
- Division of Endocrinology, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Rene Rizzoli
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Christopher T Sempos
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin
| | - John P Bilezikian
- Endocrinology Division, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
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Abstract
Glucocorticoid-induced osteoporosis remains the most common type of secondary osteoporosis, mostly due to use of oral glucocorticoids rather than due to endogenous overproduction of cortisol. Partly because glucocorticoids are prescribed by a wide variety of clinicians for many different inflammatory disorders, only a minority of older individuals have adequate and timely assessment of their enhanced fracture risk, and fewer are offered treatment. Assessment should include bone density, the FRAX calculation, and, in many cases, images of the spine. Glucocorticoids decrease osteoblast function and increase apoptosis of osteoblasts and osteocytes, leading to increased fracture risk soon after starting glucocorticoids. Guidelines provide evidence-based recommendations for evaluation and treatment, but there are differences in extant guidelines, and methods to improve adherence to the guidelines have mostly failed. A strong case can be made to use anabolic drugs first in high-risk patients based on pathophysiology and head-to-head clinical trials.
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Affiliation(s)
- Robert A Adler
- Endocrinology and Metabolism (111P), McGuire Veterans Affairs Medical Center, Richmond, VA, USA; Endocrine Division, Virginia Commonwealth University School of Medicine, Richmond, VA, USA.
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31
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Colón-Emeric CS, Pieper CF, Van Houtven CH, Grubber JM, Lyles KW, Lafleur J, Adler RA. Limited Osteoporosis Screening Effectiveness Due to Low Treatment Rates in a National Sample of Older Men. Mayo Clin Proc 2018; 93:1749-1759. [PMID: 30497697 PMCID: PMC6338211 DOI: 10.1016/j.mayocp.2018.06.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/25/2018] [Accepted: 06/04/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine the association between dual-energy x-ray absorptiometry (DXA) testing for osteoporosis and subsequent fractures in US male veterans without a previous fracture. PATIENTS AND METHODS This is a propensity score-matched observational study using Centers for Medicare and Medicaid Services and Veterans Affairs (VA) data from January 1, 2000, through December 31, 2010, with a mean follow-up time of 4.7 years (range, 0-10 years). Men receiving VA primary care aged 65 to 99 years without a previous fracture (N=2,539,812) were included. Men undergoing DXA testing were propensity score matched with untested controls in a 1:3 ratio, indicating the probability of DXA testing within the next year. Time to first clinical fracture was the primary outcome. Comorbidities, demographic characteristics, medications, DXA results, and osteoporosis treatment were defined using administrative data and natural language processing. A landmark analysis contingent on surviving to 12 months after screening was completed, accounting for competing risk of mortality. RESULTS During follow-up of 153,311 men tested by DXA and 390,158 controls, 56,083 (10.3%) had sustained a fracture and 111,774 (20.6%) died. Overall, DXA testing was not associated with a decrease in fractures; conclusions are limited by unmeasured confounders and low medication initiation and adherence in those meeting treatment thresholds (12% of follow-up time). In contrast, DXA testing in prespecified subgroups was associated with a lower risk of fracture in comparison to the overall population who underwent DXA testing: androgen deprivation therapy (hazard ratio [HR], 0.77; 95% CI, 0.66-0.89), glucocorticoids (HR, 0.77; 95% CI, 0.72-0.84), age 80 years and older (HR, 0.85; 0.81-0.90), 1 or more VA guideline risk factors (HR, 0.91; 95% CI, 0.87-0.95), and high Fracture Risk Assessment Tool using body mass index score (HR, 0.90; 95% CI, 0.86-0.95). CONCLUSION Current VA DXA testing practices are ineffective overall; interventions to improve treatment adherence are needed. Targeted DXA testing in higher-risk men was associated with a lower fracture risk.
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Affiliation(s)
- Cathleen S Colón-Emeric
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC; Durham VA Geriatric Research, Education and Clinical Center, Durham, NC.
| | - Carl F Pieper
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC
| | - Courtney H Van Houtven
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC; Durham VA Health Services Research and Development Center of Innovation, Durham, NC
| | - Janet M Grubber
- Durham VA Health Services Research and Development Center of Innovation, Durham, NC
| | - Kenneth W Lyles
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC; Durham VA Geriatric Research, Education and Clinical Center, Durham, NC
| | | | - Robert A Adler
- Hunter Holmes McGuire VA Medical Center, Richmond, VA; Department of Medicine, Virginia Commonwealth University, Richmond, VA
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32
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Nightingale TE, Moore P, Harman J, Khalil R, Gill RS, Castillo T, Adler RA, Gorgey AS. Body composition changes with testosterone replacement therapy following spinal cord injury and aging: A mini review. J Spinal Cord Med 2018; 41:624-636. [PMID: 28770686 PMCID: PMC6217462 DOI: 10.1080/10790268.2017.1357917] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Context Hypogonadism is a male clinical condition in which the body does not produce enough testosterone. Testosterone plays a key role in maintaining body composition, bone mineral density, sexual function, mood, erythropoiesis, cognition and quality of life. Hypogonadism can occur due to several underlying pathologies during aging and in men with physical disabilities, such as spinal cord injury (SCI). This condition is often under diagnosed and as a result, symptoms undertreated. Methods In this mini-review, we propose that testosterone replacement therapy (TRT) may be a viable strategy to improve lean body mass (LBM) and fat mass (FM) in men with SCI. Evidence Synthesis Supplementing the limited data from SCI cohorts with consistent findings from studies in non-disabled aging men, we present evidence that, relative to placebo, transdermal TRT can increase LBM and reduce FM over 3-36 months. The impact of TRT on bone mineral density and metabolism is also discussed, with particular relevance for persons with SCI. Moreover, the risks of TRT remain controversial and pertinent safety considerations related to transdermal administration are outlined. Conclusion Further research is necessary to help develop clinical guidelines for the specific dose and duration of TRT in persons with SCI. Therefore, we call for more high-quality randomized controlled trials to examine the efficacy and safety of TRT in this population, which experiences an increased risk of cardiometabolic diseases as a result of deleterious body composition changes after injury.
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Affiliation(s)
- Tom E. Nightingale
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA,Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Pamela Moore
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Joshua Harman
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Refka Khalil
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Ranjodh S. Gill
- Endocrinology Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA,Endocrine Division, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Teodoro Castillo
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA,Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Robert A. Adler
- Endocrinology Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA,Endocrine Division, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Ashraf S. Gorgey
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA,Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA,Correspondence to: Ashraf S. Gorgey, Department of Veterans Affairs, Hunter Holmes McGuire Medical Center, Spinal Cord Injury & Disorders Service, 1201 Broad Rock Boulevard, Richmond, VA 23249, USA.
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Lewiecki EM, Wright NC, Curtis JR, Siris E, Gagel RF, Saag KG, Singer AJ, Steven PM, Adler RA. Correction to: Hip fracture trends in the United States, 2002 to 2015. Osteoporos Int 2018; 29:2583. [PMID: 30151621 DOI: 10.1007/s00198-018-4685-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The name of the first author, E.M. Lewiecki, was rendered incorrectly in the original publication. The publisher regrets any inconvenience and is pleased to correct the error here.
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Affiliation(s)
- E M Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, USA.
| | - N C Wright
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, USA
| | - J R Curtis
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, USA
| | - E Siris
- Department of Medicine, Columbia University Medical Center, New York, USA
| | - R F Gagel
- Department of Endocrine Neoplasia, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - K G Saag
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, USA
| | - A J Singer
- Department of Obstetrics and Gynecology, MedStar Georgetown University Hospital, Washington, USA
- Department of Medicine, MedStar Georgetown University Hospital, Washington, USA
| | - P M Steven
- International Society for Clinical Densitometry, Hartford, USA
| | - R A Adler
- Endocrinology Section, McGuire Veterans Affairs Medical Center, Richmond, USA
- Virginia Commonwealth University School of Medicine, Richmond, USA
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Abilmona SM, Sumrell RM, Gill RS, Adler RA, Gorgey AS. Serum testosterone levels may influence body composition and cardiometabolic health in men with spinal cord injury. Spinal Cord 2018; 57:229-239. [PMID: 30349112 PMCID: PMC6397667 DOI: 10.1038/s41393-018-0207-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 09/20/2018] [Accepted: 10/01/2018] [Indexed: 12/16/2022]
Abstract
Study Design: Cross-sectional study Objective To establish the association between serum testosterone (T) levels, biomarkers of cardiometabolic health and regional body composition variables after spinal cord injury (SCI). Setting: Medical research center Methods Metabolic and body composition measurements were collected from thirty-six men with chronic motor complete SCI. Serum T, carbohydrate and lipid profiles were measured after an overnight fast. Body composition was measured using anthropometrics, dual energy x-ray absorptiometry and magnetic resonance imaging. Participants were evenly classified into tertiles based on their serum T levels into low, mid-normal and normal ranges. Results Low, mid-normal and normal range serum T were 288.8 ± 84.9ng/dL, 461.0 ± 52.5ng/dL and 648.0 ± 53.5ng/dL, respectively. Low range serum T group had greater total (9.6%, P= 0.04) percentage fat mass and visceral adipose tissue (VAT) area (72%, P= 0.01) compared to normal range serum T group. Serum T was related to the absolute whole thigh muscle area (r= 0.40, P< 0.05) after controlling for body mass index. Serum T was negatively related to fasting plasma glucose (r= −0.46, P= 0.006) and insulin (r= −0.42, P= 0.01), HbA1c (r= −0.39, P= 0.02) and triglycerides (r= −0.36, P= 0.03). Conclusion Men with low serum T have more unfavorable body composition and cardiometabolic health outcomes after SCI. Testosterone replacement therapy may serve as a potential strategy in preventing cardiometabolic disorders after SCI.
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Affiliation(s)
- Sally M Abilmona
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Ryan M Sumrell
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Ranjodh S Gill
- Endocrinology Section, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA.,Endocrine Division, Virginia Commonwealth University, Richmond, VA, USA
| | - Robert A Adler
- Endocrinology Section, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA.,Endocrine Division, Virginia Commonwealth University, Richmond, VA, USA
| | - Ashraf S Gorgey
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA. .,Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA.
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35
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Ebeling PR, Adler RA, Jones G, Liberman UA, Mazziotti G, Minisola S, Munns CF, Napoli N, Pittas AG, Giustina A, Bilezikian JP, Rizzoli R. MANAGEMENT OF ENDOCRINE DISEASE: Therapeutics of Vitamin D. Eur J Endocrinol 2018; 179:R239-R259. [PMID: 30131372 DOI: 10.1530/eje-18-0151] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/13/2018] [Accepted: 08/21/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The central role of vitamin D in bone health is well recognized. However, controversies regarding its clinical application remain. We therefore aimed to review the definition of hypovitaminosis D, the skeletal and extra-skeletal effects of vitamin D and the available therapeutic modalities. DESIGN Narrative and systematic literature review. METHODS An international working group that reviewed the current evidence linking bone and extra-skeletal health and vitamin D therapy to identify knowledge gaps for future research. RESULTS Findings from observational studies and randomized controlled trials (RCTs) in vitamin D deficiency are discordant, with findings of RCTs being largely negative. This may be due to reverse causality with the illness itself contributing to low vitamin D levels. The results of many RCTs have also been inconsistent. However, overall evidence from RCTs shows vitamin D reduces fractures (when administered with calcium) in the institutionalized elderly. Although controversial, vitamin D reduces acute respiratory tract infections (if not given as bolus monthly or annual doses) and may reduce falls in those with the lowest serum 25-hydroxyvitamin D (25OHD) levels. However, despite large ongoing RCTs with 21 000–26 000 participants not recruiting based on baseline 25OHD levels, they will contain a large subset of participants with vitamin D deficiency and are adequately powered to meet their primary end-points. CONCLUSIONS The effects of long-term vitamin D supplementation on non-skeletal outcomes, such as type 2 diabetes mellitus (T2DM), cancer and cardiovascular disease (CVD) and the optimal dose and serum 25OHD level that balances extra-skeletal benefits (T2DM) vs risks (e.g. CVD), may soon be determined by data from large RCTs.
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Affiliation(s)
- P R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - R A Adler
- McGuire Veterans Affairs Medical Center and Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - G Jones
- Department of Biomedical and Molecular Sciences in the School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - U A Liberman
- Department of Physiology and Pharmacology and The Felsenstein Medical Research Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - G Mazziotti
- Endocrine Unit, ASST Carlo Poma, Mantua, Italy
| | | | - C F Munns
- Department of Paediatrics, Westmead Children's Hospital, The University of Sydney, Westmead, New South Wales, Australia
| | - N Napoli
- Unit of Endocrinology and Diabetes, Department of Medicine, Università Campus Bio-Medico di Roma, Rome, Italy
- IRCCS, Istituto Ortopedico Galeazzi, Milan, Italy
| | - A G Pittas
- Division of Endocrinology, Tufts Medical Center, Boston, Massachusetts, USA
| | - A Giustina
- Vita-Salute, San Raffaele University, Milan, Italy
| | - J P Bilezikian
- Division of Endocrinology, College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - R Rizzoli
- Divison of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Balasubramanian A, Wade SW, Adler RA, Saag K, Pannacciulli N, Curtis JR. Glucocorticoid Exposure and Fracture Risk in a Cohort of US Patients With Selected Conditions. J Bone Miner Res 2018; 33:1881-1888. [PMID: 29924418 DOI: 10.1002/jbmr.3523] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 06/05/2018] [Accepted: 06/07/2018] [Indexed: 11/07/2022]
Abstract
The purpose of this work was to evaluate systemic glucocorticoid exposure and fracture among patients with newly-diagnosed inflammatory and immune-modulated conditions. Using administrative data, inception cohorts of rheumatoid arthritis (RA), asthma/chronic obstructive pulmonary disease (COPD), inflammatory bowel disease (IBD), multiple sclerosis (MS), lupus, and sarcoidosis patients age 18 to 64 years with benefits coverage ≥12 months before diagnosis (January 1, 2005 to December 31, 2012) were followed to clinical fracture, cancer diagnosis, or December 31, 2012. Glucocorticoid users were new to therapy. Fracture incidence rates (IRs) per 1000 person-years were stratified by prednisone equivalent doses. Cox's proportional hazards models assessed risk by daily and cumulative dose, and by time since discontinuation, adjusted for baseline characteristics. Most patients (72% of 403,337) had glucocorticoid exposure; 52% were under age 50. IR (95% confidence interval [CI]) of any osteoporotic fracture was elevated at doses <5 mg/day (IR 9.33; 95% CI, 7.29 to 11.77) versus 0 mg/day (IR 4.87 (95% CI, 4.72 to 5.02). Fracture rates were elevated at doses <5 mg/day in patients <50 years and those ≥50 years. In both age groups, fracture risk increased with increasing cumulative exposure, being approximately 2.5-fold higher at cumulative dose ≥5400 mg compared to <675 mg. At ≥5400 mg, IR values were 5.69 (95% CI, 4.32 to 7.35) in patients <50 years and 17.10 (95% CI, 14.97 to 19.46) in older patients. Fracture risk decreased significantly within months following glucocorticoid discontinuation. In patients with a variety of inflammatory conditions, fracture risk increased at doses as low as <5 mg/day. Risk increased with increasing cumulative exposure and decreased soon following glucocorticoid discontinuation. Trends were similar between patients older and younger than 50 years. © 2018 The Authors. Journal of Bone and Mineral Research Published by Wiley Periodicals, Inc.
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Affiliation(s)
| | - Sally W Wade
- Wade Outcomes Research and Consulting, Salt Lake City, UT, USA
| | - Robert A Adler
- McGuire Veterans Affairs Medical Center and Virginia Commonwealth University, Richmond, VA, USA
| | - Kenneth Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
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Abstract
Osteoporosis in men remains under-diagnosed and under-appreciated. After a low trauma fracture, a man is less likely to have evaluation and treatment. The lifetime risk for osteoporotic fracture in older men may range from 13 to 25%, and as men live longer, there will be more fractures. Newer strategies for determining which men should have bone density testing are emerging. Information from observational studies are providing insights that allow targeted testing and treatment of those men at the highest risk for fracture. Treatment with most of the same medications used in women is efficacious and generally safe. Nonetheless, the fear of side effects of treatments for an asymptomatic disorder (before a fracture) and other barriers have made management challenging in men at risk for fracture. This review provides updates on epidemiology, pathophysiology, evaluation and treatment of male osteoporosis.
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Affiliation(s)
- Robert A Adler
- Endocrinology and Metabolism Section, McGuire Veterans Affairs Medical Center, 1201 Broad Rock Boulevard, Richmond, VA 23249, USA; Endocrine Division, Virginia Commonwealth University School of Medicine, Richmond, VA 23298, USA.
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Beal C, Gorgey A, Moore P, Wong N, Adler RA, Gater D. Higher dietary intake of vitamin D may influence total cholesterol and carbohydrate profile independent of body composition in men with Chronic Spinal Cord Injury. J Spinal Cord Med 2018; 41:459-470. [PMID: 28812446 PMCID: PMC6055974 DOI: 10.1080/10790268.2017.1361561] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
STUDY DESIGN A case-control design. OBJECTIVES To determine the effects of dietary vitamin D intake on insulin sensitivity (Si), glucose effectiveness (Sg), and lipid profile in individuals with spinal cord injury (SCI). METHODS 20 male, paraplegic (T3-L1) with chronic (> one year) motor complete SCI (AIS A or B) were recruited. Three-day dietary records were analyzed for dietary vitamin D (calciferol), and participants were assigned to one of two groups, a high vitamin D intake group and a low vitamin D intake group based on the mid-point of vitamin D frequency distribution. Individuals in both groups were matched based on age, weight, time since injury and level of injury. Sg, Si and lipid profiles were measured of the two groups. RESULTS The high vitamin D group had an average intake of 5.33 ± 4.14 mcg compared to low vitamin D group, 0.74 ± 0.24 mcg. None of the 20 participants met the recommended guidelines for daily vitamin D intake. The higher vitamin D group had a significantly lower (P = 0.035) total cholesterol (148.00 ± 14.12 mg/dl) than the lower vitamin D group (171.80 ± 36.22 mg/dl). Vitamin D adjusted to total dietary intake was positively correlated to improvement in Si and Sg (P<0.05). CONCLUSION The findings suggest that persons with SCI consume much less than the recommended guidelines for daily vitamin D intake. However, a higher dietary intake of vitamin D may influence total cholesterol and carbohydrate profile as demonstrated by a significant decrease in total cholesterol and improvement in glucose homeostasis independent of body composition changes after SCI.
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Affiliation(s)
- Christopher Beal
- Spinal Cord Injury Service and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Ashraf Gorgey
- Spinal Cord Injury Service and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Pamela Moore
- Spinal Cord Injury Service and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Nathan Wong
- Spinal Cord Injury Service and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Robert A. Adler
- Endocrinology Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
- Endocrinology Division, Virginia Commonwealth University, Richmond, Virginia, USA
| | - David Gater
- Department of Physical Medicine and Rehabilitation, Milton S. Hershey Medical Center, Penn State University, Hershey, Pennsylvania, USA
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Gorgey AS, Khalil RE, Lavis T, Castillo T, Adler RA. Testosterone and Resistance Exercise Improved Body Composition and Basal Metabolic Rate after Spinal Cord Injury. Med Sci Sports Exerc 2018. [DOI: 10.1249/01.mss.0000535739.91696.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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40
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Gorgey AS, Cirnigliaro CM, Bauman WA, Adler RA. Estimates of the precision of regional and whole body composition by dual-energy x-ray absorptiometry in persons with chronic spinal cord injury. Spinal Cord 2018; 56:987-995. [PMID: 29511310 PMCID: PMC6127003 DOI: 10.1038/s41393-018-0079-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/27/2018] [Accepted: 02/02/2018] [Indexed: 12/22/2022]
Abstract
Study Design Longitudinal design Objectives To determine the reproducibility of total- and regional-body composition assessments from a total-body scan using dual-energy x-ray absorptiometry (DXA) in persons with spinal cord injury (SCI). Methods Twenty-four individuals with SCI completed within-day short-term precision testing by repositioning study participants between scans. An additional and separate cohort of 22 individuals with SCI were scanned twice on a GE-Lunar DXA scanner separated by a 4-week interval to assess the long-term precision assessment. The root mean square coefficient of variation percent (RMS-CV%) values for the regional and total body composition was calculated. Results For the same day, short-term precision assessment, the RMS-CV% for each region did not exceed 5.6%, 2.7%, 3.8%, 6.5%, 5.8% and 2.3% for arms, legs, trunk, android and gynoid regions and total body mass, respectively. In the long-term precision assessment, the RMS-CV% for each region did not exceed 6.0%, 3.0%, 4.4%, 8.2%, 3.4% and 2.0% for arms, legs, trunk, android, gynoid and total body mass. Moreover, the interclass-correlation coefficient in the long-term precision group demonstrated excellent linear agreement between repeat scans for all regions (r> 0.97). Conclusion The precision error of the total body composition variables in our SCI cohort was similar to those reported in the literature for nondisabled individuals, and the precision errors of the regional body composition compartments were notably higher, but similar to the regional precision errors reported in the general population.
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Affiliation(s)
- Ashraf S Gorgey
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA. .,Physical Medicine and Rehabilitation Virginia Commonwealth University, Richmond, VA, USA.
| | - Christopher M Cirnigliaro
- Department of Veterans Affairs Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
| | - William A Bauman
- Department of Veterans Affairs Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA.,Departments of Medicine and Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Robert A Adler
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA.,Endocrinology Division, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
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Adler RA. MANAGEMENT OF ENDOCRINE DISEASE: Atypical femoral fractures: risks and benefits of long-term treatment of osteoporosis with anti-resorptive therapy. Eur J Endocrinol 2018; 178:R81-R87. [PMID: 29339529 DOI: 10.1530/eje-17-1002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 01/16/2018] [Indexed: 01/04/2023]
Abstract
Modern osteoporosis treatment began in the mid-1990s with the approval of amino-bisphosphonates, anti-resorptive agents that have been shown to decrease osteoporotic fracture risk by about half. In 2005, the first cases of atypical femoral fractures (AFF), occurring in the shaft of the femur, were reported. Since then, more cases have been found, leading to great concern among patients and a dramatic decrease in bisphosphonate prescribing. The pathogenesis and incidence of AFF are reviewed herein. Management and an approach to prevention or early detection of AFF are also provided. Denosumab, a more recently approved anti-resorptive medication has also been associated with AFF. Long-term management of osteoporosis and prevention of fracture are challenging in light of this serious but uncommon side effect, yet with an aging population osteoporotic fracture is destined to increase in frequency.
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Affiliation(s)
- Robert A Adler
- Endocrinology and Metabolism Section, McGuire Veterans Affairs Medical Center, Division of Endocrinology,Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
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Lewiecki EM, Wright NC, Curtis JR, Siris E, Gagel RF, Saag KG, Singer AJ, Steven PM, Adler RA. Hip fracture trends in the United States, 2002 to 2015. Osteoporos Int 2018; 29:717-722. [PMID: 29282482 DOI: 10.1007/s00198-017-4345-0] [Citation(s) in RCA: 181] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 12/12/2017] [Indexed: 12/14/2022]
Abstract
UNLABELLED An analysis of United States (US) Medicare claims data from 2002 to 2015 for women aged ≥ 65 years found that age-adjusted hip fracture rates for 2013, 2014, and 2015 were higher than projected, resulting in an estimated increase of more than 11,000 hip fractures. INTRODUCTION Hip fractures are a major public health concern due to high morbidity, mortality, and healthcare expenses. Previous studies have reported a decrease in the annual incidence of hip fractures in the US beginning in 1995, coincident with the introduction of modern diagnostic tools and therapeutic agents for osteoporosis. In recent years, there has been less bone density testing and fewer prescriptions for osteoporosis treatments. The large osteoporosis treatment gap raises concern of possible adverse effects on hip fracture rates. METHODS We assessed hip fracture incidence in the US to determine if the previous decline in hip fracture incidence continued. Using 2002 to 2015 Medicare Part A and Part B claims for women ≥ 65 years old, we calculated age-adjusted hip fracture rates, weighting to the 2014 population. RESULTS We found that hip fracture rates declined each year from 2002 to 2012 and then plateaued at levels higher than projected for years 2013, 2014, and 2015. CONCLUSIONS The plateau in age-adjusted hip fracture incidence rate resulted in more than 11,000 additional estimated hip fractures over the time periods 2013, 2014, and 2015. We recommend further study to assess all factors contributing to this remarkable change in hip fracture rate and to develop strategies to reduce the osteoporosis treatment gap.
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Affiliation(s)
- E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, 300 Oak St. NE, Albuquerque, NM, 87106, USA.
| | - N C Wright
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J R Curtis
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - E Siris
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - R F Gagel
- Department of Endocrine Neoplasia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - K G Saag
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - A J Singer
- Department of Obstetrics and Gynecology, MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - P M Steven
- International Society for Clinical Densitometry, Hartford, CT, USA
| | - R A Adler
- Endocrinology Section, McGuire Veterans Affairs Medical Center, Richmond, VA, USA
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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Lee RH, Sloane R, Pieper C, Lyles KW, Adler RA, Van Houtven C, LaFleur J, Colón-Emeric C. Clinical Fractures Among Older Men With Diabetes Are Mediated by Diabetic Complications. J Clin Endocrinol Metab 2018; 103:281-287. [PMID: 29099931 PMCID: PMC5761492 DOI: 10.1210/jc.2017-01593] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 10/27/2017] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Type 2 diabetes mellitus among older women has been associated with increased bone mineral density, but paradoxically with increased fracture risk. Findings among older men have varied, and potential mechanisms have not been fully elucidated. METHODS A retrospective study of male veterans 65 to 99 years of age who received primary care in the Veterans Health Administration from 2000 to 2010, using administrative data from all 146 Veterans Health Administration medical centers linked to Centers for Medicare and Medicaid Services Medicare fee-for-service data. Potential mediating factors of the diabetes-associated risk were evaluated using negative binomial regression models with the outcomes of any clinical fracture and hip fracture. RESULTS Of 2,798,309 Veterans included in the cohort, 900,402 (32.3%) had a diagnosis of diabetes. After adjusting for age, race, ethnicity, body mass index, alcohol and tobacco use, rheumatoid arthritis, and corticosteroid use, the risk of any clinical fracture associated with diabetes was 1.22 (95% confidence interval, 1.21 to 1.23) and that of hip fracture was 1.21 (95% confidence interval, 1.19 to 1.23). Significant mediating factors included peripheral neuropathy, cardiovascular disease, and congestive heart failure, with 45.5% of the diabetes-associated fracture risk explained by these diagnoses. CONCLUSIONS Older male Veterans with diabetes have a 22% increased risk of incident clinical fracture compared with those without. A significant portion of this risk is explained by diabetes-related comorbidities, specifically peripheral neuropathy and congestive heart failure. Identification of these mediating factors suggests possible mechanisms, as well as potential interventions.
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Affiliation(s)
- Richard H. Lee
- Duke University School of Medicine, Durham, North Carolina 27710
- Durham Veterans Affairs Medical Center, Durham, North Carolina 27705
| | - Richard Sloane
- Duke University School of Medicine, Durham, North Carolina 27710
- Durham Veterans Affairs Medical Center, Durham, North Carolina 27705
| | - Carl Pieper
- Duke University School of Medicine, Durham, North Carolina 27710
| | - Kenneth W. Lyles
- Duke University School of Medicine, Durham, North Carolina 27710
- Durham Veterans Affairs Medical Center, Durham, North Carolina 27705
| | - Robert A. Adler
- Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia 23249
- Virginia Commonwealth University School of Medicine, Richmond, Virginia 23298
| | - Courtney Van Houtven
- Duke University School of Medicine, Durham, North Carolina 27710
- Durham Veterans Affairs Medical Center, Durham, North Carolina 27705
| | - Joanne LaFleur
- University of Utah, Salt Lake City, Utah 84112
- Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah 84148
| | - Cathleen Colón-Emeric
- Duke University School of Medicine, Durham, North Carolina 27710
- Durham Veterans Affairs Medical Center, Durham, North Carolina 27705
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Adler RA. Glucocorticoid-Induced Osteoporosis and the New ACR Guideline. Clin Rev Bone Miner Metab 2017. [DOI: 10.1007/s12018-017-9234-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Gorgey AS, Khalil RE, Gill R, O'Brien LC, Lavis T, Castillo T, Cifu DX, Savas J, Khan R, Cardozo C, Lesnefsky EJ, Gater DR, Adler RA. Effects of Testosterone and Evoked Resistance Exercise after Spinal Cord Injury (TEREX-SCI): study protocol for a randomised controlled trial. BMJ Open 2017; 7:e014125. [PMID: 28377392 PMCID: PMC5387951 DOI: 10.1136/bmjopen-2016-014125] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Individuals with spinal cord injury (SCI) are at a lifelong risk of obesity and chronic metabolic disorders including insulin resistance and dyslipidemia. Within a few weeks of injury, there is a significant decline in whole body fat-free mass, particularly lower extremity skeletal muscle mass, and subsequent increase in fat mass (FM). This is accompanied by a decrease in anabolic hormones including testosterone. Testosterone replacement therapy (TRT) has been shown to increase skeletal muscle mass and improve metabolic profile. Additionally, resistance training (RT) has been shown to increase lean mass and reduce metabolic disturbances in SCI and other clinical populations. METHODS AND ANALYSIS 26 individuals with chronic, motor complete SCI between 18 and 50 years old were randomly assigned to a RT+TRT group (n=13) or a TRT group (n=13). 22 participants completed the initial 16-week training phase of the study and 4 participants withdrew. 12 participants of the 22 completed 16 weeks of detraining. The TRT was provided via transdermal testosterone patches (4-6 mg/day). The RT+TRT group had 16 weeks of supervised unilateral progressive RT using surface neuromuscular electrical stimulation with ankle weights. This study will investigate the effects of evoked RT+TRT or TRT alone on body composition (muscle cross-sectional area, visceral adipose tissue, %FM) and metabolic profile (glucose and lipid metabolism) in individuals with motor complete SCI. Findings from this study may help in designing exercise therapies to alleviate the deterioration in body composition after SCI and decrease the incidence of metabolic disorders in this clinical population. ETHICS AND DISSEMINATION The study is currently approved by the McGuire VA Medical Center and Virginia Commonwealth University. All participants read and signed approved consent forms. Results will be submitted to peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER Pre-result, NCT01652040.
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Affiliation(s)
- Ashraf S Gorgey
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VAMC, Richmond, Virginia, USA
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Refka E Khalil
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VAMC, Richmond, Virginia, USA
| | - Ranjodh Gill
- Endocrinology Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
- Endocrine Division, Virginia Commonwealth University School of Medicine¸ Richmond, Virginia,USA
| | - Laura C O'Brien
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VAMC, Richmond, Virginia, USA
| | - Timothy Lavis
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VAMC, Richmond, Virginia, USA
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Teodoro Castillo
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VAMC, Richmond, Virginia, USA
| | - David X Cifu
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VAMC, Richmond, Virginia, USA
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jeannie Savas
- Surgical Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Rehan Khan
- Radiology Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Christopher Cardozo
- National Center for the Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
- Department of Medicine, Icahn School of Medicine at Mt. Sinai, New York City, New York, USA
| | - Edward J Lesnefsky
- Cardiology Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
- Division of Cardiology, Department of Medicine, Pauley Heart Center Virginia Commonwealth University, Richmond, Virginia, USA
| | - David R Gater
- Department of Physical Medicine and Rehabilitation, Penn State Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Robert A Adler
- Endocrinology Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
- Endocrine Division, Virginia Commonwealth University School of Medicine¸ Richmond, Virginia,USA
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Gorgey AS, Moore PD, Wade RC, Gill RS, Lavis T, Adler RA. Disruption in bone marrow fat may attenuate testosterone action on muscle size after spinal cord injury: a case report. Eur J Phys Rehabil Med 2017; 53:625-629. [PMID: 28290190 DOI: 10.23736/s1973-9087.17.04452-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Mesenchymal stem cells can be differentiated into muscle satellite cells. Testosterone replacement therapy (TRT) promotes the differentiation of satellite cells into muscle cells. CASE REPORT A 31-year-old male with a T4 complete chronic spinal cord injury (SCI) had fixation for a mid-shaft fracture of the left femur. The participant received transdermal testosterone patches (4 mg/day) daily for 16 weeks. Skeletal muscle and yellow bone marrow adiposity cross-sectional areas (CSAs) of both thighs were measured using magnetic resonance imaging. CLINICAL REHABILITATION IMPACT The yellow bone marrow CSA was 67-69% lower in the left femur compared to the right femur. Following intervention, a discrepancy was noted between the whole skeletal muscle CSAs of the right (+13%) and left (+6%) thighs. The right knee extensor CSA increased by 7% with no changes in the left CSA. Disruption in bone marrow fat may attenuate the systemic effects of TRT on muscle size.
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Affiliation(s)
- Ashraf S Gorgey
- Spinal Cord Injury Service and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA - .,Department Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA -
| | - Pamela D Moore
- Spinal Cord Injury Service and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Rodney C Wade
- Spinal Cord Injury Service and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Ranjodh S Gill
- Endocrinology Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA.,Endocrine Division, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Timothy Lavis
- Spinal Cord Injury Service and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA.,Department Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA
| | - Robert A Adler
- Endocrinology Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA.,Endocrine Division, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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Affiliation(s)
- Robert A Adler
- Endocrinology and Metabolism (111P), Virginia Commonwealth University School of Medicine, McGuire Veterans Affairs Medical Center, 1201 Broad Rock Boulevard, Richmond, VA, 23249, USA.
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Mazziotti G, Formenti AM, Adler RA, Bilezikian JP, Grossman A, Sbardella E, Minisola S, Giustina A. Glucocorticoid-induced osteoporosis: pathophysiological role of GH/IGF-I and PTH/VITAMIN D axes, treatment options and guidelines. Endocrine 2016; 54:603-611. [PMID: 27766553 DOI: 10.1007/s12020-016-1146-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 10/06/2016] [Indexed: 01/29/2023]
Abstract
Glucocorticoid-induced osteoporosis is the most frequent form of secondary osteoporosis caused by chronic exposure to glucocorticoid excess. Pathogenesis of glucocorticoid-induced osteoporosis is multifactorial including direct effects of glucocorticoids on bone cells and indirect effects of glucocorticoids on several neuroendocrine and metabolic pathways. Fragility fractures occur early in glucocorticoid-induced osteoporosis and anti-osteoporotic drugs along with calcium and vitamin D should be started soon after exposure to glucocorticoid excess. This paper summarizes some of the main topics discussed during the 9th Glucocorticoid-Induced Osteoporosis Meeting (Rome, April 2016) with a specific focus on the role of growth hormone/insulin-like growth factor-1 and parathyroid hormone/vitamin D axes in the pathogenesis of glucocorticoid-induced osteoporosis and the controversial aspects concerning therapeutic approach to skeletal fragility in this clinical setting.
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Affiliation(s)
| | | | - Robert A Adler
- McGuire Veterans Affairs Medical Center, Virginia Commonwealth University School of Medicine Richmond, Virginia, USA
| | - John P Bilezikian
- Department of Medicine Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Ashley Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, OX3 7LE, UK
| | - Emilia Sbardella
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, OX3 7LE, UK
| | - Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines "Sapienza" Rome University, Rome, Italy
| | - Andrea Giustina
- Chair of Endocrinology, University of Brescia, Brescia, Italy.
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Abstract
PURPOSE OF REVIEW Bisphosphonates are used widely for the treatment of osteoporosis and prevention of fractures. Although generally well tolerated and effective, bisphosphonates (and denosumab, a newer antiresorptive agent) have been associated with unusual fractures of the femoral shaft. RECENT FINDINGS New information about the incidence, pathophysiology, and management of atypical femoral fractures (AFFs) are reviewed. Histomorphometric studies have shown variable amounts of bone turnover suppression, but new studies suggest that healing near bone cracks may not occur in patients with AFF. Some studies suggest that hip and femur geometry make certain people more at risk for AFF. In some but not all studies, the risk of AFF appears to be related to duration of treatment. Thus, the benefit/risk ratio needs to be reassessed as bisphosphonate therapy is prolonged. SUMMARY If we can better understand the pathogenesis of AFF, it may be possible to identify those patients at highest risk. In the meantime, clinicians must periodically assess risk for osteoporotic fracture versus risk for AFF in managing patients with osteoporosis.
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Affiliation(s)
- Robert A Adler
- Endocrinology and Metabolism (111P), McGuire Veterans Affairs Medical Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
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Balasubramanian A, Wade SW, Adler RA, Lin CJF, Maricic M, O'Malley CD, Saag K, Curtis JR. Glucocorticoid exposure and fracture risk in patients with new-onset rheumatoid arthritis. Osteoporos Int 2016; 27:3239-3249. [PMID: 27273113 DOI: 10.1007/s00198-016-3646-z] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 05/19/2016] [Indexed: 01/30/2023]
Abstract
UNLABELLED Retrospective claims analysis indicated that high levels of daily and cumulative doses of systemic glucocorticoids were associated with elevated fracture risk in a large cohort of new RA patients under age 65. Heightened risk began to decline within months of discontinuation. Findings were similar among patients age <50 years. INTRODUCTION We evaluated the impact of systemic glucocorticoid exposure on fracture risk among relatively young patients with new-onset rheumatoid arthritis (RA). METHODS Using administrative data, we identified 42,127 RA patients diagnosed January 1, 2005-December 31, 2012, age 18-64 years, with benefits coverage for ≥12 months before RA diagnosis. Follow-up extended to clinical fracture, cancer diagnosis, or December 31, 2012. Glucocorticoid users were new to therapy. Fracture incidence rates (IR) were stratified by glucocorticoid exposure expressed as prednisone equivalent doses. Cox's proportional hazards models estimated fracture risk adjusted for demographics and baseline clinical characteristics to assess dose-response relationships with current (daily) and prior (cumulative) dose, and by time since discontinuation. RESULTS Most patients (85 %) had glucocorticoid exposure. Exposed and unexposed patients were demographically similar (74 % female; mean age 49.7 and 48.8 years); 1 % had prior fracture. Fracture IRs (95 % confidence intervals) were 5 to 9 per 1000 person-years at doses <15 mg/day, 16.0 (11.0, 22.6) at doses ≥15 mg/day, and 13.4 (10.7, 16.7) at cumulative doses ≥5400 mg. Adjusted fracture risk was approximately 2-fold higher at highest dose levels compared with 0 mg/day current daily dose and <675 mg cumulative dose, respectively. Fracture risk was 29 % lower at 60-182 days post-discontinuation compared with ongoing use and was similar to unexposed patients by 12 months. Findings were similar among patients age <50 years. CONCLUSIONS Among younger, new-onset RA patients, fracture risk was significantly elevated at high levels of daily and cumulative dose, and was similar to unexposed patients by 12 months post-discontinuation.
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Affiliation(s)
| | - S W Wade
- Wade Outcomes Research and Consulting, 358 South 700 East, Suite B-432, Salt Lake City, UT, USA.
| | - R A Adler
- McGuire Veterans Affairs Medical Center and Virginia Commonwealth University, Richmond, VA, USA
| | - C J F Lin
- Amgen Inc., Thousand Oaks and San Francisco, CA, USA
| | - M Maricic
- University of Arizona School of Medicine, Tucson, AZ, USA
| | - C D O'Malley
- Amgen Inc., Thousand Oaks and San Francisco, CA, USA
| | - K Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
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