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Makras P, Appelman-Dijkstra NM, Papapoulos SE, van Wissen S, Winter EM, Polyzos SA, Yavropoulou MP, Anastasilakis AD. The Duration of Denosumab Treatment and the Efficacy of Zoledronate to Preserve Bone Mineral Density After Its Discontinuation. J Clin Endocrinol Metab 2021; 106:e4155-e4162. [PMID: 33978745 DOI: 10.1210/clinem/dgab321] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [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: 02/23/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Zoledronate is used to prevent bone loss following denosumab discontinuation but its efficacy differs among studies. OBJECTIVE To test if the duration of denosumab treatment affects the efficacy of subsequent zoledronate infusion. METHODS This multicenter, prospective cohort study, conducted at 2 Greek and 1 Dutch bone centers, included 47 postmenopausal women (n = 47) who received a single zoledronate infusion 6 months after the last denosumab injection and then were followed for 1 year. Twenty-seven women received ≤ 6 denosumab injections (≤ 6 Group) and 20 received > 6 denosumab injections (> 6 Group). The main outcome measure was changes in lumbar spine (LS) bone mineral density (BMD). RESULTS At 12 months LS-BMD values were maintained in the ≤ 6 Group (0.98 ± 0.10 to 0.99 ± 0.9 g/cm2, P = 0.409) but decreased significantly in the > 6 Group (1.0 ± 0.11 to 0.93 ± 0.12 g/cm2, P < 0.001). The percent change of LS-BMD of the ≤ 6 Group (+1.0%) was significantly different (P < 0.001) from the change of the > 6 Group (-7.0%). In the whole cohort, the duration of denosumab treatment was negatively correlated with the percentage change of LS-BMD (rs = -0.669, P < 0.001) but not with the change of femoral neck (FN)-BMD. Bone turnover markers increased in all patients 6 months following zoledronate administration with no difference between the 2 groups. CONCLUSION The duration of denosumab treatment significantly affects the efficacy of subsequent zoledronate infusion to maintain BMD gains. Frequent follow-up of patients treated with denosumab longer than 3 years is advisable as additional therapeutic interventions may be needed.
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Affiliation(s)
- Polyzois Makras
- Department of Endocrinology and Diabetes and Department of Medical Research, 251 Hellenic Air Force & VA General Hospital, 11525, Athens,Greece
| | - Natasha M Appelman-Dijkstra
- Center for Bone Quality, Department of Internal Medicine, section Endocrinology, Leiden University Medical Center, 9600 2300 RC, Leiden,The Netherlands
| | - Socrates E Papapoulos
- Center for Bone Quality, Department of Internal Medicine, section Endocrinology, Leiden University Medical Center, 9600 2300 RC, Leiden,The Netherlands
| | - Sandra van Wissen
- Center for Bone Quality, Department of Internal Medicine, section Endocrinology, Leiden University Medical Center, 9600 2300 RC, Leiden,The Netherlands
| | - Elizabeth M Winter
- Center for Bone Quality, Department of Internal Medicine, section Endocrinology, Leiden University Medical Center, 9600 2300 RC, Leiden,The Netherlands
| | - Stergios A Polyzos
- First Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, 54124, Thessaloniki,Greece
| | - Maria P Yavropoulou
- Department of Endocrinology and Diabetes and Department of Medical Research, 251 Hellenic Air Force & VA General Hospital, 11525, Athens,Greece
- Endocrinology Unit, 1st Department of Propaedeutic and Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, 10679, Athens,Greece
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Miyoshi A, Kameda H, Nagai S, Nakamura A, Miya A, Takase T, Atsumi T, Miyoshi H. Beneficial effects of switching to denosumab from bisphosphonates or selective estrogen receptor modulators in postmenopausal women with type 2 diabetes and osteopenia/osteoporosis. J Diabetes Investig 2021; 12:1293-1300. [PMID: 33141482 PMCID: PMC8264394 DOI: 10.1111/jdi.13458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Received: 05/08/2020] [Revised: 10/05/2020] [Accepted: 10/26/2020] [Indexed: 01/22/2023] Open
Abstract
AIMS/INTRODUCTION Patients with type 2 diabetes mellitus have a higher bone fracture risk than patients without diabetes. Although denosumab (Dmab) is a potent bone resorption inhibitor, its efficacy in patients with type 2 diabetes mellitus has not been elucidated. In this study, we investigated the effects of switching to Dmab from bisphosphonates (BP) or a selective estrogen receptor modulator (SERM) in postmenopausal type 2 diabetes mellitus patients. MATERIALS AND METHODS This was a three medical institutions, prospective, observational study for postmenopausal patients with type 2 diabetes mellitus whose T-score of femoral neck or lumbar spine bone mineral density was under -1.0 standard deviation, even after >6 months of BP or SERM administration. After obtaining consent, participants were treated for osteopenia/osteoporosis by either continuing BP (BP-BP group)/SERM (SERM-SERM group), or by switching to Dmab (BP-Dmab or SERM-Dmab groups). Changes in bone mineral density and bone metabolism marker levels were evaluated after 6 months. RESULTS A total of 48 patients were included in this study, and each group comprised 12 patients. No significant difference existed in baseline characteristics among the groups. The average age and glycated hemoglobin were 71 ± 8 years and 7.2 ± 0.9%, respectively. In the SERM-Dmab group, lumbar spine bone mineral density was significantly increased by 5.0% compared with the SERM-SERM group (P < 0.04). Serum bone-specific alkaline phosphatase and tartrate-resistant acid phosphatase 5b were significantly decreased in the BP-Dmab and SERM-Dmab groups compared with the BP-BP and SERM-SERM groups, respectively. CONCLUSIONS Switching to Dmab from BP or SERM is beneficial to prevent osteoporosis progression in postmenopausal patients with type 2 diabetes mellitus patients.
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Affiliation(s)
- Arina Miyoshi
- Department of Diabetes and EndocrinologySapporo City General HospitalSapporoJapan
- Department of Rheumatology, Endocrinology and NephrologyFaculty of Medicine and Graduate School of MedicineHokkaido UniversitySapporoJapan
| | - Hiraku Kameda
- Department of Rheumatology, Endocrinology and NephrologyFaculty of Medicine and Graduate School of MedicineHokkaido UniversitySapporoJapan
| | - So Nagai
- Sapporo Medical Center NTT ECSapporoJapan
| | - Akinobu Nakamura
- Department of Rheumatology, Endocrinology and NephrologyFaculty of Medicine and Graduate School of MedicineHokkaido UniversitySapporoJapan
| | - Aika Miya
- Department of Rheumatology, Endocrinology and NephrologyFaculty of Medicine and Graduate School of MedicineHokkaido UniversitySapporoJapan
| | - Takahiro Takase
- Department of Rheumatology, Endocrinology and NephrologyFaculty of Medicine and Graduate School of MedicineHokkaido UniversitySapporoJapan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and NephrologyFaculty of Medicine and Graduate School of MedicineHokkaido UniversitySapporoJapan
| | - Hideaki Miyoshi
- Division of Diabetes and ObesityFaculty of Medicine and Graduate School of MedicineHokkaido UniversitySapporoJapan
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Sano K, Suehara Y, Okubo T, Sasa K, Kurihara T, Akaike K, Kubota D, Torigoe T, Hasegawa N, Ishii M, Nakamura Y, Kim Y, Takagi T, Kaneko K, Hayashi T, Saito T. Preoperative denosumab treatment with curettage may be a risk factor for recurrence of giant cell tumor of bone. J Orthop Surg (Hong Kong) 2021; 28:2309499020929786. [PMID: 32539628 DOI: 10.1177/2309499020929786] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Giant cell tumor of bone (GCTB) is a local aggressive bone tumor, histologically classified as intermediate malignancy. Recently, the RANKL inhibitor, denosumab, was developed as a novel and effective treatment option for GCTB. Since the risk of preoperative use of denosumab with curettage had been previously reported, this study aimed to investigate the relationship between recurrences and clinicopathological features associated with adjuvant denosumab treatment in GCTB. METHODS A total of 87 GCTB cases were treated at our institution. We reviewed 66 patients with conventional-type GCTB occurring in the extremities and analyzed 78 surgical treatments, including curettages and resections, with clinicopathological features and denosumab treatment. RESULTS GCTB lesions, including 66 primary and 12 recurring, underwent surgical treatment like curettage and resection. Recurrence-free survivals in 78 GCTB surgeries were 78.7% in 3 years and 71.9% in 5 years. In the resected cases of GCTBs, there was no recurrence either with or without denosumab. In curettage cases, 3-year recurrence-free survivals were 0.0% (n = 3) in preoperative treatment of denosumab, 66.7% (n = 6) in postoperative treatment, and 76.6% (n = 43) in no treatment. Interestingly, three preoperative treatment cases demonstrated low MIB-1 index despite 100% recurrence. The other clinicopathological factors did not contribute much to the risk of recurrence in curettage cases. CONCLUSION Our findings revealed the use of denosumab in GCTB, prior to curettage, to possibly increase the risk of local recurrence. Together with previous reports, our finding might provide information for beneficial treatment of GCTB.
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Affiliation(s)
- Kei Sano
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
- Department of Human Pathology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoshiyuki Suehara
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Taketo Okubo
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Keita Sasa
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
- Department of Human Pathology, Juntendo University School of Medicine, Tokyo, Japan
| | - Taisei Kurihara
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
- Department of Human Pathology, Juntendo University School of Medicine, Tokyo, Japan
| | - Keisuke Akaike
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Daisuke Kubota
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Tomoaki Torigoe
- Department of Orthopedic Oncology and Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Nobuhiko Hasegawa
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Midori Ishii
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yasuhiro Nakamura
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Youngji Kim
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Tatsuya Takagi
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Kazuo Kaneko
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Takuo Hayashi
- Department of Human Pathology, Juntendo University School of Medicine, Tokyo, Japan
| | - Tsuyoshi Saito
- Department of Human Pathology, Juntendo University School of Medicine, Tokyo, Japan
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Broadwell A, Chines A, Ebeling PR, Franek E, Huang S, Smith S, Kendler D, Messina O, Miller PD. Denosumab Safety and Efficacy Among Participants in the FREEDOM Extension Study With Mild to Moderate Chronic Kidney Disease. J Clin Endocrinol Metab 2021; 106:397-409. [PMID: 33211870 PMCID: PMC7823314 DOI: 10.1210/clinem/dgaa851] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Indexed: 12/23/2022]
Abstract
CONTEXT The effects of long-term exposure to denosumab in individuals with renal insufficiency are unknown. OBJECTIVE This post hoc analysis evaluates the long-term safety and efficacy of denosumab in individuals with mild-to-moderate chronic kidney disease (CKD) (stages 2 and 3) using data from the pivotal phase 3, double-blind, 3-year FREEDOM (NCT00089791) and open-label, 7-year extension (NCT00523341) studies. PARTICIPANTS AND METHODS Women age 60 to 90 years with a bone mineral density (BMD) T-score of less than -2.5 to greater than -4.0 at the total hip or lumbar spine were randomly assigned 1:1 to receive denosumab 60 mg subcutaneously every 6 months (long-term arm) or placebo (cross-over arm) in FREEDOM; eligible participants could enroll in the extension to receive denosumab 60 mg subcutaneously every 6 months. Change in estimated glomerular filtration rate (eGFR) from study baseline and annualized rates of fracture and adverse events (AEs) were the main outcome measures. RESULTS Most participants (1259/1969 [64%] long-term arm; 1173/1781 [66%] crossover arm) with baseline CKD stage 2 or 3 remained within the same CKD subgroup at study completion; less than 3% progressed to CKD stage 4. Participants in all eGFR subgroups showed similar, persistent BMD gains over time and a low incidence of fractures. The percentage of participants reporting serious AEs was similar among renal subgroups (normal, CKD stage 2, CKD stage 3a, CKD stage 3b) both for the long-term (54% vs 52% vs 57% vs 58%) and crossover (43% vs 42% vs 43% vs 68%) arms, except CKD stage 3b subgroup, crossover arm. CONCLUSION The safety and efficacy of denosumab did not differ among participants with mild to moderate CKD.
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Affiliation(s)
- Aaron Broadwell
- Rheumatology and Osteoporosis Specialists, Shreveport, Louisiana, USA
- Correspondence and Reprint Requests: Aaron Broadwell, MD, Rheumatology and Osteoporosis Specialists, 820 Jordan St, Ste 201, Shreveport, LA 71101, USA. E-mail:
| | | | | | - Edward Franek
- Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
| | | | | | - David Kendler
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Paul D Miller
- Colorado Center for Bone Research, Lakewood, Colorado, USA
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Sugimoto T, Matsumoto T, Hosoi T, Shiraki M, Kobayashi M, Okubo N, Takami H, Nakamura T. Efficacy of denosumab co-administered with vitamin D and Ca by baseline vitamin D status. J Bone Miner Metab 2020; 38:848-858. [PMID: 32671481 DOI: 10.1007/s00774-020-01119-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 03/24/2020] [Accepted: 06/06/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION In anti-osteoporosis drug trials, vitamin D and calcium (Ca) are common supplements; however, the optimal dose of each is unclear. Using data from the randomized, double-blind, placebo-controlled DIRECT trial, we assessed whether baseline serum 25-hydroxy vitamin D (25[OH]D) level influences the efficacy of denosumab co-administered with vitamin D and Ca. MATERIALS AND METHODS In this prespecified sub-analysis, subjects with primary osteoporosis who received denosumab or placebo, plus vitamin D (≥ 400 IU/day) and Ca (≥ 600 mg/day), were classified as 25(OH)D deficient (< 20 ng/mL), insufficient (≥ 20 to < 30 ng/mL), and sufficient (≥ 30 ng/mL). Study endpoints included absolute serum 25(OH)D level at baseline, 12 months, and 24 months; change in serum 25(OH)D and bone mineral density (BMD) status from baseline; and incidence of new vertebral fractures at 24 months. RESULTS In 475 denosumab-treated and 481 placebo-treated subjects, proportions with deficient/insufficient/sufficient 25(OH)D at baseline were 53.1%/37.1%/9.9% and 50.9%/42.0%/7.1%, respectively. Supplementation significantly increased mean serum 25(OH)D levels; at 24 months, mean levels were > 30 ng/mL (sufficient) in both treatment groups. Increase in BMD over time was higher in the denosumab group vs. placebo group in all three vitamin D status groups. At month 24, denosumab-treated subjects with deficient/insufficient baseline 25(OH)D had a significantly lower risk of new vertebral fracture vs. placebo-treated subjects. CONCLUSION Among DIRECT trial subjects supplemented with ≥ 400 IU/day of vitamin D and ≥ 600 mg/day of Ca, baseline 25(OH)D sufficiency may not influence the efficacy of denosumab in increasing BMD or preventing vertebral fractures.
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Affiliation(s)
| | - Toshio Matsumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
| | | | - Masataka Shiraki
- Research Institute and Practice for Involutional Diseases, Nagano, Japan
| | - Makiko Kobayashi
- Medical Science Department, Medical Affairs Division, Daiichi Sankyo Co. Ltd, Tokyo, Japan
| | - Naoki Okubo
- Biostatistics & Data Management Department, R&D Division, Daiichi Sankyo Co. Ltd, Tokyo, Japan
| | - Hideo Takami
- Development Function, R&D Division, Daiichi Sankyo Co. Ltd, Tokyo, Japan
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Diel I, Ansorge S, Hohmann D, Giannopoulou C, Niepel D, Intorcia M. Real-world use of denosumab and bisphosphonates in patients with solid tumours and bone metastases in Germany. Support Care Cancer 2020; 28:5223-5233. [PMID: 32086567 PMCID: PMC7547046 DOI: 10.1007/s00520-020-05357-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 06/18/2019] [Accepted: 02/11/2020] [Indexed: 12/02/2022]
Abstract
PURPOSE Bisphosphonates and denosumab prevent bone complications in patients with bone metastases from solid tumours. This retrospective, longitudinal, cohort study provides data on their real-world use in this setting in Germany. METHODS Adults with bone metastases from breast, prostate or lung cancer who were newly initiated on a bisphosphonate or denosumab between 1 July 2011 and 31 December 2015 were identified from a German healthcare insurance claims database. Primary outcomes included persistence, compliance, discontinuation and switch rates at 12 months. RESULTS This study included 1130 patients with bone metastases: 555 (49%) had breast cancer, 361 (32%) prostate cancer and 242 (21%) lung cancer. Mean age was 65 years for patients with breast or lung cancer and 74 years for those with prostate cancer. Across all tumour types, compared with any bisphosphonate, 12-month persistence was higher with denosumab (breast cancer 78% vs 54-58%, prostate cancer 58% vs 50%, lung cancer 68% vs 34-60%), median time to discontinuation was longer with denosumab and switch rates were lower for denosumab (breast cancer 5% vs 14-19%, prostate cancer 2% vs 11%, lung cancer 3% vs 7-12%). Compliance at 12 months was longer for denosumab than for any bisphosphonate in breast cancer (75% vs 42-48%) and in prostate cancer (47% vs 36%). CONCLUSIONS Patients initiated on denosumab following a diagnosis of bone metastases from breast, prostate or lung cancer had greater medication persistence, longer time to discontinuation, improved compliance and lower switch rates than those initiated on a bisphosphonate.
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Affiliation(s)
- Ingo Diel
- Centre for Gynecological Oncology, Praxisklinik am Rosengarten, Augustaanlage 7-11, 68165, Mannheim, Germany.
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Lyu H, Yoshida K, Zhao SS, Wei J, Zeng C, Tedeschi SK, Leder BZ, Lei G, Tang P, Solomon DH. Delayed Denosumab Injections and Fracture Risk Among Patients With Osteoporosis : A Population-Based Cohort Study. Ann Intern Med 2020; 173:516-526. [PMID: 32716706 DOI: 10.7326/m20-0882] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [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] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Denosumab is effective for osteoporosis, but discontinuation leads to rapid reversal of its therapeutic effect. OBJECTIVE To estimate the risk for fracture among users of denosumab who delayed subsequent doses compared with users who received doses on time. DESIGN Population-based cohort study. SETTING The Health Improvement Network U.K. primary care database, 2010 to 2019. PATIENTS Persons aged 45 years or older who initiated denosumab therapy for osteoporosis. MEASUREMENTS Observational data were used to emulate an analysis of a hypothetical trial with 3 dosing intervals: subsequent denosumab injection given within 4 weeks after the recommended date ("on time"), delay by 4 to 16 weeks ("short delay"), and delay by more than 16 weeks ("long delay"). The primary outcome was a composite of all fracture types at 6 months after the recommended date. Secondary outcomes were major osteoporotic fracture, vertebral fracture, hip fracture, and nonvertebral fracture. RESULTS Investigators identified 2594 patients initiating denosumab therapy. The risk for composite fracture over 6 months was 27.3 in 1000 for on-time dosing, 32.2 in 1000 for short delay, and 42.4 in 1000 for long delay. Compared with on-time injections, short delay had a hazard ratio (HR) for composite fracture of 1.03 (95% CI, 0.63 to 1.69) and long delay an HR of 1.44 (CI, 0.96 to 2.17) (P for trend = 0.093). For vertebral fractures, short delay had an HR of 1.48 (CI, 0.58 to 3.79) and long delay an HR of 3.91 (CI, 1.62 to 9.45). LIMITATION Dosing schedules were not randomly assigned. CONCLUSION Although delayed administration of subsequent denosumab doses by more than 16 weeks is associated with increased risk for vertebral fracture compared with on-time dosing, evidence is insufficient to conclude that fracture risk is increased at other anatomical sites with long delay. PRIMARY FUNDING SOURCE National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation.
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Affiliation(s)
- Houchen Lyu
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, General Hospital of Chinese PLA, Beijing, China, Xiangya Hospital of Central South University, Changsha, China, and Brigham and Women's Hospital, Boston, Massachusetts (H.L.)
| | - Kazuki Yoshida
- Brigham and Women's Hospital, Boston, Massachusetts (K.Y., S.K.T.)
| | - Sizheng S Zhao
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom (S.S.Z.)
| | - Jie Wei
- Health Management Center, Xiangya Hospital of Central South University, Changsha, China (J.W.)
| | - Chao Zeng
- Xiangya Hospital of Central South University, Changsha, China (C.Z.)
| | - Sara K Tedeschi
- Brigham and Women's Hospital, Boston, Massachusetts (K.Y., S.K.T.)
| | - Benjamin Z Leder
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (B.Z.L.)
| | - Guanghua Lei
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, and Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, China (G.L.)
| | - Peifu Tang
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, General Hospital of Chinese PLA, Beijing, China (P.T.)
| | - Daniel H Solomon
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (D.H.S.)
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Abstract
OPINION STATEMENT Denosumab is a RANK ligand inhibitor approved for the treatment of giant cell tumor of bone. While the role of denosumab in the setting of advanced and unresectable disease is well established, its role in surgically resectable disease is currently under discussion. Several prospective and retrospective series on neoadjuvant therapy in potentially resectable tumor with high morbidity surgery reported a relapse rate of 10-20% after resection and 30-40% after curettage. At the same time, less morbid surgery has obvious clinical advantages for the patient, and several studies have shown the efficacy of denosumab in downgrading of the surgical procedure. Currently, the role of neoadjuvant denosumab in operable GCTB is limited to selected cases in which a diffuse reactive bone formation and peripheral ossification can make an easier surgical procedure, for example, in tumors with a large soft tissue component. A planned resection may become less morbid when preoperative denosumab is administered. Whenever a segmental resection is thought to be indicated at diagnosis, denosumab may be considered in the neoadjuvant setting. A preoperative course of 6 months is considered safe and effective. Two case scenarios are presented and critically discussed. Because of the high recurrence rates after denosumab treatment followed by curettage, we discourage the use of denosumab when curettage is considered feasible. In this setting, a short course of preoperative denosumab (2-6 months) may be considered for highly selected cases, for example in pathological fractures. The role of adjuvant denosumab needs further investigation. Long-term disease control has been reported in case of non-surgical lesions, even after treatment interruption, but there is no consensus on ideal treatment duration and dosage for these scenarios. In all cases, multidisciplinary discussion with oncology, pathologist, radiologist, and surgeons is mandatory. Patient's comorbidities, dental conditions, and preferences, including family planning, should always be taken into account.
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Affiliation(s)
| | | | | | | | - Alessandra Longhi
- Chemotherapy Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Abstract
As the world grapples with the crisis of COVID-19, established economies and healthcare systems have been brought to their knees. Tough decisions regarding redirection of resources away from the management of conditions deemed "nonessential" are being made. How can we balance urgent resourcing of our acute crisis while not abandoning the real need of patients with osteoporosis? This article offers a few practical solutions.
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Affiliation(s)
- C M Girgis
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, Sydney, Australia.
- Department of Endocrinology and Diabetes, Westmead Hospital, Westmead, Sydney, Australia.
| | - R J Clifton-Bligh
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, St Leonards, Sydney, Australia
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Abstract
Aims: This study assessed the cost-effectiveness of denosumab for treating postmenopausal women with osteoporosis (PMO) at high risk of fracture in Thailand.Materials and methods: A published Markov cohort cost-effectiveness model was populated with country-specific data as available and other published data as needed. The model used a societal perspective, lifetime horizon, efficacy data from network meta-analysis of trials, and included costs for direct medical and non-medical care, informal care, and osteoporosis treatments to compare denosumab to no pharmacologic treatment (calcium and vitamin D supplements only) and to oral weekly alendronate. The base case (high-risk population) included postmenopausal women with femoral neck T-score ≤-2.5, mean age 65 years at entry, and history of vertebral fracture.Results: High-risk women with osteoporosis using denosumab had the greatest number of life years and quality-adjusted life-years (QALYs) with higher reductions in hip and vertebral fracture incidence compared with patients with no pharmacologic treatment. The incremental cost-effectiveness ratio (ICER) was 119,575 Thai Baht (THB) per QALY for denosumab versus no pharmacologic treatment and 199,186 THB per QALY for denosumab versus alendronate. Among Thai postmenopausal women with high-risk of fractures, denosumab was cost-effective compared with no pharmacologic treatment at a willingness-to-pay threshold of 160,000 THB per QALY. One-way sensitivity analysis showed models were most sensitive to changes in denosumab pricing.Limitations: Data from other countries used when country-specific data were unavailable may not accurately reflect the true experience in Thailand. The model focused explicitly on hip, vertebral, and wrist fractures, and therefore provides a conservative estimate of the overall potential impact of osteoporosis-related fracture. The fracture risk was not adjusted to reflect potential changes in risk after denosumab treatment discontinuation.Conclusions: In Thailand, denosumab offers a cost-effective osteoporosis treatment option versus no pharmacologic treatment in postmenopausal women at high risk of fracture.
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Affiliation(s)
| | | | | | - Aasis Unnanuntana
- Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
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McGrath LJ, Spangler L, Curtis JR, Ehrenstein V, Sørensen HT, Saul B, Levintow SN, Reams D, Bradbury BD, Brookhart MA. Using negative control outcomes to assess the comparability of treatment groups among women with osteoporosis in the United States. Pharmacoepidemiol Drug Saf 2020; 29:854-863. [PMID: 32537883 DOI: 10.1002/pds.5037] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/27/2020] [Accepted: 05/11/2020] [Indexed: 11/07/2022]
Abstract
PURPOSE In contrast to randomized clinical trials, comparative safety and effectiveness assessments of osteoporosis medications in clinical practice may be subject to confounding by indication. We used negative control outcomes to detect residual confounding when comparing osteoporosis medications. METHODS Using MarketScan Commercial and Supplemental claims, we identified women aged ≥55 years who initiated an oral bisphosphonate (BP) (risedronate, alendronate, or ibandronate), denosumab (an injected biologic), or intravenous zoledronic acid (ZA) from October 1, 2010 to September 30, 2015. Women with Paget's disease or cancer were excluded. We compared individual oral BPs to each other, denosumab to ZA, denosumab to oral BPs, and ZA to oral BPs, with respect to 11 negative control outcomes identified by subject matter experts. We estimated the 12-month cumulative risk difference (RD) using inverse probability of treatment and censoring weights. RESULTS Among 148 587 women, most initiated alendronate (57%), followed by ibandronate (12%), ZA (11%), risedronate (10%), and denosumab (10%). Compared with denosumab, patients initiating ZA had similar risks of all negative control outcomes. Compared with oral BPs, patients initiating denosumab had a higher risk of a wellness visit (RD = 1.2%, 95% CI: 0.4, 1.9) and a lower risk of receiving herpes zoster vaccine (RD = -0.6%, 95% CI: -1.1, -0.2). Comparing ZA with oral BP initiators resulted in two outcomes with positive associations. CONCLUSIONS Caution is warranted when comparing injectable vs oral osteoporosis medications, given the potential for unmeasured confounding. Evaluating negative control outcomes could be a standard validity check prior to conducting comparative studies.
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Affiliation(s)
| | - Leslie Spangler
- Center for Observational Research, Amgen, Thousand Oaks, California, USA
| | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Vera Ehrenstein
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | | | - Brian D Bradbury
- Center for Observational Research, Amgen, Thousand Oaks, California, USA
| | - M Alan Brookhart
- NoviSci, Inc., Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
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12
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Tanaka H, Makita C, Manabe Y, Kajima M, Matsuyama K, Matsuo M. Radiation therapy combined with bone-modifying agents ameliorates local control of osteolytic bone metastases in breast cancer. J Radiat Res 2020; 61:494-498. [PMID: 32266394 PMCID: PMC7299266 DOI: 10.1093/jrr/rraa020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/31/2020] [Indexed: 05/30/2023]
Abstract
Bone-modifying agents (BMAs) are frequently used for the treatment of bone metastases. Both BMA and radiation therapy (RT) are effective; however, there are few studies that have evaluated the efficacy of the combination treatment. We evaluated the effectiveness of RT + BMA in breast cancer-induced osteolytic bone metastasis as compared to BMA alone. A total of 43 lesions in 25 patients were evaluated. The median follow-up period was 18 (range, 2-90) months. None of the lesions was treated with chemotherapy or molecular targeted drugs during the follow-up period for evaluating the local response. Patients with complete or partial response were considered as responders, while those with stable or progressive disease were considered as non-responders. The rate of response with RT + BMA was significantly higher than that with BMA alone (P = 0.001). The cumulative incidence rate of response at 6 months was 54.4% in the RT + BMA group and 27.5% in the BMA alone group. The median time to response was 4 (range, 2-11) months in the RT + BMA group and 6 (range, 4-16) months in the BMA alone group. The overall survival rate in the responder group (83.1% at 1 year) was significantly higher than that in the non-responder group (37.5% at 1 year) (P = 0.029). In conclusion, RT combined with BMA was found to be more effective than BMA alone for the treatment of osteolytic bone metastasis, which thereby improves the prognosis.
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Affiliation(s)
- Hidekazu Tanaka
- Department of Radiology, Gifu University Hospital, Gifu, Japan
- Department of Radiation Oncology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Chiyoko Makita
- Department of Radiology, Gifu University Hospital, Gifu, Japan
| | - Yuki Manabe
- Department of Radiation Oncology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Miki Kajima
- Department of Radiation Oncology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | | | - Masayuki Matsuo
- Department of Radiology, Gifu University Hospital, Gifu, Japan
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13
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Lyu H, Zhao SS, Yoshida K, Tedeschi SK, Xu C, Nigwekar SU, Leder BZ, Solomon DH. Delayed Denosumab Injections and Bone Mineral Density Response: An Electronic Health Record-based Study. J Clin Endocrinol Metab 2020; 105:5693392. [PMID: 31894244 PMCID: PMC7089847 DOI: 10.1210/clinem/dgz321] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [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] [Received: 09/26/2019] [Accepted: 12/30/2019] [Indexed: 01/18/2023]
Abstract
CONTEXT Discontinuation of denosumab leads to a rapid reversal of its therapeutic effect. However, there are no data regarding how unintended delays or missed injections of denosumab impact bone mineral density (BMD) response. OBJECTIVE We examined the association of delays in injections of denosumab with BMD change. DESIGN We used electronic medical records from two academic hospitals from 2010 to 2017. PARTICIPANTS Patients older than 45 years of age and used at least 2 doses of 60 mg denosumab. Denosumab adherence was evaluated by the medication coverage ratio (MCR). Good adherence corresponds to a dosing interval ≤7 months (defined by MCR ≥93%), moderate adherence corresponds to an interval of 7 to 10 months (MCR 75%-93%), and poor adherence corresponds to an interval ≥10 months (MCR ≤75%). OUTCOME MEASURES Annualized percent BMD change from baseline at the lumbar spine, total hip, and femoral neck. RESULTS We identified 938 denosumab injections among 151 patients; the mean (SD) age was 69 (10) years, and 95% were female. Patients with good adherence had an annualized BMD increase of 3.9% at the lumbar spine, compared with patients with moderate (3.0%) or poor adherence (1.4%, P for trend .002). Patients with good adherence had an annualized BMD increase of 2.1% at the total hip, compared with patients with moderate (1.3%) or poor adherence (0.6%, P for trend .002). CONCLUSIONS A longer interval between denosumab injections is associated with suboptimal BMD response at both spine and total hip. Strategies to improve the timely administration of denosumab in real-world settings are needed.
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Affiliation(s)
- Houchen Lyu
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- National Clinical Research Center for Musculoskeletal Diseases, Beijing, China
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, China
- Correspondence and Reprint Requests: Houchen Lyu, MD, PhD, Division of Rheumatology, Brigham and Women’s Hospital, 60 Fenwood Road, Boston, Massachusetts 02115, United States. E-mail:
| | - Sizheng S Zhao
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool,, UK
| | - Kazuki Yoshida
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Sara K Tedeschi
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Chang Xu
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Sagar U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Benjamin Z Leder
- Harvard Medical School, Boston, Massachusetts, USA
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel H Solomon
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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14
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D’Oronzo S, Silvestris E, Paradiso A, Cives M, Tucci M. Role of Bone Targeting Agents in the Prevention of Bone Metastases from Breast Cancer. Int J Mol Sci 2020; 21:ijms21083022. [PMID: 32344743 PMCID: PMC7215395 DOI: 10.3390/ijms21083022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 02/06/2023] Open
Abstract
Breast cancer (BC) is the most common malignancy in women worldwide and leads, in more than 70% of patients with advanced disease, to skeleton colonization and formation of bone metastases (BM). This condition implies a severe disability and deterioration of the quality of life, with consequent additional social costs. In recent decades, several studies explored the role of agents acting within the bone microenvironment to counteract BM development, and several bone-targeting agents (BTAs) have been introduced in the clinical practice to manage bone lesions and reduce the risk of skeletal complications. However, long-term exposure to these agents is not free from potential toxicities and needs careful monitoring. In this context, the potential capability to prevent BM onset in selected BC patients, through the early administration of BTAs, has been explored by several researchers, with the belief that “prevention is better than cure” and that, ultimately, metastatic BC is an incurable condition. Here, we revised the mechanisms of BM development in BC as well as the strategies for selecting high-risk patients suitable for early BTA treatment.
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Affiliation(s)
- Stella D’Oronzo
- Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, 70124 Bari, Italy; (M.C.); (M.T.)
- IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy;
- Correspondence: ; Tel.: +39-080-547-8674; Fax: +39-080-547-8831
| | - Erica Silvestris
- Gynecologic Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy;
| | - Angelo Paradiso
- IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy;
| | - Mauro Cives
- Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, 70124 Bari, Italy; (M.C.); (M.T.)
| | - Marco Tucci
- Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, 70124 Bari, Italy; (M.C.); (M.T.)
- IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy;
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15
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Marques P, Appelman-Dijkstra NM, Gelderblom H, Kruit MC, van Furth WR, Pereira AM, Biermasz NR. Denosumab salvage therapy in a patient with a locally advanced and refractory sellar giant cell tumour of bone. Lancet Diabetes Endocrinol 2020; 8:348. [PMID: 32059785 DOI: 10.1016/s2213-8587(20)30041-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 01/16/2020] [Accepted: 01/30/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Pedro Marques
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Leiden, Netherlands
| | | | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, Netherlands
| | - Mark C Kruit
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Wouter R van Furth
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Alberto M Pereira
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Nienke R Biermasz
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Leiden, Netherlands.
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16
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Ramchand SK, David NL, Leder BZ, Tsai JN. Bone Mineral Density Response With Denosumab in Combination With Standard or High-Dose Teriparatide: The DATA-HD RCT. J Clin Endocrinol Metab 2020; 105:dgz163. [PMID: 31674641 PMCID: PMC7112977 DOI: 10.1210/clinem/dgz163] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 08/23/2019] [Accepted: 10/27/2019] [Indexed: 01/22/2023]
Abstract
CONTEXT In the Denosumab and High-Dose Teriparatide Administration (DATA-HD) study, we reported that 15 months of combined high-dose (HD) teriparatide and denosumab increased mean areal bone mineral density (aBMD) at the hip and spine more than combined denosumab and standard-dose (SD) teriparatide. OBJECTIVE In the current analysis, we compare the individual rates of aBMD response between the treatment groups. DESIGN Single-site, open-label, randomized controlled trial in which postmenopausal women received either teriparatide 20-μg daily (SD) or 40-μg daily (HD) given months 0 through 9, overlapped with denosumab 60 mg, given months 3 through 15 (15 months' total duration). The proportion of participants in the SD and HD groups experiencing total hip, femoral neck, and lumbar spine aBMD gains of >3%, >6%, and >9% were compared. PARTICIPANTS Postmenopausal women with osteoporosis completing all study visits (n = 60). MAIN OUTCOME MEASURE(S) aBMD (dual x-ray absorptiometry). RESULTS At the end of the 15-month treatment period, a higher proportion of women in the HD group had aBMD increases >3% (83% vs. 58%, P = .037) and >6% (45% vs. 19%, P = .034) at the total hip, and >3% at the femoral neck (86% vs. 63%, P = .044). At the lumbar spine, >3% response rates were similar, whereas the >6% and >9% response rates were greater in the HD group (100% vs. 79%, P = .012 and 93% vs. 59%, P = .003, respectively). CONCLUSION Compared with the SD regimen, more women treated with the HD regimen achieved clinically meaningful and rapid gains in hip and spine aBMD. These results suggest that this approach may provide unique benefits in the treatment of postmenopausal osteoporosis.
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Affiliation(s)
- Sabashini K Ramchand
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA
- Department of Medicine, Endocrine Unit, Austin Hospital, The University of Melbourne, Victoria, Australia
| | - Natalie L David
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA
| | - Benjamin Z Leder
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA
| | - Joy N Tsai
- Department of Medicine, Endocrine Unit, Massachusetts General Hospital, Harvard University, Boston, MA
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17
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Arase Y, Tsuruya K, Hirose S, Ogiwara N, Yokota M, Anzai K, Deguchi R, Shiraishi K, Shirai T, Kagawa T. Efficacy and Safety of 3-Year Denosumab Therapy for Osteoporosis in Patients With Autoimmune Liver Diseases. Hepatology 2020; 71:757-759. [PMID: 31429969 PMCID: PMC7028030 DOI: 10.1002/hep.30904] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 08/05/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Yoshitaka Arase
- Division of Gastroenterology and Hepatology, Department of Internal MedicineTokai University School of MedicineKanagawaJapan
- Division of Gastroenterology and HepatologyTokai University Oiso HospitalKanagawaJapan
| | - Kota Tsuruya
- Division of Gastroenterology and Hepatology, Department of Internal MedicineTokai University School of MedicineKanagawaJapan
| | - Shunji Hirose
- Division of Gastroenterology and Hepatology, Department of Internal MedicineTokai University School of MedicineKanagawaJapan
| | - Naoki Ogiwara
- Division of Gastroenterology and Hepatology, Department of Internal MedicineTokai University School of MedicineKanagawaJapan
- Division of Gastroenterology and HepatologyTokai University Oiso HospitalKanagawaJapan
| | - Masashi Yokota
- Division of Gastroenterology and Hepatology, Department of Internal MedicineTokai University School of MedicineKanagawaJapan
- Division of Gastroenterology and HepatologyTokai University Oiso HospitalKanagawaJapan
| | - Kazuya Anzai
- Division of Gastroenterology and Hepatology, Department of Internal MedicineTokai University School of MedicineKanagawaJapan
- Division of Gastroenterology and HepatologyTokai University Hachioji HospitalTokyoJapan
| | - Ryuzo Deguchi
- Division of Gastroenterology and Hepatology, Department of Internal MedicineTokai University School of MedicineKanagawaJapan
- Division of Gastroenterology and HepatologyTokai University Oiso HospitalKanagawaJapan
| | - Koichi Shiraishi
- Division of Gastroenterology and Hepatology, Department of Internal MedicineTokai University School of MedicineKanagawaJapan
- Division of Gastroenterology and HepatologyTokai University Tokyo HospitalTokyoJapan
| | - Takayuki Shirai
- Division of Gastroenterology and Hepatology, Department of Internal MedicineTokai University School of MedicineKanagawaJapan
- Division of Gastroenterology and HepatologyTokai University Oiso HospitalKanagawaJapan
| | - Tatehiro Kagawa
- Division of Gastroenterology and Hepatology, Department of Internal MedicineTokai University School of MedicineKanagawaJapan
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18
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Jähn-Rickert K, Wölfel EM, Jobke B, Riedel C, Hellmich M, Werner M, McDonald MM, Busse B. Elevated Bone Hardness Under Denosumab Treatment, With Persisting Lower Osteocyte Viability During Discontinuation. Front Endocrinol (Lausanne) 2020; 11:250. [PMID: 32499755 PMCID: PMC7243474 DOI: 10.3389/fendo.2020.00250] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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] [Received: 12/09/2019] [Accepted: 04/06/2020] [Indexed: 12/14/2022] Open
Abstract
Denosumab is a potent osteoclast inhibitor targeted to prevent osteoporotic bone loss and thereby reduce fractures in the aging population. Recently, an elevated risk of rebound fractures following denosumab discontinuation was identified, unless patients were transitioned to an alternative antiresorptive medication. How denosumab affects the interaction of mechanosensitive osteocytes and bone quality remains unknown. We hypothesized that denosumab influences osteocyte function contributing to bone reorganization and increased fractures during discontinuation. Bone quality and osteocytes were assessed in archived iliac crest bone biopsies obtained from patients with high fracture occurrence from 2011 to 2016. Biopsies were obtained due to high fracture occurrence prior and during osteoporosis therapy from (i) patients with at least two semiannual subcutaneous injections of 60 mg denosumab, (ii) patients with rebound fractures during discontinuation, and (iii) patients of a treatment-naive group. In total, biopsies from 43 individuals were analyzed (mean age, 65.5 ± 12.1 years). Our results showed that during denosumab treatment, iliac cortical bone had a higher bone tissue hardness compared to treatment-naive bone (p = 0.0077) and a higher percentage of mineralized osteocyte lacunae (p = 0.0095). The density of empty osteocyte lacunae was higher with denosumab compared to treatment-naive (p = 0.014) and remained high in trabecular bone during discontinuation (p = 0.0071). We conclude that during denosumab treatment, increased bone hardness may contribute to improved fracture resistance. In biopsies from patients with high fracture occurrence, denosumab treatment reduced osteocyte viability, an effect that persisted during treatment discontinuation. High-resolution imaging of osteocyte viability indicates a role for osteocytes as a potential future mechanistic target to understand rebound bone loss and increased fractures with denosumab discontinuation.
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Affiliation(s)
- Katharina Jähn-Rickert
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eva M. Wölfel
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Björn Jobke
- Telemedicine Clinic/Unilabs, Barcelona, Spain
| | - Christoph Riedel
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Michelle M. McDonald
- Garvan Institute of Medical Research, Bone Microenvironment Group, Darlinghurst, NSW, Australia
| | - Björn Busse
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- *Correspondence: Björn Busse
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Abstract
PURPOSE OF REVIEW Osteoporotic fractures are common and can be devastating. Although multiple different medications with unique mechanisms of action are currently available in our arsenal to attempt to prevent fractures, an ideal opportunity in which to use these medications in combination remains elusive. New data has emerged over the past few years in regards to assessing which medication combinations may be productive and efficacious. RECENT FINDINGS Previous studies performed using different medications to treat osteoporosis in combination proved either not overall beneficial or inconclusive. More recent studies suggest a potential additive and synergistic benefit of certain combination therapies, particularly with the use of denosumab and teriparatide in select situations. SUMMARY The knowledge of modern data as to when the potential use of combination therapy in treating osteoporosis may be useful is critical to the acquisition of proficiency in the ideal management of our patients at highest risk for fracture. Although not recommended yet by current guidelines, the advancement of expertise in this field, both in research studies, and clinical practice, will help us discern how to best consider the use of combination treatment now and in the future.
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Affiliation(s)
- Jennifer J Kelly
- Department of Medicine, Division of Endocrinology and Diabetes, University of Vermont Medical Center, Burlington, Vermont, USA
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20
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Majoor BCJ, Papapoulos SE, Dijkstra PDS, Fiocco M, Hamdy NAT, Appelman-Dijkstra NM. Denosumab in Patients With Fibrous Dysplasia Previously Treated With Bisphosphonates. J Clin Endocrinol Metab 2019; 104:6069-6078. [PMID: 31390018 DOI: 10.1210/jc.2018-02543] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [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: 11/26/2018] [Accepted: 08/01/2019] [Indexed: 01/12/2023]
Abstract
CONTEXT Fibrous dysplasia/McCune-Albright syndrome (FD/MAS) is a rare bone disorder commonly treated with bisphosphonates, but clinical and biochemical responses may be incomplete. OBJECTIVE To evaluate the efficacy and tolerability of the receptor activator of nuclear factor-κB ligand inhibitor denosumab in the treatment of patients with FD/MAS refractory to bisphosphonate therapy. DESIGN Case series. SETTING Academic center of expertise for rare bone diseases. PATIENTS Data were collected from 12 consecutive patients with FD/MAS with persistent pain and increased biochemical markers of bone turnover (BTMs) after long-term treatment with bisphosphonates (median, 8.8 years) and were treated with subcutaneous denosumab 60 mg at 3- or 6-month intervals with a follow-up for at least 12 months. MAIN OUTCOME(S) Sustained reduction of BTMs and bone pain. RESULTS A 60 mg dose of denosumab once every 3 months, but not once every 6 months, induced a sustained reduction of BTMs. After a median treatment period of 15.5 months (range, 12 to 19) serum alkaline phosphatase activity and propeptide of type 1 procollagen levels were respectively reduced from 212 ± 39.4 IU/L to 79 ± 6.0 IU/L (P = 0.004) and from 346.2 ± 111.1 ng/mL to 55.7 ± 16.6 ng/mL (P = 0.023) and normalized in 70% and 75% of patients, respectively. Although not quantitavely measured, 10 patients reported a reduction in bone pain of whom 6 reported complete elimination of pain. Treatment with denosumab was well tolerated. CONCLUSION Our results indicate that 60 mg of denosumab every 3 months is a promising, well-tolerated treatment of most patients with FD/MAS refractory to bisphosphonate therapy. These results together with those of previously published case reports provide the necessary background for the design of a larger, controlled study.
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Affiliation(s)
- Bas C J Majoor
- Department of Internal Medicine, Division of Endocrinology, Center for Bone Quality, Leiden University Medical Center, RC Leiden, Netherlands
- Department of Orthopaedic Surgery, Center for Bone Quality, Leiden University Medical Center, RC Leiden, Netherlands
| | - Socrates E Papapoulos
- Department of Internal Medicine, Division of Endocrinology, Center for Bone Quality, Leiden University Medical Center, RC Leiden, Netherlands
| | - P D Sander Dijkstra
- Department of Orthopaedic Surgery, Center for Bone Quality, Leiden University Medical Center, RC Leiden, Netherlands
| | - Marta Fiocco
- Medical Statistics, Department of Biochemical Data Science, Center for Bone Quality, Leiden University Medical Center, RC Leiden, Netherlands
- Mathematical Institute, Center for Bone Quality, Leiden University Medical Center, RC Leiden, Netherlands
| | - Neveen A T Hamdy
- Department of Internal Medicine, Division of Endocrinology, Center for Bone Quality, Leiden University Medical Center, RC Leiden, Netherlands
| | - Natasha M Appelman-Dijkstra
- Department of Internal Medicine, Division of Endocrinology, Center for Bone Quality, Leiden University Medical Center, RC Leiden, Netherlands
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21
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Kendler DL, Bone HG, Massari F, Gielen E, Palacios S, Maddox J, Yan C, Yue S, Dinavahi RV, Libanati C, Grauer A. Bone mineral density gains with a second 12-month course of romosozumab therapy following placebo or denosumab. Osteoporos Int 2019; 30:2437-2448. [PMID: 31628490 PMCID: PMC6877701 DOI: 10.1007/s00198-019-05146-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [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] [Received: 02/19/2019] [Accepted: 08/23/2019] [Indexed: 11/02/2022]
Abstract
UNLABELLED Romosozumab is a therapy that stimulates bone formation and reduces bone resorption. In this study of postmenopausal women with low BMD, a second course of romosozumab following a period off treatment or on denosumab increased or maintained BMD, respectively, and was well tolerated, providing insight into treatment sequence options. INTRODUCTION In patients with high fracture risk, therapies that stimulate bone formation provide rapid BMD gains; currently available agents, parathyroid hormone receptor agonists, are limited to a 2-year lifetime exposure and generally used for a single treatment course. However, for long-term osteoporosis management, a second treatment course may be appropriate. Romosozumab, a therapy with the dual effect of increasing bone formation and decreasing bone resorption, reduces fracture risk within 12 months. Here, we report efficacy and safety of a second romosozumab course. METHODS In this phase 2, dose-finding study, postmenopausal women with low bone mass (T-score ≤ - 2.0 and ≥ - 3.5) received romosozumab or placebo (month 0-24) followed by placebo or denosumab (month 24-36); participants then received a year of romosozumab (month 36-48). RESULTS Of 167 participants who entered the month 36-48 period, 35 had been initially randomized to romosozumab 210 mg monthly. In participants who received romosozumab 210 mg monthly followed by placebo, a second romosozumab course (n = 19) increased BMD by amounts similar to their initial treatment (month 0-12) at the lumbar spine (12.4%; 12.0%, respectively) and total hip (6.0%; 5.5%, respectively). Following denosumab, a second romosozumab course (n = 16) increased BMD at the lumbar spine (2.3%) and maintained BMD at the total hip. Safety profiles were similar between first and second romosozumab courses. CONCLUSIONS After 12 months off-treatment, a second romosozumab course again led to rapid and large BMD gains. Following denosumab, BMD gains with romosozumab were smaller than with initial treatment. No new safety findings were observed during the second course.
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Affiliation(s)
- D L Kendler
- Department of Medicine, University of British Columbia, 150-943 West Broadway, Vancouver, BC, V5Z 4E1, Canada.
| | - H G Bone
- Michigan Bone and Mineral Clinic, Detroit, MI, USA
| | - F Massari
- Instituto de Investigaciones Metabólicas, Buenos Aires, Argentina
| | | | | | - J Maddox
- Amgen Inc., Thousand Oaks, CA, USA
| | - C Yan
- Amgen Ltd., Cambridge, UK
- Cambridge Statistics Ltd, Cambridge, UK
| | - S Yue
- Amgen Inc., Thousand Oaks, CA, USA
- Atara Biotherapeutics, Westlake Village, CA, USA
| | | | | | - A Grauer
- Amgen Inc., Thousand Oaks, CA, USA
- Corcept Therapeutics, Menlo Park, CA, USA
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22
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Lyu H, Zhao SS, Yoshida K, Tedeschi SK, Xu C, Nigwekar SU, Leder BZ, Solomon DH. Comparison of Teriparatide and Denosumab in Patients Switching From Long-Term Bisphosphonate Use. J Clin Endocrinol Metab 2019; 104:5611-5620. [PMID: 31265071 PMCID: PMC6785688 DOI: 10.1210/jc.2019-00924] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [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: 04/18/2019] [Accepted: 06/26/2019] [Indexed: 12/17/2022]
Abstract
CONTEXT Teriparatide and denosumab are effective treatments for osteoporosis and typically reserved as second-line options after patients have used bisphosphonates. However, limited head-to-head comparative effectiveness data exist between teriparatide and denosumab. OBJECTIVE We compared changes in bone mineral density (BMD) between groups treated with teriparatide or denosumab after using bisphosphonates, focusing on the change in BMD while on either drug over 2 years. DESIGN Observational cohort study using electronic medical records from two academic medical centers in the United States. PARTICIPANTS The study population included osteoporotic patients >45 years who received bisphosphonates >1 year before switching to teriparatide or denosumab. OUTCOME MEASURES Annualized BMD change from baseline at the lumbar spine, total hip, and femoral neck. RESULTS Patients treated with teriparatide (n = 110) were compared with those treated with denosumab (n = 105); the mean (SD) age was 70 (10) years and median duration (interquartile range) of bisphosphonate use was 7.0 (5.6 to 9.7) years. Compared with denosumab users, teriparatide users had higher annualized BMD change at the spine by 1.3% (95% CI 0.02, 2.7%) but lower at the total hip by -2.2% (95% CI -2.9 to -1.5%) and the femoral neck by -1.1% (95% CI -2.1 to -0.1%). Those who switched to teriparatide had a transient loss of hip BMD for the first year, with no overall increase in the total hip BMD over 2 years. CONCLUSIONS Among patients who use long-term bisphosphonates, the decision of switching to teriparatide should be made with caution, especially for patients at high risk of hip fracture.
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Affiliation(s)
- Houchen Lyu
- Division of Rheumatology, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Orthopedics, Chinese People’s Liberation Army General Hospital, Beijing, China
- China National Clinical Research Center of Musculoskeletal Diseases, Beijing, China
- Correspondence and Reprint Requests: Houchen Lyu, MD, PhD, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, 60 Fenwood Road, Suite 6016L, Boston, Massachusetts 02115. E-mail:
| | - Sizheng S Zhao
- Division of Rheumatology, Brigham and Women’s Hospital, Boston, Massachusetts
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, United Kingdom
| | - Kazuki Yoshida
- Division of Rheumatology, Brigham and Women’s Hospital, Boston, Massachusetts
- Departments of Epidemiology and Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Sara K Tedeschi
- Division of Rheumatology, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Chang Xu
- Division of Rheumatology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Sagar U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Benjamin Z Leder
- Harvard Medical School, Boston, Massachusetts
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel H Solomon
- Division of Rheumatology, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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23
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Dupaix JP, Opanova MI, Lee LS, Christensen K. Denosumab-Associated Peri-Implant Atypical Femur Fracture: A Case Report. Hawaii J Health Soc Welf 2019; 78:47-51. [PMID: 31773111 PMCID: PMC6874689] [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] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Bisphosphonate use has been associated with atypical pathologic fracture and slowed bone turnover. We present a case of a bisphosphonate-associated peri-implant atypical femur fracture following use of a recon nail for treatment of a prior bisphosphonate-associated atypical femur fracture.
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Affiliation(s)
| | - Mariya I. Opanova
- Mariya I. Opanova MBBS; 1356 Lusitana St., 6th Fl., Honolulu, HI 96813;
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24
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Abstract
INTRODUCTION Giant cell tumor of bone with pulmonary and bone metastases is exceedingly rare in adolescents. Furthermore, Denosumab and Sunitinib in the treatment of giant cell tumor of bone has never been reported. PATIENT CONCERNS A 16-year-old boy complained of fever, chest tightness, and shortness of breath and back pain for 5 days. DIAGNOSIS Giant cell tumor of bone with pulmonary and bone metastases. INTERVENTIONS The patient underwent 2 surgeries for giant cell tumor of bone located in the spine and received Denosumab to reduce local recurrence and control the metastases. Then Sunitinib was added into treatment strategies after the progressing of metastases. OUTCOMES Within 5 months of Denosumab and Sunitinib, lung metastases were shrinking (stable disease, response evaluation criteria in solid tumors version 1.1). Until now about 4 years into treatment the patient is still survival. Pulmonary and bone metastases are stable. CONCLUSIONS This is a case of multi-center giant cell tumor of bone, it does not only provide a reference to the treatment of similar cases of the clinic but also reflects the limitations of the application of Denosumab in the real world.
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Affiliation(s)
- Guannan Wang
- Department of Medical Oncology, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou
| | - Sujing Jiang
- Department of Radiation and Medical Oncology, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhouqi Li
- Department of Medical Oncology, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou
| | - Ying Dong
- Department of Medical Oncology, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou
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25
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Takahashi M, Ozaki Y, Kizawa R, Masuda J, Sakamaki K, Kinowaki K, Umezu T, Kondoh C, Tanabe Y, Tamura N, Miura Y, Shigekawa T, Kawabata H, Baba N, Iguchi H, Takano T. Atypical femoral fracture in patients with bone metastasis receiving denosumab therapy: a retrospective study and systematic review. BMC Cancer 2019; 19:980. [PMID: 31640606 PMCID: PMC6805596 DOI: 10.1186/s12885-019-6236-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [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: 05/12/2019] [Accepted: 10/03/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND While denosumab has been shown to prevent skeletal-related events in patients with bone metastasis, there is a concern that it may cause atypical femoral fracture (AFF). While AFF has been reported in patients with osteoporosis receiving denosumab, data are scarce in the context of AFF occurring in patients with bone metastasis receiving monthly denosumab therapy. METHODS To analyze the incidence of AFF in patients with bone metastasis, we reviewed the medical records of patients who had received monthly denosumab (120 mg) treatment from May 2012 to June 2017 at any of the three participant institutions. RESULTS The study population consisted of 277 patients who had received a median of 10 doses (range, 1-79) of denosumab. Five patients were diagnosed as having AFF or symptomatic atypical femoral stress reaction (AFSR) needing surgical intervention, representing an incidence rate of 1.8% (95% confidence interval, 0.77-4.2). These patients had received 15, 45, 45, 46 or 47 doses of denosumab, respectively. Four of the patients had received prior zoledronic acid treatment. The results of our analysis suggested that long-term use of denosumab, especially for more than 3.5 years, and prior use of zoledronic acid were risk factors for the development of AFF. CONCLUSIONS We found the AFF events in 5 patients (1.8%) among 277 cancer patients who had received monthly denosumab (120 mg) treatment. Long-term denosumab treatment and prior zoledronic acid treatment were identified as risk factors for the development of AFF.
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Affiliation(s)
- Momoko Takahashi
- Department of Palliative Care, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yukinori Ozaki
- Department of Medical Oncology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan.
| | - Rika Kizawa
- Department of Medical Oncology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Jun Masuda
- Department of Medical Oncology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Kentaro Sakamaki
- Department of Biostatistics and Bioinformatics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | | | - Taro Umezu
- Department of Orthopedic Surgery, Saiseikai Yokohama-shi Tobu Hospital, Tokyo, Kanagawa, Japan
| | - Chihiro Kondoh
- Department of Medical Oncology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Yuko Tanabe
- Department of Medical Oncology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Nobuko Tamura
- Department of Breast and Endocrine Surgery, Toranomon Hospital, Tokyo, Japan
| | - Yuji Miura
- Department of Medical Oncology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | | | - Hidetaka Kawabata
- Department of Breast and Endocrine Surgery, Toranomon Hospital, Tokyo, Japan
| | - Noriyuki Baba
- Department of Breast Oncology, Tokyo Kyosai Hospital, Tokyo, Japan
| | - Haruo Iguchi
- Department of Medical Oncology, Sasebo Kyosai Hospital, Nagasaki, Japan
| | - Toshimi Takano
- Department of Medical Oncology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
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26
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Raux S, Bouhamama A, Gaspar N, Brugières L, Entz-Werlé N, Mallet C, Dijoud F, Gouin F, Marec-Bérard P. Denosumab for treating aneurysmal bone cysts in children. Orthop Traumatol Surg Res 2019; 105:1181-1185. [PMID: 31358461 DOI: 10.1016/j.otsr.2019.04.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [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: 12/05/2018] [Revised: 03/27/2019] [Accepted: 04/11/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Aneurysmal bone cyst (ABC) is a benign tumour whose progression involves the RANK/RANKL signalling pathway. Surgery is the reference standard treatment but carries risks that vary with the site of the tumour. Denosumab is a human monoclonal IgG2 antibody that targets the RANK/RANKL pathway and may therefore hold promise for inhibiting ABC progression. The objective of this study was to evaluate denosumab use in paediatric patients (younger than 18 years) with ABC and to describe the clinical and radiological outcomes, as well as the side effect profile. HYPOTHESIS Denosumab is a viable option in children with ABC refractory to standard treatments. MATERIAL AND METHODS We retrospectively reviewed the medical files of paediatric patients given denosumab to treat ABC in any of 32 centres affiliated with the French Paediatric Cancer Society (Société Française du Cancer de l'Enfant, SFCE) and French Sarcoma Group (Groupe Sarcome Français, GSF-GETO). We identified 5 patients treated between March 2015 and June 2018. Median age was 8 years (range, 7-17 years). Pain was a symptom in all 5 patients and neurological deficits were present in 3 patients. Surgery was performed in 4 patients, either before (n=3) or after (n=1) denosumab therapy; the remaining patient had no surgery. Denosumab was given as monthly injections in a dosage of 70mg/m2 for a median of 12 months (range, 4-23 months). The clinical outcomes and changes in computed tomography and/or magnetic resonance imaging findings were evaluated. RESULTS Abnormalities in calcium and phosphate levels secondary to the ABC occurred in 2 patients. At median of 24 months (range, 0-28 months) after denosumab initiation, all 5 patients were free of pain, and the neurological deficits in 3 patients had improved. Central remineralisation and cortical reconstitution were demonstrated consistently by the imaging studies. DISCUSSION Denosumab is a viable treatment option in selected paediatric patients with inoperable ABC. The immediate adverse effect profile is acceptable. A larger study with a longer follow-up would be welcome to further assess the contribution of denosumab to the treatment of ABC. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Sébastien Raux
- Département de chirurgie infantile, HFME, 59, boulevard Pinel, 69677 Bron, France.
| | | | | | | | - Natacha Entz-Werlé
- Hôpital Mère-Enfant Hautepierre, 1, avenue Molière, 67200 Strasbourg, France
| | - Cindy Mallet
- Hôpital universitaire Robert-Debré, 48, boulevard Sérurier, 75019 Paris, France
| | - Frédérique Dijoud
- Département de chirurgie infantile, HFME, 59, boulevard Pinel, 69677 Bron, France
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27
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Bilezikian JP, Lin CJF, Brown JP, Wang AT, Yin X, Ebeling PR, Fahrleitner-Pammer A, Franek E, Gilchrist N, Miller PD, Simon JA, Valter I, Zerbini CAF, Libanati C, Chines A. Long-term denosumab treatment restores cortical bone loss and reduces fracture risk at the forearm and humerus: analyses from the FREEDOM Extension cross-over group. Osteoporos Int 2019; 30:1855-1864. [PMID: 31201481 PMCID: PMC6719332 DOI: 10.1007/s00198-019-05020-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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] [Received: 07/20/2018] [Accepted: 05/15/2019] [Indexed: 12/16/2022]
Abstract
UNLABELLED Upper limb fractures (including wrist, forearm, and humerus) represent a significant burden among postmenopausal women with osteoporosis. Up to 7 years of treatment with denosumab resulted in an increase in bone mineral density and decrease in fractures in upper limb sites. INTRODUCTION Upper limb (wrist, forearm, and humerus) fractures are a significant burden in osteoporosis, associated with significant morbidity and mortality. Denosumab, a monoclonal antibody against RANK ligand, increases bone mineral density (BMD) and decreases vertebral, nonvertebral, and hip fractures. Here, we evaluated the long-term effect of denosumab treatment on upper limb fracture risk and BMD. METHODS In the FREEDOM trial, subjects were randomized 1:1 to receive every-6-month denosumab 60 mg or placebo subcutaneously for 3 years, after which all subjects could receive denosumab for up to 7 years (Extension). Among placebo subjects who completed FREEDOM and enrolled in the Extension, wrist, forearm, humerus, and upper limb fracture rates and rate ratios between different time periods (FREEDOM years 1-3, Extension years 1-3, and Extension years 4-7) were computed. BMD at the ultradistal radius, 1/3 radius, and total radius was analyzed in a subset of subjects in a BMD substudy. RESULTS This analysis included 2207 subjects (116 in the BMD substudy). Fracture rates decreased over the 7-year Extension; fracture rate ratios between Extension years 4-7 (denosumab) and FREEDOM years 1-3 (placebo) reduced significantly for the wrist (0.57), forearm (0.57), humerus (0.42), and upper limb (0.52; p < 0.05 for all). Percentage increase in BMD from Extension baseline at the ultradistal radius, 1/3 radius, and total radius was significant by Extension year 7 (p < 0.05 for all). CONCLUSIONS Long-term treatment with denosumab decreases upper limb fracture risk and increases forearm BMD, suggesting beneficial effects on both cortical and trabecular bone accruing over time.
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Affiliation(s)
- J P Bilezikian
- College of Physicians and Surgeons, Columbia University, New York, NY, USA.
| | | | - J P Brown
- CHU de Québec Research Centre and Laval University, Quebec City, QC, Canada
| | - A T Wang
- Amgen Inc., Thousand Oaks, CA, USA
| | - X Yin
- Amgen Inc., Thousand Oaks, CA, USA
| | - P R Ebeling
- Department of Medicine, Monash University, Clayton, Australia
| | | | - E Franek
- Mossakowski Medical Research Center, Polish Academy of Sciences, Warsaw, Poland
| | - N Gilchrist
- The Burwood Hospital, Christchurch, New Zealand
| | - P D Miller
- Colorado Center for Bone Research, Golden, CO, USA
| | - J A Simon
- George Washington University, Washington, DC, USA
| | - I Valter
- Center for Clinical and Basic Research, Tallinn, Estonia
| | - C A F Zerbini
- Centro Paulista de Investigação Clinica, São Paulo, Brazil
| | | | - A Chines
- Amgen Inc., Thousand Oaks, CA, USA
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28
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Ban JK, Hao BB, McCarthy L, Guilcher SJT, Cadarette SM. Denosumab utilization among older adults in Ontario: patient characteristics, persistence with therapy, and return to therapy after an extended gap. Osteoporos Int 2019; 30:1865-1872. [PMID: 31317248 DOI: 10.1007/s00198-019-05051-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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] [Received: 11/23/2018] [Accepted: 06/06/2019] [Indexed: 10/26/2022]
Abstract
UNLABELLED We studied 46,797 older adults who initiated denosumab in Ontario, Canada. Patient characteristics remained relatively stable over time and aligned with public reimbursement restrictions. Almost half of patients persisted with therapy for at least 3 years. Fifty-nine percent of patients who discontinued denosumab returned to treatment within 3.6 years. INTRODUCTION The purpose of this study was to describe the characteristics of patients who initiated denosumab and estimate persistence with therapy. METHODS We identified older adults (aged ≥ 66 years) in Ontario who initiated denosumab between 2012/02 and 2015/03 and followed them to 2016/03. Patient characteristics were summarized using medical and pharmacy claims in the year before starting denosumab and osteoporosis drug use considered since 1996/10. Persistence with denosumab and return after discontinuation (> 90-day gap) were estimated using Kaplan-Meier curves. Analyses were stratified by community and long-term care (LTC) residence. RESULTS We identified 46,797 patients (monthly mean = 1263, SD = 187); 97% female, 13% LTC. Community-dwelling patients had a higher prevalence of bone mineral density testing (62% vs. 5%), yet were younger (mean age 78.5 vs. 86.6 years) and had lower prevalence of hip fractures (3% vs. 10%) compared to LTC patients. Eighty-two percent of patients had used osteoporosis medications in the past; 99% of whom took an oral bisphosphonate. Persistence was similar between community-dwelling and LTC patients: 59% persisted ≥ 2 years, 48% ≥ 3 years, and 38% ≥ 4 years, yet a larger proportion of LTC patients returned to denosumab after discontinuation (76% vs. 57%). CONCLUSIONS Denosumab utilization is increasing at a steady rate in Ontario. However, persistence remains a concern given the highly reversible pharmacokinetic profile of denosumab that results in a rapid increased fracture risk following discontinuation. Over 80% of patients had a history of oral bisphosphonate therapy, which may persist in bone despite discontinuing denosumab. Consequently, better understanding of denosumab safety and effectiveness among real-world users is important.
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Affiliation(s)
- J K Ban
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, Canada
| | - B B Hao
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, Canada
| | - L McCarthy
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - S J T Guilcher
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - S M Cadarette
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, Canada.
- ICES, Toronto, ON, Canada.
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA.
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
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29
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Dennison EM, Cooper C, Kanis JA, Bruyère O, Silverman S, McCloskey E, Abrahamsen B, Prieto-Alhambra D, Ferrari S. Fracture risk following intermission of osteoporosis therapy. Osteoporos Int 2019; 30:1733-1743. [PMID: 31175404 DOI: 10.1007/s00198-019-05002-w] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [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] [Received: 02/06/2019] [Accepted: 03/26/2019] [Indexed: 11/27/2022]
Abstract
Given the widespread practice of recommending drug holidays, we reviewed the impact of medication discontinuation of two common anti-osteoporosis therapies (bisphosphonates and denosumab). Trial evidence suggests the risk of new clinical fractures, and vertebral fracture increases when osteoporosis treatment with bisphosphonates or denosumab is stopped. INTRODUCTION The aim of this paper was to review the available literature to assess what evidence exists to inform clinical decision-making with regard to drug holidays following treatment with bisphosphonates (BiP) or denosumab. METHODS Systematic review. RESULTS Differing pharmacokinetics lead to varying outcomes on stopping therapy. Prospective and retrospective analyses report that the risk of new clinical fractures was 20-40% higher in subjects who stopped BiP treatment, and vertebral fracture risk was approximately doubled. Rapid bone loss has been well described following denosumab discontinuation with an incidence of multiple vertebral fractures around 5%. Studies have not identified risk factors for fracture after stopping treatment other than those that provide an indication for treatment (e.g. prior fracture and low BMD). Studies that considered long-term continuation did not identify increased fracture risk, and reported only very low rates of adverse skeletal events such as atypical femoral fracture. CONCLUSIONS The view that patients on long-term treatment with bisphosphonates or denosumab should always be offered a drug holiday is not supported by the existing evidence. Different pharmacokinetic properties for different therapies require different strategies to manage drug intermission. In contrast, long-term treatment with anti-resorptives is not associated with increased risk of fragility fractures and skeletal adverse events remain rare.
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Affiliation(s)
- E M Dennison
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK.
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, University of Sheffield, Sheffield, UK
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
| | - O Bruyère
- World Health Organization Collaborating Center for Public Health Aspects of Musculoskeletal Health and Ageing, Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - S Silverman
- Cedars-Sinai/UCLA Medical Center and OMC Clinical Research Center, Beverly Hills, CA, USA
| | - E McCloskey
- Academic Unit of Bone Metabolism, Department of Oncology and Metabolism, The Mellanby Centre For Bone Research, University of Sheffield, Sheffield, UK
| | - B Abrahamsen
- Department of Medicine, Holbaek Hospital, Holbaek, Denmark
- OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - D Prieto-Alhambra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- GREMPAL Research Group, Idiap Jordi Gol and CIBERFes, Universitat Autonoma de Barcelona and Instituto de Salud Carlos III, Barcelona, Spain
| | - S Ferrari
- Division of Bone Disease, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
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30
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Campanacci L, Sambri A, Medellin MR, Cimatti P, Errani C, Donati DM. A new computerized tomography classification to evaluate response to Denosumab in giant cell tumors in the extremities. Acta Orthop Traumatol Turc 2019; 53:376-380. [PMID: 31253385 PMCID: PMC6819755 DOI: 10.1016/j.aott.2019.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 05/12/2019] [Accepted: 05/26/2019] [Indexed: 12/12/2022]
Abstract
Objectives The aim of this study was to describe the cohort of patients who have been treated with Denosumab as neoadjuvant therapy prior to surgery for aggressive giant cell tumor of bone in the extremities, to evaluate the radiological responses to Denosumab comparing Choi criteria and a newly described computerized tomography (CT) classification, and to evaluate the risk of local recurrence after intralesional curettage or radical excision. Methods We retrospectively evaluated 36 patients (20 females and 16 males; mean age at diagnosis 36 years (range, 18–64)) treated with neoadjuvant Denosumab therapy prior to surgery for aggressive giant cell tumor of bone in the extremities. The radiological responses to Denosumab treatment were analyzed on the preoperative images after the neoadjuvant course with the Choi criteria and with a newly proposed classification based on CT. All these images were independently reviewed by two of the researchers. Surgical intervention methods were noted and local recurrence rates were evaluated. The correlation between radiological response amount and local recurrence were analyzed for both Choi criteria and the new CT classification. Results Denosumab was administered for a mean of 21 weeks (range 7–133). Five patients also had a short postoperative course. According to Choi criteria there was a radiological response in 32 patients (89%), while the new CT classification identified responses in all the 36 patients (100%). The identification of changes after 7 weeks of treatment was higher using the CT classification compared to Choi criteria (p = 0.043 vs p = 0.462). The surgical interventions after Denosumab comprised curettage in 29 patients (74%) and resection in 7 (26%). Local recurrence was higher in patients managed with intralesional curettage than in those treated with en bloc resection (55.1% vs 0%, p < 0.001). At last follow up 19 patients (53%) required en bloc resections. Good responders to Denosumab (type 2C) had lower risk of local recurrence (p = 0.047) after either resection or curettage. Conclusion The new CT classification evaluated more accurately the response to Denosumab. Our experience suggests that the requirement for radical bone resection remains high despite the use of Denosumab. Level of evidence Level IV, Therapeutic Study.
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Sakaguchi K, Ono H, Nakatsukasa K, Ishikawa T, Hasegawa Y, Takahashi M, Niikura N, Koizumi K, Sakurai T, Shigematsu H, Takahashi S, Taira S, Suzuki M, Narui K, Miura D, Yamada K, Yoshimura M, Shioya H, Konishi E, Isao Y, Imai K, Fujikawa K, Taguchi T. Efficacy of denosumab for restoring normal bone mineral density in women receiving adjuvant aromatase inhibitors for early breast cancer. Medicine (Baltimore) 2019; 98:e16770. [PMID: 31393399 PMCID: PMC6708609 DOI: 10.1097/md.0000000000016770] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 11/25/2022] Open
Abstract
BACKGROUND Osteoporosis is a major side effect of aromatase inhibitors (AIs), which are greatly effective in the treatment of breast cancer. However, there are no satisfactory measures against osteoporosis. In this multicenter, randomized, comparative study, we evaluate the efficacy of denosumab for preventing loss of bone mineral density (BMD) induced by adjuvant therapy with AI s in breast cancer patients with normal BMD. PATIENTS AND METHODS The bone loss-suppressing effect of denosumab will be comparatively evaluated in postmenopausal patients scheduled to receive letrozole or anastrozole as a postoperative endocrine therapy for stage I-IIIA hormone-sensitive breast cancer and a control group. Patients will be administered letrozole 2.5 mg or anastrozole 1 mg once a day, and the treatment will be continued for 5 years unless recurrence, secondary cancer, or unacceptable toxicity develops. Patients in the denosumab group will receive a subcutaneous injection of 60 mg of denosumab every 6 months. The primary endpoint is the rate of change in the lumbar spine (L1-L4) BMD, as determined by dual-energy X-ray absorptiometry (DXA), 12 months after the start of the injection. The secondary endpoints were ETHICS AND DISSEMINATION:: The protocol was approved by the institutional review boards of Kyoto Prefectural University of Medicine and all the participating faculties. Written informed consent was obtained from all patients before registration, in accordance with the Declaration of Helsinki. Results of the study will be disseminated via publications in peer-reviewed journals. TRIAL REGISTRATION Clinical Trials.gov Identifier: NCT03324932, Japan Registry of Clinical Trial (jRCT): CRB5180001.
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Affiliation(s)
- Koichi Sakaguchi
- Division of Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, Kawaramachi-hirokoji, Kamigyo-ku, Kyoto
| | - Hisako Ono
- Division of Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, Kawaramachi-hirokoji, Kamigyo-ku, Kyoto
- Drug Discovery Center, Graduate School of Medicine
| | - Katsuhiko Nakatsukasa
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, Nakatsukasa Adachi Clinic, Japan
| | - Takashi Ishikawa
- Department of Biostatistics, Kyoto Prefectural University of Medicine Graduate School of Medical Science
| | | | - Masato Takahashi
- Department of Breast Surgical Oncology, Hirosaki Municipal Hospital
| | - Naoki Niikura
- Department of Breast Surgery, Hokkaido Cancer Center
| | - Kei Koizumi
- Department of Breast and Endocrine Surgery, Tokai University School of Medicine
| | - Teruhisa Sakurai
- Department of Breast Surgery, Hamamatsu University School of Medicine
| | - Hideo Shigematsu
- Department of Surgery, Wakayama Medical University Kihoku Hospital
| | - Shunji Takahashi
- Department of Breast Surgery, National Hospital Organization Kure Medical Center and Chugoku Cancer Center
| | - Shinichiro Taira
- Department of Breast Surgery, National Hospital Organization Kure Medical Center and Chugoku Cancer Center
| | - Masato Suzuki
- Department of Medical Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research
| | - Kazutaka Narui
- Department of Breast Surgery, National Hospital Organization Chiba Medical Center, Yokohama City University Medical Center
| | - Daishu Miura
- Department of Breast and Thyroid Surgery, Yokohama City University Medical Center
| | - Kimito Yamada
- Department of Biostatistics, Kyoto Prefectural University of Medicine Graduate School of Medical Science
| | | | | | - Eiichi Konishi
- Department of Surgical Pathology, Kyoto Prefectural University of Medicine
| | - Yokota Isao
- Department of Surgery, The Jikei University School of Medicine
| | - Kojiro Imai
- Department for Medical Innovation and Translational Medical Science
| | - Kei Fujikawa
- Kyoto Prefectural University of Medicine Graduate School of Medical Science
| | - Tetsuya Taguchi
- Division of Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, Kawaramachi-hirokoji, Kamigyo-ku, Kyoto
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Ferrari S, Butler PW, Kendler DL, Miller PD, Roux C, Wang AT, Huang S, Wagman RB, Lewiecki EM. Further Nonvertebral Fracture Reduction Beyond 3 Years for Up to 10 Years of Denosumab Treatment. J Clin Endocrinol Metab 2019; 104:3450-3461. [PMID: 31125092 DOI: 10.1210/jc.2019-00271] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 02/01/2019] [Accepted: 05/20/2019] [Indexed: 01/22/2023]
Abstract
CONTEXT Evidence for further nonvertebral fracture (NVF) reductions with long-term antiresorptive therapy in osteoporosis is lacking. OBJECTIVE To evaluate NVF risk reduction in subjects receiving ≤10 years of denosumab treatment. DESIGN Phase 3, randomized, placebo-controlled, 3-year Fracture Reduction Evaluation of Denosumab in Osteoporosis Every 6 Months (FREEDOM) trial (NCT00089791) and its open-label 7-year extension (NCT00523341). SETTING One hundred seventy-two study centers worldwide. PATIENTS Women 60 to 90 years, lumbar spine or total hip bone mineral density T-scores <-2.5 (≥-4.0 at both). INTERVENTIONS Subjects randomly assigned 1:1 denosumab 60 mg SC Q6M (long-term) or placebo (crossover) in FREEDOM; eligible subjects could enroll in the extension to receive denosumab 60 mg SC Q6M. MAIN OUTCOME MEASURES NVF Exposure-adjusted subject incidence (per 100 subject-years) during denosumab treatment years 1 to 3 and 4 to 7 (all subjects) and years 4 to 10 (long-term only), and rate ratios (RRs) for years 4 to 7 or 4 to 10 vs 1 to 3. RESULTS Among 4074 subjects (2343 long-term, 1731 crossover), NVF rates (95% CI) in all subjects were 2.15 (1.90 to 2.43) during years 1 to 3 and 1.53 (1.34 to 1.75) during years 4 to 7 of denosumab treatment [RR (95% CI) = 0.72 (0.61 to 0.86); P < 0.001]; in long-term only were 1.98 (1.67 to 2.34) during years 1 to 3 and 1.44 (1.24 to 1.66) during years 4 to 10 [RR = 0.74 (0.60 to 0.93); P = 0.008]. combined osteonecrosis of the jaw and atypical femoral fracture rate was 0.06. CONCLUSIONS Long-term denosumab treatment, >3 and ≤10 years, was associated with further reductions in NVF rates compared with the first 3 years.
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Affiliation(s)
| | | | - David L Kendler
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Paul D Miller
- Colorado Center for Bone Research, Lakewood, Colorado
| | | | | | | | | | - E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, New Mexico
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Borek DM, Smith RC, Gruber CN, Gruber BL. Long-term persistence in patients with osteoporosis receiving denosumab in routine practice: 36-month non-interventional, observational study. Osteoporos Int 2019; 30:1455-1464. [PMID: 31011760 DOI: 10.1007/s00198-019-04963-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 01/28/2019] [Accepted: 03/31/2019] [Indexed: 10/27/2022]
Abstract
UNLABELLED Persistence rates over 36 months with denosumab in patients diagnosed with osteoporosis in a real-world setting were examined, along with baseline patient characteristics predictive of persistence. This study represents the longest observational period with denosumab persistence and shows higher persistence rates when compared to bisphosphonates. INTRODUCTION The study objective was to describe long-term persistence with denosumab among patients treated for osteoporosis in a real-world setting. We also sought to examine patient characteristics predictive of persistence. Lastly, this study attempted to place the results in context by conducting a literature review of published persistence data for denosumab. METHODS This retrospective, non-interventional study analyzed 1158 patients from a specialty community private practice to assess patient persistence with denosumab in routine care. Persistence was defined as receiving seven denosumab injections, using an 8-week permissible gap, over 36 months. Non-persistent patients were further investigated retrospectively to identify reasons for discontinuation, when available. RESULTS Demographic analysis showed a population of 1158 patients with mean age 68.4 years old and baseline T-score - 2.7; nearly half of which experienced a prior osteoporosis-related fracture. In a Kaplan-Meier survival analysis, 36-month persistence overall was 50.7%. Net persistence, as defined by receiving seven injections in the allowable time frame, was 64.2% of the cohort. In a multivariate analysis, prior vertebral fractures and recent osteoporosis therapy were associated with higher persistence; age greater than 75 years was associated with non-persistence. Reasons for discontinuation were available in 91.6% of non-persistent patients and categorized to include the ten most common explanations. CONCLUSION This study to our knowledge represents the longest continuous observational period providing data on denosumab persistence in a real-world setting. The total persistence noted is quite robust when compared to bisphosphonates and is within the upper range of prior published studies of denosumab with shorter observation periods.
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Affiliation(s)
- D M Borek
- City College of New York, New York, NY, USA
| | - R C Smith
- State University of New York at Binghamton, Binghamton, NY, USA
| | - C N Gruber
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - B L Gruber
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Long Island Regional Arthritis and Osteoporosis Care, PC, Babylon, NY, USA.
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Lamy O, Fernández-Fernández E, Monjo-Henry I, Stoll D, Aubry-Rozier B, Benavent-Núñez D, Aguado P, Gonzalez-Rodriguez E. Alendronate after denosumab discontinuation in women previously exposed to bisphosphonates was not effective in preventing the risk of spontaneous multiple vertebral fractures: two case reports. Osteoporos Int 2019; 30:1111-1115. [PMID: 30613866 DOI: 10.1007/s00198-018-04820-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [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: 08/21/2018] [Accepted: 12/18/2018] [Indexed: 11/25/2022]
Abstract
At denosumab discontinuation, an antiresorptive agent is indicated to reduce the high bone turnover, the rapid bone loss, and the risk of spontaneous vertebral fractures. We report two cases of postmenopausal women, previously exposed to bisphosphonates, treated with alendronate at denosumab discontinuation. Alendronate was ineffective to avoid spontaneous clinical vertebral fractures. They presented three and nine spontaneous vertebral fractures 8 and 12 months after denosumab discontinuation, respectively. Ineffectiveness of alendronate was attributed to insufficient control of the rebound as assessed by B-crosslaps measures in the first case, and partially to the high risk of fractures in the later. In both situations, the increased fracture risk may have favoured these new fractures. It is urgent to define effective therapeutic strategies to avoid spontaneous vertebral fractures after denosumab discontinuation.
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Affiliation(s)
- O Lamy
- Center of Bone Diseases, Bone and Joint Department, Lausanne University Hospital, Lausanne, Switzerland.
- Service of Internal Medicine, CHUV, Lausanne University Hospital, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland.
| | | | - I Monjo-Henry
- Service of Rheumatology, La Paz University Hospital, Madrid, Spain
| | - D Stoll
- Center of Bone Diseases, Bone and Joint Department, Lausanne University Hospital, Lausanne, Switzerland
| | - B Aubry-Rozier
- Center of Bone Diseases, Bone and Joint Department, Lausanne University Hospital, Lausanne, Switzerland
| | - D Benavent-Núñez
- Service of Rheumatology, La Paz University Hospital, Madrid, Spain
| | - P Aguado
- Service of Rheumatology, La Paz University Hospital, Madrid, Spain
| | - E Gonzalez-Rodriguez
- Center of Bone Diseases, Bone and Joint Department, Lausanne University Hospital, Lausanne, Switzerland
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital, Lausanne, Switzerland
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Gonzalez Rodriguez E, Lamy O, Aubry-Rozier B, Stoll D, Uebelhart B. [How to manage the rebound effect at denosumab discontinuation and avoid multiple vertebral fractures?]. Rev Med Suisse 2019; 15:831-835. [PMID: 30994986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Denosumab discontinuation is associated with a severe rebound effect combining elevation of bone remodeling markers for two years and loss of the gained bone density. In the absence of a potent bisphosphonate prescription at denosumab discontinuation, multiple vertebral fractures are frequent. The median number of vertebral fractures is 5, within 7 to 20 months (median 11) after the last denosumab injection. A potent bisphosphonate prescribed at denosumab discontinuation may reduce this risk. This strategy requires close monitoring of bone remodeling markers and adjustment of treatment if bone remodeling is not controlled.
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Affiliation(s)
- Elena Gonzalez Rodriguez
- Centre des maladies osseuses, Département de l'appareil locomoteur, CHUV, 1011 Lausanne
- Service d'endocrinologie, diabétologie et métabolisme, Département de médecine, CHUV, 1011 Lausanne
| | - Olivier Lamy
- Centre des maladies osseuses, Département de l'appareil locomoteur, CHUV, 1011 Lausanne
- Service de médecine interne, Département de médecine, CHUV, 1011 Lausanne
| | - Bérengère Aubry-Rozier
- Centre des maladies osseuses, Département de l'appareil locomoteur, CHUV, 1011 Lausanne
- Service de rhumatologie, Département de l'appareil locomoteur, CHUV, 1011 Lausanne
| | - Delphine Stoll
- Centre des maladies osseuses, Département de l'appareil locomoteur, CHUV, 1011 Lausanne
| | - Brigitte Uebelhart
- Service des maladies osseuses, Département de médecine interne, HUG, 1211 Genève 14
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Moretti A, de Sire A, Curci C, Toro G, Gimigliano F, Iolascon G. Effectiveness of denosumab on back pain-related disability and quality-of-life in patients with vertebral fragility fractures. Curr Med Res Opin 2019; 35:151-155. [PMID: 30406685 DOI: 10.1080/03007995.2018.1545636] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [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: 02/08/2023]
Abstract
Background: Denosumab is a fully human IgG2 monoclonal antibody that, neutralizing the receptor activator of nuclear factor kappa-Β ligand (RANKL), inhibits the osteoclast-mediated bone resorption. It is yet to be defined if denosumab can reduce osteoporosis-related disability and improve health-related quality-of-life (HRQoL) in patients with fragility fractures.Objective: To assess the effectiveness of denosumab in reducing back pain related disability and improving HRQoL in osteoporotic post-menopausal women with vertebral fractures.Research design and methods: A real practice prospective study was carried out, enrolling women over 50 years with a post-menopausal osteoporosis that experienced at least one vertebral fracture receiving subcutaneous denosumab (60 mg, every 6 months), calcium carbonate (500-1000 mg/day) and cholecalciferol (800 IU/day) for 1 year. Back pain related disability was assessed as the primary outcome using the Spine Pain Index (SPI); secondary outcomes were: SF-12 (Physical Health Composite Score, PCS, and Mental Health Composite Score, MCS), and EuroQol-5D (EuroQol-5D-3L index and EuroQol-Visual Analog Scale, EQ-VAS). All outcome measures were assessed at baseline (T0), after 6 months (T1), and after 12 months (T2) of treatment. Trabecular Bone Score (TBS), lumbar spine (LS) and femoral neck (FN) BMD at T0 and T2 were also evaluated.Results: This study included 140 post-menopausal women, mean age = 70.60 (SD = 8.81) years. There were statistically significant differences after 12 months (T2-T0) in all outcomes assessed: SPI (p < 0.001), SF-12 PCS (p < 0.001), SF-12 MCS (p < 0.001), EQ-5D-3L index (p = 0.039), and EQ-VAS (p = 0.003). Moreover, there was a significant improvement of both LS BMD (p < 0.001) and FN BMD (p < 0.001). No local or systemic adverse events, including new vertebral fractures, osteonecrosis of the jaw and atypical femur fractures, were reported.Conclusions: The data demonstrated that denosumab was effective in reducing back pain related disability and in improving HRQoL in post-menopausal women with vertebral fractures.
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Affiliation(s)
- Antimo Moretti
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Alessandro de Sire
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Claudio Curci
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesca Gimigliano
- Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
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Tjelum L, Eiken P. [Multiple vertebral fractures after denosumab discontinuation]. Ugeskr Laeger 2018; 180:V12170948. [PMID: 30404716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Recent reports imply, that denosumab discontinuation may lead to an increased risk of multiple vertebral fractures. This is a case report about two postmenopausal women, both with previous fragility fractures, who presented multiple vertebral fractures after denosumab discontinuation. One of the women also had symptomatic hypoparathyroid hypercalcaemia, six months after denosumab was discontinued. We recommend, that denosumab treatment should not be stopped without considering an alternative treatment.
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Nakatsukasa K, Koyama H, Ouchi Y, Sakaguchi K, Fujita Y, Matsuda T, Kato M, Konishi E, Taguchi T. Effect of denosumab administration on low bone mineral density (T-score -1.0 to -2.5) in postmenopausal Japanese women receiving adjuvant aromatase inhibitors for non-metastatic breast cancer. J Bone Miner Metab 2018; 36:716-722. [PMID: 29116414 DOI: 10.1007/s00774-017-0884-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 08/10/2017] [Accepted: 10/19/2017] [Indexed: 12/22/2022]
Abstract
Although adjuvant aromatase inhibitor (AI) therapy is widely used in postmenopausal women with hormone receptor-positive breast cancer, it is known to be associated with bone loss and increased fracture risk. Denosumab, a fully human monoclonal antibody against the receptor activator of nuclear factor-κB ligand, has been shown to protect against AI-induced bone loss. However, the efficacy of denosumab in the treatment of AI-associated bone loss has not been prospectively evaluated in Japan. We prospectively monitored bone mineral density (BMD) of the lumbar spine and bilateral femoral necks in 100 postmenopausal women with hormone receptor-positive postoperative breast cancer of clinical stage I-IIIA in whom treatment with AI as adjuvant endocrine therapy was planned or had been ongoing. Study participants received supplemental calcium and vitamin D every day and denosumab (60 mg) subcutaneously every 6 months. At enrollment, patients were required to have evidence of low bone mass without meeting the criteria for osteoporosis. The primary endpoint was percentage change from baseline in lumbar spine BMD at month 12. At 6 and 12 months, lumbar spine BMD increased by 3.3 and 4.7%, respectively. BMD of the femoral necks also increased. Hypocalcemia of grade ≥2, osteonecrosis of the jaw, and non-traumatic clinical fracture did not occur. In conclusion, semi-annual treatment with denosumab was associated with increased BMD in Japanese women receiving adjuvant AI therapy, regardless of prior AI treatment.
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Affiliation(s)
- Katsuhiko Nakatsukasa
- Department of Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | | | - Yoshimi Ouchi
- Department of Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Kouichi Sakaguchi
- Department of Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Yoshifumi Fujita
- Department of Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | | | | | - Eiichi Konishi
- Department of Surgical Pathology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tetsuya Taguchi
- Department of Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan.
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Abstract
BACKGROUND Although giant cell tumors (GCTs) are benign, their aggressiveness and tendency to recur locally challenge the orthopaedic surgeon's ability to perform joint-preserving intralesional surgery with an acceptably low risk of local recurrence. Denosumab has emerged as a possible medical treatment of GCT because it seems to halt the progression of GCT, alleviate pain, and increase perilesional bone formation, but its exact role has been questioned, and specifically its efficacy and associated complications are not well characterized. QUESTIONS/PURPOSES (1) Does denosumab reduce the risk of recurrence after resection or intralesional surgery? (2) What are the complications associated with the use of denosumab? METHODS Fifty-four patients with 30 primary and 25 recurrent tumors between November 2013 and July 2016 were treated with denosumab after a confirmed histopathologic diagnosis of GCT. Another 17 patients in the same period were treated without denosumab. During the study period, we encouraged the use of denosumab in all patients except those who refused, could not afford it, or where it was contraindicated (eg, in pregnancy). In all patients undergoing intralesional surgery, we arbitrarily planned six doses before surgery. Variations in total doses before surgery were dependent on patient-related factors; in some, we gave less doses because patients expressed the inability to afford any more doses, whereas in some patients, extra doses were added when the patient wished to delay surgery as well as the because of surgeon judgment wherein in some patients, we stopped before six doses when we thought adequate bone had formed for intralesional curettage. The mean number of doses was 6.8 per patient (median, 6; range, 3-17) preoperatively. The minimum followup was 12 months (median, 27 months; range, 12-42 months). Every patient showed improvement clinically in terms of pain and halting of tumor progression within three to four doses. This was seen radiologically as a sharply defined soft tissue mass as well as hazy ossification within the tumor. For a case-matched comparison study, we identified controls as 34 patients undergoing curettage from the retrospective analysis of 68 patients curetted without denosumab between February 2010 and July 2016 matched to 25 denosumab-treated patients in terms of site, size, Campanacci grade, and recurrent versus primary status, and with a minimum 2 years followup for the control group. Fisher's exact test was used for statistical study. Patients undergoing resection were planned for surgery after three doses of denosumab to allow the tumor to solidify and potentially decrease tumor spillage at the time of surgery. The resections could not be case-matched for comparison owing to the smaller numbers. RESULTS We observed 14 recurrences out of the 37 curetted tumors (38%). In the case-matched analysis, 11 of 25 patients in the denosumab-treated curettage group had recurrences (44%) compared with seven of 34 (21%) in the nondenosumab-treated control group. The risk of denosumab-treated patients experiencing local recurrence as compared with the nondenosumab-treated patients was nonsignificant with a two-tailed p value of 0.085 (significance at p < 0.05) as derived from Fisher's exact test (odds ratio, 3.03; 95% confidence interval, 0.96-9.54). There was no recurrence in the resection group. Because we do not have a control group for resection, we are unable to comment on the importance of this finding. One major complication that we observed was a recurrence with malignant transformation in a patient with a proximal humeral GCT. We did not observe any other complications related to the denosumab therapy. CONCLUSIONS Although we could not demonstrate a higher risk of local recurrence with preoperative denosumab for intralesional surgery in the dose and frequency we administered, we advise caution in its routine use for intralesional procedures because it may be important to curette up to margins on pretreatment imaging owing to the potential residual tumor within the denosumab-mediated thick bony shell, which may result in local recurrence. We believe that denosumab treatment before resection of a large tumor aids resection without tumor spillage, particularly where important structures like the neurovascular bundle are dissected away from the tumor margin, although we cannot confirm that it helps lower the incidence of recurrence. We are concerned regarding the malignancy-causing potential from our observation in one patient as well as reports of this by others and recommend judicious use of this drug in patients with GCT. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Manish G Agarwal
- M. G. Agarwal, M. K. Gundavda, R. Reddy, Orthopedic Oncology, PD Hinduja Hospital and Medical Research Center, Mumbai, India R. Gupta, Orthopedic Oncology, Fortis Hospital Mohali, India
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Ijuin A, Yoshikata H, Asano R, Tsuburai T, Kikuchi R, Sakakibara H. Teriparatide and denosumab treatment for pregnancy and lactation-associated osteoporosis with multiple vertebral fractures: A case study. Taiwan J Obstet Gynecol 2018; 56:863-866. [PMID: 29241936 DOI: 10.1016/j.tjog.2017.10.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2017] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Pregnancy and lactation-associated osteoporosis (PLO) is a rare disease, which can lead to vertebral fractures in women of reproductive age. No treatment strategy for PLO has been established. Here we report a case of PLO treated with teriparatide followed by denosumab, in which remarkable improvement in bone mineral density (BMD) was achieved. CASE REPORT A 27-year-old woman experienced severe back pain two weeks after her first delivery. PLO was diagnosed from her low BMD and multiple vertebral compression fractures. She was treated with teriparatide for 6 months, followed by denosumab. After 1 year, her BMD increase from baseline was 16.5% in L2∼4 and her pain had been relieved. CONCLUSION In addition to weaning, administration of teriparatide followed by denosumab led to remarkable improvement in the patient's symptoms and BMD. Therefore, we regard this method as a promising choice for the treatment of PLO.
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Affiliation(s)
- Akifumi Ijuin
- Department of Obstetrics and Gynecology, Yokohama City University Hospital, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Hiromi Yoshikata
- Department of Obstetrics and Gynecology, Yokohama City University Hospital, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan; Yoshikata Obstetrics and Gynecology Clinic, 2430, Kozukue-cho, Kohoku-ku, Yokohama, Kanagawa, 222-0036, Japan
| | - Ryoko Asano
- Department of Obstetrics and Gynecology, Yokohama City University Hospital, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Taku Tsuburai
- Department of Obstetrics and Gynecology, Yokohama City University Hospital, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Ritsuko Kikuchi
- Department of Obstetrics and Gynecology, Yokohama City University Hospital, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Hideya Sakakibara
- Department of Obstetrics and Gynecology, Yokohama City University Hospital, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan; Department of Gynecology, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan.
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Tripto-Shkolnik L, Rouach V, Marcus Y, Rotman-Pikielny P, Benbassat C, Vered I. Vertebral Fractures Following Denosumab Discontinuation in Patients with Prolonged Exposure to Bisphosphonates. Calcif Tissue Int 2018; 103:44-49. [PMID: 29396698 DOI: 10.1007/s00223-018-0389-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [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: 10/24/2017] [Accepted: 01/07/2018] [Indexed: 12/23/2022]
Abstract
Denosumab (DMAB) efficacy for treatment of osteoporosis was demonstrated in a pivotal trial with a reduction in vertebral and hip fractures during 3 years, and fracture risk reduction was sustained up to 10 years in an extension study. DMAB causes potent yet reversible inhibition of bone resorption. Bone density declines rapidly upon discontinuation and bone turnover markers increase above baseline in a rebound fashion. Spontaneous multiple vertebral fractures after DMAB discontinuation were recently reported. Prior treatment with bisphosphonates (BP) was postulated to decrease the risk for this alarming phenomenon. We aimed to describe our experience of fractures following DMAB withdrawal with special attention to past history of osteoporosis treatment. A phone survey of physicians engaged in bone metabolism from nine hospitals in Israel was performed. Clinical data of the patients presenting with vertebral fractures upon DMAB discontinuation were summarized and compared to the previously published cases. Nine elderly (74.2 ± 5.3 years) female patients were identified. Most patients had a prolonged prior exposure to BP (7.4 ± 3.2 years). All but one sustained osteoporotic fractures prior to DMAB initiation and their FRAX scores were high. Thirty-six vertebral fractures were identified in nine patients. Eight patients presented with multiple fractures, and most fractures were spontaneous. In line with the previous reports, the timing and severity of the fractures raise concern of DMAB discontinuation effect. Prolonged BP exposure in most of our patients challenges the protective effect hypothesis. Care providers, patients, and regulatory authorities should be aware of the possible risk of DMAB treatment interruption.
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Affiliation(s)
| | - Vanessa Rouach
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | - Yonit Marcus
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | | | - Carlos Benbassat
- Institute of Endocrinology, Assaf Harofeh Medical Center, Tel Aviv, Israel
| | - Iris Vered
- Endocrine Institute, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
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Popp AW, Varathan N, Buffat H, Senn C, Perrelet R, Lippuner K. Bone Mineral Density Changes After 1 Year of Denosumab Discontinuation in Postmenopausal Women with Long-Term Denosumab Treatment for Osteoporosis. Calcif Tissue Int 2018; 103:50-54. [PMID: 29380013 DOI: 10.1007/s00223-018-0394-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [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: 11/11/2017] [Accepted: 01/16/2018] [Indexed: 01/22/2023]
Abstract
The aim of the present study was to document the changes in bone mineral density (BMD) 1 year after denosumab loss-of-effect following long-term treatment with subcutaneous denosumab 60 mg Q6M during 7 or 10 years and in the absence of any treatment with a bone active substance. All postmenopausal women with osteoporosis who participated to the randomized placebo-controlled FREEDOM core trial and its open-label extension at the University Hospital of Bern, Switzerland, and who accepted to undergo off-treatment follow-up during 1 year after discontinuation, were included (N = 12). After 10 years of denosumab, mean lumbar spine (LS) BMD had increased by 21.2% vs. baseline. One year after discontinuation LS BMD had decreased by - 9.1% vs. Year 10, resulting in a net gain of 10.2% vs. baseline. At total hip (TH) and femoral neck (FN), BMD had increased by 8.3 and 8.1% in Year 10 vs. baseline, respectively. 1 Year after discontinuation, BMD had decreased by - 12.7 and - 11.0% vs. Year 10, respectively, corresponding to net BMD losses of - 5.5 and - 3.8% vs. baseline, respectively. Similar albeit less pronounced changes were observed in those treated with denosumab during 7 years. Stopping denosumab after long-term exposure resulted in BMD losses of large order of magnitude at all measured sites, suggesting that treatment duration may predict the rate and amount of bone lost.
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Affiliation(s)
- Albrecht Werner Popp
- Department of Osteoporosis, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Nadshathra Varathan
- Department of Osteoporosis, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Helene Buffat
- Department of Osteoporosis, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Christoph Senn
- Department of Osteoporosis, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Romain Perrelet
- Department of Osteoporosis, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Kurt Lippuner
- Department of Osteoporosis, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
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Ebina K, Hirao M, Hashimoto J, Matsuoka H, Iwahashi T, Chijimatsu R, Etani Y, Okamura G, Miyama A, Yoshikawa H. Impact of switching oral bisphosphonates to denosumab or daily teriparatide on the progression of radiographic joint destruction in patients with biologic-naïve rheumatoid arthritis. Osteoporos Int 2018; 29:1627-1636. [PMID: 29574517 DOI: 10.1007/s00198-018-4492-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 11/23/2017] [Accepted: 03/16/2018] [Indexed: 11/25/2022]
Abstract
UNLABELLED In biologic-naïve female RA patients, switching oral BPs to DMAb significantly reduced radiographic joint destruction compared to continuing oral BPs or switching to TPTD at 12 months, which were significantly associated with a decrease of a bone resorption marker at 6 months. INTRODUCTION The aim of this study was to clarify the effects of switching oral bisphosphonates (BPs) to denosumab (DMAb) or daily teriparatide (TPTD) on the progression of radiographic joint destruction in patients with biologic-naïve rheumatoid arthritis (RA). METHODS A retrospective, case-controlled study involving 90 female RA patients (mean age 68.2 years, 96.7% postmenopausal, disease activity score assessing 28 joints with CRP (DAS28-CRP) 2.4, methotrexate treatment 81.1%, prednisolone treatment 68.9%, and prior BP treatment 44.8 months), who were allocated depending on each patient's and physician's wishes, to (1) the BP-continue group (n = 30), (2) the switch-to-DMAb group (n = 30), or (3) the switch-to-TPTD group (n = 30), was conducted. Patients were retrospectively selected to minimize the difference of possible clinical backgrounds that may affect the joint destruction of RA. The primary endpoint was to clarify the change of the modified total Sharp score (mTSS) from baseline to 12 months. RESULTS After 12 months, the mean changes of the modified Sharp erosion score were significantly lower in the switch-to-DMAb group (0.2 ± 0.1; mean ± standard error) than in the switch-to-TPTD group (1.3 ± 0.5; P < 0.05), and mTSS was significantly lower in the switch-to-DMAb group (0.3 ± 0.2) than in the BP-continue group (1.0 ± 0.3; P < 0.05) and the switch-to-TPTD group (1.7 ± 0.6; P < 0.05). The logistic regression analysis showed that mTSS changes were significantly associated with the percent changes of TRACP-5b at 6 months (β = 0.30, 95% CI = 0.002-0.016; P < 0.01). CONCLUSIONS Changes of systemic bone turnover induced by switching BPs to DMAb or TPTD may affect not only systemic bone mass, but also local joint destruction, and its clinical relevance should be considered comprehensively.
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Affiliation(s)
- K Ebina
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - M Hirao
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - J Hashimoto
- Department of Rheumatology, National Hospital Organization, Osaka Minami Medical Center, 2-1 Kidohigashi, Kawachinagano, Osaka, 586-8521, Japan
| | - H Matsuoka
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - T Iwahashi
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - R Chijimatsu
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Y Etani
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - G Okamura
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - A Miyama
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - H Yoshikawa
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
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Abstract
Romosozumab and denosumab are monoclonal antibodies for the treatment of osteoporosis. Both have a rapid offset of effect resulting in loss of bone density (BMD) gained on-treatment and, in some cases, multiple vertebral fractures following treatment cessation. We recently reported disappointing results from transitioning patients from denosumab to intravenous zoledronate at the time the next denosumab injection is due. The present report re-assesses the role of bisphosphonates following the use of denosumab. In the FRAME trial, osteoporotic women were randomized to romosozumab or placebo for 1 year, then both groups were provided with open-label denosumab for the subsequent 2 years. In women completing this study at our center, we offered treatment with either oral or intravenous bisphosphonates. In the eleven women opting for intravenous treatment, zoledronate was given after a median delay of 65 days from trial-end, in the hope that this might increase skeletal uptake of the drug and, thereby, its efficacy to maintain bone density. In these women, spine BMD was 17.3% above baseline at trial-end, and still 12.3% above baseline a year later, a 73% (CI: 61%, 85%) retention of the treatment benefit. The comparable BMD figures for the total hip were 10.7 and 9.2% above baseline, a 87% (CI: 77%, 98%) retention of treatment effect. In contrast, those not receiving treatment after the conclusion of the FRAME trial lost 80-90% of the BMD gained on-trial in the following 12 months. Women treated with risedronate showed an intermediate response. In the zoledronate group, mean PINP 6 months post-FRAME was 23 ± 4 µg/L and at 12 months it was 47 ± 8 µg/L, suggesting that repeat zoledronate dosing is needed at 1 year to maintain the BMD gains. In conclusion, delaying administration of intravenous bisphosphonate when transitioning from short-term denosumab appears to increase the extent to which the gains in BMD are maintained.
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Affiliation(s)
- Anne M Horne
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Borislav Mihov
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ian R Reid
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
- Department of Endocrinology, Auckland District Health Board, Auckland, New Zealand.
- Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand.
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Ebina K, Hirao M, Hashimoto J, Hagihara K, Kashii M, Kitaguchi K, Matsuoka H, Iwahashi T, Chijimatsu R, Yoshikawa H. Assessment of the effects of switching oral bisphosphonates to denosumab or daily teriparatide in patients with rheumatoid arthritis. J Bone Miner Metab 2018; 36:478-487. [PMID: 28766140 DOI: 10.1007/s00774-017-0861-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [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: 05/04/2017] [Accepted: 07/12/2017] [Indexed: 01/12/2023]
Abstract
The aim of this observational, non-randomized study was to clarify the unknown effects of switching oral bisphosphonates (BPs) to denosumab (DMAb) or daily teriparatide (TPTD) in patients with rheumatoid arthritis (RA). The characteristics of the 194 female patients included in the study were 183 postmenopausal, age 65.9 years, lumbar spine (LS) T score -1.8, femoral neck (FN) T score -2.3, dose and rate of taking oral prednisolone (3.6 mg/day) 75.8%, and prior BP treatment duration 40.0 months. The patients were allocated to (1) the BP-continue group (n = 80), (2) the switch-to-DMAb group (n = 74), or (3) the switch-to-TPTD group (n = 40). After 18 months, the increase in bone mineral density (BMD) was significantly greater in the switch-to-DMAb group than in the BP-continue group (LS 5.2 vs 2.3%, P < 0.01; FN 3.8 vs 0.0%, P < 0.01) and in the switch-to-TPTD group than in the BP-continue group (LS 9.0 vs 2.3%, P < 0.001; FN 4.9 vs 0.0%, P < 0.01). Moreover, the switch-to-TPTD group showed a higher LS BMD (P < 0.05) and trabecular bone score (TBS) (2.1 vs -0.7%; P < 0.05) increase than the switch-to-DMAb group. Clinical fracture incidence during this period was 8.8% in the BP-continue group, 4.1% in the switch-to-DMAb group, and 2.5% in the switch-to-TPTD group. Both the switch-to-DMAb group and the switch-to-TPTD group showed significant increases in LS and FN BMD, and the switch-to-TPTD group showed a higher increase in TBS compared to the BP-continue group at 18 months. Switching BPs to DMAb or TPTD in female RA may provide some useful osteoporosis treatment options.
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Affiliation(s)
- Kosuke Ebina
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Makoto Hirao
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Jun Hashimoto
- Department of Rheumatology, National Hospital Organization, Osaka Minami Medical Center, 2-1 Kidohigashi, Kawachinagano, Osaka, 586-8521, Japan
| | - Keisuke Hagihara
- Department of Kampo Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Masafumi Kashii
- Department of Orthopaedic Surgery, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka, 560-8565, Japan
| | - Kazuma Kitaguchi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hozo Matsuoka
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Toru Iwahashi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Ryota Chijimatsu
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hideki Yoshikawa
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
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Dempster DW, Brown JP, Fahrleitner-Pammer A, Kendler D, Rizzo S, Valter I, Wagman RB, Yin X, Yue SV, Boivin G. Effects of Long-Term Denosumab on Bone Histomorphometry and Mineralization in Women With Postmenopausal Osteoporosis. J Clin Endocrinol Metab 2018; 103:2498-2509. [PMID: 29672714 PMCID: PMC6037073 DOI: 10.1210/jc.2017-02669] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 04/11/2018] [Indexed: 12/13/2022]
Abstract
CONTEXT Denosumab is a potent antiresorptive agent that reduces fractures in postmenopausal women with osteoporosis. OBJECTIVE Determine effects of up to 10 years of denosumab on bone histology, remodeling, and matrix mineralization characteristics. DESIGN AND SETTING International, multicenter, randomized, double-blind trial [Fracture Reduction Evaluation of Denosumab in Osteoporosis Every 6 Months (FREEDOM)] with a long-term open-label extension. PATIENTS Postmenopausal women with osteoporosis (92 women in FREEDOM, 46 in extension) who provided iliac bone biopsies, including 11 who provided biopsies at multiple time points. INTERVENTIONS FREEDOM subjects were randomized 1:1 to subcutaneous denosumab 60 mg or placebo every 6 months for 3 years. Long-term extension subjects continued receiving denosumab, open-label, for 7 additional years. OUTCOMES Bone histology, histomorphometry, matrix mineralization. RESULTS Ten-year denosumab biopsies showed normal histology. Bone histomorphometry indicated normal bone structure and reduced bone remodeling after 10 years of denosumab, similar to levels after 2 and/or 3 and 5 years of denosumab. The degree of mineralization of bone was increased and mineralization heterogeneity was reduced in the denosumab years 2/3 group vs placebo. Changes in these mineralization variables progressed from years 2/3 to year 5 of denosumab, but not thereafter. CONCLUSIONS Denosumab for 2/3, 5, and 10 years was associated with normal histology, low bone remodeling rate, increased matrix mineralization, and lower mineralization heterogeneity compared with placebo. These variables were unchanged from year 5 to year 10. These data, in combination with the maintenance of low fracture rates for up to 10 years as previously reported with denosumab therapy, suggest that strong, prolonged remodeling inhibition does not impair bone strength.
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Affiliation(s)
- David W Dempster
- Department of Pathology and Cell Biology, Columbia University, New York, New York
- Helen Hayes Hospital, West Haverstraw, New York
- Correspondence and Reprint Requests: David W. Dempster, BSc (Hons), PhD, FRMS, Regional Bone Center, Helen Hayes Hospital, Route 9W, West Haverstraw, New York 10993. E-mail:
| | - Jacques P Brown
- Division of Rheumatology, Faculty of Medicine, Laval University and CHU de Quebec Research Centre, Quebec City, Quebec, Canada
| | | | - David Kendler
- Department of Medicine (Endocrinology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Sebastien Rizzo
- Bone and Chronic Diseases, INSERM, UMR 1033, Univ Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Ivo Valter
- Center for Clinical and Basic Research, Tallinn, Estonia
| | | | - Xiang Yin
- Clinical Development, Amgen Inc., Thousand Oaks, California
| | - Susan V Yue
- Clinical Development, Amgen Inc., Thousand Oaks, California
| | - Georges Boivin
- Bone and Chronic Diseases, INSERM, UMR 1033, Univ Lyon, Université Claude Bernard Lyon 1, Lyon, France
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47
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Affiliation(s)
- Elena Tsourdi
- Division of Endocrinology, Diabetes and Metabolic Bone Diseases, Department of Medicine III, Technische Universität Dresden Medical Center, Fetscherstraße 74, 01307, Dresden, Germany.
- Center for Healthy Aging, Technische Universität Dresden Medical Center, Dresden, Germany.
| | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
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Molina Gutiérrez MÁ, Sagastizabal Cardelus B, Lorente Jareño ML, Gutiérrez Díez MDP. [A new radiological image in osteogenesis imperfecta: «Smoke cloud»]. An Pediatr (Barc) 2018; 91:209-211. [PMID: 29866498 DOI: 10.1016/j.anpedi.2018.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 04/22/2018] [Accepted: 05/02/2018] [Indexed: 11/18/2022] Open
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49
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Kuiper BW, Graybill S, Tate JM, Kaufman N, Bersabe D. After the fall: improving osteoporosis treatment following hip fracture. Osteoporos Int 2018; 29:1295-1301. [PMID: 29464276 DOI: 10.1007/s00198-018-4416-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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: 11/07/2017] [Accepted: 01/25/2018] [Indexed: 10/18/2022]
Abstract
UNLABELLED Osteoporotic hip fractures can be life changing and can increase mortality. Treatment of osteoporosis following hip fracture is often delayed. We began offering osteoporosis medication during hospitalization for hip fracture, dramatically increasing the number of patients meeting standard of care. INTRODUCTION Osteoporotic hip fracture is a debilitating condition with major morbidity and mortality implications. Osteoporosis medication given within 90 days of hip fracture improves mortality and reduces risk of future fractures. The aim of this project was to improve rates of timely osteoporosis treatment following fragility hip fracture. METHODS This was a two-step intervention utilizing the Plan-Do-Study-Act cycle, beginning with resident-focused education in cycle 1. In cycle 2, we offered osteoporosis medication to inpatients for hip fracture with help from a new electronic order set. RESULTS Prior to this intervention, 32% of patients received osteoporosis medication within 90 days of fragility hip fracture; this improved to 81% after intervention. CONCLUSIONS Resident education and an electronic order set dramatically improved the percentage of patients meeting standard of care with osteoporosis pharmacotherapy following fragility fracture.
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Affiliation(s)
- B W Kuiper
- Department of Internal Medicine Residency, SAUSHEC, Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, San Antonio, TX, USA.
| | - S Graybill
- Department of Endocrinology, SAUSHEC, Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, San Antonio, TX, USA
| | - J M Tate
- Department of Endocrinology, SAUSHEC, Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, San Antonio, TX, USA
| | - N Kaufman
- Department of Internal Medicine Residency, SAUSHEC, Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, San Antonio, TX, USA
| | - D Bersabe
- Department of Internal Medicine, Wilford Hall Ambulatory Surgical Center, Joint Base San Antonio, Lackland Air Force Base, San Antonio, TX, USA
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50
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Raje N, Roodman GD, Willenbacher W, Shimizu K, García-Sanz R, Terpos E, Kennedy L, Sabatelli L, Intorcia M, Hechmati G. A cost-effectiveness analysis of denosumab for the prevention of skeletal-related events in patients with multiple myeloma in the United States of America. J Med Econ 2018; 21:525-536. [PMID: 29480139 DOI: 10.1080/13696998.2018.1445634] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 01/04/2023]
Abstract
OBJECTIVE A large, pivotal, phase 3 trial in patients with newly diagnosed multiple myeloma (MM) demonstrated that denosumab, compared with zoledronic acid, was non-inferior for the prevention of skeletal-related events (SREs), extended the observed median progression-free survival (PFS) by 10.7 months, and showed significantly less renal toxicity. The cost-effectiveness of denosumab vs zoledronic acid in MM in the US was assessed from societal and payer perspectives. METHODS The XGEVA Global Economic Model was developed by integrating data from the phase 3 trial comparing the efficacy of denosumab with zoledronic acid for the prevention of SREs in MM. SRE rates were adjusted to reflect the real-world incidence. The model included utility decrements for SREs, administration, serious adverse events (SAEs), and disease progression. Drug, administration, SRE management, SAEs, and anti-MM treatment costs were based on data from published studies. For the societal perspective, the model additionally included SRE-related direct non-medical costs and indirect costs. The net monetary benefit (NMB) was calculated using a willingness-to-pay threshold of US$150,000. One-way deterministic and probabilistic sensitivity analyses were conducted. RESULTS From a societal perspective, compared with zoledronic acid, the use of denosumab resulted in an incremental cost of US$26,329 and an incremental quality-adjusted life-year (QALY) of 0.2439, translating into a cost per QALY gained of US$107,939 and a NMB of US$10,259 in favor of denosumab. Results were sensitive to SRE rates and PFS parameters. LIMITATIONS Costs were estimated from multiple sources, which varied by tumor type, patient population, country, and other parameters. PFS and overall survival were extrapolated beyond the follow-up of the primary analysis using fitted parametric curves. CONCLUSION Denosumab's efficacy in delaying or preventing SREs, potential to improve PFS, and lack of renal toxicity make it a cost-effective option for the prevention of SREs in MM compared with zoledronic acid.
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Affiliation(s)
- Noopur Raje
- a Massachusetts General Hospital Cancer Center , Boston , MA , USA
| | | | - Wolfgang Willenbacher
- c Innsbruck University Hospital Internal Medicine V: Hematology & Oncology & OncoTyrol - Center of Personalized Cancer Medicine , Innsbruck , Austria
| | - Kazuyuki Shimizu
- d Department of Hematology/Oncology , National Hospital Organization Higashi Nagoya National Hospital , Nagoya , Japan
| | | | - Evangelos Terpos
- f University of Athens School of Medicine, Alexandra General Hospital , Athens , Greece
| | | | | | | | - Guy Hechmati
- i Global Health Economics, Amgen Inc , Thousand Oaks , CA , USA
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