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Compston J. HIV infection and osteoporosis. BONEKEY REPORTS 2015; 4:636. [PMID: 25709813 PMCID: PMC4325555 DOI: 10.1038/bonekey.2015.3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 01/07/2015] [Indexed: 01/05/2023]
Abstract
In the past two decades, the life expectancy of people living with HIV infection has increased significantly, and osteoporosis has emerged as a significant comorbidity. In addition to traditional risk factors for fracture, specific factors related to HIV infection are also likely to contribute, including antiretroviral therapy. The heterogeneity of the HIV-infected population in terms of age and ethnicity presents many challenges to the prevention and management of bone disease, and further studies are required to establish optimal approaches to risk assessment and treatment.
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Affiliation(s)
- Juliet Compston
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
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Brown TT, Hoy J, Borderi M, Guaraldi G, Renjifo B, Vescini F, Yin MT, Powderly WG. Recommendations for evaluation and management of bone disease in HIV. Clin Infect Dis 2015; 60:1242-51. [PMID: 25609682 DOI: 10.1093/cid/civ010] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Thirty-four human immunodeficiency virus (HIV) specialists from 16 countries contributed to this project, whose primary aim was to provide guidance on the screening, diagnosis, and monitoring of bone disease in HIV-infected patients. Four clinically important questions in bone disease management were identified, and recommendations, based on literature review and expert opinion, were agreed upon. Risk of fragility fracture should be assessed primarily using the Fracture Risk Assessment Tool (FRAX), without dual-energy X-ray absorptiometry (DXA), in all HIV-infected men aged 40-49 years and HIV-infected premenopausal women aged ≥40 years. DXA should be performed in men aged ≥50 years, postmenopausal women, patients with a history of fragility fracture, patients receiving chronic glucocorticoid treatment, and patients at high risk of falls. In resource-limited settings, FRAX without bone mineral density can be substituted for DXA. Guidelines for antiretroviral therapy should be followed; adjustment should avoid tenofovir disoproxil fumarate or boosted protease inhibitors in at-risk patients. Dietary and lifestyle management strategies for high-risk patients should be employed and antiosteoporosis treatment initiated.
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Affiliation(s)
- Todd T Brown
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer Hoy
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
| | - Marco Borderi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna
| | - Giovanni Guaraldi
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Boris Renjifo
- Global Medical Affairs Virology, Global Pharmaceutical Research and Development, AbbVie, North Chicago, Illinois
| | - Fabio Vescini
- Endocrinology and Metabolism Unit, University Hospital "Santa Maria della Misericordia," Udine, Italy
| | - Michael T Yin
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - William G Powderly
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri
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Effects of randomized rosuvastatin compared with placebo on bone and body composition among HIV-infected adults. AIDS 2015; 29:175-82. [PMID: 25396266 DOI: 10.1097/qad.0000000000000526] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Statins have a beneficial effect on bone mineral density (BMD) and lean mass in some studies of HIV-uninfected adults; however, this has never been investigated in the setting of HIV infection. DESIGN HIV-infected individuals on stable antiretroviral therapy with a low-density lipoprotein cholesterol level of 130 mg/dl or less and evidence of heightened immune activation or inflammation were randomized to rosuvastatin 10 mg daily or placebo for 96 weeks. METHODS This was a prespecified interim analysis at 48 weeks. Between-group and within-group differences were compared; multivariable regression models were constructed. RESULTS Seventy-two individuals were randomized to statin therapy and 75 to placebo. Modest 48-week relative increases in trochanter BMD [0.9%; 95% confidence interval (95% CI) -0.9 to 0.6] and total hip BMD (0.6%; 95% CI 0.0-1.1) in the statin arm were significantly greater than placebo (P < 0.05). The relationship between statin use and total hip BMD change was robust to adjustment of age, sex, race and smoking status (P = 0.02) and strengthened by inclusion of baseline (P = 0.01) and week 48 change in soluble tumour necrosis factor-α receptor (sTNFR)-1 (P = 0.009). Relative increases in total body, trunk and limb fat were similar between statin and placebo arms (P ≥ 0.58). Although a significant gain in leg lean mass was seen in the statin arm, this was not significantly different compared with placebo (P = 0.36). CONCLUSION The improvements seen in total hip BMD after 48 weeks of rosuvastatin therapy support further potential benefits of statin therapy in HIV, beyond a reduction of cardiovascular risk.
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Abstract
Concern has been raised that HIV infection, its treatment, or both adversely affect skeletal health. Cross-sectional studies show that bone mineral density (BMD) is 3-5% lower in patients infected with HIV than in uninfected controls, but patients with HIV infection are, on average, 5 kg lighter than uninfected people. After this weight difference is accounted for, BMD differences are smaller and not clinically relevant. Longitudinal studies show short-term BMD loss of 2-4% over 1-2 years when antiretroviral therapy is started, followed by longer periods of BMD increase or stability. Losses are greatest with treatment regimens that contain tenofovir. Patients infected with HIV have slightly higher fracture rates than controls, but the increased risk of fracture is substantially attenuated by adjustment for traditional risk factors for fracture. These reassuring findings suggest that management of skeletal health in HIV should follow guidelines for the general population. In general, effective antiretroviral treatment and avoidance of undernutrition are the two most important factors for maintenance of skeletal health in patients infected with HIV.
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Affiliation(s)
- Mark J Bolland
- Department of Medicine, University of Auckland, Auckland, New Zealand.
| | - Andrew Grey
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Ian R Reid
- Department of Medicine, University of Auckland, Auckland, New Zealand
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Soriano R, Herrera S, Nogués X, Diez-Perez A. Current and future treatments of secondary osteoporosis. Best Pract Res Clin Endocrinol Metab 2014; 28:885-94. [PMID: 25432359 DOI: 10.1016/j.beem.2014.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Osteoporosis is commonly associated with menopause and ageing. It can, however, also be caused by diseases, lifestyle, genetic diseases, drug therapies and other therapeutic interventions. In cases of secondary osteoporosis, a common rule is the management of the underlying condition. Healthy habits and calcium and vitamin D supplementation are also generally advised. In cases of high risk of fracture, specific antiosteoporosis medications should be prescribed. For most conditions, the available evidence is limited. Special attention should be paid to possible contraindications of drugs used for the treatment of postmenopausal or senile osteoporosis. Bisphosphonates are the most widely used drugs in secondary osteoporosis, and denosumab or teriparatide have been also assessed in some cases. Important research is needed to develop more tailored strategies, specific to the peculiarities of the different types of secondary osteoporosis.
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Affiliation(s)
- Raquel Soriano
- Department of Internal Medicine, Hospital del Mar, Spain; Institut Hospital del Mar d'Investigacions Mèdiques, Spain; Autonomous University of Barcelona, Spain; RETICEF, Instituto Carlos III, Spain.
| | - Sabina Herrera
- Department of Internal Medicine, Hospital del Mar, Spain; Institut Hospital del Mar d'Investigacions Mèdiques, Spain; Autonomous University of Barcelona, Spain; RETICEF, Instituto Carlos III, Spain.
| | - Xavier Nogués
- Department of Internal Medicine, Hospital del Mar, Spain; Institut Hospital del Mar d'Investigacions Mèdiques, Spain; Autonomous University of Barcelona, Spain; RETICEF, Instituto Carlos III, Spain.
| | - Adolfo Diez-Perez
- Department of Internal Medicine, Hospital del Mar, Spain; Institut Hospital del Mar d'Investigacions Mèdiques, Spain; Autonomous University of Barcelona, Spain; RETICEF, Instituto Carlos III, Spain.
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Escota GV, Cross S, Powderly WG. Vitamin D and calcium abnormalities in the HIV-infected population. Endocrinol Metab Clin North Am 2014; 43:743-67. [PMID: 25169565 DOI: 10.1016/j.ecl.2014.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The prevalence of vitamin D deficiency among HIV-infected persons is substantial and comparable to the general population. The factors associated with vitamin D deficiency are similar for both populations but additional factors (ie, use of certain antiretroviral agents) also contribute to vitamin D deficiency among HIV-infected persons. The adverse outcomes associated with vitamin D deficiency considerably overlap with non-AIDS defining illnesses (NADIs) that are increasingly becoming widespread in the aging HIV-infected population. However, there is scant evidence to support any causal inference. Further studies are warranted as efforts to identify and address modifiable risk factors contributing to NADIs continue.
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Affiliation(s)
- Gerome V Escota
- Division of Infectious Diseases, Washington University School of Medicine, 660 South Euclid, St Louis, MO 63110, USA
| | - Sara Cross
- Division of Infectious Diseases, University of Tennessee Health Sciences Center, 956 Court Avenue, E336 Coleman Building, Memphis, TN 38163, USA
| | - William G Powderly
- Division of Infectious Diseases, Washington University School of Medicine, 660 South Euclid, St Louis, MO 63110, USA.
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Compston J. Osteoporosis and fracture risk associated with HIV infection and treatment. Endocrinol Metab Clin North Am 2014; 43:769-80. [PMID: 25169566 DOI: 10.1016/j.ecl.2014.05.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Osteoporosis has emerged as an important co-morbidity of HIV infection and a modest increase in fracture risk has been documented. Bone loss from the spine and hip occurs after initiation of antiretroviral therapy but most data indicate that bone mineral density is stable in HIV-infected individuals established on long-term antiretroviral therapy. Assessment of fracture probability should be performed in individuals who have clinical risk factors for fracture. Adequate dietary calcium intake and vitamin D status should be ensured and in individuals with a high fracture probability, bisphosphonate therapy may be appropriate.
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Affiliation(s)
- Juliet Compston
- Department of Medicine, Addenbrookes Hospital, Cambridge Biomedical Campus, Box 157, Cambridge CB2 0QQ, UK.
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Lambert AA, Drummond MB, Mehta SH, Brown TT, Lucas GM, Kirk GD, Estrella MM. Risk factors for vitamin D deficiency among HIV-infected and uninfected injection drug users. PLoS One 2014; 9:e95802. [PMID: 24756000 PMCID: PMC3995810 DOI: 10.1371/journal.pone.0095802] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 03/29/2014] [Indexed: 12/31/2022] Open
Abstract
Introduction Vitamin D deficiency is highly prevalent and is associated with bone disease, cardiovascular disease, metabolic syndrome and malignancy. Injection drug users (IDUs), with or without HIV infection, are at risk for these conditions; however, limited data on vitamin D deficiency exist in this population. We determined the prevalence and correlates of vitamin D deficiency among urban IDUs in the AIDS Linked to the IntraVenous Experience (ALIVE) Study cohort. Methods For this cross-sectional sub-study, vitamin D deficiency was defined as a serum 25(OH)-vitamin D level <20 ng/mL. Multivariable logistic regression was used to identify factors independently associated with vitamin D deficiency. Results Of 950 individuals analyzed, 29% were HIV-infected. The median age was 49 years; 65% were male, and 91% were black. The median vitamin D level was 13.5 ng/mL (IQR, 9.0–20.3); 74% were deficient (68% in HIV-infected vs. 76% in HIV-uninfected, p = 0.01). Non-black race, fall/winter season, multivitamin intake, higher serum albumin, HCV seropositivity and HIV-infection were associated with significantly lower odds of vitamin D deficiency. Conclusions Vitamin D deficiency is prevalent among IDUs. Notably, HIV-infected IDUs were less likely to be vitamin D deficient. Higher vitamin D levels were associated with multivitamin intake and with higher albumin levels, suggesting that nutritional status contributes substantially to deficiency. The association between HCV serostatus and vitamin D level remains unclear. Further investigation is needed to define the clinical implications of the heavy burden of vitamin D deficiency in this high-risk, aging population with significant co-morbidities.
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Affiliation(s)
- Allison A. Lambert
- Department of Medicine, Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
| | - M. Bradley Drummond
- Department of Medicine, Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Shruti H. Mehta
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Todd T. Brown
- Department of Medicine, Division of Endocrinology and Metabolism, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Gregory M. Lucas
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Gregory D. Kirk
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Michelle M. Estrella
- Department of Medicine, Division of Nephrology, Johns Hopkins University, Baltimore, Maryland, United States of America
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Relationships between inflammation, immune activation, and bone health among HIV-infected adults on stable antiretroviral therapy. J Acquir Immune Defic Syndr 2014; 65:290-8. [PMID: 24525466 DOI: 10.1097/qai.0000000000000005] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The aim was to determine the association between bone health and inflammation, T-cell activation, and monocyte activation among HIV-infected persons on stable antiretroviral therapy. METHODS We performed a cross-sectional analysis of all the subjects enrolling in the Stopping Atherosclerosis and Treating Unhealthy bone with RosuvastatiN in HIV trial with available skeletal assessments by dual-energy x-ray absorptiometry, inflammation, and immune activation markers. Analyses used were Wilcoxon rank-sum tests, Spearman correlation coefficients, and linear regression. RESULTS One hundred forty-two subjects were included: 78% men, 69% African American, median age 46.3 years, CD4 count 604 cells per microliter, and 77% with undetectable HIV-1 RNA. Twenty-three percent had osteopenia/osteoporosis at the hip, and 21% had this at the lumbar spine. Soluble vascular cell adhesion molecule-1 was correlated with hip (r = -0.22) and spine (r = -0.23) bone mineral density (BMD), and bone turnover markers (r = 0.20-0.33; all P < 0.05). No significant correlations were observed between the BMD and T-cell activation (%CD38HLA-DR on CD4 or CD8 T cells), monocyte activation (CD14CD16, sCD14, and sCD163), or inflammatory markers [interleukin (IL)-6, tumor necrosis factor-α, highly sensitive C-reactive protein, D-dimer, receptor activator of NF-kB ligand, osteoprotegerin, soluble tumor necrosis factor-RI and II]. In regression models including traditional bone risk factors, hip BMD was associated with age, race, and body mass index; spine BMD was associated with race, family history of hip fracture, trunk fat, tenofovir, and HIV RNA; bone resorption (c-terminal collagen crosslinks) was associated with intracellular adhesion molecule-1 and trunk fat; bone formation (P1NP) was associated with soluble vascular cell adhesion molecule-1, trunk and limb fat (P ≤ 0.05). CONCLUSIONS Future studies should evaluate the longitudinal association of the adhesion molecules to further elucidate potential contributory mechanisms of bone loss among HIV-infected persons on stable antiretroviral therapy.
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Documento de consenso: Recomendaciones para el manejo de la enfermedad ósea metabólica en pacientes con virus de la inmunodeficiencia humana. Enferm Infecc Microbiol Clin 2014; 32:250-8. [DOI: 10.1016/j.eimc.2013.07.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 07/03/2013] [Indexed: 12/20/2022]
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Maffezzoni F, Porcelli T, Karamouzis I, Quiros-Roldan E, Castelli F, Mazziotti G, Giustina A. Osteoporosis in Human Immunodeficiency Virus Patients - An Emerging Clinical Concern. EUROPEAN ENDOCRINOLOGY 2014; 10:79-83. [PMID: 29872469 DOI: 10.17925/ee.2014.10.01.79] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 03/06/2014] [Indexed: 12/19/2022]
Abstract
The advent of highly active anti-retroviral therapy (HAART) has significantly improved the survival of human immunodeficiency virus (HIV)-infected patients transforming the HIV infection from a fatal illness into a manageable chronic disease. As the number of older HIV-infected individuals increases, several ageing-related co-morbidities including osteopenia/osteoporosis and fractures have emerged. Patients exposed to HIV infection and its treatment may develop fragility fractures with potential significant impact on quality of life and survival. However, the awareness of HIV-related skeletal fragility is still relatively low and most HIV-infected patients are not investigated for osteoporosis and treated with anti-osteoporotic drugs in daily clinical practice. This article reviews the literature data on osteoporosis and osteopenia in HIV infection, focusing on the pathophysiological, clinical and therapeutic aspects of fragility fractures.
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Affiliation(s)
| | | | | | | | | | | | - Andrea Giustina
- Full Professor, Division of Endocrinology, Department of Clinical and Experimental Sciences, University of Brescia, Italy
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Taras J, Arbess G, Owen J, Guiang CB, Tan DHS. Acceptability of bone antiresorptive therapy among HIV-infected adults at different stages of antiretroviral therapy. Patient Prefer Adherence 2014; 8:1311-6. [PMID: 25284989 PMCID: PMC4181646 DOI: 10.2147/ppa.s67090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
PURPOSE Both HIV infection and antiretroviral therapy (ART) are associated with significant decreases in bone mineral density (BMD) and increased fracture rates. To prepare for a randomized controlled trial of prophylactic bone antiresorptive therapy during ART initiation, we assessed the acceptability of this strategy, bone health knowledge, and fracture risk among HIV-infected adults. METHODS HIV-infected adults with no history of osteoporosis were recruited from one tertiary and one primary care HIV clinic. Participants completed a questionnaire and underwent chart review. The primary outcome was the proportion of respondents expressing interest in taking prophylactic bone antiresorptive therapy in conjunction with ART. RESULTS Of 112 respondents, 25.0% were ART naïve, 23.2% had been taking ART for ≤1 year, and 51.8% had been taking ART for >1 year. Half (51.9%) indicated interest in taking short-course prophylactic bone antiresorptive therapy; this did not differ by ART status (53.6% among ART-naïve, 51.3% among ART-treated; P=0.84, chi-square test). In exploratory multivariable analysis adjusted for ART status, a greater number of pills taken per day was positively associated with this outcome (adjusted odds ratio [OR] =1.12 per pill, 95% confidence limit [CL] =1.01, 1.25), while male sex was inversely associated (adjusted OR =0.05, 95% CL =0.01, 0.24). Among those willing to take therapy, most (80.4%) were willing to do so for "as long as needed" and preferred weekly dosing (70.9%) to daily dosing (12.7%). CONCLUSIONS Half of this sample would be willing to take bone antiresorptive therapy together with ART, with preferences for weekly dosing and for whatever duration may be required. These data will inform the design of future trials to protect bone health in HIV.
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Affiliation(s)
- Jillian Taras
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Gordon Arbess
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Family Medicine, St Michael’s Hospital, Toronto, ON, Canada
| | - James Owen
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Family Medicine, St Michael’s Hospital, Toronto, ON, Canada
| | - Charlie B Guiang
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Family Medicine, St Michael’s Hospital, Toronto, ON, Canada
| | - Darrell H S Tan
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Infectious Diseases, St Michael’s Hospital, Toronto, ON, Canada
- Correspondence: Darrell H S Tan, St Michael’s Hospital, 30 Bond St, 4CC – Room 4-179, Toronto ON, M5B 1W8, Tel +1 416 864 5568, Fax +1 416 864 5310, Email
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Abstract
SummaryThe transformation of human immunodeficiency virus (HIV) from a rapidly fatal disease to a chronic manageable illness has resulted in annual increases in the numbers of people living with HIV. The HIV cohort is therefore ageing, with numbers of older adults with HIV climbing, through both prolonged survival and late acquisition of the disease. Associated with ageing is an accumulation of HIV-associated non-AIDS related co-morbidities, creating a complex patient group affected by multi-morbidity along with polypharmacy, functional decline and complex social issues. With this in mind, this review seeks to explore areas where HIV (diagnosed or undetected) may impact on the work of clinical geriatricians.
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Aberg JA, Gallant JE, Ghanem KG, Emmanuel P, Zingman BS, Horberg MA. Primary care guidelines for the management of persons infected with HIV: 2013 update by the HIV medicine association of the Infectious Diseases Society of America. Clin Infect Dis 2013; 58:e1-34. [PMID: 24235263 DOI: 10.1093/cid/cit665] [Citation(s) in RCA: 209] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Evidence-based guidelines for the management of persons infected with human immunodeficiency virus (HIV) were prepared by an expert panel of the HIV Medicine Association of the Infectious Diseases Society of America. These updated guidelines replace those published in 2009. The guidelines are intended for use by healthcare providers who care for HIV-infected patients. Since 2009, new antiretroviral drugs and classes have become available, and the prognosis of persons with HIV infection continues to improve. However, with fewer complications and increased survival, HIV-infected persons are increasingly developing common health problems that also affect the general population. Some of these conditions may be related to HIV infection itself or its treatment. HIV-infected persons should be managed and monitored for all relevant age- and sex-specific health problems. New information based on publications from the period 2009-2013 has been incorporated into this document.
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Affiliation(s)
- Judith A Aberg
- Division of Infectious Diseases and Immunology, New York University School of Medicine, Bellevue Hospital Center, New York
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Puthanakit T, Siberry GK. Bone health in children and adolescents with perinatal HIV infection. J Int AIDS Soc 2013; 16:18575. [PMID: 23782476 PMCID: PMC3687077 DOI: 10.7448/ias.16.1.18575] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 04/10/2013] [Accepted: 04/16/2013] [Indexed: 01/02/2023] Open
Abstract
The long-term impact on bone health of lifelong HIV infection and prolonged ART in growing and developing children is not yet known. Measures of bone health in youth must be interpreted in the context of expected developmental and physiologic changes in bone mass, size, density and strength that occur from fetal through adult life. Low bone mineral density (BMD) appears to be common in perinatally HIV-infected youth, especially outside of high-income settings, but data are limited and interpretation complicated by the need for better pediatric norms. The potential negative effects of tenofovir on BMD and bone mass accrual are of particular concern as this drug may be used more widely in younger children. Emphasizing good nutrition, calcium and vitamin D sufficiency, weight-bearing exercise and avoidance of alcohol and smoking are effective and available approaches to maintain and improve bone health in all settings. More data are needed to inform therapies and monitoring for HIV-infected youth with proven bone fragility. While very limited data suggest lack of marked increase in fracture risk for youth with perinatal HIV infection, the looming concern for these children is that they may fail to attain their expected peak bone mass in early adulthood which could increase their risk for fractures and osteoporosis later in adulthood.
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Affiliation(s)
- Thanyawee Puthanakit
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- HIVNAT, Thai Red Cross AIDS Research Center, Bangkok, Thailand
| | - George K Siberry
- Maternal and Pediatric Infectious Disease (MPID) Branch, Eunice Kennedy Shriver National Institutes of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
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Abstract
Human immunodeficiency virus (HIV) infection has progressed to a chronic disease and HIV positive individuals are living longer lives. This has lead to an increase in morbidity and mortality due to secondary issues, one being HIV bone disease. HIV infected pediatric and adult populations have a greater incidence in reduction of BMD as compared to the controls. Osteoporosis has been reported to be present in up to 15 % of HIV positive patients. We are starting to understand the mechanism behind the changes in HIV bone disease. Viral proteins interfere with osteoblastic activity either by direct interaction or by the inflammatory process that they induce. Anti-viral management, including highly active antiretroviral therapy (HAART), protease inhibitors, and nucleoside/nucleotide reverse transcriptase inhibitors (NRTI) also are involved in disrupting proper bone metabolism. Vitamin D levels have strong correlation with bone disease in HIV patients, and are dependent not only to chronic disease state, but interaction of pharmacologic management and inflammatory process as well. Work up of the secondary causes of osteopenia and osteoporosis should be undertaken in all patients. DEXA scan is recommended in all post-menopausal women with HIV, all HIV infected men 50 years of age or older and in those with a history of fragility fractures regardless of age or gender. Preventive measures include adequate nutrition, calcium and Vitamin D intake daily, muscle strengthening and balance exercises to increase BMD and reduce fractures. Bisphosphonates are considered to be the first line for the treatment of HIV associated bone disease. This review will describe how the balanced mechanism of bone metabolism is interrupted by the HIV infection itself, the complications that arise from HIV/AIDS, and its treatment options.
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Affiliation(s)
- Aristotle Panayiotopoulos
- Department of Pediatric Endocrinology, Children's Hospital at SUNY Downstate, Kings County Hospital Center, and Infants and Children's Hospital at Maimonides, 977 48th Street, Brooklyn, NY 11219, USA
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Schafer JJ, Manlangit K, Squires KE. Bone health and human immunodeficiency virus infection. Pharmacotherapy 2013; 33:665-82. [PMID: 23553497 DOI: 10.1002/phar.1257] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Low bone mineral density is common among persons with human immunodeficiency virus (HIV) infection, and studies reporting increased fracture rates in this patient population are emerging. The causes of low bone mineral density, osteoporosis, and fractures in persons with HIV are likely multifactorial, involving traditional risk factors, HIV infection, and exposure to antiretroviral treatment. Specific antiretrovirals such as tenofovir may cause a greater loss of bone mineral density compared with other agents and have recently been linked to an increased risk for fracture. As a result, recent treatment guidelines suggest that clinicians consider avoiding tenofovir as initial therapy in postmenopausal women. Evaluating bone mineral density and vitamin D status in persons with HIV may be important steps in identifying those requiring pharmacotherapy; however, the appropriate timing for bone mineral density and vitamin D screening is uncertain, as is the appropriate method of replacing vitamin D in HIV-positive patients who are deficient. Further study is necessary to definitively determine the approach to evaluating bone health and managing low bone mineral density and vitamin D deficiency in patients with HIV infection.
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Affiliation(s)
- Jason J Schafer
- Department of Pharmacy Practice, Jefferson School of Pharmacy, Thomas Jefferson University, Philadelphia, Pennsylvania 19107-5233, USA.
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Abstract
PURPOSE OF REVIEW As patients with HIV are living longer because of effective treatments, rates of comorbid chronic diseases such as bone complications are increasing. There is a growing body of literature showing increased rates of osteopenia and osteporosis in the HIV population. Less is known about the risk of fracture, as well as other bone complications, such as avascular necrosis (AVN). RECENT FINDINGS Increased rates of osteopenia and osteoporosis are seen in the HIV population, likely secondary to an interaction of traditional osteoporotic and HIV-specific risk factors, and possibly the effect of antiretroviral therapy (ART). There are conflicting recent data as to whether the decrease in bone mineral density seen in the HIV population, specifically with particular ART regimens, translates into an increased risk of fracture. Conflicting evidence emerges from recent studies exploring whether supplementation of vitamin D and calcium can prevent the bone loss seen with specific ART regimens. SUMMARY Bone disease is common in the HIV population, and will likely be a medical problem increasingly seen by rheumatologists. The role of ART regimens on bone complications such as fracture and AVN is unclear, and further research in this area as well as possible prevention strategies are needed.
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Pirrone V, Libon DJ, Sell C, Lerner CA, Nonnemacher MR, Wigdahl B. Impact of age on markers of HIV-1 disease. Future Virol 2013; 8:81-101. [PMID: 23596462 PMCID: PMC3625689 DOI: 10.2217/fvl.12.127] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Aging is a complicated process characterized by a progressive loss of homeostasis, which results in an increased vulnerability to multiple diseases. HIV-1-infected patients demonstrate a premature aging phenotype and develop certain age-related diseases earlier in their lifespan than what is seen in the general population. Age-related comorbidities may include the development of bone disease, metabolic disorders, neurologic impairment and immunosenescence. Age also appears to have an effect on traditional markers of HIV-1 disease progression, including CD4+ T-cell count and viral load. These effects are not only a consequence of HIV-1 infection, but in many cases, are also linked to antiretroviral therapy. This review summarizes the complex interplay between HIV-1 infection and aging, and the impact that aging has on markers of HIV-1 disease.
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Affiliation(s)
- Vanessa Pirrone
- Department of Microbiology & Immunology, Drexel University College of Medicine, 245 N 15th Street, New College Building, Philadelphia, PA 19102, USA
- Drexel University College of Medicine, 245 N 15th Street, New College Building, Philadelphia, PA 19102, USA
| | - David J Libon
- Department of Neurology, Drexel University College of Medicine, Philadelphia, PA 19129, USA
| | - Christian Sell
- Department of Pathology, Drexel University College of Medicine, Philadelphia, PA 19129, USA
| | - Chad A Lerner
- Department of Pathology, Drexel University College of Medicine, Philadelphia, PA 19129, USA
| | - Michael R Nonnemacher
- Department of Microbiology & Immunology, Drexel University College of Medicine, 245 N 15th Street, New College Building, Philadelphia, PA 19102, USA
- Drexel University College of Medicine, 245 N 15th Street, New College Building, Philadelphia, PA 19102, USA
| | - Brian Wigdahl
- Department of Microbiology & Immunology, Drexel University College of Medicine, 245 N 15th Street, New College Building, Philadelphia, PA 19102, USA
- Drexel University College of Medicine, 245 N 15th Street, New College Building, Philadelphia, PA 19102, USA
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Abstract
Patients with HIV can develop several complications that involve bone including low bone mineral density and osteoporosis, osteonecrosis, and rarely osteomalacia. Low bone mineral density leading to osteoporosis is the most common bone pathology. This may result from HIV infection (directly or indirectly), antiretroviral toxicity, or as a consequence of other co-morbidities. The clinical relevance of osteoporosis in HIV infection has been uncertain; however, fragility fractures are increasingly reported in HIV-infected patients. Further research is required to understand the pathogenesis of osteoporosis in HIV-infected patients and determine effective management; however, initiation of antiretroviral therapy seems to accelerate (in the short-term) bone demineralization. Tenofovir may be associated with a greater degree of short-term loss of bone density than other antiviral agents and the potential long-term bone dysfunction is unclear. As the HIV-infected population ages, screening for low bone mineral density will become increasingly important.
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Affiliation(s)
- William G Powderly
- School of Medicine and Medical Sciences, University College Dublin, Belfield, Dublin 4, Ireland.
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Pepe J, Isidori AM, Falciano M, Iaiani G, Salotti A, Diacinti D, Del Fiacco R, Sbardella E, Cipriani C, Piemonte S, Romagnoli E, Lenzi A, Minisola S. The combination of FRAX and Ageing Male Symptoms scale better identifies treated HIV males at risk for major fracture. Clin Endocrinol (Oxf) 2012; 77:672-8. [PMID: 22630782 DOI: 10.1111/j.1365-2265.2012.04452.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Osteoporosis and hypogonadism are common in men with HIV infection. Ageing Male Symptoms (AMS) scale measures symptoms related to hypogonadism. FRAX provides 10-year probability of major fractures. We investigated the role of AMS scale combined with FRAX without bone mineral density (BMD), in identifying HIV men with bone fragility. DESIGN Cross-sectional observational study. METHODS Fifty HIV-positive men treated with highly active antiretroviral therapy and 27 controls underwent hormonal evaluation, BMD scan and spine X-ray. The AMS questionnaire was administered. RESULTS Osteoporosis was found in 24·0% of HIV patients and in 3·7% of controls (P = 0·05). In HIV patients, 9 radiological vertebral fractures were found (none in controls, P = 0·04). Calculated free testosterone suggested hypogonadism in 26% of HIV patients vs 4% of controls (P = 0·04); an abnormal AMS score (≥27) was found in 62% HIV patients compared with 41% controls (P = 0·04). ROC curves showed that FRAX for major fracture had a 23% sensitivity and a 100% specificity in identifying HIV patients with bone fragility (P = 0·002, with the threshold of 7% at which bisphosphonate therapy is cost-effective). Considering a value of AMS ≥27, we obtained an 82·6% sensitivity and a 42·9% specificity (P = 0·04). The combination of AMS and FRAX score achieved a 77·3% sensitivity and a 69% specificity (P = 0·02, cut-off 34). CONCLUSION Combination of FRAX (without BMD) and AMS improved sensitivity of FRAX alone in identifying HIV patients at fracture risk, at the expense of reduced specificity.
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Affiliation(s)
- Jessica Pepe
- Department of Internal Medicine and Medical Disciplines, Sapienza University, Rome, Italy.
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Lescoat A, Poinsignon Y, Dos Santos A, Cano Y, Floc'h F, Jardel H. [Vitamin D supplementation: A iatrogenic hypercalcemia concerning an HIV-infected patient with disseminated tuberculosis]. Presse Med 2012; 41:1299-301. [PMID: 22981408 DOI: 10.1016/j.lpm.2012.05.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 05/08/2012] [Accepted: 05/23/2012] [Indexed: 10/27/2022] Open
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Rozenberg S, Lanoy E, Bentata M, Viard JP, Valantin MA, Missy P, Darasteanu I, Roux C, Kolta S, Costagliola, and the ANRS 120 Fosiv D. Effect of alendronate on HIV-associated osteoporosis: a randomized, double-blind, placebo-controlled, 96-week trial (ANRS 120). AIDS Res Hum Retroviruses 2012; 28:972-80. [PMID: 22353022 DOI: 10.1089/aid.2011.0224] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Low bone mineral density (BMD) is common in HIV-infected patients. Bisphosphonates such as alendronate potently inhibit bone resorption and are effective against osteoporosis. The aim of the ANRS 120 Fosivir trial was to evaluate the effect of alendronate on low BMD in HIV-infected patients. HIV-1-infected adults with a t-score≤-2.5 at the lumbar spine and/or total hip, as assessed by dual x-ray absorptiometry, and no other known risk factors for low BMD, were randomized to receive either extended-release alendronate 70 mg weekly or placebo for 96 weeks, with stratification for gender. All the patients also received daily calcium carbonate (500 mg) and vitamin D (400 U). The primary endpoint for efficacy was the percentage change in BMD at the site with a t-score≤-2.5. Forty-four antiretroviral-treated patients (42 men, 2 women) were enrolled. The median age was 45 years, the median CD4 cell count was 422/mm(3), and viral load was <400 copies/ml in 84% of patients. Baseline characteristics were well balanced between the alendronate (n=20) and placebo (n=24) groups. At baseline, 15 patients (75%) in the alendronate group and 17 patients (71%) in the placebo group had a t-score≤-2.5 at the lumbar spine. In the main analysis, BMD at the site with a t-score≤-2.5 increased by 7.1% and 1.0%, respectively, in the alendronate (n=14) and placebo (n=20) groups at week 96 [mean difference, 6.1% (95% CI 2.8 to 9.3); p=0.0003]. Alendronate 70 mg weekly for 96 weeks improves BMD in HIV-1-infected patients on antiretroviral therapy.
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Affiliation(s)
- Sylvie Rozenberg
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Rhumatologie, Paris, France
| | - Emillie Lanoy
- INSERM U943, UPMC University Paris 06 UMR S943, Paris, France
| | - Michelle Bentata
- AP-HP, Hôpital Avicenne, Service de Médecine Interne, Bobigny, France
| | - Jean-Paul Viard
- AP-HP, Hôpital Hotel-Dieu, Centre de Diagnostic et Thérapeutique, Paris, France
| | - Marc Antoine Valantin
- INSERM U943, UPMC University Paris 06 UMR S943, Paris, France
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Service de Maladies Infectieuses, Paris, France
| | - Pascale Missy
- INSERM U943, UPMC University Paris 06 UMR S943, Paris, France
| | | | - Christian Roux
- Université Paris-Descartes, Hôpital Cochin, Département de Rhumatologie, Paris, France
| | - Sami Kolta
- Université Paris-Descartes, Hôpital Cochin, Département de Rhumatologie, Paris, France
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Ross AC, Hileman CO, Brown TT, Fedarko N, Storer N, Labbato D, McComsey GA. Bone effects of rosiglitazone in HIV-infected patients with lipoatrophy. HIV CLINICAL TRIALS 2012; 13:212-21. [PMID: 22849962 DOI: 10.1310/hct1304-212] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Thiazoledinediones increase limb fat in HIV+ patients with lipoatrophy. However, their use in the general population has been associated with bone loss and fracture. We sought to determine the effects of rosiglitazone on bone metabolism in HIV-infected patients. METHODS HIV+ patients with lipoatrophy were randomized to rosiglitazone versus placebo for 48 weeks in a double-blind, placebo-controlled trial. Limb fat, bone mineral density (BMD), bone formation markers (procollagen type 1 amino-terminal propeptide [P1NP], osteocalcin [OC]) and bone resorption markers (C-terminal telopeptide of type I collagen [CTX]) were measured, along with receptor activator for nuclear factor kappa β ligand (RANKL), osteoprotegerin (OPG), and inflammatory cytokines. RESULTS Seventy-one subjects were randomized to rosiglitazone or placebo: 17% female and 51% white. Total BMD did not change significantly in either group. In the rosiglitazone group, P1NP showed statistically significant decreases at 24 and 48 weeks; however, changes compared to placebo were only significant at 24 weeks. OC decreased significantly in the rosiglitazone group at 24 weeks, but there were no between-group differences. CTX, RANKL, or OPG did not change for either group. Multivariable regression within the rosiglitazone arm showed P1NP changes were inversely associated with limb fat changes, protease inhibitors, and tenofovir use. CONCLUSION Rosiglitazone use was associated with decreased bone formation, but it did not alter bone resorption or total BMD. The increase in limb fat that accompanies rosiglitazone use appears to be associated with decreased osteoblast activity. Further studies are needed to determine the effect of thiazoledinediones on bone health in HIV-infected persons.
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Affiliation(s)
- Allison C Ross
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia 30322, USA.
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Cejtin HE. Care of the human immunodeficiency virus-infected menopausal woman. Am J Obstet Gynecol 2012; 207:87-93. [PMID: 22284959 PMCID: PMC3408554 DOI: 10.1016/j.ajog.2011.12.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Revised: 12/07/2011] [Accepted: 12/27/2011] [Indexed: 10/14/2022]
Abstract
More women than ever before are both human immunodeficiency virus infected and menopausal, because of increased survival and more frequent diagnosis in older women. Such a woman has the combined burden of her infection, its treatment, comorbid conditions, and aging. Thus, she is at risk for a variety of problems, such as disorders of bone mineral density and deficiencies in cognitive functioning. In addition to this, she experiences menopause in a unique fashion, with more symptoms and perhaps at an earlier age. The clinician caring for her must take a proactive approach to this multitude of factors that may affect her health and well-being.
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Affiliation(s)
- Helen Elizabeth Cejtin
- Department of Obstetrics and Gynecology, John H. Stroger Hospital of Cook County, Chicago, IL, USA.
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Abstract
In the past 30 years, medical advances for those with human immunodeficiency virus (HIV) have reduced morbidity and mortality to extend life with highly active antiretroviral therapy (HAART) and with the continued development of new therapies. With this success, HIV is being managed chronically, but other health issues of an aging HIV-infected population have emerged. The challenges of treating HIV infection have shifted from AIDS-related mortality improvements to drug-induced disease from HAART, including cardiovascular disease, metabolic disorders, and bone health. Prolonged use of antiretroviral therapy maintaining immune restoration appears to represent additional, ongoing risk factors for the development of these metabolic complications. These drug-related problems continue to challenge patients and clinicians in the management of HIV disease, as well as ongoing research for drug development improvements to minimize these risks. These health risks imposed by HAART must be vigilantly monitored and aggressively addressed to improve the overall health of those treated for HIV infection.
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Affiliation(s)
- E Kelly Hester
- Auburn University Harrison School of Pharmacy, Auburn University, 1321 Walker Building, Auburn, AL 36849, USA.
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78
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Abstract
With the advent of effective antiretroviral therapy (ART), the recognition and management of long-term complications of HIV infection and ART are increasingly important for HIV physicians. Low bone mineral density (BMD) is more common in those with HIV infection and this review will outline therapeutic options for the management of low bone mineral density relevant to HIV-infected populations.
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Walker Harris V, Brown TT. Bone loss in the HIV-infected patient: evidence, clinical implications, and treatment strategies. J Infect Dis 2012; 205 Suppl 3:S391-8. [PMID: 22577213 DOI: 10.1093/infdis/jis199] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Osteoporosis is common in human immunodeficiency virus (HIV)-infected persons. The etiology of osteoporosis in HIV-infected patients is likely multifactorial, involving traditional risk factors such as low body weight, hypogonadism, and smoking, as well as direct effects of chronic HIV infection and antiretroviral therapy. Emerging evidence suggests that the increasing prevalence of osteoporosis in HIV-infected persons translates into a higher risk of fracture, likely leading to excess morbidity and mortality as the HIV-infected population ages. This review addresses the epidemiology of osteoporosis, discusses the causes of low bone mineral density in HIV-infected persons, including the impact of specific antiretroviral therapies, and offers recommendations on screening and treating vitamin D deficiency and osteoporosis.
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Affiliation(s)
- Vanessa Walker Harris
- Division of Endocrinology, Johns Hopkins University School of Medicine,1830 EMonument Street, Baltimore, MD 21287, USA
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Osteoporotic fracture risk associated with cumulative exposure to tenofovir and other antiretroviral agents. AIDS 2012; 26:825-31. [PMID: 22301411 DOI: 10.1097/qad.0b013e32835192ae] [Citation(s) in RCA: 253] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Whereas tenofovir (TDF) exposure has been associated with decreased bone density, it remains unclear whether it is associated with increased risk of osteoporotic fractures. METHODS Patients with any osteoporotic fracture (defined as wrist, vertebral or hip fracture) occurring after HIV diagnosis were identified by International Classification of Diseases - 9th Revision (ICD-9) code in the Veterans Affairs' Clinical Case Registry from 1988 to 2009. Osteoporotic fracture risk associated with cumulative exposure to TDF and other antiretrovirals was examined in univariate analysis and multivariate model 1 (MV1 - controlling for race, age, tobacco use, diabetes, body mass index, and hepatitis C status) and model 2 (MV2 - controlling for MV1 variables + concomitant antiretroviral exposures). RESULTS Among 56,660 patients evaluated, TDF exposure (total 46,062 person-years) was associated with an osteoporotic fracture hazard ratio of 1.080 [95% confidence interval (CI) 1.02-1.15, P < 0.001] in univariate analysis, 1.06 (0.99-1.12) in MV1 and 1.06 (0.99-1.14) in MV2. Among patients entering the cohort in the highly active antiretroviral therapy (HAART) era (n = 32,439), TDF exposure was associated with a yearly hazard ratio for osteoporotic fracture of 1.16 (95% CI 1.08-1.24, P < 0.001) in univariate model, 1.13 (1.05-1.21, P = 0.001) in MV1 and 1.12 (1.03-1.21, P = 0.011) in MV2. Boosted protease inhibitor exposure was associated with hazard ratio of 1.11 (1.05-1.18, P = 0.001) in univariate model, 1.08 (1.01-1.15, P = 0.026) in MV1 and 1.05 (0.97-1.13, P = 0.237) in MV2. Among protease inhibitors, lopinavir/ritonavir (LPV/RTV) had an osteoporotic fracture hazard ratio of 1.09 (CI 1.00-1.20, P = 0.051) in MV2. CONCLUSION Cumulative exposure to TDF and, among protease inhibitors, LPV/RTV was independently predictive of increased risk of osteoporotic fracture in the HAART era.
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The Role of Vitamin D Deficiency in the Pathogenesis of Osteoporosis and in the Modulation of the Immune System in HIV-Infected Patients. Clin Rev Bone Miner Metab 2012. [DOI: 10.1007/s12018-012-9131-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Comparison of bone and renal effects in HIV-infected adults switching to abacavir or tenofovir based therapy in a randomized trial. PLoS One 2012; 7:e32445. [PMID: 22479327 PMCID: PMC3315554 DOI: 10.1371/journal.pone.0032445] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Accepted: 01/26/2012] [Indexed: 11/19/2022] Open
Abstract
Introduction Our objective was to compare the bone and renal effects among HIV-infected patients randomized to abacavir or tenofovir-based combination anti-retroviral therapy. Methods In an open-label randomized trial, HIV-infected patients were randomized to switch from zidovudine/lamivudine (AZT/3TC) to abacavir/lamivudine (ABC/3TC) or tenofovir/emtricitabine (TDF/FTC). We measured bone mass density (BMD) and bone turnover biomarkers (osteocalcin, osteocalcin, procollagen type 1 N-terminal propeptide (P1NP), alkaline phosphatase, type I collagen cross-linked C-telopeptide (CTx), and osteoprotegerin). We assessed renal function by estimated creatinine clearance, plasma cystatin C, and urinary levels of creatinine, albumin, cystatin C, and neutrophil gelatinase-associated lipocalin (NGAL). The changes from baseline in BMD and renal and bone biomarkers were compared across study arms. Results Of 40 included patients, 35 completed 48 weeks of randomized therapy and follow up. BMD was measured in 33, 26, and 27 patients at baseline, week 24, and week 48, respectively. In TDF/FTC-treated patients we observed significant reductions from baseline in hip and lumbar spine BMD at week 24 (−1.8% and −2.5%) and week 48 (−2.1% and −2.1%), whereas BMD was stable in patients in the ABC/3TC arm. The changes from baseline in BMD were significantly different between study arms. All bone turnover biomarkers except osteoprotegerin increased in the TDF/FTC arm compared with the ABC/3TC arm, but early changes did not predict subsequent loss of BMD. Renal function parameters were similar between study arms although a small increase in NGAL was detected among TDF-treated patients. Conclusion Switching to TDF/FTC-based therapy led to decreases in BMD and increases in bone turnover markers compared with ABC/3TC-based treatment. No major difference in renal function was observed. Trial registration Clinicaltrials.gov NCT00647244
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Arpadi SM, McMahon DJ, Abrams EJ, Bamji M, Purswani M, Engelson ES, Horlick M, Shane E. Effect of supplementation with cholecalciferol and calcium on 2-y bone mass accrual in HIV-infected children and adolescents: a randomized clinical trial. Am J Clin Nutr 2012; 95:678-85. [PMID: 22258265 PMCID: PMC3278244 DOI: 10.3945/ajcn.111.024786] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 11/28/2011] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Skeletal abnormalities have been reported in HIV-infected children and adolescents. Although the etiology is not well understood, vitamin D deficiency may be involved. OBJECTIVE The study objective was to evaluate the effect of vitamin D and calcium supplementation on bone mass accrual in HIV-infected youth. DESIGN Perinatally HIV-infected children were randomly assigned to receive vitamin D (100,000 IU cholecalciferol given every 2 mo) and calcium (1 g/d) (supplemented group) or double placebo (placebo group) for 2 y. The total-body bone mineral content (TBBMC), total-body bone mineral density (TBBMD), spine bone mineral content (SBMC), and spine bone mineral density (SBMD) were assessed by using dual-energy X-ray absorptiometry at baseline and at 2 annual follow-up visits. RESULTS Fifty-nine participants, aged 6-16 y, were randomly assigned to either the supplemented (n = 30) or the placebo (n = 29) group. At enrollment, supplemented and placebo groups did not differ with respect to age, sex, dietary intakes of vitamin D and calcium, mean baseline serum 25-hydroxyvitamin D [25(OH)D] concentration, TBBMC, TBBMD, SBMC, or SBMD. Significant increases in serum 25(OH)D were observed in the supplemented group but not in the placebo group. TBBMC, TBBMD, SBMC, and SBMD increased significantly at 1 and 2 y in both groups. No between-group differences were observed at any time before or after adjustment for stage of sexual maturation by mixed linear model analysis. CONCLUSION One gram of calcium per day and oral cholecalciferol at a dosage of 100,000 IU every 2 mo administered to HIV-infected children and adolescents did not affect bone mass accrual despite significant increases in serum 25(OH)D concentrations. This trial was registered at clinicaltrials.gov as NCT00724178.
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Affiliation(s)
- Stephen M Arpadi
- Sergievsky Center, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA.
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Effects of vitamin D deficiency and combination antiretroviral therapy on bone in HIV-positive patients. AIDS 2012; 26:253-62. [PMID: 22112601 DOI: 10.1097/qad.0b013e32834f324b] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES In the era of combination antiretroviral therapy (cART), vitamin D deficiency, low bone mineral density (BMD) and fractures have emerged as subjects of concern in HIV-positive patients. Testing for vitamin D deficiency has been widely adopted in clinical practice even though the benefits of vitamin D supplementation in this population remain uncertain. The objective of this review was to evaluate the evidence for such a strategy. DESIGN Systematic review of the literature on vitamin D deficiency in HIV infection, the effects of cART on vitamin D status, and the effects of vitamin D deficiency and cART on parathyroid hormone (PTH), bone turnover, BMD and the incidence of fractures in HIV-positive patients. METHODS PubMed was used to identify relevant articles up to September 2011. RESULTS Vitamin D deficiency, secondary hyperparathyroidism and low BMD are common in HIV-positive patients. Efavirenz is associated with a reduction in 25-hydroxy vitamin D levels, tenofovir with secondary hyperparathyroidism, and cART with increased bone turnover and low BMD. The clinical significance of low BMD, however, remains unclear, especially in younger patients. Although the incidence of fractures may be increased in HIV-positive patients, the contribution of low BMD and vitamin D deficiency to these fractures is uncertain. Limited data on vitamin D supplementation in HIV-positive patients have shown transient, beneficial effects on PTH, but no effects on BMD. CONCLUSION The benefits of vitamin D supplementation in this population need to be demonstrated before widespread 'test and treat' policies can be recommended as part of routine clinical practice.
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Lima ALLM, de Oliveira PRD, Plapler PG, Marcolino FMDA, de Souza Meirelles E, Sugawara A, Gobbi RG, dos Santos ALG, Camanho GL. Osteopenia and osteoporosis in people living with HIV: multiprofessional approach. HIV AIDS (Auckl) 2011; 3:117-24. [PMID: 22267944 PMCID: PMC3257973 DOI: 10.2147/hiv.s6617] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Increasing bone mineralization abnormalities observed among people living with HIV (PLWHIV) result from various factors relating to the host, the virus, and the antiretrovirals used. Today, HIV infection is considered to be a risk factor for bone mineralization disorders. The test most recommended for diagnosing osteoporosis is measurement of bone mineral density by means of dual energy X-ray absorptiometry at two sites. Osteoporosis treatment has the aims of bone mass improvement and fracture control. A combination of calcium and vitamin D supplementation may reduce the risk of fractures. Antiresorptive drugs act by blocking osteoclastic activity and reducing bone remodeling. On the other hand, bone-forming drugs stimulate osteoblastogenesis, thereby stimulating the formation of bone matrix. Mixed-action medications are those that are capable of both stimulating bone formation and inhibiting reabsorption. Antiresorptive drugs form the group of medications with the greatest quantity of scientific evidence confirming their efficacy in osteoporosis treatment. Physical activity is a health promotion strategy for the general population, but only preliminary data on its real value and benefit among PLWHIV are available, especially in relation to osteoporosis.
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Affiliation(s)
- Ana Lucia Lei Munhoz Lima
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Priscila Rosalba D de Oliveira
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Perola Grimberg Plapler
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Flora Maria D Andrea Marcolino
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Eduardo de Souza Meirelles
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - André Sugawara
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Riccardo Gomes Gobbi
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Alexandre Leme Godoy dos Santos
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Gilberto Luis Camanho
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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Fitch K, Grinspoon S. Nutritional and metabolic correlates of cardiovascular and bone disease in HIV-infected patients. Am J Clin Nutr 2011; 94:1721S-1728S. [PMID: 22089442 PMCID: PMC3226025 DOI: 10.3945/ajcn.111.012120] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The treatment of HIV infection has dramatically reduced the incidence of AIDS-related illnesses. At the same time, non-AIDS-related illnesses such as cardiovascular and bone disease are becoming more prevalent in this population. The mechanisms of these illnesses are complex and are related in part to the HIV virus, antiretroviral medications prescribed for HIV infection, traditional risk factors exacerbated by HIV, and lifestyle and nutritional factors. Further prospective research is needed to clarify the mechanisms by which HIV, antiretroviral medications, and nutritional abnormalities contribute to bone and cardiovascular disease in the HIV population. Increasingly, it is being recognized that optimizing the treatment of HIV infection to improve immune function and reduce viral load may also benefit the development of non-AIDS-related illnesses such as cardiovascular and bone disease.
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Affiliation(s)
- Kathleen Fitch
- Program in Nutritional Metabolism, Massachusetts General Hospital, Boston, USA
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87
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Segarra-Newnham M, Soffler SL. Osteoporosis and Vitamin D Deficiency in HIV-Positive Patients. J Pharm Technol 2011. [DOI: 10.1177/875512251102700603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Objective: To review the epidemiology and pathophysiology of osteoporosis in patients with HIV infection and discuss vitamin D deficiency and the treatment of HIV-positive patients with osteoporosis. Data Sources: A search of PubMed (1980–June 2011) was conducted using the terms osteoporosis, HIV, vitamin D deficiency, and treatment. Study Selection and Data Extraction: Epidemiologic studies, clinical trials, and meta-analyses published in English were included. A manual review of the bibliographies of available literature was conducted and relevant articles were reviewed for inclusion. Data Synthesis: Patients with HIV infection are living longer with the use of potent antiretroviral therapy (ART) and are at increased risk for osteoporosis. Several studies have shown that HIV infection can affect bone health and increase the risk for osteoporosis. In addition, ART, and tenofovir in particular, may affect bone turnover. Studies and meta-analyses have shown an increased prevalence of osteopenia and osteoporosis in HIV-positive patients compared to noninfected controls. Recent reports also show increased prevalence of fractures and low vitamin D concentrations in HIV-positive patients. Osteoporosis treatments used in patients with HIV infection are similar to treatments for noninfected patients. HIV-positive patients should be monitored and treated to prevent the progression and complications of osteoporosis. Conclusions: HIV-positive patients are at increased risk for osteoporosis and vitamin D deficiency due to disease and treatment influences on bone health. These patients should be identified and treated to prevent the morbidity and mortality associated with osteoporosis.
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Affiliation(s)
- Marisel Segarra-Newnham
- MARISEL SEGARRA-NEWNHAM PharmD MPH FCCP BCPS, Clinical Pharmacy Specialist in Infectious Diseases, Veterans Affairs Medical Center (VAMC), West Palm Beach, FL
| | - Sarah L Soffler
- SARAH L SOFFLER, PharmD student, University of Florida, Gainesville, FL
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88
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Alteraciones osteoarticulares en la infección por el VIH. Enferm Infecc Microbiol Clin 2011; 29:515-23. [DOI: 10.1016/j.eimc.2011.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Accepted: 01/17/2011] [Indexed: 11/30/2022]
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89
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Abstract
With ongoing improvement in antiretroviral therapy, mortality among HIV-infected persons has dramatically decreased. For HIV-infected persons who remain engaged in care on suppressive therapy, life expectancy approaches that of the general population. Additionally, we have seen increases in comorbidities traditionally associated with aging: diabetes, hypertension, dyslipidemia, ischemic heart disease, and osteoporosis. Vitamin D deficiency has also been identified as a highly prevalent entity among HIV-infected populations. The association of vitamin D deficiency with several of these comorbidities and its impact on immune function provide the impetus for well-designed studies to evaluate the impact of vitamin D supplementation on HIV disease and antiretroviral therapy. This review summarizes the role of vitamin D in several disease states that are prevalent among HIV populations, with a specific focus on bone health and the interactions with antiretroviral medications.
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90
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Post FA, McCloskey EV, Compston JE, Bowman CA, Hay PE, Johnson MA, Mallon PWG, Peters BS, Samarawickrama A, Tudor-Williams G. Prevention of bone loss and management of fracture risk in HIV-infected individuals: case studies and recommendations for different patient subgroups. Future Virol 2011. [DOI: 10.2217/fvl.11.44] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Increased life-expectancy and the need for long-term antiretroviral therapy have brought new challenges to the clinical management of HIV-infected individuals. While the prevalence of osteoporosis and fractures is probably increased in HIV-infected patients, optimal strategies for risk assessment and treatment in this relatively young population are yet to be defined. Prevention of bone loss is likely to become an important component of HIV care as the HIV-infected patient population grows older. In this article, we present an overview of the literature on bone loss in individuals with HIV and discuss the practical application of the European AIDS Clinical Society (EACS) guidelines to a range of clinical case scenarios.
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Affiliation(s)
| | - Eugene V McCloskey
- WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, UK
| | - Juliet E Compston
- University of Cambridge School of Clinical Medicine, Department of Medicine, Addenbrooke’s Hospital, Cambridge, UK
| | - Christine A Bowman
- Communicable Diseases Directorate, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Phillip E Hay
- St George’s Hospital NHS Trust & Centre for Infection, St George’s, University of London, UK
| | | | - Patrick WG Mallon
- HIV Molecular Research Group, School of Medicine & Medical Sciences, University College Dublin, Ireland
| | - Barry S Peters
- King’s College London School of Medicine at Guy’s, King’s College & St Thomas’ Hospitals, Weston Education Centre, Cutcombe Road, London, SE5 9RJ, UK
- King’s College London School of Medicine at Guy’s, King’s College & St Thomas’ Hospitals, Harrison Wing, St Thomas’ Hospital, London, SE1 1UL, UK
| | | | - Gareth Tudor-Williams
- Imperial College London & Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, UK
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91
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Cotter AG, Powderly WG. Endocrine complications of human immunodeficiency virus infection: hypogonadism, bone disease and tenofovir-related toxicity. Best Pract Res Clin Endocrinol Metab 2011; 25:501-15. [PMID: 21663843 DOI: 10.1016/j.beem.2010.11.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Treatment with highly active antiretroviral therapy (HAART) has revolutionized care of patients with HIV infection. The cost of increased survival has been antiretroviral toxicity and increasing age-related co-morbidities that include significant metabolic issues. Hypogonadism was first described in the setting of advanced AIDS and can be primary or secondary. Data regarding treatment largely concern patients with wasting. Varied syndromes involving bone have been described in patients with HIV including osteonecrosis, low bone mineral density (BMD) and osteoporosis, and rarely osteomalacia. Low BMD leading to osteoporosis is the most common bone pathology and may be as a result of HIV infection, drug toxicity or co-morbidities. However, increasingly fragility fractures are reported in HIV-infected patients, suggesting bone demineralization in this population is of clinical relevance. Further research is required to understand its pathogenesis and determine effective management; however, initiation of antiretroviral therapy seems to accelerate (in the short-term) bone demineralization. One particular antiretroviral agent, tenofovir is widely used and is potentially implicated as having a greater role in long-term bone and renal dysfunction. As this population ages, screening for low BMD will become increasingly more important.
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Affiliation(s)
- Aoife G Cotter
- School of Medicine and Medical Sciences, University College Dublin, Belfield, Dublin, Ireland.
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92
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Cotter AG, Mallon PWG. HIV infection and bone disease: implications for an aging population. Sex Health 2011; 8:493-501. [DOI: 10.1071/sh11014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2011] [Accepted: 06/27/2011] [Indexed: 12/25/2022]
Abstract
Now more than ever, the management of age-related problems, from cardiovascular morbidity to bone pathology, is increasingly relevant for HIV physicians. Low bone mineral density (BMD) and fractures are more common in HIV-infected patients. Although a multifactorial aetiology underlies this condition, increasing evidence suggests a role for antiretroviral therapy in low BMD, especially upon initiation. This review will detail the epidemiology, pathogenesis, diagnosis and management of osteoporosis and low BMD in HIV-infected patients, with particular emphasis on aging.
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93
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Ofotokun I, Weitzmann MN. HIV-1 infection and antiretroviral therapies: risk factors for osteoporosis and bone fracture. Curr Opin Endocrinol Diabetes Obes 2010; 17:523-9. [PMID: 20844427 PMCID: PMC3632052 DOI: 10.1097/med.0b013e32833f48d6] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Patients with HIV-1 infection/AIDS are living longer due to the success of highly active antiretroviral therapy (HAART). However, serious metabolic complications including bone loss and fractures are becoming common. Understanding the root causes of bone loss and its potential implications for aging AIDS patients will be critical to the design of effective interventions to stem a tidal wave of fractures in a population chronically exposed to HAART. RECENT FINDINGS Paradoxically, bone loss may occur not only due to HIV/AIDS but also as a consequence of HAART. The cause and mechanisms driving these distinct forms of bone loss, however, are complex and controversial. This review examines our current understanding of the underlying causes of HIV-1 and HAART-associated bone loss, and recent findings pertaining to the relevance of the immuno-skeletal interface in this process. SUMMARY It is projected that by 2015 more than half of the HIV/AIDS population in the USA will be over the age of 50 and the synergy between HIV and/or HAART-related bone loss with age-associated bone loss could lead to a significant health threat. Aggressive antiresorptive therapy may be warranted in high-risk patients.
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Affiliation(s)
- Ighovwerha Ofotokun
- Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta
| | - M. Neale Weitzmann
- The Divisions of Endocrinology & Metabolism & Lipids, Emory University School of Medicine, Atlanta
- Atlanta VA Medical Center, Decatur, Georgia, USA
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94
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Stone B, Dockrell D, Bowman C, McCloskey E. HIV and bone disease. Arch Biochem Biophys 2010; 503:66-77. [DOI: 10.1016/j.abb.2010.07.029] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2010] [Revised: 07/27/2010] [Accepted: 07/29/2010] [Indexed: 11/26/2022]
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95
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McComsey GA, Tebas P, Shane E, Yin MT, Overton ET, Huang JS, Aldrovandi GM, Cardoso SW, Santana JL, Brown TT. Bone disease in HIV infection: a practical review and recommendations for HIV care providers. Clin Infect Dis 2010; 51:937-46. [PMID: 20839968 PMCID: PMC3105903 DOI: 10.1086/656412] [Citation(s) in RCA: 290] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Low bone mineral density (BMD) is prevalent in human immunodeficiency virus (HIV)-infected subjects. Initiation of antiretroviral therapy is associated with a 2%-6% decrease in BMD over the first 2 years, a decrease that is similar in magnitude to that sustained during the first 2 years of menopause. Recent studies have also described increased fracture rates in the HIV-infected population. The causes of low BMD in individuals with HIV infection appear to be multifactorial and likely represent a complex interaction between HIV infection, traditional osteoporosis risk factors, and antiretroviral-related factors. In this review, we make the point that HIV infection should be considered as a risk factor for bone disease. We recommend screening patients with fragility fractures, all HIV-infected post-menopausal women, and all HIV-infected men ⩾50 years of age. We also discuss the importance of considering secondary causes of osteoporosis. Finally, we discuss treatment of the more severe cases of bone disease, while outlining the caveats and gaps in our knowledge.
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Affiliation(s)
- Grace A McComsey
- Department of Pediatrics and Medicine, Case Western Reserve University, Cleveland, Ohio, USA.
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96
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Abstract
Highly active antiretroviral therapy (HAART) has had a profound impact on improving the long-term prognosis for individuals infected with human immunodeficiency virus (HIV). HAART has been available for close to two decades, and now a significant number of patients with access to HAART are over the age of 50 years. Many clinical studies have indicated that HIV infection, as well as components of HAART, can increase the risk in these individuals to a variety of noninfectious complications, including a risk to bone health. There is a significant need for detailed mechanistic analysis of the aging, HIV-infected population regarding the risk of HIV infection and therapy in order to maintain bone health. Insights from basic mechanistic studies will help to shed light on the role of HIV infection and the components of HAART that impact bone health, and will help in identifying preventative countermeasures, particularly for individuals 50 years of age and older.
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Affiliation(s)
- Kim C Mansky
- Division of Orthodontics, Department of Developmental and Surgical Sciences, School of Dentistry, University of Minnesota, Minneapolis, MN 55455, USA.
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97
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Abstract
PURPOSE OF REVIEW This review details the clinical aspects and pathogenesis of low bone mineral density (BMD) in HIV, discusses broad management issues and outlines areas in which our understanding of this condition is incomplete. RECENT FINDINGS Low BMD is prevalent in HIV-infected patients, with traditional risk factors, HIV infection and exposure to antiretroviral therapy all contributing. The role of specific antiretrovirals in the development of low BMD remains controversial, but most changes arise at either antiretroviral therapy initiation or switch. SUMMARY Further research is needed to clarify mechanisms underlying low BMD in HIV, whether low BMD will translate to increased fractures and to determine the correct therapeutic approach to low BMD in HIV, particularly in younger HIV-infected patients.
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98
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Santoro N, Fan M, Maslow B, Schoenbaum E. Women and HIV infection: the makings of a midlife crisis. Maturitas 2009; 64:160-4. [PMID: 19783389 DOI: 10.1016/j.maturitas.2009.09.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 09/02/2009] [Indexed: 11/18/2022]
Abstract
With the advent of highly active antiretroviral agents, women with HIV infection can expect to live longer than ever before. This increased survival has led to concerns about the long-term implications of HIV disease and its treatment. Women with HIV infection appear to lose ovarian function earlier in life than women without HIV infection. They also have evidence of reduced bone mineral density and increased cardiovascular risk. Moreover, many of these increases in risk factors are present even prior to the menopausal transition. All of these risks, present at midlife, augur poorly for future health and describe a substantially increased burden of disease likely to accrue to HIV-infected women as they enter older age groups. Further compounding the adversity faced by the HIV infected, the demographics of women most vulnerable to this disease include adverse social and economic influences, both of which worsen their long-term prognosis. For example, drug use and poverty are related to more severe menopausal symptoms and chronic stress is related to worse psychological and cardiovascular risk. An understanding of how menopause interacts with HIV infection is therefore most important to alert the clinician to perform surveillance for common health problems in postmenopausal women, and to address directly and appropriately symptomatology during the menopausal transition.
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Affiliation(s)
- Nanette Santoro
- Department of Obstetrics, Gynecology & Women's Health, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA.
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99
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Doggrell SA. Clinical efficacy and safety of zoledronic acid in osteoporosis and Paget's bone disease. Expert Rev Endocrinol Metab 2009; 4:405-415. [PMID: 30736183 DOI: 10.1586/eem.09.23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Osteoporosis and Paget's bone disease are the most common diseases of the bone. In addition to glucocorticoid treatment, there are many other secondary causes of osteoporosis. Bisphosphonates are used to treat these bone conditions. Zoledronic acid is the most potent bisphosphonate at inhibiting bone resorption. In osteoporosis, zoledronic acid increases bone mineral density for at least 1 year following a single intravenous administration. The efficacy and safety of zoledronic acid in the treatment of osteoporosis and Paget's bone disease are reviewed. This article also covers the studies of the effects of zoledronic acid in the bone loss associated with the secondary osteoporosis.
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Affiliation(s)
- Sheila A Doggrell
- a School of Life Sciences, Queensland University of Technology, GPO Box 2334, Brisbane, QLD 4001, Australia.
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100
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Aberg JA, Kaplan JE, Libman H, Emmanuel P, Anderson JR, Stone VE, Oleske JM, Currier JS, Gallant JE. Primary Care Guidelines for the Management of Persons Infected with Human Immunodeficiency Virus: 2009 Update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2009; 49:651-81. [PMID: 19640227 DOI: 10.1086/605292] [Citation(s) in RCA: 249] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
Evidence-based guidelines for the management of persons infected with human immunodeficiency virus (HIV) were prepared by an expert panel of the HIV Medicine Association of the Infectious Diseases Society of America. These updated guidelines replace those published in 2004. The guidelines are intended for use by health care providers who care for HIV-infected patients or patients who may be at risk for acquiring HIV infection. Since 2004, new antiretroviral drugs and classes have become available, and the prognosis of persons with HIV infection continues to improve. However, with fewer complications and increased survival, HIV-infected persons are increasingly developing common health problems that also affect the general population. Some of these conditions may be related to HIV infection itself and its treatment. HIV-infected persons should be managed and monitored for all relevant age- and gender-specific health problems. New information based on publications from the period 2003–2008 has been incorporated into this document.
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Affiliation(s)
- Judith A. Aberg
- New York University School of Medicine, Bellevue Hospital Center, New York
| | | | - Howard Libman
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Jean R. Anderson
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Valerie E. Stone
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Joel E. Gallant
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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