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Lee JH, Wei YJ, Zhou ZY, Hou YM, Wang CL, Wang LB, Wu HJ, Zhang Y, Dai WW. Efficacy of the herbal pair, Radix Achyranthis Bidentatae and Eucommiae Cortex, in preventing glucocorticoid-induced osteoporosis in the zebrafish model. JOURNAL OF INTEGRATIVE MEDICINE 2022; 20:83-90. [PMID: 34810131 DOI: 10.1016/j.joim.2021.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 08/23/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE In traditional Chinese medicine, the herbal pair, Radix Achyranthis Bidentatae (RAB) and Eucommiae Cortex (EC), is widely used to treat osteoporosis. Herein, we determined whether this herbal pair can be used to ameliorate glucocorticoid (GC)-induced osteoporosis (GIOP) and find its optimal dosage in zebrafish. METHODS The characteristics of the aqueous extract of RAB and EC were separately characterized using high-performance liquid chromatography. Osteoporosis was induced in 5-day post-fertilization zebrafish larvae by exposing them to 10 μmol/L dexamethasone (Dex) for 96 h. Seven combinations of different ratios of RAB and EC were co-administered. Treatment efficacy was determined by calculating zebrafish vertebral area and sum brightness, via alizarin red staining, and by detecting alkaline phosphatase (ALP) activity. Multiple regression analysis was conducted to test the optimal dosage ratio. RESULTS According to the Chinese Pharmacopoeia (2015), β-ecdysone (β-Ecd) is a major bioactive marker in RAB extract, while pinoresinol diglucoside (PDG) is the major marker in EC extract. Both of β-Ecd and PDG content values aligned with the Chinese Pharmacopoeia standards. Treatment with 10 μmol/L Dex reduced zebrafish vertebral area, sum brightness, and ALP activity, but RAB and EC attenuated these effects. Combining 50 µg/mL RAB and 50 µg/mL EC was optimal for preventing GIOP in zebrafish. Reverse transcription-quantitative polymerase chain reaction was used to evaluate the mRNA expression of osteogenesis-related genes. A treatment of 10 μmol/L Dex decreased runt-related transcription factor 2 (Runx2), osteogenic protein-1 (OP-1), bone γ-carboxyglutamic acid-containing protein (BGLAP), and β-catenin levels. This effect was counteracted by RAB and EC co-treatment (P < 0.05). Additionally, the effect of using the two herbal extracts together was better than single-herb treatments separately. These results demonstrated that RAB and EC preserve osteoblast function in the presence of GC. The best mass ratio was 1:1. CONCLUSION RAB and EC herbal pair could ameliorate GC-induced effects in zebrafish, with 1:1 as the optimal dosage ratio.
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Affiliation(s)
- Joon-Ho Lee
- Central Laboratory of Science and Technology Department, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
| | - Yuan-Ji Wei
- Central Laboratory of Science and Technology Department, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
| | - Zhong-Yan Zhou
- Central Laboratory of Science and Technology Department, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
| | - Yu-Ming Hou
- Cardiovascular Department, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
| | - Cheng-Long Wang
- Central Laboratory of Science and Technology Department, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
| | - Li-Bo Wang
- Central Laboratory of Science and Technology Department, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
| | - Hong-Jin Wu
- Central Laboratory of Science and Technology Department, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
| | - Yu Zhang
- Central Laboratory of Science and Technology Department, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
| | - Wei-Wei Dai
- Central Laboratory of Science and Technology Department, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China.
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Kobza AO, Herman D, Papaioannou A, Lau AN, Adachi JD. Understanding and Managing Corticosteroid-Induced Osteoporosis. Open Access Rheumatol 2021; 13:177-190. [PMID: 34239333 PMCID: PMC8259736 DOI: 10.2147/oarrr.s282606] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/03/2021] [Indexed: 11/23/2022] Open
Abstract
Glucocorticoids are effective immunosuppressants used in a wide variety of diseases. Their use results in secondary osteoporosis in about 30–50% of chronic glucocorticoid users. Glucocorticoids cause a rapid decline in bone strength within the first 3–6 months mostly due to increased bone resorption by osteoclasts. This is followed by a more gradual loss of bone partly due to decreased osteoblastogenesis and osteoblast and osteocyte apoptosis. The loss of bone strength induced by glucocorticoids is not fully captured by bone mineral density measurements. Other tools such as the trabecular bone score and advanced imaging techniques give insight into bone quality; however, these are not used widely in clinical practice. Glucocorticoid-induced osteoporosis should be seen as a widely preventable disease. Currently, only about 15% of chronic glucocorticoid users are receiving optimal care. Glucocorticoids should be prescribed at the lowest dose and shortest duration. All patients should be counselled on lifestyle measures to maintain bone strength including nutrition and weight-bearing exercise. Pharmacological therapy should be considered for all patients at moderate to high risk of fracture as there is evidence for the prevention of bone loss and fractures with a favourable safety profile. Oral bisphosphonates are the current mainstay of therapy, whereas osteoanabolic agents may be considered for those at highest risk of fracture.
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Affiliation(s)
- Alexandra O Kobza
- Division of Rheumatology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Deena Herman
- Division of Rheumatology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Alexandra Papaioannou
- Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Arthur N Lau
- Division of Rheumatology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jonathan D Adachi
- Division of Rheumatology, Department of Medicine, McMaster University, Hamilton, ON, Canada
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Malochet-Guinamand S, Lambert C, Gossec L, Soubrier M, Dougados M. Evaluation of the Implementation of Guidelines on the Treatment of Osteoporosis in Patients with Rheumatoid Arthritis. J Rheumatol 2019; 47:6-14. [PMID: 30877214 DOI: 10.3899/jrheum.180889] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess whether the 2003 and 2014 French guidelines on the prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) and the 2012 update of the French guidelines for the treatment of postmenopausal osteoporosis (PMOP) were applied in patients with rheumatoid arthritis (RA). METHODS We conducted a cross-sectional study of 776 patients with RA (19 centers). We collected the data required for the application of the various recommendations (age, sex, prednisone intake, low-energy fracture, history in the immediate family of hip fractures, and bone densitometry), anti-osteoporotic drugs, and the various factors that may be associated with the application of the recommendations. RESULTS Of the patients who should have received antiosteoporosis treatment, there were 22.6% actually treated (according to the 2014 guidelines), 27.3% actually treated according to the 2003 guidelines, and of postmenopausal women, 23.6% (according to the 2012 PMOP guidelines). Applying the 2014 GIOP guidelines increased the theoretical number of patients requiring treatment relative to the 2003 GIOP guidelines (77% vs 53%; p < 0.001). In multivariate analysis, being treated was associated with a spinal T score ≤ -2 SD according to the 2014 guidelines; with not taking part in physical activity for more than 30 min a day according to the 2003 guidelines; and with older age, lower body mass index, and a T score ≤ -2.5 SD in at least 1 site according to the PMOP guidelines. CONCLUSION Patients with RA had inadequate prevention of GIOP and PMOP. The management of osteoporosis needs to be improved in this population.
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Affiliation(s)
- Sandrine Malochet-Guinamand
- From the Rheumatology Department, and Biostatistics Unit (DRCI), University Hospital Clermont-Ferrand, Auvergne; Sorbonne University; Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University; Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité, Paris, France. .,S. Malochet-Guinamand, MD, University Hospital Clermont-Ferrand, Rheumatology Department; C. Lambert, MSc, University Hospital Clermont-Ferrand, Biostatistics Unit (DRCI); L. Gossec, PhD, Sorbonne University, and Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; M. Soubrier, PhD, University Hospital Clermont-Ferrand, Rheumatology Department; M. Dougados, PhD, Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University, and Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité.
| | - Céline Lambert
- From the Rheumatology Department, and Biostatistics Unit (DRCI), University Hospital Clermont-Ferrand, Auvergne; Sorbonne University; Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University; Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité, Paris, France.,S. Malochet-Guinamand, MD, University Hospital Clermont-Ferrand, Rheumatology Department; C. Lambert, MSc, University Hospital Clermont-Ferrand, Biostatistics Unit (DRCI); L. Gossec, PhD, Sorbonne University, and Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; M. Soubrier, PhD, University Hospital Clermont-Ferrand, Rheumatology Department; M. Dougados, PhD, Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University, and Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité
| | - Laure Gossec
- From the Rheumatology Department, and Biostatistics Unit (DRCI), University Hospital Clermont-Ferrand, Auvergne; Sorbonne University; Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University; Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité, Paris, France.,S. Malochet-Guinamand, MD, University Hospital Clermont-Ferrand, Rheumatology Department; C. Lambert, MSc, University Hospital Clermont-Ferrand, Biostatistics Unit (DRCI); L. Gossec, PhD, Sorbonne University, and Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; M. Soubrier, PhD, University Hospital Clermont-Ferrand, Rheumatology Department; M. Dougados, PhD, Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University, and Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité
| | - Martin Soubrier
- From the Rheumatology Department, and Biostatistics Unit (DRCI), University Hospital Clermont-Ferrand, Auvergne; Sorbonne University; Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University; Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité, Paris, France.,S. Malochet-Guinamand, MD, University Hospital Clermont-Ferrand, Rheumatology Department; C. Lambert, MSc, University Hospital Clermont-Ferrand, Biostatistics Unit (DRCI); L. Gossec, PhD, Sorbonne University, and Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; M. Soubrier, PhD, University Hospital Clermont-Ferrand, Rheumatology Department; M. Dougados, PhD, Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University, and Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité
| | - Maxime Dougados
- From the Rheumatology Department, and Biostatistics Unit (DRCI), University Hospital Clermont-Ferrand, Auvergne; Sorbonne University; Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University; Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité, Paris, France.,S. Malochet-Guinamand, MD, University Hospital Clermont-Ferrand, Rheumatology Department; C. Lambert, MSc, University Hospital Clermont-Ferrand, Biostatistics Unit (DRCI); L. Gossec, PhD, Sorbonne University, and Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; M. Soubrier, PhD, University Hospital Clermont-Ferrand, Rheumatology Department; M. Dougados, PhD, Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University, and Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité
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Trijau S, de Lamotte G, Pradel V, Natali F, Allaria-Lapierre V, Coudert H, Pham T, Sciortino V, Lafforgue P. Osteoporosis prevention among chronic glucocorticoid users: results from a public health insurance database. RMD Open 2016; 2:e000249. [PMID: 27486526 PMCID: PMC4947732 DOI: 10.1136/rmdopen-2016-000249] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 05/09/2016] [Accepted: 05/12/2016] [Indexed: 01/29/2023] Open
Abstract
Introduction Long-term glucocorticoid therapy is the leading cause of secondary osteoporosis. The management of glucocorticoid-induced osteoporosis (GIOP) seems to be inadequate in many European countries. Objective To evaluate the rate of screening and treatment of GIOP. Design Information was collected from a national public health-insurance database in our geographic area of Provence-Alpes-Côte-d'Azur and in Corsica, from September 2009 through August 2011. Patients We identified participants aged 15 years and over starting glucocorticoid therapy (≥7.5 mg of prednisone equivalent per day during at least 90 days consecutive). This cohort was compared with an age-matched and sex-matched population that did not receive glucocorticoids. Main outcome measures Bone mass, prescription of bone antiresorptive medication and use of calcium and/or vitamin D treatment. Results We identified 32 812 patients who were prescribed glucocorticoid therapy, yielding 1% prevalence. Incidence of glucocorticoid therapy was 2.8/1000 inhabitants/year. Males represented 44%, the mean age was 58 years. The median prednisone-equivalent dose was 11 mg/day (IQR 9–18 mg/day). 8% underwent bone mass measurement. Calcium and/or vitamin D, and bisphosphonates were prescribed in 18% and 12%, respectively. Results were lower for the control population: 3% underwent bone mass measurement and 3% received bisphosphonate therapy. The rates of osteodensitometry and treatments were higher in women over 55 years of age than in men and women 55 years of age and younger, and also when glucocorticoid therapy was initiated by a rheumatologist versus other physician specialty. Conclusions The management of GIOP remains very inadequate, despite the availability of a statutory health insurance system. Targeted interventions are needed to improve the management of GIOP.
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Affiliation(s)
- Sophie Trijau
- Service de Rhumatologie , APHM, Hôpital Sainte-Marguerite , Marseille , France
| | - Gaëlle de Lamotte
- Service de Rhumatologie, APHM, Hôpital Sainte-Marguerite, Marseille, France; Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | - Vincent Pradel
- Service de Santé Publique et d'Information Médicale , APHM, Hôpital Sainte-Marguerite , Marseille , France
| | - François Natali
- Direction Régionale du Service Médical du Régime Général de l'Assurance Maladie Paca Corse , Marseille , France
| | - Véronique Allaria-Lapierre
- Direction Régionale du Service Médical du Régime Général de l'Assurance Maladie Paca Corse , Marseille , France
| | - Hervé Coudert
- Direction Régionale du Service Médical du Régime Général de l'Assurance Maladie Paca Corse , Marseille , France
| | - Thao Pham
- Service de Rhumatologie, APHM, Hôpital Sainte-Marguerite, Marseille, France; Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | - Vincent Sciortino
- Direction Régionale du Service Médical du Régime Général de l'Assurance Maladie Paca Corse , Marseille , France
| | - Pierre Lafforgue
- Service de Rhumatologie, APHM, Hôpital Sainte-Marguerite, Marseille, France; Faculté de Médecine, Aix-Marseille Université, Marseille, France
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5
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Abstract
Glucocorticoids are widely used internationally for the treatment of inflammatory disease, such as rheumatoid arthritis (RA). Although the benefit of glucocorticoids in RA on both disease activity and severity are well known, there remain unanswered questions about the overall bone safety of chronic low-dose glucocorticoids in RA. Debate exists about the merits of glucocorticoids for bone health on the basis of their benefits in promoting activity and reducing proinflammatory cytokines. Overall current evidence supports the view that bone loss is a disease related both to RA and to glucocorticoid use independently. Calcium and vitamin D, along with prescription antiosteoporosis therapies, particularly bisphosphonates and teriparatide, play an important role in stabilizing bone mineral density and potentially lowering spinal fracture risk at the spine. International guidelines provide pathways for appropriate prevention of glucocorticoid-induced osteoporosis (GIOP). Despite the evidence and these guidelines, many patients do not receive adequate management to prevent GIOP.
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Affiliation(s)
- Kenneth G Saag
- Divisions of Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Aghamirsalim M, Sorbi R. Do the hospitalized patients with osteoporotic fractures require endocrinologists' help? J Endocrinol Invest 2012; 35:992-5. [PMID: 23013835 DOI: 10.3275/8617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
AIM Osteoporotic fractures are a crucial cause of morbidity and mortality in patients with fragility fractures and impose huge economic burden on health care services. Orthopedic surgeons are often the only clinicians seen by the patients with osteoporotic fractures. The improvement in osteoporosis management is an urgent require; therefore, the aim of this study was to determine the efficacy of consultation with an endocrinologist in osteoporosis management of patients with a fragility fracture. METHODS This survey was undertaken in three phases that focused on patients with osteoporotic fractures who were admitted to five tertiary care, level-I, trauma hospital. Patients were evaluated through a questionnaire which was designed to determine whether physicians manage underlying osteoporosis. RESULTS The number of patients who underwent a bone mineral density test increased from a rate of 3.6% to 91% after the intervention, as calcium and vitamin D supplementation from 18% to 92%, bisphosphonate prescription from 0.5% to 83%. Also, the overall medication usage increased from 9% to 87%. A small number of patients (3%) were followed up in contrast to a rate of 73% in the third phase. CONCLUSION Orthopedic surgeons are not completely engaged in osteoporosis care for patients with a fragility fracture; therefore, a consultation with an endocrinologist is required to enable orhopedic surgeons to provide an effective osteoporosis care for their patients with an osteoporotic fracture.
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Affiliation(s)
- M Aghamirsalim
- Department of Orthopedic and Trauma Surgery, Students' Scientific Research Center (SSRC), Exceptional Talent Development Center (ETDC), Tehran University of Medical Sciences (TUMS), Shariati Hospital, Tehran, Islamic Republic of Iran
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McKeown E, Bykerk VP, De Leon F, Bonner A, Thorne C, Hitchon CA, Boire G, Haraoui B, Ferland DS, Keystone EC, Pope JE. Quality assurance study of the use of preventative therapies in glucocorticoid-induced osteoporosis in early inflammatory arthritis: results from the CATCH cohort. Rheumatology (Oxford) 2012; 51:1662-9. [DOI: 10.1093/rheumatology/kes079] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Duyvendak M, Naunton M, van Roon EN, Bruyn GAW, Brouwers JRBJ. Systematic review of trends in prophylaxis of corticosteroid-induced osteoporosis: the need for standard audit guidelines. Osteoporos Int 2008; 19:1379-94. [PMID: 18629573 DOI: 10.1007/s00198-008-0598-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2007] [Accepted: 02/18/2008] [Indexed: 10/21/2022]
Abstract
UNLABELLED Corticosteroid-induced osteoporosis (CIOP) is currently undertreated. Systematic review of the literature revealed that the percentage of patients treated adequately is dependent on study quality. Therefore, it remains unknown whether adherence to the guidelines is really so poor. Five major quality criteria provide the standard for future studies on this scope. INTRODUCTION It has recently been stated that the degree of prophylaxis of corticosteroid-induced osteoporosis (CIOP) is low and effort should be put into determining reasons for non-prescribing of preventive agents. The aim of this study was to identify: how many studies adequately audit the prevalent guideline; the longitudinal trends in prevention of CIOP; which patient groups appear to be most undertreated; and which intervention strategies are effective. METHODS We performed a comprehensive search of MEDLINE and systematically recorded the outcomes and quality of published studies, using five major criteria. RESULTS Twenty-four studies were included in the analysis. The quality of the included studies was poor (31%) or moderate (37%). There was a longitudinal increase in quality of the studies and percentage of prevention. Multivariable linear regression showed that the quality of the study was the only independent predictor of the prevention rate reported in the study. CONCLUSIONS The results show undertreatment of CIOP might be due to insufficient quality of the studies rather than poor practice or failure to recognise the right patients. Future interventions should comply with five major quality criteria, and a multifaceted approach is required in order to make an impact on the underprescribing of CIOP prophylaxis.
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Affiliation(s)
- M Duyvendak
- Department of Pharmacotherapy and Pharmaceutical Care, University of Groningen, Ant. Deusinglaan 1, 9713 AV, Groningen, The Netherlands.
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Solomon DH, Polinski JM, Stedman M, Truppo C, Breiner L, Egan C, Jan S, Patel M, Weiss TW, Chen YT, Brookhart MA. Improving care of patients at-risk for osteoporosis: a randomized controlled trial. J Gen Intern Med 2007; 22:362-7. [PMID: 17356969 PMCID: PMC1824772 DOI: 10.1007/s11606-006-0099-7] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite accurate diagnostic tests and effective therapies, the management of osteoporosis has been observed to be suboptimal in many settings. We tested the effectiveness of an intervention to improve care in patients at-risk of osteoporosis. DESIGN Randomized controlled trial. PARTICIPANTS Primary care physicians and their patients at-risk of osteoporosis, including women 65 years and over, men and women 45 and over with a prior fracture, and men and women 45 and over who recently used > or =90 days of oral glucocorticoids. INTERVENTION A multifaceted program of education and reminders delivered to primary care physicians as well as mailings and automated telephone calls to patients. OUTCOME Either undergoing a bone mineral density (BMD) testing or filling a prescription for a bone-active medication during the 10 months of follow-up. RESULTS After the intervention, 144 (14%) patients in the intervention group and 97 (10%) patients in the control group received either a BMD test or filled a prescription for an osteoporosis medication. This represents a 4% absolute increase and a 45% relative increase (95% confidence interval 9-93%, p = 0.01) in osteoporosis management between the intervention and control groups. No differences between groups were observed in the incidence of fracture. CONCLUSION An intervention targeting primary care physicians and their at-risk patients increased the frequency of BMD testing and/or filling prescriptions for osteoporosis medications. However, the absolute percentage of at-risk patients receiving osteoporosis management remained low.
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Affiliation(s)
- Daniel H Solomon
- Division of Pharmacepidemiology, Brigham and Women's Hospital, Boston, MA 02120, USA.
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Abstract
Glucocorticoids continue to be used for many inflammatory diseases, and glucocorticoid-induced osteoporosis (GIOP) remains the most common secondary form of metabolic bone disease. Recent meta-analyses suggest that both active and native vitamin D can help maintain lumbar spine bone mineral density (BMD), particularly in patients receiving lower-dose glucocorticoid therapy. Recent randomized, controlled clinical trials have shown that oral bisphosphonates are superior to vitamin D in maintaining BMD and should be continued for as long as a person receives glucocorticoid treatment. Similar to the oral bisphosphonates, intravenous ibandronate has been shown to preserve BMD and also to significantly reduce vertebral fracture risk. Increasing evidence supports a role for parathyroid hormone to prevent or treat GIOP as well. Despite effective therapies, many at-risk patients fail to receive treatment for GIOP, and even among those who initiate treatment, half discontinue within 1 to 2 years. New approaches to evidence implementation are being tested to improve the quality of osteoporosis care and decrease fracture risk among long-term glucocorticoid users.
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Affiliation(s)
- Jeffrey R Curtis
- University of Alabama at Birmingham, FOT 840, 510 20th Street South, Birmingham, AL 35294, USA.
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Curtis JR, Westfall AO, Allison JJ, Becker A, Casebeer L, Freeman A, Spettell CM, Weissman NW, Wilke S, Saag KG. Longitudinal patterns in the prevention of osteoporosis in glucocorticoid-treated patients. ACTA ACUST UNITED AC 2005; 52:2485-94. [PMID: 16052570 DOI: 10.1002/art.21194] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate patient and physician factors associated with prevention of glucocorticoid-induced osteoporosis and to describe temporal trends in screening and prevention of glucocorticoid-induced osteoporosis. METHODS Using databases from a national managed care organization, enrollees who had been prescribed glucocorticoids (taken for at least 60 days) during an 18-month period were identified. Administrative data from January 2001 through June 2003 and linked survey data from October 2003 were examined for measurement of bone mass, prescription of antiresorptive medication, and use of over-the-counter calcium and/or vitamin D treatment. Factors associated with screening and bone-protective therapies were identified using multivariable logistic regression, focusing on physician specialty and survey respondent ethnicity. Trends in glucocorticoid-induced osteoporosis prevention were assessed using administrative data from 2001-2003 versus 1995-1998. RESULTS We identified 6,281 patients who were prescribed glucocorticoids in 2001-2003 (mean +/- SD prescribed prednisone-equivalent dosage 16 +/- 14 mg/day). Forty-two percent underwent bone mass measurement and/or were prescribed bone-protective medication; rates were lowest for men (25%). Compared with patients of internists, the odds of bone mass measurement were lowest among patients prescribed glucocorticoids by family physicians (odds ratio [OR] 0.56 [95% confidence interval] [95% CI] 0.30-1.04) and highest among patients prescribed glucocorticoids by rheumatologists (OR 1.48 [95% CI 1.06-2.08]). Patients prescribed glucocorticoids by gastroenterologists were less likely to be treated with antiresorptive agents (OR 0.49 [95% CI 0.28-0.86]). African American patients were less likely than white patients to be screened (OR 0.55 [95% CI 0.40-0.75]) or treated (OR 0.71 [95% CI 0.51-0.98]). The frequency of bone mass measurement among glucocorticoid-treated patients in 2001-2003 increased 3-fold compared with 1995-1998, and the use of prescription antiresorptive medication increased approximately 2-fold. CONCLUSION Despite significant temporal increases in the frequency of screening for and treatment of glucocorticoid-induced osteoporosis, absolute rates remain low, especially among men, African Americans, and patients of certain physician specialties.
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13
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Solomon DH, Morris C, Cheng H, Cabral D, Katz JN, Finkelstein JS, Avorn J. Medication use patterns for osteoporosis: an assessment of guidelines, treatment rates, and quality improvement interventions. Mayo Clin Proc 2005; 80:194-202. [PMID: 15704774 DOI: 10.4065/80.2.194] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess current osteoporosis treatment guidelines, studies of osteoporosis treatment, and interventions to improve osteoporosis treatment. METHODS We searched the medical literature for articles published between January 1, 1992, and December 31, 2003, and assessed all relevant articles using a structured data abstraction process. Because of substantial heterogeneity in study design, no attempt was made to summarize the data using meta-analytic techniques. RESULTS Seventy-six articles met criteria for inclusion. Eighteen practice guidelines were studied. Most guidelines were consistent in key treatment recommendations. Among 18 studies of treatment rates in patients who had fractures, the weighted average varied from 22% for nonhormonal treatment to 19% for calcium. We found slightly higher treatment rates for patients taking oral glucocorticoids or for those older than 65 years. There were no consistent correlates of which patients received treatment. Six studies that examined treatment frequencies after bone densitometry all found that patients with lower bone mineral density were more likely to receive treatment. Most of the 8 interventions designed to improve osteoporosis treatment showed improvement in treatment rates; however, only 3 were randomized, and these showed the smallest effects. CONCLUSIONS Frequency of treatment of osteoporosis in at-risk populations is low. However, our assessment of the literature revealed no clear and consistent predictors of undertreatment. Few carefully controlled interventions have been reported.
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Affiliation(s)
- Daniel H Solomon
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass 02120, USA.
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Blalock SJ, Norton LL, Patel RA, Dooley MA. Patient knowledge, beliefs, and behavior concerning the prevention and treatment of glucocorticoid-induced osteoporosis. ACTA ACUST UNITED AC 2005; 53:732-9. [PMID: 16208664 DOI: 10.1002/art.21446] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To obtain descriptive information concerning the extent to which patients taking oral glucocorticoids recall receiving osteoporosis prevention counseling, and to identify factors associated with the practice of 3 behaviors (i.e., calcium intake, vitamin D intake, and bone mineral density [BMD] testing) recommended for patients receiving glucocorticoid therapy. METHODS The study assessed cross-sectional data derived from telephone interviews and mailed questionnaires completed by 227 patients who were currently taking oral prednisone. Questions assessed current calcium and vitamin D intake and history of BMD testing. RESULTS Approximately one-third of participants (36.3%) reported that they had received osteoporosis prevention counseling. Among those who reported receiving counseling, most (73.2%) remembered being told about the importance of obtaining an adequate amount of calcium. Other topics were remembered less frequently. Slightly more than half of study participants (51.1%) were obtaining the recommended amount of calcium. Fewer were obtaining the recommended amount of vitamin D (35.2%) or had received a BMD test within the past year (33.5%). The most consistent predictors of behavior were counseling status and patients' perceptions of the difficulty associated with performing the behavior. CONCLUSION Most patients receiving oral glucocorticoids receive insufficient counseling concerning the prevention of osteoporosis; patients either are not being counseled or they are being counseled in a manner that is not sufficient to promote subsequent recall and behavior change. Research is needed to develop effective strategies to educate patients about the prevention of glucocorticoid-induced osteoporosis.
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Morris CA, Cabral D, Cheng H, Katz JN, Finkelstein JS, Avorn J, Solomon DH. Patterns of bone mineral density testing: current guidelines, testing rates, and interventions. J Gen Intern Med 2004; 19:783-90. [PMID: 15209594 PMCID: PMC1492483 DOI: 10.1111/j.1525-1497.2004.30240.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To identify potential obstacles to bone mineral density (BMD) testing, we performed a structured review of current osteoporosis screening guidelines, studies of BMD testing patterns, and interventions to increase BMD testing. DESIGN We searched medline and HealthSTAR from 1992 through 2002 using appropriate search terms. Two authors examined all retrieved articles, and relevant studies were reviewed with a structured data abstraction form. MEASUREMENTS AND MAIN RESULTS A total of 235 articles were identified, and 51 met criteria for review: 24 practice guidelines, 22 studies of screening patterns, and 5 interventions designed to increase BMD rates. Of the practice guidelines, almost one half (47%) lacked a formal description of how they were developed, and recommendations for populations to screen varied widely. Screening frequencies among at-risk patients were low, ranging from 1% to 47%. Only eight studies assessed factors associated with BMD testing. Female patient gender, glucocorticoid dose, and rheumatologist care were positively associated with BMD testing; female physicians, rheumatologists, and physicians caring for more postmenopausal patients were more likely to test patients. Five articles described interventions to increase BMD testing rates, but only two tested for statistical significance and no firm conclusions can be drawn. CONCLUSIONS This systematic review identified several possible contributors to suboptimal BMD testing rates. Osteoporosis screening guidelines lack uniformity in their development and content. While some patient and physician characteristics were found to be associated with BMD testing, few articles carefully assessed correlates of testing. Almost no interventions to improve BMD testing to screen for osteoporosis have been rigorously evaluated.
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Affiliation(s)
- Charles A Morris
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02120, USA.
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Morris CA, Cheng H, Cabral D, Solomon DH. Predictors of Screening and Treatment of Osteoporosis. ACTA ACUST UNITED AC 2004. [DOI: 10.1097/01.ten.0000123564.40707.84] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mudano AS, Casebeer L, Patino F, Allison JJ, Weissman NW, Kiefe CI, Person S, Gilbert D, Saag KG. Racial disparities in osteoporosis prevention in a managed care population. South Med J 2003; 96:445-51. [PMID: 12911182 DOI: 10.1097/01.smj.0000053918.93363.b0] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Osteoporosis in black women may result in increased disability, longer hospital stays, and higher mortality compared with white women. However, it is unknown whether osteoporosis treatment or bone mineral density (BMD) measurement is different in these women, particularly in those at highest risk. METHODS To examine differences and determinants of osteoporosis preventive interventions among white and black women in a large regional health maintenance organization, women 50 years of age and older were surveyed (n = 8,909) to determine their receipt of BMD testing and medical therapies for osteoporosis prevention. RESULTS After adjusting for potential confounders, black women had two- to threefold lower odds of BMD test or osteoporosis prescription treatment. Even among women with a previous fracture, blacks still had a significantly lower likelihood of both BMD testing and prescription therapy. CONCLUSION Compared with whites, black women reported significantly less BMD testing and prescription and nonprescription osteoporosis therapy. This disparity was not fully explained by other demographic or risk factor differences.
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Affiliation(s)
- Amy S Mudano
- Department of Medicine and Center for Education and Research on Therapeutics of Musculoskeletal Disorders, Division of Continuing Medical Education, University of Alabama at Birmingham, 35294-3408, USA
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Abstract
Therapeutic use of glucocorticoids can lead to many well-known adverse events. Of all potential serious side effects, glucocorticoid-induced osteoporosis (GIOP) is one of the most devastating complications of protracted glucocorticoid therapy in rheumatoid arthritis. GIOP is the most common form of drug-induced osteoporosis. Although much has been written about the association of glucocorticoids with bone disease among patients with chronic inflammatory conditions, many issues remain unsettled. This article focuses on areas of continued controversies, including the epidemiology and pathogenesis of GIOP, specification of a "safe" dose, methods for diagnosis of GIOP, and an evidence-based approach for GIOP prevention.
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Affiliation(s)
- Kenneth G Saag
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, 1813 Sixth Avenue South, Birmingham, AL 35294-3296, USA.
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Harrington JT, Broy SB, Derosa AM, Licata AA, Shewmon DA. Hip fracture patients are not treated for osteoporosis: a call to action. ARTHRITIS AND RHEUMATISM 2002; 47:651-4. [PMID: 12522840 DOI: 10.1002/art.10787] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine whether hip fracture patients, a group at very high risk for additional fragility fractures, are being evaluated and treated effectively for osteoporosis. METHODS Clinical and bone densitometry (dual x-ray absorptiometry [DXA]) records were reviewed in hip fracture patients at 4 Midwestern US health systems to determine the frequency of DXA use, calcium and vitamin D supplementation, and antiresorptive drug treatment. RESULTS DXA was performed at the 4 study sites in only 12%, 12%, 13%, and 24% of patients, respectively. Calcium and vitamin D supplements were prescribed in 27%, 1%, 3%, and 25% of the patients at the 4 study sites. Antiresorptive drugs were prescribed in 26%, 12%, 7%, and 37% of the patients with only 2-10% receiving a bisphosphonate. CONCLUSION Reducing osteoporotic fractures will require more effective approaches to managing hip fracture patients and other high-risk populations.
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21
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Ramsey-Goldman R. Missed opportunities in physician management of glucocorticoid-induced osteoporosis? ARTHRITIS AND RHEUMATISM 2002; 46:3115-20. [PMID: 12483714 DOI: 10.1002/art.10619] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Haugeberg G, Ørstavik RE, Uhlig T, Falch JA, Halse JI, Kvien TK. Bone loss in patients with rheumatoid arthritis: results from a population-based cohort of 366 patients followed up for two years. ARTHRITIS AND RHEUMATISM 2002; 46:1720-8. [PMID: 12124854 DOI: 10.1002/art.10408] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the extent of and risk factors for bone loss in a population-based cohort of patients with rheumatoid arthritis (RA) receiving conventional health care. METHODS In a longitudinal study, clinical data were collected and bone mineral density (BMD) measurements were performed at baseline and after 2 years. Dual-energy x-ray absorptiometry was used for hip and spine BMD measurements. At baseline, patients received advice about lifestyle adjustments and calcium and vitamin D supplementation; during the followup period they were treated with antirheumatic and bone-sparing drugs, according to clinical judgment. RESULTS After a mean +/- SD of 2.2 +/- 0.2 years, 366 (298 women, 68 men) of the 488 patients who were examined at baseline were reexamined. At that time, 47.9% were current users of corticosteroids and 37.0% were using antiresorptive drugs (hormone replacement therapy, bisphosphonates, or calcitonin). The mean BMD reduction was -0.64% in the femoral neck, -0.77% in the total hip, and -0.29% in the spine at L2-4. BMD was increased at all measurement sites in current users of antiresorptive drugs (0.16-1.64%) but was decreased in patients using calcium and vitamin D alone (-1.99% to -1.39%) and in patients not using any osteoporosis treatment (-1.20% to -0.43%). Current use of corticosteroids was independently associated with increased risk for BMD loss in the total hip (odds ratio [OR] 2.63, 95% confidence interval [95% CI] 1.38-5.00) and spine at L2-4 (OR 2.70, 95% CI 1.30-5.63), whereas current use of antiresorptive drugs was associated with decreased risk for bone loss in the total hip (OR 0.43, 95% CI 0.20-0.89). CONCLUSION Results of this population-based, 2-year followup study indicate that adequate management of patients with RA, addressing both the rheumatic disease and osteoporosis, protects against bone loss.
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&NA;. Prevention of osteoporosis should be standard care for patients on long-term corticosteroids. DRUGS & THERAPY PERSPECTIVES 2002. [DOI: 10.2165/00042310-200218050-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Abstract
Corticosteroid-induced osteoporosis is a major cause of morbidity and is the leading secondary cause of osteoporosis today. Unfortunately, despite this knowledge, patients receiving corticosteroid therapy are often not offered any preventative treatment. Recent research has focused attention on the critical role the osteoblast has played in the pathophysiology of corticosteroid-induced osteoporosis. In addition to an initial increase in bone resorption, there is evidence that corticosteroids induce osteoblast and osteocyte apoptosis and as a result are important contributors to bone loss. Interesting work has suggested that the bisphosphonates and calcitonin may help to prevent osteoblast apoptosis from occurring. Large scale randomised controlled trials have also been completed with a variety of therapeutic agents. Of the many different therapies, it is now clear that the bisphosphonates have the greatest evidence to support their use. Increases in bone mineral density when compared with a control group, not only at the spine but also at the hip, have been demonstrated. These studies have shown clinically significant reductions in vertebral fracture rates seen for the most part in postmenopausal women. Other therapies may well be effective, as evidenced by maintenance of bone mass in the spine; however, maintenance of bone mass in the hip and reductions in fracture rate have yet to be demonstrated for many of these therapies. Given our current knowledge and the evidence that is outlined in this review, it is hoped that patients who require therapy with corticosteroids for more than 3 months will be offered appropriate preventative treatment.
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Affiliation(s)
- J D Adachi
- Department of Medicine, St Joseph's Hospital, McMaster University, Hamilton, Ontario, Canada.
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25
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Abstract
Corticosteroid-induced osteoporosis is the leading cause of secondary osteoporosis and a significant cause of morbidity in both men and women. Long-term use of even low-dose corticosteroids has been associated with increased risk of bone loss. Recent large randomized controlled trials have generated new knowledge on treatment strategies for patients with corticosteroid-induced osteoporosis. However, the majority of individuals receiving corticosteroids are not receiving prophylaxis for osteoporosis. Calcium and vitamin D should be recommended to patients initiating therapy with corticosteroids (and should be adequate for those receiving corticosteroids for less than 3 months). For those receiving corticosteroids for greater than 3 months, bisphosphonates are the therapy of choice, with both alendronate (alendronic acid) and risedronate (risedronic acid) approved by the US FDA for use in this indication. Calcitonin can be considered a second-line agent and should be reserved for patients who are intolerant of bisphosphonates or who are experiencing pain from a vertebral fracture. Hormone replacement therapy or testosterone therapy may be offered to those individuals on long-term corticosteroid treatment who are hypogonadal. Teriparatide (recombinant human parathyroid hormone 1-34) shows promise as a future anabolic agent for the prevention and treatment of patients with corticosteroid-induced osteoporosis.
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Affiliation(s)
- Ann Cranney
- Queen's University, Kingston, Ontario, Canada
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Hougardy DM, Peterson GM, Bleasel MD, Randall CT. Is enough attention being given to the adverse effects of corticosteroid therapy? J Clin Pharm Ther 2000; 25:227-34. [PMID: 10886467 DOI: 10.1046/j.1365-2710.2000.00284.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although the corticosteroids are valuable anti-inflammatory and immunosuppressive agents, they also possess many potential adverse effects, especially with continued use. In particular, long-term corticosteroid exposure carries a significant risk of osteoporosis. AIM To review the use of corticosteroids in patients presenting to the major teaching hospital in Tasmania, Australia; principally to determine whether patients receiving long-term corticosteroid therapy were being monitored for loss of bone mineral density and offered preventive therapy for osteoporosis. METHODS A retrospective review of the medical records for 212 consecutive patients admitted to the medical wards of the hospital over a 5-month period and receiving treatment with either oral or inhaled corticosteroids, was performed. An extensive range of demographic and clinical variables was recorded for each patient. Patients were also questioned about diet and exercise, and whether they had undergone tests for measuring bone mineral density or blood glucose. RESULTS The median age of the patients was 69 years (range: 15-90 years) and 58% were female. Over half (53%) of the patients were on oral corticosteroids only, with 26% using inhaled corticosteroids only, and 21% on both oral and inhaled corticosteroid therapy. The most common conditions for which patients were receiving corticosteroid therapy were asthma (37% of patients), chronic obstructive pulmonary disease (33%) and rheumatoid arthritis (17%). The most commonly used oral corticosteroid was prednisolone (93%), the median daily dose was 10 mg prednisolone equivalent, and the median duration of oral corticosteroid treatment was 50 weeks. Disregarding short courses, the median duration of oral corticosteroid treatment was 104 weeks. Almost one-third (31%) of the patients receiving oral corticosteroid treatment had been taking the equivalent of 7.5 mg prednisolone daily for at least 6 months. Only 11% of all patients on oral corticosteroids and 21% of those who had been taking oral corticosteroids for at least one year had documented evidence of bone mineral density testing being performed in the past in the hospital. Only 21% of all patients on oral corticosteroids and 31% of those who had been taking oral corticosteroids for at least one year were receiving medication for osteoporosis prevention, and only 15% of women over 45 years of age and on oral corticosteroid therapy were taking hormone replacement therapy. Only about half of the patients on long-term systemic corticosteroid therapy had either documented evidence in their hospital medical records, or were aware, of having undergone blood glucose testing in the preceding 12 months. CONCLUSION More attention to the prevention and monitoring of possible adverse effects of long-term corticosteroid therapy is warranted. Guidelines covering preventive measures and treatment options for corticosteroid-induced osteoporosis need to be considered routinely when using these agents.
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Affiliation(s)
- D M Hougardy
- Tasmanian School of Pharmacy, Faculty of Health Science, University of Tasmania, Tasmania, Australia
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Jehle PM, Jehle DR. Use of corticosteroids in nephrology - risk and prevention of osteoporosis induction. Nephrol Dial Transplant 2000; 15:565-8. [PMID: 10809790 DOI: 10.1093/ndt/15.5.565] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
The year 2000 marks the fiftieth anniversary of the awarding of the Nobel Prize for Medicine to Hench, Kendall, and Reichstein for their discovery of glucocorticoid treatment of rheumatic diseases. The efficacy and toxicity of glucocorticoids has remained a matter of contention ever since, with debate continuing over their place in the therapeutic armamentarium of rheumatologists. Few if any rheumatologists would not prescribe glucocorticoids, however, and review of new data on their use, efficacy, and toxicity remains topical. Perceived advances in the ability to manage osteoporosis arising from glucocorticoid use has allowed focus to shift onto other toxicities, including vascular disease, but important advances in our understanding of the mechanism of action of glucocorticoids are still lacking.
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Affiliation(s)
- E F Morand
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Clayton, Australia.
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Cranney A, Welch V, Adachi JD, Homik J, Shea B, Suarez-Almazor ME, Tugwell P, Wells G. Calcitonin for the treatment and prevention of corticosteroid-induced osteoporosis. Cochrane Database Syst Rev 2000; 2000:CD001983. [PMID: 10796457 PMCID: PMC8409281 DOI: 10.1002/14651858.cd001983] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Corticosteroid-induced osteoporosis is a cause of morbidity in patients with chronic obstructive lung disease, asthma, and rheumatologic disorders. Corticosteroid treatment causes bone loss by a variety of complex mechanisms. It has been shown that bone mineral loss at the hip averages 14% in the first year after starting corticosteroid therapy. OBJECTIVES To review the efficacy of calcitonin (subcutaneous or nasal) for the treatment and prevention of corticosteroid-induced osteoporosis. SEARCH STRATEGY We conducted a search of Medline, the Cochrane Controlled Trials Register and Embase using the Cochrane Musculoskeletal Group search strategy for randomized controlled trials (RCTs) up to May 1998. We also searched bibliographic references and consulted content experts. SELECTION CRITERIA Two independent reviewers selected RCTs which met predetermined inclusion criteria. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data using predetermined forms and assessed methodological quality of randomization, blinding and dropouts. For dichotomous outcomes, relative risks (RR) were calculated. For continuous data, weighted mean differences (WMD) of the percent change from baseline were calculated. We decided a priori to use random effects models for all outcomes, because of uncertainty about whether a consistent true effect exists in such different populations. MAIN RESULTS Nine trials met the inclusion criteria, including 221 patients randomized to calcitonin and 220 to placebo. The median methodologic quality was two out of a maximum of five points. Calcitonin was more effective than placebo at preserving bone mass at the lumbar spine after six and 12 months of therapy with a WMD of 2.8% (95% CI: 1.4 to 4.3) and 3.2% (95% CI: 0.3 to 6.1). At 24 months, lumbar spine BMD was not statistically different between groups: WMD 4.5% (95% CI: -0.6 to 9.5)]. Bone density at the distal radius was also higher with calcitonin after six months of therapy, but bone density at the femoral neck was not different between placebo and calcitonin treated groups. The relative risk of fractures was not significantly different between calcitonin and placebo with a relative risk (RR) of 0.71 (95% CI: 0.26 to 1.89) for vertebral and 0.52 (95% CI: 0.14 to 1.96) for nonvertebral fractures. The subgroup analyses of methodological quality and duration of corticosteroid therapy were confounded. Trials of patients who had been taking steroids for greater than three months (which were of low methodologic quality) demonstrated a larger effect of calcitonin on spine bone density (about 6%) than prevention trials (about 1%). There was no consistent effect of different dosages (50-100 IU compared to 200-400 IU). However, subcutaneous calcitonin showed substantially greater prevention of bone loss. Withdrawals due to side effects were higher in the calcitonin-treated groups: RR 3.19 (95%CI: 0.66 to 15.47). Important side effects included nausea and facial flushing. REVIEWER'S CONCLUSIONS Calcitonin appears to preserve bone mass in the first year of glucocorticoid therapy at the lumbar spine by about 3% compared to placebo, but not at the femoral neck. Our analysis suggests that the protective effect on bone mass may be greater for the treatment of patients who have been taking corticosteroids for more than three months. Efficacy of calcitonin for fracture prevention in steroid-induced osteoporosis remains to be established.
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Affiliation(s)
- A Cranney
- Rheumatology, Ottawa Civic Hospital, 737 Parkdale Ave, Ottawa.
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