Managing Osteoporosis in Patients on Long-Term Bisphosphonate Treatment: Report of a Task Force of the American Society for Bone and Mineral Research

Mild antiresorptive activity of an anti-vascular endothelial growth factor A antibody and sunitinib in a rat model of bone resorption

Medication-Related-Osteonecrosis-of-the-Jaw (MRONJ) is an adverse event linked to antiresorptives such as bisphosphonates and denosumab. While MRONJ predominantly affects cancer patients treated with these agents, it has been less frequently reported in cancer patients receiving angiogenesis inhibitors (AgIs) like bevacizumab and sunitinib, even without concurrent use of antiresorptives. We hypothesized that certain AgIs exhibit antiresorptive activity in addition to their antiangiogenic effects, potentially influencing the pathophysiology of MRONJ. 52 five-week-old SD rats were randomized to receive vehicle (VEH), an oncologic dose of zoledronic acid (ZOL), or low (LD) and high doses (HD) of either an anti-VEGFA antibody or sunitinib (SU) for 10 days. We used the Schenk assay to assess the in vivo antiresorptive properties of these drugs/agents. We evaluated serum biomarkers of bone resorption (TRACP 5b) and formation (P1NP), pQCT variables of the femurs/tibias, and bone resorption/formation variables by bone histomorphometry at the distal femur metaphysis. ZOL reduced TRACP-5b levels, osteoclast number, and BFR while increasing vBMD, mineralized tissue volume, calcified cartilage volume, and bone volume. Both anti-VEGFA and SU decreased osteoclast number and increased calcified cartilage volume relative to total mineralized tissue volume, though to a lesser extent than ZOL. Anti-VEGFA (HD) also reduced TRACP-5b levels. Furthermore, both AgIs decreased P1NP levels, MAR, and bone elongation rate but increased growth cartilage thickness and induced physeal dysplasia. In conclusion, AgIs, particularly anti-VEGFA, exhibit significant yet milder antiresorptive activity compared to ZOL. They also affect bone formation, suggesting a complex mechanism that may play a role in the pathophysiology of MRONJ.

Clinical efficacy and safety of long-term treatment, discontinuation, and extended dosing intervals of denosumab treatment for solid cancer bone metastasis: A retrospective study

BACKGROUND

Metastatic bone tumors in solid cancer often induce excessive local bone resorption leading to skeletal related events (SRE) which may impact patients' quality of life and survival of the primary cancer. Denosumab, a bone resorption inhibitor, is commonly used to prevent SRE in patients with solid cancer bone metastasis. However, as cancer treatment advances, patients with long-term treatment, discontinuation, and extended dosing intervals of denosumab are seen in real-world clinical practice, and questions arise regarding the efficacy and safety of such cases.

METHODS

We retrospective evaluated a total of 298 patients with bone metastasis of solid cancer who received denosumab treatment between 2012 and 2022. We evaluated the rates of SRE and adverse events from the medical records. To evaluate the impact of extended dosing intervals, patients were divided to short and long interval groups consisting of patients with mean dosing interval of shorter and longer than six weeks, respectively.

RESULTS

Patients with lung and other cancers, patients with prior SRE, and patients with lung metastasis showed higher risks of SRE. Osteonecrosis of the jaw (ONJ) was seen in 11.1 % of the cases and the highest incidence rate of ONJ was seen in the third year of treatment. Atypical femoral fracture was seen in one case with a dosing period of 217 weeks. Discontinuation of denosumab led to an increase of SRE, 25 weeks after the final administration. Extended dosing intervals of denosumab did not increase the SRE risk, however, did not reduce the risk of adverse events either.

CONCLUSION

Severe adverse events should be noted in long-term treatment cases. Denosumab holiday is suggested to be limited to less than six months to mitigate SRE risk. Extending dosing intervals beyond the standard regimen did not increase the risk of SRE nor decrease the risk of adverse events.

Effects of 15 Years of Continuous Treatment with Bisphosphonate on Japanese Postmenopausal Osteoporosis Patients: An Observational Study

Bisphosphonate (BP) is mainly used for the treatment of osteoporosis because of its efficacy in increasing bone mineral density (BMD) and reducing osteoporotic fractures. Previous large-scale studies indicated that continuous 10-year treatment with BP was effective for osteoporosis treatment. However, several studies indicated an increase in the risk of serious adverse events such as atypical femoral fracture on prolonged BP treatment. The benefits and risks associated with long-term BP therapy are controversial. On the other hand, the effects of BP for more than 10 years are unknown because of few previous studies. The aim of this study to investigate effects of continuous 15-year treatment with BP on Japanese postmenopausal osteoporosis patients. The study was a retrospective observational study. Fifteen of the 55 patients, who had already received a 10-year course of oral BP treatment in our previous study, continued the treatment for an additional 5 years. All patients made the choice additional BP treatment with informed consent. BMD; hip structural analysis (HSA); limbs-muscle volume; and serum total alkaline phosphatase, tartrate-resistant acid phosphatase-5b, calcium and phosphate levels were measured for 5 years in the 15 patients. BMD values at the lumbar spine were significantly increased at 15 years in comparison with that at 10 years. Section modulus of HSA for the intertrochanter was significantly increased at 15 years. No subsequent fractures or serious adverse events were observed. We demonstrated favorable effects of an additional 5 years of BP treatment in postmenopausal osteoporosis patients who had already received a continuous 10-year treatment.

[Bisphosphonates-related osteonecrosis of the jaw: A case report]

Osteonecrosis of the mandible is also called avascular necrosis of the jaw, and it is a rare complication of bisphosphonates. It is characterized with pain, swelling, exposure of bone, local infection and pathologic fractures of the jaw. With the widespread usage of bisphosphonates in bone metastasis of malignant tumors and osteoporosis, this rare complication has received more attention in recent years. Here, we reported a case of bisphosphonates-related osteonecrosis of the jaw (BRONJ) caused by intravenous zoledronic acid for osteoporosis. A 62-year-old female patient with 7-year history of Sjögren's syndrome and 3-year history of osteoporosis developed BRONJ after 3-year treatment of zoledronic acid. Two months before she went to the Peking University International Hospital, she visited the dentist for periodontal purulent secretion and extracted one tooth from the right mandible. However, the condition was not improved and she felt persistent pain and swelling in the right mandible. Hence, she received repeated root curettage, but there was no improvement. Finally, she was diagnosed with osteonecrosis of the mandible based on the digital volume tomography scan, which showed right mandibular osteonecrosis bone destruction. She underwent surgical debridement of the necrotic bone and administered intravenous antibio-tics at the Peking University International Hospital. Histopathological analysis of the bone biopsy further confirmed the diagnosis of BRONJ. Her condition was improved successfully during a 3-year follow-up. Osteonecrosis of the mandible become more common with the increased use of bisphosphonates. Recent study has reported that osteonecrosis of the mandible is more likely to occur in patients with Sjögren's syndrome. In addition, age, long-term and irregular administration of glucocorticoids, irregular oral examination and treatment also might be the risk factors in the pathogenesis of osteonecrosis of the mandible. For the elder osteoporosis patients who would receive or had received bisphosphonate-related drugs, oral health status and the disease states associated with necrosis of the mandible such as Sjögren's syndrome should be comprehensively measured and fully evaluated during the whole process. Furthermore, to better understand and prevent or reduce the occurrence of this complication, we reviewed the patho-genesis, diagnosis, treatment, and prevention of BRONJ.

Update on the role of bone turnover markers in the diagnosis and management of osteoporosis: a consensus paper from The European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO), International Osteoporosis Foundation (IOF), and International Federation of Clinical Chemistry and Laboratory Medicine (IFCC)

PURPOSE

The International Osteoporosis Foundation (IOF) and the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) have proposed procollagen type I N propeptide (PINP) and β isomerized C-terminal telopeptide of type I collagen (β-CTX-I) as reference bone turnover markers (BTMs) for osteoporosis. This report examines the published literature since the 2011 IOF-IFCC position paper in order to determine the clinical potential of the reference BTMs and newer markers for the prediction of fracture risk and monitoring the treatment of osteoporosis.

METHODS

Evidence for the relationship between BTMs and subsequent fractures was gathered from prospective studies through literature review of the Medline database from years 2011 to May 2024. The impact of treatment on BTMs was also studied by examining publications in that period. Studies of the accuracy of BTMs in the assessment of bone turnover in the setting of advanced chronic kidney disease were also examined.

RESULTS

Increased BTM concentrations are associated with higher fracture risk in postmenopausal women. PINP and β-CTX-I measured in blood are associated with fracture risk but their interaction with other risk factors has not been sufficiently studied limiting their incorporation into fracture risk algorithms. Treatment-induced changes in PINP and β-CTX-I account for a substantial proportion of fracture risk reduction and are useful for improving adherence; they are recommended for inclusion in studies to examine adherence in individual patients. However, total PINP (tPINP) and β-CTX-I may be elevated in CKD due to renal retention. Bone alkaline phosphatase (BALP), intact PINP (iPINP), and tartrate resistant acid phosphatase 5b (TRACP5b) show the most promise in discriminating high and low turnover bone diseases in patients with advanced CKD and for predicting fracture risk, monitoring treatment response, and assessing the risk of treatment-related complications.

CONCLUSION

We re-affirm the use of serum/plasma tPINP and plasma β-CTX-I as reference BTMs with appropriate patient preparation and sample handling and measurement by standardized/harmonized assays in clinical studies to accumulate further data, and for monitoring treatment of osteoporosis in the setting of normal renal function in clinical practice. BALP and TRACP5b, measured by standardized assays, are recommended as reference BTMs for CKD-associated osteoporosis and should be included in observational and intervention studies to ascertain their utility for risk-evaluation, treatment initiation, and assessment of treatment response in CKD-associated osteoporosis.

Zoledronic acid in metastatic castrate-sensitive prostate cancer: A state-of-the-art review

Prostate cancer is the most common cancer in men in developed countries. Despite its slow growing pattern, metastatic disease to bone occurs and results in a significant number of deaths. Since more than eight decades, the classical androgen deprivation therapy (ADT) leads to clinical response in most patients with metastatic castration-sensitive prostate cancer (mCSPC). Moving backward docetaxel and androgen receptor pathway inhibitors (ARPI) from castrate-resistant setting to castrate sensitive setting improves overall survival (OS) compared to ADT alone. Recently, studies suggested that triplet therapy by adding ARPIs such as abiraterone acetate or darolutamide to ADT + docetaxel is more effective than ADT/docetaxel alone in patients with high-volume mCSPC. Although the scientific progress during the last decade, has led to improvements in outcome for patients with mCSPC, there are still several areas impacting daily practice, for which high-level evidence is lacking, especially for adding monthly zoledronic acid in this setting. We structured this review by conducting a comprehensive analysis of the existing literature. This manuscript reviews both the benefits and potential harms of zoledronic acid in the treatment of mCSPC and provides conclusions on the criteria for its use, and the possible use of alternative bone protecting agents (BPA).

Effect of Severe Bowing in Bisphosphonate-Related Atypical Femoral Fracture

Backgroud

Long-term use of bisphosphonate is a risk factor for atypical femoral fractures (AFFs). Femoral bowing is known to be associated with AFFs. However, whether femoral bowing quickens the occurrence of AFF is unknown. The purpose of this study was to determine whether AFF occurs earlier in patients with severe femoral bowing than in those without severe bowing.

Methods

One hundred and sixty-four patients (186 AFFs) from January 2006 to December 2022 were included in this study. According to severity of femoral bowing, patients were divided into 2 groups: severe bowing group (26 femurs) and minimal to moderate bowing group (160 femurs). Age, sex, and completeness and location of AFF were compared between the 2 groups. We compared the time of AFF occurrence after bisphosphonate therapy using cumulative percentage between the 2 groups.

Results

Age and sex were similar between the 2 groups, while body mass index (BMI) was lower (22.5 ± 3.0 kg/m2 vs. 24.5 ± 3.5 kg/m2, p = 0.003) in the severe bowing group. The duration of bisphosphonate use was shorter in the severe bowing group than in the minimal to moderate bowing group (3.3 ± 3.8 years vs. 5.0 ± 4.0 years, p = 0.048). In the severe bowing group, 85% of AFFs were diaphyseal in contrast to the 46% in the minimal to moderate bowing group (p < 0.001). Cumulative percentage plot of AFFs in the severe bowing group was left-shifted compared to the minimal to moderate bowing group.

Conclusions

At the time of AFF diagnosis, the severe bowing group exhibited shorter duration of bisphosphonate use, lower BMI, and a higher incidence of diaphyseal location. Shortening the duration of bisphosphonate therapy may be advisable in patients with severe femoral bowing.

Sequential and Long-term Therapy for Osteoporosis

PURPOSE OF THE REVIEW

Osteoporosis requires life-long management. This involves the use of different drugs in various sequences followed by long-term maintenance therapy. This review highlights the important transitions among osteoporosis therapies and outlines a strategy of intermittent bisphosphonate therapy for long-term maintenance.

RECENT FINDINGS

Over the past few years, the effects and limitations of long-term treatment with bisphosphonates and denosumab have become apparent as have several key factors in the sequential use of anti-remodeling drugs and osteoanabolic agents. Strategies for transitions from estrogen, bisphosphonates, denosumab and the bone-forming drugs will be discussed, based on extant evidence, clinical experience and expert opinion. By appropriate selection of both the initial and subsequent drugs for the prevention and treatment of osteoporosis, therapeutic benefits can be optimized and safety issues minimized. Developing a strategy for long-term maintenance of the benefits of the initial therapies can provide a life plan for managing patients with osteoporosis.

Osteoporosis in Men: an Overlooked Patient Population

PURPOSE OF REVIEW

The purpose of this review is to describe the approach to osteoporosis management in men in the setting of limited evidence.

RECENT FINDINGS

Although men have less fractures than women, men have greater mortality after fractures as well as increased complications, including infection and major cardiovascular events. Unfortunately, men are not routinely screened for osteoporosis, partially due to limited insurance coverage in the United States. Due to screening barriers and lack of robust evidence of fracture reduction with therapeutic agents in men, treatment rates have also been low. A 2022 network meta-analysis of osteoporosis treatment in men found that with all the randomized controlled trials performed in men, there was only sufficient power to show vertebral fracture reduction. A large case-control observational study from 2024 did find that osteoporosis treatment reduced odds of hip fracture similarly in men and women. Men have fractures, with greater morbidity and mortality than women. Although osteoporosis research is lacking in men, providers should assess fracture risk in men and allow them the opportunity to reduce their fracture risk.

Ukrainian guideline for the prevention and treatment of glucocorticoid-induced osteoporosis

INTRODUCTION

Glucocorticoid-induced osteoporosis (GIOP) is a bone metabolic disorder caused by glucocorticoid (GC) use. It is one of the leading causes of secondary osteoporosis, increasing the risk of low-energy fractures, disability, and mortality. Although limited studies on GIOP epidemiology and treatment have been conducted in Ukraine, there were no national guidelines for its management. The aim was to create national guideline for the GIOP diagnosis, prevention, and treatment based on a comprehensive review of modern literature to enhance awareness within Ukraine's medical community, improve disease management, and reduce its socio-economic impact.

MATERIALS AND METHODS

An Expert Group comprising 18 leading Ukrainian scientists from various fields was created for guideline development. A review of modern literature on GIOP epidemiology, risk factors, diagnosis, prevention, treatment, and monitoring was conducted. Evidence synthesis followed the GRADE methodology, and the quality of recommendations was critically evaluated using the AGREE II tool.

RESULTS

The guideline comprises 12 statements covering GIOP screening, diagnosis, prevention, and treatment. We highlight the need to raise awareness among healthcare providers and patients about the potential effects of GC therapy. Also, we outline approaches to clinical assessment of osteoporotic fracture risk in GC users and detail diagnostic and therapeutic methods currently available in Ukraine for managing GIOP.

CONCLUSION

The first Ukrainian national GIOP guideline is critical for healthcare providers across specialities. Endorsed by the Board of the Ukrainian Association of Osteoporosis, it is recommended for use in routine clinical practice to enhance patient outcomes and mitigate the disease's impact.

Medication related osteonecrosis (MRONJ) in the management of CTIBL in breast and prostate cancer patients. Joint report by SIPMO AND SIOMMMS

Background

Low-doses of bone modifying agents (LD-BMAs) compared to those used to treat bone metastases are used in breast or prostate cancer patients on adjuvant endocrine therapy to prevent Cancer Treatment Induced Bone Loss (CTIBL). Their use is associated with an increased risk of developing Medication-Related Osteonecrosis of the Jaw (MRONJ). However, there is not clarity about strategies aimed to minimize the MRONJ risk in cancer patients at different conditions as low- vs high-doses of BMA. This joint report from the Italian Societies of Oral Pathology and Medicine (SIPMO) and of Italian Society of Osteoporosis, Mineral Metabolism and Skeletal Diseases (SIOMMMS) aims to define the dental management of breast and prostate cancer patients with CTIBL under LD-BMAs, to reduce their risk to develop MRONJ.

Methods

This interdisciplinary SIPMO-SIOMMMS Expert Italian Panel reviewed the available international scientific literature and developed a set of recommendations to implement strategies of MRONJ prevention in breast (BC) and prostate cancer (PC) patients undertaking LD-BMAs to prevent CTIBL.

Results

The Expert Panel, after addressing some introductive topics (i.e., CTIBL and its management, pharmacology and pharmacodynamics of BMAs, definition and diagnosis of MRONJ), developed a joint report on the following five issues: a) prevention and dental management in cancer patients candidates to LD-BMAs, or under LD-BMAs; b) prophylactic drug holiday; c) MRONJ treatment; d) LD-BMAs therapeutic drug holiday; and e) restart of LD-BMA treatment after successful healing of MRONJ.Finally, ten key questions with answers were prepared and placed at the end of the document.

Conclusions

Despite obvious weaknesses of the available international literature, the Expert Panel recognized the need to tailor separate MRONJ preventive approach for breast and prostate cancer patients on adjuvant endocrine therapy who begin low-dose BMA therapy to prevent CTIBL and provided this practical guidance for bone specialists and oral healthcare providers. In view of a MRONJ risk for BC and PC patients receiving low-dose BMAs, which approximates that of patients with osteoporosis and other non-malignant diseases undergoing similar treatment schedules, the SIPMO-SIOMMMS Expert Panel recognizes the need for less stringent preventive strategies than those already developed for BC or PC patients with bone metastases taking HD-BMAs.

Bisphosphonate drug holidays in osteoporosis according to fracture risk profile

We analyzed the incidence of fractures and changes in bone mineral density and bone turnover markers in 264 patients who discontinued bisphosphonates. Fractures were recorded in 12.3%. Half were clinical vertebral fractures. We identified patients with a high-risk profile who should not discontinue treatment.

OBJECTIVE

The optimal length of bisphosphonate discontinuation is unknown, as is the type of patient who could benefit from this approach. The objectives of the study were to analyze, in clinical practice, the incidence of fractures and associated risk factors, changes in bone mineral density (BMD) and bone turnover markers (BTMs) after discontinuation of bisphosphonates.

METHODS

This observational retrospective study included 264 patients from 14 Spanish rheumatology departments. Postmenopausal women or men with osteoporosis received alendronate or risedronate for ≥ 5 years or zoledronate for ≥ 3 years and had discontinued treatment for ≥ 1 year or ≥ 2 years, respectively. Spinal X-rays were obtained before discontinuation and in suspected clinical vertebral fracture during follow-up. BMD and BTMs were determined before discontinuation and at different time points.

RESULTS

The mean discontinuation time was 2.7 (± 6.7) years. Thirty-two patients (12.3%) had 36 fractures, mainly clinical vertebral fractures. The main risk factor for fracture was a high-risk profile (femoral neck T-score ≤ -2.5 and/or a history of fracture and/or multiple fractures [≥ 5 years]) before discontinuation. At 12 months, 10.41% of patients with high-risk profile experienced a fracture, being 0.8% and 1.08% in moderate- and low-risk patients, respectively. Significant BMD loss at the femoral neck and total hip was detected, with duration of discontinuation being the key factor. PINP was the marker with the greatest changes.

CONCLUSIONS

We identified a profile of patients with osteoporosis who should not discontinue bisphosphonates, owing to the possibility of fractures, especially vertebral, which are already evident the first year after discontinuation.

Osteoporosis in Older Men: Informing Patient Management and Improving Health-Related Outcomes

Osteoporosis has been usually considered a female disease, generally causing more fracture risk and complications in adult and older women compared to older men. While vertebral fractures occur in a small proportion of men during middle age, men generally fracture about 10 years later than women, with significant increases in fracture risk after about age 75. Independent of age, men experiencing fragility fractures have a higher risk of life-threatening events compared to women, but the risk of secondary fragility fracture overlaps between men and women. Often, male osteoporosis recognizes the overlap between secondary causes and primary osteoporosis risk factors. Assessment through physical examination, history, and laboratory tests is recommended, with dual-energy X-ray absorptiometry of bone density being the preferred diagnostic test for osteoporosis in men. A treatment program should include awareness of diet and vitamin D status, fall risk reduction, and pharmaceutical therapy. Medications that are fracture-reducing in older women should also achieve fewer fractures in older men; however, there is a paucity of studies in men with the primary outcome of fracture risk reduction. Most older men with osteoporosis should be treated with oral or intravenous bisphosphonates, denosumab especially when on androgen deprivation therapy, and initial anabolic treatment should be considered for men at very high risk of fracture. This review summarizes the main features of osteoporosis and fragility fractures in men and reports findings from the available pharmacological and non-pharmacological studies conducted in men.

Injectable double-crosslinked bone cement with enhanced bone adhesion and improved osteoporotic pathophysiological microenvironment for osteoregeneration in osteoporosis

The osteoporotic bone defect caused by excessive activity of osteoclasts has posed a challenge for public healthcare. However, most existing bioinert bone cement fails to effectively regulate the pathological bone microenvironment and reconstruct bone homeostasis in the presence of osteoclast overactivity and osteoblast suppression. Herein, inspired by natural bone tissue, an in-situ modulation system for osteoporotic bone regeneration is developed by fabricating an injectable double-crosslinked PEGylated poly(glycerol sebacate) (PEGS)/calcium phosphate cement (CPC) loaded with sodium alendronate (ALN) (PEGS/CPC@ALN) adhesive bone cement. By incorporating ALN, the organic-inorganic interconnection within PEGS/CPC@ALN results in a 100 % increase in compression modulus and energy dissipation efficiency. Additionally, PEGS/CPC@ALN effectively adheres to the bone by bonding with amine and calcium ions present on the bone surface. Moreover, this in-situ regulation system comprehensively mitigates excessive bone resorption through the buffering effect of CPC to improve the acidic microenvironment of osteoporotic bone and the release of ALN to inhibit hyperactive osteoclasts, and facilitates stem cell proliferation and differentiation into osteoblasts through calcium ion release. Overall, the PEGS/CPC@ALN effectively regulates the pathological microenvironment of osteoporosis while promoting bone regeneration through synergistic effects of drugs and materials, thereby improving bone homeostasis and enabling minimally invasive treatment for osteoporotic defects.

Unexpected Increase in Bone Mineral Density With Rapamycin and Low-Dose Naltrexone: A Case Report of a 52-Year-Old Woman With Osteopenia

Osteopenia and osteoporosis are prevalent bone disorders characterized by reduced bone mineral density (BMD), leading to an increased risk of fractures. This case report presents a 52-year-old Caucasian female patient with osteopenia who experienced an unexpected 15.9% increase in lumbar spine BMD within two years after enrolling in a clinical trial involving low-dose rapamycin and subsequently starting low-dose naltrexone. This case potentially opens novel treatment strategies for bone density improvement in aging populations.

Effectiveness of Bisphosphonates in Young Adults with Fragility Fractures: Representative Population-Based Cohort Study

CONTEXT

Fragility fractures in young adults present significant clinical challenges due to the limited evidence on the effectiveness of bisphosphonates in preventing subsequent fractures.

OBJECTIVE

To evaluate the effectiveness of bisphosphonate therapy in reducing the fracture risk among premenopausal women with a history of osteoporotic fractures.

DESIGN

A population-based retrospective cohort study was conducted using data from the National Health Insurance Service-National Sample Cohort (NHIS-NSC) in South Korea, covering the years 2003 to 2014.

SETTING

A nationwide healthcare setting utilizing a representative cohort database.

PARTICIPANTS

Among 2,087 premenopausal women with osteoporotic fractures, participants were propensity score-matched based on age and body mass index at a 1:3 ratio, resulting in 132 bisphosphonate users and 396 non-users.

INTERVENTION

Bisphosphonate treatment.

MAIN OUTCOME MEASURES

The incidence of osteoporotic fractures.

RESULTS

Bisphosphonate users had a significantly lower risk of major osteoporotic fractures (HR 0.618, 95% CI 0.396 - 0.963) compared to non-users. Ibandronate users showed significant reductions in both major osteoporotic (HR 0.376, 95% CI 0.164 - 0.861) and nonvertebral fractures (HR 0.214, 95% CI 0.052 - 0.877). Also, longer duration of bisphosphonate use (≥180 days) was associated with a significantly lower risk of major osteoporotic and nonvertebral fractures (HR 0.528, 95% CI 0.300 - 0.929; HR 0.409, 95% CI 0.187 - 0.895, respectively).

CONCLUSIONS

Bisphosphonate therapy significantly reduces fracture risk in premenopausal women with previous osteoporotic fractures, especially at higher cumulative doses. These findings support considering bisphosphonates as a treatment option in premenopausal women at high risk of fractures.

Treating osteoporosis in patients with atypical femoral fracture

Patients who have suffered an atypical femoral fracture while on bisphosphonates or denosumab may continue to be at risk for typical osteoporotic fractures. There are no studies to provide guidance on safe treatment for such patients. Instead, using an illustrative case, 5 principles of management are provided that may lead to decreased osteoporotic fracture risk. The first principle is to discontinue the anti-resorptive medications, which may be challenging for the patient on denosumab because of rebound vertebral fractures reported in patients stopping denosumab. The second principle is to maximize non-pharmacologic management to reduce falls and fractures. Home safety, other methods of fall risk reduction, adequate nutrition, and an exercise prescription should help reduce fracture risk. Investigating potential secondary causes of osteoporosis, particularly if the original workup was not comprehensive, is the third principle because treatment of some specific causes may lower fracture risk. Reviewing the medication list is the fourth principle, with the goal of eliminating drugs that may increase fracture risk, and considering thiazides for some patients, which may lower fracture risk. Finally, some patients may benefit from anabolic therapy. One potential (but not FDA-approved) method is to use long-term cyclic teriparatide or abaloparatide on a 3-mo on, 3-mo off schedule. Tailoring the approach to each patient is important, based on the 5 clinical principles, in the absence of evidence-based management recommendations.

Sequential treatment from bisphosphonate to denosumab improves lumbar spine bone mineral density in postmenopausal osteoporosis patients: A meta-analysis of randomized controlled trials

BACKGROUND

Bisphosphonates are effective in the treatment of postmenopausal osteoporosis. However, their prolonged use induces adverse events and may lead to a rapid decline in bone mineral density (BMD) after discontinuation. Denosumab, a human monoclonal antibody, is a widely used antiresorptive agent that is more effective than bisphosphonates in improving bone density. Whether sequential treatment with denosumab after bisphosphonate therapy can maintain or further increase BMD at all sites has not been conclusively demonstrated. Thus, we performed a meta-analysis of randomized controlled trials (RCTs) to assess the effects of this sequential therapy on BMD.

METHODS

We searched the PubMed, Embase, and Cochrane Library databases from December 1, 1986, to May 2, 2024, for all RCTs that assessed the efficacy of sequential therapy of bisphosphonate transition to denosumab in postmenopausal women with osteoporosis. BMD changes at the lumbar spine, femoral neck, and total hip were used as outcomes. We assessed methodological quality, extracted relevant data according to the Cochrane Handbook for Systematic Reviews of Interventions, applied random-effects models for meta-analyses, performed heterogeneity analyses, and assessed publication bias.

RESULTS

A total of 3290 patients from 4 RCTs were included in the meta-analysis. Forest plot analysis showed that sequential treatment with bisphosphonate-denosumab was associated with higher lumbar spine BMD gain than continuous bisphosphonate treatment [mean difference (MD) = 5.50, 95% confidence interval (CI) = 5.26-5.75, I2 = 32.88%). No risk of bias was observed for the 4 trials, but there was an increase in femoral neck and total hip BMD. Moreover, analyses could not be performed because of high heterogeneity (femoral neck BMD: MD = 3.85, 95% CI = 2.84-4.85, I2 = 97.88%; total hip BMD: MD = 5.65, 95% CI = 4.28-7.02, I2 = 97.91%).

CONCLUSION

Sequential therapy that involves a transition from bisphosphonates to denosumab had a positive effect on lumbar spine bone density, and this type of therapy may be a potential treatment option for increasing lumbar spine bone density in postmenopausal women.

Using DEXA to diagnose impending atypical femoral fracture in an asymptomatic patient on long term bisphosphonates: A case report of a missed opportunity for fracture prevention

We report a patient who sustained an AFF (Atypical femoral fractures) after 15 years of bisphosphonate treatment. DEXA scans can be utilized to identify early evidence of AFF in asymptomatic patients up to 9 years before the development of an AFF.

Effect of Oral Bisphosphonate Drug Holiday on Mortality Following Hip Fracture

CONTEXT

Current clinical guidelines recommend a drug holiday after extended use of oral bisphosphonates. However, no studies have investigated the effect of drug holidays before hip fractures on postfracture mortality.

OBJECTIVE

This work aimed to investigate the effect of a drug holiday on postfracture mortality in patients with extended use of oral bisphosphonates.

METHODS

This retrospective, population-based cohort study took place among all patients with hip fractures in Victoria, Australia, from 2014 to 2018. Patients were adherent to oral alendronate or risedronate for 5 years or more prior to hip fracture. Group-based trajectory modeling categorized patients into different bisphosphonate usage after 5-year good adherence. The main outcome measure was postfracture mortality.

RESULTS

We identified 365 patients with good adherence (medication possession ratio ≥80%) to oral alendronate/risedronate for 5 years or more. Most patients (69%) continued to use oral bisphosphonates until admission for hip fracture; 17% had discontinued for 1 year and 14% had discontinued for 2 years. Postfracture mortality was higher in patients who had discontinued risedronate for 1 year (hazard ratio [HR] 2.37; 95% CI, 1.24-4.53) and 2 years (HR 3.08; 95% CI, 1.48-6.41) prior to hip fracture. No increase or decrease in postfracture mortality was observed in patients who had discontinued alendronate for 1 year (HR 0.59; 95% CI, 0.29-1.18) or 2 years (HR 1.05; 95% CI, 0.57-1.93) prior to hip fracture.

CONCLUSION

Postfracture mortality is higher in people who discontinue risedronate, but not alendronate, for 1 or 2 years after being adherent to treatment for at least 5 years. The type of bisphosphonate may be a factor to consider when planning drug holidays.

Bisphosphonate Use and Risk of Atypical Femoral Fractures: A Danish Case-Cohort Study With Blinded Radiographic Review

CONTEXT

Prolonged bisphosphonate (BP) treatment for osteoporosis prevents hip and other fractures but causes atypical femoral fractures (AFF).

OBJECTIVE

To establish the relationship between patterns of BP use and the risk of AFF and hip fractures. Other potential risk factors for AFF were also examined.

METHODS

This population-based case-cohort study utilized data from the Danish National Healthcare system, including longitudinal records of medication use, healthcare utilization, and x-ray images. Among all 1.9 million Danish adults ≥50, those with subtrochanteric or femoral shaft fractures between 2010 and 2015 (n = 4973) were identified and compared to a random sample (n = 37 021). Bisphosphonate use was collected from 1995-2015. Fracture radiographs (n = 4769) were reviewed by blinded study radiologists to identify AFFs (n = 189) using established criteria. Traditional hip fractures in the random sample (n = 691) were identified by ICD-10.

RESULTS

Compared to <1 year of BP use, 5 to 7 years of use was associated with a 7-fold increase in AFF (adjusted HR = 7.29 [CI: 3.07, 17.30]); the risk of AFF fell quickly after discontinuation. The 5-year number needed to harm for one AFF was 1424, while the 5-year number needed to treat to prevent one hip fracture was 56. Glucocorticoid and proton pump inhibitor use were independently associated with increased AFF risk. Thirty-one percent of those with AFF had no BP exposure.

CONCLUSION

The risk of AFF increases with duration of BP use but the beneficial effects of BP therapy in adults ≥50 dramatically exceed this increased risk. Nearly one-third of those with AFF have no BP exposure.

[Osteoporosis-Definition, risk assessment, diagnosis, prevention and treatment (update 2024) : Guidelines of the Austrian Society for Bone and Mineral Research]

BACKGROUND

Austria is among the countries with the highest incidence and prevalence of osteoporotic fractures worldwide. Guidelines for the prevention and management of osteoporosis were first published in 2010 under the auspices of the then Federation of Austrian Social Security Institutions and updated in 2017. The present comprehensively updated guidelines of the Austrian Society for Bone and Mineral Research are aimed at physicians of all specialties as well as decision makers and institutions in the Austrian healthcare system. The aim of these guidelines is to strengthen and improve the quality of medical care of patients with osteoporosis and osteoporotic fractures in Austria.

METHODS

These evidence-based recommendations were compiled taking randomized controlled trials, systematic reviews and meta-analyses as well as European and international reference guidelines published before 1 June 2023 into consideration. The grading of recommendations used ("conditional" and "strong") are based on the strength of the evidence. The evidence levels used mutual conversions of SIGN (1++ to 3) to NOGG criteria (Ia to IV).

RESULTS

The guidelines include all aspects associated with osteoporosis and osteoporotic fractures, such as secondary causes, prevention, diagnosis, estimation of the 10-year fracture risk using FRAX®, determination of Austria-specific FRAX®-based intervention thresholds, drug-based and non-drug-based treatment options and treatment monitoring. Recommendations for the office-based setting and decision makers and institutions in the Austrian healthcare system consider structured care models and options for osteoporosis-specific screening.

CONCLUSION

The guidelines present comprehensive, evidence-based information and instructions for the treatment of osteoporosis. It is expected that the quality of medical care for patients with this clinical picture will be substantially improved at all levels of the Austrian healthcare system.

Efficacy and safety of teriparatide vs. bisphosphonates and denosumab vs. bisphosphonates in osteoporosis not previously treated with bisphosphonates: a systematic review and meta-analysis of randomized controlled trials

The study found that in osteoporosis patients who had not previously received bisphosphonate treatment and were in a treatment cycle of over 12 months, both teriparatide and denosumab significantly increased bone mineral density compared to bisphosphonates. Additionally, teriparatide was also shown to significantly decrease the risk of fractures.

OBJECTIVE

The systematic review and meta-analysis aimed to assess and compare the safety and efficacy of teriparatide vs. bisphosphonates and denosumab vs. bisphosphonates in patients with osteoporosis who had not previously received bisphosphonates.

METHODS

We conducted a search of published literature from inception to May 31, 2023, including databases such as PubMed, Embase, Cochrane Library, CNKI, SinoMed, VIP, and WanFang. The study only included head-to-head randomized controlled trials (RCTs) that compared teriparatide and denosumab with bisphosphonates to treat patients with osteoporosis. Fixed-effect model and random-effect model were used due to clinical heterogeneity. Meta-analysis was performed via Stata 17.0.

RESULTS

A total of 6680 patients were enrolled across 23 eligible trials. The results of the meta-analysis showed that teriparatide was superior to bisphosphonates in decreasing the risk of fracture (risk ratio (RR) = 0.61, 95% confidence interval (CI) (0.51, 0.74), P < 0.001). Denosumab showed no benefit compared to bisphosphonates in reducing the risk of fracture in treating osteoporosis (RR 0.99, 95% CI (0.62, 1.57), P = 0.96). Compared with bisphosphonates, teriparatide and denosumab could significantly improve femoral neck, total hip, and lumbar spine bone mineral density (BMD) (P < 0.05). Furthermore, teriparatide and denosumab did not increase the incidence of adverse events (teriparatide vs. bisphosphonates, RR 0.92, 95% CI (0.79, 1.08), P = 0.32; denosumab vs. bisphosphonates, RR 0.98, 95% CI (0.95, 1.02), P = 0.37).

CONCLUSIONS

Teriparatide is superior to bisphosphonates in decreasing the risk of fracture in patients with osteoporosis. In addition, teriparatide and denosumab were more efficacious than bisphosphonates in increasing the percentage change in BMD at the femoral neck, total hip, and lumbar spine.

Risk factors for fragility fractures in patients with immunobullous diseases on long-term systemic glucocorticoids

Dear Editor, Systemic glucocorticoids remain a cornerstone of therapy in immunobullous diseases. Yet little is known about glucocorticoid induced osteoporosis (GIOP) in patients with immunobullous diseases. We performed a retrospective review of medical records at an immunodermatology clinic in a Singaporean tertiary centre. Inclusion criteria consisted of patients with a newly diagnosed immunobullous condition between January 2011 and October 2017, who were on long-term (>= 3 months) systemic glucocorticoids at a minimum daily dose of prednisolone 15mg. [...]

Kurarinone, a flavonoid from Radix Sophorae Flavescentis, inhibits RANKL-induced osteoclastogenesis in mouse bone marrow-derived monocyte/macrophages

Inflammation-induced osteoclast proliferation is a crucial contributor to impaired bone metabolism. Kurarinone (KR), a flavonoid extracted from the Radix Sophorae Flavescentis, exhibits notable anti-inflammatory properties. Nevertheless, the precise influence of KR on osteoclast formation remains unclear. This study's objective was to assess the impact of KR on osteoclast activity in vitro and unravel its underlying mechanism. Initially, a target network for KR-osteoclastogenesis-osteoporosis was constructed using network pharmacology. Subsequently, the intersecting targets were identified through the Venny platform and a PPI network was created using Cytoscape 3.9.1. Key targets within the network were identified employing topological algorithms. GO enrichment and KEGG pathway analysis were then performed on these targets to explore their specific functions and pathways. Additionally, molecular docking of potential core targets of KR was conducted, and the results were validated through cell experiments. A total of 83 target genes overlapped between KR and osteoclastogenesis-osteoporosis targets. Enrichment analysis revealed their role in inflammatory response, protein tyrosine kinase activity, osteoclast differentiation, and MAPK and NF-κB signaling pathways. PPI analysis and molecular docking demonstrate that key targets MAPK14 and MAPK8 exhibit more stable binding with KR compared to other proteins. In vitro experiments demonstrate that KR effectively inhibits osteoclast differentiation and bone resorption without cellular toxicity. It suppresses key osteoclast genes (NFATc1, c-Fos, TRAP, MMP9, Ctsk, Atp6v2), hinders IκB-α degradation, and inhibits ERK and JNK phosphorylation, while not affecting p38 phosphorylation. The results indicate that KR may inhibit osteoclast maturation and bone resorption by blocking NF-κB and MAPK signaling pathways, suggesting its potential as a natural therapeutic agent for osteoporosis.

Incidence and clinical course of femoral localized periosteal thickening and atypical femoral fracture over a 10-year period in patients with autoimmune inflammatory rheumatic disease

Atypical femoral fracture (AFF) is generally a rare complication of long-term use of bisphosphonate (BP); glucocorticoid (GC) use and Asian race are also risk factors. Femoral localized periosteal thickening (LPT, also termed "beaking") of the lateral cortex often precedes AFF. This cohort study investigated the incidence of LPT and AFF and their clinical courses over 10 yr in patients with autoimmune inflammatory rheumatic diseases (AIRDs) treated with BP and GC. The study population consisted of 121 patients with AIRDs taking BP and GC. LPT was screened by X-ray, and the LPT shape was evaluated. Prednisolone (PSL) dose was 10 (8-12) mg/d at enrollment and 9 (6-10) mg/d at the last observation. LPT was evident in 10 patients at enrollment and increased linearly to 31 patients (26%) at the last observation. AFF occurred in 9 femurs of 5 patients with LPT. All patients with AFF had bilateral LPT, and the prevalence of pointed type and LPT height were higher in the AFF-positive group than in the AFF-negative group. AFF occurred before BP discontinuation in 2 patients, 1 yr after BP discontinuation in 1, after BP discontinuation followed by 7 yr of alfacalcidol use in 1, and after switching from alfacalcidol to denosumab in 1. The prevalence rates of AFF and LPT associated with long-term BP use with concomitant use of GC (mostly PSL ≥ 6 mg/d) in Japanese patients with AIRD increased over time. The selection of long-term osteoporosis treatment for LPT-positive patients is difficult in some cases.

Lonicera japonica Fermented by Lactobacillus plantarum Improve Multiple Patterns Driven Osteoporosis

Osteoporosis (OP) represents a global health challenge. Certain functional food has the potential to mitigate OP. Honeysuckle (Lonicera japonica) solution has medicinal effects, such as anti-inflammatory and immune enhancement, and can be used in functional foods such as health drinks and functional snacks. The composition of honeysuckle changed significantly after fermentation, and 376 metabolites were enriched. In this study, we used dexamethasone to induce OP in the rat model. Research has confirmed the ability of FS (fermented Lonicera japonica solution) to enhance bone mineral density (BMD), repair bone microarchitectural damage, and increase blood calcium levels. Markers such as tartrate-resistant acid phosphatase-5b (TRACP-5b) and pro-inflammatory cytokines (TNF-α and IL-6) were notably decreased, whereas osteocalcin (OCN) levels increased after FS treatment. FS intervention in OP rats restored the abundance of 6 bacterial genera and the contents of 17 serum metabolites. The results of the Spearman correlation analysis showed that FS may alleviate OP by restoring the abundance of 6 bacterial genera and the contents of 17 serum metabolites, reducing osteoclast differentiation, promoting osteoblast differentiation, and reducing the inflammatory response. This study revealed that Lactobacillus plantarum-fermented honeysuckle alleviated OP through intestinal bacteria and serum metabolites and provided a theoretical basis for the development of related functional foods.

Bone-on-a-chip simulating bone metastasis in osteoporosis

Osteoporosis is the most common bone disorder, which is a highly dangerous condition that can promote bone metastases. As the current treatment for osteoporosis involves long-term medication therapy and a cure for bone metastasis is not known, ongoing efforts are required for drug development for osteoporosis. Animal experiments, traditionally used for drug development, raise ethical concerns and are expensive and time-consuming. Organ-on-a-chip technology is being developed as a tool to supplement such animal models. In this study, we developed a bone-on-a-chip by co-culturing osteoblasts, osteocytes, and osteoclasts in an extracellular matrix environment that can represent normal bone, osteopenia, and osteoporotic conditions. We then simulated bone metastases using breast cancer cells in three different bone conditions and observed that bone metastases were most active in osteoporotic conditions. Furthermore, it was revealed that the promotion of bone metastasis in osteoporotic conditions is due to increased vascular permeability. The bone-on-a-chip developed in this study can serve as a platform to complement animal models for drug development for osteoporosis and bone metastasis.

Improvement of osteoblast adhesion, viability, and mineralization by restoring the cell cytoskeleton after bisphosphonate discontinuation in vitro

OBJECTIVE

Bisphosphonates are prescribed to treat excessive bone resorption in patients with osteoporosis. However, its use is associated with potential adverse effects such as medication-related osteonecrosis of the jaw, prompting the introduction of the drug holiday concept in patients prior to dentoalveolar surgery. Furthermore, bisphosphonate discontinuation has been studied in vivo, in humans, and in animal models. However, it is not known whether this approach could affect bone cells in vitro. Therefore, the objective of this study was to investigate the potential effects of bisphosphonate discontinuation on pre-osteoblast and osteoblast activities in vitro.

METHODOLOGY

Pre-osteoblasts (MC3T3) and osteoblasts were treated with bisphosphonate (alendronate) at concentrations of 1, 5, and 10 µM. Alendronate was then withdrawn at different time points. The negative control consisted of untreated cells (0 µM), while the positive control consisted of cells incubated with alendronate throughout the experiment. Cell viability, cell adhesion, cell cytoskeleton, mineralization, and gene expressions were investigated.

RESULTS

Pre-osteoblasts and osteoblasts showed a decrease in cell viability after treatment with 5-10 μM alendronate for 4 days or longer. Two days of alendronate discontinuation significantly increased cell viability compared with the positive control. However, these levels did not reach those of the negative control. Bone nodule formation was reduced by alendronate. Discontinuation of alendronate regained bone nodule formation. Longer periods of discontinuation were more effective in restoring nodule formation than shorter periods. Addition of alendronate resulted in an increase in the percentage of dead cells, which, in turn, decreased when alendronate was discontinued. Alendronate affected the cell cytoskeleton by disassembling actin stress fibers. Cell adhesion and cell morphological parameters were also affected by alendronate. Discontinuation of alendronate restored cell adhesion and these parameters. Overall, the highest improvement after alendronate discontinuation was seen at 10 µM. However, alendronate treatment and discontinuation did not affect osteoblast gene expression.

CONCLUSION

Discontinuation of alendronate helps to reverse the negative effects of the drug on cell viability, cell adhesion, and mineralization by restoring the cell cytoskeleton. Our data suggest the benefits of drug holiday and/or intermittent strategies for alendronate administration at the cellular level.

[Translated article] Evaluation, differential diagnosis and treatment of vertebral osteoporosis: How to avoid the occurrence of new fractures

Osteoporosis is a highly prevalent and multifactorial disease whose main manifestation is the appearance of fragility or low-impact fractures. The most frequent locations of osteoporotic fractures occur at the vertebrae, femoral, distal end of the radius and humerus. Osteoporotic vertebral fracture deserves special mention among them due to its prevalence, importance as it often goes unnoticed and medium-long term consequences are: pain, deformity, disability and deterioration in quality of life. In this review we will focus on the classification and initial evaluation of the patient with osteoporosis, estimation of risk factors, laboratory and imaging studies for an adequate assessment using simple radiography, dual densitometry and magnetic resonance imaging. We will also address the main aspects of the differential diagnosis, treatment and prevention of vertebral fragility fracture, briefly reviewing the main therapeutic agents currently used for its prevention and treatment.

Therapeutic Potential of Quercetin as an Antioxidant for Bone-Muscle-Tendon Regeneration and Aging

Quercetin (QC), a naturally occurring bioflavonoid found in various fruits and vegetables, possesses many potential health benefits, primarily attributed to its robust antioxidant properties. The generation of oxidative stress in bone cells is a key modulator of their physiological behavior. Moreover, oxidative stress status influences the pathophysiology of mineralized tissues. Increasing scientific evidence demonstrates that manipulating the redox balance in bone cells might be an effective technique for developing bone disease therapies. The QC antioxidant abilities in skeletal muscle significantly enhance muscle regeneration and reduce muscle atrophy. In addition, QC has been shown to have protective effects against oxidative stress, inflammation, apoptosis, and matrix degradation in tendons, helping to maintain the structural integrity and functionality of tendons. Thus, the antioxidant properties of QC might be crucial for addressing age-related musculoskeletal disorders like osteoporosis, sarcopenia, and tendon-related inflammatory conditions. Understanding how QC influences redox signaling pathways involved in musculoskeletal disorders, including their effect on bone, muscle, and tendon differentiation, might provide insights into the diverse advantages of QC in promoting tissue regeneration and preventing cellular damage. Therefore, this study reviewed the intricate relationship among oxidative stress, inflammation, and tissue repair, affected by the antioxidative abilities of QC, in age-related musculoskeletal tissues to improve the overall health of bones, muscles, and tendons of the skeletal system. Also, reviewing the ongoing clinical trials of QC for musculoskeletal systems is encouraging. Given the positive effect of QC on musculoskeletal health, further scientific investigations and controlled human intervention studies are necessary to explore the therapeutic potential to its optimum strength.

Evaluation, differential diagnosis and treatment of vertebral osteoporosis: How to avoid the occurrence of new fractures

Osteoporosis is a highly prevalent and multifactorial disease whose main manifestation is the appearance of fragility or low-impact fractures. The most frequent locations of osteoporotic fractures occur at the vertebrae, femoral, distal end of the radius and humerus. Osteoporotic vertebral fracture deserves special mention among them due to its prevalence, importance as it often goes unnoticed and medium-long term consequences are: pain, deformity, disability and deterioration in quality of life. In this review we will focus on the classification and initial evaluation of the patient with osteoporosis, estimation of risk factors, laboratory and imaging studies for an adequate assessment using simple radiography, dual densitometry and magnetic resonance imaging. We will also address the main aspects of the differential diagnosis, treatment and prevention of vertebral fragility fracture, briefly reviewing the main therapeutic agents currently used for its prevention and treatment.

Surgical management and outcomes following atypical subtrochanteric femoral fractures - results from a matched-pair analysis of the registry for geriatric trauma of the German Trauma Society

BACKGROUND AND OBJECTIVES

The outcomes of patients with atypical subtrochanteric fractures (ASFs) remain unclear. Data from a large international geriatric trauma registry were analysed to examine the outcome of patients with ASFs compared to patients with typical osteoporotic subtrochanteric fractures (TSFs).

MATERIALS AND METHODS

Data from the Registry for Geriatric Trauma of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie [DGU]) (ATR-DGU) were analysed. All patients treated surgically for ASFs or TSFs were included in this analysis. Across both fracture types, a paired matching approach was conducted, where statistical twins were formed based on background characteristics sex, age, American Society of Anesthesiologists (ASA) score and walking ability. In-house mortality and mortality rates at the 120-day follow-up, as well as mobility at 7 and 120 days, the reoperation rate, hospital discharge management, the hospital readmission rate at the 120-day follow-up, health-related quality of life, type of surgical treatment and anti-osteoporotic therapy at 7 and 120 days, were assessed as outcome measures using a multivariate logistic regression analysis.

RESULTS

Amongst the 1,800 included patients, 1,781 had TSFs and 19 had ASFs. Logistic regression analysis revealed that patients with ASFs were more often treated with closed intramedullary nailing (RR = 3.59, p < 0.001) and had a higher probability of vitamin D supplementation as osteoporosis therapy at 120 days (RR = 0.88, p < 0.002). Patients with ASFs were also more likely to live at home after surgery (RR = 1.43, p < 0.001), and they also tended to continue living at home more often than patients with TSFs (RR = 1.33, p < 0.001). Accordingly, patients with TSFs had a higher relative risk of losing their self-sufficient living status, as indicated by increased rates of patients living at home preoperatively and being discharged to nursing homes (RR = 0.19, p < 0.001) or other hospitals (RR = 0.00, p < 0.001) postoperatively.

CONCLUSIONS

Surgical treatment of ASFs was marked by more frequent use of closed intramedullary fracture reduction. Furthermore, patients with ASFs were more likely to be discharged home and died significantly less often in the given timeframe. The rate of perioperative complications, as indicated by nonsignificant reoperation rates, as well as patient walking abilities during the follow-up period, remained unaffected.

Effect of Lycium barbarum polysaccharide on osteoblast proliferation and differentiation in postmenopausal osteoporosis

OBJECTIVE

We aimed to investigate the effect of Lycium barbarum polysaccharide (LBP) on the proliferation and differentiation of osteoblasts in postmenopausal individuals with osteoporosis using in vitro cell experiments.

METHODS

We assessed the effect of long-term LBP consumption on the intestinal metabolites of individuals using a simulation of the human intestinal microbiota ecosystem. We also tested the capacity of LBP in proliferating MC3T3-E1 cells using the cell counting kit-8 (CCK-8) method and analyzed the effect of intestinal metabolites on the osteogenic differentiation of MC3T3-E1 cells by testing bone metabolism viability with relevant indicators.

RESULTS

The level of short-chain fatty acids (SCFAs) significantly increased (p < 0.05), and the concentrations of acetic acid, propionic acid, and butyric acid all showed an upward trend after the treatment using LBP. At appropriate concentrations, the fermentation supernatant can enhance osteoblast proliferation by significantly increasing the active expression of bone-alkaline phosphatase (B-ALP) and osteocalcin (OCN) in osteoblasts (p < 0.05).

CONCLUSION

By modulating the metabolites of intestinal microbiota, production of SCFAs, the prebiotic properties of LBP can enhance osteoblast differentiation through in vitro simulation experiment and cell-based assay.

Organic Matrices of Calcium Carbonate Biominerals Improve Osteoblastic Mineralization

Many organisms incorporate inorganic solids into their tissues to improve functional and mechanical properties. The resulting mineralized tissues are called biominerals. Several studies have shown that nacreous biominerals induce osteoblastic extracellular mineralization. Among them, Pinctada margaritifera is well known for the ability of its organic matrix to stimulate bone cells. In this context, we aimed to study the effects of shell extracts from three other Pinctada species (Pinctada radiata, Pinctada maxima, and Pinctada fucata) on osteoblastic extracellular matrix mineralization, by using an in vitro model of mouse osteoblastic precursor cells (MC3T3-E1). For a better understanding of the Pinctada-bone mineralization relationship, we evaluated the effects of 4 other nacreous mollusks that are phylogenetically distant and distinct from the Pinctada genus. In addition, we tested 12 non-nacreous mollusks and one extra-group. Biomineral shell powders were prepared, and their organic matrix was partially extracted using ethanol. Firstly, the effect of these powders and extracts was assessed on the viability of MC3T3-E1. Our results indicated that neither the powder nor the ethanol-soluble matrix (ESM) affected cell viability at low concentrations. Then, we evaluated osteoblastic mineralization using Alizarin Red staining and we found a prominent MC3T3-E1 mineralization mainly induced by nacreous biominerals, especially those belonging to the Pinctada genus. However, few non-nacreous biominerals were also able to stimulate the extracellular mineralization. Overall, our findings validate the remarkable ability of CaCO3 biomineral extracts to promote bone mineralization. Nevertheless, further in vitro and in vivo studies are needed to uncover the mechanisms of action of biominerals in bone.

Clinical characteristics, densitometric parameters and outcomes of patients with atypical femoral fractures related to bisphosphonate treatment for osteoporosis

PURPOSE

We described the clinical and densitometric characteristics and treatment outcomes of patients who developed atypical femoral fractures (AFF) while on bisphosphonate for osteoporosis.

METHODS

We performed a retrospective cohort study including all adults aged ≥50 years who developed AFF while on bisphosphonates between 1 January 2008 and 31 December 2020, and subsequently managed in the Osteoporosis Centre at Queen Mary Hospital in Hong Kong. A control group of patients who developed fragility hip fractures while on bisphosphonates in the same period was included for comparison. We compared the clinical and densitometric characteristics between the two groups, and described the clinical outcomes for the AFF group.

RESULTS

In total, 75 patients were included (AFF: n = 35; fragility hip fracture: n = 40). All were related to oral bisphosphonates. The AFF group was characterised by a longer duration of bisphosphonate use (median of 5 years), higher bone mineral density (BMD) and more acute neck-shaft angle (all p < 0.05). Following AFF, 8 patients (22.9%) did not receive any subsequent bone-active agents: due to refusal to use an injectable, or BMD out of osteoporotic range. Most of those who received bone-active agents were given teriparatide, followed by raloxifene, and achieved stable BMD. However, subsequent fragility risk remained high. Nonetheless, AFF did not confer excess morbidity and mortality.

CONCLUSION

AFF was characterised by usually long duration of bisphosphonate use, higher BMD and more acute neck-shaft angle. AFF did not confer significant impairment in mobility or mortality. Nonetheless, further research work is necessary to optimise bone health among patients who develop AFF.

Local radiographic risk factors for MRONJ in osteoporotic patients undergoing tooth extraction

OBJECTIVE

To identify local radiographic risk factors for Medication-Related Osteonecrosis of the Jaws (MRONJ) in osteoporotic patients treated with antiresorptive drugs (ARD) and undergoing tooth extraction.

MATERIAL AND METHODS

Patients were included in this retrospective, longitudinal, case-control study, if having at least one administration of ARD, underwent tooth extraction(s), and had pre- and post-operative panoramic radiographs. Additionally, a matched control group was selected. Three calibrated, blinded, and independent observers assessed each tooth extraction site. Statistical analysis compared control against study group, and within the latter, sites MRONJ+ and MRONJ-.

RESULTS

In total, 120 patients (99 females/21 males) with 354 tooth extractions were included, from which nine patients (7.5%) and eleven tooth extraction sites (3.1%) developed MRONJ. When comparing control with study group, the latter showed significantly more thickened lamina dura, persistence of the alveolar socket, heterogeneous bone patterns, and sequestrum formation. In the study group, MRONJ developed significantly more in males (19%, p = 0.049), smokers (25%, p = 0.008), in the mandible (82%, p = 0.027), when identifying a radiolucent or sclerotic trabecular pattern (p = 0.004) or when extracting teeth with furcation involvement (p < 0.001), root remnants (p = 0.017), or unrestored caries lesions (p = 0.005).

CONCLUSIONS

Tooth extraction sites showing radiographic signs of chronic dental infection are prone to MRONJ.

Methodological guidance for the use of real-world data to measure exposure and utilization patterns of osteoporosis medications

Observational studies of osteoporosis medications can provide critical real-world evidence (RWE) that fills knowledge gaps left by clinical trials. However, careful consideration of study design is needed to yield reliable estimates of association. In particular, obtaining valid measurements of exposure to osteoporosis medications from real-world data (RWD) sources is complicated due to different medication classes, formulations, and routes of administration, each with different pharmacology. Extended half-lives of bisphosphonates and extended dosing of denosumab and zoledronic acid require particular attention. In addition, prescribing patterns and medication taking behavior often result in gaps in therapy, switching, and concomitant use of osteoporosis therapies. In this review, we present important considerations and provide specialized guidance for measuring osteoporosis drug exposures in RWD. First, we compare different sources of RWD used for osteoporosis drug studies and provide guidance on identifying osteoporosis medication use in these data sources. Next, we provide an overview of osteoporosis pharmacology and how it can influence decisions on exposure measurement within RWD. Finally, we present considerations for the measurement of osteoporosis medication exposure, adherence, switching, long-term exposures, and drug holidays using RWD. Ultimately, a thorough understanding of the differences in RWD sources and the pharmacology of osteoporosis medications is essential to obtain valid estimates of the relationship between osteoporosis medications and outcomes, such as fractures, but also to improve the critical appraisal of published studies.

Treatment of Osteoporosis after Hip Fracture: Survey of the Korean Hip Society

Purpose

To assess current practice in the treatment of osteoporosis in patients who underwent treatment for hip fracture in South Korea.

Materials and Methods

A survey of 97 members of the Korean Hip Society, orthopedic hip surgeons who administer treatment for hip fractures in South Korea, was conducted. The survey was conducted for assessment of demographic data and perceptions regarding the management of osteoporosis in patients who have undergone treatment for hip fracture. Analysis of the data was performed using descriptive statistical methods.

Results

The majority of participants were between the age of 41 and 50 years, and 74% were practicing in tertiary hospitals. Testing for serum vitamin D levels (82%) was the most commonly performed laboratory test. Calcium and vitamin D were prescribed for more than 80% of patients by 47% and 52% of participants, respectively. Denosumab was the most commonly used first-line treatment option for osteoporosis in hip fracture patients. Bisphosphonate was most often perceived as the cause of atypical femoral fractures, and the most appropriate time for reoperation was postoperative 12 months. Teriparatide was most preferred after cessation of bisphosphonate and only prescribing calcium and vitamin D was most common in high-risk patients for prevention of atypical femoral fracture.

Conclusion

The results of this study that surveyed orthopedic hip surgeons showed that most participants followed the current strategy for management of osteoporosis. Because the end result of osteoporosis is a bone fracture, active involvement of orthopedic surgeons is important in treating this condition.

The Use of Bone-Turnover Markers in Asia-Pacific Populations

Bone-turnover marker (BTM) measurements in the blood or urine reflect the bone-remodeling rate and may be useful for studying and clinically managing metabolic bone diseases. Substantial evidence supporting the diagnostic use of BTMs has accumulated in recent years, together with the publication of several guidelines. Most clinical trials and observational and reference-interval studies have been performed in the Northern Hemisphere and have mainly involved Caucasian populations. This review focuses on the available data for populations from the Asia-Pacific region and offers guidance for using BTMs as diagnostic biomarkers in these populations. The procollagen I N-terminal propeptide and β-isomerized C-terminal telopeptide of type-I collagen (measured in plasma) are reference BTMs used for investigating osteoporosis in clinical settings. Premenopausal reference intervals (established for use with Asia-Pacific populations) and reference change values and treatment targets (used to monitor osteoporosis treatment) help guide the management of osteoporosis. Measuring BTMs that are not affected by renal failure, such as the bone-specific isoenzyme alkaline phosphatase and tartrate-resistant acid phosphatase 5b, may be advantageous for patients with advanced chronic kidney disease. Further studies of the use of BTMs in individuals with metabolic bone disease, coupled with the harmonization of commercial assays to provide equivalent results, will further enhance their clinical applications.

Effect of Tempeh and Daidzein on Calcium Status, Calcium Transporters, and Bone Metabolism Biomarkers in Ovariectomized Rats

Menopause marks a critical life stage characterized by hormonal changes that significantly impact bone health, leading to a heightened susceptibility to bone fractures. This research seeks to elucidate the impact of daidzein and tempeh on calcium status, calcium transporters, and bone metabolism in an ovariectomized rat model. Forty female Wistar rats, aged 3 months, participated in a two-phase experiment. The initial phase involved inducing a calcium deficit, while the second phase comprised dietary interventions across five groups: Sham (S) and Ovariectomy (O) with a standard diet, O with bisphosphonate (OB), O with pure daidzein (OD), and O with tempeh (OT). Multiple parameters, encompassing calcium levels, calcium transporters, bone histopathology, and serum bone metabolism markers, were evaluated. The findings revealed that the OT group showcased heightened levels of bone turnover markers, such as pyridinoline, C-telopeptide of type I collagen, bone alkaline phosphatase, and procollagen type I N-terminal propeptide, in contrast to S and O groups, with statistical significance (p < 0.05). Histopathologically, both the OD and OT groups exhibited effects akin to the OB group, indicating a decrease in the surface area occupied by adipocytes in the femoral bone structure, although statistically non-equivalent, supporting the directionally similar trends. Although TRPV5 and TRPV6 mRNA expression levels in the jejunum and duodenum did not display statistically significant differences (p > 0.05), the OD and OT groups exhibited increased expression compared to the O group. We hypothesized that obtained results may be related to the effect of isoflavones on estrogen pathways because of their structurally similar to endogenous estrogen and weak estrogenic properties. In conclusion, the daily consumption of pure daidzein and tempeh could potentially improve and reinstate calcium status, calcium transport, and bone metabolism in ovariectomized rats. Additionally, isoflavone products demonstrate effects similar to bisphosphonate drugs on these parameters in ovariectomized rats.

Osteoporosis

Osteoporosis is a common systemic skeletal disorder resulting in bone fragility and increased fracture risk. Evidence-based screening strategies improve identification of patients who are most likely to benefit from drug treatment to prevent fracture. In addition, careful consideration of when pharmacotherapy should be started, choice of medication, and duration of treatment maximizes the benefits of fracture prevention while minimizing potential harms of long-term drug exposure.

Insights into the Mechanism of Osteoporosis and the Available Treatment Options

Osteoporosis, one of the most prevalent bone illnesses, majorly affects postmenopausal women and men over 50 years of age. Osteoporosis is associated with an increased susceptibility to fragility fractures and can result in persistent pain and significant impairment in affected individuals. The primary method for diagnosing osteoporosis involves the assessment of bone mineral density (BMD) through the utilisation of dual energy x-ray absorptiometry (DEXA). The integration of a fracture risk assessment algorithm with bone mineral density (BMD) has led to significant progress in the diagnosis of osteoporosis. Given that osteoporosis is a chronic condition and multiple factors play an important role in maintaining bone mass, comprehending its underlying mechanism is crucial for developing more effective pharmaceutical interventions for the disease. The effective management of osteoporosis involves the utilisation of appropriate pharmacological agents in conjunction with suitable dietary interventions and lifestyle modifications. This review provides a comprehensive understanding of the types of osteoporosis and elucidates the currently available pharmacological treatment options and their related mechanism of action and usage.

Follow-up Bone Mineral Density Testing: 2023 Official Positions of the International Society for Clinical Densitometry

Dual-energy X-ray absorptiometry (DXA) is the gold standard method for measuring bone mineral density (BMD) which is most strongly associated with fracture risk. BMD is therefore the basis for the World Health Organization's densitometric definition of osteoporosis. The International Society for Clinical Densitometry (ISCD) promotes best densitometry practices and its official positions reflect critical review of current evidence by domain experts. This document reports new official positions regarding follow-up DXA examinations based on a systematic review of literature published through December 2022. Adoption of official positions requires consensus agreement from an expert panel following a modified RAND protocol. Unless explicitly altered by the new position statements, prior ISCD official positions remain in force. This update reflects increased consideration of the clinical context prompting repeat examination. Follow-up DXA should be performed with pre-defined objectives when the results would have an impact on patient management. Testing intervals should be individualized according to the patient's age, sex, fracture risk and treatment history. Incident fractures and therapeutic approach are key considerations. Appropriately ordered and interpreted follow-up DXA examinations support diagnostic and therapeutic decision making, thereby contributing to excellent clinical care. Future research should address the complementary roles of clinical findings, imaging and laboratory testing to guide management.

Clinical Characteristics and Therapeutic Management of Osteogenesis Imperfecta in Iraqi Children

Background: Osteogenesis imperfecta (OI) is a rare congenital condition that results in bone fragility, recurrent fractures, and various extra-skeletal manifestations. Currently, intravenous bisphosphonate is the mainstay of medical treatment in OI. Objective: To identify the effect of current management strategies on Iraqi children diagnosed with OI. Methods: A retrospective study enrolled OI patients who were registered in Central Child Teaching Hospital, Baghdad, Iraq, from January 2015 to December 2022. We enrolled confirmed OI cases (either clinically and/or radiologically) who received cyclic pamidronate therapy for at least 3 cycles. They neither received other types of bisphosphonates nor underwent surgical intervention. Results: A total of 52 cases of OI had been identified, but only 36 patients were eligible for the current study. The mean age of the patients was 6.64±4.22 years. A statistically significant drop in the annual fracture rate in OI patients who received intravenous pamidronate cycles was seen, along with a significant rise in weight for age Z-score, lumbar spine bone mineral density DEXA Z-score, and alkaline phosphate levels. No significant improvement was documented in height for age Z-score in OI patients. Conclusions: Intravenous pamidronate cycles for Iraqi children with osteogenesis imperfecta work to lower their risk of breaking bones every year and raise their weight, lumbar spine bone mineral density, and alkaline phosphate levels. Pamidronate did not result in an improvement in the height of OI children.

Development of bioactive and ultrasound-responsive microdroplets for preventing ovariectomy (OVX)-induced osteoporosis

As a common bone disease in the elderly population, osteoporosis-related bone loss and bone structure deterioration represent a major public health problem. Therapeutic strategies targeting excessive osteoclast formation are frequently used for osteoporosis treatment; however, potential side effects have been recorded. Here, we have developed a novel therapeutic strategy using microdroplets (MDs) encapsulated with NFATc1-siRNA and investigated the role of bioactive MDs-NFATc1 biocompatibility in RAW 264.7 macrophages and human mesenchymal stem cells (hBMSCs), respectively. Its role in regulating osteoclast differentiation and formation was also investigated in vitro. We first fabricated MDs with spherical morphology along with a well-defined core-shell structure. The ultrasound-responsive study demonstrated time-dependent responsive structural changes following ultrasound stimulation. The internalization study into unstimulated macrophages, inflammatory macrophages, and hBMSCs indicated good delivery efficiency. Furthermore, the results from the MTT assay, the live/dead assay, and the cellular morphological analysis further indicated good biocompatibility of our bioactive MDs-NFATc1. Following MDs-NFATc1 treatment, the number of osteoclasts was greatly reduced, indicating their inhibitory effect on osteoclastogenesis and osteoclast formation. Subsequently, osteoporotic rats that underwent ovariectomy (OVX) were used for the in vivo studies. The rats treated with MDs-NFATc1 exhibited significant resistance to bone loss induced by OVX. In conclusion, our results demonstrate that MDs-NFATc1 could become an important regulator in osteoclast differentiation and functions, thus having potential applications in osteoclast-related bone diseases.