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Bjornsdottir HH, Einarsson ÓB, Gröndal G, Gudbjornsson B. Nationwide prevalence of glucocorticoid prescriptions over 17 years and osteoporosis prevention among long-term users. SAGE Open Med 2024; 12:20503121241235056. [PMID: 38516640 PMCID: PMC10956150 DOI: 10.1177/20503121241235056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/08/2024] [Indexed: 03/23/2024] Open
Abstract
Objectives Glucocorticoid steroids are frequently prescribed, and side effects are well-known, such as glucocorticoid-induced osteoporosis. Our aim was to estimate the nationwide trend in the prevalence of glucocorticoid steroid prescriptions over 17 years and to elucidate the proportion of patients on long-term glucocorticoid steroid therapy who receive active bone protective therapy. As well as to examine which medical specialties prescribe glucocorticoid steroids the most. Methods This study was a retrospective observational registry study extended over 17 years (2003-2020). Data were retrieved from the Icelandic Prescription Medicine Register on all delivered glucocorticoid steroids (Anatomic therapeutic chemical code: H02AB) for oral use. Long-term users were defined as those who annually received ⩾90 defined daily doses of glucocorticoid steroids. Results Annually, 3.8% of the population received oral glucocorticoid steroids, from 3.3% in 2006 to 4.3% in 2017. Prednisolone was most frequently prescribed. Females dispatched glucocorticoid steroid prescriptions more often than males (55.8%). Males and females reached their peak prevalence between the ages of 60 and 70. General practitioners most often prescribe glucocorticoid steroids, followed by physicians in training, rheumatologists, internists, and medical students. Of those who received prescriptions for glucocorticoid steroids, 12.2%-18.1% were classified as long-term users. A declining number of patients have been receiving bone-protective therapy in recent years. Only 13.0% of chronic users received bone protective therapy in 2020. Conclusion The use of glucocorticoid steroids has increased during the last 2 decades despite improvements in treatment for inflammatory disorders. The prevalence of long-term users has remained stable. Meanwhile, the use of parallel active bone-protective therapy among long-term users of glucocorticoid steroids is declining. Thus, improvements in prophylaxis for corticosteroid-induced osteoporosis are urgently needed for patients who require long-term treatment with glucocorticoid steroids.
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Affiliation(s)
| | | | - Gerdur Gröndal
- Department of Rheumatology, Landspitali University Hospital of Iceland, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Bjorn Gudbjornsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Centre for Rheumatology Research, Landspitali University Hospital of Iceland, Reykjavik, Iceland
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Hayes KN, Cadarette SM, Burden AM. Methodological guidance for the use of real-world data to measure exposure and utilization patterns of osteoporosis medications. Bone Rep 2024; 20:101730. [PMID: 38145014 PMCID: PMC10733639 DOI: 10.1016/j.bonr.2023.101730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/01/2023] [Accepted: 12/03/2023] [Indexed: 12/26/2023] Open
Abstract
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.
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Affiliation(s)
- Kaleen N. Hayes
- Brown University School of Public Health, Providence, RI, USA
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Suzanne M. Cadarette
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Andrea M. Burden
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute of Pharmaceutical Sciences, ETH Zurich, Zurich, Switzerland
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3
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Pofi R, Caratti G, Ray DW, Tomlinson JW. Treating the Side Effects of Exogenous Glucocorticoids; Can We Separate the Good From the Bad? Endocr Rev 2023; 44:975-1011. [PMID: 37253115 PMCID: PMC10638606 DOI: 10.1210/endrev/bnad016] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/25/2023] [Accepted: 05/26/2023] [Indexed: 06/01/2023]
Abstract
It is estimated that 2% to 3% of the population are currently prescribed systemic or topical glucocorticoid treatment. The potent anti-inflammatory action of glucocorticoids to deliver therapeutic benefit is not in doubt. However, the side effects associated with their use, including central weight gain, hypertension, insulin resistance, type 2 diabetes (T2D), and osteoporosis, often collectively termed iatrogenic Cushing's syndrome, are associated with a significant health and economic burden. The precise cellular mechanisms underpinning the differential action of glucocorticoids to drive the desirable and undesirable effects are still not completely understood. Faced with the unmet clinical need to limit glucocorticoid-induced adverse effects alongside ensuring the preservation of anti-inflammatory actions, several strategies have been pursued. The coprescription of existing licensed drugs to treat incident adverse effects can be effective, but data examining the prevention of adverse effects are limited. Novel selective glucocorticoid receptor agonists and selective glucocorticoid receptor modulators have been designed that aim to specifically and selectively activate anti-inflammatory responses based upon their interaction with the glucocorticoid receptor. Several of these compounds are currently in clinical trials to evaluate their efficacy. More recently, strategies exploiting tissue-specific glucocorticoid metabolism through the isoforms of 11β-hydroxysteroid dehydrogenase has shown early potential, although data from clinical trials are limited. The aim of any treatment is to maximize benefit while minimizing risk, and within this review we define the adverse effect profile associated with glucocorticoid use and evaluate current and developing strategies that aim to limit side effects but preserve desirable therapeutic efficacy.
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Affiliation(s)
- Riccardo Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - Giorgio Caratti
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - David W Ray
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Oxford Kavli Centre for Nanoscience Discovery, University of Oxford, Oxford OX37LE, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
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4
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Sørensen NN, Andreasen CM, Jensen PR, Hauge EM, Bollerslev J, Delaissé JM, Kassem M, Jafari A, Diaz-delCastillo M, Andersen TL. Disturbed bone marrow adiposity in patients with Cushing's syndrome and glucocorticoid- and postmenopausal- induced osteoporosis. Front Endocrinol (Lausanne) 2023; 14:1232574. [PMID: 37881495 PMCID: PMC10597666 DOI: 10.3389/fendo.2023.1232574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/19/2023] [Indexed: 10/27/2023] Open
Abstract
Background Skeletal stem/progenitor cells (SSPCs) in the bone marrow can differentiate into osteoblasts or adipocytes in response to microenvironmental signalling input, including hormonal signalling. Glucocorticoids (GC) are corticosteroid hormones that promote adipogenic differentiation and are endogenously increased in patients with Cushing´s syndrome (CS). Here, we investigate bone marrow adiposity changes in response to endogenous or exogenous GC increases. For that, we characterize bone biopsies from patients with CS and post-menopausal women with glucocorticoid-induced osteoporosis (GC-O), compared to age-matched controls, including postmenopausal osteoporotic patients (PM-O). Methods Transiliac crest bone biopsies from CS patients and healthy controls, and from postmenopausal women with GC-O and matched controls were analysed; an additional cohort included biopsies from women with PM-O. Plastic-embedded biopsies were sectioned for histomorphometric characterization and quantification of adipocytes. The fraction of adipocyte area per tissue (Ad.Ar/T.Ar) and marrow area (Ad.Ar/Ma.Ar), mean adipocyte profile area (Ad.Pf.Ar) and adipocyte profile density (N.Ad.Pf/Ma.Ar) were determined and correlated to steroid levels. Furthermore, the spatial distribution of adipocytes in relation to trabecular bone was characterized and correlations between bone marrow adiposity and bone remodeling parameters investigated. Results Biopsies from patients with CS and GC-O presented increased Ad.Ar/Ma.Ar, along with adipocyte hypertrophy and hyperplasia. In patients with CS, both Ad.Ar/Ma.Ar and Ad.Pf.Ar significantly correlated with serum cortisol levels. Spatial distribution analyses revealed that, in CS, the increase in Ad.Ar/Ma.Ar near to trabecular bone (<100 µm) was mediated by both adipocyte hypertrophy and hyperplasia, while N.Ad.Pf/Ma.Ar further into the marrow (>100 µm) remained unchanged. In contrast, patients with GC-O only presented increased Ad.Ar/Ma.Ar and mean Ad.Pf.Ar>100 µm from trabecular bone surface, highlighting the differential effect of increased endogenous steroid accumulation. Finally, the Ad.Ar/Ma.Ar and Ad.Ar/T.Ar correlated with the canopy coverage above remodeling events. Conclusion Increased cortisol production in patients with CS induces increased bone marrow adiposity, primarily mediated by adipocyte hypertrophy. This adiposity is particularly evident near trabecular bone surfaces, where hyperplasia also occurs. The differential pattern of adiposity in patients with CS and GC-O highlights that bone marrow adipocytes and their progenitors may respond differently in these two GC-mediated bone diseases.
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Affiliation(s)
- Nina N. Sørensen
- Research Unit of Pathology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark
- Department of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Christina M. Andreasen
- Research Unit of Pathology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark
- Department of Molecular Medicine, University of Southern Denmark, Odense, Denmark
- Danish Spatial Imaging Consortium (DanSIC), Denmark
| | - Pia R. Jensen
- Clinical Cell Biology (KCB), Vejle/Lillebaelt Hospital, Institute of Regional Health Research (IRS), University of Southern Denmark, Vejle, Denmark
| | - Ellen M. Hauge
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Bollerslev
- Section of Specialized Endocrinology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jean-Marie Delaissé
- Research Unit of Pathology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark
- Department of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Moustapha Kassem
- Department of Cellular and Molecular Medicine, Novo Nordisk Foundation Center for Stem Cell Biology (DanStem), University of Copenhagen, Copenhagen, Denmark
- Molecular Endocrinology & Stem Cell Research Unit (KMEB), Department of Endocrinology and Metabolism, Odense University Hospital & University of Southern Denmark, Odense, Denmark
| | - Abbas Jafari
- Department of Cellular and Molecular Medicine, Novo Nordisk Foundation Center for Stem Cell Biology (DanStem), University of Copenhagen, Copenhagen, Denmark
- Molecular Endocrinology & Stem Cell Research Unit (KMEB), Department of Endocrinology and Metabolism, Odense University Hospital & University of Southern Denmark, Odense, Denmark
| | - Marta Diaz-delCastillo
- Danish Spatial Imaging Consortium (DanSIC), Denmark
- Department of Forensic Medicine, Aarhus University, Aarhus, Denmark
| | - Thomas L. Andersen
- Research Unit of Pathology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark
- Department of Molecular Medicine, University of Southern Denmark, Odense, Denmark
- Danish Spatial Imaging Consortium (DanSIC), Denmark
- Department of Forensic Medicine, Aarhus University, Aarhus, Denmark
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Konstantelos N, Burden AM, Cheung AM, Kim S, Grootendorst P, Cadarette SM. Comparison of Fracture Identification Using Different Definitions in Healthcare Administrative (Claims) Data. PHARMACY 2023; 11:pharmacy11020053. [PMID: 36961031 PMCID: PMC10037590 DOI: 10.3390/pharmacy11020053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/17/2023] Open
Abstract
We identified inconsistency in fracture definitions in a prior review of studies that utilized claims data. Here, we aimed to compare fracture rates estimated using thirteen hip and seven radius/ulna fracture definitions. Our primary analysis compared results in a cohort of 120,363 older adults treated with oral bisphosphonates for ≥3 years. The most inclusive definition (hip: inpatient or emergency diagnosis; radius/ulna: inpatient, emergency, or outpatient diagnosis) served as a referent to compare the number and proportion of fractures captured. In sensitivity analyses, we considered a 180-day washout, excluded fractures associated with trauma; and hip only, excluded: (1) subtrochanteric fractures, and (2) hip replacement procedures. Hip fractures varied by definition in number (52-8058) and incidence (0.7-111.8/10,000 person-years). The second most inclusive definition required one inpatient diagnosis and identified 8% fewer hip fractures than the referent. Excluding hip replacements missed 33% of hip fractures relative to the primary analysis. Radius/ulna fractures also ranged in number (1589-6797) and incidence (22.0-94.3/10,000 person-years). Outpatient data were important, when restricted to inpatient or emergency data, only 78% of radius/ulna fractures were identified. Other than hip replacement procedures, sensitivity analyses had minimal impact on fracture identification. Analyses were replicated in a cohort of patients treated with long-term glucocorticoids. This study highlights the importance and impact of coding decisions on fracture outcome definitions. Further research is warranted to inform best practice in fracture outcome identification.
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Affiliation(s)
- Natalia Konstantelos
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON M5S 3M2, Canada
| | - Andrea M Burden
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON M5S 3M2, Canada
- ETH Zurich, 8092 Zurich, Switzerland
| | - Angela M Cheung
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
- Department of Medicine, University Health Network, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Sandra Kim
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON M5S 3M2, Canada
- Women's College Hospital, Toronto, ON M5S 1B2, Canada
| | - Paul Grootendorst
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON M5S 3M2, Canada
| | - Suzanne M Cadarette
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON M5S 3M2, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
- ICES, Toronto, ON M4N 1P8, Canada
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599, USA
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6
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Billups SJ, Thai VK, Denkins J, Dettman IC, Rothman MS. Bad to the bones: prescribing of drugs for the prevention and treatment of osteoporosis in patients on chronic glucocorticoids. Arch Osteoporos 2023; 18:38. [PMID: 36856881 PMCID: PMC9976654 DOI: 10.1007/s11657-023-01222-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 02/06/2023] [Indexed: 03/02/2023]
Abstract
Of patients prescribed systemic glucocorticoids, this study identifies the proportion prescribed osteoporosis pharmacologic treatment and associated characteristics. Overall, 13.2% of patients were prescribed osteoporosis pharmacologic treatment. Predictors included documented osteoporosis, past DXA or fracture, and provision of care within a department using embedded protocols, suggesting electronic medical record-based tools may be beneficial. PURPOSE This study aimed to identify a cohort of patients at risk for glucocorticoid-induced osteoporosis based on their prescribed glucocorticoid regimens and to quantify the proportion who were also prescribed osteoporosis pharmacologic treatment. The secondary objective was to recognize patient characteristics associated with receiving such treatment. METHODS A retrospective single-site cohort study used prescription order data to identify 7774 adults prescribed chronic glucocorticoids and measure the proportion also prescribed osteoporosis pharmacologic treatment. RESULTS Of the total cohort, 1026/7774 (13.2%) had osteoporosis pharmacologic treatment prescribed. Of the subgroups prescribed a prednisone-equivalent of 5, 10, or 20 mg per day or more for at least 180 days, 584/4262 (13.7%), 153/1048 (14.6%), and 47/344 (13.7%) had treatment prescribed. Factors independently associated with osteoporosis pharmacologic treatment initiation included having osteoporosis or osteopenia on the problem list (OR = 4.45, 95% CI 3.70-5.34), history of dual-energy X-ray absorptiometry (DXA) screening (OR = 2.18, 95% CI 1.82-2.62), history of fracture (OR = 1.83, 95% CI 1.54-2.167), and longer duration of glucocorticoid use (OR = 1.33, 95% CI 1.10-1.59). The prescribing department was also a significant predictor of medication initiation, with cardiac transplant (OR = 6.04, 95% CI 3.97-9.17), oncology (OR = 4.11, OR 3.28-5.14), and lung transplant (OR = 1.51, 95% CI 1.08, 2.12) being positively correlated with this outcome, and nephrology (OR = 0.51, 95% CI 0.36-0.72) and kidney transplant (OR = 0.53, 95% CI 0.37, 0.75) being negatively correlated. CONCLUSION Prescribing rate of osteoporosis pharmacologic treatment in patients using chronic glucocorticoids is low. Examining practices with higher prescribing rates may offer insight into improving protection against osteoporosis-induced fractures.
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Affiliation(s)
- Sarah J Billups
- Department of Clinical Pharmacy, University of Colorado, Anschutz Medical Campus, 12850 E Montview Blvd, Campus Box C238, Aurora, CO, 80045, USA.
| | - Vinh K Thai
- Department of Clinical Pharmacy, University of Colorado, Anschutz Medical Campus, 12850 E Montview Blvd, Campus Box C238, Aurora, CO, 80045, USA
| | - Jacob Denkins
- Department of Clinical Pharmacy, University of Colorado, Anschutz Medical Campus, 12850 E Montview Blvd, Campus Box C238, Aurora, CO, 80045, USA
| | - Ian C Dettman
- Department of Clinical Pharmacy, University of Colorado, Anschutz Medical Campus, 12850 E Montview Blvd, Campus Box C238, Aurora, CO, 80045, USA
| | - Micol S Rothman
- Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
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Iki M, Fujimori K, Nakatoh S, Tamaki J, Ishii S, Okimoto N, Kamiya K, Ogawa S. Real-world effectiveness of anti-osteoporosis medications for the prevention of incident hip and clinical vertebral fractures in patients on long-term glucocorticoid therapy: A nationwide health insurance claims database study in Japan. Bone 2023; 166:116605. [PMID: 36347433 DOI: 10.1016/j.bone.2022.116605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 10/28/2022] [Accepted: 11/02/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE Early initiation of anti-osteoporosis medications (AOMs) is recommended for patients on long-term glucocorticoid (GC) therapy. This study aimed to clarify the real-world effectiveness of AOMs against incident hip and vertebral fractures in patients undergoing GC therapy using the nationwide health insurance claims database of Japan (NDBJ). METHODS Patients aged ≥50 years who were prescribed GC (≥5 mg/day prednisolone or equivalent) for ≥90 days and who were followed up regarding AOM prescription and hip and clinical vertebral fracture incidences for the subsequent 1080 days between 2012 and 2018 were selected from NDBJ. Associations of AOMs prescribed within 90 days since GC therapy initiation with hip or vertebral fracture risk were evaluated by Cox proportional hazards regression using propensity score inverse probability weighting (IPW) for receiving any AOM or individual AOMs. RESULTS In total, 96,475 women and 98,385 men were included in the analysis; 38.0 % of women and 27.6 % of men received AOMs. Patients who received any AOM and those who received bisphosphonates or denosumab had a significantly lower risk of hip and clinical vertebral fractures than those who received no AOM in both sexes after propensity score IPW. Teriparatide was associated with an increased risk of both fractures in women and an increased risk of clinical vertebral fractures in men. Selection biases such as confounding by indication might have caused an underestimation of AOMs' protective effects. CONCLUSIONS Bisphosphonates and denosumab were associated with a lower fracture incidence in patients on long-term GC therapy in real-world settings.
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Affiliation(s)
- Masayuki Iki
- Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan.
| | - Kenji Fujimori
- Department of Health Administration and Policy, Tohoku University School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Shinichi Nakatoh
- Department of Orthopedic Surgery, Asahi General Hospital, 477 Tomari, Asahimachi, Shimo-Nikawa-gun, Toyama 939-0798, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Junko Tamaki
- Department of Hygiene and Public Health, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Shigeyuki Ishii
- Department of Regulatory Science, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachiouji, Tokyo 193-0392, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Nobukazu Okimoto
- Okimoto Clinic, 185-4 Kubi, Yutaka-machi, Kure, Hiroshima 734-0304, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Kuniyasu Kamiya
- Department of Hygiene and Public Health, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Sumito Ogawa
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8511, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
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8
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Friesen KJ, Falk J, Chateau D, Kuo IF, Bugden S. Signal and Noise: Proton Pump Inhibitors and the Risk of Dementia? Clin Pharmacol Ther 2023; 113:152-159. [PMID: 36260313 DOI: 10.1002/cpt.2767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/03/2022] [Indexed: 12/24/2022]
Abstract
The association between proton pump inhibitor (PPI) use and dementia remains controversial. This cohort study re-examines this issue, addressing shortcomings identified in previous publications using a population-based and a high-dimension propensity-score matched cohort to follow patients for up to 22 years. Cox regression models using baseline characteristics, a lag period, and time-varying variables were used to examine the risk of dementia by cumulative PPI exposure. High-dose PPI users (> 180 days of use) had significantly higher risk of dementia in crude Cox models. After adjustment for medical diagnoses and prescription drug use, these associations disappeared. Among high-dose users starting PPI therapy between 46 and 55 years old, the unadjusted hazard ratio (HR) was 1.55 (95% confidence interval (CI) 1.14, 2.10); the adjusted hazard ratio (aHR) was 1.10 (95% CI 0.80, 1.51). For high-dose users starting therapy between 56 and 65 years, HR = 1.22 (95% CI1.03, 1.44); aHR = 0.99 (95% CI 0.83, 1.17). High-dose users between the ages of 66 and 75 years had no association with the risk of dementia. The use of lag models or time-varying parameters similarly found some association with dementia in crude, but not multivariable Cox models. Although high-dose PPI users were more likely to develop dementia, they were more likely to be diagnosed with dementia risk factors, such as diabetes and cardiovascular disease, which are risk factors for dementia. Controlling for these conditions using multivariable models or a propensity-score matched cohort eliminated this association.
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Affiliation(s)
- Kevin J Friesen
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jamie Falk
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Dan Chateau
- Research School of Population Health, ANU College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
| | - I Fan Kuo
- Optimal Use and Evaluation, Clinical Services and Evaluation Branch, Pharmaceutical, Laboratory & Blood Services, British Columbia Ministry of Health, Victoria, British Columbia, Canada
| | - Shawn Bugden
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
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9
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Osteoporosis and fractures in rheumatoid arthritis - risk factors. Best Pract Res Clin Rheumatol 2022; 36:101757. [PMID: 35739049 DOI: 10.1016/j.berh.2022.101757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In this chapter, we emphasize among rheumatoid arthritis (RA) patients, whom and how to screen for osteoporosis. We highlight certain modalities, advancements in technology, secondary osteoporosis workup, and laboratory testing as well as their caveats. Finally, we discuss current guidance on how to direct the laboratory and radiology testing in the context of the individual patient with RA to guide and select from the osteoporosis treatment options currently available.
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10
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Hayes KN, Brown KA, Cheung AM, Kim SA, Juurlink DN, Cadarette SM. Comparative Fracture Risk During Osteoporosis Drug Holidays After Long-Term Risedronate Versus Alendronate Therapy : A Propensity Score-Matched Cohort Study. Ann Intern Med 2022; 175:335-343. [PMID: 35007149 DOI: 10.7326/m21-2512] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND An osteoporosis drug holiday is recommended for most patients after 3 to 5 years of therapy. Risedronate has a shorter half-life than alendronate, and thus the residual length of fracture protection may be shorter. OBJECTIVE To examine the comparative risks of drug holidays after long-term (≥3 years) risedronate versus alendronate therapy. DESIGN Population-based, matched, cohort study. SETTING Province-wide health care administrative databases providing comprehensive coverage to Ontario residents aged 65 years or older between November 2000 and March 2020. PATIENTS Persons aged 66 years or older who had long-term risedronate therapy and a drug holiday were matched 1:1 on propensity score to those who had long-term alendronate therapy and a drug holiday. MEASUREMENTS The primary outcome was hip fracture within 3 years after a 120-day ascertainment period. Secondary analyses included shorter follow-up and sex-specific estimates. Cox proportional hazards models were used to estimate hazard ratios (HRs) for fracture risk between groups. RESULTS A total of 25 077 propensity score-matched pairs were eligible (mean age, 81 years; 81% women). Hip fracture rates were higher among risedronate than alendronate drug holidays (12.4 and 10.6 events, respectively, per 1000 patient-years; HR, 1.18 [95% CI, 1.04 to 1.34]; 915 total hip fractures). The association was attenuated when any fracture was included as the outcome (HR, 1.07 [CI, 1.00 to 1.16]) and with shorter drug holidays (1 year: HR, 1.03 [CI, 0.85 to 1.24]; 2 years: HR, 1.14 [CI, 0.96 to 1.32]). LIMITATION Analyses were limited to health care administrative data (potential unmeasured confounding), and some secondary analyses contained few events. CONCLUSION Drug holidays after long-term therapy with risedronate were associated with a small increase in risk for hip fracture compared with alendronate drug holidays. Future research should examine how best to mitigate this risk. PRIMARY FUNDING SOURCE Canadian Institutes of Health Research.
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Affiliation(s)
- Kaleen N Hayes
- Brown University School of Public Health, Providence, Rhode Island, and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada (K.N.H.)
| | - Kevin A Brown
- Dalla Lana School of Public Health, University of Toronto, ICES, and Public Health Ontario, Toronto, Ontario, Canada (K.A.B.)
| | - Angela M Cheung
- Dalla Lana School of Public Health and Department of Medicine, University of Toronto, and University Health Network, Toronto, Ontario, Canada (A.M.C.)
| | - Sandra A Kim
- Department of Medicine, University of Toronto, and Centre for Osteoporosis & Bone Health, Women's College Hospital, Toronto, Ontario, Canada (S.A.K.)
| | - David N Juurlink
- Dalla Lana School of Public Health, University of Toronto, ICES, and Sunnybrook Research Institute, Toronto, Ontario, Canada (D.N.J.)
| | - Suzanne M Cadarette
- Dalla Lana School of Public Health and Leslie Dan Faculty of Pharmacy at the University of Toronto and ICES, Toronto, Ontario, Canada, and Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina (S.M.C.)
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11
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Inhibition of Cdk5 Ameliorates Skeletal Bone Loss in Glucocorticoid-Treated Mice. Biomedicines 2022; 10:biomedicines10020404. [PMID: 35203613 PMCID: PMC8962259 DOI: 10.3390/biomedicines10020404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/02/2022] [Accepted: 02/05/2022] [Indexed: 11/16/2022] Open
Abstract
Glucocorticoids (GCs) are widely used to treat inflammatory diseases. However, their long-term use leads to glucocorticoid-induced osteoporosis, increasing morbidity and mortality. Both anabolic and anti-resorptive drugs are used to counteract GC-induced bone loss, however, they are expensive and/or have major side effects. Therefore, identifying new targets for cost-effective, small-molecule inhibitors is essential. We recently identified cyclin-dependent kinase 5 (Cdk5) as a suppressor of osteoblast differentiation and showed that its inhibition with roscovitine promoted osteoblastogenesis, thus improving the skeletal bone mass and fracture healing. Here, we assessed whether Cdk5 knockdown or inhibition could also reverse the GC-mediated suppression of osteoblast differentiation, bone loss, and fracture healing. We first demonstrated that Cdk5 silencing abolished the dexamethasone (Dex)-induced downregulation of alkaline phosphatase (Alp) activity, osteoblast-specific marker gene expression (Runx2, Sp7, Alpl, and Bglap), and mineralization. Similarly, Cdk5 inhibition rescued Dex-induced suppression of Alp activity. We further demonstrated that Cdk5 inhibition reversed prednisolone (Pred)-induced bone loss in mice, due to reduced osteoclastogenesis rather than improved osteoblastogenesis. Moreover, we revealed that Cdk5 inhibition failed to improve Pred-mediated impaired fracture healing. Taken together, we demonstrated that Cdk5 inhibition with roscovitine ameliorated GC-mediated bone loss but did not reverse GC-induced compromised fracture healing in mice.
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12
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Laurent MR, Goemaere S, Verroken C, Bergmann P, Body JJ, Bruyère O, Cavalier E, Rozenberg S, Lapauw B, Gielen E. Prevention and Treatment of Glucocorticoid-Induced Osteoporosis in Adults: Consensus Recommendations From the Belgian Bone Club. Front Endocrinol (Lausanne) 2022; 13:908727. [PMID: 35757436 PMCID: PMC9219603 DOI: 10.3389/fendo.2022.908727] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/02/2022] [Indexed: 01/13/2023] Open
Abstract
Glucocorticoids are effective immunomodulatory drugs used for many inflammatory disorders as well as in transplant recipients. However, both iatrogenic and endogenous glucocorticoid excess are also associated with several side effects including an increased risk of osteoporosis and fractures. Glucocorticoid-induced osteoporosis (GIOP) is a common secondary cause of osteoporosis in adults. Despite availability of clear evidence and international guidelines for the prevention of GIOP, a large treatment gap remains. In this narrative review, the Belgian Bone Club (BBC) updates its 2006 consensus recommendations for the prevention and treatment of GIOP in adults. The pathophysiology of GIOP is multifactorial. The BBC strongly advises non-pharmacological measures including physical exercise, smoking cessation and avoidance of alcohol abuse in all adults at risk for osteoporosis. Glucocorticoids are associated with impaired intestinal calcium absorption; the BBC therefore strongly recommend sufficient calcium intake and avoidance of vitamin D deficiency. We recommend assessment of fracture risk, taking age, sex, menopausal status, prior fractures, glucocorticoid dose, other clinical risk factors and bone mineral density into account. Placebo-controlled randomized controlled trials have demonstrated the efficacy of alendronate, risedronate, zoledronate, denosumab and teriparatide in GIOP. We suggest monitoring by dual-energy X-ray absorptiometry (DXA) and vertebral fracture identification one year after glucocorticoid initiation. The trabecular bone score might be considered during DXA monitoring. Extended femur scans might be considered at the time of DXA imaging in glucocorticoid users on long-term (≥ 3 years) antiresorptive therapy. Bone turnover markers may be considered for monitoring treatment with anti-resorptive or osteoanabolic drugs in GIOP. Although the pathophysiology of solid organ and hematopoietic stem cell transplantation-induced osteoporosis extends beyond GIOP alone, the BBC recommends similar evaluation, prevention, treatment and follow-up principles in these patients. Efforts to close the treatment gap in GIOP and implement available effective fracture prevention strategies into clinical practice in primary, secondary and tertiary care are urgently needed.
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Affiliation(s)
- Michaël R. Laurent
- Centre for Metabolic Bone Diseases, Department of Geriatrics, University Hospitals Leuven, Leuven, Belgium
- Department of Geriatrics, Imelda Hospital, Bonheiden, Belgium
- *Correspondence: Michaël R. Laurent,
| | - Stefan Goemaere
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
| | - Charlotte Verroken
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
- Department of Endocrinology and Metabolism, Ghent University Hospital, Ghent, Belgium
| | - Pierre Bergmann
- Department of Nuclear Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Olivier Bruyère
- WHO Collaborating Center for Public Health Aspects of Musculoskeletal Health and Ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liège, CHU de Liège, Liège, Belgium
| | - Serge Rozenberg
- Department of Gynaecology and Obstetrics, Université Libre de Bruxelles, Brussels, Belgium
| | - Bruno Lapauw
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
- Department of Endocrinology and Metabolism, Ghent University Hospital, Ghent, Belgium
| | - Evelien Gielen
- Centre for Metabolic Bone Diseases, Department of Geriatrics, University Hospitals Leuven, Leuven, Belgium
- Gerontology and Geriatrics section, Department of Public Health and Primary Care, University Hospitals Leuven and KU Leuven, Leuven, Belgium
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13
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Autoimmune Hemolytic Anemia in Chronic Lymphocytic Leukemia: A Comprehensive Review. Cancers (Basel) 2021; 13:cancers13225804. [PMID: 34830959 PMCID: PMC8616265 DOI: 10.3390/cancers13225804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/06/2021] [Accepted: 11/11/2021] [Indexed: 12/19/2022] Open
Abstract
Simple Summary This review analyzes the occurrence, clinical characteristics, and prognostic impact and treatment of autoimmune hemolytic anemia (AIHA) in chronic lymphocytic leukemia (CLL). Autoimmune hemolytic anemia is observed in about 10% of CLL. Pathogenesis is multifactorial involving humoral, cellular, and innate immunity, so the different mechanisms are well described in this review which also focuses on drugs associated to CLL-AIHA and on difficulties to diagnose it. There is a comprehensive revision of the main published casistics and then of the treatments; in particular the paper analyzes the main chemo-immunotherapeutic agents used in this setting. Since the therapy depends on the presence and severity of clinical symptoms, disease status, and comorbidities, treatment is nowadays more individualized in CLL and also in CLL-AIHA. Patients not responding to corticosteroids and rituximab are treated with CLL-specific drugs as per current guidelines according to age and comorbidities and new targeted agents against BCR and BCL-2 which can be given orally and have few side effects, are very effective both in progressive CLL and in situations such as AIHA. Abstract Chronic lymphocytic leukemia (CLL) patients have a greater predisposition to develop autoimmune complications. The most common of them is autoimmune hemolytic anemia (AIHA) with a frequency of 7–10% of cases. Pathogenesis is multifactorial involving humoral, cellular, and innate immunity. CLL B-cells have damaged apoptosis, produce less immunoglobulins, and could be responsible for antigen presentation and releasing inflammatory cytokines. CLL B-cells can act similar to antigen-presenting cells activating self-reactive T helper cells and may induce T-cell subsets imbalance, favoring autoreactive B-cells which produce anti-red blood cells autoantibodies. Treatment is individualized and it depends on the presence and severity of clinical symptoms, disease status, and comorbidities. Corticosteroids are the standardized first-line treatment; second-line treatment comprises rituximab. Patients not responding to corticosteroids and rituximab should be treated with CLL-specific drugs as per current guidelines according to age and comorbidities. New targeted drugs (BTK inhibitors and anti BCL2) are recently used after or together with steroids to manage AIHA. In the case of cold agglutinin disease, rituximab is preferred, because steroids are ineffective. Management must combine supportive therapies, including vitamins; antibiotics and heparin prophylaxis are indicated in order to minimize infectious and thrombotic risk.
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Konstantelos N, Rzepka AM, Cadarette SM. Fracture outcome definitions in observational osteoporosis drug effects studies: a scoping review protocol. JBI Evid Synth 2021; 20:907-916. [PMID: 34636342 DOI: 10.11124/jbies-20-00509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of this review is to describe fracture outcome definitions in observational osteoporosis drug effects studies from Canada and the United States of America. INTRODUCTION Health care administrative data are commonly utilized in pharmacoepidemiologic studies. These data are used to define outcomes, such as fractures, and are critical to determining real-world safety and effectiveness of medications. However, there is no current standard for fracture outcome definitions in observational studies. As a result, fractures are inconsistently defined. To inform future research, a synthesis of how fractures are defined in observational studies using health care administrative claims data is needed. Providing clarity on how fractures are defined will provide guidance for future research. INCLUSION CRITERIA We will include observational studies from the United States and Canada published in English from 2000 to the present that consider the impact of osteoporosis pharmacotherapies on fracture risk and leverage health care administrative data. METHODS This review will follow the three-step JBI methodology for scoping reviews. We will search MEDLINE (Ovid), Embase (Ovid), and CINAHL (EBSCO). Following de-duplication, titles and abstracts will be screened independently by two reviewers. We will then conduct full-text screening for eligible studies. In addition, Canadian and American government pharmacovigilance websites will be searched to identify gray literature. Data extraction will be completed by two reviewers. Results will be presented in figures and tabular form.
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Affiliation(s)
- Natalia Konstantelos
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada ICES, Toronto, ON, Canada Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA WHO Collaborating Center for Governance, Accountability and Transparency in the Pharmaceutical Sector, University of Toronto, Toronto, ON, Canada
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15
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Evaluation of care delivery by a novel multidisciplinary bone health clinic for patients at risk of glucocorticoid-induced osteoporosis. Arch Osteoporos 2021; 16:108. [PMID: 34347188 DOI: 10.1007/s11657-021-00979-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/18/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED Glucocorticoid-induced osteoporosis (GIOP) is a common condition associated with increased risk for fracture. Many patients receive suboptimal care. We created a novel GIOP clinic model which successfully fills a gap in osteoporosis care by providing multidisciplinary intervention in key components of GIOP preventive care to an underserved patient population. INTRODUCTION This study characterizes the patient population referred to our novel glucocorticoid-induced osteoporosis (GIOP) clinic and evaluates how well the clinic performed in addressing key components of GIOP preventive care. METHODS This population-based prospective cohort study derives data from patients reviewed at the University of Alberta Multidisciplinary Bone Health Clinic from January 2017 to September 2019. To create our clinic model, key components of GIOP preventive care were summarized based on current guidelines, and clear responsibilities were delegated to each multidisciplinary team member. A REDCap database was constructed, and each patient's multidisciplinary assessment was entered at each visit. Demographic and treatment data was extracted from our database. RESULTS The clinic was able to achieve optimal GIOP preventive care in 60.1% of patients and in 78.7% of patients when excluding wait time. Of the 245 GIOP patients assessed, over half were females (56.7%) and the mean age was 56.7 years (range 16-95 years). Referrals were primarily made by specialists. Low-trauma fractures were reported in 24.9% of patients and 95.5% of patients had a baseline dual-energy X-ray absorptiometry (DXA). The mean current daily prednisone-equivalent dose was 14.1 mg. All patients received a recommendation for pharmacotherapy (100%) and the majority received counseling on vitamin D (98.8%), calcium (97.8%), smoking cessation (98.8%), alcohol reduction (98.4%), falls prevention (88.6%), and exercise (85.3%). CONCLUSION Our novel GIOP clinic model successfully fills a gap in osteoporosis care by providing multidisciplinary intervention in key components of GIOP preventive care to an underserved patient population. Further studies are required to assess the real-world long-term outcomes of our model.
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16
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Hayes KN, He N, Brown KA, Cheung AM, Juurlink DN, Cadarette SM. Over half of seniors who start oral bisphosphonate therapy are exposed for 3 or more years: novel rolling window approach and patterns of use. Osteoporos Int 2021; 32:1413-1420. [PMID: 33415374 DOI: 10.1007/s00198-020-05794-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 12/10/2020] [Indexed: 12/17/2022]
Abstract
UNLABELLED Most adherence studies only consider treatment following a first prescription. Using an extended follow-up, we found that 60% of seniors starting oral bisphosphonate therapy were exposed for ≥ 3 years (48% for ≥ 5 years). Studies are needed to examine the benefits and harms of continuing bisphosphonate therapy beyond 3 years. INTRODUCTION The purpose of this study was to identify and describe patterns of long-term oral bisphosphonate use among seniors using a novel methodological approach that considers extended follow-up. METHODS Among Ontarians aged 66 years or older, we identified subjects with a first dispensing of alendronate or risedronate between November 2000 and December 2016. We followed them until death or December 2019 to identify patients with ≥ 3 years of bisphosphonate use, defined as a proportion of days covered ≥ 80%, using 3-year rolling windows. We calculated the proportion of patients with long-term therapy (≥ 3 years of use) using Kaplan-Meier estimates. We described patterns of long-term use and compared patient characteristics between patients with and without long-term therapy. RESULTS We identified 260,784 eligible seniors initiating bisphosphonate therapy. Of these, 60% continued therapy ≥ 3 years (77% women), and 48% continued ≥ 5 years. Characteristics did not meaningfully differ between patients with or without long-term therapy. The median length of long-term therapy was 7.0 (IQR 5.1) years for women and 6.1 (IQR 4.3) years for men. Only 20% experienced a treatment gap before long-term therapy, yet 50% experienced a treatment gap of ≥ 120 days after a median 5.3 years of therapy. Eighty-one percent who returned to therapy following a treatment gap re-initiated an oral bisphosphonate, with 18% switching to denosumab. CONCLUSIONS Among seniors initiating oral bisphosphonates, we found that 60% receive at least 3 years of therapy when using an extended follow-up. Studies are needed to examine the benefits and harms of continuing bisphosphonate therapy beyond 3 years.
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Affiliation(s)
- K N Hayes
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, M5S 3M2, Canada.
| | - N He
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, M5S 3M2, Canada
- ICES, Toronto, ON, Canada
| | - K A Brown
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Public Health Ontario, Toronto, ON, Canada
| | - A M Cheung
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - D N Juurlink
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - S M Cadarette
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, M5S 3M2, Canada
- ICES, Toronto, ON, Canada
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
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17
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Messina OD, Vidal LF, Wilman MV, Bultink IEM, Raterman HG, Lems W. Management of glucocorticoid-induced osteoporosis. Aging Clin Exp Res 2021; 33:793-804. [PMID: 33751462 DOI: 10.1007/s40520-021-01823-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 02/19/2021] [Indexed: 12/19/2022]
Abstract
Long-term glucocorticoid (GC) therapy is frequently indicated to treat autoimmune and chronic inflammatory diseases in daily clinical practice. Two of the most devastating untoward effects are bone loss and fractures. Doses as low as 2.5 mg of prednisone for more than 3 months can impair bone integrity. Population at risk is defined based on the dose and duration of GC therapy and should be stratified according to FRAX (Fracture Risk Assessment Tool), major osteoporotic fracture, prior fractures, and bone mineral density values (BMD). General measures include to prescribe the lowest dose of GC to control the underlying disease for the shortest possible time, maintain adequate vitamin D levels and calcium intake, maintain mobility, and prescribe a bone acting agent in patients at high risk of fracture. These agents include oral and intravenous bisphosphonates, denosumab, and teriparatide.
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18
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Duration of Bisphosphonate Drug Holidays in Osteoporosis Patients: A Narrative Review of the Evidence and Considerations for Decision-Making. J Clin Med 2021; 10:jcm10051140. [PMID: 33803095 PMCID: PMC7963175 DOI: 10.3390/jcm10051140] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/23/2021] [Accepted: 03/04/2021] [Indexed: 12/21/2022] Open
Abstract
Bisphosphonates are first-line therapy for osteoporosis, with alendronate, risedronate, and zoledronate as the main treatments used globally. After one year of therapy, bisphosphonates are retained in bone for extended periods with extended anti-fracture effects after discontinuation. Due to this continued fracture protection and the potential for rare adverse events associated with long-term use (atypical femoral fractures and osteonecrosis of the jaw), a drug holiday of two to three years is recommended for most patients after long-term bisphosphonate therapy. The recommendation for a drug holiday up to three years is derived primarily from extensions of pivotal trials with alendronate and zoledronate and select surrogate marker studies. However, certain factors may modify the duration of bisphosphonate effects on a drug holiday and warrant consideration when determining an appropriate time off-therapy. In this narrative review, we recall what is currently known about drug holidays and discuss what we believe to be the primary considerations and areas for future research regarding drug holiday duration: total bisphosphonate exposure, type of bisphosphonate used, bone mineral density and falls risk, and patient sex and body weight.
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Hayes KN, Baschant U, Hauser B, Burden AM, Winter EM. When to Start and Stop Bone-Protecting Medication for Preventing Glucocorticoid-Induced Osteoporosis. Front Endocrinol (Lausanne) 2021; 12:782118. [PMID: 34975756 PMCID: PMC8715727 DOI: 10.3389/fendo.2021.782118] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/19/2021] [Indexed: 01/28/2023] Open
Abstract
Glucocorticoid-induced osteoporosis (GIOP) leads to fractures in up to 40% of patients with chronic glucocorticoid (GC) therapy when left untreated. GCs rapidly increase fracture risk, and thus many patients with anticipated chronic GC exposures should start anti-osteoporosis pharmacotherapy to prevent fractures. In addition to low awareness of the need for anti-osteoporosis therapy among clinicians treating patients with GCs, a major barrier to prevention of fractures from GIOP is a lack of clear guideline recommendations on when to start and stop anti-osteoporosis treatment in patients with GC use. The aim of this narrative review is to summarize current evidence and provide considerations for the duration of anti-osteoporosis treatment in patients taking GCs based on pre-clinical, clinical, epidemiologic, and pharmacologic evidence. We review the pathophysiology of GIOP, outline current guideline recommendations on initiating and stopping anti-osteoporosis therapy for GIOP, and present considerations for the duration of anti-osteoporosis treatment based on existing evidence. In each section, we illustrate major points through a patient case example. Finally, we conclude with proposed areas for future research and emerging areas of interest related to GIOP clinical management.
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Affiliation(s)
- Kaleen N. Hayes
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States
| | - Ulrike Baschant
- Division of Endocrinology, Diabetes and Bone Diseases, Department of Medicine III and Center for Healthy Aging, Technische Universität Dresden, Dresden, Germany
- *Correspondence: Ulrike Baschant,
| | - Barbara Hauser
- Rheumatic Disease Unit, Western General Hospital, National Health Service (NHS) Lothian, Edinburgh, United Kingdom
- Rheumatology and Bone Disease Unit, Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Andrea M. Burden
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, Swiss Federal Institute of Technology [Eidgenössische Technische Hochschule (ETH)] Zurich, Zurich, Switzerland
| | - Elizabeth M. Winter
- Center for Bone Quality, Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, Netherlands
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Qiu M, Ding L, Zhang M, Lin J, Huang H, Li K. Meta-regression analysis of the efficacy of alendronate for prevention of glucocorticoid-induced fractures. Medicine (Baltimore) 2020; 99:e22690. [PMID: 33080717 PMCID: PMC7571885 DOI: 10.1097/md.0000000000022690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND What affects the efficacy of alendronate for prevention of glucocorticoid-induced (GI) fractures remains unclear. We aimed to explore the factors affecting alendronate's efficacy, and further identify subgroup effects of alendronate in preventing GI fractures. METHODS We searched 3 databases. Random-effects meta-analysis was conducted to synthesize risk ratio (RR) and 95% confidence interval (CI) for each endpoint. Meta-regression analysis was used to explore sources of heterogeneity, and subgroup analysis was used to address heterogeneity and evaluate subgroup effects. We detected publication bias using funnel plots and Egger tests. RESULTS We included 13 papers from 12 unique studies involving 46431 participants. Glucocorticoid (GC) dosage (P = .053) and proportion of previous vertebral fracture (PVF) (P = .047) were probably 2 sources of heterogeneity in meta-analysis for vertebral fractures, while GC duration (P = .020) was probably 1 for nonvertebral fractures. Alendronate reduced vertebral fractures in the high dosage subgroup (RR 0.61, 95% CI 0.44-0.86), but didn't in the low dosage subgroup (RR 1.56, 95% CI 0.20-12.02). Alendronate reduced vertebral fractures (RR 0.53, 95% CI 0.40-0.68) in the subgroup of PVF proportion <5%, but didn't (RR 0.76, 95% CI 0.42-1.37) in the subgroup of this proportion ≥5%. Alendronate reduced nonvertebral and hip fractures, whether in primary or in secondary prevention subgroup. CONCLUSIONS The findings in our study support that alendronate is used for the primary and secondary prevention of GI fractures, but do not support that alendronate is recommended as a first-line agent for patients receiving a low dose of GCs or patients with PVF.
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Affiliation(s)
- Mei Qiu
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen
| | - Liangliang Ding
- Department of Endocrinology, First Affiliated Hospital of Yangtze University, Jingzhou
| | | | - Jinhao Lin
- Department of Gastroenterology, Shenzhen Hospital of Beijing University of Chinese Medicine, Shenzhen
| | - Hua Huang
- Department of Neurology, Hankou Hospital of Wuhan City, Wuhan
| | - Kaikai Li
- Department of General Medicine, The Central Hospital of Tuoshi Town, Tianmen, China
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Chiodini I, Falchetti A, Merlotti D, Eller Vainicher C, Gennari L. Updates in epidemiology, pathophysiology and management strategies of glucocorticoid-induced osteoporosis. Expert Rev Endocrinol Metab 2020; 15:283-298. [PMID: 32584619 DOI: 10.1080/17446651.2020.1772051] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Endogenous or exogenous (corticosteroid-induced) glucocorticoids (GCs) excess represents, together with diabetes, the most common cause of secondary osteoporosis. AREAS COVERED We present a comprehensive overview about the pathophysiology, clinical management and treatment of GCs induced osteoporosis (GIOP). According to PRISMA guidelines, a literature search identifying articles about bone and GCs was done. EXPERT OPINION Despite the progress over the years and the increase in therapeutic options, there still are controversial issues about the management of GIOP. These mainly include the failure of BMD or FRAX to completely account for the rapid increase in fracture risk of most GC-treated patients, the understanding about the independent contribution on bone fragility of the underlying disease requiring GCs therapy, and the necessity of clearer information about the anti-fracture efficacy and long term-safety of most therapeutic options. Moreover, there are no specific indications for the management of bone fragility in endogenous hypercortisolism. Notwithstanding the above limitations there is a general consensus to recommend an assessment of fracture risk in all individuals >40 years committed to receive (or continuing) high dose (>7.5 mg of prednisone equivalent) GCs for ≥3 months and in all patients with fragility fracture history.
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Affiliation(s)
- Iacopo Chiodini
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Milan , Italy
| | - Alberto Falchetti
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Milan , Italy
| | - Daniela Merlotti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena , Italy
| | - Cristina Eller Vainicher
- Endocrinology and Diabetology Units, Department of Medical Sciences and Community, Fondazione Ca'Granda Ospedale Maggiore Policlinico IRCCS , Milan, Italy
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena , Italy
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Abstract
PURPOSE OF REVIEW Steroid-induced osteoporosis or glucocorticoid-induced osteoporosis (GIOP) is a common form of secondary osteoporosis and is a cause of increased morbidity and mortality. The pathogenesis of GIOP includes decreased bone formation and increased bone resorption. Clinicians can rely on several effective medications for the treatment and prevention of GIOP, including antiresorptive drugs (i.e. bisphosphonates) and bone anabolic drugs (i.e. teriparatide). RECENT FINDINGS Recent studies have further highlighted that GIOP is a major public health concern and have provided new insights on the pathogenesis of GIOP, in particular, the dose-dependent effects of glucocorticoids on bone. New evidence on the real-world effectiveness of established GIOP therapies have been recently published as well as the results of the 24-months denosumab randomized controlled trial in GIOP. SUMMARY GIOP and fragility fractures are important adverse events related to the long-term use of glucocorticoids. Recent studies have provided additional data on the epidemiology and pathogenesis of GIOP and on the efficacy and effectiveness of GIOP therapies.
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Liu L, Zheng J, Yang Y, Ni L, Chen H, Yu D. Hesperetin alleviated glucocorticoid-induced inhibition of osteogenic differentiation of BMSCs through regulating the ERK signaling pathway. Med Mol Morphol 2020; 54:1-7. [PMID: 32253606 DOI: 10.1007/s00795-020-00251-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 03/29/2020] [Indexed: 12/11/2022]
Abstract
The objective of this study is to investigate the protective role of hesperetin for the glucocorticoid-induced osteoporosis (GIOP) and related mechanisms. In this study, we investigated the protective effects of hesperetin on dexamethasone (DEX)-induced osteogenic inhibition in bone marrow mesenchymal stem cells (BMSCs). The mineralization, real-time quantitative polymerase chain reaction assays (RT-qPCR), immunofluorescence and western blot were used to assess the protective effects of hesperetin in DEX-treated BMSCs during osteogenic differentiation. Our results showed that hesperetin promoted alkaline phosphatase (ALP) activity and the mineralization in DEX-treated BMSCs during osteogenic differentiation. The expression of osteogenic mRNA and proteins further confirmed the protective effect of hesperetin in DEX-treated BMSCs. Furthermore, hesperetin activated ERK signal pathway in DEX-treated BMSCs. ERK inhibitor U0126 could abolish the protective effect of hesperein in DEX-treated BMSCs. In conclusion, our study demonstrated that hesperetin alleviated glucocorticoid-induced inhibition of osteogenic differentiation through ERK signal pathway in BMSCs. It may be a potential therapeutic agent for protecting against glucocorticoid-induced osteoporosis.
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Affiliation(s)
- Ling Liu
- Department of Nephrology, Hangzhou Hospital of Traditional Chinese Medicine, Tiyuchang Road 453, Hangzhou, 310007, Zhejiang, People's Republic of China.,Department of Nephrology (Key Laboratory of Zhejiang Province, Management of Kidney Disease), Hangzhou Hospital of Traditional Chinese Medicine, Tiyuchang Road 453, Hangzhou, 310007, People's Republic of China
| | - Jie Zheng
- Department of Nephrology, Hangzhou Hospital of Traditional Chinese Medicine, Tiyuchang Road 453, Hangzhou, 310007, Zhejiang, People's Republic of China.,Department of Nephrology (Key Laboratory of Zhejiang Province, Management of Kidney Disease), Hangzhou Hospital of Traditional Chinese Medicine, Tiyuchang Road 453, Hangzhou, 310007, People's Republic of China
| | - YaZhen Yang
- Department of Nephrology, Hangzhou Hospital of Traditional Chinese Medicine, Tiyuchang Road 453, Hangzhou, 310007, Zhejiang, People's Republic of China.,Department of Nephrology (Key Laboratory of Zhejiang Province, Management of Kidney Disease), Hangzhou Hospital of Traditional Chinese Medicine, Tiyuchang Road 453, Hangzhou, 310007, People's Republic of China
| | - Lingjuan Ni
- Department of Nephrology, Hangzhou Hospital of Traditional Chinese Medicine, Tiyuchang Road 453, Hangzhou, 310007, Zhejiang, People's Republic of China.,Department of Nephrology (Key Laboratory of Zhejiang Province, Management of Kidney Disease), Hangzhou Hospital of Traditional Chinese Medicine, Tiyuchang Road 453, Hangzhou, 310007, People's Republic of China
| | - Hongyu Chen
- Department of Nephrology, Hangzhou Hospital of Traditional Chinese Medicine, Tiyuchang Road 453, Hangzhou, 310007, Zhejiang, People's Republic of China. .,Department of Nephrology (Key Laboratory of Zhejiang Province, Management of Kidney Disease), Hangzhou Hospital of Traditional Chinese Medicine, Tiyuchang Road 453, Hangzhou, 310007, People's Republic of China.
| | - Dongrong Yu
- Department of Nephrology, Hangzhou Hospital of Traditional Chinese Medicine, Tiyuchang Road 453, Hangzhou, 310007, Zhejiang, People's Republic of China. .,Department of Nephrology (Key Laboratory of Zhejiang Province, Management of Kidney Disease), Hangzhou Hospital of Traditional Chinese Medicine, Tiyuchang Road 453, Hangzhou, 310007, People's Republic of China.
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Compston J. Management of glucocorticoid-induced osteoporosis: What is new? Int J Rheum Dis 2020; 22:1595-1597. [PMID: 31478605 DOI: 10.1111/1756-185x.13680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 07/24/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Juliet Compston
- Emeritus of Bone Medicine, Cambridge Biomedical Campus, Cambridge, UK
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Chiodini I, Merlotti D, Falchetti A, Gennari L. Treatment options for glucocorticoid-induced osteoporosis. Expert Opin Pharmacother 2020; 21:721-732. [PMID: 32004105 DOI: 10.1080/14656566.2020.1721467] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Glucocorticoid (GC) induced osteoporosis (GIOP) is the most common form of secondary osteoporosis. It develops in a dose and time dependent manner, due to a rapid and transient increase in bone resorption, followed by the inhibition of bone formation. AREAS COVERED In this review, the authors summarize the pathophysiology of GIOP and give discussion to the clinical management of patients taking GCs, focusing on the currently available drugs that have antiresorptive or anabolic activity on bone. EXPERT OPINION Despite the widespread use of GCs and their well-established detrimental skeletal effects, GIOP remains an under-diagnosed and under-treated condition. Indeed, the clinical management of GIOP is still debated, so that the recent guidelines differ in their indications for pharmacological intervention. Either bone mineral density (BMD) or algorithms such as FRAX do not completely account for the remarkable and rapid increase in fracture risk of most GC-treated patients. Moreover, while oral bisphosphonates remain the most used and cost-effective option, the potential increased benefits of more potent antiresorptive agents (e.g. denosumab and zoledronate) or anabolic compounds (e.g. teriparatide) warrant further investigation. Despite the above limitations, the assessment of fracture risk is recommended for all individuals committed to receiving oral GCs for 3 months or longer.
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Affiliation(s)
- Iacopo Chiodini
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research , Milan, Italy
| | - Daniela Merlotti
- Department of Medicine, Surgery and Neurosciences, University of Siena , Italy
| | - Alberto Falchetti
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research , Milan, Italy
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena , Italy
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Abstract
Numerous safe and efficient drug therapies are currently available to decrease risk of low trauma fractures in patients with osteoporosis including postmenopausal, male, and secondary osteoporosis. In this chapter, we give first an overview of the most important outcomes regarding fracture risk reduction, change in bone mineral density (BMD by DXA) and/or bone markers of the phase III clinical studies of well-established therapies (such as Bisphosphonates, Denosumab or Teriparatide) and also novel therapies (such as Romosozumab or Abaloparatide) and highlight their mechanisms of action at bone tissue/material level. The latter understanding is not only essential for the choice of drug, duration and discontinuation of treatment but also for the interpretation of the clinical outcomes (in particular of eventual changes in BMD) after drug administration. In the second part of this chapter, we focus on the management of different forms of osteoporosis and give a review of the respective current guidelines for treatment. Adverse effects of treatment such as atypical femoral fractures, osteonecrosis of the jaw or influence of fracture healing are considered also in this context.
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Diagnosis and treatment of autoimmune hemolytic anemia in adults: Recommendations from the First International Consensus Meeting. Blood Rev 2019; 41:100648. [PMID: 31839434 DOI: 10.1016/j.blre.2019.100648] [Citation(s) in RCA: 226] [Impact Index Per Article: 45.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 11/21/2019] [Accepted: 11/25/2019] [Indexed: 12/15/2022]
Abstract
Autoimmune hemolytic anemias (AIHAs) are rare and heterogeneous disorders characterized by the destruction of red blood cells through warm or cold antibodies. There is currently no licensed treatment for AIHA. Due to the paucity of clinical trials, recommendations on diagnosis and therapy have often been based on expert opinions and some national guidelines. Here we report the recommendations of the First International Consensus Group, who met with the aim to review currently available data and to provide standardized diagnostic criteria and therapeutic approaches as well as an overview of novel therapies. Exact diagnostic workup is important because symptoms, course of disease, and therapeutic management relate to the type of antibody involved. Monospecific direct antiglobulin test is considered mandatory in the diagnostic workup, and any causes of secondary AIHA have to be diagnosed. Corticosteroids remain first-line therapy for warm-AIHA, while the addition of rituximab should be considered early in severe cases and if no prompt response to steroids is achieved. Rituximab with or without bendamustine should be used in the first line for patients with cold agglutinin disease requiring therapy. We identified a need to establish an international AIHA network. Future recommendations should be based on prospective clinical trials whenever possible.
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Adami G, Rahn EJ, Saag KG. Glucocorticoid-induced osteoporosis: from clinical trials to clinical practice. Ther Adv Musculoskelet Dis 2019; 11:1759720X19876468. [PMID: 31565078 PMCID: PMC6755635 DOI: 10.1177/1759720x19876468] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 08/26/2019] [Indexed: 01/15/2023] Open
Abstract
Glucocorticoid-induced osteoporosis (GIOP) is the most common form of secondary
osteoporosis. To date, six large randomized controlled clinical trials on the
efficacy of pharmaceutical treatment in GIOP have been conducted. All of these
studies have focused predominately on bone mineral density outcomes, and none of
them have been statistically powered to address fracture endpoints. The purpose
of this review is to highlight differences in the design and results within
these large randomized GIOP clinical trials, and how these differences might
affect clinical decisions. Differences between studies in trial design,
populations studied, and variable efficacy impact the comparability and
generalizability of these findings, and ultimately should affect practitioners’
behavior. We review the clinical trials that provide the best quality evidence
on comparative efficacy and safety of GIOP treatments. We also propose
suggestions on the design of future GIOP clinical trials with attention to
improved generalizability, and, ideally, study designs that might achieve
fracture outcomes.
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Affiliation(s)
- Giovanni Adami
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 510 20th Street South, Faculty Office Tower 820D, Birmingham, AL 35294, USA
| | - Elizabeth J Rahn
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kenneth G Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
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Abstract
INTRODUCTION Glucocorticoid-induced osteoporosis is the most common secondary cause of osteoporosis. Despite this, many patients receiving glucocorticoids are not evaluated for their skeletal health. AREAS COVERED Glucocorticoids have profound effects on bone cells, resulting in increases in bone resorption and impairments in bone formation. Bone loss and subsequent increases in fracture risk occur early after the administration of glucocorticoids. Incidence of fractures is highest within the first 6 months of glucocorticoid treatment, and declines with longer exposure. Decreases in bone mass follow a dose-dependent relationship with glucocorticoid dosage. Pharmacologic prevention and treatment for osteoporosis are recommended for all patients receiving glucocorticoids. Oral bisphosphonates, with concomitant vitamin D and calcium supplementation, are considered as the first-line treatment option. However, a number of alternative treatment options, including intravenous bisphosphonates, anabolic agents, and denosumab have all proven efficacy in increasing lumbar spine or hip bone mineral density. The mechanism of action and recent controlled trials for these therapies are reviewed. The literature search was conducted within PubMed in November 2018. 492 articles were found and 45 were included. EXPERT OPINION Future studies will likely evaluate the safety profiles of alternative treatments, while focusing on its ability to reduce fracture risk.
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Affiliation(s)
- Kira Hu
- a Department of Medicine , McMaster University , Hamilton , ON , Canada
| | - Jonathan D Adachi
- a Department of Medicine , McMaster University , Hamilton , ON , Canada
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30
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Current Treatments and New Developments in the Management of Glucocorticoid-induced Osteoporosis. Drugs 2019; 79:1065-1087. [DOI: 10.1007/s40265-019-01145-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Hill QA, Grainger JD, Thachil J, Provan D, Evans G, Garg M, Bradbury C, Bagot C, Kanis JA, Compston JE. The prevention of glucocorticoid‐induced osteoporosis in patients with immune thrombocytopenia receiving steroids: a British Society for Haematology Good Practice Paper. Br J Haematol 2019; 185:410-417. [DOI: 10.1111/bjh.15735] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
| | - John D. Grainger
- Royal Manchester Children's Hospital Manchester University Hospitals NHS Foundation Trust Manchester Academic Health Science Centre Manchester UK
- Faculty of Medical & Human Sciences University of Manchester Manchester UK
| | - Jecko Thachil
- Department of Haematology Manchester Royal Infirmary Manchester UK
| | - Drew Provan
- Department of Haematology Barts& The London School of Medicine & Dentistry London UK
| | - Gillian Evans
- Department of Haematology Kent and Canterbury Hospital Canterbury UK
| | - Mamta Garg
- Department of Haematology Leicester Royal Infirmary Leicester UK
| | - Charlotte Bradbury
- University Hospitals Bristol NHS Foundation Trust Bristol UK
- Department of Cellular and Molecular Medicine University of Bristol Bristol UK
| | - Catherine Bagot
- Department of Haematology Glasgow Royal Infirmary Glasgow UK
| | - John A. Kanis
- Centre for Metabolic Bone Diseases University of Sheffield Medical School Sheffield UK
- Institute for Health and Ageing Australian Catholic University Melbourne Australia
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Jagpal A, Saag KG. Glucocorticoid-Induced Osteoporosis: Update on Management. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2018. [DOI: 10.1007/s40674-018-0105-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
Glucocorticoid-induced osteoporosis is the most common secondary cause of osteoporosis and the resulting fractures cause significant morbidity. Following initiation of oral glucocorticoids, rapid bone loss occurs, and fracture risk increases within a few months in a dose-dependent manner. These adverse effects are due to inhibition of bone formation accompanied by an early but transient increase in bone resorption. Multiple mechanisms underlie these changes in bone remodeling; direct effects include upregulation of PPARγR2, increased expression of sclerostin and increased RANKL/OPG ratio, whilst hypogonadism, altered renal and intestinal calcium handling, and reduced production of insulin-like growth factor 1 also contribute. Fracture risk assessment should be performed as soon as possible after glucocorticoids are initiated and bone protective therapy started promptly in individuals at high-risk, with calcium and vitamin D supplements where appropriate. Oral bisphosphonates are currently regarded as first line options on the grounds of their low cost. However, teriparatide has been shown to be superior in its effects on BMD and vertebral fracture risk in glucocorticoid-treated individuals with osteoporosis and should be considered as an alternative first line option in high-risk patients.
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Affiliation(s)
- Juliet Compston
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, CB2 0SL, UK.
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