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Anagnostis P, Lampropoulou-Adamidou K, Bosdou JK, Trovas G, Galanis P, Chronopoulos E, Goulis DG, Tournis S. Comparative Effectiveness of Therapeutic Interventions in Pregnancy and Lactation-Associated Osteoporosis: A Systematic Review and Meta-analysis. J Clin Endocrinol Metab 2024; 109:879-901. [PMID: 37708365 PMCID: PMC10876413 DOI: 10.1210/clinem/dgad548] [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: 06/07/2023] [Revised: 09/09/2023] [Accepted: 09/12/2023] [Indexed: 09/16/2023]
Abstract
CONTEXT The optimal management of pregnancy and lactation-associated osteoporosis (PLO) has not been designated. OBJECTIVE To systematically review the best available evidence regarding the effect of different therapeutic interventions on bone mineral density (BMD) and risk of fractures in these patients. METHODS A comprehensive search was conducted in PubMed/Scopus databases until December 20, 2022. Data were expressed as weighted mean difference (WMD) with 95% CI. The I2 index was employed for heterogeneity. Studies conducted in women with PLO who received any antiosteoporosis therapy were included. Studies including women with secondary causes of osteoporosis or with transient osteoporosis of the hip were excluded. Data extraction was independently completed by 2 researchers. RESULTS Sixty-six studies were included in the qualitative analysis (n = 451 [follow-up time range 6-264 months; age range 19-42 years]). The increase in lumbar spine (LS) BMD with calcium/vitamin D (CaD), bisphosphonates, and teriparatide was 2.0% to 7.5%, 5.0% to 41.5%, and 8.0% to 24.4% at 12 months, and 11.0% to 12.2%, 10.2% to 171.9%, and 24.1% to 32.9% at 24 months, respectively. Femoral neck (FN) BMD increased by 6.1% with CaD, and by 0.7% to 18% and 8.4% to 18.6% with bisphosphonates and teriparatide (18-24 months), respectively. Meta-analysis was performed for 2 interventional studies only. Teriparatide induced a greater increase in LS and FN BMD than CaD (WMD 11.5%, 95% CI 4.9-18.0%, I2 50.9%, and 5.4%, 95% CI 1.2-9.6%, I2 8.1%, respectively). CONCLUSION Due to high heterogeneity and lack of robust comparative data, no safe conclusions can be made regarding the optimal therapeutic intervention in women with PLO.
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Affiliation(s)
- Panagiotis Anagnostis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki 56403, Greece
| | - Kalliopi Lampropoulou-Adamidou
- Laboratory for the Research of Musculoskeletal System “Th. Garofalidis”, School of Medicine, National and Kapodistrian University of Athens, KAT General Hospital, Athens 14561, Greece
| | - Julia K Bosdou
- Unit for Human Reproduction, 1st Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki 11527, Greece
| | - Georgios Trovas
- Laboratory for the Research of Musculoskeletal System “Th. Garofalidis”, School of Medicine, National and Kapodistrian University of Athens, KAT General Hospital, Athens 14561, Greece
| | - Petros Galanis
- Clinical Epidemiology Laboratory, Faculty of Nursing, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Efstathios Chronopoulos
- Laboratory for the Research of Musculoskeletal System “Th. Garofalidis”, School of Medicine, National and Kapodistrian University of Athens, KAT General Hospital, Athens 14561, Greece
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki 56403, Greece
| | - Symeon Tournis
- Laboratory for the Research of Musculoskeletal System “Th. Garofalidis”, School of Medicine, National and Kapodistrian University of Athens, KAT General Hospital, Athens 14561, Greece
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Stürznickel J, Butscheidt S, Amling M, Oheim R. Dynamics of Skeletal Status under Optimized Management during Subsequent Pregnancy in Three Women with a History of Pregnancy- and Lactation-Associated Osteoporosis Carrying pathogenic Variants in WNT1 and LRP5. JBMR Plus 2023; 7:e10779. [PMID: 37614308 PMCID: PMC10443073 DOI: 10.1002/jbm4.10779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 05/02/2023] [Accepted: 05/11/2023] [Indexed: 08/25/2023] Open
Abstract
Pregnancy- and lactation-associated osteoporosis (PLO) is a rare but clinically highly relevant condition, characterized by reduced bone mineral density (BMD) and acute onset of severe pain due to symptomatic bone marrow edema of the hip or vertebral and/or insufficiency fractures, among others. Previous reports showed a high frequency of hereditary bone disorders unmasked by PLO, predisposing for more severe forms. To date, no data on the risk for additional fractures during subsequent pregnancy in women with PLO and genetic bone disorder have been available. To address this question, we retrospectively analyzed the clinical, biochemical, and densitometric course of three women with a history of PLO and detected variants in WNT1 or LRP5 and subsequent pregnancies. Calcium homeostasis and bone turnover were optimized by basic treatment, and timely initiation of weaning was recommended. Teriparatide treatment for 12 months under strict contraception was initiated in one woman after the diagnosis of PLO. In none of the women did additional fractures or symptomatic bone marrow edemas occur, and BMD by dual-energy X-ray absorptiometry as bone microarchitecture by high-resolution peripheral quantitative computed tomography remained stable. In conclusion, this report expands the understanding of this rare but severe condition and helps to improve clinical counseling and management. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Julian Stürznickel
- Department of Osteology and BiomechanicsUniversity Medical Center Hamburg‐EppendorfHamburgGermany
- Department of Trauma and Orthopaedic SurgeryUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Sebastian Butscheidt
- Department of Trauma and Orthopaedic SurgeryUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Michael Amling
- Department of Osteology and BiomechanicsUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Ralf Oheim
- Department of Osteology and BiomechanicsUniversity Medical Center Hamburg‐EppendorfHamburgGermany
- Martin Zeitz Center for Rare DiseasesUniversity Medical Center Hamburg‐EppendorfHamburgGermany
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Wang GX, Han JH, Zhou RZ, Gao CP. Response of vertebral fractures to treatment with denosumab in a patient with postpartum osteoporosis: a case report and literature review. J Int Med Res 2023; 51:3000605231187951. [PMID: 37523158 PMCID: PMC10392288 DOI: 10.1177/03000605231187951] [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: 08/01/2023] Open
Abstract
Postpartum osteoporosis (PO) is a rare condition characterized by low bone mineral density (BMD) and an increased risk of vertebral fragility fracture. We encountered a 34-year-old woman who developed back pain 1 week after delivery. Magnetic resonance imaging of the lumbar spine revealed three vertebral compression fractures. Pretreatment BMD evaluation by dual-energy X-ray absorptiometry revealed a low T-score and Z-score (-2.0 and -2.0, respectively; BMD, 0.876 g/cm2) in the affected region of the spine. The patient was diagnosed with PO and treated with subcutaneous injection of denosumab 60 mg (Prolia; Amgen, Inc., Thousand Oaks, CA, USA) every 6 months. After two treatments, the BMD had significantly increased and the back pain was improved; the patient therefore decided to terminate the treatment. Two months later, her back pain worsened and BMD decreased as measured by dual-energy X-ray absorptiometry examination of the lumbar spine. Therefore, the patient resumed treatment with denosumab, and the BMD of the lumbar spine increased after another two treatments. Therefore, we consider denosumab to be promising in the management of PO with respect to increased BMD and decreased pain.
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Affiliation(s)
- Guan-Xi Wang
- Department of Radiology, Songshan Hospital of Qingdao University Medical College, Qingdao, China
| | - Jin-Hua Han
- Department of Radiology, Qingdao Central Hospital, Qingdao, China
| | - Rui-Zhi Zhou
- Department of Radiology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chuan-Ping Gao
- Department of Radiology, the Affiliated Hospital of Qingdao University, Qingdao, China
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Carsote M, Turturea MR, Valea A, Buescu C, Nistor C, Turturea IF. Bridging the Gap: Pregnancy-And Lactation-Associated Osteoporosis. Diagnostics (Basel) 2023; 13:diagnostics13091615. [PMID: 37175006 PMCID: PMC10177839 DOI: 10.3390/diagnostics13091615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/29/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023] Open
Abstract
Early diagnosis of pregnancy- and lactation-associated osteoporosis (PLO) is mandatory for a good outcome. Standard care is not a matter of conventional guidelines, rather it requires an individualized strategy while true overall incidence and pathogeny remain open issues. This is a narrative review based on full-length English articles, published between January 2021 and March 2023 and accessed via PubMed (no traumatic fractures or secondary osteoporosis are included). Our case-sample-based analysis included 836 females with PLO (the largest cohort based on published cases so far) through 12 studies and 24 single case reports. Except for one survey, these involved retrospective cohorts of small size (6-10 females/study) to medium size (23-47 women/study), and large cohorts with >50 subjects per study (a maximum of 379). Age of diagnosis: from 24 to 40 years for case reports (most subjects being over 30 and primigravida), while original studies indicated an average age between 31 and 34.18 years. Type of fractures underlined a most frequent vertebral phenotype (a mean of 2 to 5.8 vertebral fractures per patient) versus a most severe non-vertebral phenotype (hip and femoral neck fractures mostly requiring surgery). Potential contributors varied: smoking (1/3-1/2 of subjects), family history of osteoporosis (1/3), heparin and glucocorticoid use in pregnancy, low body mass index (majority of cases), hypovitaminosis D; and (with a low level of statistical significance) anti-psychotic medication, gestational diabetes, lupus, thrombophilia, anemia, in vitro fertilization (1/3 in one study), twin pregnancy, tocolysis with MgSO4, and postpartum thyroiditis. Most remarkably, up to 50% of PLO patients harbor mutations of LRP5, WNT1, and COL1A1/A2 (more damaged form with potential benefits from osteoanabolic drugs); gene testing might become the new norm in PLO. The low index of clinical suspicion should be supported by performing magnetic resonance imaging (gold standard in pregnancy) with DXA (in lactation). Low bone mineral density is expected (Z-score varying from -2.2 SD to -4 SD, unless normal which does not exclude PLO). Bone turnover markers might be useful in individuals with normal DXA, in pregnancy when DXA cannot be performed, and in following the response to anti-osteoporosis drugs. Alternatively, microarchitecture damage might be reflected by DXA-trabecular bone score and high-resolution peripheral quantitative computed tomography. Specific medical interventions are currently focused on teriparatide (TPT) use (3 studies; n = 99 females treated with TPT and an additional subgroup of 18 patients from the gene-analysis-based study, thus a total of 117 females) which seems to be the therapy of choice as reflected by these new data: 6-24 months, 20 µg/day, no sequential therapy needed; case selection based on high fracture risk is necessary). The first case using romosozumab was reported in 2022. PAO/LAO remains a challenging condition which is a battle for the wellbeing of two individuals, on one hand, considering maternal-fetal outcomes and taking care of the offspring, but it is a battle for a multidisciplinary team, on the other hand, since a standardized approach is lacking.
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Affiliation(s)
- Mara Carsote
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy & C.I. Parhon National Institute of Endocrinology, 011683 Bucharest, Romania
| | | | - Ana Valea
- Department of Endocrinology, Iuliu Hatieganu University of Medicine and Pharmacy & Clinical County Hospital, 400347 Cluj-Napoca, Romania
| | - Cristian Buescu
- Department of Orthopedics and Traumatology, Cluj Emergency County Hospital, 400347 Cluj-Napoca, Romania
| | - Claudiu Nistor
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Carol Davila University of Medicine and Pharmacy & Thoracic Surgery Department, Dr. Carol Davila Central Emergency University Military Hospital, 011683 Bucharest, Romania
| | - Ionut Florin Turturea
- Department of Orthopedics and Traumatology, Cluj Emergency County Hospital, 400347 Cluj-Napoca, Romania
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Chakrabarti K, McCune WJ. Glucocorticoid-induced osteoporosis in premenopausal women: management for the rheumatologist. Curr Opin Rheumatol 2023; 35:161-169. [PMID: 36943706 DOI: 10.1097/bor.0000000000000934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
PURPOSE OF REVIEW This review seeks to summarize the literature relevant to the treatment of glucocorticoid-induced osteoporosis in premenopausal women; an issue commonly encountered by rheumatologists and yet lacking good clinical practice guidelines. RECENT FINDINGS Although most of the relevant literature on osteoporosis includes postmenopausal women only, data from both randomized controlled trials and case reports suggest bisphosphonates can be an effective and well tolerated treatment for premenopausal patients. Data for other medications to treat premenopausal osteoporosis is less robust. SUMMARY The use of bisphosphonates in young women may be safer than initially thought and should likely be used for the treatment of glucocorticoid-induced osteoporosis in rheumatology clinics. Further research is needed to continue to understand long-term risk.
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Affiliation(s)
- Katherine Chakrabarti
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Michigan, USA
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Pregnancy and Lactation-Associated Osteoporosis Successfully Treated with Romosozumab: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2022; 59:medicina59010019. [PMID: 36676643 PMCID: PMC9862917 DOI: 10.3390/medicina59010019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 12/15/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022]
Abstract
Pregnancy- and lactation-associated osteoporosis (PLO) is a rare type of premenopausal osteoporosis that occurs mainly in the third trimester or immediately after delivery; one of its most common symptoms is back pain caused by a vertebral fracture. The pathogenesis of PLO is unclear, and there is no accepted consensus regarding the treatment of PLO. Although treatments with drugs such as bisphosphonate, strontium ranelate, denosumab, and teriparatide were reported, there is no report of a patient with PLO treated with romosozumab. We present the first case of a patient with PLO treated with romosozumab following 4-month teriparatide treatment. A 34-year-old primiparous and breastfeeding Japanese woman experienced severe low back pain 1 month postdelivery. She was diagnosed with PLO on the basis of low bone marrow density (BMD) and multiple vertebral fractures with no identified cause of secondary osteoporosis. She was treated with teriparatide injection for 4 months, but the treatment was discontinued because of the patient feeling severe nausea after every teriparatide injection and the appearance of new vertebral fractures. Thereafter, we used romosozumab for 12 months. After the romosozumab treatment, her BMD was increased from the baseline by 23.6% at L1-L4, 6.2% at the femoral neck, and 11.2% at the total hip. Treating PLO with 12-month romosozumab after 4 months of teriparatide injection remarkably increased the BMD of the lumbar spine, femoral neck, and total hip without subsequent fracture. Romosozumab has potential as a therapeutic option to improve the BMD and reduce the subsequent fracture risk of patients with PLO.
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Ferreira DA, Taborda F, Mendonça T, Farinha F. Pregnancy and lactation-associated osteoporosis in a Systemic Lupus Erythematosus patient. Lupus 2022; 31:1829-1833. [DOI: 10.1177/09612033221136102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pregnancy and lactation-associated osteoporosis (PLO) is a rare disease that occurs in late pregnancy or early postpartum and is associated with multiple vertebral fractures. We present a case of a 34-year-old woman with a history of Systemic Lupus Erythematosus and Antiphospholipid Syndrome, who started postpartum back pain. After an ineffective response to analgesic escalation, she performed imaging exams with evidence of multiple dorsal and lumbar vertebral fractures. After an exhaustive etiological study, PLO represented the most likely diagnosis. Early diagnosis, interruption of breastfeeding, and initiation of targeted anti-osteoporotic therapy are essential for symptomatic control, increase the quality of life of these patients, and prevent new fractures in the future.
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Affiliation(s)
| | - Filipa Taborda
- Internal medicine, Hospital de Cascais Dr Jose de Almeida, Alcabideche, Portugal
| | - Teresa Mendonça
- Internal medicine, Centro Hospitalar Universitário do Porto EPE, Porto, Portugal
- Clinical Immunology Unit, Centro Hospitalar Universitário do Porto EPE, Porto, Portugal
| | - Fátima Farinha
- Internal medicine, Centro Hospitalar Universitário do Porto EPE, Porto, Portugal
- Clinical Immunology Unit, Centro Hospitalar Universitário do Porto EPE, Porto, Portugal
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