Effectiveness of oral bisphosphonates for primary prevention of osteoporotic fractures

Initiation of Bisphosphonates Prior to Total Joint Arthroplasty Does Not Lower Periprosthetic Fracture Risk

BACKGROUND

Many patients are diagnosed with osteoporosis shortly prior to scheduling total joint arthroplasty (TJA). The purpose of this study was to determine if initiation of bisphosphonates prior to TJA decreased the risks of periprosthetic fractures (PPFx).

METHODS

A national database was used to identify all patients diagnosed with osteoporosis prior to primary TJA. Patients who had osteoporosis without preoperative bisphosphonate use were designated as our control group. Patients on preoperative bisphosphonates were stratified based on duration and timing of bisphosphonate use: long-term preoperative users (initiation 3 to 5 years preoperatively), intermediate-term preoperative users (initiation 1 to 3 years preoperatively), and short-term preoperative users (initiation 0 to 1 year preoperatively). Rates of PPFx at 90-day and 2-year follow-up were compared between groups.

RESULTS

In patients undergoing primary total hip arthroplasty, there was no difference in PPFx rate between our control group and preoperative bisphosphonate users of all durations at 90-day (P = .12) and 2-year follow-up (P = .22). In patients undergoing primary total knee arthroplasty, there was no difference in PPFx rate between our control group and preoperative bisphosphonate users of all durations at 90-day (P = .76) and 2-year follow-up (P = .39).

CONCLUSIONS

In patients undergoing primary TJA, preoperative bisphosphonate users did not have a decreased PPFx rate compared to our control group at 90-day and 2-year follow-up. Our findings suggest that preoperative bisphosphonate use, regardless of the duration of treatment, does not confer protective benefits against PPFx in patients undergoing TJA.

LEVEL OF EVIDENCE

Prognostic Level III.

A systematic review of quantitative bias analysis applied to epidemiological research

BACKGROUND

Quantitative bias analysis (QBA) measures study errors in terms of direction, magnitude and uncertainty. This systematic review aimed to describe how QBA has been applied in epidemiological research in 2006-19.

METHODS

We searched PubMed for English peer-reviewed studies applying QBA to real-data applications. We also included studies citing selected sources or which were identified in a previous QBA review in pharmacoepidemiology. For each study, we extracted the rationale, methodology, bias-adjusted results and interpretation and assessed factors associated with reproducibility.

RESULTS

Of the 238 studies, the majority were embedded within papers whose main inferences were drawn from conventional approaches as secondary (sensitivity) analyses to quantity-specific biases (52%) or to assess the extent of bias required to shift the point estimate to the null (25%); 10% were standalone papers. The most common approach was probabilistic (57%). Misclassification was modelled in 57%, uncontrolled confounder(s) in 40% and selection bias in 17%. Most did not consider multiple biases or correlations between errors. When specified, bias parameters came from the literature (48%) more often than internal validation studies (29%). The majority (60%) of analyses resulted in >10% change from the conventional point estimate; however, most investigators (63%) did not alter their original interpretation. Degree of reproducibility related to inclusion of code, formulas, sensitivity analyses and supplementary materials, as well as the QBA rationale.

CONCLUSIONS

QBA applications were rare though increased over time. Future investigators should reference good practices and include details to promote transparency and to serve as a reference for other researchers.

Protective effect of Glycyrrhiza glabra roots extract on bone mineral density of ovariectomized rats

Objective: The aim of this study was to evaluate the potential effect of the methanolic extract of plant Glycyrrhiza glabra roots on bone mineral density and femoral bone strength of ovariectomized rats.

Methods: Thirty 10-month-old Wistar rats were randomly separated into three groups of ten, Control, Ovariectomy and Ovariectomy-plus-Glycyrrhiza in their drinking water. Total and proximal tibial bone mineral density was measured in all groups before ovariectomy (baseline) and after 3 and 6 months post ovariectomy. Three-point-bending of the femurs and uterine weight and histology were examined at the end of the study.

Results: No significant difference was noted in bone density percentage change of total tibia from baseline to 3 months between Control and Ovariectomy-plus-Glycyrrhiza groups (+5.31% ± 4.75 and +3.30% ± 6.31 respectively, P = non significant), and of proximal tibia accordingly (+5.58% ± 6.92 and +2.61% ± 13.62, P = non significant) demonstrating a strong osteoprotective effect. There was notable difference in percentage change of total tibia from baseline to 6 months between groups Ovariectomy and Ovariectomy-plus-Glycyrrhiza (−13.03% ± 5.11 and −0.84% ± 7.63 respectively, P < 0.005), and of proximal tibia accordingly (−27.9% ± 3.69 and −0.81% ± 14.85 respectively, P < 0.001), confirming the protective effect of Glycyrrhiza glabra extract in preserving bone density of the Ovariectomy-plus-Glycyrrhiza group. Three-point-bending did not reveal any statistically significant difference between Ovariectomy and Ovariectomy-plus-Glycyrrhiza groups. Uterine weights of the Ovariectomy-plus-Glycyrrhiza group ranged between the other two groups with no statistically significant difference to each.

Conclusions: Glycyrrhiza glabra root extract notably protected tibial bone mineral density loss in Ovariectomy-plus-Glycyrrhiza rats in comparison with ovariectomized rats, but did not improve biomechanical strength.

Alendronate improves bone density and type I collagen accumulation but increases the amount of pentosidine in the healing dental alveolus of ovariectomized rabbits

BACKGROUND

It has been shown that the oral aminobisphosphonate sodium alendronate (ALN) therapy reduces the risk of main fractures in osteoporotic women, but its effect on the jaw bones is poorly known. Here, we hypothesized that ALN affects the newly formed alveolar bone, particularly the quality of the type I collagen cross-linking.

METHODS

Osteoporosis was induced by ovariectomy (OVX) in 6-month old rabbits. Six weeks following surgery, eight animals were treated by oral gavage with ALN (OVX + ALN) and ten received placebo (OVX + Pbo). Another six rabbits which were sham operated also received placebo (SHAM + Pbo). One month following the beginning of treatment, the upper and lower left first premolars were removed. Six weeks later, the upper and the lower right first premolars were also extracted. One month after the second extraction, biopsies were collected from the maxillary extraction sites and collagen crosslinks were analyzed in the newly formed bone tissue by HPLC. Also, at this time, mandibular bone segments were subjected to μCT.

RESULTS

Animals treated with ALN achieved a roughly 2-time greater bone volume fraction value at a late healing period than animals in the other groups (p < 0.05). Collagen mean results were 2- to 4-times superior in the OVX + ALN group than in the control groups (p < 0.05). ALN-treated animals presented higher amounts of the non-enzymatic collagen cross-link pentosidine (PEN) than the sham-operated rabbits (p < 0.05), whereas the OVX + Pbo group presented the highest amount of PEN (p < 0.05).

CONCLUSION

Alendronate increases bone volume and collagen accumulation, but does not fully rescue the non-osteoporotic alveolar tissue quality as is evident from the increased quantity of pentosidine.

The Role of European Healthcare Databases for Post-Marketing Drug Effectiveness, Safety and Value Evaluation: Where Does Italy Stand?

Enormous progress has been made globally in the use of evidence derived from patients' clinical information as they access their routine medical care. The value of real-world data lies in their complementary nature compared with data from randomised controlled trials: less detailed information on drug efficacy but longer observational periods and larger, more heterogeneous study populations reflecting clinical practice because individuals are included who would not usually be recruited in trials. Real-world data can be collected in various types of electronic sources, such as electronic health records, claims databases and drug or disease registries. These data sources vary in nature from country to country, according to national healthcare system structures and national policies. In Italy, a growing number of healthcare databases have been used to evaluate post-marketing drug utilisation and safety in the last two decades. The aim of this narrative review is to describe the available Italian sources of real-world data and their contribution to generating post-marketing evidence on drug use and safety. We also discuss the strengths and limitations of the most commonly used Italian healthcare databases in addressing various research questions concerning drug utilisation, comparative effectiveness and safety studies, as well as health technology assessment and other areas.

Correlations of Serum Hormones and Bone Mineral Density with Fracture and Balance Ability of Postmenopausal Patients and Effects of Calcitriol

Background

The aim of this study was to analyze the correlations of serum hormones and bone mineral density (BMD) with fracture and balance ability of postmenopausal patients and effects of calcitriol on them.

Material/Methods

The clinical data of 164 postmenopausal female patients with osteoporosis (OP) treated in our hospital were retrospectively analyzed.

Results

The incidence rates of OVCF, balance index score (BIS), front-back ratio (FBR), and right-left ratio (RLR) in the normal BMD group, reduced BMD group, and OP group showed increasing trends, and there were statistically significant differences in comparisons among groups (p<0.05). The levels of serum estradiol (E2) and progesterone (P) in the OVCF group were lower than those in the non-OVCF group, and there were statistically significant differences in comparisons between the 2 groups (p<0.05). However, there was no statistically significant difference in the comparison of serum luteinizing hormone (LH) level between the 2 groups (p>0.05). BIS, FBR, and RLR were negatively correlated with E2 and testosterone (T) (p<0.05). With the prolongation of calcitriol treatment time, BIS, FBR, and RLR gradually decreased, but T value gradually increased. At 6 months and 12 months after intervention, BIS, FBR, and RLR had significant differences compared to those before the experiment (p<0.05). (5) Total hip BMD, height, age, and body mass index (BMI) were the independent factors affecting SDI.

Conclusions

Hip BMD, age, height, and BMI are significantly correlated with OVCF. Calcitriol treatment can increase lumbar BMD and improve balance ability, and these effects become more obvious with prolongation of intervention time.

Tomatidine suppresses osteoclastogenesis and mitigates estrogen deficiency-induced bone mass loss by modulating TRAF6-mediated signaling

Postmenopausal osteoporosis is initiated by estrogen withdrawal and is characterized mainly by overactivated osteoclastic bone resorption. Targeting TNF receptor-associated factor 6 (TRAF6) or its downstream signaling pathways to modulate osteoclast formation and function is an appealing strategy for osteoclast-related disorders. In the present study, we determined the effect of tomatidine, a steroidal alkaloid derived from Solanaceae, on the formation and function of receptor activator of NF-κB (RANK) ligand-induced osteoclasts and the underlying mechanism. Tomatidine inhibited osteoclast formation in a dose-dependent manner and decreased the expression of osteoclast marker genes. Actin ring formation and osteoclastic bone resorption were attenuated in the presence of tomatidine in vitro. Eight weeks after ovariectomy, tomatidine prevented estrogen deficiency-induced bone loss and restored the mechanical properties of the femur. At the molecular level, tomatidine abrogated phosphorylation of c-Jun N-terminal kinase (JNK)/p38, NF-κB, and protein kinase B (Akt) pathway proteins by suppressing RANK expression, inhibiting the binding of TRAF6 to RANK, and downregulating the osteoclastogenesis marker-related protein expression. In summary, these data demonstrated that tomatidine attenuated osteoclast formation and function by modulating multiple TRAF6-mediated pathways. Therefore, tomatidine could be a novel candidate for the treatment of osteoclast-related disorders, including osteoporosis.-Hu, B., Sun, X., Yang, Y., Ying, Z., Meng, J., Zhou, C., Jiang, G., Li, S., Wu, F., Zhao, X., Zhu, H., Wu, H., Cai, X., Shi, Z., Yan, S. Tomatidine suppresses osteoclastogenesis and mitigates estrogen deficiency-induced bone mass loss by modulating TRAF6-mediated signaling.

Bisphosphonate Use and the Risk of Undergoing Total Knee Arthroplasty in Osteoporotic Patients with Osteoarthritis: A Nationwide Cohort Study in Taiwan

BACKGROUND

The use of bisphosphonates has been reported to have potential beneficial effects on knee osteoarthritis, but existing studies have limitations. The purpose of this study was to examine the association of bisphosphonate use with the risk of undergoing total knee arthroplasty and with the consumption of pain medication among osteoporotic patients with knee osteoarthritis.

METHODS

We identified patients who were newly diagnosed with knee osteoarthritis among a cohort of patients with osteoporosis from 2009 to 2012 in the National Health Insurance Research Database in Taiwan. We further categorized these patients into 2 groups: those who were treated with bisphosphonates (bisphosphonate users) and those who were not treated with any anti-osteoporosis drug (nonusers). Bisphosphonate treatment adherence was calculated by the medication possession ratio (MPR) as the proportion of days of bisphosphonate treatment within a fixed duration; an MPR of ≥80% was considered high adherence. The primary and secondary outcomes of interest were undergoing total knee arthroplasty and the use of pain medication, respectively. Analyses using Cox proportional hazard models with propensity-score adjustment were performed to estimate the association between bisphosphonate use and the risk of undergoing total knee arthroplasty. The incremental change in the mean accumulated defined daily doses of pain medications among both bisphosphonate users and nonusers was calculated.

RESULTS

We identified 16,276 bisphosphonate users and 123,791 nonusers of any anti-osteoporosis drug among the patients with osteoporosis who were newly diagnosed with osteoarthritis. Bisphosphonate use was significantly associated with a decreased risk of total knee arthroplasty (adjusted hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.69 to 0.83; p < 0.001). In patients with a follow-up period of ≥24 months and an MPR of ≥80%, the effect size was significantly greater (adjusted HR, 0.66; p = 0.048). Over the 5 years of follow-up, we found a significantly greater decrease in the use of pain medication among bisphosphonate users than among nonusers (p < 0.001; Chow test).

CONCLUSIONS

Among patients with osteoporosis and osteoarthritis, bisphosphonate use was associated with a significantly lower risk of total knee arthroplasty, especially in patients with high adherence and longer treatment duration. A lower consumption of pain medication was also found for bisphosphonate users among the patients with osteoporosis and osteoarthritis.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Probabilistic bias analysis in pharmacoepidemiology and comparative effectiveness research: a systematic review

PURPOSE

We systematically reviewed pharmacoepidemiologic and comparative effectiveness studies that use probabilistic bias analysis to quantify the effects of systematic error including confounding, misclassification, and selection bias on study results.

METHODS

We found articles published between 2010 and October 2015 through a citation search using Web of Science and Google Scholar and a keyword search using PubMed and Scopus. Eligibility of studies was assessed by one reviewer. Three reviewers independently abstracted data from eligible studies.

RESULTS

Fifteen studies used probabilistic bias analysis and were eligible for data abstraction-nine simulated an unmeasured confounder and six simulated misclassification. The majority of studies simulating an unmeasured confounder did not specify the range of plausible estimates for the bias parameters. Studies simulating misclassification were in general clearer when reporting the plausible distribution of bias parameters. Regardless of the bias simulated, the probability distributions assigned to bias parameters, number of simulated iterations, sensitivity analyses, and diagnostics were not discussed in the majority of studies.

CONCLUSION

Despite the prevalence and concern of bias in pharmacoepidemiologic and comparative effectiveness studies, probabilistic bias analysis to quantitatively model the effect of bias was not widely used. The quality of reporting and use of this technique varied and was often unclear. Further discussion and dissemination of the technique are warranted. Copyright © 2016 John Wiley & Sons, Ltd.

Osteotropic nanoscale drug delivery systems based on small molecule bone-targeting moieties

Bone-targeted drug delivery is an active research area because successful clinical applications of this technology can significantly advance the treatment of bone injuries and disorders. Molecules with bone-targeting potential have been actively investigated as promising moieties in targeted drug delivery systems. In general, bone-targeting molecules are characterized by their high affinity for bone and their predisposition to persist in bone tissue for prolonged periods, while maintaining low systemic concentrations. Proteins, such as monoclonal antibodies, have shown promise as bone-targeting molecules; however, they suffer from several limitations including large molecular size, high production cost, and undesirable immune responses. A viable alternative associated with significantly less side effects is the use of small molecule-based targeting moieties. This review provides a summary of recent findings regarding small molecule compounds with bone-targeting capacity, as well as nanoscale targeted drug delivery approaches employing these molecules.

Prevalence and "Red Flags" Regarding Specified Causes of Back Pain in Older Adults Presenting in General Practice

BACKGROUND

In a small proportion of patients experiencing unspecified back pain, a specified underlying pathology is present.

OBJECTIVE

The purposes of this study were: (1) to identify the prevalence of physician-specified causes of back pain and (2) to assess associations between "red flags" and vertebral fractures, as diagnosed by the patients' general practitioner (GP), in older adults with back pain.

METHODS

The Back Complaints in the Elders (BACE) study is a prospective cohort study. Patients (aged >55 years) with back pain were included when consulting their GP. A questionnaire was administered and a physical examination and heel bone densitometry were performed, and the results determined back pain and patient characteristics, including red flags. Participants received a radiograph, and reports were sent to their GP. The final diagnoses established at 1 year were collected from the GP's patient registry.

RESULTS

Of the 669 participants included, 6% were diagnosed with a serious underlying pathology during the 1-year follow-up. Most of these participants (n=33, 5%) were diagnosed with a vertebral fracture. Multivariable regression analysis showed that age of ≥75 years, trauma, osteoporosis, a back pain intensity score of ≥7, and thoracic pain were associated with a higher chance of getting the diagnosis of a vertebral fracture. Of these variables, trauma showed the highest positive predictive value for vertebral fracture of 0.25 (95% confidence interval=0.09, 0.41) and a positive likelihood ratio of 6.2 (95% confidence interval=2.8, 13.5). A diagnostic prediction model including the 5 red flags did not increase these values.

LIMITATIONS

Low prevalence of vertebral fractures could have led to findings by chance.

CONCLUSIONS

In these older adults with back pain presenting in general practice, 6% were diagnosed with serious pathology, mainly a vertebral fracture (5%). Four red flags were associated with the presence of vertebral fracture.

The analysis of DKK1 polymorphisms in relation to skeletal phenotypes and bone response to alendronate treatment in Chinese postmenopausal women

Aim: To investigate the correlation between DKK1 polymorphisms with bone phenotypes and response to alendronate treatment. Materials & methods: Five tag single nucleotide polymorphisms of DKK1 were analyzed in 639 Chinese postmenopausal women with osteoporosis or osteopenia. Bone mineral density (BMD), β-CTX and ALP were measured before and after alendronate treatment. Results: Genotypes at rs1896367, rs1528877 and rs2241529 correlated to baseline BMD (p < 0.05). rs1528877 and rs2241529 polymorphisms correlated to baseline β-CTX levels (p < 0.05). rs2241529 polymorphisms of DKK1 had a small influence on the skeletal response to alendronate treatment (p < 0.05). Conclusion: DKK1 polymorphisms may correlate to baseline BMD and serum β-CTX levels, but present a weak effect on the response to alendronate.

Adherence to alendronic or risedronic acid treatment, combined or not to calcium and vitamin D, and related determinants in Italian patients with osteoporosis

PURPOSE

Osteoporosis is a chronic disease and an important health and social burden due to its worldwide prevalence. Literature and clinical experience report incomplete adherence to the therapy. This retrospective observational study aimed at assessing the adherence to first-line antiosteoporosis drugs (AODs; reimbursed by the National Health System, according to the Italian Medicine Agency recommendation number 79), alendronate or risedronate, with or without calcium and/or vitamin D supplements, in a real, Italian clinical setting.

PATIENTS AND METHODS

Analyses were carried out on data present in the ARNO Observatory, a population-based patient-centric Italian database. From a population of 5,808,832 inhabitants with available data, a cohort of 3.3 million of patients aged ≥40 years was selected. New users of first-line AODs as monotherapy (accrual period, 2007-2009) were followed up over 3 years to assess adherence at 6, 12, and 36 months to AODs and to supplements and related determinants.

RESULTS

Approximately 40,000 new users were identified: mostly women, aged on average (standard deviation) 71±10 years. Alendronate was the most prescribed (38.2% of patients), followed by risedronate (34.9%) and alendronate with colecalciferol as a fixed-dose combination (25.8%). Adherence at the 6-month follow-up was 54%, and this constantly and significantly decreased after 1 year to 46%, and after 3 years to 33% (P<0.01). Adherence to the fixed-dose combination was higher than to plain alendronate throughout the follow-up period. Similarly, adherence to supplements constantly decreased with the duration of treatment. Women and patients aged >50 years were more likely to adhere to treatment regimen (P<0.001). The use of drugs for peptic ulcer and gastroesophageal reflux disease and of corticosteroids for systemic use were significantly associated with high adherence at different times. Polytherapy (>5 drugs), cardiovascular, and neurological therapies were significantly associated with low adherence throughout the follow-up period.

CONCLUSION

In a huge clinical practice sample, this study highlights suboptimal adherence to first-line AODs and to supplements and important determinants, such as concomitant therapies.

Aging in Italy: The Need for New Welfare Strategies in an Old Country

Italy, a Southern European country with 60.8 million inhabitants, has the largest proportion of elderly citizens (aged ≥65) in Europe of 21.4%. The aging of the population is due to a number of reasons, such as baby boomers growing old, an increase in longevity, and low birth rate. Although international migration has increased in recent years, the addition of a foreign segment of the population has neither compensated for nor significantly curtailed the aging phenomenon. The impact of aging on the economic sustainability concerns the progressive reduction of the workforce, high incidence of pension spending in the overall resources allocated to welfare, recent reform of the pension system, and the growing issue of "non-self-sufficiency" in the elderly. Despite limited financial measures dedicated to research, Italy is conducting important studies on aging, both at the national and international level. Physicians and researchers in the field of geriatrics and gerontology are not only promoting quality of life in the elderly, and healthy-active aging, but also contributing to economic stability and social organization. Finally, nutritional and lifestyle habits-and their role in preventing chronic diseases-are the focus of the current international event EXPO 2015, with many sections dedicated to the elderly.

Ursolic acid derivatives as bone anabolic agents targeted to tryptophan hydroxylase 1 (Tph-1)

Tryptophan hydroxylase 1 (Tph-1) initiates the biosynthesis of peripheral serotonin. As peripheral serotonin suppresses bone formation, inhibitor of Tph-1 provides a useful tool to discover anabolic agents for osteoporosis. In the present study, series of ursolic acid (UA) derivatives were synthesized, and their inhibitory activity on serotonin biosynthesis and cytotoxicity were evaluated. Among the derivatives, 8d with potent inhibitory activity on serotonin was applied for further research. The data revealed that 8d significantly inhibited protein and mRNA expressions of Tph-1, and an SPR study indicated that 8d directly interacted to Tph-1 with a binding affinity of KD=15.09μM. Oral administration of 8d significantly prevented bone loss via suppressing serotonin biosynthesis without estrogenic side-effects in ovariectomized (OVX) rats.