The Impact of Antihypertensive Medications on Bone Mineral Density and Fracture Risk

Cross-Disciplinary Approach of Adrenal Tumors: Insights into Primary Aldosteronism-Related Mineral Metabolism Status and Osteoporotic Fracture Risk

Our objective was to overview the novel aspects in the field of adrenal gland neoplasms, namely, the management of bone status with respect to primary aldosteronism (PA). In the current narrative review, a PubMed study was conducted from inception until June 2023. The inclusion criteria were: human (clinically relevant) studies of any study design (at least 10 patients per study); English papers; and the following combination of key words within the title and/or abstract: "aldosterone" AND "bone", "skeleton", "osteoporosis", "fracture", "calcium", "parathyroid", "DXA", "osteocalcin", "P1NP", "alkaline phosphatase", "bone marker", "trabecular bone score", or "FRAX". The exclusion criteria were in vitro or animal studies, reviews, and case reports/series. We screened 1027 articles and finally included 23 studies (13 of case-control type, 3 cross-sectional, 5 prospective, 1 observational cohort, and 1 retrospective study). The assessments provided in these studies were as follows: nine studies addressed Dual-Energy X-ray Absorptiometry (DXA), another study pointed out a bone microarchitecture evaluation underlying trabecular bone score (TBS), and seven studies investigated the bone turnover markers (BTMs) profile. Moreover, 14 studies followed the subjects after adrenalectomy versus medical treatment, and 21 studies addressed secondary hyperparathyroidism in PA patients. According to our study on published data during a period of almost 40 years (n = 23, N = 3965 subjects aged between 38 and 64, with a mean age 56.75, and a female-to-male ratio of 1.05), a higher PTH in PA versus controls (healthy persons or subjects with essential hypertension) is expected, secondary hyperparathyroidism being associated in almost half of the adults diagnosed with PA. Additionally, mineral metabolism anomalies in PA may include lower serum calcium and higher urinary calcium output, all these three parameters being reversible under specific therapy for PA, regardless medical or surgical. The PA subgroup with high PTH seems at higher cardiovascular risk, while unilateral rather than bilateral disease was prone to this PTH anomaly. Moreover, bone mineral density (BMD) according to central DXA might show a higher fracture risk only in certain adults, TBS being a promising alternative (with a still unknown perspective of diabetes' influence on DXA-TBS results in PA). However, an overall increased fracture prevalence in PA is described in most studies, especially with respect to the vertebral site, the fracture risk that seems correctable upon aldosterone excess remission. These data recommend PA as a cause of secondary osteoporosis, a treatable one via PA intervention. There is still an area of debate the way to address BMTs profile in PA, the case's selection toward specific bone evaluation in every day practice, and further on, the understanding of the potential genetic influence at the level of bone and mineral complications in PA patients.

Azilsartan inhibits inflammation-triggered bone resorption and osteoclastogenesis in vivo via suppression of TNF-α expression in macrophages

Introduction

Hypertension is a major risk factor for cardiovascular disease (CVD) and is associated with increased bone loss due to excessive activity of the local renin-angiotensin system (RAS). Angiotensinogen/Angiotensin (ANG) II/Angiotensin II type 1 receptor (AT1R) axis is considered as the core axis regulating RAS activity. Azilsartan is an FDA-approved selective AT1R antagonist that is used to treat hypertension. This study aimed to determine whether azilsartan affects formation of osteoclast, resorption of bone, and the expression of cytokines linked with osteoclastogenesis during lipopolysaccharide (LPS)-triggered inflammation in vivo.

Methods

In vivo, following a 5-day supracalvarial injection of LPS or tumor necrosis factor-alpha (TNF-α) with or without azilsartan, the proportion of bone resorption and the number of tartrate-resistant acid phosphatase (TRAP)-positive multinucleated cells, which are identified as osteoclasts on mice calvariae were counted. The mRNA expression levels of TRAP, cathepsin K, receptor activator of NF-κB ligand (RANKL), and TNF-α were also evaluated. In vitro, the effect of azilsartan (0, 0.01, 0.1, 1, and 10 μM) on RANKL and TNF-α-triggered osteoclastogenesis were investigated. Also, whether azilsartan restrains LPS-triggered TNF-α mRNA and protein expression in macrophages and RANKL expression in osteoblasts were assessed. Furthermore, western blotting for analysis of mitogen-activated protein kinases (MAPKs) signaling was conducted.

Results

Azilsartan-treated calvariae exhibited significantly lower bone resorption and osteoclastogenesis than those treated with LPS alone. In vivo, LPS with azilsartan administration resulted in lower levels of receptor activator of RANKL and TNF-α mRNA expression than LPS administration alone. Nevertheless, azilsartan did not show inhibitory effect on RANKL- and TNF-α-triggered osteoclastogenesis in vitro. Compared to macrophages treated with LPS, TNF-α mRNA and protein levels were lower in macrophages treated by LPS with azilsartan. In contrast, RANKL mRNA and protein expression levels in osteoblasts were the same in cells co-treated with azilsartan and LPS and those exposed to LPS only. Furthermore, azilsartan suppressed LPS-triggered MAPKs signaling pathway in macrophages. After 5-day supracalvarial injection, there is no difference between TNF-α injection group and TNF-α with azilsartan injection group.

Conclusion

These findings imply that azilsartan prevents LPS-triggered TNF-α production in macrophages, which in turn prevents LPS-Triggered osteoclast formation and bone resorption in vivo.

Estimating the Incidence and Key Risk Factors of Cardiovascular Disease in Patients at High Risk of Imminent Fracture Using Routinely Collected Real-World Data From the UK

The objective of this work was to estimate the incidence rate of cardiovascular disease (CVD) events (myocardial infarction, stroke, or CVD death) at 1 year among three cohorts of patients at high risk of fracture (osteoporosis, previous fracture, and anti-osteoporosis medication) and to identify the key risk factors of CVD events in these three cohorts. To do so, this prospective cohort study used data from the Clinical Practice Research Datalink, a primary care database from United Kingdom. Major adverse cardiovascular events (MACE, a composite outcome for the occurrence of either myocardial infarction [MI], stroke, or CVD death) were identified in patients aged 50 years or older at high or imminent fracture risk identified in three different cohorts (not mutually exclusive): recently diagnosed with osteoporosis (OST, n = 65,295), incident fragility fracture (IFX, n = 67,065), and starting oral bisphosphonates (OBP, n = 145,959). About 1.90%, 4.39%, and 2.38% of the participants in OST, IFX, and OBP cohorts, respectively, experienced MACE events. IFX was the cohort with the higher risk: MACE incidence rates (cases/1000 person-years) were 19.63 (18.54-20.73) in OST, 52.64 (50.7-54.5) in IFX, and 26.26 (25.41-27.12) in OBP cohorts. Risk of MACE events at 1 year was predicted in the three cohorts. Models using a set of general, CVD, and fracture candidates selected by lasso regression had a good discrimination (≥70%) and internal validity and generally outperformed the models using only the CVD risk factors of general population listed in QRISK tool. Main risk factors common in all MACE models were sex, age, smoking, alcohol, atrial fibrillation, antihypertensive medication, prior MI/stroke, established CVD, glomerular filtration rate, systolic blood pressure, cholesterol levels, and number of concomitant medicines. Identified key risk factors highlight the differences of patients at high risk of fracture versus general population. Proposed models could improve prediction of CVD events in patients with osteoporosis in primary care settings. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Antihypertensive Drugs and Risk of Bone Fractures

Antihypertensive drugs are among the most documented regimens worldwide with an overall survival and cardioprotective benefit. However, there is evidence that they cause symptoms of orthostatic hypotension (i.e., dizziness and syncope) placing patients at risk for falls and fall-related injuries such as bone fractures. Moreover, it seems that they might impact bone metabolism and architecture impairing bone health. The aim of this review was to summarize the accumulative literature exploring any potential association between several antihypertensive medications including diuretics, renin-angiotensin-aldosterone system inhibitors, beta-blockers and calcium channel blockers and the risk of fractures.

Elevated blood pressure, antihypertensive medications and bone health in the population: revisiting old hypotheses and exploring future research directions

Blood pressure and bone metabolism appear to share commonalities in their physiologic regulation. Specific antihypertensive drug classes may also influence bone mineral density. However, current evidence from existing observational studies and randomised trials is insufficient to establish causal associations for blood pressure and use of blood pressure-lowering drugs with bone health outcomes, particularly with the risks of osteoporosis and fractures. The availability and access to relevant large-scale biomedical data sources as well as developments in study designs and analytical approaches provide opportunities to examine the nature of the association between blood pressure and bone health more reliably and in greater detail than has ever been possible. It is unlikely that a single source of data or study design can provide a definitive answer. However, with appropriate considerations of the strengths and limitations of the different data sources and analytical techniques, we should be able to advance our understanding of the role of raised blood pressure and its drug treatment on the risks of low bone mineral density and fractures. As elevated blood pressure is highly prevalent and blood pressure-lowering drugs are widely prescribed, even small effects of these exposures on bone health outcomes could be important at a population level.

Update on the pathogenesis and treatment of skeletal fragility in type 2 diabetes mellitus

Fracture risk is increased in patients with type 2 diabetes mellitus (T2DM). In addition, these patients sustain fractures despite having higher levels of areal bone mineral density, as measured by dual-energy X-ray absorptiometry, than individuals without T2DM. Thus, additional factors such as alterations in bone quality could have important roles in mediating skeletal fragility in patients with T2DM. Although the pathogenesis of increased fracture risk in T2DM is multifactorial, impairments in bone material properties and increases in cortical porosity have emerged as two key skeletal abnormalities that contribute to skeletal fragility in patients with T2DM. In addition, indices of bone formation are uniformly reduced in patients with T2DM, with evidence from mouse studies published over the past few years linking this abnormality to accelerated skeletal ageing, specifically cellular senescence. In this Review, we highlight the latest advances in our understanding of the mechanisms of skeletal fragility in patients with T2DM and suggest potential novel therapeutic approaches to address this problem.

Regulation of bone metabolism mediated by β-adrenergic receptor and its clinical application

Recent studies have confirmed that β-adrenergic receptors (β-ARs) are expressed on the surface of osteoblasts and osteoclasts, and that the sympathetic nervous system can regulate bone metabolism by activating them. β-AR blockers (BBs) are commonly used in the treatment of cardiovascular diseases in the elderly. It is important to investigate whether BBs have a beneficial effect on bone metabolism in the treatment of cardiovascular diseases, so as to expand their clinical application. This article reviews the effects of BB on bone metabolism and the progress of clinical research.

Hepatocyte growth factor administration increases bone soluble phosphate and alters bone chemical structure in diabetic hypertensive rats

Hepatocyte growth factor (HGF) is a novel potential therapy for improving bone health in patients with type II diabetes and hypertension, but its effect on the bone molecular structure is not revealed yet. Here, X-ray absorption near edge structure (XANES) spectroscopy was used to explore the effects elicited by HGF on the bone chemical structure. This study assessed local calcium (Ca) and phosphorus (P) coordination of diabetic hypertensive rat bones, each with and without HGF treatment. Results revealed that HGF has significant effects on Ca and P coordination chemistry as confirmed by presence of more soluble phosphates in the HGT-treated groups. Data indicated that treated bones have a poorly developed phosphate structure as evidenced by drastic drop in post-edge shoulder in P L2,3-edge compared to diabetic hypertensive and diabetic control bone. Presence of soluble Ca and P, products of bone resorption, with HGF treatment suggests unbalanced bone resorption and formation.

Quantitative analysis of tegmen bone mineral density in obese and non-obese patients

BACKGROUND

Certain factors have been linked to lateral skull base demineralisation or erosion, which may predispose to spontaneous cerebrospinal fluid leak. There are relatively few quantitative reports of skull base changes in patient populations.

METHOD

A novel refined measurement algorithm for quantification of tegmen bone mineral density was developed, and bone mineral density between obese and non-obese patient groups was compared. Computed tomography scans were analysed by three blinded reviewers, and tegmen bone mineral densities were compared.

RESULTS

There were 23 patients in the obese group and 27 matched controls in the non-obese group. Inter-rater reliability was 'strong' to 'near complete' (κ = 0.75-0.86). No differences in tegmen bone mineral density were found between the groups (p = 0.64). The number of active blood pressure medications correlated positively with lateral skull base bone mineral density.

CONCLUSION

A novel, refined, quantitative measurement algorithm for the assessment of tegmen bone mineral density was developed and validated. Obesity was not found to significantly affect tegmen bone mineral density.

Diabetes and Bone Fragility

Diabetes is a highly prevalent disease with complications that impact most bodily systems. However, the impact of diabetes on bone health is frequently ignored or underestimated. Both type 1 (T1D) and type 2 diabetes (T2D) are associated with a higher risk of fractures, albeit through different mechanisms. T1D is characterized by near total insulinopenia, which affects the anabolic tone of bone and results in reduced bone mineral density (BMD). Meanwhile, patients with T2D have normal or high BMD, but carry an increased risk of fractures due to alterations of bone microarchitecture and a local humoral environment that stimulates osteoclast activity. Chronic hyperglycemia induces non-enzymatic glycation of collagen in both types of diabetes. Epidemiological evidence confirms a largely increased fracture risk in T1D and T2D, but also that it can be substantially reduced by opportune monitoring of fracture risk and appropriate treatment of both diabetes itself and osteopenia or osteoporosis if they are present. In this review, we summarize the mechanistic, epidemiological, and clinical evidence that links diabetes and bone fragility, and describe the impact of available diabetes treatments on bone health.

Effect of pharmacological treatment prior to admission on the outcome of older hip fracture patients

PURPOSE

We aim to relate the pharmacological treatment at admission of hip fracture patients with their prognosis.

METHODS

We designed a prospective study including 436 hip fracture patients. We classified all the pharmacological treatment prior to admission of each patient into 25 groups according to their active agent and indications. We followed-up patients for one year for survival, emergency department visits (EDV), and in-hospital re-admissions (RAD). Differential analysis was performed by chi-square test, U-Mann Whitney test, and logistic regression. In all cases, p ≤ 0.05 was considered statistically significant.

RESULTS

At 30-day follow-up, 14.9% patients noted EDV, 9.2% RAD, and 3.2% dead. Patients taking beta-blockers (p = 0.046), loop diuretics (p = 0.018) or antiparkinsonian (p = 0.009) showed an increased 30-day EDV; patients taking benzodiazepines (p = 0.014), loop diuretics (p = 0.009) or antiparkinsonian (p = 0.009), an increased 30-day RAD. At one-year follow-up, 50.7% patients noted EDV, 30.7% RAD, and 22.7% dead. Patients taking oral antidiabetics (p = 0.006) noted a greater one-year EDV; patients taking major opioids (p = 0.001), benzodiazepines (p = 0.016), cardiac agents (p = 0.046), loop diuretics (p = 0.042), beta-blockers (p = 0.018), oral anticoagulants (p = 0.013) or gastric prophylaxis (p = 0.020), greater RAD; patients taking cardiac agents (p = 0.024), loop diuretics (p = 0.006) or oral anticoagulants (p = 0.015), increased 1-year mortality rate.

CONCLUSIONS

The pharmacological treatment noted at admission for hip fracture patients is related to the outcome, in a dose-independent way. The pharmacological treatment could be an additional parameter that could help us to improve the decision-making process and the resource assignation of hip fracture patients. A proper medication review upon admission because of a hip fracture is warranted.

Helicobacter pylori Related Diseases and Osteoporotic Fractures (Narrative Review)

Osteoporosis (OP) and osteoporotic fractures (OFs) are common multifactorial and heterogenic disorders of increasing incidence. Helicobacter pylori (H.p.) colonizes the stomach approximately in half of the world's population, causes gastroduodenal diseases and is prevalent in numerous extra-digestive diseases known to be associated with OP/OF. The studies regarding relationship between H.p. infection (HPI) and OP/OFs are inconsistent. The current review summarizes the relevant literature on the potential role of HPI in OP, falls and OFs and highlights the reasons for controversies in the publications. In the first section, after a brief overview of HPI biological features, we analyze the studies evaluating the association of HPI and bone status. The second part includes data on the prevalence of OP/OFs in HPI-induced gastroduodenal diseases (peptic ulcer, chronic/atrophic gastritis and cancer) and the effects of acid-suppressive drugs. In the next section, we discuss the possible contribution of HPI-associated extra-digestive diseases and medications to OP/OF, focusing on conditions affecting both bone homeostasis and predisposing to falls. In the last section, we describe clinical implications of accumulated data on HPI as a co-factor of OP/OF and present a feasible five-step algorithm for OP/OF risk assessment and management in regard to HPI, emphasizing the importance of an integrative (but differentiated) holistic approach. Increased awareness about the consequences of HPI linked to OP/OF can aid early detection and management. Further research on the HPI-OP/OF relationship is needed to close current knowledge gaps and improve clinical management of both OP/OF and HPI-related disorders.

Spironolactone reduces biochemical markers of bone turnover in postmenopausal women with primary aldosteronism

CONTEXT

Primary aldosteronism (PA) is the most frequent form of endocrine hypertension. Besides its deleterious impact on cardiovascular target organ damage, PA is considered to cause osteoporosis.

PATIENTS AND METHODS

We assessed bone turnover in a subset of 36 postmenopausal women with PA. 18 patients had unilateral PA and were treated by adrenalectomy, whereas 18 patients had bilateral PA and received mineralocorticoid receptor antagonist (MRA) therapy respectively. 18 age- and BMI-matched females served as controls. To estimate bone remodeling, we measured the bone turnover markers intact procollagen 1 N-terminal propeptide, bone alkaline phosphatase, osteocalcin and tartrate resistant acid phosphatase 5b in plasma by chemiluminescent immunoassays at time of diagnosis and one year after initiation of treatment.

STUDY DESIGN

Observational longitudinal cohort study.

SETTING

Tertiary care hospital.

RESULTS

Compared with controls, patients with PA had mildly elevated osteocalcin at baseline (p = 0.013), while the other bone markers were comparable between both groups. There were no differences between the unilateral and the bilateral PA subgroup. One year after initiation of MRA treatment with spironolactone bone resorption and bone formation markers had significantly decreased in patients with bilateral PA. In contrast, patients adrenalectomized because of unilateral PA showed no significant change of bone turnover markers.

CONCLUSION

This study shows that aldosterone excess in postmenopausal women with PA is not associated with a relevant increase of bone turnover markers at baseline. However, we observed a significant decrease of bone markers in patients treated with spironolactone, but not in patients treated by adrenalectomy.

Evaluation of the effects of β1-selective beta-blockers on bone mineral density and fracture risk in postmenopausal women

Background/aim

β1-selective beta-blockers (BBs) are sympatholytic agents, and discerning their effects on bone health would be of great importance. This study aimed to investigate the influence of β1-selective BBs on bone mineral density (BMD) and fracture risk.

Materials and methods

This study included postmenopausal women who used β1-selective BBs (BB group) and control group. Sociodemographic characteristics, BMD and previous fragility fractures were recorded. Additionally, the 10-year probability of a major osteoporotic and hip fracture was calculated using the fracture risk assessment tool (FRAX).

Results

A total of 60 participants were included in the study. L1-4 and L2-4 BMD values were significantly higher in BB group than control group (P = 0.015 and P = 0.025, respectively). Moreover, T-scores of lumbar and femur total were significantly higher in the BB group. Two patients in BB and 6 patients in control group had previous fragility fracture. No statistically significant intergroup difference was noted regarding FRAX.

Conclusion

Based on our results, β1-selective BB usage was associated with higher BMD at the lumbar region in postmenopausal women.

Untreated adult GH deficiency is not associated with the development of metabolic risk factors: a long-term observational study

PURPOSE

Uncertainties exist about the predictors of the severity of the clinical picture of GH deficiency (GHD) syndrome. Aim of the study was to evaluate, in adult patients with GHD, the predictors of the development of hypercholesterolemia, hypertension, diabetes mellitus, and osteoporosis.

METHODS

We retrospectively studied 327 adult patients (age 47.1 ± 17.1 years) with untreated severe GHD (mean follow-up 110.9 ± 56.8 months). GHD was defined by GHRH + arginine test using BMI cut-offs. The possible development of hypercholesterolemia, hypertension, diabetes mellitus, and osteoporosis was investigated by Kaplan-Meier survival analysis. For each clinical outcome, either a univariate or multivariate analysis according to the Cox proportional-hazards model was performed to identify those factors that were associated with the development of the event.

RESULTS

GH secretion parameters were not associated with the outcomes. Hypercholesterolemia was positively and negatively predicted by a BMI ≥ 30 kg/m² (HR 2.50, p 0.00) and the dose of l-thyroxine possibly in place (HR 0.98, p 0.02), respectively. Hypertension was positively predicted by a BMI ≥ 30 kg/m² (HR 2.64, p 0.00) and IGF-I SDS values (HR 2.26, p 0.00). Diabetes mellitus was positively predicted by hypertension (HR 11.76, p 0.01). Osteoporosis was positively and negatively predicted by hypercholesterolemia (HR 3.25, p 0.01) and hypertension (HR 0.21, p 0.00), respectively.

CONCLUSIONS

The severity of the impairment of GH secretion does not predict the development of the clinical picture of GHD syndrome: untreated adult GHD does not increase the development of metabolic risk factors in hypopituitaric patients.

Metabolic factors and hip fracture risk in a large Austrian cohort study

To explore the association of incident hip fractures with metabolic syndrome (MetS) and its single components, we designed a prospective cohort study of hip fracture incidence among 117,053 participants of a population-based health surveillance program in Vorarlberg, the westernmost Austrian province. Incident hip fractures were recorded between 5 and 10 years after inclusion at baseline from 2003 to 2009. Applying Cox proportional hazard models for each MetS component and for a composite z-score for MetS, hazards for fracture were estimated in quintiles, as continuous z-score variables, and as pathological cut off values. Mean age was 50.1 ± 15.6 years at baseline, 5-10 years after which 947 incident hip fractures occurred. An association of a higher composite MetS score with decreased hip fracture risk was observed in women (HR 0.80, 95%-CI 0.88-0.96, p < 0.01) which disappeared upon adjustment for BMI. BMI was inversely associated with hip fracture risk in women and men (HR for the highest compared with the lowest quintile: 0.83 (95%-CI: 0.63-1.10, p _trend < 0.05) and 0.55 (95%-CI: 0.38-0.79, p _trend < 0.001), respectively). Only in women, hip fracture risk was reduced at high cholesterol levels (HR for the highest relative to the lowest quintile: 0.64, 95%-CI: 0.48-0.84, p _trend < 0.05) and in hypercholesterolemic patients (HR 0.82, 95%-CI: 0.67-0.99, p < 0.05), but elevated in hyperglycemic patients (HR 1.33, 95%-CI: 1.05-1.70, p < 0.05). Hypertriglyceridemia was associated with increased male hip fracture risk (HR 1.33, 95%-CI: 1.03-1.72, p < 0.05). The inverse association between the MetS and hip fracture risk is mainly driven by one single component, namely BMI.

The renin-angiotensin aldosterone system and osteoporosis: findings from the Women's Health Initiative

New users of RAAS inhibitors, including ACE inhibitors and ARBs, have a small increased risk for fracture in the first 3 years of use, with a reduced risk of fracture with longer duration of use.

INTRODUCTION

Pharmacological inhibitors of the renin-angiotensin aldosterone system (RAAS) are used to treat hypertension. However, the relationship of these medications to osteoporosis is inconsistent, and no study has included simultaneous measurements of both incident fractures and bone mineral density (BMD).

METHODS

The association of RAAS inhibitor use (n = 131,793) with incident fractures in new users of these medications in women in the Women's Health Initiative over a minimum median follow-up of 6.5 years was assessed by Cox proportional hazard models. The association of incident fractures by a cumulative duration of use of these medications (< 3 years.) and (> 3 years.) was also estimated. Subgroup analysis of fracture risk by RAAS inhibitor use confined to women with hypertension was also performed (n = 33,820). The association of RAAS inhibitor use with changes in BMD of the hip was estimated by linear regression in 8940 women with dual energy X-ray absorptiometry measurements.

RESULTS

There was no significant association between RAAS inhibitor use and all fractures in the final adjusted multivariable models including hip BMD (HR 0.86 (0.59, 1.24)). However, among users of RAAS inhibitors, including ACE inhibitors and angiotensin receptor blockers (ARBs), hazard ratios for all incident fracture sites in final multivariable models including hip BMD showed dramatic differences by duration of use, with short duration of use (3 years or less) associated with a marked increased risk for fracture (HR 3.28 (1.66, 6.48)) to (HR 6.23 (3.11, 12.46)) and use for more than 3 years associated with a reduced fracture risk (HR 0.40 (0.24, 0.68) to (HR 0.44 (0.20, 0.97)) . Findings were similar in the subgroup of women with a history of hypertension. There was no significant change in BMD of the hip by RAAS inhibitor use.

CONCLUSIONS

In postmenopausal women, use of RAAS inhibitors, including ACE inhibitors and ARBs, is associated with an increased risk for fracture among new users of these medications in the first 3 years of use. However, long-term use (> 3 years) is associated with a reduced risk. Consideration for fracture risk may be part of the decision-making process for initiation of these medications for other disease states.

A retrospective cohort analysis of the effects of renin-angiotensin system inhibitors on spinal fusion in ACDF patients

BACKGROUND CONTEXT

Recently, preclinical and clinical studies suggest an association between renin-angiotensin system (RAS) blockers and bone healing, particularly in the context of osteoporotic bone fractures.

PURPOSE

To determine the correlation between the use of RAS inhibitors and fusion outcomes and neurologic status in anterior cervical discectomy and fusion (ACDF) surgery.

STUDY DESIGN

Retrospective observational study.

PATIENT SAMPLE

Patients who underwent ACDF for degenerative disorders.

OUTCOME MEASURES

Spinal fusion status and neurologic function (modified Japanese Orthopedic Association [mJOA] and Nurick grading scales).

METHODS

A retrospective chart review was performed, including 200 patients who underwent ACDF for degenerative disorders with 1-year minimum follow-up. Demographic data, comorbidities, antihypertensive medication, neurologic examination, and fusion status were collected. Spinal fusion was assessed via plain cervical x-ray, resorting to dynamic radiographs and/or computer tomography (CT) in cases of uncertainty. Preoperative mJOA and Nurick scores and recovery rates were calculated to determine neurologic status.

RESULTS

Of the 200 patients (42.5% females, 57.5% males, median age of 53.7 years), 82 hypertensive patients were identified. Seventy-seven (93.9%) were taking antihypertensive medication as follows: 36.4% angiotensin-II receptor blockers (ARBs), 35.1% angiotensin-converting enzyme inhibitors (ACEIs), and the remaining patients were taking other medication. In the analysis of fusion rates, patients treated with ARBs exhibited a higher fusion rate, while those treated with ACEIs displayed a lower fusion rate compared to untreated nonhypertensive patients (p = .04 and .02, respectively). The difference in fusion rates between ARBs and ACEIs was also significant, with the former displaying higher rates (p < .001). Smoking exhibited a negative correlation with spinal fusion (p < .001). In the multivariate analysis, ARBs remained an independent factor for successful fusion (p = .02), while smoking remained a risk factor for failed fusion (p = .002). In the neurologic examination, ACEIs, hypertension status, and older age correlated with lower modified Japanese Orthopedic Association (mJOA) recovery rates (p = .001, <.001, and <.001, respectively) in the univariate analysis.

CONCLUSIONS

In ACDF patients, we observed that ARBs were associated with higher fusion rates. Conversely, ACEIs and smoking were related to failed fusion. Prospective case-control studies are needed to confirm these RAS inhibitors effects on spinal fusion.

Osteoporosis and vascular calcification: A shared scenario

Osteoporosis is a systemic skeletal disease, characterised by low bone mass and deterioration in the micro-architecture of bone tissue, which causes increased bone fragility and consequently greater susceptibility to fractures. It is the most frequent metabolic bone disease in our population, and fractures resulting from osteoporosis are becoming more common. Furthermore, vascular calcification is a recognised risk factor of cardiovascular morbidity and mortality that historically has been considered a passive and degenerative process. However, it is currently recognised as an active process, which has histopathological characteristics, mineral composition and initiation and development mechanisms characteristic of bone formation. Paradoxically, patients with osteoporosis frequently show vascular calcifications. Traditionally, they have been considered as independent processes related to age, although more recent epidemiological studies have shown that there is a close relationship between the loss of bone mass and vascular calcification, regardless of age. In fact, both conditions share risk factors and pathophysiological mechanisms. These include the relationship between proteins of bone origin, such as osteopontin and osteoprotegerin (OPG), with vascular pathology, and the intercellular protein system RANK/RANKL/OPG and the Wnt signalling pathway. The mechanisms linked in both pathologies should be considered in clinical decisions, given that treatments for osteoporosis could have unforeseen effects on vascular calcification, and vice versa. In short, a better understanding of the relationship between both entities can help in proposing strategies to reduce the increasing prevalence of vascular calcification and osteoporosis in the aging population.

Anemia and Risk of Fractures in Older Korean Adults: A Nationwide Population-Based Study

Anemia is a common health problem in older adults and is associated with risk factors for fracture such as low physical function and low bone mass. The aim of this study was to examine the relationship between anemia and fracture risk in older adults. We conducted a retrospective cohort study from 2003 to 2013. The participants were community-dwelling Korean adults aged 65 years and older who participated in the National Health Screening Program (n = 72,131) between 2003 and 2008. Anemia (<12 g/dL for women and <13 g/dL for men) and severity of anemia (mild: 11 g/dL ≤ Hb < 12 g/dL; moderate to severe: Hb < 11 g/dL) were defined by World Health Organization (WHO) criteria. The incidence of any fractures, vertebral fractures, and femur fractures was identified using ICD-10 codes. Cox proportional hazard regression models were used to assess risk of fracture according to anemia. Anemia was associated with increased risk of fracture in men (any: adjusted hazard ratio [aHR] = 1.29, 95% confidence interval [CI] 1.18-1.41; vertebral: aHR = 1.20, 95% CI 1.03-1.40; femur: aHR = 1.71, 95% CI 1.44-2.04), and less strongly but still significantly in women (any: aHR = 1.10, 95% CI 1.11-1.41; vertebral: aHR = 1.11, 95% CI 1.03-1.20; femur: aHR = 1.37, 95% CI 1.25-1.52). Higher risk was observed in subjects with moderate-to-severe anemia in both sexes. Considering the high prevalence of anemia in older adults, it is important that health professionals recognize increased fracture risk in older adults with anemia. © 2019 American Society for Bone and Mineral Research.

Forearm bone density is not elevated in Inuit women with impaired fasting glucose or type 2 diabetes mellitus

Bone mineral density (BMD) and fracture risk are elevated in adults with impaired fasting glucose (IFG) or type 2 diabetes mellitus (T2D). This study aimed to compare bone health among Inuit women with IFG, T2D and normoglycemia. The study included Inuit women (≥40 y) with IFG (n = 57), T2D (n = 72) or normoglycemia (n = 340) from the International Polar Year Inuit Health Survey 2007-2008 in Canada. Distal one-third forearm BMD (FaBMD) was measured using a peripheral instantaneous x-ray imager. Anthropometry, fasting plasma glucose (FPG), serum adiponectin, leptin and 25-hydroxyvitamin D (25(OH)D) were measured. Traditional food intakes were surveyed. Data were analysed using mixed model ANOVA and regression models. The median age was 53 (IFG: IQR 48, 67) y and 56 (T2D: IQR 49, 63) y. Compared to normoglycemic women, FaBMD and T-scores were significantly lower in women with T2D, but not with IFG. Frequency of marine mammal intakes (ß = 0.145; 95%CI: 0.018, 0.053, p = 0.0001) positively related to FaBMD. The odds ratio of having a T-score consistent with osteoporosis was lower among women with T2D and higher BMI, while aging increased the risk. Although T2D associates with lower BMD among Inuit women, risk of osteoporosis is tempered, possibly by maintenance of a traditional lifestyle.

Atherosclerosis and Osteoporosis. Common Targets for the Effects of Cardiovascular and Anti-osteoporotic Drugs (Part I). The Effect of Cardiovascular Drugs on Bone Strength

Daily use of antihypertensive and lipid-lowering drugs in clinical practice dictates the need for knowledge of their pleiotropic effects. The article presents the results of studies of the effect of cardiovascular drugs, such as statins, beta-blockers, ACE inhibitors, diuretics, calcium antagonists and nitrates on bone mineral density and fractures associated with osteoporosis. The mechanisms of action of drugs on bone mass, markers of bone metabolism, the frequency of fractures in osteoporosis are discussed. Most studies show that the use of cardiac drugs along with a positive effect on the vascular wall, slow bone resorption and increase bone mass. Knowledge of the additional effect on bone metabolism of drugs used in cardiovascular diseases allows to choose an adequate therapy and improve the prognosis of both diseases.

Type 1 Diabetes and Bone Fragility: Links and Risks

Type 1 diabetes (T1D) is associated with an increased fracture risk, which is present at young and old age. Reductions in bone mineral density do not explain the increased fracture risk. Novel scanning modalities suggest that structural deficits may contribute to the increased fracture risk. Furthermore, T1D may due to insulinopenia be a state of low bone turnover. However, diabetes complications and comorbidities may influence fracture risk. Patients with T1D are fearful of falls. The diabetes related complications, hypoglycemic events, and antihypertensive treatment may all lead to falls. Thus, the increased fracture risk in T1D seems to be multifactorial, and earlier intervention with antiosteoporotic medication and focus on fall prevention is needed. This systematic review addresses the epidemiology of fractures and osteoporosis in patients with T1D and the factors that influence fracture risk.

Heart Rate and Bone Mineral Density in Older Women with Hypertension: Results from the Korea National Health and Nutritional Examination Survey

OBJECTIVES

To determine whether high heart rate is associated with low bone mineral density (BMD) in older women with hypertension.

DESIGN

Retrospective cohort study.

SETTING

Population-based study conducted in Korea (Korea National Health and Nutritional Examination Survey 2009-10).

PARTICIPANTS

Postmenopausal women aged 60 and older with hypertension (N=981) divided into 2 groups according to resting heart rate, with a cut-off value of 80 bpm, which has been found to be associated with osteoporosis.

MEASUREMENTS

BMD profiles and clinical and laboratory data were collected. Osteoporosis was defined as a T-score of -2.5 or less, according to World Health Organization criteria.

RESULTS

BMD was significantly lower in participants with a high heart rate, even after adjustment for age, diabetes mellitus, white blood cell count, and fasting glucose and triglyceride levels. The prevalence of osteoporosis was also significantly higher in those participants. In multivariate logistic regression analysis, the group with high heart rate was 1.7 times as likely (95% confidence interval=1.2-2.3) to have osteoporosis as those with a lower heart rate, independent of age, body mass index, comorbidities, and laboratory findings.

CONCLUSION

High heart rate is independently associated with lower BMD in older women with hypertension; proactive surveillance of BMD could be helpful when managing older women with hypertension and a high heart rate.