Osteoporosis care amidst the prolonged pandemic

Molecular mechanisms and targeted therapy of progranulin in metabolic diseases

Progranulin (PGRN) is a secreted glycoprotein with cytokine-like properties, exerting tripartite mechanisms of inflammation suppression, tissue repair promotion, and metabolic regulation. This multifaceted functionality positions PGRN as a potential "multi-effect therapeutic strategy" for metabolic disorders characterised by cartilage degradation and imbalanced bone remodelling, potentially establishing it as a novel therapeutic target for such conditions. Osteoarthritis, rheumatoid arthritis, intervertebral disc degeneration, osteoporosis, periodontitis, and diabetes-related complications-representing the most prevalent metabolic diseases-currently lack effective treatments due to incomplete understanding of their precise pathogenic mechanisms. Recent studies have revealed that PGRN expression levels are closely associated with the onset and progression of these metabolic disorders. However, the exact regulatory role of PGRN in these diseases remains elusive, partly owing to its tissue-specific actions and context-dependent dual roles (anti-inflammatory vs. pro-inflammatory). In this review, we summarise the structure and functions of PGRN, explore its involvement in neurological disorders, immune-inflammatory diseases, and metabolic conditions, and specifically focus on its molecular mechanisms in metabolic diseases. Furthermore, we consolidate advances in targeting PGRN and the application of its engineered derivative, Atsttrin, in metabolic bone disorders. We also discuss potential unexplored mechanisms through which PGRN may exert influence within this field or other therapeutic domains. Collectively, this work aims to provide a new framework for elucidating PGRN's role in disease pathogenesis and advancing strategies for the prevention and treatment of metabolic disorders.

Kinesiophobia, limits of stability, and functional balance assessment in geriatric patients with chronic low back pain and osteoporosis: a comprehensive study

Background

The significance of studying Kinesiophobia, Limits of Stability (LOS), and functional balance in geriatric patients with CLBP and osteoporosis lies in their profound impact on rehabilitation outcomes and fall risk, ultimately affecting patients' quality of life. This study aimed to examine LOS and functional balance in the geriatric population concurrently experiencing Chronic Low Back Pain (CLBP) and osteoporosis, in comparison to age-matched healthy controls; to assess the correlations between Kinesiophobia, LOS, and functional balance assessments; and to evaluate the mediating influence of Kinesiophobia on the association between LOS and functional balance tests.

Methods

This cross-sectional study included a total of 86 participants in each group. Kinesiophobia was assessed using the Tampa Scale of Kinesiophobia (TSK). LOS variables were evaluated with a computerized Iso-free platform in eight different directions. Functional balance was measured using the Timed Up and Go (TUG) test and the Berg Balance Scale (BBS).

Results

Patients with CLBP and osteoporosis showed significantly lower LOS percentages (45.78 ± 6.92) and impaired Functional Balance, reflected in a TUG Score (10.45 ± 2.23), compared to asymptomatic controls (LOS: 76.95 ± 8.21; TUG: 8.73 ± 1.90). Kinesiophobia showed a significant moderate negative correlation with LOS, indicated by r = -0.362 (p < 0.01). Additionally, Kinesiophobia was found to correlate with functional balance tests. Specifically, there was a moderate positive correlation with the TUG Score (r = 0.322, p < 0.01), indicating that higher Kinesiophobia is associated with slower TUG performance. Conversely, a stronger moderate negative correlation was observed with the Berg Balance Scale (BBS) Score (r = -0.436, p < 0.001), suggesting that increased Kinesiophobia is associated with lower BBS scores, indicating poorer balance performance. Mediation analysis revealed that Kinesiophobia significantly influences LOS and Functional Balance. For LOS and the TUG score, Kinesiophobia showed a direct effect (B = 0.24), an indirect effect (B = 0.09), and a total effect (B = 0.13). Similarly, for LOS and the BBS score, the direct effect of Kinesiophobia was B = 0.38, with an indirect effect of B = 0.10 and a total effect of B = 0.20.

Conclusion

This study underscores the substantial impact of Kinesiophobia on both stability and functional balance in individuals coping with CLBP and osteoporosis. The findings emphasize the clinical relevance of addressing Kinesiophobia as a potential target for interventions aimed at improving LOS and functional balance in this specific patient population.

The interruption of romosozumab treatment during COVID lockdown among US post-menopausal women enrolled in Medicare

PURPOSE

To evaluate the impact of the COVID lock-down on treatment interruptions of romosozumab, a first in class biologic therapy, administered by healthcare providers once monthly.

METHODS

We used Medicare data from 1/1/2017 to 9/30/2021 to identify women age ≥65 initiating romosozumab between 4/1/2019 and 6/30/2021. Patient demographics, provider specialty, and baseline comorbidities were identified. Romosozumab dispensations were grouped into five 6-month periods based on the dispensing date from FDA licensure to the end of the data (Period 1 to 5). "Treatment interruption" was defined as any interval gap between 2 dispensations >60 days. The numbers of treatment interruption event were aggregated per period per patient. Mixed effect Poisson regression with patient-level random effects was performed, including an interaction term between Period and number of prior doses.

RESULTS

There were 12,216 romosozumab new users identified. A total of 2724 treatment interruption events were identified among 2229 romosozumab users. After adjustment, comparing with the period immediately before the lockdown (Period 2: 2019-10-1-2020-3-30), the IRRs (95 % CI) for treatment interruption were 0.49 (0.29, 0.81), 1.65 (1.48, 1.85), 1.79 (1.60, 2.01), and 1.67 (1.49, 1.87) for periods 1, 3, 4, and 5, respectively, per 1 prior dose change (p < 0.01 for all IRRs), where Periods 3, 4, and 5 were post-lockdown.

CONCLUSION

Compared to the pre-COVID period, the lockdown negatively impacted the continuity of romosozumab treatment among Medicare beneficiaries. Prioritizing in-time assistance for patients receiving a provider-administered parenteral therapy is critical when patients' in-person access to their provider is compromised.

Difficulties in decision making on a long standing, complicated case of osteoporosis – a real challenge for functional rehabilitation

We aim was to present a case of severe osteoporosis with concern to an adult female who was under specific medication against the condition while she experienced inexplicable weight loss in association with an incidental fracture inconsistent with DXA changes. Challenges of the case management and decision making are further on explained. Real-life-medicine poses multiple issues that require an individual decision while respecting the standard protocols. That is why a generalized decision is rather impractical. Here we introduce the clinical case of a lady in her late 60s with a known 6-year history of osteoporosis that required several difficult decisions along surveillance: at first, zoledronic acid represented an available solution, yet after one year, BMD decreased and adjustment was done by initiating a second sequence according to the teriparatide protocol. DXA-BMD, as well as the spectrum of bone turnover markers, qualified the patient as responsive and she further continued with oral bisphosphonates while being monitored via telemedicine amid COVID-19 pandemic. After 24 more months, a second decision of zoledronic acid was done, despite prior partial response, but digestive complains restricted the oral administration of anti-osteoporotic drugs. After one more year, denosumab was initiated and consecutive follow-up is essential. At this point, another challenging aspect was revealed: the discordance between DXA – based scores increase and the presence of an incidental fracture. A supplementary investigation was considered useful (Tc- whole body scintigraphy) noting the clinical presentation with local pain, dysfunctionality, and mild weight loss that also required rehabilitation management.

Cost-effectiveness analysis of five drugs for treating postmenopausal women in the United States with osteoporosis and a very high fracture risk

PURPOSE

Five strategies were recommended by the American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) guidelines for the treatment of postmenopausal osteoporosis (PMO) patients with a very high fracture risk. We aimed to assess their cost-effectiveness in the United States (US).

METHODS

A microsimulation Markov model was created to compare the cost-effectiveness of five treatment strategies, including zoledronate, denosumab, abaloparatide, teriparatide, and romosozumab in PMO patients with a recent fracture from the healthcare perspective of the US. The data used in the model were obtained from published studies or online resources. Base-case analysis, one-way deterministic sensitivity analysis (DSA) and probability sensitivity analysis (PSA) were conducted for 65-, 70-, 75-, and 80-year-old patients.

RESULTS

In base case, at 65 years, zoledronate was the cheapest strategy. The incremental cost-effectiveness ratios (ICER, which represent incremental costs per QALY gained) of denosumab, teriparatide, abaloparatide, and romosozumab against zoledronate were $13,020/QALY (quality-adjusted years), $477,331 /QALY, $176,287/QALY, and $98,953/QALY, respectively. Under a willing-to-pay (WTP, which means the highest price a consumer will pay for one unit of a good of service) threshold of $150,000/QALY, denosumab and romosozumab were cost-effective against zoledronate. The PSA results showed that denosumab was the most cost-effective option with WTP thresholds of $50,000/QALY, $100,000/QALY and $150,000/QALY. The results were similar in other age groups. The DSA results indicated that the most common parameters that have important influence on the outcome were drug persistence, incidence of adverse events, the efficacy of drugs on hip fractures and the cost of the drug.

CONCLUSION AND RELEVANCE

Among PMO patients with a very high fracture risk in the US, zoledronate is the cheapest strategy and denosumab is the most cost-effective choice among these five strategies.

Bone mineral density changes in osteoporotic and osteopenic patients after COVID-19 infection

Background

Coronavirus disease 2019 (COVID-19) infection is linked to high levels of inflammatory cytokines and prolonged immobilization; furthermore, corticosteroid treatment leads to increased bone loss and resorption. We aimed to study the change in bone mineral density (BMD) after COVID-19 infection in osteoporotic and osteopenic patients. One hundred osteoporotic or osteopenic patients were selected in this single-center retrospective study; the patients were divided into two groups. Group 1 included 56 patients who got COVID-19 infection. Group 2 included 44 patients who did not get COVID-19 infection. BMD was assessed at baseline, after 9 months of COVID infection, and then after 1 year follow-up using dual energy x-ray absorptiometry (DXA) scan.

Results

There was no significant difference between two groups regarding demographic data (p > 0.05); there was a significant decrease in BMD of the lumbar region and femur at 9 months as compared to baseline in group1 (p < 0.001), while there was a significant increase in the lumbar BMD of osteoporotic patients who did not get COVID infection after 21 months. Concerning activity of COVID infection, there was a significant difference between the three subgroups of COVID patients regarding percentage of change in BMD after 9 months, the severe group having the highest decrease in BMD (p < 0.001).

Conclusions

COVID-19 may have deleterious effect on BMD in osteoporotic patients. It is recommended to assess BMD in osteoporotic/osteopenic patients who got COVID infection to detect if there is an increased risk of fracture which may necessitate post-COVID change in the therapeutic intervention plan.

The current role of telehealth in the management of patients with osteoporosis

INTRODUCTION

Telehealth is the use of electronic technologies for communication, storage, and analysis of health-related information. Telemedicine is a form of telehealth that involves remote patient care. This is a review and update of the use of these modalities as they apply to the education of healthcare professionals who provide care for patients with osteoporosis and the delivery of their care.

AREAS COVERED

This review focuses on technology-enabled collaborative learning and its prototype model, Project ECHO (Extension for Community Healthcare Outcomes). Bone Health TeleECHO and similar programs apply the ECHO model of learning to mentor healthcare professionals on implementation of best practice care for patients with osteoporosis and other skeletal diseases. Telemedicine, which has seen widespread uptake during the COVID-19 pandemic, is an alternative to in-person visits for patients with osteoporosis as well as for those with other conditions.

EXPERT OPINION

Remote education of healthcare professionals and the remote delivery of patient care provides opportunities, as well as challenges, for achieving the goal of reducing the global burden of osteoporotic fractures.

Tryptophan-Kynurenine Pathway in COVID-19-Dependent Musculoskeletal Pathology: A Minireview

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), affecting multiple organ systems, including the respiratory tract and lungs. Several studies have reported that the tryptophan-kynurenine pathway is altered in COVID-19 patients. The tryptophan-kynurenine pathway plays a vital role in regulating inflammation, metabolism, immune responses, and musculoskeletal system biology. In this minireview, we surmise the effects of the kynurenine pathway in COVID-19 patients and how this pathway might impact muscle and bone biology.

The Impact of COVID-19 on the Optimal Management of Osteoporosis

Osteoporosis does not take a break while Coronavirus disease 2019 (COVID-19) stunned and overtook everyone’s lives. Medical resources were immediately shifted, self-isolation and telemedicine were expanded, ambulatory care services such as bone densitometry and osteoporosis-centered clinics came to a near halt. Progress with fracture prevention has been challenged because osteoporotic fracture with low energy injury is more prevalent even though restriction of people’s movement. Thus we must re-engage with chronic bone health concerns and fracture prevention. This review discusses challenges in management of osteoporosis during the COVID-19 pandemic and reinforces the need to implementing recommendations concerning the importance of bone fragility care with at least those patients who are already treated with antiosteoporotic drugs maintaining their adherence to treatments.