An update of the Malaysian Clinical Guidance on the management of glucocorticoid-induced osteoporosis, 2015

Comparison of different intervention thresholds for the treatment of glucocorticoid-induced osteoporosis: a cross-sectional study

BACKGROUND

Glucocorticoid-induced osteoporosis (GIO) is the most common drug-induced osteoporosis. Early detection and treatment may decrease the fragility fractures. Several GIO guidelines exist, although they vary in recommended intervention thresholds for initiating pharmacologic treatment. This study aimed to evaluate the performance of intervention thresholds in treating GIO under various guidelines.

METHODS

Rheumatic disease patients receiving ≥ 2.5 mg/day prednisolone or equivalent for longer than 3 months between January 2013 and 2023 were retrospectively reviewed. Patients who were previously treated with anti-osteoporotic medications or had other secondary causes of osteoporosis were excluded. Bone mineral density (BMD) and Thailand-specific FRAX with glucocorticoid adjustment (GC-FRAX) were recorded. The performances of different intervention thresholds from six GIO guidelines (ACR 2022, Belgian 2022, TOPF 2021, Korean 2018, Malaysian 2015, and Japanese 2023) were examined against the incidence of actual fragility fractures.

RESULTS

This study included 226 rheumatic patients, with a mean (SD) age of 62.9 (10.1) years. Most of the patients were female (88.9%). The average (SD) daily dose, cumulative dose, and duration of glucocorticoid use were 4.6 (10.6) mg/day, 9,223.4 (9,223.4) mg, and 58.3 (55.8) months, respectively. Diagnoses included rheumatoid arthritis (59.8%), systemic lupus erythematosus (22%), inflammatory myositis (4.7%), systemic sclerosis (4.7%), and others. The prevalence of major osteoporotic fractures and hip fractures was 14.2% and 0.9%, respectively. The ten-year probabilities of major osteoporotic and hip fractures (FRAX) with and without BMD were 12.6 ± 9.1, 5.4 ± 6, 10.7 ± 7.2, and 4.6 ± 4.8, respectively. The mean (SD) ten-year FRAX probabilities of major osteoporotic and hip fractures were 12.6% (9.1) and 5.4% (6) with the inclusion of BMD result, and 10.7% (7.2) and 4.6% (4.8) without the inclusion of the BMD result. The sensitivity, specificity and accuracy of the ACR 2022, Belgian 2022, TOPF 2021, Korean 2018, Malaysian 2015, and Japanese 2023 guidelines were 100%/ 3.1%/ 16.8%, 93.8%/ 14.4%/ 25.7%, 93.8%/ 43.8%/ 50.9%, 100%/ 17.5%/ 29.2%, 78.1%/ 62.9%/ 65% and 100%/ 24.2%/ 35%, respectively.

CONCLUSIONS

Among evaluated guidelines, ACR 2022, Korean 2018, and Japan 2023 had the highest sensitivity for GIO treatment, while Malaysian 2015 showed the highest specificity and accuracy. These findings can improve clinical decision-making in GIO management for rheumatic disease patients.

Unveiling drug-induced osteotoxicity: A machine learning approach and webserver

Drug-induced osteotoxicity refers to the harmful effects certain pharmaceuticals have on the skeletal system, posing significant safety risks. These toxic effects are critical concerns in clinical practice, drug development, and environmental management. However, current toxicity assessment models lack specialized datasets and algorithms specifically designed to predict osteotoxicity In this study, we compiled a dataset of osteotoxic molecules and used clustering analysis to classify them into four distinct groups Furthermore, target prediction identified key genes (IL6, TNF, ESR1, and MAPK3), while GO and KEGG analyses were employed to explore the complex underlying mechanisms Additionally, we developed prediction models based on molecular fingerprints and descriptors. We further advanced our approach by incorporating models such as Transformer, SVM, XGBoost, and molecular graphs integrated with Weave GNN, ViT, and a pre-trained KPGT model. Specifically, the descriptor-based model achieved an accuracy of 0.82 and an AUC of 0.89; the molecular graph model reached an accuracy of 0.84 and an AUC of 0.86; and the KPGT model attained both an accuracy and an AUC of 0.86. These findings led to the creation of Bonetox, the first online platform specifically designed for predicting osteotoxicity. This tool aids in assessing the impact of hazardous substances on bone health during drug development, thereby improving safety protocols, mitigating skeletal side effects, and ultimately enhancing therapeutic outcomes and public safety.

Challenges in the diagnosis and management of glucocorticoid-induced osteoporosis in younger and older adults

OBJECTIVE

Glucocorticoids constitute a considerable risk for developing osteoporosis in both younger and older adults. However, currently available bone imaging modalities and fracture-risk assessment tools do not adequately capture the dramatic changes in bone microarchitecture, heterogeneity of glucocorticoid exposure, the impact of chronic disease and other osteoporosis risk factors on the assessment of osteoporosis in these individuals.

DESIGN

A narrative review is presented, following a systematic search of the literature from 2000 to 2021.

RESULTS

Our current appreciation of glucocorticoid-induced osteoporosis (GIO) is focused on older populations, with limited evidence to guide the investigation, risk assessment and treatment in premenopausal women and men less than 50 years. The impact of the underlying chronic disease on secondary osteoporosis in these younger adults is also poorly understood.

CONCLUSION

Through this narrative review, we provide a comprehensive overview of and recommendations for optimising the management of this common cause of secondary osteoporosis younger and older adults.

What traditional, complementary, and integrative medicine recommendations exist across osteoporosis clinical practice guidelines? A systematic review and quality assessment

Background

Traditional, complementary and integrative medicine (TCIM) is sought by more than 50% of patients with osteoporosis. Despite this, many healthcare providers lack the knowledge to adequately counsel patients on safe and effective TCIM use. The purpose of this study was to determine the quantity and quality of TCIM recommendations in clinical practice guidelines (CPGs) for the treatment and/or management of osteoporosis.

Methods

MEDLINE, EMBASE and CINAHL databases, in addition to the Guidelines International Network, and the National Center for Complementary and Integrative Health website were searched from 2009–2020. CPGs making TCIM recommendations for the treatment/management of osteoporosis were assessed with the AGREE II instrument.

Results

Of 536 unique search results, 27 osteoporosis CPGs made mention of TCIM therapies. From highest to lowest, scaled domain percentages of all eligible CPGs averaged to 92.59% for scope and purpose, 88.79% for clarity in presentation, 55.04% for stakeholder involvement, 47.84% for editorial independence, 46.53% for rigor of development, and 36.96% for applicability. Of the 27 CPGs assessed, 4 CPGs were recommended as is by both appraisers, while 23 CPGs were recommended with modifications.

Conclusions

Recommendations pertaining to calcium and vitamin D supplementation and exercise were favorably recommended across nearly all CPGs. In the case of other TCIM interventions, recommendations varied greatly, which may present challenges for CPGs target users due to a lack of consistency. Given the varying quality of osteoporosis CPGs found, those requiring improvement may benefit from their guideline development panel utilizing the AGREE II instrument to inform future updates.

Mesenchymal Stem Cell in Mice Uterine and Its Therapeutic Effect on Osteoporosis

Osteoporosis is a silent disease caused by low bone mineral density and is complicated by fractures. This study was designed to examine the differentiation of uterine stem cell-derived osteoprogenitor cells (UOPCs) both in vitro and in vivo, assessing their effectiveness in treating osteoporosis. CD271⁺/CD45^- UOPCs were isolated from the endometrial tissue of inbred Balb/c mice through magnetic activated cell sorting. Stem cell differentiation assays were used for CD271⁺/CD45^- UOPCs in vitro. In vivo, the UOPCs were implanted into mouse osteoporosis models through tail-vein injection for 8 weeks. Osteogenic differentiation was examined by X-rays and computed tomography (CT) scans. Enhanced green fluorescent protein (EGFP)-labeled UOPCs, obtained from C57BL/6-Tg (ACTb-EGFP) 1Osb/J mice, were used to assess cell survival in the osteoporosis model. The levels of osteogenic markers were assessed by enzyme-linked immunosorbent assay. In vitro, UOPCs were able to form into typical spheres and various differentiations. In vivo, implantation of UOPCs into osteoporosis model significantly increased bone mineral densities and bone microstructure parameters. The levels of a biochemical marker of bone metabolism, Semaphorin-3A, increased significantly. However, levels of receptor activator of nuclear factor kappa-B ligand decreased. Immunofluorescence staining of osteoporosis mice injected with green fluorescent protein+ UOPCs showed their survival for up to 7 days. In conclusion, stem cells with osteogenic differentiation potential can be isolated from uterine or endometrial tissue. These UOPCs can stably proliferate and differentiate in vitro or in vivo, which can inhibit bone resorption and osteoclast marker expression. In vivo, UOPCs significantly improved reduction in bone density caused by reduced estrogen levels. Such cell transplantation approach is potentially useful in the treatment of osteoporosis.

Rheumatology in Malaysia

Malaysia is a developing country in the South-East Asian region with a significant burden of disability from musculoskeletal disease. Rheumatology in Malaysia is a relatively young speciality. Currently, there is approximately 1 rheumatologist per 390,000 population, mostly concentrated in the urban areas. This article aims to give a brief overview of the research in rheumatology, the healthcare system, and rheumatology training and education in Malaysia. From 1950 until mid-2019, there were 547 publications about rheumatological conditions from Malaysia, with a 27-fold increase in the numbers from the period before 1980 compared to 2010-2019. Although there is universal access to healthcare through the public (government funded) hospitals and clinics, as well as a system of private healthcare, funding for expensive biological therapies remain patchy and scarce, leading to significant under-utilization of such treatments in rheumatology patients. Training in rheumatology in Malaysia is well established with a formalised training curriculum introduced in 2004, followed by the introduction of training in musculoskeletal ultrasound in 2006. To improve care for patients with musculoskeletal conditions, there has been regular continuing educational meetings and courses, not just for rheumatologists, but also for other medical professionals, as not all areas in Malaysia have easy access to rheumatology services. Thus overall, despite the small number of rheumatologists, rheumatology in Malaysia has made encouraging progress over the past 2 decades, but improvements in patient care, training, education and research need to continue in the future.